a client asks the nurse about including her 2 and 12 year old sons in the care of their newborn sister which of the following is an appropriate initi

NCLEX-RN

NCLEX RN Practice Questions Exam Cram

1. A client asks the nurse about including her 2 and 12-year-old sons in the care of their newborn sister. Which of the following is an appropriate initial statement by the nurse?

A. Focus on your sons' needs during the first days at home.
B. Tell each child what he can do to help with the baby.
C. Suggest that your husband spend more time with the boys.
D. Ask the children what they would like to do for the newborn.

Correct answer: A

Rationale: It is essential for the nurse to guide the client on the initial steps in involving her 2 and 12-year-old sons in the care of their newborn sister. The most appropriate response is to 'Focus on your sons' needs during the first days at home.' In an expanded family, parents should prioritize reassuring older children that they are loved and as important as the newborn. This response acknowledges the importance of ensuring the well-being and emotional adjustment of the older siblings during the transition period. Choices B, C, and D are less appropriate as they do not directly address the emotional needs and adjustment of the older children during this significant family change.

2. The mother of a newborn infant with hypospadias asks the nurse why circumcision cannot be performed. Which is the most appropriate response by the nurse?

A. Circumcision will cause an infection.
B. Circumcision is not performed in a newborn.
C. Circumcision will cause difficulty with urination.
D. Circumcision has been delayed to save tissue for surgical repair.

Correct answer: D

Rationale: The reason circumcision is not performed in a newborn with hypospadias is that the dorsal foreskin tissue will be needed for the surgical repair of hypospadias. Delaying circumcision allows for the preservation of tissue that will be crucial for the corrective surgery. This surgical repair is typically done within the first year of life to minimize the psychological impact on the child. Choices A, B, and C are incorrect as they do not address the specific reason for delaying circumcision in this case.

3. A patient scheduled for cataract surgery asks the nurse why they developed cataracts and how to prevent it in the future. What is the nurse's best response?

A. Age is the biggest factor contributing to cataracts.
B. Unprotected exposure to UV lights can cause cataracts.
C. Age, eye injury, corticosteroids, and unprotected sunlight exposure are contributing factors to cataracts.
D. Unfortunately, there is really nothing you can do to prevent cataracts, but they are amongst the most easily treated eye conditions.

Correct answer: C

Rationale: The correct answer is C: 'Age, eye injury, corticosteroids, and unprotected sunlight exposure are contributing factors to cataracts.' This response is the best choice as it covers the most common contributing factors for cataracts and includes preventable risk factors. Choice A is incorrect because while age is a significant factor in cataract development, it is not the only one. Choice B is incorrect as UV light exposure is a risk factor for cataracts but not the most comprehensive response. Choice D is incorrect as there are preventive measures individuals can take to reduce their risk of developing cataracts, such as protecting their eyes from UV light and managing other risk factors.

4. A nurse is caring for a patient admitted to the emergency room for an ischemic stroke with marked functional deficits. The physician is considering the use of fibrinolytic therapy with TPA (tissue plasminogen activator). Which history-gathering question would not be important for the nurse to ask?

A. What time did you first notice symptoms consistently appearing?
B. Have you been taking any blood thinners such as heparin, lovenox, or warfarin?
C. Have you had another stroke or head trauma in the previous 3 months?
D. Have you had any blood transfusions within the previous year?

Correct answer: D

Rationale: The correct answer is 'Have you had any blood transfusions within the previous year?' This question is not relevant in the context of considering fibrinolytic therapy with TPA for an ischemic stroke. Blood transfusions within the previous year do not directly impact the decision to use TPA in the treatment of an acute ischemic stroke. The focus should be on factors such as the time of symptom onset, current medications like blood thinners, and recent history of strokes or head trauma, as these are more directly related to the decision-making process for administering TPA in this emergency situation.

5. Why is it important to genotype HCV before initiating drug therapy?

A. Side effects of nucleotide analogs
B. Measures for improving the appetite
C. Ways to increase activity and exercise
D. Administering alpha-interferon (Intron A)

Correct answer: B

Rationale: Genotyping of HCV plays a crucial role in managing treatment as it helps determine the most effective therapy for the specific viral strain. It allows healthcare providers to personalize treatment regimens and predict response rates. The statement about acute HCV infection converting to chronic state is accurate, highlighting the need for appropriate management. Immune globulin and vaccines are not available for HCV, and Ribavirin is commonly used for chronic HCV infection. Improving appetite is essential in liver health as adequate nutritional intake supports hepatocyte regeneration. Choices A, C, and D are incorrect as they do not address the specific importance of genotyping in HCV treatment or the significance of appetite improvement in liver function.