Nokea
The nurse working on a medical-surgical floor feels a pulling in the back when lifting a client up in the bed. Which should be the first action taken by the nurse?
- A. Continue working until the shift is over and then try to sleep on a heating pad.
- B. Go immediately to the emergency department for treatment and muscle relaxants.
- C. Inform the charge nurse and nurse manager on duty and document the occurrence.
- D. See a private health-care provider on the nurse's off time but charge the hospital.
Correct Answer: C
Rationale: Reporting and documenting the injury ensures workplace safety protocols and workers’ compensation processes are followed. Continuing work risks further injury, ED is premature, and private care is secondary.
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Which nursing instruction is most beneficial to minimize stress on the client's painful joints?
- A. Maintain a normal weight.
- B. Apply a topical analgesic cream.
- C. Take a calcium supplement.
- D. Become more physically active.
Correct Answer: A
Rationale: Maintaining a normal weight reduces mechanical stress on weight-bearing joints like the hip, alleviating pain and slowing osteoarthritis progression. The other options are less impactful for joint stress.
Which observation indicates that the child has a Gowers sign in a 4-year-old with Duchenne muscular dystrophy?
- A. Rises from the floor to stand by walking the hands up the legs
- B. Unable to initiate an effective cough or expectorate secretions
- C. Has difficulty lifting the head and supporting it in an upright position
- D. Tests at a high IQ and is advanced for the child's developmental age
Correct Answer: A
Rationale: Gowers sign is characterized by a child using their hands to walk up their legs to stand due to muscle weakness.
The nurse explains that the primary reason for the client's increased risk for altered skin integrity due to a T12 SCI is which factor?
- A. The inability to perceive extremes in temperature leading to burns
- B. The inability to feel skin irritation such as wrinkled linens or clothing
- C. The increased likelihood of bowel and bladder dysfunction and skin irritation
- D. The circulatory changes that cause vasoconstriction and decreased blood supply
Correct Answer: B
Rationale: Loss of sensation below T12 prevents the perception of skin irritants, increasing the risk of pressure ulcers.
The home health nurse is caring for clients who had a THR through the posterior surgical approach 2 weeks ago. It is most important for the nurse to intervene immediately for which client?
- A. After a THR, the client should not flex the hip greater than 90 degrees or have adduction of the hip because it can cause hip dislocation. Wearing socks that do not have grippers on the bottom increases the client's risk for a fall.
- B. After a THR the client may sit at 90 degrees.
- C. After a THR the client may lie supine.
- D. After a THR the client may be up. However, this client should be wearing shoes or gripper socks or slippers to prevent a fall.
Correct Answer: A
Rationale: A. After a THR, the client should not flex the hip greater than 90 degrees or have adduction of the hip because it can cause hip dislocation. Wearing socks that do not have grippers on the bottom increases the client's risk for a fall.
Which information is most appropriate to teach the client before the arthroscopy procedure?
- A. Signs and symptoms of arthritis
- B. Technique for using crutches
- C. Adverse effects of drug therapy
- D. The need to balance rest and exercise
Correct Answer: B
Rationale: Crutch use is critical post-arthroscopy for safe ambulation.