Nokea
The 84-year-old client is a resident in a long-term care facility. Which intervention should be implemented to help prevent complications secondary to osteoporosis?
- A. Keep the bed in the high position.
- B. Perform passive range-of-motion exercises.
- C. Turn the client every two (2) hours.
- D. Provide nighttime lights in the room.
Correct Answer: D
Rationale: Nighttime lights reduce fall risk, a major osteoporosis complication causing fractures. High beds increase fall risk, ROM does not prevent falls, and turning addresses skin integrity, not fractures.
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The nurse is preparing the care plan for a client with a fractured lower extremity. Which outcome is most appropriate for the client?
- A. The client will maintain function of the leg.
- B. The client will ambulate with assistance.
- C. The client will be turned every two (2) hours.
- D. The client will have no infection.
Correct Answer: A
Rationale: Maintaining leg function is the primary goal for fracture recovery. Ambulation, turning, and infection prevention are interventions, not outcomes.
The Jewish client with peripheral vascular disease is scheduled for a left AKA. Which question is most important for the operating room nurse to ask the client?
- A. Have you made any special arrangements for your amputated limb?'
- B. What types of food would you like to eat while you're in the hospital?'
- C. Would you like a rabbi to visit you while you are in the recovery room?'
- D. Will you start checking your other foot at least once a day for cuts?'
Correct Answer: A
Rationale: Jewish cultural practices may require special handling of amputated limbs (e.g., burial); this question respects beliefs. Food, rabbi visits, and foot checks are secondary.
The nurse is assessing the client 3 months following a left shoulder arthroplasty. Which assessment findings should prompt the nurse to consider that the client may have developed osteomyelitis? Select all that apply.
- A. Sudden onset of chills
- B. Temperature 103°F (39.4°C)
- C. Sudden onset of bradycardia
- D. Pulsating shoulder pain that is worsening
- E. Painful, swollen area on the left shoulder
Correct Answer: A,B,D,E
Rationale: A. A sudden onset of chills suggests the infection of osteomyelitis is blood-borne. B. A high fever suggests the infection of osteomyelitis is blood-borne. D. The pulsating shoulder pain is caused from the pressure of the collecting pus. E. The infected area becomes swollen, painful, and extremely tender.
When preparing the client for cast application, which statement by the nurse is most accurate?
- A. The cast will feel tight as it's applied.
- B. Your arm will feel warm as the wet plaster sets.
- C. You can expect a foul odor until the cast is dry.
- D. You may feel itchy while the cast is wet.
Correct Answer: B
Rationale: Wet plaster generates heat as it sets, causing a warm sensation, which is a normal part of the process. Tightness may indicate a problem, odors are not typical, and itching is more common as the cast dries.
The 34-year-old male client presents to the outpatient clinic complaining of numbness and pain radiating down the left leg. Which further data should the nurse assess?
- A. Posture and gait.
- B. Bending and stooping.
- C. Leg lifts and arm swing.
- D. Waist twists and neck mobility.
Correct Answer: A
Rationale: Numbness and radiating leg pain suggest sciatica from a herniated disk; assessing posture and gait evaluates nerve impingement effects. Other options are less specific to lumbar radiculopathy.