Nokea
A nurse is reviewing a client's medical history to identify risk factors for osteoporosis. The nurse should identify that which of the following findings is a risk factor for developing osteoporosis?
- A. Age 45 years
- B. Regular aerobic exercise
- C. Uses NSAIDS for pain relief
- D. Smokes cigarettes
Correct Answer: D
Rationale: Smoking is a known risk factor for osteoporosis as it reduces bone density. Age 45 isn't a strong risk unless postmenopausal, exercise helps, and NSAIDs aren't a direct risk.
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A nurse at a rehabilitation facility is contributing to the plan of care for a client who has had a below-the-knee amputation. Which of the following interventions should the nurse include in the plan of care?
- A. Ask the client to describe her feelings about the loss of the affected limb.
- B. Encourage the client to talk with another client who completed rehabilitation for amputation.
- C. Restrict visitors to family members until the client is able to wear a prosthesis.
- D. Suggest that family members bring clothing for the client from home.
- E. Instruct the client to ignore phantom pain sensations.
- F. Apply heat to the stump.
- G. Limit physical therapy.
Correct Answer: A,B,D
Rationale: Expressing feelings aids coping, peer support helps adjustment, and familiar clothing boosts morale; phantom pain should be addressed, not ignored.
A nurse is initiating the use of a continuous passive motion (CPM) device for a client following a total knee arthroplasty. Which of the following actions should the nurse take?
- A. Set the degree of flexion and extension as tolerated by client.
- B. Pad the CPM device with a thick pillow.
- C. Place the client in high-Fowler's position.
- D. Align the client's joints with the joints on the frame.
Correct Answer: D
Rationale: Aligning the client's joints with the CPM frame ensures proper movement and prevents injury. Flexion/extension should be preset by the provider, padding isn't typically needed, and high-Fowler's position is inappropriate for this therapy.
A nurse in a health clinic is collecting data from an older adult client. Which of the following information in the client's history increases her risk for osteoporosis?
- A. The client is a gardener.
- B. The client is lactose intolerant.
- C. The client has a glass of red wine every evening
- D. The client walks 3.2 km (2 mi) daily.
- E. The client smokes daily.
- F. The client has a family history of osteoporosis.
- G. The client takes corticosteroids long-term.
Correct Answer: B
Rationale: Lactose intolerance limits calcium intake, a key risk factor for osteoporosis; gardening and walking are protective, and moderate wine has minimal impact.
A nurse is contributing to the plan of care for a client who has developed an infectious wound with foul-smelling drainage. Which of the following actions should the nurse include in the plan of care?
- A. Discard soiled wound care supplies in a trash receptacle outside the client's room.
- B. Administer antibiotic therapy before culturing the client's wound.
- C. Place the client in a private room with a private bathroom.
- D. Instruct visitors to perform hand hygiene for 5 seconds after leaving the client's room.
Correct Answer: C
Rationale: A private room with a private bathroom helps control infection spread from a foul-smelling, infectious wound. Supplies should be discarded in biohazard containers, cultures taken before antibiotics, and hand hygiene should be thorough, not just 5 seconds.
Diagnostic Results
Day 1:
X-ray of right leg: open spiral tibial shaft fracture
For each finding, click to specify if the finding is consistent with acute compartment syndrome, infection, and/or fat embolism syndrome. Finding: Dyspnea
- A. Dyspnea
- B. Tingling sensation to right foot
- C. Increased pain at incision site
- D. Swelling at incision site
Correct Answer:
Rationale: Dyspnea is a hallmark of fat embolism syndrome due to pulmonary involvement.