The nurse observes an 18-month-old toddler keeping a bottle of milk in the mouth throughout the history-taking and assessment process during a well-child visit.

The mother confirms that the child has a bottle available most of the day and remarks that it makes a great pacifier.

Which response should the nurse provide?

A bottle is generally much better than using a pacifier.

The bottle will assist in preventing thumb sucking.

Prolonged bottle use can increase the risk for cavities.

Using milk rather than juice helps to avoid tooth decay.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

A bottle is generally much better than using a pacifier. This statement is not accurate. Prolonged bottle use, especially with sugary liquids like milk, can have adverse effects on a child's dental health. It can lead to an increased risk of cavities, similar to prolonged pacifier use.

Choice B rationale:

The bottle will assist in preventing thumb sucking. This statement is incorrect. While a bottle may provide comfort to a child, it does not prevent thumb sucking. Thumb sucking is a separate behavior that may also have dental implications if it persists beyond a certain age.

Choice C rationale:

Prolonged bottle use can increase the risk for cavities. This response is correct. Prolonged bottle use, especially with milk or sugary beverages, can expose the child's teeth to prolonged contact with sugars, increasing the risk of cavities. It's important for the nurse to educate the mother about the potential dental risks associated with extended bottle use.

Choice D rationale:

Using milk rather than juice helps to avoid tooth decay. While milk is generally considered a healthier choice than juice, the key issue in this scenario is the prolonged use of the bottle, regardless of its content. Prolonged bottle use with any liquid, including milk, can still increase the risk of cavities.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is ["A","C","E"]

Explanation

The observation(s) by the nurse that require immediate intervention to reduce the likelihood of harm to this client are:

A. The client’s oxygen saturation level is 85%. This is a sign of hypoxemia, which can lead to tissue hypoxia, organ damage, and cardiac arrest. The nurse should administer oxygen therapy and monitor the client’s respiratory status closely.

C. The client’s heart rate is 110 beats per minute. This is a sign of tachycardia, which can indicate worsening heart failure, dehydration, infection, or anxiety. The nurse should assess the client’s fluid balance, vital signs, and symptoms and report any changes to the physician. The nurse should also administer medications as prescribed to control the heart rate and reduce the cardiac workload.

E. The client’s blood pressure is 160/90 mmHg. This is a sign of hypertension, which can increase the risk of stroke, myocardial infarction, and renal failure. The nurse should administer antihypertensive medications as prescribed and monitor the client’s blood pressure and urine output. The nurse should also educate the client on lifestyle modifications to lower blood pressure, such as reducing salt intake, exercising, and managing stress .

The other observations do not require immediate intervention, but they should be addressed as part of the comprehensive nursing care plan for the client with heart failure and COPD. These include:

B. The client is eating less than half of meals. This can indicate poor appetite, nausea, dyspnea, or fatigue, which can affect the client’s nutritional status and energy level. The nurse should encourage the client to eat small, frequent, and balanced meals that are low in sodium, fat, and cholesterol. The nurse should also provide oral hygiene and offer supplements or enteral feeding if needed .

D. The client is reading a book. This can indicate that the client is coping well with the condition and engaging in leisure activities that promote relaxation and mental health. The nurse should praise the client for this positive behavior and provide emotional support and counseling as needed. The nurse should also teach the client about the signs and symptoms of exacerbation and when to seek medical help .

A. Granulating tissue in foot ulcer. B. Reduced level of pain. C. Improved visual acuity. D. Full volume of pedal pulses. E. Full volume of pedal pulses.

Correct Answer is B

Explanation

Choice A rationale:

Granulating tissue in a foot ulcer is a positive sign of wound healing, but it may not be directly related to the effectiveness of pregabalin in treating diabetic peripheral neuropathy. The primary goal of pregabalin in this context is to reduce pain and neuropathic symptoms.

Choice B rationale:

A reduced level of pain is the most relevant indicator of the effectiveness of pregabalin in treating diabetic peripheral neuropathy. Pregabalin is an antiepileptic medication used to manage neuropathic pain. A decrease in pain indicates that the medication is effectively managing the client's symptoms.

Choice C rationale:

Improved visual acuity is not directly related to the effectiveness of pregabalin in treating diabetic peripheral neuropathy. Pregabalin primarily targets neuropathic pain and sensory symptoms, not visual function.

Choice D rationale:

A full volume of pedal pulses is a positive sign of adequate circulation in the lower extremities, but it may not be directly related to the effectiveness of pregabalin in treating neuropathy symptoms. The primary goal of pregabalin in this context is pain management.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is admitted with an exacerbation of heart failure secondary to chronic obstructive pulmonary disease (COPD). Which observation(s) by the nurse require immediate intervention to reduce the likelihood of harm to this client? (Select all that apply.).

Correct Answer is ["A","C","E"]

Explanation

A client with diabetic peripheral neuropathy has been taking pregabalin for 4 days. Which finding indicates to the nurse that the medication is effective?

Correct Answer is B

Explanation

Which client is best to assign to the practical nurse (PN) who is assisting the registered nurse (RN) with the care of a group of clients?

A nurse is teaching a group of older adults about the effects of aging on the neurological system. Which of the following statements should the nurse include as correct? (Select all that apply.).

A client tells the nurse about beginning an exercise program a month ago to lose weight and improve sleep. The client states that it still takes at least two hours to fall asleep at night. Which action should the nurse implement?

A nurse is teaching a client who has a urinary tract infection (UTI) about trimethoprim/sulfamethoxazole. The client asks why he needs to take two antibiotics together. What should the nurse say?

When conducting diet teaching for a client who was diagnosed with hypertension, which food(s) should the nurse encourage the client to eat? (Select all that apply.).

The nurse completes percussion of the abdomen on an older adult client. Which finding is considered normal for this client?

The nurse requests a meal tray for a client who follows Mormon beliefs and who is on a clear liquid diet following abdominal surgery. Which menu item(s) should the nurse request for this client? (Select all that apply).