Nokea
Which intervention(s) should the nurse include in the child's plan of care immediately following insertion of a ventriculoperitoneal (VP) shunt for treatment of hydrocephalus?
- A. Maintain the head of the bed in an elevated position.
- B. Ensure that the child minimizes movement of the extremities.
- C. Provide a pressure dressing over the cephalic insertion site.
- D. Maintain a flat position and reposition the child every 2 hours.
Correct Answer: D
Rationale: Maintaining a flat position and repositioning every 2 hours helps prevent complications and ensures shunt function post-VP shunt insertion.
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Which most immediate treatment by the HCP should the nurse anticipate for a child with a dislocated kneecap?
- A. Open surgical intervention to repair the kneecap
- B. Arthroscopy to surgically repair the torn cartilage
- C. Realignment of the kneecap by sliding it back into position
- D. Application of a cast to the affected leg until the kneecap heals
Correct Answer: C
Rationale: Immediate treatment for a dislocated kneecap involves manual realignment to restore position.
Which intervention should the nurse implement for a client with a fractured hip in Buck’s traction?
- A. Assess the insertion sites for signs and symptoms of infection.
- B. Monitor for drainage or odor from under the plaster covering the pins.
- C. Check the condition of the skin beneath the Velcro boot frequently.
- D. Take weights off for one (1) hour every eight (8) hours and as needed.
Correct Answer: C
Rationale: Checking skin under the Velcro boot prevents irritation or breakdown in Buck’s traction. Insertion sites and plaster are for skeletal traction, and weights must remain constant.
Which interventions are appropriate for an adolescent experiencing a seizure?
- A. A tongue blade inserted into the adolescent's mouth during a seizure can cause injury.
- B. Padding protects the adolescent's limbs from injury against the hard side rails during a seizure.
- C. Airway obstruction can occur during or after the seizure. An oropharyngeal airway should be available but should not be inserted during the seizure. If the seizure has commenced, nothing should be forced into the adolescent's mouth.
- D. The etiology is unknown. Only if an airborne or droplet infectious disease were suspected as the cause would droplet precautions be considered.
- E. Suctioning equipment may be needed to clear secretions after the seizure.
Correct Answer: B,C,E
Rationale: Padding protects limbs from injury, an oropharyngeal airway should be available but not inserted during a seizure, and suctioning equipment may be needed post-seizure to clear secretions.
The day after an amputation, the client begins to hemorrhage from his stump. What action should the nurse take first?
- A. Apply a pressure dressing to the stump
- B. Place a tourniquet above the stump
- C. Notify the physician
- D. Apply an ice pack to the stump
Correct Answer: A
Rationale: Applying a pressure dressing is the first action to control hemorrhage, followed by notifying the physician.
Which risk factor found in the client's medical record does the nurse identify as most significant for sustaining a hip fracture?
- A. The client is postmenopausal.
- B. The client is somewhat obese.
- C. The client has type 2 diabetes.
- D. The client is lactose intolerant.
Correct Answer: A
Rationale: Postmenopausal status is the most significant risk factor for hip fractures due to estrogen loss, which accelerates bone density reduction, increasing fracture risk. Obesity, diabetes, and lactose intolerance are less directly related.