Nokea
A 16-year-old mother complaining of breast engorgement feels unhappy living with her husband. The MOST appropriate action is
- A. refer her to an obstetrician
- B. advise her to apply stimulant medications for milk expression
- C. explain that this is a normal phenomenon
- D. stop feeding the baby
Correct Answer: A
Rationale: Referral to an obstetrician is necessary for proper evaluation and management.
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Which is an effective strategy to reduce the stress of burn dressing procedures?
- A. Give the child as many choices as possible.
- B. Reassure the child that dressing changes are not painful.
- C. Explain to the child why analgesics cannot be used.
- D. Encourage the child to master stress with controlled passivity.
Correct Answer: A
Rationale: Giving the child as many choices as possible is an effective strategy to reduce the stress of burn dressing procedures. Allowing the child to have some control over the situation can help them feel more empowered and less anxious. By giving choices, such as letting the child choose the order in which things are done or the type of dressing used, the child is more likely to feel a sense of autonomy and reduced stress during the procedure. This approach can help the child cope better with the dressing changes and make the experience more manageable for them.
Which intervention is appropriate for the nurse caring for a client in severe pain receiving a continuous I.V. infusion of morphine?
- A. Assisting with a naloxone challenge test before therapy begins
- B. Discontinuing the drug immediately if signs of dependence appear
- C. Changing the administration route to P.O. if the client can tolerate fluids
- D. Obtaining baseline vital signs before administering the first dose
Correct Answer: D
Rationale: Obtaining baseline vital signs before administering the first dose is appropriate for the nurse caring for a client in severe pain receiving a continuous I.V. infusion of morphine. Monitoring vital signs, including blood pressure, heart rate, respiratory rate, and oxygen saturation, is essential to assess the client's response to opioid therapy. Baseline vital signs provide a comparison for evaluating changes in the client's physical status and help identify any adverse effects or complications related to morphine administration. This proactive approach allows the nurse to detect and address any abnormalities promptly, ensuring the client's safety and optimal pain management.
By the age of 7 months, the infant is able to do all the following EXCEPT
- A. transfer object from hand to hand
- B. actively bounces
- C. uses radial palm grasp
- D. cruises
Correct Answer: D
Rationale: Cruising typically occurs later, around 9-10 months.
Which is included in the diet of a child with minimal change nephrotic syndrome?
- A. High protein
- B. Salt restriction
- C. Low fat
- D. High carbohydrate
Correct Answer: B
Rationale: In children with minimal change nephrotic syndrome, it is important to include salt restriction in the diet. Salt restriction helps in managing edema by reducing fluid retention in the body. Excessive salt intake can contribute to fluid retention and edema in these patients. This dietary modification can help in controlling symptoms and managing the condition effectively. Other considerations for the diet may include monitoring protein intake to prevent complications related to kidney function.
Which of the following would the nurse evaluate as laboratory data that support the occurrence of AIDS?
- A. 900 CD 4+ cells
- B. 500 CD 4+ cells
- C. 700 CD 4+ cells
- D. 200 CD 4+ cells
Correct Answer: D
Rationale: The nurse would evaluate 200 CD 4+ cells as laboratory data that support the occurrence of AIDS. In patients with AIDS, there is a significant decrease in the CD4+ T-lymphocyte count, typically falling below 200 cells/mm³. This low CD4+ cell count increases the risk of opportunistic infections and indicates severe immune suppression, which is characteristic of AIDS. A CD4+ count of 200 or less is an important criterion for the diagnosis of AIDS according to the Centers for Disease Control and Prevention (CDC) and World Health Organization (WHO) guidelines.