Nokea
A nursing student is asked to conduct a clinical conference about autism. Which characteristic associated with autism should the student plan to include?
- A. Normal social play that ceases by age 5
- B. Lack of social interaction and awareness
- C. The consistent imitation of others' actions
- D. Normal verbal but abnormal nonverbal communication
Correct Answer: B
Rationale: Autism is a severe developmental disorder that begins in infancy or toddlerhood. A primary characteristic is a lack of social interaction and awareness. Social behaviors in children with autism include a lack of or abnormal imitations of others' actions and a lack of or abnormal social play. Additional characteristics include a lack of or impaired verbal communication and marked abnormal nonverbal communication.
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A perinatal client is admitted to the obstetric unit during an exacerbation of a heart condition. When planning for the nutritional requirements which dietary intervention should the nurse consult the dietitian about?
- A. A low-calorie diet to prevent weight gain
- B. A diet low in fluids and fiber to decrease blood volume
- C. A diet adequate in fluids and fiber to decrease constipation
- D. Unlimited sodium intake to increase circulating blood volume
Correct Answer: C
Rationale: Constipation can cause the client to use Valsalva's maneuver. This maneuver can cause blood to rush to the heart and overload the cardiac system. A low-calorie diet is not recommended during pregnancy. Diets low in fluid and fiber can cause a decrease in blood volume that can deprive the fetus of nutrients; it can also lead to constipation. Therefore, adequate fluid intake and high-fiber foods are important. Sodium should be restricted to some degree as prescribed by the primary health care provider because this will cause an overload to the circulating blood volume and contribute to cardiac complications.
The nurse is informed that a newborn infant whose mother is Rh negative will be admitted to the nursery. When planning care for the infant's arrival, which action should the nurse take?
- A. Obtain the newborn infant's blood type and direct Coombs' results from the laboratory.
- B. Obtain the necessary equipment from the blood bank needed for an exchange transfusion.
- C. Call the maintenance department and ask for a phototherapy unit to be brought to the nursery.
- D. Obtain a vial of vitamin K from the pharmacy and prepare to administer an injection to prevent isoimmunization.
Correct Answer: A
Rationale: To further plan for the newborn infant's care, the infant's blood type and direct Coombs' results must be known. Umbilical cord blood is taken at the time of delivery to determine blood type, Rh factor, and antibody titer (direct Coombs' test) of the newborn infant. The nurse should obtain these results from the laboratory. Options 2 and 3 are inappropriate at this time, and additional data are needed to determine whether these actions are needed. Option 4 is incorrect because vitamin K is given to prevent hemorrhagic disease of the newborn infant.
A client hospitalized after a stroke is prepared for discharge. The primary health care provider has prescribed range-of-motion (ROM) exercises for the client's right side. Which intervention should the home care nurse's plan include when planning for the client's care?
- A. Implements ROM exercises to the point of pain for the client
- B. Considers the use of active, passive, or active-assisted exercises in the home
- C. Encourages dependence on the home care nurse to complete the exercise program
- D. Develops a schedule involving ROM exercises every 3 hours during daylight hours
Correct Answer: B
Rationale: The home care nurse must consider all forms of ROM for the client. Even if the client has right hemiplegia, the client can assist with some of his or her own rehabilitative care. In addition, the goal of home care nursing is for the client to assume as much self-care and independence as possible. The nurse needs to teach so that the client becomes self-reliant. Options 1 and 4 are incorrect from a physiological standpoint.
The nurse is preparing discharge plans for a hospitalized client who attempted suicide. Which intervention should the nurse include in the plan as an immediate resource?
- A. Scheduling weekly follow-up appointments
- B. Establishing contracts with available crisis resources
- C. Encouraging family and friends to be with the client at all times
- D. Providing phone numbers for the hospital and primary health care provider
Correct Answer: B
Rationale: Crisis times may occur between appointments. Contracts facilitate a client's feeling of responsibility for keeping a promise, which gives him or her control. Providing phone numbers will not ensure available and immediate crisis intervention. Family and friends cannot always be present.
A nursing student is preparing to conduct a clinical conference regarding cerebral palsy. Which characteristic related to this disorder should the student plan to include in the discussion?
- A. Cerebral palsy is an infectious disease of the central nervous system.
- B. Cerebral palsy is an inflammation of the brain as a result of a viral illness.
- C. Cerebral palsy is a chronic disability characterized by difficulty with muscle control.
- D. Cerebral palsy is a congenital condition that results in moderate to severe retardation.
Correct Answer: C
Rationale: Cerebral palsy is a chronic disability that is characterized by difficulty with controlling the muscles because of an abnormality in the extrapyramidal or pyramidal motor system. Meningitis is an infectious process of the central nervous system. Encephalitis is an inflammation of the brain that occurs as a result of viral illness or central nervous system infections. Down syndrome is an example of a congenital condition that results in moderate to severe retardation.