Nokea
A nurse is reinforcing teaching about accidental poisoning to a parent during a routine well-child visit.
- A. "I will give my child a dose of ipecac."'
- B. "I will place my child on her back."'
- C. "I will call the Poison Control Center."'
- D. "I will get my child to drink a full glass of water."'
Correct Answer: C
Rationale: The correct answer is C: "I will call the Poison Control Center." This is the best course of action in case of accidental poisoning as they provide expert advice on managing poison exposure. Calling them ensures prompt and accurate guidance to prevent further harm. Option A (ipecac) is not recommended anymore as it can cause more harm. Option B (placing the child on her back) is irrelevant to poisoning treatment. Option D (full glass of water) is not recommended as it can dilute the poison and may worsen the situation.
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A woman in active labor is admitted to the labor and delivery unit, accompanied by her partner. As labor progresses, the nurse notes he is not interacting with the woman and sits in the corner, looking out the window. How may the nurse understand the man's actions?
- A. He is likely to be very concerned about the woman's health to the point that his ability to cope with the situation is compromised
- B. His actions reflect personality or cultural differences, which do not necessarily indicate a lack of concern.
- C. Due to his embarrassment and discomfort regarding the woman's expressions of pain, he withdraws from the situation
- D. His religious beliefs regarding participation in the birth experience affect his interactivity and communication in this situation.
Correct Answer: B
Rationale: The correct answer is B because it recognizes that the man's actions may be influenced by his personality or cultural differences, rather than indicating a lack of concern. This choice acknowledges that individuals may react differently in stressful situations based on their upbringing, beliefs, or personal characteristics. This understanding is crucial for the nurse to provide appropriate support and address any potential misunderstandings.
Choice A suggests that the man's concern about the woman's health is compromising his ability to cope, which is not supported by the information provided. Choice C assumes the man's withdrawal is due to embarrassment and discomfort, which may not be the case. Choice D attributes the man's behavior to religious beliefs, which is not mentioned in the scenario. These choices do not align with the evidence presented and do not consider the complexity of human behavior in different contexts.
Which assessment finding suggests thrombophlebitis in a postpartum client?
- A. These signs and symptoms are indications of pulmonary embolism.
- B. These signs and symptoms do not relate to thrombophlebitis. Dyspnea, tachypnea, and apprehension
- C. Chills, hypotension, and abdominal tenderness
- D. Positive Homan's sign, calf warmth, and pain
Correct Answer: D
Rationale: The correct answer is D because a positive Homan's sign, calf warmth, and pain are classic signs of thrombophlebitis in a postpartum client. A positive Homan's sign indicates pain in the calf upon dorsiflexion of the foot, which can indicate a blood clot in the leg veins. Calf warmth and pain are also indicative of a possible deep vein thrombosis.
Choices A and B are incorrect because they relate to pulmonary embolism, not thrombophlebitis. Choice C describes signs of sepsis or intra-abdominal pathology, not specifically thrombophlebitis.
In summary, the key indicators of thrombophlebitis in a postpartum client are a positive Homan's sign, calf warmth, and pain, making choice D the correct answer.
Which method of temperature regulation would safely and effectively prevent cold stress in a newly delivered infant?
- A. Wrap the baby loosely with a blanket.
- B. Be sure the baby's feet are covered.
- C. Cover the baby's head with a hat.
- D. Position the baby on a heating pad.
Correct Answer: C
Rationale: The correct answer is C: Cover the baby's head with a hat. Infants lose a significant amount of heat through their heads, so covering the head with a hat helps prevent heat loss and cold stress. Option A does not provide enough insulation to prevent cold stress. Option B only addresses the feet, while the head is a major heat loss area. Option D poses a risk of overheating and burns.
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.
The nursery nurse delays the first bottle feeding of a newborn. Which is the most common reason for the nurse's actions? The infant has:
- A. a blood glucose of 45 gm/dL
- B. a respiratory rate above 60
- C. blue hands and feet
- D. a heart murmur
Correct Answer: B
Rationale: The correct answer is B: a respiratory rate above 60. The nurse delays feeding because a high respiratory rate may indicate respiratory distress, making feeding unsafe. Feeding can lead to aspiration in infants with respiratory issues. A blood glucose of 45 gm/dL (choice A) is low but not typically a reason to delay feeding. Blue hands and feet (choice C) may indicate poor circulation, but it's not a common reason to delay feeding. A heart murmur (choice D) doesn't directly impact feeding safety.