Nokea
The client is ordered to be in a semi-reclining position following a myelogram. The nurse understands that the primary reason for this is which of the following?
- A. To prevent infection
- B. To prevent spinal headache
- C. To prevent seizures
- D. To promote excretion of dye
Correct Answer: B
Rationale: A semi-reclining position post-myelogram prevents spinal headache by reducing cerebrospinal fluid leakage.
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The client with rheumatoid arthritis has been taking 15 to 20 extra-strength aspirin a day. Which additional statement that the client makes would be of greatest concern to the nurse?
- A. I sometimes have ringing in my ears.'
- B. I have a rash under my arms.'
- C. My fingers are swollen sometimes.'
- D. I don't have very much energy.'
Correct Answer: A
Rationale: Ringing in the ears (tinnitus) is a sign of aspirin toxicity, a serious concern requiring immediate attention.
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 nurse explains that the primary reason for the client's increased risk for altered skin integrity due to a T12 SCI is which factor?
- A. The inability to perceive extremes in temperature leading to burns
- B. The inability to feel skin irritation such as wrinkled linens or clothing
- C. The increased likelihood of bowel and bladder dysfunction and skin irritation
- D. The circulatory changes that cause vasoconstriction and decreased blood supply
Correct Answer: B
Rationale: Loss of sensation below T12 prevents the perception of skin irritants, increasing the risk of pressure ulcers.
Which statement by the nurse provides the best explanation about the purpose of antiembolism stockings?
- A. Antiembolism stockings prevent blood from pooling in the legs.
- B. Antiembolism stockings reduce blood flow to the exercises.
- C. Antiembolism stockings keep the blood pressure lower in the legs.
- D. Antiembolism stockings keep the blood vessels constricted.
Correct Answer: A
Rationale: Antiembolism stockings apply graduated compression to promote venous return, preventing blood pooling and reducing the risk of deep vein thrombosis in immobile clients. The other options are inaccurate.
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.