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Questions 163

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Question 1 of 5

The nurse on a pediatric unit is caring for a preschooler who exhibits separation anxiety when the parents go to work. Which interventions should the nurse implement? Select all that apply.

Correct Answer: A,B,D

Rationale:
To manage separation anxiety: a stuffed animal provides comfort, a familiar schedule offers stability, and play distracts and engages. Isolating the child may worsen anxiety, and removing parental reminders could increase distress.

Question 2 of 5

The nurse is discussing mammogram screening with a family. No one in the family has had a mammogram. The mother is 52, there are four daughters, ages 10, 15, 21, and 34, and the grandmother is 75. Which of the following women should receive a mammogram? Select all that apply.

Correct Answer: D,E,F

Rationale: Women aged 40 and older, or earlier with risk factors, should have mammograms. The 34-year-old, 52-year-old, and 75-year-old women meet screening age criteria.

Question 3 of 5

The nurse is reinforcing information to a diabetic client with a new prescription for metoclopramide. Which of the following side effects must the nurse remind the client to report immediately to the health care provider? Select all that apply.

Correct Answer: A,D,E

Rationale: Metoclopramide can cause tardive dyskinesia, with symptoms like excess blinking , lip smacking , and cheek puffing , requiring immediate reporting. Dry mouth and headache are common and less urgent.

Question 4 of 5

The nurse in the emergency department is caring for a newborn who has been vomiting. Which of the following findings may indicate that the newborn is experiencing a bowel obstruction?

Correct Answer: A

Rationale: Green-colored vomit in a newborn suggests bile, indicating a possible bowel obstruction like malrotation or volvulus. Occasional vomiting , blood streaks , and nasal vomit are less specific.

Question 5 of 5

While sitting in the cafeteria, a nurse overhears two students discussing a client admitted for chemical detoxification. The nurse should:

Correct Answer: C

Rationale: Confronting the students addresses the breach of confidentiality directly and educates them. Reporting to the teacher or supervisor escalates unnecessarily, and ignoring the behavior allows the violation to persist.

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