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: The great toe is commonly affected in gout due to uric acid crystal deposition.
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Which statement indicates that the client understands the restrictions to be followed?
- A. I should avoid pointing my toes.
- B. I shouldn't cross my legs.
- C. I shouldn't lie flat in bed.
- D. I shouldn't stand upright.
Correct Answer: B
Rationale: Avoiding crossing legs prevents adduction of the hip, which could lead to dislocation after total hip replacement. The other restrictions are less critical or inaccurate.
The nurse identifies the concept of impaired functional ability for a client diagnosed with rheumatoid arthritis. Which intervention should the nurse implement?
- A. Teach the client to apply antiembolism (TED) hose.
- B. Administer the nonsteroidal medication before the morning meal.
- C. Encourage the client to perform low-impact exercises daily.
- D. Refer the client to occupational therapy for gait training.
Correct Answer: C
Rationale: Low-impact exercises maintain joint function in RA, addressing impaired ability. TED hose are for DVT, NSAIDs are for pain, and OT is for specific tasks, not gait.
The 35-year-old client who sustained a crushing injury to the left hand and forearm is being discharged. Which referral should the nurse implement?
- A. Refer the client to physical therapy at home.
- B. Refer the client to an assistive living facility.
- C. Refer the client to a workforce commission for job training.
- D. Refer the client to the dietitian.
Correct Answer: A
Rationale: Home PT restores hand/forearm function post-crushing injury. Assisted living, job training, and dietitian referrals are premature or unrelated.
When the nurse makes rounds at the beginning of the shift, which observation requires the nurse's immediate attention?
- A. The halter rests under the client's chin and occiput.
- B. The client's ears are clear of the traction ropes.
- C. The weight hangs between the headboard and wall.
- D. There is a soft pillow beneath the client's head.
Correct Answer: D
Rationale: A pillow under the head in cervical traction can alter the alignment and reduce traction effectiveness, requiring immediate removal. The other observations indicate proper setup.
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 levels confirm gout, as they reflect the hyperuricemia leading to crystal formation in joints. Other tests are not specific to gout diagnosis.