Nokea
An appraisal of self-care practices involves an assessment of:
- A. all diagnostic tests.
- B. home treatment practices, including nurse visits for the sick or disabled.
- C. the family's capability to get health insurance.
- D. caregiving needs and the potential for strain.
Correct Answer: D
Rationale: Short-term stressors impinging on a family include unemployment, being on welfare, the threat of termination, health, hospitalization, convalescence, depression, and suicidal thoughts. Long-term stressors impinging on the family include emotional distance, lack of communication in families (especially within marital relationships), continual geographical movement from one community to the next (so that no stable and sufficient social network is established), a spouse's minimal participation in family life, and excessive and frequent drinking bouts. Family strengths include the presence of a social support system, interest in and capability to provide child care, motivation for employment, and financial self-sufficiency, self-care beliefs, values, health-seeking behaviors, and realistic goals and limitations.
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A syringe pump is a type of electronic infusion pump used to infuse fluids or medications directly from a syringe. This device is commonly used for:
- A. solutions administered in obstetrics.
- B. dilute antibiotics.
- C. large volumes of IV solution.
- D. the neonatal and pediatric populations.
Correct Answer: D
Rationale: Small volumes of medication or fluids are delivered and sometimes at slow rates to neonates and pediatric clients. The syringe pump allows precise infusion of small volumes. Choice 1 is incorrect because a syringe pump can be used in almost any setting, but is not generally for adult clients. Choices 2 and 3 are incorrect because large volumes of fluids are not administered with a syringe pump.
Which of the following infant behaviors demonstrates the concept of object permanence?
- A. The infant cries when his mother leaves the room.
- B. The infant looks at the floor to find a toy that he was playing with and dropped.
- C. The infant picks up another toy after the one he was playing with rolls under the couch.
- D. The infant participates in a game of patty-cake.
Correct Answer: B
Rationale: Object permanence occurs when the infant learns that something/someone still exists even though they might not be able to see it/them. This develops between 9 and 10 months of age. If the infant cries when his mother leaves the room, it might be because he believes she is no longer in the house when he can't see her. If an infant picks up another toy after the one he is playing with rolls under the couch and the infant fails to look for it, he believes the toy that rolled under the couch no longer exists. Patty-cake is a game infants engage in but, it has nothing to do with object permanence. An infant game that does show object permanence is peek-a-boo. In this game, an infant continues to hunt for a hidden face because he believes it is still there.
A complication of total parenteral nutrition (TPN) is the development of cholestasis. What is this condition?
- A. An inflammatory process of the extrahepatic bile ducts
- B. An arrest of the normal flow of bile
- C. An inflammation of the gallbladder
- D. The formation of gallstones
Correct Answer: B
Rationale: Cholestasis from TPN is an intrahepatic interruption of bile flow, unlike cholangitis (duct inflammation), cholecystitis (gallbladder inflammation), or gallstone formation.
The physician orders the antibiotics ampicillin (Omnipen) and gentamicin (Garamycin) for a newly admitted client with an infection. The nurse should:
- A. administer both medications simultaneously.
- B. give the medications sequentially, and flush well between them.
- C. ask the physician or pharmacy which medication to give first and how long to wait before giving the other drug.
- D. start one medication now and begin the other medication in 2-4 hours.
Correct Answer: B
Rationale: A client with an infection needs both antibiotics as soon as possible. However, the pH of ampicillin is 8-10, and the pH of gentamicin is 3-5.5 (making them incompatible when given together). Flushing well between drugs is necessary.
After 12 months of cessation of menses, which of the following assessment findings in a client who is taking hormone replacement therapy should the nurse report to the physician immediately?
- A. breast tenderness
- B. weight gain
- C. fluid retention
- D. uterine bleeding
Correct Answer: D
Rationale: Uterine bleeding on combination hormone replacement therapy, after 12 months of menses cessation, indicates an increased risk of carcinoma and should be reported to the physician immediately. Breast tenderness, weight gain, and fluid retention are all routine side effects of hormone replacement therapy. They should be noted in the record and reported to the physician, but they are not urgent.