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| Section | Weight | Objectives |
|---|---|---|
| Safe and Effective Care Environment | 17–33% | - Safety and Infection Control - Management of Care |
| Health Promotion and Maintenance | 6–12% | |
| Psychosocial Integrity | 6–12% | |
| Physiological Integrity | 43–67% | - Physiological Adaptation - Reduction of Risk Potential - Pharmacological and Parenteral Therapies - Basic Care and Comfort |
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NEW QUESTION # 822
A 20-year-old female client delivers a stillborn infant. Following the delivery, an appropriate response by the labor nurse to the question, "Why did this happen to my baby?" is:
Answer: B
Explanation:
Explanation
(A) The mother and the father require support; the nurse should not minimize their grief in this situation. (B) Attachment to this infant occurs during the pregnancy for both the mother and father. Another child cannot replace this child. (C) Attachment to this infant occurs during the pregnancy for both the mother and father.
Siblings will not replace their feelings or minimize their loss of this infant. (D) Holding and viewing the infant decreases denial and may facilitate the grief process. The nurse should prepare family members for how the infant appears ("she is bruised") and provide support.
NEW QUESTION # 823
A measurable outcome criterion in the nursing care of an adolescent with anorexia nervosa would be:
Answer: C
Explanation:
Explanation/Reference:
Explanation:
(A) This outcome criterion is inadequate because the term "accepts" is not directly measurable. (B) This outcome criterion is directly measurable because specific goal-related verbalizations can be heard and verified by the nurse. (C) "Improved perception of body image" is not directly measurable and is therefore open to many interpretations. (D) Although long-term goals for the anorexic client should focus on increased self-esteem, this outcome criterion (as stated) does not include specific indicators or behaviors for which to observe.
NEW QUESTION # 824
A client at 6 months' gestation complains of tiredness and dizziness. Her hemoglobin level is 10 g/dL, and her hematocrit value is 32%. Her nutritional intake is assessed as sufficient. The most likely diagnosis is:
Answer: B
Explanation:
Section: Questions Set F
Explanation:
(A) This clinical situation is indicative of iron-deficiency anemia because the client has inadequate nutritional intake. Her blood volume is increasing faster than her red blood cell volume. Anemia is present in the second trimester when the hemoglobin level is <10.5 and the hematocrit value falls below 35%. She needs increased iron supplements with follow-up. (B) The client's values are below levels for physiological anemia. (C) The client is fatigued because of a low hemoglobin level. (D) Her hemoglobin level is low and will probably decrease even more when the blood volume peaks at 28 weeks.
NEW QUESTION # 825
Clinical manifestations seen in left-sided rather than in right-sided heart failure are:
Answer: C
Explanation:
Explanation
(A, B, C) Clinical manifestations of right-sided heart failure are weakness, peripheral edema, jugular venous distention, hepatomegaly, jaundice, and elevated central venous pressure. (D) Clinical manifestations of left-sided heart failure are left ventricular dysfunction, decreased cardiac output, hypotension, and the backward failure as a result of increased left atrium and pulmonary artery pressures, pulmonary edema, and rales.
NEW QUESTION # 826
Nursing care for the substance abuse client experiencing alcohol withdrawal delirium includes:
Answer: B
Explanation:
(A) These clients are at high risk for seizures during the 1st week after cessation of alcohol intake. (B) Fluid intake should be increased to prevent dehydration. (C) Environmental stimuli should be decreased to prevent precipitation of seizures. (D) Application of restraints may cause the client to increase his or her physical activity and may eventually lead to exhaustion.
NEW QUESTION # 827
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