Nokea
The clinic nurse is collecting data on a client at 22 weeks gestation during a prenatal visit. Which finding is most concerning?
- A. Client has not consistently taken prenatal vitamins
- B. Client is taking lisinopril to control hypertension
- C. Client reports a whitish vaginal discharge
- D. Client reports mild cramping pain in the lower abdomen
Correct Answer: B
Rationale: Lisinopril is contraindicated in pregnancy due to the risk of fetal harm and requires immediate discontinuation.
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An anxious parent of a 4 year-old consults the nurse for guidance in how to answer the child's question, 'Where do babies come from?' What is the nurse's best response to the parent?
- A. When a child asks a question, give a simple answer.
- B. Children ask many questions, but are not looking for answers.
- C. This question indicates interest in sexual development.
- D. Full and detailed answers should be given to all questions.
Correct Answer: A
Rationale: When a child asks a question, give a simple answer. Honesty is important, but answers should be simple and age-appropriate, providing only the information the child is ready to understand.
The nurse reinforces teaching for the parents of a child with impetigo. Which of the following statements by a parent indicates correct understanding of teaching? Select all that apply.
- A. I should wash my hands before and after touching the infected area.
- B. I will clean the infected area with alcohol before applying the antibiotic ointment.
- C. I will separate my child's clothing from other laundry and wash them with hot water.
- D. My child's fingernails should be kept short and well-filed.
- E. The infection could easily spread to other children who come in contact with my child.
Correct Answer: A,C,D,E
Rationale: Hand hygiene, separating laundry, keeping nails short, and recognizing the contagious nature of impetigo are correct. Cleaning with alcohol is inappropriate as it may irritate the skin.
The nurse is teaching the parent of a 6-year-old client about sleep. Which of the following information should the nurse include? Select all that apply.
- A. Your child should sleep 9 to 12 hours every night.
- B. As your child grows, the hours of required sleep increase.
- C. Encourage active play before bedtime to promote restful sleep.
- D. Avoid giving your child large amounts of liquid after dinnertime.
- E. It is important to establish and maintain a regular bedtime routine.
Correct Answer: A,D,E
Rationale: Children aged 6 need 9-11 hours of sleep, limited liquids prevent bedwetting, and routines promote sleep. Sleep needs decrease with age, and active play close to bedtime may disrupt sleep.
Following a stroke, an elderly client develops ptosis. When assessing the client, the nurse will note:
- A. Drooping of the eyelid on the affected side
- B. Inverted eyelid margins
- C. Eversion of eyelid margins
- D. Granulomatous inflammation of the eyelids
Correct Answer: A
Rationale: Ptosis or drooping of the eyelid can occur as the result of a stroke or Bell's palsy. Answer B refers to entropion, and answer C refers to ectropion, so they are incorrect. Answer D refers to chalazion, so it's incorrect. Answers B, C, and D are incorrect because they do not relate to ptosis.
An 8-year-old child is admitted to the hospital with pneumonia. The child has had frequent respiratory infections. A chloride sweat test is ordered. The nurse knows that the reason for this test is to rule out which condition?
- A. Pernicious anemia
- B. Diabetes insipidus
- C. Cystic fibrosis
- D. Glomerulonephritis
Correct Answer: C
Rationale: Frequent respiratory infections and pneumonia suggest cystic fibrosis, diagnosed via chloride sweat test, which detects elevated sweat chloride levels.