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After a client undergoes a contraction stress test that is negative, which of the following should the nurse assess next?
- A. Evidence of ruptured membranes.
- B. Viability status of the fetus.
- C. Indications that contractions have ceased.
- D. Fetal heart rate variability.
Correct Answer: C
Rationale: A negative contraction stress test indicates no fetal distress, so the nurse should next ensure contractions have ceased to prevent preterm labor. The other assessments are less immediate.
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The home care nurse visits a client who started wandering around at 10:00 pm each evening and got out of the house for the first time last night. The family asks for help. Which therapeutic response should the nurse make to the family?
- A. What prevented her from leaving the house in the past?
- B. You cannot handle this alone because she could get hurt.
- C. I think you need to consider a nursing home immediately.
- D. This is a common problem known as sundowner's syndrome.
Correct Answer: A
Rationale: The nurse responds to the family by assessing the situation and collecting additional data regarding the change in the client's behavior. The best response focuses on the family's problem so that the nurse can help develop potential strategies. Option 2 is giving advice. Option 3 is histrionic, invalidates the family's attempt to manage the client's care, and potentially causes resentment. Option 4 provides the nurse's conclusion based on an incomplete assessment; other factors may be causing confusion.
The A, B, C, and Ds of a complete and comprehensive nutritional assessment includes:
- A. Assessment data, biochemical data, clinical data and dietary data
- B. Ancestral cultural data, biochemical data, clinical data and dietary data
- C. Anthropometric data, biological data, chemical data and dietary data
- D. Anthropometric data, biochemical data, clinical data and dietary data
Correct Answer: D
Rationale: A comprehensive nutritional assessment includes Anthropometric data (e.g., height, weight), Biochemical data (e.g., lab values), Clinical data (e.g., physical signs), and Dietary data (e.g., intake history).
The nurse is teaching a client with a new diagnosis of hypertension about lifestyle modifications. Which of the following instructions should be included? Select all that apply.
- A. Reduce sodium intake.
- B. Engage in regular aerobic exercise.
- C. Limit alcohol consumption.
- D. Quit smoking.
- E. Increase saturated fat intake.
Correct Answer: A, B, C, D
Rationale: Reducing sodium, exercising, limiting alcohol, and quitting smoking lower blood pressure. Saturated fats should be avoided.
To reduce the risk of pressure ulcer formation, which of the following activities should the nurse teach the client who is wheelchair-bound as a result of a spinal cord injury?
- A. Bathe daily.
- B. Eat a high-carbohydrate diet.
- C. Shift your weight every 15 minutes.
- D. Move from the bed to the wheelchair every 2 hours.
Correct Answer: C
Rationale: Shifting weight every 15 minutes relieves pressure on bony prominences, reducing pressure ulcer risk. The other options are less directly related to prevention.
A newborn infant is diagnosed with imperforate anus. Which description of this disorder should the nurse provide to the parents?
- A. The presence of fecal incontinence
- B. Incomplete development of the anus
- C. The infrequent and difficult passage of dry stools
- D. Invagination of a section of the intestine into the distal bowel
Correct Answer: B
Rationale: Imperforate anus (anal atresia, anal agenesis) is the incomplete development or absence of the anus in its normal position in the perineum. Option 1 describes encopresis. Encopresis generally affects preschool and school-age children. Option 3 describes constipation. Constipation can affect any child at any time, although it peaks at age 2 to 3 years. Option 4 describes intussusception.