Nokea
The nurse is participating in discharge teaching for the postpartal client. The nurse is aware that an effective means of managing discomfort associated with an episiotomy after discharge is:
- A. Promethazine
- B. Aspirin
- C. Sitz baths
- D. Ice packs
Correct Answer: C
Rationale: A sitz bath is an effective method for managing discomfort associated with an episiotomy after discharge. It helps reduce swelling and promotes healing in the perineal area. Ice packs (option D) are typically used immediately after delivery to provide pain relief. Promethazine (option A) and aspirin (option B) are not indicated for managing discomfort associated with an episiotomy. Promethazine is an antihistamine, and aspirin is a nonsteroidal anti-inflammatory drug, both of which are not commonly used for this purpose.
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A client asks the nurse if all donor blood products are cross-matched with the recipient to prevent a transfusion reaction. Which of the following always requires cross-matching?
- A. packed red blood cells
- B. platelets
- C. plasma
- D. granulocytes
Correct Answer: A
Rationale: Corrected Rationale: Packed red blood cells contain antigens and antibodies that must be matched between the donor and recipient to prevent transfusion reactions. Platelets, plasma, and granulocytes do not contain red blood cells, so they do not require cross-matching. Platelets are matched based on ABO compatibility, while plasma and granulocytes are not routinely cross-matched as they lack red cell antigens.
A man reports his wife is constantly cleaning, which interferes with family life. Friends avoid visiting due to feeling uncomfortable. The husband finds her cleaning even at night. The nurse should consult and recommend the husband help with therapy by:
- A. telling his wife to stop cleaning whenever he notices her actions.
- B. making a baseline record of the time the wife spends cleaning.
- C. decreasing the stimuli in the home.
- D. helping his wife with the cleaning.
Correct Answer: C
Rationale: The correct answer is to decrease the stimuli in the home. The wife's behavior suggests obsessive-compulsive disorder, an anxiety disorder. By reducing stimuli in the environment, such as clutter or triggers that prompt cleaning, it helps in managing the condition and promoting a calmer atmosphere. Option A is incorrect as directly telling the wife to stop can escalate her anxiety. Option B is not the priority initially, as addressing the root cause is more crucial. Option D may reinforce the behavior rather than addressing the underlying issue.
The nurse is developing a care plan for a client with severe anxiety. An appropriate outcome for the client is that within 4 days the client should:
- A. Have decreased anxiety.
- B. Talk to the nurse for 10 minutes.
- C. Sit quietly for 30 minutes.
- D. Develop an adaptive coping mechanism.
Correct Answer: B
Rationale: When developing outcome criteria for a client with severe anxiety, it is crucial for the goals to be specific, measurable, and realistic. In this scenario, the most appropriate outcome is for the client to talk to the nurse for 10 minutes within 4 days. This goal is specific (talking for a defined duration), measurable (10 minutes), and realistic given the client's condition. Expecting a severely anxious client to sit quietly for 30 minutes is not realistic and may even exacerbate their anxiety. While developing an adaptive coping mechanism is important, it is a broader long-term goal and may not be achievable within the specified timeframe. Having decreased anxiety is a desirable outcome, but it lacks specificity and measurability, making it less suitable as an immediate goal.
A nurse is teaching the mother of an 11-month-old infant how to clean the infant's teeth. The nurse tells the mother to take which action?
- A. Use a small amount of toothpaste and a soft-bristle toothbrush
- B. Use water and a cotton swab and rub the teeth
- C. Use diluted fluoride and rub the teeth with a soft washcloth
- D. Dip the infant's pacifier in maple syrup so that the infant will suck
Correct Answer: C
Rationale: The correct action when cleaning an infant's teeth is to use water and a cotton swab to gently rub the teeth. This method helps in removing any food particles or plaque buildup without the risks associated with toothpaste ingestion. Using a small amount of toothpaste and a soft-bristle toothbrush is not recommended for infants as they may swallow the toothpaste, leading to potential fluoride ingestion issues. Using diluted fluoride and rubbing the teeth with a soft washcloth is unnecessary at this age since infants typically receive fluoride through other sources like formula. Dipping the infant's pacifier in maple syrup is highly inappropriate and poses a significant risk of tooth decay due to the high sugar content, which can harm the infant's teeth.
The nurse is caring for a client with epilepsy who is being treated with carbamazepine (Tegretol). Which laboratory value might indicate a serious side effect of this drug?
- A. Uric acid of 5 mg/dL
- B. Hematocrit of 33%
- C. WBC 2,000 per cubic millimeter
- D. Platelets 150,000 per cubic millimeter
Correct Answer: C
Rationale: Carbamazepine (Tegretol) can suppress the bone marrow, leading to a decrease in the white blood cell count. A laboratory value of WBC 2,000 per cubic millimeter indicates a serious side effect of the drug. Choices A and D are within normal limits, while choice B is at the lower limit of normal. Therefore, choices A, B, and D are incorrect.