Nokea
During the active phase of rheumatic fever, the nurse teaches parents of a child with acute rheumatic fever to assist in minimizing joint pain and promoting healing by:
- A. Putting all joints through full range-of-motion twice daily
- B. Massaging the joints briskly with lotion or liniment after bath
- C. Immobilizing the joints in functional position using splints, rolls, and pillows
- D. Applying warm water bottle or heating pads over involved joints
Correct Answer: C
Rationale: Any movement of the joint causes severe pain. Touching or moving the joint causes severe pain. Immobilization in a functional position allows the joint to rest and heal. Pressure from the warm water bottle or pads can cause severe pain or burning of the skin.
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The nurse is caring for a client with B-thalassemia major. Which therapy is used to treat B-thalassemia major?
- A. IV fluids
- B. Frequent blood transfusions
- C. Oxygen therapy
- D. Iron therapy
Correct Answer: B
Rationale: B-thalassemia major causes severe anemia due to defective hemoglobin synthesis, requiring frequent blood transfusions to maintain hemoglobin levels. IV fluids, oxygen, and iron therapy (which can cause overload) are not primary treatments.
Which of the following describes a positive Kernig's sign?
- A. Pain on flexion of the hip and knee
- B. Nuchal rigidity on flexion of the neck
- C. Pain when the head is turned to the left side
- D. Dizziness when changing positions
Correct Answer: A
Rationale: A positive Kernig’s sign is pain or resistance when flexing the hip and extending the knee often indicating meningeal irritation (e.g. meningitis). The other options describe different symptoms or signs unrelated to Kernig’s.
A 17-year-old client has a T-4 spinal cord injury. At present, he is learning to catheterize himself. When he says, 'This is too much trouble. I would rather just have a Foley.' An appropriate response for the RN teaching him would be:
- A. I know. It is a lot to learn. In the long run, though, you will be able to reduce infections if you do an intermittent catheterization program.
- B. It is not too much trouble. This is the best way to manage urination.
- C. OK. I'll ask your physician if we can replace the Foley.
- D. You need to learn this because your doctor ordered it.
Correct Answer: A
Rationale: This response validates the client's feelings, provides education on reduced infection risk with intermittent catheterization, and encourages autonomy.
A 27-year-old healthy primigravida is brought to the labor and birthing room by her husband at 32 weeks' gestation. She experienced a sudden onset of painless vaginal bleeding. Following an ultrasound examination, the diagnosis of bleeding secondary to complete placenta previa is made. Expected assessment findings concerning the abdomen would include:
- A. A rigid, boardlike abdomen
- B. Uterine atony
- C. A soft relaxed abdomen
- D. Hypertonicity of the uterus
Correct Answer: C
Rationale: A rigid, boardlike abdomen is an assessment finding indicative of placenta abruptio. A cause of postbirth hemorrhage is uterine atony. With placenta previa, uterine tone is within normal range. The placenta is located directly over the cervical os in complete previa. Blood will escape through the os, resulting in the uterus and abdomen remaining soft and relaxed. In placenta abruptio, hypertonicity of the uterus is caused by the entrapment of blood between the placenta and uterine wall, a retroplacental bleed. This does not exist in placenta previa.
A 70-year-old homeless woman is admitted with pneumonia. She is weak, emaciated, and febrile. The physician orders enteral feedings intermittently by nasogastric tube. When inserting the nasogastric tube, once the tube passes through the oropharynx, the nurse will instruct the client to:
- A. Tilt her head backwards
- B. Swallow as tube passes
- C. Hold breath as tube passes
- D. Cough as tube passes
Correct Answer: B
Rationale: Swallowing assists with insertion of tube and closes off airway.