Nokea
A client is diagnosed with diabetes mellitus. Which assessment finding best supports a nursing diagnosis of Ineffective individual coping related to diabetes mellitus?
- A. Recent weight gain of 20 lb
- B. Skipping insulin doses during illness
- C. Failure to monitor blood glucose
- D. Crying whenever diabetes is levels mentioned
Correct Answer: D
Rationale: Crying whenever diabetes is mentioned indicates a maladaptive coping mechanism, which can be a sign of ineffective individual coping related to diabetes mellitus. Coping with a chronic condition like diabetes can be overwhelming, and excessive emotional distress may hinder the client's ability to effectively manage their disease. It is important for the nurse to identify maladaptive coping strategies in order to provide appropriate interventions and support for the client.
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A young couple of a 2-month-old baby girl with excessive crying seeks medical advice. The LEAST important advice is to
- A. master the situation in a relaxed manner
- B. adhere to precry cues
- C. change milk formula
- D. avoid sensory overstimulation
Correct Answer: C
Rationale: Changing the milk formula is less critical unless there is evidence of intolerance or allergy.
What is the best method to obtain a urine sample in an 8-month-old being evaluated for a UTI?
- A. Clean the perineum front-to-back and apply a urine collection bag.
- B. Insert an indwelling Foley catheter.
- C. Place a sterile cotton ball in the diaper and collect with a syringe.
- D. Perform an in-and-out (straight) catheterization.
Correct Answer: D
Rationale: For infants who are not toilet-trained, an in-and-out catheterization is the most reliable method for obtaining a sterile urine sample.
Which of the following statements would be the nurse's response to a famiiy member asking questions about a client's transient ischemic attack (TIA)?
- A. "I think you should ask the doctor. Would you like me to cail him for you?"
- B. " The blood supply to the brain has decreased causing permanent brain damage."
- C. "It Is a temporary interruption in the blood flow to the brain."
- D. "TIA means a transient ischemic attack."
Correct Answer: C
Rationale: The correct response would be: "It is a temporary interruption in the blood flow to the brain." This response provides a clear and accurate explanation of a transient ischemic attack (TIA), which is commonly known as a "mini-stroke." A TIA is indeed a temporary episode where there is a brief interruption in the blood flow to the brain, leading to symptoms similar to those of a stroke, but without lasting damage. This response would give the family member a better understanding of what a TIA is and help alleviate concerns about permanent brain damage.
Which explanation regarding cardiac catheterization is appropriate for a preschool child?
- A. Postural drainage will be performed every 4 to 6 hours after the test.
- B. It is necessary to be completely "asleep" during the test.
- C. The test is short, usually taking less than 1 hour.
- D. When the procedure is done, you will have to keep your leg straight for at least 4 hours.
Correct Answer: C
Rationale: For a preschool child, the appropriate explanation about cardiac catheterization would be that the test is short, usually taking less than 1 hour. This explanation is suitable for a preschool child because it provides a simple and clear understanding of what to expect during the procedure. Preschool-aged children have limited attention spans and may become anxious about medical procedures, so providing a concise and reassuring explanation can help alleviate their fears. Additionally, knowing that the test will not take a long time can help the child feel more at ease about the procedure.
What might you conclude if you notice a wide perineum and unequal gluteal and thigh folds when assessing a newborn?
- A. Osteogenesis imperfecta
- B. Torticollis
- C. Scoliosis
- D. Hip dysplasia
Correct Answer: D
Rationale: When assessing a newborn and noticing a wide perineum and unequal gluteal and thigh folds, it may signal the possibility of developmental dysplasia of the hip (DDH), also known as hip dysplasia. DDH is a condition where the hip joint does not properly form in newborns, leading to instability and potential dislocation. The wide perineum and unequal gluteal and thigh folds are physical signs that can be indicative of hip dysplasia. It is essential to diagnose and treat hip dysplasia early to prevent long-term complications like difficulty walking and osteoarthritis. Regular screening of newborns for hip dysplasia risk factors and physical exam findings is crucial for early detection and intervention.