Nokea
An elderly client who has just had a prosthetic hip implant.
The nurse should position the client
- A. with the affected hip internally rotated and flexed.
- B. with the affected hip adducted when turned.
- C. in the supine position with the knees elevated 90°.
- D. side-lying with the affected hip in a position of abduction.
Correct Answer: D
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) flexion beyond 60°, adduction and internal rotation should be avoided in the early postoperative period (2) flexion beyond 60°, adduction and internal rotation should be avoided in the early postoperative period (3) flexion beyond 60°, adduction and internal rotation should be avoided in the early postoperative period (4) correct-position of abduction should be maintained
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A client comes to the clinic for treatment of recurrent pelvic inflammatory disease (PID). The nurse recognizes that this condition most frequently follows which type of infection?
- A. Trichomoniasis
- B. Chlamydia
- C. Staphylococcus
- D. Streptococcus
Correct Answer: B
Rationale: Chlamydia. Chlamydial infections are one of the most frequent causes of salpingitis or pelvic inflammatory disease.
The nurse is performing a post-op assessment of an elderly client with a total hip repair. Although he has not requested medication for pain, the nurse suspects that the client's discomfort is severe and prepares to administer pain medication. Which of the following signs would not support the nurse's assessment of acute post-op pain?
- A. Increased blood pressure
- B. Inability to concentrate
- C. Dilated pupils
- D. Decreased heart rate
Correct Answer: D
Rationale: Acute pain typically increases heart rate, blood pressure, and pupil dilation. Decreased heart rate is not consistent with acute pain.
The nurse is caring for a client with a history of schizophrenia who is receiving haloperidol (Haldol) 5 mg PO bid. Which of the following symptoms should the nurse report immediately?
- A. Dry mouth.
- B. Mild sedation.
- C. Muscle stiffness and tremors.
- D. Insomnia.
Correct Answer: C
Rationale: Muscle stiffness and tremors suggest extrapyramidal symptoms, a serious haloperidol side effect. Options A, B, and D are less urgent.
When admitting a client who has acute glomerulonephritis, the nurse expects that the client will report which information?
- A. Recent bladder infection
- B. History of previous kidney infections
- C. Pharyngitis three weeks ago
- D. Multiple sexual partners
Correct Answer: C
Rationale: Acute glomerulonephritis is often post-streptococcal, following pharyngitis. Bladder/kidney infections or sexual partners are less directly related.
The nurse discusses symptoms of the onset of labor with a 26-year-old primipara. Which of the following statements, if made by the client to the nurse, indicates a need for further teaching?
- A. I will note an increase in fetal movement.
- B. I may feel a gush of fluid run down my legs.
- C. I may see some blood in my vaginal discharge.
- D. I may experience a low backache.
Correct Answer: A
Rationale: Fetal movement decreases at labor onset due to limited space; expecting an increase indicates misunderstanding. Options B, C, and D are correct labor signs.