Nokea
The nurse is teaching a mother care of her child's spica cast. The mother states that he complains of itching under the edge of the cast. One nonpharmacological technique the nurse might suggest would be:
- A. Blowing air under the cast using a hair dryer on cool setting often relieves itching.
- B. Slide a ruler under the cast and scratch the area.
- C. Guide a towel under and through the cast and move it back and forth to relieve the itch.
- D. Gently thump on cast to dislodge dried skin that causes the itching.
Correct Answer: A
Rationale: Cool air will often relieve pruritus without damaging the cast or irritating the skin. The nurse should never force anything under the cast, because the cast may become damaged and skin breakdown may occur. Forcing an object under the cast could lead to cast damage and skin breakdown. The object may become lodged under the cast necessitating cast removal. This technique does not dislodge skin cells. It could damage the cast and cause skin breakdown.
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The physician has ordered a low-sodium diet for a client with hypertension. Which food should the nurse instruct the client to avoid?
- A. Fresh fruit
- B. Grilled chicken
- C. Canned soup
- D. Brown rice
Correct Answer: C
Rationale: Canned soups are high in sodium, which exacerbates hypertension. Fresh fruit, grilled chicken, and brown rice are low-sodium options suitable for a hypertension diet.
The client at 30 weeks gestation is admitted with preterm labor. The physician orders indomethacin. The nurse should monitor for which side effect?
- A. Maternal hypertension
- B. Fetal bradycardia
- C. Oligohydramnios
- D. Maternal hypoglycemia
Correct Answer: C
Rationale: Indomethacin a tocolytic can reduce fetal urine output leading to oligohydramnios (low amniotic fluid). Maternal hypertension fetal bradycardia and hypoglycemia are not common side effects of indomethacin.
The client is admitted with a diagnosis of gestational hypertension. Which vital sign change is most concerning?
- A. Blood pressure of 160/110
- B. Heart rate of 90 bpm
- C. Respiratory rate of 20 breaths per minute
- D. Temperature of 98.6°F
Correct Answer: A
Rationale: A blood pressure of 160/110 indicates severe gestational hypertension increasing the risk of complications like stroke or eclampsia and requires immediate intervention. The other vital signs are normal.
One of the most dramatic and serious complications associated with bacterial meningitis is Waterhouse-Friderichsen syndrome, which is:
- A. Peripheral circulatory collapse
- B. Syndrome of inappropriate antidiuretic hormone
- C. Cerebral edema resulting in hydrocephalus
- D. Auditory nerve damage resulting in permanent hearing loss
Correct Answer: A
Rationale: Waterhouse-Friderichsen syndrome is peripheral circulatory collapse, which may result in extensive and diffuse intravascular coagulation and thrombocytopenia resulting in death. Syndrome of inappropriate antidiuretic hormone is a complication of meningitis, but it is not Waterhouse-Friderichsen syndrome. Cerebral edema resulting in hydrocephalus is a complication of meningitis, but it is not Waterhouse-Friderichsen syndrome. Auditory nerve damage resulting in permanent hearing loss is a complication of meningitis, but it is not Waterhouse-Friderichsen syndrome.
A 20-year-old female client delivers a stillborn infant. Following the delivery, an appropriate response by the labor nurse to the question, 'Why did this happen to my baby?' is:
- A. It's God's will. It was probably for the best. There was something probably wrong with your baby.'
- B. You're young. You can have other children later.'
- C. I know your other children will be a great comfort to you.'
- D. I can see you're upset. Would you like to see and hold your baby?'
Correct Answer: D
Rationale: The mother and the father require Wsupport; the nurse should not minimize their grief in this situation. Attachment to this infant occurs during the pregnancy for both the mother and father. Another child cannot replace this child. Attachment to this infant occurs during the pregnancy for both the mother and father. Siblings will not replace their feelings or minimize their loss of this infant. Holding and viewing the infant decreases denial and may facilitate the grief process. The nurse should prepare family members for how the infant appears ('she is bruised') and provide support.