Nokea
The nurse is assigned to work with the parents of a retarded child.
- A. What should the nurse include in the care plan for the parents of a retarded child?
- B. Interpret the grieving process for the parents.
- C. Discuss the reality of institutional placement.
- D. Assist the parents in making decisions and long-term plans for the child.
- E. Perform a family assessment to assist in the planning of intervention.
Correct Answer: D
Rationale: A family assessment is essential to understand the parents’ grieving, coping, and support needs, guiding tailored interventions. Interpreting grief, discussing placement, or assisting with plans are premature without first assessing the family’s situation.
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A 26-year-old woman has missed her menstrual period. The client's last menstrual period began May 8 and ended May 12.
The nurse determines that her EDC (estimated date of confinement) is
- A. February 1.
- B. February 15.
- C. February 19.
- D. March 14.
Correct Answer: B
Rationale: Strategy: Remember Naegele's rule. (1) should add seven days (2) correct-when using the Naegele rule, add seven days to first day of last menstrual period and subtract three months (3) incorrectly started with the last day of the menstrual cycle (4) incorrect
A client is readmitted with a recurrent urinary tract infection. The client is to be discharged home on methenamine mandelate (Mandelamine). The nurse should instruct the client to limit intake of which of the following fluids?
- A. Milk.
- B. Juices.
- C. Water.
- D. Tea.
Correct Answer: A
Rationale: should limit intake of alkaline foods and fluids, such as milk
One hour after receiving 7 U of regular insulin, the client presents with diaphoresis, pallor, and tachycardia. The priority nursing action would be to
- A. notify the physician.
- B. call the lab for a blood glucose level.
- C. offer the client milk and crackers.
- D. administer glucagon.
Correct Answer: C
Rationale: Diaphoresis, pallor, and tachycardia indicate hypoglycemia, a medical emergency. Milk and crackers provide fast-acting carbohydrates. Options A, B, and D delay treatment or are reserved for severe cases.
Which of the following instructions should be included in the pre-op teaching of a client scheduled for a transphenoidal hypophysectomy for the removal of a pituitary tumor?
- A. It will be necessary to shave some of your hair.
- B. It will be important for you to cough and deep breathe after the surgery.
- C. You will need to lie supine for 24 hours after surgery.
- D. You will not be able to brush your teeth for at least a week after surgery.
Correct Answer: D
Rationale: Post-transphenoidal hypophysectomy, clients avoid brushing teeth for about a week to prevent disruption of the surgical site in the nasal cavity.
A child is admitted in sickle cell crisis. Which factor in the child's history is most likely related to the onset of the crisis?
- A. The child just completed final exams at school.
- B. The child ran a marathon yesterday.
- C. The child recently had a cold.
- D. The child received a hepatitis A immunization two weeks ago.
Correct Answer: C
Rationale: Infections, like a recent cold, can trigger sickle cell crisis by increasing oxygen demand and causing dehydration, leading to sickling of red blood cells.