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The nurse is assessing a client with a suspected fracture of the radius. Which of the following findings would support this diagnosis?
- A. Swelling and deformity at the wrist.
- B. Pain in the shoulder with movement.
- C. Numbness in the lower leg.
- D. Fever and joint stiffness.
Correct Answer: A
Rationale: A radius fracture typically causes swelling and deformity at the wrist due to bone disruption. Shoulder pain (B) suggests a proximal injury, leg numbness (C) is unrelated, and fever/stiffness (D) indicate infection or arthritis.
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The nurse is taking a health history from a Native American client. It is critical that the nurse must remember that eye contact with such clients is considered
- A. Expected
- B. Rude
- C. Professional
- D. Enjoyable
Correct Answer: B
Rationale: Rude. Native Americans consider direct eye contact to be impolite or aggressive among strangers.
You were about to give AM care, a patient requested for pain medication after returning from surgery 24 hours ago.
What do you do first?
- A. Take VS, assess pain, do AM care.
- B. Give medication, take VS, assess pain, do AM care.
- C. Take VS, give medication, do AM care.
- D. Perform AM care, give medication, assess pain.
Correct Answer: C
Rationale: Vital signs must be assessed before administering pain medication to ensure the patient is stable and to establish a baseline.
An adult is scheduled for a magnetic resonance imaging (MRI) exam today. Which finding must be reported immediately?
- A. The client has pins in her toes.
- B. The client usually wears a necklace.
- C. The client used to work in the x-ray department.
- D. The client has a pacemaker.
Correct Answer: D
Rationale: Pacemakers are contraindicated for MRI due to magnetic field interference, risking device malfunction, requiring immediate reporting, unlike pins, necklaces, or prior x-ray work.
The nurse is caring for a 13 year-old following spinal fusion for scoliosis. Which of the following interventions is appropriate in the immediate post-operative period?
- A. Raise the head of the bed at least 30 degrees
- B. Encourage ambulation within 24 hours
- C. Maintain in a flat position, logrolling as needed
- D. Encourage leg contraction and relaxation after 48 hours
Correct Answer: C
Rationale: Maintain in a flat position, logrolling as needed. The bed should remain flat for at least the first 24 hours to prevent injury.
Following a small-bowel resection, a client develops fever and anemia. The surface surrounding the surgical wound is warm to the touch and necrotizing fasciitis is suspected. Another manifestation that would most suggest necrotizing fasciitis is:
- A. erythema
- B. leukocytosis
- C. pressurelike pain
- D. swelling
Correct Answer: C
Rationale: Severe pressurelike pain out of proportion to visible signs distinguishes necrotizing fasciitis from cellulitis. Erythema, leukocytosis, and swelling are present in both cellulitis and necrotizing fasciitis.