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The physician orders local application of epinephrine 1:1000 solution to treat a nosebleed. The patient asks how this will help. Which of the ff. responses by the nurse is best?
- A. "It will raise you BP, which is necessary because of blood loss."
- B. "It will dilate your bronchioles and make your breathing easier."
- C. "It will help your blood to clot to reduce bleeding."
- D. "It will constrict your vessels and slow down the bleeding."
Correct Answer: D
Rationale: Epinephrine is a vasoconstrictor, which means it causes blood vessels to narrow. When applied locally to the site of a nosebleed, epinephrine constricts the blood vessels in the nose, slowing down and stopping the bleeding. By constricting the blood vessels, epinephrine helps to reduce the blood flow to the area, allowing a clot to form and stop the bleeding. This is why option D, "It will constrict your vessels and slow down the bleeding," is the best response by the nurse to explain how epinephrine will help treat a nosebleed.
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The nurse observes that a new mother avoids making eye contact with her newborn. The nurse should perform which action?
- A. Examine newborn's eyes for ability to focus.
- B. Assess for other attachment behaviors.
- C. Recognize this as a common reaction in new mothers.
- D. Ask mother why she won't look at newborn.
Correct Answer: B
Rationale: The nurse should assess for other attachment behaviors when a new mother avoids making eye contact with her newborn. This behavior may indicate difficulty forming an emotional bond with the newborn, which can impact the mother-infant relationship. By assessing for other attachment behaviors, the nurse can gather more information to understand the mother's response and provide appropriate support and interventions. Simply recognizing this as a common reaction or asking the mother why she won't look at the newborn may not address the underlying attachment issues that may be present. Examining the newborn's eyes for ability to focus is not relevant in this situation and does not address the mother's behavior.
A nurse plans therapeutic play time for a hospitalized child. What are the benefits of play? (Select all that apply.)
- A. Serves as method to assist disturbed children
- B. Allows the child to express feelings
- C. The nurse can gain insight into the child's feelings.
- D. The child can deal with concerns and feelings.
Correct Answer: A
Rationale: Play serves as a method to assist disturbed children by providing them with a therapeutic outlet to express themselves and work through their emotions in a safe and constructive manner.
Autism screening is recommended for all children at age of
- A. 12 to 18 months
- B. 18 to 24 months
- C. 24 to 36 months
- D. 36 to 48 months
Correct Answer: B
Rationale: Autism screening is recommended between 18 and 24 months.
By the age of 7 months, the infant is able to do all the following EXCEPT
- A. transfer object from hand to hand
- B. actively bounces
- C. uses radial palm grasp
- D. roll over
Correct Answer: D
Rationale: Rolling over is usually achieved earlier, by 4-6 months, while other skills are typical for 7 months.
The parents of a newborn with a strawberry hemangioma ask the nurse what the treatment will be. What information does the nurse need to include in the response?
- A. Excision of the lesion will be necessary.
- B. Injections of prednisone into the lesion will reduce it.
- C. No treatment is usually necessary because of the high rate of spontaneous involution.
- D. Pulsed dye laser treatments will be necessary immediately to prevent permanent disability.
Correct Answer: C
Rationale: The correct information the nurse should provide to the parents is that no treatment is usually necessary for a strawberry hemangioma because of the high rate of spontaneous involution. Strawberry hemangiomas are common vascular tumors in infants that typically appear in the first few weeks of life. They usually grow rapidly for the first several months and then begin to shrink and eventually disappear on their own. In most cases, the hemangioma resolves without the need for any intervention. Therefore, reassuring the parents that observation is the primary management approach is important, unless complications such as ulceration, bleeding, or obstruction occur.