Nokea
During a physical exam on the 18-month-old, the nurse observes genu varum. What should the nurse do?
- A. Document the finding as normal
- B. Report this finding to the HCP
- C. Teach the parents about rickets
- D. Prepare the parent about using braces
Correct Answer: A
Rationale: Genu varum (bowlegs) is a normal finding in children up to 2 years old and should be documented as normal.
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Which information should the nurse teach the client regarding sports injuries?
- A. Apply heat intermittently for the first 48 hours.
- B. An injury is not serious if the extremity can be moved.
- C. Only return to the health-care provider if the foot becomes cold.
- D. Keep the injury immobilized and elevated for 24 to 48 hours.
Correct Answer: D
Rationale: Immobilization and elevation reduce swelling in sports injuries. Heat worsens swelling, movement does not rule out severity, and cold feet are a late sign.
What is the expected Glasgow Coma Scale score for a child with a mild head injury?
- A. A score of 0 is not possible on the Glasgow Coma Scale. The lowest possible score is 3.
- B. A score of 3 on the Glasgow Coma Scale indicates that the child has an absent eye opening, verbal, and motor response. This score is not expected with a mild head injury.
- C. A score of 10 on the Glasgow Coma Scale indicates an altered eye opening, verbal, or motor response and would not be expected with a mild head injury.
- D. Glasgow Coma Scale scores range from 3 (no response) to 15 (normal response). A score of 15 indicates that brain function is intact. A child with a mild head injury should have intact neurological function.
Correct Answer: D
Rationale: A score of 15 on the Glasgow Coma Scale indicates intact neurological function, expected in a mild head injury.
After the client's total hip replacement surgery, which nursing actions are essential? Select all that apply.
- A. Keeping the client's knees apart at all times
- B. Avoiding flexing the client's hips more than 90 degrees
- C. Having the client use a raised toilet seat
- D. Raising the head of the client's bed 90 degrees
- E. Placing two pillows beneath the client's knees
- F. Keeping the client's legs internally rotated
Correct Answer: A,B,C
Rationale: To prevent dislocation after total hip replacement, keep knees apart (using an abductor pillow), avoid hip flexion beyond 90 degrees, and use a raised toilet seat to maintain safe hip angles. Raising the bed 90 degrees or placing pillows under knees risks dislocation, and internal rotation is contraindicated.
A cast has just been applied to a client's left forearm, and he has 10 lbs of Russell's traction on his left leg. Which of the following nursing concerns takes priority in the care of this client?
- A. The casted extremity may swell, and the cast will become a tourniquet.
- B. Heat conduction from the wet cast can cause burning to the skin below.
- C. Muscle atrophy of the areas involved can lead to decreased muscle tone.
- D. Skin irritation from the cast edges can cause abrasions.
Correct Answer: A
Rationale: Swelling in a newly casted extremity can cause the cast to act as a tourniquet, compromising circulation, which is the priority concern. Heat from a wet cast does not burn skin, muscle atrophy is a long-term issue, and skin irritation is less urgent.
Which statement indicates that the client understands the restrictions to be followed?
- A. I should avoid pointing my toes.
- B. I shouldn't cross my legs.
- C. I shouldn't lie flat in bed.
- D. I shouldn't stand upright.
Correct Answer: B
Rationale: Crossing legs can dislocate the hip prosthesis.