When preparing the client for cast application, which statement by the nurse is most accurate?
- A. The cast will feel tight as it's applied.
- B. Your arm will feel warm as the wet plaster sets.
- C. You can expect a foul odor until the cast is dry.
- D. You may feel itchy while the cast is wet.
Correct Answer: B
Rationale: Wet plaster generates heat as it sets, causing a warm sensation, which is a normal part of the process. Tightness may indicate a problem, odors are not typical, and itching is more common as the cast dries.
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Which assessment findings should the nurse associate with the development of hydrocephalus in a 7-year-old child?
- A. Headache
- B. Vomiting
- C. Angioedema
- D. Personality change
- E. Increased head circumference
Correct Answer: A,B,D
Rationale: Headache, vomiting, and personality changes are common symptoms of hydrocephalus due to increased intracranial pressure.
The nurse is assessing the leg of a client in Russell's traction. Which area is it essential to assess?
- A. Pedal area
- B. Femoral area
- C. Popliteal area
- D. Inner aspect of the thigh
Correct Answer: A
Rationale: Assessing the pedal area checks for circulation, sensation, and movement, critical in traction to detect neurovascular compromise.
Which nursing assessment finding is the best indication that the client has an infection at the pin site?
- A. Serous drainage at the pin site
- B. Bloody drainage at the pin site
- C. Mucoid drainage at the pin site
- D. Purulent drainage at the pin site
Correct Answer: D
Rationale: Purulent (pus-like) drainage is the clearest sign of infection at the pin site, indicating bacterial presence. Serous, bloody, or mucoid drainage is less specific to infection.
The nurse is to give the client with gout one tablet of colchicine every hour until relief or toxicity occurs. Which of the following is an indication for stopping the colchicine?
- A. Ringing in the ears
- B. Nausea and vomiting
- C. A rash on the client's hips
- D. A temperature of 101°F
Correct Answer: B
Rationale: Nausea and vomiting are signs of colchicine toxicity, indicating the need to stop the medication.
The 75-year-old client continues to experience phantom limb pain following an AKA, despite being given the prescribed morphine sulfate and using distraction. Which interventions, if prescribed by the HCP, should the nurse plan to implement? Select all that apply.
- A. Apply lidocaine patch 5% to the residual limb
- B. Start transcutaneous electrical nerve stimulation (TENS)
- C. Give atenolol 12.5 mg orally twice daily with food
- D. Give oxcarbazepine 300 mg orally twice daily
- E. Limit the client's activity until the sensations resolve
Correct Answer: A,B,C,D
Rationale: A. A local anesthetic provides pain relief for some with phantom limb pain. B. A TENS unit sends stimulating pulses across the skin surface and along the nerve to help prevent pain signals from reaching the brain. C. Beta blockers such as atenolol (Tenormin) may relieve dull, burning discomfort. D. Antiseizure medication such as oxcarbazepine (Trileptal) has been shown to control stabbing and cramping pain.
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