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A nurse is working in a pediatric clinic and a 25 year-old mother comes in with a 4 week-old baby. The mother is stressed out about loss of sleep and the baby exhibits signs of colic. Which of the following techniques should the nurse teach the mother?
- A. Distraction of the infant with a red object
- B. Prone positioning techniques
- C. Tapping reflex techniques
- D. Neural warmth techniques
Correct Answer: D
Rationale: Neural warmth will help to lower the baby's agitation level, soothing the colic symptoms.
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Teaching the client with gonorrhea how to prevent reinfection and further spread is an example of:
- A. primary prevention.
- B. secondary prevention.
- C. tertiary prevention.
- D. primary health care prevention.
Correct Answer: B
Rationale: Secondary prevention targets the reduction of disease prevalence and disease morbidity through early diagnosis and treatment.
Clients who take iron preparations should be warned of the possible side effects, which might include:
- A. dizziness and orthostatic hypotension
- B. nausea, vomiting, diarrhea or constipation, and stomach cramps
- C. drowsiness, lethargy, and fatigue
- D. neuropathy and tingling in the extremities
Correct Answer: B
Rationale: Iron supplements commonly cause gastrointestinal side effects like nausea, vomiting, diarrhea, constipation, and stomach cramps, requiring client education.
Which of the following nursing diagnoses is most appropriate for the client experiencing acute pancreatitis?
- A. Confusion
- B. Latex Allergy
- C. Acute Pain
- D. Constipation
Correct Answer: C
Rationale: Acute Pain is most appropriate for the client experiencing acute pancreatitis, as pancreatitis causes severe abdominal pain due to inflammation and autodigestion of the pancreas.
A client begins a regimen of chemotherapy. Her platelet counts falls to 98,000. Which action is least likely to increase the risk of hemorrhage?
- A. Test all excreta for occult blood.
- B. Use a soft toothbrush or foam cleaner for oral hygiene.
- C. Implement reverse isolation.
- D. Avoid IM injections.
Correct Answer: C
Rationale: Reverse isolation does not affect the risk of hemorrhage.
Laboratory tests reveal the following electrolyte values for Mr. Smith: Na 135 mEq/L, Ca 8.5 mg/dL, Cl 102 mEq/L, and K 2.0 mEq/L. Which of the following values should the nurse report to the physician because of its potential risk to the client?
- A. Ca
- B. K
- C. Na
- D. Cl
Correct Answer: B
Rationale: A potassium level of 2.0 mEq/L is critically low (normal 3.5-5.5 mEq/L), risking cardiac arrhythmias, and should be reported immediately.