Nokea
In providing care to a 14 year-old adolescent with scoliosis, which of the following will be most difficult for this client?
- A. Compliance with treatment regimens
- B. Looking different from their peers
- C. Lacking independence in activities
- D. Reliance on family for their social support
Correct Answer: B
Rationale: Looking different from their peers. Conformity is critical at age 14, and visible differences due to scoliosis treatment can be challenging.
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The nurse and a student nurse are discussing the specific points about infants born to HBsAg-positive mothers. Which of these comments by the student indicates a need for clarification of information?
- A. The infant will get the hepatitis B vaccine and the hepatitis B immune globulin within 12 hours at birth at separate injection sites.
- B. The second dose can be given at 1 to 2 months of age.
- C. The third dose should be given at least 16 weeks from the second dose.
- D. The last dose in the series is not to be given before age 24 weeks.
Correct Answer: C
Rationale: The third dose should be given at least 16 weeks from the first dose and 8 weeks from the second dose. All of the other options are correct information.
The nurse performs an assessment of an 8-year-old girl diagnosed with scoliosis.
- A. Which observation is expected in an 8-year-old girl with scoliosis?
- B. The girl’s thoracic area is asymmetrical.
- C. The girl walks with a waddling gait.
- D. The girl’s lower legs are edematous.
- E. The girl has a protruding sternum.
Correct Answer: A
Rationale: Scoliosis causes lateral spinal curvature, leading to thoracic asymmetry. Waddling gait is associated with hip issues, edema with circulatory problems, and a protruding sternum with pectus carinatum, none of which are typical of scoliosis.
A client with a necrotizing spider bite is to perform his own dressing changes at home.
The nurse is aware that which of the following statements, if made by the client, indicates a correct understanding of aseptic technique?
- A. I need to buy sterile gloves to redress this wound.'
- B. I should wash my hands before redressing my wound.'
- C. I should keep the wound covered at all times.'
- D. I should use an over-the-counter antimicrobial ointment.'
Correct Answer: B
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) not most important (2) correct-indicates understanding of asepsis, whose hallmark is handwashing (3) is not possible to carry out (4) should use only the prescribed medications on the wound
A client is receiving a nitroglycerin infusion for unstable angina. What assessment would be a priority when monitoring the effects of this medication?
- A. Blood pressure
- B. Cardiac enzymes
- C. ECG analysis
- D. Respiratory rate
Correct Answer: A
Rationale: Since an effect of this drug is vasodilation, the client must be monitored for hypotension.
In planning care for a 6 month-old infant, what must the nurse provide to assist in the development of trust?
- A. Food
- B. Warmth
- C. Security
- D. Comfort
Correct Answer: C
Rationale: Security. Providing consistent, loving care fosters trust, a key developmental need for infants per Erikson's theory.