Nokea
A baby girl is born with a meningomyelocele. To prevent trauma to the sac, the nurse should place the infant:
- A. Supine and flat
- B. Prone with the hips slightly elevated
- C. Prone with the head slightly elevated
- D. Side lying
Correct Answer: B
Rationale: Placing the infant prone with hips slightly elevated protects the meningomyelocele sac from trauma and pressure.
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Which of the following assessments by the nurse would indicate that the client is having a possible adverse response to the isoniazid (INH)?
- A. Severe headache
- B. Appearance of jaundice
- C. Tachycardia
- D. Decreased hearing
Correct Answer: B
Rationale: Clients receiving INH therapy are at risk for developing drug-induced hepatitis. The appearance of jaundice may indicate that the client has liver damage.
A nurse is conducting a community wide seminar on childhood safety issues. Which of these children is at the highest risk for poisoning?
- A. 9 month-old who stays with a sitter 5 days a week
- B. 20 month-old who has just learned to climb stairs
- C. 10 year-old who occasionally stays at home unattended
- D. 15 year-old who likes to repair bicycles
Correct Answer: B
Rationale: 20 month-old who has just learned to climb stairs. Increased mobility and curiosity put toddlers at high risk for poisoning.
The nurse is caring for a client who is receiving heparin 5,000 units subcutaneously every 12 hours. Which of the following laboratory results would be of GREATest concern to the nurse?
- A. Platelet count of 100,000/mm^3.
- B. INR of 1.2.
- C. PTT of 40 seconds.
- D. Hemoglobin of 14 g/dL.
Correct Answer: A
Rationale: A platelet count of 100,000/mm^3 suggests thrombocytopenia, a serious complication of heparin therapy, increasing bleeding risk and possibly indicating heparin-induced thrombocytopenia. Options B, C, and D are normal or less concerning: INR and PTT are not significantly affected by subcutaneous heparin, and hemoglobin 14 g/dL is normal.
A client is being treated for paranoid schizophrenia. When the client became loud and boisterous, the nurse immediately placed him in seclusion as a precautionary measure. The client willingly complied. The nurse's action
- A. may result in charges of unlawful seclusion and restraint
- B. leaves the nurse vulnerable for charges of assault and battery
- C. was appropriate in view of a client history of violence
- D. was necessary to maintain the therapeutic milieu of the unit
Correct Answer: A
Rationale: Seclusion should only be used when there is an immediate threat of violence or threatening behavior toward the staff, the other clients, or the client himself.
The nurse is to move a client up in bed without any help. Where should the nurse place the client's pillow?
- A. At the bottom of the bed
- B. On the bedside stand
- C. At the head of the bed
- D. Under the client's head
Correct Answer: C
Rationale: Placing the pillow at the head of the bed supports the client's head after moving up, ensuring comfort and proper positioning.