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Questions 158

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Question 1 of 5

A 20-year-old female client delivers a stillborn infant. Following the delivery, an appropriate response by the labor nurse to the question, 'Why did this happen to my baby?' is:

Correct Answer: D

Rationale: The mother and the father require Wsupport; the nurse should not minimize their grief in this situation. Attachment to this infant occurs during the pregnancy for both the mother and father. Another child cannot replace this child. Attachment to this infant occurs during the pregnancy for both the mother and father. Siblings will not replace their feelings or minimize their loss of this infant. Holding and viewing the infant decreases denial and may facilitate the grief process. The nurse should prepare family members for how the infant appears ('she is bruised') and provide support.

Question 2 of 5

Goal setting for a client with Meniere's disease should include which of the following?

Correct Answer: B

Rationale: Although not contraindicated, initially ambulation may be difficult because of vertigo and is recommended only with assistance. Vertigo resulting in balance problems is one of the most common manifestations of Meniere's disease. Adequate nutrition is important, but the emphasis in Meniere's disease is not the number of meals per day but a decrease in intake of sodium. Infection is not an anticipated problem.

Question 3 of 5

A five-year-old is admitted to the unit following a tonsillectomy. Which of the following would indicate a complication of the surgery?

Correct Answer: D

Rationale: Constant swallowing post-tonsillectomy suggests bleeding, as the child may be swallowing blood from the surgical site, a serious complication requiring immediate attention. Decreased appetite and low-grade fever are expected, and chest congestion is unrelated.

Question 4 of 5

The nurse is teaching a pregnant client about nutritional needs during pregnancy. Which menu selection will best meet the nutritional needs of the pregnant client?

Correct Answer: C

Rationale: Baked chicken fruit potato salad coleslaw and yogurt provide a balanced mix of protein calcium vitamins and fiber meeting pregnancy nutritional needs. The other options are higher in fat or lack key nutrients.

Question 5 of 5

A client with a history of a brain tumor is receiving Decadron (dexamethasone). The nurse should monitor the client for:

Correct Answer: A

Rationale: Dexamethasone, a corticosteroid, causes weight gain due to fluid retention and increased appetite. Hypotension, hypoglycemia, and hair loss are not typical side effects.

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