Nokea
To maintain Bryant's traction, the nurse must make certain that the child's:
- A. Hips are resting on the bed, with the legs suspended at a right angle to the bed
- B. Hips are slightly elevated above the bed and the legs are suspended at a right angle to the bed
- C. Hips are elevated above the level of the body on a pillow and the legs are suspended parallel to the bed
- D. Hips and legs are flat on the bed, with the traction positioned at the foot of the bed
Correct Answer: B
Rationale: Bryant's traction requires hips slightly elevated and legs at a right angle to the bed to maintain alignment and traction.
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The nurse is caring for an infant receiving intravenous fluid. Signs of fluid overload in an infant include:
- A. Swelling of the hands and increased temperature
- B. Increased heart rate and increased blood pressure
- C. Swelling of the feet and increased temperature
- D. Decreased heart rate and decreased blood pressure
Correct Answer: B
Rationale: Fluid overload in infants can cause increased heart rate and blood pressure due to increased intravascular volume.
A nurse creates a care plan for a client diagnosed with a cerebellar brain tumor. The correct nursing diagnosis for this client is 'Client at risk for injury related to
- A. impaired balance.'
- B. decreased visual acuity.'
- C. decreased level of consciousness.'
- D. impaired ability to make decisions.'
Correct Answer: A
Rationale: Cerebellar tumors impair coordination and balance, increasing fall risk, making 'impaired balance' the most relevant diagnosis.
A client is admitted with suspected Legionnaires' disease. Which factor increases the risk of developing Legionnaires' disease?
- A. Treatment of arthritis with steroids
- B. Foreign travel
- C. Eating fresh shellfish twice a week
- D. Doing volunteer work at the local hospital
Correct Answer: A
Rationale: Steroid use increases the risk of Legionnaires' disease by suppressing the immune system, making individuals more susceptible to Legionella infection.
The physician has ordered a homocysteine blood level on a client. The nurse recognizes that the results will be increased in a client with a deficiency in:
- A. Vitamin B12
- B. Vitamin C
- C. Vitamin A
- D. Vitamin E
Correct Answer: A
Rationale: Homocysteine levels rise with vitamin B12 deficiency, as B12 is needed for homocysteine metabolism, unlike other vitamins listed.
The nurse is caring for a first-time mother who is asking how to help her baby sleep through the night as the baby gets older. Which recommendation should the nurse tell the mother?
- A. Rock her to sleep every night until she is in a deep sleep.
- B. Give diphenhydramine 12.5 mg orally to put the baby to sleep.
- C. If she starts waking up a lot in the middle of the night, put her in the bed with you.
- D. Give the last feeding as late as possible, and put her in the bed awake without a bottle.
Correct Answer: D
Rationale: Placing the baby in bed awake after a late feeding promotes self-soothing and healthy sleep habits, unlike the other options, which may create dependencies or safety risks.