Nokea
Which assessment is most important for the nurse to perform prior to the application of a heating pad?
- A. Muscle strength and tone.
- B. Presence of rebound phenomenon.
- C. Limitations to range of motion.
- D. Degree of neurosensory impairment.
Correct Answer: D
Rationale: Neurosensory impairment risks burns.
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The nurse is teaching a client about how to use crutches. Which action performed by the client demonstrates to the nurse a correct understanding of how to use the crutches?
- A. Avoids adjusting the height of the hand grips.
- B. Holds the crutch 6 inches (15 cm) to the side.
- C. Fits the crutch 2 finger widths from axilla.
- D. Walks with the arms fully extended.
Correct Answer: C
Rationale: Proper crutch fit prevents nerve damage.
History and physical
The client is a 28-year-old male who was admitted to the hospital for seizure medication adjustment. Has been having breakthrough seizures over the past month. Has a neurological disorder causing spasticity and limited ability to speak. Currently, has pain in the right leg of unexplained origin.
Nurses Notes
Administered seizure medication. Moved from chair to bed. Made a sound like moaning. Withdrew right leg from touch. Attempted to place leg in position of comfort but experienced muscle spasm. Facial grimacing
Flowsheet
Heart rate 102 beats/minute
The nurse is planning care for the client.Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.
- A. Assign a sitter to stay with the client;Have family stay at the bedside;Request antispasmodic medication;Request prescription for pain medication;Use objective symptoms to assess pain
- B. Chronic pain;Visceral pain;Referred pain;Acute pain
- C. Vital signs;Decrease in seizures;Response to pain medications;Joint mobility;Severity of muscle spasms
Correct Answer:
Rationale: Acute pain: The client’s symptoms, such as moaning, facial grimacing, and muscle spasms in the right leg, suggest they are experiencing acute pain. This condition is consistent with the sudden onset of pain and physical reactions.
Request prescription for pain medication: This action addresses the client’s immediate pain needs, helping to alleviate discomfort and improve overall well-being.
Request antispasmodic medication: The muscle spasms observed indicate that an antispasmodic may help reduce the muscle tension and associated pain, providing relief from the spasms.
Response to pain medications: Monitoring the client's response to the prescribed pain medication will help determine the effectiveness of the intervention and whether further adjustments are needed.
Severity of muscle spasms: Assessing the severity of muscle spasms will help evaluate the impact of the antispasmodic treatment and provide insight into the client’s progress in managing the pain.
The nurse plans to encourage a group of young adult clients to engage in problem-solving strategies. Which action is most useful for the nurse to include during the teaching session?
- A. Incorporate verbal analogies.
- B. Offer positive reinforcement.
- C. Provide physical demonstrations.
- D. Use simulation activities.
Correct Answer: D
Rationale: Simulations engage active problem-solving.
A bedfast female client awakens during the night, reporting to the nurse that she is 'uncomfortable.' What action should the nurse implement first?
- A. Engage the client in relaxation exercises.
- B. Offer to sit with the client until she relaxes.
- C. Administer a prescribed PRN analgesic.
- D. Assist the client to a different position.
Correct Answer: D
Rationale: Repositioning often relieves discomfort.
The nurse is preparing a client placed on droplet precautions for transport from the client's room to another department. The client wears eyeglasses and refuses to remove them while being transported. Which action should the nurse take?
- A. Obtain permission from the nursing supervisor to transport the client without protective equipment.
- B. Place protective goggles over the client's eyeglasses after first positioning the face mask.
- C. Instruct the client about the need to wear a fitted respirator-style mask when leaving the room.
- D. Secure a surgical face mask over the bridge of the client's nose just below the eyeglasses.
Correct Answer: D
Rationale: Surgical mask ensures droplet precaution compliance.