Nokea
Which description by the nurse most accurately states the purpose of halo-cervical traction?
- A. It restricts neck movement but enables physical activity.
- B. It allows head movement while immobilizing the spine.
- C. It accelerates healing by facilitating physical therapy.
- D. It promotes faster bone repair within a shorter time span.
Correct Answer: A
Rationale: Halo-cervical traction immobilizes the cervical spine to promote healing while allowing some physical activity (e.g., walking), unlike other options that inaccurately describe its function.
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Later the client says, 'I know my arm isn't there, but I feel it throbbing.' Which response by the nurse would be most accurate?
- A. You may be experiencing referred pain from an adjacent muscle.
- B. You may be experiencing phantom pain from the amputated site.
- C. You may be experiencing psychogenic pain from emotional distress.
- D. You may be experiencing intractable pain that can best be treated with opioids.
Correct Answer: B
Rationale: Phantom pain is a common sensation of pain in the amputated limb due to nerve endings firing, accurately describing the client's experience. The other options misattribute the cause.
The client is now over an acute episode of gout. He is to be discharged on allopurinol (Zyloprim). What instruction must the nurse give to this client?
- A. Take your medicine on an empty stomach.'
- B. Report any nausea to your physician at once.'
- C. Drink two to three quarts of fluids daily.'
- D. Do not take over-the-counter cold medicine.'
Correct Answer: C
Rationale: Drinking 2-3 quarts of fluids daily prevents uric acid stone formation, a key instruction for clients on allopurinol.
The client is scheduled for a magnetic resonance imaging (MRI) scan. Which intervention should the nurse delegate to the unlicensed assistive personnel (UAP)?
- A. Prepare the client by removing all metal objects.
- B. Inject the contrast into the intravenous site.
- C. Administer a sedative to the client to decrease anxiety.
- D. Explain why the client cannot have any breakfast.
Correct Answer: A
Rationale: Removing metal objects is a safe UAP task, ensuring MRI safety. Contrast injection, sedation, and explanations require nursing judgment.
The nurse is discussing the importance of an exercise program for pain control to a client diagnosed with OA. Which intervention should the nurse include in the teaching?
- A. Wear supportive tennis shoes with white socks when walking.
- B. Carry a complex carbohydrate while exercising.
- C. Alternate walking briskly and jogging when exercising.
- D. Walk at least 30 minutes three (3) times a week.
Correct Answer: D
Rationale: Walking 30 minutes thrice weekly reduces OA pain and stiffness through low-impact exercise. Supportive shoes are helpful but secondary, carbohydrates are irrelevant, and jogging may worsen OA.
Which instruction should the nurse include when reinforcing teaching with the parents about safety considerations for a child with a surgically corrected myelomeningocele?
- A. Make sure braces lie smoothly against the child's skin.
- B. Ensure that the child shifts position at least every 3 hours.
- C. Place a blanket between the child and the wheelchair seat.
- D. Check all of the child's skin daily for redness or irritation.
Correct Answer: D
Rationale: Daily skin checks are essential to prevent pressure ulcers and other skin complications in children with myelomeningocele.