Nokea
The new mother asks why her baby has lost weight since he was born. The best explanation of the weight loss is:
- A. The baby is dehydrated due to polyuria.
- B. The baby is hypoglycemic due to lack of glucose.
- C. The baby is allergic to the formula the mother is giving him.
- D. The baby can lose up to 10% of weight due to meconium stool, loss of extracellular fluid, and initiation of breastfeeding.
Correct Answer: D
Rationale: After birth, newborns can lose weight due to meconium stool, loss of extracellular fluid, and the initiation of breastfeeding. This weight loss is a normal and expected physiological process, and infants can lose up to 10% of their birth weight during this period. There is no indication of dehydration (polyuria), hypoglycemia (lack of glucose), or allergy to the formula as reasons for weight loss in newborns. Therefore, answers A, B, and C are incorrect. Answer D provides the most accurate explanation for the observed weight loss in the newborn.
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Which of the following coping mechanisms protects an individual from anxiety?
- A. denial and fantasy
- B. rationalization and suppression
- C. regression and displacement
- D. reaction formation and projection
Correct Answer: A
Rationale: The correct answer is 'denial and fantasy.' Denial involves blocking external events from awareness to avoid anxiety, while fantasy is escaping to a more comfortable, less threatening place. These mechanisms can protect individuals from anxiety by providing temporary relief or distraction. Choices B, C, and D are incorrect. Rationalization and suppression do not directly protect individuals from anxiety. Regression and displacement involve reverting to earlier developmental stages or redirecting emotions to a substitute target, which do not directly shield individuals from anxiety. Reaction formation and projection entail behaving in the opposite way to one's impulses or attributing one's feelings to others respectively, which do not directly protect individuals from anxiety.
Several clients are admitted to the emergency room following a three-car vehicle accident. Which clients can be assigned to share a room in the emergency department during the disaster?
- A. The schizophrenic client experiencing visual and auditory hallucinations and the client with ulcerative colitis
- B. The client who is 6 months pregnant with abdominal pain and the client with facial lacerations and a broken arm
- C. A child with fixed and dilated pupils and his parents, and the client with a frontal head injury
- D. The client who arrives with a large puncture wound to the abdomen and the client with chest pain
Correct Answer: B
Rationale: The correct answer is to assign the client who is 6 months pregnant with abdominal pain and the client with facial lacerations and a broken arm to share a room. The pregnant client needs close monitoring due to the abdominal pain, and the client with facial lacerations and a broken arm requires immediate attention for wound care and possible fracture management. Choice A should not be assigned together as the schizophrenic client experiencing visual and auditory hallucinations needs a separate room for privacy and safety, and the client with ulcerative colitis may require isolation due to the risk of infection. Choice C is incorrect because the child with fixed and dilated pupils is likely in a critical condition and should be in a private room with parents, while the client with a frontal head injury needs a separate room for focused care. Choice D is also incorrect as the client with a large puncture wound to the abdomen needs immediate attention in a separate room, and the client with chest pain requires evaluation and monitoring in a separate setting as well.
The client is visiting a home health client with osteoporosis. The client has a new prescription for alendronate (Fosamax). Which instruction should be given to the client?
- A. Rest in bed after taking the medication for at least 30 minutes
- B. Avoid rapid movements after taking the medication
- C. Take the medication with water only
- D. Allow at least 1 hour between taking the medicine and taking other medications
Correct Answer: B
Rationale: When a client is prescribed alendronate (Fosamax), instructing them to avoid rapid movements after taking the medication is crucial to prevent esophageal irritation. Resting in bed after taking the medication for at least 30 minutes (choice A) is not necessary and can increase the risk of side effects. While taking the medication with water only (choice C) is generally recommended, the key instruction to prevent esophageal irritation is to avoid rapid movements. Allowing at least 1 hour between taking the medicine and other medications (choice D) is not specifically related to the administration of alendronate and is not the primary concern when giving instructions to the client.
What should the charge nurse do after overhearing the patient care assistant speaking harshly to the client with dementia?
- A. Change the patient care assistant's assignment
- B. Explore the interaction with the patient care assistant
- C. Discuss the matter with the client's family
- D. Initiate a group session with the patient care assistant
Correct Answer: B
Rationale: The best action for the charge nurse to take is to explore the interaction with the patient care assistant. This step allows for clarification of the situation and direct addressing of the issue. Changing the patient care assistant's assignment (choice A) might be necessary, but understanding the situation should come first. Discussing the matter with the client's family (choice C) as an initial step could escalate the situation. Initiating a group session with the patient care assistant (choice D) could be considered later as a preventive measure to avoid similar incidents in the future.
During the history assessment of an 80-year-old client, which statement made by the client might indicate a possible fluid and electrolyte imbalance?
- A. "My skin is always so dry."?
- B. "I often use a laxative for constipation."?
- C. "I have always liked to drink a lot of iced tea."?
- D. "I sometimes have a problem with dribbling urine."?
Correct Answer: B
Rationale: The correct answer is "I often use a laxative for constipation." Frequent use of laxatives can lead to diarrhea and electrolyte loss, indicating a possible fluid and electrolyte imbalance. Statements A, C, and D are not directly related to fluid and electrolyte imbalance. Statement A about dry skin may suggest dehydration, but it is less specific to electrolyte imbalance than the frequent use of laxatives. Statement C about drinking a lot of iced tea could potentially relate to fluid intake, but it doesn't directly indicate an imbalance. Statement D about dribbling urine is more indicative of a potential urinary issue rather than a fluid and electrolyte imbalance.