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Questions 158

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Question 1 of 5

The nurse is teaching basic newborn care to a group of first-time parents. The nurse should explain that a sponge bath is recommended for the first two weeks of life because:

Correct Answer: B

Rationale: Sponge baths are recommended until the umbilical cord separates (typically within 1-2 weeks) to keep the cord dry and prevent infection. The other reasons are not the primary rationale for this practice.

Question 2 of 5

A 24-year-old graduate student recognizes that he has a phobia傳He suffers severe anxiety when he is in darkness. It has altered his lifestyle because he is unable to go to a movie theater, concert, and other events that may require absence of light. The client is seeking assistance because he is no longer able to socialize with friends due to his phobia. The psychologist working with him is using desensitization. He has asked the nursing staff to assist the client in muscle relaxation techniques. What result would indicate client education has been successful?

Correct Answer: A

Rationale: This situation provides specific evidence that the client is able to integrate muscle relaxation technique into his lifestyle to alleviate anxiety. The client may not experience anxiety at the concert, but there is no evidence regarding the technique that he used to alleviate anxiety. The client may state he no longer experiences anxiety, but there is no evidence demonstrating this. He may be denying anxiety to discontinue therapy prematurely. Does he experience anxiety in the darkroom? He may have taken this job to force himself to deal with the phobia directly.

Question 3 of 5

A client with a history of a hiatal hernia is being discharged. The nurse should teach the client to:

Correct Answer: C

Rationale: Carbonated beverages increase gastric pressure, worsening hiatal hernia symptoms. Sleeping upright, small meals, and avoiding lying down post-meals are also recommended.

Question 4 of 5

The nurse is caring for a client with a cerebrovascular accident (CVA) who is complaining of being nauseated and is requesting an emesis basin. Which action would the nurse take first?

Correct Answer: C

Rationale: Turning the client to one side prevents aspiration, a priority in a nauseated CVA client with potential swallowing deficits. Administering an antiemetic (
A) or notifying the physician (
D) is secondary, and ice (
B) is ineffective.

Question 5 of 5

A 3-year-old child is admitted with a diagnosis of possible noncommunicating hydrocephalus. What is the first symptom that indicates increased intracranial pressure?

Correct Answer: C

Rationale: Headache is the earliest symptom of increased intracranial pressure in children, preceding other signs like seizures or ataxia.

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