Nokea
After the arm cast has been applied, which nursing observation is the best indication that the client may be developing compartment syndrome?
- A. The client's head becomes severe pain.
- B. The client's hand becomes reddened.
- C. The fingers develop muscle spasms.
- D. The radial pulse feels bounding.
Correct Answer: A
Rationale: Severe pain disproportionate to the injury is a hallmark of compartment syndrome, indicating increased pressure within the cast compromising neurovascular status. Redness, spasms, or a bounding pulse are less specific.
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The occupational health nurse is planning health promotion activities for a group of factory workers. Which activity is an example of primary prevention for clients at risk for low back pain?
- A. Teach back exercises to workers after returning from an injury.
- B. Place signs in the work area about how to perform first aid.
- C. Start a weight-reduction group to meet at lunchtime.
- D. Administer a nonnarcotic analgesic to a client complaining of back pain.
Correct Answer: C
Rationale: Weight reduction reduces spinal stress, a primary prevention strategy for low back pain. Post-injury exercises are secondary, first aid signs are tertiary, and analgesics treat symptoms, not prevent.
Which statements made by a parent indicate that appropriate care is being provided for a 4-year-old with spastic-type CP?
- A. "I perform range of motion (ROM) exercises every 4 hours to help prevent contractures."
- B. "I give my child a therapeutic massage after the stretching exercises to help manage pain."
- C. "I minimize the calories I provide with meals because my child is more prone to obesity."
- D. "I have my child wear a helmet during the day because of chronic tonic-clonic seizures."
- E. "Using utensils with large, padded handles makes it easier for my child to feed himself."
Correct Answer: A,B,D,E
Rationale: ROM exercises, therapeutic massage, helmet use for seizures, and adaptive utensils indicate appropriate care for spastic CP.
The nurse is caring for the client involved in an MVA who sustained an unstable pelvic fracture. Which HCP order should be the nurse's priority?
- A. Urinalysis and culture and sensitivity
- B. Blood alcohol level and toxicology screen
- C. Computed tomography (CT) scan of the pelvis
- D. Give two units of cross-matched whole blood
Correct Answer: D
Rationale: D. Significant blood loss occurs because the pelvis is a highly vascular area. A type and cross-match must be completed prior to administering blood, which takes time.
Later the client says, 'I know my arm isn't there, but I feel it throbbing.' Which response by the nurse would be most accurate?
- A. You may be experiencing referred pain from an adjacent muscle.
- B. You may be experiencing phantom pain from the amputated site.
- C. You may be experiencing psychogenic pain from emotional distress.
- D. You may be experiencing intractable pain that can best be treated with opioids.
Correct Answer: B
Rationale: Phantom pain is a common sensation of pain in the amputated limb due to nerve endings firing, accurately describing the client's experience. The other options misattribute the cause.
How should the nurse explain the purpose of methotrexate in treating a child with juvenile arthritis?
- A. Improves functional ability
- B. Controls the febrile response
- C. Minimizes the effects of uveitis
- D. Decreases the inflammatory response
Correct Answer: D
Rationale: Methotrexate is a disease-modifying antirheumatic drug that reduces inflammation in juvenile arthritis.