Nokea
Which client goal is most appropriate for a client diagnosed with OA?
- A. Perform passive range-of-motion exercises.
- B. Maintain optimal functional ability.
- C. Client will walk three (3) miles every day.
- D. Client will join a health club.
Correct Answer: B
Rationale: Maintaining optimal function aligns with OA management, promoting mobility and independence. Passive ROM is inappropriate, 3 miles daily is unrealistic, and joining a health club is nonspecific.
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The 75-year-old client continues to experience phantom limb pain following an AKA, despite being given the prescribed morphine sulfate and using distraction. Which interventions, if prescribed by the HCP, should the nurse plan to implement? Select all that apply.
- A. Apply lidocaine patch 5% to the residual limb
- B. Start transcutaneous electrical nerve stimulation (TENS)
- C. Give atenolol 12.5 mg orally twice daily with food
- D. Give oxcarbazepine 300 mg orally twice daily
- E. Limit the client's activity until the sensations resolve
Correct Answer: A,B,C,D
Rationale: A. A local anesthetic provides pain relief for some with phantom limb pain. B. A TENS unit sends stimulating pulses across the skin surface and along the nerve to help prevent pain signals from reaching the brain. C. Beta blockers such as atenolol (Tenormin) may relieve dull, burning discomfort. D. Antiseizure medication such as oxcarbazepine (Trileptal) has been shown to control stabbing and cramping pain.
The college student consults the clinic nurse for advice on managing lower back pain. Which instructions should the nurse include? Select all that apply.
- A. Continue routine activity within your pain tolerance while paying attention to correct posture.
- B. Temporarily avoid lifting and other activities that increase mechanical stress on your spine.
- C. When sleeping on your side, flex your hips and knees and place a pillow between your knees.
- D. Stay at home for 1 week on bedrest to minimize physical activity and straining your back.
- E. Stand intermittently during classes, and sit with a soft support at the small of your back.
Correct Answer: A,B,C,E
Rationale: A. Remaining active is best. Using good posture will minimize back strain. B. Mechanical stress can increase pain. Prolonged unsupported sitting, heavy lifting, and bending or twisting the back, especially while lifting, should be avoided. C. Using pillows and hip and knee flexion promotes lumbar flexion and back alignment. E. Prolonged sitting should be avoided because fatigue contributes to spasm of the back muscles. Lordosis can be decreased by using a soft support at the small of the back.
The nurse is to give the client with gout one tablet of colchicine every hour until relief or toxicity occurs. Which of the following is an indication for stopping the colchicine?
- A. Ringing in the ears
- B. Nausea and vomiting
- C. A rash on the client's hips
- D. A temperature of 101°F
Correct Answer: B
Rationale: Nausea and vomiting are signs of colchicine toxicity, indicating the need to stop the medication.
While the client is waiting for the ankle to be X-rayed, which nursing measure is most helpful for relieving the soft-tissue swelling?
- A. Place a heating pad on the ankle.
- B. Apply ice to the ankle.
- C. Exercise the client's foot.
- D. Immobilize the client's foot.
Correct Answer: B
Rationale: Applying ice is the most effective initial measure to reduce soft-tissue swelling by causing vasoconstriction, which decreases blood flow and fluid accumulation in the injured area. Heat may increase swelling, exercise could exacerbate the injury, and immobilization alone does not address swelling as directly.
Which statement by the client prescribed calcitonin, a thyroid hormone, indicates to the nurse the teaching has been effective?
- A. I should administer the mediation in a different nostril each day.'
- B. I need to drink a lot of water when I take my medicine.'
- C. I have to dilute the medication with vitamin D before I take it.'
- D. This medication will help the calcium leave my bones.'
Correct Answer: A
Rationale: Alternating nostrils for nasal calcitonin prevents irritation, indicating effective teaching. Water intake, vitamin D dilution, and calcium loss are incorrect.