The nurse is caring for a child with cystic fibrosis. The nurse would anticipate that the child would be deficient in which vitamins?
- A. B, D, and K
- B. A, D, and K
- C. A, C, and D
- D. A, B, and C
Correct Answer: B
Rationale: Children with cystic fibrosis often have difficulty absorbing fat-soluble vitamins (A, D, and K) due to pancreatic insufficiency, making supplementation necessary. Choice A (B, D, and K) is incorrect because vitamin A deficiency is not commonly associated with cystic fibrosis. Choice C (A, C, and D) is incorrect as vitamin C deficiency is not typically related to cystic fibrosis. Choice D (A, B, and C) is incorrect as vitamin B deficiencies are not commonly seen in cystic fibrosis but rather fat-soluble vitamin deficiencies.
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Diabetes has become a major health problem. How can healthcare professionals contribute to reducing the incidence of diabetes?
- A. Conducting extensive diabetes patient screenings
- B. Supporting the implementation of Republic Act 8191-National Diabetes Act
- C. Creating support groups for diabetes patients
- D. Raising community awareness about diabetes prevention
Correct Answer: D
Rationale: Raising community awareness about diabetes prevention is an effective way to reduce the incidence of diabetes. By educating the public about healthy lifestyle choices, risk factors, and preventive measures, healthcare professionals can empower individuals to make informed decisions regarding their health. Choice A is not as proactive as raising awareness in the community. While screening is important, prevention through awareness can have a broader impact. Choice B is specific to a particular act and may not apply universally. Choice C, establishing support groups, is beneficial for those already affected by diabetes but may not directly reduce the incidence of the disease.
A female client diagnosed with genital herpes simplex virus 2 (HSV 2) complains of dysuria, dyspareunia, leukorrhea, and lesions on the labia and perianal skin. A primary nursing action with the focus of comfort should be to
- A. Suggest 3 to 4 warm sitz baths per day
- B. Cleanse the genitalia twice a day with soap and water
- C. Spray warm water over genitalia after urination
- D. Apply heat or cold to lesions as desired
Correct Answer: A
Rationale: The correct answer is to suggest 3 to 4 warm sitz baths per day. Warm sitz baths can soothe the irritated genital area, reduce pain, and promote healing of the lesions associated with genital herpes. Cleansing the genitalia with soap and water or spraying warm water over the genitalia after urination may further irritate the lesions. Applying heat or cold to lesions as desired may not provide the same level of comfort and healing as warm sitz baths.
While assessing an Rh-positive newborn whose mother is Rh-negative, the nurse recognizes the risk for hyperbilirubinemia. Which of the following should be reported immediately?
- A. Jaundice evident at 26 hours
- B. Hematocrit of 55%
- C. Serum bilirubin of 12 mg/dL
- D. Positive Coombs test
Correct Answer: C
Rationale: A serum bilirubin level of 12 mg/dL in a newborn is concerning and can indicate a significant risk of hyperbilirubinemia, which requires immediate medical intervention to prevent complications like kernicterus. Jaundice at 26 hours (Choice A) is a symptom, not a laboratory result, and needs monitoring but not an immediate report. Hematocrit of 55% (Choice B) may be elevated but is not indicative of hyperbilirubinemia. A positive Coombs test (Choice D) indicates the presence of antibodies on the newborn's red blood cells but does not directly correlate with the risk of hyperbilirubinemia.
A client has just returned to the medical-surgical unit following a segmental lung resection. After assessing the client, the first nursing action would be to:
- A. Administer pain medication
- B. Suction excessive tracheobronchial secretions
- C. Assist the client to turn, deep breathe, and cough
- D. Monitor oxygen saturation
Correct Answer: B
Rationale: After a segmental lung resection, the priority nursing action should be to suction excessive tracheobronchial secretions. This helps in preventing airway obstruction from secretions, ensuring the patency of the airway and optimizing respiratory function. Administering pain medication can be important but addressing airway clearance takes precedence. Assisting the client to turn, deep breathe, and cough is essential for respiratory hygiene but not the first action immediately post-op. Monitoring oxygen saturation is crucial, but ensuring airway clearance is the priority to prevent complications.
The nurse working in a community health clinic that serves recent Somali immigrants notes that most mothers refuse to give permission for routine immunizations of their preschoolers. Which individual is likely to have the most influence on these women's perceptions about their children's healthcare needs?
- A. husbands
- B. clinic healthcare providers
- C. older females
- D. tribal chief
Correct Answer: D
Rationale: In many Somali communities, the tribal chief holds significant influence over health decisions. The tribal chief often plays a crucial role in shaping community beliefs and practices, including healthcare decisions. While husbands may have some influence, the tribal chief typically holds more authority in community matters. Clinic healthcare providers have a role in educating and advising, but the tribal chief's influence is often more profound in this cultural context. Older females may have some influence, especially in familial matters, but the tribal chief is usually the key decision-maker in community health issues.