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The nurse is screening pediatric clients for developmental dysplasia of the hip (DDH). Which of the following findings would be consistent with DDH in a 3-week-old client?
- A. the leg on the affected side appears longer
- B. narrowing of the perineum
- C. presence of extra gluteal folds on the affected side
- D. pelvic tilt with lordosis
Correct Answer: C
Rationale: Extra gluteal folds (C) are a sign of DDH. The affected leg appears shorter, not longer (A). Narrowing of the perineum (B) and pelvic tilt (D) are not typical.
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The nurse is caring for a child newly diagnosed with cystic fibrosis. What interventions does the nurse expect to be included in the client's multidisciplinary plan of care?
- A. Chest physiotherapy
- B. Genetic counseling
- C. Low-calorie diet
- D. Oral fluid restriction
- E. Spiritual support
Correct Answer: A,B,E
Rationale: Chest physiotherapy (A) clears mucus, genetic counseling (B) addresses hereditary aspects, and spiritual support (E) aids coping. A high-calorie diet, not low-calorie (C), is needed for nutrition. Fluid restriction (D) is inappropriate, as hydration is encouraged.
An elderly client who experiences nighttime confusion wanders from his room into the room of another client. The nurse can best help decrease the client's confusion by:
- A. Assigning a nursing assistant to sit with him until he falls asleep
- B. Allowing the client to room with another elderly client
- C. Administering a bedtime sedative
- D. Leaving a night light on during the evening and night shifts
Correct Answer: D
Rationale: A night light reduces confusion by improving visibility and orientation. Constant supervision is impractical, room-sharing may worsen confusion, and sedatives increase fall risk.
The client with a colostomy does not feel that the irrigating solution has drained completely. The nurse can enhance the effectiveness of the colostomy irrigation by telling the client to:
- A. Massage the abdomen gently.
- B. Reduce the amount of irrigation solution.
- C. Increase his oral intake.
- D. Place a heating pad on the abdomen.
Correct Answer: A
Rationale: Gentle abdominal massage can stimulate peristalsis and help the irrigation solution drain completely from the colostomy. Reducing solution or using a heating pad is not standard, and increasing oral intake is unrelated.
Which of these clients, all of whom have the findings of a board-like abdomen, would the nurse suggest that the provider examine first?
- A. An elderly client who stated, 'My awful pain in my right side suddenly stopped about 3 hours ago.'
- B. A pregnant woman of 8 weeks newly diagnosed with an ectopic pregnancy
- C. A middle-aged client admitted with diverticulitis who has taken only clear liquids for the past week
- D. A teenager with a history of falling off a bicycle without hitting the handle bars
Correct Answer: A
Rationale: An elderly client who stated, 'My awful pain in my right side suddenly stopped about 3 hours ago.' This client has the highest risk for hypovolemic and septic shock since the appendix has most likely ruptured, based on the history of the pain suddenly stopping over three hours ago. Elderly clients have less functional reserve for the body to cope with shock and infection over long periods. The others are at risk for shock also, however given that they fall in younger age groups, they would more likely be able to tolerate an imbalance in circulation. A common complication of falling off a bicycle is hitting the handle bars in the upper abdomen often on the left, resulting in a ruptured spleen.
The nurse is assessing a young child at a clinic visit for a mild respiratory infection. Koplik spots are noted on the oral mucous membranes. The nurse should then assess which area of the body?
- A. The skin
- B. The lungs
- C. The muscles
- D. Bowel and bladder
Correct Answer: A
Rationale: The skin. A characteristic sign of rubeola is Koplik spots (small red spots with a bluish white center). These are found on the buccal mucosa about 2 days before and after the onset of the measles rash.