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Which screening test is a neonatal nurse likely to use to detect developmental dysplasia of the hip (DDH)?
- A. Barlow's maneuver
- B. Pavlik's maneuver
- C. Gower's maneuver
- D. Allis's maneuver
Correct Answer: B
Rationale: Neonatal nurses are likely to use Pavlik's maneuver to detect developmental dysplasia of the hip (DDH) in newborns. Pavlik's maneuver is a technique used to diagnose, treat, and manage DDH in infants. It involves positioning the infant's hips in a flexed and abducted position to help stabilize the hip joint and promote proper development. This technique is gentle and non-invasive, making it suitable for screening infants for hip dysplasia. Other maneuvers listed, such as Barlow's, Gower's, and Allis's maneuvers, are different techniques used to assess hip stability or alignment and are not specific to DDH screening in newborns.
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A 34 year old male client is diagnosed with encephalitis. Medication has been started for him and he is receiving nursing care. Which of the ff nursing interventions are the most critical for such a client? Choose all that apply
- A. Measuring fluid intake and output
- B. Evaluating the clients ventilation capacity and lung sound frequently
- C. Observing closely for signs of respiratory distress
- D. Administering an indwelling urethral catheter
Correct Answer: B
Rationale: B. Evaluating the client's ventilation capacity and lung sounds frequently is crucial in encephalitis because the inflammation of the brain can affect the respiratory center, leading to respiratory compromise. Any changes in ventilation capacity or abnormal lung sounds should be addressed immediately to prevent respiratory distress.
Which nursing diagnosis should the nurse expect to see in a plan of care for a client in sickle cell crisis?
- A. Imbalanced nutrition:Less than body requirements related to poor intake
- B. Disturbed sleep pattern related to external stimuli
- C. Impaired skin integrity related to pruritus
- D. Pain related to sickle cell crisis
Correct Answer: D
Rationale: Sickle cell crisis is characterized by intense pain due to the vaso-occlusive properties of sickled red blood cells leading to tissue ischemia. Therefore, pain is the primary nursing diagnosis that the nurse should expect to see in the plan of care for a client experiencing a sickle cell crisis. Managing and alleviating the pain is a priority in the care of these clients to improve quality of life and prevent complications. Other nursing diagnoses such as imbalanced nutrition, disturbed sleep pattern, and impaired skin integrity may not be directly related to the acute crisis and would not be the priority focus of care in this situation.
The nurse has given medication instruction to the client receiving phenyton (Dilantin). The nurse determines that the client has an adequate understanding if the client states that:
- A. "Alcohol is not contraindicated while taking this medication."
- B. "Good oral hygiene is needed, including brushing and flossing."
- C. "The medication dose may be self-adjusted depending on side effects."
- D. "The morning dose of the medication should be taken before a serum drug level is drawn."
Correct Answer: B
Rationale: Phenytoin (Dilantin) can cause gingival hyperplasia, a side effect manifested by overgrowth of the gums. To help prevent this side effect, patients taking phenytoin should maintain good oral hygiene practices, including regular brushing and flossing. This statement shows an understanding of the importance of oral care while on phenytoin therapy, making it the correct answer choice.
A client's IV fluid orders for 24 hour's are 1500 ml D5W followed by 1250 ml of NS. The IV tubing has a drop factor of 15 gtt/ml. To administer the required fluids the nurse should set the drip rate at;
- A. 13 gtt/min
- B. 29 gtt/min
- C. 16 gtt/min
- D. 32 gtt/min Situation 5: Protection of self and patient can be done by supporting the body's immunity.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client is admitted for postoperative assessment and recovery after surgery for a kidney tumor. The nurse needs to assess for signs of urinary tract infection. Which of the ff measures can be used to help detect UTI?
- A. Encourage the client to breathe deeply and cough every 2hrs
- B. Monitor temperature every 4hrs
- C. Splint the incision when repositioning the client
- D. Irrigate tubes as ordered CARING FOR CLIENTS WITH DISORDERS OF THE BLADDER AND URETHRA
Correct Answer: B
Rationale: Monitoring temperature every 4 hours is crucial in detecting signs of a urinary tract infection in a postoperative client. An increase in temperature can indicate the presence of an infection, and early identification is essential for prompt treatment. While coughing and deep breathing (Option A) are beneficial for postoperative clients to prevent respiratory complications, they are not directly related to detecting UTI. Splinting the incision (Option C) is important for incisional care but does not specifically help in detecting UTI. Irrigating tubes (Option D) should only be done as ordered by the healthcare provider and is not a routine measure for detecting UTI.