Nokea
An infant with a positive PKU blood Test .
The nurse knows that which of the following plans would be a priority for an infant with a positive PKU blood Test ?
- A. Place the infant on Lofenlac formula.
- B. Administer medium-chain triglyceride (MCT) oil with each feeding.
- C. Provide genetic counseling for the family.
- D. Place the infant on Lorenzo's Oil treatments.
Correct Answer: A
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct-Guthrie blood Test evaluates neonate for phenylketonuria (PKU); Lofenalac formula is low in phenylalanine, but contains minerals and vitamins to provide a balanced nutritional formula (2) could be a plan for a child with cystic fibrosis (3) important, but is not as high a priority as answer choice #1 (4) would be a plan of care for a child with adrenoleukodystrophy (ALD)
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The nurse is teaching a client who is preparing to breast-feed. What is the best approach to promote successful breast-feeding?
- A. Give her a pamphlet on breast-feeding
- B. Discuss the advantages of breast milk
- C. Assist her to position the newborn at the breast
- D. Tell her to always breast-feed when the infant cries
Correct Answer: C
Rationale: Assist her to position the newborn at the breast. While all of the responses are helpful in teaching, the priority is placing the infant to breast as soon after birth as possible to establish contact and allow the newborn to begin to suck.
The client is admitted to the intensive care unit with severe chest pain. Which information provides the nurse with the most data that can be utilized in planning care?
- A. The blood pressure
- B. The vital signs
- C. The pulse oximeter
- D. The EEG
Correct Answer: B
Rationale: Vital signs include blood pressure, pulse, respirations, and temperature, providing the most comprehensive data for planning care in a client with severe chest pain. Blood pressure and pulse oximeter are included in vital signs, and EEG is irrelevant for chest pain.
Which of these parents' comments about a newborn would most likely reveal an initial finding of a suspected pyloric stenosis?
- A. I noticed a little lump a little above the belly button.
- B. The baby seems hungry all the time.
- C. Mild vomiting turned into vomiting that shot across the room.
- D. We notice irritation and spitting up immediately after feedings.
Correct Answer: C
Rationale: Mild vomiting turned into vomiting that shot across the room. Projectile vomiting is a hallmark of pyloric stenosis.
When the nurse walks into a client's room, the client states, 'I just love hot-blooded redheads.' The client pats his bed and says, 'Why don't you sit down here and get off your feet for a while.'
Which of the following responses by the nurse is BEST?
- A. I feel very uncomfortable when you make those suggestive remarks. It makes it difficult for me to do my job.'
- B. I don't think my husband or your wife would like me doing that.'
- C. You must be very lonesome. I'll come back later and spend some time with you.'
- D. I bet you flirt with all the nurses like that.'
Correct Answer: A
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct-nurse should confront client about inappropriate sexual behavior (2) should confront the client (3) reinforces inappropriate behavior (4) confront the client about inappropriate and unwanted behavior
A client who has been treated for syphilis.
In preparing discharge plans for a client who has been treated for syphilis, it is MOST important for the community health nurse to include which of the following information?
- A. Practice restraint of sexual activity.
- B. The practice of safe sex.
- C. Information about Planned Parenthood.
- D. Signs of a secondary infection.
Correct Answer: B
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) not effective in the prevention of transmission of sexually transmitted diseases (2) correct-practice of safe sex, e.g., use of condoms, is primary prevention for transmission of sexually transmitted diseases (3) not as effective in the prevention of transmission of sexually transmitted diseases (4) not as effective in the prevention of transmission of sexually transmitted diseases