Nokea
A nurse is assessing an older client and discovers back pain with tenderness along L2 and L3. What action by the nurse is best?
- A. Consult the provider about an X-ray
- B. Encourage the client to use ibuprofen (Motrin)
- C. Have the client perform hip range of motion
- D. Apply a cervical collar
Correct Answer: A
Rationale: Back pain with tenderness at L2 and L3 suggests a spinal compression fracture, common in osteoporosis. Consulting the provider for an X-ray is the priority to confirm the diagnosis. Ibuprofen may be considered post-diagnosis, and hip range of motion is unrelated. A cervical collar is inappropriate for lumbar issues.
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A client with bone cancer is hospitalized for a limb salvage procedure. How can the nurse best address the client's psychosocial needs?
- A. Assess coping skills and support systems
- B. Explain that the surgery leads to a longer life expectancy
- C. Refer the client to the social worker or hospital chaplain
- D. Reinforce physical therapy to aid with ambulating normally
Correct Answer: A
Rationale: Assessing coping skills and support systems is the first step in addressing psychosocial needs, as it identifies the client's resources and challenges. Explaining life expectancy does not address psychosocial needs directly, referrals may follow assessment, and physical therapy focuses on physical rather than psychosocial needs.
A client is admitted with a large draining wound on the leg. What action does the nurse take first?
- A. Administer ordered antibiotics
- B. Insert an intravenous line
- C. Give pain medications if needed
- D. Obtain cultures of the leg wound
Correct Answer: D
Rationale: Obtaining wound cultures is the priority to identify the causative organism before administering antibiotics, which could alter culture results. IV insertion and pain management follow, as they are secondary to accurate diagnosis.
Which diagnostic tests are used to confirm muscular dystrophy? (Select all that apply.)
- A. Electromyography
- B. Muscle biopsy
- C. Nerve conduction studies
- D. Serum aldolase
- E. Creatinine kinase levels
Correct Answer: A,B,D,E
Rationale: Electromyography, muscle biopsy, serum aldolase, and creatinine kinase levels are used to diagnose muscular dystrophy. Nerve conduction studies are not relevant to this condition.
An older client with diabetes is admitted with a heavily draining leg wound. The client's white blood cell count is 38,000/mm³ but the client is afebrile. What action does the nurse take first?
- A. Administer acetaminophen (Tylenol)
- B. Place the client on contact isolation
- C. Refer the client to the wound care nurse
- D. Obtain wound cultures
Correct Answer: C
Rationale: A heavily draining wound suggests potential infection, and the elevated white blood cell count supports this. Placing the client on contact isolation is the priority to prevent the spread of infection. Acetaminophen is unnecessary without fever, wound cultures follow isolation, and referral to a wound care nurse is secondary.
A client has an ingrown toenail. About what self-management measure does the nurse teach the client?
- A. Long-term antibiotic use
- B. Shoe padding
- C. Toenail trimming by the client
- D. Warm moist soaks and proper nail trimming by a podiatrist
Correct Answer: D
Rationale: Proper treatment for an ingrown toenail includes warm moist soaks and professional nail trimming by a podiatrist to prevent recurrence. Long-term antibiotics are unnecessary, shoe padding does not treat the condition, and self-trimming can worsen it.