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On the basis of the nurse's knowledge of the client's culture and beliefs, which statement regarding the health-seeking behavior is probably most accurate?
- A. Home remedies have been unsuccessful, and the condition threatens the client's self-image.
- B. The power to cure comes from physicians and is passed to nurses.
- C. Both of the above
- D. None of the above
Correct Answer: A
Rationale: Hispanic clients may initially rely on home remedies due to cultural practices, seeking medical care when these fail, especially if pain (e.g., bursitis) impacts self-image or function.
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The nurse is caring for clients on an orthopedic floor. Which client should be assessed first?
- A. The client diagnosed with back pain who is complaining of a '4' on a 1-to-10 scale.
- B. The client who has undergone a myelogram who is complaining of a slight headache.
- C. The client two (2) days post-disk fusion who has T 100.4, P 96, R 24, and BP 138/78.
- D. The client diagnosed with back pain who is being discharged and whose ride is here.
Correct Answer: C
Rationale: Fever, tachycardia, and tachypnea post-disk fusion suggest infection or complications, requiring urgent assessment. Mild pain, headache, and discharge are lower priority.
What should the nurse admitting the child with autism do about the room assignment?
- A. Request that the child be transferred to a private room.
- B. Request that the child be transferred to a double room.
- C. Admit the child to the room that has been preassigned.
- D. Request that the child be assigned to an isolation room.
Correct Answer: A
Rationale: A private room is preferred for a child with autism to minimize sensory overload and ensure a calm environment.
What is the goal of therapy for a child newly diagnosed with scoliosis as explained by the nurse?
- A. Limit or stop progression of the curvature of the spine.
- B. Prepare the child for surgical correction at a later date.
- C. Minimize the complications of prolonged immobilization.
- D. Develop a pain management plan to minimize complications.
Correct Answer: A
Rationale: The primary goal of scoliosis treatment is to halt or limit the progression of spinal curvature.
The nurse assesses that the client has some finger swelling of a newly casted right arm fracture with no other abnormal findings. Which is the nurse's priority action?
- A. Notify the HCP immediately.
- B. Split the cast to prevent constriction.
- C. Elevate the casted arm on pillows.
- D. Document the degree of finger swelling.
Correct Answer: C
Rationale: C. Swelling is an expected finding; elevating the extremity decreases edema.
The 50-year-old female client is being evaluated for osteoporosis. Which data should the nurse assess? Select all that apply.
- A. Family history of osteoporosis.
- B. Estrogen or androgen deficit.
- C. Exposure to secondhand smoke.
- D. Level and amount of exercise.
- E. Alcohol intake.
Correct Answer: A,B,C,D,E
Rationale: Family history, hormonal deficits, smoking, exercise, and alcohol are all risk factors for osteoporosis, requiring comprehensive assessment.