Nokea
The nurse is planning care for a family expecting their newborn to die. The nurse's interventions should be based on which statement?
- A. Tangible remembrances of the newborn (e.g., lock of hair, picture) prolong grief.
- B. Photographs of newborns should not be taken after the death has occurred.
- C. Funerals are not recommended because mother is still recovering from childbirth.
- D. Parents should be encouraged to name their newborn if they have not done so already.
Correct Answer: D
Rationale: Parents should be encouraged to name their newborn if they have not done so already because giving the baby a name can help the parents acknowledge their baby as a unique individual. It can also provide a sense of connection and identity, which can be important for the grieving process and coping with the loss. Naming the baby allows the parents to honor their child's existence and memory, and it can be a meaningful part of their healing journey.
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Blood cells are formed in the:
- A. Arterioles
- B. Lymphoid tissue
- C. Bone marrow
- D. Muscle tissue
Correct Answer: C
Rationale: Blood cells are formed in the bone marrow, which is a soft tissue found in the center of most bones in the body. The process of blood cell formation is known as hematopoiesis. Bone marrow contains stem cells that can develop into different types of blood cells, including red blood cells, white blood cells, and platelets. These blood cells play essential roles in carrying oxygen, fighting infections, and assisting in blood clotting. While the other choices listed (arterioles, lymphoid tissue, and muscle tissue) have important functions in the body, blood cell formation specifically occurs primarily in the bone marrow.
A client with a cerebellar brain tumor is admitted to an acute care facility. The nurse formulates a nursing diagnosis of Risk for injury. Which "related-to" phrase should the nurse add to complete the nursing diagnosis statement?
- A. Related to visual field deficits
- B. Related to impaired balance
- C. Related to difficulty swallowing
- D. Related to psychomotor seizures
Correct Answer: B
Rationale: A client with a cerebellar brain tumor is likely to experience impaired balance due to the location of the tumor affecting the cerebellum, which is responsible for coordinating movement and balance. Impaired balance increases the risk for falls and other injuries, making it a priority concern for the client. Therefore, adding "Related to impaired balance" to the nursing diagnosis statement would be the most appropriate choice to address the client's risk for injury in this situation.
When evaluating the effectiveness of nursing interventions for sinusitis discomfort, which of the following does the nurse assess?
- A. WBC count
- B. Capillary refill
- C. Amount and color of sinus drainage
- D. Comfort level
Correct Answer: C
Rationale: When evaluating the effectiveness of nursing interventions for sinusitis discomfort, assessing the amount and color of sinus drainage is crucial. Changes in these aspects can provide valuable information about the progression of the sinusitis and the effectiveness of the interventions being implemented. Increased or purulent sinus drainage can indicate infection or inflammation, while clearer drainage may suggest improvement. Monitoring these parameters helps the nurse make informed decisions about continuing, modifying, or discontinuing interventions to manage the patient's sinusitis discomfort effectively. Evaluating WBC count, capillary refill, and comfort level are also important assessments in certain situations, but assessing the amount and color of sinus drainage is most directly related to sinusitis symptoms.
The nurse should expect to assess which causative agent in a child with warts?
- A. Bacteria
- B. Fungus
- C. Parasite
- D. Virus
Correct Answer: D
Rationale: Warts are typically caused by a viral infection, specifically the human papillomavirus (HPV). This virus infects the top layer of the skin, causing the skin cells to grow rapidly, leading to the formation of a wart. Other causative agents such as bacteria, fungus, and parasites do not typically cause warts in children. Therefore, when assessing a child with warts, the nurse should expect the causative agent to be a virus, specifically HPV.
Which client statement would indicate to the nurse that the client with polycythemia vera is in need further of instruction?
- A. I'll be flying overseas to see my son and grandchildren for the holidays
- B. I plan to do my leg exercises at least three times a week
- C. I'm going to be walking in the mall everyday to build up my strength
- D. At night when I sleep, I like to use two pillows to raise my head up CARING FOR CLIENTS FOR DISORDERS OF THE LYMPHATIC SYSTEM
Correct Answer: A
Rationale: Clients with polycythemia vera are at an increased risk for developing blood clots due to the increased thickness of their blood. Flying long distances, especially overseas, can further increase this risk. Therefore, traveling long distances by plane can be dangerous for clients with polycythemia vera. The nurse should provide instructions to the client regarding the importance of discussing travel plans with their healthcare provider to ensure appropriate measures are in place to minimize the risk of blood clots.