A mother brings her 4-month-old son to the clinic with a quarter taped over his umbilicus, and tells the nurse the quarter is supposed to fix her child's hernia. Which explanation should the nurse provide?
An abdominal binder can be worn daily to reduce the protrusion.
This hernia is a normal variation that resolves without treatment.
The quarter should be secured with an elastic bandage wrap.
Restrictive clothing will be adequate to help the hernia go away.
The Correct Answer is B
Choice A reason: An abdominal binder can be worn daily to reduce the protrusion is not a correct explanation for the nurse to provide, as this is not an effective or recommended method to treat a hernia. This is a distractor choice.
Choice B reason: This hernia is a normal variation that resolves without treatment is a correct explanation for the nurse to provide, as this refers to an umbilical hernia, which is a common and harmless condition in infants that usually disappears by age 2. Therefore, this is the correct choice.
Choice C reason: The quarter should be secured with an elastic bandage wrap is not a correct explanation for the nurse to provide, as this is a folk remedy that has no scientific basis and can cause skin irritation and infection. This is another distractor choice.
Choice D reason: Restrictive clothing will be adequate to help the hernia go away is not a correct explanation for the nurse to provide, as this is not a proven or safe way to treat a hernia. This is another distractor choice.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Observing insertion site is an essential assessment for a client who has a suprapubic catheter. The insertion site is located in the lower abdomen, where urine drains from an opening in the bladder through a catheter into a drainage bag. The nurse should inspect the site for signs of infection, inflammation, bleeding, or leakage. The nurse should also clean the site with soap and water and apply a sterile dressing as needed.
Choice B reason: Palpating flank area is not a relevant assessment for a client who has a suprapubic catheter. The flank area is located on the sides of the back, where the kidneys are located. Palpating the flank area can detect tenderness or pain that may indicate kidney infection or stones, but it does not provide information about the suprapubic catheter or its function.
Choice C reason: Measuring abdominal girth is not a relevant assessment for a client who has a suprapubic catheter. The abdominal girth is the circumference of the abdomen at the level of the umbilicus. Measuring abdominal girth can detect changes in fluid balance, ascites, or bowel obstruction, but it does not provide information about the suprapubic catheter or its function.
Choice D reason: Assessing perineal area is not a relevant assessment for a client who has a suprapubic catheter. The perineal area is located between the anus and the genitals. Assessing perineal area can detect signs of infection, irritation, or injury in the genital or anal regions, but it does not provide information about the suprapubic catheter or its function.
Correct Answer is ["A"]
Explanation
Choice A reason: Avoid salt substitutes. This client needs additional education, as salt substitutes may contain potassium, which can increase the risk of hyperkalemia in clients with coronary artery disease. The nurse should teach the client to use herbs, spices, or lemon juice to flavor food instead of salt or salt substitutes.
Choice B reason: Consume canned vegetables. This client needs additional education, as canned vegetables may contain sodium, which can increase the blood pressure and worsen coronary artery disease. The nurse should teach the client to choose fresh or frozen vegetables instead of canned ones.
Choice C reason: Include oatmeal for breakfast. This client does not need additional education, as oatmeal is a good source of soluble fiber, which can lower cholesterol and reduce the risk of atherosclerosis. The nurse should praise the client for this healthy choice.
Choice D reason: Identify foods with saturated fats. This client does not need additional education, as identifying foods with saturated fats is an important step to avoid them. Saturated fats can raise cholesterol and increase the risk of coronary artery disease. The nurse should teach the client to limit saturated fats to less than 10% of total calories per day.
Choice E reason: Walk 30 minutes per day. This client does not need additional education, as walking 30 minutes per day is a recommended physical activity for clients with coronary artery disease. Physical activity can improve blood circulation, lower blood pressure, and reduce stress. The nurse should encourage the client to walk at a moderate pace and consult with the healthcare provider before starting any exercise program.
Choice F reason: Keep a food diary. This client does not need additional education, as keeping a food diary is a helpful tool to monitor dietary intake and identify areas for improvement. The nurse should teach the client to record the type, amount, and time of food consumed, as well as any symptoms or feelings associated with eating.
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