Nokea
The home health nurse asks a child's mother many questions as part of the assessment. The mother answers many questions, then stops and says, "I don't know why you ask me all this. Who gets to know this information?" The nurse should take which action?
- A. Determine why the mother is so suspicious.
- B. Determine what the mother does not want to tell.
- C. Explain who will have access to the information.
- D. Explain that everything is confidential and that no one else will know what is said.
Correct Answer: C
Rationale: The correct action for the nurse to take in this situation is to explain who will have access to the information. This can help build trust with the child's mother and alleviate any concerns she may have about the confidentiality of the information shared during the assessment. By explaining clearly who will have access to the information and how it will be used, the nurse can address the mother's concerns and ensure that she feels comfortable sharing necessary information for the child's care. This open communication is essential in building a supportive and trusting relationship between the nurse and the child's mother.
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A client with thrombocytopenia secondary to leukemia develops epistaxis. The nurse should instruct the client to:
- A. Lie supine with his neck extended
- B. Sit upright, leaning slightly forward
- C. Blow his nose and then put lateral pressure on his nose
- D. Hold his nose while bending forward at the waist
Correct Answer: B
Rationale: The nurse should instruct the client to sit upright, leaning slightly forward when experiencing epistaxis (nosebleed). This position helps prevent blood from dripping down the back of the throat, reducing the risk of aspiration. In the case of a client with thrombocytopenia secondary to leukemia, the blood may have difficulty clotting due to low platelet counts. Therefore, it is important to minimize bleeding as much as possible. Lying supine with the neck extended may increase the risk of blood flowing down the throat, while blowing the nose or putting lateral pressure on it may aggravate the bleeding. Holding the nose while bending forward at the waist may also increase blood flow towards the head. Sitting upright, leaning slightly forward is the safest position to prevent complications associated with epistaxis in this case.
The age by which the child can make a tower of 9 cubes and imitates circular stroke is
- A. 24 months
- B. 30 months
- C. 36 months
- D. 42 months
Correct Answer: C
Rationale: This milestone is typically achieved around 36 months.
When assessing a female adolescent for scoliosis, what should the nurse ask the client to do?
- A. Bend forward at the waist with arms hanging freely.
- B. Lie flat on the floor and extend her legs straight from the trunk.
- C. Sit in a chair while lifting her feet and legs to a right angle with the trunk.
- D. Stand against a wall while pressing the length of her back against the wall.
Correct Answer: A
Rationale: When assessing a female adolescent for scoliosis, the nurse should ask the client to bend forward at the waist with arms hanging freely. This Adams forward bend test allows the nurse to evaluate the spine for any asymmetry, curvature, or rib hump that may indicate scoliosis. By observing the alignment of the spine while the client is in a forward bent position, the nurse can gather important information to determine if further evaluation or referral to a healthcare provider is necessary.
A client with pernicious anemia is receiving parenteral vitamin B12 therapy. Which client statement indicates effective teaching about this therapy?
- A. "I will receive parenteral vitamin B12 therapy until my signs and symptoms disappear."
- B. "I will receive parenteral vitamin B12 therapy until my vitamin B12 level returns to normal."
- C. "I will receive parenteral vitamin B12 therapy monthly for 6 months to a year."
- D. "I will receive parenteral vitamin B12 therapy for the rest of my life."
Correct Answer: D
Rationale: The correct client statement indicating effective teaching about parenteral vitamin B12 therapy for pernicious anemia is, "I will receive parenteral vitamin B12 therapy for the rest of my life." Pernicious anemia is a condition in which the body cannot absorb enough vitamin B12 from food due to a lack of intrinsic factor, a protein produced in the stomach. As a result, lifelong B12 supplementation is necessary to maintain adequate levels of the vitamin. Monthly injections are typically recommended for life to ensure proper B12 levels and prevent complications associated with the deficiency.
The nurse understands that for the parathyroid hormone to exert its effect, what must be present?
- A. Decreased phosphate level
- B. Functioning thyroid gland
- C. Adequate vitamin D level
- D. Increased calcium level
Correct Answer: D
Rationale: Parathyroid hormone (PTH) is released by the parathyroid glands in response to low calcium levels in the blood. Its primary function is to regulate calcium and phosphorus levels in the body. When calcium levels in the blood are low, PTH is released, leading to increased calcium levels by stimulating the release of calcium from the bones, increasing calcium absorption in the intestines, and promoting calcium reabsorption in the kidneys. Therefore, for PTH to exert its effect, increased calcium levels must be present.