Nokea
The HCP's progress note states that the infant with meningitis is in an opisthotonus position. What should the nurse observe when performing an assessment?
- A. Resistance with specific leg movement
- B. Knee or hip flexion with head flexion
- C. A high-pitched cry with neck flexion
- D. Hyperextension of the head and neck
Correct Answer: D
Rationale: Opisthotonus is characterized by severe hyperextension of the head and neck, often seen in meningitis.
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To which member of the health-care team should the nurse refer the client diagnosed with OA who is complaining of not being able to get in and out of the bathtub?
- A. Physiatrist.
- B. Social worker.
- C. Physical therapist.
- D. Counselor.
Correct Answer: C
Rationale: A physical therapist can teach adaptive techniques and exercises to improve bathtub mobility for OA. Physiatrists focus on rehabilitation plans, social workers address resources, and counselors focus on mental health.
Postoperatively, the client screams obscenities at the nurse after realizing that the injured forearm is missing. Which nursing action is most appropriate at this time?
- A. Leave until the client works through the anger.
- B. Stay quietly with the client at the bedside.
- C. Tell the client to gain emotional control.
- D. Call the physician and request a sedative.
Correct Answer: B
Rationale: Staying quietly with the client provides emotional support during a grief reaction to amputation, promoting trust. Leaving, reprimanding, or medicating without engagement dismisses the client's feelings.
The experienced nurse observes the new nurse caring for the client who is in skeletal traction to stabilize a proximal femur fracture prior to surgery. Which observation by the experienced nurse indicates the new nurse needs additional orientation?
- A. Positions the client so the client's feet stay clear of the bottom of the bed
- B. Checks ropes so that they are positioned in the wheel groves of the pulleys
- C. Removes weights from ropes until the weights hang free of the bed frame
- D. Performs pin site care with chlorhexidine solution once during the 8-hour shift
Correct Answer: C
Rationale: C. Weights should be hanging freely, but weights should never be removed (unless a life-threatening situation occurs) because removal could result in injury and defeats the purpose of the traction. The lengths of the ropes need to be adjusted so the weights do not rest on the bed frame.
If the client is allergic to penicillin, the nurse must question a medical order for which type of antibiotic?
- A. An aminoglycoside such as gentamicin sulfate (Garamycin)
- B. A cephalosporin such as cefaclor (Ceclor)
- C. A tetracycline such as doxycycline (Vibramycin)
- D. A sulfonamide such as trimethoprim/sulfamethoxazole (Bactrim)
Correct Answer: B
Rationale: Cephalosporins (e.g., cefaclor) have a cross-sensitivity with penicillin, risking allergic reactions in penicillin-allergic clients. The other antibiotics listed do not share this cross-reactivity.
Which response by the nurse is most appropriate when the mother, concerned about her unborn daughter developing DMD, states that her brother and son have DMD?
- A. "You already have one child with muscular dystrophy; it's unlikely you'll have another."
- B. "Your brother and son have DMD; it's unlikely that you'll have another child with DMD."
- C. "As many as one-third of children born with DMD have no family history of the disease."
- D. "If your unborn child is a girl, she may carry the gene, but she will not develop DMD."
Correct Answer: D
Rationale: DMD is X-linked; females may be carriers but do not develop the disease.