Nokea
The primary health care provider tells a mother that her newborn has multiple visible birth defects. The mother seems composed and asks to see her baby. Which nursing action will be most helpful in easing the mother's stress when she sees her child for the first time?
- A. Bringing the infant as requested before she changes her mind
- B. Describing how the infant looks before bringing the infant to her
- C. Staying with her after bringing the infant to help her verbalize her feelings
- D. Showing the mother pictures of the birth defects, then bringing the infant to her
Correct Answer: C
Rationale: Allowing the mother time to verbalize her feelings and providing support when she sees her newborn with birth defects for the first time is crucial. Staying with her allows for immediate emotional support, acceptance, and understanding, which can help ease her stress. Bringing the infant as requested without proper emotional support may overwhelm the mother. Describing the infant's appearance before she sees the baby might not be accurate and could add to her distress. Showing pictures of the birth defects before the mother sees her baby may not be helpful and could increase her anxiety. Engaging in discussions about treatment at this point may be premature and overwhelming for the mother.
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Which type of toy would be most suitable for enhancing the development of a toddler-age client?
- A. Clay
- B. Rattle
- C. Video games
- D. Musical mobile
Correct Answer: A
Rationale: The most suitable toy to recommend for enhancing the development of a toddler-age child is clay. Clay promotes creativity and fine motor skills in toddlers. A rattle is typically recommended for infants as it aids in sensory development. Video games, which are often battery-operated, are not suitable for toddlers due to potential negative effects on development. A musical mobile is more appropriate for infants as it can aid in soothing and sensory stimulation.
Which statement best describes the pathophysiology of dementia of the Alzheimer type?
- A. There is a genetic predisposition and dysregulation of neurotransmitters.
- B. The dementia is transient and secondary to a physical imbalance or disorder.
- C. Hypoxia and decreased perfusion of select areas of the brain cause tissue damage.
- D. The presence of amyloid plaques is associated with brain tissue destruction.
Correct Answer: D
Rationale: In Alzheimer's disease, the accumulation of amyloid plaques in the brain is a hallmark feature. These plaques are associated with the destruction of brain tissue, contributing to the cognitive decline seen in dementia. Genetic predisposition and dysregulation of neurotransmitters are factors linked to the development of Alzheimer's disease, but the primary pathology lies in the amyloid plaques. Transient dementia is not characteristic of Alzheimer's disease, which is a progressive neurodegenerative disorder. Hypoxia and decreased perfusion are more typical of vascular dementia, where blood flow to the brain is compromised.
The nurse is caring for a newly admitted patient. Which intervention is the best example of a culturally appropriate nursing intervention?
- A. Insist that family members provide most of the patient's personal care.
- B. Maintain a personal space of at least 2 feet when assessing the patient.
- C. Ask permission before touching a patient during the physical assessment.
- D. Consider the patient's ethnicity as an important factor in planning care.
Correct Answer: C
Rationale: Culturally appropriate nursing care requires sensitivity to the beliefs and practices of diverse cultural groups. Asking permission before touching a patient during a physical assessment is a universally respectful practice, as many cultures consider it disrespectful to touch a person without consent. This approach demonstrates respect for the patient's autonomy and cultural preferences. Maintaining a personal space of at least 2 feet can be a good practice for infection control or personal comfort but may not be culturally significant for all patients. Insisting that family members provide most of the patient's personal care may not align with the patient's cultural norms or preferences. Considering a patient's ethnicity as the most important factor in care planning overlooks the individuality of the patient and may lead to stereotyping or assumptions that are not accurate or helpful in providing tailored care.
Which of the following is a symptom associated with sensory overload?
- A. Disorientation
- B. Drowsiness
- C. Emotional lability
- D. Depression
Correct Answer: A
Rationale: Disorientation is a common symptom associated with sensory overload. When an individual experiences sensory overload, their brain may become overwhelmed with excessive information, leading to disorientation. This can manifest as an inability to concentrate, racing thoughts, and restless behavior. Sensory overload occurs when a person is unable to either control the amount of environmental stimuli they are exposed to or process the stimuli effectively. Drowsiness, emotional lability, and depression are not typical symptoms of sensory overload. Drowsiness may indicate fatigue or boredom, emotional lability refers to rapid and exaggerated changes in mood, and depression is a mood disorder characterized by persistent feelings of sadness and hopelessness.
A client who is at 28 weeks' gestation and in active labor is crying. She says, 'I just know that this baby is going to die. What's the use of doing all this to save it?' Which explanation would interpret the client's statements?
- A. She is depressed and needs gentle, positive support during labor.
- B. She is experiencing anticipatory grief and withdrawing from bonding.
- C. She is in need of emotional support to help her cope with the impending birth.
- D. She is struggling to cope with the birth by using the word 'it.'
Correct Answer: B
Rationale: The client's statement indicates anticipatory grief, where she is preparing for a potential loss. This grief is not necessarily about the literal death of the baby but about the loss of the anticipated healthy full-term baby. The client may not be ready to bond with the reality of a preterm baby. Providing gentle, positive support is essential to help her cope with her feelings, as firm support may come across as dismissive. Sedation is not appropriate as it could hinder the client's emotional processing. Allowing the client to express her emotions and work through anticipatory grieving is crucial. The use of the word 'it' reflects the client's emotional struggle and is not the primary issue at hand.