Nokea
The nurse is teaching the parents of an infant with osteogenesis imperfecta. The nurse should tell the parents:
- A. That the infant will need daily calcium supplements
- B. To lift the infant by the buttocks when diapering
- C. That the condition is a temporary one
- D. That only the bones are affected by the disease
Correct Answer: B
Rationale: Lifting by the buttocks prevents fractures in osteogenesis imperfecta, a brittle bone disorder calcium doesn't strengthen defective collagen, it's lifelong, and other systems (e.g., hearing) may be affected. Nurses teach gentle handling, ensuring safety in this genetic condition.
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The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) receiving long-term oxygen therapy at home. What should the nurse include in the client's teaching regarding oxygen safety?
- A. Ensure you have a fire extinguisher readily available
- B. Keep the oxygen tubing loose to prevent tangling
- C. Avoid using electric heating devices in your home
- D. Use an oxygen concentrator for outdoor activities
Correct Answer: C
Rationale: Avoiding electric heating devices (C) is critical in COPD oxygen therapy teaching, as oxygen accelerates combustion, posing a fire risk. Fire extinguisher (A) is supplementary. Loose tubing (B) risks disruption. Concentrator use (D) depends on need. Safety education, per home care standards, prioritizes fire prevention.
An 8.5 lb, 6 oz infant is delivered to a diabetic mother. Which nursing intervention would be implemented when the neonate becomes jittery and lethargic?
- A. Administer insulin
- B. Administer oxygen
- C. Feed the infant glucose water (10%)
- D. Place infant in a warmer
Correct Answer: C
Rationale: Jitteriness and lethargy suggest hypoglycemia, common in infants of diabetic mothers; glucose water corrects this.
The nurse is teaching the mother of a child with cystic fibrosis how to do chest percussion. The nurse should tell the mother to:
- A. Use the heel of her hand during percussion
- B. Change the child's position every 20 minutes
- C. Do percussion after the child eats and at bedtime
- D. Use cupped hands during percussion
Correct Answer: D
Rationale: Cupped hands during chest percussion loosen mucus in cystic fibrosis, creating vibrations without pain, a key physiotherapy technique to clear airways. Heel strikes are harsh, frequent repositioning isn't routine, and post-meal percussion risks reflux. Nurses teach this method for effective secretion management, improving breathing and reducing infection risk in this chronic condition.
When a client's skin is dry, which of the following nursing interventions would be most helpful?
- A. Limit bathing to once or twice a week.
- B. Bathing is daily, but no soap is used.
- C. Bathing daily with mineral oil added to the water.
- D. Bathing with lotion instead of water.
Correct Answer: A
Rationale: Limiting bathing to once or twice weekly prevents further drying of already dry skin, preserving natural oils. Daily bathing, even without soap or with oil, risks exacerbation, and lotion isn't a bath substitute. Nurses apply this to maintain skin integrity.
When giving a client a diagnosis of acute pain, the nurse 'using NANDA diagnostic categories' will use this diagnosis only when the pain last no longer than which of the following lengths of time?
- A. 3 days
- B. 2 weeks
- C. 1 month
- D. 6 months
Correct Answer: D
Rationale: NANDA defines acute pain as lasting up to 6 months, beyond which it's chronic. Nurses use this timeframe for diagnosis accuracy.