Nokea
Which intervention should the nurse implement for a hospitalized child with autism?
- A. Hold and stroke the child while doing the assessment
- B. Play the radio or turn on the television for distraction
- C. Have the parent bring the child's favorite toy from home
- D. Provide plenty of age-appropriate foods on the meal tray
Correct Answer: C
Rationale: Bringing a favorite toy can provide comfort and reduce anxiety for a child with autism in a hospital setting.
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The client who had a total knee replacement is being discharged home. To which multidisciplinary team member should the nurse refer the client?
- A. The occupational therapist.
- B. The physiatrist.
- C. The recreational therapist.
- D. The home health nurse.
Correct Answer: D
Rationale: A home health nurse monitors recovery, manages complications, and supports mobility post-TKR. OT, physiatrists, and recreational therapists are less critical at discharge.
If the client is in shock, how should the nurse position the client while continuing to assess and provide care?
- A. Prone with the arm supported
- B. In Fowler's position with the knees flexed
- C. Supine with the legs elevated
- D. Lateral with the back extended
Correct Answer: C
Rationale: Supine with legs elevated improves venous return in shock.
The nurse assesses the client 6 hours following a lumbar spinal fusion. The client has a throbbing headache, but VS and CMS of the lower extremities are WNL. The lungs have fine basilar crackles. The back dressing has a dime-sized bloody spot surrounded by clear yellow drainage. Which nursing action demonstrates the nurse's best clinical judgment?
- A. Give prescribed morphine sulfate IV
- B. Have the client cough and deep breathe
- C. Reinforce the incisional dressing
- D. Notify the health care provider
Correct Answer: D
Rationale: D. A bloody area surrounded by clear yellowish fluid on the dressing and the client's headache suggest a CSF leak. The nurse should notify the HCP.
The nurse is caring for the client 24 hours following total hip arthroplasty using the traditional posterior approach. Which interventions should the nurse plan to implement? Select all that apply.
- A. Place pillows or a wedge pillow between the client's legs to keep them abducted.
- B. Have the client flex the unaffected hip and use the trapeze to help move up in bed.
- C. Raise the head of the bed to no more than 90 degrees when the bed is placed contour.
- D. Place a pillow between the client's knees when initially assisting the client out of bed.
- E. Applies antiembolism stockings that should not be removed for 24 hours postoperatively.
Correct Answer: A,B,D
Rationale: A. A pillow should be used to maintain abduction to prevent dislocation. B. Using the trapeze and flexing the unaffected legs while keeping the affected leg straight help prevent flexion with position changes. The client's hip should not be flexed more than 90 degrees. D. In initial transfers, a pillow is used to remind the client to maintain abduction and prevent internal and external hip rotation.
While teaching the client, what can the nurse explain about the purpose for prescribing this medication?
- A. To reduce emotional depression
- B. To relax skeletal muscles
- C. To promote restful sleep
- D. To relieve inflammation
Correct Answer: B
Rationale: Cyclobenzaprine (Flexeril) is a muscle relaxant used to reduce muscle spasms associated with a herniated disk, alleviating pain and improving mobility. It does not primarily address depression, sleep, or inflammation.