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Which intervention for bladder emptying should the nurse plan to implement for a 14-year-old with a neurogenic bladder from an SCI with a lower motor neuron lesion?
- A. Intermittent catheterization
- B. Insertion of a retention catheter
- C. Insertion of a suprapubic catheter
- D. Giving an anticholinergic medication
Correct Answer: A
Rationale: Intermittent catheterizationelevation is preferred for neurogenic bladder due to lower motor neuron lesions to prevent urinary retention.
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Which nursing observation provides the best indication that the halo-cervical traction device is applied appropriately?
- A. The client has full range of motion in the neck.
- B. The client's neck pain is within a tolerable level.
- C. The client can speak and hear at preinjury levels.
- D. The client reports the ability to see straight ahead.
Correct Answer: D
Rationale: The ability to see straight ahead indicates proper alignment of the halo device, ensuring the cervical spine is stabilized correctly. Full neck motion contradicts the purpose, and pain or speech/hearing are less specific.
A client sustained a fractured femur in a motor-vehicle accident. Which data require immediate intervention by the nurse? Select all that apply.
- A. The client requests pain medication to sleep.
- B. The client has eupnea and normal sinus rhythm.
- C. The client has petechiae over the neck and chest.
- D. The client has a high arterial oxygen level.
- E. The client has yellow globules floating in the urine.
Correct Answer: C,E
Rationale: Petechiae and yellow globules suggest fat embolism syndrome, requiring immediate intervention. Pain medication, normal breathing, and high oxygen are not urgent.
While caring for multiple clients, the nurse delegates client skin care to the UAP on a musculoskeletal unit. Which client is most appropriate for the nurse to delegate skin care to the UAP?
- A. The client with osteomyelitis of the tibia who needs a wound dressing change
- B. The client with an inoperable hip fracture who is in Buck's traction
- C. The client with a pelvic fracture who is in skeletal traction
- D. The client with a femur fracture who has an external fixator in place
Correct Answer: B
Rationale: B. Buck's traction is skin traction. Because there is no open site that needs care with this type of traction, it would be appropriate to delegate skin care.
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 common post-amputation, arising from nerve endings.
An adolescent male was in an accident and is hospitalized with multiple fractures. The nurse enters the room and observes that he has his back to the door and is staring at the wall with a sad expression on his face. What is the best response for the nurse to make at this time?
- A. You seem sad.'
- B. Don't be too down on yourself.'
- C. I know it is hard to be out of school.'
- D. Do you miss your family and friends?'
Correct Answer: A
Rationale: Acknowledging the client's sadness ('You seem sad') is therapeutic, encouraging expression of feelings. Other responses assume causes or dismiss emotions, which are less supportive.