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Sunshine, age 13, has had a lumbar puncture to examine the CSF to determine if bacterial infection exists. The best position to keep her in after the procedure is:
- A. Prone for two hours to prevent aspiration, should she vomit.
- B. Semi-Fowler's so she can watch TV for five hours and be entertained.
- C. Supine for several hours, to prevent a headache.
- D. On her right sides to encourage return of CSF
Correct Answer: C
Rationale: The best position to keep Sunshine in after a lumbar puncture is in the supine position for several hours. This position helps prevent a post-lumbar puncture headache, which is a common complication of the procedure. Keeping Sunshine supine helps reduce the chances of leaking CSF and minimizes the risk of developing a headache due to decreased CSF pressure. Additionally, it is vital to encourage increased fluid intake post-procedure to help replenish the lost CSF and prevent dehydration.
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Which of the ff. is a symptom that the nurse would expect to find during assessment of a patient experiencing acute angle-closure glaucoma?
- A. Flashing lights
- B. Lens opacity
- C. Halos around lights A1 PASSERS TRAINING, RESEARCH, REVIEW & DEVELOPMENT COMPANY MEDICAL SURGICAL NURSING SET N
Correct Answer: C
Rationale: Halos around lights are a common symptom observed in patients experiencing acute angle-closure glaucoma. This occurs due to the increased intraocular pressure causing corneal edema, which leads to light scattering and the appearance of halos. Other symptoms may include severe eye pain, redness in the eye, decreased vision, and headache. It is important for the nurse to recognize these symptoms promptly as acute angle-closure glaucoma is a medical emergency that requires immediate treatment to prevent permanent vision loss.
Which of the following diets would the nurse include in the plan of care for a person with AIDS?
- A. A high-protein, high-calorie diet divided into six small meals.
- B. A low-fat, soft diet divided into 8 small meals.
- C. A high-carbohydrate, fat-restricted diet divided into 4 meals.
- D. A high-fat, high-calorie diet divided into 3 meals.
Correct Answer: A
Rationale: People with AIDS often experience weight loss and malnutrition due to the disease's impact on the immune system. A high-protein, high-calorie diet can help support the immune system and maintain or improve weight. Dividing the meals into six servings can help with better absorption of nutrients and provide a steady source of energy throughout the day. This type of diet can also help manage symptoms and side effects of the disease and its treatments, such as maintaining muscle mass, managing nausea, and supporting overall health.
The physical abuse of children by parents affects children of all ages. It is estimated that 1% to 2% of children are physically abused during childhood and that significant number of them are fatally injured each year. Of the following, the second LEADING cause of mortality from physical abuse is
- A. rib fractures
- B. head trauma
- C. abdominal injury
- D. hot tap water burn
Correct Answer: B
Rationale: Head trauma is a leading cause of mortality in abused children, as it can result in severe brain damage or death.
A nurse is assessing a preterm newborn for the possibility of necrotizing enterocolitis (NEC). Which assessment findings should the nurse expect to find if NEC is confirmed? (Select all that apply.)
- A. Minimal gastric residual
- B. Abdominal distention
- C. Apnea
- D. Urinary output at 2 ml/kg/hr
Correct Answer: B
Rationale: Abdominal distention: NEC is characterized by abdominal distention due to gas and fluid accumulation in the intestines, leading to a bloated appearance of the abdomen.
One nursing diagnosis for JRA is impaired physical mobility. Select all nursing interventions that apply.
- A. Give pain medication prior to ambulation.
- B. Assist with range-of-motion activities.
- C. Encourage the child to eat a high-fat diet.
- D. Provide oxygen as necessary.
Correct Answer: A
Rationale: Giving pain medication prior to ambulation can help alleviate discomfort and improve the child's ability to perform physical activities, thus promoting mobility.