Nokea
A highly careful mother of a 10-month-old baby boy complains of inadequate weight gain due to refusal of spoon feeding. The LEAST helpful advice is to
- A. respect infant independence
- B. offer softer diet
- C. use 2 spoons (1 for the child and 1 for the parent)
- D. use finger foods
Correct Answer: B
Rationale: Offering softer food may not address the underlying issue of refusal.
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When communicating with other professionals, what is important for the nurse to do?
- A. Ask others what they want to know.
- B. Share everything known about the family.
- C. Restrict communication to clinically relevant information.
- D. Recognize that confidentiality is not possible.
Correct Answer: C
Rationale: When communicating with other professionals, it is important for the nurse to restrict communication to clinically relevant information. This ensures that only necessary and pertinent information is shared, maintaining patient confidentiality and preventing the unnecessary dissemination of sensitive details. By focusing on clinically relevant information, healthcare professionals can collaborate effectively and make well-informed decisions about patient care without compromising confidentiality or violating ethical guidelines.
Which of the ff nursing actions is helpful for older clients who are experiencing lens changes associated with aging?
- A. Offering teaching aids with larged-sized letters
- B. Suggesting reduced visual activity such as reading or watching television
- C. Suggesting use of eye drops for comfort
- D. Suggesting use of glasses or contact lenses CARING FOR CLIENTS WITH EYE DISORDERS
Correct Answer: D
Rationale: As people age, changes in the lens of the eye can lead to difficulty focusing on close objects, a condition known as presbyopia. Suggesting the use of glasses or contact lenses can help older clients compensate for these age-related lens changes and improve their visual acuity for tasks such as reading or other close-up activities. Glasses or contact lenses prescribed by an eye care professional can provide the appropriate magnification needed to address the visual changes associated with aging, promoting comfort and maintaining independence for older clients.
Which is the most common causative agent of bacterial endocarditis?
- A. Staphylococcus albus
- B. Streptococcus hemolyticus
- C. Staphylococcus albicans
- D. Streptococcus viridans
Correct Answer: D
Rationale: Streptococcus viridans is the most common causative agent of bacterial endocarditis. This group of bacteria consists of various species, including S. sanguinis and S. mutans, which normally reside in the oral cavity and are commonly associated with endocarditis following dental procedures. Streptococcus viridans can enter the bloodstream due to dental work, oral infections, or trauma to the oral tissues, and cause infective endocarditis by adhering to damaged heart valves or endocardium. Staphylococcus aureus and Enterococcus species are other common pathogens associated with endocarditis, but Streptococcus viridans remains the most prevalent causative agent.
The screening test for PKU is most reliable if the blood sample is:
- A. from cord blood.
- B. taken 14 days after birth.
- C. taken before oral feedings are initiated.
- D. fresh blood from the heel.
Correct Answer: D
Rationale: The screening test for PKU (Phenylketonuria) is most reliable when the blood sample is fresh and taken from the heel. This is because the test requires a small amount of blood, and obtaining a fresh sample from the heel minimizes the risk of contamination and ensures accurate results. Additionally, collecting the blood sample from the heel is less invasive for the newborn and is a common practice for newborn screening tests. Blood samples taken from cord blood, 14 days after birth, or before oral feedings are initiated may not provide accurate results for the PKU screening test.
In a client who has human immunodeficiency virus (HIV) infection, CD4+ levels are measured to determine the:
- A. Presence of opportunistic infections
- B. Extent of immune system damage
- C. Level of the viral load
- D. Resistance to antigens
Correct Answer: B
Rationale: CD4+ T cells are a type of white blood cell that plays an essential role in coordinating the immune system's response to infections. In individuals with HIV infection, the virus specifically targets and destroys CD4+ T cells. Therefore, measuring CD4+ levels provides valuable information about the extent of damage to the immune system caused by HIV. Monitoring CD4+ levels helps in assessing the progression of the disease and determining when to initiate antiretroviral therapy to prevent opportunistic infections. Additionally, CD4+ levels are used to determine the prognosis and guide treatment decisions in individuals with HIV.