Nokea
The nurse is assigned to work with the parents of a retarded child. Which of the following should the nurse include in the care plan for the parents?
- A. Interpret the grieving process for the parents.
- B. Discuss the reality of institutional placement.
- C. Assist the parents in making decisions and long-term plans for the child.
- D. Perform a family assessment to assist in the planning of intervention.
Correct Answer: D
Rationale: assessment, this will help the nurse to know where the family is in regard to grieving, coping, etc.
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A client is admitted for suspected bladder cancer. Which one of the following factors is most significant in the client's diagnosis?
- A. Smoking a pack of cigarettes a day for 30 years
- B. Use of nonsteroidal anti-inflammatories
- C. Eating foods with preservatives
- D. Past employment involving asbestos
Correct Answer: A
Rationale: Long-term smoking is a major risk factor for bladder cancer due to carcinogenic chemicals in tobacco being excreted in urine, irritating the bladder.
The nurse is caring for a neonate whose mother is diabetic. The nurse will expect the neonate to be:
- A. Hypoglycemic, small for gestational age
- B. Hyperglycemic, large for gestational age
- C. Hypoglycemic, large for gestational age
- D. Hyperglycemic, small for gestational age
Correct Answer: C
Rationale: Neonates of diabetic mothers are often large for gestational age and at risk for hypoglycemia due to maternal glucose levels.
The nurse is reviewing the lab results of four clients. Which finding should be reported to the physician?
- A. A client with chronic renal failure with a serum creatinine of 5.6 mg/dL
- B. A client with rheumatic fever with a positive C reactive protein
- C. A client with gastroenteritis with a hematocrit of 52%
- D. A client with epilepsy with a white cell count of 3,800 mm³
Correct Answer: C
Rationale: A hematocrit of 52% in gastroenteritis suggests dehydration, which requires immediate reporting.
The charge nurse is formulating a discharge teaching plan for a client with mild preeclampsia. The nurse should give priority to:
- A. Teaching the client to report a nosebleed
- B. Instructing the client to maintain strict bed rest
- C. Telling the client to notify the doctor of pedal edema
- D. Advising the client to avoid sodium sources in the diet
Correct Answer: A
Rationale: A nosebleed may indicate worsening hypertension in preeclampsia, a critical symptom requiring immediate reporting.
A client with angina is experiencing migraine headaches. The physician has prescribed Sumatriptan succinate (Imitrex). Which nursing action is most appropriate?
- A. Call the physician to question the prescription order
- B. Try to obtain samples for the client to take home
- C. Perform discharge teaching regarding this drug
- D. Consult social services for financial assistance with obtaining the drug
Correct Answer: A
Rationale: Sumatriptan is contraindicated in clients with angina due to its vasoconstrictive effects, which can exacerbate ischemia. The nurse should question the prescription.