Nokea
The nurse teaches the mother of a newly circumcised infant about postcircumcision care. Which statement by the mother indicates an understanding of the care required?
- A. I need to clean the penis every hour with baby wipes.
- B. I need to check for bleeding every hour for the first 12 hours.
- C. My baby will not urinate for the next 24 hours because of swelling.
- D. I need to wrap the penis completely in dry sterile gauze, making sure that it is dry when I change his diaper.
Correct Answer: B
Rationale: After circumcision, the mother needs to be taught to observe for bleeding and assess the site hourly for 8 to 12 hours. Water is used for cleaning because soap or baby wipes may irritate the area and cause discomfort. Voiding needs to be assessed. The mother should call the primary health care provider if the baby has not urinated within 24 hours because swelling or damage may obstruct urine output. When the diaper is changed, Vaseline gauze should be reapplied (if prescribed). Frequent diaper changing prevents contamination of the site.
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The nurse is working at an osteoporosis screening clinic and is interviewing and performing health assessments on women. Which clients are at greatest risk for developing osteoporosis? Select all that apply.
- A. An Asian woman
- B. A large-boned, dark-skinned woman
- C. A client who started menopause early
- D. A client with a family history of the disease
- E. A client who has a physically active lifestyle
- F. A client with an inadequate intake of calcium and vitamin D
Correct Answer: A,C,D,F
Rationale: Risk factors for osteoporosis include being of Asian or Caucasian descent, early menopause, a family history of osteoporosis, and inadequate intake of calcium and vitamin D. Large-boned, dark-skinned women (e.g., those of African descent) have a lower risk due to higher bone density. A physically active lifestyle is protective against osteoporosis, reducing the risk.
A client who is taking tranylcypromine sulfate requests information about foods that are acceptable to eat while taking the medication. Which foods are safe to consume while taking this medication?
- A. Yogurt
- B. Raisins
- C. Oranges
- D. Smoked fish
Correct Answer: C
Rationale: Tranylcypromine sulfate is classified as a monoamine oxidase inhibitor (MAOI); as such, tyramine-containing food should be avoided. Oranges are permissible. Types of food to be avoided include—but are not limited to—yogurt, raisins, and smoked fish. Additionally, beer, wine, caffeinated beverages, pickled meats, yeast preparations, avocados, bananas, and plums are to be avoided.
The nurse is preparing to assess cranial nerve VIII on a client. Which tests will the nurse perform? Select all that apply.
- A. Allen's test
- B. Phalen's test
- C. the Rinne test
- D. the Weber test
Correct Answer: C,D
Rationale: Cranial nerve VIII (vestibulocochlear) is assessed with the Rinne and Weber tests for hearing. Allen's and Phalen's tests assess circulation and carpal tunnel, respectively.
The nurse is discussing developmental stages with the mother of a six-month-old infant. Which statement indicates an unexpected deviation from normal development?
- A. The infant is walking alone by 15 months.
- B. The infant waves good-bye by 7 months.
- C. The infant rolls from the tummy to the side at 12 months.
- D. The infant transfers a toy from one hand to the other at age 9 months.
Correct Answer: C
Rationale: Rolling tummy to side should occur by 6 months; delay to 12 months is concerning. Other milestones are age-appropriate or expected later.
The nurse is discharging a female client from the hospital who has a diagnosis of a thoracic 11 (T11) fracture with cord transection. The nurse has provided home care instructions to the client. Which action indicates the need for further teaching before discharge?
- A. The client jokes about no longer needing to worry about birth control.
- B. The client states that she will be careful to not eat as many dairy products.
- C. The client verbalizes the need to eat her meals at the same time every day.
- D. The client states that she will wash her hands, her perineum, and the catheter with soap and water before performing self-catheterization.
Correct Answer: A
Rationale: Female spinal cord trauma clients remain fertile during their reproductive years, and contraception is necessary for those who are sexually active. However, oral contraceptives may increase the risk for thrombophlebitis. Clients with paralysis should avoid dairy products to control the formation of urinary calculi. Meals should be eaten at the same time every day, and they should include fiber and warm solid and liquid foods to promote and maintain the regular evacuation of the bowel. Clients who lack bladder control are taught to self-catheterize using clean technique.