Nokea
The nurse is caring for a client with a ventricular shunt for hydrocephalus. Which finding requires immediate reporting?
- A. Clear drainage from the incision
- B. Mild headache
- C. Temperature of 98.6°F (37°C)
- D. Pupils equal and reactive
Correct Answer: A
Rationale: Clear drainage from a shunt incision may indicate cerebrospinal fluid leakage, a serious complication requiring immediate reporting.
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Which of the following types of restraints is best for the nurse to use for a child in the immediate postoperative period after cleft palate repair?
- A. Safety jacket.
- B. Elbow restraints.
- C. Wrist restraints.
- D. Body restraints.
Correct Answer: B
Rationale: Elbow restraints are most appropriate post-cleft palate repair to prevent the child from touching or damaging the surgical site while allowing some mobility.
A client diagnosed with trigeminal neuralgia asks the nurse what can be done to minimize the episodes of pain. The nurse's response is based on an understanding that what can trigger the pain?
- A. Infection or stress
- B. Hypoglycemia and fatigue
- C. Facial pressure or extreme temperature
- D. Excessive watering of the eyes or nasal stuffiness
Correct Answer: C
Rationale: The paroxysms of pain that accompany this neuralgia are triggered by stimulation of the terminal branches of the trigeminal nerve. Symptoms can be triggered by pressure from washing the face, brushing the teeth, shaving, eating and drinking, and yawning. Symptoms can also be triggered by thermal stimuli such as a draft of cold air. The items listed in the other options do not trigger the spasm.
A client with pneumonia is receiving oxygen therapy. The nurse notes cyanosis and a respiratory rate of 32 breaths/min. What should the nurse do first?
- A. Increase the oxygen flow rate.
- B. Notify the physician.
- C. Encourage coughing and deep breathing.
- D. Reposition the client.
Correct Answer: B
Rationale: Cyanosis and tachypnea indicate worsening hypoxia, requiring immediate physician notification to adjust treatment.
Your 87 year old client has a history of heart disease and fibromyalgia. This client has an internal pacemaker and is also a diabetic client. During your annual visit with this client, the client tells you that they would like to begin some alternative and homeopathic health care practices. What should you include in your teaching plan for this client?
- A. Information about the lack of scientific evidence regarding the effectiveness of all herbs.
- B. Data to support the fact that magnets can be effective in terms of fibromyalgia pain, and as such, may be a good choice for this client.
- C. Research that suggests that prayer is an effective alternative method to relieve pain and stress that can be helpful to this client.
- D. Information that contraindicates the use of biofeedback because this alternative, complementary health practice can interfere with the client's pacemaker functioning.
Correct Answer: C
Rationale: Prayer is a safe and evidence-supported complementary practice that can help reduce stress and pain, suitable for this client. There is insufficient evidence for magnets in fibromyalgia treatment, and biofeedback is not contraindicated for pacemakers. Not all herbs lack scientific evidence, so option A is overly broad.
A 4-year-old child is admitted for a cardiac catheterization. Which of the following is most important to include as the nurse teaches this child about the cardiac catheterization?
- A. A plastic model of the heart.
- B. A catheter that will be inserted into the artery.
- C. The parents.
- D. Other children undergoing a catheterization.
Correct Answer: C
Rationale: Including the parents in teaching provides emotional support and reassurance to the child, which is critical for a 4-year-old facing a procedure. While a model or catheter explanation may be useful, parental presence is most important for the child's comfort and understanding.