Nokea
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.
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To minimize the extent of the damage to the spinal cord in a teen with a possible SCI, which classification of medication should the nurse expect to administer?
- A. An antibiotic
- B. An analgesic
- C. A steroid medication
- D. An antihypertensive medication
Correct Answer: C
Rationale: Steroids, such as methylprednisolone, are used acutely in SCI to reduce inflammation and swelling.
The client with a lower leg amputation has edema, so the NA elevates the client's residual left limb on pillows. What is the most appropriate action by the nurse when observing that the client's leg has been elevated?
- A. Thank the nursing assistant (NA) for being so observant and intervening appropriately to treat the client's edema of the residual limb.
- B. Remove the pillows, raise the foot of the bed, and inform the NA that the limb should not be elevated on pillows because it could cause a flexion contracture.
- C. Inform the NA that this was the correct action at this time in the client's recovery, but once the client's incision heals, the leg should not be elevated.
- D. Report the incident to the surgeon and tell the NA to complete a variance report because the client's leg should not have been elevated.
Correct Answer: B
Rationale: B. The nurse should perform this action. Flexion, abduction, and external rotation of the residual lower limb are avoided to prevent hip contracture.
What is true about absence seizures in children?
- A. For most children, absence seizures stop during early teen years.
- B. Absence seizures rarely progress to other seizures.
- C. Teachers often note signs of absence seizures, but seeing them is not adequate for diagnosis.
- D. Absence seizures usually exist in isolation; usually the child has no other neurological condition.
Correct Answer: A
Rationale: Most children outgrow absence seizures during their early teen years.
The client with a pelvic fracture developed a fat embolism. The nurse should assess the client for which specific sign?
- A. Dyspnea
- B. Chest pain
- C. Delirium
- D. Petechiae
Correct Answer: D
Rationale: D. The nurse should assess for petechiae. Petechiae (small purplish hemorrhagic spots on the skin) are thought to be due to transient thrombocytopenia. They can occur over the chest, anterior axillary folds, hard palate, buccal membranes, and conjunctival sacs.
In this case, from whom is it most appropriate for the physician, with the nurse as a witness, to obtain consent to perform the surgical procedure?
- A. The client
- B. The client's physician
- C. The client's youth leader
- D. The client's parent
Correct Answer: D
Rationale: A 17-year-old is typically a minor, requiring parental consent for surgical procedures unless emancipated or in an emergency where consent cannot be obtained. The client, physician, or youth leader cannot provide legal consent.