A mother brings her 4-month-old son to the clinic with a quarter taped over his umbilicus, and tells the nurse the quarter is supposed to fix her child's hernia. Which explanation should the nurse provide?
An abdominal binder can be worn daily to reduce the protrusion.
This hernia is a normal variation that resolves without treatment.
The quarter should be secured with an elastic bandage wrap.
Restrictive clothing will be adequate to help the hernia go away.
The Correct Answer is B
Choice A: An abdominal binder can be worn daily to reduce the protrusion is not a correct explanation for the nurse to provide, as this is not an effective or recommended method to treat a hernia. This is a distractor choice.
Choice B: This hernia is a normal variation that resolves without treatment is a correct explanation for the nurse to provide, as this refers to an umbilical hernia, which is a common and harmless condition in infants that usually disappears by age 2. Therefore, this is the correct choice.
Choice C: The quarter should be secured with an elastic bandage wrap is not a correct explanation for the nurse to provide, as this is a folk remedy that has no scientific basis and can cause skin irritation and infection. This is another distractor choice.
Choice D: Restrictive clothing will be adequate to help the hernia go away is not a correct explanation for the nurse to provide, as this is not a proven or safe way to treat a hernia. This is another distractor choice.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","E","F"]
Explanation
Choice B is correct because weight management is an important factor in preventing and controlling hypertension. Taking daily walks for thirty minutes can help reduce weight and lower blood pressure.
Choice C is correct because salt substitutes can help with maintaining a healthy diet by reducing sodium intake. Sodium intake is associated with increased blood pressure and should be limited to less than 2,300 mg per day.
Choice E is correct because sodium intake can be regulated by rinsing canned foods in water. Canned foods often contain high amounts of sodium as a preservative and rinsing them can remove some of the excess sodium.
Choice F is correct because uncontrolled hypertension can lead to renal damage. Hypertension can cause damage to the blood vessels and impair the function of the kidneys, leading to chronic kidney disease or failure.
Choice A is incorrect because alcohol consumption can produce vascular changes that increase blood pressure. Alcohol intake should be limited to no more than one drink per day for women and two drinks per day for men.
Choice D is incorrect because blood pressure readings should not be taken at noontime. Blood pressure readings should be taken at the same time each day, preferably in the morning before breakfast or in the evening before dinner.
Correct Answer is A
Explanation
Choice A: Obtain a blood pressure reading before the client gets out of bed. This is the most important intervention, as it can prevent or detect orthostatic hypotension, which is a drop in blood pressure when changing position from lying to standing. Orthostatic hypotension can cause dizziness, fainting, or falls, and it can be caused by medications, dehydration, or cardiac problems.
Choice B: Monitor and record the client's urinary output every day. This is not the most important intervention, as it does not address the client's anxiety or adjustment issues. The urinary output should be monitored for signs of fluid balance, kidney function, or infection, but it is not a priority for this client.
Choice C: Provide the client with teaching regarding a cardiac diet. This is not the most important intervention, as it does not address the client's anxiety or adjustment issues. The cardiac diet should be taught to promote heart health, lower cholesterol, and reduce sodium intake, but it is not a priority for this client.
Choice D: Assess the client's vital signs every 4 hours when awake. This is not the most important intervention, as it does not address the client's anxiety or adjustment issues. The vital signs should be assessed for signs of infection, pain, or hemodynamic instability, but they are not a priority for this client.
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