Nokea
A woman asks, "How much alcohol can I safely drink while pregnant?"? The nurse's best response is:
- A. "The amount of alcohol that is safe during pregnancy is unknown."?
- B. "Consuming one or two beers or glasses of wine a day is considered safe for a healthy pregnant woman."?
- C. "Drinking three or more drinks on any given occasion is the only harmful type of drinking during pregnancy."?
- D. "You can have a drink to help you relax and get to sleep at night."?
Correct Answer: A
Rationale: The correct answer is, "The amount of alcohol that is safe during pregnancy is unknown."? This response is appropriate because there is no known safe amount of alcohol consumption during pregnancy. Consuming any amount of alcohol during pregnancy can pose risks to the developing fetus, leading to conditions like fetal alcohol syndrome, which is a combination of mental and physical abnormalities in infants. Choices B, C, and D are incorrect. Choice B suggests that consuming one or two drinks a day is safe during pregnancy, which is not supported by current medical guidelines. Choice C incorrectly states that only drinking three or more drinks on any given occasion is harmful, when in reality, any amount of alcohol can be harmful to the fetus. Choice D is inappropriate as it suggests that having a drink to relax and sleep is acceptable during pregnancy, which is not the case.
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The client with diverticulosis is being assisted by the nurse in selecting appropriate foods. Which food should be avoided?
- A. Bran
- B. Fresh peaches
- C. Cucumber salad
- D. Yeast rolls
Correct Answer: C
Rationale: The food that should be avoided for a client with diverticulosis is Cucumber salad. Foods with seeds should be avoided as they can aggravate diverticulosis by causing irritation and inflammation in the diverticula. Choices A, B, and D are allowed and even beneficial. Bran cereal and fruit like fresh peaches can help prevent constipation, which is beneficial for individuals with diverticulosis. Yeast rolls are also acceptable unless the client has specific dietary restrictions related to yeast or gluten.
During a school screening, a nurse notices small bruises on the anterior and posterior ribs of an 8-year-old Asian child. The nurse should ask the child:
- A. if the family practices coining
- B. who performs coinings
- C. if the child has fallen
- D. how long the child has been abused
Correct Answer: A
Rationale: The correct answer is to ask if the family practices coining. In Asian cultures, coining is a traditional practice believed to draw infections from the body. It involves rubbing a heated coin on the chest and torso, which can cause bruising similar to what the nurse noticed on the child's ribs. This question is important to differentiate between cultural practices and potential child abuse. Choices B, C, and D are incorrect because assuming abuse without considering cultural practices can lead to misinterpretation and inappropriate actions. It's crucial for healthcare providers to be culturally sensitive and gather all relevant information before making conclusions.
In the emergency room, a nurse is responsible for triaging four clients injured in a motor vehicle accident. Which of the following clients should receive priority in care?
- A. A 10-year-old with lacerations on the face
- B. A 15-year-old with sternal bruises
- C. A 34-year-old with a fractured femur
- D. A 50-year-old with a dislocated elbow
Correct Answer: B
Rationale: The 15-year-old with sternal bruises should receive priority in care as this client might be experiencing airway and oxygenation problems. Airway issues take precedence in triage. The 10-year-old with lacerations on the face, although looking bad, is not in immediate distress. The 34-year-old with a fractured femur should be immobilized but can be seen after the client with sternal bruising. The 50-year-old with a dislocated elbow can also be seen later as dislocated elbows are not life-threatening compared to potential airway compromise.
The client is admitted to the unit after a cholecystectomy. Montgomery straps are utilized with this client. The nurse is aware that Montgomery straps are utilized on this client because:
- A. The client is at risk for evisceration.
- B. The client will require frequent dressing changes.
- C. The straps provide support for drains that are inserted in the incision.
- D. No sutures or clips are used to secure the incision.
Correct Answer: B
Rationale: Montgomery straps are used to secure dressings that require frequent changes due to the large amount of drainage usually present after a cholecystectomy. They are also beneficial for clients allergic to various types of tape. Answer A is incorrect as the client is not at higher risk of evisceration. Answer C is incorrect because Montgomery straps are not used to support drains. Answer D is incorrect as sutures or clips are typically used to secure the incision after gallbladder surgery, not Montgomery straps.
Which of the following roommates would be most suitable for the client with myasthenia gravis?
- A. A client with hypothyroidism
- B. A client with Crohn's disease
- C. A client with pyelonephritis
- D. A client with bronchitis
Correct Answer: A
Rationale: The most suitable roommate for the client with myasthenia gravis is the client with hypothyroidism because they are quiet. A client with Crohn's disease (choice B) would be up to the bathroom frequently due to gastrointestinal issues, which could disturb the roommate with myasthenia gravis. A client with pyelonephritis (choice C) suffering from a kidney infection will need to urinate frequently, causing disturbances. A client with bronchitis (choice D) will be coughing, potentially disrupting the rest and quiet environment needed by a roommate with myasthenia gravis to manage their symptoms effectively.