Nokea
After a client develops left-sided hemiparesis from a cerebral vascular accident (CVA), there is a decrease in muscle tone.
- A. Which nursing diagnosis is a priority for a client with left-sided hemiparesis post-CVA?
- B. Alteration in mobility related to paralysis.
- C. Alteration in skin integrity related to decrease in tissue oxygenation.
- D. Alteration in skin integrity related to immobility.
- E. Alteration in communication related to decrease in thought processes.
Correct Answer: B
Rationale: Decreased tissue oxygenation from impaired circulation in hemiparesis is the leading cause of skin breakdown, making this the priority nursing diagnosis. Mobility and immobility are concerns, but tissue perfusion is more critical, and communication issues are more relevant to right-sided CVA.
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A four-month-old child is admitted with a tentative diagnosis of meningitis.
- A. What is the most important nursing action during a lumbar puncture for a four-month-old with suspected meningitis?
- B. Appropriately restrain the child.
- C. Instruct the parents about the procedure.
- D. Provide support to the child.
- E. Elevate the head of the bed.
Correct Answer: A
Rationale: Restraining the child during a lumbar puncture prevents movement, reducing the risk of spinal trauma. Parental instruction and emotional support are important but secondary, and elevating the head is inappropriate for positioning.
A young woman who is at 32 weeks gestation reports to the physician's office for a routine prenatal visit. Which comment by the woman must be reported to the physician?
- A. I had to stop wearing my rings because my fingers are swollen.'
- B. I seem to be hotter than everyone else.'
- C. My feet tend to swell in the hot weather.'
- D. My breasts are so big and tender.'
Correct Answer: A
Rationale: Finger swelling severe enough to prevent wearing rings may indicate preeclampsia, requiring physician evaluation. Heat sensation, foot edema, and breast changes are normal in pregnancy.
The nurse is working with parents to plan home care for a 2 year-old with a heart problem. A priority nursing intervention would be to
- A. Encourage the parents to enroll in cardiopulmonary resuscitation (CPR) class
- B. Assist the parents to plan quiet play activities at home
- C. Stress to the parents the need to avoid overexertion
- D. Instruct the parents to avoid contact with persons with infection
Correct Answer: A
Rationale: Encourage the parents to enroll in cardiopulmonary resuscitation (CPR) class. While all suggestions are appropriate, the education of the parents/caregivers should include techniques of cardiopulmonary resuscitation in order to provide for emergency care of their child.
An infant with a positive PKU blood Test .
The nurse knows that which of the following plans would be a priority for an infant with a positive PKU blood Test ?
- A. Place the infant on Lofenlac formula.
- B. Administer medium-chain triglyceride (MCT) oil with each feeding.
- C. Provide genetic counseling for the family.
- D. Place the infant on Lorenzo's Oil treatments.
Correct Answer: A
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct-Guthrie blood Test evaluates neonate for phenylketonuria (PKU); Lofenalac formula is low in phenylalanine, but contains minerals and vitamins to provide a balanced nutritional formula (2) could be a plan for a child with cystic fibrosis (3) important, but is not as high a priority as answer choice #1 (4) would be a plan of care for a child with adrenoleukodystrophy (ALD)
A client with dementia.
The nurse knows that which of these plans would be MOST successful in caring for a client with dementia?
- A. Teach new skills for adjusting to the aging process.
- B. Adjust the environment to meet the client's individual needs.
- C. Encourage competitive activities to keep the client physically strong.
- D. Provide unstructured activities with frequent changes to increase stimulation.
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) unable to learn new skills (2) correct-client with dementia does not have cognitive abilities to learn new skills or to adapt, environment must be adapted for client with attention to safety and predictability (3) requires skills the client with dementia does not have (4) requires skills the client with dementia does not have