Nokea
The client is a 64-year-old male admitted to the hospital with severe pain in his right big toe, which is red and swollen. Which nursing care measure is most essential for the nurse to perform at this time?
- A. Use a bed cradle on the bed
- B. Put a bed board on the bed
- C. Obtain a heat lamp
- D. Prepare to catheterize the client
Correct Answer: A
Rationale: A bed cradle keeps bedding off the painful, swollen toe in gout, reducing discomfort.
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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.
Which interventions are appropriate for an adolescent experiencing a seizure?
- A. A tongue blade inserted into the adolescent's mouth during a seizure can cause injury.
- B. Padding protects the adolescent's limbs from injury against the hard side rails during a seizure.
- C. Airway obstruction can occur during or after the seizure. An oropharyngeal airway should be available but should not be inserted during the seizure. If the seizure has commenced, nothing should be forced into the adolescent's mouth.
- D. The etiology is unknown. Only if an airborne or droplet infectious disease were suspected as the cause would droplet precautions be considered.
- E. Suctioning equipment may be needed to clear secretions after the seizure.
Correct Answer: B,C,E
Rationale: Padding protects limbs from injury, an oropharyngeal airway should be available but not inserted during a seizure, and suctioning equipment may be needed post-seizure to clear secretions.
The nurse knows that elderly women have a high incidence of hip fracture for which reason?
- A. Decreased progesterone secretion
- B. Decreased mobility due to arthritic conditions
- C. Increased calcium absorption
- D. Osteoporosis in the skeletal structure
Correct Answer: D
Rationale: Osteoporosis, common in elderly women, weakens bones, increasing hip fracture risk.
When assessing the characteristics of pain in a client with a herniated disk, the nurse would expect to document increased intensity of pain during which activity?
- A. Eating
- B. Coughing
- C. Sleeping
- D. Urinating
Correct Answer: B
Rationale: Coughing increases intraspinal pressure, exacerbating pain from a herniated disk by compressing the affected nerve root. Other activities are less likely to intensify disk-related pain.
The nurse completes teaching the client who has a plaster cast following a right wrist fracture. Which statement, if made by the client, indicates the need for additional teaching?
- A. I should keep my cast uncovered while drying so that moisture can evaporate.'
- B. My cast initially may smell musty. When dry, it should be odorless and shiny white.'
- C. My cast may feel sticky and very warm initially, but it will dry in about 30 minutes.'
- D. I should avoid sharp or hard surfaces while drying because it causes dents in the cast.'
Correct Answer: C
Rationale: C. Although the cast will feel very warm for about 15 to 20 minutes, a plaster cast requires 24 to 72 hours (not 30 minutes) to dry completely.