Nokea
During a routine health screening, the nurse should talk to the parents of a 1-year-old child about which of the following?
- A. the potential hazards of accidents
- B. appropriate nutrition now that the child has been weaned from breast-feeding
- C. toilet training
- D. how to purchase appropriate shoes now that the child is walking
Correct Answer: A
Rationale: Accidents are the primary source of injury in children and can be life threatening. Appropriate nutrition should have been discussed during the weaning process and while the purchase of appropriate shoes is important, it is not life threatening. One year of age is too early to discuss toilet training.
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A nurse is supervising a student in preparing the physical environment for an interview with a client. Which action by the student is correct?
- A. Setting the room temperature at a comfortable level
- B. Placing a chair for the client across from the nurse's desk
- C. Providing seating for the client so that the client faces a strong light
- D. Setting up seating so that the client and nurse are not at eye level
Correct Answer: A
Rationale: When preparing the physical environment for an interview with a client, it is crucial to ensure the client's comfort. Setting the room temperature at a comfortable level is essential for the client's well-being. Additionally, providing privacy, sufficient lighting, and removing distractions are crucial factors. It is recommended to maintain a distance of around 4 to 5 feet between the client and the nurse. Seating should be arranged so that the client and nurse are at eye level to facilitate effective communication and prevent barriers. Placing a chair across from the nurse's desk may create a physical barrier, positioning the client to face a strong light can be uncomfortable and distracting, and setting up seating so that the client and nurse are not at eye level may impede effective communication.
A nurse is telling a pregnant client about the signs that must be reported to the health care provider. The nurse tells the client that the health care provider should be contacted if which occurs?
- A. Puffiness of the face
- B. Breast tenderness
- C. Morning sickness
- D. Urinary frequency
Correct Answer: A
Rationale: During pregnancy, it is important to be aware of danger signs that warrant contacting the healthcare provider. Puffiness of the face, especially around the eyes, can indicate a serious condition like preeclampsia. Other danger signs include vaginal bleeding, rupture of membranes, severe abdominal pain, visual disturbances, persistent vomiting, and changes in fetal movements. Morning sickness, breast tenderness, and urinary frequency are common symptoms of pregnancy and are not typically concerning unless they become severe or persistent, and do not usually require immediate medical attention.
A patient has been diagnosed with diabetes mellitus. Which of the following is not a clinical sign of diabetes mellitus?
- A. Polyphagia
- B. Polyuria
- C. Metabolic acidosis
- D. Lower extremity edema
Correct Answer: D
Rationale: A-C are associated with diabetes mellitus.
Intramuscular (IM) phytonadione (vitamin K) 0.5 mg is prescribed for a newborn. After the medication is prepared, in which anatomic site does the nurse administer it?
- A. Rectus femoris muscle
- B. Deltoid muscle
- C. Gluteal muscle
- D. Vastus lateralis muscle
Correct Answer: D
Rationale: Vitamin K is administered to newborn infants to help prevent hemorrhagic disease. The best site for intramuscular injection in infants is the vastus lateralis muscle. This site is preferred due to its location away from the sciatic nerve, femoral artery, and vein, reducing the risk of complications. The rectus femoris muscle may be used if necessary; however, it is less favorable than the vastus lateralis due to its proximity to vital structures, making injections there more hazardous. The deltoid muscle is not typically used for IM injections in newborns. The gluteal muscles should be avoided until the child has been walking for at least a year, as they are poorly developed and close to the sciatic nerve.
A pregnant client asks a nurse about the use of noninvasive acupressure as a complementary alternative therapy to relieve nausea. The nurse provides which instruction?
- A. It is safe to try any type of complementary alternative therapy to relieve nausea
- B. The physician or nurse-midwife needs to provide a prescription for acupressure devices
- C. Devices that apply pressure alone are available over the counter
- D. Complementary alternative therapies should not be used during pregnancy
Correct Answer: C
Rationale: The correct answer is 'Devices that apply pressure alone are available over the counter.' Acupressure over the Neiguan acupuncture point can be used as a complementary alternative therapy to relieve nausea during pregnancy. It can be performed with devices that apply pressure alone, which are available over the counter. Acupressure devices that apply electrical impulses over this point require a prescription. It is not safe to try any type of complementary alternative therapy during pregnancy, as some may be harmful to the mother and fetus. Therefore, the nurse should instruct the client about the availability of over-the-counter pressure devices for acupressure, which are generally safe to use.