Nokea
The nurse is caring for a client with hyperparathyroidism who had a parathyroidectomy 4 hours ago. Which technique should the nurse use to check for complications in this client?
- A. Ask the client to place the backs of the hands against each other to provide hyperextension of the wrist while the elbows remain flexed
- B. Perform the Romberg test by asking the client to stand with the eyes closed and the feet together
- C. Place a blood pressure (BP) cuff on the client's arm, inflate to pressure greater than systolic BP, and monitor for carpal spasm
Correct Answer: C
Rationale: Post-parathyroidectomy, hypocalcemia is a potential complication due to reduced parathyroid hormone levels. Trousseau’s sign (C), elicited by inflating a BP cuff to induce carpal spasm, indicates hypocalcemia, a critical complication requiring prompt intervention. The wrist hyperextension test (A) is unrelated to hypocalcemia, and the Romberg test (B) assesses balance, not relevant to this scenario.
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A nurse discovers a cyanotic newborn with excessive frothy mucus in the mouth. What should be the nurse’s first action?
- A. Administer 100% oxygen
- B. Auscultate the lungs
- C. Place infant in knee-chest position
- D. Suction the infant’s mouth
Correct Answer: D
Rationale: Suctioning the mouth (D) clears mucus, addressing potential airway obstruction causing cyanosis. Oxygen (A), auscultation (B), and positioning (C) are secondary until the airway is clear.
The nurse reinforces teaching about self-management strategies for a client with urge incontinence. Which of the following statements indicate that teaching has been effective? Select all that apply.
- A. I am going to join a walking program to lose excess weight.
- B. I may have dry mouth as a side effect from the oxybutynin.
- C. I really need caffeine to get myself going in the morning.
- D. I should perform Kegel exercises several times daily.
- E. I will void every 2 hours until I am having fewer accidents.
Correct Answer: A,B,D,E
Rationale: Weight loss (A) reduces bladder pressure, oxybutynin’s dry mouth side effect (B) is correct, Kegel exercises (D) strengthen pelvic floor muscles, and scheduled voiding (E) prevents urgency. Caffeine (C) irritates the bladder, worsening incontinence, indicating ineffective teaching.
A mother noticed a large abdominal mass when helping her 3-year-old child bathe. The child is taken to the physician and admitted to the hospital after an intravenous pyelogram (IVP) confirms the diagnosis of Wilms' tumor. Which nursing action is essential to include in the nursing care plan?
- A. Strain all urine and save for analysis.
- B. Avoid palpating the abdomen.
- C. Prepare the child for permanent dialysis.
- D. Help the family understand the poor prognosis.
Correct Answer: B
Rationale: Avoiding abdominal palpation prevents potential tumor rupture or metastasis in Wilms' tumor, a critical precaution. Urine straining, dialysis, or poor prognosis are inappropriate.
The nurse is caring for a child receiving chest physiotherapy (CPT). Which of the following actions by the nurse would be appropriate?
- A. Schedule the therapy thirty minutes after meals
- B. Teach the child not to cough during the treatment
- C. Continue the percussion to the rib cage area
- D. Place the child in a prone position for the therapy
Correct Answer: C
Rationale: Continue the percussion to the rib cage area. Percussion should target the rib cage to mobilize secretions effectively.
A 6-year-old child is receiving chemotherapy for leukemia. Which comment by the child indicates to the nurse that the child is adjusting well to the therapy?
- A. I am so tired. I want Mommy to hold me.'
- B. Look at my new hat. I wear it all the time. It's pretty.'
- C. See all my bruises. They are funny colors.'
- D. I wish I could eat pizza, but everything makes me throw up.'
Correct Answer: B
Rationale: Wearing a hat proudly suggests positive coping with hair loss from chemotherapy, indicating adjustment, unlike complaints of fatigue, bruising, or nausea.