Nokea
The nurse is teaching the parents of an infant with osteogenesis imperfecta. The nurse should explain the need for:
- A. Additional calcium in the infant's diet
- B. Careful handling to prevent fractures
- C. Providing extra sensorimotor stimulation
- D. Frequent testing of visual function
Correct Answer: B
Rationale: Osteogenesis imperfecta causes brittle bones, so careful handling is critical to prevent fractures in infants with this condition.
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The client has an order for FeSO4 liquid. Which method of administration would be best?
- A. Administer the medication with milk
- B. Administer the medication with a meal
- C. Administer the medication with orange juice
- D. Administer the medication undiluted
Correct Answer: C
Rationale: Administering FeSO4 with orange juice enhances iron absorption due to its vitamin C content.
The nurse recognizes all of the following as part of the Cushing reflex triad EXCEPT
- A. cardiac arrhythmia.
- B. increased blood pressure.
- C. irregular respirations.
- D. decreased heart rate.
Correct Answer: A
Rationale: Cushing reflex (response to increased intracranial pressure) includes hypertension, bradycardia, and irregular respirations. Cardiac arrhythmia is not part of the triad.
The nurse is assisting in the care of a patient who is 2 days post-operative from a hemorrhoidectomy. The nurse would be correct in instructing the patient to:
- A. Avoid a high-fiber diet
- B. Continue to use ice packs
- C. Take a laxative daily to prevent constipation
- D. Use a sitz bath after each bowel movement
Correct Answer: D
Rationale: A sitz bath promotes healing and relieves pain after a hemorrhoidectomy by keeping the area clean and reducing inflammation.
An elderly female is admitted with a fractured right femoral neck. Which clinical manifestation would the nurse expect to find?
- A. Free movement of the right leg
- B. Abduction of the right leg
- C. Internal rotation of the right hip
- D. Shortening of the right leg
Correct Answer: D
Rationale: A femoral neck fracture typically causes shortening of the affected leg due to muscle contraction pulling the bone fragments together, along with external rotation and limited movement.
The physician has ordered cultures for cytomegalovirus (CMV). Which statement is true of the collection of cultures for cytomegalovirus?
- A. Stool cultures are preferred for definitive diagnosis.
- B. Pregnant caregivers may obtain cultures.
- C. Collection of one specimen is sufficient.
- D. Accurate diagnosis depends on fresh specimens.
Correct Answer: D
Rationale: Fresh specimens are critical for accurate CMV culture results, as the virus is labile and degrades quickly.