Nokea
An infant diagnosed with spina bifida cystica (meningomyelocele type) has had the sac surgically removed. The nurse plans which intervention in the postoperative period to maintain the infant's safety?
- A. Covering the back dressing with a binder
- B. Placing the infant in a head-down position
- C. Strapping the infant in a baby seat sitting up
- D. Elevating the head with the infant in the prone position
Correct Answer: D
Rationale: Spina bifida is a central nervous system defect that results from failure of the neural tube to close during embryonic development. Care of the operative site is carried out under the direction of the surgeon and includes close observation for signs of leakage of cerebrospinal fluid. The prone position is maintained after surgical closure to decrease the pressure on the surgical site on the back; however, many neurosurgeons allow side-lying or partial side-lying position unless it aggravates a coexisting hip dysplasia or permits undesirable hip flexion. Elevating the head will decrease the chance of cerebrospinal fluid collecting in the cranial cavity.
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The nurse creates a discharge plan for a client diagnosed with peripheral neuropathy of the lower extremities. Which instructions should the nurse include in the plan? Select all that apply.
- A. Wear support or elastic stockings.
- B. Wear well-fitted shoes and walk barefoot when at home.
- C. Wear dark-colored stockings or socks and change them daily.
- D. Use a heating pad set at low setting on the feet if they feel cold.
- E. Apply lanolin or lubricating lotion to the legs and feet once or twice daily.
- F. Wash the feet and legs with mild soap and water and rinse and dry them well.
Correct Answer: A,E,F
Rationale: Peripheral neuropathy is any functional or organic disorder of the peripheral nervous system. Clinical manifestations can include muscle weakness, stabbing pain, paresthesia or loss of sensation, impaired reflexes, and autonomic manifestations. Home care instructions include wearing support or elastic stockings for dependent edema, applying lanolin or lubricating lotion to the legs and feet once or twice daily, washing the feet and legs with mild soap and water and rinsing and drying them well, inspecting the legs and feet daily and reporting any skin changes or open areas to the primary health care provider.
A client has been admitted with a diagnosis of acute glomerulonephritis. During history taking, the nurse should ask the client about a recent history of which event?
- A. Bleeding ulcer
- B. Myocardial infarction
- C. Deep vein thrombosis
- D. Streptococcal infection
Correct Answer: D
Rationale: The predominant cause of acute glomerulonephritis is infection with beta-hemolytic Streptococcus 3 weeks before the onset of symptoms. In addition to bacteria, other infectious agents that could trigger the disorder include viruses, fungi, and parasites. Bleeding ulcer, myocardial infarction, and deep vein thrombosis are not precipitating causes.
A multidisciplinary team working with the spouse of a home care client who has end-stage liver failure is teaching the spouse about pain management. Which statement by the spouse indicates the need for further teaching?
- A. My husband can use breathing exercises to control pain.
- B. I will help prevent constipation with increased fluids.
- C. If the pain increases, I will report it to the nurse promptly.
- D. The medication causes very deep sleep that my husband needs.
Correct Answer: D
Rationale: In the client with liver disease, the ability to metabolize medication is affected. A decreased level of consciousness is a potential clinical indicator of medication overdose, as well as fluid, electrolyte, and oxygenation deficiencies; thus, the nurse teaches the client's spouse about the differences between sleep related to pain relief and a deteriorating change in neurological status. Options 1, 2, and 3 all indicate an understanding of suitable steps to be taken in pain management.
The nurse is assessing the respiratory status of the client after a thoracentesis has been performed. The nurse would become concerned with which assessment finding?
- A. Equal bilateral chest expansion
- B. Respiratory rate of 22 breaths per minute
- C. Diminished breath sounds on the affected side
- D. Few scattered wheezes, unchanged from baseline
Correct Answer: C
Rationale: After thoracentesis, the nurse assesses vital signs and breath sounds. The nurse especially notes increased respiratory rates, dyspnea, retractions, diminished breath sounds, or cyanosis, which could indicate pneumothorax. Any of these manifestations should be reported to the primary health care provider. Options 1 and 2 are normal findings. Option 4 indicates a finding that is unchanged from the baseline.
A client who has sustained a burn injury receives a prescription for a regular diet. Which is the best meal for the nurse to provide to the client to promote wound healing?
- A. Peanut butter and jelly sandwich, apple, tea
- B. Chicken breast, broccoli, strawberries, milk
- C. Veal chop, boiled potatoes, Jell-O, orange juice
- D. Pasta with tomato sauce, garlic bread, ginger ale
Correct Answer: B
Rationale: The meal with the best potential to promote wound healing includes nutrient-rich food choices, including protein, such as chicken and milk, and vitamin C, such as broccoli and strawberries. The remaining options include one or more items with a low nutritional value, especially the tea, jelly, Jell-O, and ginger ale.