Nokea
A gravida para 1 reports that a prior pregnancy ended in loss of the baby early in the pregnancy. Which of the following instructions should be given to the client?
- A. She should refrain from sex during this pregnancy
- B. She should avoid stimulation of the breasts
- C. She should quit work until after the baby is born
- D. She should report any nausea and vomiting
Correct Answer: D
Rationale: Reporting nausea and vomiting is important, as severe symptoms could indicate complications like hyperemesis gravidarum, especially given the history of pregnancy loss.
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An 80-year-old client is prescribed codeine for a severe cough. The home health nurse is reinforcing instructions on how to prevent the common adverse effects associated with codeine. Which client statements indicate an understanding of how to prevent them? Select all that apply.
- A. I'll be sure to apply sunscreen if I go outside.
- B. I'll drink at least 8 glasses of water a day.
- C. I'll drink decaffeinated coffee so I can sleep at night.
- D. I'll sit on the side of my bed for a few minutes before getting up.
- E. I'll take my medicine with food.
Correct Answer: B,D,E
Rationale: Drinking water (B) prevents constipation, sitting before standing (D) avoids orthostatic hypotension, and taking with food (E) reduces nausea. Sunscreen (A) and decaf coffee (C) are unrelated to codeine effects.
A client who had bowel surgery is to be NPO for several days. The nurse anticipates that the client will have an order for:
- A. diet therapy.
- B. enteral nutrition.
- C. parenteral nutrition.
- D. nasogastric tube feedings.
Correct Answer: C
Rationale: Parenteral nutrition provides nutrients intravenously for clients NPO post-bowel surgery, bypassing the gastrointestinal tract.
The nurse is caring for a toddler with atopic dermatitis. The nurse should instruct the parents to
- A. Dress the child warmly to avoid chilling
- B. Keep the child away from other children for the duration of the rash
- C. Clean the affected areas with tepid water and detergent
- D. Wrap the child's hand in mittens or socks to prevent scratching
Correct Answer: D
Rationale: Wrap the child's hand in mittens or socks to prevent scratching. This prevents worsening of lesions and secondary infections.
When using an interpreter to teach a client about a procedure to do in the home, the nurse should take which approach?
- A. Speak directly to the interpreter while presenting information and use pauses for questions
- B. Talk to the interpreter in advance and leave the client and interpreter alone
- C. Include a family member and direct communications to that person
- D. Face the client while presenting the information as the interpreter talks in the native language
Correct Answer: D
Rationale: Face the client while presenting the information as the interpreter talks in the native language. This allows non-verbal communication and maintains a client-focused approach.
The mother of a 2 year-old hospitalized child asks the nurse's advice about the child's screaming every time the mother gets ready to leave the hospital room. What is the best response by the nurse?
- A. I think you or your partner needs to stay with the child while in the hospital.'
- B. Oh, that is expected, so I would just ignore the behavior.'
- C. Perhaps you could gradually leave for short periods.'
- D. You should leave quickly to minimize the child's distress.'
Correct Answer: C
Rationale: Gradually increasing the time of separation can help the child adjust to the mother's absence, reducing anxiety and screaming over time.