Complete Solutions
A 10-year-old child who is developmentally delayed
and blind must be fed all meals. The child has
problems swallowing and frequently chokes and
coughs during the feeding. What technique should
the nurse use when feeding this child?
a. Holding the child in an upright position and using
a soft-tipped bulb syringe
b. Placing the child in the supine position and
turning the child's head to the right
c. Seating the child in a wheelchair, giving small
bites of food with metal tableware, and
encouraging participation
d. Propping the child in a semisitting position,
providing chopped food, and placing it in the child's
mouth with plastic tableware Correct Answers C!
An upright position helps prevent aspiration;
gravity facilitates movement of food down the
esophagus and into the stomach. Metal tableware
is safer than plastic tableware because it is
unbreakable; a mentally challenged child could
easily bite down on and break a plastic utensil and
choke on the fragments. Encouraging participation,
,with socialization, and treating the child with
dignity should be part of the meal. Although the
child might assume an upright position, using a
syringe is a form of forced feeding; in addition, the
child should be encouraged to eat solid foods.
Feeding in the supine position puts the child at risk
for aspiration and choking. Solid, not chopped, food
should be encouraged.
A 16-year-old male student who was injured while
skateboarding arrives in the emergency
department with a deep laceration of his leg. He
does not remember when he received his last
tetanus immunization. The nurse explains that
tetanus immunoglobulin (TIG) and tetanus toxoid
are required because:
a. Neither medication is effective alone.
b. Both eliminate the need for additional
medications.
c. Different mechanisms are used to stimulate the
immune response.
d. Tetanus toxoid minimizes the risks related to the
tetanus immunoglobulin. Correct Answers C!
TIG provides immediate protection, whereas the
tetanus toxoid initiates an active immune
,response. Each is effective alone, but the
combination is preferred. They do not confer
lifelong immunity. After the initial routine
immunizations and boosters, it is recommended
that the tetanus toxoid be administered every 10
years. TIG does not carry major side effects
because it is derived from human
A 26-year-old homosexual client is diagnosed with
acquired immune deficiency syndrome (AIDS). The
primary nurse reports to the nursing team that the
client cried when told of the diagnosis. One of the
nursing assistants responds, "I don't feel sorry for
him. He made his bed, and now he can lie in it." To
best help the nursing assistant, the nurse manager
must first identify that this comment most likely is
a result of the nursing assistant's:
a. Values and beliefs about sexual lifestyles.
b. Anger and mistrust of homosexual males in
general.
c. Discomfort with men who are unable to control
their emotions.
d. Hostility over having to care for someone with a
sexually transmitted infection Correct Answers A!
, This statement reflects values and beliefs
regarding homosexuality as being bad and
deserving of punishment. There is not enough
evidence presented to justify drawing the
conclusion that the nursing assistant has anger and
mistrust of homosexual males in general or
discomfort with men who are unable to control
their emotions. Although there may be hostility
over having to care for someone with a sexually
transmitted infection, no information is given to
suggest that the nursing assistant has been
assigned to care for this client.
A 4-month-old infant is admitted to the pediatric
unit. How does the primary nurse expect the infant
to behave when approached?
a. Smile socially in recognition of the nurse
b. Cry when the nurse approaches for the first time
c. Reach out to the nurse for the attention that is
being offered
d. Cling to the mother when the nurse tries to
establish contact Correct Answers C!
The infant has not yet recognized boundaries
between self and mother and is not particular
about who meets and resolves needs. The infant is