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What is the expected Glasgow Coma Scale score for a child with a mild head injury?
- A. A score of 0 is not possible on the Glasgow Coma Scale. The lowest possible score is 3.
- B. A score of 3 on the Glasgow Coma Scale indicates that the child has an absent eye opening, verbal, and motor response. This score is not expected with a mild head injury.
- C. A score of 10 on the Glasgow Coma Scale indicates an altered eye opening, verbal, or motor response and would not be expected with a mild head injury.
- D. Glasgow Coma Scale scores range from 3 (no response) to 15 (normal response). A score of 15 indicates that brain function is intact. A child with a mild head injury should have intact neurological function.
Correct Answer: D
Rationale: A score of 15 on the Glasgow Coma Scale indicates intact neurological function, expected in a mild head injury.
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The nurse is caring for the client who has had a total hip replacement. Which data indicate the surgical treatment is effective?
- A. The client states the pain is at a '3' on a 1-to-10 scale.
- B. The client has a limited ability to ambulate.
- C. The client's left leg is shorter than the right leg.
- D. The client ambulates to the bathroom.
Correct Answer: D
Rationale: Ambulating to the bathroom indicates effective THR, restoring mobility. Mild pain is expected, limited ambulation is negative, and leg length discrepancy is a complication.
One month after discharge, the client who had a left THR calls a clinic reporting acute, constant pain in the left groin and hip area and feeling like the left leg is shorter than the right. The nurse advises the client to come to the clinic immediately, suspecting which problem?
- A. An infection of the wound
- B. Deep vein thrombosis (DVT)
- C. Dislocation of the prosthesis
- D. Aseptic loosening of the prosthesis
Correct Answer: C
Rationale: C. Indicators of a prosthesis dislocation include increased surgical site pain, acute groin pain, shortening of the leg, abnormal external or internal rotation, restricted ability or inability to move the leg, and reports of a popping sensation in the hip.
A cast has just been applied to a client's left forearm, and he has 10 lbs of Russell's traction on his left leg. Which of the following nursing concerns takes priority in the care of this client?
- A. The casted extremity may swell, and the cast will become a tourniquet.
- B. Heat conduction from the wet cast can cause burning to the skin below.
- C. Muscle atrophy of the areas involved can lead to decreased muscle tone.
- D. Skin irritation from the cast edges can cause abrasions.
Correct Answer: A
Rationale: Swelling in a newly casted extremity can cause the cast to act as a tourniquet, compromising circulation, which is the priority concern. Heat from a wet cast does not burn skin, muscle atrophy is a long-term issue, and skin irritation is less urgent.
The client is taken to the emergency department with an injury to the left arm. Which intervention should the nurse implement first?
- A. Assess the nailbeds for capillary refill time.
- B. Remove the client's clothing from the arm.
- C. Call radiology for a STAT x-ray of the extremity.
- D. Prepare the client for the application of a cast.
Correct Answer: A
Rationale: Assessing capillary refill evaluates neurovascular status, the priority in arm injury to detect compromise. Clothing removal, x-rays, and casting follow assessment.
Which statement to the nurse indicates a good understanding by the client of the use of methotrexate and cyclosporine?
- A. I am having an exacerbation of symptoms so two medications are needed.
- B. Cyclosporine is given to enhance the effect of the methotrexate.
- C. Methotrexate and cyclosporine together decrease unwanted side effects.
- D. My symptoms are severe enough to indicate the use of two strong medications.
Correct Answer: D
Rationale: Severe symptoms may necessitate combination therapy with methotrexate and cyclosporine, both potent immunosuppressants, to control rheumatoid arthritis. Cyclosporine does not enhance methotrexate, and side effects are not necessarily reduced.