Nokea
When the nurse assesses the client, which finding is the best indication that the shoulder has been dislocated?
- A. The client is experiencing intense pain.
- B. The client is receiving intense pain.
- C. The client is hesitant to move the arm.
- D. The affected arm is longer than the other.
Correct Answer: D
Rationale: A dislocated shoulder often results in the affected arm appearing longer due to the humeral head being displaced from the glenoid fossa, altering the arm's alignment. Pain and hesitancy to move are common but less specific, and 'receiving intense pain' is a typographical error.
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The nurse is admitting the client with OA to the medical floor. Which statement by the client indicates an alternative form of treatment for OA?
- A. I take medication every two (2) hours for my pain.'
- B. I use a heating pad when I go to bed at night.'
- C. I wear a copper bracelet to help with my OA.'
- D. I always wear my ankle splints when I sleep.'
Correct Answer: C
Rationale: Copper bracelets are an alternative therapy for OA, believed to reduce symptoms. Pain medication and heating pads are conventional, and splints are for support, not alternative.
The client with a right AKA is being taught how to toughen the residual limb. Which intervention should the nurse implement?
- A. Instruct the client to push the residual limb against a pillow.
- B. Demonstrate how to apply an elastic bandage around the residual limb.
- C. Encourage the client to apply vitamin B12 to the surgical incision.
- D. Teach the client to elevate the residual limb at least three (3) times a day.
Correct Answer: A
Rationale: Pushing the residual limb against a pillow toughens skin for prosthesis use. Elastic bandages reduce edema, vitamin B12 is irrelevant, and elevation is for swelling, not toughening.
The nurse is discharging a client who had a total hip replacement. Which statement indicates further teaching is needed?
- A. I should not cross my legs because my hip may come out of the socket.'
- B. I will call my HCP if I have a sudden increase in pain.'
- C. I will sit on a chair with arms and a firm seat.'
- D. After three (3) weeks, I don’t have to worry about infection.'
Correct Answer: D
Rationale: Infection risk persists beyond 3 weeks post-THR; this statement requires correction. Avoiding leg crossing, reporting pain, and proper seating are correct.
Which intervention is an example of a secondary nursing intervention when discussing osteoporosis?
- A. Obtain a bone density evaluation test.
- B. Perform non-weight-bearing exercises regularly.
- C. Increase the intake of dietary calcium.
- D. Refer clients to a smoking cessation program.
Correct Answer: A
Rationale: Bone density testing (e.g., DEXA) is secondary prevention, detecting osteoporosis early. Calcium intake and smoking cessation are primary, and non-weight-bearing exercises are less effective.
Which of the following might interfere with the effectiveness of Russell's traction?
- A. The rope is strung tautly from pulley to pulley.
- B. The trapeze is hanging above the client's chest.
- C. The rope is knotted at the location of a pulley.
- D. The weight is about 24'' (61 cm) from the floor.
Correct Answer: C
Rationale: A knotted rope at the pulley disrupts smooth movement, reducing traction effectiveness by altering the pull. Taut ropes, a properly placed trapeze, and weights hanging freely are correct for effective traction.