Nokea
The mother of a one-year-old wants to know when she should begin toilet-training her child. The nurse's response is based on the knowledge that sufficient sphincter control for toilet training is present by:
- A. 12-15 months of age
- B. 18-24 months of age
- C. 26-30 months of age
- D. 32-36 months of age
Correct Answer: B
Rationale: Sufficient sphincter control for toilet training typically develops between 18-24 months, when children gain the physical and cognitive ability to control urination and defecation.
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After 3 weeks of treatment, a severely depressed client suddenly begins to feel better and starts interacting appropriately with other clients and staff. The nurse knows that this client has an increased risk for:
- A. Suicide
- B. Exacerbation of depressive symptoms
- C. Violence toward others
- D. Psychotic behavior
Correct Answer: A
Rationale: When the severely depressed client suddenly begins to feel better, it often indicates that the client has made the decision to kill himself or herself and has developed a plan to do so. Improvement in behavior is not indicative of an exacerbation of depressive symptoms. The depressed client has a tendency for self-violence, not violence toward others. Depressive behavior is not always accompanied by psychotic behavior.
A client in active labor asks the nurse for coaching with her breathing during contractions. The client has attended Lamaze birth preparation classes. Which of the following is the best response by the nurse?
- A. Keep breathing with your abdominal muscles as long as you can.
- B. Make sure you take a deep cleansing breath as the contractions start, focus on an object, and breathe about 16-20 times a minute with shallow chest breaths.
- C. Find a comfortable position before you start a contraction. Once the contraction has started, take slow breaths using your abdominal muscles.
- D. If a woman in labor listens to her body and takes rapid, deep breaths, she will be able to deal with her contractions quite well.
Correct Answer: B
Rationale: Lamaze childbirth preparation teaches the use of chest, not abdominal, breathing. In Lamaze preparation, every patterned breath is preceded by a cleansing breath; as labor progresses, shallow, paced breathing is found to be effective. It is important to assume a comfortable position in labor, but the Lamaze-prepared laboring woman is taught to breathe with her chest, not abdominal, muscles. When deep chest breathing patterns are used in Lamaze preparation, they are slowly paced at a rate of 6-9 breaths/min.
A client with myasthenia gravis is admitted in a cholinergic crisis. Signs of of cholinergic crisis include:
- A. Decreased blood pressure and constricted pupils
- B. Increased heart rate and increased respirations
- C. Increased respirations and increased blood pressure
- D. Anoxia and absence of the cough reflex
Correct Answer: A
Rationale: Cholinergic crisis, often from excessive anticholinesterase medication, causes parasympathetic overstimulation, leading to decreased blood pressure and constricted pupils.
The client is diagnosed with a urinary tract infection. Which instruction should the nurse include in the discharge teaching?
- A. Limit fluid intake to reduce bladder irritation.'
- B. Take all prescribed antibiotics as directed.'
- C. Avoid sexual activity permanently.'
- D. Use heating pads to relieve discomfort.'
Correct Answer: B
Rationale: Completing the full course of antibiotics is essential to eradicate the infection and prevent resistance in a urinary tract infection. Fluid intake should increase, sexual activity can resume after treatment, and heating pads may not be advised.
A healthcare worker is referred to the nursing office with a suspected latex allergy. The first symptom of latex allergy is usually:
- A. Oral itching after eating bananas
- B. Swelling of the eyes and mouth
- C. Difficulty in breathing
- D. Swelling and itching of the hands
Correct Answer: D
Rationale: Latex allergy often first presents as localized skin reactions, such as swelling and itching of the hands, due to direct contact with latex products.