Nokea
While assessing the psychosocial aspects of a primigravid client at 30 weeks' gestation, which of the following feelings are expected?
- A. Vulnerability.
- B. Confirmation.
- C. Ambivalence.
- D. Body image disturbance.
Correct Answer: C
Rationale: Ambivalence is common in pregnancy, reflecting mixed emotions about impending motherhood and life changes.
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Which of the following patient care tasks is coupled with the appropriate member of the nursing care team in terms of their legal scope of practice?
- A. An unlicensed staff member who has been 'certified' by the employing agency to monitor telemetry: Monitoring cardiac telemetry
- B. An unlicensed assistive staff member like a nursing assistant who has been 'certified' by the employing agency to insert a urinary catheter: Inserting a urinary catheter
- C. A licensed practical nurse: The circulating nurse in the perioperative area
- D. A licensed practical nurse: The first assistant in the perioperative area
Correct Answer: A
Rationale: Monitoring cardiac telemetry is within the scope of practice for unlicensed staff who are specifically trained and certified by the employing agency. Inserting a urinary catheter typically requires a higher level of licensure (e.g., LPN or RN), and LPNs are not typically authorized to serve as circulating nurses or first assistants in the perioperative area, as these roles require advanced training or RN licensure.
To reduce the risk of pressure ulcer formation, which of the following activities should the nurse teach the client who is wheelchair-bound as a result of a spinal cord injury?
- A. Bathe daily.
- B. Eat a high-carbohydrate diet.
- C. Shift your weight every 15 minutes.
- D. Move from the bed to the wheelchair every 2 hours.
Correct Answer: C
Rationale: Shifting weight every 15 minutes relieves pressure on bony prominences, reducing pressure ulcer risk. The other options are less directly related to prevention.
The physician has prescribed nitroglycerin to a client with angina. The client also has closed-angle glaucoma. The nurse contacts the physician to discuss the potential for:
- A. Decreased intraocular pressure
- B. Increased intraocular pressure
- C. Hypotension
- D. Hypertension
Correct Answer: B
Rationale: Nitroglycerin can increase intraocular pressure, which is a concern in closed-angle glaucoma, potentially worsening the condition. Hypotension is a common side effect but not specific to glaucoma.
A newborn infant is diagnosed with imperforate anus. Which description of this disorder should the nurse provide to the parents?
- A. The presence of fecal incontinence
- B. Incomplete development of the anus
- C. The infrequent and difficult passage of dry stools
- D. Invagination of a section of the intestine into the distal bowel
Correct Answer: B
Rationale: Imperforate anus (anal atresia, anal agenesis) is the incomplete development or absence of the anus in its normal position in the perineum. Option 1 describes encopresis. Encopresis generally affects preschool and school-age children. Option 3 describes constipation. Constipation can affect any child at any time, although it peaks at age 2 to 3 years. Option 4 describes intussusception.
A client who has Ménière's disease is experiencing an acute attack of vertigo. Which of the following interventions should the nurse include in the plan of care?
- A. Darken the client's room and provide a quiet environment.
- B. Provide a low-sodium, bland diet.
- C. Administer an opioid to relieve headache.
- D. Encourage fluid intake to prevent dehydration.
Correct Answer: A
Rationale: A dark, quiet environment reduces stimuli that can exacerbate vertigo in Ménière's disease.