Nokea
Which assessment finding indicates a potential musculoskeletal complication of immobility?
- A. Increased muscle tone
- B. Active range of motion (ROM)
- C. Contractures
- D. Strong and flexible joints
Correct Answer: C
Rationale: Contractures permanent muscle and tendon shortening indicate a musculoskeletal complication of immobility, restricting joint movement due to prolonged stillness. High muscle tone might suggest other conditions, while active motion and strong joints reflect health, not issues. Nurses assess for this to initiate stretching or therapy, countering the stiffening that immobility causes, ensuring musculoskeletal function is preserved as much as possible in affected patients.
You may also like to solve these questions
These are nursing intervention that requires knowledge, skills and expertise of multiple health professionals.
- A. Dependent
- B. Independent
- C. Interdependent
- D. Intradependent
Correct Answer: C
Rationale: Interdependent interventions involve collaboration across health disciplines e.g., a nurse and dietician planning a high-protein diet for nephrotic syndrome. Unlike dependent (physician-ordered), independent (nurse-initiated), or intradependent (non-existent), these require shared expertise, ensuring comprehensive care. This teamwork, common in complex cases, leverages diverse skills for optimal outcomes, a staple in multidisciplinary healthcare settings.
What interventions should the nurse implement in caring for a client with diabetes insipidus (DI) following a head injury? Select all that apply.
- A. Providing adequate fluids within easy reach
- B. Reporting an increasing urine specific gravity
- C. Administering prescribed erythromycin
- D. Assessing for and reporting changes in neurological status
Correct Answer: A
Rationale: For diabetes insipidus (DI) post-head injury, providing fluids (A) prevents dehydration from polyuria. Increasing urine specific gravity (B) contradicts DI's dilute urine. Erythromycin (C) is unrelated. Neurological changes (D) are monitored but secondary. A is correct. Rationale: Fluid replacement matches DI's excessive output, a primary intervention per endocrine care standards, maintaining hydration.
Which actions are examples of an RN participating in illness prevention for a client with hypertension?
- A. Teaching lifestyle modifications
- B. Reporting low blood pressure to the health care provider
- C. Administering ordered medication
- D. Performing risk screenings for hypertension
Correct Answer: A
Rationale: Illness prevention in nursing focuses on proactive measures to stop disease development, particularly for conditions like hypertension. Teaching lifestyle modifications, such as diet and exercise, empowers clients to manage blood pressure and reduce risk, aligning with primary prevention's educational emphasis. Performing risk screenings identifies hypertension early, enabling timely intervention before complications arise, another primary prevention strategy. Providing heart-healthy diet literature reinforces these efforts, equipping clients with practical tools for prevention. Reporting low blood pressure or administering medications, while critical interventions, address existing conditions rather than prevent onset, falling under treatment or management. Nurses' preventive role leverages education and screening to foster healthy habits and early detection, significantly impacting chronic disease trajectories like hypertension, where lifestyle plays a pivotal role.
The nurse double-checked Mr. Gary's meds to avoid mistakes. This is an example of?
- A. Safety
- B. Quality improvement
- C. Patient-centered care
- D. Telemedicine
Correct Answer: A
Rationale: Double-checking meds is safety (A) preventing harm, per care standards. QI (B) enhances, patient-centered (C) tailors, telemedicine (D) remote not error-specific. A fits safety's focus, making it correct.
Which of the following statement best describe disability?
- A. Temporary loss of function
- B. Permanent loss of function
- C. Absence of disease
- D. A state of well being
Correct Answer: B
Rationale: Disability is permanent loss of function (B), per definition e.g., amputation impact. Temporary (A) is impairment, absence (C) health, well-being (D) opposite. B best defines disability's chronicity, making it correct.