Nokea
The nurse is interviewing the mother of an infant. She reports, "I had a difficult delivery, and my baby was born preterm." This information should be recorded under which of the following headings?
- A. Past history
- B. Present illness
- C. Chief complaint
- D. Review of systems
Correct Answer: A
Rationale: The information given by the mother about having a difficult delivery and her baby being born preterm is considered part of the past medical history. Past medical history includes previous medical conditions, surgeries, hospitalizations, and significant events related to the patient's health before the current encounter. This information helps healthcare providers understand the patient's background and any potential risks or complications relevant to their current health condition.
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The nurse is conducting teaching for an adolescent being discharged to home after a renal transplant. The adolescent needs further teaching if which statement is made?
- A. "I will report any fever to my primary health care provider."
- B. "I am glad I only have to take the immunosuppressant medication for two weeks."
- C. "I will observe my incision for any redness or swelling."
- D. "I won't miss doing kidney dialysis every week."
Correct Answer: B
Rationale: The statement "I am glad I only have to take the immunosuppressant medication for two weeks" indicates a misunderstanding about the long-term nature of immunosuppressant therapy following a renal transplant. In reality, individuals who undergo a renal transplant need to take immunosuppressant medications for the rest of their lives to prevent rejection of the donor kidney. Failure to adhere to this medication regimen can result in rejection of the transplanted kidney. Therefore, this statement indicates a need for further teaching to ensure the adolescent understands the importance of lifelong immunosuppressant therapy.
On what is successful breastfeeding most dependent?
- A. Mother's socioeconomic level
- B. Size of mother's breasts
- C. Mother's desire to breastfeed
- D. Birth weight of newborn
Correct Answer: C
Rationale: Successful breastfeeding is most dependent on the mother's desire to breastfeed. A mother who is committed and motivated to breastfeed is more likely to overcome any challenges that may arise, such as difficulty latching, low milk supply, or lack of support. The mother's determination and willingness to persevere through any difficulties play a significant role in the success of breastfeeding. Additionally, a positive attitude and mindset can greatly impact the mother's breastfeeding experience and enhance the bond between the mother and baby.
Nurse Kara is giving instructions to an elderly client on diabetic foot care. Which teaching is not part of foot care?
- A. wear comfortable shoes that fit well and protect your feet
- B. trim your toenails straight across and file edges with emery board
- C. wash your feet in hot water to keep feet soft
- D. wear shoes at the beach or on hot pavement
Correct Answer: C
Rationale: Washing your feet in hot water is not recommended as it can actually worsen diabetic foot conditions. Hot water can lead to burns and damage the skin, especially for individuals with reduced sensation in their feet due to diabetes. It is advised to wash feet in warm water instead, avoiding hot temperatures to prevent injuries and complications. The other options provide important aspects of diabetic foot care such as wearing appropriate shoes, trimming toenails carefully, and being mindful of footwear choices to protect the feet.
A 5-year old boy presents with afebrile generalized tonic-clonic seizure lasting for 5 minutes. Previously he was healthy and had no such problem. On examination there is no abnormality. Your plan of management should be:
- A. Start anticonvulsant therapy
- B. Request for an EEG and wait for its report
- C. Request for an EEG and start anticonvulsant therapy immediately
- D. Request for EEG and MRI brain
Correct Answer: C
Rationale: In a first-time generalized seizure, an immediate EEG and starting anticonvulsant therapy is prudent to prevent recurrence, especially if the EEG shows epileptiform activity.
Which gauge IV cannula should the nurse choose when preparing to initiate a blood transfusion?
- A. 18
- B. 24
- C. 22
- D. 28
Correct Answer: A
Rationale: An 18-gauge IV cannula is the most appropriate choice when preparing to initiate a blood transfusion. This larger size allows for the rapid administration of blood products, which is important to prevent clotting and ensure a stable flow of the transfusion. Smaller gauge sizes, such as 22, 24, or 28, may be too slow for transfusion purposes and could potentially lead to delays or complications during the procedure. Therefore, the optimal choice for initiating a blood transfusion is an 18-gauge IV cannula.