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.
A 50 milliliter (ml) bolus of normal saline fluid is ordered by the physician. The physician wants it to infuse in 30 minutes. The nurse should set the pump rate at:
- A. 100 ml per hour for one hour.
- B. 60 ml per hour for one-half hour.
- C. 120 ml per hour for one hour.
- D. 50 ml per hour for one hour.
Correct Answer: A
Rationale: One hundred ml in one hour equals 50 ml in 30 minutes, which is what the physician prescribed. Choice 2 is 10 ml more than the physician prescribed for 30 minutes. Choice 3 is the same as Choice 2; it is 10 ml more than the physician prescribed for 30 minutes. Choice 4 only provides 25 ml over 30 minutes, or half the volume prescribed.
Central venous access devices (CVADs) are frequently utilized to administer chemotherapy. What is an advantage of using CVADs for chemotherapeutic agent administration?
- A. CVADs are less expensive than a peripheral IV
- B. Weekly administration is possible
- C. Chemotherapeutic agents can be caustic to smaller veins
- D. The client or family can administer the drug at home
Correct Answer: C
Rationale: CVADs allow administration of vesicant chemotherapeutic drugs into larger veins, reducing damage to smaller peripheral veins. They are more expensive, dosing varies, and home administration is not standard.
Which of the following developmental milestones for a 6-month-old child should be screened by the nurse during a routine office visit?
- A. standing while holding something
- B. rolling over
- C. sitting up
- D. creeping
Correct Answer: B
Rationale: Rolling over occurs between 4 and 6 months of age. Sitting up occurs between 7 and 8 months, creeping between 9 and 10 months, and standing between 8 and 10 months.
A mother brings her 1-year-old child to the clinic. The child has no record of previous immunizations, and the mother confirms the child has not been immunized. Teaching by the nurse should include which of the following?
- A. Immunizations may be started at any age.
- B. The recommended immunization schedule must be followed exactly.
- C. If a primary series of immunizations is interrupted, the series must be restarted.
- D. This child is at increased risk for reaction to the vaccines, when they are started.
Correct Answer: A
Rationale: While a recommended immunization schedule exists, immunizations may be started at any age. An interrupted series may be continued and need not be restarted. There is no increased risk for reaction to vaccines due to delay.