A nurse is reinforcing teaching about toilet training with the guardians of a toddler who has a cognitive impairment. Which of the following instructions should the nurse include?

Encourage the toddler to flush the toilet while still seated.

Have the toddler remain on the toilet for a minimum of 20 min.

Wake the toddler every 2 hr. in the night to prevent bed-wetting.

Give the toddler a sticker after each successful toileting attempt.

Answer and Explanation

The Correct Answer is D

A. Encouraging the toddler to flush the toilet while still seated is incorrect. Some children may be startled by the flushing sound, which can create fear and resistance to toilet training. It is better to allow the child to stand before flushing if they show hesitation.

B. Having the toddler remain on the toilet for a minimum of 20 minutes is incorrect. Extended sitting can lead to discomfort and frustration, making the experience negative. Shorter, 5- to 10-minute sessions are more effective and developmentally appropriate.

C. Waking the toddler every 2 hours in the night to prevent bed-wetting is incorrect. Nighttime bladder control develops gradually, and disrupting sleep can be counterproductive. Instead, using protective bedding and encouraging toileting before bedtime is recommended.

D. Giving the toddler a sticker after each successful toileting attempt is correct. Positive reinforcement, such as stickers or praise, encourages consistency and motivation, which is particularly beneficial for children with cognitive impairments.

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Correct Answer is A

Explanation

A. The client develops chest pain each time he talks about his partner is an indication of complicated grief. The client’s experience of intense, physical symptoms like chest pain when discussing their partner suggests that the grief process may not be progressing and could indicate unresolved or complicated grief.

B. The client keeps a framed picture of his partner on the wall is a normal expression of grief. Keeping a picture of a lost loved one is common and doesn’t necessarily indicate complicated grief. It can be part of the natural grieving process.

C. The client reports he has no interest in dating is not necessarily a sign of complicated grief. It's common for people grieving to not have an interest in dating or forming new romantic relationships immediately after the loss, but it does not suggest a problem unless the client expresses prolonged avoidance of all social interaction.

D. The client attends a grief support group twice each month is a positive coping mechanism. Attending support groups shows the client is actively engaging with the grieving process and seeking support, which is part of healthy adjustment after a loss.

A. Obtain a baseline reading of the FHR and contraction pattern. B. Document the procedure in the electronic medical record. C. Pass the sterile hook to the provider. D. Position the client with a rolled towel under her hips E. Check the fluid for color, odor, and consistency

Correct Answer is A,D,C,E,B

Explanation

A. Obtain a baseline reading of the FHR and contraction pattern.
- Establishing a baseline of fetal heart rate (FHR) and contraction pattern is crucial to assess for any immediate changes following the amniotomy.
D. Position the client with a rolled towel under her hips.
- Positioning the client with a rolled towel under her hips helps to relieve pressure on the vena cava, improve uterine blood flow, and optimize fetal positioning.
C. Pass the sterile hook to the provider.
- The sterile hook is used to break the amniotic sac, and the nurse should pass it to the provider during the procedure.
E. Check the fluid for color, odor, and consistency.
- After the amniotomy, the nurse should assess the amniotic fluid for color (should be clear), odor (should be odorless), and consistency to check for any signs of meconium or infection.
B. Document the procedure in the electronic medical record.
- The nurse should document the amniotomy procedure and any findings (e.g., FHR changes, amniotic fluid assessment) in the medical record after the procedure has been completed.

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A nurse is reinforcing teaching about toilet training with the guardians of a toddler who has a cognitive impairment. Which of the following instructions should the nurse include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client whose partner died 1 year ago. Which of the following findings indicates that the client is experiencing complicated grief?

Correct Answer is A

Explanation

A nurse is assisting in the care of a client who is in active labor and is to undergo an amniotomy. Which of the following actions should the nurse take? (Move the steps into the box, placing them in the order of performance. Use all the steps.)

Correct Answer is A,D,C,E,B

Explanation

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