Nokea
A nurse is teaching the mother of an 11-month-old infant how to clean the infant's teeth. The nurse tells the mother to take which action?
- A. Use a small amount of toothpaste and a soft-bristle toothbrush
- B. Use water and a cotton swab and rub the teeth
- C. Use diluted fluoride and rub the teeth with a soft washcloth
- D. Dip the infant's pacifier in maple syrup so that the infant will suck
Correct Answer: C
Rationale: The correct action when cleaning an infant's teeth is to use water and a cotton swab to gently rub the teeth. This method helps in removing any food particles or plaque buildup without the risks associated with toothpaste ingestion. Using a small amount of toothpaste and a soft-bristle toothbrush is not recommended for infants as they may swallow the toothpaste, leading to potential fluoride ingestion issues. Using diluted fluoride and rubbing the teeth with a soft washcloth is unnecessary at this age since infants typically receive fluoride through other sources like formula. Dipping the infant's pacifier in maple syrup is highly inappropriate and poses a significant risk of tooth decay due to the high sugar content, which can harm the infant's teeth.
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The client is scheduled for a pericentesis. Which instruction should be given to the client before the exam?
- A. "You will need to lie flat during the exam."?
- B. "You need to empty your bladder before the procedure."?
- C. "You will be asleep during the procedure."?
- D. "The doctor will inject a medication to treat your illness during the procedure."?
Correct Answer: B
Rationale: The client scheduled for a pericentesis should be instructed to empty the bladder to prevent the risk of bladder puncture when the needle is inserted. A pericentesis involves removing fluid from the peritoneal cavity. The client is typically positioned sitting up or leaning over a table, making answer A incorrect. During a pericentesis, the client is usually awake, so answer C is incorrect. Medications are not commonly injected into the peritoneal cavity during this procedure, making answer D incorrect. However, it's important to note that the administration of medications during the procedure could vary based on specific circumstances.
After the client discusses her relationship with her father, the nurse says, "Tell me whether I am understanding your relationship with your father. You feel dominated and controlled by him?"? This is an example of:
- A. verbalizing the implied.
- B. seeking consensual validation.
- C. encouraging evaluation.
- D. suggesting collaboration.
Correct Answer: B
Rationale: Seeking consensual validation is the correct answer. Consensual validation is a technique used to check one's understanding of what the client has said. It involves confirming with the client whether the nurse's interpretation aligns with the client's feelings or thoughts. This process helps build rapport, trust, and a shared understanding between the nurse and the client. Verbalizing the implied (choice A) refers to expressing the underlying or implicit meaning of a client's statement. Encouraging evaluation (choice C) involves prompting the client to assess or judge a situation. Suggesting collaboration (choice D) entails proposing working together with the client on a shared goal, which is not the primary focus in the scenario provided.
A client asks the nurse if all donor blood products are cross-matched with the recipient to prevent a transfusion reaction. Which of the following always requires cross-matching?
- A. packed red blood cells
- B. platelets
- C. plasma
- D. granulocytes
Correct Answer: A
Rationale: Corrected Rationale: Packed red blood cells contain antigens and antibodies that must be matched between the donor and recipient to prevent transfusion reactions. Platelets, plasma, and granulocytes do not contain red blood cells, so they do not require cross-matching. Platelets are matched based on ABO compatibility, while plasma and granulocytes are not routinely cross-matched as they lack red cell antigens.
In which age group does the highest incidence of child abuse occur?
- A. Birth-3 years old
- B. 4-6 years old
- C. 6-10 years old
- D. More than 10 years old
Correct Answer: A
Rationale: The correct answer is 'Birth-3 years old.' Children between birth and 3 years of age have the highest rates of victimization (at 16 per 1,000 children). This age group is most vulnerable due to their dependency and inability to report or protect themselves effectively. Child abuse can occur at any age, but statistics show that infants and toddlers are at the highest risk due to their developmental stage and reliance on caregivers. Choices B, C, and D are incorrect because while child abuse can happen at any age, the prevalence is highest among children in the 0-3 age group.
The nurse is assigning staff for the day. Which assignment should be given to the nursing assistant?
- A. Taking the vital signs of the 5-month-old with bronchiolitis
- B. Taking the vital signs of the 10-year-old with a 2-day postappendectomy
- C. Administering medication to the 2-year-old with periorbital cellulitis
- D. Adjusting the traction of the 1-year-old with a fractured tibia
Correct Answer: B
Rationale: The most appropriate assignment for a nursing assistant is to take the vital signs of a stable patient. A 10-year-old with a 2-day postappendectomy is considered stable, and routine vital signs monitoring can be safely delegated to a nursing assistant. Clients with bronchiolitis, periorbital cellulitis, and a fractured tibia require more specialized care and assessment by a licensed nurse. Bronchiolitis involves an airway alteration, periorbital cellulitis indicates an infection, and a fractured tibia may raise concerns of abuse. Therefore, options A, C, and D are incorrect for delegation to a nursing assistant.