Nokea
The nurse is caring for a hospitalized 14-year-old child who is placed in Crutchfield traction. The child is having difficulty adjusting to the length of the hospital confinement. Which nursing action would be appropriate to meet the child's needs?
- A. Allow the child to play loud music in the hospital room.
- B. Let the child wear his or her own clothing when friends visit.
- C. Allow the child to have his or her hair dyed if the parent agrees.
- D. Allow the child to keep the shades closed and the room darkened.
Correct Answer: B
Rationale: An adolescent needs to identify with peers and has a strong need to belong to a group. The child should be allowed to wear his or her own clothes to feel a sense of belonging to the group. The adolescent likes to dress like the group and to wear similar hairstyles. Loud music may disturb others in the hospital. Because Crutchfield traction involves the use of skeletal pins, hair dye is not appropriate. The child's request for a darkened room is indicative of a possible problem with depression that may require further evaluation and intervention.
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The nurse caring for a child who has sustained a head injury notes that the primary health care provider has documented decorticate posturing. During the assessment of the child, the nurse notes the extension of the upper extremities and the internal rotation of the upper arms and wrists. The nurse also notes that the lower extremities are extended, with some internal rotation noted at the knees and feet. On the basis of these findings, what is the initial nursing action?
- A. Document that the original positioning is unchanged.
- B. Attempt to assess the flexibility of the child's lower extremities.
- C. Plan to continue to monitor the child for posturing every 2 hours.
- D. Notify the primary health care provider of the change in posturing.
Correct Answer: D
Rationale: Decorticate (flexion) posturing refers to the flexion of the upper extremities and the extension of the lower extremities. Plantar flexion of the feet may also be observed. Decerebrate (extension) posturing involves the extension of the upper extremities with the internal rotation of the upper arms and wrists. The lower extremities will extend with some internal rotation noted at the knees and feet. The progression from decorticate to decerebrate posturing usually indicates deteriorating neurological function and warrants primary health care provider notification. Although documentation is appropriate, it is not the initial action in this situation. The other options are not appropriate.
The nurse needs to administer 7.5 mg of a medication intramuscularly. The medication label reads '10 mg/mL.' How much medication should the nurse prepare to administer? Fill in the blank.
Correct Answer: 0.75
Rationale: Use the following formula to calculate the medication dose: Desired / Available × Volume = mL per dose. 7.5 mg / 10 mg × 1 mL = 0.75 mL.
A client diagnosed with obsessive-compulsive rituals often misses the unit's morning activities because of a bed-making ritual. What nursing action would be therapeutic?
- A. Verbalize tactful, mild disapproval of the behavior.
- B. Discuss the social implications of the behavior with the client.
- C. Help the client to make the bed so that the task can be finished quicker.
- D. Offer reflective feedback, such as, 'I see that you have made your bed several times.'
Correct Answer: D
Rationale: Reflective feedback acknowledges the client's behavior. Verbalizing disapproval and discussing social implications would increase the client's anxiety and reinforce the need to perform the ritual. The client is usually aware of the implications of the behavior. Helping with the ritual is nontherapeutic and also reinforces the behavior.
The nurse is planning care for an infant with a diagnosis of an encephalocele located in the occipital area. Which item should the nurse use to assist with positioning the child to avoid pressure on the encephalocele?
- A. Sandbags
- B. Sheepskin
- C. Feather pillows
- D. Foam half donut
Correct Answer: D
Rationale: The infant is positioned to avoid pressure on the lesion. If the encephalocele is in the occipital area, a foam half donut may be useful for positioning to prevent this pressure. A sandbag, sheepskin, or feather pillow will not protect the encephalocele from pressure.
A client who has undergone internal fixation after fracturing a left hip has developed a reddened left heel. What equipment should the nurse obtain to manage this problem?
- A. Trapeze
- B. Bed cradle
- C. Draw sheet
- D. Alternating pressure mattress
Correct Answer: D
Rationale: The reddened heel results from the pressure of the foot against the mattress. An alternating pressure mattress is effective at minimizing pressure points. The bed cradle will keep the linens off of the client's lower extremities but will not assist with the management of a reddened heel. A draw sheet and trapeze are of general use for this client, but they are not specific for dealing with the reddened heel.