Nokea
Mrs. Peterson complains of difficulty falling asleep, awakening earlier than desired, and not feeling rested. She attributes these problems to leg pain that is secondary to her arthritis. What is the most appropriate nursing diagnosis for her?
- A. Sleep Pattern Disturbances (related to arthritis)
- B. Fatigue (related to leg pain)
- C. Knowledge Deficit (regarding sleep hygiene measures)
- D. Sleep Pattern Disturbances (related to chronic leg pain)
Correct Answer: D
Rationale: The client's sleep pattern is directly disturbed by the chronic leg pain, which is secondary to the arthritis. This nursing diagnosis is the appropriate one to directly deal with comfort measures and the like.
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The client reports pain in the right leg even though it was amputated. Which complementary therapy should the nurse use to control the phantom pain associated with the client's amputation?
- A. A small dose of alprazolam at 8-hour intervals in addition to prescribed oxycodone and acetaminophen q6h pm
- B. A high-fiber diet and 2000 mL fluid intake in 24 hours while taking hydromorphone at 4- to 6-hour intervals pm
- C. Progressive relaxation exercises three times daily in addition to use of a transdermal patch of fentanyl
- D. A local anesthetic as a nerve block in addition to prescribed long-acting oxycodone
Correct Answer: C
Rationale: C: Progressive relaxation is a complementary therapy that aids phantom pain relief with analgesics. A: Alprazolam is conventional, not complementary. B: Diet addresses opioid side effects, not pain. D: Nerve blocks are conventional medical interventions.
The 24-hour day-night cycle is known as:
- A. circadian rhythm
- B. infradian rhythm
- C. ultradian rhythm
- D. non-REM rhythm
Correct Answer: A
Rationale: The circadian rhythm governs the 24-hour cycle of physiological processes. Infradian rhythms are longer than 24 hours (e.g., menstrual cycle), ultradian rhythms are shorter (e.g., sleep cycles), and non-REM rhythm is not a recognized term.
Which of the following individuals may legally give informed consent?
- A. an 86-year-old male with advanced Alzheimer's disease
- B. a 14-year-old girl needing an appendectomy who is not an emancipated minor
- C. a 72-year-old female scheduled for a heart transplant
- D. a 6-month-old baby needing bowel surgery
Correct Answer: C
Rationale: Only competent adults can legally give informed consent. The 72-year-old female is presumed competent unless stated otherwise. An individual with advanced Alzheimer's lacks decision-making capacity, a non-emancipated minor cannot consent, and infants are legally incapable of consenting; their guardians must provide consent.
The LPN is observing a client using crutches for a leg injury. Which of these would indicate a need for more education?
- A. The client places the top padding 1-2 inches below the axilla with a firm grip on the handles.
- B. The client rests the axilla on the top padding and loosely grips the handles with hands.
- C. The client has a slight bend in the elbow when using the handles.
- D. When going down the stairs, the client leads with the injured leg.
Correct Answer: B
Rationale: Resting the axilla on the top of the crutch can cause nerve damage and the client should have a firm grip on the handles.
The LPN is auscultating for bowel sounds and hears between 3 and 4 bowel sounds per minute. This is a somewhat expected finding for which of these clients?
- A. a 63-year-old female undergoing chemotherapy for breast cancer
- B. a 56-year-old female with dementia undergoing a swallow study
- C. a 34-year-old male with a PEG tube newly admitted for diabetic ketoacidosis
- D. a 45-year-old male recovering from a knee replacement under general anesthesia
Correct Answer: D
Rationale: When recovering from general anesthesia, hypoactive bowel sounds can be expected. For other clients, less than 5 bowel sounds per minute is an abnormal finding.