Which of the ff nursing interventions is taken as a precautionary measure if shock develops when a client with a spinal cord injury is hospitalized?

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Burns Pediatric Primary Care 7th Edition Test Bank Questions

Question 1 of 5

Which of the ff nursing interventions is taken as a precautionary measure if shock develops when a client with a spinal cord injury is hospitalized?

Correct Answer: A

Rationale: In a hospital setting, if shock develops in a client with a spinal cord injury, one of the initial nursing interventions as a precautionary measure is to establish intravenous access by inserting an IV line. This is important for administering fluids, medications, and blood products promptly to help stabilize the client's condition. IV access is crucial in managing shock to ensure proper fluid resuscitation and support the circulatory system to maintain adequate perfusion to vital organs. It also allows for continuous monitoring of the client's hemodynamic status, electrolyte levels, and responses to interventions. Therefore, inserting an IV line is a critical nursing intervention in addressing shock in clients with spinal cord injuries to promote timely and effective management.

Question 2 of 5

a woman who is pregnant is undergoing an amniocentesis. during the test, elevated levels of AFP are found. this indicate to which of the following conditions :

Correct Answer: B

Rationale: Elevated levels of AFP (alpha-fetoprotein) in the amniotic fluid during an amniocentesis often indicate neural tube defects, such as spina bifida. Spina bifida is a condition where the spinal cord does not develop properly, leading to a range of possible issues depending on the severity of the defect. In this case, the elevated AFP levels point towards a higher likelihood of spina bifida rather than other conditions like CP (cerebral palsy), Down syndrome, or hydrocephalus.

Question 3 of 5

A 10-month-old child can do all the following EXCEPT

Correct Answer: D

Rationale: Speaking inhibition words like 'no' typically occurs later.

Question 4 of 5

The physical manifestations of fetal alcohol syndrome include:

Correct Answer: C

Rationale: Fetal alcohol syndrome is characterized by microcephaly, a short philtrum, and intrauterine growth restriction, among other features.

Question 5 of 5

A 3-month-old infant, born at 38 weeks of gestation, will hold a rattle if it is put in her hands, but she will not voluntarily grasp it. How should the nurse interpret this action?

Correct Answer: C

Rationale: At 3 months of age, most infants should be able to voluntarily grasp objects placed in their hands. This infant, who was born at 38 weeks of gestation, is showing signs of slight delay in development. Premature infants often have developmental delays, especially in motor skills, compared to full-term infants. The fact that the infant can hold a rattle if it is put in her hands is a positive sign, indicating that she is on the right track developmentally but might be a little behind schedule. Continuing to monitor the infant's progress and providing appropriate developmental stimulation can help promote further motor skill development. There is no indication at this point to suspect a significant developmental lag or a neurologic disorder like cerebral palsy without further assessment and observation.

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