Nokea
The nurse is teaching a new grad about contractures. The nurse knows which statement about contractures secondary to immobility is accurate?
- A. Contractures cannot be prevented because of muscular spasticity.
- B. Contractures cannot be prevented because of muscular tension.
- C. Flexion contractures are the least commonly occurring contracture.
- D. Flexion contractures are the most commonly occurring contracture.
Correct Answer: D
Rationale: Flexion contractures are the most common due to immobility, as muscles shorten in a flexed position. Contractures can be prevented with range of motion and positioning, despite spasticity or tension.
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While caring for a patient who has recently suffered from a fracture, the nurse sees that the patient's injured extremity will be placed in traction. Which of the following actions should the nurse refrain from performing?
- A. Keeping the pulley system tightened so that they may not move freely
- B. Check the ropes for fraying or breaks
- C. Keep the weights above the floor
- D. Ensure proper body alignment
Correct Answer: A
Rationale: Tightening the pulley system to prevent free movement can disrupt traction's purpose of maintaining alignment and pull. Checking ropes, keeping weights off the floor, and ensuring alignment are all appropriate.
The nurse performs a home safety assessment for an older adult with rheumatoid arthritis. The nurse should make which recommendation to promote safety in the bathroom?
- A. Recommend using a handheld (adjustable) shower head
- B. Advise the client to lower the toilet seat to its lowest level
- C. Instruct the client to reduce bathroom lighting
- D. Recommend the use of towel racks for grab bars
Correct Answer: A
Rationale: A handheld shower head allows the client with rheumatoid arthritis to bathe more easily, accommodating limited mobility and joint stiffness. Lowering the toilet seat may make standing difficult, reduced lighting increases fall risk, and towel racks are not sturdy enough for support.
The nurse is caring for a client with a newly applied plaster cast. The nurse should
- A. Use a small object like a pencil or ruler to itch the leg if it becomes uncomfortable.
- B. Expedite drying by using a hot blow dryer on the cast.
- C. Let the cast hang below the heart to promote blood flow.
- D. Handle the cast with the palms of the hands.
Correct Answer: D
Rationale: Handling a wet plaster cast with the palms prevents denting, which could cause pressure points. Scratching inside risks skin damage, hot dryers can burn, and a dependent position increases swelling.
Following the application of a fiberglass cast to treat the client's severe ankle sprain (i.e., Grade 3), a nurse performs client education. During this discussion, the client asks, 'How long will my cast take to dry?' Based on this type of cast, the nurse should respond:
- A. Eight hours
- B. 30 minutes
- C. At least 24 hours
- D. At least 48 hours
Correct Answer: B
Rationale: Fiberglass casts typically dry within 30 minutes to an hour, much faster than plaster casts, allowing for quick hardening and stability.
The nurse performs a physical assessment on a client and observes a tremor in the client's hand when their arm is extended. The nurse understands that this finding is consistent with which of the following?
- A. Rheumatic fever
- B. End-stage renal disease
- C. Neuroleptic Malignant Syndrome (NMS)
- D. Human Immunodeficiency Virus (HIV)
Correct Answer: C
Rationale: A tremor with an extended arm (postural tremor) can be consistent with Neuroleptic Malignant Syndrome, a reaction to certain medications causing muscle rigidity and tremors. Other options are less directly linked to this finding.