Nokea
A 6-year-old with muscular dystrophy was recently injured falling out of bed at home. What intervention should the nurse suggest to prevent further injury?
- A. Recommend raising the bed's side rails when a caregiver is not present.
- B. Suggest a caregiver be present continuously to prevent falls from bed.
- C. Encourage the use of loose restraints while in bed.
- D. Recommend raising the bed's side rails throughout the day and night.
Correct Answer: A
Rationale: In this scenario, the most appropriate intervention to prevent further injury is to raise the bed's side rails when a caregiver is not present. This measure helps in preventing falls without the need for constant supervision. Choice B is not practical as continuous caregiver presence may not always be feasible. Choice C is unsafe as loose restraints can pose a strangulation risk. Choice D does not address the need for intervention when a caregiver is absent, potentially leading to an increased risk of falls.
You may also like to solve these questions
Which best describes a full-thickness (third-degree) burn?
- A. Erythema and pain
- B. Skin showing erythema followed by blister formation
- C. Destruction of all layers of skin evident with extension into subcutaneous tissue
- D. Destruction injury involving underlying structures such as muscle, fascia, and bone
Correct Answer: C
Rationale: The correct answer is C: Full-thickness burns involve the destruction of all layers of skin, extending into the subcutaneous tissue. This type of burn causes severe damage and loss of sensation due to nerve destruction. Choice A, erythema and pain, describes superficial burns (first-degree). Choice B, skin showing erythema followed by blister formation, describes partial-thickness burns (second-degree). Choice D, destruction injury involving underlying structures such as muscle, fascia, and bone, goes beyond the description of full-thickness burns.
A 7-year-old child has an altered mental status, high fever, and a generalized rash. You perform your assessment and initiate oxygen therapy. En route to the hospital, you should be most alert for
- A. vomiting
- B. seizures
- C. combativeness
- D. respiratory distress
Correct Answer: B
Rationale: Seizures are a common complication in children with high fever and altered mental status, indicating a risk of febrile seizures. While vomiting can occur with altered mental status, seizures are of higher concern due to the association with febrile illnesses in children. Combativeness may be a concern in some altered mental status cases but is not as common as seizures. Respiratory distress, although important, is not the primary concern in this scenario given the symptoms presented.
When explaining the occurrence of febrile seizures to a parents' class, what information should the nurse include?
- A. They may occur in minor illnesses.
- B. The cause is usually readily identified.
- C. They usually do not occur during the toddler years.
- D. The frequency of occurrence is greater in females than males.
Correct Answer: A
Rationale: The correct answer is A: 'They may occur in minor illnesses.' Febrile seizures can occur even in minor illnesses, particularly in young children, and are often triggered by a rapid increase in body temperature. Choice B is incorrect because the cause of febrile seizures is not always readily identified. Choice C is incorrect as febrile seizures commonly occur in children between the ages of 6 months to 5 years, which includes the toddler years. Choice D is incorrect as febrile seizures are slightly more common in males than females.
A child with a diagnosis of cystic fibrosis is admitted to the hospital. What is the priority nursing intervention?
- A. Administering pancreatic enzymes
- B. Providing respiratory therapy
- C. Providing nutritional support
- D. Encouraging physical activity
Correct Answer: A
Rationale: The correct answer is administering pancreatic enzymes. In cystic fibrosis, the pancreas is often affected, leading to insufficient production of digestive enzymes. Administering pancreatic enzymes is crucial to ensure proper digestion and absorption of nutrients. While respiratory therapy, nutritional support, and physical activity are essential components of care for individuals with cystic fibrosis, addressing the digestive aspect by administering pancreatic enzymes takes priority to prevent malnutrition and promote overall health.
An 8-year-old child diagnosed with meningitis is to undergo a lumbar puncture. What should the nurse explain is the purpose of this procedure?
- A. To measure the pressure of cerebrospinal fluid
- B. To obtain a sample of cerebrospinal fluid for analysis
- C. To relieve intracranial pressure
- D. To assess the presence of infection in the spinal fluid
Correct Answer: B
Rationale: A lumbar puncture is performed to obtain a sample of cerebrospinal fluid for analysis. This fluid is then examined for signs of infection, bleeding, or other abnormalities. Measuring the pressure of cerebrospinal fluid is typically done during the procedure itself, but it is not the primary purpose of the lumbar puncture. While a lumbar puncture can indirectly help relieve intracranial pressure by removing excess cerebrospinal fluid, this is not its primary purpose. Assessing the presence of infection in the spinal fluid is part of the analysis that follows the collection of the sample, making it a secondary outcome of the procedure.