Nokea
A client asks the nurse about the benefits of breastfeeding. Which response by the nurse provides the most accurate information?
- A. Breastfeeding helps women lose weight faster.
- B. Breast milk contains a greater amount of protein.
- C. Breast milk is easier to digest than formula.
- D. Breastfeeding is a good method of contraception.
Correct Answer: C
Rationale: The correct answer is C: Breast milk is easier to digest than formula. Breast milk contains specific enzymes and antibodies that aid in digestion and are easily absorbed by the baby's immature digestive system. This promotes better nutrient absorption and reduces the risk of digestive issues. Option A is incorrect because weight loss varies for each woman and should not be the primary reason for breastfeeding. Option B is incorrect as breast milk has a balanced composition of nutrients, not just higher protein content. Option D is incorrect as breastfeeding is not a reliable form of contraception.
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A nurse is monitoring a 9-year-old child on the first postoperative day following abdominal surgery.
- A. "Poker chip tool"'
- B. "FACES rating scale"'
- C. "Visual analog scale"'
- D. "Numerical 1 to 10 rating scale"'
Correct Answer: B
Rationale: The correct answer is B: "FACES rating scale." This tool uses facial expressions to assess pain in children, making it suitable for a 9-year-old who may find it challenging to express pain verbally. The other choices are not as appropriate for this age group postoperatively: A is not a recognized pain assessment tool, C and D may be too abstract for a child, and E-G are missing options.
Which of the following approaches is the most accurate way to measure the heart rate of a 10-month-old infant?
- A. "Apical"'
- B. "Radial"'
- C. "Ulna"'
- D. "Brachial"'
Correct Answer: A
Rationale: The correct answer is A: "Apical." This method involves placing the stethoscope over the apex of the heart to directly listen to the heart sounds. In infants, especially 10-month-olds, the apical pulse is more accurate as it allows for a direct assessment of the heart rate without interference from other factors like peripheral pulses. The apical pulse is easier to locate in infants due to their smaller chest size and thinner chest walls. Choices B, C, and D (Radial, Ulna, and Brachial) are incorrect for measuring heart rate in infants as they involve peripheral pulse sites which may not provide an accurate representation of the heart rate due to various factors like weak pulses or difficulty in palpating them accurately in infants.
A nurse is reinforcing home care instructions with the parents of a 5-year-old child who has acute bronchitis. In order to prevent the transmission of the virus, which of the following should the nurse include in the instructions?
- A. Isolate the child in a bedroom separated from the rest of the family.
- B. Teach the child to wash his hands after coughing secretions into a tissue.
- C. Serve food to the child on disposable dishes with plastic utensils.
- D. Have the child wear a mask whenever leaving the bedroom.
Correct Answer: B
Rationale: The correct answer is B: Teach the child to wash his hands after coughing secretions into a tissue. This is because handwashing is one of the most effective ways to prevent the transmission of viruses, including acute bronchitis. By washing hands after coughing into a tissue, the child can reduce the spread of germs to others.
Choice A is incorrect because isolating the child in a bedroom may not be practical or necessary for preventing transmission. Choice C is incorrect as there is no evidence to support that serving food on disposable dishes with plastic utensils prevents transmission of the virus. Choice D is incorrect as wearing a mask whenever leaving the bedroom may not be necessary if proper hand hygiene is practiced.
A nurse is caring for a 4-year-old child diagnosed with leukemia who is admitted with myelosuppression.
- A. "Provide a diet high in carbohydrates."'
- B. "Monitor rectal temperature every 4 hr."'
- C. "Use lemon or glycerin swabs for oral care."'
- D. "Inspect the skin daily for lesions."'
Correct Answer: D
Rationale: The correct answer is D: "Inspect the skin daily for lesions." This is important because myelosuppression can lead to decreased platelets, increasing the risk of skin lesions and bleeding. Monitoring the skin daily can help detect any lesions early and prevent complications.
A: Providing a high-carbohydrate diet is not directly related to managing myelosuppression.
B: Monitoring rectal temperature is important but not directly related to skin lesion detection.
C: Using lemon or glycerin swabs for oral care is important for mucositis, not skin lesions.
A 1-year-old receives routine health maintenance care at the pediatric clinic. The child receives an MMR immunization. The mother asks the nurse, 'When will my child get the next dose of MMR vaccine?' Which is the correct response by the nurse?
- A. In six months with the next DPT
- B. No further vaccination needed
- C. With the Hepatitis B series
- D. After the child is 10 years of age
Correct Answer: D
Rationale: A second MMR, often called a booster, will be needed when the child enters middle school at age eleven or twelve years of age. This ensures full immunity from the diseases covered by the MMR vaccine.