Nokea
What is the most frequent cause for suicide in adolescents?
- A. Progressive failure to adapt
- B. Feelings of anger or hostility
- C. Reunion wish or fantasy
- D. Feelings of alienation or isolation
Correct Answer: D
Rationale: Feelings of alienation or isolation are the most frequent cause for suicide in adolescents. Adolescents may experience a gradual isolation leading to a loss of meaningful social contacts, which can be self-imposed or result from an inability to express feelings. During this developmental stage, achieving a sense of identity and peer acceptance is crucial. Choices A, B, and C are incorrect: Progressive failure to adapt, feelings of anger or hostility, and reunion wish or fantasy are not typically identified as the primary cause of suicide in adolescents.
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Parents of a 6-month-old breastfed baby ask the nurse about increasing the baby's diet. Which of the following should be added first?
- A. Cereal
- B. Eggs
- C. Meat
- D. Juice
Correct Answer: A
Rationale: The correct answer is 'Cereal.' The guidelines of the American Academy of Pediatrics recommend introducing one new food at a time, starting with strained cereal. Cereal is often recommended as a first solid food for infants due to its soft texture and iron-fortified properties, which are important for the baby's development. Eggs and meat are common allergenic foods and are usually introduced later. Juice is not recommended for infants under 1 year old due to its high sugar content and lack of nutritional value compared to whole fruits.
A client is being assessed for risks of a pressure ulcer by a healthcare professional. What is the best description of what may be found with an early pressure ulcer in an African American client?
- A. Skin has a purple/bluish color
- B. Capillary refill is 1 second
- C. Skin appears blanched at the pressure site
- D. Tenting appears when checking skin turgor
Correct Answer: A
Rationale: When assessing for signs of developing pressure ulcers in a client with dark skin, traditional signs like blanching may not be evident. In individuals with darker skin tones, the skin of an early pressure ulcer may present with a purple or bluish hue. This discoloration can be a crucial indicator of compromised circulation and tissue damage. Capillary refill, blanching, and tenting are more commonly used in the assessment of skin integrity and hydration levels but may not be as reliable in individuals with darker skin tones, making the purple/bluish color a key finding in this context.
The nurse is discussing negativism with the parents of a 30-month-old child. How should the nurse advise the parents to best respond to this behavior?
- A. Reprimand the child and give a 15-minute 'time out'
- B. Maintain a permissive attitude for this behavior
- C. Use patience and a sense of humor to deal with this behavior
- D. Assert authority over the child through limit setting
Correct Answer: C
Rationale: Use patience and a sense of humor to deal with this behavior. The nurse should help the parents understand that negativism is a normal part of a toddler's growth towards autonomy. Reacting with patience and humor can help diffuse the situation and maintain a positive relationship with the child. Reprimanding the child and giving a 'time out' (Choice A) may not be effective for addressing negativism and can lead to power struggles. Maintaining a permissive attitude (Choice B) may reinforce negative behavior. Asserting authority through limit setting (Choice D) may be necessary in some situations, but using patience and humor is a more effective initial approach for handling negativism.
Following a diagnosis of acute glomerulonephritis (AGN) in their 6-year-old child, the parent remarks, 'We just don't know how he caught the disease!' The nurse's response is based on an understanding that
- A. AGN is a streptococcal infection that involves the kidney tubules
- B. The disease is easily transmissible in schools and camps
- C. The illness is usually associated with chronic respiratory infections
- D. It is not 'caught' but is a response to a previous B-hemolytic strep infection
Correct Answer: D
Rationale: Acute glomerulonephritis (AGN) is generally considered an immune-complex disease in response to a previous B-hemolytic streptococcal infection, typically occurring 4 to 6 weeks prior. It is not an infectious disease but a noninfectious renal condition. Therefore, the parent's belief that the child 'caught' the disease is inaccurate. Choice A is incorrect because AGN is not a direct streptococcal infection involving the kidney tubules but an immune response to a prior streptococcal infection. Choice B is incorrect as AGN is not easily transmissible in schools and camps. Choice C is incorrect as AGN is not usually associated with chronic respiratory infections but with a previous streptococcal infection.
A newborn is having difficulty maintaining a temperature above 98 degrees Fahrenheit and has been placed in a warming isolette. Which action is a nursing priority?
- A. Protect the neonate's eyes from the heat lamp
- B. Monitor the neonate's temperature
- C. Warm all medications and liquids before administration
- D. Avoid touching the neonate with cold hands
Correct Answer: B
Rationale: When a newborn is placed in a warming isolette due to difficulty maintaining temperature, the priority action is to continuously monitor the neonate's temperature to prevent overheating. Using heat lamps is unsafe as their temperature cannot be regulated, potentially causing harm. Warming medications and fluids before administration is not necessary in this situation. While touching the neonate with cold hands may startle them, it does not pose a safety risk compared to monitoring and controlling the temperature.