Nokea
In teaching parents to associate prevention with the lifestyle of their child with sickle cell disease, the nurse should emphasize that a priority for their child is to
- A. Avoid overheating during physical activities
- B. Maintain normal activity with some restrictions
- C. Be cautious of others with viruses or temperatures
- D. Maintain routine immunizations
Correct Answer: A
Rationale: Avoid overheating during physical activities. Dehydration from overheating can trigger a sickle cell crisis.
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The nurse is caring for a client who is to be on bed rest for two weeks. What should the nurse do to prevent atelectasis?
- A. Encourage the client to deep breathe and cough every two hours
- B. Encourage the client to flex and extend her feet every two hours
- C. Apply antiembolism stockings as ordered
- D. Perform range-of-motion exercises several times a day
Correct Answer: A
Rationale: Deep breathing and coughing expand the lungs, preventing atelectasis in bedridden clients. Foot exercises, stockings, and ROM prevent other complications but not atelectasis.
A 3 year-old had a hip spica cast applied two hours ago. In order to facilitate drying, the nurse should
- A. Expose the cast to air and turn the child frequently
- B. Use a heat lamp to reduce the drying time
- C. Handle the cast with the abductor bar
- D. Turn the child as little as possible
Correct Answer: A
Rationale: Expose the cast to air and turn the child frequently. The child should be turned every two hours, with the cast's surface exposed to the air.
Which of the following infants is in need of additional growth assessment?
- A. Baby girl A: age 4 months, BW 7 lbs. 6 oz., present weight 14 lbs. 14 oz.
- B. Baby girl B: age 2 weeks, BW 6 lbs. 10 oz., present weight 6 lbs. 11 oz.
- C. Baby girl C: age 6 months, BW 8 lbs. 9 oz., present weight 15 lbs. 0 oz.
- D. Baby girl D: age 2 months, BW 7 lbs. 2 oz., present weight 9 lbs. 10 oz.
Correct Answer: B
Rationale: Baby B has gained only 1 oz. in 2 weeks, indicating poor growth (normal is 0.5-1 oz./day). Others show appropriate weight gain.
A client with paralysis from a cerebrovascular accident (CVA).
Which of the following is a priority nursing goal in the plan of care for a client with paralysis from a cerebrovascular accident (CVA)?
- A. Maintain adduction of the affected shoulder.
- B. Prevent flexion of the affected extremities.
- C. Observe active range of motion (ROM) daily to all extremities.
- D. Maintain external rotation of the affected hip.
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) to prevent deformities, the nurse needs to prevent adduction of the affected shoulder (2) correct-flexor muscles are stronger than extensor muscles (3) client will be unable to perform active ROM, will need assistance from nurse (4) to prevent deformities, the nurse needs to prevent external rotation of the hip joint, prevent foot drop (plantar flexion), and place the hand in slight supination so that the fingers are barely flexed
While explaining an illness to a 10 year-old, what should the nurse keep in mind about the cognitive development at this age?
- A. They are able to make simple association of ideas
- B. They are able to think logically in organizing facts
- C. Interpretation of events originate from their own perspective
- D. Conclusions are based on previous experiences
Correct Answer: B
Rationale: They are able to think logically in organizing facts. The child in the concrete operations stage is capable of mature thought when organizing objects.