Nokea
What is the goal of therapy for a child newly diagnosed with scoliosis as explained by the nurse?
- A. Limit or stop progression of the curvature of the spine.
- B. Prepare the child for surgical correction at a later date.
- C. Minimize the complications of prolonged immobilization.
- D. Develop a pain management plan to minimize complications.
Correct Answer: A
Rationale: The primary goal of scoliosis treatment is to halt or limit the progression of spinal curvature.
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The client diagnosed with osteomyelitis of the left foot and ankle is being prepared for a below-the-knee amputation. Which intervention to improve the client’s functional ability is a priority after rehabilitation?
- A. Keep a large tourniquet at the bedside to stop potential bleeding from the amputation site.
- B. Place a pillow in the bed for the client to push the stump against many times per day.
- C. Take and document the client’s vital signs every four (4) hours.
- D. Have the dietary department send high protein, high-carbohydrate meals six (6) times a day.
Correct Answer: B
Rationale: Pushing the stump against a pillow toughens the residual limb, improving prosthesis use and function post-amputation. Tourniquets are for emergencies, vitals are routine, and frequent meals are excessive.
The nurse completes teaching the client who has a plaster cast following a right wrist fracture. Which statement, if made by the client, indicates the need for additional teaching?
- A. I should keep my cast uncovered while drying so that moisture can evaporate.'
- B. My cast initially may smell musty. When dry, it should be odorless and shiny white.'
- C. My cast may feel sticky and very warm initially, but it will dry in about 30 minutes.'
- D. I should avoid sharp or hard surfaces while drying because it causes dents in the cast.'
Correct Answer: C
Rationale: C. Although the cast will feel very warm for about 15 to 20 minutes, a plaster cast requires 24 to 72 hours (not 30 minutes) to dry completely.
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 interventions are appropriate for an adolescent experiencing a seizure?
- A. A tongue blade inserted into the adolescent's mouth during a seizure can cause injury.
- B. Padding protects the adolescent's limbs from injury against the hard side rails during a seizure.
- C. Airway obstruction can occur during or after the seizure. An oropharyngeal airway should be available but should not be inserted during the seizure. If the seizure has commenced, nothing should be forced into the adolescent's mouth.
- D. The etiology is unknown. Only if an airborne or droplet infectious disease were suspected as the cause would droplet precautions be considered.
- E. Suctioning equipment may be needed to clear secretions after the seizure.
Correct Answer: B,C,E
Rationale: Padding protects limbs from injury, an oropharyngeal airway should be available but not inserted during a seizure, and suctioning equipment may be needed post-seizure to clear secretions.
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.