Nokea
Which problems should the nurse counsel adoptive parents about encountering? Select all that apply.
- A. Setting unrealistically high standard for themselves
- B. Lacking basic knowledge about the child's biological health history
- C. Having difficulty assimilating if the child is adopted from another country
- D. Having difficulty deciding when and how to tell the child about being adopted
- E. Feeling the need for more assistance and support in child-rearing than biological parents do
- F. Dealing with feelings of loss and grief in the child regarding family social history and traditions
Correct Answer: A,B,C,D,F
Rationale: Adoptive parents may add pressure to themselves by setting unrealistically high standards for themselves. Additional problems adoptive families may face include possible lack of knowledge about the child's biological health history, difficulty assimilating if the child is adopted from another country, difficulty deciding when and how to tell the child about being adopted, and dealing with social and traditional issues of the biological family. Otherwise, most problems faced by adoptive parents are no different from those encountered by natural parents. All parents want to be good parents. Both adoptive parents and biological parents need information, support, and guidance to prepare them to care for their child.
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The nurse is giving instructions to an adult client with heart failure who is beginning therapy with digoxin. To detect early complications of therapy, which action should the nurse teach the client to perform?
- A. Take the pulse daily.
- B. Have electrolyte levels drawn weekly.
- C. Monitor the blood pressure once a week.
- D. Measure the weight each morning before breakfast.
Correct Answer: A
Rationale: Daily pulse monitoring helps detect digoxin-related complications like bradycardia (pulse <60 beats/min) or tachycardia (>100 beats/min), which require provider notification. Weekly electrolyte levels, blood pressure monitoring, and daily weight are not specific to early digoxin complications.
A mother infected with hepatitis B asks the nurse about the possibility of breastfeeding her neonate. Which response by the nurse would be most appropriate?
- A. Yes, breastfeeding is an acceptable option.
- B. No, you should not breastfeed your baby.
- C. Yes, breastfeeding is an acceptable option once your baby is immunized with the hepatitis B vaccine.
- D. Bottled formula is just as nutritious for your baby.
Correct Answer: C
Rationale: Breastfeeding is safe for hepatitis B-positive mothers if the neonate is vaccinated and receives immunoglobulin, reducing transmission risk.
The home care nurse is evaluating a client's understanding of the self-management of trigeminal neuralgia. Which client statement indicates that there is a need for further teaching?
- A. I should chew on my good side.
- B. An analgesic will relieve my pain.
- C. I should use warm mouthwash for oral hygiene.
- D. Taking my carbamazepine will help control my pain.
Correct Answer: B
Rationale: Chronic irritation of cranial nerve V results in trigeminal neuralgia, and it is characterized by intermittent episodes of intense pain of sudden onset on the affected side of the face. The pain is rarely relieved by analgesics. It is recommended that clients chew on the unaffected side and use warm mouthwash for oral hygiene. Medications such as carbamazepine help control the pain of trigeminal neuralgia.
The nurse is preparing to assess cranial nerve VIII on a client. Which tests will the nurse perform? Select all that apply.
- A. Allen's test
- B. Phalen's test
- C. the Rinne test
- D. the Weber test
Correct Answer: C,D
Rationale: Cranial nerve VIII (vestibulocochlear) is assessed with the Rinne and Weber tests for hearing. Allen's and Phalen's tests assess circulation and carpal tunnel, respectively.
The nurse has given the client with a nonplaster (fiberglass) leg cast instructions regarding cast care at home. The nurse determines that the client needs further teaching if the client makes which statement?
- A. I should avoid walking on wet, slippery floors.
- B. I'm not supposed to scratch the skin underneath the cast.
- C. It's all right to wipe dirt off of the top of the cast with a damp cloth.
- D. If the cast gets wet, I can dry it with a hair dryer turned to the hot setting.
Correct Answer: D
Rationale: Using a hair dryer on a hot setting to dry a wet fiberglass cast can cause burns or damage the cast. Avoiding slippery floors, not scratching under the cast, and wiping the cast with a damp cloth are correct care instructions.