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 dont understand why my chi
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Nursing Elites

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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?

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. Miss CEE is admitted for treatment of major depression. She appears withdrawn, disheveled, and states 'Nobody wants me'. What does the nurse most likely expect that Miss CEE is to be placed on?

Correct answer: C

Rationale: Given Miss CEE's state of major depression and her expressed feelings of worthlessness ('Nobody wants me'), the nurse would most likely expect her to be placed on suicide precaution. This means that measures would be taken to ensure her safety and to prevent her from harming herself. While medications like neuroleptics (Choice A) and anxiolytics (Choice D) might be employed as part of her overall treatment, these medicines are primarily used for conditions like psychosis and anxiety respectively, not specifically for depression or suicidal ideation. A special diet (Choice B) may be part of a comprehensive treatment plan, but it is not as immediate or as directly related to her current emotional and psychological state as suicide precaution is.

3. A nurse is assessing a client who reports muscle spasms in his calves and tingling in his hands. The client indicates consuming a low intake of milk products and green leafy vegetables. The nurse should identify that the client's findings indicate a deficiency in which of the following sources of nutrition?

Correct answer: D

Rationale: The correct answer is D, Calcium. Muscle spasms and tingling suggest a calcium deficiency, which is commonly associated with a low intake of milk products and green leafy vegetables. Iron (choice A) deficiency typically presents with fatigue and weakness, not muscle spasms and tingling. Omega-3 fatty acids (choice B) are essential for brain function and heart health, but their deficiency does not manifest as muscle spasms and tingling. Vitamin C (choice C) deficiency leads to scurvy with symptoms like bleeding gums and bruising, not muscle spasms and tingling.

4. Overdosage of medication or anesthetic can happen even with the aid of technology like infusion pumps, sphygmomanometer, and similar devices/machines. As a staff member, how can you improve the safety of using infusion pumps?

Correct answer: D

Rationale: To enhance the safety of using infusion pumps, it is crucial to verify the flow rate against your calculation. This step ensures that the prescribed dosage is being delivered accurately, reducing the risk of medication errors. Checking the functionality of the pump before use (Choice A) is also important to ensure it is working properly. Allowing the technician to set the pump (Choice C) may not always guarantee the correct settings. Selecting the brand of infusion pump carefully (Choice B) is not directly related to the safe use of the pump.

5. Mrs. Seva also tells the nurse that she is often constipated. Because she is aging, what physical changes predispose her to constipation?

Correct answer: C

Rationale: Effective nursing care involves comprehensive assessments that address all aspects of a patient's condition, ensuring that interventions are appropriately targeted and outcomes are optimized.

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