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The client with Alzheimer's dementia is being admitted to the nursing unit following a hip hemiarthroplasty to treat a hip fracture. Which initial intervention should the nurse plan for the client's pain control?
- A. Apply a fentanyl transdermal patch and replace after 24 hours.
- B. Start morphine sulfate per patient-controlled analgesia (PCA) with a basal rate.
- C. Administer intravenous morphine sulfate based on the client's report of pain.
- D. Administer scheduled doses of morphine sulfate intravenously around the clock.
Correct Answer: D
Rationale: D. In addition to scheduling pain medication around the clock, supplemental NSAIDs can be given to reduce inflammation and enhance the effects of the analgesic.
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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.
The nurse is caring for a client with a newly applied plaster cast. How should the nurse touch and move the wet cast?
- A. Use the palms of the hands
- B. Use the fingertips only
- C. Use a towel sling
- D. Touch the cast only on the petals at the edges
Correct Answer: A
Rationale: Using the palms prevents indentations in a wet cast, which could cause skin irritation. Fingertips create indentations, a towel sling is inappropriate, and petaling occurs after drying.
Which assessment findings should the nurse associate with the development of hydrocephalus in a 7-year-old child?
- A. Headache
- B. Vomiting
- C. Angioedema
- D. Personality change
- E. Increased head circumference
Correct Answer: A,B,D
Rationale: Headache, vomiting, and personality changes are common symptoms of hydrocephalus due to increased intracranial pressure.
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.
The 34-year-old male client presents to the outpatient clinic complaining of numbness and pain radiating down the left leg. Which further data should the nurse assess?
- A. Posture and gait.
- B. Bending and stooping.
- C. Leg lifts and arm swing.
- D. Waist twists and neck mobility.
Correct Answer: A
Rationale: Numbness and radiating leg pain suggest sciatica from a herniated disk; assessing posture and gait evaluates nerve impingement effects. Other options are less specific to lumbar radiculopathy.