Nokea
The nurse is caring for a newborn who has a large myelomeningocele. It would be a priority for the nurse to
- A. check the newborn's anus for muscle tone
- B. cover the area with a sterile, moist dressing
- C. measure the occipital frontal circumference
- D. place the newborn in the supine position
Correct Answer: B
Rationale: A myelomeningocele requires a sterile, moist dressing (B) to prevent infection and drying. Checking anus tone (A), measuring head circumference (C), and supine positioning (D) are secondary or contraindicated.
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A pediatric client has been receiving Amoxil (amoxicillin) for acute otitis media. It is important the child receive all the medication. Which secondary disorder is associated with improper management of acute otitis media?
- A. Cholesteatoma
- B. Mastoiditis
- C. Acoustic neuroma
- D. Presbycusis
Correct Answer: B
Rationale: Improper management of acute otitis media can lead to mastoiditis, an infection of the mastoid bone that can result from untreated or inadequately treated ear infections. Answer A (cholesteatoma) is a possible complication but less directly associated with improper antibiotic management. Answer C (acoustic neuroma) is unrelated to otitis media. Answer D (presbycusis) is age-related hearing loss, not a complication of otitis media.
The nurse is caring for a client with benign prostatic hypertrophy (BPH). Which of the following assessments would the nurse anticipate finding?
- A. Large volume of urinary output with each voiding
- B. Involuntary voiding with coughing and sneezing
- C. Frequent urination
- D. Urine is dark and concentrated
Correct Answer: C
Rationale: Frequent urination. BPH causes overflow incontinence with frequent urination in small amounts due to bladder obstruction.
The nurse is reinforcing instructions about the use of regular and neutral protamine Hagedorn (NPH) insulin. Which statement by the client indicates that further instruction is needed?
- A. I will always check my blood glucose prior to using the sliding scale.
- B. I will eat breakfast 30 minutes after taking my morning NPH and regular insulin.
- C. I will use a new insulin syringe each time I give myself an injection.
- D. I will use the sliding scale to determine my NPH dose 4 times a day.
Correct Answer: B
Rationale: Eating 30 minutes after NPH and regular insulin (B) risks hypoglycemia, as regular insulin acts within 30 minutes. Checking glucose (A), using new syringes (C), and sliding scale for regular insulin (D) are correct.
A nurse who is evaluating a developmentally challenged 2 year-old should stress which goal when talking to the child's mother?
- A. Teaching the child self care skills
- B. Preparing for independent toileting
- C. Promoting the child's optimal development
- D. Helping the family decide on long term care
Correct Answer: C
Rationale: Promoting the child's optimal development. The primary goal is to promote the child's optimum development.
A client receiving end-of-life care is no longer able to make decisions. The client's appointed medical power of attorney (MPOA) is considering placement of a percutaneous enterogastric feeding tube. The MPOA asks the nurse, 'What would you do if this was your family member?' How should the nurse respond?
- A. I'm not sure what I would do, but I feel confident that you will make the right decision.
- B. I will call the chaplain to help you sort through the options and discuss the issue.
- C. What do you think are the advantages and disadvantages of a feeding tube?
- D. You should meet with the family to discuss what the patient would have wanted.
Correct Answer: C
Rationale: Exploring pros and cons (C) empowers the MPOA to make an informed decision. Personal opinions (A), chaplain referral (B), or family meetings (D) are less direct.