The nurse is planning care for an 18 month-old child. Which of the following should be included the in the child’s care?
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Solution
Encourage the child to feed himself finger food
According to Erikson, the toddler is in the stage of autonomy versus shame and doubt. The nurse should encourage increasingly independent activities of daily living.
A 27-year-old woman has Type I diabetes mellitus. She and her husband want to have a child, so they consulted her diabetologist, who gave her information on pregnancy and diabetes. Of primary importance for the diabetic woman who is considering pregnancy should be
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Solution
Early prenatal medical care.
Pregnancy makes metabolic control of diabetes more difficult. It is essential that the client starts prenatal care early so that potential complications can be controlled or minimized by the efforts of the client and health care team.
Option A: A review of dietary modifications is important once the woman is pregnant. However, it is not of primary importance when considering pregnancy.
Option C: The alternative of adoption is not necessary just because the client is a diabetic. Many diabetic women have pregnancies with successful outcomes if they receive good care.
Option D: While there is some risk to the pregnant diabetic woman, it is not considered a major health risk. The greater risk is to the fetus.
The nurse prepares for a Denver Screening test with a 3-year-old child in the clinic. The mother asks the nurse to explain the purpose of the test. The BEST response is to tell her that the test
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Solution
Assesses a child’s development
The Denver Developmental Test II is a screening test to assess children from birth through 6 years in personal/social, fine motor adaptive, language and gross motor development. A child experiences the fun of play during the test.
A woman who is 32 years old and 35 weeks pregnant has had rupture of membranes for eight hours and is four (4) cm dilated. Since she is a candidate for infection, the nurse should include which of the following in the care plan?
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Solution
Frequent temperature monitoring.
Temperature elevation will indicate beginning infection. This is the most important measure to help assess the client for infections since the lost mucous plug and the ruptured membranes increase the potential for ascending bacteria from the reproductive tract. This will infect the fetus, membranes, and uterine cavity.
Option A: Universal precautions are necessary for all clients but a specific assessment of the client’s temperature will give an indication the client is becoming infected.
Option B: Oxytocin may be needed to induce labor if it is not progressing, but it is not done initially.
Option D: More frequent vaginal examinations are not recommended, as frequent vaginal exams can increase chances of infection.
While giving nursing care to a hospitalized adolescent, the nurse should be aware that the MAJOR threat felt by the hospitalized adolescent is
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Solution
Altered body image
The hospitalized adolescent may see each of these as a threat, but the major threat that they feel when hospitalized is the fear of altered body image, because of the emphasis on physical appearance.
When caring for an elderly client it is important to keep in mind the changes in color vision that may occur. What colors are apt to be most difficult for the elderly to distinguish?
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Solution
Blue and green.
The elderly have poor blue-green discrimination. The effects of age are greatest on short wavelengths. These changes are related to the yellowing of the lens with age.
Option A: The elderly are better able to distinguish between red and blue because of the difference in wavelengths.
Option B: The elderly are better able to distinguish between blue and gold because of the difference in wavelengths.
Option C: The elderly are better able to distinguish between red and green because of the difference in wavelengths. Red and green color blindness is an inherited disorder that is unrelated to age.
While teaching a 10-year-old child about their impending heart surgery, the nurse should
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Solution
Explain the surgery using a model of the heart
According to Piaget, the school-age child is in the concrete operations stage of cognitive development. Using something concrete, like a model will help the child understand the explanation of the heart surgery.
The nurse is assessing a six-month-old child. Which developmental skills are normal and should be expected?
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Solution
Sits alone.
A six-month-old child is learning to sit alone.
Option A: The child develops language skills between the ages of one and three.
Option C: The child begins to use a spoon at 12-15 months of age.
Option D: The baby pulls himself to a standing position about ten months of age.
A client telephones the clinic to ask about a home pregnancy test she used this morning. The nurse understands that the presence of which hormone strongly suggests a woman is pregnant?
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Solution
HCG
Human chorionic gonadotropin (HCG) is the biologic marker on which pregnancy tests are based. Reliability is about 98%, but the test does not positively confirm pregnancy.
The nurse is caring for the mother of a newborn. The nurse recognizes that the mother needs more teaching regarding cord care because she
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Solution
Washes the cord and surrounding area well with water at each diaper change.
Washing the surrounding area is fine but wetting the cord keeps it moist and predisposes it to infection.
Option A: Exposure to air helps dry the cord.
Option B: Good hand washing is the prime mechanism for preventing infection.
Option D: It is important to check for complications of bleeding and drainage that might occur.