Nokea
Which assessment findings should the nurse associate with the development of hydrocephalus in a 7-year-old child?
- A. Headache
- B. Vomiting
- C. Angioedema
- D. Personality change
- E. Increased head circumference
Correct Answer: A,B,D
Rationale: Headache, vomiting, and personality changes are common symptoms of hydrocephalus due to increased intracranial pressure.
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Which intervention should the nurse include for a client diagnosed with carpal tunnel syndrome?
- A. Teach hyperextension exercises to increase flexibility.
- B. Monitor safety during occupational hazards.
- C. Prepare for the insertions of pins or screws.
- D. Monitor dressing and drain after the fasciotomy.
Correct Answer: B
Rationale: Monitoring occupational hazards (e.g., repetitive tasks) prevents carpal tunnel exacerbation. Hyperextension worsens symptoms, and surgical interventions are not first-line.
Which explanation by the nurse is best when the parents ask how their child with Duchenne muscular dystrophy will be treated knowing that the life expectancy is limited?
- A. "Due to your child's cognitive impairment, your child will be unaware of a shortened life."
- B. "We will focus on maximizing your child's abilities and promoting your child's comfort."
- C. "There is not enough known about this disease to know what will happen in the future."
- D. "Nothing is likely to happen for a long time; we'll deal with it when the time comes."
Correct Answer: B
Rationale: Treatment for DMD focuses on maximizing function and comfort to improve quality of life.
The child with an SCI is prescribed baclofen 5 mg tid orally to treat muscle spasticity. How many tablets should the nurse administer for one dose if 20-mg tablets are available?
Correct Answer: 0.25
Rationale: 5 mg divided by 20 mg per tablet equals 0.25 tablets per dose.
The client is being seen in the clinic for a second-degree ankle sprain. Which treatments should the nurse plan?
- A. Rest, elevate the extremity, apply ice intermittently, and apply a compression bandage.
- B. Do range of motion to determine the extent of injury, apply heat, and check circulation.
- C. Use moist heat and then apply ice; check circulation, motion, and sensation; and elevate.
- D. Refer to an orthopedic surgeon, apply ice, give an analgesic, elevate, and encourage rest.
Correct Answer: A
Rationale: A. Rest prevents further injury and promotes healing. Ice and elevation control swelling. Compression with an elastic bandage controls bleeding, reduces edema, and provides support for injured tissues.
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.