Nokea
A 2 year-old child has just been diagnosed with cystic fibrosis. The child's father asks the nurse 'What is our major concern now, and what will we have to deal with in the future?' Which of the following is the best response?
- A. There is a probability of life-long complications.
- B. Cystic fibrosis results in nutritional concerns that can be dealt with.
- C. Thin, tenacious secretions from the lungs are a constant struggle in cystic fibrosis.
- D. You will work with a team of experts and also have access to a support group that the family can attend.
Correct Answer: C
Rationale: Thin, tenacious secretions from the lungs are a constant struggle in cystic fibrosis. Respiratory issues are the primary concern due to chronic lung complications.
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While giving care to a 2 year-old client, the nurse should remember that the toddler's tendency to say 'no' to almost everything is an indication of what psychosocial skill?
- A. Stubborn behavior
- B. Rejection of parents
- C. Frustration with adults
- D. Assertion of control
Correct Answer: D
Rationale: Assertion of control. Negativity is a normal behavior in toddlers. The nurse must be aware that this behavior is an important sign of the child's progress from dependency to autonomy and independence.
A client after a bronchoscopy.
The nurse would be MOST concerned if which of the following was observed?
- A. Depressed gag reflex.
- B. Sputum streaked with blood.
- C. Tachypnea.
- D. Complaints of a sore throat.
Correct Answer: C
Rationale: Strategy: 'MOST concerned' indicates a complication. (1) would cause a complication if client is given fluids before the gag reflex has returned (2) common for a few days after a biopsy (3) correct-client should be assessed for symptoms of respiratory distress from swelling due to the procedure; signs of respiratory distress include tachypnea, tachycardia, respiratory stridor, and retractions (4) expected after this procedure
During auscultation of the fetal heart rate during labor, the nurse assesses a rate of 59 beats per minute.
The FIRST action the nurse should take is
- A. turn the mother on her right side, increase the intravenous flow rate, and call the physician.
- B. turn the mother on her left side, administer oxygen by nasal cannula, and start an IV.
- C. call the physician, and make preparations for an immediate emergency cesarean section.
- D. position the mother in Trendelenburg's position, administer oxygen, and force fluids.
Correct Answer: B
Rationale: Strategy: 'FIRST' indicates that this is a priority question. All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) should be placed on left side to increase blood flow to the uterus (2) correct-persistent fetal bradycardia may indicate cord compression or separation of the placenta, but always indicates fetal distress, left side reduces compression of vena cava and aorta (3) should be done after positioning patient (4) this position is used only if there is cord prolapsed
The nurse is preparing discharge teaching for the parents of a newborn. Which of the following information should the nurse provide to the parents regarding the accuracy of a PKU (phenylketonuria) Test ?
- A. Breast-fed babies need to be a week old for the Test , and infants on formula can be Test ed in three days.
- B. The Test will need to be repeated at six weeks and at the three-month.pnlcheck-up.
- C. Blood will be drawn at three one-hour intervals; there is no specific preparation.
Correct Answer: A
Rationale: formula or cow's milk contains high phenylalanine levels; Test can be done after three days of formula intake; if mother is breastfeeding, infant will need to return in one week for Test
In evaluating the growth of a 12 month-old child, which of these findings would the nurse expect to be present in the infant?
- A. Increased 10% in height
- B. 2 deciduous teeth
- C. Tripled the birth weight
- D. Head > chest circumference
Correct Answer: C
Rationale: Tripled the birth weight. Infants typically triple their birth weight by 12 months.