Nokea
A nurse is checking children at an orthopedic outpatient setting. Which of the following should the nurse expect to see as manifestations of scoliosis?
- A. Pain and an exaggerated lumbar curvature'
- B. Uneven shoulder heights and poorly fitting slacks'
- C. Tenderness and swelling of the spine'
- D. Limited range of motion of the back and a limp'
Correct Answer: B
Rationale: The correct answer is B. Uneven shoulder heights and poorly fitting slacks are common manifestations of scoliosis because the condition causes an abnormal curvature of the spine, leading to uneven shoulders and hips. Pain and exaggerated lumbar curvature (choice A) are not specific manifestations of scoliosis. Tenderness and swelling of the spine (choice C) could indicate other conditions like infection or inflammation, not necessarily scoliosis. Limited range of motion of the back and a limp (choice D) are more indicative of musculoskeletal injuries or disorders, not scoliosis.
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A nurse is initiating a plan of care for a toddler who is hospitalized. Which of the following instructions is important to communicate to the nursing assistant?
- A. Have the toddler dress himself.
- B. Offer the toddler finger foods for snacks.
- C. Provide opportunities to share toys with others.
- D. Ask the child simple yes or no questions.
Correct Answer: B
Rationale: The correct answer is B: Offer the toddler finger foods for snacks. This instruction is important to communicate to the nursing assistant because toddlers are at risk for choking on certain foods due to their developing chewing and swallowing abilities. Finger foods are safer for toddlers to eat as they are easier to manage and reduce the risk of choking.
Other choices are incorrect because:
A: Having the toddler dress himself may not be appropriate as toddlers may need assistance and supervision due to their limited motor skills.
C: Providing opportunities to share toys with others is important for social development but is not as critical as ensuring the toddler's safety during meal times.
D: Asking the child simple yes or no questions is a good communication strategy but not as essential for the toddler's safety during snack times.
A nurse is caring for a 3-year-old child with strabismus. Which of the following actions should the nurse advise the parents to implement to help prevent amblyopia?
- A. Wear corrective biconcave lenses.
- B. Prevent trauma to the eyes.
- C. Patch the strong eye.
- D. Instill artificial tears.
Correct Answer: C
Rationale: The correct answer is C: Patch the strong eye. Patching the strong eye helps improve vision in the weaker eye, which is essential in preventing amblyopia. By covering the strong eye, the brain is forced to rely on the weaker eye, strengthening its visual acuity. Wearing corrective biconcave lenses may help with refractive errors but does not directly address amblyopia prevention. Preventing trauma to the eyes is important for overall eye health but does not specifically target amblyopia prevention. Instilling artificial tears is used for dry eye syndrome and does not play a role in preventing amblyopia.
A nurse is assessing a client who has gestational diabetes and is experiencing hyperglycemia. Which of the following findings should the nurse expect?
- A. Reports increased urinary output
- B. Diaphoresis
- C. Reports blurred vision
- D. Shallow respirations
Correct Answer: A
Rationale: The correct answer is A: Reports increased urinary output. In hyperglycemia, the body tries to eliminate excess glucose through urine, leading to increased urinary output. This is known as osmotic diuresis. Diaphoresis (B) is sweating, which is not typically associated with hyperglycemia. Blurred vision (C) is a symptom of prolonged hyperglycemia affecting the eyes but not an immediate finding. Shallow respirations (D) are not directly related to hyperglycemia.
What is the main cause of mastitis in the postpartum client?
- A. Poor breastfeeding technique
- B. Inadequate hand washing
- C. Systemic maternal infection
- D. Prolonged nursing
Correct Answer: A
Rationale: The correct answer is A: Poor breastfeeding technique. Mastitis in postpartum clients is commonly caused by milk stasis due to inadequate milk removal, which can result from poor breastfeeding technique such as improper latch or infrequent feedings. This leads to inflammation and infection. Inadequate hand washing (B) is important for preventing infection but not the main cause of mastitis. Systemic maternal infection (C) may contribute but is not the primary cause. Prolonged nursing (D) can actually help prevent mastitis by promoting milk flow.
A nurse is caring for an infant with a history of vomiting due to gastroenteritis. Which of the following nursing interventions is considered the priority?
- A. Place the infant in a side or semi-reclined position.
- B. Administer oral rehydration and electrolyte therapy.
- C. Administer antiemetic medications as prescribed.
- D. Maintain a high-carbohydrate intake to prevent ketosis.
Correct Answer: A
Rationale: Positioning the infant prevents aspiration, which is the highest priority.