Nokea
With a breech presentation, the nurse must be particularly alert for which of the following?
- A. quickening
- B. ophthalmia neonatorum
- C. pica
- D. prolapsed umbilical cord
Correct Answer: D
Rationale: Prolapsed umbilical cord is the descent of the umbilical cord into the vagina before the fetal presenting part and compression of the cord between the presenting part and the maternal pelvis, compromising or completely cutting off fetoplacental perfusion. This is an emergency situation; immediate delivery should be attempted to save the fetus.
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A client with a diagnosis of Schizophrenia has been released from an acute care setting. The client had a prolonged recovery from relapse. One of the parents says to the discharge nurse, 'I do not understand what is going on. The hospital said she was better, but all she does is sit around all day and smoke. We cannot get her to go to the vocational training you arranged.' The nurse recognizes that more teaching is needed about:
- A. the pathophysiology and acting out behaviors of schizophrenia.
- B. support groups that can help the parents release their feelings of frustration.
- C. the prolonged recovery time and depressive effects of medicines to prevent relapse.
- D. motivational techniques that are effective in clients with schizophrenia.
Correct Answer: C
Rationale: The nurse conducting discharge teaching must stress the lengthy recuperation process with emphasis on the sedative qualities of the medication used to prevent relapse. Support groups are useful for caregivers. The emphasis during recuperation is on maintaining nutrition and hygiene.
Support-system enhancement includes all of the following except:
- A. determining the barriers to using support systems.
- B. discussing ways to help with others who are concerned.
- C. exploring life problems of the support-team members.
- D. involving spouse, family, and friends in the care and planning.
Correct Answer: C
Rationale: The exploration of life problems of support-team members is not necessary to enhance the support system. Choices 1, 2, and 4 are all enhancements for a support system.
Ten-year-old Jackie is admitted to the hospital with a medical diagnosis of Rheumatic Fever. She relates a history of 'a sore throat about a month ago.' Bed rest with bathroom privileges is prescribed. Which of the following nursing assessments should be given the highest priority when assessing Jackie's condition?
- A. her response to being hospitalized
- B. the presence of a macular rash on her trunk
- C. her cardiac status
- D. the presence of polyarthritis and pain in her joints
Correct Answer: C
Rationale: Monitoring cardiac status is of the highest priority. Permanent cardiac damage can result from rheumatic fever. The second priority is assessing the client's joints for the presence of polyarthritis and accompanying pain.
The nurse observes bilateral bruises on the arms of an elderly client in a long-term care facility. Which of the following questions should the nurse ask this client?
- A. How did you get those bruises?'
- B. Did someone grab you by your arms?'
- C. Do you fall often?'
- D. What did you bump against?'
Correct Answer: B
Rationale: Using a direct approach is best when asking about suspected abuse. Clients are reluctant to report abuse because of shame and fear of reprisal.
A nurse is instructing a person who had a left CVA and right lower extremity hemiparesis to use a quad cane. Which of the following is the most appropriate gait sequence?
- A. Place the cane in the patient's left upper extremity, encourage cane, then right lower extremity, then left upper extremity gait sequence.
- B. Place the cane in the patient's left upper extremity, encourage cane, then left lower extremity, then right upper extremity gait sequence.
- C. Place the cane in the patient's right upper extremity, encourage cane, then right lower extremity, then left upper extremity gait sequence.
- D. Place the cane in the patient's right upper extremity, encourage cane, then left lower extremity, then right upper extremity gait sequence.
Correct Answer: A
Rationale: The cane should be placed in the patient's strong upper extremity (left), and the sequence should coordinate the weak side (right leg) with the cane for support, followed by the strong side (left leg).