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A nurse is developing a plan of care for a client who will be placed in halo traction following surgical repair of the cervical spine. Which of the following interventions should the nurse include in the plan?
- A. Inspect the pin site every 4 hours
- B. Monitor the client's skin under the halo vest
- C. Ensure two personnel hold the halo device when repositioning the client
- D. Apply powder to the client's skin under the vest to decrease itching
Correct Answer: B
Rationale: The correct answer is to monitor the client's skin under the halo vest. This is important to assess for signs of skin issues such as excessive sweating, redness, or blistering, which can lead to skin breakdown and infection. Choice A is incorrect because while inspecting the pin site is important, it should be done more frequently than every 4 hours. Choice C is incorrect as the halo device should be supported by the client's body weight, not personnel, when repositioning. Choice D is incorrect because applying powder frequently can increase the risk of skin irritation and infection.
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A nurse is assessing a client who has a permanent spinal cord injury and is scheduled for discharge. Which of the following client statements indicates that the client is coping effectively?
- A. I would like to play wheelchair basketball. When I get stronger, I think I'll look for a league.
- B. I'm glad I'll only be in this wheelchair temporarily. I can't wait to get back to running.
- C. I'm so upset that this happened to me. What did I do to deserve this?
- D. I feel like I'll never be able to do anything that I want to again. All I am is a burden to my family.
Correct Answer: A
Rationale: Choice A is the correct answer because it shows that the client has accepted their disability and is looking towards the future with realistic goals. This positive attitude and focus on engaging in activities that are achievable despite the disability indicate effective coping mechanisms. Choice B is incorrect as it reflects denial of the permanent nature of the disability. Choice C is incorrect as it shows feelings of anger and possible self-blame, which are not indicative of effective coping. Choice D is incorrect as it demonstrates a sense of hopelessness and self-perceived burden, which are signs of maladaptive coping.
A nurse is teaching a group of clients about the risk factors for osteoporosis. Which of the following should the nurse include as a risk factor for osteoporosis?
- A. Early menopause
- B. History of falls
- C. African American race
- D. Obesity
Correct Answer: A
Rationale: The correct answer is A: Early menopause. A client who goes into early menopause, from natural or surgical causes, is at a greater risk for developing osteoporosis due to the rapid drop in estrogen levels. Choice B, history of falls, is not a direct risk factor for osteoporosis but rather a risk for fractures related to osteoporosis. Choice C, African American race, is actually associated with a lower risk of osteoporosis. Choice D, obesity, is considered a protective factor against osteoporosis as excess weight can provide additional support to bones.
A client at high risk for iron deficiency anemia should increase the consumption of which of the following foods?
- A. Yogurt
- B. Apples
- C. Raisins
- D. Cheddar cheese
Correct Answer: C
Rationale: The correct answer is C: Raisins. Raisins are a good source of iron, making them beneficial for a client at high risk for iron deficiency anemia. Yogurt (Choice A), apples (Choice B), and cheddar cheese (Choice D) are not significant sources of iron. Other iron-rich foods include dried fruits, red meat, and green leafy vegetables.
A client who has burn injuries covering their upper body is concerned about their altered appearance. Which of the following statements should the nurse make?
- A. It is okay to not want to touch the burned areas of your body.
- B. Cosmetic surgery should be performed within the next year to be effective.
- C. Reconstructive surgery can completely restore your previous appearance.
- D. It could be helpful for you to attend a support group for people who have burn injuries.
Correct Answer: D
Rationale: The nurse should encourage the client to attend a support group for individuals who have burn injuries. Support groups can provide emotional support, shared experiences, and coping strategies for accepting their altered appearance. Choice A is not the best response as it does not offer proactive support. Choice B is not appropriate as the timing of cosmetic surgery should be determined by healthcare providers, not immediate. Choice C is misleading as reconstructive surgery may improve appearance but may not completely restore the previous look.
A client is being taught about fecal occult blood testing (FOBT) for colorectal cancer screening. Which of the following statements should the nurse include in the teaching?
- A. Your provider will use a stool sample obtained during a digital rectal examination to perform the test.
- B. Your provider will recommend a stimulant laxative before the test to empty the bowel.
- C. You should start annual fecal occult blood testing for colorectal cancer screening at the age of 40.
- D. You should avoid corticosteroids before the test.
Correct Answer: D
Rationale: The correct answer is D because the nurse should advise the client to avoid corticosteroids, anti-inflammatory medications, and vitamin C before fecal occult blood testing to prevent false-positive results. Choice A is incorrect as stool samples for FOBT are usually collected using a kit at home. Choice B is incorrect because stimulant laxatives are not typically used before FOBT. Choice C is incorrect as guidelines recommend starting colorectal cancer screening at the age of 50, not 40.