Nokea
While a two-day-old infant is in surgery for repair of spina bifida, the infant's mother expresses concern to the nurse because the doctor told her the infant would be confined to a wheelchair. Which of the following statements, if made by the nurse, is BEST?
- A. Physical therapy can restore the function to affected muscles.
- B. Orthopedic devices will allow your child to strengthen lower extremity muscles.
- C. Corrective surgery will return function to the affected muscles.
- D. The corrective surgery will not change your child's physical disability.
Correct Answer: D
Rationale: spinal nerves that are destroyed by the myelomeningocele cannot be corrected; nothing can return function to portions of the body that are innervated by the spinal nerves below the site of the myelomeningocele
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The nurse is caring for a client who is receiving a continuous IV infusion of fentanyl for pain management. Which of the following findings should the nurse report immediately?
- A. Respiratory rate of 10 breaths/min
- B. Blood pressure of 120/80 mmHg
- C. Heart rate of 80 bpm
- D. Oxygen saturation of 95%
Correct Answer: A
Rationale: A respiratory rate of 10 breaths/min indicates respiratory depression, a serious fentanyl side effect. Options B, C, and D are normal findings.
The nurse is preparing a client for a herniorrhaphy. It would be MOST important for the nurse to complete which of the following one hour prior to surgery?
- A. Administer an enema.
- B. Confirm that the consent form has been signed.
- C. Perform a preoperative shave and scrub.
- D. Evaluate for food or medication allergies.
Correct Answer: B
Rationale: surgical consent should be rechecked prior to going to surgery
Which of the following strategies would be MOST therapeutic as the nurse tries to analyze a bulimic client's eating habits and the circumstances that precipitate the client's eating problems?
- A. Observe family communication patterns at a 'monitored mealtime.'
- B. Distract the client at mealtime.
- C. Assign the client a food/feelings/thoughts/actions journal.
- D. Assign the client to write a 'lifeline' in relation to eating behaviors.
Correct Answer: C
Rationale: implementation, nurse is trying to analyze and understand what triggers the client's binging and purging activities, so therapeutic nursing intervention of assigning a thought/feelings/actions (T/F/A) journal relating to client's eating behaviors will be most helpful to the nurse and therapeutic to the client; after this information is gained and reviewed, collaboration by the nurse and client on other strategies such as delay and distraction techniques, stress reduction, and developing a 'lifeline' in relation to eating behaviors will further benefit the client
On a home health visit, an elderly client states, 'This neighborhood has really gone down. I feel like a prisoner in my own home with all the trouble out there.' Which of the following nursing responses by the nurse is BEST?
- A. Have you and your neighbors formed a neighborhood watch?
- B. It must be very difficult for you to live in this neighborhood.
- C. I see a lot of police cars, so you should be pretty safe.
- D. Tell me what has happened to make you feel that you are not safe.
Correct Answer: D
Rationale: assessing the basis for client's fears and encouraging client to talk about them is the first positive step
The nurse is caring for a postoperative patient. Four hours after surgery, the patient voids 200 cc of urine with a specific gravity of 1.019. The nurse should
- A. palpate the patient's lower abdomen for distention.
- B. encourage an increased intake of oral fluids.
- C. record the time and the amount of urine.
- D. encourage the patient to void again in two hours.
Correct Answer: C
Rationale: amount and specific gravity normal (1.010-1.030)