Nokea
The HCP's progress note states that the infant with meningitis is in an opisthotonus position. What should the nurse observe when performing an assessment?
- A. Resistance with specific leg movement
- B. Knee or hip flexion with head flexion
- C. A high-pitched cry with neck flexion
- D. Hyperextension of the head and neck
Correct Answer: D
Rationale: Opisthotonus is characterized by severe hyperextension of the head and neck, often seen in meningitis.
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The nurse is caring for the client 24 hours following total hip arthroplasty using the traditional posterior approach. Which interventions should the nurse plan to implement? Select all that apply.
- A. Place pillows or a wedge pillow between the client's legs to keep them abducted.
- B. Have the client flex the unaffected hip and use the trapeze to help move up in bed.
- C. Raise the head of the bed to no more than 90 degrees when the bed is placed contour.
- D. Place a pillow between the client's knees when initially assisting the client out of bed.
- E. Applies antiembolism stockings that should not be removed for 24 hours postoperatively.
Correct Answer: A,B,D
Rationale: A. A pillow should be used to maintain abduction to prevent dislocation. B. Using the trapeze and flexing the unaffected legs while keeping the affected leg straight help prevent flexion with position changes. The client's hip should not be flexed more than 90 degrees. D. In initial transfers, a pillow is used to remind the client to maintain abduction and prevent internal and external hip rotation.
The nurse is concerned about the spinal curve in the young child and documents the exaggerated lumbar curve. Which condition was likely documented?
- A. Scoliosis
- B. Lordosis
- C. Kyphosis
- D. Kyphoscoliosis
Correct Answer: B
Rationale: Lordosis is characterized by an exaggerated lumbar curve.
How can the nurse best support the wet cast while the physician wraps the arm with rolls of wet plaster?
- A. By using a soft mattress
- B. By resting it on a firm surface
- C. By using the client's knee on the fingers
- D. By using the palms of the hands
Correct Answer: D
Rationale: Using the palms of the hands to support the wet cast prevents indentations that could cause pressure points, ensuring the cast maintains its shape. A soft mattress or fingers may deform the cast, and a firm surface is less precise.
Which level of participation should the nurse expect when assessing a 9-year-old who has mental retardation with an IQ level of 45?
- A. Able to communicate verbally only with two-letter words
- B. Able to read and comprehend simple written instructions
- C. Able to walk independently and perform a simple skill
- D. Able to perform tasks that require careful manual dexterity
Correct Answer: C
Rationale: An IQ of 45 indicates moderate intellectual disability, allowing independent walking and simple tasks.
Which assessment finding would the nurse consider a likely adverse effect of the client's methotrexate therapy?
- A. Constipation
- B. Dry mouth
- C. Mouth sores
- D. Chest pain
Correct Answer: C
Rationale: Mouth sores are a common side effect of methotrexate due to its effect on mucosal cells.