Nokea
Which intervention(s) should the nurse include in the child's plan of care immediately following insertion of a ventriculoperitoneal (VP) shunt for treatment of hydrocephalus?
- A. Maintain the head of the bed in an elevated position.
- B. Ensure that the child minimizes movement of the extremities.
- C. Provide a pressure dressing over the cephalic insertion site.
- D. Maintain a flat position and reposition the child every 2 hours.
Correct Answer: D
Rationale: Maintaining a flat position and repositioning every 2 hours helps prevent complications and ensures shunt function post-VP shunt insertion.
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The client is taken to the emergency department with an injury to the left arm. Which intervention should the nurse implement first?
- A. Assess the nailbeds for capillary refill time.
- B. Remove the client's clothing from the arm.
- C. Call radiology for a STAT x-ray of the extremity.
- D. Prepare the client for the application of a cast.
Correct Answer: A
Rationale: Assessing capillary refill evaluates neurovascular status, the priority in arm injury to detect compromise. Clothing removal, x-rays, and casting follow assessment.
What is the goal of therapy for a child newly diagnosed with scoliosis as explained by the nurse?
- A. Limit or stop progression of the curvature of the spine.
- B. Prepare the child for surgical correction at a later date.
- C. Minimize the complications of prolonged immobilization.
- D. Develop a pain management plan to minimize complications.
Correct Answer: A
Rationale: The primary goal of scoliosis treatment is to halt or limit the progression of spinal curvature.
On the basis of the nurse's knowledge of the client's culture and beliefs, which statement regarding the health-seeking behavior is probably most accurate?
- A. Home remedies have been unsuccessful, and the condition threatens the client's self-image.
- B. The power to cure comes from physicians and is passed to nurses.
- C. Both of the above
- D. None of the above
Correct Answer: A
Rationale: Hispanic clients may initially rely on home remedies due to cultural practices, seeking medical care when these fail, especially if pain (e.g., bursitis) impacts self-image or function.
The client with newly diagnosed rheumatoid arthritis asks what can happen if no treatment is done. The nurse knows that if rheumatoid arthritis is left untreated, which of the following would be most apt to develop?
- A. Bony ankylosis
- B. Chronic osteomyelitis
- C. Pathological fractures
- D. Joint hypermobility
Correct Answer: A
Rationale: Untreated rheumatoid arthritis can lead to bony ankylosis, where joints fuse due to chronic inflammation.
Which illustration demonstrates abduction for a 10-year-old who had an SCI?
- A. ROM-1.png
- B. ROM-2.png
- C. ROM-3.png
- D. ROM-4.png
Correct Answer: A
Rationale: Abduction involves moving a limb away from the body's midline, as shown in the correct illustration.