Nokea
The nurse is caring for a client in Buck traction. The nurse plans on elevating the head of the bed to
- A. 15 degrees.
- B. 90 degrees.
- C. 60 degrees.
- D. 45 degrees.
Correct Answer: A
Rationale: Elevating the head to 15 degrees maintains alignment in Buck traction while allowing comfort. Higher angles (60 or 90 degrees) may disrupt traction, and 45 degrees is less optimal.
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A nurse is caring for a client admitted to the emergency department with suspected rhabdomyolysis. Which of the following findings would the nurse anticipate in a client with this condition?
- A. Elevated creatinine kinase (CK) levels
- B. Decreased serum potassium levels
- C. Hypertension and bradycardia
- D. Clear urine output
Correct Answer: A
Rationale: Rhabdomyolysis causes muscle breakdown, releasing creatinine kinase (CK) into the blood, elevating levels. Potassium levels typically rise, blood pressure and heart rate vary, and urine is dark from myoglobin.
A nurse is caring for a client who recently had a cast placed on their right lower extremity. Which statement from the client should be of the greatest concern to the nurse?
- A. I've been having pain in my right calf.'
- B. My right leg feels really itchy.'
- C. I have not been keeping my leg elevated while in bed.'
- D. My hands and arms support my body weight while using crutches.'
Correct Answer: A
Rationale: Pain in the calf may indicate compartment syndrome or deep vein thrombosis, both serious complications requiring urgent attention. Itching is common, elevation is helpful but less urgent, and crutch use is expected.
The nurse performs a home safety assessment for an older adult with rheumatoid arthritis. The nurse should make which recommendation to promote safety in the bathroom?
- A. Recommend using a handheld (adjustable) shower head
- B. Advise the client to lower the toilet seat to its lowest level
- C. Instruct the client to reduce bathroom lighting
- D. Recommend the use of towel racks for grab bars
Correct Answer: A
Rationale: A handheld shower head allows the client with rheumatoid arthritis to bathe more easily, accommodating limited mobility and joint stiffness. Lowering the toilet seat may make standing difficult, reduced lighting increases fall risk, and towel racks are not sturdy enough for support.
The nurse performs a focused assessment on a casted patient experiencing increased pain in the affected limb. The nurse notes pallor and swelling distal to the cast area. The patient reports increased pain upon passively moving the extremity. Which of the following fracture-related complications should the nurse be concerned about?
- A. Fat embolism
- B. Infection
- C. Pulmonary embolism
- D. Compartment syndrome
Correct Answer: D
Rationale: Pallor, swelling, and increased pain with passive movement are classic signs of compartment syndrome, a serious complication from pressure buildup in a casted limb. Fat and pulmonary embolisms involve systemic symptoms, and infection typically includes fever.
The nurse is caring for a client diagnosed with osteomalacia. The nurse is correct in characterizing osteomalacia as
- A. Bone softening from insufficient levels of vitamin D.
- B. Invasion of bacteria into the bone.
- C. Decreased bone mass caused by a deficiency of calcium.
- D. A bone fracture caused by minimal trauma.
Correct Answer: A
Rationale: Osteomalacia is bone softening due to inadequate vitamin D, impairing calcium absorption and mineralization. Bacterial invasion is osteomyelitis, decreased bone mass is osteoporosis, and minimal trauma fractures are not osteomalacia.