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A mother brings her 4-month-old son to the clinic with aquarter taped
over his umbilicus, and tells the nurse the quarter is supposed to fix her
child's hernia. Which explanation should the nurse provide?
This hernia is a normal variation that resolves withouttreatment.
Restrictive clothing will be adequate to help the hernia goaway.
An abdominal binder can be worn daily to reduce theprotrusion.
The quarter should be secured with an elastic bandagewrap.
This hernia is a normal variation that resolves withouttreatment.
,Rationale:
An umbilical hernia is a normal variation in infants thatoccurs due to
an incomplete fusion of the abdominal musculature through the
umbilical ring that usually resolves spontaneously as the child learns
to walk.
A young adult female presents at the emergency centerwith acute
lower abdominal pain. Which assessment finding is most important
for the nurse to report to thehealthcare provider?
Pain scale rating of a "9" on a 0 to10 scale.Last
menstrual period was 7 weeks ago.
Reports white, curdy vaginal discharge. History of
irritable bowel syndrome (IBS).
Last menstrual period was 7 weeks ago.Rationale:
Acute lower abdominal pain in a young adult female can be indicative of
an ectopic pregnancy, which can be life- threatening. Since the client's
last menstrual period was 7 weeks ago, a pregnancy test should be
obtained to rule outectopic pregnancy, which can result in intra-
abdominal hemorrhage caused by a ruptured fallopian tube.
, A client is admitted to the hospital after experiencing astroke or
cerebral vascular accident (CVA). The nurse should request a referral
for speech therapy if the clientexhibits which finding?
Abnormal responses for cranial nerves I and II.Unilateral
facial drooping.
Persistent coughing while drinking.
Inappropriate or exaggerated mood swings.Persistent
coughing while drinking.
Rationale:
After a stroke, clients may experience dysphagia and an impaired gag
reflex that is evaluated by a speech pathology team. Coughing while
drinking results from impaired swallowing and gag reflex, so a referral
to a speech therapist is indicated to evaluate the coordinationof oral
movements associated with speech and deglutition(swallowing).
A male client who is participating in an anger management assignment
asks if he can make a leather beltin occupational therapy. The client
begins pounding the leather vigorously with a mallet to imprint designs
on the belt. Which defense mechanism is the client using?
Sublimation.
Regression.