Nokea
The nurse is caring for a client with a fractured tibia placed in an external fixator. Which of the following should be included in the plan of care?
- A. Keeping the leg flat at all times
- B. Checking the pin sites for signs of infection
- C. Massaging the leg to promote circulation
- D. Ambulating the client within 12 hours of application
Correct Answer: B
Rationale: Checking pin sites for infection (redness, drainage) is critical in external fixator care for a fractured tibia, preventing osteomyelitis flat legs, massage, or early ambulation risk stability or healing. Nurses monitor this, ensuring site care and antibiotics if needed, supporting bone recovery.
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All of the following are purpose of inflammation except
- A. Increase heat, thereby produce abatement of phagocytosis
- B. Localized tissue injury by increasing capillary permeability
- C. Protect the issue from injury by producing pain
- D. Prepare for tissue repair
Correct Answer: A
Rationale: Inflammation aims to protect and heal tissue, not hinder it. Increasing heat (A) enhances phagocytosis by boosting immune cell activity, not abating it, making this statement incorrect and the exception. Localized injury response (B) occurs as capillary permeability increases, delivering immune cells to the site. Pain (C) protects by discouraging movement, aiding healing. Preparing for tissue repair (D) is a key goal as inflammation clears debris and initiates recovery. The misstatement in A reverses the biological role of heat, which supports immune function rather than suppressing it, confirming A as the answer since it does not align with inflammation's purposes.
The nurse is teaching the parents of an infant with osteogenesis imperfecta. The nurse should tell the parents:
- A. That the infant will need daily calcium supplements
- B. To lift the infant by the buttocks when diapering
- C. That the condition is a temporary one
- D. That only the bones are affected by the disease
Correct Answer: B
Rationale: Lifting by the buttocks prevents fractures in osteogenesis imperfecta, a brittle bone disorder calcium doesn't strengthen defective collagen, it's lifelong, and other systems (e.g., hearing) may be affected. Nurses teach gentle handling, ensuring safety in this genetic condition.
Which of the following statement is NOT true about crisis intervention?
- A. Aims to restore pre-crisis state
- B. Short term
- C. Requires long term therapy
- D. Focuses on immediate needs
Correct Answer: C
Rationale: Crisis intervention restores pre-crisis (A), is short-term (B), immediate-focused (D) 'requires long-term therapy' (C) isn't true, as it's brief, per Caplan. C's duration contradicts, making it untrue.
Which of the following is the appropriate nursing intervention for a patient with a terminal illness who is passing through the acceptance stage?
- A. Allowing the patient to cry
- B. Encouraging unrestricted visiting
- C. Explaining the patient what is being done
- D. Being around though not speaking
Correct Answer: D
Rationale: In Kübler-Ross's acceptance stage, patients often seek peace, preferring quiet presence over active intervention. Being nearby without speaking respects their emotional state, offering comfort without disruption. Crying aligns with earlier stages (e.g., depression), unrestricted visiting may overwhelm, and explaining procedures suits denial or bargaining. Nurses provide silent support, aligning with the patient's need for calm reflection, enhancing dignity and comfort in end-of-life care.
The nurse enters the room to give a prescribed medication but the patient is inside the bathroom. What should the nurse do?
- A. Leave the medication at the bedside and leave the room.
- B. After a few minutes, return to that patient's room and do not leave until the patient takes the medication.
- C. Instruct the patient to take the medication and leave it at the bedside.
- D. Wait for the patient to return to bed and just leave the medication at the bedside.
Correct Answer: B
Rationale: Returning after a few minutes and staying until the patient takes the medication ensures safe administration, adhering to the 'Five Rights' right patient, drug, dose, route, and time. The nurse verifies ingestion, preventing errors like missed doses or misuse, and documents accurately. Leaving medication unattended risks it being lost, taken incorrectly, or accessed by others, violating safety protocols. Instructing without supervision assumes compliance but lacks confirmation, potentially falsifying records if the dose isn't taken. Waiting briefly then leaving it bedside still neglects oversight. Returning and remaining present balances respect for the patient's privacy with accountability, ensuring the medication reaches its intended recipient at the prescribed time, critical for treatment efficacy and legal standards in nursing practice.