Nokea
The nurse reviews the pattern of a nonstress test performed on a pregnant client and interprets the finding as which result? (Refer to figure.)
- A. Reactive
- B. Abnormal
- C. Nonreactive
- D. Non-reassuring
Correct Answer: A
Rationale: A nonstress test assesses fetal well-being and evaluates the ability of the fetal heart to accelerate, often in association with fetal movement. Accelerations of the fetal heart rate are associated with adequate oxygenation, a healthy neural pathway, and the fetal heart's ability to respond to stimuli. A reactive test is described as at least two fetal heart rate accelerations, with or without fetal movement, occurring within a 20-minute period and peaking at least 15 beats/minute above the baseline and lasting 15 seconds from baseline to baseline. This recording (see figure) identifies a reactive nonstress test. The fetal heart rate acceleration peaks at least 15 beats/minute and lasts for at least 15 seconds in response to fetal movement. A nonreactive test is an abnormal or nonreassuring test. In a nonreactive test, the recording does not demonstrate the required characteristics of a reactive test within a 40-minute period.
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The nurse is caring for a client diagnosed with end-stage renal disease. What areas are appropriate to assess to determine the client's wishes for end-of-life nursing care?
- A. Preferred place for death
- B. Client expectations for nursing care
- C. Financial responsibilities for the funeral
- D. Where the funeral and burial will take place
- E. Use of and the level of life-sustaining measures
- F. Expectations regarding pain control and symptom management
Correct Answer: A,B,E,F
Rationale: The nurse must assess the client's wishes for end-of-life nursing care because these can influence how the nurse sets priorities for planning and implementing care. End-of-life assessment related to nursing care should include the preferred place for death, client expectations for nursing care, the use of and the level of life-sustaining measures, and expectations regarding pain control and symptom management. Financial responsibilities for the funeral and where the funeral and burial will take place are issues that the client may want to discuss, but they are unrelated to nursing care.
The nurse is teaching health education classes to a group of expectant parents, and the topic is preventing cognitive impairment caused by congenital hypothyroidism. What should the nurse tell the parents is the most effective means of promoting early intervention?
- A. Vitamin intake
- B. Neonatal screening
- C. Adequate protein intake
- D. Limiting alcohol consumption
Correct Answer: B
Rationale: Congenital hypothyroidism is a common preventable cause of cognitive impairment. Neonatal screening is the only means of early diagnosis followed by intervention and the subsequent prevention of cognitive impairment. Newborn infants are screened for congenital hypothyroidism before discharge from the newborn nursery and before 7 days of life. Treatment is begun immediately, if necessary. Vitamin intake and adequate protein will not specifically prevent this disorder. Alcohol consumption during pregnancy needs to be restricted rather than just limited.
The nurse is talking to a 67-year-old client who has just retired from the job he's had since age 17-the only job he's ever had. The nurse understands that the client is in which of Erikson's stages?
- A. intimacy versus isolation
- B. ego integrity versus despair
- C. identity versus role confusion
- D. generativity versus stagnation
Correct Answer: B
Rationale: A 67-year-old retiree is in Erikson's ego integrity versus despair stage, reflecting on life's accomplishments.
The nurse caring for a child with congestive heart failure who will be discharged to home provides instructions to the parents regarding the administration of digoxin. Which statement by the mother indicates a need for further teaching?
- A. I will mix the medication with food.
- B. I will check my child's pulse before giving the medication.
- C. If my child vomits after I give the medication, I will not repeat the dose.
- D. I will check the dose of medication with my husband before I give the medication.
Correct Answer: A
Rationale: Digoxin is a cardiac glycoside and should not be mixed with food or formula because this method may not ensure the child receives the entire dose if the food is not fully consumed. Checking the child's pulse, not repeating the dose after vomiting, and verifying the dose with another person are correct interventions to ensure safe administration.
The home care nurse visits a child diagnosed with scarlet fever who is being treated with penicillin G potassium. The mother tells the nurse that the child has only voided a small amount of tea-colored urine since the previous day. The mother also reports that the child's appetite has decreased and that the child's face was swollen this morning. How should the nurse interpret these new signs/symptoms?
- A. Nothing to be concerned about
- B. Signs/symptoms of acute glomerulonephritis
- C. Signs/symptoms of the normal progression of scarlet fever
- D. Symptoms of an allergic reaction to penicillin G potassium
Correct Answer: B
Rationale: Scarlet fever is an infectious and communicable disease caused by group A beta-hemolytic streptococci. The signs/symptoms identified in the question indicate acute glomerulonephritis, indicative of nephrotoxicity. These signs/symptoms are not normal and should not be ignored. Although the child is receiving penicillin G potassium, these are not signs/symptoms of an allergic reaction.