Nokea
Which information should the nurse teach the client regarding sports injuries?
- A. Apply heat intermittently for the first 48 hours.
- B. An injury is not serious if the extremity can be moved.
- C. Only return to the health-care provider if the foot becomes cold.
- D. Keep the injury immobilized and elevated for 24 to 48 hours.
Correct Answer: D
Rationale: Immobilization and elevation reduce swelling in sports injuries. Heat worsens swelling, movement does not rule out severity, and cold feet are a late sign.
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What is the expected Glasgow Coma Scale score for a child with a mild head injury?
- A. A score of 0 is not possible on the Glasgow Coma Scale. The lowest possible score is 3.
- B. A score of 3 on the Glasgow Coma Scale indicates that the child has an absent eye opening, verbal, and motor response. This score is not expected with a mild head injury.
- C. A score of 10 on the Glasgow Coma Scale indicates an altered eye opening, verbal, or motor response and would not be expected with a mild head injury.
- D. Glasgow Coma Scale scores range from 3 (no response) to 15 (normal response). A score of 15 indicates that brain function is intact. A child with a mild head injury should have intact neurological function.
Correct Answer: D
Rationale: A score of 15 on the Glasgow Coma Scale indicates intact neurological function, expected in a mild head injury.
Which statement by the client diagnosed with a fractured ulna indicates to the nurse the client needs further teaching?
- A. I need to eat a high-protein diet to ensure healing.'
- B. I need to wiggle my fingers every hour to increase circulation.'
- C. I need to take my pain medication before my pain is too bad.'
- D. I need to keep this immobilizer on when lying down only.'
Correct Answer: D
Rationale: Immobilizers must be worn continuously to stabilize a fractured ulna, not just when lying down. High-protein diet, finger movement, and proactive pain management are correct.
The client is taken to the emergency department with an injury to the left arm. Which intervention should the nurse implement first?
- A. Assess the nailbeds for capillary refill time.
- B. Remove the client's clothing from the arm.
- C. Call radiology for a STAT x-ray of the extremity.
- D. Prepare the client for the application of a cast.
Correct Answer: A
Rationale: Assessing capillary refill evaluates neurovascular status, the priority in arm injury to detect compromise. Clothing removal, x-rays, and casting follow assessment.
Which statement should the nurse include in the instructions for parents of an infant with osteogenesis imperfecta (OI)?
- A. "Check the color of your infant's nailbeds and mucous membranes for signs of circulatory impairment."
- B. "If you note signs of infection, bring your infant to the clinic because the infant has a significant immune dysfunction."
- C. "Protect your infant from injury and handle your baby carefully because your infant's bones can break very easily."
- D. "Notify your physician if your infant does not respond to sound because the infant's CNS fails to develop completely."
Correct Answer: C
Rationale: OI causes brittle bones, so careful handling is essential to prevent fractures.
A person's right thumb was accidentally severed with an axe. The amputated right thumb was recovered. Which action by the nurse preserves the thumb so it could possibly be reattached in surgery?
- A. Place the right thumb directly on ice.
- B. Put the right thumb in a glass of warm water.
- C. Wrap the thumb in a clean piece of material.
- D. Secure the thumb in a plastic bag and place on ice.
Correct Answer: D
Rationale: Wrapping the thumb and placing it in a bag on ice preserves viability for reattachment without freezing tissue. Direct ice causes frostbite, warm water promotes decay, and wrapping alone is insufficient.