Nokea
When a middle-age woman says to the nurse, 'I'm really worried about menopause. When my mom went through it, she got really depressed.' The nurse's best response is:
- A. It is a myth that women get depressed because of menopause.
- B. Menopause is a normal developmental process.
- C. It sounds like you are worried that you might become depressed during menopause.
- D. When women experience depression during menopause it is usually because of social stresses.
Correct Answer: C
Rationale: Choice 3 not only acknowledges the client's fear but invites more disclosure and discussion. Reflective listening is very therapeutic and in this case acknowledges the woman's unspoken fear that she might become depressed like her mother. When her fears have been acknowledged and she feels that the nurse understands, she will be more open to the teaching or interventions to follow. It is a myth that menopause causes depression, but to say that to this client does not acknowledge the fear she shared with the nurse and gives the impression the nurse doesn't care about her concern. It closes down communication. It is also true that menopause is a normal developmental process. This can certainly be used in teaching but not to address her immediate concern; the client might feel the nurse doesn't think her concern is appropriate because menopause is normal. If women experience depression during menopause, it is usually due to social stresses such as loss of loved ones, loss of roles, caregiver demands, and physical problems. Choice 4 is true but is a nontherapeutic response in this situation.
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The mother of a newborn who was circumcised before discharge from the hospital calls the nurse at the pediatrician's office and tells the nurse that she is concerned because she has noticed a yellow crust over the circumcision site. The nurse provides which information to the mother?
- A. That it could indicate a sign of an infection and the infant's temperature should be checked every 2 hours
- B. That the crust is to be expected as a normal part of healing
- C. To bring the infant to the pediatrician's office to be checked
- D. To remove the crust, using a warm, wet face cloth and a mild soap
Correct Answer: B
Rationale: After circumcision, a yellow crust may form over the circumcision site, which is a normal part of healing and should not be removed. The mother should be reassured that this crust is to be expected. Yellow crusting or discharge is not indicative of an infection, and there is no need to notify the pediatrician. Checking the infant's temperature every 2 hours is unnecessary and may cause unnecessary alarm to the mother.
A pregnant client is scheduled to undergo a transabdominal ultrasound, and the nurse provides information to the client about the procedure. The nurse provides which information?
- A. The procedure typically takes 10 to 30 minutes.
- B. She may need to drink fluids before the test and may not void until the test has been completed.
- C. A probe coated with gel will be inserted into the vagina.
- D. She will be positioned on her back, with her head elevated and turned slightly to one side.
Correct Answer: B
Rationale: The correct answer is that the client may need to drink fluids before the test and may not void until the test has been completed. For a transabdominal ultrasound, the woman is positioned on her back with her head elevated and turned slightly to one side to prevent supine hypotension. A wedge or rolled blanket is placed under one hip to help her maintain this position comfortably. If a full bladder is necessary, the woman is instructed to drink several glasses of clear fluid 1 hour before the test and told that she should not void until the test has been completed. Warm mineral oil or transmission gel is spread over her abdomen, and the sonographer slowly moves a transducer over the abdomen to obtain a picture. The procedure typically takes 10 to 30 minutes, making choice A incorrect. Choice C is incorrect because a probe is not inserted into the vagina for a transabdominal ultrasound. Choice D is incorrect because the woman is positioned on her back with her head elevated and turned slightly to one side, not specifically on her back.
A pregnant client tells the nurse that she has a 2-year-old child at home and expresses concern about how the toddler will adapt to a newborn infant being brought into the home. Which statement is the most appropriate response for the nurse to make to the client?
- A. If your 2-year-old becomes angry or jealous, you should consider preparing the child for the new sibling rather than seeking psychological intervention.
- B. Don't worry; every 2-year-old may need time to adjust to a newborn sibling.
- C. Even though a 2-year-old may have little perception of time, any changes in sleeping arrangements for the newborn should be made several weeks before birth.
- D. A 2-year-old toddler focuses on exploring the environment, but it's important to prepare the child for the new sibling.
Correct Answer: C
Rationale: The correct response by the nurse is, 'Even though a 2-year-old may have little perception of time, any changes in sleeping arrangements for the newborn should be made several weeks before birth.' Toddlers are generally unaware of the changes during pregnancy and may not understand the impending arrival of a new sibling. It is essential to prepare the child gradually for the new baby's arrival by making any necessary changes in sleeping arrangements beforehand. Expecting a young child to immediately welcome a new sibling without prior preparation is unrealistic. Option A is incorrect as suggesting psychological intervention prematurely is not appropriate. Option B is incorrect as assuming all 2-year-olds would immediately welcome a newborn is unrealistic. Option D is incorrect as dismissing the concerns without addressing the need for preparation is not appropriate in this situation.
A patient has just been prescribed Minipress to control hypertension. The nurse should instruct the patient to be observant of the following:
- A. Dizziness and light headed sensations
- B. Weight gain
- C. Sensory changes in the lower extremities
- D. Fatigue
Correct Answer: A
Rationale: Hypotension may be result of over correction of a hypertensive condition.
The home health nurse has made a visit to an 85-year-old female client's home who has recently had surgery to replace her left knee. The client has been discharged from a rehab facility and has been able to walk on her own. The nurse assesses the need for teaching related to fall prevention. What should the nurse include in this teaching plan?
- A. The client should remove all scatter rugs from the floor and minimize clutter.
- B. The client should not get up and move around the house.
- C. The client does not need to install a raised toilet and grab bar because she is able to walk on her own.
- D. The client should wear a robe and socks while walking in the house.
Correct Answer: A
Rationale: Rugs and clutter are a primary cause of falls in the home and should be eliminated if possible to decrease the risk of a fall.