Nursing Elites

1. The nurse is caring for a postpartum woman who has relinquished her baby for adoption. The care plan for the client should include which of the following priority strategies?

• A. Make a referral for grief counseling.
• B. Allow the woman to see her baby initially and respect her wishes for further visits.
• C. Provide opportunities for the woman to express her feelings.
• D. Inform the woman she has the right to change her mind about relinquishment.

Correct answer: C

Rationale: When caring for a postpartum woman who has relinquished her baby for adoption, it is crucial for the nurse to provide opportunities for the woman to express her feelings. Most women who make this decision have done so with love and pain, and it is essential to allow them to verbalize their emotions, which may include grief, loneliness, and guilt. Referring the woman for grief counseling may be necessary if she lacks a support system or requests help to navigate her grief. Allowing the woman to see her baby is important, and the nurse should respect her wishes regarding visitation as it can aid in the grief process. While the woman does have the right to change her mind about relinquishment until final legal arrangements are made, suggesting this option may inadvertently influence her decision and should be approached cautiously. Therefore, providing emotional support and opportunities for expression are the priority strategies in this situation.

2. The LPN is caring for a 9-month-old infant. Which of these behaviors exhibited by the child warrants further investigation?

• A. She prefers crawling over walking and makes no attempt to walk.
• B. She seems distressed by new adults.
• C. She does not respond to her own name.
• D. She only babbles "mama"? and "dada."?

Correct answer: C

Rationale: The correct answer is that the child does not respond to her own name. By 9 months, children should be babbling simple words, crawling, and responding to their name. Not responding to one's name can be an early indicator of a potential developmental delay, warranting further investigation. Preferring crawling over walking, being distressed by new adults, and babbling 'mama' and 'dada' are typical behaviors for a 9-month-old and do not necessarily require immediate concern.

3. A client with dumping syndrome should..........................while a client with GERD should..........................

• A. Sit up 1 hour after meals; lie flat 30 minutes after meals
• B. Lie down 1 hour after eating; sit up at least 30 minutes after eating
• C. Sit up after meals; sit up after meals
• D. Lie down after meals; lie down after meals

Correct answer: D

Rationale: For a client with dumping syndrome, lying down 1 hour after eating helps reduce symptoms by slowing down the movement of food through the digestive tract, aiding in symptom management. This position assists in symptom management for dumping syndrome. Conversely, for a client with GERD, sitting up at least 30 minutes after eating can help prevent the backflow of stomach acid into the esophagus, reducing reflux symptoms. This upright position is beneficial for managing GERD. Choice A is incorrect because sitting up is recommended for GERD, not dumping syndrome. Choice C is incorrect as it suggests sitting up for both conditions, which is not appropriate. Choice D is incorrect as lying down after meals is not recommended for GERD; it can worsen symptoms by promoting acid reflux.

4. A nurse is auscultating for vesicular breath sounds in a client. Of which quality would the nurse expect these normal breath sounds to be?

• A. Harsh
• B. Hollow
• C. Tubular
• D. Rustling

Correct answer: D

Rationale: The correct answer is D: 'Rustling.' Vesicular breath sounds are described as rustling and resemble the sound of wind blowing through trees. Harsh, hollow, and tubular sounds are associated with bronchial (tracheal) breath sounds, not vesicular breath sounds. Harsh sounds are high-pitched, hollow sounds are reverberating, and tubular sounds are like blowing air into a tube. Therefore, options A, B, and C are incorrect descriptions of vesicular breath sounds and are more characteristic of bronchial breath sounds.

5. A healthcare professional reviewing a client's record notes documentation that the client has melena. How does the healthcare professional detect the presence of melena?

• A. By checking the client's urine for blood
• B. By checking the client's stool for blood
• C. By checking the client's urine for a decrease in output
• D. By checking the client's bowel movements for diarrhea

Correct answer: B

Rationale: Melena' is the term used to describe abnormal black tarry stool that has a distinctive odor and contains digested blood. It usually results from bleeding in the upper gastrointestinal tract and is often a sign of peptic ulcer disease or small bowel disease. The presence of melena is detected by checking the client's stool for blood. Blood in the client's urine, decreased urine output, and diarrhea are not associated with the assessment for melena.

Similar Questions