Nokea
A client who sustained a fractured leg has learned how to use crutches. The nurse should determine that the client has a need for further teaching if the client makes which statement about using crutches?
- A. I will keep spare crutch tips available.
- B. I will keep crutch tips dry so they don't slip.
- C. I will inspect the crutch tips for wear from time to time.
- D. I will keep the set of crutches my son used as a spare pair.
Correct Answer: D
Rationale: The client should use only crutches measured for the client. Crutches belonging to another person should not be used unless they have been adjusted to fit the client. Spare tips and crutches fitted to the client should be available if needed. Crutch tips should remain dry. Water could cause slipping by decreasing the surface friction of the rubber tip on the floor. If crutch tips get wet, the client should dry them with a cloth or paper towel. The tips should be regularly inspected for wear.
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The nurse is caring for a client with a history of peripheral arterial disease. Which of the following interventions should be included in the plan of care?
- A. Elevate the legs above heart level.
- B. Apply heating pads to the affected limbs.
- C. Encourage walking to tolerance.
- D. Restrict fluid intake.
Correct Answer: C
Rationale: Walking to tolerance improves collateral circulation in peripheral arterial disease.
A client with a history of Parkinson's disease is prescribed levodopa/carbidopa (Sinemet). Which instruction should the nurse include?
- A. Take it with high-protein meals
- B. Avoid driving if drowsy
- C. Take it at bedtime only
- D. Crush the tablet for faster absorption
Correct Answer: B
Rationale: Levodopa/carbidopa can cause drowsiness, so clients should avoid driving if affected to ensure safety.
The nurse is assessing a client with a suspected gastrointestinal bleed. Which of the following findings is most indicative of this condition?
- A. Bright red stools.
- B. Hypotension.
- C. Fever.
- D. Abdominal distension.
Correct Answer: B
Rationale: Hypotension is a critical sign of a gastrointestinal bleed due to significant blood loss.
To reduce the risk of pressure ulcer formation, which of the following activities should the nurse teach the client who is wheelchair-bound as a result of a spinal cord injury?
- A. Bathe daily.
- B. Eat a high-carbohydrate diet.
- C. Shift your weight every 15 minutes.
- D. Move from the bed to the wheelchair every 2 hours.
Correct Answer: C
Rationale: Shifting weight every 15 minutes relieves pressure on bony prominences, reducing pressure ulcer risk. The other options are less directly related to prevention.
A 6-month-old infant is admitted with a diagnosis of bacterial meningitis. The nurse should expect to observe which of the following symptoms?
- A. Positive Babinski reflex.
- B. High-pitched cry.
- C. Hypothermia.
- D. Kernig's sign.
Correct Answer: B
Rationale: A high-pitched cry is a common symptom of bacterial meningitis in infants, indicating neurological irritation.