Nokea
A male client tells the nurse, 'I am so stressed because I am expected to achieve excellence in everything. My job, my marriage, and my children must be perfect!' Which coping response should the nurse recognize that the client is using?
- A. Repression
- B. Sublimation
- C. Rationalization
- D. Displacement
Correct Answer: C
Rationale: The correct answer is C: Rationalization. Rationalization is a defense mechanism where the client justifies their stress and need for perfection by creating logical explanations or excuses. In this case, the client is rationalizing their stress by believing that everything in their life must be perfect. Repression (choice A) involves unconsciously blocking out thoughts or feelings. Sublimation (choice B) is redirecting unacceptable impulses into socially acceptable activities. Displacement (choice D) involves transferring emotions from one target to another.
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When obtaining an admission history for a client who is at 9 weeks gestation, the client states, 'I had a miscarriage 2 years ago.' Which information is most important for the nurse to obtain?
- A. How long was your previous pregnancy?
- B. How long did it take for you to become pregnant after your miscarriage?
- C. Was your miscarriage during the first trimester?
- D. Do you have any children now?
Correct Answer: A
Rationale: The correct answer is A. Understanding the duration of the previous pregnancy helps assess the client's obstetric history. Choice B focuses on the time it took to conceive after the miscarriage, which is less relevant at this point. Choice C asks about the timing of the miscarriage rather than the duration of the previous pregnancy. Choice D inquires about the current status of having children, which is not directly related to the client's obstetric history.
When caring for a laboring client whose contractions are occurring every 2 to 3 min, the nurse should document that the pump is infusing how many ml/hr?
- A. 42
- B. 50
- C. 60
- D. 70
Correct Answer: A
Rationale: To calculate the infusion rate, we first need to determine the frequency of contractions per hour. If contractions are occurring every 2 to 3 minutes, this corresponds to 20 to 30 contractions in an hour (60 minutes). The average is 25 contractions in an hour. The pump should be infusing 1 ml for each contraction, so the infusion rate should be 25 ml/hr. Therefore, the correct answer is 42 ml/hr. Choices B, C, and D are incorrect as they do not align with the calculation based on the given data.
The nurse is preparing a client for discharge who has a prescription for enoxaparin (Lovenox) self-administration. What information is most important for the nurse to provide the client about this medication?
- A. Self-administration techniques for subcutaneous injection
- B. Avoiding foods high in vitamin K
- C. Signs of bleeding to report to the healthcare provider
- D. Proper disposal of used syringes
Correct Answer: A
Rationale: Teaching the client about self-administration techniques for subcutaneous injection is crucial for safe and effective use of enoxaparin. Option A is the correct answer as it directly addresses the client's need to know how to properly administer the medication. Options B, C, and D are important aspects of care but are not the most critical information needed for the client's self-administration of enoxaparin.
The mother of a 6-year-old anemic boy is taught by the nurse to give iron supplements. Which statement indicates that the mother understands the proper administration of iron?
- A. The iron tablets will be absorbed between meals, on an empty stomach
- B. I should give the iron tablets with his milk and cereal each morning
- C. Iron preparations can be taken with antibiotics if he develops an infection
- D. The iron tablets may cause him to sunburn more easily so he should wear sunscreen
Correct Answer: A
Rationale: The correct answer is A because iron supplements are best absorbed on an empty stomach, which maximizes their effectiveness. Giving iron tablets with milk or calcium-rich foods, as mentioned in choice B, should be avoided as they can decrease iron absorption. Choice C is incorrect because iron preparations should not be taken with antibiotics due to potential interactions. Choice D is also incorrect as iron tablets do not cause an increased risk of sunburn, so sunscreen is not necessary specifically due to iron supplementation.
An 18-year-old gravida 1, at 41-weeks gestation, is undergoing an oxytocin (Pitocin) induction and has an epidural catheter in place for pain control. With each of the last three contractions, the nurse notes a late deceleration. The client is repositioned and oxygen provided, but the late decelerations continue to occur with each contraction. What action should the nurse take first?
- A. Prepare for immediate cesarean birth
- B. Turn off the oxytocin (Pitocin) infusion
- C. Notify the anesthesiologist that the epidural infusion needs to be disconnected
- D. Apply an internal fetal monitoring device and continue to monitor carefully
Correct Answer: B
Rationale: In the scenario described, the presence of late decelerations during contractions indicates fetal compromise. To address this, the nurse's initial action should be to turn off the oxytocin (Pitocin) infusion. Oxytocin can contribute to uteroplacental insufficiency, leading to late decelerations. This intervention aims to improve fetal oxygenation and prevent further stress on the fetus. Immediate cesarean birth is not the first-line action unless other interventions fail. Notifying the anesthesiologist about disconnecting the epidural infusion is not the priority in this situation. Applying an internal fetal monitoring device is invasive and not the immediate step needed when late decelerations are present.