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The nurse is assessing a child's weight and height during a clinic visit prior to starting school. The nurse plots the child's weight on the growth chart and notes that the child's weight is in the 95th percentile for the child's height. What action should the nurse take?
- A. Question the type and quantity of foods eaten in a typical day.
- B. Encourage giving two additional snacks each day to the child.
- C. Recommend a daily intake of at least four glasses of whole milk.
- D. Assess for signs of poor nutrition, such as a pale appearance.
Correct Answer: A
Rationale: The correct answer is A: Question the type and quantity of foods eaten in a typical day. When a child's weight is in the 95th percentile for their height, it indicates possible overweight or obesity. To address this, the nurse should assess the child's dietary habits to identify any unhealthy eating patterns contributing to excess weight. By questioning the type and quantity of foods eaten, the nurse can provide appropriate guidance on nutrition and healthy eating habits.
Summary:
B: Encouraging additional snacks may further contribute to weight gain and is not recommended without knowing the current eating habits.
C: Recommending a high intake of whole milk may increase calorie intake and potentially worsen the weight concern.
D: Assessing for signs of poor nutrition, such as a pale appearance, is important but not directly addressing the weight concern in this scenario.
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The patient’s significant other is terrified by the prospect o f removing life-sustaining treatments from the patient and asks why anyone would do that. What explanation should the nurse provide?
- A. “It is to save you money so you won’t have such a large financial burden.”
- B. “It will preserve limited resources for the hospital so oatbhirebr.c pomat/tieesnt ts may benefit from them.”
- C. “It is to discontinue treatments that are not helping and may be very uncomfortable.”
- D. “We have done all we can for your wife and any more treatment would be futile.”
Correct Answer: C
Rationale: The correct answer is C because it explains that the decision to remove life-sustaining treatments is based on the fact that these treatments are not helping the patient and may actually be causing discomfort. This rationale aligns with the principle of beneficence, which emphasizes doing good and avoiding harm to the patient. It also respects the patient's autonomy by prioritizing their well-being and quality of life.
Choice A is incorrect as it focuses on financial reasons rather than the patient's best interest. Choice B is incorrect because it prioritizes hospital resources over individual patient care. Choice D is incorrect as it lacks clarity and may come across as insensitive to the significant other's concerns.
A patient in the ICU is recovering from open-heart surgery. The nurse enters his room and observes that his daughter is performing effleurage on his arms and talking in a low voice about an upcoming family vacation that is planned. The room is dimly lit, and she hears the constant beeping of his heart monitor. From the hall she hears the cries of a patient in pain. Which of the following are likely stressors for the patient? Select all that apply.
- A. His daughters conversation
- B. His daughters effleurage
- C. The beeping of the heart monitor
- D. The dim lighting of the room
Correct Answer: C
Rationale: The correct answer is C: The beeping of the heart monitor is a likely stressor for the patient recovering from open-heart surgery in the ICU. The constant beeping can cause anxiety and uncertainty about their health status. The daughter's conversation and effleurage are likely comforting and supportive for the patient, reducing stress. The dim lighting may create a calming environment, and the distant cries of a patient in pain may evoke empathy but may not directly stress the recovering patient. Therefore, the beeping of the heart monitor stands out as a stressor among the choices provided.
A 28-year-old patient who has deep human bite wounds on the left hand is being treated in the urgent care center. Which action will the nurse plan to take?
- A. Prepare to administer rabies immune globulin (BayRab).
- B. Assist the health care provider with suturing the bite wounds.
- C. Teach the patient the reason for the use of prophylactic antibiotics.
- D. Keep the wounds dry until the health care provider can assess them.
Correct Answer: C
Rationale: The correct answer is C: Teach the patient the reason for the use of prophylactic antibiotics. This is the most important action because human bites can introduce harmful bacteria into the wound, leading to infection. Prophylactic antibiotics help prevent infection in deep human bite wounds.
Choice A is incorrect because rabies immune globulin is not indicated for human bite wounds. Choice B is incorrect because suturing human bite wounds can trap bacteria and increase the risk of infection. Choice D is incorrect because keeping the wounds dry is not sufficient; proper wound cleaning and antibiotic treatment are essential in this case.
A client who has active tuberculosis (TB) is admitted to the medical unit. What action is most important for the nurse to implement?
- A. Fit the client with a respirator mask.
- B. Assign the client to a negative air-flow room.
- C. Don a clean gown for client care.
- D. Place an isolation cart in the hallway.
Correct Answer: B
Rationale: The correct answer is B: Assign the client to a negative air-flow room. This is crucial to prevent the spread of TB to other patients and healthcare workers. Negative air-flow rooms help contain airborne pathogens. Option A is not sufficient as it only protects the client, not others. Option C is important for infection control but not the priority in this situation. Option D is not as effective as placing the client in a negative air-flow room. Overall, option B is the best choice to ensure the safety of everyone in the unit.
What is a strategy for preventing thromboembolism in pat ients at risk who cannot take anticoagulants?
- A. Administration of two aspirin tablets every 4 hours.
- B. Infusion of thrombolytics.
- C. Insertion of a vena cava filter.
- D. Subcutaneous heparin administration every 12 hours.
Correct Answer: C
Rationale: The correct answer is C: Insertion of a vena cava filter. This is a strategy for preventing thromboembolism in patients at risk who cannot take anticoagulants. The vena cava filter prevents blood clots from traveling to the lungs by trapping them in the inferior vena cava. It is a mechanical device that does not interfere with the body's clotting process.
Explanation of why other choices are incorrect:
A: Administration of two aspirin tablets every 4 hours is not an effective strategy for preventing thromboembolism in high-risk patients. Aspirin is an antiplatelet agent and may not be sufficient for preventing blood clots in these patients.
B: Infusion of thrombolytics is used for breaking down blood clots that have already formed, not for prevention. It is not a suitable option for preventing thromboembolism in at-risk patients.
D: Subcutaneous heparin administration every 12