Nokea
Which intervention should the nurse implement for a hospitalized child with autism?
- A. Hold and stroke the child while doing the assessment
- B. Play the radio or turn on the television for distraction
- C. Have the parent bring the child's favorite toy from home
- D. Provide plenty of age-appropriate foods on the meal tray
Correct Answer: C
Rationale: Bringing a favorite toy can provide comfort and reduce anxiety for a child with autism in a hospital setting.
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The nurse is caring for a client diagnosed with a fracture of the right distal humerus. Which data indicate a complication? Select all that apply.
- A. Numbness and mottled cyanosis.
- B. Paresthesia and paralysis.
- C. Proximal pulses and point tenderness.
- D. Coldness of the extremity and crepitus.
- E. Palpable radial pulse and functional movement.
Correct Answer: A,B,D
Rationale: Numbness, cyanosis, paresthesia, paralysis, coldness, and crepitus indicate compartment syndrome or neurovascular compromise, serious fracture complications. Pulses and tenderness are expected.
Which level of participation should the nurse expect when assessing a 9-year-old who has mental retardation with an IQ level of 45?
- A. Able to communicate verbally only with two-letter words
- B. Able to read and comprehend simple written instructions
- C. Able to walk independently and perform a simple skill
- D. Able to perform tasks that require careful manual dexterity
Correct Answer: C
Rationale: An IQ of 45 indicates moderate intellectual disability, allowing independent walking and simple tasks.
The nurse is discharge teaching for a client with a short leg cast. Which statement indicates the client understands the discharge teaching?
- A. I need to keep my leg elevated on two pillows for the first 24 hours.'
- B. I must wear my sequential compression device all the time.'
- C. I can remove the cast for one (1) hour so I can take a shower.'
- D. I will be able to walk on my cast and not have to use crutches.'
Correct Answer: A
Rationale: Elevating the leg reduces swelling post-casting, indicating understanding. SCDs are for DVT, cast removal is unsafe, and walking without crutches depends on the fracture.
The client diagnosed with rule-out osteosarcoma asks the nurse, 'Why am I having a bone scan?' Which statement is the nurse’s best response?
- A. You seem anxious. Tell me about your anxieties.'
- B. Why are you concerned? Your HCP ordered it.'
- C. I’ll have the radiologist come back to explain it again.'
- D. A bone scan looks for cancer or infection inside the bones.'
Correct Answer: D
Rationale: A bone scan detects cancer or infection, directly answering the client’s question. Addressing anxiety, deferring to the HCP, or radiologist involvement is less informative.
The HCP is adducting the newborn's hip while pushing the thigh forward to detect developmental dysplasia of the hip (DDH). The nurse should identify this screening test as which maneuver?
- A. Barlow maneuver
- B. Pavlik maneuver
- C. Gowers maneuver
- D. Allis maneuver
Correct Answer: A
Rationale: The Barlow maneuver involves adducting the hip and pushing the thigh to detect DDH by assessing for hip dislocation.