Nokea
A woman is being seen to confirm a possible pregnancy. When the nurse asks the woman how she has been feeling, which statement reflects the expected signs of pregnancy? Select all that apply.
- A. I have been so nauseous.
- B. I am having so much trouble with diarrhea.
- C. I have not had a menstrual period in 2 months.
- D. I have to go to the restroom to urinate all the time.
- E. I have been going to the health club regularly because I have so much energy.
Correct Answer: A,C,D
Rationale: Because the nurse is asking the woman, she would expect presumptive signs of pregnancy to be vocalized. Specifically the presumptive signs of pregnancy are nausea, vomiting, breast changes, amenorrhea, urinary frequency, fatigue, and quickening. Diarrhea is not a typical sign of early pregnancy, and increased energy is less common as fatigue is more typical.
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A client with a history of cirrhosis is admitted with hepatic encephalopathy. The nurse should include which of the following in the plan of care?
- A. Administer lactulose as prescribed.
- B. Encourage a high-protein diet.
- C. Restrict fluid intake.
- D. Administer sedatives for agitation.
Correct Answer: A
Rationale: Lactulose reduces ammonia levels in hepatic encephalopathy.
During a home visit to a primiparous client 1 week postpartum who is bottle-feeding her neonate, the clientiant tells the nurse that her mother has suggested that she feed the neonate cereal so he will sleep through the night. Which of the following would be the nurse's best response?
- A. It is permissible to give the baby cereal if it is thinned with formula.'
- B. The time for starting cereal varies, so check with your pediatrician.'
- C. Formula is the food best digested by the baby until about 4 to 6 months of age.'
- D. If cereal is given too early in life, the undigested food can lead to a need for surgery.'
Correct Answer: C
Rationale: Formula is best for infants until 4-6 months, as early introduction of solids like cereal can cause digestive issues.
The nurse collecting data from the client is providing instructions regarding a new prescription for disulfiram. Which datum is important for the nurse to obtain before beginning the administration of this medication?
- A. When the last full meal was consumed
- B. When the last alcoholic drink was consumed
- C. If the client has a history of hyperthyroidism
- D. If the client has a history of diabetes insipidus
Correct Answer: B
Rationale: Disulfiram may be used as an adjunct treatment for selected clients with chronic alcoholism who want to remain in a state of enforced sobriety. Clients must abstain from alcohol intake for at least 12 hours before the initial dose of the medication is administered. Therefore, it is important for the nurse to determine when the last alcoholic drink was consumed. The medication is used with caution in clients with diabetes mellitus, hypothyroidism, epilepsy, cerebral damage, nephritis, and hepatic disease. It is also contraindicated in severe heart disease, psychosis, or hypersensitivity related to the medication.
The nurse is teaching a client about the use of a transdermal nicotine patch for smoking cessation. Which instruction is correct?
- A. Apply it to the same site daily
- B. Remove it at night
- C. Keep it on during showers
- D. Apply it to the face
Correct Answer: B
Rationale: Removing the nicotine patch at night reduces the risk of side effects like insomnia and allows a nicotine-free period.
The nurse should instruct a woman taking folic acid supplements for folic acid-deficiency anemia that:
- A. It will take several months to notice an improvement.
- B. Folic acid should be taken on an empty stomach.
- C. Iron supplements are contraindicated with folic acid supplementation.
- D. Oral contraceptive use, pregnancy, and lactation increase daily requirements.
Correct Answer: D
Rationale: Pregnancy, lactation, and oral contraceptive use increase folic acid requirements due to increased metabolic demands.