Nokea
The parents of a one-month-old boy bring their son to the clinic for evaluation of a possible right dislocated hip. If a diagnosis of unilateral dislocation of the right hip is made, which of the following symptoms will the nurse observe?
- A. Limited adduction of the right leg.
- B. Uneven gluteal fold and thigh creases.
- C. Increase in length of the right limb.
- D. Internal rotation of the right leg.
Correct Answer: B
Rationale: folds and creases will be longer and deeper on affected side
You may also like to solve these questions
A gravida III para II is admitted to the labor unit. Vaginal exam reveals that the client's cervix is 8 cm dilated, with complete effacement. The priority nursing diagnosis at this time is:
- A. Alteration in coping related to pain
- B. Potential for injury related to precipitate delivery
- C. Alteration in elimination related to anesthesia
- D. Potential for fluid volume deficit related to NPO status
Correct Answer: B
Rationale: At 8 cm dilation with complete effacement, the client is in advanced labor, and the risk of precipitate delivery is high, posing a potential for injury.
A client is admitted with disseminated herpes zoster. According to the Centers for Disease Control Guidelines for Infection Control:
- A. Airborne precautions will be needed.
- B. No special precautions will be needed.
- C. Contact precautions will be needed.
- D. Droplet precautions will be needed.
Correct Answer: A
Rationale: Disseminated herpes zoster requires airborne precautions due to the risk of varicella-zoster virus transmission through respiratory droplets and contact.
The nurse is talking in the lounge with other nurses about grief and loss. The nurse understands which to be true regarding grief and loss? Select all that apply.
- A. The process of grief is detrimental to physical and emotional health.
- B. Age, gender, and culture are a few factors that influence the grieving process.
- C. The nurse must explore his own feelings about death before he may effectively help others.
- D. The nurse should discourage expression of grief and loss because it may upset other clients nearby.
- E. The nurse can help the family develop ways to relieve loneliness and depression following the death of a loved one.
Correct Answer: B, C, E
Rationale: Age, gender, and culture influence grief; nurses must process their own feelings to help others, and supporting families post-loss is key. Grief is not inherently detrimental, and expression should be encouraged.
In planning care for the patient with ulcerative colitis, the nurse identifies which nursing diagnosis as a priority?
- A. Anxiety
- B. Impaired skin integrity
- C. Fluid volume deficit
- D. Nutrition altered, less than body requirements
Correct Answer: C
Rationale: Fluid volume deficit is a priority in ulcerative colitis due to frequent diarrhea, which can lead to dehydration.
A mother asks the home health nurse for guidance on what foods are safe to give her child, who is on strict neutropenic precautions. The nurse looks at the mother's grocery list and advises her to avoid
- A. canned peaches.
- B. pasteurized whole milk.
- C. the fresh veggie tray.
- D. fresh bananas.
Correct Answer: C
Rationale: Neutropenic precautions require avoiding fresh, unprocessed foods (e.g., fresh veggies) due to bacterial risk. Canned, pasteurized, or peeled foods are safer.