Nokea
The client is diagnosed with osteoarthritis. Which sign/symptom should the nurse expect the client to exhibit?
- A. Severe bone deformity.
- B. Joint stiffness.
- C. Waddling gait.
- D. Swan-neck fingers.
Correct Answer: B
Rationale: Joint stiffness, especially in the morning, is a hallmark of OA due to cartilage loss. Severe deformity and swan-neck fingers are more typical of rheumatoid arthritis, and waddling gait is nonspecific.
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The client with a right AKA is being taught how to toughen the residual limb. Which intervention should the nurse implement?
- A. Instruct the client to push the residual limb against a pillow.
- B. Demonstrate how to apply an elastic bandage around the residual limb.
- C. Encourage the client to apply vitamin B12 to the surgical incision.
- D. Teach the client to elevate the residual limb at least three (3) times a day.
Correct Answer: A
Rationale: Pushing the residual limb against a pillow toughens skin for prosthesis use. Elastic bandages reduce edema, vitamin B12 is irrelevant, and elevation is for swelling, not toughening.
When the nurse assesses the client, which finding is the best indication that the shoulder has been dislocated?
- A. The client is experiencing intense pain.
- B. The client is receiving intense pain.
- C. The client is hesitant to move the arm.
- D. The affected arm is longer than the other.
Correct Answer: D
Rationale: A dislocated shoulder often results in the affected arm appearing longer due to the humeral head being displaced from the glenoid fossa, altering the arm's alignment. Pain and hesitancy to move are common but less specific, and 'receiving intense pain' is a typographical error.
When planning the client's postoperative care, which is the least desirable position in which the nurse can place the client?
- A. Lying supine
- B. Sitting in a chair
- C. Lying prone
- D. Standing to shower
Correct Answer: C
Rationale: Prone positioning stresses the stump and impairs healing.
Which question best helps the nurse determine whether the client is experiencing an adverse effect from taking nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen?
- A. Do you have any stomach pain or dark stools?
- B. Are you experiencing headaches or dizziness?
- C. Do you notice any swelling in your legs?
- D. Are you having trouble sleeping at night?
Correct Answer: A
Rationale: NSAIDs like ibuprofen commonly cause gastrointestinal adverse effects, such as stomach pain or dark stools (indicating bleeding). These are more specific than headaches, swelling, or sleep issues.
The nurse is caring for an 80-year-old client admitted with a fractured right femoral neck who is oriented x3. Which intervention should the nurse implement first?
- A. Check for a positive Homans' sign.
- B. Encourage the client to take deep breaths and cough.
- C. Determine the client's normal orientation status.
- D. Monitor the client's Buck's traction.
Correct Answer: C
Rationale: Confirming baseline orientation ensures accurate neurological assessment in an elderly fracture patient. Homans’ sign, breathing exercises, and traction monitoring follow.