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A client is pleased about being pregnant, yet states, 'It is really not the best time, but I guess it will be OK.' The nurse's assessment of this response is:
- A. Initial maternal-infant bonding may be poor.
- B. Client may have a poor relationship with her husband.
- C. This response is normal in the first trimester.
- D. This response is abnormal, to be re-evaluated at the next visit.
Correct Answer: C
Rationale: Ambivalence is normal during the first trimester. Reva Rubin addresses the issue of 'not now' in the first trimester. The statement still leaves room for exploration. There are no data to support this. This statement by the mother still leaves room for exploration. Ambivalence is normal during the first trimester. Reva Rubin addresses the issue of 'not now.' This fact should be shared with the mother during further exploration of the comment. It is not abnormal. If it were, another month would also be too long to wait.
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The nurse is teaching a mother care of her child's spica cast. The mother states that he complains of itching under the edge of the cast. One nonpharmacological technique the nurse might suggest would be:
- A. Blowing air under the cast using a hair dryer on cool setting often relieves itching.
- B. Slide a ruler under the cast and scratch the area.
- C. Guide a towel under and through the cast and move it back and forth to relieve the itch.
- D. Gently thump on cast to dislodge dried skin that causes the itching.
Correct Answer: A
Rationale: Cool air will often relieve pruritus without damaging the cast or irritating the skin. The nurse should never force anything under the cast, because the cast may become damaged and skin breakdown may occur. Forcing an object under the cast could lead to cast damage and skin breakdown. The object may become lodged under the cast necessitating cast removal. This technique does not dislodge skin cells. It could damage the cast and cause skin breakdown.
The nurse is caring for a client with a history of type 2 diabetes. The nurse should expect the client to have:
- A. Polyuria
- B. Weight loss
- C. Bradycardia
- D. Constipation
Correct Answer: A
Rationale: Type 2 diabetes causes hyperglycemia, leading to polyuria due to osmotic diuresis.
In preparation for the removal of the client's chest tubes, the nurse should instruct the client to:
- A. Breathe normally
- B. Hold his breath and bear down
- C. Take deep breaths
- D. Take shallow breaths
Correct Answer: B
Rationale: During chest tube removal, the client should hold their breath and bear down (Valsalva maneuver) to increase intrathoracic pressure, reducing the risk of air entering the pleural space.
The nurse is caring for a client with a diagnosis of gestational hypertension. Which symptom is most characteristic?
- A. Hypertension
- B. Proteinuria
- C. Fetal macrosomia
- D. Painful vaginal bleeding
Correct Answer: A
Rationale: Hypertension (BP ≥140/90) is the defining symptom of gestational hypertension. Proteinuria indicates preeclampsia and fetal macrosomia or painful bleeding are unrelated.
A client arrives in the emergency room with severe burns of the hands, right arm, face, and neck. The nurse needs to start an IV.
- A. Top of client's right hand
- B. Left antecubital fossa
- C. Top of either foot
- D. Left forearm
Correct Answer: B
Rationale: The left antecubital fossa is suitable for IV placement, avoiding burned areas (right hand, arm, face, neck). The foot (C) is less ideal due to infection risk, and the left forearm (D) may be too close to burn sites.