Nokea
A client with a fracture is placed in skeletal traction. What is the nurse's priority assessment?
- A. Skin integrity at pin sites.
- B. Range of motion in the affected limb.
- C. Pain level during movement.
- D. Muscle strength in the unaffected limb.
Correct Answer: A
Rationale: Monitoring skin integrity at pin sites is critical to detect infection or tissue breakdown in skeletal traction.
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Which of the following terms is used to describe the sound, timely, smooth, unfragmented and seamless transition of the client from one level of acuity to another?
- A. Case management
- B. Continuity of care
- C. Medical necessity
- D. Critical pathway
Correct Answer: B
Rationale: Continuity of care refers to the seamless, coordinated transition of a client across different levels of care, ensuring consistent and effective treatment.
You are the supervising nurse in a physical rehabilitation center that has the philosophy that clients have the need to cope with their disabilities and its limitations are the result of a discrepancy between the client's abilities and the limitations of the physical and social environment within which the client lives. Which model of disability is this philosophy based on?
- A. Orem's Self Care Model
- B. Nagis Model
- C. A cognitive model of disability
- D. A biomedical model of disability
Correct Answer: C
Rationale: This philosophy aligns with the cognitive model of disability, which emphasizes the interaction between an individual's abilities and environmental barriers, focusing on adaptation and coping strategies.
The nurse is performing an assessment on a client with a diagnosis of systemic lupus erythematosus (SLE). Which finding should the nurse expect to note? Select all that apply.
- A. Fever
- B. Bradycardia
- C. Lymphadenopathy
- D. Butterfly rash on the face
- E. Muscular aches and pains
Correct Answer: A,C,D,E
Rationale: Manifestations of SLE may include fever, musculoskeletal aches and pains, butterfly rash on the face, pleural effusion, basilar pneumonia, generalized lymphadenopathy, pericarditis, tachycardia, hepatosplenomegaly, nephritis, delirium, seizures, psychosis, and coma.
The nurse is planning to teach the client how to properly use a metered-dose inhaler to treat asthma. Which of the following instructions should be included in the teaching?
- A. Rinse the mouth after each use of a steroid inhaler.
- B. Inhale quickly when administering the medication.
- C. Inhale the medication and then exhale through the nose.
- D. Cough and deep-breathe before inhaling the medication.
Correct Answer: A
Rationale: Rinsing the mouth after using a steroid inhaler prevents oral thrush, a common side effect. Quick inhalation, nasal exhalation, or coughing before use are not standard techniques.
A 10-year-old child is admitted with a brain tumor. Which assessment made by the nurse is most critical to report to the child's physician?
- A. Vomiting after lunch.
- B. Difficulty in recalling the day of the week.
- C. Blood pressure of 102/62 mm Hg.
- D. Incontinence of urine and difficulty voiding.
Correct Answer: B
Rationale: Difficulty recalling the day of the week suggests neurological impairment, which is critical to report in a child with a brain tumor, as it may indicate tumor progression or increased intracranial pressure.