Nokea
A 46 y.o. woman is admitted to the rehabilitation unit with left-sided hemiparesis resulting from a subarachnoid hemorrhage. She is not oriented to her surroundings or situation, but she does recognize her family. On admission, she tells her nurse that she can walk to the bathroom without assistance. Which of the ff. responses by the nurse is best?
- A. Allow her to ambulate unassisted, to encourage positive self-esteem.
- B. Ask her to demonstrate her ability to ambulate.
- C. Explain that someone will assist her as long as she is in the rehabilitation facility.
- D. Ask another staff member to help ambulate the patient the first time.
Correct Answer: C
Rationale: The best response by the nurse is to explain that someone will assist the patient as long as she is in the rehabilitation facility. This is important for ensuring the safety of the patient, especially considering her condition with left-sided hemiparesis resulting from a subarachnoid hemorrhage. While encouraging independence is important in rehabilitation, it should not compromise the patient's safety. The nurse should prioritize the patient's well-being and provide necessary assistance to prevent any potential falls or injuries during ambulation.aising the risk of falling or getting injured.
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An 8-day-old is admitted with vomiting and dehydration. His HR is 170, RR is 44, BP is 85/52, and T is 99°F. The parents ask if these vital signs are normal. Which is the best response?
- A. The BP is elevated.
- B. The temperature is elevated.
- C. The heart rate is elevated; normal for a neonate is 90-160 bpm.
- D. The respiratory rate is elevated.
Correct Answer: C
Rationale: A neonatal heart rate of 170 is above the normal range (90-160 bpm), which is concerning for dehydration.
Parents have a concern that their child is depressed. The nurse relates that which characteristic best describes children with depression?
- A. Increased range of affective response
- B. Preoccupation with need to perform well in school
- C. Change in appetite, resulting in weight loss or gain
- D. Tendency to prefer play instead of schoolwork
Correct Answer: C
Rationale: Change in appetite, resulting in weight loss or gain, is a common characteristic seen in children with depression. Some children may experience a significant decrease in appetite, leading to weight loss, while others may have an increased appetite, resulting in weight gain. This change in eating habits is often a noticeable sign that may indicate the presence of depression in children. It is important for parents and caregivers to be aware of any significant changes in a child's eating patterns and behavior, as it could be a potential indicator of underlying mental health issues such as depression.
Vitamin A supplementation may be recommended for the young child who has which disease?
- A. Mumps
- B. Rubella
- C. Measles (rubeola)
- D. Erythema infectiosum
Correct Answer: C
Rationale: Vitamin A supplementation may be recommended for children with measles (rubeola) due to the disease's association with vitamin A deficiency. Measles can lead to reduced levels of vitamin A in the body, which can result in increased severity of symptoms, complications, and even death. Supplementing with vitamin A during and after a measles infection helps reduce the risk of complications and mortality, particularly in young children under the age of 5 in areas where vitamin A deficiency is common. Therefore, providing vitamin A supplementation to children with measles is an important intervention to support their recovery and improve outcomes.
The nurse is assigned to care for a postoperative client who has diabetes mellitus. During the assessment interview, the client reports that he's impotent and says he's concerned about its effect on his marriage. In planning this client's care, the most appropriate intervention would be to:
- A. Encourage the client to ask questions about personality sexuality
- B. Provide time for privacy
- C. Provide support for the spouse or significant other
- D. Suggest referral to a sex counselor or other appropriate professional
Correct Answer: D
Rationale: Suggesting a referral to a sex counselor or other appropriate professional would be the most appropriate intervention in this case. Impotence or erectile dysfunction can have significant emotional and psychological implications, especially in the context of a marital relationship. A sex counselor or therapist who specializes in sexual health can provide the necessary support, guidance, and strategies to help the client and his spouse navigate this issue effectively. This intervention is aimed at addressing the client's concerns about impotence, its impact on his marriage, and ultimately promoting holistic well-being.
A 52-year old female tells the nurse that she has found a painless lump in her right breast during her monthly self- examination. Which assessment finding would strongly suggest that this client's lump is cancerous?
- A. Eversion of the right nipple and mobile mass
- B. Mobile mass that is soft and easily
- C. Non-mobile mass with irregular edges delineated
- D. Non palpable right axillary lymph nodes
Correct Answer: C
Rationale: The assessment finding that strongly suggests that the client's lump is cancerous is a non-mobile mass with irregular edges delineated. Generally, cancerous breast lumps tend to have irregular shapes/edges and lack mobility. This finding is concerning for malignancy because it indicates that the lump is fixed in place and possibly invading nearby tissues, which are characteristics often associated with cancerous tumors. It's essential for the client to undergo further diagnostic tests, such as a biopsy, to confirm the presence of cancer and establish a proper treatment plan.