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Which of the following actions should the nurse take?
- A. Assist the caregiver to arrange a daycare program for the client.
- B. Advise the caregiver to take time for themselves when possible.
- C. Encourage the caregiver to focus on the positive aspects of caregiving.
- D. Remind the caregiver that their loved one depends on them completely.
Correct Answer: A
Rationale: The correct answer is A because arranging a daycare program for the client allows the caregiver to have a break and attend to their own needs. This promotes self-care, prevents burnout, and ensures the well-being of both the caregiver and the client. Choice B, advising the caregiver to take time for themselves, is not as effective as it doesn't provide a concrete solution like arranging daycare. Choice C, encouraging the caregiver to focus on the positive aspects, may be helpful but does not address the need for respite. Choice D, reminding the caregiver of their loved one depending on them, may increase guilt and stress.
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Which of the following actions should the nurse take?
- A. Obtain the specimen immediately upon the client waking up.
- B. Wait 1 day to collect the specimen if the client cannot provide sputum.
- C. Ask the client to provide 15 to 20 ml of sputum in the container.
- D. Wear sterile gloves to collect specimen from the client.
Correct Answer: A
Rationale: The correct answer is A because obtaining the specimen immediately upon the client waking up is crucial for accurate results in sputum collection. In the morning, the sputum is usually more concentrated and provides a better sample. Waiting or collecting at other times may lead to diluted or contaminated samples, affecting test results. Choice B is incorrect as it suggests delaying collection, which could compromise the accuracy of the test. Choice C is incorrect because the amount specified is too high for sputum collection, risking contamination. Choice D is incorrect as sterile gloves are not always necessary for sputum collection, regular gloves are usually sufficient.
Which of the following sites should the nurse use?
- A. Axillary
- B. Rectal
- C. Oral
- D. Tympanic
Correct Answer: B
Rationale: The nurse should use the rectal site for temperature measurement as it provides the most accurate core body temperature reading. Rectal temperature closely reflects internal body temperature, making it the preferred site for assessing critically ill patients or infants who cannot cooperate for oral measurements. Axillary, oral, and tympanic sites may not accurately represent core body temperature due to external factors affecting the readings. Rectal temperature is the gold standard for accurate temperature measurement in certain clinical situations.
For each potential assessment finding, click to specify if the assessment finding is consistent with mastitis or endometritis.
- A. Foul-smelling lochia
- B. Painful, tender breast
- C. Temperature
- D. Chills
Correct Answer: B,C,D
Rationale:
The correct answer is B, C, D.
B: Painful, tender breast - This finding is consistent with mastitis, which is an infection of the breast tissue.
C: Temperature - This finding is common in both mastitis and endometritis, indicating an infection.
D: Chills - This finding is more indicative of a systemic infection, often seen in endometritis.
Explanation for incorrect choices:
A: Foul-smelling lochia - This finding is more specific to endometritis, not mastitis.
E, F, G: Since these parameters are not provided, they cannot be selected or checked.
which of the following findings should the nurse recognize as an expected finding?
- A. The anterior fontanel is open
- B. The posterior fontanel is open
- C. The anterior fontanel is sunken
- D. The anterior fontanel is bulging
Correct Answer: A
Rationale: The correct answer is A: The anterior fontanel is open. This is an expected finding in infants as the anterior fontanel typically remains open until around 18-24 months of age, allowing for the growth and expansion of the skull bones. It is a normal part of development and closure indicates maturation. The posterior fontanel closes earlier than the anterior fontanel, so option B is incorrect. Option C, sunken anterior fontanel, indicates dehydration, while option D, bulging anterior fontanel, is a sign of increased intracranial pressure, both of which are abnormal findings.
Which of the following instructions by the nurse is appropriate?
- A. Tighten your muscles before relaxing them when using muscle relaxation techniques
- B. Avoid deep breathing exercises, as they can increase stress.
- C. Focus on multiple thoughts at once to distract yourself from stress.
- D. Keep your emotions bottled up to maintain control over stress.
Correct Answer: A
Rationale: The correct answer is A because tightening muscles before relaxing them helps to enhance the effectiveness of muscle relaxation techniques by creating a greater sense of contrast between tension and relaxation. This sequence promotes deeper relaxation and can help reduce stress more effectively. Choice B is incorrect as deep breathing exercises are commonly used to reduce stress and promote relaxation. Choice C is incorrect as focusing on multiple thoughts at once can increase stress and overwhelm the individual. Choice D is incorrect as bottling up emotions can lead to increased stress and negatively impact mental health.