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A 27-year old adult is admitted for treatment of Crohn's disease. Which information is most significant when the nurse assesses nutritional health?
- A. Anthropometric measurements
- B. dry skin
- C. bleeding gums
- D. facialrubor
Correct Answer: A
Rationale: Anthropometric measurements, such as height, weight, body mass index (BMI), and waist circumference, are essential in assessing the nutritional health of a patient with Crohn's disease. These measurements provide objective data about the patient's nutritional status, body composition, and risk for malnutrition. Monitoring changes in these measurements over time can help identify nutritional deficiencies, weight loss, or malnutrition in patients with Crohn's disease. Dry skin, bleeding gums, and facial rubor can be symptoms of other health conditions, but anthropometric measurements directly assess the nutritional health of the patient.
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A 13-year-old boy is hospitalized for a femur fracture after being hit by a car while racing bikes. The parents are concerned about his judgment. The nurse should tell the parents that this behavior is:
- A. Typical of young teens.
- B. Related to hormonal surges during adolescence.
- C. An isolated incident that will not likely happen again.
- D. Related to underdeveloped judgment and impulse control in adolescence.
Correct Answer: D
Rationale: The adolescent brain is still developing, which can lead to poor judgment and impulsive behavior.
A 4-month-old was born at 35 weeks of gestation. She seems to be developing normally, but her parents are concerned because she is a "more difficult" baby than their other child, who was term. What should the nurse's explanation include?
- A. Infants' temperaments are part of their unique characteristics.
- B. Infants become less difficult if they are not kept on scheduled feedings and structured routines.
- C. The infant's behavior is suggestive of failure to bond completely with her parents.
- D. The infant's difficult temperament is the result of painful experiences in the neonatal period.
Correct Answer: A
Rationale: The nurse should explain to the parents that infants' temperaments are part of their unique characteristics. Temperament refers to an individual's natural predisposition towards certain behaviors and emotional responses. It is not uncommon for babies to have different temperaments, even within the same family. This 4-month-old baby may simply have a more difficult temperament compared to her sibling who was born at term. It is important for parents to understand and accept their baby's temperament as part of her individuality, rather than attributing it to other factors such as failure to bond or painful experiences in the neonatal period. While schedules and routines can help with managing challenging behaviors, it is essential for the parents to recognize and appreciate the uniqueness of their baby's temperament.
A 13-year-old boy is hospitalized for a femur fracture after being hit by a car while racing bikes. The parents are concerned about his judgment. The nurse should tell the parents that this behavior is:
- A. Typical of young teens.
- B. Related to hormonal surges during adolescence.
- C. An isolated incident that will not likely happen again.
- D. Related to underdeveloped judgment and impulse control in adolescence.
Correct Answer: D
Rationale: The adolescent brain is still developing, which can lead to poor judgment and impulsive behavior.
Which of the ff nursing interventions is required when caring for a client after cardiac surgery who is at risk for ineffective tissue perfusion?
- A. Restrict fluid intake
- B. Ensure that the client avoids prolonged sitting
- C. Position lower extremities below level of heart
- D. Instruct the client to avoid leg exercises
Correct Answer: C
Rationale: When caring for a client after cardiac surgery who is at risk for ineffective tissue perfusion, it is important to promote optimal blood flow to the tissues. Positioning the lower extremities below the level of the heart helps to facilitate venous return and improve circulation to the extremities. This position helps reduce the workload on the heart and promotes better perfusion to the tissues, ultimately aiding in the prevention of complications related to ineffective tissue perfusion. The other options (A. Restrict fluid intake, B. Ensure that the client avoids prolonged sitting, D. Instruct the client to avoid leg exercises) are not directly related to improving tissue perfusion and may not be appropriate interventions in this situation.
Many neuromuscular disorders can impair respiratory function. What intervention can a home care nurse recommend to help prevent complications in patients with impaired respiratory function?
- A. Antibiotics as needed
- B. Bedrest
- C. Elevate the head of bed
- D. Suction q4h
Correct Answer: C
Rationale: Elevating the head of the bed is an important intervention to help prevent complications in patients with impaired respiratory function. By elevating the head of the bed, gravity assists in improving lung expansion and ventilation, making breathing easier for the patient. This position promotes better airflow and can help reduce the risk of respiratory complications such as aspiration. It is a non-invasive and simple intervention that can be easily implemented in a home care setting to support the patient's respiratory function and overall well-being. Antibiotics, bedrest, and scheduled suctioning are not directly related to improving respiratory function in this context.