Nokea
The nurse observes that a new mother avoids making eye contact with her newborn. The nurse should perform which action?
- A. Examine newborn's eyes for ability to focus.
- B. Assess for other attachment behaviors.
- C. Recognize this as a common reaction in new mothers.
- D. Ask mother why she won't look at newborn.
Correct Answer: B
Rationale: The nurse should assess for other attachment behaviors when a new mother avoids making eye contact with her newborn. This behavior may indicate difficulty forming an emotional bond with the newborn, which can impact the mother-infant relationship. By assessing for other attachment behaviors, the nurse can gather more information to understand the mother's response and provide appropriate support and interventions. Simply recognizing this as a common reaction or asking the mother why she won't look at the newborn may not address the underlying attachment issues that may be present. Examining the newborn's eyes for ability to focus is not relevant in this situation and does not address the mother's behavior.
You may also like to solve these questions
For a patient who is being discharged on digoxin, the nurse should include which of the ff. in an explanation to the patient on the signs and symptoms of digoxin toxicity?
- A. Poor appetite
- B. Halos around lights
- C. Constipation
- D. Tachycardia
Correct Answer: B
Rationale: Digoxin toxicity can manifest in various ways, but one common sign is the presence of visual disturbances such as seeing halos around lights. This is due to digoxin's effect on the optic nerve. Patients experiencing halos around lights should seek medical attention promptly as it may indicate a serious reaction to the medication. The other options (poor appetite, constipation, tachycardia) may occur with digoxin toxicity as well, but the visual disturbance of halos around lights is a classic and important sign to be aware of.
A patient who is being tested for HIV asks what tests are used. The nurse would correct in stating that the tests used to confirm HIV infection are which of the following?
- A. CD 4+ cell count and thymus function.
- B. ELISA and Western Blot
- C. B-cell and T-cell count.
- D. CD 4+, viral load, and ELISA
Correct Answer: B
Rationale: ELISA (Enzyme-Linked Immunosorbent Assay) and Western Blot are the two main tests used to confirm HIV infection. ELISA is typically the first test performed to detect HIV antibodies in the blood. If the ELISA test is positive, the Western Blot test is then used to confirm the presence of HIV antibodies and differentiate between HIV-1 and HIV-2 antibodies. Both tests are highly sensitive and specific in diagnosing HIV infection. Other tests like CD4+ count and viral load are used to monitor disease progression but are not used primarily to confirm HIV infection.
Tretinoin (Retin-A) is a topical agent commonly used to treat acne. Nursing considerations with this drug should include:
- A. teaching to avoid use of sunscreen agents.
- B. applying generously to the skin.
- C. explaining that medication should not be applied until at least 20 to 30 minutes after washing.
- D. explaining that erythema and peeling are indications of toxicity.
Correct Answer: C
Rationale: Nursing considerations with Tretinoin (Retin-A) should include explaining that the medication should not be applied until at least 20 to 30 minutes after washing. This wait time allows the skin to fully dry and reduces the risk of irritation. Applying the medication too soon after washing can increase the likelihood of skin irritation, dryness, and peeling. It is essential to follow this guideline to ensure the effectiveness of the treatment and minimize adverse effects on the skin.
the characteristic symptoms of nephrosis in children is:
- A. dyspnea, albuminuria and weight loss
- B. hematuria, hyperlipedemia and proteinuria
- C. albuminuria, hypoproteinemia and edema
- D. hypertension, hematuria and malnutrition
Correct Answer: C
Rationale: Nephrosis in children is also known as nephrotic syndrome, which is characterized by the presence of albuminuria (loss of protein in the urine), hypoproteinemia (low levels of protein in the blood), and edema (swelling due to fluid retention). This condition results from damage to the filters in the kidneys, leading to increased permeability and loss of protein in the urine. The classic triad of symptoms in nephrotic syndrome includes proteinuria, hypoalbuminemia, and edema. Other symptoms may include weight gain, frothy urine, and susceptibility to infections. Hematuria, hyperlipidemia, and hypertension are not typical features of nephrotic syndrome in children.
In Langerhans cell histiocytosis (LCH), all the following manifestations are at high risk of mortality in patients EXCEPT
- A. liver
- B. spleen
- C. lung
- D. hematopoietic system
Correct Answer: C
Rationale: Lung involvement, while serious, is less lethal compared to liver, spleen, or hematopoietic system involvement.