Nokea
Which statement should the nurse include when teaching parents about bacterial meningitis?
- A. Symptoms of meningitis often develop over time, making it easier to diagnose than other infections.
- B. Having a seizure associated with a high temperature usually indicates a problem other than meningitis.
- C. High-risk children 2 to 10 years and other children 11 years and older should receive the meningococcal conjugate vaccine (MCV4).
- D. Intravenous antibiotics are administered to family members who may have been in close contact with the child.
Correct Answer: C
Rationale: The meningococcal conjugate vaccine (MCV4) is recommended for high-risk children and those 11 years and older to prevent bacterial meningitis.
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The client who underwent a left above-the-knee amputation as a result of uncontrolled diabetes questions the nurse, asking, 'Why did this happen to me? I have always been a good person.' Which is the nurse’s most therapeutic response?
- A. Tell me about how it feels to have caused this to happen to you.'
- B. I know how you feel; having your leg cut off is sad.'
- C. Why do you think that you had to have your leg amputated?'
- D. I can see you are hurting. Would you like to talk?'
Correct Answer: D
Rationale: Acknowledging distress and offering to talk is therapeutic, validating emotions. Blaming the client, claiming empathy, or questioning beliefs is less supportive.
Which is the best technique for the nurse to use when applying the elastic bandage to the client's lower extremity?
- A. Making figure-eight turns with the bandage
- B. Making spiral-reverse turns with the bandage
- C. Making recurrent turns with the bandage
- D. Making spica turns with the bandage
Correct Answer: A
Rationale: The figure-eight technique provides even compression and support around the ankle joint, stabilizing it while allowing some flexibility. Spiral-reverse turns are better for cylindrical limbs, recurrent turns are used for stumps, and spica turns are typically for larger joints like the hip or shoulder.
Which description by the nurse most accurately states the purpose of halo-cervical traction?
- A. It restricts neck movement but enables physical activity.
- B. It allows head movement while immobilizing the spine.
- C. It accelerates healing by facilitating physical therapy.
- D. It promotes faster bone repair within a shorter time span.
Correct Answer: A
Rationale: Halo-cervical traction immobilizes the cervical spine to promote healing while allowing some physical activity (e.g., walking), unlike other options that inaccurately describe its function.
The client is ordered to be in a semi-reclining position following a myelogram. The nurse understands that the primary reason for this is which of the following?
- A. To prevent infection
- B. To prevent spinal headache
- C. To prevent seizures
- D. To promote excretion of dye
Correct Answer: B
Rationale: A semi-reclining position post-myelogram prevents spinal headache by reducing cerebrospinal fluid leakage.
The client is being evaluated for osteoporosis. Which diagnostic test is the most accurate when diagnosing osteoporosis?
- A. X-ray of the femur.
- B. Serum alkaline phosphatase.
- C. Dual-energy x-ray absorptiometry (DEXA).
- D. Serum bone Gla-protein test.
Correct Answer: C
Rationale: DEXA is the gold standard for osteoporosis diagnosis, measuring bone mineral density. X-rays detect fractures, alkaline phosphatase is nonspecific, and bone Gla-protein is not diagnostic.