Nokea
A nurse is working in a pediatric clinic and a mother brings in her 13 month old child who has Down Syndrome. The mother reports, 'My child's muscles feel weak and he isn't moving well. My RN friend checked his reflexes and she said they are diminished.' Which of the following actions should the nurse take first?
- A. Contact the physician immediately
- B. Have the patient go to X-ray for a c-spine work-up.
- C. Start an IV on the patient
- D. Position the child's neck in a neutral position
Correct Answer: D
Rationale: An atlanto-axial dislocation may have occurred, common in Down Syndrome. Positioning the child's neck in a neutral c-spine posture is the first step to prevent further injury, followed by contacting the doctor.
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The nurse is giving report to the NA on the care of four clients. The nurse should inform the NA to avoid taking a rectal temperature for which client?
- A. Adult who underwent ileostomy surgery because of a perforated bowel
- B. Adult who has a productive cough and is receiving oxygen by nasal cannula
- C. Adult who develops thrombocytopenia after receiving chemotherapy treatments
- D. Adult who has hypothermia after being outside in a below-zero temperature
Correct Answer: C
Rationale: C: Thrombocytopenia increases bleeding risk, making rectal temperatures unsafe. A: Ileostomy doesn't affect rectal area. B: Cough and oxygen don't contraindicate rectal temperatures. D: Rectal temperatures are used for hypothermia.
A standard walker is used when clients:
- A. have poor balance, cannot stand up, have weak arms, and have good hand strength.
- B. have poor balance, have a broken leg, or have experienced amputation.
- C. have poor balance, have cardiac problems, or cannot use crutches or a cane.
- D. have poor balance, have an autoimmune disease, or have weak arms.
Correct Answer: C
Rationale: A walker is used for clients who have balance problems, cardiac problems, or cannot use crutches or a cane. The client needs to bear partial weight and have strength in her wrists and arms. The client uses her upper body to propel the walker forward.
Which of the following statements to the client's family would be appropriate when preparing to provide postmortem care to the client?
- A. You will not be allowed to see your family member after the post-mortem care is performed.
- B. I am not able to assist you, but we can call pastoral care if you need any comfort.
- C. Unfortunately, we are not allowed to incorporate any cultural practices in my preparations.
- D. I will be ensuring that your family member is properly identified before they are transported.
Correct Answer: D
Rationale: When providing post-mortem care, ensure the patient is properly identified and labeled before transporting. If possible, cultural practices should be incorporated, and the family should be allowed to see the client. When possible, the nurse should provide comfort to the family.
The nurse is transferring a client from a wheelchair to the bed. Which is the correct procedure?
- A. Pull the client toward you, and pivot him on the unaffected limb
- B. Pull the client toward you, and pivot him on the affected limb
- C. Push the client toward the bed, and pivot him on the affected limb
- D. Stand the client on both legs, and push him toward the bed
Correct Answer: A
Rationale: Pulling the client and pivoting on the unaffected limb ensures safety and leverages the client's stronger side for support.
Which of the following devices may be applicable to a bedridden patient to address potential venous insufficiency? A .Shear-reducing mattress B. Sequential compression devices C. Compression stockings D.Non-skid socks
- A. B and C
- B. A and D
- C. B and D
- D. A and C
Correct Answer: A
Rationale: For a client with venous insufficiency, sequential compression devices (SCDs) and compression stockings can be applied to improve venous return from the lower extremities.