Nokea
When preparing to meet with the parents and their 5-year-old child with autism, which behaviors should the nurse anticipate that the child might display?
- A. Polydactyly
- B. Leukoderma
- C. Poor eye contact
- D. Restricted interests
- E. Atypical language
Correct Answer: C,D,E
Rationale: Children with autism often exhibit poor eye contact, restricted interests, and atypical language patterns.
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When planning the client's discharge, the nurse must help the client obtain which essential piece of equipment for home care?
- A. A wheelchair
- B. A hospital bed
- C. A raised toilet seat
- D. A mechanical lift
Correct Answer: C
Rationale: A raised toilet seat prevents excessive hip flexion, reducing dislocation risk.
The nurse is caring for a client in a hip spica cast. Which intervention should the nurse include in the plan of care?
- A. Assess the client’s popliteal pulses every shift.
- B. Elevate the leg on pillows and apply ice packs.
- C. Teach the client how to ambulate with a tripod walker.
- D. Assess the client for distention and vomiting.
Correct Answer: D
Rationale: Distention and vomiting indicate GI complications (e.g., ileus) in a hip spica cast, requiring assessment. Pulses are accessible, elevation is impractical, and ambulation is limited.
When preparing the client for cast application, which statement by the nurse is most accurate?
- A. The cast will feel tight as it's applied.
- B. Your arm will feel warm as the wet plaster sets.
- C. You can expect a foul odor until the cast is dry.
- D. You may feel itchy while the cast is wet.
Correct Answer: B
Rationale: Wet plaster generates heat as it sets, causing a warm sensation, which is a normal part of the process. Tightness may indicate a problem, odors are not typical, and itching is more common as the cast dries.
The nurse is to give the client with gout one tablet of colchicine every hour until relief or toxicity occurs. Which of the following is an indication for stopping the colchicine?
- A. Ringing in the ears
- B. Nausea and vomiting
- C. A rash on the client's hips
- D. A temperature of 101°F
Correct Answer: B
Rationale: Nausea and vomiting are signs of colchicine toxicity, indicating the need to stop the medication.
Which is the nurse's best explanation regarding the goal of surgery for an adolescent requiring surgical treatment for scoliosis?
- A. "The surgery will allow you to grow to be taller."
- B. "The surgery will decrease the recurrence of pain."
- C. "The surgery will prevent problems with breathing."
- D. "The surgery will allow your clothes to fit you better."
Correct Answer: C
Rationale: Scoliosis surgery aims to correct spinal deformity and prevent respiratory complications.