What is the most important factor for the nurse to consider when teaching the child who has CP?
- A. Current age
- B. Type of cerebral palsy
- C. Prior illness experience
- D. Developmental level
Correct Answer: D
Rationale: Developmental level is critical to tailor teaching to the child's cognitive and physical abilities.
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The client with a cervical neck injury as a result of a motor-vehicle accident is complaining of unrelieved pain after administration of a narcotic analgesic. Which alternative method of pain control is an independent nursing action?
- A. Medicate the client with a muscle relaxant.
- B. Heat alternating with ice applied by a physical therapist.
- C. Watch television or listen to music.
- D. Discuss surgical options with the health-care provider.
Correct Answer: C
Rationale: Distraction via TV or music is an independent nursing action to manage pain. Muscle relaxants require a prescription, heat/ice involves PT, and surgical discussions are physician-driven.
The nurse writes a concept of 'impaired mobility' for a client diagnosed with a fractured right hip. Which would the nurse include in the plan of care? Select all that apply.
- A. Request a physical therapy referral.
- B. Administer enoxaparin (Lovenox) subcutaneously.
- C. Utilize a gait belt when ambulating the client.
- D. Assess the client’s pain levels on a 1-to-10 scale.
- E. Provide a high-carbohydrate, high-fat, high-sodium diet.
Correct Answer: A,B,C,D
Rationale: PT referral, enoxaparin, gait belt, and pain assessment promote mobility and prevent complications in hip fracture. High-carb/fat/sodium diet is inappropriate.
The client with arthritis is receiving sodium salicylate and asks the nurse what the drug will do for her. The nurse's reply should include information that the drug is given for which of the following effects?
- A. Antipyretic
- B. Antibiotic
- C. Anticoagulant
- D. Anti-inflammatory
Correct Answer: D
Rationale: Sodium salicylate is primarily used for its anti-inflammatory effects in arthritis, reducing joint pain and swelling.
The nurse teaches the trainers that adolescent soccer players are at increased risk for which abnormality?
- A. Varus knee deformities
- B. Valgus knee deformities
- C. Varus ankle deformities
- D. Valgus ankle deformities
Correct Answer: A
Rationale: Adolescent soccer players are at risk for varus knee deformities due to repetitive stress on the knees.
In which conditions might the nurse assess for the presence of papilledema?
- A. Eczema
- B. Craniosynostosis
- C. Shaken baby syndrome
- D. Hydrocephalus
- E. Chest trauma
Correct Answer: B,C,D
Rationale: Papilledema, indicating increased intracranial pressure, can be associated with craniosynostosis, shaken baby syndrome, and hydrocephalus.
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