Nokea
The client is at risk for developing ------- and--------
- A. Hypoglycemia
- B. bronchopulmonary dysplasia
- C. transient tachypnea of the newborn
- D. Tachycardia
Correct Answer: A, C
Rationale: The correct answer is A and C. Hypoglycemia and transient tachypnea of the newborn are common risks for newborns. Hypoglycemia can occur due to immature liver function, while transient tachypnea results from retained lung fluid. The other choices are incorrect because bronchopulmonary dysplasia is a chronic lung condition seen in premature infants, and tachycardia is a symptom of various conditions but not typically a primary risk for newborns.
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A home health nurse is caring for a child who has Lyme disease. Which of the following is an appropriate action for the nurse to take
- A. Ensure the state health department has been notified
- B. Administer antitoxin.
- C. Educate the family to avoid sharing personal belongings
- D. Assess for skin necrosis
Correct Answer: A
Rationale: Correct Answer: A: Ensure the state health department has been notified.
Rationale:
1. Lyme disease is a reportable infectious disease, so notifying the state health department is crucial for tracking and controlling its spread.
2. Reporting to the health department allows for proper surveillance and monitoring of the disease in the community.
3. By notifying the health department, appropriate public health interventions can be implemented to prevent further cases.
Summary of Incorrect Choices:
B: Administer antitoxin - Lyme disease is caused by a bacterium, not a toxin, so antitoxin administration is not appropriate.
C: Educate the family to avoid sharing personal belongings - While important for hygiene, it does not directly address the management of Lyme disease.
D: Assess for skin necrosis - Skin necrosis is not a common manifestation of Lyme disease, so this action is not a priority in caring for a child with Lyme disease.
A nurse is assessing a client who is taking haloperidol and is experiencing pseudo parkinsonism. Which of the following findings should the nurse document as a manifestation of pseudo parkinsonism?
- A. Serpentine limb movement
- B. Shuffling gait
- C. Nonreactive pupils
- D. Smacking lips
Correct Answer: B
Rationale: The correct answer is B: Shuffling gait. Pseudo parkinsonism is a common side effect of antipsychotic medications like haloperidol. A shuffling gait is a characteristic manifestation, which includes slow, shuffling, and stiff movements resembling those seen in Parkinson's disease. This occurs due to the blockade of dopamine receptors in the brain.
Choice A, serpentine limb movement, is not a typical manifestation of pseudo parkinsonism. Choice C, nonreactive pupils, is more indicative of a possible neurological issue. Choice D, smacking lips, is a manifestation of tardive dyskinesia, not pseudo parkinsonism.
A nurse is preparing to reposition a client who had a stroke. Which of the following actions should the nurse take?
- A. Evaluate the client's ability to help with repositioning
- B. Reposition the client without the use of assistive devices.
- C. Raise the side rails on both sides of the client's bed during repositioning.
- D. Discuss the client's preferences for determining a repositioning schedule.
Correct Answer: A
Rationale: The correct answer is A: Evaluate the client's ability to help with repositioning. This is crucial as it assesses the client's capability and involvement in the process, promoting independence and preventing complications. Choice B is incorrect as assistive devices may be necessary for safety. Choice C is incorrect as raising side rails can limit access and may not be needed. Choice D is incorrect as discussing preferences is important but not directly related to repositioning.
A nurse is caring for a client who is experiencing expressive aphasia and right hemiparesis following a stroke. Which of the following actions by the nurse best promotes communication among staff caring for the client?
- A. Posting swallowing precautions at the head of the client’s bed
- B. Noting changes in the treatment plan in the client's medical record
- C. Recording the client's progress in the nurses’ notes
- D. Having interdisciplinary team meetings for the client on a regular basis.
Correct Answer: D
Rationale: Rationale for the Correct Answer (D): Having interdisciplinary team meetings for the client on a regular basis is the best action to promote communication among staff caring for the client. This approach ensures that all healthcare team members are regularly updated on the client's condition, progress, and treatment plan. It allows for collaborative decision-making and coordination of care, leading to a holistic and effective approach to managing the client's needs. Additionally, it provides an opportunity for staff to discuss any challenges, share insights, and adjust interventions as needed to optimize the client's outcomes.
Summary of Incorrect Choices:
A: Posting swallowing precautions at the head of the client's bed is important for safety but does not directly promote communication among staff.
B: Noting changes in the treatment plan in the client's medical record is essential for documentation but may not facilitate real-time communication among staff members.
C: Recording the client's progress in the nurses' notes is necessary for tracking the client's status but does not ensure comprehensive communication among all team
A nurse is preparing to feed a newly admitted client who has dysphagia. Which of the following actions should the nurse plan to take?
- A. Instruct the client to lift her chin when swallowing
- B. Talk with the client during her feeding.
- C. Sit at or below the client's eye level during feedings
- D. Discourage the client from coughing during feedings
Correct Answer: C
Rationale: The correct answer is C: Sit at or below the client's eye level during feedings. This is important for clients with dysphagia as it helps facilitate safe swallowing by promoting proper alignment of the head and neck. Sitting at or below the client's eye level reduces the risk of aspiration and choking during feeding. This position also allows the nurse to closely monitor the client for signs of difficulty swallowing.
Choice A is incorrect because instructing the client to lift her chin when swallowing can actually increase the risk of aspiration in individuals with dysphagia. Choice B is incorrect as talking with the client during feeding may distract them and increase the risk of swallowing difficulties. Choice D is incorrect because coughing is a protective mechanism that helps clear the airway, so discouraging coughing during feedings is not recommended for clients with dysphagia.