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Sucking provides the infant with a sense of security and comfort. It also is an outlet for releasing tension. The infant should not be discouraged from sucking on the pacifier. Fussiness after feeding may indicate that the infant's appetite is not satisfied. Sucking is not manipulative in the sense of seeking parental attention.
- A. Encourage the infant to suck on a pacifier.
- B. Discourage pacifier use.
- C. Feed the infant more frequently.
- D. Ignore the infant's fussiness.
Correct Answer: A
Rationale: Sucking on a pacifier is a normal, comforting behavior for infants, supporting emotional regulation.
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A 56-year-old woman is admitted for a modified radical mastectomy. The client appears anxious and asks many questions. The nurse's best course of action is to:
- A. Tell the client as much as she wants to know and is able to understand.
- B. Delay discussing the client's questions with her until the convalescent phase of her care.
- C. Delay discussing the client's questions with her until her apprehension subsides.
- D. Explain to the client that she should discuss her questions with her physician.
Correct Answer: A
Rationale: Addressing the client's questions thoroughly and at her level of understanding reduces anxiety and supports informed consent.
Two days after being placed in a cast for a fracture, the client suddenly develops chest pain and dyspnea. The client is confused and has an elevated temperature. The nurse should assess the client for:
- A. Osteomyelitis.
- B. Compartment syndrome.
- C. Venous thrombosis.
- D. Fat embolism syndrome.
Correct Answer: D
Rationale: Chest pain, dyspnea, confusion, and fever suggest fat embolism syndrome, a complication of fractures, particularly within 48 hours.
A client with a history of depression is prescribed trazodone (Desyrel). The nurse should instruct the client to take the medication:
- A. In the morning to avoid sedation.
- B. At bedtime to promote sleep.
- C. With meals to enhance absorption.
- D. As needed for low mood.
Correct Answer: B
Rationale: Trazodone is sedating and should be taken at bedtime to promote sleep and manage depression.
The nurse assesses the assigned clients for the shift. Of the following assigned clients, which client is at greatest risk for falling?
- A. A 22-year-old man with three fractured ribs and a fractured left arm.
- B. A 70-year-old woman with episodes of syncope.
- C. A 50-year-old man with angina.
- D. A 30-year-old woman with a fractured ankle.
Correct Answer: B
Rationale: Syncope increases fall risk due to sudden loss of consciousness, particularly in an elderly client with potential comorbidities.
A primiparous client at 38 weeks' gestation is admitted in early labor. The client's membranes rupture, and the nurse observes that the amniotic fluid is meconium-stained. The nurse should:
- A. Notify the physician immediately.
- B. Perform a vaginal exam to assess dilation.
- C. Encourage the client to ambulate.
- D. Administer oxygen to the client.
Correct Answer: A
Rationale: Meconium-stained amniotic fluid may indicate fetal distress, requiring immediate notification of the physician for further evaluation and management.