A 13-year-old child is diagnosed with Ewing's sarcoma of the femur. After a course of radiation and chemotherapy, it has been decided that leg amputation is necessary. After the amputation, the child becomes very frightened because of aching and cramping felt in the missing limb. Which nursing statement would be appropriate to assist in alleviating the child's fear?
- "This aching and cramping is normal and temporary and will subside."
- "This normally occurs after the surgery and we will teach you ways to deal with it."
- "The pain medication that I give you will take these feelings away."
- "This pain is not real pain, and relaxation exercises will help it go away."A. After amputation,
phantom limb pain is a temporary condition that some children may experience. This sensation of burning, aching, or cramping in the missing limb is most distressing to the child. The child needs to be reassured that the condition is normal and only temporary. Options 2, 3, & 4 are inappropriate to the child. Use therapeutic communication techniques. Note that the subject of the question relates to alleviating the child's fear. Options 2, 3, & 4 imply that this pain may be permanent. Review care of a child after amputation if you had difficulty with this question.The nurse is assigned to care for a client with complete right-sided hemiparesis. The nurse plans care
knowing that in this condition:
- the client has complete bilateral paralysis of the arms and legs
- the client has weakness on the right side of the body, including the face and tongue
- the client has lost the ability to move the right arm but is able to walk independently
- the client has lost the ability to ambulate independently but is able to feed and bathe himself or
herself without assistance.B. Hemiparesis is a weakness of one side of the body that may occur after a stroke. Complete hemiparesis is weakness of the face and tongue, arm, and leg on one side.Complete bilateral paralysis does not occur in this condition. The client with right-sided hemiparesis has weakness of the right arm and leg and needs assistance with feeding, bathing, and ambulating. Use the process of elimination. Note the strategic words complete right-sided and focus on the subject: hemiparesis. Recalling that hemiparesis indicates weakness and focusing on the strategic words will direct you to option B. Review the description of hemiparesis and care of the client with hemiparesis if you had difficulty with this question.A nurse is caring for a child recently diagnosed with cerebral palsy, and the parents of the child ask the nurse about the disorder. The nurse bases her response on the understanding that cerebral palsy is:
a) An infectious disease of the central nervous system
b) An inflammation of the brain as a result of a viral illness
c) A congenital condition that results in moderately to severe retardation
d) A chronic disability characterized by impaired muscle movement and postureD. Cerebral palsy is a
chronic disability characterized by impaired movement and posture resulting from an abnormality in the extrapyramidal or pyramidal motor system.
ADN FINAL HESI QUESTIONS AND ANSWERS 1 / 4
Meningitis is an infection process of the CNS.Encephalitis is an inflammation of the brain that occurs as a result of a viral illness or CNS infection.Down syndrome is an example of a congenital condition that results in moderate to severe retardation.Use the process of elimination. Eliminate options 1&2 first, noting that they are comparable or alike.Next, note the relationship between the words "palsy" in the question and "impaired muscle movement" in D.A 32-year-old woman recently diagnosed with Hodgkin's disease is admitted for staging by undergoing a bone marrow aspiration and biopsy. To obtain more information about the client's nutrition status the nurse should review the results of which of the following tests?
a) Albumin level.
b) Reticulocyte count.
c) Red blood cell count.
d) Direct and indirect bilirubin levels.A - Serum albumin levels help determine whether protein intake
is sufficient. Proteins are broken down into amino acids during digestion. Amino acids are absorbed in the small intestine, and albumin is built from amino acids. The red blood cell count, bilirubin levels, and reticulocyte count do not indicate protein intake.An infant underwent surgery to remove a myelomeningocele. The infant has bulging fontanels. Which of the following is the nurse's best action?
a) Calm the infant
b) Teach parent about procedure
c) Notify the healthcare provider
d) Reposition infantC - Bulging fontanels in an infant may indicated increased intracranial pressure, a
possible postoperative complication. Calming the infant, teaching the parent, and repositioning the infant will not address the underlying problem of increased intracranial pressure within the skull. Calling the healthcare provider is indicated.Which of the following is a common method of evaluating the urine output for newborns, infants, and toddlers who are not potty trained.
a) Monitoring the amount of time for breast feeding
b) Measuring the formula before the child ingests it
c) Weighing the child before and after feeds 2 / 4
d) Weighing the diaper before and after micturitionD - Weighing the diaper before applying it to the
newborn, infant, or toddler, and then weighing it after micturition will help evaluate the urine output.The difference between the wet diaper and the dry one will give the amount of urine (1 g = 1 mL, so amounts may be recorded in milliliters). Weighing the child or measuring the formula will not give an indication of evaluating the urine output in this situation.According to the antenatal record, a newborn is 12 days post-mature. A nurse completes the initial assessment of the newborn and notes increased amounts of vernix. The mother asks why the nurse seems concerned about the presence of the vernix. Which of the following statements by the nurse is most appropriate?
