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, like kyphosis, is a common sign of osteoporosis.
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When the client asks the nurse what is meant by the term manipulation, which explanation is most accurate?
- A. Manipulation involves making an incision to realign the bones.
- B. Manipulation involves the insertion of a pin or wire into the joint.
- C. Manipulation repositions the bone ends manually.
- D. Manipulation strengthens the joint with exercise.
Correct Answer: C
Rationale: Manipulation for a dislocated shoulder involves manually repositioning the bone ends into their normal alignment without surgical intervention. Incisions or pins are used in surgical procedures, and exercise is for rehabilitation, not repositioning.
Until a translator is available, which nursing action is best when teaching the client who speaks English as a second language about body mechanics?
- A. Speak slowly while looking at the client.
- B. Write the instructions on paper.
- C. See the client and the patient.
- D. Have the client watch a video.
Correct Answer: A
Rationale: Speaking slowly while maintaining eye contact enhances comprehension for a non-native speaker, using nonverbal cues to reinforce verbal instructions until a translator is available.
The client with a long arm cast is complaining of unrelenting severe pain and feeling as if the fingers are asleep. Which complication should the nurse suspect the client is experiencing?
- A. Fat embolism.
- B. Compartment syndrome.
- C. Pressure ulcer under the cast.
- D. Surgical incision infection.
Correct Answer: B
Rationale: Severe pain and numbness in a casted arm suggest compartment syndrome, a medical emergency. Fat embolism, pressure ulcers, and infections present differently.
Which is the best method to assess circulation in the casted extremity?
- A. Ask the client to wiggle the fingers.
- B. Feel the cast to determine if it is unusually hot or cold.
- C. Depress the client's nail beds, and document the client's knee on the center to return.
- D. See if there is enough room to insert a finger between the cast and the extremity.
Correct Answer: C
Rationale: Depressing the nail beds to assess capillary refill (color return within 2-3 seconds) is the most reliable method to evaluate circulation in a casted extremity, indicating adequate blood flow. Wiggling fingers assesses motor function, not circulation directly, and the other options are less specific.
The client admitted with a diagnosis of a fractured hip who is in Buck's traction is complaining of severe pain. Which intervention should the nurse implement?
- A. Adjust the patient-controlled analgesia (PCA) machine for a lower dose.
- B. Ensure the weights of the Buck's traction are off the floor and hang freely.
- C. Raise the head of the bed to 45 degrees and the foot to 15 degrees.
- D. Turn the client on the affected leg using pillows to support the other leg.
Correct Answer: B
Rationale: Proper Buck’s traction alignment (weights off floor) reduces pain from misalignment. Adjusting PCA, bed positioning, or turning may worsen pain or are inappropriate.