Nokea
After surgery and insertion of a total joint prosthesis, a client develops severe sudden pain and an inability to move the extremity. The nurse correctly interprets these findings as indicating which of the following?
- A. A developing infection.
- B. Bleeding in the operative site.
- C. Joint dislocation.
- D. Glue seepage into soft tissue.
Correct Answer: C
Rationale: Sudden pain and inability to move suggest joint dislocation, a surgical emergency.
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A 42-year-old husband and father of a 7-year-old girl and a 10-year-old boy is concerned about what he should tell his children regarding his wife's impending death from aggressive breast cancer. The nurse should:
- A. Refer the family to pastoral care services.
- B. Encourage the husband to come to terms with his own grief first.
- C. Suggest that the children be told nothing until after death occurs.
- D. Begin education about strategies for communication with his children.
Correct Answer: D
Rationale: Educating the husband on communication strategies helps him prepare his children for their mother's death, fostering understanding and emotional support.
Which of the following is most likely to cause the client to experience postoperative nausea and vomiting?
- A. Total hip replacement.
- B. Mitral valve repair.
- C. Abdominal hysterectomy.
- D. Mastectomy of the left breast.
Correct Answer: C
Rationale: Abdominal hysterectomy involves manipulation of the gastrointestinal tract, increasing the risk of postoperative nausea and vomiting due to vagal stimulation and slowed gastric motility.
A client with multiple sclerosis (MS) lives with her daughter and 3-year-old granddaughter. The daughter asks the nurse what she can do at home to help her mother. Which of the following measures would be most beneficial?
- A. Psychotherapy.
- B. Regular exercise.
- C. Day care for the granddaughter.
- D. Weekly visits by another person with MS.
Correct Answer: B
Rationale: Regular exercise is most beneficial, as it maintains mobility, strength, and overall health in MS. Psychotherapy, daycare, or peer visits may help but are less directly impactful.
Sensorineural hearing loss results from which of the following conditions?
- A. Presence of fluid and cerumen in the external canal.
- B. Sclerosis of the bones of the middle ear.
- C. Change to the cochlear or vestibulocochlear nerve.
- D. Emotional disturbance resulting in a functional hearing loss.
Correct Answer: C
Rationale: Sensorineural hearing loss results from damage to the cochlear or vestibulocochlear nerve, affecting the inner ear or neural pathways.
A client post-cystoscopy reports severe pain. The nurse should:
- A. Administer analgesics as prescribed.
- B. Encourage ambulation.
- C. Apply a cold pack.
- D. Notify the physician.
Correct Answer: D
Rationale: Severe pain post-cystoscopy is abnormal and requires physician notification to rule out complications.