Nokea
The school nurse is completing spinal screenings. Which data require a referral to an HCP?
- A. Bilateral arm lengthening while bending over at the waist.
- B. A deformity which resolves when the head is raised.
- C. Equal spacing of the arms and body at the waist.
- D. A right arm lower than the left while bending over at the waist.
Correct Answer: D
Rationale: Asymmetrical arm positioning (right lower than left) suggests scoliosis, requiring HCP referral. Symmetrical arms, resolving deformities, and equal spacing are normal.
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What equipment is best for preventing external rotation of the operative leg when caring for a client with a total hip replacement?
- A. A footboard
- B. A trochanter roll
- C. A turning sheet
- D. A foam mattress
Correct Answer: B
Rationale: A trochanter roll prevents external rotation, maintaining hip alignment.
Which nursing intervention is most appropriate for preventing a pathological fracture?
- A. Encouraging a high fluid intake
- B. Providing a nutritional diet
- C. Supporting the limb during movement
- D. Relieving pressure on bony prominences
Correct Answer: C
Rationale: Supporting the limb during movement minimizes stress on the necrotic bone, reducing the risk of a pathological fracture in osteomyelitis. Fluid, diet, and pressure relief are less directly preventive.
Which return demonstration indicates that the client has understood the correct way to ambulate with the walker?
- A. The client advances the walker and operative leg while putting most of the weight on the walker's handgrips.
- B. The client advances the walker and operative leg while putting most of the weight on the back legs of the walker.
- C. The client advances the walker and operative leg while putting most of the weight on the toes of the operative leg.
- D. The client advances the walker and operative leg while putting most of the weight on the heel of the nonoperative leg.
Correct Answer: D
Rationale: In a three-point partial weight-bearing gait, the client advances the walker and operative leg together, placing most weight on the nonoperative leg's heel to minimize stress on the operative hip, ensuring stability and safety.
The client has been diagnosed with OA for the last seven (7) years and has tried multiple medical treatments and alternative treatments but still has significant joint pain. Which psychosocial client problem should the nurse identify?
- A. Severe pain.
- B. Body image disturbance.
- C. Knowledge deficit.
- D. Depression.
Correct Answer: D
Rationale: Chronic OA pain often leads to depression due to persistent discomfort and functional limitations. Pain is physiological, body image is less relevant, and knowledge deficit is not indicated.
Which statement by the nurse about fiberglass casts is most accurate?
- A. Fiberglass casts are less expensive than plaster
- B. Fiberglass casts are lightweight.
- C. Fiberglass casts are flexible.
- D. Fiberglass casts are less restrictive than plaster casts.
Correct Answer: B
Rationale: Fiberglass casts are lightweight compared to plaster, making them more comfortable for clients. They are not necessarily less expensive, flexible, or less restrictive, as both types immobilize effectively.