Nokea
The client is being seen in the clinic for a second-degree ankle sprain. Which treatments should the nurse plan?
- A. Rest, elevate the extremity, apply ice intermittently, and apply a compression bandage.
- B. Do range of motion to determine the extent of injury, apply heat, and check circulation.
- C. Use moist heat and then apply ice; check circulation, motion, and sensation; and elevate.
- D. Refer to an orthopedic surgeon, apply ice, give an analgesic, elevate, and encourage rest.
Correct Answer: A
Rationale: A. Rest prevents further injury and promotes healing. Ice and elevation control swelling. Compression with an elastic bandage controls bleeding, reduces edema, and provides support for injured tissues.
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Which assessment finding would the nurse consider a likely adverse effect of the client's methotrexate (Rheumatrex) therapy?
- A. Constipation
- B. Arrhythmia
- C. Mouth sores
- D. Chest pain
Correct Answer: C
Rationale: Mouth sores (stomatitis) are a common adverse effect of methotrexate due to its impact on rapidly dividing cells, like those in the oral mucosa. The other symptoms are less commonly associated.
The 75-year-old client continues to experience phantom limb pain following an AKA, despite being given the prescribed morphine sulfate and using distraction. Which interventions, if prescribed by the HCP, should the nurse plan to implement? Select all that apply.
- A. Apply lidocaine patch 5% to the residual limb
- B. Start transcutaneous electrical nerve stimulation (TENS)
- C. Give atenolol 12.5 mg orally twice daily with food
- D. Give oxcarbazepine 300 mg orally twice daily
- E. Limit the client's activity until the sensations resolve
Correct Answer: A,B,C,D
Rationale: A. A local anesthetic provides pain relief for some with phantom limb pain. B. A TENS unit sends stimulating pulses across the skin surface and along the nerve to help prevent pain signals from reaching the brain. C. Beta blockers such as atenolol (Tenormin) may relieve dull, burning discomfort. D. Antiseizure medication such as oxcarbazepine (Trileptal) has been shown to control stabbing and cramping pain.
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 client symptom indicates that the nurse should discontinue the medication and notify the physician even if the client's pain is unrelieved?
- A. Vomiting
- B. Dizziness
- C. Drowsiness
- D. Headache
Correct Answer: A
Rationale: Vomiting is a sign of colchicine toxicity, requiring immediate discontinuation and physician notification, as it can precede serious complications like bone marrow suppression. Other symptoms are less urgent.
The nurse is preparing the plan of care for the client with a closed fracture of the right arm. Which problem is most appropriate for the nurse to identify?
- A. Risk for ineffective coping related to the inability to perform ADLs.
- B. Risk for compartment syndrome-related injured muscle tissue.
- C. Risk for infection related to exposed bone and tissue.
- D. Risk for complications related to compromised neurovascular status.
Correct Answer: B
Rationale: Compartment syndrome is a critical risk in closed fractures due to swelling, threatening limb viability. Coping, infection (more for open fractures), and general complications are secondary.