Nokea
Nursing care for a patient who is experiencing a convulsive seizure includes all of the following except:
- A. Loosening constrictive clothing
- B. Opening the patient's jaw and inserting a mouth gag
- C. Positioning the patient on his or her side with head flexed forward
- D. Providing for privacy
Correct Answer: B
Rationale: Opening the patient's jaw and inserting a mouth gag is not part of the appropriate nursing care for a patient experiencing a convulsive seizure. Doing so can potentially harm the patient by causing injury to the teeth, jaw, or airway. It is important to protect the patient's airway during a seizure, but this can be done by positioning the patient on their side with the head flexed forward, ensuring a clear airway without the need for a mouth gag.
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Tretinoin (Retin-A) is a topical agent commonly used to treat acne. Nursing considerations with this drug should include:
- A. teaching to avoid use of sunscreen agents.
- B. applying generously to the skin.
- C. explaining that medication should not be applied until at least 20 to 30 minutes after washing.
- D. explaining that erythema and peeling are indications of toxicity.
Correct Answer: C
Rationale: Nursing considerations with Tretinoin (Retin-A) should include explaining that the medication should not be applied until at least 20 to 30 minutes after washing. This wait time allows the skin to fully dry and reduces the risk of irritation. Applying the medication too soon after washing can increase the likelihood of skin irritation, dryness, and peeling. It is essential to follow this guideline to ensure the effectiveness of the treatment and minimize adverse effects on the skin.
Autism screening is recommended for all children at age of
- A. 12 to 18 months
- B. 18 to 24 months
- C. 24 to 36 months
- D. 36 to 48 months
Correct Answer: B
Rationale: Autism screening is recommended between 18 and 24 months.
Which of the ff. nursing actions prepares a patient for a lumbar puncture?
- A. Administering enemas until clear
- B. Positioning the patient on his or her side
- C. Removing all metal jewelry
- D. Removing the patient's dentures
Correct Answer: B
Rationale: Positioning the patient on their side is a critical nursing action that prepares a patient for a lumbar puncture. This position is usually used during the procedure to allow easier access to the lumbar region. Placing the patient on their side helps provide better visualization of the spinal landmarks and facilitates the correct positioning of the needle for the lumbar puncture. This position also helps minimize the risk of complications and ensures the safety and comfort of the patient during the procedure. Administering enemas until clear, removing all metal jewelry, and removing the patient's dentures are not specifically associated with preparing a patient for a lumbar puncture.
For a 14-month-old whose cleft palate was repaired 12 hours ago, which should be included in the plan of care?
- A. Allow familiar comfort items (e.g., favorite stuffed animal) and a 'sippy' cup (avoid suction items).
- B. Once liquids are tolerated, encourage a bland diet (e.g., soup, Jell-O, saltine crackers).
- C. Administer scheduled pain medication rather than PRN only.
- D. Use a Yankauer suction catheter to decrease aspiration risk.
Correct Answer: A
Rationale: Providing comfort items and avoiding suction items helps reduce distress and supports healing.
Which of the ff is the most important factor in the nursing management of clients who undergo treatment for a malignant tumor ff the urinary diversion procedure?
- A. Placement of IV and central venous pressure lines
- B. Administrating cleansing enemas
- C. Observing for leakage of urine or stool from the anastomosis
- D. Assessing the clients ability to manage self catheterization
Correct Answer: C
Rationale: When a client undergoes treatment for a malignant tumor requiring a urinary diversion procedure, such as a urostomy, it is crucial for nurses to closely monitor for any signs of leakage of urine or stool from the anastomosis site. This is important because it can indicate complications such as infection, poor wound healing, or a breakdown in the surgical site. Detecting and addressing leakage promptly can help prevent further complications and ensure the client's recovery progresses smoothly. While the other options may be important aspects of nursing care, observing for leakage of urine or stool from the anastomosis is the most critical factor in managing clients undergoing treatment for a malignant tumor affecting the urinary system.