Nokea
A nurse is caring for a 4-year-old client with full-thickness burns. Which of the following nursing actions are essential for the care of this child? (Select all that apply.)
- A. Monitor level of consciousness
- B. Maintain intravenous fluids
- C. Document vital signs
- D. Provide a low-calorie,high carbohydrate diet
Correct Answer: A,B,C
Rationale: Level of consciousness, IV fluids, vital signs, and urinary output are critical in burn management; a high-protein, high-calorie diet is recommended instead of a low-calorie diet.
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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.
Which of the following physical manifestations of a client with anorexia nervosa best indicates compliance with the treatment plan of care?
- A. "A weekly weight gain of 1 kg (2.2 lb)"'
- B. "Daily bowel movements that are soft"'
- C. "Return of regular menstrual periods"'
- D. "Improvement of the oral mucosa"'
Correct Answer: A
Rationale: The correct answer is A: "A weekly weight gain of 1 kg (2.2 lb)". In anorexia nervosa, weight restoration is a key goal of treatment to address malnutrition and restore physiological functioning. A weekly weight gain of 1 kg indicates the client is consuming adequate nutrition and their body is responding appropriately to treatment. This physical manifestation suggests the client is compliant with the treatment plan.
Choice B, daily bowel movements that are soft, is not necessarily a direct indicator of compliance with the treatment plan for anorexia nervosa. While bowel movements can be influenced by dietary changes, they are not as specific or reliable as weight gain in assessing treatment compliance.
Choice C, return of regular menstrual periods, is a potential physical manifestation of improved health in anorexia nervosa, but it may not be the best indicator of compliance with the treatment plan, as it can be influenced by various factors.
Choice D, improvement of the oral mucosa, is important for
A 38 week gestation newborn weighs 4020 grams, is sluggish, and has limp muscle tone. The baby experienced a broken clavicle during delivery. Based on this information, which can the nurse conclude about the baby?
- A. Neonatal abstinence symptoms
- B. Large for gestational age
- C. Congenital cardiac defect
- D. Respiratory depression
Correct Answer: B
Rationale: The correct answer is B: Large for gestational age. A newborn weighing 4020 grams at 38 weeks is considered large for gestational age. The sluggishness and limp muscle tone can be attributed to the baby's size, which can make movement more challenging. The broken clavicle could have occurred during delivery due to the baby's size and the forces involved. Neonatal abstinence symptoms (choice A) typically present with irritability, tremors, and poor feeding, not sluggishness. Congenital cardiac defects (choice C) usually manifest with cyanosis, tachypnea, and poor feeding. Respiratory depression (choice D) is characterized by poor respiratory effort, not sluggishness and limp muscle tone.
The client who is scheduled for a nonstress test (NST) asks the nurse to explain the purpose of the test. Which of the following is the correct response?
- A. The purpose of the NST is to assess the fetal CNS.
- B. The purpose of the NST helps to determine gestational age.
- C. The purpose of the NST is to determine fetal lie.
- D. The purpose of the NST is to determine fetal breathing.
Correct Answer: A
Rationale: The correct answer is A: The purpose of the NST is to assess the fetal CNS. The nonstress test (NST) evaluates the fetal CNS by measuring the fetal heart rate in response to fetal movement. This test assesses the overall well-being of the fetus by monitoring for accelerations in the heart rate, indicating a healthy CNS. Choices B, C, and D are incorrect because the NST is not used to determine gestational age, fetal lie, or fetal breathing. The primary focus of the NST is to evaluate the fetal CNS function through monitoring the fetal heart rate patterns.
A woman enters the birthing center in active labor. She tells the nurse that her membranes ruptured 26 hours ago. The nurse immediately takes the client's vital signs. Which is the rationale for the nurse's actions?
- A. Pulse rates rise the longer the membranes are ruptured
- B. Respiratory rates decrease due to lack of fluid in the uterus
- C. Prolonged rupture of membranes can lead to transient hypertension
- D. Infection is a complication of prolonged rupture of membranes
Correct Answer: D
Rationale: The correct answer is D. When the membranes rupture, it increases the risk of infection as it provides a direct pathway for bacteria to enter the uterus. Taking vital signs is crucial to monitor for signs of infection such as fever, tachycardia, and hypotension. Elevated temperature and increased heart rate can indicate an infection. Choice A is incorrect because pulse rate may not necessarily rise with prolonged rupture of membranes. Choice B is also incorrect as respiratory rates are not directly affected by ruptured membranes. Choice C is incorrect as prolonged rupture can lead to infection rather than transient hypertension.