Nokea
The nurse is caring for an 80-year-old client admitted with a fractured right femoral neck who is oriented x3. Which intervention should the nurse implement first?
- A. Check for a positive Homans' sign.
- B. Encourage the client to take deep breaths and cough.
- C. Determine the client's normal orientation status.
- D. Monitor the client's Buck's traction.
Correct Answer: C
Rationale: Confirming baseline orientation ensures accurate neurological assessment in an elderly fracture patient. Homans’ sign, breathing exercises, and traction monitoring follow.
You may also like to solve these questions
Which assessment finding most likely indicates that a client has osteoporosis?
- A. Swollen joints
- B. Discomfort when sitting
- C. Spinal deformity
- D. Diminished energy level
Correct Answer: C
Rationale: Spinal deformity, such as kyphosis, is a common sign of osteoporosis due to vertebral compression fractures from reduced bone density. Swollen joints, discomfort, or low energy are less specific.
The nurse is admitting the client with OA to the medical floor. Which statement by the client indicates an alternative form of treatment for OA?
- A. I take medication every two (2) hours for my pain.'
- B. I use a heating pad when I go to bed at night.'
- C. I wear a copper bracelet to help with my OA.'
- D. I always wear my ankle splints when I sleep.'
Correct Answer: C
Rationale: Copper bracelets are an alternative therapy for OA, believed to reduce symptoms. Pain medication and heating pads are conventional, and splints are for support, not alternative.
Which statement regarding the performance of ROM exercises is correct?
- A. ROM exercises should be completed independently with verbal cues from the nurse.
- B. Force may be needed during ROM exercises to achieve maximum benefit.
- C. Support should be maintained to the proximal and distal areas of the joint during movement.
- D. ROM exercises should be performed until the client verbalizes discomfort.
Correct Answer: C
Rationale: Supporting the joint's proximal and distal areas prevents strain during ROM.
When the nurse observes the client walking, which assessment finding indicates the need for more instruction regarding the use of the cane?
- A. The tip of the cane is covered with a rubber cap.
- B. The client wears athletic shoes with nonskid soles.
- C. The client uses the cane on the painful side.
- D. The client looks straight ahead when walking.
Correct Answer: C
Rationale: The cane should be used on the unaffected side to support the painful hip.
Which activity is best to begin implementing immediately after the client's surgery?
- A. Standing at the side of the bed
- B. Balancing between parallel bars
- C. Lifting oneself with the trapeze
- D. Transferring from the bed to a chair
Correct Answer: C
Rationale: Lifting with a trapeze strengthens upper body muscles safely immediately post-surgery, preparing for crutch use without stressing the stump. Other activities are more advanced.