Nokea
Which assessment finding most likely indicates that a client has osteoporosis?
- A. Swollen joints
- B. Discomfort when sitting
- C. Spinal deformity
- D. Diminished energy level
Correct Answer: C
Rationale: Spinal deformity, such as kyphosis, is a common sign of osteoporosis due to vertebral compression fractures from reduced bone density. Swollen joints, discomfort, or low energy are less specific.
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Which statement regarding the performance of ROM exercises is correct?
- A. ROM exercises should be completed independently with verbal cues from the nurse.
- B. Force may be needed during ROM exercises to achieve maximum benefit.
- C. Support should be maintained to the proximal and distal areas of the joint during movement.
- D. ROM exercises should be performed until the client verbalizes discomfort.
Correct Answer: C
Rationale: Supporting the joint's proximal and distal areas prevents strain during ROM.
The client diagnosed with cervical disk degeneration has undergone a laminectomy. Which interventions should the nurse implement?
- A. Position the client prone with the knees slightly elevated.
- B. Assess the client for difficulty speaking or breathing.
- C. Measure the drainage in the Jackson Pratt bulb every day.
- D. Encourage the client to postpone the use of narcotic medications.
Correct Answer: B
Rationale: Cervical laminectomy risks airway or neurological complications; assessing speech and breathing is critical. Prone positioning is inappropriate, JP drainage is routine, and delaying narcotics is unsafe.
Which assessment finding is the best indication that the client in halo traction is developing a serious complication?
- A. The client experiences orthostatic hypotension.
- B. The client needs assistance with shaving.
- C. The client cannot open the mouth widely.
- D. The client complains about irritation under the axillae.
Correct Answer: C
Rationale: Inability to open the mouth widely may indicate cranial nerve compression or device misalignment, a serious complication requiring immediate attention. The other findings are less urgent or unrelated.
The nurse knows that a client who sustains multiple fractures of long bones is at risk for developing fat embolism syndrome. Which findings suggest that the client is developing this complication? Select all that apply.
- A. Bradycardia
- B. Petechiae
- C. Dyspnea
- D. Mental status changes
- E. Hypertension
- F. Hematuria
Correct Answer: B,C,D
Rationale: Fat embolism syndrome typically presents with petechiae (small red spots from fat emboli in the skin), dyspnea (from pulmonary involvement), and mental status changes (from cerebral hypoxia). Bradycardia, hypertension, and hematuria are not characteristic.
Which question best helps the nurse determine whether the client is experiencing an adverse effect from taking nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen?
- A. Do you have any stomach pain or dark stools?
- B. Are you experiencing headaches or dizziness?
- C. Do you notice any swelling in your legs?
- D. Are you having trouble sleeping at night?
Correct Answer: A
Rationale: NSAIDs like ibuprofen commonly cause gastrointestinal adverse effects, such as stomach pain or dark stools (indicating bleeding). These are more specific than headaches, swelling, or sleep issues.