Nokea
A nurse is providing care for a patient who has a recent diagnosis of Paget's disease. When planning this patient's nursing care, interventions should address what nursing diagnoses?
- A. Impaired Physical Mobility
- B. Acute Pain
- C. Disturbed Auditory Sensory Perception
- D. Risk for Injury
- E. Risk for Unstable Blood Glucose
Correct Answer: A,B,C,D
Rationale: Patients with Paget's disease are at risk of decreased mobility, pain, hearing loss, and injuries resulting from decreased bone density. Paget's disease does not affect blood glucose levels.
You may also like to solve these questions
An 80-year-old man in a long-term care facility has a chronic leg ulcer and states that the area has become increasingly painful in recent days. The nurse notes that the site is now swollen and warm to the touch. The patient should undergo diagnostic testing for what health problem?
- A. Osteomyelitis
- B. Osteoporosis
- C. Osteomalacia
- D. Septic arthritis
Correct Answer: A
Rationale: When osteomyelitis develops from the spread of an adjacent infection, no signs of septicemia are present, but the area becomes swollen, warm, painful, and tender to touch. Osteoporosis is the most prevalent bone disease in the world. Osteomalacia is a metabolic bone disease characterized by inadequate mineralization of bone. Septic arthritis occurs when joints become infected through spread of infection from other parts of the body (hematogenous spread) or directly through trauma or surgical instrumentation.
A patient presents to a clinic complaining of a leg ulcer that isn't healing; subsequent diagnostic testing suggests osteomyelitis. The nurse is aware that the most common pathogen to cause osteomyelitis is what?
- A. Staphylococcus aureus
- B. Proteus
- C. Pseudomonas
- D. Escherichia coli
Correct Answer: A
Rationale: S. aureus causes over 50% of bone infections. Proteus, Pseudomonas, and E. coli are also causes, but to a lesser extent.
A nurse is collaborating with the physical therapist to plan the care of a patient with osteomyelitis. What principle should guide the management of activity and mobility in this patient?
- A. Stress on the weakened bone must be avoided.
- B. Increased heart rate enhances perfusion and bone healing.
- C. Bed rest results in improved outcomes in patients with osteomyelitis.
- D. Maintenance of baseline ADLs is the primary goal during osteomyelitis treatment.
Correct Answer: A
Rationale: The patient with osteomyelitis has bone that is weakened by the infective process and must be protected by avoidance of stress on the bone. This risk guides the choice of activity in a patient with osteomyelitis. Bed rest is not normally indicated, however. Maintenance of prediagnosis ADLs may be an unrealistic short-term goal for many patients.
A nurse is caring for a patient who is 12 hours postoperative following foot surgery. The nurse assesses the presence of edema in the foot. What nursing measure will the nurse implement to control the edema?
- A. Elevate the foot on several pillows.
- B. Apply warm compresses intermittently to the surgical area.
- C. Administer a loop diuretic as ordered.
- D. Increase circulation through frequent ambulation.
Correct Answer: A
Rationale: To control the edema in the foot of a patient who experienced foot surgery, the nurse will elevate the foot on several pillows when the patient is sitting or lying. Diuretic therapy is not an appropriate intervention for edema related to inflammation. Intermittent ice packs should be applied to the surgical area during the first 24 to 48 hours after surgery to control edema and provide some pain relief. Ambulation will gradually be resumed based on the guidelines provided by the surgeon.
A nurse is discussing conservative management of tendonitis with a patient. Which of the following may be an effective approach to managing tendonitis?
- A. Weight reduction
- B. Use of oral opioid analgesics
- C. Intermittent application of ice and heat
- D. Passive range of motion exercises
Correct Answer: C
Rationale: Conservative management of tendonitis includes rest of the extremity, intermittent ice and heat to the joint, and NSAIDs. Weight reduction may prevent future injuries but will not relieve existing tendonitis. Range-of-motion exercises may exacerbate pain. Opioids would not be considered a conservative treatment measure.