Nokea
Appropriate nursing interventions for J.E. would be
- A. Skin care and position q2h and prn; maintain alignment of extremities; respiratory exercises
- B. Skin care/bathe daily; passive leg exercises daily; respiratory therapy for intermittent positive pressure breathing therapy
- C. Skin care and position q2h; teach use of overhead trapeze; respiratory exercises, and intermittent positive pressure breathing q2h
- D. Skin care q2h; teach use of overhead trapeze; respiratory exercises; use pressure relief devices Situation - Mr. Reyes suffered head injuries in a motor vehicle accident
Correct Answer: A
Rationale: For J.E., who suffered head injuries in a motor vehicle accident, appropriate nursing interventions should focus on holistic care to prevent complications and promote recovery. Option A includes skin care and position changes every 2 hours (q2h) and as needed, which is crucial for preventing pressure injuries in the immobile patient. Maintaining alignment of extremities helps prevent muscle contractures. Respiratory exercises are essential for preventing atelectasis and improving lung function in patients at risk for pneumonia due to decreased mobility. These interventions address the immediate needs of the patient and aim to prevent further complications related to immobility and head injury. Options B, C, and D lack the comprehensive approach to care provided in option A, making it the most appropriate choice for J.E.
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Nurse Dorothy is caring for a child with Cushing's syndrome; which of the following should she include in the plan of care?
- A. Increase fluids to prevent dehydration
- B. Encourage a diet high in carbohydrates
- C. Monitor weight each day and report for weight loss
- D. Encourage a diet high in potassium
Correct Answer: C
Rationale: When caring for a child with Cushing's syndrome, it is important to monitor weight each day and report any weight loss. Cushing's syndrome is characterized by a metabolic disorder that can lead to weight gain, particularly in the abdominal area. However, sudden weight loss in a child with Cushing's syndrome can be a sign of worsening condition or inadequate treatment. Therefore, monitoring weight regularly is crucial in managing the child's condition and adjusting the treatment plan accordingly.
Which is the most commonly used method in completed suicides?
- A. Firearms
- B. Drug overdose
- C. Self-inflected laceration
- D. Carbon monoxide poisoning
Correct Answer: A
Rationale: Firearms are the most commonly used method in completed suicides, accounting for nearly 50% of all suicide deaths in the United States. Firearms are particularly lethal and result in a higher success rate compared to other methods. The quick and irreversible nature of firearm suicides contributes to their high prevalence. Additionally, the easy access to firearms in many households increases the likelihood of their use in suicide attempts.
In neuroblastoma, metastatic spread can occur via local invasion or distant hematogenous/lymphatic routes. The LEAST common site of metastases in neuroblastoma is
- A. long bone
- B. bone marrow
- C. lung
- D. skin
Correct Answer: D
Rationale: Skin metastases are rare in neuroblastoma compared to bone, bone marrow, and lung involvement.
A client has the following blood lab values: platelets 50,000/ul, RBC's 3.5 (X 106), hemoglobin 10 g/dl, hematocrit 30 percent, WBCs 10,000/ul. Which nursing instruction should be included in the teaching plan?
- A. Bleeding precautions
- B. Isolation to prevent infection
- C. Seizure precautions
- D. Control of pain with analgesics
Correct Answer: A
Rationale: The client's platelet count of 50,000/ul is significantly low (normal range is around 150,000-450,000/ul). A low platelet count places the client at risk for bleeding tendencies. Therefore, the most appropriate nursing instruction to include in the teaching plan is bleeding precautions. This would involve educating the client on measures to prevent bleeding such as avoiding activities that may cause injury, using a soft toothbrush, avoiding tight clothing, and being cautious while shaving.
A parent reports to the nurse that her child has inflamed conjunctivae of both eyes with purulent drainage and crusting of the eyelids, especially on awakening. These manifestations suggest:
- A. viral conjunctivitis.
- B. allergic conjunctivitis.
- C. bacterial conjunctivitis.
- D. conjunctivitis caused by foreign body.
Correct Answer: C
Rationale: The symptoms described by the parent, which include inflamed conjunctivae of both eyes with purulent drainage and crusting of the eyelids, are indicative of bacterial conjunctivitis. Bacterial conjunctivitis is typically associated with these symptoms, along with redness, irritation, and a sensation of a foreign body in the eye. It is common for bacterial conjunctivitis symptoms to be most pronounced upon awakening due to the accumulation of discharge overnight. Treatment for bacterial conjunctivitis often involves antibiotic eye drops.