Nokea
A client is receiving treatment for a head injury. What action would the nurse take related to positioning to reduce the risk of further injury?
- A. Maintain the client in a sitting position for as long as possible.
- B. Elevate the rest of the client's body slightly above the neck and head.
- C. Position the neck and head in line with the rest of the client's body.
- D. Elevate the client's head slightly while keeping the neck neutral.
Correct Answer: D
Rationale: In cases of head injury, the nurse should elevate the client's head slightly while keeping the neck neutral to reduce the risk of further injury because of increased intracranial pressure. Maintaining the client in a sitting position or elevating the rest of the client's body slightly above the neck and head may cause discomfort to the client. On the other hand, if the neck and the head are positioned in line with the rest of the client's body, the risk of further injury to the client will not be reduced.
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The nurse is working on an orthopedic floor caring for a client injured in a football game. The nurse is reviewing the client's chart noting that the client has previously had an injured tendon. The nurse anticipates an injury between the periosteum of the bone and which of the following?
- A. Joint
- B. Muscle
- C. Ligament
- D. Cartilage
Correct Answer: B
Rationale: Tendons attach muscles to the periosteum of bone. Joints are a junction between two or more bones. Ligaments connect two freely movable bones. Cartilage is a dense connective tissue used to reduce friction between two structures.
A nurse is preparing a presentation for a health class about ways to ensure bone health, including the need for an adequate calcium intake. The participants are high school-aged girls. The nurse would encourage them to consume adequate calcium to maximize peak bone mass by which age?
- A. 20 years
- B. 30 years
- C. 40 years
- D. 50 years
Correct Answer: B
Rationale: Peak bone mass is attained sometime around 30 years of age. An adequate calcium intake before that time helps to maximize peak bone mass. This would result in denser bones that would be less susceptible to fracture. Bone mass begins to decrease after age 30.
A nurse is caring for a client with an undiagnosed bone disease. When instructing on the normal process to maintain bone tissue, which process transforms osteoblasts into mature bone cells?
- A. Remodelling
- B. Resorption
- C. Ossification and calcification
- D. Epiphyses and diaphysis formation
Correct Answer: C
Rationale: Ossification and calcification transform osteoblasts into mature bone cells called osteocytes. Osteocytes are involved in maintaining bone tissue. Resorption and remodelling are involved in bone destruction. Epiphyses and diaphysis are bone tissues that provide strength and support to the human skeleton.
The nurse is teaching a nutrition class at the community center. Which instruction is most important to stress when teaching on calcium intake?
- A. Eat green, leafy vegetables.
- B. Drink calcium- and vitamin D-fortified orange juice
- C. Provide age-related calcium intake recommendations.
- D. Maintain dairy sources of calcium intake.
Correct Answer: C
Rationale: Providing accurate and specific age-related daily calcium intake guidelines empowers clients to meet those recommendations in a manner that fits their lifestyle. It is also important to emphasize that calcium intake guidelines increase to 1200 mg/day for those older than age 50 years. Eating green, leafy vegetables is an important source of calcium as well as drinking fortified orange juice. Dairy sources also provide calcium intake in varying degrees.
The nurse is employed at a long-term care facility caring for geriatric clients. Which assessment finding is characteristic of an age-related change?
- A. Cognitive decline
- B. Loss of height
- C. Depressive symptoms
- D. Increased muscle mass
Correct Answer: B
Rationale: A common age-related change is the loss of height due to the loss of bone mass and vertebral collapse. Cognitive decline is not an age-related change. Depression occurs in all age groups. Geriatric clients have a decrease in muscle mass.