Page 2596 - Saunders Comprehensive Review For NCLEX-RN

pregnancy. Rubella titer determination is a standard prenatal test for pregnant
women during their initial screening and entry into the health care delivery system.
As noted in this client’s chart, she is immune to rubella. The correct option is the
only option that helps clarify maternal concerns with accurate information.
Test-Taking Strategy: Note the strategic word, best, and recall knowledge
regarding the transmission of rubella virus to the fetus. Also, use of therapeutic
communication techniques will direct you to the correct option. The correct option
addresses the client’s concerns.
Level of Cognitive Ability: Applying
Client Needs: Psychosocial Integrity
Integrated Process: Caring
Content Area: Maternity: Antepartum
Health Problem: Maternity: Infections/Inflammations
Priority Concepts: Immunity; Safety
Reference: Lowdermilk et al. (2016), p. 166.

892. Answer: 2, 3, 5

Rationale: Breast-feeding mothers with lactose-intolerant infants need to be
encouraged to limit dairy products. Milk and cheese are dairy products. Alternative
calcium sources that can be consumed by the mother include egg yolk, dried beans,
green leafy vegetables, cauliflower, and molasses.
Test-Taking Strategy: Focus on the subject, foods acceptable for a breast-feeding
mother with a lactose-intolerant infant. Recall that lactose is the sugar found in dairy
products. Also note that options 1 and 4 are comparable or alike and are dairy
products.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Teaching and Learning
Content Area: Foundations of Care: Nutrition
Health Problem: Newborn: Newborn feeding
Priority Concepts: Client Education; Nutrition
Reference: Lowdermilk et al. (2016), pp. 352–353.

893. Answer: 1

Rationale: The nurse needs to be aware of the effective and ineffective coping
mechanisms that can occur in a client when loss is anticipated. The expression of
anger is known to be a normal response to impending loss, and the anger may be
directed toward the self, God or other spiritual being, or caregivers. Notifying the
hospital lawyer is inappropriate. Guilt may or may not be a component of the
client’s feelings, and the data in the question do not indicate that guilt is present.
Test-Taking Strategy: Note the subject, psychosocial care of a client needing
amputation. Also note the strategic word, best. Note that the correct option and
option 2 address coping and defense mechanisms. This provides you with the clue
that one of these options may be the correct response. In addition, knowledge of the
stages of grief associated with loss will direct you to the correct option.

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