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When assisting with data collection on language development in a toddler from a bilingual family, what characteristic would a nurse expect?
- A. Is more advanced than expected
- B. Is developing as expected
- C. Is slower than expected
- D. Will require assistance from a speech therapist
Correct Answer: C
Rationale: When assessing language development in a toddler from a bilingual family, a nurse would expect the child's language development to be slower than expected. Various factors, such as physical maturity and reinforcement received, can influence the pace of language development. Children from bilingual families, twins, and non-firstborn children may exhibit slower language development. Therefore, it is common for the language development of a toddler from a bilingual family to be slower than expected. This characteristic does not necessarily imply a need for speech therapy. Choices A, B, and D are incorrect because, in this context, the language development of the child is more likely to be slower than expected rather than more advanced, developing as expected, or requiring speech therapy.
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A nurse observes a nursing assistant communicating with a hearing-impaired client in later adulthood. The nurse should intervene if the nursing assistant performs which action?
- A. Uses short sentences
- B. Speaks at a normal rate and volume
- C. Uses facial expressions or gestures
- D. Overarticulates words
Correct Answer: D
Rationale: The correct answer is 'Overarticulates words.' When communicating with a hearing-impaired client who may rely on lip-reading, it is essential to speak clearly at a normal rate and volume. Overarticulating words can distort lip movements, making it harder for the client to understand. Using short sentences helps in conveying information effectively, allowing the client time to process. While facial expressions and gestures provide additional visual cues that aid in communication, overarticulating words can be counterproductive in this scenario. Therefore, the nursing assistant should avoid overarticulating words to ensure clear and concise communication for the client.
A community health nurse is providing information to a group of older clients about measures to decrease the risk of contracting influenza during peak flu season. The nurse should provide which information?
- A. Clients must stay at home and ask a neighbor or family member to run their errands.
- B. It is best to do grocery shopping and other errands early in the morning when crowds are smaller.
- C. Clients should wash their hands frequently and keep hands away from the face, especially during peak flu season.
- D. Drinking eight 8-oz glasses of fluid each day will reduce the risk of contracting influenza.
Correct Answer: C
Rationale: During peak influenza season, older clients should take measures to reduce the risk of contracting the flu. The most effective preventive measure is frequent hand hygiene and refraining from touching the face, as this reduces the transmission of the flu virus. While it is advisable to avoid crowds, the direct action of hand hygiene is more impactful. Doing errands early in the morning when crowds are smaller is a good suggestion to reduce exposure but does not address the direct transmission through hands. Drinking enough fluid daily is important for overall health but does not directly reduce the risk of contracting influenza.
When reviewing a client's medical notes to confirm pregnancy, a nurse should look for which finding to determine that pregnancy is confirmed?
- A. Amenorrhea
- B. Thinning of the cervix
- C. Palpable fetal movement
- D. Positive result on a home urine test for pregnancy
Correct Answer: C
Rationale: To confirm pregnancy, the presence of palpable fetal movement is a positive indicator. Palpable fetal movement is a certain sign of pregnancy, known as a fetal movement felt by the examiner. Amenorrhea is a presumptive sign of pregnancy as it is reported by the woman but is not confirmatory. Thinning of the cervix (Hegar sign) is a probable sign of pregnancy, which is not confirmatory. A positive result on a home urine test for pregnancy is also a probable indicator. However, a positive pregnancy test result can sometimes yield false-positive results due to various factors like medication, recent pregnancy, or errors in reading.
A nurse is participating in a planning conference to improve dietary measures for an older client experiencing dysphagia. Which action should the nurse suggest including in the plan of care?
- A. Monitoring the client during meals to ensure that food is swallowed
- B. Encouraging the client to feed themselves
- C. Consulting with the physician regarding feeding through an enteral tube
- D. Ensuring that the diet consists of both solids and liquids
Correct Answer: A
Rationale: For clients with dysphagia, ensuring successful swallowing of food and preventing aspiration is crucial. Therefore, the nurse should suggest monitoring the client closely during meals to provide assistance as needed. While a balanced diet is important, special considerations like adding thickeners for liquids may be required for dysphagia clients. Consulting with a physician about enteral tube feeding should be based on the severity of the condition, making it a premature step without clear indications. Encouraging self-feeding may not be appropriate for dysphagia clients who require close monitoring and assistance, as it could increase the risk of complications.
A female client asks a nurse about the advantages of using a female condom. The nurse discusses which advantage with the client?
- A. That it offers protection against sexually transmitted infections (STIs)
- B. That it cannot be used along with a male condom
- C. That it does not have to be discarded after use and can be used several times before a new one must be obtained
- D. That it is 100% effective in preventing pregnancy
Correct Answer: A
Rationale: The correct answer is that the female condom offers protection against sexually transmitted infections (STIs). Unlike the male condom, the female condom is a loose-fitting tubular polyurethane pouch that is anchored over the labia and cervix. It is used once and then discarded, making choice C incorrect. Female and male condoms should not be used together, so choice B is incorrect. Additionally, no contraceptive method is 100% effective in preventing pregnancy, making choice D incorrect.