Nokea
The nurse is caring for a 14 month-old just diagnosed with cystic fibrosis. The parents state this is the first child in either family with this disease, and ask about the risk to future children. What is the best response by the nurse?
- A. 1 in 4 chance for each child to carry that trait
- B. 1 in 4 risk for each child to have the disease
- C. 1 in 2 chance of avoiding the trait and disease
- D. 1 in 2 chance that each child will have the disease
Correct Answer: B
Rationale: 1 in 4 risk for each child to have the disease. Cystic fibrosis is autosomal recessive, with a 25% chance of the disease per pregnancy if both parents are carriers.
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Following a stroke, a client is found to have receptive aphasia. This finding is consistent with damage to:
- A. The frontal lobe
- B. The parietal lobe
- C. The temporal lobe
- D. The occipital lobe
Correct Answer: C
Rationale: Receptive aphasia, difficulty understanding language, is associated with damage to the temporal lobe, specifically Wernicke's area.
An adult client who has a fractured tibia is ordered to take one baby aspirin a day. He says to the nurse, 'I don't think the aspirin is doing any good. I still have pain.' What should the nurse include when replying to this client?
- A. The aspirin is given to prevent clots from forming.'
- B. The aspirin is given to keep your temperature normal.'
- C. The aspirin is given to control your pain and should be helping.'
- D. The aspirin is given to decrease inflammation at the fracture site.'
Correct Answer: A
Rationale: Low-dose aspirin is used to prevent thrombus formation in immobilized clients with fractures. It's not primarily for fever, pain, or inflammation in this context.
The physician has ordered Prednisone 50 mg daily to promote diuresis in a client with nephrotic syndrome. The nurse should administer the medication:
- A. In a single dose at bedtime
- B. With a snack or glass of milk
- C. With water to promote absorption
- D. Prior to arising in the morning
Correct Answer: B
Rationale: Prednisone, a steroid, should be given with a snack or meal to prevent gastric irritation. Answer C would cause pain and gastric upset, making it incorrect. Answers A and D do not include providing food with the medication, so they are incorrect.
A nurse performing actions that would be considered negligence.
Which of the following actions, if performed by the nurse, would be considered negligence?
- A. Obtaining a Guthrie Blood Test on a four-day-old infant.
- B. Massaging lotion on the abdomen of a three-year-old diagnosed with Wilm's tumor.
- C. Instructing a five-year-old asthmatic to blow on a pinwheel.
- D. Playing kickball with a 10-year-old with juvenile arthritis (JA).
Correct Answer: B
Rationale: Strategy: 'Would be considered negligence' indicates an incorrect action. (1) obtain after ingestion of protein, no later than 7 days after delivery (2) correct-manipulation of mass may cause dissemination of cancer cells (3) this exercise extends expiratory time and increases expiratory pressure (4) excellent moving and stretching exercise
While giving care to a 2 year-old client, the nurse should remember that the toddler's tendency to say 'no' to almost everything is an indication of what psychosocial skill?
- A. Stubborn behavior
- B. Rejection of parents
- C. Frustration with adults
- D. Assertion of control
Correct Answer: D
Rationale: Assertion of control. Negativity is a normal behavior in toddlers. The nurse must be aware that this behavior is an important sign of the child's progress from dependency to autonomy and independence.