Nokea
During a clinic visit for a postpartum examination, the mother of a 2-week-old infant tearfully tells the nurse she feels very tired and thinks she is not a good mother to her baby. Which statement by the nurse would be best?
- A. The hormonal changes your body is experiencing are causing you to feel this way.'
- B. Most new mothers feel the same way that you do. I hear that a lot from others.'
- C. You need to have your husband and family help you so that you can get some rest.'
- D. I'm concerned about what you are experiencing. Tell me more about what you are thinking and feeling.'
Correct Answer: D
Rationale: Acknowledging the mother's feelings and encouraging her to elaborate promotes therapeutic communication and helps assess for postpartum depression or other concerns. Attributing feelings solely to hormones, normalizing without exploration, or suggesting family help without assessment may miss underlying issues.
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The nurse teaches the mother of a toddler who has had cleft palate repair that her child is at risk for developing which of the following in the future?
- A. Hearing problems.
- B. Speech defect.
- C. Chronic sinus infections.
- D. Tonsillitis.
Correct Answer: A, B
Rationale: Cleft palate repair increases the risk of hearing problems (due to Eustachian tube dysfunction) and speech defects.
A client with a history of hypothyroidism is prescribed levothyroxine (Synthroid). The nurse should monitor the client for which of the following signs of overdose?
- A. Tachycardia.
- B. Weight gain.
- C. Cold intolerance.
- D. Bradycardia.
Correct Answer: A
Rationale: Tachycardia indicates levothyroxine overdose due to excessive thyroid hormone.
A client with a history of type 1 diabetes is admitted with hypoglycemia. The nurse should administer which of the following if the client is conscious?
- A. Glucagon intramuscularly.
- B. 50% dextrose intravenously.
- C. Orange juice orally.
- D. Insulin subcutaneously.
Correct Answer: C
Rationale: Orange juice provides fast-acting carbohydrates to raise blood glucose in a conscious client with hypoglycemia.
A client in a cardiac rehabilitation program states that he would like to make sure he is eating the right foods to ensure adequate endurance on the treadmill. Which of the following nutrients is most helpful for promoting endurance during sustained activity?
- A. Protein.
- B. Carbohydrate.
- C. Fat.
- D. Water.
Correct Answer: B
Rationale: Carbohydrates are the primary energy source for sustained physical activity, providing glycogen stores for endurance.
When giving a client a tube feeding the nurse should:
- A. Warm the feeding solution before administration.
- B. Place the client in a left side-lying position.
- C. Aspirate residual gastric contents before the feeding and discard.
- D. Verify position of the tube before beginning feeding.
Correct Answer: D
Rationale: Verifying tube position (e.g., via pH testing or X-ray) is critical to ensure safe administration and prevent aspiration.