Nokea
A nurse is preparing to feed a 12-month-old infant with failure to thrive. Which intervention should the nurse implement?
- A. Provide stimulation during feeding.
- B. Avoid being persistent during feeding time.
- C. Limit feeding time to 10 minutes.
- D. Maintain a face-to-face posture with the infant during feeding.
Correct Answer: A
Rationale: Providing stimulation during feeding is the most appropriate intervention for a 12-month-old infant with failure to thrive. Infants with failure to thrive may have decreased interest in feeding or difficulty with obtaining adequate nutrition. By providing stimulation during feeding, such as making eye contact, talking gently, and playing soft music, the nurse can help increase the infant's interest and engagement in feeding. This can lead to improved feeding outcomes and help the infant receive the necessary nutrition for growth and development.
You may also like to solve these questions
A client is undergoing a diagnostic work-up for suspected testicular cancer. When obtaining the client's history, the nurse checks for known risk factors for this type of cancer. Testicular cancer has been linked to:
- A. Testosterone therapy during childhood
- B. Early onset of puberty
- C. Sexually transmitted disease
- D. Cryptorchidism
Correct Answer: D
Rationale: Cryptorchidism, also known as undescended testicle, is a known risk factor for testicular cancer. Men who had cryptorchidism, a condition where one or both testicles fail to descend into the scrotum before birth, have a higher risk of developing testicular cancer compared to those without this condition. The abnormal positioning of the testicle outside the scrotum may disrupt normal testicular development and increase the likelihood of malignant transformation. Therefore, clients with a history of cryptorchidism are at increased risk for testicular cancer and warrant close monitoring and follow-up.
When caring for a client diagnosed with a brain tumor of the parietal lobe, the nurse expects to assess:
- A. Short-term memory impairment.
- B. Seizures.
- C. Tactile agnosia.
- D. Contralateral homonymous hemianopia. Situation: The American cancer Society recommends routine screening to detect colorectal cancer.
Correct Answer: C
Rationale: The parietal lobe is responsible for processing sensory information, including touch and spatial awareness. Tactile agnosia is a condition where individuals have difficulty recognizing objects by touch, which can result from damage or tumors in the parietal lobe. The nurse caring for a client with a brain tumor in the parietal lobe would expect to assess for signs of tactile agnosia, as this type of sensory impairment is commonly associated with lesions in this area of the brain. Short-term memory impairment, seizures, and contralateral homonymous hemianopia are more commonly associated with lesions in different areas of the brain, such as the temporal lobes for memory, the frontal or temporal lobes for seizures, and the occipital lobe for visual field deficits, respectively.
Which of the ff factors makes it important for the nurse to provide special care to older clients with an immune system disorder?
- A. Age-related changes
- B. Use of multiple drugs (Polypharmacy)
- C. Poor diet
- D. Reduced activity levels
Correct Answer: A
Rationale: Age-related changes contribute significantly to the vulnerability of older clients with an immune system disorder. As people age, their immune system undergoes various alterations that can compromise its effectiveness in fighting off infections and diseases. These changes include thymic involution (decrease in thymus size and function), decrease in T-cell production, impaired immune response to infections, and decline in overall immune function. Older individuals are more susceptible to infections due to these age-related changes, which makes it essential for nurses to provide special care tailored to their specific needs. By understanding and considering these age-related immune system changes, nurses can develop appropriate care plans to support the health and well-being of older clients with immune system disorders.
Which of the ff nursing interventions is essential for a client during the Schilling test?
- A. Collecting urine 24-48 hrs after the client has received nonradioactive B12
- B. Collecting blood samples of 50 ml for 24-48 hrs after the client has received the nonradioactive B12
- C. Not allowing any oral fluid consumption for 24-48 hrs after the client has received nonradioactive B12
- D. Making the client lie down in the supine position for 24-48 hrs after the client has received nonradioactive B12 CARING FOR CLIENTS WITH DISORDERS OF THE HEMATOPOIETIC SYSTEM
Correct Answer: A
Rationale: During the Schilling test, which is used to evaluate the absorption of vitamin B12 in the gastrointestinal system, the essential nursing intervention is to collect urine samples 24-48 hours after the client has received nonradioactive B12. The test involves administering both radioactive and nonradioactive forms of vitamin B12 to the client. The client's ability to absorb the vitamin B12 is assessed by measuring the amount of labeled B12 in the urine over the specified time period. This helps in diagnosing conditions such as pernicious anemia or malabsorption of vitamin B12. Blood samples are not typically collected for this test, and allowing fluid consumption is important to keep the client hydrated. The client does not need to lie down in a specific position for an extended period following nonradioactive B12 administration.
A 34 year old male client is diagnosed with encephalitis. Medication has been started for him and he is receiving nursing care. Which of the ff nursing interventions are the most critical for such a client? Choose all that apply
- A. Measuring fluid intake and output
- B. Evaluating the clients ventilation capacity and lung sound frequently
- C. Observing closely for signs of respiratory distress
- D. Administering an indwelling urethral catheter
Correct Answer: B
Rationale: B. Evaluating the client's ventilation capacity and lung sounds frequently is crucial in encephalitis because the inflammation of the brain can affect the respiratory center, leading to respiratory compromise. Any changes in ventilation capacity or abnormal lung sounds should be addressed immediately to prevent respiratory distress.