Nokea
The nurse is developing a self-management teaching plan for a client with low back pain. Which of the following should the nurse include?
- A. Avoid bending at the waist and lifting heavy objects.'
- B. Weight-bearing exercises are recommended.'
- C. Wear shoes with a higher heel.'
- D. Lay on your stomach four times daily and flex your legs.'
Correct Answer: A
Rationale: Avoiding bending at the waist and heavy lifting prevents back strain. Weight-bearing exercises help bones but not always back pain, high heels strain the back, and stomach lying with leg flexion can worsen pain.
You may also like to solve these questions
The nurse is caring for a client who is in Buck traction. Which of the following actions should the nurse take?
- A. Ensure that weight is between 15 to 30 lb (6.8 to 13.6 kg)
- B. Turn the client using a foam wedge every two hours
- C. Ensure that a client's heels are supported with a pillow
- D. Elevate the foot of the bed to provide counter traction
Correct Answer: D
Rationale: Elevating the foot of the bed provides counter traction to maintain alignment in Buck traction. Excessive weight risks injury, turning disrupts traction, and heel support is good but not the priority.
The nurse in the medical-surgical unit is caring for a newly admitted client.
Item 4 of 6
History and Physical
1930: Client is a 45-year-old male who has a one-and-a-half-week history of pain, redness, and swelling in his right foot. He reported that the symptoms began after he accidentally cut his foot while walking barefoot in his backyard. Over the next few days, he developed pain and swelling around the cut, accompanied by redness and warmth. He went to urgent care two days later and was diagnosed with cellulitis in his right foot. He was prescribed antibiotics but could not afford the treatment. Three days ago, the pain escalated and was described as throbbing and constant, with a severity rating of 7/10 on the Numerical Pain Rating Scale. He states, "the pain is now in the bone of my foot; I don't know how else to describe it." He also noted occasional fever 101°F (38.3°C), chills, and general malaise. On physical examination, his right foot was erythematous, swollen, and warm to the touch. A 3 cm ulcer was noted on the plantar aspect of the right foot, with moderate purulent discharge present. The ulcer appeared deep, and palpation of the surrounding tissue elicited tenderness. There was limited range of motion in the right ankle due to pain. The distal pulses were palpable 2+, and there were signs of neuropathy in the feet (decreased sensation to light touch and pinprick). He has a medical history of uncontrolled diabetes mellitus (type two), obesity, peripheral neuropathy in all extremities, hypertension, hyperlipidemia, and epilepsy.
Consultation
Infectious Disease Consultation
2050: Client was evaluated and I strongly suspect osteomyelitis in his right foot. Labs are pending. Agree with admission and will follow closely.
The nurse plans care for this client. For each potential intervention, click to specify whether the intervention is indicated or not indicated for the client.
- A. Warm compress to the client's right foot
- B. Serum complete blood count (CBC)
- C. Serum blood cultures
- D. Administration of prescribed pain medication
- E. Magnetic Resonance Imaging (MRI)
- F. Intravenous fluids: Dextrose 5% in water (D5W)
Correct Answer: A: Not Indicated, B: Indicated, C: Indicated, D: Indicated, E: Indicated, F: Indicated
Rationale: A: Warm compresses may worsen inflammation and infection. B: CBC monitors infection and inflammation. C: Blood cultures identify systemic infection. D: Pain medication addresses severe pain. E: MRI confirms osteomyelitis. F: IV fluids support hydration and antibiotic delivery.
The nurse is teaching a client with osteomalacia regarding ways to strengthen their bones. Which statement by the client would necessitate further teaching by the nurse?
- A. I've started to walk more frequently under the sun.'
- B. I don't like dairy products so I've stopped eating them.'
- C. I've enrolled myself in an exercise program for seniors at the community center.'
- D. I've been taking Vitamin D supplements lately.'
Correct Answer: B
Rationale: Avoiding dairy removes a key calcium source, critical for bone strength in osteomalacia. Sun exposure, exercise, and vitamin D supplements all support bone health.
The following scenario applies to the next 1 items
The nurse is caring for an older adult 4 days postoperative hip arthroplasty.
Item 1 of 1
Nurses' Notes
0900: Assessment completed, and the client was in bed alert and oriented to person, place, time, and situation. Clear lung fields bilaterally, with an infrequent dry cough. Heart tones S1 and S2. Peripheral pulses palpable and 2+. Skin was warm and dry. Bowel sounds were normoactive and present in all four quadrants. Incision was pink, approximated with staples, with scant serous drainage. Pain rated 4/10 on the Numerical Pain Rating Scale. Client refused to ambulate to the bedside chair for breakfast.
1159: Client informed nurse of their refusal to participate in physical therapy. Once up with PT, the client reported intense pain. The client reports that they have intense 'heaviness' in their left calf and that she needs a 'water pill' because it is swollen. The client was placed back in bed. She reports dyspnea immediately after failed ambulation attempt.
Vital Signs
0900
Blood pressure 139/88 mm Hg
Heart rate 77/min
Respiratory rate 21/min
Temperature 99°F (37.2°C)
Pulse oximetry 92% on room air
1200
Blood pressure 149/91 mm Hg
Heart rate 87/min
Respiratory rate 24/min
Temperature 99°F (37.2°C)
Pulse oximetry 90% on room air
Medical History
• hyperlipidemia
• generalized anxiety disorder
• irritable bowel syndrome
• chronic obstructive pulmonary disease
• diabetes mellitus (type two)
• osteoarthritis
The nurse should recognize that the client may be experiencing
- A. Wound infection
- B. Hypoxia
- C. Venous thromboembolism
- D. Wound dehiscence
- E. Left lower extremity assessment.
- F. Vital signs.
- G. Pain at the surgical incision site.
Correct Answer: C, E
Rationale: Venous thromboembolism is suggested by dyspnea, elevated heart and respiratory rates, and calf swelling/tenderness post-hip arthroplasty, indicating possible deep vein thrombosis. Wound infection, hypoxia, and dehiscence are less directly supported.
The nurse is caring for a client being admitted to the medical-surgical unit with an acute flare of gout. After performing medication reconciliation, which medication does the nurse suspect could have triggered the acute gout flare? See the exhibit.
- A. hydrochlorothiazide
- B. temazepam
- C. rosuvastatin
- D. escitalopram
Correct Answer: A
Rationale: Hydrochlorothiazide, a thiazide diuretic, can increase serum uric acid levels by reducing renal excretion, potentially triggering an acute gout flare. Temazepam, rosuvastatin, and escitalopram do not significantly affect uric acid levels or gout.