Nokea
A client with a history of stroke is admitted with complaints of hemiparesis. The nurse should give priority to:
- A. Providing physical therapy
- B. Administering pain medication
- C. Monitoring blood pressure
- D. Administering anticoagulants
Correct Answer: A
Rationale: Physical therapy improves strength and mobility in hemiparesis post-stroke, promoting recovery.
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A five-year-old child is hospitalized for correction of congenital hip dysplasia. During the assessment of the child, the nurse can expect to find the presence of:
- A. Scarf sign
- B. Harlequin sign
- C. Cullen's sign
- D. Trendelenburg sign
Correct Answer: D
Rationale: Trendelenburg sign, where the pelvis tilts downward on the unaffected side when standing on the affected leg, is associated with congenital hip dysplasia due to weak hip abductors. The other signs are unrelated.
The nurse receives report on the group of clients listed here. Place the client list in sequential priority order for the nurse to assess. (Most important for the nurse to assess first, second, third, and fourth.)
- A. Client admitted from the emergency room previous shift with unrelieved migraine headache.
- B. Client transferred from surgical intensive care after traumatic brain injury. Pulse oximetry reading 94%.
- C. Client with a Glasgow coma scale (GCS) of 5 with evidence of cerebral aneurysm rupture on CT scan.
- D. Client admitted from the emergency room after a motor vehicle accident and GCS of 13
Correct Answer: C, B, D, A
Rationale: Priority: GCS 5 with aneurysm (C) is life-threatening, followed by traumatic brain injury (B, potential deterioration), motor vehicle accident with GCS 13 (D, stable but needs monitoring), and migraine (A, non-emergent).
The nurse is caring for a client with a diagnosis of preterm labor. Which medication is most likely to be ordered?
- A. Betamethasone
- B. Terbutaline
- C. Magnesium sulfate
- D. All of the above
Correct Answer: D
Rationale: Betamethasone promotes fetal lung maturity terbutaline and magnesium sulfate are tocolytics to halt preterm contractions and magnesium may also provide neuroprotection. All are commonly ordered in preterm labor.
Which behavior by a female client feeding her newborn demonstrates that she needs more teaching related to safety and infant feeding?
- A. She uses the bulb syringe to help clear her baby's nose when milk is regurgitated.
- B. She places her infant on her right side after feeding her.
- C. She props the bottle in the crib to feed her baby, which allows her to write birth announcements and feed her baby at the same time.
- D. She burps her baby by placing her in a sitting position, supporting her head and neck and gently massaging her back.
Correct Answer: C
Rationale: This practice is the proper use of the bulb syringe to clear the infant's airway in case of regurgitation. Placing the infant on either side or on the stomach prevents aspiration of regurgitated milk. 'Bottle propping' is an unsafe practice because it increases the likelihood of aspiration. This practice is one correct way of burping an infant.
A client with a history of a stroke is being discharged. The nurse should teach the client to:
- A. Avoid all physical activity
- B. Use assistive devices as needed
- C. Limit social interactions
- D. Eat a high-sodium diet
Correct Answer: B
Rationale: Assistive devices (e.g., cane, walker) promote safety and mobility post-stroke. Physical activity is encouraged, social interactions are beneficial, and sodium should be limited.