Nokea
The nurse is discharging a female client from the hospital who has a diagnosis of a thoracic 11 (T11) fracture with cord transection. The nurse has provided home care instructions to the client. Which action indicates the need for further teaching before discharge?
- A. The client jokes about no longer needing to worry about birth control.
- B. The client states that she will be careful to not eat as many dairy products.
- C. The client verbalizes the need to eat her meals at the same time every day.
- D. The client states that she will wash her hands, her perineum, and the catheter with soap and water before performing self-catheterization.
Correct Answer: A
Rationale: Female spinal cord trauma clients remain fertile during their reproductive years, and contraception is necessary for those who are sexually active. However, oral contraceptives may increase the risk for thrombophlebitis. Clients with paralysis should avoid dairy products to control the formation of urinary calculi. Meals should be eaten at the same time every day, and they should include fiber and warm solid and liquid foods to promote and maintain the regular evacuation of the bowel. Clients who lack bladder control are taught to self-catheterize using clean technique.
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A mother infected with hepatitis B asks the nurse about the possibility of breastfeeding her neonate. Which response by the nurse would be most appropriate?
- A. Yes, breastfeeding is an acceptable option.
- B. No, you should not breastfeed your baby.
- C. Yes, breastfeeding is an acceptable option once your baby is immunized with the hepatitis B vaccine.
- D. Bottled formula is just as nutritious for your baby.
Correct Answer: C
Rationale: Breastfeeding is safe for hepatitis B-positive mothers if the neonate is vaccinated and receives immunoglobulin, reducing transmission risk.
The nurse is giving instructions to an adult client with heart failure who is beginning therapy with digoxin. To detect early complications of therapy, which action should the nurse teach the client to perform?
- A. Take the pulse daily.
- B. Have electrolyte levels drawn weekly.
- C. Monitor the blood pressure once a week.
- D. Measure the weight each morning before breakfast.
Correct Answer: A
Rationale: Daily pulse monitoring helps detect digoxin-related complications like bradycardia (pulse <60 beats/min) or tachycardia (>100 beats/min), which require provider notification. Weekly electrolyte levels, blood pressure monitoring, and daily weight are not specific to early digoxin complications.
The nurse is preparing to assess cranial nerve VIII on a client. Which tests will the nurse perform? Select all that apply.
- A. Allen's test
- B. Phalen's test
- C. the Rinne test
- D. the Weber test
Correct Answer: C,D
Rationale: Cranial nerve VIII (vestibulocochlear) is assessed with the Rinne and Weber tests for hearing. Allen's and Phalen's tests assess circulation and carpal tunnel, respectively.
A nurse working in the neonatal intensive care unit (NICU) teaches handwashing techniques to the parents of an infant who is receiving antibiotic treatment for a neonatal infection. The nurse determines that the parents understand the primary purpose of hand washing if which statement is made?
- A. It is primarily done to reduce their fears.
- B. It is primarily done to minimize the spread of infection to other siblings.
- C. It is primarily done to allow them an opportunity to communicate with each other and staff.
- D. It is primarily done to reduce the possibility of transmitting an environmental infection to the infant.
Correct Answer: D
Rationale: Appropriate hand washing by staff and parents has been effective for the prevention of nosocomial infections in nursery units. This action also promotes parents taking an active part in the care of their infant. Reducing fears and encouraging communication are not the primary reasons to perform hand washing. Because the infant already has an infection and is in the NICU, transference to siblings is not the best choice.
Which problems should the nurse counsel adoptive parents about encountering? Select all that apply.
- A. Setting unrealistically high standard for themselves
- B. Lacking basic knowledge about the child's biological health history
- C. Having difficulty assimilating if the child is adopted from another country
- D. Having difficulty deciding when and how to tell the child about being adopted
- E. Feeling the need for more assistance and support in child-rearing than biological parents do
- F. Dealing with feelings of loss and grief in the child regarding family social history and traditions
Correct Answer: A,B,C,D,F
Rationale: Adoptive parents may add pressure to themselves by setting unrealistically high standards for themselves. Additional problems adoptive families may face include possible lack of knowledge about the child's biological health history, difficulty assimilating if the child is adopted from another country, difficulty deciding when and how to tell the child about being adopted, and dealing with social and traditional issues of the biological family. Otherwise, most problems faced by adoptive parents are no different from those encountered by natural parents. All parents want to be good parents. Both adoptive parents and biological parents need information, support, and guidance to prepare them to care for their child.