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The nurse plans care for a client with alcohol abuse disorder based on which support system?
- A. Fresh Start, is an option for families of addicts.
- B. Families Anonymous, an option for those addicted to nicotine.
- C. Al-Anon, an option for parents of children who abuse substances.
- D. Alcoholics Anonymous, a major self-help organization for the treatment of alcohol abuse.
Correct Answer: D
Rationale: Alcoholics Anonymous is a major self-help organization for the treatment of alcoholism. Option 1 is a group for families of alcoholics. Option 2 is for nicotine addicts. Option 3 is for the parents of children who abuse substances.
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A nursing student is preparing to conduct a clinical conference regarding cerebral palsy. Which characteristic related to this disorder should the student plan to include in the discussion?
- A. Cerebral palsy is an infectious disease of the central nervous system.
- B. Cerebral palsy is an inflammation of the brain as a result of a viral illness.
- C. Cerebral palsy is a chronic disability characterized by difficulty with muscle control.
- D. Cerebral palsy is a congenital condition that results in moderate to severe retardation.
Correct Answer: C
Rationale: Cerebral palsy is a chronic disability that is characterized by difficulty with controlling the muscles because of an abnormality in the extrapyramidal or pyramidal motor system. Meningitis is an infectious process of the central nervous system. Encephalitis is an inflammation of the brain that occurs as a result of viral illness or central nervous system infections. Down syndrome is an example of a congenital condition that results in moderate to severe retardation.
Which interventions are appropriate to include in the plan of care for a child after a tonsillectomy?
- A. Offer clear, cool liquids when awake.
- B. Administer pain medication as prescribed
- C. Monitor for bleeding from the surgical site.
- D. Suction every 15 minutes and PRN as necessary.
- E. Initially eliminate milk or milk products from the diet.
Correct Answer: A,B,C,E
Rationale: After tonsillectomy, clear, cool liquids are encouraged. Options 2 and 3 are important interventions after any type of surgery. Suction equipment should be available, but suctioning is not performed unless there is an airway obstruction. Milk and milk products are avoided initially because they coat the throat; this causes the child to clear the throat, thereby increasing the risk of bleeding.
The nurse is informed that a newborn infant whose mother is Rh negative will be admitted to the nursery. When planning care for the infant's arrival, which action should the nurse take?
- A. Obtain the newborn infant's blood type and direct Coombs' results from the laboratory.
- B. Obtain the necessary equipment from the blood bank needed for an exchange transfusion.
- C. Call the maintenance department and ask for a phototherapy unit to be brought to the nursery.
- D. Obtain a vial of vitamin K from the pharmacy and prepare to administer an injection to prevent isoimmunization.
Correct Answer: A
Rationale: To further plan for the newborn infant's care, the infant's blood type and direct Coombs' results must be known. Umbilical cord blood is taken at the time of delivery to determine blood type, Rh factor, and antibody titer (direct Coombs' test) of the newborn infant. The nurse should obtain these results from the laboratory. Options 2 and 3 are inappropriate at this time, and additional data are needed to determine whether these actions are needed. Option 4 is incorrect because vitamin K is given to prevent hemorrhagic disease of the newborn infant.
A perinatal client is admitted to the obstetric unit during an exacerbation of a heart condition. When planning for the nutritional requirements which dietary intervention should the nurse consult the dietitian about?
- A. A low-calorie diet to prevent weight gain
- B. A diet low in fluids and fiber to decrease blood volume
- C. A diet adequate in fluids and fiber to decrease constipation
- D. Unlimited sodium intake to increase circulating blood volume
Correct Answer: C
Rationale: Constipation can cause the client to use Valsalva's maneuver. This maneuver can cause blood to rush to the heart and overload the cardiac system. A low-calorie diet is not recommended during pregnancy. Diets low in fluid and fiber can cause a decrease in blood volume that can deprive the fetus of nutrients; it can also lead to constipation. Therefore, adequate fluid intake and high-fiber foods are important. Sodium should be restricted to some degree as prescribed by the primary health care provider because this will cause an overload to the circulating blood volume and contribute to cardiac complications.
The nurse is preparing to care for an infant diagnosed with pertussis. Which priority problem should the nurse address when planning care?
- A. Infection
- B. Fluid overload
- C. Impaired sleep patterns
- D. Inability to expectorate secretions
Correct Answer: D
Rationale: The priority problem for the child with pertussis relates to adequate air exchange. Because of the copious, thick secretions that occur with pertussis and the small airways of an infant, air exchange is critical. Infection is an important consideration, but airway is the priority. A deficient fluid volume is more likely to occur in this infant because of the thick secretions and vomiting. Sleep patterns may be disturbed because of the coughing, but this is not the critical issue.