Nokea
A pediatric nurse in an ambulatory care clinic is admitting a neonate for the 2-week office visit. Which comment by the mother should alert the nurse to suspect colic?
- A. My baby looks yellow.
- B. After feedings, my baby pulls his legs up and cries.
- C. My baby is quiet and doesn't cry much.
- D. My baby is alert for brief periods of 10-20 minutes at a time.
Correct Answer: B
Rationale: Pulling legs up and crying after feedings suggests colic. Jaundice, quietness, or brief alertness are not indicative of colic.
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The nurse has provided home-care instructions to a client who is taking lithium carbonate. Which client statement indicates that the client understands the prescribed regimen?
- A. I will restrict my water intake.
- B. I will make sure that my diet contains salt.
- C. I will keep my medication in the refrigerator.
- D. I will be careful to avoid eating foods high in potassium.
Correct Answer: B
Rationale: Lithium is a mood stabilizer used to treat bipolar disorder. It replaces sodium ions in the cells and induces the excretion of sodium and potassium from the body. Client teaching includes the maintenance of sodium intake in the daily diet and increased fluid intake (at least 1 to 1½ L per day) during maintenance therapy. Lithium is stored at room temperature and protected from light and moisture.
The nurse is demonstrating colostomy care to a client with a newly created colostomy. The nurse demonstrates the correct cutting of the appliance by making the circle how much larger than the client's stoma?
- A. 1/8 inch
- B. 1/4 inch
- C. 1/2 inch
- D. 1 inch
Correct Answer: A
Rationale: The size of the opening for the appliance is generally cut 1/8 inch larger than the size of the client's stoma. This minimizes the amount of exposed skin but does not put pressure on the stoma. The larger sizes leave too much skin area exposed for irritation by gastrointestinal contents.
A clinic nurse provides information to a married couple regarding measures to prevent infertility. Which statement made by the husband indicates the need for further education?
- A. We need to eat a nutritious diet.'
- B. We need to avoid the excessive intake of alcohol.'
- C. We need to decrease exposure to environmental hazards.'
- D. I need to maintain warmth to my scrotum by taking hot baths frequently.'
Correct Answer: D
Rationale: Keeping the testes cool by avoiding hot baths and tight clothing appears to improve the sperm count. Avoiding factors that depress spermatogenesis (such as the use of drugs, alcohol, and marijuana), maintaining good nutrition, and limiting exposure to occupational and environmental hazards are vital components of preventing infertility.
The nurse prepares a client with a peripheral intravenous (IV) site for home IV therapy for discharge. Which should the nurse teach the client to help prevent phlebitis and infiltration?
- A. Massage the IV site daily.
- B. Immobilize the extremity.
- C. Stabilize the cannula with tape.
- D. Cleanse the site daily with alcohol.
Correct Answer: C
Rationale: Stabilizing the cannula with tape prevents movement, reducing the risk of phlebitis and infiltration. Massaging the site can cause tissue damage, immobilizing the extremity is unnecessary, and alcohol cleansing causes skin drying and discomfort.
A client with a compound (open) fracture of the radius has a plaster cast applied in the emergency department. The nurse provides home care instructions and tells the client to seek medical attention if which finding occurs?
- A. Numbness and tingling are felt in the fingers.
- B. The cast feels heavy and damp after 24 hours of application.
- C. The entire cast feels warm during the first 24 hours after application.
- D. Slightly bloody drainage is noted on the cast during the first 6 hours after application.
Correct Answer: A
Rationale: A limb encased in a cast is at risk for nerve damage and diminished circulation from increased pressure caused by edema. Signs/symptoms of increased pressure from the cast include numbness, tingling, and increased pain. A cast can take up to 48 hours to dry and generates heat while drying. Some drainage may occur initially with a compound (open) fracture.