Nokea
Which of the following physical manifestations of a client with anorexia nervosa best indicates compliance with the treatment plan of care?
- A. "A weekly weight gain of 1 kg (2.2 lb)"'
- B. "Daily bowel movements that are soft"'
- C. "Return of regular menstrual periods"'
- D. "Improvement of the oral mucosa"'
Correct Answer: A
Rationale: The correct answer is A: "A weekly weight gain of 1 kg (2.2 lb)". In anorexia nervosa, weight restoration is a key goal of treatment to address malnutrition and restore physiological functioning. A weekly weight gain of 1 kg indicates the client is consuming adequate nutrition and their body is responding appropriately to treatment. This physical manifestation suggests the client is compliant with the treatment plan.
Choice B, daily bowel movements that are soft, is not necessarily a direct indicator of compliance with the treatment plan for anorexia nervosa. While bowel movements can be influenced by dietary changes, they are not as specific or reliable as weight gain in assessing treatment compliance.
Choice C, return of regular menstrual periods, is a potential physical manifestation of improved health in anorexia nervosa, but it may not be the best indicator of compliance with the treatment plan, as it can be influenced by various factors.
Choice D, improvement of the oral mucosa, is important for
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A nurse is caring for a child with Wilms' tumor. The parents ask why the sign 'Do not palpate the abdomen' has to be placed on their child's bed. Which of the following is the correct response by the nurse?
- A. Any manipulation of the abdomen can result in pain for your child.
- B. Palpation of the abdomen could cause the tumor to grow.
- C. Palpation of the abdomen could result in some of the tumor cells breaking loose, causing it to spread.
- D. Any manipulation of the abdomen will put pressure on the bladder and cause urine to leak.
Correct Answer: C
Rationale: The correct response is C: Palpation of the abdomen could result in some of the tumor cells breaking loose, causing it to spread. Palpating the abdomen in a child with Wilms' tumor can potentially lead to the dissemination of tumor cells into surrounding tissues and blood vessels, increasing the risk of metastasis. This precaution is crucial to prevent the spread of cancer cells and to contain the tumor within the kidney. Choices A, B, and D are incorrect as they do not address the specific risk associated with manipulating the abdomen in a child with Wilms' tumor. Option A focuses solely on pain, which is not the primary concern in this case. Option B is inaccurate as palpation does not cause tumor growth. Option D is irrelevant to the potential consequences of abdominal manipulation in this context.
Two days after delivery, a postpartum client prepares for discharge. What should the nurse teach her about lochia flow?
- A. Lochia does change color but goes from lochia rubra (bright red) on days 1-3, to lochia serosa (pinkish brown) on days 4-9, to lochia alba (creamy white) days 10-21.
- B. Numerous clots are abnormal and should be reported to the physician.
- C. Saturation of the perineal pad is considered abnormal and may indicate postpartum hemorrhage.
- D. Lochia normally lasts for about 21 days, and changes from a bright red, to pinkish brown, to creamy white.
Correct Answer: D
Rationale: The correct answer is D. Lochia normally lasts for about 21 days, and changes from a bright red, to pinkish brown, to creamy white. This is accurate information regarding the typical progression of lochia flow postpartum. Lochia rubra is the initial discharge, followed by lochia serosa, and finally, lochia alba. This teaching is important for the client to understand what to expect in terms of postpartum bleeding.
Choice A is incorrect as it inaccurately describes the color changes of lochia. Choice B is incorrect because the presence of numerous clots is common in the immediate postpartum period and not necessarily abnormal. Choice C is incorrect as perineal pad saturation is expected initially, and significant saturation may not always indicate hemorrhage.
An hour after delivery, the nurse instills erythromycin (Ilotycin) ointment into the eyes of a newborn. The main objective of the treatment is to prevent infection caused by which organism?
- A. Rubella
- B. Gonorrhea
- C. Syphilis
- D. Human immunodeficiency virus (HIV)
Correct Answer: B
Rationale: The correct answer is B: Gonorrhea. Erythromycin ointment is used to prevent ophthalmia neonatorum, a purulent conjunctivitis that can result from gonorrhea infection in newborns during passage through the birth canal. Gonorrhea is a common cause of this condition, and timely administration of erythromycin helps prevent its development. Rubella, syphilis, and HIV do not typically cause ophthalmia neonatorum, so choices A, C, and D are incorrect in this context.
Which conditions create a risk for uterine atony in the immediate postpartum period?
- A. Breastfeeding and delivery of an infant with chromosome defects
- B. Postterm birth and an amniotomy during labor
- C. Gestational diabetes and pregnancy-induced hypertension
- D. Multiparity and multiple gestation
Correct Answer: D
Rationale: Step-by-step rationale for why choice D is correct:
1. Multiparity: Women who have had multiple pregnancies are at higher risk for uterine atony due to uterine muscle fatigue.
2. Multiple gestation: The presence of more than one fetus puts increased demands on the uterus, increasing the risk of uterine atony.
Summary of why other choices are incorrect:
- A: Breastfeeding and chromosome defects are not directly linked to uterine atony.
- B: Postterm birth and amniotomy do not inherently increase the risk of uterine atony.
- C: Gestational diabetes and pregnancy-induced hypertension are not specific risk factors for uterine atony.
A nurse is initiating a plan of care for a toddler who is hospitalized. Which of the following instructions is important to communicate to the nursing assistant?
- A. Have the toddler dress himself.
- B. Offer the toddler finger foods for snacks.
- C. Provide opportunities to share toys with others.
- D. Ask the child simple yes or no questions.
Correct Answer: B
Rationale: The correct answer is B: Offer the toddler finger foods for snacks. This instruction is important to communicate to the nursing assistant because toddlers are at risk for choking on certain foods due to their developing chewing and swallowing abilities. Finger foods are safer for toddlers to eat as they are easier to manage and reduce the risk of choking.
Other choices are incorrect because:
A: Having the toddler dress himself may not be appropriate as toddlers may need assistance and supervision due to their limited motor skills.
C: Providing opportunities to share toys with others is important for social development but is not as critical as ensuring the toddler's safety during meal times.
D: Asking the child simple yes or no questions is a good communication strategy but not as essential for the toddler's safety during snack times.