Nokea
The nurse has been caring for a newborn who just died. The parents are present but say they are "afraid" to hold the dead newborn. Which is the most appropriate nursing intervention?
- A. Tell them there is nothing to fear.
- B. Insist that they hold newborn "one last time."
- C. Respect their wishes and release body to morgue.
- D. Keep newborn's body available for a few hours in case they change their minds.
Correct Answer: D
Rationale: The most appropriate nursing intervention in this situation is to keep the newborn's body available for a few hours in case the parents change their minds. It is important to respect the parents' feelings and fears while also providing them with the opportunity to hold their child if they decide to do so later on. By keeping the newborn's body available, the parents can have the time and space they need to process their emotions and make a decision that feels right for them. This approach supports the parents' autonomy and allows them to grieve in a way that is meaningful to them.
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Which is a common side effect of short-term corticosteroid therapy?
- A. Fever
- B. Hypertension
- C. Weight loss
- D. Increased appetite
Correct Answer: D
Rationale: Increased appetite is a common side effect of short-term corticosteroid therapy. Corticosteroids can affect the areas of the brain that control appetite, leading to an increase in hunger and potentially weight gain. While weight loss can occur with long-term corticosteroid use, short-term therapy is more likely to cause increased appetite as a side effect. Fever and hypertension are less commonly associated with short-term corticosteroid therapy.
The nurse practitioner assesses a client in the physician's office. Which assessment findings support a suspicion of systemic lupus erythematosus (SLE)?
- A. Facial erythema, profuse proteinuria, pleuritis, fever, and weight loss
- B. Pericarditis, photosensitivity, polyarthralgia, and painful mucous membrane ulcers
- C. Weight gain, hypervigilance, hypothermia, and edema of the legs
- D. Hypothermia, weight gain, lethargy, and edema of the arms
Correct Answer: B
Rationale: Systemic lupus erythematosus (SLE) is a chronic autoimmune disease that can affect various organs and tissues in the body. The assessment findings listed in option B are more indicative of SLE:
The parents of a newborn plan to have him circumcised. They ask the nurse about pain associated with this procedure. What knowledge should the nurse's response be based on?
- A. Experience pain with circumcision
- B. Do not experience pain with circumcision
- C. Quickly forget about the pain of circumcision
- D. Are too young for anesthesia or analgesia
Correct Answer: B
Rationale: The response should be based on the fact that newborns do not experience pain with circumcision. This is because newborns do not have a fully developed neurological system to perceive pain in the same way that adults do. Studies have shown that the pain response in newborns is limited, and they are able to quickly recover from minor procedures like circumcision without experiencing long-lasting pain. Therefore, the nurse should inform the parents that newborns do not experience pain with circumcision. This is important for providing accurate information and alleviating the concerns of the parents.
Which of the following actions should the nurse take to maintain patient safety when ambulating a patient for the first time postoperatively?
- A. Use one person to assist patient.
- B. Use two people to assist patient.
- C. Encourage patient to "dangle" self 1 hour before ambulation.
- D. Give narcotic 15 minutes before ambulation.
Correct Answer: B
Rationale: When ambulating a patient for the first time postoperatively, it is crucial to ensure patient safety by using two people to assist the patient. This helps in providing adequate support and stability, especially if the patient is weak, dizzy, or at risk of falling. Having two people allows for better control over the patient's movement and reduces the risk of accidents or falls during ambulation. Additionally, having an extra person provides assistance in case the patient becomes unsteady or requires immediate support.
The mother of a child with a congenital cardiac defect asks the nurse why her child squats after exertion. The nurse should reply that this position:
- A. Reduces muscle aches
- B. Increases cardiac efficiency
- C. Enhances the pull of gravity
- D. Decreases blood volume in the extremities
Correct Answer: B
Rationale: The position of squatting after exertion increases cardiac efficiency in children with congenital cardiac defects, specifically those with Tetralogy of Fallot. By squatting, the child decreases systemic vascular resistance and increases systemic venous return, which helps to enhance cardiac output by improving blood flow to the lungs. This position allows for better oxygenation of the blood and helps alleviate cyanosis in children with Tetralogy of Fallot.