Nokea
The nurse is preparing an in-service education to staff about atraumatic care for pediatric patients. Which intervention should the nurse include?
- A. Prepare the child for separation from parents during hospitalization by reviewing a video.
- B. Prepare the child before any unfamiliar treatment or procedure by demonstrating on a stuffed animal.
- C. Help the child accept the loss of control associated with hospitalization.
- D. Help the child accept pain that is connected with a treatment or procedure.
Correct Answer: B
Rationale: Atraumatic care for pediatric patients aims to minimize emotional and psychological distress during hospitalization or medical procedures. Option B, preparing the child before any unfamiliar treatment or procedure by demonstrating it on a stuffed animal, is an appropriate intervention. This technique allows the child to understand what will happen, reduces fear of the unknown, and promotes a sense of control. By using a stuffed animal as a teaching tool, the nurse can provide clear information to the child in a non-threatening way, helping to alleviate anxiety and stress. This intervention encourages trust between the child and healthcare provider and promotes a positive healthcare experience for the pediatric patient.
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The nurse encourages a client with an immunologic disorder to eat a nutritionally balanced diet to promote optimal immunologic function. Autoimmunity has been linked to excessive ingestion of:
- A. Protein
- B. Vitamin A
- C. Fat
- D. Zinc
Correct Answer: C
Rationale: Excessive ingestion of fat has been linked to autoimmunity. A diet high in saturated and trans fats can lead to chronic inflammation and disrupt the balance of immune cells, potentially triggering autoimmune responses in the body. Conversely, a nutritionally balanced diet that includes healthy fats like omega-3 fatty acids from sources such as fish, nuts, and seeds can help support optimal immunologic function and reduce the risk of autoimmune disorders.
Which of the ff is the most important factor in the nursing management of clients who undergo treatment for a malignant tumor ff the urinary diversion procedure?
- A. Placement of IV and central venous pressure lines
- B. Administrating cleansing enemas
- C. Observing for leakage of urine or stool from the anastomosis
- D. Assessing the clients ability to manage self catheterization
Correct Answer: C
Rationale: When a client undergoes treatment for a malignant tumor requiring a urinary diversion procedure, such as a urostomy, it is crucial for nurses to closely monitor for any signs of leakage of urine or stool from the anastomosis site. This is important because it can indicate complications such as infection, poor wound healing, or a breakdown in the surgical site. Detecting and addressing leakage promptly can help prevent further complications and ensure the client's recovery progresses smoothly. While the other options may be important aspects of nursing care, observing for leakage of urine or stool from the anastomosis is the most critical factor in managing clients undergoing treatment for a malignant tumor affecting the urinary system.
The nurse is teaching a client with type 1 diabetes mellitus how to treat adverse reactions to insulin. To reverse a hypoglycemic reaction, the client ideally should ingest an oral carbohydrate. However, this treatment isn't always a possible or safe. Therefore, the nurse should advise the client to keep which alternate treatment on hand?
- A. Epinephrine
- B. 50% dextrose
- C. Glucagon
- D. Hydrocortisone
Correct Answer: C
Rationale: Glucagon is the hormone responsible for raising blood sugar levels in the body. In cases of severe hypoglycemic reactions where the client is unconscious or unable to ingest oral carbohydrates, glucagon can be administered via injection to help raise blood sugar levels rapidly. It is important for clients with type 1 diabetes mellitus to have glucagon on hand as a precautionary measure in case of severe hypoglycemic episodes. Epinephrine is typically used for severe allergic reactions, 50% dextrose is a form of oral carbohydrate, and hydrocortisone is a corticosteroid medication used for various conditions but not for treating hypoglycemia in clients with diabetes.
The nurse is instructing a premenopausal woman about breast self-examination. The nurse should tell the client to do her self-examination:
- A. at the end of her menstrual cycle
- B. on the 1st day of the menstrual cycle
- C. on the same day each month
- D. immediately after her menstrual period
Correct Answer: C
Rationale: The nurse should advise the premenopausal woman to perform her breast self-examination on the same day each month. Regular monthly self-examination helps the woman become familiar with the normal texture and appearance of her breasts, making it easier to detect any changes or abnormalities that may indicate a problem. Performing the examination on the same day each month helps ensure consistency in timing and facilitates the woman to establish a routine for self-examination. This consistent approach increases the likelihood of detecting any changes early, which is crucial for timely medical evaluation and intervention if needed.
A 90 y.o. nursing home resident with stage 2 Alzheimer's disease is found alone and crying in the dining room. She says she lost her mother and doesn't know what to do. Which response by the nurse will help calm the resident?
- A. "Remember your mother has been dead for 30 years. You forgot again, didn't you?"
- B. "I'm sorry you lost your mother; let's go and try to find her."
- C. "Are you feeling frightened? I'm here and I will help you."
- D. "You are 90 years old. It is impossible for your mother to still be living. I know if you try, you can figure out what to do."
Correct Answer: C
Rationale: Option C, "Are you feeling frightened? I'm here and I will help you," is the most appropriate response to help calm the resident. The resident is experiencing confusion and distress, likely due to her Alzheimer's disease. Invalidating her feelings by reminding her of the reality may lead to more confusion and distress. Instead, acknowledging the resident's emotions, offering support, and reassuring her of your presence can help calm her down and provide comfort in the moment. It is important to provide emotional support and reassurance to individuals with Alzheimer's disease, rather than focusing on correcting their statements or reminding them of reality.