Nokea
The nurse provides instructions regarding home care to a parent of a 3-year-old child who has been hospitalized with hemophilia. Which statement by the parent indicates the need for further teaching?
- A. I should not leave my child unattended.
- B. I need to pad table corners in my home.
- C. My child should not have any immunizations.
- D. I need to remove household items that can tip over.
Correct Answer: C
Rationale: Immunizations are important for children with hemophilia to prevent infections, and the parent's statement about avoiding them indicates a misunderstanding. Not leaving the child unattended, padding table corners, and removing tippable items are appropriate safety measures to prevent bleeding injuries.
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The nurse is planning discharge teaching for the parents of a child who sustained a head injury and who is now receiving tapering doses of dexamethasone. The nurse plans to make which statement to the parents?
- A. This medication decreases the chance of infection.
- B. This medication will be discontinued after two doses.
- C. If your child's face becomes puffy, the medication dose needs to be increased.
- D. This medication is tapered to decrease the chance of recurring swelling in the brain.
Correct Answer: D
Rationale: Dexamethasone sodium phosphate is a corticosteroid. The rebounding of cerebral edema is a side effect of dexamethasone sodium phosphate withdrawal if it is done abruptly. This medication decreases inflammation rather than infection. Facial edema is a common side effect that disappears when the medication is discontinued.
A mother brings her 6-month-old baby to the nurse practitioner for a routine well-baby check. Which behavior reported by the mother is concerning to the nurse?
- A. looks at self in a mirror
- B. brings things to mouth
- C. does not laugh or make squealing sounds
- D. begins to sit without support
Correct Answer: C
Rationale: Lack of laughing or squealing at 6 months suggests a developmental delay, as these are expected social behaviors. Other behaviors are age-appropriate.
When preparing the client with a spinal cord injury who is experiencing bladder spasms and reflex incontinence for discharge to home, the nurse should provide which instruction to prevent the problem?
- A. Avoid caffeine in your diet.
- B. Take your temperature every day.
- C. Limit your fluid intake to 1000 mL per 24 hours.
- D. Catheterize yourself every 2 hours as needed to prevent spasm.
Correct Answer: A
Rationale: Caffeine in the diet can contribute to bladder spasms and reflex incontinence; thus, it should be eliminated in the diet of the client with a spinal cord injury. The self-monitoring of the temperature is useful to detect infection, but it does nothing to alleviate bladder spasms. Limiting fluid intake does not prevent spasm, and it could place the client at further risk for urinary tract infection. Self-catheterization every 2 hours is too frequent and serves no useful purpose.
To promote self-care, the nurse is planning to teach a client in skeletal leg traction about measures to increase bed mobility. Which item is most helpful for this client for achievement of this goal?
- A. Fracture bedpan
- B. Overhead trapeze
- C. Isometric exercises
- D. Range-of-motion exercises
Correct Answer: B
Rationale: The use of an overhead trapeze is extremely helpful for assisting a client with moving about in bed and getting on and off the bedpan. This device has the greatest value for increasing overall bed mobility. A fracture bedpan is useful for reducing discomfort with elimination. Isometric exercises will not increase bed mobility and could be harmful for a client in skeletal traction. Range-of-motion exercises can also be harmful to a client in skeletal traction and should not be initiated unless there are specific prescriptions to do so.
The nurse has provided instructions to a new mother with a urinary tract infection regarding foods and fluids to consume that will acidify the urine. The nurse determines that further teaching is needed if the mother indicates that which fluid will acidify the urine?
- A. Prune juice
- B. Apricot juice
- C. Cranberry juice
- D. Carbonated drinks
Correct Answer: D
Rationale: Acidification of the urine inhibits the multiplication of bacteria. Carbonated drinks should be avoided because they increase urine alkalinity. Fluids that acidify the urine include prune, apricot, and cranberry juice.