Nokea
The nurse is assessing the client immediately following a C5-C6 anterior cervical discectomy. Which potential problem should be the nurse's priority?
- A. Altered breathing pattern
- B. Impaired tissue perfusion
- C. Altered mobility
- D. Impaired skin integrity
Correct Answer: A
Rationale: A. Retractors used during surgery can injure the recurrent laryngeal nerve, resulting in the inability to cough effectively to clear secretions. Edema and bleeding can also compromise the airway and compress the spinal cord.
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Which action by the nurse would be most appropriate for a child newly diagnosed with Reye's syndrome?
- A. Determining if the child had a bacterial infection recently
- B. Placing the child in a private room with droplet precautions
- C. Taking the child to the unit's play area to interact with others
- D. Assessing for signs of bleeding and for prolonged bleeding time
Correct Answer: D
Rationale: Assessing for bleeding is critical in Reye's syndrome due to liver dysfunction and potential coagulopathy.
The nurse is assessing the client diagnosed with a left femoral neck fracture. Which findings should the nurse expect? Select all that apply.
- A. Left leg is in an abducted position.
- B. Left leg is externally rotated.
- C. Left leg is shorter than the right.
- D. Pain is in the lateral left knee.
- E. Pain is in the groin area.
Correct Answer: B,C,E
Rationale: B. With a left femoral neck fracture, the leg is externally rotated. C. With a left femoral neck fracture, the leg is shortened. E. With a left femoral neck fracture, pain is experienced in the groin area.
The client is a 73-year-old woman who fell in her home and suffered a right hip fracture. She tells the nurse that she was walking across the kitchen and felt something 'snap' in her hip and this made her fall. What type of fracture is the client most likely to have?
- A. Comminuted fracture
- B. Greenstick fracture
- C. Open fracture
- D. Pathological fracture
Correct Answer: D
Rationale: A 'snap' before falling suggests a pathological fracture, likely due to weakened bone (e.g., osteoporosis) in an elderly woman.
A client sustained a fractured femur in a motor-vehicle accident. Which data require immediate intervention by the nurse? Select all that apply.
- A. The client requests pain medication to sleep.
- B. The client has eupnea and normal sinus rhythm.
- C. The client has petechiae over the neck and chest.
- D. The client has a high arterial oxygen level.
- E. The client has yellow globules floating in the urine.
Correct Answer: C,E
Rationale: Petechiae and yellow globules suggest fat embolism syndrome, requiring immediate intervention. Pain medication, normal breathing, and high oxygen are not urgent.
In which conditions might the nurse assess for the presence of papilledema?
- A. Eczema
- B. Craniosynostosis
- C. Shaken baby syndrome
- D. Hydrocephalus
- E. Chest trauma
Correct Answer: B,C,D
Rationale: Papilledema, indicating increased intracranial pressure, can be associated with craniosynostosis, shaken baby syndrome, and hydrocephalus.