Nokea
A nurse is teaching the parent of a nine month-old infant about diaper dermatitis. Which of the following measures would be appropriate for the nurse to include?
- A. Use only cloth diapers that are rinsed in bleach
- B. Do not use occlusive ointments on the rash
- C. Use commercial baby wipes with each diaper change
- D. Discontinue a new food that was added to the infant's diet just prior to the rash
Correct Answer: D
Rationale: Discontinue a new food that was added to the infant's diet just prior to the rash. New foods can be a cause of diaper dermatitis.
You may also like to solve these questions
The nurse is caring for an adult male who is receiving haloperidol (Haldol). Which complaint by the client is of most concern to the nurse and should be immediately reported?
- A. I have gained so much weight in the last few months.
- B. I am having trouble getting an erection.
- C. My legs are cramping and I feel like I need to walk all the time.
- D. It's really embarrassing. I'm drooling a lot.
Correct Answer: C
Rationale: Leg cramping and restlessness suggest akathisia, a serious extrapyramidal side effect of haloperidol, requiring immediate reporting.
A football player is well paid for his superior athletic ability. Described by his friends as quiet and brooding, on the field he is known for his overly aggressive plays. The client's behavior is an example of:
- A. Displacement
- B. Conversion
- C. Sublimation
- D. Repression
Correct Answer: C
Rationale: Sublimation involves channeling emotions (e.g., aggression) into socially acceptable outlets, like sports. Displacement, conversion, and repression do not fit.
The nurse is reinforcing teaching of proper technique for colostomy irrigation for the home health client. Which client action indicates that further instruction is required?
- A. Attaches an enema set to the irrigation bag, lubricates it, gently inserts it into the stoma, and holds it in place
- B. Fills irrigation container with 500-1000 mL of lukewarm tap water and flushes the irrigation tubing
- C. Hangs the irrigation container on a hook at the level of the shoulder approximately 18-24 inches above the stoma
- D. Slowly opens the roller clamp, allowing the irrigation solution to flow, but clamps the tubing when cramping occurs
Correct Answer: A
Rationale: Using an enema set is incorrect; a cone-tipped irrigator is required for safe colostomy irrigation. Water volume , height , and clamping are correct.
The nurse is caring for a client with anorexia nervosa. After experiencing a weight gain of 2 lb (0.9 kg), the client states, 'See what you have done to me? I am fatter and uglier than ever.' Which of the following actions would be most appropriate for the nurse to take?
- A. Acknowledge the client's distress and explore the client's underlying feelings.
- B. Remind the client that gaining weight is a criterion for discharge home.
- C. Encourage the client to write about the client's feelings in a journal
- D. Recommend the client receive cognitive behavioral therapy.
Correct Answer: A
Rationale: Acknowledging distress and exploring feelings builds trust and addresses body image issues. Discharge criteria , journaling , or therapy are less immediate.
A patient has been ordered to get Klonapin for the first time. Which of the following side effects is not associated with Klonapin?
- A. Drowsiness
- B. Ataxia
- C. Salivation elevated
- D. Diplopia
Correct Answer: D
Rationale: A-C are associated side effects of Klonapin.