Nokea
A pregnant client is receiving rehabilitative services for alcohol abuse. How should the nurse provide supportive care?
- A. Assist the client in identifying supportive strategies.
- B. Initiate the possibility of placing the baby up for adoption.
- C. Stress the need for Alcoholics Anonymous (AA) meetings.
- D. Encourage the client to continue counseling after the birth.
- E. Encourage the client to participate in her rehabilitation care.
- F. Minimize communication with codependent family members.
Correct Answer: A,C,D,E
Rationale: The nurse provides supportive care by encouraging the client to participate in care and to identify coping strategies. Counseling needs to continue after the infant is born. Communication with family members is important but not when they are supporting the addiction. It is not appropriate to suggest adoption.
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The nurse caring for a child who has sustained a head injury notes that the primary health care provider has documented decorticate posturing. During the assessment of the child, the nurse notes the extension of the upper extremities and the internal rotation of the upper arms and wrists. The nurse also notes that the lower extremities are extended, with some internal rotation noted at the knees and feet. On the basis of these findings, what is the initial nursing action?
- A. Document that the original positioning is unchanged.
- B. Attempt to assess the flexibility of the child's lower extremities.
- C. Plan to continue to monitor the child for posturing every 2 hours.
- D. Notify the primary health care provider of the change in posturing.
Correct Answer: D
Rationale: Decorticate (flexion) posturing refers to the flexion of the upper extremities and the extension of the lower extremities. Plantar flexion of the feet may also be observed. Decerebrate (extension) posturing involves the extension of the upper extremities with the internal rotation of the upper arms and wrists. The lower extremities will extend with some internal rotation noted at the knees and feet. The progression from decorticate to decerebrate posturing usually indicates deteriorating neurological function and warrants primary health care provider notification. Although documentation is appropriate, it is not the initial action in this situation. The other options are not appropriate.
The nurse is preparing to suction a tracheotomy on an infant. The nurse prepares the equipment for the procedure and should turn the suction to which setting?
- A. 60 mm Hg
- B. 90 mm Hg
- C. 110 mm Hg
- D. 120 mm Hg
Correct Answer: B
Rationale: The suctioning procedure for pediatric clients varies from that used for adults. Suctioning in infants and children requires the use of a smaller suction catheter and lower suction settings as compared with those used for adults. Suction settings for a neonate are usually 60 to 80 mm Hg; for an infant, 80 to 100 mm Hg; and, for larger children, 100 to 120 mm Hg. The primary health care provider prescription and agency procedures are always followed.
The nurse is asked to assist another health care team member with providing care for a client. On entering the client's room, the nurse notes that the client is placed in this position (refer to figure). After maintaining the client position, what should the nurse interpret that this client is most likely being treated for?
- A. Shock
- B. A head injury
- C. Respiratory insufficiency
- D. Increased intracranial pressure
Correct Answer: A
Rationale: A client in shock is placed in a modified Trendelenburg's position that includes elevating the legs, leaving the trunk flat, and elevating the head and shoulders slightly. This position promotes increased venous return from the lower extremities without compressing the abdominal organs against the diaphragm. The Trendelenburg position is no longer recommended for hypotensive clients because the client is predisposed to aspiration and worsens gas exchange. The remaining options identify conditions in which the head of the client's bed would be elevated.
The nurse is caring for an infant diagnosed with laryngomalacia (congenital laryngeal stridor). In which position should the nurse place the infant to decrease the incidence of stridor?
- A. Prone
- B. Supine
- C. Supine with the neck flexed
- D. Prone with the neck hyperextended
Correct Answer: D
Rationale: The prone position with the neck hyperextended improves the child's breathing. Based on that information, none of the remaining options are appropriate positions.
Which action should the nurse implement as part of care for a client after a bone biopsy?
- A. Monitoring the vital signs once per day.
- B. Keeping the area in a dependent position.
- C. Administering intramuscular opioid analgesics.
- D. Monitoring the site for swelling, bleeding, or hematoma formation.
Correct Answer: D
Rationale: Nursing care after bone biopsy includes monitoring the site for swelling, bleeding, or hematoma formation. The vital signs are monitored every 4 hours for 24 hours. The biopsy site is elevated for 24 hours to reduce edema. A dependent position will increase the risk for bleeding. The client usually requires mild analgesics; more severe pain usually indicates that complications are arising.