Nokea
An 18-month-old child presents with fever, nasal flaring, intercostal retractions, and a respiratory rate of 50 bpm. What is the most appropriate nursing diagnosis?
- A. High risk for altered body temperature - hyperthermia
- B. Ineffective breathing pattern
- C. Ineffective individual coping
- D. Knowledge deficit
Correct Answer: B
Rationale: In this case, the child is showing signs of respiratory distress, such as nasal flaring, intercostal retractions, and an increased respiratory rate. These are indicative of an ineffective breathing pattern. The child's compromised respiratory function requires immediate attention and intervention, making 'Ineffective breathing pattern' the most appropriate nursing diagnosis. Choices A, C, and D do not address the respiratory distress the child is experiencing and are not the priority in this situation.
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Which of the following interventions is NOT appropriate for a hospitalized adolescent?
- A. Allow the adolescent to assist with procedures when possible.
- B. Encourage them to discuss their thoughts and feelings about the hospitalization.
- C. Encourage them to remain in the room throughout the hospitalization to ensure adequate rest periods.
- D. Encourage peer visitation.
Correct Answer: C
Rationale: Encouraging the adolescent to remain in the room throughout the hospitalization may lead to social isolation, hinder the adolescent's emotional well-being, and impede their recovery. It is essential for adolescents to have social interaction, engage in meaningful conversations, and receive support from peers to cope with the stress of hospitalization. Choices A, B, and D are appropriate interventions as they promote involvement in care, emotional expression, and social support, which are beneficial for the adolescent's overall well-being during hospitalization.
A new mother asks the nurse when she should begin to breastfeed her newborn. The nurse's best response is:
- A. Within the first half-hour after birth
- B. After the newborn's first bath
- C. When the newborn begins to cry
- D. After administering vitamin K
Correct Answer: A
Rationale: Initiating breastfeeding within the first half-hour after birth is crucial for successful breastfeeding and bonding, as recommended by the World Health Organization. This early initiation helps establish breastfeeding and supports the newborn's health by providing colostrum, the nutrient-rich first milk. Choice B, 'After the newborn's first bath,' is incorrect because initiating breastfeeding should not be delayed after birth. Choice C, 'When the newborn begins to cry,' is incorrect as it does not promote timely initiation of breastfeeding. Choice D, 'After administering vitamin K,' is incorrect because breastfeeding initiation should not be delayed for this procedure.
Sometimes, people with congestive heart failure develop arrhythmias of the heart. These irregular rhythms can be conducive to developing a blood clot. Physicians frequently treat people with 'blood thinning' medicines that require regulation of the density of the blood. Which of these is the name for a blood-thinner?
- A. Erythromycin
- B. Tetracycline
- C. Warfarin
- D. Amoxicillin
Correct Answer: C
Rationale: Warfarin is a medication commonly used as a blood thinner to prevent blood clot formation. It works by inhibiting the clotting factors in the blood, thereby reducing the risk of clot formation and helping in the management of conditions like congestive heart failure and arrhythmias. Choices A, B, and D are antibiotics and do not have blood-thinning properties like Warfarin.
How can a new mother tell if her baby is getting enough breast milk?
- A. If your baby sleeps through the night, they are getting enough milk.
- B. If your baby has six to eight wet diapers a day, they are getting enough milk.
- C. If your baby cries frequently, they are getting enough milk.
- D. If your baby is awake and alert, they are getting enough milk.
Correct Answer: B
Rationale: The correct answer is B. If a new mother observes that her baby has six to eight wet diapers a day, it indicates that the baby is getting enough breast milk. This is a crucial indicator of adequate milk intake and hydration in infants. Conversely, choices A, C, and D are incorrect. A baby sleeping through the night, crying frequently, or being awake and alert are not reliable indicators of sufficient breast milk intake. It is essential for new mothers to track their baby's diaper output to ensure they are receiving the necessary nutrition.
What intervention should the nurse encourage for a postpartum client complaining of perineal pain?
- A. Use of ice packs for the first 24 hours
- B. Application of heat packs immediately
- C. Avoiding the use of peri-bottles
- D. Using tampons to manage lochia
Correct Answer: A
Rationale: The correct intervention for perineal pain in a postpartum client is the use of ice packs for the first 24 hours. Ice packs help reduce swelling and discomfort in the perineal area, especially during the initial post-delivery period. Applying heat packs can exacerbate swelling and discomfort. Avoiding peri-bottles may lead to poor perineal hygiene. Using tampons is contraindicated postpartum as it increases the risk of infection.