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. Calcium
- B. Folate
- C. Iron
- D. Zinc
Correct Answer: B
Rationale: The correct answer is B: Folate. Folate is essential for preventing neural tube defects in newborns. It helps in the formation of the neural tube during early pregnancy. Calcium (A) is important for bone health but not specifically for preventing neural tube defects. Iron (C) is crucial for preventing anemia but not directly related to neural tube defects. Zinc (D) is important for immune function and wound healing but not specifically for neural tube defects.
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A nurse is collecting a sputum specimen from a client who has tuberculosis. Which of the following actions should the nurse take?
- A. Wait 1 day to collect the specimen if the client cannot provide sputum.
- B. Wear sterile gloves to collect the specimen from the client.
- C. Ask the client to provide 15 to 20 mL of sputum into the container
- D. Obtain the specimen immediately upon the client waking up.
Correct Answer: D
Rationale: The correct answer is D: Obtain the specimen immediately upon the client waking up. This is the correct action because sputum is most concentrated in the morning, making it easier to collect a good sample for testing. Waiting 1 day (A) can delay treatment. Wearing sterile gloves (B) is important but not specific to sputum collection. Asking for 15-20mL of sputum (C) is appropriate, but the timing of collection is crucial.
Drag words from the choices below to fill in each blank in the following sentence. The client is at greatest risk for developing-----and-----
- A. Placental Abruption
- B. Hypoglycemia
- C. Heart failure
- D. Cervical insufficiency
- E. Seizures
Correct Answer: C,E
Rationale: The correct answer is C, Heart failure, and E, Seizures. The client is at greatest risk for developing heart failure and seizures due to complications during pregnancy. Heart failure can occur due to the increased stress on the heart from pregnancy, especially in individuals with pre-existing heart conditions. Seizures can arise from conditions like eclampsia, which is a severe form of preeclampsia characterized by high blood pressure and organ damage. Placental abruption (A) is a separation of the placenta from the uterus, not directly related to heart failure or seizures. Hypoglycemia (B) is low blood sugar levels, which may occur but is not the greatest risk in this scenario. Cervical insufficiency (D) is the inability of the cervix to stay closed during pregnancy, which is not directly linked to heart failure or seizures.
Complete the following sentence by using the lists of options. The nurse understands that the patient has likely developed-----and will need to be monitored for-------
- A. Lithium toxicity
- B. Hyponatremia
- C. cardiac dysrhythmias
- D. nephrotoxicity
- E. metabolic alkalosis
- F. Hypertension
Correct Answer: A,D
Rationale: The correct answer is A and D. Lithium toxicity and nephrotoxicity are commonly associated with the use of lithium. The nurse needs to monitor the patient for signs and symptoms of lithium toxicity, such as tremors, confusion, and increased thirst, as well as signs of nephrotoxicity, like decreased urine output and electrolyte imbalances. Hyponatremia (B), cardiac dysrhythmias (C), metabolic alkalosis (E), and hypertension (F) are not directly related to lithium use. Monitoring for these conditions would not be the priority in a patient who has likely developed lithium toxicity and nephrotoxicity.
A nurse is caring for a client whose child died from cancer. The client states, 'It's hard to go on without him.' Which of the following questions should the nurse ask the client first?
- A. What has helped you through difficult times in the past?'
- B. Has anyone in your family committed suicide?'
- C. Is there anyone you would like involved in your care?'
- D. Are you thinking about ending your life?'
Correct Answer: D
Rationale: The correct question to ask first is D: "Are you thinking about ending your life?" This is important to assess the client's risk of suicide, as the statement "It's hard to go on without him" can indicate suicidal ideation. It is crucial to address safety concerns immediately. Asking about coping strategies (A) can come later. Inquiring about family suicide history (B) may not be relevant at this stage. Involving others in care (C) is important but not as urgent as assessing suicidal thoughts.
A nurse is caring for a client who is in active labor and notes the FHR baseline has been 100/min for the past 15 min. The nurse should identify which of the following conditions as a possible cause of fetal bradycardia?
- A. Maternal hypoglycemia
- B. Chorioamnionitis
- C. Fetal anemia
- D. Maternal fever
Correct Answer: C
Rationale: Correct Answer: C (Fetal anemia)
Rationale: Fetal anemia can lead to decreased oxygen delivery to the fetus, causing fetal bradycardia. Anemia reduces the oxygen-carrying capacity of the blood, resulting in the heart working harder to compensate for the decreased oxygen levels, leading to a lower fetal heart rate.
Summary of Incorrect Choices:
A: Maternal hypoglycemia - Unlikely to cause fetal bradycardia directly.
B: Chorioamnionitis - Typically presents with maternal fever and tachycardia, not fetal bradycardia.
D: Maternal fever - Can cause fetal tachycardia, not bradycardia.