- (Topic 3)
A client is 2 hours post ventriculoperitoneal shunt placement. How should the nurse position the client?
Correct Answer:
D
(A) Elevation of head on nonoperative side would be the position for the late postoperative period. (B) Positioning on operative side puts pressure on the suture lines and on the shunt valve. Elevation of head in immediate postoperative period may cause rapid reduction of cerebrospinal fluid. (C) Placement on operative side puts pressure on the suture lines and shunt valve. (D) Flat position on nonoperative side in the immediate postoperative period prevents pressure on shunt valve and rapid reduction in cerebrospinal fluid.
- (Topic 7)
A family by court order undergoes treatment by a family therapist for child abuse. The nurse, who is the child??s case manager knows that treatment has been effective when:
Correct Answer:
D
(A) Removing an abused child from the home and placement in a foster home are not the desired outcome of treatment. (B) Children who are perceived as ??different?? from the rest of the family are more likely to be abused. (C) Although legal action may be taken against abusive parents, it is not an indicator of an effective treatment program. (D) Identification of age-appropriate behaviors is essential to the role of parents, because misunderstanding children??s normal developmental needs often contributes to abuse or neglect.
- (Topic 3)
A laboring client presents with a prolapsed cord. The nurse should immediately place the client in what position?
Correct Answer:
C
(A) Reverse Trendelenburg position increases pressure on the perineum. This position will not relieve cord pressure. (B) Fowler??s position increases perineal pressure. Cord pressure would not be relieved. (C) Trendelenburg position will decrease perineal pressure. Cord compression will be decreased and increase in fetal blood flow occurs. (D) Sims?? position does not relieve pressure on cord or perineum.
- (Topic 7)
Parents of a child with rheumatic fever express concern that she will always be arthritic. The nurse discusses their concerns and tells them the joint pain usually:
Correct Answer:
A
(A) Joints usually remain inflamed and tender until the disease runs its course in<3 weeks.
(B) This response does not answer the question of whether she will always be arthritic. (C) This response does not answer the question asked. (D) The disease takes<3 weeks to run its course.
- (Topic 2)
Which of the following signs might indicate a complication during the labor process with vertex presentation?
Correct Answer:
D
(A) Fetal tachycardia may indicate fetal hypoxia; however, 170 bpm is only mild tachycardia. (B) Nausea and vomiting occur frequently during transition and are not a complication. (C) Contractions frequently last 60–90 seconds during the transitional phase of labor and are not considered a complication as long as the uterus relaxes completely between contractions. (D) Passage of meconium in a vertex presentation is a sign of fetal distress; this may be normal in a breech presentation owing to pressure on the presenting part.
