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Which of the following is information the nurse would be correct in giving the patient about smoking and its effect on BP?
- A. It is associated with stages 1 and 2 hypertension.
- B. It does not affect BP regulation.
- C. It vasodilates the peripheral blood vessels.
- D. It causes sustained BP elevation.
Correct Answer: D
Rationale: Smoking is a known risk factor for hypertension. Chronic smoking leads to sustained elevation in blood pressure by causing vasoconstriction of the blood vessels, increasing heart rate, and promoting the formation of plaques in the arteries. This can contribute to the development of hypertension over time. Therefore, the nurse would be correct in informing the patient that smoking causes sustained elevation in blood pressure.
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A 36 y.o. woman who has had no prenatal care comes into the hospital in active labor for her fourth child. She has vesicles evident on her perineum. The following nursing actions are appropriate to protect the unborn baby and the staff, EXCEPT:
- A. Maintain standard precautions
- B. Prepare for the possibility that the baby may be delivered by CS.
- C. Notify the obstetrician and nurse midwife about the vesicles as soon as possible.
- D. Apply antibiotic ointment to the vesicles and place the mother in reverse isolation
Correct Answer: D
Rationale: When a woman with vesicles on her perineum comes into the hospital in active labor, it is important to take precautions to protect the unborn baby and the staff. However, applying antibiotic ointment to the vesicles and placing the mother in reverse isolation is not appropriate in this situation. This is because her condition is most likely due to herpes simplex virus (HSV) infection, which can be transmitted to the baby during birth leading to severe complications. Placing the mother in reverse isolation can increase the risk of transmission to the healthcare staff as well. Instead, notifying the obstetrician and nurse midwife about the vesicles as soon as possible is crucial for proper management and preparing for the possibility that the baby may be delivered by cesarean section is important to reduce the risk of transmission during vaginal birth. Maintaining standard precautions is essential to prevent the spread of infection.
Mr. and Ms. Byers' child failed to pass meconium within the first 24 hours after birth; this may indicate which of the following?
- A. Celiac disease
- B. Intussusception
- C. Hirschsprung's disease
- D. Abdominal-wall defect
Correct Answer: C
Rationale: Failure to pass meconium within the first 24 hours after birth is a characteristic sign of Hirschsprung's disease. This condition is a congenital disorder in which there is a lack of ganglion cells in certain portions of the large intestine. As a result, the affected segment of the bowel is unable to relax and pass stool, leading to the accumulation of meconium in the intestine. This condition can present with symptoms such as abdominal distension, constipation, and failure to pass stool. Early diagnosis and treatment are crucial to prevent complications such as bowel perforation.
You are meeting parents of a 5-year-old boy; the mother is wondering about the normal sexual behavior of her child. Of the following, the sexual behavior that is considered HIGHLY unusual in this age group is
- A. touching his genitals in public
- B. showing his genitals to others
- C. undressing in public
- D. imitating intercourse or other adult sexual behaviors
Correct Answer: D
Rationale: Imitating adult sexual behaviors is highly unusual and concerning in young children, suggesting possible exposure to inappropriate content or experiences.
The nurse has been teaching an adult who has iron deficiency anemia about those foods that she needs to include in her meal plans. Which of the following, if selected, would indicate to the nurse that the client understands the dietary instructions?
- A. Citrus fruits and green leafy vegetables
- B. Bananas and nuts
- C. Coffee and tea
- D. Dairy products
Correct Answer: A
Rationale: Citrus fruits and green leafy vegetables are good sources of vitamin C and non-heme iron, which can help improve iron absorption in individuals with iron deficiency anemia. Bananas and nuts do not have a direct impact on iron absorption. Coffee and tea contain compounds that can inhibit iron absorption. Dairy products, while an important part of a balanced diet, do not specifically aid in improving iron levels. Thus, selecting citrus fruits and green leafy vegetables indicates that the client understands the dietary instructions provided by the nurse to manage iron deficiency anemia.
Which is most suggestive that a nurse has a nontherapeutic relationship with a patient and family?
- A. Staff is concerned about the nurse's actions with the patient and family.
- B. Staff assignments allow the nurse to care for same patient and family over an extended time.
- C. Nurse is able to withdraw emotionally when emotional overload occurs but still remains committed.
- D. Nurse uses teaching skills to instruct patient and family rather than doing everything for them.
Correct Answer: A
Rationale: Option A is the most suggestive that a nurse has a nontherapeutic relationship with a patient and family because when the staff is concerned about the nurse's actions with the patient and family, it indicates that there may be issues or red flags in the nurse's interactions. This could imply that the nurse's behavior is not promoting a positive, therapeutic relationship with the patient and family, which is crucial for effective care delivery. Staff concerns may arise due to behaviors that are inappropriate, unprofessional, or lacking empathy, which can hinder the development of a therapeutic relationship and affect the quality of care provided.