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Why would a Heimlich maneuver be performed on a client?
- A. To increase the absorption of the prescribed medication
- B. To clear the airway if the client cannot speak or breathe after swallowing food
- C. To reduce the potential for injuries as a result of falls
- D. To maintain extremities in proper anatomic position CARING FOR CLIENT WITH HEAD AND SPINAL CORD TRAUMA
Correct Answer: B
Rationale: The Heimlich maneuver, also known as abdominal thrusts, is performed on a client to clear the airway if the client is choking and cannot speak or breathe after swallowing food. The maneuver involves applying upward pressure on the abdomen in an effort to forcefully expel the object blocking the airway. It is a crucial life-saving technique that can prevent the client from suffocating due to an obstructed airway. In cases of choking emergencies, the Heimlich maneuver should be administered promptly to effectively remove the obstruction and restore breathing.
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While planning for proportionate distribution of restricted fluid volumes, what is the reason for a nurse to ensure that the client is actively involved during the development of the plan?
- A. It promotes the clients compliance with therapy
- B. It minimizes the chances of adverse effects
- C. It promotes a strict food and fluid intake habit
- D. It raises the self esteem of the client
Correct Answer: A
Rationale: It is essential for a nurse to ensure that the client is actively involved in the development of the plan for proportionate distribution of restricted fluid volumes because it promotes the client's compliance with therapy. When the client participates in creating the plan, they are more likely to understand the importance of following it and be motivated to adhere to the recommended fluid restrictions. This active involvement fosters a sense of ownership and responsibility, leading to better treatment outcomes and improved overall health.
Children with severe traumatic brain injury (TBI) may experience autonomic dysfunction characterized by all the following EXCEPT
- A. elevated temperature
- B. elevated heart rate
- C. elevated respiratory rate
- D. lowered blood pressure
Correct Answer: D
Rationale: Autonomic dysfunction in TBI typically involves elevated temperature, heart rate, and respiratory rate due to dysregulation of the autonomic nervous system. Lowered blood pressure is less common and may indicate hypovolemia or other conditions rather than autonomic dysfunction.
A nurse is assessing a 12-month-old infant. Which statement best describes the infant's physical development a nurse should expect to find?
- A. Anterior fontanel closes by age 6 to 10 months.
- B. Binocularity is well established by age 8 months.
- C. Birth weight doubles by age 5 months and triples by age 1 year.
- D. Maternal iron stores persist during the first 12 months of life.
Correct Answer: C
Rationale: The statement that best describes the infant's physical development that a nurse should expect to find is that birth weight doubles by age 5 months and triples by age 1 year. This characteristic growth pattern is typical in the first year of life. Infants usually regain their birth weight by around 2 weeks of age, double it by about 5 months, and triple it by 1 year. This steady growth reflects the healthy development of the infant and is an important marker of overall well-being and nutrition. It is a key aspect that healthcare providers, including nurses, monitor closely to ensure the infant is thriving.
A baby, exhibiting no obvious signs of congestive heart failure, has been diagnosed with a small ventricular septal defect. Which of the following information should the nurse explain to the baby's parents?
- A. The baby will likely need open-heart surgery within a week.
- B. The defect will likely close without therapy.
- C. The defect likely developed early in the second trimester.
- D. The baby will likely be placed on high-calorie formula.
Correct Answer: B
Rationale: The nurse should explain to the baby's parents that the ventricular septal defect will likely close without therapy. Small ventricular septal defects have a high likelihood of closing on their own as the child grows. Surgical intervention is usually not necessary for small defects, especially when the baby does not exhibit signs of congestive heart failure. It is important for the parents to be aware of the natural course of the defect and to follow up with the healthcare provider for monitoring and management.
An infant experienced an apparent life-threatening event (ALTE) and is being placed on home apnea monitoring. Parents have understood the instructions for use of a home apnea monitor when they state?
- A. "We can adjust the monitor to eliminate false alarms."
- B. "We should sleep in the same bed as our monitored infant."
- C. "We will check the monitor several times a day to be sure the alarm is working."
- D. "We will place the monitor in the crib with our infant."
Correct Answer: C
Rationale: The correct statement indicating understanding of the instructions for use of a home apnea monitor is "We will check the monitor several times a day to be sure the alarm is working." This is important because regular monitoring of the device's functioning ensures that it is able to detect any potential apnea episodes or abnormalities in the infant's breathing patterns. Checking the monitor several times a day helps in maintaining the safety and effectiveness of the monitor in alerting the parents to any potential issues with the infant's breathing. The other options are incorrect: A is incorrect because adjusting the monitor to eliminate false alarms can compromise its accuracy, B is incorrect as the infant should sleep in a separate safe sleep environment to reduce the risk of SIDS, and D is incorrect as the monitor should be placed near the infant's crib but not directly in it for safety reasons.