Nokea
A five-year-old is scheduled for a lumbar puncture (LP). Which of the following nursing actions would BEST prepare the child for the procedure?
- A. Explain the procedure in detail.
- B. Show a video of the procedure.
- C. Do a mock run-through of the procedure.
- D. Answer all questions simply and honestly.
Correct Answer: C
Rationale: excellent method to use with a child because it incorporates actually 'feeling' many aspects of the procedure as they are explained
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While scheduling the administration of bromocriptine (Parlodel), which nursing action has the HIGHEST priority?
- A. The medication should be taken once a day for six weeks.
- B. The medication should be taken with orange juice.
- C. The medication should be taken in the morning and at bedtime.
- D. The medication should be taken with meals.
Correct Answer: D
Rationale: will decrease GI upset
A client is admitted with a fractured right hip. The doctor writes an order for Buck's traction. Which of the following actions, if taken by the nurse, is MOST important?
- A. Turn the client every two hours to the unaffected side.
- B. Maintain the client in a supine position.
- C. Encourage the client to use a bedside commode.
- D. Placing a footboard on the bed.
Correct Answer: A
Rationale: immobility is a leading cause of problems with Buck's traction; important to turn client to unaffected side
A 47-year-old woman comes to the outpatient psychiatric clinic for treatment of a fear of heights.
Which of the following is the best plan of care that would meet the needs of this client INITIALLY?
- A. Point out to the client the secondary gain that results from her behavior.
- B. Demonstrate to the client the irrational nature of these fears.
- C. Encourage the client to rely on significant others for support.
- D. Allow the client to avoid the situations that are anxiety provoking.
Correct Answer: D
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) secondary gain (attention and assistance received) is not the motivation of a phobic patient, remain nonjudgmental (2) ineffective in relieving behavior, may increase anxiety and feelings of guilt (3) should encourage patient to remain independent (4) correct-phobia is fixed channel for discharge of tension from unconscious conflict
While a two-day-old infant is in surgery for repair of spina bifida, the infant's mother expresses concern to the nurse because the doctor told her the infant would be confined to a wheelchair. Which of the following statements, if made by the nurse, is BEST?
- A. Physical therapy can restore the function to affected muscles.
- B. Orthopedic devices will allow your child to strengthen lower extremity muscles.
- C. Corrective surgery will return function to the affected muscles.
- D. The corrective surgery will not change your child's physical disability.
Correct Answer: D
Rationale: spinal nerves that are destroyed by the myelomeningocele cannot be corrected; nothing can return function to portions of the body that are innervated by the spinal nerves below the site of the myelomeningocele
A 23-year-old woman at 32-weeks gestation is seen in the outpatient clinic.
- A. Which finding indicates a possible complication in a 23-year-old woman at 32-weeks gestation?
- B. The client’s urine Test is positive for glucose and acetone.
- C. The client has 1+ pedal edema in both feet at the end of the day.
- D. The client complains of an increase in vaginal discharge.
- E. The client says she feels pressure against her diaphragm when the baby moves.
Correct Answer: A
Rationale: Glucose and acetone in urine suggest possible gestational diabetes, which can lead to placental insufficiency and fetal complications, requiring immediate evaluation. Mild edema, increased vaginal discharge, and diaphragmatic pressure are common in late pregnancy and not necessarily indicative of complications.