LPN Adaptive questions Respiratory
A mother asks why her 2-year-old toddler's cleft palate was not repaired at the same time that the cleft lip was repaired. What is the best response by the nurse? <p>A mother asks why her 2-year-old toddler's cleft palate was not repaired at the same time that the cleft lip was repaired. What is the best response by the nurse?</p> "Waiting leaves time for other birth defects to be detected and corrected." "The cleft lip was so disfiguring that surgery was done as quickly as possible." "Your surgeon prefers to separate the operations to minimize the potential for complications." "The palate usually is repaired before a child starts to speak. Some surgeons prefer to wait up to 2 years."
"The palate usually is repaired before a child starts to speak. Some surgeons prefer to wait up to 2 years." Although the palate may be repaired during the neonatal period, performing the repair so early is controversial. However, the surgical repair should be done before the child talks so that the child can learn to speak coherently. Although both cleft lip and palate may occur with other birth defects, it is not always so; most birth defects are diagnosed at the time of birth. Focusing on the disfigurement may raise anxiety and increase guilt. There is a specific reason why the two surgeries are done separately, not merely to minimize complications.
A client who is in the first trimester is being discharged after a week of hospitalization for hyperemesis gravidarum. She is to be maintained at home with rehydration infusion therapy. What is the priority nursing activity for the home health nurse? Determining fetal well-being Monitoring for signs of infection Monitoring the client for signs of electrolyte imbalances Teaching about changes in nutritional needs during pregnancy
**Monitoring the client for signs of electrolyte imbalances** Rehydration fluids contain only saline and dextrose; if the client continues to vomit, she will lose electrolytes. Monitoring the fetus is not the priority. Early in the pregnancy the mother's well-being will be reflected by the fetus. Although there is a danger of infection when an IV is in place, monitoring for it is not the priority. Teaching about nutritional needs is a nontherapeutic nursing action while the client is still vomiting.
A client with Crohn's disease is admitted to the hospital with a history of chronic, bloody diarrhea, weight loss, and signs of general malnutrition. The client has anemia, a low serum albumin level, and signs of negative nitrogen balance. The nurse concludes that the client's health status is related to a major deficiency of: Iron Protein Vitamin C Linoleic acid
**Protein** Protein deficiency causes a low serum albumin level, which permits fluid shifts from the intravascular to the interstitial compartment, resulting in edema. Decreased protein also causes anemia; protein intake must be increased. Although a deficiency of iron will result in anemia, it will not cause the other adaptations. Vitamin C is unrelated to these adaptations. Linoleic acid is unrelated to these adaptations.
How can a nurse best evaluate the effectiveness of communication with a client? Client feedback Medical assessments Health care team conferences Client's physiologic responses
Client feedback Feedback permits the client to ask questions and express feelings and allows the nurse to verify client understanding. Medical assessments do not always include nurse-client relationships. Team conferences are subject to all members' evaluations of a client's status. Nurse-client communication should be evaluated by the client's verbal and behavioral responses.
The mother of 10-year-old twin boys tells the nurse in the pediatric clinic that she is concerned because the boys want to spend all their time with their father. What is the best response regarding this behavior? </p> It is typical of twins. It indicates that they dislike girls. Gender identification is natural at this age. Counseling should be considered at this time.
Gender identification is natural at this age. During the school-age years, learning of the sex role becomes more prominent. At this age children prefer friendships with children of the same sex and spend more time with the parent of the same sex. This behavior is not because they are twins but because they are boys. Their behavior is unrelated to a dislike of girls. There is no need for counseling, because this behavior is expected at this age.
