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Exhibits

Two days later, the nurse completes an assessment of the client. Which assessment findings indicate that the client has stabilized? Select all that apply.

Electrocardiogram: Tall T wave and widened QRS complex

Blood pressure: 126/76 mm Hg

Basilar crackles

Urine output: 20 mL in the last hour

Respirations: 26 breaths/minute

Heart rate: 72 beats/minute

Oxygen saturation 98% on room air

A normal body temperature (98.9°F or 37.1°C orally).

Answer and Explanation

Correct Answer : B,F,G,H

A. An electrocardiogram with a tall T wave and widened QRS complex may indicate electrolyte imbalances or cardiac issues, which are not indicative of stabilization.

C. Basilar crackles can be a sign of pulmonary or cardiac issues and are not indicative of stabilization.

D. A urine output of 20 mL in the last hour may suggest reduced kidney function or hydration status and is not indicative of stabilization.

E. A respiratory rate of 26 breaths/minute may indicate respiratory distress and is not indicative of stabilization.

The assessment findings that suggest stabilization include:

A blood pressure within the normal range (126/76 mm Hg).

A heart rate within the normal range (72 beats/minute).

Oxygen saturation of 98% on room air, indicating adequate oxygenation.

A normal body temperature (98.9°F or 37.1°C orally).

These vital signs and clinical parameters are within normal ranges, suggesting that the client's condition is stable at this time.

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Correct Answer is ["A","D","E"]

Explanation

To help the parents decrease their anxiety, the nurse can:

A. Provide the parents with ideas about how to make their child feel better after the procedure. This can help reassure the parents that they can support their child during the recovery process.

D. Find a comfortable area that the parents can wait that is close to the procedure area. Being close to the procedure area allows the parents to stay informed and feel more connected to their child during the procedure.

E. Do not give any specifics on the amount of time the procedure will take. Providing a specific time may increase anxiety, so it's often better to provide a general idea of the timeframe.

Option B is not appropriate because stating that the procedure is 100% effective and safe may not be accurate and could lead to false expectations.

Option C is not appropriate because limiting visitation based on the parents' anxiety is not typically recommended. Supportive presence is generally encouraged for both the child and parents.

A. Normal gait is not fully expected. B. Growth and development will be delayed. C. Heredity influences the outcome of clubfoot. D. Correction will require serial casting

Correct Answer is D

Explanation

A. Normal gait can be expected with appropriate management and treatment for clubfoot. With early and effective intervention, many children with clubfoot can achieve a normal gait.

B. Growth and development are not typically delayed as a long-term outcome of clubfoot when it is appropriately managed. The goal of treatment is to achieve normal foot development and function.

C. While heredity can play a role in clubfoot, it is not typically a sole determinant of the outcome. The success of treatment primarily depends on the timeliness and effectiveness of the interventions.

D Correction will require serial casting.

Unilateral clubfoot is a congenital deformity of the foot that can often be effectively managed with non-surgical interventions. Serial casting is a common and successful approach used to gradually correct the deformity. Parents should be informed that serial casting is likely to be a part of the treatment plan for their child's clubfoot.

Therefore, it is essential to educate parents that correction of unilateral clubfoot will likely require serial casting and that with appropriate treatment, the child can achieve a normal gait and experience normal growth and development.

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Exhibits Two days later, the nurse completes an assessment of the client. Which assessment findings indicate that the client has stabilized? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","D","E"]

Explanation

The nurse is caring for an infant with unilateral clubfoot. Which information should the nurse include in parent education about long-term outcomes?

Correct Answer is D

Explanation

A 3-year-old boy in a daycare facility scratches his head frequently, and the nurse confirms the presence of head lice. The nurse washes the child's hair with permethrin shampoo and calls his parents. Which instruction should the nurse provide to the parents about treatment for head lice?

The mother of an 11-year-old boy who has juvenile idiopathic arthritis tells the nurse, "I really don't want my son to become dependent on pain medication, so I only allow him to take it when he is really hurting." Which information is most important for the nurse to provide this mother?

The nurse is assessing the growth and development of a 3-year-old child. Which speech and language skills should the nurse identify as normal developmental milestones for this child?

A mother brings her 3-month-old infant to the clinic because the baby does not sleep through the night. Which finding is most significant in planning care for this family?

During her sports physical examination, a 15-year-old female requests oral contraceptives. She explains that she is sexually active and does not want her parents to know. Which action should the nurse take?

The nurse is giving an intramuscular injection of an antibiotic to a 16-month-old toddler with pneumonia. The toddler does not have any known allergies and has been walking without assistance for one month. Which technique should the nurse select for administration?

A 10-year-old boy has been seen frequently by the school nurse over the past three weeks after school begins in the fall. He reports headaches, stomach aches, and difficulty sleeping. Which intervention should the nurse implement?

Exhibits

Two days later, the nurse completes an assessment of the client. Which assessment findings indicate that the client has stabilized? Select all that apply.