Nokea
An adolescent has been diagnosed with lactose maldigestion intolerance. The nurse teaches the adolescent about lactose maldigestion intolerance and notes the teen needs further teaching if which statement is made?
- A. "I will limit my milk consumption to one to two glasses a day."
- B. "I should drink the milk alone and not with other foods."
- C. "Hard cheese, cottage cheese, or yogurt can be substituted for milk."
- D. "I will take a calcium supplement daily."
Correct Answer: B
Rationale: This statement is incorrect because drinking milk alone without other foods is not necessary for someone with lactose maldigestion intolerance. Mixing milk with other foods or consuming dairy products alongside other foods can sometimes help to reduce symptoms. Therefore, the adolescent does not need further teaching if they make this statement. The other statements are all appropriate for managing lactose maldigestion intolerance.
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Stroking the newborn's cheek along the side of the mouth causes the newborn to turn the head toward that side and begin to suck. This is which reflex?
- A. Perez
- B. Sucking
- C. Rooting
- D. Extrusion
Correct Answer: C
Rationale: The described reflex involving stroking the newborn's cheek along the side of the mouth causing the newborn to turn the head toward that side and begin to suck is known as the rooting reflex. This reflex is essential for newborns to find the nipple and start breastfeeding. Stroking the cheek triggers the baby to turn towards the stimulus, helping them locate the source of food for feeding.
The nurse teaches a patient how to live with a new tracheostomy. Which of the ff. instructions is appropriate?
- A. "Never suction your tracheostomy; you might damage your trachea."
- B. ""You should not feel bad about the tracheostomy – you should be feel lucky to be alive."
- C. "Be sure to protect your tracheostomy from pollutants such as powders, hair and chemicals."
- D. "Your tracheostomy will be cleaned each time you visit your doctor."
Correct Answer: C
Rationale: Option C, "Be sure to protect your tracheostomy from pollutants such as powders, hair and chemicals," is the most appropriate instruction for a patient with a new tracheostomy. It is important to keep the tracheostomy site clean and free from any potential irritants or contaminants that could cause infection or complications. Powders, hair, and chemicals can lead to irritation or clogging of the tracheostomy tube, so it is crucial for the patient to be mindful of avoiding such pollutants near the tracheostomy site.
The nurse is preparing to administer a unit of blood to a client's who's anemic. After its removal from the refrigerator, the blood should be administered within:
- A. 1 hour
- B. 4 hours
- C. 2 hours
- D. 6 hours
Correct Answer: B
Rationale: After blood is removed from the refrigerator, it should be administered within 4 hours. Blood should be stored in a controlled temperature environment to prevent bacterial growth and to maintain its effectiveness. In order to minimize the risk of bacterial contamination, it is important for the nurse to adhere to the recommended time frame for administering blood products. Administering the blood within 4 hours helps ensure its safety and effectiveness for the client.
The physical abuse of children by parents affects children of all ages. It is estimated that 1% to 2% of children are physically abused during childhood and that significant number of them are fatally injured each year. Of the following, the second LEADING cause of mortality from physical abuse is
- A. rib fractures
- B. head trauma
- C. abdominal injury
- D. hot tap water burn
Correct Answer: B
Rationale: Head trauma is a leading cause of mortality in abused children, as it can result in severe brain damage or death.
A male client age 78, complaints of dizziness, especially when he stands up after sleeping or sitting. The client also informs the nurse that he periodically experiences nosebleeds and blurred vision. Which of the ff conditions should the nurse assess for the client?
- A. Postural hypotension
- B. Postural Hypertension
- C. White coat hypertension
- D. White coat hypotension
Correct Answer: A
Rationale: The client's symptoms of dizziness upon standing up, along with nosebleeds and blurred vision, are suggestive of postural hypotension. Postural hypotension, also known as orthostatic hypotension, is a drop in blood pressure that occurs when a person stands up from a sitting or lying position. This drop in blood pressure can lead to symptoms such as dizziness, lightheadedness, blurred vision, and in some cases, nosebleeds. It is more common in older adults, like the 78-year-old male client in this scenario. Therefore, the nurse should assess for postural hypotension in this client to manage his symptoms and prevent complications.