Nokea
To prevent skin breakdown while the client is in Russell's traction, the nurse must frequently inspect the skin in which area?
- A. Over the ischial spines
- B. In the popliteal space
- C. Near the iliac crests
- D. At the zygomatic arch
Correct Answer: B
Rationale: Russell's traction involves a sling under the knee, placing pressure on the popliteal space, which is prone to skin breakdown due to prolonged contact and immobility. Frequent inspection here prevents pressure ulcers.
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The nurse teaches the trainers that adolescent soccer players are at increased risk for which abnormality?
- A. Varus knee deformities
- B. Valgus knee deformities
- C. Varus ankle deformities
- D. Valgus ankle deformities
Correct Answer: A
Rationale: Adolescent soccer players are at risk for varus knee deformities due to repetitive stress on the knees.
An adolescent male was in an accident and is hospitalized with multiple fractures. The nurse enters the room and observes that he has his back to the door and is staring at the wall with a sad expression on his face. What is the best response for the nurse to make at this time?
- A. You seem sad.'
- B. Don't be too down on yourself.'
- C. I know it is hard to be out of school.'
- D. Do you miss your family and friends?'
Correct Answer: A
Rationale: Acknowledging the client's sadness ('You seem sad') is therapeutic, encouraging expression of feelings. Other responses assume causes or dismiss emotions, which are less supportive.
The physician orders passive range-of-motion (ROM) exercises for an elderly client on bed rest. Which statement regarding the performance of ROM exercises is correct?
- A. ROM exercises should be completed independently with verbal cues from the nurse.
- B. Force may be needed during ROM exercises to achieve maximum benefit.
- C. Support should be maintained to the proximal and distal areas of the joint during movement.
- D. ROM exercises should be performed until the client verbalizes discomfort.
Correct Answer: C
Rationale: Supporting the proximal and distal areas of the joint during passive ROM exercises ensures controlled, safe movement, preventing injury. Independent completion, force, or continuing until discomfort risks harm.
Which interventions should the nurse implement for a child with a newly applied fiberglass hip-Spica cast?
- A. Use a hair dryer on a low setting to help dry the cast.
- B. Place on a Bradford frame for elevation off the bed.
- C. Place pillows to support the child's lower extremities.
- D. Turn the child every 2 hours and monitor the CMS.
- E. Petal the perineal area and other edges of the cast.
Correct Answer: C,D,E
Rationale: Pillows provide support, turning prevents pressure sores, and petaling protects skin around cast edges.
The nurse is assessing the client diagnosed with a left femoral neck fracture. Which findings should the nurse expect? Select all that apply.
- A. Left leg is in an abducted position.
- B. Left leg is externally rotated.
- C. Left leg is shorter than the right.
- D. Pain is in the lateral left knee.
- E. Pain is in the groin area.
Correct Answer: B,C,E
Rationale: B. With a left femoral neck fracture, the leg is externally rotated. C. With a left femoral neck fracture, the leg is shortened. E. With a left femoral neck fracture, pain is experienced in the groin area.