Nokea
A nine-year-old client with an ostomy.
Which of the following statements, if made by the parents of a nine-year-old client with an ostomy, would indicate to the nurse that they are providing quality home care?
- A. We change the bag at least once a week, and we carefully inspect the stoma at that time.'
- B. We change the bag every day so that we can inspect the stoma and the skin.'
- C. We encourage our daughter to watch TV while we change her ostomy bag.'
- D. We only have to change the ostomy bag every ten days.'
Correct Answer: A
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct-ostomy bags should be changed at least once a week; good time for stoma to be closely inspected (2) bag should be changed at least once a week or when seal around stoma is loose or leaking (3) does not encourage client participation or foster independence (4) bag should be changed more often
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The nurse is aware that Rh immune globulin (RhoGAM) is administered.
The nurse is aware that Rh immune globulin (RhoGAM) is administered to prevent complications in which of the following situations?
- A. The baby is Rh-negative, the mother is Rh-negative, and the father is Rh-positive.
- B. The mother is Rh-negative, the baby is Rh-positive, and there is a negative direct Coombs'.
- C. The mother is Rh-positive and previously sensitized, and the baby is Rh-negative.
- D. The mother is Rh-positive, the baby is Rh-negative, and there is a history of one incomplete pregnancy.
Correct Answer: B
Rationale: Strategy: Think about each answer choice. (1) if both mother and baby are Rh-negative, there is no problem (2) correct-RhoGAM is given to an Rh-negative mother who delivers an Rh-positive baby when baby has a negative Coombs' Test (3) medication is not given if the mother has been sensitized by a previous pregnancy (4) there is no incompatibility here, but the mother needs to be evaluated regarding sensitization in the incomplete pregnancy
An 18-year-old client with anorexia nervosa is admitted to the hospital.
In planning to care for the client, the nurse would expect the client to
- A. view her appearance as 'skinny.'
- B. be hypoactive and withdrawn.
- C. want to talk about and plan her meals.
- D. have a close relationship with her mother.
Correct Answer: C
Rationale: Strategy: Determine how each answer choice relates to anorexia. (1) usually view their appearance as fat (2) inaccurate for client with anorexia nervosa (3) correct-display a marked preoccupation with food (4) inaccurate for client with anorexia nervosa
The nurse is teaching a client with a new diagnosis of gastroesophageal reflux disease (GERD) about omeprazole (Prilosec). Which of the following instructions should the nurse include?
- A. Take the medication at bedtime
- B. Report any diarrhea
- C. Stop the medication if symptoms resolve
- D. Avoid taking with meals
Correct Answer: B
Rationale: Diarrhea may indicate Clostridium difficile infection, a serious omeprazole side effect. Options A, C, and D are incorrect: morning dosing is preferred, stopping the medication risks relapse, and it can be taken with meals.
The nurse is caring for a newborn with tracheoesophageal fistula. Which nursing diagnosis is a priority?
- A. Risk for dehydration
- B. Ineffective airway clearance
- C. Altered nutrition
- D. Risk for injury
Correct Answer: B
Rationale: The most common form of TEF is one in which the proximal esophageal segment terminates in a blind pouch and the distal segment is connected to the trachea or primary bronchus by a short fistula. Thus, a priority is maintaining an open airway, preventing aspiration.
The physician diagnoses Graves' disease for a 28-year-old woman seen in the clinic. The nurse would expect the client to exhibit which of the following symptoms?
- A. Lethargy in the early morning.
- B. Sensitivity to cold.
- C. Weight loss of 10 lb in 3 weeks.
- D. Reduced deep tendon reflexes.
Correct Answer: C
Rationale: increased metabolic rate causes weight loss even with increased appetite