A housekeeping staff member in a mental health unit reports to the nurse that food was found hidden in a client's room. Knowing that the client was admitted with a fluid and electrolyte imbalance because of anorexia nervosa, the nurse should ask housekeeping personnel to: <p>A housekeeping staff member in a mental health unit reports to the nurse that food was found hidden in a client's room. Knowing that the client was admitted with a fluid and electrolyte imbalance because of anorexia nervosa, the nurse should ask housekeeping personnel to:</p> Point this out to the client and remove the food Report it to the nursing staff if this happens again Disregard this because it is a common behavior in clients with anorexia Keep a record of when this happens and report it to the nursing staff weekly
Report it to the nursing staff if this happens again Asking the housekeeping staff to keep the nursing staff informed shows that housekeeping members are part of the health team and their input is valued; this will help keep lines of communication open. Pointing this out to the client and removing the food is not the responsibility of the housekeeping staff. Disregarding input from members of the health care team does not promote collaboration. Client behaviors should never be disregarded. The housekeeping staff should notify a nursing team member if this behavior occurs again. Keeping a record of when this happens and reporting to the nursing staff weekly is not the responsibility of the housekeeping staff.
A client's laboratory report indicates hyperkalemia. Which responses should the nurse expect the client to exhibit? <p>A client's laboratory report indicates hyperkalemia. Which responses should the nurse expect the client to exhibit? <b/> <i/> </p> Anorexia Vomiting Constipation Muscle weakness Irregular heart rate
Vomiting Muscle weakness Irregular heart rate Bouts of nausea and vomiting are common with hyperkalemia. Because of potassium's role in the sodium-potassium pump, an increase in potassium interferes with muscle contractions; it results in muscle weakness and areflexia. An increase in potassium can cause muscle twitching. The heart is a muscle and hyperkalemia can cause palpitations and cardiac dysrhythmias. On an ECG tracing the T wave will be peaked with hyperkalemia. Anorexia occurs with hypokalemia, not hyperkalemia. Diarrhea, not constipation, occurs with hyperkalemia.
A parent of a 13-year-old adolescent with recently diagnosed Hodgkin disease tells a nurse, "I don't want her to know about the diagnosis." How should the nurse respond? <p>A parent of a 13-year-old adolescent with recently diagnosed Hodgkin disease tells a nurse, "I don't want her to know about the diagnosis." How should the nurse respond?</p> "It's best for your child to know the diagnosis." "Did you know that the cure rate for Hodgkin disease is high?" "Would you like someone with Hodgkin disease to talk with you?" "Let's talk about how you're feeling about your child's diagnosis."
"Let's talk about how you're feeling about your child's diagnosis." Initiating a conversation about the client's feelings does not prejudge the parent; it encourages communication. Stating that it is best for the child to know the diagnosis disregards the parent's feelings and cuts off further communication. Asking the client about the cure rate may stop communication and does not recognize the parent's concerns. Offering to have someone with Hodgkin disease speak to the client is premature and does not recognize the parent's concerns.
A depressed client is brought to the emergency department after taking an overdose of a sedative. After lavage the client says, "Let me die. I'm no good." What is the most appropriate response by the nurse? "Tell me why you did this." "You must have been upset to try to take your life." "Of course you're good; we'll take excellent care of you." "You've been through a rough time; let me take care of you."
*"You must have been upset to try to take your life."*** Identifying and showing understanding of the client's feelings by giving feedback helps establish a therapeutic relationship and promotes exploration of feelings. Asking why the client attempted suicide is too direct; it does not allow the client time to reflect and explore feelings. Telling the client he or she is good and promising to take care of him or her negates the client's feelings and cuts off any further communication of feelings. Telling the client to let the nurse take care of him or her encourages dependence; it does not permit exploration of feelings.
A client who was admitted to the hospital with metastatic cancer has a temperature of 100.4° F, a distended abdomen, and abdominal pain. The client asks the nurse, "Do you think that I'm going to have surgery?" How should the nurse respond? "You seem concerned about having surgery." "Some people with your problem do have surgery." "I'll find out for you. Your record will show if surgery is scheduled." "I don't know about any surgery. You'll have to ask your health care provider."
**"You seem concerned about having surgery."** The correct statement is open-ended and encourages the client to verbalize concerns. Nothing in the situation indicates that surgery is planned; this response may increase anxiety. "I'll find out for you. Your record will show if surgery is scheduled" and "I don't know about any surgery. You'll have to ask your health care provider" cut off communication.
