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When preparing to listen to a client's breath sounds, what technique should a nurse use?
- A. Ask the client to sit and lean forward slightly, with the arms resting comfortably across the lap.
- B. Listen to the right lung first, then the left lung, moving from top to bottom systematically.
- C. Ask the client to take deep breaths through the mouth.
- D. Use the diaphragm of the stethoscope, holding it firmly against the client's chest.
Correct Answer: D
Rationale: When preparing to listen to a client's breath sounds, a nurse should ask the client to sit and lean forward slightly, with the arms resting comfortably across the lap. The client should be instructed to breathe through the mouth a little more deeply than usual but to stop if feeling dizzy. The nurse should use the flat diaphragm end-piece of the stethoscope, holding it firmly on the chest wall. By using the diaphragm, the nurse can listen for at least one full respiration in each location, moving from side to side to compare sounds. This technique ensures a systematic and thorough assessment of lung sounds. Choice A is correct as it includes the proper positioning of the client and specifies the use of the diaphragm of the stethoscope. Choice B is incorrect as both lungs should be auscultated systematically, starting from the top and moving down. Choice C is incorrect as deep breaths, not shallow ones, are recommended for an accurate assessment of breath sounds.
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When working with multicultural populations, the nurse should consider all of the following when planning care for a client with an altered sexuality pattern except:
- A. some Hispanic and Native-American cultures are very open when discussing sexuality.
- B. some cultures view the postpartum period as a state of impurity.
- C. some women in the African-American culture view childbearing as a validation of their femaleness.
- D. some Native-American women believe monthly menstruation maintains physical well-being and harmony.
Correct Answer: A
Rationale: When working with multicultural populations, it is essential to understand cultural variations in beliefs and practices related to sexuality. While it is true that some cultures view the postpartum period as a state of impurity and that some women in the African-American culture view childbearing as a validation of their femaleness, the statement 'some Hispanic and Native-American cultures are very open when discussing sexuality' is incorrect. In reality, many cultures, including Hispanic and Native-American cultures, are sometimes hesitant to discuss sexuality. For example, some Navajos, Hispanics, and Orthodox Jews may consider the postpartum period as impure, leading to seclusion of women until the end of bleeding, marked by a ritual bath. Additionally, many Native-American women believe in the importance of monthly menstruation for physical well-being and harmony. Therefore, the statement about Hispanic and Native-American cultures being very open about discussing sexuality is not accurate in the context of working with multicultural populations.
While performing a physical assessment on a 6-month-old infant, the nurse observes head lag. Which of the following nursing actions should the nurse perform first?
- A. Ask the parents to allow the infant to lie on his stomach to promote muscle development.
- B. Notify the physician because a developmental or neurological evaluation is indicated.
- C. Document the findings as abnormal in the nurse's notes.
- D. Explain to the parents that their child is likely to have developmental delays.
Correct Answer: B
Rationale: Head lag should be completely resolved by 4 months of age. Continuing head lag at 6 months of age indicates the need for further developmental or neurological evaluation. Laying the infant on his stomach promotes muscle development of the neck and shoulder muscles, but because of the age of this child, a referral should be the first action. The findings are abnormal for a 6-month-old infant. Significant head lag can be seen in infants with Down syndrome and hypoxia, as well as neurological and other metabolic disorders. While some of these disorders might include developmental delays, stating this to the parents without a proper evaluation can cause unnecessary distress. The priority is to identify the cause of the head lag through a medical evaluation before discussing potential outcomes with the parents.
When a client who is having trouble conceiving says to the nurse, 'I have started taking ginseng,' the best response by the nurse is:
- A. "There is some evidence that ginseng may enhance in vitro sperm motility."?
- B. "Some studies show that ginseng enhances in vitro sperm motility."?
- C. "Ginseng is not proven to be effective for infertility; have you considered other options?"?
- D. "It's probably not going to hurt you, but it's also probably not going to help. Let's look at some other alternatives."?
Correct Answer: B
Rationale: Some studies have shown that ginseng enhances in vitro sperm motility, making Choice B the correct response. It directly addresses the client's comments about taking ginseng and provides valuable information regarding its potential effect on sperm motility. Alternative therapies are often sought by couples struggling with infertility, and acknowledging the potential benefits of ginseng can empower the client. Choice A is incorrect as it slightly misrepresents the evidence by overgeneralizing its effectiveness. Choice C dismisses ginseng without acknowledging its potential benefits, potentially closing off a fruitful discussion with the client. Choice D, while neutral, misses the opportunity to validate the client's choice and explore further options collaboratively. It is crucial for nurses to respect clients' choices, provide accurate information, and guide them effectively in exploring different alternatives.
When teaching parents how their children learn sex role identification, the nurse should include which of the following statements?
- A. Sex role identification begins in infancy.
- B. Sex role identification begins in the preschool years.
- C. Sex role identification begins during the school-age years.
- D. Sex role identification begins during early adolescence.
Correct Answer: A
Rationale: Sex role identification begins during infancy as infants can identify body parts by the end of the first year. Preschoolers often engage in masturbation and sex play. School-age children continue to develop awareness of their sexual identity, including behaviors like hugging and kissing. Early adolescence sees further development influenced by sexual maturation and experimentation with sex roles. Therefore, the correct statement is that sex role identification begins in infancy. Choices B, C, and D are incorrect as they misrepresent the timeline of the development of sex role identification in children.
The client provides information to a pregnant client who is experiencing nausea and vomiting about measures to relieve the discomfort. Which statement by the mother indicates the need for further information?
- A. ''I should eat five or six small meals a day rather than three full meals.''
- B. ''I need to be sure not to drink liquids with my meals.''
- C. ''I should keep dry crackers at my bedside and eat them before I get out of bed in the morning.''
- D. ''I need to avoid eating fried or greasy foods.''
Correct Answer: B
Rationale: To alleviate nausea and vomiting, the client should avoid drinking liquids with meals. The client should keep dry crackers at her bedside, avoid fried foods, and eat smaller meals. Additionally, the client should eat dry crackers every 2 hours to prevent an empty stomach and avoid spicy foods and foods with strong odors, such as onion and cabbage. The incorrect choices are: A) Eating five or six small meals a day instead of three full meals is a correct recommendation. C) Keeping dry crackers at her bedside and eating them before getting out of bed in the morning is a helpful suggestion. D) Avoiding fried or greasy foods is a valid advice to alleviate nausea and vomiting.