Nokea
A client who suffered a vehicular accident a few days ago is in skeletal traction. Which nursing action would BESt promote INDEPENDENCE for this patient?
- A. tell the client to call for an analgesic before the pain felt becomes severe
- B. encourage the patient to do leg exercises within the limits of his traction
- C. provide an overhead trapeze for client use on the Balkan frame
- D. provide skin care to prevent skin breakdown
Correct Answer: B
Rationale: Encouraging the patient to do leg exercises within the limits of his skeletal traction is the best nursing action to promote independence for the client. By engaging in leg exercises, the patient can maintain muscle strength and joint flexibility, which can prevent complications such as muscle atrophy and joint stiffness. This activity empowers the client to actively participate in their own care and promotes a sense of independence and control over their health during a period of immobility. Additionally, it can help improve circulation and prevent complications related to immobility such as deep vein thrombosis.
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When teaching umbilical cord care to a new mother, the nurse would include which information?
- A. Apply peroxide to the cord with each diaper change
- B. Cover the cord with petroleum jelly after bathing
- C. Keep the cord dry and open to air
- D. Wash the cord with soap and water each day during a tub bath
Correct Answer: C
Rationale: Keeping the cord dry and open to air is the recommended practice for umbilical cord care. This helps the cord to dry out and fall off naturally. Applying substances like peroxide or petroleum jelly can create a moist environment, which can increase the risk of infection. Washing the cord with soap and water daily can also prolong the time it takes for the cord to fall off. Thus, the best approach is to simply keep the cord clean and dry, allowing it to heal and detach on its own.
Why should the nurse wake up a client who is to undergo an EEG at midnight?
- A. Because excess sleep may make the client lazy and nervous for the EEG
- B. Because optimum sleep helps regulate the breathing patterns during the EEG
- C. Because it helps the client to fall asleep naturally during the EEG
- D. Because it reduces the chances of getting a headache when electrodes are fixed to the scalp of the client
Correct Answer: B
Rationale: The nurse should wake up a client who is to undergo an EEG at midnight to ensure that the client receives optimum sleep before the procedure. Optimum sleep helps regulate the client's breathing patterns during the EEG, resulting in more accurate readings. Adequate rest is essential for brain activity monitoring to be as normal as possible. Waking the client at midnight allows for enough time for the client to fall back asleep before the EEG is conducted, ensuring the best possible conditions for the procedure.
Which statement is true about smoking in adolescence?
- A. Smoking is related to other high-risk behaviors.
- B. Smoking will not continue unless peer pressure continues.
- C. Smoking is less common when the adolescent's parent(s) smokes.
- D. Smoking among adolescents is becoming more prevalent.
Correct Answer: A
Rationale: Research has shown that smoking during adolescence is closely linked to engaging in other high-risk behaviors, such as alcohol and drug use, risky sexual behavior, and delinquency. Adolescents who smoke are more likely to experiment with other substances and engage in risky activities compared to non-smokers. This is due to common psychological and sociocultural factors that contribute to the clustering of risky behaviors among adolescents. Therefore, statement A is the most accurate description of the relationship between smoking and high-risk behaviors in adolescence.
The school nurse is conducting a class for school-age children on Lyme disease. Which is characteristic of Lyme disease?
- A. Difficult to prevent
- B. Treated with oral antibiotics in stages 1, 2, and 3
- C. Caused by a spirochete that enters the skin through a tick bite
- D. Common in geographic areas where the soil contains the mycotic spores that cause the disease
Correct Answer: C
Rationale: Lyme disease is caused by a spirochete bacterium called Borrelia burgdorferi, which enters the skin through the bite of an infected deer tick. It is primarily transmitted to humans through the bite of infected black-legged ticks, commonly known as deer ticks. These ticks carry the bacterium in their gut and can transmit it to humans when they feed on blood. Therefore, Lyme disease is characterized by being caused by a spirochete that enters the skin through a tick bite. Option C is the correct answer in this case, as options A, B, and D do not accurately describe the characteristics of Lyme disease.
Where is the appropriate placement of a tongue blade for assessment of the mouth and throat?
- A. Center back area of tongue
- B. Side of the tongue
- C. Against the soft palate
- D. On the lower jaw
Correct Answer: A
Rationale: The appropriate placement of a tongue blade for assessment of the mouth and throat is at the center back area of the tongue. This location allows the healthcare provider to depress the tongue gently to have a clear view of the oral cavity, tonsils, and throat structures. Placing the tongue blade on the side of the tongue may not provide adequate visualization, and placing it against the soft palate or on the lower jaw would not help in examining the mouth and throat effectively.