Nokea
The client has been diagnosed with OA for the last seven (7) years and has tried multiple medical treatments and alternative treatments but still has significant joint pain. Which psychosocial client problem should the nurse identify?
- A. Severe pain.
- B. Body image disturbance.
- C. Knowledge deficit.
- D. Depression.
Correct Answer: D
Rationale: Chronic OA pain often leads to depression due to persistent discomfort and functional limitations. Pain is physiological, body image is less relevant, and knowledge deficit is not indicated.
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Which explanation most accurately explains to the client the primary purpose of the splints?
- A. Splints are used to slow joint deterioration.
- B. Splints are used to improve hand strength.
- C. Splints are used to increase range of motion.
- D. None of the above
Correct Answer: A
Rationale: Splints in rheumatoid arthritis are used to rest joints, reducing inflammation and slowing joint deterioration during acute episodes. They do not primarily strengthen hands or increase motion.
What equipment is best for preventing external rotation of the operative leg when caring for a client with a total hip replacement?
- A. A footboard
- B. A trochanter roll
- C. A turning sheet
- D. A foam mattress
Correct Answer: B
Rationale: A trochanter roll prevents external rotation, maintaining hip alignment.
When the nurse makes rounds at the beginning of the shift, which observation requires the nurse's immediate attention?
- A. The halter rests under the client's chin and occiput.
- B. The client's ears are clear of the traction ropes.
- C. The weight hangs between the headboard and wall.
- D. There is a soft pillow beneath the client's head.
Correct Answer: D
Rationale: A pillow under the head in cervical traction can alter the alignment and reduce traction effectiveness, requiring immediate removal. The other observations indicate proper setup.
The nurse is preparing to administer subcutaneous Lovenox, a low molecular weight heparin. Which intervention should the nurse implement?
- A. Monitor the client’s serum aPTT.
- B. Encourage oral and intravenous fluids.
- C. Do not eat foods high in vitamin K.
- D. Administer in the anterolateral upper abdomen.
Correct Answer: D
Rationale: Lovenox is administered in the anterolateral abdomen for optimal absorption. aPTT is for unfractionated heparin, fluids are unrelated, and vitamin K affects warfarin.
The elderly client is admitted to the hospital for severe back pain. Which data should the nurse assess first during the admission assessment?
- A. The client’s use of herbs.
- B. The client’s current pain level.
- C. The client’s sexual orientation.
- D. The client’s ability to care for self.
Correct Answer: B
Rationale: Pain level assessment is the priority in severe back pain to guide treatment. Herbs, orientation, and self-care are secondary.