Nokea
The client in the rehabilitation hospital refuses to participate in physical therapy following surgery for repair of a fractured right femur sustained in a motor-vehicle accident (MVA). The client also fractured the left forearm. Which should the nurse implement first when encouraging the client to participate in therapy?
- A. Medicate the client for pain 30 minutes prior to the therapy.
- B. Have the health-care provider make the client go to therapy.
- C. Explain that insurance will not pay if the client does not participate in therapy daily.
- D. Determine why the client refuses to participate in therapy sessions.
Correct Answer: D
Rationale: Understanding the refusal reason (e.g., pain, fear) guides interventions to encourage therapy participation. Pain medication, HCP orders, and insurance threats are secondary.
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Which nursing assessment finding is the best indication that the client has an infection at the pin site?
- A. Serous drainage at the pin site
- B. Bloody drainage at the pin site
- C. Mucoid drainage at the pin site
- D. Purulent drainage at the pin site
Correct Answer: D
Rationale: Purulent (pus-like) drainage is the clearest sign of infection at the pin site, indicating bacterial presence. Serous, bloody, or mucoid drainage is less specific to infection.
The nurse is administering 0730 medications to clients on a medical orthopedic unit. Which medication should be administered first?
- A. The daily cardiac glycoside to a client diagnosed with back pain and heart failure.
- B. The routine insulin to a client diagnosed with neck strain and type 1 diabetes.
- C. The oral proton pump inhibitor to a client scheduled for a laminectomy this a.m.
- D. The fourth dose of IV antibiotic for a client diagnosed with a surgical infection.
Correct Answer: B
Rationale: Insulin for type 1 diabetes prevents hyperglycemia, a life-threatening risk, and takes priority. Cardiac glycoside, PPI, and antibiotics are important but less urgent.
When planning the client's discharge, the nurse must help the client obtain which essential piece of equipment for home care?
- A. A wheelchair
- B. A hospital bed
- C. A raised toilet seat
- D. A mechanical lift
Correct Answer: C
Rationale: A raised toilet seat prevents excessive hip flexion, reducing dislocation risk.
Which intervention should the nurse include for a client diagnosed with carpal tunnel syndrome?
- A. Teach hyperextension exercises to increase flexibility.
- B. Monitor safety during occupational hazards.
- C. Prepare for the insertions of pins or screws.
- D. Monitor dressing and drain after the fasciotomy.
Correct Answer: B
Rationale: Monitoring occupational hazards (e.g., repetitive tasks) prevents carpal tunnel exacerbation. Hyperextension worsens symptoms, and surgical interventions are not first-line.
Which type of seizure involves a brief loss of awareness and minor motor movements such as eye blinking?
- A. Myoclonic seizure involves muscle movement and not just loss of awareness.
- B. Febrile seizures occur when the child's temperature is excessively elevated and usually includes tonic-clonic muscle movement.
- C. An absence seizure is a generalized seizure (involving loss of awareness) that might involve minor motor movements (e.g., eye blinking). The child appears to be staring.
- D. Atonic means absence of tone and would involve loss of muscle control and not eye blinking, which requires muscle control.
Correct Answer: C
Rationale: Absence seizures are characterized by brief loss of awareness and minor motor movements like eye blinking, with the child appearing to stare.