Nokea
The child with an SCI is prescribed baclofen 5 mg tid orally to treat muscle spasticity. How many tablets should the nurse administer for one dose if 20-mg tablets are available?
Correct Answer: 0.25
Rationale: 5 mg divided by 20 mg per tablet equals 0.25 tablets per dose.
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When preparing to meet with the parents and their 5-year-old child with autism, which behaviors should the nurse anticipate that the child might display?
- A. Polydactyly
- B. Leukoderma
- C. Poor eye contact
- D. Restricted interests
- E. Atypical language
Correct Answer: C,D,E
Rationale: Children with autism often exhibit poor eye contact, restricted interests, and atypical language patterns.
Which nursing assessment finding is the best indication that the client has an infection at the pin site?
- A. Serous drainage at the pin site
- B. Bloody drainage at the pin site
- C. Mucoid drainage at the pin site
- D. Purulent drainage at the pin site
Correct Answer: D
Rationale: Purulent (pus-like) drainage is the clearest sign of infection at the pin site, indicating bacterial presence. Serous, bloody, or mucoid drainage is less specific to infection.
Which of the following evening snacks would the nurse encourage for the client with immobility due to the fractured hip?
- A. An orange
- B. Rice cakes
- C. Peanut butter and celery
- D. Potato chips
Correct Answer: C
Rationale: Peanut butter and celery provide protein and healthy fats, supporting tissue repair and nutrition during immobility. Oranges offer vitamin C but less protein, while rice cakes and potato chips lack substantial nutritional value.
The 84-year-old client is a resident in a long-term care facility. Which intervention should be implemented to help prevent complications secondary to osteoporosis?
- A. Keep the bed in the high position.
- B. Perform passive range-of-motion exercises.
- C. Turn the client every two (2) hours.
- D. Provide nighttime lights in the room.
Correct Answer: D
Rationale: Nighttime lights reduce fall risk, a major osteoporosis complication causing fractures. High beds increase fall risk, ROM does not prevent falls, and turning addresses skin integrity, not fractures.
If the client is typical of others with a herniated disk, the nurse would expect the client to report which additional symptom?
- A. Pain radiating into the buttocks and leg
- B. Tenderness over one or both iliac crests
- C. Diminished sensation in one or both knees
- D. Brief periods when the toes feel quite cold
Correct Answer: A
Rationale: A herniated lumbar disk commonly causes sciatica, with pain radiating into the buttocks and leg due to nerve root compression. Other symptoms are less typical or specific.