You are caring for a post-operative client who is complaining of abdominal distention and flatus. Which intervention would you most likely do for this client?

Correct Answer: C

Rationale: In the context of caring for a post-operative client complaining of abdominal distention and flatus, the most appropriate intervention would be option C: A return-flow enema. A return-flow enema is designed to help relieve abdominal distention and flatus by introducing warm fluid into the rectum to stimulate peristalsis and promote the passage of gas. This intervention can help alleviate discomfort and promote bowel movement without the harsh effects of other interventions. Option A, a cleansing enema, is not indicated in this situation as the goal is not to cleanse the bowel but to relieve distention and flatus. Option B, a retention enema, is used to introduce medication or nutrients into the body and would not address the client's current symptoms. Option D, a laxative, may be too harsh for a post-operative client and could exacerbate abdominal distention. In an educational context, understanding the rationale behind choosing the appropriate intervention is crucial for providing safe and effective care to post-operative clients. By selecting the correct intervention, nurses can help alleviate discomfort, promote recovery, and prevent potential complications associated with inappropriate interventions.

Correct Answer: B

Rationale: In neonatal care, administering intramuscular injections requires precision and knowledge of anatomical considerations to ensure safety and efficacy. The correct answer is B) Vastus lateralis muscle. The vastus lateralis muscle is the preferred site for intramuscular injections in neonates due to several reasons. Firstly, it is a large, well-developed muscle in neonates, allowing for consistent and reliable drug absorption. Secondly, it is located away from major nerves and blood vessels, reducing the risk of injury or complications. Option A) Gluteus maximus muscle is not recommended for neonates due to the risk of injury to the sciatic nerve and other structures in this area. Option C) Deltoid muscle is typically used for adults and older children, as it may not provide adequate muscle mass for neonates. Option D) The sternocleidomastoid muscle is used for specific medications but is not a common site for routine intramuscular injections in neonates. Educationally, understanding the rationale behind selecting the appropriate injection site in neonates is crucial for nursing students and healthcare providers working in neonatal care settings. It ensures safe medication administration and promotes optimal patient outcomes by minimizing risks and maximizing therapeutic benefits.

Correct Answer: D

Rationale: The correct answer is D) 12 years of age to adulthood. This aligns with Jean Piaget's theory of cognitive development, specifically the formal operational stage, which typically occurs from adolescence through adulthood. During this stage, individuals develop the ability to think abstractly, engage in hypothetical reasoning, and consider multiple perspectives. Option A) Birth to 2 years of age corresponds to Piaget's sensorimotor stage, characterized by sensory experiences and motor activities to explore the world. Option B) 2 to 7 years of age is the preoperational stage, marked by egocentrism and symbolic thinking. Option C) 8 to 12 years of age represents the concrete operational stage, where children begin to think logically about concrete events. In an educational context, understanding Piaget's stages of cognitive development is crucial for nurses practicing family-centered care. By recognizing the cognitive abilities of individuals across different stages, nurses can tailor their communication and interventions to better support patients and families at various developmental levels. This knowledge allows for more effective patient education, improved therapeutic relationships, and enhanced care outcomes.

Correct Answer: A

Rationale: In the context of family-centered care in nursing, understanding the dynamics of child abuse and its perpetrators is crucial for providing effective support and intervention. The most likely perpetrator of child abuse is typically the parent (Option A). This is supported by research and statistics indicating that a significant percentage of child abuse cases involve biological parents. Parents are often the primary caregivers and have the most direct and frequent contact with the child, which unfortunately can sometimes lead to abusive behaviors. Additionally, factors such as stress, lack of parenting skills, mental health issues, and substance abuse can contribute to a parent becoming an abuser. Other relatives (Option B), while capable of being perpetrators, statistically are less likely to abuse a child compared to parents. Hired babysitters (Option C) and teachers (Option D) are also potential perpetrators but are less common in reported cases of child abuse compared to parents. From an educational standpoint, understanding the prevalence and common perpetrators of child abuse is essential for nurses working with families. By recognizing the signs of abuse and understanding the potential risk factors associated with different caregivers, nurses can better advocate for the safety and well-being of children within a family-centered care approach.

Correct Answer: C

Rationale: The correct answer is C) her grief is interfering with her functioning. This option is correct because it identifies a key characteristic of maladaptive behavior, which is when grief or any emotional response significantly impacts an individual's ability to carry out daily activities and maintain their well-being. In Anna's case, her profound grief over the loss of her dog Lucky has led to weight loss, social withdrawal, and fixation on the deceased pet, all of which are signs that her functioning is being compromised. Option A is incorrect because the length of time since Lucky's death is not the determining factor in assessing the maladaptive nature of Anna's behavior. Grieving is a highly individual process, and there is no set timeline for when one should "get over" a loss. Option B is also incorrect as the intensity of grief can vary greatly among individuals, and the significance of the bond between a person and their pet should not be underestimated. It is not for others to judge the depth of someone's grief over the loss of a beloved companion. Option D is incorrect because cultural norms and expectations around grief can vary widely. While some cultures may not prioritize grieving for pets as much as for humans, it is essential to recognize and respect an individual's unique emotional response to loss, regardless of cultural context. In an educational context, understanding maladaptive responses to grief is crucial for healthcare providers, especially in the field of family-centered care nursing. By recognizing when a person's grief is interfering with their functioning, nurses can provide appropriate support, interventions, and referrals to help individuals like Anna cope with their loss and improve their overall well-being.