Nokea
The nurse is preparing to admit a client from the postanesthesia care unit who has had microvascular decompression of the trigeminal nerve. Which equipment should the nurse ask the unlicensed assistive personnel to make sure is at the bedside when the client arrives?
- A. Flashlight and pulse oximeter
- B. Cardiac monitor and suction equipment
- C. Padded bed rails and suction equipment
- D. Blood pressure cuff and cardiac monitor
Correct Answer: A
Rationale: The postoperative care of the client having microvascular decompression of the trigeminal nerve is the same as for the client undergoing craniotomy. This client requires hourly neurological assessment as well as monitoring of the cardiovascular and respiratory statuses. Therefore, a flashlight and pulse oximetry are necessary items. Cardiac monitoring and padded bed rails are not indicated unless there is a special need based on a client history of cardiac disease or seizures, respectively. Suctioning is performed cautiously and only when necessary after craniotomy to avoid increasing the intracranial pressure.
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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.
The nurse is informed that a newborn infant whose mother is Rh negative will be admitted to the nursery. When planning care for the infant's arrival, which action should the nurse take?
- A. Obtain the newborn infant's blood type and direct Coombs' results from the laboratory.
- B. Obtain the necessary equipment from the blood bank needed for an exchange transfusion.
- C. Call the maintenance department and ask for a phototherapy unit to be brought to the nursery.
- D. Obtain a vial of vitamin K from the pharmacy and prepare to administer an injection to prevent isoimmunization.
Correct Answer: A
Rationale: To further plan for the newborn infant's care, the infant's blood type and direct Coombs' results must be known. Umbilical cord blood is taken at the time of delivery to determine blood type, Rh factor, and antibody titer (direct Coombs' test) of the newborn infant. The nurse should obtain these results from the laboratory. Options 2 and 3 are inappropriate at this time, and additional data are needed to determine whether these actions are needed. Option 4 is incorrect because vitamin K is given to prevent hemorrhagic disease of the newborn infant.
The nurse is caring for a client diagnosed with dementia. Which nutritional goal should the nurse plan for with this client?
- A. Client will be free of hallucinations.
- B. Client will feed self with cueing within 24 hours.
- C. Client will be able to prepare simple foods by discharge.
- D. Client will identify favorite foods by the time of discharge.
Correct Answer: B
Rationale: The correct option identifies a goal that is directly related to the client's ability to care for self. None of the remaining options are related to the client's self-care needs.
The nurse is preparing to care for an infant diagnosed with pertussis. Which priority problem should the nurse address when planning care?
- A. Infection
- B. Fluid overload
- C. Impaired sleep patterns
- D. Inability to expectorate secretions
Correct Answer: D
Rationale: The priority problem for the child with pertussis relates to adequate air exchange. Because of the copious, thick secretions that occur with pertussis and the small airways of an infant, air exchange is critical. Infection is an important consideration, but airway is the priority. A deficient fluid volume is more likely to occur in this infant because of the thick secretions and vomiting. Sleep patterns may be disturbed because of the coughing, but this is not the critical issue.
A child with a diagnosis of Reye's syndrome is being admitted to the hospital. The nurse develops a plan of care for the child that includes which priority nursing action?
- A. Monitoring for hearing loss
- B. Monitoring intake and output (I&O)
- C. Repositioning the child every 2 hours
- D. Providing a quiet environment with dimmed lighting
Correct Answer: D
Rationale: Cerebral edema is a progressive part of the disease process of Reye's syndrome. A priority component of care for a child with Reye's syndrome is maintaining effective cerebral perfusion and controlling intracranial pressure. Decreasing stimuli in the environment would decrease the stress on the cerebral tissue, as well as neuron responses. Hearing loss does not occur in clients with this disorder. Although monitoring I&O may be a component of the plan, it is not the priority nursing action. Changing the body position every 2 hours would not affect the cerebral edema and intracranial pressure directly. The child should be in a head-elevated position to decrease the progression of cerebral edema and promote the drainage of cerebrospinal fluid.