Nokea
A nurse is doing preconception counseling with a woman who is planning a pregnancy. Which of the following statements suggests that the client understands the connection between alcohol consumption and fetal alcohol syndrome?
- A. I understand that a glass of wine with dinner is healthy.
- B. Beer is not really hard alcohol, so I guess I can drink some.
- C. If I drink, my baby may be harmed before I know I am pregnant.
- D. Drinking with meals reduces the effects of alcohol.
Correct Answer: C
Rationale: If I drink, my baby may be harmed before I know I am pregnant. This reflects awareness of alcohol's early fetal risks.
You may also like to solve these questions
The nurse is to administer Lanoxin(digoxin) elixir to a 6-month old with a congenital heart defect. The nurse auscultates an apical pulse rate of 100 . The nurse should:
- A. Record the heart rate and call the physician.
- B. Record the heart rate and administer the medication.
- C. Administer the medication and recheck the heart rate in 15 minutes.
- D. Hold the medication and recheck the heart rate in 30 minutes.
Correct Answer: B
Rationale: A pulse of 100 in a 6-month-old is normal (80-150 bpm), so the nurse should administer digoxin . Calling the physician or holding the dose is unnecessary. Rechecking later is not standard.
The nurse is assessing the nursing care unit in a long-term facility for fire hazards. Which finding is the greatest fire hazard?
- A. Some of the nurses and nursing assistants smoke in the restroom.
- B. There are several cardboard boxes and cleaning supplies stored in the room with the emergency oxygen supply.
- C. Several residents have dust under their beds.
- D. Two of the residents have closets that are stuffed full of photo albums and sewing supplies.
Correct Answer: B
Rationale: Storing flammable materials near oxygen increases fire risk, as oxygen supports combustion. Smoking, dust, or cluttered closets are less hazardous.
A nursing assistant states that her five-year-old child has developed chickenpox.
It would be MOST important for the nurse to ask which of the following questions?
- A. Have your other children had chickenpox?'
- B. Does your child have a temperature?'
- C. Have you had the chickenpox?'
- D. Do you have someone to watch your child?'
Correct Answer: C
Rationale: Strategy: 'MOST important' indicates there may be more than one answer that you would like to select. Remember, you can only ask one question. (1) chickenpox spread by direct contact, airborne route; not the most important question (2) fever, malaise, and anorexia occur during first 24 hours; treat with Tylenol (3) correct-need to ascertain if staff has had the disease; if not, VZIG can be given; exclude from patient care from the 10th day after first exposure through the 21st day (28th day if VZIG given) after last exposure (4) important information, but assessing staff is most important
A five-year-old boy in the playroom.
The school nurse observes a group of preschool children in the playroom. The nurse recognizes which of the following activities as appropriate behavior for a five-year-old boy?
- A. The boy plays with a large truck with another child.
- B. The boy talks on a toy telephone and imitates his father.
- C. The boy works on a puzzle with several other children.
- D. The boy holds and cuddles a large stuffed animal.
Correct Answer: B
Rationale: Strategy: Picture the child. (1) play begins to be cooperative at this age (2) correct-imitative behavior seen at this age (3) too advanced for this age (4) too regressed for this age
A client with a marked depression of T cells.
To promote safety in the environment of a client with a marked depression of T cells, the nurse should
- A. keep a linen hamper immediately outside the room.
- B. restrict eating utensils to spoons made of plastic.
- C. provide masks for anyone entering the room.
- D. remove any standing water left in containers or equipment.
Correct Answer: D
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) protocol for handling soiled articles is accomplished within universal guidelines with double biohazard bags (2) universal precautions and client protection may call for plastic utensils, but not just spoons (3) not protocol unless the client has an active pulmonary infection (4) correct-water should not be allowed to stand in containers, such as respiratory or suction equipment, because this could act as a culture medium