The nurse should plan to include information about which common practice that can increase the risk for developmental dysplasia of the hip (DDH)?
- A. Carrying a child in a backpack
- B. Carrying a child in a frontpack
- C. Swaddling of a child
- D. Extended time in a car seat
Correct Answer: C
Rationale: Tight swaddling can restrict hip movement and increase the risk of DDH.
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A college student visits a campus health service reporting knee pain, clicking when walking, 'locking,' and 'giving way' of the affected knee. The injury occurred when twisting the knee wrong during a tennis match. The nurse should further assess for which problem?
- A. Injury of the meniscus cartilage
- B. Fracture of the lateral tibial condyle
- C. Injury and possible fractured patella
- D. Lateral collateral ligament injury
Correct Answer: A
Rationale: A. The nurse should assess for injury to the meniscus (knee) cartilage. Abrupt twisting can tear the cartilage, and the loose cartilage can cause locking of the joint, clicking, and the knee to 'give way.'
The nurse is caring for a client six (6) hours postoperative right total knee replacement. Which data should the nurse report to the surgeon?
- A. A total of 100 mL of red drainage in the autotransfusion drainage system.
- B. Pain relief after using the patient-controlled analgesia (PCA) pump.
- C. Cool toes, distal pulses palpable, and pale nailbeds bilaterally.
- D. Urinary output of 60 mL of clear yellow urine in three (3) hours.
Correct Answer: C
Rationale: Cool toes and pale nailbeds suggest vascular compromise, requiring surgeon notification. Expected drainage, pain relief, and low urine output are less urgent.
Which explanation by the nurse is best when the parents ask how their child with Duchenne muscular dystrophy will be treated knowing that the life expectancy is limited?
- A. "Due to your child's cognitive impairment, your child will be unaware of a shortened life."
- B. "We will focus on maximizing your child's abilities and promoting your child's comfort."
- C. "There is not enough known about this disease to know what will happen in the future."
- D. "Nothing is likely to happen for a long time; we'll deal with it when the time comes."
Correct Answer: B
Rationale: Treatment for DMD focuses on maximizing function and comfort to improve quality of life.
The nurse is caring for the client after a right TKR. To prevent circulatory complications, the nurse should ensure that the client is performing which action?
- A. Flexing both feet and exercising uninvolved joints every hour while awake
- B. Using the continuous passive motion device (CPM) every 2 hours for 30 minutes
- C. Being assisted up to a chair as soon as the effects of anesthesia have worn off
- D. Using the trapeze to lift off the bed and then rotating each leg intermittently
Correct Answer: A
Rationale: A. Dorsiflexion of the foot promotes muscle contraction, which compresses veins. This reduces venous stasis and risk of thrombus formation. It should be performed every hour while awake.
The child with an SCI is prescribed baclofen 5 mg tid orally to treat muscle spasticity. How many tablets should the nurse administer for one dose if 20-mg tablets are available?
Correct Answer: 0.25
Rationale: 5 mg divided by 20 mg per tablet equals 0.25 tablets per dose.
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