Nokea
To which member of the health-care team should the nurse refer the client diagnosed with OA who is complaining of not being able to get in and out of the bathtub?
- A. Physiatrist.
- B. Social worker.
- C. Physical therapist.
- D. Counselor.
Correct Answer: C
Rationale: A physical therapist can teach adaptive techniques and exercises to improve bathtub mobility for OA. Physiatrists focus on rehabilitation plans, social workers address resources, and counselors focus on mental health.
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The HCP's progress note states that the infant with meningitis is in an opisthotonus position. What should the nurse observe when performing an assessment?
- A. Resistance with specific leg movement
- B. Knee or hip flexion with head flexion
- C. A high-pitched cry with neck flexion
- D. Hyperextension of the head and neck
Correct Answer: D
Rationale: Opisthotonus is characterized by severe hyperextension of the head and neck, often seen in meningitis.
Which staff nurse should the charge nurse assign to the client recovering from a repair of the hallux valgus?
- A. A new graduate nurse.
- B. An experienced nurse.
- C. A nurse practitioner.
- D. An unlicensed assistive personnel.
Correct Answer: B
Rationale: An experienced nurse is best suited for postoperative hallux valgus care, requiring skilled assessment. New graduates lack experience, NPs focus on advanced care, and UAPs cannot assess.
The nurse is discharge teaching for a client with a short leg cast. Which statement indicates the client understands the discharge teaching?
- A. I need to keep my leg elevated on two pillows for the first 24 hours.'
- B. I must wear my sequential compression device all the time.'
- C. I can remove the cast for one (1) hour so I can take a shower.'
- D. I will be able to walk on my cast and not have to use crutches.'
Correct Answer: A
Rationale: Elevating the leg reduces swelling post-casting, indicating understanding. SCDs are for DVT, cast removal is unsafe, and walking without crutches depends on the fracture.
Which client symptom indicates that the nurse should discontinue the medication and notify the physician even if the client's pain is unrelieved?
- A. Vomiting
- B. Dizziness
- C. Drowsiness
- D. Headache
Correct Answer: A
Rationale: Vomiting is a sign of colchicine toxicity, requiring immediate cessation.
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.