Nokea
The nurse is assessing an infant with developmental dysplasia of the hip. Which finding would the nurse anticipate?
- A. Unequal leg length
- B. Limited adduction
- C. Diminished femoral pulses
- D. Symmetrical gluteal folds
Correct Answer: A
Rationale: The correct answer is A: Unequal leg length. In developmental dysplasia of the hip, there is abnormal development of the hip joint. This can lead to unequal leg lengths due to hip instability and dislocation. Limited adduction may be present due to hip joint abnormalities. Diminished femoral pulses are not typically associated with developmental dysplasia of the hip. Symmetrical gluteal folds are usually present in healthy infants.
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Which of the following is an example of low health literacy skills?
- A. A nurse is unable to explain the dose, indications, side effects, and structural formula of carbamazepine
- B. A client cannot read an admission form to sign it
- C. A nurse cannot calculate the correct IV rate for Ringer's lactate
- D. A nurse is unable to explain the dose, indications, side effects, and structural formula of carbamazepine
Correct Answer: B
Rationale: The correct answer is B. Low health literacy refers to an individual's ability to obtain, process, and understand basic health information and services to make appropriate health decisions. In this scenario, the client's inability to read an admission form indicates low health literacy as they are unable to access important health information required for decision-making.
Choice A is incorrect as it describes a nurse's knowledge deficit, not health literacy skills. Choice C involves a nurse's clinical competency in calculations, not health literacy. Choice D is a duplicate of Choice A.
Which of the following clients is most likely ready to be dismissed from an inpatient care setting to home?
- A. A 65-year old male with urine output of 60cc in the past four hours
- B. A 2-month old female with a temperature of 100.6 rectally
- C. A 38-year old female who transitioned from IV TPN to full liquids six hours ago
- D. A 4-year old male with an oxygen saturation of 96% on room air
Correct Answer: D
Rationale: The correct answer is D because an oxygen saturation of 96% on room air indicates adequate oxygenation, suggesting the client is stable and can be discharged home. A: Low urine output may indicate dehydration or kidney issues, requiring further monitoring. B: A fever in an infant warrants evaluation for infection, not ready for discharge. C: Recent transition from IV TPN to full liquids may require ongoing monitoring for tolerance and nutritional status.
A woman presents with bruises on her face and back in various stages of healing. She states, 'sometimes he just gets so angry.' Which of the following statements is most appropriate as a response from the nurse?
- A. Do you mean your boyfriend?
- B. Do you mean your boyfriend?
- C. No one will ever hurt you again.
- D. Tell me more about what happens when he gets angry.
Correct Answer: D
Rationale: The correct answer is D: "Tell me more about what happens when he gets angry." This response is appropriate because it encourages the woman to share more information about the situation, allowing the nurse to assess the potential abuse and provide appropriate support. Choice A and B are identical and do not prompt further discussion. Choice C is dismissive and unrealistic. Asking for more details, as in choice D, helps gather crucial information for intervention.
A nurse is caring for a dying client whose family wants to be with him in the operating suite. The surgeon, however, does not allow families to be present during surgery. The nurse recognizes this as an ethical dilemma. What is the initial step of the nurse when managing this situation?
- A. Contact the physician to amend the order for the client
- B. Document an account of the situation to ensure adequate coverage of details
- C. Consult with the medical ethics committee to determine a safe and workable solution
- D. Speak with the chief nursing officer to change the policy governing this situation
Correct Answer: A
Rationale: The correct initial step is to choose option A: Contact the physician to amend the order for the client. This is the most appropriate action because the conflict arises from the surgeon's policy, which can potentially be changed with physician involvement. By discussing the situation with the physician, the nurse can advocate for the family's wishes and potentially negotiate a compromise. This step prioritizes the client's and family's needs while also respecting the surgeon's authority. Options B, C, and D are not the initial steps because they involve escalating the situation before attempting direct communication with the physician, which can be seen as bypassing the appropriate chain of command.
In which situation might an occupational health nurse consultation be necessary?
- A. A nurse is injured from using incorrect body mechanics to lift a client
- B. A nurse receives a subpoena to testify in court about a client's case
- C. A client who has been injured in a diving accident needs assistance with planning rehabilitation and surgery
- D. A nursing unit is implementing a new electronic health record system
Correct Answer: A
Rationale: The correct answer is A: A nurse is injured from using incorrect body mechanics to lift a client. Occupational health nurse consultation would be necessary in this situation to assess the nurse's injury, provide appropriate care, and prevent future injuries. This aligns with the role of occupational health nurses in promoting workplace safety and employee health.
Choice B is incorrect because receiving a subpoena to testify in court does not directly relate to the need for an occupational health nurse consultation.
Choice C is incorrect as it involves the client needing assistance with rehabilitation and surgery, which would typically involve medical professionals other than occupational health nurses.
Choice D is also incorrect as implementing a new electronic health record system does not necessitate an occupational health nurse consultation.