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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 of the following would the nurse identify as the highest priority when documenting the postoperative circulation status of the recently casted extremity?
- A. Adequate neurovascular functioning
- B. Minimal pain on movement
- C. Vital signs within normal limits
- D. No drainage noted on the cast
Correct Answer: A
Rationale: Adequate neurovascular functioning (circulation, sensation, and movement) is the highest priority to ensure no complications like compartment syndrome or vascular compromise, which can lead to tissue damage. Pain, vital signs, and drainage are secondary.
The nurse is analyzing the serum laboratory report for the client diagnosed with lung cancer that has metastasized to the pelvic bone. Which specific finding should the nurse anticipate?
- A. Elevated calcium
- B. Decreased hemoglobin
- C. Elevated creatinine (SCr)
- D. Elevated creatine kinase (CK)
Correct Answer: A
Rationale: A. Malignant tumors cause hypercalcemia through a variety of mechanisms, one being an increased release of calcium from the bones.
The client with a cervical neck injury as a result of a motor-vehicle accident is complaining of unrelieved pain after administration of a narcotic analgesic. Which alternative method of pain control is an independent nursing action?
- A. Medicate the client with a muscle relaxant.
- B. Heat alternating with ice applied by a physical therapist.
- C. Watch television or listen to music.
- D. Discuss surgical options with the health-care provider.
Correct Answer: C
Rationale: Distraction via TV or music is an independent nursing action to manage pain. Muscle relaxants require a prescription, heat/ice involves PT, and surgical discussions are physician-driven.
The occupational health nurse is teaching a class on the risk factors for developing osteoarthritis (OA). Which is a modifiable risk factor for developing OA?
- A. Being overweight.
- B. Increasing age.
- C. Previous joint damage.
- D. Genetic susceptibility.
Correct Answer: A
Rationale: Excess weight increases joint stress, a modifiable risk for OA. Age, prior damage, and genetics are nonmodifiable.
What is the purpose of the continuous passive motion (CPM) machine that the nurse should explain while teaching the client?
- A. A CPM machine is used to strengthen the leg muscles.
- B. A CPM machine is used to relieve foot swelling.
- C. A CPM machine is used to reduce surgical pain.
- D. A CPM machine is used to restore joint function.
Correct Answer: D
Rationale: CPM promotes joint mobility and prevents stiffness post-arthroplasty.