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Which of the following would be the most appropriate nursing intervention when caring for a client with a fractured rib?
- A. Apply immobilization device after examination by physician
- B. Discourage taking deep breaths if breathing is painful
- C. Advise against using analgesics and regional nerve blocks
- D. Encouraged increased fluid intake if pulmonary contusion exists
Correct Answer: A
Rationale: Applying an immobilization device, such as a rib belt or rib binder, is a common nursing intervention for a client with a fractured rib. However, it is essential to first ensure that the client is examined by a physician to confirm the diagnosis and assess the severity of the fracture. Immobilizing the area helps reduce pain, support the chest wall, and promote healing by limiting movement that can further irritate the injured rib. Additionally, the physician's assessment is crucial for determining the appropriate treatment plan and ruling out any complications that may require further medical intervention.
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A nurse is planning a teaching session for parents of a newborn who plan to bottle-feed. Which should the nurse include in the teaching session? (Select all that apply.)
- A. Limiting the feeding to 15 minutes
- B. Propping the bottle for night feedings is acceptable
- C. Proper technique for cleansing the bottles and nipples
- D. Feeding infant on alternate sides of the lap
Correct Answer: C
Rationale: Proper technique for cleansing the bottles and nipples - It is essential to educate parents on the proper technique for cleaning bottles and nipples to prevent bacteria growth and ensure the newborn's milk is not contaminated.
Primary amenorrhea should be considered for any female adolescent who has not reached menarche by
- A. 13 years or has not done so within 3 years of thelarche
- B. 14 years or has not done so within 2 years of thelarche
- C. 14 years or has not done so within 3 years of thelarche
- D. 15 years or has not done so within 3 years of thelarche
Correct Answer: D
Rationale: Primary amenorrhea is suspected if menarche has not occurred by age 15 or within 3 years of thelarche.
Which nursing diagnosis is most appropriate for a client with Addison's disease?
- A. Risk for infection
- B. Urinary retention
- C. Excessive fluid volume
- D. Hypothermia
Correct Answer: C
Rationale: Addison's disease is a condition characterized by adrenal insufficiency, resulting in a deficiency of aldosterone and cortisol. Without aldosterone, the body is unable to regulate fluid and electrolyte balance properly, leading to sodium loss and potassium retention. This imbalance can result in excessive fluid volume, as the kidneys retain water and sodium. Symptoms of excessive fluid volume in Addison's disease can include edema, weight gain, and hypertension. Therefore, the most appropriate nursing diagnosis for a client with Addison's disease would be Excessive Fluid Volume.
Why may an ice collar be ordered for a client who is undergoing drainage of a peritonsillar abscess?
- A. To reduce swelling and pain
- B. To prevent respiratory obstruction
- C. To help the client drink fluids
- D. To prevent excessive bleeding
Correct Answer: B
Rationale: An ice collar may be ordered for a client undergoing drainage of a peritonsillar abscess to prevent respiratory obstruction. Peritonsillar abscess is a collection of pus behind the tonsils, and the inflammation and swelling from the abscess can lead to difficulty in breathing or swallowing. Applying an ice collar can help reduce the swelling and prevent the abscess from compressing the airway, thus reducing the risk of respiratory obstruction. It can provide comfort to the client and support the drainage process by minimizing the swelling and promoting better drainage of the abscess.
In Langerhans cell histiocytosis (LCH), all the following manifestations are at high risk of mortality in patients EXCEPT
- A. liver
- B. spleen
- C. lung
- D. hematopoietic system
Correct Answer: C
Rationale: Lung involvement, while serious, is less lethal compared to liver, spleen, or hematopoietic system involvement.