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The nurse is teaching health education classes to a group of expectant parents, and the topic is preventing cognitive impairment caused by congenital hypothyroidism. What should the nurse tell the parents is the most effective means of promoting early intervention?
- A. Vitamin intake
- B. Neonatal screening
- C. Adequate protein intake
- D. Limiting alcohol consumption
Correct Answer: B
Rationale: Congenital hypothyroidism is a common preventable cause of cognitive impairment. Neonatal screening is the only means of early diagnosis followed by intervention and the subsequent prevention of cognitive impairment. Newborn infants are screened for congenital hypothyroidism before discharge from the newborn nursery and before 7 days of life. Treatment is begun immediately, if necessary. Vitamin intake and adequate protein will not specifically prevent this disorder. Alcohol consumption during pregnancy needs to be restricted rather than just limited.
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The nurse reviews the pattern of a nonstress test performed on a pregnant client and interprets the finding as which result? (Refer to figure.)
- A. Reactive
- B. Abnormal
- C. Nonreactive
- D. Non-reassuring
Correct Answer: A
Rationale: A nonstress test assesses fetal well-being and evaluates the ability of the fetal heart to accelerate, often in association with fetal movement. Accelerations of the fetal heart rate are associated with adequate oxygenation, a healthy neural pathway, and the fetal heart's ability to respond to stimuli. A reactive test is described as at least two fetal heart rate accelerations, with or without fetal movement, occurring within a 20-minute period and peaking at least 15 beats/minute above the baseline and lasting 15 seconds from baseline to baseline. This recording (see figure) identifies a reactive nonstress test. The fetal heart rate acceleration peaks at least 15 beats/minute and lasts for at least 15 seconds in response to fetal movement. A nonreactive test is an abnormal or nonreassuring test. In a nonreactive test, the recording does not demonstrate the required characteristics of a reactive test within a 40-minute period.
The nurse teaches a preoperative client about the nasogastric (NG) tube that will be inserted in preparation for surgery. The nurse determines that the client understands when the tube will be removed during the postoperative period based on which statement by the client?
- A. When my doctor says so.
- B. When I can tolerate food without vomiting.
- C. When my gastrointestinal (GI) system is healed.
- D. When my bowels begin to function again and I begin to pass gas.
Correct Answer: D
Rationale: NG tubes are discontinued when normal function returns to the GI tract. Although the surgeon determines when the NG tube will be removed, 'When my doctor says so' does not determine the effectiveness of teaching. Food would not be administered unless bowel function returns. The tube will be removed well before GI healing occurs.
The home care nurse visits a child diagnosed with scarlet fever who is being treated with penicillin G potassium. The mother tells the nurse that the child has only voided a small amount of tea-colored urine since the previous day. The mother also reports that the child's appetite has decreased and that the child's face was swollen this morning. How should the nurse interpret these new signs/symptoms?
- A. Nothing to be concerned about
- B. Signs/symptoms of acute glomerulonephritis
- C. Signs/symptoms of the normal progression of scarlet fever
- D. Symptoms of an allergic reaction to penicillin G potassium
Correct Answer: B
Rationale: Scarlet fever is an infectious and communicable disease caused by group A beta-hemolytic streptococci. The signs/symptoms identified in the question indicate acute glomerulonephritis, indicative of nephrotoxicity. These signs/symptoms are not normal and should not be ignored. Although the child is receiving penicillin G potassium, these are not signs/symptoms of an allergic reaction.
The client diagnosed with prostatitis asks the nurse, 'Why do I need to take a stool softener? The problem is with my urine, not my bowels!' Which response should the nurse make to the client?
- A. This is a standard medication prescription for anyone with a urine problem.
- B. This will keep the bowel free of feces, which helps decrease the swelling inside.
- C. Being constipated puts you at more risk for developing complications of prostatitis.
- D. This will help you prevent constipation because straining is painful with prostatitis.
Correct Answer: D
Rationale: Stool softeners prevent constipation, which can cause painful straining in clients with prostatitis, exacerbating discomfort. They are not standard for all urinary issues, do not directly reduce swelling, and constipation does not cause complications of prostatitis.
A battered woman seen in the emergency department requires tertiary intervention because of repeated abuse. Which nursing interventions are appropriate? Select all that apply.
- A. Report the abuse to the police.
- B. Provide medications to relieve pain and anxiety.
- C. Explore family and friends as support possibilities.
- D. Focus on the woman's strengths, endurance, and abilities.
- E. Avoid discussing the implications of pressing charges against the batterer.
- F. Discourage the woman from discussing the events leading to past and present abuse situations.
Correct Answer: A,B,C,D
Rationale: Tertiary prevention for repeated abuse focuses on overcoming physical and psychological effects and preventing future abuse. Appropriate interventions include reporting abuse to ensure safety, providing medications for pain and anxiety, exploring support options, and focusing on the woman's strengths to boost self-esteem. Avoiding discussions about pressing charges or past events is not helpful, as these help address implications and reduce guilt.