Nokea
Which intervention should the nurse include for a client diagnosed with carpal tunnel syndrome?
- A. Teach hyperextension exercises to increase flexibility.
- B. Monitor safety during occupational hazards.
- C. Prepare for the insertions of pins or screws.
- D. Monitor dressing and drain after the fasciotomy.
Correct Answer: B
Rationale: Monitoring occupational hazards (e.g., repetitive tasks) prevents carpal tunnel exacerbation. Hyperextension worsens symptoms, and surgical interventions are not first-line.
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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.
What should the nurse do after noting serosanguineous drainage on the cast of a child with myelodysplasia post-TEV repair?
- A. Cut a window where the drainage is seeping through the cast.
- B. Petal the cast to minimize skin irritation and decrease leakage.
- C. Measure the area of drainage on the cast and document this.
- D. Telephone the surgeon to report the serosanguineous drainage.
Correct Answer: C
Rationale: Measuring and documenting the drainage allows monitoring without compromising the cast's integrity.
The client continues to recover following a below-the-knee amputation. What nursing action should the nurse employ to help prevent the most common complication following leg amputation?
- A. Clean the wound with hydrogen peroxide three times a day
- B. Have the client lie prone several times a day
- C. Ask the client to flex and extend the toes on the remaining leg
- D. Encourage the client to completely empty his/her bladder
Correct Answer: B
Rationale: Lying prone prevents hip flexion contractures, the most common complication post-amputation.
The client tells the nurse, 'My father is furious with me. He does not want me to ride a motorcycle.' Which response by the nurse is most appropriate?
- A. As they say, 'Father knows best.''
- B. I'll be sure it is a safe.'
- C. It can be frustrating when you disagree with your father.'
- D. I think you should obey your father's wishes.'
Correct Answer: C
Rationale: Acknowledging the client's frustration validates their feelings without judgment, fostering therapeutic communication. The other responses either dismiss the client's emotions or impose the nurse's opinion, which is inappropriate.
Which statement to the nurse indicates a good understanding by the client of the use of methotrexate and cyclosporine?
- A. I am having an exacerbation of symptoms so two medications are needed.
- B. Cyclosporine is given to enhance the effect of the methotrexate.
- C. Methotrexate and cyclosporine together decrease unwanted side effects.
- D. My symptoms are severe enough to indicate the use of two strong medications.
Correct Answer: D
Rationale: Severe symptoms justify the use of two potent immunosuppressive drugs.