Nokea
A nurse is caring for a patient with chronic heart failure. Which of the following interventions is the priority?
- A. Administering diuretics as prescribed.
- B. Encouraging the patient to rest.
- C. Monitoring vital signs and fluid status.
- D. Teaching the patient about dietary changes.
Correct Answer: C
Rationale: The correct answer is C because monitoring vital signs and fluid status is crucial in managing chronic heart failure. This intervention helps in assessing the patient's condition, detecting any signs of deterioration, and ensuring appropriate fluid balance. Administering diuretics (A) may be necessary but should be based on the patient's fluid status. Encouraging rest (B) is important, but monitoring vital signs takes precedence. Teaching about dietary changes (D) is essential, but ensuring the patient's immediate stability through monitoring is the priority.
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While obtaining the history from the mother of a 2-year-old with pneumonia, the nurse asks the mother if she smoked or used drugs during her pregnancy. Her response is, "What does that have to do with pneumonia?" How would the nurse answer her question?
- A. "You don't need to answer if it makes you uncomfortable."
- B. "It's not really that important; we have to ask everyone these questions."
- C. "The use of tobacco during your pregnancy could be the cause of your daughter's pneumonia."
- D. "Knowing about your pregnancy will help us get a more complete picture of your daughter's health."
Correct Answer: D
Rationale: The correct answer is D because understanding the mother's pregnancy history can provide crucial insights into potential risk factors or exposures that could have contributed to the child's pneumonia. By knowing about the mother's smoking or drug use during pregnancy, the healthcare team can better assess the child's overall health and potential underlying conditions.
Choice A is incorrect as it dismisses the importance of the question and fails to address the potential significance of the information. Choice B is incorrect as it downplays the relevance of the question, which is essential for gathering comprehensive information for the child's care. Choice C is incorrect as it makes an unsupported and potentially misleading statement about the direct cause of pneumonia without considering other factors.
Which choice is *not* allowed when planning care for a client undergoing diagnostic genetic counseling?
- A. Terminating the pregnancy
- B. Preparing for the birth of a child with special needs
- C. Accessing support services before birth
- D. Completing the grieving process before birth
Correct Answer: D
Rationale: The correct answer is D because completing the grieving process before birth is not appropriate when planning care for a client undergoing genetic counseling. This is because genetic counseling aims to provide information and support to help clients make informed decisions about their pregnancy or future child's health. Grieving before birth implies assuming a negative outcome before all information is gathered, which can be premature and may not align with the purpose of genetic counseling. Choices A, B, and C are allowed as they involve valid actions such as decision-making, preparation, and accessing support services, all of which are important aspects of genetic counseling.
A nurse is caring for a patient who is undergoing treatment for cancer. Which of the following symptoms would most likely indicate the need for palliative care?
- A. Severe pain and nausea.
- B. Uncontrolled symptoms despite treatment.
- C. Psychosocial support needs.
- D. All of the above.
Correct Answer: D
Rationale: The correct answer is D because palliative care aims to improve the quality of life for patients with serious illnesses like cancer. Severe pain and nausea (A) are common symptoms that palliative care helps manage. Uncontrolled symptoms despite treatment (B) indicate the need for specialized palliative care interventions. Psychosocial support needs (C) are also addressed in palliative care to address emotional and social aspects of the patient's well-being. Therefore, all of the above (D) are indicative of the need for palliative care as it focuses on holistic symptom management and support for the patient.
What is the most appropriate intervention for a client with suspected peritonitis?
- A. Administer antibiotics
- B. Administer IV fluids
- C. Place the client in a supine position
- D. Administer epinephrine
Correct Answer: A
Rationale: The correct answer is A: Administer antibiotics. Peritonitis is an inflammation of the peritoneum typically caused by infection. Administering antibiotics is crucial to treat the underlying infection. IV fluids (B) may be necessary to maintain hydration, but antibiotics address the root cause. Placing the client in a supine position (C) is not a specific intervention for peritonitis. Administering epinephrine (D) is not indicated for peritonitis as it is not a treatment for infection.
How many teeth should an 18-month-old child have?
- A. 6
- B. 8
- C. 12
- D. 16
Correct Answer: C
Rationale: The correct answer is C: 12. At 18 months, a child should have 12 teeth, which include 8 incisors and 4 molars. This is because children typically start teething around 6 months, with the lower central incisors coming first. By 18 months, they should have all 8 incisors and usually the first set of molars. Options A, B, and D are incorrect because they do not align with the typical dental development timeline for children. Having only 6, 8, or 16 teeth at 18 months would indicate a delay or abnormality in dental growth.