Parents ask the nursery staff what the light does for their jaundiced infant. What is the nurse's best response?
a. "The light increases the infant's metabolism."
b. "The light stimulates liver function."
c. "The light dilates blood vessels."
d. "The light breaks down bilirubin."
ANS: D
Severe jaundice can cause kernicterus, an accumulation of bilirubin in the brain tissue, which can lead to serious brain damage. The light breaks down excess bilirubin so that it can be excreted.
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The nurse is caring for a patient who is constipated and has not had a bowel movement for 3 days. The nurse performs a rectal examination and finds hard dry stool in the rectum. What is the best option to help the patient have a bowel movement?
a. Glass of warmed prune juice b. Loperamide (Imodium) c. Oral fiber supplement d. An oil retention enema
The nurse is caring for a client who has a recent diagnosis of pancreatic cancer with metastasis. The client states, "This can't be happening to me! Why, God, why?" Which of the following nursing diagnosis would be MOST appropriate?
a. Anxiety elated to ineffective coping b. Decisional conflict related to powerlessness c. Spiritual distress related to concerns for her role in life d. Ineffective coping related anxiety and anger
The nurse keeps a promise made to a client yesterday afternoon. The action of the nurse demonstrates which of the following characteristics of a caring helper?
A) Congruency B) Empathy C) Authenticity D) Trustworthy
The nurse is caring for a child who has been admitted for a sickle cell crisis. What would the nurse do first to provide adequate pain management?
A) Administer a nonsteroidal anti-inflammatory drug (NSAID) as ordered. B) Use guided imagery and therapeutic touch. C) Administer meperidine as ordered. D) Initiate pain assessment with a standardized pain scale.