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 who had a total knee replacement is being discharged home. To which multidisciplinary team member should the nurse refer the client?
- A. The occupational therapist.
- B. The physiatrist.
- C. The recreational therapist.
- D. The home health nurse.
Correct Answer: D
Rationale: A home health nurse monitors recovery, manages complications, and supports mobility post-TKR. OT, physiatrists, and recreational therapists are less critical at discharge.
Postoperatively, the client screams obscenities at the nurse after realizing that the injured forearm is missing. Which nursing action is most appropriate at this time?
- A. Leave until the client works through the anger.
- B. Stay quietly with the client at the bedside.
- C. Tell the client to gain emotional control.
- D. Call the physician and request a sedative.
Correct Answer: B
Rationale: Staying quietly with the client provides emotional support during a grief reaction to amputation, promoting trust. Leaving, reprimanding, or medicating without engagement dismisses the client's feelings.
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.
The nurse is caring for a client diagnosed with a fracture of the right distal humerus. Which data indicate a complication? Select all that apply.
- A. Numbness and mottled cyanosis.
- B. Paresthesia and paralysis.
- C. Proximal pulses and point tenderness.
- D. Coldness of the extremity and crepitus.
- E. Palpable radial pulse and functional movement.
Correct Answer: A,B,D
Rationale: Numbness, cyanosis, paresthesia, paralysis, coldness, and crepitus indicate compartment syndrome or neurovascular compromise, serious fracture complications. Pulses and tenderness are expected.
The client with a lower leg amputation has edema, so the NA elevates the client's residual left limb on pillows. What is the most appropriate action by the nurse when observing that the client's leg has been elevated?
- A. Thank the nursing assistant (NA) for being so observant and intervening appropriately to treat the client's edema of the residual limb.
- B. Remove the pillows, raise the foot of the bed, and inform the NA that the limb should not be elevated on pillows because it could cause a flexion contracture.
- C. Inform the NA that this was the correct action at this time in the client's recovery, but once the client's incision heals, the leg should not be elevated.
- D. Report the incident to the surgeon and tell the NA to complete a variance report because the client's leg should not have been elevated.
Correct Answer: B
Rationale: B. The nurse should perform this action. Flexion, abduction, and external rotation of the residual lower limb are avoided to prevent hip contracture.