Question

385. Which of the following is a priority nursing goal in the plan of care for a client with paralysis from a cerebrovascular accident (CVA? 1. Maintain adduction of the affected shoulder 2. Prevent flexion of the affected extremities 3. Observe active range of motion (ROM) daily to all extremities 4. Maintain external rotation of the affected hip. 386. Which of the following statements, if made by the parents of a nine year old client with anostomy, would indicate to the nurse that they are providing quality home care? 1. "We change the bag at least once a week, and we carefully inspect the stoma at that time." 2. "We change the bag every day so that can inspect the stoma and the skin." 3. "We encourage our daughter to watch TV while we change herostomy bag." 4. "We only have to change the ostomy bag every ten days." 387. A child comes to the school nurse with a honey-colored crusted lesion below her right nostril. Which of the following actions should the nurse take FIRST? 1. Remove the scab 2. Apply a wet cloth to the lesion 3. Notify the child's parents 4. Contact the health department 388. The nurse would identify which of the following clients as being the highest risk for developing a pulmonary embolus? 1. A 19 year old four days postpartum with an obstetrical history of placenta previa. 2. An obsess 40 year old man with multiple pelvic fractures from an auto accident two days 3. A 65 year old woman who had a fractured hip repaired 10 days ago and who is in physical therapy daily. 4. A 22 year old leukemic client with a platelet count of 120,000/mm3 and a hemoglobin level of 9.0 g.

Answer 1

385. The correct option is 3. Observe active range of motion daily to all extremities so that we can manage any complications related to CVA at the earliest.

386. The correct option is 1. We change the bag at least once a week and we carefully inspect the stoma at that time .

387. The correct option is 2. Soak the area for 15 to 20 minutes in warm soapy water.

388. The correct option is 2. An obsess 40 year old man with multiple pelvic fractures from auto accident two days ago is at highest risk for developing a pulmonary embolism.