Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A 3-year-old boy was successfully toilet trained prior to his admission to the hospital for injuries sustained from a fall. His parents are very concerned that the child has regressed in his toileting behaviors. Which information should the nurse provide to the parents?
A. Diapering will be provided since hospitalization is stressful to preschoolers.
While it is true that hospitalization can be stressful for preschoolers, providing diapers may not be necessary. Regression in toileting is often temporary and related to the stress of the hospital environment.
B. A retraining program will need to be initiated when the child returns home.
Initiating a retraining program immediately after returning home may not be necessary. Most children will naturally resume their previous toileting behaviors once they are back in a familiar and less stressful environment.
C. A potty chair should be brought from home so he can maintain his toileting skills.
Bringing a potty chair from home can be helpful in some cases, but it is not always practical or necessary. The child is likely to resume normal toileting behaviors once they are back in their usual environment.
D. Children usually resume their toileting behaviors when they leave the hospital.
This is the correct answer because children often regress in their toileting behaviors due to the stress and unfamiliarity of the hospital environment. Once they return home, they typically resume their previous toileting habits.
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Full Explanation
The correct answer is choice d. Children usually resume their toileting behaviors when they leave the hospital.
Choice A rationale:
While it is true that hospitalization can be stressful for preschoolers, providing diapers may not be necessary. Regression in toileting is often temporary and related to the stress of the hospital environment.
Choice B rationale:
Initiating a retraining program immediately after returning home may not be necessary. Most children will naturally resume their previous toileting behaviors once they are back in a familiar and less stressful environment.
Choice C rationale:
Bringing a potty chair from home can be helpful in some cases, but it is not always practical or necessary. The child is likely to resume normal toileting behaviors once they are back in their usual environment.
Choice D rationale:
This is the correct answer because children often regress in their toileting behaviors due to the stress and unfamiliarity of the hospital environment. Once they return home, they typically resume their previous toileting habits.
Similar Questions
The nurse has completed the diet teaching of a client who is being discharged following treatment of a leg wound. A high protein diet is encouraged to promote wound healing. Which lunch choice by the client indicates that the teaching was effective?
A. A salad with three kinds of lettuce and fruit.
Incorrect - While a salad includes vegetables and fruits, it may not provide sufficient protein for wound healing.
B. Vegetable soup, crackers, and milk.
Incorrect - Vegetable soup and crackers might not provide enough protein compared to other options.
C. A peanut butter sandwich with soda and cookies.
Incorrect - While a peanut butter sandwich includes some protein, soda and cookies are not rich sources of protein.
D. A tuna fish sandwich with chips and ice cream.
Correct- A tuna fish sandwich is a good source of protein. Protein is essential for wound healing as it supports tissue repair and regeneration. The choice of a tuna fish sandwich along with chips and ice cream suggests a balanced meal with adequate protein content, which aligns with the teaching of a high protein diet to promote wound healing.
Full Explanation
A) Incorrect - While a salad includes vegetables and fruits, it may not provide sufficient protein for wound healing.
B) Incorrect - Vegetable soup and crackers might not provide enough protein compared to other options.
C) Incorrect - While a peanut butter sandwich includes some protein, soda and cookies are not rich sources of protein.
D) Correct- A tuna fish sandwich is a good source of protein. Protein is essential for wound healing as it supports tissue repair and regeneration. The choice of a tuna fish sandwich along with chips and ice cream suggests a balanced meal with adequate protein content, which aligns with the teaching of a high protein diet to promote wound healing.
In assessing a client at 34 weeks gestation, the nurse notes that she has a slightly elevated total T4 with a slightly enlarged thyroid, a hematocrit of 28% (0.28 volume fraction), a heart rate of 92 beats per minute, and a systolic murmur. Which finding requires follow-up?
Reference Range:
Hematocrit [37% to 47% (0.37 to 0.47 volume fraction)]
A. Hematocrit of 28% (0.28 volume fraction).
Correct- Hematocrit values below the reference range during pregnancy could indicate anemia, which requires further evaluation and intervention. The other findings can be attributed to normal physiological changes during pregnancy (elevated total T4, heart rate increase) or can be common findings (systolic murmur).
B. Heart rate of 92 beats per minute.
Incorrect - A heart rate of 92 beats per minute is within the normal range for pregnancy due to increased blood volume and hormonal changes.
C. Systolic murmur.
Incorrect - A systolic murmur can be a common finding during pregnancy due to increased cardiac output.
D. Elevated thyroid hormone level.
Incorrect - An elevated total T4 can be a normal finding during pregnancy due to hormonal changes.
Full Explanation
A) Correct- Hematocrit values below the reference range during pregnancy could indicate anemia, which requires further evaluation and intervention. The other findings can be attributed to normal physiological changes during pregnancy (elevated total T4, heart rate increase) or can be common findings (systolic murmur).
B) Incorrect - A heart rate of 92 beats per minute is within the normal range for pregnancy due to increased blood volume and hormonal changes.
C) Incorrect - A systolic murmur can be a common finding during pregnancy due to increased cardiac output.
D) Incorrect - An elevated total T4 can be a normal finding during pregnancy due to hormonal changes.
After a spider bite on the lower extremity, a client is admitted for treatment of an infection that is spreading up the leg. Which admission assessment finding(s) should the nurse report to the healthcare provider? (Select all that apply.)
A. Red blood cell count (RBC).
Incorrect - Red blood cell count (RBC) is not directly relevant to the assessment of infection and its spread.
B. Core body temperature.
Correct- Core body temperature can be an indicator of systemic infection and needs to be reported to the healthcare provider for assessment and intervention.
C. Swollen lymph nodes in the groin.
Correct- Swollen lymph nodes in the groin suggest local and regional lymphatic involvement, indicating possible spread of infection. This finding needs further assessment and intervention.
D. Location of the initial intravenous (IV) site.
Incorrect - The location of the initial intravenous (IV) site is not directly relevant to the assessment of infection and its spread.
E. White blood cell count (WBC).
Full Explanation
A) Incorrect - Red blood cell count (RBC) is not directly relevant to the assessment of infection and its spread.
B) Correct- Core body temperature can be an indicator of systemic infection and needs to be reported to the healthcare provider for assessment and intervention.
C) Correct- Swollen lymph nodes in the groin suggest local and regional lymphatic involvement, indicating possible spread of infection. This finding needs further assessment and intervention.
D) Incorrect - The location of the initial intravenous (IV) site is not directly relevant to the assessment of infection and its spread.
E) Correct- An elevated white blood cell count (WBC) can indicate an inflammatory response to infection. This finding should be reported to the healthcare provider for further evaluation and treatment.