Nokea
A two-year-old has been in the hospital for 3 weeks and has seldom seen family members due to isolation precautions. Which of the following hospitalization changes is most likely to be occurring?
- A. Guilt
- B. Trust
- C. Separation anxiety
- D. Shame
Correct Answer: C
Rationale: The correct answer is 'Separation anxiety.' Separation anxiety is a common response in young children when they are separated from their primary caregivers for extended periods. In this case, the two-year-old being in the hospital for three weeks and not being able to see family members due to isolation precautions can trigger separation anxiety. 'Guilt' is a feeling of responsibility for wrongdoing, which is not the most likely change occurring in this scenario. 'Trust' involves reliance and confidence in others, not typically associated with prolonged separation from family. 'Shame' is a negative emotion related to feeling disgrace, which is not the most appropriate response in this hospitalization situation.
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The physician orders the antibiotics ampicillin (Omnipen) and gentamicin (Garamycin) for a newly admitted client with an infection. The nurse should:
- A. administer both medications simultaneously.
- B. give the medications sequentially, and flush well between them.
- C. ask the physician or pharmacy which medication to give first and how long to wait before giving the other drug.
- D. start one medication now and begin the other medication in 2-4 hours.
Correct Answer: B
Rationale: A client with an infection needs both antibiotics as soon as possible. However, the pH of ampicillin is 8-10, and the pH of gentamicin is 3-5.5, making them incompatible when given together. Flushing well between drugs is necessary to prevent interaction. Choice C is incorrect because the nurse, not the physician or pharmacy, should determine the correct administration sequence. Consulting with the pharmacist is appropriate if uncertain. Choice D is incorrect because delaying the second medication by several hours can slow the treatment of the client's infection, as both antibiotics are needed promptly to address the infection effectively. Therefore, the correct action is to give the medications sequentially and flush well between them to prevent any potential interactions.
A nurse notes that an elderly client suddenly does not keep appointments and is not wearing appropriate clothing. Which statement by the client raises the suspicion of financial abuse?
- A. "I am having difficulty paying for this new antibiotic the physician prescribed."?
- B. "I am a little short on cash since my daughter moved in to help me."?
- C. "I have not felt like shopping since the weather has gotten worse."?
- D. "People do not realize how difficult it is to make ends meet on a fixed income."?
Correct Answer: B
Rationale: The correct answer is B: "I am a little short on cash since my daughter moved in to help me."? This statement raises suspicion of financial abuse as it suggests a recent change in financial circumstances after the daughter moved in. Financial abuse in elderly clients can be indicated by sudden unexplained financial deficits or changes, such as difficulty paying for necessities despite previously being able to do so. Choices A, C, and D do not directly imply a recent financial change due to external factors, making them less indicative of potential financial abuse. Option B is the most concerning statement that warrants further investigation into possible financial exploitation.
A client can receive the mumps, measles, rubella (MMR) vaccine if he or she:
- A. is pregnant.
- B. is immunocompromised.
- C. is allergic to neomycin.
- D. has a cold.
Correct Answer: D
Rationale: A client can receive the MMR vaccine if he or she has a cold. A simple cold without fever does not preclude vaccination. Pregnant women and immunocompromised individuals cannot receive the MMR vaccine due to the live rubella component, which may lead to birth defects or disease. Choice C is incorrect because individuals with anaphylactic reactions to neomycin should not receive the measles vaccine according to the American Academy of Pediatrics.
Support-system enhancement includes all of the following except:
- A. determining the barriers to using support systems.
- B. discussing ways to help others who are concerned.
- C. exploring life problems of the support-team members.
- D. involving spouse, family, and friends in the care and planning.
Correct Answer: C
Rationale: Support-system enhancement involves various strategies to strengthen the support system. Determining the barriers to using support systems, discussing ways to help others who are concerned, and involving spouse, family, and friends in the care and planning are all essential aspects of enhancing the support system. However, exploring the life problems of the support-team members is not directly related to enhancing the support system. This approach could potentially invade personal boundaries and may not be necessary for improving the support system, making it the correct answer in this case. Therefore, option C is the correct answer as it does not align with the appropriate methods of support-system enhancement.
A woman asks, "How much alcohol can I safely drink while pregnant?"? The nurse's best response is:
- A. "The amount of alcohol that is safe during pregnancy is unknown."?
- B. "Consuming one or two beers or glasses of wine a day is considered safe for a healthy pregnant woman."?
- C. "Drinking three or more drinks on any given occasion is the only harmful type of drinking during pregnancy."?
- D. "You can have a drink to help you relax and get to sleep at night."?
Correct Answer: A
Rationale: The correct answer is, "The amount of alcohol that is safe during pregnancy is unknown."? It is crucial for pregnant women to avoid alcohol as there is no known safe amount during pregnancy. Consuming any amount of alcohol can harm the developing fetus and increase the risk of fetal alcohol syndrome, a condition characterized by mental and physical abnormalities in infants. Choices B, C, and D are incorrect because they provide misleading information that can potentially harm the fetus. Pregnant women should abstain from alcohol to ensure the health and well-being of their baby.