Nokea
Which of the following statements, if made by the parents of a newborn, does not indicate a need for further teaching about cord care?
- A. "I should put alcohol on my baby's cord 3-4 times a day."?
- B. "I should put the baby's diaper on so that it covers the cord."?
- C. "I should call the physician if the cord becomes dark."?
- D. "I should wash my hands before and after I take care of the cord."?
Correct Answer: A
Rationale: Explanation: Parents should be taught that putting alcohol or other antimicrobials on the cord is no longer recommended for cord care. This can interfere with the natural healing process and may increase the risk of irritation or infection. Washing hands before and after providing cord care is essential to prevent the transfer of pathogens. Placing the baby's diaper below the cord allows it to be exposed to air and promotes drying, reducing the risk of infection. It is normal for the cord to turn dark as it dries, so calling the physician only if the cord becomes red, swollen, or has discharge is appropriate. Therefore, the statement '"I should put alcohol on my baby's cord 3-4 times a day."?' indicates a need for further teaching about cord care.
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The nurse is caring for a client who has dysphagia related to a stroke. The nurse works with the client to explain what food and beverages might minimize aspiration. What is this an example of?
- A. Health promotion
- B. Secondary prevention
- C. Tertiary prevention
- D. Primary prevention
Correct Answer: B
Rationale: The nurse working with the client to explain what food and beverages might minimize aspiration is an example of secondary prevention. Secondary prevention involves early detection and intervention to prevent complications or worsening of a condition. In this case, the nurse is helping to prevent aspiration pneumonia by providing education and guidance on safe eating and drinking practices after the client has already experienced dysphagia due to a stroke.
Choice A, health promotion, focuses on empowering individuals to adopt healthy behaviors to improve overall well-being and prevent illness. It is more about promoting general health rather than specific interventions related to a particular condition like dysphagia.
Choice C, tertiary prevention, involves managing and rehabilitating a condition to prevent further complications or disabilities. In this scenario, the nurse is not yet addressing complications but rather actively preventing them.
Choice D, primary prevention, aims to prevent the onset of a disease or condition before it occurs. The client in this case already has dysphagia, so the focus is on preventing further complications, making it a secondary prevention intervention.
A nurse is preparing to screen a client's vision with the use of a Snellen chart. The nurse uses which technique?
- A. Tests the right eye, then tests the left eye, and finally tests both eyes together
- B. Assesses both eyes together, then assesses the right and left eyes separately
- C. Asks the client to stand 40 feet from the chart and read the largest line on the chart
- D. Asks the client to stand 40 feet from the chart and read the line that can be read 200 feet away by someone with unimpaired vision
Correct Answer: A
Rationale: To test visual acuity with the use of a Snellen chart, the nurse places the chart in a well-lit spot at the client's eye level, with the client positioned exactly 20 feet from the chart. The client shields one eye at a time with an opaque card during the test. After testing each eye separately, both eyes are assessed together. The client is asked to read the smallest line of letters visible and encouraged to read the next smallest line as well. Therefore, option A is correct as it describes the correct technique of testing one eye at a time before assessing both eyes together. Option B is incorrect as it assesses both eyes together first, which is not the standard procedure. Options C and D are incorrect as they suggest standing 40 feet from the chart, which contradicts the standard distance of 20 feet for a Snellen chart test.
A nurse assisting with data collection notes that the client exhibits rapid, involuntary oscillating movements of the eyeball when looking at the nurse. The nurse documents this finding using which term?
- A. Ptosis
- B. Nystagmus
- C. Scleral icterus
- D. Exophthalmos
Correct Answer: B
Rationale: When a nurse observes rapid, involuntary oscillating movements of the eyeball in a client, this is described as nystagmus. Nystagmus appears as a fine oscillating movement, most notable around the iris. It is important to assess for nystagmus when evaluating ocular muscle weakness. Mild nystagmus at extreme lateral gaze is considered normal; nystagmus in any other position is not. Ptosis refers to a drooping of the eyelid, not rapid eye movements. Scleral icterus is the yellowing of the sclera up to the cornea, indicating jaundice, not related to eye movements. Exophthalmos is a noticeable protrusion of the eyeball, typically seen in hyperthyroidism, not associated with rapid oscillating eye movements.
An adult client tells the clinic nurse that he is susceptible to middle ear infections. About which risk factor related to infection of the ears does the nurse question this client?
- A. Loud music
- B. Use of power tools
- C. Occupational noise
- D. Exposure to cigarette smoke
Correct Answer: D
Rationale: The correct answer is 'Exposure to cigarette smoke.' Otitis media (middle ear infection) is associated with various factors like colds, allergies, sore throats, and blockage of the eustachian tubes. Risk factors include exposure to cigarette smoke, youth (as otitis media is usually a childhood disease), congenital abnormalities, immune deficiencies, family history of otitis media, recent upper respiratory infections, and allergies. Choices A, B, and C (Loud music, Use of power tools, and Occupational noise) are more likely to cause hearing loss rather than being direct risk factors for middle ear infections.
A nurse palpates a client’s radial pulse, noting the rate, rhythm, and force, and concludes that the client’s pulse is normal. Which notation would the nurse make in the client’s record to document the force of the client’s pulse?
- A. 4+
- B. 3+
- C. 2+
- D. 1+
Correct Answer: C
Rationale: When assessing a pulse, the nurse should note the rhythm, amplitude, and symmetry of pulses and should compare peripheral pulses on the two sides for rate, rhythm, and quality. A 4-point scale may be used to assess the force (amplitude) of the pulse: 4+ for a bounding pulse, 3+ for an increased pulse, 2+ for a normal pulse, and 1+ for a weak pulse. In this case, the nurse would grade the client’s pulse as 2+ based on the description of a normal pulse. Therefore, the correct notation for the force of the client’s pulse is '2+' as it indicates a normal pulse. Choices A, B, and D are incorrect as they represent different levels of pulse force that do not align with the description given in the scenario.