Introduction to Maternity and Pediatric Nursing Test Bank

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The nurse should plan to teach the client with pancytopenia caused by a chemotherapy to;

  • A. Begin a program of aggressive, strict mouth care
  • B. Avoid traumatic injuries and exposure to any infection
  • C. increase oral fluid intake to a minimum of 3000 ml daily
  • D. Report any unusual muscle cramps or tingling sensations in the extremities
Correct Answer: B

Rationale: The correct action for the nurse to teach a client with pancytopenia caused by chemotherapy is to avoid traumatic injuries and exposure to any infection. Pancytopenia is a condition characterized by low levels of all blood cell types - red blood cells, white blood cells, and platelets. This leaves the individual vulnerable to infections, easy bruising, and bleeding. By advising the client to avoid traumatic injuries and exposure to infection, the nurse is helping to reduce the risk of further complications that can arise from low blood cell counts. This includes advising the client on taking precautions such as gentle handling to prevent skin injury, using a soft toothbrush for oral care, and avoiding contact with individuals who are sick to minimize the risk of infection.

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During an ophthalmic assessment, which of the ff are the nurses expected to observe carefully? Choose all that apply

  • A. Level of central vision
  • B. Pupil responses
  • C. External eye appearance
  • D. Eye movements
Correct Answer: B

Rationale: During an ophthalmic assessment, the nurses are expected to observe the following carefully:

In terms of fine motor development, what should the infant of 7 months be able to do?

  • A. Transfer objects from one hand to the other and bang cubes on a table.
  • B. Use thumb and index finger in crude pincer grasp and release an object at will.
  • C. Hold a crayon between the fingers and make a mark on paper.
  • D. Release cubes into a cup and build a tower of two blocks.
Correct Answer: A

Rationale: At 7 months old, infants are typically able to transfer objects from one hand to the other and bang cubes on a table. This demonstrates the development of their fine motor skills related to coordination, dexterity, and object manipulation. They are refining their hand-eye coordination and grasping abilities at this stage, preparing for more complex fine motor tasks in the future. The ability to purposefully transfer objects between hands and make intentional actions, like banging cubes on a table, shows the progression of their fine motor development at this age.

When administering spironolactone (Aldactone) to a client who has had a unilateral adrenalectomy, the nurse should instruct the client about which of the following possible adverse effects of the drug?

  • A. Breast tenderness
  • B. Increased facial hair
  • C. Menstrual irregularities
  • D. Hair loss
Correct Answer: C

Rationale: Spironolactone (Aldactone) is a potassium-sparing diuretic and aldosterone antagonist that is commonly used to treat conditions such as hypertension, heart failure, and edema. One of its common side effects is hormonal effects due to its antiandrogenic properties. In women, spironolactone can lead to menstrual irregularities, including amenorrhea (absence of menstrual periods) or breakthrough bleeding. Therefore, in a client who has had a unilateral adrenalectomy (removal of one adrenal gland), which can already disrupt hormonal balance, the nurse should educate the client about the potential for menstrual irregularities when taking spironolactone.

is softening of the bones as result of nutritional deficiencies or limited exposure to sunlight :

  • A. COXA
  • B. scoliosis
  • C. Rickets
  • D. Talipes
Correct Answer: C

Rationale: Rickets is a condition that involves softening and weakening of the bones in children, usually due to a vitamin D deficiency, inadequate calcium intake, or lack of exposure to sunlight. Vitamin D is essential for the absorption of calcium and phosphorus in the body, which are important for bone health. Without sufficient vitamin D, the body is unable to properly mineralize the bones, leading to softening and deformities. Common symptoms of rickets include bowed legs, delayed growth, and muscle weakness. Treatment typically involves vitamin D supplementation, dietary changes, and adequate exposure to sunlight.

Which food should be avoided by the patient on a low-sodium diet?

  • A. Apples
  • B. Chicken
  • C. Cheese
  • D. Broccoli
Correct Answer: C

Rationale: Cheese is high in sodium and should be avoided by patients on a low-sodium diet. It is a common source of hidden sodium in many diets. Other high-sodium foods that should be limited or avoided include processed meats, canned soups, processed snacks, and condiments. Patients should focus on eating fresh fruits and vegetables, lean proteins like chicken (with no added salt), and whole grains to maintain a low-sodium diet.

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