Nokea
An adolescent sustains a T3 spinal cord injury. After insertion of an intravenous line, a nasogastric tube, and an indwelling urinary (Foley) catheter, the adolescent is admitted to the intensive care unit. What should the nurse do next when assessment reveals that the adolescent's feet and legs are cool to the touch?
- A. Cover the adolescent's legs with blankets.
- B. Report this finding to the physician immediately.
- C. Reposition the adolescent's legs.
- D. Lay the adolescent flat to aid circulation.
Correct Answer: A
Rationale: Cool extremities indicate poor circulation, common in spinal cord injury; covering with blankets promotes warmth and comfort.
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The nurse is teaching the parents of an 8-month-old about what the child should be eating. The nurse should include which of the following points in the teaching plan?
- A. Items from all four food groups should be introduced to the infant by the time the child is 10 months old.
- B. Solid foods should not be introduced until the infant is 10 months old.
- C. Iron deficiency rarely develops before 12 months of age, so iron-fortified cereals should not be introduced until the infant is 12 months old.
- D. The infant's diet can be changed from formula to whole milk when the infant is 12 months old.
Correct Answer: D
Rationale: Whole milk can be introduced at 12 months, as infants need the fat content for brain development.
To assess a 9-year-old's social development, the nurse asks the parent if the child:
- A. Thinks independently.
- B. Is able to organize and plan.
- C. Has a best friend.
- D. Enjoys active play.
Correct Answer: C
Rationale: Having a best friend indicates healthy social development at 9 years.
The nurse is teaching an adolescent with asthma how to use an inhaler. In which order should the nurse instruct the client to follow the steps from first to last?
- A. Inhale through an open mouth.
- B. Breathe out through the mouth.
- C. Hold the breath for 5 to 10 seconds.
- D. Press the canister to release the medication.
Correct Answer: B,D,A,C
Rationale: Exhale, press canister, inhale, and hold breath ensures proper medication delivery.
After teaching the mother of a young child with a peritoneal catheter about the signs and symptoms of peritonitis, the nurse determines that the mother has understood the teaching when she identifies which of the following as an important sign?
- A. Cloudy dialysate drainage return.
- B. Distended abdomen.
- C. Shortness of breath.
- D. Weight gain of 3 lb in 2 days.
Correct Answer: A
Rationale: Cloudy drainage indicates infection.
The parents of a neonate with hypospadias and chordee wish to have him circumcised. Which of the following explanations should the nurse incorporate into the discussion with the parents concerning the recommendation to delay circumcision?
- A. The associated chordee is difficult to remove during circumcision.
- B. The foreskin is used to repair the deformity surgically.
- C. The meatus can become stenosed, leading to urinary obstruction.
- D. The infant is too small to have a circumcision.
Correct Answer: B
Rationale: The foreskin is needed for surgical repair.