Nokea
Which of the following findings should lead the nurse to decide that spinal shock was resolving in the adolescent with a spinal cord injury?
- A. Atonic urinary bladder.
- B. Flaccid paralysis.
- C. Hyperactive reflexes.
- D. Widened pulse pressure.
Correct Answer: C
Rationale: Hyperactive reflexes indicate the resolution of spinal shock, as the nervous system begins to recover from initial flaccidity.
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After having a blood sample drawn, a 5-year-old child insists that the site be covered with a bandage. When the parent tries to remove the bandage before leaving the office, the child screams that all the blood will come out. The nurse encourages the parent to leave the bandage in place and tells the parent that the child:
- A. Fears another procedure.
- B. Does not understand body integrity.
- C. Is expressing pain.
- D. Is attempting to regain control.
Correct Answer: B
Rationale: Preschoolers may fear loss of body integrity, believing blood will leak out without a bandage.
A 14-year-old is using glargine (Lantus) and lispro (Humolog) to manage type I diabetes. The order for sliding scale lispro reads: Lispro subcutaneous give units according to sliding scale: Blood glucose: 70-150 mg/dL = 0 units, 151-200 mg/dL = 1 unit, 201-250 mg/dL = 2 units, 251-300 mg/dL = 3 units, 301-350 mg/dL = 4 units, Call for Blood glucose >350. In addition give 1 unit for every 15 grams of carbohydrate. The morning blood glucose is $202 \mathrm{mg} / \mathrm{dL}$ and the client is going to eat 2 carbohydrate exchanges. The nurse has the client administer how many units of lispro?
Correct Answer: 4
Rationale: Blood glucose of 202 mg/dL requires 2 units (sliding scale). Two carbohydrate exchanges (30 g) require 2 units (1 unit/15 g). Total: 2 + 2 = 4 units of lispro.
The parents of a 3-year-old suspect that the child has recently ingested a large amount of acetaminophen. The child does not appear in immediate distress. The nurse should anticipate doing which of these interventions in order of priority, from first to last?
- A. Draw acetaminophen serum levels.
- B. Attempt to determine the exact time and amount of drug ingested.
- C. Administer acetylcysteine (Acetadote IV).
- D. Administer activated charcoal.
Correct Answer: B,D,A,C
Rationale: First, determine ingestion details (B) to assess risk. Administer charcoal (D) within 1-2 hours to reduce absorption. Draw serum levels (A) at 4 hours to confirm toxicity. Administer acetylcysteine (C) if levels are toxic.
A 17-year-old female with severe nodular acne is considering treatment with isotretinoin (Accutane). Prior to beginning the medication, the nurse explains that the client will be required to:
- A. Enroll in a risk management plan.
- B. Egypt in a risk management plan.
- C. Begin an effective form of birth control.
- D. Temporarily give up sports.
Correct Answer: C
Rationale: Isotretinoin has a high risk of teratogenicity, requiring strict contraception to prevent pregnancy during treatment. A risk management plan (e.g., iPLEDGE) is also required, but the most critical initial step emphasized is effective birth control.
When taking a diet history from the mother of a 7-year-old child with phenylketonuria, a report of which of the following foods indicates a need for further teaching?
- A. Low-protein bread.
- B. Special PKU formula.
- C. Fresh apples.
- D. Chicken nuggets.
Correct Answer: D
Rationale: Chicken nuggets are high in phenylalanine, contraindicated in PKU. Low-protein bread, PKU formula, and apples are appropriate for a PKU diet.