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A client is having a myologgraphy. What action by the nurse is most important?
- A. Assesses with any nursing microctioning (AST) levels.
- B. Ensure that informed consent is on the chart.
- C. Position the client that after the procedure.
- D. Reinforce the dressing if it becomes saturated.
Correct Answer: B
Rationale: The diagnostic procedure is invasive and requires informed consent. The AST does not need to be assessed prior to the procedure. The client is positioned with the head of the bed elevated after the test to keep the contrast material out of the brain. The dressing should not become saturated; if it does, the nurse calls the provider.
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A hospitalized clients strength of the upper extremities is rated at 3. What does the nurse understand about this clients ability to perform activities of daily living (ADL)?
- A. The client is able to perform ADLs but not for some items.
- B. No difficulties are expected with ADL.
- C. The client is unable to perform ADL alone.
- D. The client would need near-total assistance with ADLs.
Correct Answer: A
Rationale: This rating indicates fair muscle strength with full range of motion against gravity but not resistance. The client could complete ADLs independently unless they required lifting objects.
A client is distressed at body changes related to kyphosis. What response by the nurse is best?
- A. Ask the client to explain more about these feelings.
- B. Explain that these changes are irreversible.
- C. Offer to help select clothes to hide the deformity.
- D. Tell the client safety is more important than looks.
Correct Answer: A
Rationale: Assessment is the first step of the nursing process, and the nurse should begin by getting as much information about the client's feelings as possible. Explaining that the changes are irreversible discounts the client's feelings. Depending on the extent of the deformity, clothing will not hide it. While safety is more objectively important than looks, the client is worried about looks and the nurse needs to address this issue.
A student nurse learns about changes that occur to the musculoskeletal system due to aging. Which changes clearly lead to increased safety risks?
- A. Increased bone density leads to stiffness.
- B. Increased joint flexibility enhances mobility.
- C. Osteoporosis is a universal occurrence.
- D. Decreased muscle mass reduces strength.
Correct Answer: D
Rationale: Decreased muscle mass reduces strength, which increases the risk of falls and injuries in older adults. Increased bone density is not typical with aging; osteoporosis, not universal, increases fracture risk but is not guaranteed. Increased joint flexibility is not a common aging change.
A client is undergoing computed tomography (CT) of a joint. What action by the nurse is most important before the test?
- A. Administer sedation as prescribed.
- B. Assess for seafood or iodine allergy.
- C. Ensure that the client has no metal on the body.
- D. Reinforce the dressing if it becomes saturated.
Correct Answer: B
Rationale: Because CT uses iodine-based contrast material, the nurse assesses the client for allergies to iodine or seafood (which often contains iodine). The other actions are not needed.
A client had an arthroscopy 1 hour ago on the left knee. The nurse finds the left lower leg to be pale and cool, with 1+ pedal pulses. What action by the nurse is best?
- A. Assess the neurovascular status of the right leg.
- B. Document the findings in the clients chart.
- C. Elevate the left leg on at least two pillows.
- D. Notify the provider of the findings immediately.
Correct Answer: A
Rationale: The nurse should compare findings of the two legs as these findings may be normal for the client. If a difference is observed, the nurse notifies the provider. Documentation should occur after the nurse has all the data. Elevating the left leg will not improve perfusion if there is a problem.