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The nurse explains that the primary reason for the client's increased risk for altered skin integrity due to a T12 SCI is which factor?
- A. The inability to perceive extremes in temperature leading to burns
- B. The inability to feel skin irritation such as wrinkled linens or clothing
- C. The increased likelihood of bowel and bladder dysfunction and skin irritation
- D. The circulatory changes that cause vasoconstriction and decreased blood supply
Correct Answer: B
Rationale: Loss of sensation below T12 prevents the perception of skin irritants, increasing the risk of pressure ulcers.
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The occupational health nurse is planning health promotion activities for a group of factory workers. Which activity is an example of primary prevention for clients at risk for low back pain?
- A. Teach back exercises to workers after returning from an injury.
- B. Place signs in the work area about how to perform first aid.
- C. Start a weight-reduction group to meet at lunchtime.
- D. Administer a nonnarcotic analgesic to a client complaining of back pain.
Correct Answer: C
Rationale: Weight reduction reduces spinal stress, a primary prevention strategy for low back pain. Post-injury exercises are secondary, first aid signs are tertiary, and analgesics treat symptoms, not prevent.
The nursing student is caring for the client who had a right TKR 1 day ago. Which action by the student requires the nurse to intervene?
- A. Hands the client the control for the continuous passive motion (CPM) machine
- B. Offers the client an analgesic when pain is rated at 3 on a 0 to 10 scale
- C. Repositions the leg to insert an abductor pillow between the client's legs
- D. Places an ice pack wrapped within a towel on the client's operative knee
Correct Answer: C
Rationale: C. Attempting to insert an abductor pillow may cause knee misalignment. An abductor pillow may be used for the client following a THR.
Which nursing instruction is most beneficial to minimize stress on the client's painful joints?
- A. Maintain a normal weight.
- B. Apply a topical analgesic cream.
- C. Take a calcium supplement.
- D. Become more physically active.
Correct Answer: A
Rationale: Maintaining a normal weight reduces mechanical stress on weight-bearing joints like the hip, alleviating pain and slowing osteoarthritis progression. The other options are less impactful for joint stress.
The client has an external fixator for reduction of a tibia fracture. The nurse is evaluating the client's effectiveness in ambulating with crutches. Place an X on each of the three areas where the client should be bearing weight When crutch walking.
- A. The client should be bearing weight on the hand grips when bringing legs forward. When moving crutches, the weight should be borne on the unaffected leg.
Correct Answer: image
Rationale: The client should be bearing weight on the hand grips when bringing legs forward and on the unaffected leg when moving crutches to ensure proper crutch-walking technique and stability.
The client is being evaluated for osteoporosis. Which diagnostic test is the most accurate when diagnosing osteoporosis?
- A. X-ray of the femur.
- B. Serum alkaline phosphatase.
- C. Dual-energy x-ray absorptiometry (DEXA).
- D. Serum bone Gla-protein test.
Correct Answer: C
Rationale: DEXA is the gold standard for osteoporosis diagnosis, measuring bone mineral density. X-rays detect fractures, alkaline phosphatase is nonspecific, and bone Gla-protein is not diagnostic.