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If the client is typical of others with a herniated disk, the nurse would expect the client to report which additional symptom?
- A. Pain radiating into the buttocks and leg
- B. Tenderness over one or both iliac crests
- C. Diminished sensation in one or both knees
- D. Brief periods when the toes feel quite cold
Correct Answer: A
Rationale: A herniated lumbar disk commonly causes sciatica, with pain radiating into the buttocks and leg due to nerve root compression. Other symptoms are less typical or specific.
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Which is the nurse's best explanation regarding the goal of surgery for an adolescent requiring surgical treatment for scoliosis?
- A. "The surgery will allow you to grow to be taller."
- B. "The surgery will decrease the recurrence of pain."
- C. "The surgery will prevent problems with breathing."
- D. "The surgery will allow your clothes to fit you better."
Correct Answer: C
Rationale: Scoliosis surgery aims to correct spinal deformity and prevent respiratory complications.
Which nursing assessment finding is the best indication that the client has an infection at the pin site?
- A. Serous drainage at the pin site
- B. Bloody drainage at the pin site
- C. Mucoid drainage at the pin site
- D. Purulent drainage at the pin site
Correct Answer: D
Rationale: Purulent (pus-like) drainage is the clearest sign of infection at the pin site, indicating bacterial presence. Serous, bloody, or mucoid drainage is less specific to infection.
When preparing to meet with the parents and their 5-year-old child with autism, which behaviors should the nurse anticipate that the child might display?
- A. Polydactyly
- B. Leukoderma
- C. Poor eye contact
- D. Restricted interests
- E. Atypical language
Correct Answer: C,D,E
Rationale: Children with autism often exhibit poor eye contact, restricted interests, and atypical language patterns.
The nurse is caring for a client in a hip spica cast. Which intervention should the nurse include in the plan of care?
- A. Assess the client’s popliteal pulses every shift.
- B. Elevate the leg on pillows and apply ice packs.
- C. Teach the client how to ambulate with a tripod walker.
- D. Assess the client for distention and vomiting.
Correct Answer: D
Rationale: Distention and vomiting indicate GI complications (e.g., ileus) in a hip spica cast, requiring assessment. Pulses are accessible, elevation is impractical, and ambulation is limited.
The nurse is assessing the leg of a client in Russell's traction. Which area is it essential to assess?
- A. Pedal area
- B. Femoral area
- C. Popliteal area
- D. Inner aspect of the thigh
Correct Answer: A
Rationale: Assessing the pedal area checks for circulation, sensation, and movement, critical in traction to detect neurovascular compromise.