Nokea
A nurse is caring for a 2 year-old child after corrective surgery for Tetralogy of Fallot. The mother reports that the child has suddenly begun seizing. The nurse recognizes this problem is probably due to
- A. A cerebral vascular accident
- B. Postoperative meningitis
- C. Medication reaction
- D. Metabolic alkalosis
Correct Answer: A
Rationale: A cerebral vascular accident. Polycythemia occurs as a physiological reaction to chronic hypoxemia, increasing the risk of thromboembolic events like cerebrovascular accidents, which can manifest as seizures.
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The parents of a one-month-old boy bring their son to the clinic for evaluation of a possible right dislocated hip.
- A. Which symptom will the nurse observe in a one-month-old with unilateral right hip dislocation?
- B. Limited adduction of the right leg.
- C. Uneven gluteal fold and thigh creases.
- D. Increase in length of the right limb.
- E. Internal rotation of the right leg.
Correct Answer: B
Rationale: Unilateral hip dislocation causes uneven gluteal folds and thigh creases, with deeper and longer folds on the affected side due to hip displacement. Limited abduction (not adduction), shortened limb length, and variable rotation are more typical findings.
An older woman hospitalized with a fractured left hip, placed in Buck's traction with a seven-pound weight while awaiting surgery.
Which of the following instructions for moving should be discussed by the nurse to encourage the patient to participate in her care?
- A. Pull up on the overhead trapeze while you push down on your right foot to lift your body.'
- B. With your right arm, grasp the bedside rail on the opposite side and pull yourself over gently.'
- C. I'll raise the head of the bed 45°, and then you lean forward and rotate your hips to the left.'
- D. Swing your right leg over your left leg, and turn from your waist down, keeping your legs straight.'
Correct Answer: A
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct-body must move as single, straight unit (2) turning or twisting from the waist down interferes with countertraction (3) prevents proper pull of weights (4) can't turn from side to side, can only move up and down
A client returned from surgery for a perforated appendix with localized peritonitis. In view of this diagnosis, how would the nurse position the client?
- A. Prone
- B. Dorsal recumbent
- C. Semi-Fowler
- D. Supine
Correct Answer: C
Rationale: Semi-Fowler. The semi-Fowler position assists drainage and prevents spread of infection throughout the abdominal cavity.
Which of the following assessment findings should the nurse recognize as pertinent to a diagnosis of Cushing's syndrome?
- A. Low blood pressure and weight loss.
- B. Thin extremities with easy bruising.
- C. Decreased urinary output and decreased serum potassium.
- D. Tachycardia with complaints of night sweats.
Correct Answer: B
Rationale: clients with Cushing's syndrome tend to lose weight in their legs and have petechiae and bruising
A client administering his own insulin.
Which observation indicates to the nurse that the client needs further teaching before he can administer his own insulin?
- A. The client draws up his regular insulin first, then the NPH.
- B. The client gently rotates the insulin bottle before withdrawing the dose.
- C. The client rotates injection sites following the guide on his printed diagram.
- D. The client administers the insulin while it is still cold from the refrigerator.
Correct Answer: D
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) when mixing regular insulin with other types of insulin, the client should draw up the clear (regular) before the cloudy (NPH) (2) bottle of insulin should never be vigorously shaken, but rather gently mixed (3) imperative to rotate injection sites to avoid tissue irritation/infection and ensure proper absorption (4) correct-insulin should be administered at room temperature, temperature extremes should be avoided