How often should the casts be changed for a newborn with talipes who is wearing casts?
- A. Daily
- B. Weekly
- C. Biweekly
- D. Monthly
Correct Answer: B
Rationale: The correct answer is B: Weekly. Treatment of talipes involves manipulation and applying short leg casts. The casts need to be changed weekly to allow for further manipulation and to accommodate the rapid growth of the infant. Changing the casts daily (choice A) would be too frequent and may not provide enough time for the correction to take place. Changing the casts biweekly (choice C) or monthly (choice D) would not provide adequate support for the ongoing correction process required for talipes.
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The nurse is caring for a child who has been diagnosed with attention deficit hyperactivity disorder (ADHD). What is the most important intervention for the nurse?
- A. Help the child enroll in a special education class.
- B. Allay any feelings of guilt the parents may have.
- C. Explain to the parents that medications are lifelong.
- D. Teach the parents how to set limits.
Correct Answer: B
Rationale: The most important intervention for the nurse in caring for a child with ADHD is to allay any feelings of guilt the parents may have. Parents of children with ADHD often experience guilt or self-blame, thinking they are responsible for their child's condition. By addressing and alleviating these feelings, the nurse can support the parents in a crucial way. Choice A is not the most important intervention because enrolling the child in a special education class might be a consideration but does not address the emotional needs of the parents. Choice C is incorrect because stating that medications are lifelong may cause unnecessary distress to the parents. Choice D is also not the most important intervention as setting limits is important but not as critical as addressing parental guilt and emotions.
During a home visit, the nurse assesses the skin of a client with eczema who reports that an exacerbation of symptoms has occurred during the last week. Which information is most useful in determining the possible cause of the symptoms?
- A. An old friend with eczema came for a visit.
- B. Recently received an influenza immunization.
- C. A grandson and his new dog recently visited.
- D. Corticosteroid cream was applied to eczema.
Correct Answer: C
Rationale: The correct answer is C. Contact with the grandson's new dog could have introduced new allergens or irritants, exacerbating the eczema symptoms. Choice A is unrelated to the exacerbation of symptoms. Choice B, receiving an influenza immunization, is unlikely to directly cause an exacerbation of eczema symptoms. Choice D, applying corticosteroid cream, is a common treatment for eczema and would not likely be the cause of the exacerbation.
A client with Cushing's Syndrome is recovering from an elective laparoscopic procedure. Which assessment finding warrants immediate intervention by the nurse?
- A. Irregular apical pulse
- B. Purple marks on the skin of the abdomen
- C. Quarter-sized blood spot on the dressing
- D. Pitting ankle edema
Correct Answer: A
Rationale: The correct answer is A: Irregular apical pulse. In a client recovering from a laparoscopic procedure with Cushing's Syndrome, an irregular apical pulse can be indicative of a life-threatening arrhythmia and requires immediate intervention. Choices B, C, and D are not as urgent as an irregular apical pulse. Purple marks on the skin of the abdomen may be related to Cushing's Syndrome, a quarter-sized blood spot on the dressing can be managed with appropriate wound care, and pitting ankle edema may be expected postoperatively but does not require immediate intervention.
The healthcare provider is assessing a client with a chest tube. Which finding indicates that the chest tube is functioning properly?
- A. Continuous bubbling in the water seal chamber
- B. Tidaling in the water seal chamber
- C. Absence of drainage in the collection chamber
- D. Fluid level in the suction control chamber is below the prescribed level
Correct Answer: B
Rationale: Tidaling in the water seal chamber indicates proper chest tube function. Tidaling refers to the rise and fall of fluid in the water seal with inhalation and exhalation, demonstrating the patency of the system. Continuous bubbling (Choice A) in the water seal chamber indicates an air leak. Absence of drainage in the collection chamber (Choice C) is not a desired finding as it suggests no drainage is occurring. A fluid level below the prescribed level in the suction control chamber (Choice D) may indicate inadequate suction.
A client with a history of chronic pain requests a nonopioid analgesic. The client is alert but has difficulty describing the exact nature and location of the pain to the nurse. What action should the nurse implement next?
- A. Administer the analgesic as requested.
- B. Request a pain assessment from another nurse.
- C. Ask the client to describe the pain more precisely.
- D. Delay administration until the pain is better described.
Correct Answer: D
Rationale: The correct action for the nurse to implement next is to delay administration until the pain is better described. It is essential to have a clear understanding of the nature and location of the pain before administering any analgesic to ensure appropriate and effective pain management. Requesting a pain assessment from another nurse or asking the client to describe the pain more precisely would also be appropriate actions to obtain more information before administering the analgesic. Administering the analgesic as requested without a clear description of the pain may not address the client's needs effectively and could potentially lead to ineffective pain management.
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