Nokea
The child refusing to go to bed and remaining active is likely due to
- A. thyrotoxicosis
- B. ADHD
- C. primary sleep disorder
- D. limit-setting behavioral insomnia of childhood
Correct Answer: D
Rationale: Limit-setting insomnia involves resistance to bedtime routines.
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A female client with human immunodeficiency virus (HIV) receives family-planning counseling. Which statement about safer sex practices for persons with HIV is accurate?
- A. If the client and her sexual partners are HIV positive, unprotected sex is permitted
- B. A latex condom with spermicide provides the best protection against HIV transmission during sexual intercourse
- C. Contraceptive methods like birth control pills, implants, and injections are recommended to prevent HIV transmission
- D. The intrauterine device is recommended for a client with HIV
Correct Answer: B
Rationale: A latex condom with spermicide provides the best protection against HIV transmission during sexual intercourse. Safer sex practices for persons with HIV involve using condoms consistently and correctly during every sexual encounter to reduce the risk of HIV transmission to partners, regardless of their HIV status. Spermicide, while offering additional protection against pregnancies, does not provide additional protection against HIV transmission. Other contraceptive methods like birth control pills, implants, and injections are not effective in preventing HIV transmission. The intrauterine device is also not specifically recommended for clients with HIV as it does not provide protection against HIV transmission during sexual activities.
Alex is taking carbamazepine (tegretol) for seizure disorder. He should be monitored for which of the following potential complications?
- A. adult respiratory distress syndrome
- B. elevated leves of phenytoin (Dilantin)
- C. diplopia
- D. leukocytosis
Correct Answer: B
Rationale: Carbamazepine is a known enzyme inducer, and it can increase the metabolism of other drugs, such as phenytoin (Dilantin). This can lead to lower levels of phenytoin in the blood and potentially reduce its effectiveness. Therefore, patients taking carbamazepine should be monitored for elevated levels of phenytoin to ensure optimal seizure control. Diplopia (double vision), leukocytosis, and adult respiratory distress syndrome are not typically associated with carbamazepine use.
What should nursing interventions to maintain a patent airway in a newborn include?
- A. Sleeping in the prone (on abdomen) position
- B. Wrapping neonate as snugly as possible
- C. Positioning neonate supine while sleeping
- D. Using bulb syringe to suction as needed, suctioning nose first, and then pharynx
Correct Answer: D
Rationale: Nursing interventions to maintain a patent airway in a newborn should prioritize safety and best practices. Positioning the neonate supine while sleeping is crucial to reduce the risk of sudden infant death syndrome (SIDS) and ensure proper airway alignment. Using a bulb syringe to suction as needed, with the correct technique of suctioning the nose first and then the pharynx, helps effectively remove secretions and keep the airway clear. This intervention promotes optimal respiratory function and reduces the risk of airway obstruction in newborns. Sleeping in the prone position is not recommended due to the increased risk of SIDS. Wrapping the neonate as snugly as possible can also pose risks of overheating and compromising the airway, making it an unsafe practice.
Which nursing intervention is most appropriate for a client with multiple myeloma?
- A. Monitoring respiratory status
- B. Restricting fluid intake
- C. Balancing rest and activity
- D. Preventing bone injury
Correct Answer: D
Rationale: One of the primary concerns in clients with multiple myeloma is bone damage and fractures due to weakened bones caused by the disease. Preventing bone injury is a crucial nursing intervention to focus on for these clients. Measures to prevent bone injury include implementing fall precautions, encouraging safe mobility, providing supportive devices such as walkers or canes, and educating the client on strategies to prevent falls and fractures. Additionally, pain management and regular assessment for signs of bone damage are essential in caring for clients with multiple myeloma. Other interventions such as monitoring respiratory status, balancing rest and activity, and restricting fluid intake may be important in certain situations for these clients but preventing bone injury takes precedence due to the increased risk of skeletal complications associated with multiple myeloma.
A patient understands the common causes of urinary tract infection if he or she states the following, EXCEPT:
- A. "UTI can be caused by holding the urge to urinate."
- B. "Insertion of instruments and catheter to the urinary tract can introduce bacteria that can cause infection."
- C. "I usually drink lots of water at night and it might have caused my UTI."
- D. "UTI can be caused by unhygienic cleaning after defecation."
Correct Answer: C
Rationale: Drinking lots of water at night is actually a good practice for promoting urinary health and preventing urinary tract infections (UTIs). Adequate hydration helps to flush out bacteria from the urinary tract, reducing the risk of infections. Therefore, the statement that drinking lots of water at night might have caused a UTI is incorrect. The other choices describe common causes of UTIs such as holding the urge to urinate, introducing bacteria through instruments or catheters, and poor hygiene practices after defecation.