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The parent of a 7-year-old with continued bed-wetting at night says they've tried getting the child up at 11:30 p.m. Which is the best next step?
- A. There is a medication (DDAVP) that may help decrease urine volume.
- B. Be firm and show how much work is involved in changing sheets.
- C. Limit fluids in the evening and consider a reward system for dry nights.
- D. Bed-wetting alarms are available and effective.
Correct Answer: C
Rationale: Reducing evening fluids and using positive reinforcement (reward system) are effective and developmentally appropriate strategies.
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An adolescent has been diagnosed with lactose maldigestion intolerance. The nurse teaches the adolescent about lactose maldigestion intolerance and notes the teen needs further teaching if which statement is made?
- A. "I will limit my milk consumption to one to two glasses a day."
- B. "I should drink the milk alone and not with other foods."
- C. "Hard cheese, cottage cheese, or yogurt can be substituted for milk."
- D. "I will take a calcium supplement daily."
Correct Answer: B
Rationale: This statement is incorrect because drinking milk alone without other foods is not necessary for someone with lactose maldigestion intolerance. Mixing milk with other foods or consuming dairy products alongside other foods can sometimes help to reduce symptoms. Therefore, the adolescent does not need further teaching if they make this statement. The other statements are all appropriate for managing lactose maldigestion intolerance.
While assessing a 2-hour old neonate, the nurse observes the neonate to have acrocyanosis. Which of the following nursing actions should be performed initially?
- A. Activate the code blue or emergency system
- B. Do nothing because acrocyanosis is normal in the neonate
- C. Immediately take the newborn's temperature according to hospital policy
- D. Notify the physician of the need for a cardiac consult
Correct Answer: B
Rationale: Acrocyanosis is a normal finding in newborns, characterized by bluish discoloration of the hands and feet due to immature circulation. It usually resolves on its own within 24 hours after birth and does not require any intervention. It is essential for the nurse to recognize this normal physiological process to avoid unnecessary interventions. Activating the code blue system, taking the newborn's temperature immediately, or notifying the physician of the need for a cardiac consult is not indicated in this scenario because acrocyanosis is a benign condition in neonates.
Which of the following responses indicates sympathetic nervous system function?
- A. Tachycardia, dilated pupils
- B. Hypoglycaemia, headache
- C. Increased peristalsis, abdominal cramping
- D. Pupil constriction, bronchoconstriction
Correct Answer: A
Rationale: The sympathetic nervous system is responsible for the body's "fight or flight" response. Tachycardia (increased heart rate) and dilated pupils are classic responses of the sympathetic nervous system activation during times of stress or danger. These physiological responses prepare the body for action, such as running away from a threat.
Which of the following diets would the nurse include in the plan of care for a person with AIDS?
- A. A high-protein, high-calorie diet divided into six small meals.
- B. A low-fat, soft diet divided into 8 small meals.
- C. A high-carbohydrate, fat-restricted diet divided into 4 meals.
- D. A high-fat, high-calorie diet divided into 3 meals.
Correct Answer: A
Rationale: People with AIDS often experience weight loss and malnutrition due to the disease's impact on the immune system. A high-protein, high-calorie diet can help support the immune system and maintain or improve weight. Dividing the meals into six servings can help with better absorption of nutrients and provide a steady source of energy throughout the day. This type of diet can also help manage symptoms and side effects of the disease and its treatments, such as maintaining muscle mass, managing nausea, and supporting overall health.
The nurse is caring for a client with bronchogenic carcinoma. Which nursing diagnosis takes highest priority?
- A. Disturbed body image related to changes in body functions
- B. Ineffective airway clearance related to obstruction by a tumor or secretions
- C. Anxiety related to actual threat to health status and changes in family dynamics
- D. Imbalanced nutrition: Less than body requirements related to anorexia and vomiting secondary to chemotherapy
Correct Answer: B
Rationale: In caring for a client with bronchogenic carcinoma, the highest priority nursing diagnosis would be Ineffective airway clearance related to obstruction by a tumor or secretions. This is crucial because any blockage in the airway can lead to serious respiratory complications, such as respiratory distress or respiratory failure. Ensuring effective airway clearance is essential to maintain adequate oxygenation and ventilation for the client. Addressing this priority nursing diagnosis promptly can help prevent potential life-threatening situations and promote optimal respiratory function for the client.