Nokea
The nurse is reinforcing teaching about constipation prevention to a client. Which of the following client statements indicate appropriate understanding of the teaching? Select all that apply.
- A. Drinking more caffeinated drinks such as tea and soda helps to stimulate the bowel.
- B. Having a routine for bowel movements is important, but I should not wait if I feel the urge.
- C. I can use an over-the-counter laxative every other day if needed.
- D. I should try to eat more fruits and vegetables every day.
- E. Increasing my daily exercise level may help keep my bowel movements regular.
Correct Answer: B,D,E
Rationale: A routine, high-fiber diet, and exercise prevent constipation. Caffeine can dehydrate, and frequent laxative use is not recommended.
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The nurse is caring for a woman who is admitted for a hysterectomy. The woman does not speak English. No staff members speak the client's language. Which approach by the nurse would be most appropriate when communicating with the client about her care before and after the surgery?
- A. Ask the woman's 8-year-old daughter who speaks English to interpret.
- B. Draw pictures and gesture when speaking to the client.
- C. Speak very slowly when giving the client instructions.
- D. Request an interpreter from social services.
Correct Answer: D
Rationale: The nurse should request an interpreter from social services to ensure accurate communication. Using a child to interpret is inappropriate due to medical terminology and privacy concerns. Pictures, gestures, or slow speech in English are insufficient for surgical care discussions.
A nurse is caring for a client following the delivery of a stillborn infant. Which of the following actions should the nurse take? Select all that apply.
- A. Ask the parents if they would like to help bathe the infant
- B. Discourage the parents from naming the infant
- C. Discuss the importance of organ donation with the parents
- D. Encourage the parents and family members to hold the infant
- E. Offer to obtain handprints, footprints, and photographs of the infant
Correct Answer: A,D,E
Rationale: Bathing, holding, and obtaining mementos support grieving. Naming is a personal choice, and organ donation discussions may be inappropriate at this time.
Which of the following signs is highly suggestive of impaired hearing in an infant?
- A. The absence of the Moro reflex
- B. The absence of babbling by age 7 months
- C. A lack of eye contact when spoken to
- D. A lack of hand gesture to indicate wants
Correct Answer: B
Rationale: Absence of babbling by 7 months is a red flag for hearing impairment, as infants typically begin vocalizing in response to sounds. Other signs are less specific to hearing.
A client with a recent spinal cord injury is experiencing dysreflexia and is noted to have a BP of $240 / 110$. The nurse's initial response should be to:
- A. Check the client's pulse and respiratory rate.
- B. Elevate the client's head to a $45^{\circ}$ angle.
- C. Place the client flat and supine.
- D. Administer antihypertensive and recheck BP in 15 minutes.
Correct Answer: B
Rationale: Elevating the head to a 45° angle helps reduce blood pressure in autonomic dysreflexia by promoting venous return and reducing intracranial pressure.
Which of the following musical instruments is best for a teen with asthma?
- A. Guitar
- B. Piano
- C. Drums
- D. Clarinet
Correct Answer: A
Rationale: The guitar does not require breath control, making it suitable for a teen with asthma, unlike wind instruments like the clarinet.