Nokea
A nurse admits a 3 week-old infant to the special care nursery with a diagnosis of bronchopulmonary dysplasia. As the nurse reviews the birth history, which data would be most consistent with this diagnosis?
- A. Gestational age assessment suggested growth retardation
- B. Meconium was cleared from the airway at delivery
- C. Phototherapy was used to treat Rh incompatibility
- D. The infant received mechanical ventilation for 2 weeks
Correct Answer: D
Rationale: The infant received mechanical ventilation for 2 weeks. Bronchopulmonary dysplasia is often caused by prolonged mechanical ventilation.
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The nurse is teaching a client with a new diagnosis of hypothyroidism about levothyroxine (Synthroid). Which of the following statements by the client indicates a need for further teaching?
- A. I should take this medication in the morning.
- B. I should report chest pain to my doctor.
- C. I should avoid taking this with calcium supplements.
- D. I should stop this medication if I feel better.
Correct Answer: D
Rationale: Stopping levothyroxine when feeling better is incorrect, as hypothyroidism requires lifelong replacement therapy to maintain euthyroid status. Options A, B, and C are correct: morning dosing minimizes insomnia, chest pain may indicate overdose, and calcium supplements interfere with absorption.
A client preparing for surgery.
Which of the following statements by the client BEST indicates to the nurse an emotional readiness for surgery?
- A. I know the doctor isn't telling me everything, but at this point I can't do anything about it.'
- B. I've never heard of this specialist before. Does he do much work here?'
- C. I'm glad the trapeze is on my bed so I can start working on my exercises as soon as I wake up.'
- D. Can you please check my record to be sure it says I'm diabetic?'
Correct Answer: C
Rationale: Strategy: Think about each answer choice. (1) indicates feelings of fear and helplessness (2) indicates fear and lack of trust (3) correct-indicates acceptance and a readiness to participate in postoperative care (4) indicates fear that something will be missed
The nurse knows which of the following would be MOST likely to help the family of an emotionally disturbed client manage behaviors at home after discharge from inpatient treatment?
- A. Refer the family to Alliance for the Mentally Ill meetings for educational programs and support groups.
- B. Provide the family with pamphlets that describe the desired action and side effects of medications the client is taking.
- C. Tell the family that it is not their fault that the client behaves inappropriately.
- D. Involve the family in the assessment of the client when s/he is first admitted to the hospital.
Correct Answer: A
Rationale: The Alliance for the Mentally Ill offers ongoing education and support groups, equipping families with skills to manage behaviors long-term. Pamphlets, reassurance, and early involvement are helpful but lack the sustained impact of a support network.
A toddler with otitis media has just completed antibiotic therapy. A recheck appointment should be made to:
- A. Determine whether the ear infection has affected her hearing.
- B. Determine whether she needs a tympanoplasty.
- C. Document that the infection has completely cleared.
- D. Obtain a new prescription in case the infection recurs.
Correct Answer: C
Rationale: A recheck confirms the otitis media has cleared, preventing complications. Hearing tests or tympanoplasty are not routine, and new prescriptions are unnecessary unless recurrence occurs.
A client is going to have an endoscopy performed. Which of the following is not a probable reason for an endoscopy procedure?
- A. Aspiration noted on honey thick diet.
- B. Pain with a bowel movement
- C. Pain felt in the left upper quadrant
- D. Right shoulder pain
Correct Answer: B
Rationale: Bowel movement pain should be examined with a colonoscopy not an endoscopy.