A 3-year-old boy is hospitalized after falling down the stairs. His mother cries, 'This is all my fault.' Which is the nurse's best response?

Correct Answer: B

Rationale: Reassuring the parent that falls are common in young children can help reduce guilt and anxiety.

Correct Answer: B

Rationale: Tinnitus is a known adverse drug reaction to aspirin, especially at higher doses. Tinnitus is described as ringing, buzzing, or other noises in the ears. If a client experiences tinnitus while taking aspirin, it is important to notify the physician promptly as it could be a sign of aspirin toxicity. Monitoring and managing this adverse reaction are crucial to prevent further complications for the client.

Correct Answer: A

Rationale: Before administering digoxin, it is crucial for the nurse to check the patient's pulse rate. Digoxin is a medication commonly used to treat heart conditions such as atrial fibrillation and heart failure by increasing the strength and efficiency of the heart's contractions. However, digoxin can also cause adverse effects such as bradycardia (slow heart rate) or heart block. Therefore, it is important to assess the patient's pulse rate to ensure that it is within the safe range before administering digoxin.

Correct Answer: D

Rationale: Responding to name usually occurs earlier, around 6-9 months.

Correct Answer: D

Rationale: Involvement of two lymph node regions above the diaphragm with systemic symptoms corresponds to stage IIB.