Nokea
Which level of participation should the nurse expect when assessing a 9-year-old who has mental retardation with an IQ level of 45?
- A. Able to communicate verbally only with two-letter words
- B. Able to read and comprehend simple written instructions
- C. Able to walk independently and perform a simple skill
- D. Able to perform tasks that require careful manual dexterity
Correct Answer: C
Rationale: An IQ of 45 indicates moderate intellectual disability, allowing independent walking and simple tasks.
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What is true about absence seizures in children?
- A. For most children, absence seizures stop during early teen years.
- B. Absence seizures rarely progress to other seizures.
- C. Teachers often note signs of absence seizures, but seeing them is not adequate for diagnosis.
- D. Absence seizures usually exist in isolation; usually the child has no other neurological condition.
Correct Answer: A
Rationale: Most children outgrow absence seizures during their early teen years.
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 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.
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.
The client with a lower leg amputation has edema, so the NA elevates the client's residual left limb on pillows. What is the most appropriate action by the nurse when observing that the client's leg has been elevated?
- A. Thank the nursing assistant (NA) for being so observant and intervening appropriately to treat the client's edema of the residual limb.
- B. Remove the pillows, raise the foot of the bed, and inform the NA that the limb should not be elevated on pillows because it could cause a flexion contracture.
- C. Inform the NA that this was the correct action at this time in the client's recovery, but once the client's incision heals, the leg should not be elevated.
- D. Report the incident to the surgeon and tell the NA to complete a variance report because the client's leg should not have been elevated.
Correct Answer: B
Rationale: B. The nurse should perform this action. Flexion, abduction, and external rotation of the residual lower limb are avoided to prevent hip contracture.