1. A nurse is planning care for a preschool-age child who is in the

acute phase of Kawasaki disease. Which of the following

interventions should the nurse include in the plan of care?

a. Give acetaminophen to control the child’s fever

B. Monitor the client’s cardiac status (Peds p120)

c. Administer antibiotics via intermittent IV bolus for 24 hrs

d. Provide stimulation with children of the same age in the

playroom

2. A nurse observes a client on the psychiatric unit muttering and

standing near a window. The client states, “The voices are telling me

to jump.” Which of the following is an appropriate response by the

nurse?

a. “Do you recognize the voices as belonging to anyone you

know?”

B. “I understand the voices are frightening you, but I do not

hear any voices.”

c. “That can’t be true. The only voices in this room are yours and

mine.”

d. “You shouldn’t be afraid when you think the voices are telling

you to hurt yourself.”

Rationale: try to reorient the client back to reality.

3. A nurse is caring for a client who is preparing his advance

directives. Which of the following statements by the client indicates

an understanding of advance directives? (Select all that apply.)

a. “I need an attorney to witness my signature on the advance

directives.” *(nurse witnesses it)

b. “I have the right to refuse treatment.” (Leadership p38)