Proper positioning for the child who is in Bryant's traction is:
- A. Both hips flexed at a 90-degree angle with the knees extended and the buttocks elevated off the bed
- B. Both legs extended, and the hips are not flexed
- C. The affected leg extended with slight hip flexion
- D. Both hips and knees maintained at a 90-degree flexion angle, and the back flat on the bed
Correct Answer: A
Rationale: The child's weight supplies the countertraction for Bryant's traction; the buttocks are slightly elevated off the bed, and the hips are flexed at a 90-degree angle. Both legs are suspended by skin traction. The child in Buck's extension traction maintains the legs extended and parallel to the bed. The child in Russell traction maintains hip flexion of the affected leg at the prescribed angle with the leg extended. The child in '90-90' traction maintains both hips and knees at a 90-degree flexion angle and the back is flat on the bed.
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Which of the following is an adverse effect associated with the use of Adriamycin (doxorubicin)?
- A. Ventricular arrhythmias
- B. Alopecia
- C. Leukopenia
- D. Stomatitis
Correct Answer: B
Rationale: Alopecia (hair loss) is a common adverse effect of doxorubicin, a chemotherapeutic agent, due to its impact on rapidly dividing cells, including hair follicles.
The client is admitted with a diagnosis of acute diverticulitis. Which dietary order should the nurse anticipate?
- A. High-fiber diet
- B. Low-residue diet
- C. Clear liquid diet
- D. Regular diet
Correct Answer: C
Rationale: A clear liquid diet is ordered during acute diverticulitis to rest the bowel and reduce irritation. High-fiber is for prevention, low-residue is for chronic management, and regular diets are inappropriate.
Which of the following risk factors associated with breast cancer would a nurse consider most significant in a client's history?
- A. Menarche after age 13
- B. Nulliparity
- C. Maternal family history of breast cancer
- D. Early menopause
Correct Answer: C
Rationale: Women who begin menarche late (after 13 years old) have a lower risk of developing breast cancer than women who have begun earlier. Average age for menarche is 12.5 years. Women who have never been pregnant have an increased risk for breast cancer, but a positive family history poses an even greater risk. A positive family history puts a woman at an increased risk of developing breast cancer. It is recommended that mammography screening begin 5 years before the age at which an immediate female relative was diagnosed with breast cancer. Early menopause decreases the risk of developing breast cancer.
A client with BPH has undergone a TURP. Which nursing interventions are parts of the client's post-operative care?
- A. Monitoring the client's vital signs
- B. Maintaining constant bladder irrigation
- C. Limiting fluid intake to 1000 mL per day
- D. Checking for post-operative bleeding
- E. Maintaining bed rest for 48 hours
Correct Answer: A, B, D
Rationale: Post-TURP care includes monitoring vital signs (A), constant bladder irrigation (B) to prevent clots, and checking for bleeding (D). Fluid intake is encouraged (C), and bed rest is typically 24 hours (E).
A 40-year-old client is admitted to the hospital for tests to diagnose cancer. Since his admission, he has become dependent and demanding to the nursing staff. The nurse identifies this behavior as which defense mechanism?
- A. Denial
- B. Displacement
- C. Regression
- D. Projection
Correct Answer: C
Rationale: Regression involves reverting to an earlier developmental stage, such as dependency, in response to stress like a cancer diagnosis.
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