Nokea
An assistive personnel (AP) is caring for a child diagnosed with leukemia and undergoing chemotherapy.
- A. "The AP offers a soft toothbrush for oral care."'
- B. "The AP applies a soft cotton cap to the child's head."'
- C. "The AP maintains a restriction of all visitors and health personnel with infections."'
- D. "The AP prepares to take a rectal temperature."'
Correct Answer: D
Rationale: Correct answer: D. "The AP prepares to take a rectal temperature."
Rationale: Taking a rectal temperature is crucial in monitoring the child's health during chemotherapy, as it provides a more accurate reading of the body's core temperature. Chemotherapy can suppress the immune system, increasing the risk of infections, so monitoring for fever is essential. Additionally, rectal temperature is the most accurate method for infants and young children.
Option A: Offering a soft toothbrush for oral care is important, but it is not the most critical action to take in this scenario.
Option B: Applying a soft cotton cap to the child's head may provide comfort but is not as essential as monitoring the child's temperature.
Option C: Maintaining a restriction of visitors and health personnel with infections is important for infection control, but this does not directly address the immediate need of monitoring the child's temperature.
In summary, taking a rectal temperature is the most critical action to ensure early detection of fever and prompt intervention
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Which method of temperature regulation would safely and effectively prevent cold stress in a newly delivered infant?
- A. Wrap the baby loosely with a blanket.
- B. Be sure the baby's feet are covered.
- C. Cover the baby's head with a hat.
- D. Position the baby on a heating pad.
Correct Answer: C
Rationale: The correct answer is C: Cover the baby's head with a hat. Infants lose a significant amount of heat through their heads, so covering the head with a hat helps prevent heat loss and cold stress. Option A does not provide enough insulation to prevent cold stress. Option B only addresses the feet, while the head is a major heat loss area. Option D poses a risk of overheating and burns.
A nurse is performing a routine physical examination on an adolescent client who asks, 'Why do I have to use a condom if my girlfriend is on the pill?' Which of the following is the most appropriate response by the nurse?
- A. You need to use two forms of birth control so if one fails you have a second form of protection against pregnancy.
- B. Using a condom allows you to share the responsibility for birth control.
- C. Oral contraceptives are less than 99 percent effective in adolescents. Therefore, a second form of contraception is needed.
- D. Oral contraceptives are highly effective in preventing pregnancy but do not prevent sexually transmitted diseases.
Correct Answer: D
Rationale: The correct answer is D. The nurse should explain that while oral contraceptives are highly effective in preventing pregnancy, they do not protect against sexually transmitted diseases (STDs). This is important because even if the girlfriend is on the pill, using a condom is necessary to prevent STD transmission. Adolescents are at higher risk for STDs, so it is crucial to emphasize the importance of dual protection. Choice A is incorrect as it does not specifically address the risk of STD transmission. Choice B is incorrect because it focuses on shared responsibility rather than the health implications of using a condom. Choice C is incorrect as it emphasizes the effectiveness of oral contraceptives rather than the need for STD protection.
A nurse is reinforcing teaching with the parent of an infant who has club feet with bilateral casts.
- A. "Check the toes for any swelling or discoloration."'
- B. "Monthly recasting should be scheduled with the orthopedist."'
- C. "Use a heated fan or dryer to facilitate the drying of the cast."'
- D. "Give the baby Tylenol every 4 hr to help with pain."'
Correct Answer: A
Rationale: The correct answer is A because checking the toes for swelling or discoloration is crucial in monitoring circulation and preventing complications like pressure sores. Choice B is incorrect as casts are typically changed more frequently. Choice C is incorrect as heat can cause burns. Choice D is incorrect as giving Tylenol every 4 hours without a physician's recommendation is not advisable for pain management in infants.
A nurse is assessing the newborn of a client who took a selective serotonin reuptake inhibitor (SSRI) during pregnancy. Which of the following manifestations should the nurse identify as an indication of withdrawal from an SSRI?
- A. Large for gestational age
- B. Hyperglycemia
- C. Bradypnea
- D. Vomiting
Correct Answer: D
Rationale: The correct answer is D: Vomiting. Newborns exposed to SSRIs in utero may experience withdrawal symptoms, including gastrointestinal issues like vomiting. This is due to the sudden absence of the drug after birth. Choices A, B, and C are unrelated to SSRI withdrawal. Large for gestational age is more indicative of maternal diabetes, hyperglycemia is not a typical SSRI withdrawal symptom, and bradypnea is not commonly associated with SSRI use.
A client in active labor receives a regional anesthetic. Which is the main purpose of regional anesthetics?
- A. To relieve pain by decreasing the client's level of consciousness
- B. To provide general loss of sensation by blocking sensory nerves to an area
- C. To provide pain relief by blocking descending impulses from the central nervous system
- D. To relieve pain by decreasing the perception of pain leading to the pain centers in the brain
Correct Answer: B
Rationale: The correct answer is B: To provide general loss of sensation by blocking sensory nerves to an area. Regional anesthetics work by blocking specific nerve pathways in a targeted area, leading to loss of sensation while maintaining consciousness. This is ideal for laboring clients as it allows pain relief without affecting consciousness or motor function. Choice A is incorrect as regional anesthetics do not aim to decrease consciousness. Choice C is incorrect as regional anesthetics block sensory nerves locally, not descending impulses. Choice D is incorrect as the goal is to block sensation locally, not perception in the brain.