Nokea
The nurse is caring for a child in Bryant's traction (see figure). The nurse should:
- A. Adjust the weights on the legs until the buttocks rest on the bed.
- B. Provide frequent skin care.
- C. Place a pillow under the buttocks.
- D. Remove the elastic leg wraps every 8 hours for 10 minutes.
Correct Answer: B
Rationale: Frequent skin care is essential in Bryant's traction to prevent pressure ulcers due to prolonged immobility.
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When interviewing the parents of a 2-year-old child, a history of which of the following illnesses should lead the nurse to suspect pneumococcal meningitis?
- A. Bladder infection.
- B. Middle ear infection.
- C. Fractured clavicle.
- D. Septic arthritis.
Correct Answer: B
Rationale: Middle ear infections are a common precursor to pneumococcal meningitis due to the spread of Streptococcus pneumoniae.
The nurse is discharging an 8-month-old who weighs 15 lb from the hospital. The parents have put the child in the back seat of the car with the car seat facing the front. The nurse should:
- A. Ask the parents to wait while obtaining the correct car seat.
- B. Complete the discharge with the child sitting facing the front seat.
- C. Give the parents a manual on proper car seat placement.
- D. Explain the need for the rear-facing position and request assistance from a car seat technician.
Correct Answer: D
Rationale: Rear-facing car seats are recommended for infants under 2 years to protect their neck and spine.
An adolescent with a history of surgical repair for an undescended testis comes to the clinic for a sports physical. Anticipatory guidance for the parents and adolescent should focus on which of the following as most important?
- A. The adolescent's sterility.
- B. The adolescent's future plans.
- C. Technique for monthly testicular self-examinations.
- D. Need for a lot of psychological support.
Correct Answer: C
Rationale: Monthly self-exams help detect issues early.
When developing the plan of care for a child with early Duchenne's muscular dystrophy, which of the following nursing goals is the priority?
- A. Encouraging early wheelchair use.
- B. Fostering social interactions.
- C. Maintaining function of unaffected muscles.
- D. Prevent circulatory impairment.
Correct Answer: C
Rationale: Maintaining function of unaffected muscles is the priority to prolong mobility and independence in early Duchenne's muscular dystrophy.
The nurse is preparing to administer furosemide (Lasix) to a 3-year-old with a heart defect. The nurse verifies the child's identity by checking the arm band and:
- A. Asking the child to state her name.
- B. Checking the room number.
- C. Asking the child to tell her birth date.
- D. Asking the parent the child's name.
Correct Answer: D
Rationale: Asking the parent is appropriate for a 3-year-old, who may not reliably state their name or birth date. Room numbers are not reliable identifiers.