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Several days before admission, a client reports finding a small lump in the left breast near the nipple. What should the nurse tell the client to do?
- A. Inform the physician immediately
- B. Check the area after the next menstrual
- C. Squeeze the nipple to check for period
- D. Put a heating pad on the area to reduce inflammation
Correct Answer: A
Rationale: The nurse should advise the client to inform the physician immediately. Finding a lump in the breast near the nipple can be concerning as it might indicate a potential issue like breast cancer. Prompt assessment by a healthcare provider is essential for proper evaluation and timely intervention if needed. It is crucial not to delay seeking medical attention for any breast abnormalities to ensure early detection and management of any possible health conditions.
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Parents tell the nurse that their 1-year-old son often sleeps with them. They seem unconcerned about this. The nurse's response should be based on which statement?
- A. Children should not sleep with their parents.
- B. Separation from parents should be completed by this age.
- C. Daytime attention should be increased.
- D. This is a common and accepted practice, especially in some cultural groups.
Correct Answer: D
Rationale: The correct response is D because it acknowledges that co-sleeping with children, especially infants and toddlers, is a common and accepted practice in various cultural groups. Co-sleeping can have benefits such as promoting bonding and facilitating breastfeeding. However, it is essential for the nurse to educate the parents on safe sleep practices to reduce the risk of Sudden Infant Death Syndrome (SIDS) or other sleep-related accidents. It is important to provide guidance on creating a safe sleep environment for the child if they continue co-sleeping.
What dietary advice should the nurse give to clients with HIV/AIDS?
- A. Encourage the intake of fat soluble vitamins in amounts 2 to 5 times the recommended daily allowance (RDA)
- B. Encourage intake of water soluble vitamins in amounts 2 to 5 times the RDA
- C. Increase the intake of iron and zinc
- D. Decrease the intake of trace elements and antioxidant supplements
Correct Answer: D
Rationale: It is important for clients with HIV/AIDS to maintain a balanced diet that includes a variety of healthy foods to help support their immune system and overall health. While it may be beneficial for them to increase their intake of certain vitamins and minerals, such as vitamin C and zinc, it is generally recommended to get these nutrients from food sources rather than supplements. In fact, there is no evidence to support the routine use of trace elements and antioxidant supplements in individuals with HIV/AIDS. It is always best to consult with a healthcare provider or a dietitian for tailored dietary advice based on individual needs and health status.
Ms. CC's laboratory values indicate hemoconcentration secondary to fluid loss. Which of the following intravenous solutions would be most appropriate during initial fluid replacement therapy?
- A. 10% dextrose and saline
- B. 5% dextrose and water
- C. 5% dextrose and water with 60 mEq
- D. Distilled water KCl
Correct Answer: A
Rationale: In hemoconcentration due to fluid loss, the primary goal is to rapidly expand the intravascular volume and correct the deficit. The most appropriate intravenous solution for initial fluid replacement therapy in this case is 10% dextrose and saline. This solution is isotonic, which means it has an osmolarity close to that of blood and is effective in quickly restoring intravascular volume without causing significant shifts in electrolytes. The saline component helps to replenish lost electrolytes while the dextrose provides energy and helps prevent hypoglycemia. The combination of dextrose and saline is beneficial for addressing both intravascular volume depletion and dehydration causing hemoconcentration.
When caring for a child that has undergone a tonsillectomy, the nurse should do which of the following?
- A. Observe for continuous swallowing.
- B. Encourage gargling with warm saline water.
- C. Apply warm compresses to the throat.
- D. Apply cold compresses to the throat.
Correct Answer: A
Rationale: When caring for a child that has undergone a tonsillectomy, the nurse should observe for continuous swallowing. Continuous swallowing may indicate bleeding, and it is important to monitor for this postoperatively as it can be a sign of hemorrhage, which is a potential complication following a tonsillectomy. Encouraging the child to take sips of clear fluids can help in assessing if there is bleeding. Observing for any signs of bleeding, such as frequent swallowing, along with monitoring vital signs and overall assessment, is crucial during the initial postoperative period.
Although infants may be allergic to a variety of foods, the most common allergens are:
- A. fruit and eggs.
- B. fruit, vegetables, and wheat.
- C. cow's milk and green vegetables.
- D. eggs, cow's milk, and wheat.
Correct Answer: D
Rationale: The most common allergens in infants are eggs, cow's milk, and wheat. These three items are among the top allergens that can trigger allergic reactions in infants. It is important for parents to be aware of these common allergens to help prevent potential allergic reactions in their infants.