Nokea
Which of the following is most likely to impact the body image of an infant newly diagnosed with Hemophilia?
- A. immobility
- B. altered growth and development
- C. hemarthrosis
- D. altered family processes
Correct Answer: D
Rationale: Altered Family Processes is a potential nursing diagnosis for the family and client with a new diagnosis of Hemophilia. Infants are aware of how their caregivers respond to their needs. Stresses can have an immediate impact on the infant's development of trust and how others relate to them because of their diagnosis. The long-term effects of hemophilia can include problems related to immobility. Altered growth and development could not have developed in a newly diagnosed client. Hemarthrosis is acute bleeding into a joint space that is characteristic of hemophilia. It does not have an immediate effect on the body image of a newly diagnosed hemophiliac.
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This is an example of:
- A. professional nurturing.
- B. networking.
- C. mentoring.
- D. collegiality.
Correct Answer: B
Rationale: Networking involves the process of developing and using contacts throughout one's professional career for information, advice, and support. Nurturing and mentoring are both examples of assistance to other colleagues in formal and informal relationships for support and career building. Collegiality is the professional camaraderie or rapport established among persons through shared experiences.
When obtaining a health history on a menopausal woman, which information should a nurse recognize as a contraindication for hormone replacement therapy?
- A. family history of stroke
- B. ovaries removed before age 45
- C. frequent hot flashes and/or night sweats
- D. unexplained vaginal bleeding
Correct Answer: D
Rationale: Unexplained vaginal bleeding is a contraindication for hormone replacement therapy. Family history of stroke is not a contraindication for hormone replacement therapy. If the woman herself had a history of stroke or other blood-clotting events, hormone therapy could be contraindicated. Frequent hot flashes and/or night sweats can be relieved by hormone replacement therapy.
The nursing staff has a normal nurse-to-client ratio of three clients per nurse on the floor. Nurse Ann tells nurse Christine that one of her client's status is declining but that she will do her best to juggle her other two clients. Which action is most appropriate?
- A. Nurse Christine should offer to give medications to nurse Ann's other two clients.
- B. Nurse Christine should inform their supervisor that assignments may need to be changed.
- C. Nurse Christine should ask the other nurses who might be able to help nurse Ann.
- D. Nurse Ann should try not to burden the other nurses and continue caring for her assigned clients.
Correct Answer: B
Rationale: When there is a change in the client's status, the supervisor should be made aware so that client care assignments can be changed as needed.
A client, age 28, is 8-12 months pregnant. She is most likely to display which normal skin-color variation?
- A. Vitiligo
- B. Erythema
- C. Cyanosis
- D. Chloasma
Correct Answer: D
Rationale: Chloasma, also known as the mask of pregnancy, is described as tan-to-brown patches on the face due to hormonal changes during pregnancy.
All of the following tasks could be delegated to a nursing assistant or unlicensed assistive personnel (UAP) except:
- A. monitoring intravenous infusion.
- B. assisting a client to the bathroom.
- C. offering fluid intake every 1-2 hours.
- D. monitoring/recording the amount of fluid taken.
Correct Answer: A
Rationale: Monitoring an intravenous infusion must be performed by an RN or LPN. Assisting during activity, offering fluids and recording intake are in the job scope of the nursing assistant.