The nurse is meeting a 5-year-old child for the first time and would like the child to cooperate during a dressing change. The nurse decides to do a simple magic trick using gauze. How should this action be interpreted?

Correct Answer: B

Rationale: Using a simple magic trick with gauze to engage a 5-year-old child during a dressing change is a way to establish rapport. This approach can help build trust and reduce anxiety by making the procedure more engaging and less intimidating for the child. By creating a positive interaction through a fun activity, the nurse can promote cooperation and make the dressing change a smoother experience for the child. Overall, the use of a magic trick in this context is appropriate and beneficial for enhancing the child's cooperation and comfort.

Correct Answer: C

Rationale: When performing perineal care on an uncircumcised male patient, it is important to replace the foreskin over the head of the penis after washing. The foreskin should not be left retracted or pulled back forcibly as it can cause irritation and discomfort to the patient. Leaving the foreskin retracted can also lead to potential complications such as paraphimosis, where the foreskin becomes trapped behind the head of the penis. Proper hygiene involves gently retracting the foreskin to clean underneath it and then returning it to its natural position to protect the sensitive glans penis. Using gentle, warm water with mild soap is typically sufficient for cleaning, and alcohol should be avoided as it can cause irritation and dryness to the sensitive genital area.

Correct Answer: C

Rationale: When suctioning a patient, it is important to limit the suctioning time to avoid hypoxia and tissue trauma. The maximum recommended time for suctioning an adult patient is usually around 10-15 seconds. However, in some cases, such as when dealing with thick or excessive secretions, the maximum time can be extended up to 30 seconds. In this particular case, where James is likely experiencing respiratory distress due to his symptoms, it would be appropriate for Wilma to suction him for a maximum of 30 seconds to effectively clear his airways while minimizing the risk of complications.

Correct Answer: C

Rationale: Paroxysms, or sudden attacks, of shortness of breath are a common sign or symptom of asthma. Asthma is a chronic respiratory condition characterized by inflammation and narrowing of the airways, which leads to difficulty breathing. During an asthma attack, individuals may experience sudden and severe shortness of breath, often accompanied by wheezing, coughing, and chest tightness. These paroxysms of breathlessness are a hallmark feature of asthma and indicate the presence of airway inflammation and constriction.

Correct Answer: A

Rationale: Patients with multiple myeloma are at an increased risk of bleeding due to low levels of platelets, which play a key role in blood clotting. Uncontrolled bleeding can occur in multiple myeloma patients, leading to serious complications such as hemorrhage and anemia. Therefore, the nurse should monitor for signs of bleeding, such as easy bruising, petechiae, or prolonged bleeding from minor cuts or procedures, and take appropriate interventions to manage and prevent further bleeding episodes in the patient with multiple myeloma. Monitoring for and addressing uncontrolled bleeding is crucial in ensuring the safety and well-being of the patient.