Nokea
The client who has sustained a left-sided cerebrovascular accident (stroke) has residual right-sided paralysis. The nurse identifies a concept of impaired functional ability. Which should be included in the care map? Select all that apply.
- A. Refer to the occupational therapist.
- B. Assess the client for neglect of the right side.
- C. Place the client in a room where the door is on the left side.
- D. Teach the client to call for assistance prior to getting out of bed.
- E. Encourage the client to participate in physical therapy daily.
Correct Answer: A,B,D,E
Rationale: OT referral, neglect assessment, fall prevention, and PT promote functional ability post-stroke. Room orientation is less critical.
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While teaching the client, what can the nurse explain about the purpose of stump bandaging?
- A. It lengthens and tones the muscles.
- B. It maintains joint flexibility.
- C. It shapes the stump for prosthesis use.
- D. It absorbs blood and drainage.
Correct Answer: C
Rationale: Stump bandaging shapes the residual limb into a conical form, facilitating prosthetic fitting and reducing swelling. It does not primarily tone muscles, maintain flexibility, or absorb drainage.
The 62-year-old client diagnosed with type 2 diabetes who has a gangrenous right toe is being admitted for a below-the-knee amputation. Which nursing intervention should the nurse implement?
- A. Assess the client's nutritional status.
- B. Refer the client to an occupational therapist.
- C. Determine if the client is allergic to IVP dye.
- D. Start a 22-gauge Angiocath in the right arm.
Correct Answer: A
Rationale: Nutritional status assessment ensures adequate healing post-amputation, critical in diabetes. OT referral is postoperative, IVP dye is irrelevant, and a 22-gauge IV is too small for surgery.
What equipment is best for preventing external rotation of the operative leg when caring for a client with a total hip replacement?
- A. A footboard
- B. A trochanter roll
- C. A turning sheet
- D. A foam mattress
Correct Answer: B
Rationale: A trochanter roll placed along the hip prevents external rotation of the operative leg, maintaining proper alignment post-hip replacement. The other options do not specifically address rotation.
A client diagnosed with osteoporosis receives nursing instructions on methods to reduce disease progression. Which substances should the nurse advise the client to avoid?
- A. Aspirin and fiber-containing laxatives
- B. Tobacco products and carbonated beverages
- C. Orange juice and caffeinated drinks
- D. Calcium-enriched dairy products
Correct Answer: B
Rationale: Tobacco reduces bone density, and carbonated beverages (containing phosphoric acid) may interfere with calcium absorption, worsening osteoporosis. The other substances are not primarily harmful.
The client diagnosed with OA is a resident in a long-term care facility. The resident is refusing to bathe because she is hurting. Which instruction should the nurse give the unlicensed assistive personnel (UAP)?
- A. Allow the client to stay in bed until the pain becomes bearable.
- B. Tell the UAP to give the client a bed bath this morning.
- C. Try to encourage the client to get up and go to the shower.
- D. Notify the family the client is refusing to be bathed.
Correct Answer: C
Rationale: Encouraging the client to shower promotes mobility, which reduces OA stiffness, while addressing pain. Bed rest worsens stiffness, bed baths enable immobility, and family notification is unnecessary.