Nokea
The nurse is caring for a postpartum client with thromboembolytic disease. Which intervention is most important to include when planning care to prevent the complication of pulmonary embolism?
- A. Enforce bed rest.
- B. Monitor the vital signs frequently.
- C. Assess the breath sounds frequently.
- D. Administer prescribed anticoagulant therapy.
Correct Answer: D
Rationale: The purposes of anticoagulant therapy for the treatment of thromboembolytic disease are to prevent the formation of a clot and to prevent a clot from moving to another area, thus preventing pulmonary embolism. Although the remaining options may be implemented for a client with thromboembolytic disease, the correct option will specifically assist in the prevention of pulmonary embolism.
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The home care nurse is preparing a plan of care for a client diagnosed with Ménière's syndrome. Which nursing intervention should the nurse include to assist the client with controlling vertigo?
- A. Instruct the client to cut down on cigarette smoking.
- B. Encourage the client to increase the daily fluid intake.
- C. Encourage the client to avoid sudden head movements.
- D. Instruct the client to increase the amount of sodium in the diet.
Correct Answer: C
Rationale: Ménière's syndrome refers to dilation of the endolymphatic system by overproduction or decreased resorption of endolymphatic fluid. The nurse instructs the client to make slow head movements to prevent worsening of the vertigo. Clients are advised to stop smoking because of its vasoconstrictive effects. Dietary changes such as salt and fluid restrictions that reduce the amount of endolymphatic fluid are sometimes prescribed.
A client is admitted to a mental health unit with a diagnosis of anorexia nervosa. When planning care for this client, which primary intervention should health promotion focus on?
- A. Providing a supportive environment
- B. Examining intrapsychic conflicts and past issues
- C. Emphasizing social interaction with clients who are withdrawn
- D. Helping the client identify and examine dysfunctional thoughts and beliefs
Correct Answer: D
Rationale: Health promotion focuses on helping clients identify and examine dysfunctional thoughts, as well as identifying and examining the values and beliefs that maintain these thoughts. Providing a supportive environment is important, but it is not as primary as option 4 for this client. Examining intrapsychic conflicts and past issues is not directly related to the client's problem. Emphasizing social interaction is not appropriate at this time.
The nurse is preparing a plan of care for a child diagnosed with leukemia who is beginning chemotherapy. Which intervention should the nurse include?
- A. Monitor rectal temperatures every 4 hours.
- B. Monitor the mouth and anus each shift for signs of breakdown.
- C. Encourage the child to consume fresh fruits and vegetables to maintain nutritional status.
- D. Provide meticulous mouth care several times daily using an alcohol-based mouthwash and a toothbrush.
Correct Answer: B
Rationale: When the child is receiving chemotherapy, the nurse should assess the mouth and anus each shift for ulcers, erythema, or breakdown. The nurse should avoid taking rectal temperatures. Oral temperatures are also avoided if mouth ulcers are present. Axillary or temporal temperatures should be taken to prevent alterations in skin integrity. Bland, nonirritating foods and liquids should be provided to the child. Fresh fruits and vegetables need to be avoided because they can harbor organisms. Chemotherapy can cause neutropenia, and the child should be maintained on a low-bacteria diet if the white blood cell count is low. Meticulous mouth care should be performed, but the nurse should avoid alcohol-based mouthwashes and should use a soft-bristled toothbrush.
The school nurse is preparing to perform health screening for scoliosis on children aged 9 through 14. Which instruction should the nurse plan to provide to the children?
- A. Lie flat and lift the legs straight up.
- B. Lie on the right side and then roll to the left side while the arms are held overhead.
- C. Walk 10 feet forward and then 10 feet backward with the arms held overhead at both sides.
- D. Stand with weight equally on both feet with the legs straight, and the arms hanging loosely at both sides.
Correct Answer: D
Rationale: To perform this screening test, the child should be asked to disrobe or wear underpants only so that the chest, back, and hips can be clearly seen. The child is asked to stand with weight equally on both feet with the legs straight and the arms hanging loosely at both sides. The nurse assesses the child's posture, spinal column, shoulder height, and leg lengths. Lying down positions and walking forward and backward are incorrect assessment techniques.
A 10-month-old infant is hospitalized for respiratory syncytial virus (RSV). On the basis of the developmental stage of the infant, what intervention should the nurse include in the plan of care?
- A. Restrain the infant with a total body restraint to prevent any tubes from being dislodged.
- B. Follow the home feeding schedule, and allow the infant to be held only when the parents visit.
- C. Wash hands, wear a mask when caring for the infant, and keep the infant as quiet as possible.
- D. Provide a consistent routine, and touch, rock, and cuddle the infant throughout the hospitalization.
Correct Answer: D
Rationale: A 10-month-old infant is in the trust versus mistrust stage of psychosocial development, according to Erik Erikson, and the sensorimotor period of cognitive development, according to Jean Piaget. Hospitalization may have an adverse effect. A consistent routine accompanied by touching, rocking, and cuddling will help the child develop trust and provide sensory stimulation. Total body restraint is unnecessary and an incorrect action. Touching and holding the infant only when the parents visit will not provide adequate stimulation and interpersonal contact for the infant. RSV is not airborne (a mask is not required), and it is usually transmitted by the hands.