Nokea
The nurse is caring for a 6-week-old girl with meningitis. To help her develop a sense of trust, the nurse should:
- A. Give her a small soft blanket to hold
- B. Give her good perineal care after each diaper change
- C. Leave the door open to her room
- D. Pick her up when she cries
Correct Answer: D
Rationale: A soft blanket may be comforting, but it is not directed toward developing a sense of trust. Good perineal care is important, but it is not directed toward developing a sense of trust. An infant with meningitis needs frequent attention, but leaving the door open does not foster trust. Consistently picking her up when she cries will help the child feel trust in her caregivers.
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Which one of the following situations represents a maturational crisis for the family?
- A. A four-year-old entering nursery school
- B. Development of preeclampsia during pregnancy
- C. Loss of employment and health benefits
- D. Hospitalization of a grandfather with a stroke
Correct Answer: A
Rationale: A maturational crisis involves normal developmental transitions, such as a child entering nursery school, which can stress family dynamics.
The predominant purpose of the first Apgar scoring of a newborn is to:
- A. Determine gross abnormal motor function
- B. Obtain a baseline for comparison with the infant's future adaptation to the environment
- C. Evaluate the infant's vital functions
- D. Determine the extent of congenital malformations
Correct Answer: C
Rationale: Apgar scores are not related to the infant's care, but to the infant's physical condition. Apgar scores assess the current physical condition of the infant and are not related to future environmental adaptation. The purpose of the Apgar system is to evaluate the physical condition of the newborn at birth and to determine if there is an immediate need for resuscitation. Congenital malformations are not one of the areas assessed with Apgar scores.
The client is diagnosed with glaucoma. Which medication is most likely to be prescribed?
- A. Timolol (Timoptic)
- B. Atropine (Isopto Atropine)
- C. Pilocarpine (Isopto Carpine)
- D. Acetazolamide (Diamox)
Correct Answer: A
Rationale: Timolol, a beta-blocker, is commonly prescribed for glaucoma to reduce intraocular pressure by decreasing aqueous humor production. Atropine increases pressure, pilocarpine is less common, and acetazolamide is used acutely.
A 45-year-old male client experiences a sense of depression because he has not yet achieved his life's goals. His career has not been satisfying. He is still looking for the right job. His wife spends too much money, and his children seem to ignore him while being very selfish. He is tired of all of their attitudes and is considering buying a red Corvette convertible. While obtaining these data concerning the client's feelings about his life, the nurse is able to determine he is experiencing what psychological crisis according to Erikson's stages?
- A. Identity versus role confusion
- B. Integrity versus despair
- C. Intimacy versus isolation
- D. Generativity versus self-absorption
Correct Answer: D
Rationale: Identity versus role confusion is experienced by adolescents making the transition from childhood to adulthood as they attempt to develop a sense of identity. Integrity versus despair is experienced by the elderly as they reflect on their life in an attempt to find meaning. Intimacy versus isolation is experienced by young adults as they establish intimate bonds of love and friendship. Generativity versus self-absorption is experienced by middle-aged adults as they fulfill life goals that involve family, career, and society. The client is experiencing this crisis.
Because a client is taking an MAO inhibitor, it is necessary to discuss the need for adherence to a low-tyramine diet. Which of the following are foods that she should avoid?
- A. Pickled, aged, smoked, and fermented foods
- B. Fresh vegetables
- C. Broiled fresh fish and fowl
- D. Fresh fruit such as apples and oranges
Correct Answer: A
Rationale: These foods may produce elevation in blood pressure when consumed during MAO inhibition therapy. These foods have not been pickled, fermented, smoked, or aged. They contain very little, if any, tyramine or tryptophan. As long as the meat has not been aged or smoked, it is within the dietary regimen. Fresh fruits can be consumed as desired. However, the consumption of bananas is limited.