Nokea
A client with a spinal cord injury is at risk of developing footdrop. What intervention should the nurse use as a preventive measure?
- A. Mole skin-lined heel protectors
- B. Regular use of posterior splints
- C. Application of pneumatic boots
- D. Avoiding dorsal flexion of the foot
Correct Answer: B
Rationale: The effective means of preventing footdrop (plantar flexion) is the use of posterior splints or high-top sneakers. Dorsal flexing of the foot would help to counteract the effects of footdrop. Heel protectors protect the skin but do not prevent footdrop. Pneumatic boots prevent deep vein thrombosis but not footdrop.
You may also like to solve these questions
The nurse monitors a client prescribed a thiazide diuretic for which clinical manifestations of hypokalemia? Select all that apply.
- A. Muscle twitches
- B. Deep tendon hyporeflexia
- C. Prominent U wave on ECG
- D. General skeletal muscle weakness
- E. Hypoactive to absent bowel sounds
- F. Tall T waves on electrocardiogram (ECG)
Correct Answer: B,C,D,E
Rationale: Hypokalemia is a serum potassium level less than 3.5 mEq/L. Clinical manifestations include ECG abnormalities such as ST depression, inverted T wave, prominent U wave, and heart block. Other manifestations include deep tendon hyporeflexia, general skeletal muscle weakness, decreased bowel motility and hypoactive to absent bowel sounds, shallow ineffective respirations and diminished breath sounds, polyuria, decreased ability to concentrate urine, and decreased urine specific gravity. Tall T waves and muscle twitches are manifestations of hyperkalemia.
The nurse is monitoring a client in the telemetry unit who has recently been admitted with the diagnosis of chest pain and notes this heart rate pattern on the monitoring strip. What is the initial action to be taken by the nurse?
- A. Notify the primary health care provider.
- B. Initiate cardiopulmonary resuscitation (CPR).
- C. Continue to monitor the client and the heart rate patterns.
- D. Administer oxygen with a face mask at 8 to 10 L per minute.
Correct Answer: B
Rationale: The monitor is showing ventricular fibrillation, a life-threatening dysrhythmia that requires CPR and defibrillation to maintain life. Although the primary health care provider must be notified, CPR is the initial action. Oxygen is necessary, but again the initiation of CPR is the priority because it will provide more than just oxygen to the client. Monitoring the client is necessary, but not as an initial action; emergency resuscitative treatment must be provided to the client immediately.
A client in labor has a diagnosis of sickle cell anemia. Which action will the nurse take to assist in preventing the client from experiencing a sickling crisis during labor?
- A. Being reassuring
- B. Administering oxygen
- C. Preventing bearing down
- D. Maintaining strict asepsis
Correct Answer: B
Rationale: During the labor process, the client with sickle cell anemia is at high risk for being unable to meet the oxygen demands of labor. Administering oxygen will prevent sickle cell crisis during labor. Intravenous (IV) fluid therapy will also reduce the risk of a sickle cell crisis.
The nurse notes this cardiac rhythm on the cardiac monitor (refer to figure). What should the nurse interpret that the client is experiencing?
- A. Atrial fibrillation
- B. Sinus bradycardia
- C. Ventricular fibrillation (VF)
- D. Premature ventricular contractions (PVCs)
Correct Answer: D
Rationale: PVCs are abnormal ectopic beats (occurring in otherwise normal sinus rhythm) originating in the ventricles. They are characterized by an absence of P waves, wide and bizarre QRS complexes, and a compensatory pause that follows the ectopy. In atrial fibrillation, no definitive P wave usually can be observed; only fibrillatory waves before each QRS complex are observed. In sinus bradycardia, atrial and ventricular rhythms are regular, and the rates are less than 60 beats per minute. In ventricular fibrillation, impulses from many irritable foci in the ventricles fire in a totally disorganized manner, which appears as a chaotic rapid rhythm in which the ventricles quiver.
An adult client arrives in the emergency department with burns to both entire legs and the perineal area. Using the rule of nines, the nurse should determine that approximately what percentage of the client's body surface has been burned? Fill in the blank.
Correct Answer: 37%
Rationale: The most rapid method used to calculate the size of a burn injury in adult clients whose weights are in normal proportion to their heights is the rule of nines. This method divides the body into areas that are multiples of 9%, except for the perineum. Each entire leg is 18%, each arm is 9%, and the head is 9%. The trunk is 36%, and the perineal area is 1%. Both legs and perineal area equal 37%.