Nokea
When assessing the characteristics of pain in a client with a herniated disk, the nurse would expect to document increased intensity of pain during which activity?
- A. Eating
- B. Coughing
- C. Sleeping
- D. Urinating
Correct Answer: B
Rationale: Coughing increases intraspinal pressure, exacerbating pain from a herniated disk by compressing the affected nerve root. Other activities are less likely to intensify disk-related pain.
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What should the nurse admitting the child with autism do about the room assignment?
- A. Request that the child be transferred to a private room.
- B. Request that the child be transferred to a double room.
- C. Admit the child to the room that has been preassigned.
- D. Request that the child be assigned to an isolation room.
Correct Answer: A
Rationale: A private room is preferred for a child with autism to minimize sensory overload and ensure a calm environment.
Which material added by the nurse is best for covering the tips of the pin to prevent injuries while the client is in skeletal leg.
- A. Gauze squares
- B. Cotton balls
- C. Cork blocks
- D. Rubber tubes
Correct Answer: C
Rationale: Cork blocks securely cover pin tips, preventing injury to the client or staff while maintaining stability. Gauze and cotton are less durable, and rubber tubes may not fit securely.
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.
Which risk factor found in the client's medical record does the nurse identify as most significant for sustaining a hip fracture?
- A. The client is postmenopausal.
- B. The client is somewhat obese.
- C. The client has type 2 diabetes.
- D. The client is lactose intolerant.
Correct Answer: A
Rationale: Postmenopausal status is the most significant risk factor for hip fractures due to estrogen loss, which accelerates bone density reduction, increasing fracture risk. Obesity, diabetes, and lactose intolerance are less directly related.
The nurse knows that elevated findings on which laboratory test typically validate a diagnosis of gout?
- A. Creatinine clearance
- B. Blood urea nitrogen
- C. Serum uric acid
- D. Serum calcium
Correct Answer: C
Rationale: Elevated serum uric acid confirms gout, as it causes crystal formation.