Nokea
The nurse is teaching a client how to do active range of motion (ROM) exercises.To exercise the hinge joints, which action should the nurse instruct the client to perform?
- A. Tap the feet forwards and backwards.
- B. Bend the arm by flexing the ulna to the humerus.
- C. Turn the head to the right and left.
- D. Extend the arm at the side and rotate in circles.
Correct Answer: B
Rationale: To exercise the hinge joints, the nurse should instruct the client to bend the arm by flexing the ulna to the humerus. Hinge joints allow for movement in one direction, like a door hinge. The elbow joint is an example of a hinge joint.
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Prior to performing digital removal of a fecal impaction, what is the most important assessment for the nurse to perform?
- A. Abdominal girth.
- B. Breath sounds.
- C. Bowel sounds.
- D. Vital signs.
Correct Answer: D
Rationale: Prior to performing digital removal of a fecal impaction, it is important for the nurse to assess the client's vital signs. This includes checking the client's blood pressure, pulse rate, respiratory rate, and temperature. These measurements can provide important information about the client's overall health status and can help the nurse determine if it is safe to proceed with the procedure.
The nurse observes the skin over a client's greater trochanter, as seen in the picture with pressure sores.What actions should the nurse implement?
- A. Instruct the unlicensed assistive personnel to frequently offer oral fluids.
- B. Prepare to implement a pressure redistribution mattress.
- C. Explain to the client that the wound needs debridement.
- D. Obtain hemoglobin of the side to check for anemia and sensitivity.
Correct Answer: B
Rationale: Pressure redistribution is an important part of preventing and treating pressure sores.
How should the nurse document the finding of pain, numbness, and tingling sensations in the lower legs?
- A. Acute pain.
- B. Neuropathic pain.
- C. Visceral pain.
- D. Nociceptive pain.
Correct Answer: B
Rationale: The symptoms of pain, numbness, and tingling sensations in the lower legs are consistent with neuropathic pain. Neuropathic pain is a complex type of pain initiated or caused by a primary lesion or dysfunction in the nervous system.
When using a client with a serum potassium level of 7.5 mEq/L (7.5 mmol/L), which intervention is most important for the nurse to implement?
- A. Compare muscle strength bilaterally.
- B. Determine apical pulse rate and rhythm.
- C. Measure color and amount of urine.
- D. Assess strength of deep tendon reflexes.
Correct Answer: B
Rationale: Hyperkalemia can lead to life-threatening cardiac conduction disturbances. Therefore, it is important for the nurse to determine the apical pulse rate and rhythm.
The nurse plans to encourage a group of young adult clients to engage in problem-solving strategies.Which of the following is most useful for the nurse to include?
- A. Providing physical demonstration.
- B. Using simulation activities.
- C. Incorporating verbal analogies.
- D. Offering positive reinforcement.
Correct Answer: B
Rationale: Simulation activities provide a safe and controlled environment for young adult clients to practice problem-solving strategies and learn from their experiences.