Nokea
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.
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The nurse is asked to assist another health care team member with providing care for a client. On entering the client's room, the nurse notes that the client is placed in this position (refer to figure). After maintaining the client position, what should the nurse interpret that this client is most likely being treated for?
- A. Shock
- B. A head injury
- C. Respiratory insufficiency
- D. Increased intracranial pressure
Correct Answer: A
Rationale: A client in shock is placed in a modified Trendelenburg's position that includes elevating the legs, leaving the trunk flat, and elevating the head and shoulders slightly. This position promotes increased venous return from the lower extremities without compressing the abdominal organs against the diaphragm. The Trendelenburg position is no longer recommended for hypotensive clients because the client is predisposed to aspiration and worsens gas exchange. The remaining options identify conditions in which the head of the client's bed would be elevated.
A mother of a child with mumps calls the health care clinic to tell the nurse that the child has been lethargic and vomiting. What instruction should the nurse give to the mother?
- A. To continue to monitor the child
- B. That lethargy and vomiting are normal manifestations of mumps
- C. To bring the child to the clinic to be seen by the primary health care provider
- D. That, as long as there is no fever, there is nothing to be concerned about
Correct Answer: C
Rationale: Mumps generally affects the salivary glands, but it can also affect multiple organs. The most common complication is septic meningitis, with the virus being identified in the cerebrospinal fluid. Common signs include nuchal rigidity, lethargy, and vomiting. The child should be seen by the primary health care provider.
Which is the most important laboratory result for the nurse to present to the primary health care provider on a client who is receiving total parenteral nutrition (TPN)?
- A. White blood cell count
- B. Serum electrolyte levels
- C. Arterial blood gas levels
- D. Hemoglobin and hematocrit levels
Correct Answer: B
Rationale: Serum electrolyte levels are critical to monitor in a client receiving TPN because TPN solutions contain high concentrations of glucose and electrolytes, which can lead to imbalances such as hyperkalemia, hypokalemia, or hyponatremia. These imbalances can cause serious complications, including cardiac dysrhythmias or neurological issues. While white blood cell count, arterial blood gas levels, and hemoglobin and hematocrit levels are important, they are not as directly related to the immediate risks associated with TPN administration as electrolyte levels.
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 prepares for a client in leg traction to be admitted to the nursing unit. The nurse asks the unlicensed assistive personnel to obtain which essential item that will be needed to assist the client to move in bed while in leg traction?
- A. A foot board
- B. Extra pillows
- C. A bed trapeze
- D. An electric bed
Correct Answer: C
Rationale: A trapeze is essential to allow the client to lift straight up while being moved so that the amount of pull exerted on the limb in traction is not altered. A foot board and extra pillows do not facilitate moving. Either an electric bed or a manual bed can be used for traction, but this does not specifically assist the client with moving in bed.