Nokea
A client turns her ankle. She is diagnosed as having a Pulled Ligament. This should be documented as a:
- A. sprain.
- B. strain.
- C. subluxation.
- D. distoration.
Correct Answer: B
Rationale: A strain is excessive stretching of a ligament. A sprain involves a twisting motion involving muscles.
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The nurse is using Cognitive-Behavioral methods of pain control and knows that these methods can be expected to do all the following except:
- A. completely relieve all pain.
- B. provide benefit by restoring the client's sense of self-control.
- C. help the client to control symptoms.
- D. help the client actively participate in his or her own care.
Correct Answer: A
Rationale: These interventions (strategies) help the client in all areas of client well-being. Focusing on perception and thought, cognitive techniques are designed to influence how one interprets events and bodily sensations.
To remove a client's gown when she has an intravenous line, the nurse should:
- A. temporarily disconnect the intravenous tubing at a point close to the client and thread it through the gown.
- B. cut the gown with scissors.
- C. thread the bag and tubing through the gown sleeve, keeping the line intact.
- D. temporarily disconnect the tubing from the intravenous container and thread it through the gown.
Correct Answer: C
Rationale: Threading the bag and tubing through the gown sleeve keeps the system intact. Opening an intravenous line causes a break in a sterile system and introduces the potential for infection. Cutting a gown off is not an alternative except in an emergency. IV gowns, which open along sleeves, are widely available.
Safety measures for using crutches must be taught to clients. Safety measures for the use of crutches include:
- A. properly fitting crutches with rubber tips at the end that provide a four-point gait.
- B. properly fitting crutches, education in the appropriate gait, and strength in the arms.
- C. crutches that fit the way the client chooses and a gait chosen by client.
- D. both legs touching the floor for all gaits.
Correct Answer: B
Rationale: In addition to the rubber tips on the ends of the crutches, the client needs to know the appropriate gait. Arm strength exercises are important, and it is critical that the client be fitted properly for the crutches.
On first meeting, a new nurse manager makes eye contact, smiles, initiates conversation about the previous work experience of nurses, and encourages active participation by nurses in the dialogue. Her behavior is an example of:
- A. aggressiveness.
- B. passive aggressiveness.
- C. passiveness.
- D. assertiveness.
Correct Answer: D
Rationale: This nurse manager is demonstrating assertive behavior. Aggressive behavior dominates or embarrasses. Passive behavior is nervous or timid. Passive-aggressive behavior is dominating or manipulative without directness.
Which type of diet should the nurse provide to help a client who has major burns maintain a positive nitrogen balance?
- A. high protein
- B. high carbohydrate
- C. low carbohydrate
- D. low protein
Correct Answer: A
Rationale: Clients with burns are hypermetabolic and require increased protein levels to maintain a positive nitrogen balance. Choices 2 and 3 are incorrect; carbohydrate levels do not help clients to meet this goal. Choice 4 is incorrect; a client with major burns requires a high-protein diet.