Nokea
The nurse is creating a plan of care for a newborn diagnosed with bilateral club feet. Which information should the nurse plan to include in the parents education?
- A. The regimen of manipulation and casting is effective in all cases of bilateral club feet.
- B. Genetic testing is wise for future pregnancies because other children born to this couple may also be affected.
- C. If casting is needed, it will begin at birth and continue for 12 weeks, at which time the condition will be reevaluated.
- D. Surgery performed immediately after birth has been found to be the most effective for achieving a complete recovery.
Correct Answer: C
Rationale: For the infant with clubfoot, casting should begin at birth and continue for at least 12 weeks or until maximum correction is achieved. At this time, corrective shoes may provide support to maintain alignment, or surgery can be performed. Surgery is usually delayed until the child is 4 to 12 months old. Options 1 and 4 are inaccurate. Option 2 does not specifically address the subject of the question.
You may also like to solve these questions
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.
The nurse determines that a tuberculin skin test is positive. Which diagnostic test should the nurse anticipate will be prescribed to confirm a diagnosis tuberculosis (TB)?
- A. Chest x-ray
- B. Sputum culture
- C. Complete blood cell count
- D. Computed tomography scan of the chest
Correct Answer: B
Rationale: Although the findings of the chest x-ray examination are important, it is not possible to make a diagnosis of TB solely on the basis of this examination because other diseases can mimic the appearance of TB. The demonstration of tubercle bacilli bacteriologically is essential for establishing a diagnosis. The microscopic examination of sputum for acid-fast bacilli is usually the first bacteriological evidence of the presence of tubercle bacilli. Options 3 and 4 will not diagnose TB.
A client is experiencing diabetes insipidus as a result of cranial surgery. Which anticipated therapy should the nurse plan to implement?
- A. Fluid restriction
- B. Administering diuretics
- C. Increased sodium intake
- D. Intravenous (IV) replacement of fluid losses
Correct Answer: D
Rationale: The client with diabetes insipidus excretes large amounts of extremely dilute urine. This usually occurs as a result of decreased synthesis or the release of antidiuretic hormone in clients with conditions such as head injury, surgery near the hypothalamus, or increased intracranial pressure. Corrective measures include allowing ample oral fluid intake, administering IV fluid as needed to replace sensible and insensible losses, and administering vasopressin. Diuretics are not administered. Sodium is not administered because the serum sodium level is usually high, as is the serum osmolality.
The nurse is planning care for an infant who has a diagnosis of hypertrophic pyloric stenosis and is scheduled for surgery. Which intervention should the nurse include to meet the infant's preoperative needs?
- A. Administer enemas until returns are clear.
- B. Provide the mother privacy to breast-feed every 2 hours.
- C. Monitor the intravenous (IV) infusion, intake, output, and weight.
- D. Provide small, frequent feedings of glucose, water, and electrolytes.
Correct Answer: C
Rationale: Preoperatively, important nursing responsibilities for the child with hypertrophic pyloric stenosis include monitoring the IV infusion, intake, output, and weight and obtaining urine specific gravity measurements. Additionally, weighing the infant's diapers provides information regarding output. Enemas until clear would further compromise the fluid volume status. Preoperatively, the infant receives nothing by mouth unless otherwise prescribed by the primary health care provider.
The nurse is creating a plan of care for a client prescribed bed rest. Which intervention should the nurse include in the plan to limit the complications of prolonged immobility?
- A. Maintain the client in a supine position.
- B. Provide a daily fluid intake of 1000 mL.
- C. Limit the intake of milk and milk products.
- D. Monitor for signs of a low serum calcium level.
Correct Answer: C
Rationale: The formation of renal and urinary calculi is a complication of immobility. Limiting milk and milk products is the best measure to prevent the formation of calcium stones. A supine position increases urinary stasis; therefore, this position should be limited or avoided. Daily fluid intake should be 2000 mL or more per day. The nurse should monitor for signs and symptoms of hypercalcemia, such as nausea, vomiting, polydipsia, polyuria, and lethargy.