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 nurse is caring for a client diagnosed with a fracture of the right distal humerus. Which data indicate a complication? Select all that apply.
- A. Numbness and mottled cyanosis.
- B. Paresthesia and paralysis.
- C. Proximal pulses and point tenderness.
- D. Coldness of the extremity and crepitus.
- E. Palpable radial pulse and functional movement.
Correct Answer: A,B,D
Rationale: Numbness, cyanosis, paresthesia, paralysis, coldness, and crepitus indicate compartment syndrome or neurovascular compromise, serious fracture complications. Pulses and tenderness are expected.
The experienced nurse observes the new nurse caring for the client who is in skeletal traction to stabilize a proximal femur fracture prior to surgery. Which observation by the experienced nurse indicates the new nurse needs additional orientation?
- A. Positions the client so the client's feet stay clear of the bottom of the bed
- B. Checks ropes so that they are positioned in the wheel groves of the pulleys
- C. Removes weights from ropes until the weights hang free of the bed frame
- D. Performs pin site care with chlorhexidine solution once during the 8-hour shift
Correct Answer: C
Rationale: C. Weights should be hanging freely, but weights should never be removed (unless a life-threatening situation occurs) because removal could result in injury and defeats the purpose of the traction. The lengths of the ropes need to be adjusted so the weights do not rest on the bed frame.
Which is most important for the nurse to include in the child's plan of care for a child with spina bifida (myelodysplasia)?
- A. Avoid the child's exposure to latex.
- B. Do intermittent urinary catheterization.
- C. Provide dietary fiber supplements daily.
- D. Complete a referral for physical therapy.
Correct Answer: A
Rationale: Avoiding latex exposure is critical due to the high risk of latex allergy in children with spina bifida.
The nurse is discharge teaching for a client with a short leg cast. Which statement indicates the client understands the discharge teaching?
- A. I need to keep my leg elevated on two pillows for the first 24 hours.'
- B. I must wear my sequential compression device all the time.'
- C. I can remove the cast for one (1) hour so I can take a shower.'
- D. I will be able to walk on my cast and not have to use crutches.'
Correct Answer: A
Rationale: Elevating the leg reduces swelling post-casting, indicating understanding. SCDs are for DVT, cast removal is unsafe, and walking without crutches depends on the fracture.
Which nursing instruction about heating pads is essential to include in the client's teaching plan?
- A. Use the lowest setting on the heating pad.
- B. Place the heating pad directly on the skin.
- C. Cover the heating pad with plastic during use.
- D. Apply the heating pad for 2 hours at a time.
Correct Answer: A
Rationale: Using the lowest setting on the heating pad minimizes the risk of burns, especially in older clients with potentially reduced skin sensitivity. Direct skin contact, plastic covers, or prolonged use increase burn risk.