Nokea
The nurse is caring for a patient who experienced a thermal injury two weeks ago. The nurse would be MOST concerned if which of the following is observed?
- A. Increased heart rate and elevated blood pressure.
- B. Temperature of 100.6°F (38.1°C) and decreased respiratory rate.
- C. Increased heart rate and decreased respiratory rate.
- D. Increased respiratory rate and decreased blood pressure.
Correct Answer: D
Rationale: may indicate burn wound sepsis, a life-threatening complication of thermal injury
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The homecare nurse is visiting an infant who had a myelomeningocele repair.
The homecare nurse determines that the parents are accepting of their infant if which of the following is observed?
- A. The parents state that the infant will outgrow this problem in time.
- B. The parents ask a neighbor to perform bladder expression.
- C. The parents measure the head circumference daily.
- D. The parents relate that they believe the child will walk in one year.
Correct Answer: C
Rationale: Strategy: Think about each statement and how it relates to myelomeningocele. (1) child has a chronic problem (2) indicates the parents' lack of interest and inability to care for the child (3) correct-parents' participation in care may be first sign of acceptance; head circumference measurement is important due to risk of hydrocephalus following surgery; even simple care like bathing child could bring acceptance (4) shows a lack of understanding about myelomeningocele
A 20-year-old primipara attends a class for women who plan to breastfeed. To prepare for breastfeeding, the nurse should encourage the women to
- A. apply moisturizer to their breasts every day after bathing.
- B. expose their breasts to air every day for 20 minutes.
- C. wash their breasts with water and rub with a towel every day.
- D. massage their breasts to increase circulation twice daily.
Correct Answer: C
Rationale: prepares nipples for stretching action of sucking during breastfeeding, soap avoided to prevent drying
The nurse takes a history from a woman in the prenatal clinic. The nurse identifies that which of the following pregnant women is MOST likely to have an Rh-incompatibility problem?
- A. An Rh-positive woman pregnant for the third time who conceived with an Rh-negative man and never has received RhoGAM.
- B. An Rh-negative woman who conceived with an Rh-positive man who has Rh antibodies.
- C. An Rh-positive woman who previously aborted a fetus at 12 weeks gestation and did not receive RhoGAM and now conceived with an Rh-positive man.
- D. An Rh-negative woman who never received RhoGAM and now conceived with an Rh-negative man.
Correct Answer: B
Rationale: Rh-positive dominant, fetus will be Rh-positive, Rh antibodies from the mother will break down fetus's blood cells
Which of the following nursing observations documented in the client's chart MOST clearly indicates the client's mood?
- A. Client states, 'I see snakes climbing on the walls at all times of the day.'
- B. Unable to sustain a train of thought for long periods of time during history-taking.
- C. Clenches her fists and shouts in an angry tone of voice when asked about family problems.
- D. Is unaware of where she is, what day and year it is, or what time it is.
Correct Answer: C
Rationale: gives data that reflect client's feelings, tone, and behavior associated with those feelings, as well as content area of conversation that evoked that mood
The nurse is assessing a pregnant client with problems of mitral stenosis and congestive heart failure (CHF). Which of the following in the client's history would have a direct correlation with her current problem?
- A. History of rheumatic fever four years ago.
- B. Presence of ventricular septal defect as an infant.
- C. Heart disease in both the maternal and the paternal families.
- D. Persistent ear infections and mastoiditis as a child.
Correct Answer: A
Rationale: most common cause of mitral valve problems is a history of rheumatic fever with a subsequent complication of carditis, which affects the valve