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A mother of a newborn notices a nurse placing liquid in her baby's eyes. Which of the following is an inaccurate statement about the need for eyedrops following birth?
- A. Eyedrops following birth help reduce the risk of eye infection.
- B. Eyedrops are required by the law.
- C. Eyedrops will keep the eye moist.
- D. Eyedrops are required by law every 6 hours following birth.
Correct Answer: D
Rationale: Laws do require placement of eyedrops; however, physicians indicate a timeframe, and it is not required every 6 hours following birth.
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The PN is caring for a client with diabetes insipidus. The nurse can expect the lab work to show:
- A. elevated urine osmolarity and elevated serum osmolarity.
- B. decreased urine osmolarity and decreased serum osmolarity.
- C. elevated urine osmolarity and decreased serum osmolarity.
- D. decreased urine osmolarity and elevated serum osmolarity.
Correct Answer: D
Rationale: In diabetes insipidus, the pituitary releases too much antidiuretic hormone (ADH) causing the client to produce a large amount of dilute (decreased osmolarity) urine and causing dehydration (elevated serum osmolarity). Choice 3 might be seen in a client with SIADH (syndrome of inappropriate ADH). Choices 1 and 2 generally don't occur- urine and serum osmolarity typically move in opposite directions.
The nurse should utilize data about which of the following to provide information about the nutritional status of a client being evaluated for malnutrition?
- A. triceps skinfold measurement
- B. fasting blood glucose level
- C. hemoglobin A1c level
- D. serum lipid profile results
Correct Answer: A
Rationale: Objective anthropometric measurements such as triceps skinfold and mid-arm circumference (MAC), along with weight, are usually used to diagnose malnutrition. While all the other choices represent tests that might provide useful information, they also might be affected by variables other than malnutrition.
A hospitalized client has just been informed that he has terminal cancer. He says to the nurse, 'There must be some mistake in the diagnosis.' The nurse determines that the client is demonstrating which of the following?
- A. denial
- B. anger
- C. bargaining
- D. acceptance
Correct Answer: A
Rationale: Denial (Kübler-Ross's Stages of Grieving) is the refusal to believe that loss is happening.
Which of the following coping mechanisms protects an individual from anxiety?
- A. denial and fantasy
- B. rationalization and suppression
- C. regression and displacement
- D. reaction formation and projection
Correct Answer: A
Rationale: Denial and fantasy reduce anxiety by avoiding or reimagining reality, serving as protective coping mechanisms, unlike the other options, which may not consistently reduce anxiety.
The nurse who was not promoted tells another friend, 'I knew I'd never get the job. The hospital administrator hates me.' If she actually believes this of the administrator, who, in reality, knows little of her, she is demonstrating:
- A. compensation.
- B. reaction formation.
- C. projection.
- D. denial.
Correct Answer: C
Rationale: Projection results in unconsciously adopting blaming behavior. It attributes unacceptable attributes to other people.