Nokea
The nurse is admitting a female client who is complaining of severe back pain radiating down the left leg whenever she tries to ambulate. The concepts of impaired mobility and comfort are implemented on the care map. Which nursing interventions should the nurse implement?
- A. Assist the client when ambulating to the bathroom and administer medications based on the pain scale.
- B. Place the client on strict bedrest and have the client use a regular bedpan for elimination of urine and feces.
- C. Ambulate the client in the hallway at least four (4) times per day and discourage the use of pharmacological pain relief.
- D. Request the health-care provider (HCP) to assist the client in ambulating in the hallway so the HCP can observe the client’s pain.
Correct Answer: A
Rationale: Assisting with ambulation and pain medication addresses mobility and comfort in sciatica. Strict bedrest hinders recovery, excessive ambulation without pain control is unsafe, and HCP observation is unnecessary.
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When planning the client's postoperative care, which is the least desirable position in which the nurse can place the client?
- A. Lying supine
- B. Sitting in a chair
- C. Lying prone
- D. Standing to shower
Correct Answer: C
Rationale: Prone positioning stresses the stump and impairs healing.
The client diagnosed with cervical disk degeneration has undergone a laminectomy. Which interventions should the nurse implement?
- A. Position the client prone with the knees slightly elevated.
- B. Assess the client for difficulty speaking or breathing.
- C. Measure the drainage in the Jackson Pratt bulb every day.
- D. Encourage the client to postpone the use of narcotic medications.
Correct Answer: B
Rationale: Cervical laminectomy risks airway or neurological complications; assessing speech and breathing is critical. Prone positioning is inappropriate, JP drainage is routine, and delaying narcotics is unsafe.
When the nurse assesses the client, which finding is the best indication that the shoulder has been dislocated?
- A. The client is experiencing intense pain.
- B. The client is receiving intense pain.
- C. The client is hesitant to move the arm.
- D. The affected arm is longer than the other.
Correct Answer: D
Rationale: A dislocated shoulder often results in the affected arm appearing longer due to the humeral head being displaced from the glenoid fossa, altering the arm's alignment. Pain and hesitancy to move are common but less specific, and 'receiving intense pain' is a typographical error.
The nurse knows that a client who sustains multiple fractures of long bones is at risk for developing fat embolism syndrome. Which findings suggest that the client is developing this complication? Select all that apply.
- A. Bradycardia
- B. Petechiae
- C. Dyspnea
- D. Mental status changes
- E. Hypertension
- F. Hematuria
Correct Answer: B,C,D
Rationale: Fat embolism syndrome typically presents with petechiae (small red spots from fat emboli in the skin), dyspnea (from pulmonary involvement), and mental status changes (from cerebral hypoxia). Bradycardia, hypertension, and hematuria are not characteristic.
Which assessment finding is the best indication that the client in halo traction is developing a serious complication?
- A. The client experiences orthostatic hypotension.
- B. The client needs assistance with shaving.
- C. The client cannot open the mouth widely.
- D. The client complains about irritation under the axillae.
Correct Answer: C
Rationale: Inability to open the mouth widely may indicate cranial nerve compression or device misalignment, a serious complication requiring immediate attention. The other findings are less urgent or unrelated.