A nurse is reinforcing teaching with the parents of a newborn who had a circumcision. Which of the following client statements indicates understanding of the teaching?
"I will keep the penis clean of yellow exudate."
"I will apply petroleum jelly to the penis with each diaper change."
"I will make sure my baby's diaper fits snugly."
"I will use soap to wash the penis until it heals."
The Correct Answer is B
The correct answer is b. "I will apply petroleum jelly to the penis with each diaper change."
Choice A rationale:
- It is incorrect to focus on removing all yellow exudate. A small amount of yellow exudate is normal during the healing process after circumcision. Attempting to aggressively clean it off can irritate the delicate healing tissues and cause discomfort for the baby.
- Instead, parents should gently cleanse the area with warm water during diaper changes, allowing any mild exudate to naturally drain.
Choice B rationale:
- Applying petroleum jelly with each diaper change is an essential step in promoting healing and preventing discomfort after circumcision. Here's why:
- Protects against moisture: Petroleum jelly forms a barrier that protects the delicate healing tissues from moisture from urine and feces. This helps to prevent irritation and keeps the area clean.
- Reduces friction: The lubricating properties of petroleum jelly reduce friction between the penis and the diaper, which can minimize discomfort and pain for the baby.
- Promotes healing: Petroleum jelly creates a moist environment that promotes healing and reduces scab formation. This helps the circumcision site to heal faster and more comfortably.
Choice C rationale:
- While ensuring a proper diaper fit is important for overall hygiene, it's not the most crucial aspect of post-circumcision care. A snug diaper can put unnecessary pressure on the healing penis, potentially causing irritation and discomfort. It's generally recommended to choose a diaper that fits comfortably without being too tight.
Choice D rationale:
- Using soap to wash the penis is not recommended during the healing process. Soap can be harsh and drying to the delicate tissues, potentially causing irritation and delaying healing.
- Warm water is sufficient for cleansing the area during diaper changes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The nurse should apply a heat pack 5 to 10 minutes prior to the procedure when planning to obtain blood from a newborn via a heel stick. This helps to increase blood flow to the area and makes it easier to obtain the specimen.
a) Puncturing the heel to a depth of 4 mm is too deep and can cause injury to the newborn. The recommended depth for a heel stick is 2.4 mm or less.
b) Withholding feeding prior to collecting the specimen is not necessary.
d) Elevating the newborn's foot for 15 minutes following the procedure is not necessary.
Correct Answer is C
Explanation
c. Hallucination
In the scenario described, the client's experience of receiving special audible messages from the Central Intelligence Agency that no one else can hear indicates a hallucination. Hallucinations are perceptual disturbances in which a person experiences sensory perceptions without any external stimuli. They can occur in any sensory modality, such as hearing (auditory hallucinations), seeing (visual hallucinations), smelling (olfactory hallucinations), tasting (gustatory hallucinations), or feeling (tactile hallucinations).
In this case, the client is experiencing auditory hallucinations, as he is perceiving auditory stimuli (audible messages) that are not present in the external environment. Auditory hallucinations are most commonly associated with schizophrenia, although they can occur in other psychiatric disorders as well.
Derealization (option a) refers to a subjective feeling of unreality or detachment from the environment. It involves a perception that the external world is strange, distorted, or unreal. This is not the primary alteration in perception described in the scenario.
Illusion (option b) is a misinterpretation or misperception of a real sensory stimulus. It occurs when a person's perception of an actual stimulus is distorted or misunderstood. There is no indication of a misperception of a real stimulus in the scenario.
Depersonalization (option d) is a subjective experience of being detached from one's own body, thoughts, or emotions. It involves a feeling of being outside of oneself or observing oneself from a distance. This is not the primary alteration in perception described in the scenario.
Therefore, the correct answer is c. Hallucination, as the client's experience of receiving special audible messages that no one else can hear represents an auditory hallucination.
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