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What is the primary nursing concern when caring for patients being treated with splints, casts, or traction?
- A. To assess for and prevent neurovascular complications or dysfunction
- B. To ensure adequate nutrition during the healing process
- C. To provide patient education for maintenance of splints, casts, or traction in the community
- D. To treat acute pain
Correct Answer: A
Rationale: The primary nursing concern when caring for patients with splints, casts, or traction is to assess for and prevent neurovascular complications or dysfunction. This is crucial to ensure adequate circulation and nerve function, preventing long-term complications such as ischemia or nerve damage. While adequate nutrition and patient education are important aspects of care, they are not the primary concern in this scenario. Acute pain management is important but is secondary to preventing neurovascular complications in patients treated with splints, casts, or traction.
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To prevent a Valsalva maneuver in a client recovering from an acute myocardial infarction, the nurse would:
- A. Assist the client in using the bedside commode
- B. Administer stool softeners daily as prescribed
- C. Administer antidysrhythmics PRN as prescribed
- D. Maintain the client on strict bed rest
Correct Answer: B
Rationale: Administering stool softeners daily as prescribed is essential to prevent straining during defecation, which can lead to a Valsalva maneuver. Straining can increase intra-abdominal pressure, hinder venous return, and elevate blood pressure, risking cardiac complications in a client recovering from a heart attack. Using a bedside commode might be useful to minimize exertion during toileting but does not directly address the risk of a Valsalva maneuver. Administering antidysrhythmics PRN is not the primary intervention for preventing a Valsalva maneuver; these medications are used to manage dysrhythmias if they occur. Keeping the client on strict bed rest is not the best option as early mobilization is encouraged in post-myocardial infarction recovery to prevent complications such as deep vein thrombosis and muscle weakness.
A client with asthma has low-pitched wheezes present on the final half of exhalation. One hour later the client has high-pitched wheezes extending throughout exhalation. This change in assessment indicates to the nurse that the client
- A. Has increased airway obstruction
- B. Has improved airway obstruction
- C. Needs to be suctioned
- D. Exhibits hyperventilation
Correct Answer: B
Rationale: The higher pitched a sound is, the more narrow the airway. Therefore, the obstruction has increased or worsened. With no evidence of secretions, there is no support to indicate the need for suctioning. Wheezes changing from low-pitched to high-pitched and extending throughout exhalation suggest a progression in airway constriction, indicating an increase in airway obstruction. Option B is incorrect because the change in wheezes from low to high pitch does not suggest an improvement in airway obstruction. Option C is incorrect as there is no indication of secretions requiring suctioning. Option D is incorrect as hyperventilation is not typically associated with the described change in wheezes.
Why are subdural hemorrhages more common in the elderly?
- A. Increased anticoagulant use
- B. Increased risk of falls
- C. Brain atrophy
- D. Inconsistent care giving
Correct Answer: C
Rationale: Subdural hemorrhages are more common in the elderly due to cerebral atrophy resulting from the natural aging process. This atrophy can lead to the stretching of bridging veins, making them more fragile and prone to tearing even with minor trauma. While increased anticoagulant use and a higher risk of falls are common in the elderly, brain atrophy plays a more direct role in the increased incidence of subdural hemorrhages. Inconsistent caregiving, on the other hand, is not a direct cause of subdural hemorrhages but may impact the overall management and outcome of such cases.
A home health nurse is at the home of a client with diabetes and arthritis. The client has difficulty drawing up insulin. It would be most appropriate for the nurse to refer the client to
- A. A social worker from the local hospital
- B. An occupational therapist from the community center
- C. A physical therapist from the rehabilitation agency
- D. Another client with diabetes mellitus who takes insulin
Correct Answer: B
Rationale: An occupational therapist from the community center would be the most appropriate referral for this client. Occupational therapists specialize in helping individuals improve fine motor skills, which are essential for tasks like drawing up insulin injections. A social worker typically focuses on psychosocial aspects, a physical therapist on physical mobility, and another client with diabetes would not have the professional expertise to address the client's specific needs related to insulin preparation.
The infection control nurse is assigned to a patient with osteomyelitis related to a heel ulcer. The wound is 5cm in diameter and the drainage saturates the dressing so that it must be changed every hour. What is her priority intervention?
- A. Place the patient under contact precautions
- B. Use strict aseptic technique when caring for the wound
- C. Place another dressing to reinforce the first one
- D. Elevate the patient's leg to prevent more drainage
Correct Answer: A
Rationale: The priority intervention for a patient with osteomyelitis related to a heel ulcer, with a wound that saturates the dressing every hour, is to place the patient under contact precautions. Contact precautions are essential when managing infectious wounds to prevent the spread of infection to healthcare workers, other patients, and visitors. Strict aseptic technique (Choice B) should always be used with wound care but is secondary to implementing contact precautions in this scenario. Placing another dressing (Choice C) or elevating the patient's leg (Choice D) may be necessary but do not address the immediate need for infection control measures.