Nokea
A 23-year-old woman at 32-weeks gestation is seen in the outpatient clinic. Which of the following findings, if assessed by the nurse, would indicate a possible complication?
- A. The client's urine test is positive for glucose and acetone.
- B. The client has 1+ pedal edema in both feet at the end of the day.
- C. The client complains of an increase in vaginal discharge.
- D. The client says she feels pressure against her diaphragm when the baby moves.
Correct Answer: A
Rationale: Positive urine glucose and acetone suggest gestational diabetes mellitus (GDM), which can lead to placental insufficiency and fetal complications, requiring immediate evaluation. Pedal edema (B), increased vaginal discharge (C), and diaphragmatic pressure (D) are common in late pregnancy and not typically concerning unless accompanied by other symptoms.
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The school nurse is teaching a group of preschool mothers about poison prevention in the home. Which of the following statements, if made by a mother to the nurse, indicates that further teaching is necessary?
- A. I should have a bottle of Ipecac for each of my children.'
- B. I should induce vomiting if my child swallows lighter fluid.'
- C. Giving my child water or milk may help dilute the poison.'
- D. Proper storage is the key to poison prevention in the home.'
Correct Answer: B
Rationale: Inducing vomiting after ingesting hydrocarbons like lighter fluid is contraindicated due to the risk of aspiration, which can cause severe lung damage. Choice A is correct (Ipecac dosing is appropriate), choice C is accurate (dilution can help), and choice D is true (locked storage prevents poisoning). Further teaching is needed for choice B.
A client with mastoiditis has a left mastoidectomy with tympanoplasty. The nurse should observe the client for signs of damage to the sixth crania nerve, which include:
- A. Inability to chew
- B. Inability to look laterally
- C. Inability to swallow
- D. Loss of scalp sensation
Correct Answer: B
Rationale: The sixth cranial nerve (abducens) controls lateral eye movement, so damage would result in an inability to look laterally.
Which statement describes factors that help build personal power in an organization?
- A. Longevity in an organization, social ties to people in power, and a history as someone who does not back down in conflict ends with success
- B. Goals are met with the use of networking, mentoring, and coalition building
- C. High visibility and formal power are maintained with a confrontational style
- D. Credibility to one's position is enhanced when professional dress and demeanor are employed
Correct Answer: B
Rationale: Networking, mentoring, and coalition building are positive uses of personal power to meet goals.
The patient with DM has flu.
Which nursing action is more appropriate?
- A. Frequent monitoring of blood glucose.
- B. Expected increase in the patient insulin requirement.
- C. Implement respiratory isolation.
- D. Monitor the patient's respiratory status frequently.
Correct Answer: A
Rationale: Flu can disrupt glucose control, making frequent monitoring critical.
Teaching the client with gonorrhea how to prevent reinfection and further spread is an example of:
- A. primary prevention.
- B. secondary prevention.
- C. tertiary prevention.
- D. primary health care prevention.
Correct Answer: B
Rationale: Secondary prevention targets the reduction of disease prevalence and disease morbidity through early diagnosis and treatment. Physiological Adaptation