Nokea
The nurse is assessing a client with a suspected hip fracture. Which of the following findings is most likely to be present?
- A. External rotation of the affected leg.
- B. Increased range of motion in the hip.
- C. Absence of pain on weight-bearing.
- D. Symmetrical leg lengths.
Correct Answer: A
Rationale: External rotation of the affected leg is a common sign of a hip fracture due to muscle and bone displacement.
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A physician is calling the pediatric unit and asking the nurse to go into the electronic medical record (EMR) for test results of a fellow pediatrician. How should the nurse respond to this request?
- A. Identify if the calling physician is the physician of record or has a need to know.
- B. Access the EMR and give the physician the test results.
- C. Decline to give the physician the information requested.
- D. Determine whether the nurse can access the EMR.
Correct Answer: A
Rationale: Verifying the physician's need to know ensures compliance with privacy regulations (e.g., HIPAA) before sharing EMR data, protecting patient confidentiality.
A client with a fractured femur is placed in skeletal traction. The nurse should assess the client for which of the following complications?
- A. Pressure ulcers.
- B. Deep vein thrombosis.
- C. Hypovolemia.
- D. Infection at the pin sites.
Correct Answer: B,D
Rationale: Skeletal traction increases the risk of deep vein thrombosis due to immobility and infection at pin sites due to skin penetration.
Clozapine (Clozaril) therapy has been initiated for a client with schizophrenia who has been unresponsive to other antipsychotics. The client states, 'Why do I have to have a blood test every week?' Which of the following responses by the nurse would be most appropriate?
- A. Weekly blood tests are necessary to determine safe dosage and to monitor the effect of the medication on the blood.'
- B. Weekly blood tests are done so that you can receive another week's supply of the medication.'
- C. Your physician will want to know how well you are personally progressing with the medication therapy.'
- D. Everyone who takes this drug must go through the same procedure because it is required by the drug company.'
Correct Answer: A
Rationale: Weekly blood tests monitor for agranulocytosis, a serious side effect of clozapine, ensuring safe dosing and early detection of blood abnormalities.
A client has been diagnosed with multi-infarct (or vascular) dementia (MID). When preparing a teaching plan for the client and family, which of the following should the nurse include?
- A. Strategies to manage memory loss and confusion.
- B. Instructions to limit physical activity to prevent falls.
- C. The need for a low-protein diet to reduce metabolic stress.
- D. The importance of avoiding all medications that affect the brain.
Correct Answer: A
Rationale: Multi-infarct dementia involves memory loss and confusion due to multiple small strokes. Teaching strategies to manage these symptoms, such as memory aids and structured routines, is essential for supporting the client and family.
The school nurse planning to give a class on testicular self-examination (TSE) at a local high school should include which instruction to the participants?
- A. Perform the self-examination every other month.
- B. Perform the self-examination after a cold shower.
- C. Expect the self-examination to be slightly painful.
- D. Roll the testicle between the thumb and forefinger.
Correct Answer: D
Rationale: TSE is a self-screening examination for testicular cancer, which predominantly affects men in their late teens and twenties. The self-examination is performed once a month, as is breast self-examination. As an aid to remember to do it, the examination should be done on the same day each month. The scrotum is held in one hand and the testicle is rolled between the thumb and forefinger of the other hand. The self-examination should not be painful. It is easiest to do either during or after a warm shower (or bath) when the scrotum is relaxed.