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A nurse is caring for a client who recently had a cast placed on their right lower extremity. Which statement from the client should be of the greatest concern to the nurse?
- A. I've been having pain in my right calf.'
- B. My right leg feels really itchy.'
- C. I have not been keeping my leg elevated while in bed.'
- D. My hands and arms support my body weight while using crutches.'
Correct Answer: A
Rationale: Pain in the calf may indicate compartment syndrome or deep vein thrombosis, both serious complications requiring urgent attention. Itching is common, elevation is helpful but less urgent, and crutch use is expected.
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A nurse is caring for a client admitted to the emergency department with suspected rhabdomyolysis. Which of the following findings would the nurse anticipate in a client with this condition?
- A. Elevated creatinine kinase (CK) levels
- B. Decreased serum potassium levels
- C. Hypertension and bradycardia
- D. Clear urine output
Correct Answer: A
Rationale: Rhabdomyolysis causes muscle breakdown, releasing creatinine kinase (CK) into the blood, elevating levels. Potassium levels typically rise, blood pressure and heart rate vary, and urine is dark from myoglobin.
The nurse performs a home safety assessment for an older adult with rheumatoid arthritis. The nurse should make which recommendation to promote safety in the bathroom?
- A. Recommend using a handheld (adjustable) shower head
- B. Advise the client to lower the toilet seat to its lowest level
- C. Instruct the client to reduce bathroom lighting
- D. Recommend the use of towel racks for grab bars
Correct Answer: A
Rationale: A handheld shower head allows the client with rheumatoid arthritis to bathe more easily, accommodating limited mobility and joint stiffness. Lowering the toilet seat may make standing difficult, reduced lighting increases fall risk, and towel racks are not sturdy enough for support.
The nurse educates a client about the application of a plaster cast to a fractured radius. Which of the following statements by the client would require follow-up?
- A. If my arm feels itchy, I can use a hair dryer on the cool setting for relief.'
- B. I can reduce my arm's swelling by elevating it with a pillow.'
- C. I should be okay to shower with my cast.'
- D. It will be normal for me to feel heat after the cast is applied.'
Correct Answer: C
Rationale: Showering with a plaster cast risks wetting it, leading to breakdown or infection, requiring follow-up. Cool air for itching, elevation for swelling, and initial heat from cast setting are appropriate.
The nurse in the medical-surgical unit is caring for a newly admitted client.
Item 3 of 6
History and Physical
1930: Client is a 45-year-old male who has a one-and-a-half-week history of pain, redness, and swelling in his right foot. He reported that the symptoms began after he accidentally cut his foot while walking barefoot in his backyard. Over the next few days, he developed pain and swelling around the cut, accompanied by redness and warmth. He went to urgent care two days later and was diagnosed with cellulitis in his right foot. He was prescribed antibiotics but could not afford the treatment. Three days ago, the pain escalated and was described as throbbing and constant, with a severity rating of 7/10 on the Numerical Pain Rating Scale. He states, "the pain is now in the bone of my foot; I don't know how else to describe it." He also noted occasional fever 101°F (38.3°C), chills, and general malaise. On physical examination, his right foot was erythematous, swollen, and warm to the touch. A 3 cm ulcer was noted on the plantar aspect of the right foot, with moderate purulent discharge present. The ulcer appeared deep, and palpation of the surrounding tissue elicited tenderness. There was limited range of motion in the right ankle due to pain. The distal pulses were palpable 2+, and there were signs of neuropathy in the feet (decreased sensation to light touch and pinprick). He has a medical history of uncontrolled diabetes mellitus (type two), obesity, peripheral neuropathy in all extremities, hypertension, hyperlipidemia, and epilepsy.
Consultation
Infectious Disease Consultation
2050: Client was evaluated and I strongly suspect osteomyelitis in his right foot. Labs are pending. Agree with admission and will follow closely.
The nurse reviews the consultation report from the infectious disease physician. Select the complications that the client is at risk for developing? Select all that apply.
- A. Rheumatoid arthritis
- B. Osteosarcoma
- C. Avascular necrosis
- D. Sepsis
- E. Paget's disease
- F. Hyperosmolar hyperglycemic nonketotic syndrome
Correct Answer: C, D
Rationale: With suspected osteomyelitis and uncontrolled diabetes, the client risks avascular necrosis due to poor blood supply and sepsis from untreated infection spreading. Rheumatoid arthritis and osteosarcoma are unrelated, and Paget's is a chronic bone disorder.
The following scenario applies to the next 1 items
The nurse in the emergency department (ED) is caring for a 17-year-old male client.
Item 1 of 1
History and Physical
1722: The client has had an external fixation on the left wrist for the past two weeks. Today, he noticed swelling, increased pain, fever, and reports purulent drainage from the pin sites. The client reports poor adherence to performing pin care at home. On exam, the client is febrile and has an oral temperature of 103.4° F (39.7° C). The left wrist is erythemic, swollen, and tender to the touch.
The nurse has reviewed the history and physical. For each potential intervention, click to specify whether the intervention is indicated or not indicated for the client.
- A. Obtain a prescription for an antibiotic
- B. Culture the pin sites
- C. Apply a pressure dressing over the pins
- D. Obtain a prescription for analgesia
- E. Position the client's wrist so it is extended
Correct Answer: A: Indicated, B: Indicated, C: Not Indicated, D: Indicated, E: Not Indicated
Rationale: A: Antibiotics treat infection suggested by fever and drainage. B: Cultures identify the organism. C: Pressure dressings may damage pins or tissue. D: Analgesia addresses pain. E: Extension may worsen swelling and pain.