Nokea
A nurse is providing education to a group of adolescents who are pregnant and attending high school. Which of the following information should the nurse include in their teaching?
- A. The need for supplemental folic acid is greatest during the third trimester
- B. The incidence of high birth weight infants is higher in adolescent pregnancy
- C. Pregnant adolescents need to gain less weight than adult mothers
- D. Caffeinated beverages should be replaced with caffeine-free beverages
Correct Answer: D
Rationale: The correct answer is D: Caffeinated beverages should be replaced with caffeine-free beverages. Pregnant adolescents should limit their caffeine intake as excessive caffeine can lead to complications during pregnancy. Caffeine can cross the placenta and affect the baby's heart rate and sleep patterns. It is important for pregnant adolescents to switch to caffeine-free beverages to ensure the health and well-being of both the mother and baby.
A: The need for supplemental folic acid is not specific to the third trimester, it is important throughout pregnancy.
B: The incidence of high birth weight infants is not necessarily higher in adolescent pregnancy compared to adult mothers.
C: Pregnant adolescents actually need to gain weight within the recommended range, similar to adult mothers, to support fetal growth and development.
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A first response team is working at the location of a bombing incident. A nurse triaging a group of clients should give treatment priority to which of the following clients?
- A. A client who has superficial partial-thickness burn injuries over 5% of his body
- B. A client who has a femur fracture with a 2+ pedal pulse
- C. A client who is ambulatory and exhibits manic behavior
- D. A client who has a rigid abdomen with manifestations of shock
Correct Answer: D
Rationale: The correct answer is D: A client who has a rigid abdomen with manifestations of shock. This client should receive treatment priority because a rigid abdomen can indicate internal bleeding or organ damage, which are life-threatening conditions requiring immediate medical attention to prevent further complications. Manifestations of shock, such as hypotension and tachycardia, also indicate a critical condition that needs urgent intervention to stabilize the client's condition and prevent deterioration.
Choice A is incorrect because superficial partial-thickness burn injuries, although painful and requiring treatment, are not immediately life-threatening compared to internal injuries like in choice D. Choice B is incorrect as a femur fracture with a palpable pedal pulse indicates distal circulation is intact, making it a lower priority compared to the critical condition in choice D. Choice C is incorrect as manic behavior, while concerning, does not pose an immediate threat to the client's life compared to the potentially life-threatening conditions in choice D.
A community health nurse is educating a parent about the importance of hepatitis B immunization. Which of the following explanations should the nurse give the parent about the disease?
- A. One dose of the immunization gives children lifelong protection from hepatitis B
- B. Hepatitis B spreads easily among children through casual contact
- C. Many people who acquire acute hepatitis B develop chronic hepatitis
- D. People who have had a hepatitis B infection still need the immunization
Correct Answer: C
Rationale: The correct answer is C: Many people who acquire acute hepatitis B develop chronic hepatitis. This explanation is important for the parent to understand the potential long-term consequences of hepatitis B infection. Acute hepatitis B can progress to chronic hepatitis in some cases, leading to liver damage and other complications. It highlights the seriousness of the disease and the importance of prevention through vaccination.
Choice A is incorrect because although hepatitis B vaccination provides long-lasting protection, it may not necessarily offer lifelong immunity. Choice B is incorrect as hepatitis B is primarily transmitted through exposure to infected blood or body fluids, not casual contact among children. Choice D is incorrect because prior infection does not confer complete immunity, so immunization is still recommended.
A community health nurse is providing screening for lipid disorders. Which of the following is the primary goal of this activity?
- A. Early detection of disease
- B. Client enrollment in prevention programs
- C. Promotion of appropriate lifestyle changes
- D. Identification of family history of medical problems
Correct Answer: A
Rationale: The correct answer is A: Early detection of disease. The primary goal of screening for lipid disorders is to identify individuals at risk for developing lipid disorders such as high cholesterol levels. Early detection allows for timely intervention and treatment to prevent complications like heart disease. Choice B is incorrect because enrollment in prevention programs is a secondary outcome of screening, not the primary goal. Choice C is also incorrect as promoting lifestyle changes is a part of the intervention phase, not the primary goal of screening. Choice D is incorrect as identifying family history is important but not the primary goal of screening for lipid disorders.
A school nurse is assessing a child who has been stung by a bee. The child's hand is swelling, and the nurse notes that the child is allergic to insect stings. Which of the following findings should the nurse expect if the child develops anaphylaxis? (SATA)
- A. Bradycardia
- B. Nausea
- C. Hypertension
- D. Urticaria
- E. Stridor
Correct Answer: B, D, E
Rationale: Correct Answer: B, D, E
Rationale:
1. Nausea: Anaphylaxis can cause gastrointestinal symptoms like nausea due to the release of inflammatory mediators.
2. Urticaria: Anaphylaxis commonly presents with hives (urticaria) as a manifestation of allergic reaction.
3. Stridor: Anaphylaxis can lead to upper airway swelling, causing stridor due to compromised breathing.
Summary of Incorrect Choices:
A. Bradycardia: Anaphylaxis typically causes tachycardia due to the body's response to the allergen.
C. Hypertension: Anaphylaxis usually results in hypotension due to vasodilation and increased vascular permeability.
A nurse of a community clinic is preparing an educational guide about cultural variances in expression of pain. Which of the following information should the nurse include?
- A. Middle Eastern cultural practices include hiding pain from close family members
- B. Native American cultural practices include being outspoken about pain
- C. Puerto Rican cultural practices include the view that outspoken expressions of pain are shameful
- D. Chinese cultural practices include enduring pain to prevent family dishonor
Correct Answer: D
Rationale: The correct answer is D: Chinese cultural practices include enduring pain to prevent family dishonor. In Chinese culture, there is a strong emphasis on family honor and saving face. Expressing pain openly may be viewed as a sign of weakness and may bring shame to the family. Therefore, individuals may choose to endure pain silently to avoid dishonoring their family.
Explanation for other choices:
A: Middle Eastern cultural practices include hiding pain from close family members - This is not necessarily a common practice in Middle Eastern cultures and may not accurately represent the diverse ways pain is expressed.
B: Native American cultural practices include being outspoken about pain - While some Native American cultures may value openness about pain, it is not a universal practice among all tribes and communities.
C: Puerto Rican cultural practices include the view that outspoken expressions of pain are shameful - While there may be individuals within Puerto Rican culture who hold this belief, it is not a widely recognized cultural practice.