Nokea
The clinic nurse completed teaching the client with a rotator cuff tear who is being treated conservatively. Which client statement indicates that further teaching is needed?
- A. I received a corticosteroid injection in my shoulder to reduce the inflammation and pain.'
- B. Now that the pain is controlled, I can do progressive stretching and strengthening exercises.'
- C. I will continue to take ibuprofen for pain control, but I should take it with food.'
- D. I will need an open acromioplasty to repair the torn cuff after the swelling is reduced.'
Correct Answer: D
Rationale: D. Conservative treatment for a rotator cuff tear typically involves non-surgical methods like corticosteroid injections, physical therapy, and NSAIDs. An open acromioplasty is a surgical procedure and not part of conservative management, indicating a misunderstanding by the client.
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A femoral head replacement was performed on an elderly client. Postoperatively, the nurse positions the client with an abductor pillow between the client's legs. What is the primary reason for this?
- A. This position will promote greater comfort.
- B. Abduction promotes greater circulation to the hip joint.
- C. Abduction will prevent the prosthesis from snapping out of the socket.
- D. This position will help to prevent pressure on the sciatic nerve.
Correct Answer: C
Rationale: An abductor pillow maintains abduction, preventing prosthesis dislocation post-femoral head replacement.
Which intervention should the nurse implement for a hospitalized child with autism?
- A. Hold and stroke the child while doing the assessment
- B. Play the radio or turn on the television for distraction
- C. Have the parent bring the child's favorite toy from home
- D. Provide plenty of age-appropriate foods on the meal tray
Correct Answer: C
Rationale: Bringing a favorite toy can provide comfort and reduce anxiety for a child with autism in a hospital setting.
The client with a lower leg amputation has edema, so the NA elevates the client's residual left limb on pillows. What is the most appropriate action by the nurse when observing that the client's leg has been elevated?
- A. Thank the nursing assistant (NA) for being so observant and intervening appropriately to treat the client's edema of the residual limb.
- B. Remove the pillows, raise the foot of the bed, and inform the NA that the limb should not be elevated on pillows because it could cause a flexion contracture.
- C. Inform the NA that this was the correct action at this time in the client's recovery, but once the client's incision heals, the leg should not be elevated.
- D. Report the incident to the surgeon and tell the NA to complete a variance report because the client's leg should not have been elevated.
Correct Answer: B
Rationale: B. The nurse should perform this action. Flexion, abduction, and external rotation of the residual lower limb are avoided to prevent hip contracture.
The nurse is teaching the client with gout about a diet low in purines. Which of the following is lowest in purine?
- A. Roast chicken
- B. Beef liver
- C. Fried shrimp
- D. Scrambled eggs
Correct Answer: D
Rationale: Scrambled eggs are low in purines, suitable for a gout diet, unlike high-purine foods like liver and shrimp.
Which area of health teaching is essential to include in the discharge instructions for a client who has undergone a total hip replacement?
- A. Modifying ways of donning clothing
- B. Using special equipment for bathing
- C. Taking vigorous daily walks
- D. Receiving a daily stool softener
Correct Answer: A
Rationale: Modifying clothing application prevents excessive hip flexion.