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The nurse, caring for a client with Buck's traction, is monitoring the client for complications of the traction. Which assessment finding indicates a complication of this form of traction?
- A. Weak pedal pulses
- B. Drainage at the pin sites
- C. Complaints of leg discomfort
- D. Toes demonstrating a brisk capillary refill
Correct Answer: A
Rationale: Buck's traction is skin traction. Weak pedal pulses are a sign of vascular compromise, which can be caused by pressure on the tissues of the leg by the elastic bandage or prefabricated boot used to secure this type of traction. Skeletal (not skin) traction uses pins. Discomfort is expected. Warm toes with brisk capillary refill is a normal finding.
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The nurse is performing an otoscopic examination on a client with a suspected diagnosis of mastoiditis. Which finding should the nurse expect to note if this disorder was present?
- A. A dull red tympanic membrane
- B. A mobile tympanic membrane
- C. A transparent tympanic membrane
- D. A pearly colored tympanic membrane
Correct Answer: A
Rationale: Otoscopic examination of a client with mastoiditis reveals a red, dull, thick, and immobile tympanic membrane with or without perforation. Options 2, 3, and 4 indicate normal findings in an otoscopic examination.
A client with a central venous catheter who is receiving total parenteral nutrition (TPN) suddenly experiences signs/symptoms associated with an air embolism. The nurse should implement which interventions to minimize the client's risk for injury? Select all that apply.
- A. Monitors vital signs
- B. Clamps the catheter
- C. Checks the line for air
- D. Notifies the primary health care provider
- E. Boluses the client with 500 mL normal saline
- F. Places the client in Trendelenburg position on the left side
Correct Answer: B,D,F
Rationale: If the client experiences air embolus, the client is placed in the lateral Trendelenburg position on the left side to trap the air in the right atrium. The nurse should also clamp the catheter and notify the primary health care provider. Although vital signs are monitored continuously, doing without a related action does not directly assist the client. A fluid bolus would cause the air embolus to travel.
The nurse in the mental health unit is preparing to admit a severely depressed client. Which findings on assessment support the diagnosis of this client? Select all that apply.
- A. Insomnia
- B. Flat affect
- C. Hypersomnia
- D. Substantial weight loss
- E. Weight gain since onset of depression
- F. Reports, 'I don't have any more tears to cry.'
Correct Answer: A,B,D,F
Rationale: In the severely depressed client, loss of weight is typical, whereas the mildly depressed client may experience a gain in weight. Sleep is generally affected in a similar way, with hypersomnia in the mildly depressed client and insomnia in the severely depressed client. The severely depressed client may report that no tears are left for crying. A flat affect may be associated with depression.
An infant has been found to be human immunodeficiency virus (HIV) positive. When teaching condition-specific care, which action should the nurse instruct the mother to take to minimize the child's risk for condition-related injury?
- A. Check the anterior fontanel for bulging and the sutures for widening each day.
- B. Feed the infant in an upright position with the head and chest tilted slightly back to avoid aspiration.
- C. Provide meticulous skin care to the infant and change the infant's diaper after each voiding or stool.
- D. Feed the infant with a special nipple and burp the infant frequently to decrease the tendency to swallow air.
Correct Answer: C
Rationale: Meticulous skin care helps protect the HIV-infected infant from secondary infections. Bulging fontanels, feeding the infant in an upright position, and using a special nipple are unrelated to the pathology associated with HIV.
The nurse is assessing a client diagnosed with pleurisy 48 hours ago. When auscultating the chest the nurse is unable to detect the pleural friction rub, which was auscultated on admission. This change in the client's condition confirms which event has occurred?
- A. The prescribed medication therapy has been effective.
- B. The client has been taking deep breaths as instructed.
- C. The effects of the inflammatory reaction at the site decreased.
- D. There is now an accumulation of pleural fluid in the inflamed area.
Correct Answer: D
Rationale: Pleurisy is the inflammation of the visceral and parietal membranes. These membranes rub together during respiration and cause pain. Pleural friction rub is auscultated early in the course of pleurisy, before pleural fluid accumulates. Once fluid accumulates in the inflamed area, there is less friction between the visceral and parietal lung surfaces, and the pleural friction rub disappears. Options 1, 2, and 3 are incorrect interpretations.