Nokea
The nurse is teaching the mother of a 5 month-old about nutrition for her baby. Which statement by the mother indicates the need for further teaching?
- A. I'm going to try feeding my baby some rice cereal.'
- B. When he wakes at night for a bottle, I feed him.'
- C. I dip his pacifier in honey so he'll take it.'
- D. I keep formula in the refrigerator for 24 hours.'
Correct Answer: C
Rationale: I dip his pacifier in honey so he'll take it.' Honey has been associated with infant botulism and should be avoided. Older children and adults have digestive enzymes that kill the botulism spores.
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The nurse manager identifies that time spent by staff in charting is excessive, requiring overtime for completion. The nurse manager states that 'staff will form a task force to investigate and develop potential solutions to the problem, and report on this at the next staff meeting.' The nurse manager's leadership style is best described as
- A. Laissez-faire
- B. Autocratic
- C. Participative
- D. Group
Correct Answer: C
Rationale: Participative. A participative style of management involves staff in decision-making processes. Staff/manager interactions are open and trusting. Most work efforts are joint endeavors.
An adult woman is admitted to an acute locked psychiatric unit one month prior to an election.
Which of the following responses by the nurse is BEST?
- A. You are not eligible to vote because you are a psychiatric patient.'
- B. I'll make the appropriate arrangements for you to vote.'
- C. You may vote only if you are discharged by Election Day.'
- D. I'll contact the Election Board to see if you are registered to vote.'
Correct Answer: B
Rationale: Strategy: Determine the outcome of each answer choice. (1) psychiatric patients do not forfeit their constitutional rights (2) correct-patient can vote by absentee ballot (3) can vote by absentee ballot (4) not the nurse's responsibility
The nurse is caring for a client who had a subtotal thyroidectomy yesterday. Which of the following client statements would be of GREATest concern to the nurse?
- A. I have a sore throat when I swallow.
- B. My legs feel cramped and tingly.
- C. I feel like my heart is skipping beats.
- D. I feel sleepy all the time.
Correct Answer: B
Rationale: Muscle cramps and tingling in the legs post-thyroidectomy suggest hypocalcemia, a serious complication due to possible parathyroid gland damage, which regulates calcium. This requires immediate assessment and intervention. Options A, C, and D are less urgent: sore throat is expected, palpitations may indicate hyperthyroidism, and sleepiness is nonspecific.
An older adult is diagnosed with Parkinson's disease. The client asks the nurse what causes Parkinson's disease. In addition to telling the client that we are not really sure what causes it, the nurse should include which information?
- A. There is not enough dopamine in the brain.
- B. The myelin sheath is being destroyed.
- C. There is not enough acetylcholine at the myoneural junction.
- D. There is an obstruction in the circulation of the brain.
Correct Answer: A
Rationale: Parkinson's disease results from dopamine deficiency in the basal ganglia, impairing movement, unlike myelin destruction, acetylcholine issues, or circulatory obstruction.
A patient with a cuffed tracheostomy tube in place after surgery.
The nurse knows the purpose of the cuff on the tracheostomy tube is to
- A. guarantee secure placement of the tracheostomy tube in the airway.
- B. prevent ischemia of the tracheal wall by distributing the pressure applied to it.
- C. decrease the chance of aspiration into the trachea.
- D. protect the trachea from ischemia and edema.
Correct Answer: C
Rationale: Strategy: Think about each answer choice. (1) inaccurate, not the purpose of the cuff on a tracheostomy tube (2) complication of using a cuffed tracheostomy tube (3) correct-seals trachea, helps to prevent aspiration (4) trauma from overinflated tube may cause edema