Nokea
The nurse is performing an admission assessment on a client admitted with a diagnosis of Raynaud's disease. The nurse assesses for the associated symptoms by performing which actions?
- A. Checking for a rash on the digits
- B. Observing for softening of the nails or nail beds
- C. Palpating for a rapid or irregular peripheral pulse
- D. Palpating for diminished or absent peripheral pulses
Correct Answer: D
Rationale: Raynaud's disease is vasospasm of the arterioles and arteries of the upper and lower extremities. It produces closure of the small arteries in the distal extremities in response to cold, vibration, or external stimuli. Palpation for diminished or absent peripheral pulses checks for interruption of circulation. Skin changes include hair loss, thinning or tightening of the skin, and delayed healing of cuts or injuries. A rash on the digits is not a characteristic of this disorder. The nails grow slowly become brittle or deformed, and heal poorly around the nail beds when infected. Although palpation of peripheral pulses is correct, a rapid or irregular pulse would not be noted.
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The nurse is caring for a client who develops compartment syndrome as a result of a severely fractured arm. When the client asks why this happens, how should the nurse respond?
- A. A bone fragment has injured the nerve supply in the area.
- B. An injured artery causes impaired arterial perfusion through the compartment.
- C. Bleeding and swelling cause increased pressure in an area that cannot expand.
- D. The fascia expands with injury, causing pressure on underlying nerves and muscles.
Correct Answer: C
Rationale: Compartment syndrome is caused by bleeding and swelling within a compartment, which is lined by fascia that does not expand. The bleeding and swelling place pressure on the nerves, muscles, and blood vessels in the compartment, triggering the symptoms. Therefore, options 1, 2, and 4 are incorrect statements.
The nurse is performing range-of-motion (ROM) exercises on a client when the client unexpectedly develops spastic muscle contractions. Which interventions should the nurse implement? Select all that apply.
- A. Stop movement of the affected part.
- B. Massage the affected part vigorously.
- C. Notify the primary health care provider immediately.
- D. Force movement of the joint supporting the muscle.
- E. Ask the client to stand and walk rapidly around the room.
- F. Place continuous gentle pressure on the muscle group until it relaxes.
Correct Answer: A,F
Rationale: ROM exercises should put each joint through as full a range of motion as possible without causing discomfort. An unexpected outcome is the development of spastic muscle contraction during ROM exercises. If this occurs, the nurse should stop movement of the affected part and place continuous gentle pressure on the muscle group until it relaxes. Once the contraction subsides, the exercises are resumed using slower, steady movement. Massaging the affected part vigorously may worsen the contraction. There is no need to notify the primary health care provider unless intervention is ineffective. The nurse should never force movement of a joint. Asking the client to stand and walk rapidly around the room is an inappropriate measure.
A client diagnosed with gestational hypertension has just been admitted and is in early active labor. Which assessment finding should the nurse most likely expect to note?
- A. Increased urine output
- B. Increased blood pressure
- C. Decreased fetal heart rate
- D. Decreased brachial reflexes
Correct Answer: B
Rationale: The major manifestation of gestational hypertension is increased blood pressure. As the disease progresses, it is possible that increased brachial reflexes, decreased fetal heart rate and variability, and decreased urine output will occur, particularly during labor.
The nurse has a prescription to ambulate a client with a nephrostomy tube four times a day. The nurse determines that the safest way to ambulate the client while maintaining the integrity of the nephrostomy tube is to implement which intervention?
- A. Change the drainage bag to a leg collection bag.
- B. Tie the drainage bag to the client's waist while ambulating.
- C. Use a walker to hang the drainage bag from while ambulating.
- D. Tell the client to hold the drainage bag higher than the level of the bladder.
Correct Answer: A
Rationale: The safest approach to protect the integrity and safety of the nephrostomy tube with a mobile client is to attach the tube to a leg collection bag. This allows for greater freedom of movement, while preventing accidental disconnection or dislodgment. The drainage bag is kept below the level of the bladder. Option 3 presents the risk of tension or pulling on the nephrostomy tube by the client during ambulation.
The nurse has applied the prescribed dressing to the leg of a client with an ischemic arterial leg ulcer. Which method should the nurse use to cover the dressing?
- A. Apply a Kerlix roll and tape it to the skin.
- B. Apply a large, soft pad and tape it to the skin.
- C. Apply small Montgomery straps and tie the edges together.
- D. Apply a Kling roll and tape the edge of the roll onto the bandage.
Correct Answer: D
Rationale: Standard dressing technique includes the use of Kling rolls on circumferential dressings. With an arterial leg ulcer, the nurse applies tape only to the bandage. Tape is never used directly on the skin because it could cause further tissue damage. For the same reason, Montgomery straps should not be applied to the skin (although these are generally intended for use on abdominal wounds, anyway).