Nokea
The nurse is assessing an 8 month-old child with atonic cerebral palsy. Which statement from the parent supports the presence of this problem?
- A. When I put my finger in the left hand the baby doesn't respond with a grasp.'
- B. My baby doesn't seem to follow when I shake toys in front of its face.'
- C. When it thundered loudly last night the baby didn't even jump.'
- D. When I put the baby in a back lying position that's how I find it hours later.'
Correct Answer: D
Rationale: When I put the baby in a back lying position that's how I find it hours later.' Atonic cerebral palsy is characterized by low muscle tone and lack of movement, so the baby remaining in the same position for hours supports this diagnosis.
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After a myocardial infarction, a client is placed on a sodium restricted diet. When the nurse is teaching the client about the diet, which meal plan would be the most appropriate to suggest?
- A. 3 oz broiled fish, 1 baked potato, 1/2 cup canned beets, 1 orange, and milk
- B. 3 oz. canned salmon, fresh broccoli, 1 biscuit, tea, and 1 apple
- C. A bologna sandwich, fresh eggplant, 2 oz fresh fruit, tea, and apple juice
- D. 3 oz turkey, 1 fresh sweet potato, 1/2 cup fresh green beans, milk, and 1 orange
Correct Answer: D
Rationale: 3 oz turkey, 1 fresh sweet potato, 1/2 cup fresh green beans, milk, and 1 orange. Canned fish and vegetables and cured meats are high in sodium. This meal does not contain any canned fish and/or vegetables or cured meats.
The nurse completed discharge teaching for the client with sutures in place after a skin biopsy. Which statements by the client indicate an understanding of the teaching? Select all that apply.
- A. "The incision should be clean, dry, and not separated."
- B. "I will return in 2 to 3 days to have the stitches removed."
- C. "If I have an elevated temperature, I'll contact my provider."
- D. "I'll keep the bandage on for a week before I check the incision."
- E. "Excessive redness, pain, or drainage may mean it is infected."
Correct Answer: A,C,E
Rationale: A: Clean, dry, intact incisions indicate proper care. C: Fever suggests infection, requiring follow-up. E: Redness, pain, or drainage are infection signs. B: Sutures are removed in 7-10 days. D: Incisions should be checked daily.
The nurse is caring for hospitalized clients. Which nursing actions require the nurse to use sterile gloves? Select all that apply.
- A. Insertion of a nasogastric tube
- B. Administration of an enema
- C. Administration of a subcutaneous injection
- D. Insertion of an indwelling urinary catheter
- E. Suctioning of a tracheostomy tube
Correct Answer: D,E
Rationale: D: Sterile gloves are required for urinary catheter insertion to prevent introducing pathogens. E: Sterile gloves are needed for tracheostomy suctioning to minimize infection risk. A, B, C involve non-sterile procedures.
The nurse is caring for the client with an IV. Which findings should prompt the nurse to conclude that the client is experiencing inflammation (phlebitis) at the IV insertion site? Select all that apply.
- A. Pain
- B. Redness
- C. Warmth
- D. Drainage
- E. Mottling
- F. Swelling
Correct Answer: A,B,C,F
Rationale: A: Pain indicates tissue irritation. B: Redness results from vasodilation. C: Warmth is caused by inflammation. F: Swelling occurs from fluid leakage. D: Drainage suggests infection. E: Mottling is unrelated.
The nurse is caring for a client in atrial fibrillation. The atrial heart rate is 250 and the ventricular rate is controlled at 75. Which of the following findings is cause for the most concern?
- A. Diminished bowel sounds
- B. Loss of appetite
- C. A cold, pale lower leg
- D. Tachypnea
Correct Answer: C
Rationale: A cold, pale lower leg. This assessment suggests the presence of an embolus probably from the atrial fibrillation. Peripheral pulses should be checked immediately.