Nokea
While sitting at the nurse's station, the nurse observes that a client uses a tissue to pick up magazines and change channels on the television. There has been no such behavior in the past. The nurse should:
- A. Talk with the client about the behavior.
- B. Provide the client with a pair of nonsterile gloves.
- C. Take the tissues away from the client.
- D. Recognize the behavior as a means of getting attention.
Correct Answer: A
Rationale: Talking with the client assesses potential obsessive-compulsive behavior or anxiety. Gloves or removing tissues may escalate distress. Attention-seeking is an assumption without evidence.
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The nurse is caring for a newborn. Which of the following signs would indicate neonatal abstinence syndrome? Select all that apply.
- A. Irritability and restlessness
- B. Meconium ileus and floppy muscle tone
- C. Microcephaly and cleft palate
- D. Nasal congestion and frequent sneezing
- E. Poor feeding and loose stools
Correct Answer: A,D,E
Rationale: Neonatal abstinence syndrome includes irritability , nasal congestion and sneezing , and poor feeding with loose stools due to withdrawal. Meconium ileus and hypotonia suggest cystic fibrosis, and microcephaly and cleft palate are congenital anomalies.
Which statement by the parent of a child with sickle cell anemia indicates an understanding of the disease.
- A. The pain he has is due to the presence of too many red blood cells.'
- B. He will be able to go snow skiing with his friends as long as he stays warm.'
- C. He will need extra fluids in the summer to prevent dehydration.'
- D. There is very little chance that his brother will have sickle cell.'
Correct Answer: C
Rationale: Extra fluids in summer prevent dehydration, which can trigger sickle cell crises. Pain is due to vaso-occlusion, not excess RBCs; skiing risks hypoxia; siblings have a 25% chance of inheriting the disease.
A client is receiving oxygen therapy via a nasal cannula. When providing nursing care, which of the following interventions would be appropriate?
- A. Determine that adequate mist is supplied
- B. Inspect the nares and ears for skin breakdown
- C. Lubricate the tips of the cannula before insertion
- D. Maintain sterile technique when handling cannula
Correct Answer: B
Rationale: Inspect the nares and ears for skin breakdown. Oxygen therapy can cause drying of the nasal mucosa. Pressure from the tubing can cause skin irritation.
A client with Cushing's syndrome should be instructed to:
- A. Avoid alcoholic beverages
- B. Limit the sodium in her diet
- C. Increase servings of dark green vegetables
- D. Limit the amount of protein in her diet
Correct Answer: B
Rationale: A client with Cushing's syndrome has adrenocortical hypersecretion, so she retains sodium and water. The client may drink alcohol in moderation, so answer A is incorrect, and there is no need to eat more green vegetables or limit protein, so answers C and D are incorrect.
The nurse is assessing a 1-month-old infant with atrial septal defect. Which of the following findings would be consistent with the condition?
- A. cyanosis
- B. muffled heart tones
- C. murmur
- D. weak femoral pulses
Correct Answer: C
Rationale: An atrial septal defect often presents with a heart murmur due to abnormal blood flow. Cyanosis is rare unless severe, muffled tones are not typical, and weak femoral pulses suggest coarctation of the aorta.