A woman who is six months pregnant is seen in antepartal clinic. She states she is having trouble with constipation. To minimize this condition, the nurse should instruct her to
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Solution
increase her fluid intake to three liters/day.
In pregnancy, constipation results from decreased gastric motility and increased water reabsorption in the colon caused by increased levels of progesterone. Increasing fluid intake to three liters a day will help prevent constipation. The client should increase fluid intake, increase roughage in the diet, and increase exercise as tolerated. Laxatives are not recommended because of the possible development of laxative dependence or abdominal cramping. Iron supplements are necessary during pregnancy, as ordered, and should not be discontinued. The client should increase fluid intake, increase roughage in the diet, and increase exercise as tolerated. Laxatives are not recommended because of the possible development of laxative dependence or abdominal cramping. Mineral oil is especially bad to use as a laxative because it decreases the absorption of fat-soluble vitamins (A, D, E, K) if taken near mealtimes.
When a client wishes to improve the appearance of their eyes by removing excess skin from the face and neck, the nurse should provide teaching regarding which of the following procedures?
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Solution
Rhytidectomy
Rhytidectomy is the procedure for removing excess skin from the face and neck. It is commonly called a face lift. Dermabrasion involves the spraying of a chemical to cause light freezing of the skin, which is then abraded with sandpaper or a revolving wire brush. It is used to remove facial scars, severe acne, and pigment from tattoos. Rhinoplasty is done to improve the appearance of the nose and involves reshaping the nasal skeleton and overlying skin. Blepharoplasty is the procedure that removes loose and protruding fat from the upper and lower eyelids.
A client is admitted to the hospital with a history of confusion. The client has difficulty remembering recent events and becomes disoriented when away from home. Which statement would provide the best reality orientation for this client?
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Solution
“Good morning. You’re in the hospital. I am your nurse Elaine Jones.”
As cognitive ability declines, the nurse provides a calm, predictable environment for the client. This response establishes time, location and the caregiver’s name.
The family of a 6-year-old with a fractured femur asks the nurse if the child’s height will be affected by the injury. Which statement is true concerning long bone fractures in children?
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Solution
Epiphyseal fractures often interrupt a child’s normal growth pattern
Epiphyseal fractures often interrupt a child’s normal growth pattern
The nurse is assessing a client who states her last menstrual period was March 17, and she has missed one period. She reports episodes of nausea and vomiting. Pregnancy is confirmed by a urine test. What will the nurse calculate as the estimated date of delivery (EDD)?
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Solution
December 24
Naegele’s rule: add 7 days and subtract 3 months from the first day of the last regular menstrual period to calculate the estimated date of delivery.
A 64-year-old client scheduled for surgery with a general anesthetic refuses to remove a set of dentures prior to leaving the unit for the operating room. What would be the most appropriate intervention by the nurse?
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Solution
Ask the client if the preference would be to remove the dentures in the operating room receiving area
Clients anticipating surgery may experience a variety of fears. This choice allows the client control over the situation and fosters the client’s sense of self-esteem and self-concept.
Which of these statements, when made by the nurse, is most effective when communicating with a 4-year-old?
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Solution
“Tell me where you hurt.”
Four-year-olds are egocentric and interested in having the focus on themselves. They will not be interested in what it feels like to other children. Preschoolers are concrete thinkers and would literally interpret any analogies so they are not helpful in explaining procedures. Assurance of confidential communication is most appropriate for the adolescent. In addition, confidentiality is not maintained if the child plans to harm themselves, harm someone else, or discloses abuse.
When assessing a newborn whose mother consumed alcohol during the pregnancy, the nurse would assess for which of these clinical manifestations?
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Solution
wide-spaced eyes, smooth philtrum, flattened nose
The nurse should anticipate that the infant may have fetal alcohol syndrome and should assess for signs and symptoms of it. These include the characteristics listed in choice A.
All of the following characteristics would indicate to the nurse that an elder client might experience undesirable effects of medicines except:
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Solution
increased oxidative enzyme levels.
Oxidative enzyme levels decrease in the elderly, which affects the disposition of medication and can alter the therapeutic effects of medication. Alcohol has a smaller water distribution level in the elderly, resulting in higher blood alcohol levels. Alcohol also interacts with various drugs to either potentiate or interfere with their effects. Magnesium is contained in a lot of medications elder clients routinely obtain over the counter. Magnesium toxicity is a real concern. Albumin is the major drug-binding protein. Decreased levels of serum albumin mean that higher levels of the drug remain free and that there are less therapeutic effects and increased drug interactions.
The nurse should recognize that all of the following physical changes of the head and face are associated with the aging client except:
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Solution
decreased size of the nose and ears.
The nose and ears of the aging client actually become longer and broader. The chin line is also altered. Wrinkles on the face become more pronounced and tend to take on the general mood of the client over the years. For example laugh or frown wrinkles about the eyebrows, lips, cheeks, and outer edges of the eye orbit. The change in the androgen-estrogen ratio causes an increase in growth of facial hair in most older adults. The aging process shortens the platysma muscle, which contributes to neck wrinkles.
The nurse is assessing a 4 month-old infant. Which motor skill would the nurse anticipate finding?
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Solution
Hold a rattle
The age at which a baby will develop the skill of grasping a toy with help is 4 to 6 months.
While the nurse is administering medications to a client, the client states “I do not want to take that medicine today.” Which of the following responses by the nurse would be best?
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Solution
“Is there a reason why you don’t want to take your medicine?”
When a new problem is identified, it is important for the nurse to collect accurate assessment data. This is crucial to ensure that client needs are adequately identified in order to select the best nursing care approaches. The nurse should try to discover the reason for the refusal which may be that the client has developed untoward side effects.
The nurse is teaching the parents of a 3 month-old infant about nutrition. What is the main source of fluids for an infant until about 12 months of age?
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Solution
Formula or breastmilk
Formula or breast milk are the perfect food and source of nutrients and liquids up to 1 year of age.
When observing 4-year-old children playing in the hospital playroom, what activity would the nurse expect to see the children participating in?
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Solution
Playing cooperatively with other preschoolers
Playing cooperatively with other preschoolers. Cooperative play is typical of the late preschool period.
While caring for a client, the nurse notes a pulsating mass in the client’s periumbilical area. Which of the following assessments is appropriate for the nurse to perform?
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Solution
Auscultate the mass
Auscultate the mass. Auscultation of the abdomen and finding a bruit will confirm the presence of an abdominal aneurysm and will form the basis of information given to the provider. The mass should not be palpated because of the risk of rupture.