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| Section | Weight | Objectives |
|---|---|---|
| Psychosocial Integrity | 6โ12% | |
| Physiological Integrity | 43โ67% | - Pharmacological and Parenteral Therapies - Reduction of Risk Potential - Basic Care and Comfort - Physiological Adaptation |
| Health Promotion and Maintenance | 6โ12% | |
| Safe and Effective Care Environment | 17โ33% | - Management of Care - Safety and Infection Control |
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NEW QUESTION # 312
An 11-month-old infant is admitted with a possible diagnosis of pyloric stenosis. Which of the following best describes the characteristic clinical manifestations of pyloric stenosis?
Answer: D
Explanation:
Explanation/Reference:
Explanation:
(A) There is no evidence of pain in infants with pyloric stenosis whether eating or not. (B) There are both good appetite and feeding habits in these children. (C) Because of regurgitation, there is usually decreased frequency and quantity of stools and also signs of dehydration and weight loss. (D) Along with upper abdominal distention, there is a characteristic palpable olive-shaped mass located to the right of the umbilicus.
NEW QUESTION # 313
In evaluating the effectiveness of magnesium sulfate (MgSO4), which of the following might indicate that the client was developing MgSO4 toxicity?
Answer: B
Explanation:
Explanation
(A) Diminished (not accentuated) patellar tendon reflex is a sign of developing MgSO4 toxicity. A value of 21 is considered a normal tendon reflex; 3+ is considered brisker than normal. (B) MgSO4 is a central nervous system (CNS) depressant. It also relaxes smooth muscle. If the respiratory rate is <16 bpm magnesium toxicity may be developing. (C) Urine output of 40mL/hr is enough to allow elimination of toxic levels of magnesium.
Urinary output of <100 mL in a 4-hour period may result in toxic levels of magnesium. (D) Presence of protein in the urine is a symptom of pregnancy-induced hypertension (PIH), a clinical syndrome for which magnesium sulfate is frequently used in medical management. Protein in the urine is not induced by magnesium sulfate intake.
NEW QUESTION # 314
A client in active labor asks the nurse for coaching with her breathing during contractions. The client has attended Lamaze birth preparation classes. Which of the following is the best response by the nurse?
Answer: D
Explanation:
Explanation
(A) Lamaze childbirth preparation teaches the use of chest, not abdominal, breathing. (B) In Lamaze preparation, every patterned breath is preceded by a cleansing breath; as labor progresses, shallow, paced breathing is found to be effective. (C) It is important to assume a comfortable position in labor, but the Lamazeprepared laboring woman is taught to breathe with her chest, not abdominal, muscles. (D) When deep chest breathing patterns are used in Lamaze preparation, they are slowly paced at a rate of 6-9 breaths/min.
NEW QUESTION # 315
Which of the following risk factors associated with breast cancer would a nurse consider most significant in a client's history?
Answer: A
Explanation:
Explanation/Reference:
Explanation:
(A) Women who begin menarche late (after 13 years old) have a lower risk of developing breast cancer than women who have begun earlier. Average age for menarche is 12.5 years. (B) Women who have never been pregnant have an increased risk for breast cancer, but a positive family history poses an even greater risk. (C) A positive family history puts a woman at an increased risk of developing breast cancer. It is recommended that mammography screening begin 5 years before the age at which an immediate female relative was diagnosed with breast cancer. (D) Early menopause decreases the risk of developing breast cancer.
NEW QUESTION # 316
A client tells the nurse that she has had a history of urinary tract infections. The nurse would do further health teaching if she verbalizes she will:
Answer: D
Explanation:
(A)
Cranberry juice helps to maintain urine acidity, thereby retarding bacterial growth. (B) A generous fluid intake will help to irrigate the bladder and to prevent bacterial growth within the bladder. (C) Hand washing is an effective means of preventing pathogen transmission.
(D)
Restricting fluid intake would contribute to urinary stasis, which in turn would contribute to bacterial growth.
NEW QUESTION # 317
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