Nokea
Which type of traction can the nurse expect to be used on a 7 year-old with a fractured femur and extensive skin damage?
- A. Ninety-ninety
- B. Buck's
- C. Bryant
- D. Russell
Correct Answer: A
Rationale: Ninety degree-ninety degree traction is used for fractures of the femur or tibia. A skeletal pin or wire is surgically placed through the distal part of the femur, while the lower part of the extremity is in a boot cast. Traction ropes and pulleys are applied.
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The nurse is teaching a parent about side effects of routine immunizations. Which of the following must be reported immediately?
- A. Irritability
- B. Slight edema at site
- C. Local tenderness
- D. Seizure activity
Correct Answer: D
Rationale: Seizure activity. Other reactions that should be reported include crying for >3 hours, temperature over 104.8 degrees Fahrenheit following DPT immunization, and tender, swollen, reddened areas.
A client has been admitted for meningitis. In reviewing the laboratory analysis of cerebrospinal fluid (CSF), the nurse would expect to note
- A. High protein
- B. Clear color
- C. Elevated red blood cell count
- D. Increased glucose
Correct Answer: A
Rationale: High protein. A positive CSF for meningitis would include presence of protein, a positive blood culture, decreased glucose, cloudy color with an increased opening pressure, and an elevated white blood cell count.
The nurse is caring for a client with a history of diabetic ketoacidosis.
- A. Which intervention is most important for a client with diabetic ketoacidosis?
- B. Administer insulin as ordered.
- C. Restrict all oral fluids.
- D. Administer oral glucose.
- E. Monitor blood pressure every 4 hours.
Correct Answer: A
Rationale: Insulin administration corrects hyperglycemia and ketosis in diabetic ketoacidosis, the primary treatment. IV fluids are used, oral glucose is contraindicated, and blood pressure monitoring is less frequent.
An insulin-dependent diabetic is admitted with a blood sugar of 415 mg/dL. His wife states, 'He always follows his diabetic diet religiously and administers his insulin using a sliding scale twice a day.' Upon reviewing his chart, the nurse notes that the client has been hospitalized four times during the past three months for a medical diagnosis of hyperglycemia secondary to noncompliance with medical regimen. When questioned, he says, 'It's a little too complicated to keep track of when I need to eat and when I need to check my blood and take my medicine.' Which nursing diagnosis is most appropriate?
- A. Impaired adjustment
- B. Impaired home maintenance
- C. Ineffective family therapeutic regimen management
- D. Noncompliance
Correct Answer: D
Rationale: Repeated hospitalizations for hyperglycemia due to difficulty managing the regimen indicate noncompliance, the most appropriate diagnosis.
The nurse is caring for a client with a history of schizophrenia who is receiving haloperidol (Haldol) 5 mg PO bid. Which of the following client statements would be of GREATest concern to the nurse?
- A. I feel stiff when I walk.
- B. I have a dry mouth.
- C. I feel sleepy in the afternoon.
- D. I have a headache sometimes.
Correct Answer: A
Rationale: Stiffness when walking suggests extrapyramidal symptoms (EPS), a serious side effect of haloperidol, requiring evaluation for possible dose adjustment or antiparkinsonian medication. Options B, C, and D are common, less urgent side effects: dry mouth, sedation, and headaches.