Nokea
A client with a fracture of the right femur has had skeletal traction applied. Which intervention should the nurse include in the client's nursing care plan?
- A. Assess the pin sites for signs of infection.
- B. Administer pain medication at designated intervals around the clock.
- C. Assess the pulses proximal to the fracture site.
- D. Remove traction every shift and provide skin care.
Correct Answer: A
Rationale: Assessing pin sites for signs of infection is essential to detect early signs of complications in skeletal traction.
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When conducting discharge teaching for a client diagnosed with diverticulosis, which diet instruction should the nurse include?
- A. Eat a bland diet and avoid spicy foods.
- B. Have small frequent meals and sit up for at least two hours after meals.
- C. Eat a soft diet with increased intake of milk and milk products.
- D. Eat a high fiber diet and increase fluid intake.
Correct Answer: D
Rationale: Eating a high-fiber diet and increasing fluid intake are key recommendations for managing diverticulosis, promoting regular bowel movements and preventing constipation.
While caring for a client with amyotrophic lateral sclerosis (ALS), the nurse performs a neurological assessment every four hours. Which assessment finding warrants immediate intervention by the nurse?
- A. Increasing anxiety.
- B. Inappropriate laughter.
- C. Asymmetrical weakness.
- D. Weakened cough effort.
Correct Answer: D
Rationale: Weakened cough effort is a critical finding in a client with ALS, as it can lead to ineffective airway clearance and increase the risk of aspiration pneumonia. Immediate intervention, such as suctioning or respiratory support, may be necessary to maintain airway patency and prevent complications.
The nurse is assessing a client who has herpes zoster. Which question will allow the nurse to gather further information about this condition?
- A. Have the antifungal creams been effective?
- B. Do your family members share combs and brushes?
- C. Do you have any dry patches on your feet and hands?
- D. Has everyone at home already had varicella?
Correct Answer: D
Rationale: Asking whether everyone at home has had varicella is important, as herpes zoster can transmit the varicella-zoster virus to non-immune individuals, causing chickenpox.
History and Physical Nurses' Notes
Flow Sheet
A 59-year-old male client presents to the clinic reporting pain in the right great toe. The client says that the pain feels like it is another attack of gout, which he has had on 2 other occasions in the last 4 months.
The client tells the nurses that the pain started about 9 days ago in the evening and that it got very painful and swollen shortly thereafter. In the past, the gout attacks have resolved without treatment after about 5 days, but the client reports that his condition has not
Which finding(s) in the client's health record should the nurse recognize places the client at a greater risk of developing gout? Select all that apply.
- A. Obesity
- B. Hypertension
- C. Drinks beer nightly
- D. Daily aspirin
- E. Type 2 diabetes mellitus
- F. Sleep apnea
- G. Ibuprofen for pain
Correct Answer: A,B,C,D,E,F
Rationale: Obesity, hypertension, alcohol consumption (especially beer), low-dose aspirin, type 2 diabetes mellitus, and sleep apnea are all associated with increased uric acid levels or decreased excretion, contributing to gout risk. Ibuprofen, smoking status, and osteoarthritis do not directly increase gout risk.
The nurse is developing a plan of care for a client who reports blurred vision and who is newly diagnosed with cardiovascular disease. Which outcome should the nurse include in the plan of care for this client?
- A. The client's blood pressure readings will be less than 160/90 mm Hg.
- B. The nurse will encourage the client to walk thirty minutes every day.
- C. The client's family will repeat signs and symptoms about the disease.
- D. The client's daily blood pressure will be less than 140/80 mm Hg this month.
Correct Answer: D
Rationale: Achieving a daily blood pressure reading of less than 140/80 mm Hg is an appropriate outcome to reduce cardiovascular complications, including those contributing to blurred vision.