Nokea
The elderly client is admitted to the hospital for severe back pain. Which data should the nurse assess first during the admission assessment?
- A. The client’s use of herbs.
- B. The client’s current pain level.
- C. The client’s sexual orientation.
- D. The client’s ability to care for self.
Correct Answer: B
Rationale: Pain level assessment is the priority in severe back pain to guide treatment. Herbs, orientation, and self-care are secondary.
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The 35-year-old client who sustained a crushing injury to the left hand and forearm is being discharged. Which referral should the nurse implement?
- A. Refer the client to physical therapy at home.
- B. Refer the client to an assistive living facility.
- C. Refer the client to a workforce commission for job training.
- D. Refer the client to the dietitian.
Correct Answer: A
Rationale: Home PT restores hand/forearm function post-crushing injury. Assisted living, job training, and dietitian referrals are premature or unrelated.
The male nurse is helping his friend cut wood with an electric saw. His friend cuts two fingers of his left hand off with the saw. Which action should the nurse implement first?
- A. Wrap the left hand with towels and apply pressure.
- B. Instruct the friend to hold his hand above his head.
- C. Apply pressure to the radial artery of the left hand.
- D. Go into the friend's house and call 911.
Correct Answer: A
Rationale: Applying pressure with towels controls bleeding, the priority in traumatic amputation. Elevation is secondary, radial pressure is less effective, and calling 911 delays hemorrhage control.
Which statement indicates that the client understands the restrictions to be followed?
- A. I should avoid pointing my toes.
- B. I shouldn't cross my legs.
- C. I shouldn't lie flat in bed.
- D. I shouldn't stand upright.
Correct Answer: B
Rationale: Avoiding crossing legs prevents adduction of the hip, which could lead to dislocation after total hip replacement. The other restrictions are less critical or inaccurate.
Which explanation most accurately explains to the client the primary purpose of the splints?
- A. Splints are used to slow joint deterioration.
- B. Splints are used to improve hand strength.
- C. Splints are used to increase range of motion.
- D. None of the above
Correct Answer: A
Rationale: Splints in rheumatoid arthritis are used to rest joints, reducing inflammation and slowing joint deterioration during acute episodes. They do not primarily strengthen hands or increase motion.
The nurse knows that elevated findings on which laboratory test typically validate a diagnosis of gout?
- A. Creatinine clearance
- B. Blood urea nitrogen
- C. Serum uric acid
- D. Serum calcium
Correct Answer: C
Rationale: Elevated serum uric acid levels confirm gout, as they reflect the hyperuricemia leading to crystal formation in joints. Other tests are not specific to gout diagnosis.