Nokea
All of the following should be performed when fetal heart monitoring indicates fetal distress except:
- A. increase maternal fluids.
- B. administer oxygen.
- C. decrease maternal fluids.
- D. turn the mother.
Correct Answer: C
Rationale: Decreasing maternal fluids is the only intervention that should not be performed when fetal distress is indicated.
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Which of the following statements by an adult child of a client with late-stage Alzheimer's disease indicates a need for further teaching by the nurse?
- A. I should provide a regular schedule for toileting
- B. I should talk to my father less because he can't communicate
- C. I should give my father oral care after every meal and bedtime
- D. I should assist my father with eating and drinking
Correct Answer: B
Rationale: Communication through talking and touching remains important for Alzheimer's clients, even if they can't respond, to provide comfort and connection. The other statements reflect appropriate care.
Which of the following nursing diagnoses is most appropriate for a client with a new colostomy?
- A. Excess Fluid Volume
- B. Risk for Aspiration
- C. Disturbed Body Image
- D. Urinary Retention
Correct Answer: C
Rationale: Disturbed Body Image is the most appropriate nursing diagnosis for a client with a new colostomy, due to the adjustments that need to be made with the physical alteration of a colostomy. The other diagnoses are not applicable.
A 27 year-old woman has delivered twins in the OB unit. The patient develops a condition of 5 centimeter diastasis recti abdominis. Which of the following statements is the most accurate when instructing the patient?
- A. Sit-ups are o.k. to do as long as you don't strain.
- B. This condition leads to surgery in $80 \%$ of cases.
- C. Guarding the abdominal region is important at this time.
- D. Antibiotics are required for this condition in $70 \%$ of patients.
Correct Answer: C
Rationale: Protection of the abdominal wall is critical at this point in time.
Which of the following syndromes associated with incomplete lesions of the spinal cord is a result of damage to one-half of the spinal cord?
- A. Brown-Séquard syndrome
- B. posterior cord syndrome
- C. central cord syndrome
- D. cauda equina syndrome
Correct Answer: A
Rationale: Brown-Séquard syndrome is a result of damage to one-half of the spinal cord. The other choices are also incomplete lesions of the spinal cord, but they have different defining characteristics.
How often must physical restraints be released?
- A. every 2 hours
- B. between 1 and 3 hours
- C. every 30 minutes
- D. at least every 4 hours
Correct Answer: A
Rationale: Restraints must be released every 2 hours to assess circulation, skin integrity, and client comfort, with assessments every 30 minutes while restrained.