Nokea
The nurse is caring for an infant with developmental dysplasia of the hip. The nurse should expect to:
- A. Prepare the infant for application of a body cast
- B. Teach the mother to keep the infant in the prone position
- C. Explain that surgery will be necessary within the first 3 months
- D. Tell the mother that the condition will correct itself without treatment
Correct Answer: A
Rationale: For developmental dysplasia of the hip (DDH), a body cast (spica) is often applied to maintain hip alignment, a common intervention post-reduction in infants, guided by orthopedics. Prone positioning, early surgery, or spontaneous correction aren't standard treatment stabilizes the joint. Nurses prepare families for this, explaining its role in preventing long-term disability, ensuring compliance and comfort.
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What can you expect from Marianne, who is currently at the ONSET stage of fever?
- A. Hot, flushed skin
- B. Increase thirst
- C. Convulsion
- D. Pale,cold skin
Correct Answer: D
Rationale: Fever's onset (chill phase) features vasoconstriction e.g., pale, cold skin as the body raises its setpoint. Hot, flushed skin (flush phase), thirst (later), or convulsions (hyperpyrexia) follow. Nurses expect this initial response e.g., shivering in Marianne, guiding warming measures, per fever physiology.
The nurse is caring for a client receiving oxygen therapy via a simple face mask. Which nursing intervention is important to prevent skin breakdown?
- A. Changing the position of the mask every 2 hours
- B. Applying a protective barrier cream to the client's face
- C. Padding the pressure points on the client's face with soft material
- D. Encouraging the client to remove the mask intermittently for facial skin care
Correct Answer: C
Rationale: Padding pressure points with soft material (C) prevents skin breakdown from a simple face mask by reducing friction and pressure on the face. Repositioning q2h (A) helps but isn't enough alone. Barrier cream (B) is for moisture, not pressure. Intermittent removal (D) disrupts therapy. Padding, per skin integrity standards, is proactive.
Myra, 21 year old nursing student has difficulty sleeping. She told Nurse Budek 'I really think a lot about my x boyfriend recently' Budek told Myra 'And that causes you difficulty sleeping?' Which therapeutic technique is used in this situation?
- A. Reflecting
- B. Restating
- C. Exploring
- D. Seeking clarification
Correct Answer: D
Rationale: Budek's 'And that causes you difficulty sleeping?' seeks clarification (D), asking Myra to confirm the link between her ex and insomnia. Reflecting (A) mirrors feelings (e.g., 'You're upset?'). Restating (B) repeats (e.g., 'You think about him a lot?'). Exploring (C) probes broadly. Clarification ensures understanding, per therapeutic models, fitting Budek's intent, making D correct.
A client with chronic obstructive pulmonary disease (COPD) presents with severe dyspnea and hypoxemia. What is the appropriate indication for initiating oxygen therapy in this client?
- A. Maintaining oxygen saturation above 95%
- B. Correcting underlying lung pathology
- C. Relieving shortness of breath
- D. Preventing complications of hypoxia
Correct Answer: D
Rationale: Preventing complications of hypoxia (D) is the primary indication for oxygen therapy in COPD with severe dyspnea and hypoxemia, averting tissue damage and organ failure (target SpO2 88-92%). Saturation above 95% (A) risks CO2 retention in COPD. Correcting pathology (B) requires other treatments. Relieving dyspnea (C) is a benefit, not the goal. Hypoxia prevention aligns with GOLD guidelines, prioritizing survival and function over symptom relief alone.
Type of respiration that occurs when there is an increase in depth and rate of respiration usually seen in people who engages in strenuous exercise.
- A. Kussmaul's breathing
- B. Eupnea
- C. Hyperpnea
- D. Bradypnea
Correct Answer: C
Rationale: Hyperpnea (C) is increased depth and rate of respiration, common in strenuous exercise, per respiratory terminology. Kussmaul's (A) is deep, rapid breathing in metabolic acidosis, not exercise. Eupnea (B) is normal breathing, and bradypnea (D) is slow. Hyperpnea matches the physiological response to heightened oxygen demand during activity, making C the correct answer based on its specific context.