Nokea
A college student visits a campus health service reporting knee pain, clicking when walking, 'locking,' and 'giving way' of the affected knee. The injury occurred when twisting the knee wrong during a tennis match. The nurse should further assess for which problem?
- A. Injury of the meniscus cartilage
- B. Fracture of the lateral tibial condyle
- C. Injury and possible fractured patella
- D. Lateral collateral ligament injury
Correct Answer: A
Rationale: A. The nurse should assess for injury to the meniscus (knee) cartilage. Abrupt twisting can tear the cartilage, and the loose cartilage can cause locking of the joint, clicking, and the knee to 'give way.'
You may also like to solve these questions
When preparing the client for cast application, which statement by the nurse is most accurate?
- A. The cast will feel tight as it's applied.
- B. Your arm will feel warm as the wet plaster sets.
- C. You can expect a foul odor until the cast is dry.
- D. You may feel itchy while the cast is wet.
Correct Answer: B
Rationale: Wet plaster generates heat as it sets, causing a warm sensation, which is a normal part of the process. Tightness may indicate a problem, odors are not typical, and itching is more common as the cast dries.
The client is being seen in the clinic for a second-degree ankle sprain. Which treatments should the nurse plan?
- A. Rest, elevate the extremity, apply ice intermittently, and apply a compression bandage.
- B. Do range of motion to determine the extent of injury, apply heat, and check circulation.
- C. Use moist heat and then apply ice; check circulation, motion, and sensation; and elevate.
- D. Refer to an orthopedic surgeon, apply ice, give an analgesic, elevate, and encourage rest.
Correct Answer: A
Rationale: A. Rest prevents further injury and promotes healing. Ice and elevation control swelling. Compression with an elastic bandage controls bleeding, reduces edema, and provides support for injured tissues.
The nurse is assessing the client 3 months following a left shoulder arthroplasty. Which assessment findings should prompt the nurse to consider that the client may have developed osteomyelitis? Select all that apply.
- A. Sudden onset of chills
- B. Temperature 103°F (39.4°C)
- C. Sudden onset of bradycardia
- D. Pulsating shoulder pain that is worsening
- E. Painful, swollen area on the left shoulder
Correct Answer: A,B,D,E
Rationale: A. A sudden onset of chills suggests the infection of osteomyelitis is blood-borne. B. A high fever suggests the infection of osteomyelitis is blood-borne. D. The pulsating shoulder pain is caused from the pressure of the collecting pus. E. The infected area becomes swollen, painful, and extremely tender.
The Jewish client with peripheral vascular disease is scheduled for a left AKA. Which question is most important for the operating room nurse to ask the client?
- A. Have you made any special arrangements for your amputated limb?'
- B. What types of food would you like to eat while you're in the hospital?'
- C. Would you like a rabbi to visit you while you are in the recovery room?'
- D. Will you start checking your other foot at least once a day for cuts?'
Correct Answer: A
Rationale: Jewish cultural practices may require special handling of amputated limbs (e.g., burial); this question respects beliefs. Food, rabbi visits, and foot checks are secondary.
The client continues to recover following a below-the-knee amputation. What nursing action should the nurse employ to help prevent the most common complication following leg amputation?
- A. Clean the wound with hydrogen peroxide three times a day
- B. Have the client lie prone several times a day
- C. Ask the client to flex and extend the toes on the remaining leg
- D. Encourage the client to completely empty his/her bladder
Correct Answer: B
Rationale: Lying prone prevents hip flexion contractures, the most common complication post-amputation.