Nokea
The nurse writes the problem of 'pain' for a client diagnosed with lumbar strain. Which nursing interventions should be included in the plan of care? Select all that apply.
- A. Assess pain on a 1-to-10 scale.
- B. Administer pain medication prn.
- C. Provide a regular bedpan for elimination.
- D. Assess surgical dressing every four (4) hours.
- E. Perform a position change by the log roll method every two (2) hours.
Correct Answer: A,B,E
Rationale: Pain assessment, PRN medication, and log rolling address pain and prevent exacerbation in lumbar strain. Bedpans are unnecessary, and surgical dressings are irrelevant without surgery.
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The physician directs the nurse to wrap the client's lower extremity with an elastic bandage. Where should the nurse begin applying the bandage?
- A. Below the knee
- B. Above the ankle
- C. Across the phalanges
- D. At the metatarsals
Correct Answer: D
Rationale: Starting the elastic bandage at the metatarsals (the foot's midsection) ensures distal-to-proximal compression, promoting venous return and reducing swelling effectively. Beginning higher up, such as below the knee or above the ankle, may not adequately address swelling in the foot, and starting at the phalanges is too distal.
The client is three (3) hours postoperative left AKA. The client tells the nurse, 'My left foot is killing me. Please do something.' Which intervention should the nurse implement?
- A. Explain to the client his left leg has been amputated.
- B. Medicate the client with a narcotic analgesic immediately.
- C. Instruct the client on how to perform biofeedback exercises.
- D. Place the client's residual limb in the dependent position.
Correct Answer: B
Rationale: Phantom limb pain is treated with analgesics; narcotics provide immediate relief. Explaining the amputation dismisses pain, biofeedback is long-term, and dependent positioning is inappropriate.
Which assessment finding would the nurse consider a likely adverse effect of the client's methotrexate therapy?
- A. Constipation
- B. Dry mouth
- C. Mouth sores
- D. Chest pain
Correct Answer: C
Rationale: Mouth sores are a common side effect of methotrexate due to its effect on mucosal cells.
The nurse is concerned about the spinal curve in the young child and documents the exaggerated lumbar curve. Which condition was likely documented?
- A. Scoliosis
- B. Lordosis
- C. Kyphosis
- D. Kyphoscoliosis
Correct Answer: B
Rationale: Lordosis is characterized by an exaggerated lumbar curve.
The nurse is caring for a client diagnosed with a fracture of the right distal humerus. Which data indicate a complication? Select all that apply.
- A. Numbness and mottled cyanosis.
- B. Paresthesia and paralysis.
- C. Proximal pulses and point tenderness.
- D. Coldness of the extremity and crepitus.
- E. Palpable radial pulse and functional movement.
Correct Answer: A,B,D
Rationale: Numbness, cyanosis, paresthesia, paralysis, coldness, and crepitus indicate compartment syndrome or neurovascular compromise, serious fracture complications. Pulses and tenderness are expected.