Nokea
The nurse identifies a concept of impaired mobility for a male client with degenerative disk disease. Which assessment data best support this concept?
- A. The client reports a history of chronic back pain and multiple back surgeries.
- B. The client reports that taking NSAIDs caused the development of peptic ulcers.
- C. The client reports a three (3)-year history of difficulty initiating a urinary stream.
- D. The client states he fell a year ago and had to have a cast on the right arm for a month.
Correct Answer: A
Rationale: Chronic back pain and surgeries directly impair mobility in degenerative disk disease. Ulcers, urinary issues, and past arm fractures are unrelated to current mobility.
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Which is most important for the nurse to include in the child's plan of care for a child with spina bifida (myelodysplasia)?
- A. Avoid the child's exposure to latex.
- B. Do intermittent urinary catheterization.
- C. Provide dietary fiber supplements daily.
- D. Complete a referral for physical therapy.
Correct Answer: A
Rationale: Avoiding latex exposure is critical due to the high risk of latex allergy in children with spina bifida.
The nurse writes the problem of 'pain' for a client diagnosed with lumbar strain. Which nursing interventions should be included in the plan of care? Select all that apply.
- A. Assess pain on a 1-to-10 scale.
- B. Administer pain medication prn.
- C. Provide a regular bedpan for elimination.
- D. Assess surgical dressing every four (4) hours.
- E. Perform a position change by the log roll method every two (2) hours.
Correct Answer: A,B,E
Rationale: Pain assessment, PRN medication, and log rolling address pain and prevent exacerbation in lumbar strain. Bedpans are unnecessary, and surgical dressings are irrelevant without surgery.
The client with a pelvic fracture developed a fat embolism. The nurse should assess the client for which specific sign?
- A. Dyspnea
- B. Chest pain
- C. Delirium
- D. Petechiae
Correct Answer: D
Rationale: D. The nurse should assess for petechiae. Petechiae (small purplish hemorrhagic spots on the skin) are thought to be due to transient thrombocytopenia. They can occur over the chest, anterior axillary folds, hard palate, buccal membranes, and conjunctival sacs.
The physician directs the nurse to wrap the client's lower extremity with an elastic bandage. Where should the nurse begin applying the bandage?
- A. Below the knee
- B. Above the ankle
- C. Across the phalanges
- D. At the metatarsals
Correct Answer: D
Rationale: Starting the elastic bandage at the metatarsals (the foot's midsection) ensures distal-to-proximal compression, promoting venous return and reducing swelling effectively. Beginning higher up, such as below the knee or above the ankle, may not adequately address swelling in the foot, and starting at the phalanges is too distal.
If the client is in shock, how should the nurse position the client while continuing to assess and provide care?
- A. Prone with the arm supported
- B. In Fowler's position with the knees flexed
- C. Supine with the legs elevated
- D. Lateral with the back extended
Correct Answer: C
Rationale: Supine with legs elevated improves venous return in shock.