Nokea
To promote the safe use of a cane for a client who is recovering from a minor musculoskeletal injury of the left lower extremity, which of the following instructions should the nurse provide? Select all.
- A. Hold the cane on the right side
- B. Keep 2 points of support on the floor
- C. Place the cane 15 inches in front of the feet before advancing
- D. After advancing the cane, move the weaker leg forward
- E. Advance the stronger leg so that it aligns evenly with the cane
Correct Answer: A, B, D
Rationale: Correct Answer: A, B, D
Rationale:
A: Holding the cane on the right side provides support for the weaker left lower extremity, aiding balance.
B: Keeping 2 points of support on the floor enhances stability and reduces the risk of falls.
D: Moving the weaker leg forward after advancing the cane promotes weight-bearing on the stronger leg first, reducing strain on the injured limb.
Summary:
C: Placing the cane 15 inches in front of the feet before advancing is too far and may lead to overreaching.
E: Advancing the stronger leg to align with the cane may shift the body weight incorrectly, increasing the risk of injury.
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A nurse is assessing a client who is reporting severe pain despite analgesia. The nurse can best assess the intensity of the client's pain by:
- A. Asking what precipitates the pain
- B. Questioning the client about the location of the pain
- C. Offering the client a pain scale to measure his pain
- D. Using open-ended questions to identify the situation
Correct Answer: C
Rationale: The correct answer is C: Offering the client a pain scale to measure his pain. This is the best way to assess the intensity of the client's pain objectively. Pain scales provide a standardized way for clients to communicate their pain levels, allowing for more accurate assessment and monitoring. Asking what precipitates the pain (choice A) focuses on triggers, not intensity. Questioning about the location of pain (choice B) is important but doesn't directly measure intensity. Using open-ended questions (choice D) may not provide a quantitative measure of pain.
A nurse educator is presenting a module on basic first aid for newly licensed home health nurses. The nurse educator evaluates the teaching as effective when the newly licensed nurse states the client who has heat stroke will have which of the following?
- A. Hypotension
- B. Bradycardia
- C. Clammy skin
- D. Bradypnea
Correct Answer: A
Rationale: The correct answer is A: Hypotension. Heat stroke is characterized by the body's inability to regulate its temperature due to prolonged exposure to high temperatures. This leads to excessive sweating and dehydration, resulting in a drop in blood pressure (hypotension). Bradycardia (B) is a slow heart rate, which is not typically seen in heat stroke. Clammy skin (C) is common in heat exhaustion, not heat stroke. Bradypnea (D) is slow breathing, which is not a common sign of heat stroke. Therefore, hypotension is the most appropriate choice as it aligns with the pathophysiology of heat stroke.
A nurse is reviewing the reported medications of a client who was recently admitted. The medications include cimetidine (Tagamet) and imipramine hydrochloride (Tofranil). Knowing that cimetidine decreases the metabolism of imipramine hydrochloride, the nurse should identify that this combination is likely to result in which of the following effects?
- A. Decreased therapeutic effects of cimetidine
- B. Increased risk of imipramine hydrochloride toxicity
- C. Decreased risk of adverse effects of cimetidine
- D. Increased therapeutic effects of imipramine hydrochloride
Correct Answer: B
Rationale: The correct answer is B: Increased risk of imipramine hydrochloride toxicity. Cimetidine inhibits the metabolism of imipramine hydrochloride, leading to increased levels of imipramine in the body. This can result in a higher concentration of imipramine, potentially causing toxicity. This interaction is known as a pharmacokinetic drug-drug interaction.
Incorrect choices:
A: Decreased therapeutic effects of cimetidine - This is incorrect because cimetidine's therapeutic effects are not directly impacted by its interaction with imipramine.
C: Decreased risk of adverse effects of cimetidine - This is incorrect as there is no evidence to suggest that the interaction with imipramine decreases the risk of adverse effects of cimetidine.
D: Increased therapeutic effects of imipramine hydrochloride - This is incorrect as the increased risk of toxicity does not equate to increased therapeutic effects.
The skin barrier covering a client's intestinal fistula keeps falling off when she stands up to ambulate. The nurse has reapplied it twice during the shift, but it remains intact only when the client is supine in bed. The nurse telephoned the physical therapist about the difficulties containing the drainage from the fistula, so the therapist didn't ambulate the client today. The client sat in a chair during lunch w/an absorbent pad over the fistula. The client ate all the food on her tray. The wound care nurse confirmed that she will see the client later today. The client states she feels frustrated at not having physical therapy, but the nurse thinks the client welcomed having a day to rest. Which of the following information should the nurse include in the change-of-shift report? Select all.
- A. The physical therapist didn't ambulate the client today
- B. The skin barrier's seal stays on in bed but loosens when the client stands.
- C. The client seemed to welcome having a 'day off' from physical therapy
- D. The wound care nurse will see the client later today
- E. The client ate all the food on her lunch tray
Correct Answer: A, B, D
Rationale: The correct choices to include in the change-of-shift report are A, B, and D. Choice A is important to communicate as it highlights that the physical therapist did not ambulate the client due to difficulties with the skin barrier and fistula drainage. Choice B is crucial as it explains the specific issue with the skin barrier, emphasizing that it stays intact when the client is supine but loosens when standing. Choice D is essential to include as it informs about the upcoming visit from the wound care nurse. Choices C and E, although relevant to the client's well-being, are not directly related to the current care plan and should not be included in the report.
A goal for a client who has difficulty w/self-feeding due to rheumatoid arthritis is to use adaptive devices. The nurse caring for the client should initiate a referral w/which of the following members of the interprofessional care team?
- A. Social worker
- B. Certified nursing assistant
- C. Registered dietitian
- D. Occupational therapist
Correct Answer: D
Rationale: The correct answer is D: Occupational therapist. Occupational therapists specialize in helping individuals with physical limitations to maximize their ability to perform daily activities, such as self-feeding. They can assess the client's specific needs, recommend appropriate adaptive devices, and provide training on how to use them effectively. Social workers (A) focus more on psychosocial support, certified nursing assistants (B) provide direct care but may not have the expertise in adaptive devices, and registered dietitians (C) focus on nutrition-related issues. Therefore, the occupational therapist (D) is the most appropriate member of the interprofessional care team to address the client's self-feeding difficulties due to rheumatoid arthritis.