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The school nurse is preparing to perform health screening for scoliosis on children aged 9 through 14. Which instruction should the nurse plan to provide to the children?
- A. Lie flat and lift the legs straight up.
- B. Lie on the right side and then roll to the left side while the arms are held overhead.
- C. Walk 10 feet forward and then 10 feet backward with the arms held overhead at both sides.
- D. Stand with weight equally on both feet with the legs straight, and the arms hanging loosely at both sides.
Correct Answer: D
Rationale: To perform this screening test, the child should be asked to disrobe or wear underpants only so that the chest, back, and hips can be clearly seen. The child is asked to stand with weight equally on both feet with the legs straight and the arms hanging loosely at both sides. The nurse assesses the child's posture, spinal column, shoulder height, and leg lengths. Lying down positions and walking forward and backward are incorrect assessment techniques.
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The nurse is receiving a client from the emergency department who has a diagnosis of Guillain-Barré syndrome. The client's chief sign/symptom is an ascending paralysis that has reached the level of the waist. Which items should the nurse plan to have available for emergency use?
- A. Nebulizer and pulse oximeter
- B. Blood pressure cuff and flashlight
- C. Flashlight and incentive spirometer
- D. Cardiac monitor and intubation tray
Correct Answer: D
Rationale: The client with Guillain-Barré syndrome is at risk for respiratory failure as a result of ascending paralysis. An intubation tray should be available for emergency use. Another complication of this syndrome is cardiac dysrhythmias, which necessitates the need for cardiac monitoring. Although some of the items in the remaining options may be kept at the bedside (e.g., pulse oximeter, blood pressure cuff, flashlight), they are not necessarily needed for emergency use in this situation.
A client is experiencing diabetes insipidus as a result of cranial surgery. Which anticipated therapy should the nurse plan to implement?
- A. Fluid restriction
- B. Administering diuretics
- C. Increased sodium intake
- D. Intravenous (IV) replacement of fluid losses
Correct Answer: D
Rationale: The client with diabetes insipidus excretes large amounts of extremely dilute urine. This usually occurs as a result of decreased synthesis or the release of antidiuretic hormone in clients with conditions such as head injury, surgery near the hypothalamus, or increased intracranial pressure. Corrective measures include allowing ample oral fluid intake, administering IV fluid as needed to replace sensible and insensible losses, and administering vasopressin. Diuretics are not administered. Sodium is not administered because the serum sodium level is usually high, as is the serum osmolality.
A child with a diagnosis of Reye's syndrome is being admitted to the hospital. The nurse develops a plan of care for the child that includes which priority nursing action?
- A. Monitoring for hearing loss
- B. Monitoring intake and output (I&O)
- C. Repositioning the child every 2 hours
- D. Providing a quiet environment with dimmed lighting
Correct Answer: D
Rationale: Cerebral edema is a progressive part of the disease process of Reye's syndrome. A priority component of care for a child with Reye's syndrome is maintaining effective cerebral perfusion and controlling intracranial pressure. Decreasing stimuli in the environment would decrease the stress on the cerebral tissue, as well as neuron responses. Hearing loss does not occur in clients with this disorder. Although monitoring I&O may be a component of the plan, it is not the priority nursing action. Changing the body position every 2 hours would not affect the cerebral edema and intracranial pressure directly. The child should be in a head-elevated position to decrease the progression of cerebral edema and promote the drainage of cerebrospinal fluid.
The nurse is preparing to admit a client from the postanesthesia care unit who has had microvascular decompression of the trigeminal nerve. Which equipment should the nurse ask the unlicensed assistive personnel to make sure is at the bedside when the client arrives?
- A. Flashlight and pulse oximeter
- B. Cardiac monitor and suction equipment
- C. Padded bed rails and suction equipment
- D. Blood pressure cuff and cardiac monitor
Correct Answer: A
Rationale: The postoperative care of the client having microvascular decompression of the trigeminal nerve is the same as for the client undergoing craniotomy. This client requires hourly neurological assessment as well as monitoring of the cardiovascular and respiratory statuses. Therefore, a flashlight and pulse oximetry are necessary items. Cardiac monitoring and padded bed rails are not indicated unless there is a special need based on a client history of cardiac disease or seizures, respectively. Suctioning is performed cautiously and only when necessary after craniotomy to avoid increasing the intracranial pressure.
The student nurse is listening to a lecture on serum electrolyte levels and the use of isotonic solutions. Which statement by the student nurse indicates that the teaching has been effective?
- A. 10% dextrose in water is a hypotonic solution.
- B. 3% sodium chloride solution is a hypotonic solution.
- C. 5% dextrose in water is considered an isotonic solution.
- D. 0.45% sodium chloride solution is a hypertonic solution.
Correct Answer: C
Rationale: Five percent dextrose in water is an isotonic solution, which means that the osmolality of this solution matches normal body fluids. Other examples of isotonic fluids include 0.9% sodium chloride solution (normal saline) and lactated Ringer's solution. Ten percent dextrose in water and 3% sodium chloride solution are hypertonic solutions, and 0.45% sodium chloride solution is hypotonic.