Nokea
A nurse is performing a routine physical examination on an adolescent client who asks, 'Why do I have to use a condom if my girlfriend is on the pill?' Which of the following is the most appropriate response by the nurse?
- A. You need to use two forms of birth control so if one fails you have a second form of protection against pregnancy.
- B. Using a condom allows you to share the responsibility for birth control.
- C. Oral contraceptives are less than 99 percent effective in adolescents. Therefore, a second form of contraception is needed.
- D. Oral contraceptives are highly effective in preventing pregnancy but do not prevent sexually transmitted diseases.
Correct Answer: D
Rationale: The correct answer is D. The nurse should explain that while oral contraceptives are highly effective in preventing pregnancy, they do not protect against sexually transmitted diseases (STDs). This is important because even if the girlfriend is on the pill, using a condom is necessary to prevent STD transmission. Adolescents are at higher risk for STDs, so it is crucial to emphasize the importance of dual protection. Choice A is incorrect as it does not specifically address the risk of STD transmission. Choice B is incorrect because it focuses on shared responsibility rather than the health implications of using a condom. Choice C is incorrect as it emphasizes the effectiveness of oral contraceptives rather than the need for STD protection.
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A nurse is caring for an adolescent with inadequate weight gain.
- A. "Identify food preferences high in complex carbohydrates."'
- B. "Identify food preferences high in saturated and unsaturated fats."'
- C. "Identify food preferences high in calcium and protein."'
- D. "Identify food preferences high in calories."'
Correct Answer: C
Rationale: The correct answer is C: "Identify food preferences high in calcium and protein." Inadequate weight gain in adolescents can be due to lack of essential nutrients like calcium and protein for growth and development. Calcium is crucial for bone health, while protein is essential for muscle development. Both are important for overall growth. Choices A and D focus on carbohydrates and calories, which are important but not the primary nutrients needed for weight gain in this scenario. Choice B suggests high intake of saturated and unsaturated fats, which can be detrimental to overall health if consumed in excess. Therefore, identifying food preferences high in calcium and protein is the most appropriate choice to address inadequate weight gain in the adolescent.
For a client in the second trimester of pregnancy, which assessment data support a diagnosis of pregnancy-induced hypertension (PIH)?
- A. Hemoglobin 10.2 mg/dL and uterine tenderness
- B. Polyuria and weight loss of 3 pounds in the last month
- C. Blood pressure 168/110 and 3+ proteinuria
- D. Hematuria and blood glucose of 160 mg/dL
Correct Answer: C
Rationale: The correct answer is C: Blood pressure 168/110 and 3+ proteinuria. Pregnancy-induced hypertension (PIH) is characterized by high blood pressure (systolic ≥140 mmHg and/or diastolic ≥90 mmHg) and proteinuria. In this case, the blood pressure reading of 168/110 indicates hypertension, and 3+ proteinuria indicates significant protein in the urine, both of which are key diagnostic criteria for PIH.
A: Hemoglobin 10.2 mg/dL and uterine tenderness - These are not specific indicators of PIH.
B: Polyuria and weight loss of 3 pounds in the last month - These symptoms are not typically associated with PIH.
D: Hematuria and blood glucose of 160 mg/dL - Hematuria suggests blood in the urine, which is not a typical finding in PIH, and elevated blood glucose is more indicative of diabetes rather than PIH.
Therefore,
A nurse is caring for a child with measles.
- A. "Provide diversional activities such as video games."'
- B. "Maintain isolation for 48 hr after the rash resolves."'
- C. "Keep the child warm with adequate undergarments and bedding."'
- D. "Administer vitamin A supplements as prescribed."'
Correct Answer: D
Rationale: The correct answer is D because administering vitamin A supplements is a standard treatment for measles to reduce complications and improve recovery. Vitamin A deficiency is common in children with measles, and supplementation can help boost the immune system and reduce the severity of the illness. Providing diversional activities (choice A) may be suitable but does not directly address the medical needs of the child. Maintaining isolation (choice B) is important but typically lasts until 4 days after rash onset, not just 48 hours after rash resolution. Keeping the child warm (choice C) is a general comfort measure and may not directly impact measles treatment.
Which nursing instruction should be given to the breastfeeding mother regarding care of the breasts after discharge?
- A. Engorgement occurs on about the third or fourth postpartum day and is a result of the breast milk formation. The primary way to relieve engorgement is by pumping or longer nursing. Giving a bottle of formula will compound the problem because the baby will not be hungry and will not empty the breasts well.
- B. Applying lotion to the nipples is not effective for keeping them soft. Excessive amounts of lotion may harbor microorganisms.
- C. In order to stimulate adequate milk production, the breasts should be pumped if the infant is not sucking or eating well, or if the breasts are not fully emptied.
- D. Using soap on the breasts dries the nipples and can cause cracking. The baby should be given a bottle of formula if engorgement occurs.
Correct Answer: C
Rationale: The correct answer is C. It is important to stimulate adequate milk production by pumping if the infant is not sucking or eating well, or if the breasts are not fully emptied. This helps maintain milk supply and prevents engorgement. Option A is incorrect as giving a bottle of formula does not effectively relieve engorgement and can lead to decreased milk production. Option B is incorrect as applying lotion to the nipples is not necessary and may introduce harmful microorganisms. Option D is incorrect as using soap can dry the nipples and lead to cracking, and giving formula is not the recommended solution for engorgement.
Which preoperative nursing interventions should be included for a client who is scheduled to have an emergency cesarean birth?
- A. Monitoring O2 saturations and administering pain medications are postoperative interventions.
- B. Taking vital signs every 15 minutes is a postoperative intervention. Instructing the client regarding breathing exercises is not appropriate in a crisis situation when the client's anxiety is high, because information would probably not be retained. In an emergency, there is time only for essential interventions.
- C. Because this is an emergency, surgery must be performed quickly. Anxiety of the client and the family will be high. Inserting an indwelling catheter helps to keep the bladder empty and free from injury when the incision is made.
- D. The nurse should have assessed breath sounds upon admission. Breath sounds are important if the client is to receive general anesthesia, but the anesthesiologist will be listening to breath sounds in surgery in that case.
Correct Answer: C
Rationale: The correct answer is C because in an emergency cesarean birth, surgery must be performed quickly to ensure the safety of the mother and baby. Inserting an indwelling catheter is crucial to keep the bladder empty and prevent injury during the incision. This intervention helps maintain a sterile field and reduces the risk of infection. Additionally, a full bladder can impede the progress of surgery. Monitoring O2 saturations and administering pain medications (A) are postoperative interventions and not relevant in the preoperative phase. Taking vital signs every 15 minutes (B) is more appropriate for the postoperative period. Assessing breath sounds (D) is important but typically done by the anesthesiologist during surgery. Instructing the client about breathing exercises (B) may not be effective in an emergency situation where immediate interventions are necessary.