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1. A nurse is caring for an 8-month-old infant who screams when the parent leaves the room. The parent begins to cry and says, 'I don't understand why my child is so upset. I've never seen my child act this way around others before.' Which of the following statements should the nurse make?
- A. This is a normal, expected reaction for a child of this age.
- B. This is a response to an overstimulating environment.
- C. This is a common reaction to an overexposure to caregivers.
- D. This is a typical reaction for a child who is sick.
Correct answer: A
Rationale: The correct answer is 'This is a normal, expected reaction for a child of this age.' Separation anxiety typically peaks around 8-10 months of age, leading to distress when separated from caregivers. Choice B is incorrect because the infant's behavior is more likely due to separation anxiety rather than overstimulation. Choice C is incorrect as the infant's behavior is not related to overexposure to caregivers but rather a natural developmental stage. Choice D is incorrect as the infant's behavior is not indicative of illness but rather a normal emotional response.
2. A nurse is reviewing the laboratory results for a client who has a history of atherosclerosis and notes elevated cholesterol levels. Which of the following statements by the client indicates the nurse should plan follow-up teaching on a low-cholesterol diet?
- A. "I flavor my meat with lemon juice."?
- B. "I eat two eggs for breakfast each morning."?
- C. "I cook my food with canola oil."?
- D. "I take an omega-3 supplement daily."?
Correct answer: B
Rationale: The correct answer is B. Eggs are high in cholesterol, so someone with elevated cholesterol levels, especially with a history of atherosclerosis, should be cautious about egg consumption. Choices A, C, and D are not as concerning for cholesterol levels. Lemon juice, canola oil, and omega-3 supplements do not significantly impact cholesterol levels compared to consuming eggs regularly.
3. Which type of bath would you recommend for a patient experiencing pruritus?
- A. Saline
- B. Colloidal (oatmeal)
- C. Water
- D. Sodium bicarbonate
Correct answer: B
Rationale: The best choice for a pruritus (itching) patient is a colloidal (oatmeal) bath, as it is known for its soothing effect on itchy, irritated skin. Saline, water, and sodium bicarbonate baths may not provide the same level of relief for pruritus. The nursing care should involve comprehensive assessments and appropriate interventions to optimize patient outcomes. In this case, a colloidal bath is the most suitable intervention for a patient experiencing pruritus.
4. Which foods are the biggest contributors of saturated fats consumed by Americans?
- A. Butter, coconut, and palm oils
- B. Corn oil
- C. Meat and milk
- D. Cheese, pizza, desserts, and chicken
Correct answer: D
Rationale: The correct answer is D: Cheese, pizza, desserts, and chicken. These foods are significant contributors to the intake of saturated fats in the American diet, often found in processed and fast foods. Choices A, B, and C are incorrect because while butter, coconut, and palm oils (A) are sources of saturated fats, they are not the biggest contributors in the American diet. Corn oil (B) is a source of unsaturated fats, and meat and milk (C) contain saturated fats but are not the primary contributors compared to cheese, pizza, desserts, and chicken.
5. A nurse is providing teaching about formula feeding to the parents of an infant. Which of the following instructions should the nurse include?
- A. Formula that remains in the bottle should not be used for one more feeding.
- B. Formula should be changed to whole milk when the infant is 12 months old.
- C. If the infant is gaining weight too rapidly, do not dilute the formula.
- D. If the infant turns away after taking most of the feeding, stop the feeding.
Correct answer: D
Rationale: If the infant turns away after taking most of the feeding, it indicates they are full, and continuing to feed may lead to overfeeding. Choice A is incorrect because it is not safe to use formula that remains in the bottle for another feeding due to the risk of bacterial contamination. Choice B is incorrect as whole milk should be introduced after the infant is 12 months old, not 9 months old. Choice C is incorrect as diluting formula can compromise the infant's nutrition and should not be done without healthcare provider guidance.
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