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A woman in active labor is admitted to the labor and delivery unit, accompanied by her partner. As labor progresses, the nurse notes he is not interacting with the woman and sits in the corner, looking out the window. How may the nurse understand the man's actions?
- A. He is likely to be very concerned about the woman's health to the point that his ability to cope with the situation is compromised
- B. His actions reflect personality or cultural differences, which do not necessarily indicate a lack of concern.
- C. Due to his embarrassment and discomfort regarding the woman's expressions of pain, he withdraws from the situation
- D. His religious beliefs regarding participation in the birth experience affect his interactivity and communication in this situation.
Correct Answer: B
Rationale: The correct answer is B because it recognizes that the man's actions may be influenced by his personality or cultural differences, rather than indicating a lack of concern. This choice acknowledges that individuals may react differently in stressful situations based on their upbringing, beliefs, or personal characteristics. This understanding is crucial for the nurse to provide appropriate support and address any potential misunderstandings.
Choice A suggests that the man's concern about the woman's health is compromising his ability to cope, which is not supported by the information provided. Choice C assumes the man's withdrawal is due to embarrassment and discomfort, which may not be the case. Choice D attributes the man's behavior to religious beliefs, which is not mentioned in the scenario. These choices do not align with the evidence presented and do not consider the complexity of human behavior in different contexts.
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A client asks the nurse about the benefits of breastfeeding. Which response by the nurse provides the most accurate information?
- A. Breastfeeding helps women lose weight faster.
- B. Breast milk contains a greater amount of protein.
- C. Breast milk is easier to digest than formula.
- D. Breastfeeding is a good method of contraception.
Correct Answer: C
Rationale: The correct answer is C: Breast milk is easier to digest than formula. Breast milk contains specific enzymes and antibodies that aid in digestion and are easily absorbed by the baby's immature digestive system. This promotes better nutrient absorption and reduces the risk of digestive issues. Option A is incorrect because weight loss varies for each woman and should not be the primary reason for breastfeeding. Option B is incorrect as breast milk has a balanced composition of nutrients, not just higher protein content. Option D is incorrect as breastfeeding is not a reliable form of contraception.
A nurse is preparing to admit a 15-year-old client with HIV/AIDS. Based on the client's diagnosis, which of the following nursing actions is appropriate?
- A. Contribute to planning client education on standard precautions in age-appropriate manner.
- B. Contact the dietary department to request foods be delivered on disposable dishes.
- C. Prepare for infection control in a negative pressure room for this client.
- D. Instruct visitors to wear gowns and masks when entering the client's room.
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
1. Client education on standard precautions is crucial to prevent the spread of infections.
2. The nurse should tailor the education in an age-appropriate manner to ensure understanding.
3. Contributing to planning education empowers the client to take an active role in their health.
4. This action promotes client safety and reduces the risk of transmission to others.
Summary:
B: Contacting the dietary department for disposable dishes is not directly related to HIV/AIDS education or infection control.
C: Preparing a negative pressure room is not necessary for standard precautions and may not be feasible in all settings.
D: Instructing visitors to wear gowns and masks is excessive for standard precautions and may cause distress to the client.
An assistive personnel (AP) is caring for a child diagnosed with leukemia and undergoing chemotherapy.
- A. "The AP offers a soft toothbrush for oral care."'
- B. "The AP applies a soft cotton cap to the child's head."'
- C. "The AP maintains a restriction of all visitors and health personnel with infections."'
- D. "The AP prepares to take a rectal temperature."'
Correct Answer: D
Rationale: Correct answer: D. "The AP prepares to take a rectal temperature."
Rationale: Taking a rectal temperature is crucial in monitoring the child's health during chemotherapy, as it provides a more accurate reading of the body's core temperature. Chemotherapy can suppress the immune system, increasing the risk of infections, so monitoring for fever is essential. Additionally, rectal temperature is the most accurate method for infants and young children.
Option A: Offering a soft toothbrush for oral care is important, but it is not the most critical action to take in this scenario.
Option B: Applying a soft cotton cap to the child's head may provide comfort but is not as essential as monitoring the child's temperature.
Option C: Maintaining a restriction of visitors and health personnel with infections is important for infection control, but this does not directly address the immediate need of monitoring the child's temperature.
In summary, taking a rectal temperature is the most critical action to ensure early detection of fever and prompt intervention
A nurse is caring for a 4-year-old child diagnosed with leukemia who is admitted with myelosuppression.
- A. "Provide a diet high in carbohydrates."'
- B. "Monitor rectal temperature every 4 hr."'
- C. "Use lemon or glycerin swabs for oral care."'
- D. "Inspect the skin daily for lesions."'
Correct Answer: D
Rationale: The correct answer is D: "Inspect the skin daily for lesions." This is important because myelosuppression can lead to decreased platelets, increasing the risk of skin lesions and bleeding. Monitoring the skin daily can help detect any lesions early and prevent complications.
A: Providing a high-carbohydrate diet is not directly related to managing myelosuppression.
B: Monitoring rectal temperature is important but not directly related to skin lesion detection.
C: Using lemon or glycerin swabs for oral care is important for mucositis, not skin lesions.
A nurse in the antepartum clinic is assessing a client's adaptation to pregnancy. The client states that she is, ''happy one min and crying the next.'' The nurse should interpret the client's statement as an indication of which of the following?
- A. Emotional lability
- B. Focusing phase
- C. Cognitive restructuring
- D. Couvade syndrome
Correct Answer: A
Rationale: The correct answer is A: Emotional lability. Emotional lability refers to rapid, unpredictable changes in emotions. During pregnancy, hormonal fluctuations can lead to mood swings, causing the client to feel happy one minute and crying the next. Focusing phase (B) is not relevant to the client's emotional state. Cognitive restructuring (C) involves changing negative thought patterns, which is not mentioned in the scenario. Couvade syndrome (D) is a condition where male partners experience pregnancy-like symptoms, which is not applicable here.