Nokea
A child with a diagnosis of Reye's syndrome is being admitted to the hospital. The nurse develops a plan of care for the child that includes which priority nursing action?
- A. Monitoring for hearing loss
- B. Monitoring intake and output (I&O)
- C. Repositioning the child every 2 hours
- D. Providing a quiet environment with dimmed lighting
Correct Answer: D
Rationale: Cerebral edema is a progressive part of the disease process of Reye's syndrome. A priority component of care for a child with Reye's syndrome is maintaining effective cerebral perfusion and controlling intracranial pressure. Decreasing stimuli in the environment would decrease the stress on the cerebral tissue, as well as neuron responses. Hearing loss does not occur in clients with this disorder. Although monitoring I&O may be a component of the plan, it is not the priority nursing action. Changing the body position every 2 hours would not affect the cerebral edema and intracranial pressure directly. The child should be in a head-elevated position to decrease the progression of cerebral edema and promote the drainage of cerebrospinal fluid.
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The nurse is preparing to assist in the administration of a chemotherapeutic agent via intraperitoneal (IP) therapy. In which position should the nurse plan to place the client before administering this therapy?
- A. Supine
- B. Semi-Fowler's
- C. Trendelenburg's
- D. Dorsal recumbent
Correct Answer: B
Rationale: IP therapy is the administration of chemotherapeutic agents into the peritoneal cavity. This therapy is used for intra-abdominal malignancies such as ovarian and gastrointestinal tumors that have moved into the peritoneum after surgery. The client should be placed in a semi-Fowler's position for this infusion because the client may experience nausea and vomiting caused by increasing pressure on the internal organs. Additionally, this treatment may also place pressure on the diaphragm. The positions indicated in the rest of the options would increase pressure in the peritoneal cavity.
The nurse is preparing discharge plans for a hospitalized client who attempted suicide. Which intervention should the nurse include in the plan as an immediate resource?
- A. Scheduling weekly follow-up appointments
- B. Establishing contracts with available crisis resources
- C. Encouraging family and friends to be with the client at all times
- D. Providing phone numbers for the hospital and primary health care provider
Correct Answer: B
Rationale: Crisis times may occur between appointments. Contracts facilitate a client's feeling of responsibility for keeping a promise, which gives him or her control. Providing phone numbers will not ensure available and immediate crisis intervention. Family and friends cannot always be present.
The nurse is admitting a client who recently underwent a bilateral adrenalectomy. Which intervention is essential for the nurse to include in the client's plan of care?
- A. Prevent social isolation.
- B. Consider occupational therapy.
- C. Discuss changes in body image.
- D. Avoid stress-producing situations.
Correct Answer: D
Rationale: Adrenalectomy can lead to adrenal insufficiency. Adrenal hormones are essential to maintaining homeostasis in response to stressors. None of the remaining options are essential interventions specific to this client's problem.
The nurse is planning care for an infant who has a diagnosis of hypertrophic pyloric stenosis and is scheduled for surgery. Which intervention should the nurse include to meet the infant's preoperative needs?
- A. Administer enemas until returns are clear.
- B. Provide the mother privacy to breast-feed every 2 hours.
- C. Monitor the intravenous (IV) infusion, intake, output, and weight.
- D. Provide small, frequent feedings of glucose, water, and electrolytes.
Correct Answer: C
Rationale: Preoperatively, important nursing responsibilities for the child with hypertrophic pyloric stenosis include monitoring the IV infusion, intake, output, and weight and obtaining urine specific gravity measurements. Additionally, weighing the infant's diapers provides information regarding output. Enemas until clear would further compromise the fluid volume status. Preoperatively, the infant receives nothing by mouth unless otherwise prescribed by the primary health care provider.
A client hospitalized after a stroke is prepared for discharge. The primary health care provider has prescribed range-of-motion (ROM) exercises for the client's right side. Which intervention should the home care nurse's plan include when planning for the client's care?
- A. Implements ROM exercises to the point of pain for the client
- B. Considers the use of active, passive, or active-assisted exercises in the home
- C. Encourages dependence on the home care nurse to complete the exercise program
- D. Develops a schedule involving ROM exercises every 3 hours during daylight hours
Correct Answer: B
Rationale: The home care nurse must consider all forms of ROM for the client. Even if the client has right hemiplegia, the client can assist with some of his or her own rehabilitative care. In addition, the goal of home care nursing is for the client to assume as much self-care and independence as possible. The nurse needs to teach so that the client becomes self-reliant. Options 1 and 4 are incorrect from a physiological standpoint.