Nokea
A nurse is caring for a 10 year-old boy who has just been diagnosed with a congenital heart defect. Which of the following clinical signs does not indicate CHF?
- A. Increased body weight
- B. Elevated heart rate
- C. Lower extremity edema
- D. Compulsive behavior
Correct Answer: D
Rationale: Compulsive behavior does not indicate CHF.
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The nurse is assessing the dental status of an 18-month-old child. How many teeth should the nurse expect to examine?
- A. 6
- B. 8
- C. 12
- D. 16
Correct Answer: C
Rationale: In general, children begin dentition around 6 months of age. During the first 2 years of life, a quick guide to the number of teeth a child should have is as follows: Subtract the number 6 from the number of months in the age of the child. In this example, the child is 18 months old, so the formula is 18 - 6 = 12. An 18-month-old child should have approximately 12 teeth.
Which of the following behaviors is least appropriate when dealing with fellow staff members?
- A. Provide positive feedback and constructive criticism.
- B. Serve as a resource.
- C. Only report conflicts that interfere with client care.
- D. Provide input for performance evaluations.
Correct Answer: C
Rationale: When conflicts are recognized, they should be reported. Conflicts can involve all components of healthcare practice including client care, nursing staff interaction, interactions with other hospital staff, and resource use/availability.
The nurse teaching an obese client about nutritional needs and weight loss should include all of the following except:
- A. knowledge of food and food products
- B. development of a positive mental attitude
- C. adequate exercise
- D. starting a fast weight-loss diet
Correct Answer: D
Rationale: Fast weight-loss diets are unsustainable and potentially harmful. Education should focus on nutrition knowledge, positive mindset, and exercise for healthy, gradual weight loss.
A nurse discharge planner is preparing a client for discharge from an acute care setting. The nurse assesses that skilled home care services are clinically indicated. This assessment is based on all of the following indicators except:
- A. the client has been admitted to the hospital three times in the last 2 months.
- B. the client has a Foley catheter.
- C. the client's family is available to care for him 24 hours a day.
- D. the client is ordered to continue IV antibiotics 5 days post discharge.
Correct Answer: C
Rationale: Family availability to provide care and assistance is not an indicator for skilled home care. In fact, the nurse might see some opportunity for family education in meeting the client's needs so that less community support is needed. Frequent hospital readmissions imply that the client has not been able to manage either due to condition instability or lack of care needs being met. This is a red flag for home care services to be able to meet those needs and appropriately monitor the client. A Foley catheter is an indication for home care due to infection potential and care requirements. IV antibiotics involve home care due to maintaining line patency and assessment of the site.
Which of the following methods of contraception is able to reduce the transmission of HIV and other STDs?
- A. intrauterine device (IUD)
- B. Norplant
- C. oral contraceptives
- D. vaginal sponge
Correct Answer: D
Rationale: The vaginal sponge is a barrier method of contraception that, when used with foam or jelly contraception, reduces the transmission of HIV and other STDs as well as reducing the risk of pregnancy. IUDs, Norplant, and oral contraceptives can prevent pregnancy but not the transmission HIV and STDs. Clients using the contraceptive methods in Choices A, B, and C should be counseled to use a chemical or barrier contraceptive to decrease transmission of HIV or STDs.