Nokea
The nurse is caring for a child with a unilateral long-leg cast applied for the correction of club foot. Which action is most important for the nurse to perform?
- A. Palpate femoral pulses.
- B. Compare temperature of both legs.
- C. Monitor capillary refill of the toes.
- D. Examine for spontaneous movement.
Correct Answer: C
Rationale: Monitoring capillary refill ensures adequate circulation in the casted limb, detecting complications like compartment syndrome.
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Based on the assessment findings, the priority diagnosis suspected is... This diagnosis places the client at risk of...
- A. Mastitis
- B. Engorgement
- C. Blocked milk duct
- D. Inflammatory breast cancer
- E. Abscess
- F. Breastfeeding intolerance
- G. Nipple thrush
Correct Answer: A
Rationale: Mastitis, indicated by fever, localized breast symptoms, and systemic signs, is the priority diagnosis. It risks progressing to an abscess if untreated, requiring prompt intervention.
An 8-year-old girl with precocious sexual development is being treated medically with injections of luteinizing hormone-releasing hormone (LHRH) to regulate the pituitary gland. Which statement by the parents indicates that they understand the treatment?
- A. We should be sure to start our daughter on birth control pills.'
- B. Sexual maturity differences between my daughter and her peers will disappear within a few years.'
- C. Our daughter will be on this hormone treatment the rest of her life.'
- D. We should encourage her to dress in clothing that suits her sexual maturity level.'
Correct Answer: B
Rationale: LHRH therapy delays premature puberty, allowing physical maturity to align with peers over time, with treatment stopping at an appropriate age.
The parent of an 11-year-old client who has juvenile idiopathic arthritis tells the nurse, 'I really don't want my child to become dependent on pain medication, so I only allow taking the medication when the pain is really bad.' Which information is most important for the nurse to provide this parent?
- A. Giving pain medication around the clock helps control the pain.
- B. The use of hot baths can be used as an alternative for pain medication.
- C. The child should be encouraged to rest when experiencing pain.
- D. Encourage quiet activities such as watching television as a pain distracter.
Correct Answer: A
Rationale: Scheduled pain medication maintains consistent pain control, reduces inflammation, and prevents severe pain episodes in juvenile idiopathic arthritis, improving mobility and preventing joint damage.
A nurse is speaking with a client who is addicted to heroin and who just learned that she is pregnant. The client states, 'I just started taking methadone. Is there anything else I can do to make sure my baby is healthy?' Which information should the nurse provide?
- A. Describe genetic testing protocols.
- B. Sign up for group therapy sessions.
- C. Start a prenatal care plan as soon as possible.
- D. Discontinue the methadone right away.
Correct Answer: C
Rationale: Early prenatal care monitors methadone effects, fetal development, and complications like neonatal abstinence syndrome, ensuring a healthy pregnancy.
The nurse is preparing to administer oxytocin IV to a client after the delivery of her infant. Which outcome should the nurse expect from the administration of oxytocin?
- A. Return of the uterus to prepregnancy size.
- B. Expulsion of the placenta.
- C. Activation of the let down reflex.
- D. Stimulation of uterine contractions.
Correct Answer: D
Rationale: Oxytocin stimulates uterine contractions to reduce postpartum bleeding by compressing blood vessels.