Nokea
An 8-year-old boy is brought to the physician’s office by his mother. The mother is concerned because the boy has a fever, vomited twice, and slept all day yesterday with the curtains closed. The boy complains of headache, nausea, and has a temperature of 103°F (39.3°C). The nurse observes the boy has a petechial rash on the trunk of his body. Which of the following assessments would be MOST important for the nurse to perform?
- A. Grasp the child’s hands and ask him to squeeze the nurse’s hands.
- B. Stroke the plantar surface of the child’s foot with a reflex hammer.
- C. Gently flex the child’s head and neck onto the chest.
- D. Have the child stand with his eyes closed, his arms at his sides, and his feet and knees close together.
Correct Answer: C
Rationale: Fever, headache, nausea, and petechial rash suggest meningitis; flexing the neck (Brudzinski’s sign) assesses meningeal irritation, a priority. Options A, B, and D are less relevant: hand squeeze is nonspecific, Babinski’s sign is not indicated, and Romberg’s sign assesses balance.
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The nurse is teaching a client with a new diagnosis of Parkinson’s disease about levodopa-carbidopa (Sinemet). Which of the following instructions should the nurse include?
- A. Take the medication with a high-protein meal
- B. Report any uncontrolled movements
- C. Stop the medication if symptoms improve
- D. Avoid regular neurological exams
Correct Answer: B
Rationale: Uncontrolled movements, such as dyskinesias, are a side effect of levodopa-carbidopa, requiring dose adjustment. Options A, C, and D are incorrect: high-protein meals reduce absorption, stopping the medication risks symptom return, and exams are essential.
The mother of an eight-month-old infant prepares to take her child home after treatment for bacterial meningitis. The mother confides to the nurse that she is afraid that her child will have brain damage as a result of his illness. Which of the following is the BEST response by the nurse?
- A. Trust your doctors. They are excellent pediatricians and will know what to look for.
- B. There is a 20% incidence of residual brain damage after this type of illness, but the odds are in your favor.
- C. It is an unlikely possibility, but if your child doesn't develop normally, your pediatrician will help you with any problems.
- D. You feel guilty about your son's illness, and that's understandable. You will feel better after you get home.
Correct Answer: C
Rationale: if treated early, good prognosis; may be complications and long-term effects (seizure disorders, hydrocephalus, impaired intelligence, visual and hearing defects), therapeutic response
The lab reports a lecithin/sphingomyelin (L/S) ratio of 3:1 for a client who has been on bedrest 48 hours in an unsuccessful attempt to arrest premature labor at 33-weeks gestation. Based on this result, the nurse would anticipate
- A. administration of ritodrine hydrochloride (Yutopar).
- B. initiation of an oxytocin (Pitocin) drip.
- C. delivery of the infant by cesarean section.
- D. continuation of bedrest until otherwise indicated.
Correct Answer: C
Rationale: because the lungs are adequately mature, there is no need to attempt to postpone labor; delivery by cesarean section is generally preferred for preterm infants
The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who is receiving oxygen at 2 L/min via nasal cannula. The client reports increased shortness of breath. Which of the following actions should the nurse take FIRST?
- A. Increase the oxygen flow to 4 L/min.
- B. Check the client's oxygen saturation.
- C. Place the client in a supine position.
- D. Administer a bronchodilator as ordered.
Correct Answer: B
Rationale: checking oxygen saturation provides objective data to assess the client's respiratory status
A client has a bovine graft inserted into the left arm for hemodialysis. During the immediate postoperative period, which of the following actions, if performed by the nurse, is BEST?
- A. Restart the IV above the level of the graft.
- B. Take blood pressures only on the right arm.
- C. Elevate the left arm above the level of the heart.
- D. Check the radial pulse on the left arm q 4h.
Correct Answer: B
Rationale: BP should always be taken on the opposite arm from the graft