Nokea
A nurse is reviewing discharge teaching with the parents of a child who has pediculosis.Which of the following should the nurse include in the teaching?
- A. "Children can share scarves and coats ,but not hats or combs."'
- B. "Household pets can carry and transmit lice to people."'
- C. "After washing clothing,hang clothes outside to dry."'
- D. "Seal nonwashable items in plastic bags for 14 days."'
Correct Answer: D
Rationale: The correct answer is D. The nurse should include sealing nonwashable items in plastic bags for 14 days in the teaching for pediculosis. This is important to prevent reinfestation as lice can survive for up to 48 hours without a host. By sealing items in plastic bags for 14 days, any remaining lice or eggs will die off.
Choice A is incorrect because lice can be transmitted through shared hats and combs, not just scarves and coats. Choice B is incorrect as lice do not live on household pets. Choice C is incorrect as hanging clothes outside will not effectively eliminate lice.
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A client is admitted to the hospital with severe pregnancy-induced hypertension (PIH). The physician orders magnesium sulfate. Which nursing intervention is important when administering this drug?
- A. Assess blood pressure and respiratory rate every fifteen minutes
- B. Monitor blood glucose levels every eight hours
- C. Evaluate for orthostatic hypotension when getting the client up to walk
- D. Observe for premature labor every shift
Correct Answer: A
Rationale: The correct answer is A because magnesium sulfate is a central nervous system depressant used to prevent seizures in PIH. It can cause respiratory depression and hypotension. Assessing blood pressure and respiratory rate every fifteen minutes is crucial to monitor for signs of magnesium toxicity and ensure the client's safety. Monitoring blood glucose levels (B) is not directly related to magnesium sulfate administration. Evaluating for orthostatic hypotension (C) and observing for premature labor (D) are not specific to the administration of magnesium sulfate in treating PIH.
A nurse is caring for an adolescent with inadequate weight gain.
- A. "Identify food preferences high in complex carbohydrates."'
- B. "Identify food preferences high in saturated and unsaturated fats."'
- C. "Identify food preferences high in calcium and protein."'
- D. "Identify food preferences high in calories."'
Correct Answer: C
Rationale: The correct answer is C: "Identify food preferences high in calcium and protein." Inadequate weight gain in adolescents can be due to lack of essential nutrients like calcium and protein for growth and development. Calcium is crucial for bone health, while protein is essential for muscle development. Both are important for overall growth. Choices A and D focus on carbohydrates and calories, which are important but not the primary nutrients needed for weight gain in this scenario. Choice B suggests high intake of saturated and unsaturated fats, which can be detrimental to overall health if consumed in excess. Therefore, identifying food preferences high in calcium and protein is the most appropriate choice to address inadequate weight gain in the adolescent.
In a child diagnosed with Tetralogy of Fallot, which of the following is a compensatory mechanism to decrease venous return to the heart?
- A. Squatting
- B. Clubbing
- C. Shortness of breath
- D. Polycythemia
Correct Answer: A
Rationale: Squatting is a compensatory mechanism that decreases venous return (deoxygenated blood) to the heart. This clinical sign is commonly seen in young children with Tetralogy of Fallot, a type of cyanotic heart disease. Squatting helps reduce the workload on the heart by decreasing the amount of deoxygenated blood returning to it.
A nurse is planning discharge for a client who is 3 days postpartum. Which of the following non pharmacological interventions should the nurse include in the plan of care for lactation suppression?
- A. Place warm, moist packs on the breast.
- B. Apply cabbage leaves to the breast.
- C. Wear a loose-fitting bra.
- D. Put green tea bags on the breasts.
Correct Answer: B
Rationale: The correct answer is B: Apply cabbage leaves to the breast. Cabbage leaves have been shown to help with lactation suppression due to their anti-inflammatory properties. Placing cabbage leaves on the breasts can help reduce milk supply by decreasing blood flow to the area. This method is safe, inexpensive, and easily accessible.
Choice A (Place warm, moist packs on the breast) is incorrect as warmth can actually stimulate milk production. Choice C (Wear a loose-fitting bra) is also incorrect as it does not directly address lactation suppression. Choice D (Put green tea bags on the breasts) is not effective for lactation suppression and may not be safe for the newborn if ingested.
A nurse is reinforcing teaching with the parent of a child with a urinary tract infection.
- A. "I will bring my child to the bathroom before we leave for extended trips."'
- B. "I need to switch my child from cotton underwear to nylon underwear."'
- C. "I should teach my child to wipe from back to front after urinating."'
- D. "I will have my child soak in a bubble bath once or twice a week."'
Correct Answer: A
Rationale: Correct Answer: A. "I will bring my child to the bathroom before we leave for extended trips."
Rationale: Bringing the child to the bathroom before extended trips helps prevent urinary stasis and decreases the risk of urinary tract infections by promoting regular voiding. This practice ensures that the bladder is emptied regularly, reducing the chances of bacterial growth. It is important to encourage frequent urination to flush out bacteria and prevent infection.
Summary of other choices:
B: Switching from cotton to nylon underwear can increase moisture retention and promote bacterial growth, leading to an increased risk of urinary tract infections.
C: Teaching a child to wipe from back to front can introduce bacteria from the anal area to the urethra, increasing the risk of urinary tract infections.
D: Soaking in a bubble bath can irritate the urethra and disrupt the natural balance of bacteria in the genital area, potentially leading to urinary tract infections.