Nokea
The nurse is assessing the client 3 months following a left shoulder arthroplasty. Which assessment findings should prompt the nurse to consider that the client may have developed osteomyelitis? Select all that apply.
- A. Sudden onset of chills
- B. Temperature 103°F (39.4°C)
- C. Sudden onset of bradycardia
- D. Pulsating shoulder pain that is worsening
- E. Painful, swollen area on the left shoulder
Correct Answer: A,B,D,E
Rationale: A. A sudden onset of chills suggests the infection of osteomyelitis is blood-borne. B. A high fever suggests the infection of osteomyelitis is blood-borne. D. The pulsating shoulder pain is caused from the pressure of the collecting pus. E. The infected area becomes swollen, painful, and extremely tender.
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Which area of health teaching is essential to include in the discharge instructions for a client who has undergone a total hip replacement?
- A. Modifying ways of donning clothing
- B. Using special equipment for bathing
- C. Taking vigorous daily walks
- D. Receiving a daily stool softener
Correct Answer: A
Rationale: Modifying clothing application (e.g., avoiding bending or crossing legs) prevents hip dislocation, making it essential for discharge teaching. Vigorous walks are contraindicated, and the other options are less critical.
The client has been in a body cast for the past 2 days to treat numerous broken vertebrae from a fall. The client is reporting dyspnea, vomiting, epigastric pain, and abdominal distention. Which action demonstrates the nurse's best clinical judgment?
- A. Immediately notify the health care provider.
- B. Initiate oxygen at 2 liters per nasal cannula.
- C. Place ice packs around the outside of the cast.
- D. Administer ondansetron prescribed q6h prn.
Correct Answer: A
Rationale: A. The nurse should immediately notify the HCP. A window in the abdominal portion of the cast or bivalving is needed to relieve the pressure.
When preparing to meet with the parents and their 5-year-old child with autism, which behaviors should the nurse anticipate that the child might display?
- A. Polydactyly
- B. Leukoderma
- C. Poor eye contact
- D. Restricted interests
- E. Atypical language
Correct Answer: C,D,E
Rationale: Children with autism often exhibit poor eye contact, restricted interests, and atypical language patterns.
If the client is typical of others with a herniated disk, the nurse would expect the client to report which additional symptom?
- A. Pain radiating into the buttocks and leg
- B. Tenderness over one or both iliac crests
- C. Diminished sensation in one or both knees
- D. Brief periods when the toes feel quite cold
Correct Answer: A
Rationale: A herniated lumbar disk commonly causes sciatica, with pain radiating into the buttocks and leg due to nerve root compression. Other symptoms are less typical or specific.
The nurse is preparing the plan of care for the client with a closed fracture of the right arm. Which problem is most appropriate for the nurse to identify?
- A. Risk for ineffective coping related to the inability to perform ADLs.
- B. Risk for compartment syndrome-related injured muscle tissue.
- C. Risk for infection related to exposed bone and tissue.
- D. Risk for complications related to compromised neurovascular status.
Correct Answer: B
Rationale: Compartment syndrome is a critical risk in closed fractures due to swelling, threatening limb viability. Coping, infection (more for open fractures), and general complications are secondary.