A nurse is caring for a 36-hr old infant.

Exhibits

For each nursing action, click to specify if the action is indicated or contraindicated for the newborn.

Apply lotion to skin every 4 hr.

Supplement feeding with sterile water.

Brestfeed every 2 to 3 hr.

Cover newborn's eyes with a shield.

Dress in only a diaper.

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}

A. Applying lotion to the skin is contraindicated during phototherapy because it can interfere with the effectiveness of the therapy by blocking the light from reaching the skin. B. Supplementing feeding with sterile water is contraindicated because it can decrease the newborn's intake of breast milk or formula, which is essential for hydration and nutrition, especially during phototherapy. C. Breastfeeding is indicated and encouraged every 2 to 3 hours because it helps to maintain hydration and promotes bilirubin excretion, which can help in reducing jaundice levels. D. Covering the newborn's eyes with a shield is indicated during phototherapy to protect the eyes from the bright lights used in the treatment, which can potentially damage the retina and cause eye problems. E. Dressing the newborn in only a diaper is indicated during phototherapy to maximize the exposure of the skin to the light, which enhances the effectiveness of the treatment in reducing bilirubin levels.

Nursing Test Bank

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Correct Answer is A

Explanation

A. Setting a routine, including a toileting schedule, helps manage incontinence and reduces confusion and anxiety for a client with dementia. Regular schedules provide structure and can improve cooperation and quality of life.
B. Simplifying clothing with easy fasteners like Velcro instead of buttons and zippers can help maintain independence in dressing for a person with dementia.
C. Physical activity should be encouraged as it can help reduce agitation, improve mood, and promote better sleep patterns.
D. Excessive sensory stimulation can be overwhelming and confusing for clients with dementia; activities should be calming and familiar.

A. "That can't be true. The only voices in this room are yours and mine." B. "You shouldn't be afraid when you think the voices are telling you to hurt yourself." C. "I understand the voices are frightening you, but I do not hear any voices." D. "Do you recognize the voices as belonging to anyone you know?"

Correct Answer is C

Explanation

A: This response invalidates the client's experience and may cause them to feel misunderstood or alienated.
B: This response does not address the seriousness of the client's statement and dismisses their fear.
C: This is an appropriate response because it acknowledges the client's experience without agreeing with the delusion, helping to maintain a grasp on reality.
D: While this question could be useful during a more in-depth conversation, it does not address the immediate safety concern and may not help deescalate the situation.

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A nurse is caring for a 36-hr old infant. Exhibits For each nursing action, click to specify if the action is indicated or contraindicated for the newborn.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to family members of a client who has dementia. Which of the following Instructions should the nurse include in the teaching?

Correct Answer is A

Explanation

A nurse observes a client on the psychiatric unit muttering and standing near a window. The client states, "The voices are telling me to jump." Which of the following is an appropriate response by the nurse?

Correct Answer is C

Explanation

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A nurse is caring for a 36-hr old infant.

Exhibits

For each nursing action, click to specify if the action is indicated or contraindicated for the newborn.