Which of the following is an inappropriate item to include in planning care for a severely neutropenic client?
Correct Answer: A
Section: Physiological Integrity Explanation: Granulocyte transfusion is not indicated to prevent infection. Produced in the bone marrow, granulocytes normally comprise 70% of all WBCs. They are subdivided into three types based on staining properties: neutrophils, eosinophils, and basophils. They can be beneficial in a selected population of infected, severely granulocytopenic clients (less than 500 mm3) who do not respond to antibiotic therapy and who are expected to experience prolonged suppression of granulocyte production.
Question 42
Client room environments should include:
Correct Answer: B
Explanation/Reference: Explanation: Preparing a client's room environment should include making the client's bed, ensuring comfort and safety at all times, keeping the area free of clutter, and keeping the client's hygiene articles nearby. All procedures should be explained before they are performed, and the client should assist with personal arrangement of articles. Basic Care and Comfort
Question 43
An appraisal of self-care practices involves an assessment of:
Correct Answer: D
Explanation/Reference: Explanation: Short-tem stressors impinging on a family include unemployment, being on welfare, the threat of termination, health, hospitalization, convalescence, depression, and suicidal thoughts. Long-term stressors impinging on the family include emotional distance, lack of communication in families (especially within marital relationships), continual geographical movement from one community to the next (so that no stable and sufficient social network is established), a spouse's minimal participation in family life, and excessive and frequent drinking bouts. Family strengths include the presence of a social support system, interest in and capability to provide child care, motivation for employment, and financial self-sufficiency, self-care beliefs, values, health-seeking behaviors, and realistic goals and limitations. Health Promotion and Maintenance
Question 44
A thirty-seven year-old female in room 307 has a diagnosis of acquired immune deficiency syndrome (AIDS). Which of the following situations requires nurse intervention?
Correct Answer: C
Patient confidentiality should be observed, especially in public places. The nurse should tell the nursing student do not discuss confidential information in public.
Question 45
Which of the following infant behaviors demonstrates the concept of object permanence?
Correct Answer: B
Section: Health Promotion and Maintenance Explanation: Object permanence occurs when the infant learns that something/someone still exists even though they might not be able to see it/them. This develops between 9 and 10 months of age. If the infant cries when his mother leaves the room, it might be because he believes she is no longer in the house when he can't see her. If an infant picks up another toy after the one he is playing with rolls under the couch and the infant fails to look for it, he believes the toy that rolled under the couch no longer exists. Patty-cake is a game infants engage in but, it has nothing to do with object permanence. An infant game that does show object permanence is peek-a-boo. In this game, an infant continues to hunt for a hidden face because he believes it is still there.
