Nokea
A nursing student is preparing to conduct a clinical conference regarding cerebral palsy. Which characteristic related to this disorder should the student plan to include in the discussion?
- A. Cerebral palsy is an infectious disease of the central nervous system.
- B. Cerebral palsy is an inflammation of the brain as a result of a viral illness.
- C. Cerebral palsy is a chronic disability characterized by difficulty with muscle control.
- D. Cerebral palsy is a congenital condition that results in moderate to severe retardation.
Correct Answer: C
Rationale: Cerebral palsy is a chronic disability that is characterized by difficulty with controlling the muscles because of an abnormality in the extrapyramidal or pyramidal motor system. Meningitis is an infectious process of the central nervous system. Encephalitis is an inflammation of the brain that occurs as a result of viral illness or central nervous system infections. Down syndrome is an example of a congenital condition that results in moderate to severe retardation.
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The nurse is caring for a client diagnosed with dementia. Which nutritional goal should the nurse plan for with this client?
- A. Client will be free of hallucinations.
- B. Client will feed self with cueing within 24 hours.
- C. Client will be able to prepare simple foods by discharge.
- D. Client will identify favorite foods by the time of discharge.
Correct Answer: B
Rationale: The correct option identifies a goal that is directly related to the client's ability to care for self. None of the remaining options are related to the client's self-care needs.
A client is admitted to a mental health unit with a diagnosis of anorexia nervosa. When planning care for this client, which primary intervention should health promotion focus on?
- A. Providing a supportive environment
- B. Examining intrapsychic conflicts and past issues
- C. Emphasizing social interaction with clients who are withdrawn
- D. Helping the client identify and examine dysfunctional thoughts and beliefs
Correct Answer: D
Rationale: Health promotion focuses on helping clients identify and examine dysfunctional thoughts, as well as identifying and examining the values and beliefs that maintain these thoughts. Providing a supportive environment is important, but it is not as primary as option 4 for this client. Examining intrapsychic conflicts and past issues is not directly related to the client's problem. Emphasizing social interaction is not appropriate at this time.
The nurse is preparing a plan of care for a child diagnosed with leukemia who is beginning chemotherapy. Which intervention should the nurse include?
- A. Monitor rectal temperatures every 4 hours.
- B. Monitor the mouth and anus each shift for signs of breakdown.
- C. Encourage the child to consume fresh fruits and vegetables to maintain nutritional status.
- D. Provide meticulous mouth care several times daily using an alcohol-based mouthwash and a toothbrush.
Correct Answer: B
Rationale: When the child is receiving chemotherapy, the nurse should assess the mouth and anus each shift for ulcers, erythema, or breakdown. The nurse should avoid taking rectal temperatures. Oral temperatures are also avoided if mouth ulcers are present. Axillary or temporal temperatures should be taken to prevent alterations in skin integrity. Bland, nonirritating foods and liquids should be provided to the child. Fresh fruits and vegetables need to be avoided because they can harbor organisms. Chemotherapy can cause neutropenia, and the child should be maintained on a low-bacteria diet if the white blood cell count is low. Meticulous mouth care should be performed, but the nurse should avoid alcohol-based mouthwashes and should use a soft-bristled toothbrush.
The nurse is preparing to admit a client from the postanesthesia care unit who has had microvascular decompression of the trigeminal nerve. Which equipment should the nurse ask the unlicensed assistive personnel to make sure is at the bedside when the client arrives?
- A. Flashlight and pulse oximeter
- B. Cardiac monitor and suction equipment
- C. Padded bed rails and suction equipment
- D. Blood pressure cuff and cardiac monitor
Correct Answer: A
Rationale: The postoperative care of the client having microvascular decompression of the trigeminal nerve is the same as for the client undergoing craniotomy. This client requires hourly neurological assessment as well as monitoring of the cardiovascular and respiratory statuses. Therefore, a flashlight and pulse oximetry are necessary items. Cardiac monitoring and padded bed rails are not indicated unless there is a special need based on a client history of cardiac disease or seizures, respectively. Suctioning is performed cautiously and only when necessary after craniotomy to avoid increasing the intracranial pressure.
The nurse creates a plan of care for a client with a spica cast that covers a lower extremity. Which action should the nurse include in the plan of care to promote bowel elimination?
- A. Use a bedside commode.
- B. Ambulate to the bathroom.
- C. Administer an enema daily.
- D. Use a low-profile (fracture) bedpan.
Correct Answer: D
Rationale: A client with a spica cast (body cast) that covers a lower extremity cannot bend at the hips to sit up. A low-profile bedpan or fracture pan is designed for use by clients with body or leg casts and for clients who have difficulty raising the hips to use a standard bedpan; therefore, using a commode or the bathroom is contraindicated. Daily enemas are not a part of routine care.