Nokea
The clients chart indicates genu varum. What does the nurse understand this to mean?
- A. Bow-legged
- B. Fluid accumulation
- C. Knock-kneed
- D. Spinal curvature
Correct Answer: A
Rationale: Genu varum is a bow-legged deformity. A fluid accumulation is an effusion. Genu valgum is knock-kneed. A spinal curvature could be kyphosis or scoliosis.
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A nurse is providing community education about preventing traumatic musculoskeletal injuries related to car crashes. Which group does the nurse target as the priority for this education?
- A. High school football team
- B. High school home room
- C. Middle-aged men
- D. Older adult women
Correct Answer: A
Rationale: Young men are at highest risk for musculoskeletal injury due to trauma, especially due to motor vehicle crashes. The high school football team, with its roster of young males, is the priority group.
A student nurse learns about changes that occur to the musculoskeletal system due to aging. Which changes clearly lead to increased safety risks?
- A. Increased bone density leads to stiffness.
- B. Increased joint flexibility enhances mobility.
- C. Osteoporosis is a universal occurrence.
- D. Decreased muscle mass reduces strength.
Correct Answer: D
Rationale: Decreased muscle mass reduces strength, which increases the risk of falls and injuries in older adults. Increased bone density is not typical with aging; osteoporosis, not universal, increases fracture risk but is not guaranteed. Increased joint flexibility is not a common aging change.
A client is having a myologgraphy. What action by the nurse is most important?
- A. Assesses with any nursing microctioning (AST) levels.
- B. Ensure that informed consent is on the chart.
- C. Position the client that after the procedure.
- D. Reinforce the dressing if it becomes saturated.
Correct Answer: B
Rationale: The diagnostic procedure is invasive and requires informed consent. The AST does not need to be assessed prior to the procedure. The client is positioned with the head of the bed elevated after the test to keep the contrast material out of the brain. The dressing should not become saturated; if it does, the nurse calls the provider.
A client is distressed at body changes related to kyphosis. What response by the nurse is best?
- A. Ask the client to explain more about these feelings.
- B. Explain that these changes are irreversible.
- C. Offer to help select clothes to hide the deformity.
- D. Tell the client safety is more important than looks.
Correct Answer: A
Rationale: Assessment is the first step of the nursing process, and the nurse should begin by getting as much information about the client's feelings as possible. Explaining that the changes are irreversible discounts the client's feelings. Depending on the extent of the deformity, clothing will not hide it. While safety is more objectively important than looks, the client is worried about looks and the nurse needs to address this issue.
A hospitalized clients strength of the upper extremities is rated at 3. What does the nurse understand about this clients ability to perform activities of daily living (ADL)?
- A. The client is able to perform ADLs but not for some items.
- B. No difficulties are expected with ADL.
- C. The client is unable to perform ADL alone.
- D. The client would need near-total assistance with ADLs.
Correct Answer: A
Rationale: This rating indicates fair muscle strength with full range of motion against gravity but not resistance. The client could complete ADLs independently unless they required lifting objects.