Nokea
The nurse is caring for a client who underwent an invasive joint examination of the knee. The nurse would closely monitor the client for what complication?
- A. Lack of sleep and appetite
- B. Serious drainage
- C. Signs of depression
- D. Signs of shock
Correct Answer: B
Rationale: When the client undergoes an invasive knee joint examination, the nurse should inspect the knee area for swelling, bleeding, and serious drainage. An invasive joint examination does not cause lack of sleep or appetite, depression, or shock. The client may be in shock due to the injury itself.
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A nurse is caring for a client with an undiagnosed bone disease. When instructing on the normal process to maintain bone tissue, which process transforms osteoblasts into mature bone cells?
- A. Remodelling
- B. Resorption
- C. Ossification and calcification
- D. Epiphyses and diaphysis formation
Correct Answer: C
Rationale: Ossification and calcification transform osteoblasts into mature bone cells called osteocytes. Osteocytes are involved in maintaining bone tissue. Resorption and remodelling are involved in bone destruction. Epiphyses and diaphysis are bone tissues that provide strength and support to the human skeleton.
A client is receiving treatment for a head injury. What action would the nurse take related to positioning to reduce the risk of further injury?
- A. Maintain the client in a sitting position for as long as possible.
- B. Elevate the rest of the client's body slightly above the neck and head.
- C. Position the neck and head in line with the rest of the client's body.
- D. Elevate the client's head slightly while keeping the neck neutral.
Correct Answer: D
Rationale: In cases of head injury, the nurse should elevate the client's head slightly while keeping the neck neutral to reduce the risk of further injury because of increased intracranial pressure. Maintaining the client in a sitting position or elevating the rest of the client's body slightly above the neck and head may cause discomfort to the client. On the other hand, if the neck and the head are positioned in line with the rest of the client's body, the risk of further injury to the client will not be reduced.
The nurse is performing a musculoskeletal assessment for a client whose right leg muscles exhibit no tone and are limp. Which descriptor should the nurse use to document this condition?
- A. Flaccid
- B. Spastic
- C. Atonic
- D. Atrophic
Correct Answer: A
Rationale: The term flaccid describes muscles that have no tone or are limp. Spastic describes muscles that have greater-than-normal tone. Atonic describes muscles that are not enervated and become soft and flabby. Atrophic describes muscles deterioration that occurs with lack of use and exercise.
A client is experiencing muscle weakness in the upper extremities. The client raises an arm above the head but then loses the ability to maintain the position. Muscular dystrophy is suspected. Which diagnostic test would evaluate muscle weakness or deterioration?
- A. A serum calcium test
- B. An electromyography
- C. An arthroscopy
- D. A magnetic resonance imaging (MRI)
Correct Answer: B
Rationale: An electromyography tests the electrical potential of muscles and nerves leading to the muscles. It is done to evaluate muscle weakness or deterioration. A serum calcium test evaluates the calcium in the blood. An arthroscopy assesses changes in the joint. An MRI identifies abnormalities in the targeted area.
The emergency department nurse is reporting the location of a fracture to the client's primary care physician. When stating the location of the fracture on the long shaft of the femur, the nurse would be most correct to state which terminology locating the fractured site?
- A. The fracture is on the diaphysis.
- B. The fracture is ventially located.
- C. The fracture is on the epiphysis.
- D. The fracture is on the tuberosity.
Correct Answer: A
Rationale: A fracture that is on the diaphysis is understood to be chiefly found in the long shafts of the arms and legs. The epiphysis are rounded, irregular ends of the bones. Saying a fracture is ventially located does not assist in providing adequate details of the location of the fracture. A tuberosity is a projection from the bone or a protuberance.