Nokea
A mother continues to breast-feed her 3-month-old infant. She tells the nurse that over the past 3 days she has not been producing enough milk to satisfy the infant. The nurse advises the mother to do which of the following?
- A. Start the child on solid food.
- B. Nurse the child more frequently during this growth spurt.
- C. Provide supplements for the child between breastfeeding so you will have enough milk.
- D. Wait 4 hours between feedings so that your breasts will fill up.
Correct Answer: B
Rationale: Solid foods introduced before 4-6 months of age are not compatible with the abilities of the GI tract and the nutritional needs of the infant. Production of milk is supply and demand. A common growth spurt occurs at 3 months of age, and more frequent nursing will increase the milk supply to satisfy the infant. Supplementation will decrease the infant's appetite and in turn decrease the milk supply. When the infant nurses less often or with less vigor, the amount of milk produced decreases. Rigid feeding schedules lead to a decreased milk supply, whereas frequent nursing signals the mother's body to produce a correspondingly increased amount of milk.
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A male client has burns over 90% of his body after an automobile accident resulting in a fire. He was trapped inside the auto and pulled out by a bystander. After several months in the hospital and over 20 surgeries, discharge planning has begun. Throughout his hospitalization the nursing staff has been aware of psychological changes the client faces after burns over a large portion of his body resulting in disfigurement. The nursing staff can best foster the client's self-esteem by:
- A. Adhering to a strict schedule of diet, exercise, and wound care
- B. Allowing him to go to physical therapy for whirlpool treatment when other clients were not in physical therapy
- C. Following a standardized plan of care for burn clients formulated by a world-renowned burn center
- D. Allowing him to plan, assist in, and perform his own care whenever possible
Correct Answer: D
Rationale: A regimented schedule, allowing no flexibility, will not foster the client's self-esteem. Isolating the client may only enhance his feelings of social isolation due to his disfigurement. Standardized care plans must be personalized and adapted to each client's situation. Allowing the client control over his care will foster his self-esteem and prepare him for life outside of the hospital.
The nurse is caring for a client with a history of chronic kidney disease. Which dietary restriction is most important?
- A. Low potassium
- B. Low calcium
- C. Low magnesium
- D. Low iron
Correct Answer: A
Rationale: Chronic kidney disease impairs potassium excretion, risking hyperkalemia, which can cause arrhythmias. Low potassium diets are critical. Calcium, magnesium, and iron are less commonly restricted.
A client with a history of pulmonary embolism is admitted with complaints of chest pain. The nurse should give priority to:
- A. Administering anticoagulants
- B. Monitoring respiratory status
- C. Administering pain medication
- D. Monitoring blood pressure
Correct Answer: A
Rationale: Anticoagulants prevent further clot formation in pulmonary embolism, making them the priority to reduce complications.
A client with AIDS tells the nurse that he has been using herbal supplements in addition to the regimen of drugs prescribed by the physician. The nurse should tell the client that:
- A. Most herbals are well suited to use with prescription medications.
- B. He should buy only FDA-approved herbal supplements for use.
- C. The use of herbals may alter the effect of the medication he is taking.
- D. The herbal supplements should be taken at the same time as his medication.
Correct Answer: C
Rationale: Herbal supplements can interact with antiretroviral drugs, altering their efficacy or toxicity (e.g., St. John’s wort reduces protease inhibitor levels). The nurse should advise the client to discuss herbals with the physician, as they are not inherently safe or FDA-regulated for this purpose.
When planning care for the passive-aggressive client, the nurse includes the following goal:
- A. Allow the client to use humor, because this may be the only way this client can express self.
- B. Allow the client to express anger by using 'I' messages, such as 'I was angry when . . .,' etc.
- C. Allow the client to have time away from therapeutic responsibilities.
- D. Allow the client to give excuses if he forgets to give staff information.
Correct Answer: B
Rationale: Ceasing to use humor and sarcasm is a more appropriate goal, because this client uses these behaviors covertly to express aggression instead of being open with anger. Use of 'I' messages demonstrates proper use of assertive behavior to express anger instead of passive-aggressive behavior. Client is expected to complete share of work in therapeutic community because he has often obstructed other's efforts by failing to do his share. Client has used conveniently forgetting or withholding information as a passive-aggressive behavior, which is not acceptable.