【最新ISPN测试题】ISPN测试题(480) 【最新ISPN测试题】ISPN测试题(480)"

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Exercise:

1、The nurse is caring for an infant with spina bifida (myelomeningocele type) who had the sac on the back containing cerebrospinal fluid, the meninges, and the nerves (gibbus) surgically removed. The nursing plan of care for the postoperative period should include which nursing action to maintain the infant"s safety?

1.Covering the back dressing with a binder

2.Placing the infant in a head-down position

3.Strapping the infant in a baby seat sitting up

4.Elevating the head with the infant in the prone position

Correct Answer:4

Elevating the head will decrease the chance that cerebrospinal fluid will accumulate in the cranial cavity. The infant needs to be prone or side-lying to decrease the pressure on the surgical site on the back. Binders and a baby seat should not be used because of the pressure they would exert on the surgical site.

2、A child is brought to the emergency department after being accidentally struck in the lower back region with a baseball bat. When gathering assessment data, the nurse discovers that the child has hemophilia. The nurse shouldimmediately assess for which data?

1.The respiratory rate

2.The urine for hematuria

3.For signs of slurred speech

4.For complaints of headache

Correct Answer:2

Because the kidneys are located in the flank region of the body, trauma to the back area can cause hematuria, particularly in a child with hemophilia. The nurse would be most concerned about the child"s airway and respiratory rate if the child sustained an injury to the neck region. Slurred speech and headache are associated with head trauma.

3、An adolescent with type 1 diabetes mellitus is attending a dance in the school gym. The adolescent suddenly becomes flushed and complains of hunger and dizziness. The school nurse, who is present at the dance, takes the child to the nurse"s office and performs a blood glucose level test that shows 60 mg/dL. Which is the initial nursing intervention?

1.Call the child"s mother.

2.Assist the child with administering regular insulin.

3.Give the child ? cup of a sugar-sweetened carbonated beverage.

4.Call an ambulance to take the child to the hospital emergency department.

Correct Answer:3

A blood glucose level lower than 70 mg/dL indicates hypoglycemia. The child is attending an activity that is different from the normal routine at school. Insulin requirements change with unfamiliar situations. When signs of hypoglycemia occur, the child needs an immediate source of glucose. Regular insulin will lower the blood glucose level and is thus a harmful action. Although the child"s mother will need to be notified of the occurrence, this is not the immediate action. There is no reason to take the child to the emergency department.

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