A nurse is contributing to the plan of care for a 12-month-old infant following cleft palate repair. Which of the following actions should the nurse include?
Allow the infant to have soft foods.
Maintain elbow restraints on the infant.
Instruct the parents to feed the infant with a spoon.
Tell the parents to avoid brushing the infant's teeth for two weeks.
The Correct Answer is B
The nurse should include maintaining elbow restraints on the infant in the plan of care following cleft palate repair. This helps to prevent the infant from touching their surgical site and disrupting the healing process.
a) Allowing the infant to have soft foods may be appropriate, but it is not the highest priority. The infant's diet should be determined by the provider and based on the infant's individual needs.
c) Instructing the parents to feed the infant with a spoon may be appropriate, but it is not the highest priority. The infant's feeding method should be determined by the provider and based on the infant's individual needs.
d) Telling the parents to avoid brushing the infant's teeth for two weeks may be appropriate, but it is not the highest priority. The infant's oral care should be determined by the provider and based on the infant's individual needs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
c. Initiate a client referral to Reach to Recovery.
Explanation:
When caring for a female client who has a new diagnosis of breast cancer and expresses concerns about potential changes to her body image, the nurse should initiate a client referral to Reach to Recovery. Reach to Recovery is a program provided by the American Cancer Society that connects breast cancer patients with trained volunteers who have gone through a similar experience. These volunteers can provide emotional support, information, and resources to help the client cope with the physical and emotional changes that may occur due to breast cancer and its treatment.
Explanation for the other options:
a .Reassure the client that she will adjust to changes to her body:
While providing reassurance is important, it may not be sufficient to address the client's concerns about potential changes to her body image. Initiating a referral to Reach to Recovery can provide the client with additional support and resources tailored to her specific needs.
b. Contact an occupational therapist to talk with the client:
While an occupational therapist may have valuable input on certain aspects of the client's care, such as functional abilities and adaptations, initiating a referral to Reach to Recovery would be more appropriate for addressing the client's concerns related to body image.
d. Explain that surgery can restore the breast to its original appearance:
While surgery options such as breast reconstruction can restore the breast to a similar appearance, it is not appropriate for the nurse to make guarantees about the outcome or appearance of the breast after surgery. Every individual's situation is unique, and the decision to undergo surgery and the results of such procedures are dependent on various factors. Referring the client to Reach to Recovery would be more beneficial in addressing her concerns holistically.
In summary, when a client with a new diagnosis of breast cancer expresses concerns about potential changes to her body image, the nurse should initiate a client referral to Reach to Recovery. This program can provide the client with the necessary emotional support and resources to navigate the physical and emotional changes associated with breast cancer and its treatment.
Correct Answer is D
Explanation
As individuals age, there is a natural decline in kidney function. This can result in a reduced ability to filter and excrete medications and their metabolites from the body. The decreased kidney function can lead to a longer half-life of medications, increased drug accumulation, and an increased risk of adverse drug reactions. It is important for the nurse to adjust medication dosages and frequencies based on the individual's renal function to prevent drug toxicity.
Increased liver function: Aging is associated with a gradual decline in liver function. While there may be some individual variations, in general, liver function decreases rather than increases with age. However, changes in liver function can affect the metabolism and elimination of medications. Some medications may require dosage adjustments based on liver function, but it is not a common physiological change in older adults.
Increased metabolism: Aging is generally associated with a decrease in metabolism rather than an increase. The metabolic rate tends to slow down with age, which can affect the pharmacokinetics of medications. Slower metabolism can result in medications taking longer to be metabolized and cleared from the body, potentially leading to prolonged drug effects.

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