Nokea
A nurse has reinforced teaching to the parent of a 9-month-old infant who has redness in the diaper area and inner thighs. Which of the following statements by the parent indicates a correct understanding of this teaching?
- A. I can use a hair dryer on the reddened skin to help with the drying.
- B. I can use powder after diaper changes to absorb excess moisture.
- C. I can use cloth diapers with rubber outer pants until the rash clears.
- D. I can keep the diaper off to expose the skin to air.
Correct Answer: D
Rationale: Exposing the skin to air helps prevent irritation and promotes healing.
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An 8-year-old child is admitted to a pediatric unit with a fractured femur and is placed in skeletal traction. Which of the following nursing interventions is the most appropriate?
- A. Position the weights securely against the foot of the bed.
- B. Provide small frequent high-fat meals to the child.
- C. Compare pulses on affected site to contralateral side.
- D. Provide diversional activities to minimize the child's movement.
Correct Answer: C
Rationale: The correct answer is C: Compare pulses on affected site to contralateral side. This is the most appropriate nursing intervention because it assesses for any circulatory compromise due to the skeletal traction. Checking pulses helps monitor perfusion distal to the fracture site and ensures early detection of any complications like compartment syndrome. Positioning the weights against the foot of the bed (A) is incorrect as it can cause uneven traction. Providing high-fat meals (B) and diversional activities (D) are irrelevant to the immediate care of the child's fracture.
A nurse is reinforcing teaching to a group of parents about preventing accidental poisoning in preschoolers. Which of the following should the nurse include?
- A. Have syrup of ipecac available in the home.
- B. Explain to preschool children that plants can be eaten only after they are cooked.
- C. Keep labels on containers of toxic substances and never remove them.
- D. Place medications in a cabinet above the sink.
Correct Answer: C
Rationale: The correct answer is C: Keep labels on containers of toxic substances and never remove them. This is important to prevent accidental poisoning in preschoolers as it helps parents and caregivers easily identify and differentiate toxic substances from safe ones. Removing labels can lead to confusion and increase the risk of accidental ingestion. Having syrup of ipecac available (choice A) is no longer recommended as a first-aid treatment for poisoning. Teaching children to cook plants before eating them (choice B) is not a practical or safe approach. Placing medications in a cabinet above the sink (choice D) may not be effective as preschoolers can still access them if the cabinet is not securely locked.
A nurse in the antepartum clinic is assessing a client's adaptation to pregnancy. The client states that she is, ''happy one min and crying the next.'' The nurse should interpret the client's statement as an indication of which of the following?
- A. Emotional lability
- B. Focusing phase
- C. Cognitive restructuring
- D. Couvade syndrome
Correct Answer: A
Rationale: The correct answer is A: Emotional lability. Emotional lability refers to rapid, unpredictable changes in emotions. During pregnancy, hormonal fluctuations can lead to mood swings, causing the client to feel happy one minute and crying the next. Focusing phase (B) is not relevant to the client's emotional state. Cognitive restructuring (C) involves changing negative thought patterns, which is not mentioned in the scenario. Couvade syndrome (D) is a condition where male partners experience pregnancy-like symptoms, which is not applicable here.
A nurse in the clinic instructs a primigravida about the danger signs of pregnancy. The client demonstrates understanding of the instructions, stating she will notify the physician if which sign occurs?
- A. White vaginal discharge
- B. Dull backache
- C. Frequent,urgent urination
- D. Abdominal pain
Correct Answer: D
Rationale: The correct answer is D: Abdominal pain. Abdominal pain is a significant danger sign in pregnancy that could indicate various complications such as ectopic pregnancy, placental abruption, or preterm labor. Prompt medical evaluation is crucial to ensure the health of both the mother and the baby. White vaginal discharge (A) is not necessarily a danger sign unless it is accompanied by other symptoms like itching or a foul smell. Dull backache (B) is common in pregnancy and usually not a cause for concern unless severe or accompanied by other symptoms. Frequent, urgent urination (C) is a common symptom in pregnancy due to increased pressure on the bladder and is not typically a danger sign unless associated with pain or burning.
Two hours after delivery the nurse assesses the client and documents that the fundus is soft, boggy, above the level of the umbilicus, and displaced to the right side. The nurse encourages the client to void. Which is the rationale for this nursing action?
- A. A full bladder prevents normal contractions of the uterus.
- B. An overdistended bladder may press against the episiotomy causing dehiscence.
- C. Distention of the bladder can cause urinary stasis and infection.
- D. It makes the client more comfortable when the fundus is massaged.
Correct Answer: A
Rationale: The correct answer is A: A full bladder prevents normal contractions of the uterus. A full bladder can impede the involution process of the uterus by exerting pressure on it, inhibiting proper contraction. This can lead to postpartum hemorrhage and increased risk of retained placental fragments. Encouraging the client to void helps to relieve the pressure on the uterus, allowing it to contract effectively and aiding in the expulsion of lochia and prevention of complications.
Other choices are incorrect because:
B: An overdistended bladder may press against the episiotomy causing dehiscence - While this is a potential risk, it is not directly related to fundal assessment and contraction.
C: Distention of the bladder can cause urinary stasis and infection - While true, this is not the primary concern when assessing the fundus post-delivery.
D: It makes the client more comfortable when the fundus is massaged - Massaging the fundus is a separate intervention and does