Nokea
A 10-year-old client with a pin in the right femur is immobilized in traction. He is exhibiting behavioral changes including restlessness, difficulty with problem solving, inability to concentrate on activities, and monotony. Which of the following nursing implementations would be most effective in helping him cope with immobility?
- A. Providing him with books, challenging puzzles, and games as diversionary activities
- B. Allowing him to do as much for himself as he is able, including learning to do pin-site care under supervision
- C. Having a volunteer come in to sit with the client and to read him stories
- D. Stimulating rest and relaxation by gentle rubbing with lotion and changing the client's position frequently
Correct Answer: B
Rationale: Self-care is usually well received by the child, and it is one of the most useful interventions to help the child cope with immobility, providing a sense of control.
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The nurse would expect to include which of the following when planning the management of the client with Lyme disease?
- A. Complete bed rest for 6-8 weeks
- B. Tetracycline treatment
- C. IV amphotericin B
- D. High-protein diet with limited fluids
Correct Answer: B
Rationale: The client is not placed on complete bed rest for 6 weeks. Tetracycline is the treatment of choice for children with Lyme disease who are over the age of 9. IV amphotericin B is the treatment for histoplasmosis. The client is not restricted to a high-protein diet with limited fluids.
The nurse is teaching a child's parents how to protect the child from lead poisoning. The nurse knows that a common source of lead poisoning in children is:
- A. Dandelion leaves
- B. Pencils
- C. Old paint
- D. Stuffing from toy animals
Correct Answer: C
Rationale: Dandelion leaves are not a source of lead. Pencils are not a source of lead poisoning. Chewing on objects painted before 1960 is a common source of lead poisoning in children. Gasoline is another source. Stuffed animals are not a source of lead.
A client with a history of breast cancer is admitted with complaints of fatigue. The nurse should give priority to:
- A. Monitoring for anemia
- B. Administering pain medication
- C. Monitoring blood pressure
- D. Administering chemotherapy
Correct Answer: A
Rationale: Fatigue in breast cancer may indicate anemia, so monitoring for anemia is the priority.
The client is admitted with a diagnosis of preterm labor at 32 weeks gestation. The physician orders a tocolytic. The nurse should monitor for which complication?
- A. Fetal hypoglycemia
- B. Maternal tachycardia
- C. Fetal macrosomia
- D. Maternal hypokalemia
Correct Answer: B
Rationale: Tocolytics (e.g. nifedipine terbutaline) can cause maternal tachycardia as a side effect due to their effects on smooth muscle relaxation or beta-adrenergic stimulation. Fetal hypoglycemia macrosomia and maternal hypokalemia are not typical complications.
A client is being admitted with syndrome of inappropriate diuretic hormone. Which does the nurse expect to observe?
- A. Increased thirst
- B. Tachycardia
- C. Polyuria
- D. Hostility
- E. Muscle weakness
Correct Answer: B,D,E
Rationale: SIADH causes water retention, leading to hyponatremia, which can cause tachycardia (B), hostility (D), and muscle weakness (E). Increased thirst (A) and polyuria (C) are more associated with diabetes insipidus.