Nokea
Which of the following statements, if made to the nurse, indicates parental understanding about the cause of their newborn's diagnosis of cystic fibrosis (CF)?
- A. The gene came from my husband's side of the family.
- B. The gene came from my wife's side of the family.
- C. There is a 50 percent chance that our next child will have the disease.
- D. Both of us carry a recessive trait for cystic fibrosis.
Correct Answer: D
Rationale: cystic fibrosis is inherited by an autosomal recessive trait
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The nurse is caring for a client who is postoperative day 1 following a total knee replacement. Which of the following findings should the nurse report to the physician immediately?
- A. Pain at the surgical site rated 6/10.
- B. Swelling and warmth at the incision site.
- C. Urine output of 150 mL over 8 hours.
- D. Serosanguineous drainage on the dressing.
Correct Answer: B
Rationale: swelling and warmth may indicate infection or a deep vein thrombosis, which requires immediate attention
The nurse is caring for a 33-year-old woman after delivering an 8 lb 4 oz girl with talipes equinovarus. The woman confides to the nurse, 'I feel so bad that my baby is abnormal.' Which of the following responses by the nurse is BEST?
- A. It's understandable that you feel this way, but there are treatments to correct your baby's problem.
- B. Your baby is not really abnormal. Her feet just look different because of the way the muscles pull.
- C. You have nothing to feel guilty about. The abnormality is not your fault.
- D. Don't feel bad. You baby's abnormality can be corrected surgically.
Correct Answer: A
Rationale: accepts feelings and gives correct information, serial casting is used
Which of the following nursing observations documented in the client's chart MOST clearly indicates the client's mood?
- A. Client states, 'I see snakes climbing on the walls at all times of the day.'
- B. Unable to sustain a train of thought for long periods of time during history-taking.
- C. Clenches her fists and shouts in an angry tone of voice when asked about family problems.
- D. Is unaware of where she is, what day and year it is, or what time it is.
Correct Answer: C
Rationale: gives data that reflect client's feelings, tone, and behavior associated with those feelings, as well as content area of conversation that evoked that mood
Which of the following nursing actions should be the priority for an infant admitted with a positive stool culture for Salmonella?
- A. Change the diet to clear liquids.
- B. Initiate intravenous fluids.
- C. Maintain contact precautions.
- D. Apply cloth diapers.
Correct Answer: C
Rationale: prevents transmission of this bacterium to other individuals
A family member of a client who has sustained an electrical burn states, 'I don't understand why he has been here a week. The burn does not look that bad.' Which of the following responses by the nurse is BEST?
- A. Electrical burns are more prone to infection.
- B. Electrical burns are always much worse than they look on the outside.
- C. Cardiac monitoring is important because electrical burns affect cardiac function.
- D. Electrical burns can be deceptive because underlying tissue is also damaged.
Correct Answer: D
Rationale: electrical burn injuries are typically more injurious to underlying tissue such as nerve and vascular tissue, which require complex and timely treatment