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Nurse reviewing car seat safety with parents of 1 mo infant. When reviewing this, which instructions should nurse include?
- A. Use car seat that has 3-point harness
- B. Position car seat so that infant is rear-facing
- C. Secure car seat in front passenger seat of car
- D. Put soft padding in car seat behind infant's back & neck
Correct Answer: B
Rationale: The correct answer is B: Position car seat so that infant is rear-facing. This is crucial for newborn safety as it reduces the risk of injury in the event of a crash. Rear-facing car seats provide optimal support for the infant's head, neck, and spine. Choice A is incorrect because a 5-point harness is recommended for infants for better protection. Choice C is incorrect as the back seat is the safest location for a car seat. Choice D is incorrect because soft padding can compress in a crash, leading to injury.
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Nurse is talking with 45 yo client with no specific family hx of cancer or DM, about planning routine screenings. Which client statement indicates client understands how to proceed?
- A. So I don't need colon cancer procedure for another 2-3 yrs
- B. For now, I should continue to have mammogram each year
- C. Because doctor just did pap smear, I'll come back next year for another
- D. I had my blood glucose test last year so I won't need it again till next year
Correct Answer: B
Rationale: The correct answer is B: "For now, I should continue to have a mammogram each year." This response shows understanding of the need for annual mammograms for breast cancer screening, which is recommended for women aged 45 and older. The other choices are incorrect because: A suggests delaying colon cancer screening, which is typically recommended starting at age 50; C implies annual pap smears, which are usually done every 3-5 years depending on age and risk factors; D indicates a lack of understanding about the frequency of blood glucose testing for diabetes screening.
During evaluation, nurse must gather info about the client to...
- A. identify whether client outcomes have been met
- B. organize resources to proceed with implementing interventions
- C. establish client-centered, measurable & realistic outcomes
- D. determine priority of care & appropriate interventions
Correct Answer: A
Rationale: The correct answer is A because during evaluation, nurses must gather information about the client to identify whether client outcomes have been met. This step is crucial in determining the effectiveness of the care provided and if the client's needs have been addressed. Gathering this information helps in assessing the success of the interventions implemented.
Choice B is incorrect as organizing resources is part of the planning phase, not evaluation. Choice C is incorrect because establishing client-centered outcomes is part of the planning phase, not evaluation. Choice D is incorrect as determining priority of care and appropriate interventions is typically done during the assessment and planning phases, not evaluation.
Nurse cautioning mother of 8 mo infant about safety. Which statement by mother indicates understanding of safety for infant?
- A. My baby loved to play with crib gym, but I took it from him
- B. I just bought a soft mattress so my baby will sleep better
- C. My baby really likes sleeping on fluffy pillow we just got for him
- D. I just bought a child-safety gate that folds like accordion
Correct Answer: A
Rationale: Correct Answer: A
Rationale: Removing the crib gym is crucial as it can pose a choking hazard. Infants should sleep on a firm mattress to reduce the risk of suffocation, making option B incorrect. Option C is unsafe as soft pillows increase the risk of suffocation. Option D, while mentioning a safety gate, doesn't directly address infant safety.
Nurse planning diversionary activities for children on an inpatient unit. Which should nurse incorporate as appropriate play activities for toddler? (Select all that apply.)
- A. Building simple models
- B. Working with clay
- C. Filling & emptying containers
- D. Playing with blocks
- E. Looking at books
Correct Answer: C,D,E
Rationale: The correct activities for a toddler include filling & emptying containers (C) to promote sensory exploration, playing with blocks (D) for fine motor skills and spatial awareness, and looking at books (E) to encourage language development and cognitive skills. Building simple models (A) may be too complex for toddlers. Working with clay (B) can pose a choking hazard. The other options are not developmentally appropriate for toddlers.
Client who will undergo neurosurgery in 1 week tells the nurse in office that he will prepare his advance directives before he goes to the hospital. Which of the following statements by the client indicates to the nurse that he understands them?
- A. I'd rather have my brother make decisions for me, but I know it has to be my wife.
- B. I know they won't go ahead with the surgery unless I prepare these forms.
- C. I plan to write that I don't want them to keep me on a breathing machine.
- D. I will get my regular doctor to approve my plan before I hand it in at the hospital.
Correct Answer: C
Rationale: The correct answer is C: "I plan to write that I don't want them to keep me on a breathing machine." This statement indicates understanding of advance directives as it demonstrates the client's specific wishes regarding life-sustaining treatment. By stating his preference clearly, the client shows he understands the purpose of advance directives in communicating his healthcare decisions.
Choice A: This indicates a lack of understanding as the client is unsure about who should make decisions for him, showing confusion about the purpose of advance directives.
Choice B: While this choice shows awareness of the importance of advance directives, it does not demonstrate understanding of the content or purpose of the document.
Choice D: Involving the regular doctor is not necessary for advance directives and does not indicate comprehension of the document's purpose.
In summary, choice C is correct as it directly addresses a specific healthcare decision, while the other choices do not demonstrate a clear understanding of advance directives.