Nokea
Which action by the nurse would be most appropriate for a child newly diagnosed with Reye's syndrome?
- A. Determining if the child had a bacterial infection recently
- B. Placing the child in a private room with droplet precautions
- C. Taking the child to the unit's play area to interact with others
- D. Assessing for signs of bleeding and for prolonged bleeding time
Correct Answer: D
Rationale: Assessing for bleeding is critical in Reye's syndrome due to liver dysfunction and potential coagulopathy.
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While caring for multiple clients, the nurse delegates client skin care to the UAP on a musculoskeletal unit. Which client is most appropriate for the nurse to delegate skin care to the UAP?
- A. The client with osteomyelitis of the tibia who needs a wound dressing change
- B. The client with an inoperable hip fracture who is in Buck's traction
- C. The client with a pelvic fracture who is in skeletal traction
- D. The client with a femur fracture who has an external fixator in place
Correct Answer: B
Rationale: B. Buck's traction is skin traction. Because there is no open site that needs care with this type of traction, it would be appropriate to delegate skin care.
The client with arthritis is receiving sodium salicylate and asks the nurse what the drug will do for her. The nurse's reply should include information that the drug is given for which of the following effects?
- A. Antipyretic
- B. Antibiotic
- C. Anticoagulant
- D. Anti-inflammatory
Correct Answer: D
Rationale: Sodium salicylate is primarily used for its anti-inflammatory effects in arthritis, reducing joint pain and swelling.
The nurse documents the admission assessment for the client who is to have a left total hip arthroplasty to treat chronic degenerative joint disease. Which statements indicate that the client uses alternative therapies for CA treatment? Select all that apply.
- A. I take ibuprofen every 4 to 6 hours.'
- B. I wear a copper bracelet all the time.'
- C. I take glucosamine sulfate 1000 mg daily.'
- D. I apply special magnets to the hip joint.'
- E. I sleep on the unaffected hip, turning often.'
Correct Answer: B,C,D
Rationale: B. Wearing a copper bracelet is an alternative therapy used by some with CA for pain control and reduction of joint stiffness. C. Taking glucosamine sulfate is an alternative therapy used by some with CA. Glucosamine is taken to modify cartilage structure, but studies supporting this have been inconclusive. D. Using magnets designed for body application is an alternative therapy used by some with CA for pain control and reduction of joint stiffness.
The nurse advises the client on the need for maintenance of the bandage. When should the nurse advise the client with a sprained ankle to rewrap the elastic bandage?
- A. When the toes appear pink
- B. When the ankle feels painful
- C. When the toes look swollen
- D. When the joint feels stiff
Correct Answer: C
Rationale: Swollen toes indicate compromised circulation or inadequate compression, necessitating rewrapping to ensure proper fit and pressure. Pink toes suggest normal circulation, pain may not always indicate bandage issues, and joint stiffness is expected with a sprain but not directly related to bandage maintenance.
Which response by the nurse would be most accurate?
- A. You may be experiencing referred pain from an adjacent muscle.
- B. You may be experiencing phantom pain from the amputated site.
- C. You may be experiencing psychogenic pain from emotional distress.
- D. You may be experiencing intractable pain that can best be treated with opioids.
Correct Answer: B
Rationale: Phantom pain is common post-amputation, arising from nerve endings.