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The nurse is teaching a client with low back pain. Which of the following statements, if made by the client, would require follow-up?
- A. I am planning to stop smoking cigarettes.'
- B. I should sleep on my stomach.'
- C. I have decided to purchase a firm mattress.'
- D. I will bend my knees when lifting objects.'
Correct Answer: B
Rationale: Sleeping on the stomach can strain the lower back, requiring follow-up teaching. Quitting smoking, a firm mattress, and bending knees when lifting are all beneficial for back health.
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The nurse is planning a staff development conference regarding contractures. Which of the following information should the nurse include? Select all that apply.
- A. Range-of-motion exercises of the extremities help prevent contractures.
- B. Splinting the extremities may increase the risk of contractures.
- C. Too many pillows under the head may cause a neck flexion contracture.
- D. Using multiple staff members to reposition a client may prevent a contracture.
- E. Contractures after a hip arthroplasty can be prevented with an abduction pillow.
Correct Answer: A, C, E
Rationale: Range-of-motion exercises maintain joint flexibility and help prevent contractures. Too many pillows under the head can cause the neck to remain flexed, increasing the risk of a flexion contracture. An abduction pillow keeps the legs properly aligned and prevents adduction contractures after hip surgery.
The nurse is teaching a client scheduled for a dual-energy x-ray absorptiometry (DEXA) scan. Which of the following information should the nurse include?
- A. Do not eat or drink 6-8 hours prior to your test.'
- B. You will feel flushing as you receive the intravenous contrast.'
- C. The scan takes several hours to complete.'
- D. Please remove all metallic objects before this exam.'
Correct Answer: D
Rationale: Removing metallic objects prevents interference with the DEXA scan, which measures bone density. Fasting and contrast are not required, and the scan typically takes 10-30 minutes.
While training a new RN in the emergency department, the nurse attends to a client with Guillain-Barre Syndrome. The new RN asks what may have caused this condition. Which of the following occurrences in the patient's history is most likely a contributing factor?
- A. A spinal cord injury at age 12
- B. An upper respiratory infection about a month ago
- C. Hydrocephaly as an infant
- D. A joint injury as a teenager
Correct Answer: B
Rationale: Guillain-Barre Syndrome is often triggered by a recent infection, commonly an upper respiratory infection, leading to an autoimmune response against peripheral nerves. Spinal cord injury, hydrocephaly, and joint injury are unrelated.
The nurse is caring for a client who is bedbound. Which intervention should the nurse implement to reduce this client's risk of developing contractures?
- A. Apply sequential compression devices to the lower extremities
- B. Perform passive range of motion exercises
- C. Obtain a specialty low-air loss mattress
- D. Turn the client every two hours
Correct Answer: B
Rationale: Passive range of motion exercises maintain joint mobility and prevent contractures in bedbound clients. Compression devices prevent clots, mattresses reduce pressure ulcers, and turning aids skin but not primarily joints.
The nurse is caring for a 41-year-old female in the outpatient clinic
Item 1 of 1
• Progress Note
1300:
• Client presenting for the initial dose of etanercept following the diagnosis of rheumatoid arthritis.
• The client reported joint pain in the hands not improving with acetaminophen.
• Will prescribe better pain control and follow up in six weeks.
• Physician Orders
• Etanercept 50 mg SubQ every week
• Naproxen 500 mg PO Daily, as needed for pain
The nurse prepares to administer the prescribed etanercept.Complete the sentences below by selecting the appropriate option:The nurse should instruct the client that the prescribed etanercept
--------------------------Prior to the first dose, the nurse should ensure the client has had a----------------------After administering the medication, the nurse should----------------------
- A. raises the blood glucose
- B. increases the risk for infection
- C. causes weight gain.
- D. fasting blood glucose
- E. negative purified protein derivative (PPD) test
- F. baseline lipid panel.
- G. assess for an injection site reaction.
Correct Answer: B,E,G
Rationale: Etanercept is a tumor necrosis factor (TNF) blocking agent used to treat autoimmune disorders such as psoriasis or rheumatoid arthritis (RA). This medication increases the client's risk of infection, requiring baseline testing for TB, such as a PPD. If the client has latent TB, it may be activated again. Etanercept does not cause weight gain or raise blood glucose. This would be true if the client were prescribed a corticosteroid which may be used in exacerbations of RA. A lipid panel has no relevance to etanercept. Etanercept is administered subcutaneously at a 45 to a 90-degree angle. This medication is not administered in the deltoid; this would be appropriate for an intramuscular injection. Aspiration for subcutaneous injections is unnecessary as piercing a blood vessel is rare. The most common adverse effect of this medication is injection site reaction (redness, pain, discomfort). The area should not be rubbed or massaged as it could worsen the injection site reaction.