Nokea
During an outpatient clinic visit, a 13-year-old client is diagnosed with infectious mononucleosis. The nurse should expect which of the following to be included in the client's plan of care?
- A. Take acetaminophen (Tylenol) with codeine as prescribed for pain.
- B. Encourage gargling with warm water to alleviate pain.
- C. Start a short course of ampicillin.
- D. Encourage social activity to prevent depression.
Correct Answer: B
Rationale: The correct answer is B: Encourage gargling with warm water to alleviate pain. Gargling with warm water can help soothe a sore throat, a common symptom of infectious mononucleosis. Acetaminophen with codeine (A) is not typically recommended for mononucleosis pain management in children due to the risk of respiratory depression. Starting a short course of ampicillin (C) is contraindicated in mononucleosis as it can cause a rash. Encouraging social activity (D) may not be appropriate as the client may need rest to recover.
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A nurse is assessing a newborn 12 hr after birth. Which of the following manifestations should the nurse report to the provider?
- A. Acrocyanosis
- B. Transient strabismus
- C. Jaundice
- D. Caput succedaneum
Correct Answer: C
Rationale: The correct answer is C: Jaundice. Jaundice in a newborn 12 hours after birth could indicate physiological jaundice, but it should still be reported to the provider for further evaluation. Jaundice can be a sign of hyperbilirubinemia, which if left untreated, can lead to complications like kernicterus. Acrocyanosis (A), transient strabismus (B), and caput succedaneum (D) are common and expected findings in newborns and do not typically require immediate reporting unless they are severe or persistent.
Which information is most important for the nurse to gather when a client is admitted to the unit in labor?
- A. Name of the support person
- B. Medical problems or complications
- C. Fluid preferences
- D. Amount of weight gained during the pregnancy
Correct Answer: B
Rationale: The correct answer is B: Medical problems or complications. This information is crucial for assessing the client's risk status and determining appropriate care during labor. Knowing the medical history helps identify potential complications that may arise and allows the nurse to plan for necessary interventions. Gathering information on the support person (choice A) is important but not as critical as the client's medical history. Fluid preferences (choice C) and weight gained during pregnancy (choice D) are relevant but do not directly impact the immediate care needed during labor. Without additional choices provided, it is evident that medical problems or complications (choice B) takes precedence in ensuring the safety and well-being of both the client and the baby.
A 16-year-old client reports to the school nurse because of nausea and vomiting. After exploring the signs and symptoms with the client, the nurse asks the girl whether she could be pregnant. The girl confirms that she is pregnant, but states that she does not know how it happened. Which nursing diagnosis is most important?
- A. Altered nutrition: less than body requirements related to nausea and vomiting
- B. Risk for altered family processes related to the client's age
- C. Ineffective individual coping related to denial of pregnancy
- D. Knowledge deficit related to the client's developmental stage and age
Correct Answer: D
Rationale: The correct answer is D: Knowledge deficit related to the client's developmental stage and age. This nursing diagnosis is most important because the client's lack of understanding about how pregnancy occurs indicates a significant gap in knowledge. It is crucial to provide education on sexual health and reproduction to prevent future unplanned pregnancies and promote informed decision-making.
Choice A is incorrect as addressing altered nutrition is important but not the priority in this situation. Choice B is incorrect as the client's age does not necessarily indicate a need for immediate intervention in family processes. Choice C is incorrect as the primary issue is the client's lack of knowledge, not denial of pregnancy.
In summary, choice D is the most important nursing diagnosis as it directly addresses the root cause of the client's situation and has the potential to positively impact her future health and well-being.
A nurse is teaching a newly licensed nurse about collecting a specimen for the universal newborn screening. Which of the following statements should the nurse include in the teaching?
- A. Obtain an informed consent prior to obtaining the specimen
- B. Collect at least milliliter of the urine for the test
- C. Ensure that the newborn has been receiving feedings for 24 hours prior to obtaining the specimen.
- D. Premature newborns may have false negative tests due to immature development of liver enzymes.
Correct Answer: C
Rationale: The correct answer is C: Ensure that the newborn has been receiving feedings for 24 hours prior to obtaining the specimen. This is important because certain metabolic disorders can only be detected if the baby has been feeding normally. Without proper feeding, the test results may not be accurate.
Choice A is incorrect because informed consent is not required for universal newborn screening; it is a routine procedure. Choice B is incorrect as urine is not typically used for the universal newborn screening. Choice D is incorrect because premature newborns may have false positive tests, not false negative tests, due to immature liver enzyme development.
A nurse is discussing the use of condoms with a female client. Which of the following statements by client represents a need for further teaching?
- A. My partner will put the condom on while his penis is erect.
- B. I will remove the condom 30 minutes after intercourse.
- C. My partner should leave an empty space at the tip.
- D. I can use spermicidal gels or creams to increase effectiveness.
Correct Answer: B
Rationale: The correct answer is B because removing the condom 30 minutes after intercourse is incorrect. Condoms should be removed immediately after ejaculation to prevent leakage or spillage of semen. Leaving the condom on for too long increases the risk of pregnancy and STIs. Choice A is correct as putting the condom on while the penis is erect is the proper way to ensure it fits securely. Choice C is also correct as leaving a small space at the tip allows room for semen collection. Choice D is incorrect because spermicidal gels or creams are not recommended with condoms as they can cause irritation and may not increase effectiveness.