Nokea
The client diagnosed with cervical disk degeneration has undergone a laminectomy. Which interventions should the nurse implement?
- A. Position the client prone with the knees slightly elevated.
- B. Assess the client for difficulty speaking or breathing.
- C. Measure the drainage in the Jackson Pratt bulb every day.
- D. Encourage the client to postpone the use of narcotic medications.
Correct Answer: B
Rationale: Cervical laminectomy risks airway or neurological complications; assessing speech and breathing is critical. Prone positioning is inappropriate, JP drainage is routine, and delaying narcotics is unsafe.
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What is the best technique a nurse can use for drying the wet plaster arm cast?
- A. Leave the casted arm uncovered.
- B. Apply a heating blanket to the cast.
- C. Use a hair dryer to blow hot air onto the cast.
- D. Place a heat lamp directly above the cast.
Correct Answer: A
Rationale: Leaving the cast uncovered allows natural air drying, which is the safest and most effective method for plaster casts. Heat sources like blankets, dryers, or lamps can cause burns or uneven drying, risking skin damage.
Which assessment finding most likely indicates that a client has osteoporosis?
- A. Swollen joints
- B. Discomfort when sitting
- C. Spinal deformity
- D. Diminished energy level
Correct Answer: C
Rationale: Spinal deformity, such as kyphosis, is a common sign of osteoporosis due to vertebral compression fractures from reduced bone density. Swollen joints, discomfort, or low energy are less specific.
The nurse is admitting a female client who is complaining of severe back pain radiating down the left leg whenever she tries to ambulate. The concepts of impaired mobility and comfort are implemented on the care map. Which nursing interventions should the nurse implement?
- A. Assist the client when ambulating to the bathroom and administer medications based on the pain scale.
- B. Place the client on strict bedrest and have the client use a regular bedpan for elimination of urine and feces.
- C. Ambulate the client in the hallway at least four (4) times per day and discourage the use of pharmacological pain relief.
- D. Request the health-care provider (HCP) to assist the client in ambulating in the hallway so the HCP can observe the client’s pain.
Correct Answer: A
Rationale: Assisting with ambulation and pain medication addresses mobility and comfort in sciatica. Strict bedrest hinders recovery, excessive ambulation without pain control is unsafe, and HCP observation is unnecessary.
Which question best helps the nurse determine whether the client is experiencing an adverse effect from taking nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen?
- A. Do you have any stomach pain or dark stools?
- B. Are you experiencing headaches or dizziness?
- C. Do you notice any swelling in your legs?
- D. Are you having trouble sleeping at night?
Correct Answer: A
Rationale: NSAIDs like ibuprofen commonly cause gastrointestinal adverse effects, such as stomach pain or dark stools (indicating bleeding). These are more specific than headaches, swelling, or sleep issues.
The client is diagnosed with osteoarthritis. Which sign/symptom should the nurse expect the client to exhibit?
- A. Severe bone deformity.
- B. Joint stiffness.
- C. Waddling gait.
- D. Swan-neck fingers.
Correct Answer: B
Rationale: Joint stiffness, especially in the morning, is a hallmark of OA due to cartilage loss. Severe deformity and swan-neck fingers are more typical of rheumatoid arthritis, and waddling gait is nonspecific.