Nokea
A 2-month-old recently diagnosed with developmental dysplasia of the hip is beginning treatment with a Pavlik harness. Which instructions should the nurse reinforce to the parents? Select all that apply.
- A. Apply lotion under the straps to protect the skin.
- B. Dress the child in a shirt and knee socks under the straps.
- C. Lightly massage the skin under the straps daily.
- D. Place the diaper under the straps.
- E. Remove the harness during diaper changes.
Correct Answer: B,C,D
Rationale: Shirts and socks under straps prevent chafing, daily massage promotes circulation, and diapers under straps ensure hygiene. Lotion traps moisture, risking irritation. The harness should not be removed, even for diaper changes, to maintain correction.
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Unlicensed assistive personnel on the cardiac floor report to the nurse that, during the first vital sign measurement on the shift, a client's blood pressure measured 196/102 mm Hg on the automated blood pressure machine. What action should the nurse take first?
- A. Have unlicensed assistive personnel recheck the client's blood pressure
- B. Immediately notify the supervising registered nurse
- C. Obtain the client's pm labetalol from the medication dispensing machine
- D. Recheck the client's blood pressure with a manual cuff
Correct Answer: D
Rationale: Automated BP readings can be inaccurate. Rechecking with a manual cuff ensures accuracy before escalating or medicating, as severe hypertensionزه://www.youtube.com/watch?v=9Q7sE1Xh_1Qsevere hypertension (≥180/110 mm Hg) requires prompt action if confirmed.
The nurse is collecting data from assigned clients. It would require follow-up if a
- A. 3-week-old client has an anterior fontanel that pulsates slightly and bulges when crying
- B. 4-week-old client has a posterior fontanel that is soft and flat to palpation
- C. 6-month-old client had a birth weight of 7 lb 3 oz (3300 g) and now weighs 12 lb (5400 g)
- D. 12-month-old client had a birth weight of 6 lb 4 oz (2800 g) and now weighs 19 lb 2 oz (8700 g)
Correct Answer: C
Rationale: A 6-month-old weighing only 12 lb (5400 g) from a birth weight of 7 lb 3 oz (3300 g) indicates failure to thrive, requiring follow-up. Other findings (fontanels, 12-month-old weight) are within normal ranges.
A client is being admitted with a diagnosis of active shingles with a disseminated rash. Which room assignment is most appropriate for this client?
- A. A private room with contact and droplet precautions
- B. A private room with negative airflow and contact and airborne precautions
- C. A private room with positive airflow and airborne precautions
- D. A semi-private 2-bed room with standard precautions
Correct Answer: B
Rationale: Disseminated shingles in immunocompromised clients requires contact and airborne precautions due to varicella-zoster virus transmission risk. A private room with negative airflow prevents spread. Droplet or standard precautions are insufficient, and positive airflow is inappropriate.
The nurse is reinforcing education about lifestyle modifications for a client newly diagnosed with Meniere disease. Which statement by the client indicates a need for further teaching?
- A. I need to enroll in a smoking cessation program.
- B. I need to restrict the amount of potassium in my diet.
- C. I will lie down and avoid walking unassisted during acute attacks.
- D. I will limit the amount of caffeine and alcohol that I consume.
Correct Answer: B
Rationale: Restricting potassium isn't indicated for Ménière's disease; a low-sodium diet is typically recommended to reduce fluid retention. Smoking cessation, lying down during attacks, and limiting caffeine/alcohol are appropriate.
The clinic nurse has contributed to the teaching plan for the following 6 clients. The nurse reinforces the teaching by instructing which client to avoid the Valsalva maneuver when defecating? Select all that apply.
- A. 22-year-old man with a head injury sustained during a college football game
- B. 30-year-old woman recently hospitalized for reconstructive augmentation mammoplasty
- C. 56-year-old man 2 weeks post myocardial infarction
- D. 68-year-old woman recently diagnosed with pancreatic cancer
- E. 74-year-old man with portal hypertension related to alcohol-induced cirrhosis
- F. 82-year-old woman 1 week post cataract surgery
Correct Answer: A,C,E,F
Rationale: The Valsalva maneuver increases intracranial pressure (head injury), cardiac strain (post-MI), intra-abdominal pressure (portal hypertension), and intraocular pressure (post-cataract surgery), risking complications. Mammoplasty and pancreatic cancer have less direct risks.