Nokea
A 24-year-old client has been diagnosed with acute osteomyelitis in the left leg. He complains of acute pain in the leg that intensifies when he moves it. The client has a temperature of 101°F (38.3°C) and a reddened, warm area in the midcalf region over the shaft of the tibia. Based on this information, which of the following nursing diagnoses would be most appropriate for this client?
- A. Grieving related to possible left lower leg amputation.
- B. Activity intolerance related to severe left leg pain.
- C. A disturbed body image related to left leg swelling and inflammation.
- D. Deficient fluid volume related to elevated temperature of 101°F (38.3°C).
Correct Answer: B
Rationale: Activity intolerance due to severe pain is the most appropriate diagnosis, as pain limits mobility. Amputation is not indicated, body image is secondary, and fever does not directly cause fluid volume deficit.
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Which of the following clients is at greatest risk for extravasation?
- A. The client with heart failure who is receiving Ringer's lactate
- B. The client with cancer who is receiving bendamustine
- C. The client who is receiving potassium supplementation intravenously
- D. The client who is receiving total parenteral nutrition
Correct Answer: B
Rationale: Bendamustine, a chemotherapy drug, is a vesicant, posing a high risk for extravasation, which can cause severe tissue damage if it leaks into surrounding tissues.
The nurse administers an intradermal injection to a client. Proper technique has been used if the injection site demonstrates which of the following?
- A. No swelling.
- B. Tissue pallor.
- C. Evidence of a bleb.
- D. Erythema.
Correct Answer: C
Rationale: A bleb (small wheal) at the injection site indicates correct intradermal technique, as the medication is deposited just under the skin.
The nurse is assessing a client with suspected appendicitis. Which test should the nurse perform to confirm the diagnosis?
- A. Rovsing's sign
- B. Murphy's sign
- C. Psoas sign
- D. Both A and C
Correct Answer: D
Rationale: Rovsing's sign (pain in the right lower quadrant with left-sided pressure) and psoas sign (pain with leg extension) support an appendicitis diagnosis.
The nurse is talking with a client who was diagnosed with bulimia 3 months ago. The client needs more education about the illness if she makes which of the following comments? Select all that apply.
- A. I know that this illness is chronic and intermittent. I'll always have to control it
- B. If I start severely restricting my eating, I may be building up to a bingeing episode
- C. When I'm not bingeing and purging, I can skip that Eating Disorder support group
- D. I've made a real effort to be more social and involved in activities
- E. My depression is gone so I don't need my antidepressant any longer
Correct Answer: C,E
Rationale: Skipping support groups during non-bingeing periods and stopping antidepressants due to improved mood indicate a need for further education, as bulimia requires ongoing support and medication adherence. Other statements reflect accurate understanding.
A primary concern of the hospitalized adolescent is:
- A. Respect for the need for privacy.
- B. Allowing parents to visit after hours.
- C. Wearing a hospital gown.
- D. The fear of loss of control when in pain.
Correct Answer: A
Rationale: Adolescents value autonomy and privacy, which is a primary concern during hospitalization, as it supports their developmental need for independence.