Nokea
The nurse is concerned about the spinal curve in the young child and documents the exaggerated lumbar curve. Which condition was likely documented?
- A. Scoliosis
- B. Lordosis
- C. Kyphosis
- D. Kyphoscoliosis
Correct Answer: B
Rationale: Lordosis is characterized by an exaggerated lumbar curve.
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The client is three (3) hours postoperative left AKA. The client tells the nurse, 'My left foot is killing me. Please do something.' Which intervention should the nurse implement?
- A. Explain to the client his left leg has been amputated.
- B. Medicate the client with a narcotic analgesic immediately.
- C. Instruct the client on how to perform biofeedback exercises.
- D. Place the client's residual limb in the dependent position.
Correct Answer: B
Rationale: Phantom limb pain is treated with analgesics; narcotics provide immediate relief. Explaining the amputation dismisses pain, biofeedback is long-term, and dependent positioning is inappropriate.
The client with a pelvic fracture developed a fat embolism. The nurse should assess the client for which specific sign?
- A. Dyspnea
- B. Chest pain
- C. Delirium
- D. Petechiae
Correct Answer: D
Rationale: D. The nurse should assess for petechiae. Petechiae (small purplish hemorrhagic spots on the skin) are thought to be due to transient thrombocytopenia. They can occur over the chest, anterior axillary folds, hard palate, buccal membranes, and conjunctival sacs.
Which intervention should the nurse implement for a hospitalized child with autism?
- A. Hold and stroke the child while doing the assessment
- B. Play the radio or turn on the television for distraction
- C. Have the parent bring the child's favorite toy from home
- D. Provide plenty of age-appropriate foods on the meal tray
Correct Answer: C
Rationale: Bringing a favorite toy can provide comfort and reduce anxiety for a child with autism in a hospital setting.
The client diagnosed with rule-out osteosarcoma asks the nurse, 'Why am I having a bone scan?' Which statement is the nurse’s best response?
- A. You seem anxious. Tell me about your anxieties.'
- B. Why are you concerned? Your HCP ordered it.'
- C. I’ll have the radiologist come back to explain it again.'
- D. A bone scan looks for cancer or infection inside the bones.'
Correct Answer: D
Rationale: A bone scan detects cancer or infection, directly answering the client’s question. Addressing anxiety, deferring to the HCP, or radiologist involvement is less informative.
Which information is most appropriate to teach the client before the arthroscopy procedure?
- A. Signs and symptoms of arthritis
- B. Technique for using crutches
- C. Adverse effects of drug therapy
- D. The need to balance rest and exercise
Correct Answer: B
Rationale: Teaching crutch use prepares the client for post-arthroscopy mobility, as weight-bearing may be limited. Other topics are relevant but less immediately critical before the procedure.