Nokea
During an initial interview at an outpatient clinic, a 34-year-old single mother tells the nurse that she has always had difficulty forming relationships and is worried that her 7-year-old daughter will have the same problem. Which of the following statements, if made by the nurse, is BEST?
- A. Children develop trust from birth to 18 months of age.
- B. Children develop trust from 18 months to three years of age.
- C. Children develop trust from three to six years of age.
- D. Children develop trust from six to twelve years of age.
Correct Answer: A
Rationale: Erikson states that trust results from interaction with dependable, predictable primary caretaker
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A mother brings her 17-month-old son to the well-baby clinic for a routine check-up. She confides to the nurse that she is concerned because her son sucks his thumb, especially at night when he is put to bed.
Which of the suggestions by the nurse would be BEST?
- A. If you want the behavior to stop put a negative reinforcer, such as red pepper, on this thumb.'
- B. Don't intervene at this time. This behavior usually subsides after 24 months of age.'
- C. What you are seeing is a common form of self-stimulation. You should discourage this behavior.'
- D. This behavior will cause malformation of his teeth. You should wrap his thumb at bedtime.'
Correct Answer: B
Rationale: Strategy: 'BEST' indicates there may be more than one correct response. Remember growth and development concepts. (1) controversial treatment for an older child (2) correct-normal behavior, peaks at 18-20 months, most prevalent when child is hungry or tired (3) normal behavior in child this age, should not be discouraged (4) malocclusion occurs if thumb sucking persists past 4 years old or when permanent teeth erupt
Which of the following should the nurse include in his teaching plan for the client taking Vasopressin (Lypressin)?
- A. The client will need to take her medication with meals.
- B. The client will need to learn how to check the specific gravity of her urine.
- C. The client will need to modify her daily activities.
- D. The client will need to learn the proper method of drug administration.
Correct Answer: D
Rationale: Vasopressin is often administered nasally or by injection, so teaching the proper administration method is essential.
A client comes to the clinic for treatment of recurrent pelvic inflammatory disease (PID). The nurse recognizes that this condition most frequently follows which type of infection?
- A. Trichomoniasis
- B. Chlamydia
- C. Staphylococcus
- D. Streptococcus
Correct Answer: B
Rationale: Chlamydia. Chlamydial infections are one of the most frequent causes of salpingitis or pelvic inflammatory disease.
The physician has ordered Prednisone 50 mg daily to promote diuresis in a client with nephrotic syndrome. The nurse should administer the medication:
- A. In a single dose at bedtime
- B. With a snack or glass of milk
- C. With water to promote absorption
- D. Prior to arising in the morning
Correct Answer: B
Rationale: Prednisone, a steroid, should be given with a snack or meal to prevent gastric irritation. Answer C would cause pain and gastric upset, making it incorrect. Answers A and D do not include providing food with the medication, so they are incorrect.
A newborn weighed 7 pounds 2 ounces at birth. The nurse assesses the newborn at home 2 days later and finds the weight to be 6 pounds 7 ounces. What should the nurse tell the parents about this weight loss?
- A. The newborn needs additional assessments
- B. The mother should breast feed more often
- C. A change to formula is indicated
- D. The loss is within normal limits
Correct Answer: D
Rationale: The loss is within normal limits. A newborn is expected to lose 5-10% of the birth weight in the first few days post-partum because of changes in elimination and feeding.