The twelve-year-old boy has fractured his arm because of a fall from his bike. After the injury has been casted, the nurse knows it is most important to perform all of the following assessments on the area distal to the injury except:
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Solution
skin integrity
Capillary refill, pulses, and skin temperature and color are indicative of intact circulation and absence of compartment syndrome. Skin integrity is less important.
The nurse is drawing blood from the diabetic patient for a glycosylated hemoglobin test. She explains to the woman that the test is used to determine:
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Solution
glucose levels over the past several months.
The glycosylated hemoglobin test measures glucose levels for the previous 3 to 4 months.
The adolescent patient has symptoms of meningitis: nuchal rigidity, fever, vomiting, and lethargy. The nurse knows to prepare for the following test:
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Solution
lumbar puncture.
Meningitis is an infection of the meninges, the outer membrane of the brain. Since it is surrounded by cerebrospinal fluid, a lumbar puncture will help to identify the organism involved.
Kim is using bronchodilators for asthma. The side effects of these drugs that you need to monitor this patient for include:
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Solution
tachycardia, nausea, vomiting, heart palpitations, inability to sleep, restlessness, and seizures.
Bronchodilators can produce the side effects listed in answer choice (A) for a short time after the patient begins using them.
Buck’s traction with a 10 lb. weight is securing a patient’s leg while she is waiting for surgery to repair a hip fracture. It is important to check circulation- sensation-movement:
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Solution
every 4 hours.
The patient can lose vascular status without the nurse being aware if left for more than 4 hours, yet checks should not be so frequent that the patient becomes anxious. Vital signs are generally checked q4h, at which time the CSM checks can easily be performed.
Sunshine, age 13, has had a lumbar puncture to examine the CSF to determine if bacterial infection exists. The best position to keep her in after the procedure is:
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Solution
supine for several hours, to prevent a headache.
Lying flat keeps the patient from having a “spinal headache.” Increasing the fluid intake will assist in replenishing the lost fluid during this time.
Cherry, the mother of an 11-month-old girl, Elizabeth, is in the clinic for her daughter’s immunizations. She expresses concern to the nurse that Elizabeth cannot yet walk. The nurse correctly replies that, according to the Denver Developmental Screen, the median age for walking is:
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Solution
12 months.
By 12 months, 50 percent of children can walk well.
The nurse is assessing a 9-month-old boy for a well-baby check up. Which of the following observations would be of most concern?
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Solution
The child does not sit unsupported.
Over 90% percent of babies can sit unsupported by nine months. Most babies cannot say “mama” in the sense that it refers to their mother at this time.
At the community center, the nurse leads an adolescent health information group, which often expands into other areas of discussion. She knows that these youths are trying to find out “who they are,” and discussion often focuses on which directions they want to take in school and life, as well as peer relationships. According to Erikson, this stage is known as:
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Solution
identity vs. role confusion.
During this period, which lasts up to the age of 18-21 years, the individual develops a sense of “self.” Peers have a major big influence over behavior, and the major decision is to determine a vocational goal.
The nurse answers a call bell and finds a frightened mother whose child, the patient, is having a seizure. Which of these actions should the nurse take?
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Solution
The nurse should clear the area and position the client safely.
The primary role of the nurse when a patient has a seizure is to protect the patient from harming him or herself.