Nokea
A client arrives at the clinic for a follow-up after an emergency department visit the night before. The client sustained an ulnar fracture, and a fiberglass cast was applied. Which of the following teachings related to cast care should the nurse reinforce? Select all that apply.
- A. Contact the clinic if any hot areas or foul odors develop in the cast
- B. Cover the cast with a plastic bag for bathing, and avoid getting the cast wet
- C. Elevate the affected extremity above heart level for the first 48 hours
- D. Expect some numbness and tingling of the fingers during the first week
- E. Use only soft, padded objects to scratch the skin under the cast
Correct Answer: A,B,C,E
Rationale: Hot areas or odors (A) suggest infection, keeping the cast dry (B) prevents skin breakdown, elevation (C) reduces swelling, and soft objects (E) avoid injury. Numbness and tingling (D) are not normal and may indicate nerve compression, requiring immediate reporting.
You may also like to solve these questions
The nurse is caring for assigned clients. The nurse should first check the
- A. 3-year-old client who has fever and right hip pain and is refusing to move the right leg
- B. 7-year-old client who has sinus congestion and a productive cough
- C. 10-year-old client who has an active nosebleed and is applying pressure to the nose
- D. 12-year-old client who has fever, urinary frequency, and dysuria
Correct Answer: A
Rationale: A 3-year-old with fever, hip pain, and refusal to move the leg (A) may indicate a serious condition like septic arthritis or osteomyelitis, requiring immediate assessment to prevent joint damage or systemic infection. Sinus congestion (B) and urinary symptoms (D) are less urgent, and the nosebleed (C) is being managed with pressure, making them lower priorities.
While caring for a woman who delivered a healthy term infant six hours ago, the nurse notes that the fundus is soft, 2 cm above the umbilicus, and off to the left. The lochia is red. The nurse suspects that the client has which problem?
- A. Retained placental fragments
- B. Perineal laceration
- C. Urinary retention
- D. Normal involution
Correct Answer: C
Rationale: A soft, displaced fundus suggests urinary retention, causing bladder pressure on the uterus. Normal involution shows a firm, midline fundus; fragments or lacerations present differently.
The nurse assists with a community teaching program for parents and caregivers of infants. Which statement by a participant indicates that teaching has been successful?
- A. After age 6 months, it's safe to use honey to sweeten my infant's formula
- B. I should wait until my infant is 1 year old to introduce egg products
- C. I switch my 1-year-old to low-fat milk instead of commercial formula
- D. My infant should be able to pick up small finger foods by age 12 months
Correct Answer: B,D
Rationale: Honey (A) is unsafe for infants under 1 year due to the risk of botulism. Waiting until 1 year to introduce egg products (B) is correct to reduce allergy risks. Switching to low-fat milk (C) is incorrect, as infants need whole milk or formula for adequate fat and nutrients. The ability to pick up finger foods by 12 months (D) is a correct developmental milestone, indicating successful teaching.
The nurse is talking with a client with stable angina who has a prescription for sublingual nitroglycerin. Which of the following statements by the client would require follow-up?
- A. I shall sit down if possible before taking this medication to prevent dizziness.
- B. I may experience flushing or a headache when taking this medication.
- C. I will avoid taking the medication with grapefruit juice.
Correct Answer: C
Rationale: Nitroglycerin is not contraindicated with grapefruit juice (C), indicating a misunderstanding. Sitting down (A) prevents falls from hypotension, and flushing/headache (B) are expected side effects, both correct.
The nurse is caring for a client with schizophrenia who is experiencing visual hallucinations. The client states, 'There is a bad person standing in my room.' Which of the following responses would be most appropriate for the nurse to make?
- A. Your illness is making you experience visual hallucinations.'
- B. I know you are frightened, but I do not see anyone in your room.'
- C. Do not worry. I will give you medication that will make the bad person go away.'
- D. We will go into the dayroom and play a game. I know you like to play board games.'
Correct Answer: B
Rationale: When addressing hallucinations, the nurse should acknowledge the client’s fear while gently reinforcing reality. Response B validates the client’s emotions and clarifies that the nurse does not see the hallucination, maintaining trust without reinforcing the delusion. Labeling the hallucination as part of the illness (A) may confuse or alienate the client. Promising medication will resolve it (C) oversimplifies treatment, and distracting with games (D) dismisses the client’s distress.