Nokea
A nurse provides instructions to a mother about crib safety for her infant. Which statement by the mother indicates a need for further instructions?
- A. ''Wood surfaces on the crib need to be free of splinters and cracks.''
- B. ''I need to keep large toys out of the crib.''
- C. ''The distance between the slats needs to be no more than 4 inches wide to prevent entrapment of my infant's head or body.''
- D. ''The drop side needs to be impossible for my infant to release.''
Correct Answer: C
Rationale: The correct answer is, ''The distance between the slats needs to be no more than 4 inches wide to prevent entrapment of my infant's head or body.'' This statement indicates a need for further instructions as the distance between the slats should be no more than 2⅜ inches to prevent entrapment of the infant's head and body, not 4 inches. Allowing a larger gap can pose a risk of entrapment or injury to the infant. Keeping large toys out of the crib is essential to prevent the infant from using them to climb out, which could result in serious injuries. Ensuring the drop side of the crib is impossible for the infant to release is crucial to prevent falls and injuries. Additionally, maintaining wood surfaces on the crib free of splinters, cracks, and lead-based paint is vital for the infant's safety and well-being.
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What are the hazards of improper splinting?
- A. Aggravation of a bone or joint injury
- B. Reduced distal circulation
- C. Delay in transporting a client with a life-threatening injury
- D. All of the above
Correct Answer: D
Rationale: Hazards of improper splinting can lead to the aggravation of a bone or joint injury, reduced distal circulation, and delay in transporting a client with a life-threatening injury. Choosing 'All of the above' (Option D) is the correct answer as it encompasses all the hazards mentioned. Option A is incorrect because it only addresses one aspect of the hazards. Option B is incorrect as it does not cover all the hazards associated with improper splinting. Option C is incorrect as it focuses on only one hazard and does not account for the others.
Which of the following statements by a client with gastroesophageal reflux disease (GERD) indicates adequate understanding?
- A. "I should eat right before bedtime."?
- B. "I should eat large meals."?
- C. "I should sit up after eating."?
- D. "I should lie flat after eating."?
Correct Answer: C
Rationale: The correct statement for a client with GERD is, 'I should sit up after eating.' This helps prevent reflux by keeping the stomach contents down. Choice A is incorrect as eating right before bedtime can exacerbate GERD symptoms by increasing the likelihood of reflux during the night. Choice B is incorrect because consuming large meals can lead to increased stomach pressure and worsen reflux symptoms. Choice D is incorrect because lying flat after eating can promote reflux due to gravity assisting the flow of stomach contents into the esophagus, worsening GERD.
A 20-year-old male client had a diving accident with subsequent paraplegia. He says to the nurse, "No woman will ever want to marry me now."? Which of the following responses by the nurse is most therapeutic?
- A. "Don't worry. Maybe you'll meet a paraplegic woman."?
- B. "There is someone for everyone in this world."?
- C. "You are still an attractive man, even though you can't walk."?
- D. "Tell me more about your feelings on this issue."?
Correct Answer: D
Rationale: The correct response is 'Tell me more about your feelings on this issue.' This answer is the most therapeutic as it encourages the client to express his emotions and concerns, fostering a supportive and open dialogue between the client and the nurse. Option A may come across as dismissive and does not directly address the client's emotional state. Option B, while positive, oversimplifies the client's complex feelings. Option C focuses only on physical appearance, missing the opportunity to delve deeper into the client's emotional well-being. Therefore, the most therapeutic response is to encourage further discussion about the client's feelings.
Which of the following clients requires airborne precautions?
- A. a client with fever, chills, vomiting, and diarrhea
- B. a client suspected of varicella (chickenpox)
- C. a client with abdominal pain and purpura
- D. a client diagnosed with AIDS
Correct Answer: B
Rationale: The correct answer is 'a client suspected of varicella (chickenpox).' Chickenpox is an acute, infectious airborne illness that requires airborne precautions, including wearing a respirator mask for direct contact with the patient. Choices A, C, and D do not typically require airborne precautions. Choice A describes symptoms that may indicate a gastrointestinal infection but do not require airborne precautions. Choice C mentions abdominal pain and purpura, which are not specific to an airborne illness. Choice D, a client diagnosed with AIDS, does not necessitate airborne precautions unless there are additional infectious conditions present that require such measures.
What is a common side effect of Rifampin concerning the client's contact lenses?
- A. The client's urine might turn blue.
- B. The client remains infectious to others for 48 hours.
- C. The client's contact lenses might be stained orange.
- D. The client's skin might take on a crimson glow.
Correct Answer: C
Rationale: The correct answer is that the client's contact lenses might be stained orange. Rifampin has the unusual effect of turning body fluids an orange color. Soft contact lenses might become permanently stained, making this an important side effect for the client to be aware of. Choices A, B, and D are incorrect. There is no documented effect of Rifampin causing the client's urine to turn blue, the client remaining infectious for 48 hours, or the client's skin taking on a crimson glow.