Nokea
One of the complications associated with the improper use of crutches is:
- A. Axillary nerve damage
- B. Solar plexus nerve damage
- C. Carpal tunnel syndrome
- D. Trigeminal nerve damage
Correct Answer: A
Rationale: Improper crutch use can compress the axillary nerve, causing nerve damage. Other options are unrelated to crutches.
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The nurse is caring for a child immediately post-operative following a tonsillectomy. Which assessment finding requires immediate follow-up?
- A. Discomfort while speaking
- B. Frequent swallowing
- C. Drowsiness
- D. Pain with occasional coughing
Correct Answer: B
Rationale: Frequent swallowing in a post-tonsillectomy child may indicate bleeding in the throat, as the child swallows blood, requiring immediate follow-up to prevent hemorrhage. Discomfort, drowsiness, and pain with coughing are expected findings and less urgent.
The nurse is helping the unlicensed assistive personnel pass meal trays. When providing a meal tray for a client diagnosed with pheochromocytoma, which dietary item should the nurse remove?
- A. Macaroni and cheddar cheese
- B. Watermelon slices
- C. Caffeine free cola
- D. Baked chicken
Correct Answer: C
Rationale: Pheochromocytoma requires avoiding stimulants like caffeine, even in decaffeinated cola, which may contain trace amounts. Other items are safe.
The nurse is discussing the risk of delayed wound healing following surgery with another healthcare team member. It would be correct for the nurse to identify which condition is a potential cause of this complication?
- A. Diabetes insipidus
- B. Cushing's syndrome
- C. Hemophilia
- D. Inflammatory bowel disease
Correct Answer: B
Rationale: Cushing’s syndrome involves elevated cortisol levels, which impair wound healing by suppressing immune responses and collagen synthesis. Diabetes insipidus primarily affects fluid balance, hemophilia affects clotting but not healing directly, and inflammatory bowel disease is less directly related to wound healing compared to Cushing’s syndrome.
The nurse is interviewing a 25-year-old female client who recently experienced domestic violence. What is the rationale for excluding the family from the interview to ensure a safe and confidential environment? Select all that apply.
- A. Promote client autonomy
- B. Maintain family dynamics and support
- C. Maintains privacy and confidentiality
- D. Prevent potential intimidation or coercion
- E. Minimize the risk of retaliation
Correct Answer: A,C,D,E
Rationale: Excluding family promotes autonomy, privacy, and prevents intimidation or retaliation. Maintaining family dynamics is not a priority in this context.
The nurse is preparing a client scheduled for hip arthroplasty in two hours. The nurse has received a prescription for tranexamic acid. The nurse understands that this medication has had a therapeutic effect when the client has
- A. decreased postoperative pain
- B. increased postoperative vital capacity
- C. less postoperative blood loss
- D. no surgical site infection
Correct Answer: C
Rationale: Tranexamic acid is an antifibrinolytic that reduces bleeding by inhibiting clot breakdown. Its therapeutic effect is evident with less postoperative blood loss. It does not directly affect pain, vital capacity, or infection rates.