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The nurse teaches a client about their newly applied halo fixator device with a vest. Which of the following statements should the nurse make?
- A. You should ride a bicycle instead of driving a car.'
- B. Report any fever or drainage at the pin sites.'
- C. Always keep the wrench taped to the front of the vest.'
- D. When getting out of bed, roll to your side and push on the mattress.'
- E. Wear a cotton t-shirt under the vest to absorb any moisture.'
Correct Answer: B, C, E
Rationale: Report fever or drainage for infection, keep the wrench taped for emergency adjustments, and wear a cotton t-shirt for comfort. Bicycling risks falls, and rolling to the side is safe but not the only method.
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Which of the following best describes an appropriate outcome for a 75-yr-old patient with a history of Huntington's disease, which has developed contractures?
- A. The patient will monitor for signs of skin breakdown as a result of the contractures.
- B. The patient will learn to reposition himself in bed and in his chair without assistance.
- C. The patient will participate in range of motion exercises to reduce the effects of contractures.
- D. The patient will verbalize the effects of contractures on activities of daily living.
Correct Answer: C
Rationale: For a patient with Huntington's disease and contractures, participating in range of motion exercises is an appropriate outcome to help maintain joint mobility and reduce the severity of contractures. Monitoring for skin breakdown is important but not the primary outcome. Independent repositioning may not be feasible due to the progressive nature of Huntington's, and verbalizing effects is less actionable than active intervention.
The nurse is developing a self-management teaching plan for a client with low back pain. Which of the following should the nurse include?
- A. Avoid bending at the waist and lifting heavy objects.'
- B. Weight-bearing exercises are recommended.'
- C. Wear shoes with a higher heel.'
- D. Lay on your stomach four times daily and flex your legs.'
Correct Answer: A
Rationale: Avoiding bending at the waist and heavy lifting prevents back strain. Weight-bearing exercises help bones but not always back pain, high heels strain the back, and stomach lying with leg flexion can worsen pain.
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 following scenario applies to the next 1 items
The nurse in the emergency department (ED) is caring for a 62-year-old female client.
Item 1 of 1
Triage Note
1211: The client was brought to the ED by her neighbor, who was concerned about her increasing pain and immobility. The client's neighbor reported that the client called her a few hours ago, asking her to go to the ED because of increasing pain and the inability to perform her activities of daily living. History of osteoporosis, hypertension, and gout. She reports that she recently started seeing a rheumatologist because of persistent fatigue, low-grade fevers, and lack of appetite. Vital signs: T 99.7° F (37.6° C), P 82, RR 16, BP 134/76, pulse oximetry reading 98% on room air. Pain rated 7/10 on the Numerical Rating Scale, which is described as throbbing of both feet, especially in her toes. She also reports having stiffness in her wrists and fingers that starts in the morning and persists throughout the day. Triage assessment: the client is alert and fully oriented to person, place, and situation. Peripheral pulses 2+. Clear lung sounds bilaterally. Swollen, errythemic toes that are warm and tender to touch. She does not recall her weight but reports significant weight loss over the past three months.
For each assessment finding below, click to specify if the finding is consistent with the disease process of osteoarthritis, acute gout flare, or rheumatoid arthritis. Each finding may support more than 1 disease process.
- A. Low-grade fever
- B. Weight loss
- C. Redness and warmth of the affected joint
- D. Morning joint stiffness in the wrists that lasts throughout the day
- E. Pain with movement in the affected joint
- F. Reduced range of motion in the affected joint
- G. Pain level
Correct Answer: A: Rheumatoid Arthritis, Acute Gout Flare, B: Rheumatoid Arthritis, C: Rheumatoid Arthritis, Acute Gout Flare, D: Rheumatoid Arthritis, E: Osteoarthritis, Rheumatoid Arthritis, Acute Gout Flare, F: Osteoarthritis, Rheumatoid Arthritis, Acute Gout Flare, G: Osteoarthritis, Rheumatoid Arthritis, Acute Gout Flare
Rationale: Seen in inflammatory conditions; not typical in osteoarthritis. Chronic systemic inflammation may lead to unintentional weight loss. Indicates joint inflammation; osteoarthritis does not usually present with warmth or redness. Stiffness >1 hour, especially in small joints, is classic for RA. Movement worsens pain in all these conditions, though the cause differs. All limit ROM due to stiffness, inflammation, or damage. Pain is a shared feature, though severity and timing vary.
The nurse is caring for a client being admitted to the medical-surgical unit with an acute flare of gout. After performing medication reconciliation, which medication does the nurse suspect could have triggered the acute gout flare? See the exhibit.
- A. hydrochlorothiazide
- B. temazepam
- C. rosuvastatin
- D. escitalopram
Correct Answer: A
Rationale: Hydrochlorothiazide, a thiazide diuretic, can increase serum uric acid levels by reducing renal excretion, potentially triggering an acute gout flare. Temazepam, rosuvastatin, and escitalopram do not significantly affect uric acid levels or gout.