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Questions 164

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Question 1 of 5

The nurse is reinforcing teaching to the parents of a hospitalized 3-month-old about separation anxiety. The nurse notices that the parents still seem concerned about leaving the infant while they work. Which statement by one of the parents indicates that the teaching has been effective?

Correct Answer: C

Rationale: Infants at 3 months (
C) do not yet exhibit separation anxiety and cannot sense parental anxiety. Crying (
A), feeling abandoned (
B), and understanding return (
D) occur later in development.

Question 2 of 5

The nurse is caring for a college football player who recently sustained an accidental, forceful, helmet-to-helmet collision with another running football player. Which sign/symptom is most concerning and alerts the practical nurse to contact the registered nurse immediately?

Correct Answer: B

Rationale: A 'halo' across vision (
B) suggests a serious neurological issue, such as a concussion or brain injury, requiring immediate attention. Epistaxis (
A), emesis (
C), and headache (
D) are concerning but less urgent unless persistent or worsening.

Question 3 of 5

The nurse is talking with the parents of a 4-year-old client. The parents are concerned because the client was previously toilet trained but has started wetting the bed again while hospitalized. Which of the following responses would be most appropriate for the nurse to make?

Correct Answer: D

Rationale: Regression, such as bedwetting, is common in hospitalized children due to stress (
D). Reinforcing toileting behaviors (
A) may help but doesn't address the underlying cause. Fluid restriction (
B) is not appropriate without medical indication. Assuming misbehavior (
C) dismisses the emotional impact of hospitalization.

Question 4 of 5

The client with a colostomy does not feel that the irrigating solution has drained completely. The nurse can enhance the effectiveness of the colostomy irrigation by telling the client to:

Correct Answer: A

Rationale: Gentle abdominal massage can stimulate peristalsis and help the irrigation solution drain completely from the colostomy. Reducing solution or using a heating pad is not standard, and increasing oral intake is unrelated.

Question 5 of 5

A client with emphysema visits the clinic. While teaching about proper nutrition, the nurse should emphasize that the client should

Correct Answer: B

Rationale: Use oxygen during meals to improve gas exchange. This supports breathing and energy needs during eating.

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