Nokea
When the nurse examines the client, which body part is usually affected by gout?
- A. Great toe
- B. Index finger
- C. Sacrococcygeal vertebrae
- D. Temporomandibular joint
Correct Answer: A
Rationale: Gout typically affects the great toe (first metatarsophalangeal joint) due to uric acid crystal deposition, causing acute pain and swelling. Other areas are less commonly involved.
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Which diagnostic test result should the nurse monitor when assessing for evidence of metastasis?
- A. Lung scan
- B. Urinalysis
- C. Spinal tap
- D. Blood glucose
Correct Answer: A
Rationale: A lung scan detects metastasis, as skeletal tumors often spread to the lungs.
The female client diagnosed with osteoporosis tells the nurse she is going to perform swim aerobics for 30 minutes every day. Which response is most appropriate by the nurse?
- A. Praise the client for committing to do this activity.
- B. Explain to the client walking 30 minutes a day is a better activity.
- C. Encourage the client to swim every other day instead of daily.
- D. Discuss with the client how sedentary activities help prevent osteoporosis.
Correct Answer: B
Rationale: Walking, a weight-bearing exercise, better promotes bone density than swimming for osteoporosis. Daily swimming is less effective, sedentary activities worsen osteoporosis, and praise ignores efficacy.
A client diagnosed with osteoporosis receives nursing instructions on methods to reduce disease progression. Which substances should the nurse advise the client to avoid?
- A. Aspirin and fiber-containing laxatives
- B. Tobacco products and carbonated beverages
- C. Orange juice and caffeinated drinks
- D. Calcium-enriched dairy products
Correct Answer: B
Rationale: Tobacco reduces bone density, and carbonated beverages (containing phosphoric acid) may interfere with calcium absorption, worsening osteoporosis. The other substances are not primarily harmful.
Of the following emergency measures, which one should the nurse perform first?
- A. Check the victim's breathing.
- B. Cover the victim with a blanket.
- C. Move the victim to the curb.
- D. Assess the victim for injuries.
Correct Answer: A
Rationale: In an emergency, the nurse must first assess the victim's breathing to ensure airway patency and adequate oxygenation, following the ABCs (Airway, Breathing, Circulation) of basic life support. Other actions are secondary.
The client diagnosed with OA is a resident in a long-term care facility. The resident is refusing to bathe because she is hurting. Which instruction should the nurse give the unlicensed assistive personnel (UAP)?
- A. Allow the client to stay in bed until the pain becomes bearable.
- B. Tell the UAP to give the client a bed bath this morning.
- C. Try to encourage the client to get up and go to the shower.
- D. Notify the family the client is refusing to be bathed.
Correct Answer: C
Rationale: Encouraging the client to shower promotes mobility, which reduces OA stiffness, while addressing pain. Bed rest worsens stiffness, bed baths enable immobility, and family notification is unnecessary.