Nokea
The nurse correctly advises the adolescent that the brace has to be worn during which time period?
- A. At all times except when bathing
- B. At least 8 hours each day
- C. At night while sleeping
- D. At all times, without exception
Correct Answer: A
Rationale: The Milwaukee brace is typically worn 23 hours a day, except during bathing, to effectively correct scoliosis by maintaining spinal alignment.
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After assisting in the delivery of a full-term infant with anencephaly,the parents ask the nurse to explain treatments that might be available for their infant. Which statement should be the basis for the nurse’s response?
- A. Immediate surgery is necessary to repair the congenital defect.
- B. Anencephaly is incompatible with life; only palliative care should be provided.
- C. A shunting procedure will be necessary initially to relieve intracranial pressure.
- D. Antibiotics are needed initially before any treatment is started.
Correct Answer: B
Rationale: Anencephaly lacking cerebral hemispheres and skull is incompatible with life warranting only palliative care. Surgery shunting or antibiotics cannot correct it.
Which client symptoms documented by the nurse best indicate that the child is having a hypoglycemic reaction? Select all that apply.
- A. The child complains of being thirsty.
- B. The child's breathing is labored and prolonged.
- C. The child is more hungry than usual.
- D. The child complains of feeling shaky.
- E. The child reports feeling light-headed.
- F. The child states his or her heart is racing.
Correct Answer: D,E,F
Rationale: Hypoglycemia causes shakiness, light-headedness, and tachycardia due to low blood glucose triggering the sympathetic nervous system. Thirst and hunger are less specific, and labored breathing is unrelated.
If the child weighs 30 kg, what is the hourly flow rate in milliliters? Use the standard 100 mL/kg/day for the first 10 kg of body weight, 50 mL/kg/day for the next 10 kg of body weight, and 20 mL/kg/day for each kilogram above 20 kg of body weight for daily maintenance.
Correct Answer: 70.83 mL/hour
Rationale: Calculation: First 10 kg = 100 mL/kg/day × 10 = 1000 mL/day; Next 10 kg = 50 mL/kg/day × 10 = 500 mL/day; Last 10 kg = 20 mL/kg/day × 10 = 200 mL/day. Total = 1000 + 500 + 200 = 1700 mL/day. Hourly rate = 1700 ÷ 24 = 70.83 mL/hour. Since no exact option is provided, the closest reasonable answer is assumed as correct based on standard practice.
An infant had four wet diapers during the 8-hour shift. The weight of a dry diaper is 15 g. The four wet diapers weighed 30 g, 24 g, 21 g, and 25 g. What amount in milliliters should the nurse record for the total 8-hour urine? _______ mL (Record your answer as a whole number.)
Correct Answer: 40
Rationale: Subtract dry diaper weight (15 g): 30–15=15 g 24–15=9 g 21–15=6 g 25–15=10 g. Total: 15+9+6+10=40 g equaling 40 mL urine output.
When teaching an adolescent male client about testicular self-examination, which instruction should the nurse include?
- A. Have examination after a warm bath or shower.
- B. Report any difference in the size of your testicles to the physician.
- C. Malignant lumps are usually located on the front side of the testicles.
- D. Both testicles should be examined simultaneously to detect differences.
Correct Answer: A
Rationale: Performing testicular self-examination after a warm bath or shower relaxes the scrotum, making it easier to detect abnormalities, a key instruction for effective screening.