NCLEX PN 2023 Quizlet - Nurselytic

Correct Answer: C

Rationale: The most appropriate course of action for the nurse is to observe the hairline and scalp for possible signs of lice. The student's behavior of excessively rubbing her scalp raises concerns about a potential infestation, making it necessary to look for signs firsthand. Contacting the parents or the physician should be considered after observing for signs of lice to provide more information and take appropriate action. Requesting a private evaluation from the parents may not be required initially, as lice infestation is a common concern among children and observing for signs is the immediate step to address the situation.

Correct Answer: A

Rationale: Erythropoietin is used to stimulate red blood cell production in clients with renal failure.
To effectively increase red blood cell production, adequate levels of iron, folic acid, and B12 are necessary. These nutrients play crucial roles in erythropoiesis.

Choices B, an increase in protein in the diet, is not directly related to enhanced erythropoiesis and can potentially worsen uremia.

Choices C and D, vitamins A and C, and an increase in calcium in the diet, are not directly involved in red blood cell production and are not essential in this context.

Correct Answer: C

Rationale: The most appropriate course of action for the nurse is to observe the hairline and scalp for possible signs of lice. The student's behavior of excessively rubbing her scalp raises concerns about a potential infestation, making it necessary to look for signs firsthand. Contacting the parents or the physician should be considered after observing for signs of lice to provide more information and take appropriate action. Requesting a private evaluation from the parents may not be required initially, as lice infestation is a common concern among children and observing for signs is the immediate step to address the situation.

Correct Answer: C

Rationale: The best initial response in this situation is to acknowledge the mother's concern, express uncertainty, and offer to obtain more information from the physician. By saying, "I'm not sure, but I'll call the physician to discuss this with you promptly,"? the nurse demonstrates empathy, honesty, and a commitment to providing accurate information. Offering vague reassurance (
Choice
A) may raise false hopes as outcomes for spinal cord injuries are unpredictable. While maintaining a calm demeanor (
Choice
B) is important, it does not directly address the mother's immediate need for information. Discouraging the mother from feeling upset (
Choice
D) is dismissive of her emotions and does not address her question, which is seeking information about her son's prognosis.

Correct Answer: D

Rationale: With a breech presentation, the nurse must be particularly alert for a prolapsed umbilical cord. Prolapsed umbilical cord is a critical emergency situation where the umbilical cord descends into the vagina before the fetal presenting part, leading to compression between the presenting part and the maternal pelvis. This compression can compromise or completely cut off fetoplacental perfusion, endangering the fetus. Immediate delivery should be attempted to save the fetus. Quickening refers to fetal movements felt by the mother, ophthalmia neonatorum is an eye infection in newborns, and pica is a condition characterized by cravings for non-nutritive substances, none of which are directly related to the risks associated with a breech presentation and prolapsed umbilical cord.