Nokea
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.
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After the client's total hip replacement surgery, which nursing actions are essential? Select all that apply.
- A. Keeping the client's knees apart at all times
- B. Avoiding flexing the client's hips more than 90 degrees
- C. Having the client use a raised toilet seat
- D. Raising the head of the client's bed 90 degrees
- E. Placing two pillows beneath the client's knees
- F. Keeping the client's legs internally rotated
Correct Answer: A,B,C
Rationale: To prevent dislocation after total hip replacement, keep knees apart (using an abductor pillow), avoid hip flexion beyond 90 degrees, and use a raised toilet seat to maintain safe hip angles. Raising the bed 90 degrees or placing pillows under knees risks dislocation, and internal rotation is contraindicated.
The client is to be discharged after receiving treatment for right shoulder tendonitis. Which actions indicate to the nurse that the client is ready for discharge? Select all that apply.
- A. Verbalizes about resuming normal activities within a day or two
- B. Demonstrates proper use of an arm sling and the need to wear it during sleep
- C. Verbalizes to keep the arm extended and flat on the mattress when lying in bed
- D. Demonstrates how to properly apply the ice packs on the shoulder joint
- E. States will take ibuprofen every four to six hours as needed for pain
Correct Answer: B,D,E
Rationale: B. An arm sling helps to rest the joint and keep it stabilized, especially during sleep. D. Ice application reduces joint inflammation and pain associated with tendonitis. E. NSAIDs such as ibuprofen (Motrin) are effective for controlling pain and reducing inflammation with tendonitis.
The nurse is caring for the client who has had a total hip replacement. Which data indicate the surgical treatment is effective?
- A. The client states the pain is at a '3' on a 1-to-10 scale.
- B. The client has a limited ability to ambulate.
- C. The client's left leg is shorter than the right leg.
- D. The client ambulates to the bathroom.
Correct Answer: D
Rationale: Ambulating to the bathroom indicates effective THR, restoring mobility. Mild pain is expected, limited ambulation is negative, and leg length discrepancy is a complication.
Which material added by the nurse is best for covering the tips of the pin to prevent injuries while the client is in skeletal leg.
- A. Gauze squares
- B. Cotton balls
- C. Cork blocks
- D. Rubber tubes
Correct Answer: C
Rationale: Cork blocks securely cover pin tips, preventing injury to the client or staff while maintaining stability. Gauze and cotton are less durable, and rubber tubes may not fit securely.
Which statement indicates that the client understands the restrictions to be followed?
- A. I should avoid pointing my toes.
- B. I shouldn't cross my legs.
- C. I shouldn't lie flat in bed.
- D. I shouldn't stand upright.
Correct Answer: B
Rationale: Crossing legs can dislocate the hip prosthesis.