Nokea
A male client in skeletal traction tells the nurse that he is frustrated because he needs help repositioning himself in bed. Which intervention should the nurse implement?
- A. Provide an overhead trapeze to the bed for the client to use
- B. Assist the client with repositioning every hour to prevent discomfort.
- C. Encourage the client to use a bedpan instead of getting up to the bathroom.
- D. Offer additional pain medication to help the client relax.
Correct Answer: A
Rationale: An overhead trapeze allows the client to reposition independently, promoting autonomy and reducing frustration.
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Epiphyseal changes are seen in:
- A. Non-accidental injury
- B. Rickets
- C. Chronic renal failure
- D. Lead poisoning
Correct Answer: B
Rationale: Rickets is characterized by epiphyseal changes due to defective mineralization of growing bones.
The following are true about water excretion:
- A. It is influenced by the proximal tubule
- B. It is influenced by vasopressin
- C. It depends on erythropoietin
- D. It is influenced by the ascending limb of the loop of Henle
Correct Answer: B
Rationale: It is influenced by vasopressin: Vasopressin (ADH) regulates water reabsorption in the kidneys, primarily by acting on the collecting ducts, enhancing water retention in response to dehydration.
A client who took a camping vacation two weeks ago in a county with a tropical climate comes to the clinic describing vague symptoms and diarrhea for the past week. Which finding is most important for the nurse report to the healthcare provider?
- A. Weakness and fatigue
- B. Intestinal cramping
- C. Weight loss
- D. Jaundiced sclera
Correct Answer: D
Rationale: Jaundiced sclera indicates possible liver involvement, which could be due to a tropical disease such as hepatitis or leptospirosis.
Adverse reactions to angiotensin-converting enzyme inhibitors (ACEIs) include the following EXCEPT
- A. hypotension
- B. hypokalemia
- C. maculopapular rash
- D. renal toxicity
Correct Answer: B
Rationale: ACEIs can cause hyperkalemia, not hypokalemia.
An 18-month-old with a myelomeningocele is undergoing a cardiac catheterization. The mother expresses concern about the use of dye in the procedure. The child does not have any allergies. In addition to an iodine allergy, which other allergy should the nurse bring to the attention of the catheterization staff?
- A. Soy
- B. Latex
- C. Penicillin
- D. Dairy
Correct Answer: B
Rationale: Children with spina bifida (myelomeningocele) are often allergic to latex; catheter balloons and other materials may contain latex.