Nokea
A nurse is monitoring a child whose parents are suspected of child neglect. Which of the following is an expected finding of neglect?
- A. Lack of required immunizations
- B. Parental lack of education
- C. Lower socioeconomic group
- D. Faded clothing with large shoes
Correct Answer: A
Rationale: The correct answer is A: Lack of required immunizations. Neglect refers to the failure to provide for a child's basic needs, including healthcare. Lack of immunizations puts the child at risk for preventable diseases, indicating neglect. Parental lack of education (B) or being in a lower socioeconomic group (C) do not directly indicate neglect. Faded clothing with large shoes (D) may suggest financial difficulties but does not necessarily indicate neglect.
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A nurse smells an odor identified as marijuana coming from a room. Which of the following client findings would confirm inhalation of the substance?
- A. Poor coordination, red eyes, and euphoria
- B. Slurred speech, confusion, and combativeness
- C. Loss of consciousness, respiratory depression, and coma
- D. Hypertension, tachycardia, and hyperflexia
Correct Answer: A
Rationale: The correct answer is A because poor coordination, red eyes, and euphoria are classic signs of marijuana inhalation. Poor coordination is a common effect due to impairment of motor skills. Red eyes result from vasodilation caused by marijuana. Euphoria is a psychological effect of the drug. Slurred speech, confusion, and combativeness (Option B) are more indicative of alcohol or sedative use. Loss of consciousness, respiratory depression, and coma (Option C) are severe symptoms more likely associated with opioid or sedative overdose. Hypertension, tachycardia, and hyperflexia (Option D) are not typically seen with marijuana use; they are more consistent with stimulant use.
A nurse is caring for a 3-year-old child who is diagnosed with a urinary tract infection (UTI). The parent is concerned about recognizing the signs and symptoms of future UTIs. Which of the following statements made by the parent indicates a correct understanding of the manifestations of a UTI?
- A. I should look for more frequent urination and strong-smelling urine.
- B. My child would have tea-colored urine and puffiness around the eyes.
- C. I should observe for episodes of nausea and less frequent urination.
- D. My child would have pale-colored urine and abdominal tenderness and pain.
Correct Answer: A
Rationale: Frequent urination and strong-smelling urine are classic signs of a UTI.
Which preoperative nursing interventions should be included for a client who is scheduled to have an emergency cesarean birth?
- A. Monitoring O2 saturations and administering pain medications are postoperative interventions.
- B. Taking vital signs every 15 minutes is a postoperative intervention. Instructing the client regarding breathing exercises is not appropriate in a crisis situation when the client's anxiety is high, because information would probably not be retained. In an emergency, there is time only for essential interventions.
- C. Because this is an emergency, surgery must be performed quickly. Anxiety of the client and the family will be high. Inserting an indwelling catheter helps to keep the bladder empty and free from injury when the incision is made.
- D. The nurse should have assessed breath sounds upon admission. Breath sounds are important if the client is to receive general anesthesia, but the anesthesiologist will be listening to breath sounds in surgery in that case.
Correct Answer: C
Rationale: The correct answer is C because in an emergency cesarean birth, surgery must be performed quickly to ensure the safety of the mother and baby. Inserting an indwelling catheter is crucial to keep the bladder empty and prevent injury during the incision. This intervention helps maintain a sterile field and reduces the risk of infection. Additionally, a full bladder can impede the progress of surgery. Monitoring O2 saturations and administering pain medications (A) are postoperative interventions and not relevant in the preoperative phase. Taking vital signs every 15 minutes (B) is more appropriate for the postoperative period. Assessing breath sounds (D) is important but typically done by the anesthesiologist during surgery. Instructing the client about breathing exercises (B) may not be effective in an emergency situation where immediate interventions are necessary.
Which physiological change takes place during the puerperium?
- A. The endometrium begins to undergo alterations necessary for menstruation.
- B. The placenta begins to separate from the uterine wall.
- C. The uterus returns to a pre-pregnant size and location.
- D. The uterus contracts at regular intervals with dilation of the cervix occurring.
Correct Answer: C
Rationale: During the puerperium, the correct physiological change is that the uterus returns to a pre-pregnant size and location (Choice C). This is because after childbirth, the uterus undergoes involution, gradually decreasing in size back to its pre-pregnant state. This process involves the shedding of excess tissue and contraction of uterine muscles. The endometrium (Choice A) does not undergo alterations for menstruation until after the puerperium, as menstruation typically resumes around 6-8 weeks postpartum. The placenta (Choice B) should have been expelled completely during the third stage of labor, so it does not separate during the puerperium. The uterus does contract, but it is not at regular intervals with cervical dilation (Choice D) during the puerperium.
A nurse is reinforcing teaching with the parent of an infant who has club feet with bilateral casts.
- A. "Check the toes for any swelling or discoloration."'
- B. "Monthly recasting should be scheduled with the orthopedist."'
- C. "Use a heated fan or dryer to facilitate the drying of the cast."'
- D. "Give the baby Tylenol every 4 hr to help with pain."'
Correct Answer: A
Rationale: The correct answer is A because checking the toes for swelling or discoloration is crucial in monitoring circulation and preventing complications like pressure sores. Choice B is incorrect as casts are typically changed more frequently. Choice C is incorrect as heat can cause burns. Choice D is incorrect as giving Tylenol every 4 hours without a physician's recommendation is not advisable for pain management in infants.