Nokea
The nurse is caring for a 5-year-old child who has the left leg in skeletal traction. Which of the following activities would be an appropriate diversional activity?
- A. Kicking balloons with the right leg
- B. Playing 'Simon Says'
- C. Playing handheld games
- D. Throwing bean bags
Correct Answer: C
Rationale: Playing handheld games is an appropriate diversional activity for a child in skeletal traction because it does not require physical movement of the affected limb. This activity can help keep the child entertained and engaged without risking any harm to the tractioned leg. Choices A, B, and D involve physical movements that could potentially interfere with the skeletal traction or cause discomfort to the child.
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What is the primary function of a public health nurse?
- A. Provide bedside care
- B. Administer medications
- C. Promote and protect the health of populations
- D. Perform surgical procedures
Correct Answer: C
Rationale: The primary function of a public health nurse is to promote and protect the health of populations. Public health nurses focus on preventing diseases, promoting healthy behaviors, and addressing health disparities within communities. Providing bedside care (choice A) is typically done by nurses in clinical settings, not public health nurses. Administering medications (choice B) is part of nursing practice but not the primary role of a public health nurse. Performing surgical procedures (choice D) is usually the responsibility of surgical nurses or healthcare providers specializing in surgery, not public health nurses.
A 16-year-old female client returns to the clinic because she is pregnant for the third time by a new boyfriend. Which vaccine should the nurse plan to administer?
- A. MMR
- B. Hepatitis B
- C. Human papillomavirus
- D. Pneumococcal
Correct Answer: B
Rationale: The correct answer is B, Hepatitis B. The Hepatitis B vaccine is crucial for pregnant women to prevent transmission of the virus to the baby during childbirth. Option A, MMR (Measles, Mumps, Rubella) vaccine, is not indicated during pregnancy. Option C, Human papillomavirus vaccine, is recommended for prevention of HPV infections but is not specifically indicated during pregnancy. Option D, Pneumococcal vaccine, is important for certain populations but is not the priority vaccine for a pregnant woman in this scenario.
A newborn presents with a pronounced cephalic hematoma following a birth in the posterior position. Which nursing diagnosis should guide the plan of care?
- A. Pain related to periosteal injury
- B. Impaired mobility related to bleeding
- C. Parental anxiety related to knowledge deficit
- D. Injury related to intracranial hemorrhage
Correct Answer: C
Rationale: The correct nursing diagnosis to guide the plan of care for a newborn with a pronounced cephalic hematoma following a birth in the posterior position is 'Parental anxiety related to knowledge deficit.' This is appropriate because the parents may be worried about the appearance and potential complications of the cephalic hematoma. They may require education and reassurance from the nurse. Choices A, B, and D are incorrect because they do not address the emotional needs of the parents and the knowledge deficit they may have regarding the condition.
When assisting a family who fails to take action during a sick member despite suggestions, you will:
- A. explain the consequences of inaction
- B. identify the courses of action open to the family and the resources needed for each
- C. discuss the consequences of each course of action available
- D. influence the family to act on what you think is best for the situation
Correct Answer: B
Rationale: When helping a family decide on actions to take, it is essential to identify the courses of action available to them and the resources needed for each. This empowers the family to make informed decisions based on their specific situation. Explaining the consequences of inaction (Choice A) may be necessary but does not provide a range of options. Discussing the consequences of each course of action (Choice C) is important but does not actively guide the family on the available actions. Influencing the family (Choice D) to act based on personal judgment undermines their autonomy and may not lead to the best outcome.
A client is admitted with a diagnosis of myocardial infarction (MI). The client is complaining of chest pain. The nurse knows that pain related to an MI is due to
- A. Insufficient oxygenation of the cardiac muscle
- B. Potential circulatory overload
- C. Left ventricular overload
- D. Electrolyte imbalance
Correct Answer: A
Rationale: The correct answer is A: Insufficient oxygenation of the cardiac muscle. Myocardial infarction pain is primarily caused by inadequate oxygen reaching the heart muscle, leading to ischemia and tissue damage. Choices B, C, and D are incorrect because circulatory overload, left ventricular overload, and electrolyte imbalance are not the primary causes of chest pain in myocardial infarction. Circulatory overload may lead to other symptoms like edema, left ventricular overload can result in heart failure symptoms, and electrolyte imbalance may present with various manifestations, but none of these directly cause the characteristic chest pain associated with an MI.