Nokea
A client is complaining of difficulty walking secondary to a mass in the foot. The nurse should document this finding as:
- A. plantar fasciitis.
- B. hallux valgus.
- C. hammertoe.
- D. Morton's neuroma.
Correct Answer: D
Rationale: Morton's neuroma is a small mass or tumor in a digital nerve of the foot. Hallux valgus is referred to in lay terms as a bunion. Hammertoe is where one toe is cocked up over another toe. Plantar fasciitis is an inflammation of, or pain in, the arch of the foot.
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The hospitalized client is at risk for thromboembolism. Which direction should the nurse include when teaching this client about wearing antiembolism hose stockings?
- A. Wearing the hose is unnecessary if ambulating 10 times daily for 5 minutes at a time.
- B. When at home, apply the stockings in the morning before you stand to get out of bed.
- C. The hose can cause pain to underlying skin; request pain medication to help alleviate this.
- D. Cross your legs only while wearing these stockings; otherwise keep the legs uncrossed.
Correct Answer: B
Rationale: B: Applying stockings before standing maximizes compression and prevents edema. A: Stockings complement ambulation. C: Pain suggests circulation issues, not requiring pain medication. D: Crossing legs impedes circulation.
A standard walker is used when clients:
- A. have poor balance, cannot stand up, have weak arms, and have good hand strength.
- B. have poor balance, have a broken leg, or have experienced amputation.
- C. have poor balance, have cardiac problems, or cannot use crutches or a cane.
- D. have poor balance, have an autoimmune disease, or have weak arms.
Correct Answer: C
Rationale: A walker is used for clients who have balance problems, cardiac problems, or cannot use crutches or a cane. The client needs to bear partial weight and have strength in her wrists and arms. The client uses her upper body to propel the walker forward.
While repositioning the client, the LPN notices a shallow, open ulcer on the sacrum with partial-thickness skin loss. What is the classification stage of this ulcer?
- A. Stage I
- B. Stage IV
- C. Stage II
- D. Stage III
Correct Answer: C
Rationale: An ulcer is classified as stage II when the skin is not intact and there is partial-thickness skin loss. An ulcer with full-thickness skin loss would be stage III.
The client with intermittent abdominal pain recently had a barium enema. The client calls the nurse to report passage of a soft-formed, pale-colored stool. What is the nurse's best response?
- A. This is an expected finding after administration of barium.
- B. Describe any abdominal pain you had when passing the stool.
- C. What foods or fluids did you eat after you completed the test?
- D. You need to increase the amount of water you are drinking.
Correct Answer: A
Rationale: A: Pale stools are expected due to residual barium. B: Pain doesn't cause pale stools. C: Diet doesn't affect barium-related stool color. D: Water aids barium passage but isn't indicated for soft stools.
Using the FLACC pain scale, how should the LPN document pain for a non-verbal client with these findings: 1.Face-occasional grimacing 2.Legs-relaxed 3.Activity-Squirming 4.Cry-moans and whimpers 5.Consolability-distractible
- A. 5
- B. 4
- C. 3
- D. 8
Correct Answer: B
Rationale: The points add up like this: Face-1 Legs-0 Activity-1 Cry-1 Consolability-1 Total pain score-4