Nokea
A nurse is teaching a client who is trying to conceive. Which of the following should the nurse instruct the client to increase in her diet to prevent a neural tube defect?
- A. Zinc
- B. Calcium
- C. Folate
- D. Iron
Correct Answer: C
Rationale: The correct answer is C: Folate. Folate is essential for preventing neural tube defects in newborns. It helps in the development of the baby's brain and spinal cord. Zinc (A) is important for overall health but not specifically for preventing neural tube defects. Calcium (B) is crucial for bone health, not neural tube development. Iron (D) is vital for preventing anemia but not directly related to neural tube defects.
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Which client statement should the nurse report as an indication of major depressive disorder?
- A. I am unable to feel any joy since my child died
- B. I have lost interest in activities I once enjoyed.
- C. I have trouble sleeping and have no appetite.
- D. I feel guilty and worthless every day.
- E. I have been thinking about ending my own life.
Correct Answer: E
Rationale: The correct answer is E because suicidal ideation is a significant red flag for major depressive disorder. This statement indicates severe emotional distress and potential risk for self-harm. Choices A, B, C, and D are common symptoms of depression but do not necessarily point to the severity and immediate risk of suicide like choice E does. Reporting suicidal thoughts is crucial for timely intervention and ensuring the client's safety.
Which of the following sites should the nurse use?
- A. Axillary
- B. Rectal
- C. Oral
- D. Tympanic
Correct Answer: B
Rationale: The nurse should use the rectal site for temperature measurement as it provides the most accurate core body temperature reading. Rectal temperature closely reflects internal body temperature, making it the preferred site for assessing critically ill patients or infants who cannot cooperate for oral measurements. Axillary, oral, and tympanic sites may not accurately represent core body temperature due to external factors affecting the readings. Rectal temperature is the gold standard for accurate temperature measurement in certain clinical situations.
A charge nurse is teaching a newly licensed nurse about medication Administration. Which of the following information should the charge nurse include?
- A. Avoid preparing medications for more than two clients at one time.
- B. Inform clients about the action of the medication Prior to administration.
- C. Read medication labels at least two times prior to administration.
- D. Complete an incident report if a client vomits after taking a medication.
Correct Answer: C
Rationale: The correct answer is C: Read medication labels at least two times prior to administration. This is crucial to ensure accurate medication administration and prevent medication errors. Reading labels twice helps in verifying the right medication, dose, route, and time. It is a standard safety practice in medication administration. Option A is incorrect as there is no specific rule about preparing medications for multiple clients. Option B is important but not as critical as double-checking the medication labels. Option D is important in certain situations but not directly related to medication administration technique.
Which finding should the nurse identify as an indication that the medication is effective?
- A. Heart rate 140/min
- B. Capillary refill 3 seconds
- C. Cessation of nocturnal enuresis
- D. Absence of hypoglycemic episodes
Correct Answer: C
Rationale: The correct answer is C: Cessation of nocturnal enuresis. This indicates the medication is effective because it shows improvement in the condition being treated, which in this case is nocturnal enuresis. Nocturnal enuresis is the involuntary passage of urine during sleep and it can be a result of various factors such as hormonal imbalance or bladder control issues. Therefore, if the medication is effective, it should lead to the cessation of this symptom.
Heart rate (A) and capillary refill (B) are not necessarily indicators of the effectiveness of the medication in treating nocturnal enuresis. Absence of hypoglycemic episodes (D) is more related to diabetes management rather than nocturnal enuresis.
Which finding should the nurse expect?
- A. Spotting
- B. Painless, bright red vaginal bleeding
- C. Soft, relaxed, and non-tender uterus
- D. Fundal height greater than expected for gestational age
- E. Fetal heart rate within normal limits unless significant blood loss occurs
Correct Answer: B
Rationale: The correct answer is B: Painless, bright red vaginal bleeding. This finding is indicative of placenta previa, a condition where the placenta partially or completely covers the cervix. The bright red color indicates fresh bleeding. Spotting (choice A) is more commonly associated with implantation bleeding in early pregnancy. A soft, relaxed, and non-tender uterus (choice C) is not specific to any particular condition. A fundal height greater than expected for gestational age (choice D) could indicate fetal macrosomia or polyhydramnios, but it is not related to the scenario described. While fetal heart rate within normal limits (choice E) is important, it is not the most relevant finding in this case.