Nokea
After a cervical spine fracture, this device (refer to figure) is placed on the client. The nurse creates a discharge plan for the client to ensure safety and includes which measures? Select all that apply.
- A. Teach the client how to ambulate with a walker.
- B. Instruct the client to bend at the waist to pick up needed items.
- C. Demonstrate the procedure for scanning the environment for vision.
- D. Inform the client about the importance of wearing rubber-soled shoes.
- E. Teach the spouse to use the metal frame to assist the client to turn in bed.
Correct Answer: A,C,D
Rationale: The client with a halo fixation device should be taught that the use of a walker and rubber-soled shoes may help prevent falls and injury and are therefore also helpful. It is helpful for the client to scan the environment visually because the client's peripheral vision is diminished from keeping the neck in a stationary position. The client with a halo fixation device should avoid bending at the waist because the halo vest is heavy, and the client's trunk is limited in flexibility. The nurse instructs the client and family that the metal frame on the device is never used to move or lift the client because this will disrupt the attachment to the client's skull, which is stabilizing the fracture.
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The nurse is caring for a client diagnosed with heart failure who has a magnesium level of 0.75 mEq/L (0.375 mmol/L). Which action should the nurse take?
- A. Monitor the client for irregular heart rhythms.
- B. Encourage the intake of antacids with phosphate.
- C. Teach the client to avoid foods high in magnesium.
- D. Provide a diet of ground beef, eggs, and chicken breast.
Correct Answer: A
Rationale: The normal magnesium level ranges from 1.3 to 2.1 mEq/L (0.65 to 1.05 mmol/L); therefore, this client is experiencing hypomagnesemia. The client should be monitored for dysrhythmias because magnesium plays an important role in myocardial nerve cell impulse conduction; thus, hypomagnesemia increases the client's risk of ventricular dysrhythmias. The nurse avoids administering phosphate in the presence of hypomagnesemia because it aggravates the condition. The nurse instructs the client to consume foods high in magnesium; ground beef, eggs, and chicken breast are low in magnesium.
The nurse is admitting a client with a diagnosis of hypothyroidism. What assessment should the nurse perform to obtain data related to this diagnosis?
- A. Inspect facial features.
- B. Auscultate lung sounds.
- C. Percuss the thyroid gland.
- D. Inspect ability to ambulate safely.
Correct Answer: A
Rationale: Inspection of facial features will reveal the characteristic coarse features, presence of edema around the eyes and face, and the blank expression that are characteristics of hypothyroidism. The assessment techniques in options 2, 3, and 4 will not reveal information related to the diagnosis of hypothyroidism.
The nurse is caring for an obese client on a weight loss program. Which method should the nurse use to most accurately assess the program's effectiveness?
- A. Monitor the client's weight.
- B. Monitor the client's intake and output.
- C. Calculate the client's daily caloric intake.
- D. Frequently check the client's serum protein levels.
Correct Answer: A
Rationale: The most accurate measurement of weight loss is weighing of the client. This should be done at the same time of the day, in the same clothes, and using the same scale. Options 2, 3, and 4 measure nutrition and hydration status but are not associated with effectiveness of the weight loss program.
A client experiencing a severe major depressive episode is unable to address activities of daily living (ADL). Which nursing intervention best meets the client's current needs therapeutically?
- A. Have the client's peers approach the client about how noncompliance in addressing ADL affects the milieu.
- B. Structure the client's day so that adequate time can be devoted to the client's assuming responsibility for ADL.
- C. Offer the client choices and describe the consequences for the failure to comply with the expectation of maintaining her or his own ADL.
- D. Feed, bathe, and dress the client as needed until the client's condition improves so that she or he can perform these activities independently.
Correct Answer: D
Rationale: The symptoms of major depression include depressed mood, loss of interest or pleasure, changes in appetite and sleep patterns, psychomotor agitation or retardation, fatigue, feelings of worthlessness or guilt, diminished ability to think or concentrate, and recurrent thoughts of death. Often, the client does not have the energy or interest to complete activities of daily living. Option 1 will increase the client's feelings of poor self-esteem and of unworthiness. Option 2 is incorrect because the client still lacks the energy and motivation to do these independently. Option 3 may lead to increased feelings of worthlessness as the client fails to meet expectations.
A child sustains a greenstick fracture of the humerus from a fall out of a tree house. The nurse describes this type of fracture to the parents and should provide them with which picture? Refer to figures 1 to 4.
- A. fracture_1.PNG
- B. fracture_2.PNG
- C. fracture_3.PNG
- D. fracture_4.PNG
Correct Answer: A
Rationale: A greenstick fracture is an incomplete fracture where the bone bends and breaks on one side without breaking completely through, common in children due to their flexible bones. The nurse should select the picture that depicts this type of fracture, typically showing a bend with a partial break on one side of the bone. This distinguishes it from complete fractures or other types like comminuted or spiral fractures.