Nokea
Phototherapy is instituted for an infant. What is the most appropriate nursing action for the infant having phototherapy?
- A. Cover the infant's head with a hat.
- B. Dress the infant lightly in a T-shirt.
- C. Keep the infant's eyes covered.
- D. Reposition the infant at least every 4 to 8 hours.
Correct Answer: C
Rationale: The correct answer is C: Keep the infant's eyes covered. This is important during phototherapy to protect the infant's eyes from potential damage due to exposure to light. Direct light can harm the infant's developing eyes, so covering them is crucial.
Choice A: Cover the infant's head with a hat - This is not necessary for phototherapy as the focus should be on protecting the eyes, not the head.
Choice B: Dress the infant lightly in a T-shirt - While dressing the infant lightly is recommended, it is not as critical as protecting the eyes.
Choice D: Reposition the infant at least every 4 to 8 hours - Repositioning is important for preventing pressure ulcers but is not directly related to the safety of the eyes during phototherapy.
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Which should the nurse recommend to the client to relieve premenstrual syndrome (PMS) symptoms? Select all that apply.
- A. NSAIDs to decrease pain
- B. Exercise 5 to 6 times a week
- C. Decrease caffeine
- D. Decrease fiber
Correct Answer: D
Rationale: The correct answer is D, decrease fiber intake. High-fiber foods can worsen bloating and digestive issues associated with PMS. By reducing fiber intake, gas and bloating can be minimized, alleviating these symptoms. NSAIDs (A) can help with pain but do not address other PMS symptoms. Exercise (B) can be beneficial, but it may not directly target PMS symptoms. Decreasing caffeine (C) can help with mood swings, but it is not as effective for physical symptoms compared to reducing fiber intake.
Which are major risk factors for breast cancer? Select all that apply.
- A. Female gender
- B. Increasing age over 50 years
- C. Personal history of breast cancer (in situ or invasive), family history of breast cancer in first-degree relatives (parent, sibling, child)
- D. High-fat diet, Alcohol consumption (two or more drinks/day)
Correct Answer: C
Rationale: The correct answer is C because having a personal history of breast cancer, a family history of breast cancer in first-degree relatives, or both are major risk factors for developing breast cancer. This is due to the presence of genetic mutations that increase the likelihood of developing the disease. Choices A and B are not specific risk factors for breast cancer, although being female and increasing age are associated with higher risk. Choice D, high-fat diet and alcohol consumption, are not considered major risk factors for breast cancer.
A client who has been diagnosed with HIV develops an oral candida infection. When teaching the client, which instructions will the health care provider include?
- A. Rinse your mouth often with a commercial mouthwash.
- B. Include plenty of citrus juices in your diet.
- C. Select foods that are soft or pureed.
- D. Include hot soups and beverages with each meal.
Correct Answer: C
Rationale: The correct answer is C: Select foods that are soft or pureed. This is because soft or pureed foods are easier to swallow and less likely to irritate the oral mucosa affected by the candida infection. Rinsing with a commercial mouthwash (choice A) may temporarily relieve symptoms but won't address the root cause. Citrus juices (choice B) can be irritating to the oral mucosa. Hot soups and beverages (choice D) can worsen the discomfort in the mouth. Overall, choosing soft or pureed foods will help alleviate discomfort and promote healing.
Intrapartum nursing care for a woman who has sickle cell disease focuses on:
- A. Maintaining oxygenation and preventing dehydration
- B. Controlling pain and avoiding unnecessary movement
- C. Preventing excess exertion and limiting visitors
- D. Increasing calorie intake and avoiding internal monitoring
Correct Answer: A
Rationale: The correct answer is A because maintaining oxygenation is crucial due to the risk of vaso-occlusive crisis in sickle cell disease. Dehydration can worsen sickling of red blood cells. Choice B is incorrect because pain control is important but not the primary focus. Choice C is incorrect as excess exertion can trigger a crisis, and limiting visitors is not a priority. Choice D is incorrect as calorie intake and internal monitoring are not directly related to intrapartum care for sickle cell disease.
The client calls the nurse and states she has not had a menstrual cycle in 3 months. What does the nurse know is the most common cause of secondary amenorrhea?
- A. Weight loss
- B. Pregnancy
- C. Cancer
- D. Menopause
Correct Answer: B
Rationale: The correct answer is B: Pregnancy. In the case of secondary amenorrhea, where a woman stops menstruating after previously having regular cycles, pregnancy is the most common cause. Pregnancy leads to a halt in the menstrual cycle due to hormonal changes to support the developing fetus. Other choices are incorrect: A) Weight loss can affect menstruation but is not the most common cause of secondary amenorrhea. C) Cancer can also disrupt the menstrual cycle, but it is not the primary cause in this scenario. D) Menopause typically occurs in women in their late 40s to early 50s, and would not be the most common cause of secondary amenorrhea in a younger woman.