The nurse is caring for a 5-year-old child with Reye's syndrome. Which goal of treatment most clearly relates to caring for this child?
- A. Reduce cerebral edema and lower intracranial pressure
- B. Avert hypotension and septic shock
- C. Prevent cardiac arrhythmias and heart failure
- D. Promote kidney perfusion and normal blood pressure
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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The client is 24 hours postpartum and is being discharged. The nurse explains that vaginal discharge will change from red to pink and then to white. If the client starts having red bleeding after the color changes, what should the nurse instruct the client to do?
- A. Reduce activity level and notify the healthcare provider.
- B. Go to bed and assume a knee-chest position.
- C. Massage the uterus and go to the emergency room.
- D. Do not worry as this is a normal occurrence.
Correct Answer: A
Rationale: If the client experiences red bleeding after the color changes, it may indicate possible hemorrhage or retained placental fragments, which require immediate attention. Instructing the client to reduce activity level and notify the healthcare provider is crucial for prompt evaluation and management of potential complications.
When teaching a gravid client how to perform kick (fetal movement) counts, which instruction should the nurse include?
- A. If 10 kicks are not felt within one hour, drink orange juice and count for another hour.
- B. Count the movements once daily, for one hour, before breakfast.
- C. Avoid caffeinated drinks for 24 hours before conducting the kick test.
- D. Exercise for 15 minutes before starting the counting to help increase fetal movement.
Correct Answer: A
Rationale: When teaching a gravid client about kick (fetal movement) counts, the nurse should instruct them that if 10 kicks are not felt within one hour, they should drink orange juice and continue counting for another hour. This instruction is crucial as a drop in fetal movements could indicate potential issues with fetal well-being, and taking action such as rechecking after food intake is recommended to monitor the situation closely.
A 6-year-old with heart failure (HF) gained 2 pounds in the last 24 hours. Which intervention is more important for the nurse to implement?
- A. Graph the daily weight for the past week.
- B. Decrease IV flow rate.
- C. Assess bilateral lung sounds.
- D. Restrict intake of oral fluids.
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Client teaching is an important part of the maternity nurse's role. Which factor has the greatest influence on successful teaching of the gravid client?
- A. The client's readiness to learn.
- B. The client's educational background.
- C. The order in which the information is presented.
- D. The extent to which the pregnancy was planned.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
In caring for a 4-year-old boy recently diagnosed with Duchenne muscular dystrophy (DMD), which characteristic of the disease is most important for the nurse to focus on during the initial teaching?
- A. Lower legs become progressively weaker, causing a waddling, unsteady gait.
- B. Growth and development have been abnormal since birth.
- C. Muscular strength can be regained with physical exercise and therapy.
- D. Respiratory dysfunction and aspiration are prime concerns at this stage of the disease.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.