Nokea
The client is admitted to the ED after a sports injury. The client verbalizes extreme shoulder pain, and the nurse sees that the client's right arm is shorter than the left. What should the nurse do initially? Select all that apply.
- A. Lift the right arm to support it with a pillow.
- B. Apply a covered ice pack to the left shoulder.
- C. Prepare the client for immediate surgical repair.
- D. Check the pulses and sensation of the right arm.
- E. Prepare to administer an analgesic as prescribed
- F. Inspect the left shoulder for swelling and bruising.
Correct Answer: D,E
Rationale: D. Assessment of pulses and sensation is important because compression of nerves and blood vessels can occur with shoulder dislocation. A shortened arm on the right indicates that the right shoulder is affected. E. The client is in severe pain and requires pain control.
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Which antiepileptic medication is associated with gingival hyperplasia?
- A. Gingival hyperplasia (overgrowth of gum tissue) is unique to phenytoin (Dilantin) among antiepileptic medications. About 20% of people taking phenytoin have gingival hyperplasia. This can be minimized with thorough oral care.
- B. Valproic acid (Depakote) does not have a side effect of gingival hyperplasia.
- C. Gingival hyperplasia is not a side effect of carbamazepine (Tegretol).
- D. Gingival hyperplasia is not a side effect of phenobarbital (Luminal).
Correct Answer: A
Rationale: Phenytoin (Dilantin) is uniquely associated with gingival hyperplasia, which can be mitigated with good oral hygiene.
Which instruction should the nurse include when reinforcing teaching with the parents about safety considerations for a child with a surgically corrected myelomeningocele?
- A. Make sure braces lie smoothly against the child's skin.
- B. Ensure that the child shifts position at least every 3 hours.
- C. Place a blanket between the child and the wheelchair seat.
- D. Check all of the child's skin daily for redness or irritation.
Correct Answer: D
Rationale: Daily skin checks are essential to prevent pressure ulcers and other skin complications in children with myelomeningocele.
Which information is most appropriate to teach the client before the arthroscopy procedure?
- A. Signs and symptoms of arthritis
- B. Technique for using crutches
- C. Adverse effects of drug therapy
- D. The need to balance rest and exercise
Correct Answer: B
Rationale: Crutch use is critical post-arthroscopy for safe ambulation.
The client is now over an acute episode of gout. He is to be discharged on allopurinol (Zyloprim). What instruction must the nurse give to this client?
- A. Take your medicine on an empty stomach.'
- B. Report any nausea to your physician at once.'
- C. Drink two to three quarts of fluids daily.'
- D. Do not take over-the-counter cold medicine.'
Correct Answer: C
Rationale: Drinking 2-3 quarts of fluids daily prevents uric acid stone formation, a key instruction for clients on allopurinol.
The nurse gently elevates the client's newly casted arm on a pillow and explains that this is necessary for the first 24 to 48 hours after casting. What is the chief purpose of this action?
- A. It helps a damp cast to dry more evenly.
- B. It reduces the amount of pain medication needed.
- C. Venous return is enhanced, and edema is decreased.
- D. It is more comfortable than keeping the arm dependent.
Correct Answer: C
Rationale: Elevation enhances venous return and reduces edema, the primary reason for this action. It does not directly affect cast drying, pain medication needs, or comfort alone.