- "The vernix indicates a different gestational age than expected."
- "The vernix is difficult and painful to remove from a newborn."
- "The presence of vernix affects the newborn's immune system."
- "The vernix should be a thicker coating for a newborn."A - Vernix caseosa is a whitish substance
that serves as a protective covering over the fetal body throughout the pregnancy. Vernix usually disappears by term gestation. It is highly unusual for a 12-day post-mature baby to have increased amounts of vernix. A discrepancy between EDC (estimated date of conception) and gestational age by physical examination must have occurred.a whitish substance that serves as a protective covering over the fetal body throughout the pregnancy
VERNIX CASEOSA
During the postoperative period after a modified radical mastectomy, the client confides in the nurse that she thinks she got breast cancer because she had an abortion and she did not tell her husband. The best response by the nurse is which of the following?
- "You might feel better if you confided in your husband."
- "Cancer is not a punishment; it is a disease."
- "I can have the social worker talk to you if you would like."
- "Tell me more about your feelings on this."D - The nurse should respond with an open-ended
statement that elicits further exploration of the client's feelings. Women with cancer may feel guilt or shame. Previous life decisions, sexuality, and religious beliefs may influence a client's adjustment to a diagnosis of cancer. The nurse should not contradict the client's feelings of punishment or offer advice such as confiding in the husband. A social worker referral may be beneficial in the future, but is not the first response needed to elicit exploration of the client's feelings.A nurse is caring for an infant who is to be administered an enema. What spiritually oriented interventions could the nurse follow with newborns and infants? 3 / 4
a) Encourage parents to be present during the treatment.
b) Tell the infant that it will be over within a minute.
c) Provide the infant with soft toys or a feeding bottle.
d) Ask a child specialist to be present during treatment.A - When caring for infants and newborns, the
best nursing intervention is to encourage the parents to be present during the medical treatment. There is no need for the nurse to ask for a child specialist to be present during the treatment. Instead, the nurse should involve the parents in the caring process as the infant will feel more secure and comfortable in the presence of the parents. Providing the infant with toys, a feeding bottle, or trying to explain that it will be over soon will not pacify the child A client is scheduled to undergo surgical creation of an ileal conduit. The primary nurse educates the client about surgery and the postoperative period. The nurse informs the client that many members of the health care team (including a mental health practitioner) will see him. A mental health practitioner
should be involved in the client's care to:
- help the client cope with the anxiety associated with changes in body image.
- assess whether the client is a good candidate for surgery.
- evaluate the client's need for mental health intervention.
- assess suicidal risk postoperatively.A - Many clients who undergo surgery for creation of an ileal
conduit experience anxiety associated with changes in body image. The mental health practitioner can help the client cope with these feelings of anxiety. Mental health practitioners don't evaluate whether the client is a surgical candidate. None of the evidence suggests that urinary diversion surgery, such as creation of an ileal conduit, places the client at risk for suicide. Although evaluating the need for mental health intervention is always important, this client displays no behavioral changes that suggest intervention is necessary at this time.A client with a diagnosis of cancer is frequently disruptive and challenges the nurse. This behavior may
be caused by:
a) The one-time crisis from learning of the diagnosis.
b) The usual trajectory of a short-term illness.
c) Uncertainty and an underlying fear of recurrence.
d) A history of a behavioral illness.C - Cancer clients report that the lifelong fear of recurrence is
one of the most disruptive aspects of the disease. The trajectory of the disease is unpredictable and can be intertwined with many short- and long-term illnesses related to cancer and the treatment modalities.A diagnosis of cancer challenges the individual and the family with a series of crises rather than a time- limited episode. There are no data to indicate that the client has an underlying behavioral disorder.
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