Nokea
Which is the nurse's best explanation regarding the goal of surgery for an adolescent requiring surgical treatment for scoliosis?
- A. "The surgery will allow you to grow to be taller."
- B. "The surgery will decrease the recurrence of pain."
- C. "The surgery will prevent problems with breathing."
- D. "The surgery will allow your clothes to fit you better."
Correct Answer: C
Rationale: Scoliosis surgery aims to correct spinal deformity and prevent respiratory complications.
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A college student visits a campus health service reporting knee pain, clicking when walking, 'locking,' and 'giving way' of the affected knee. The injury occurred when twisting the knee wrong during a tennis match. The nurse should further assess for which problem?
- A. Injury of the meniscus cartilage
- B. Fracture of the lateral tibial condyle
- C. Injury and possible fractured patella
- D. Lateral collateral ligament injury
Correct Answer: A
Rationale: A. The nurse should assess for injury to the meniscus (knee) cartilage. Abrupt twisting can tear the cartilage, and the loose cartilage can cause locking of the joint, clicking, and the knee to 'give way.'
When preparing to meet with the parents and their 5-year-old child with autism, which behaviors should the nurse anticipate that the child might display?
- A. Polydactyly
- B. Leukoderma
- C. Poor eye contact
- D. Restricted interests
- E. Atypical language
Correct Answer: C,D,E
Rationale: Children with autism often exhibit poor eye contact, restricted interests, and atypical language patterns.
If the client is in shock, how should the nurse position the client while continuing to assess and provide care?
- A. Prone with the arm supported
- B. In Fowler's position with the knees flexed
- C. Supine with the legs elevated
- D. Lateral with the back extended
Correct Answer: C
Rationale: In shock, positioning the client supine with legs elevated improves venous return and cerebral perfusion, stabilizing blood pressure. Other positions are less effective or contraindicated.
The nurse is caring for the client after a right TKR. To prevent circulatory complications, the nurse should ensure that the client is performing which action?
- A. Flexing both feet and exercising uninvolved joints every hour while awake
- B. Using the continuous passive motion device (CPM) every 2 hours for 30 minutes
- C. Being assisted up to a chair as soon as the effects of anesthesia have worn off
- D. Using the trapeze to lift off the bed and then rotating each leg intermittently
Correct Answer: A
Rationale: A. Dorsiflexion of the foot promotes muscle contraction, which compresses veins. This reduces venous stasis and risk of thrombus formation. It should be performed every hour while awake.
Which explanation by the nurse can best help this client understand the injury that has occurred?
- A. One bone end is driven into the other.
- B. One bone end is driven into the other.
- C. There is no open break in the skin.
- D. A portion of the bone is split away.
Correct Answer: C
Rationale: A comminuted fracture involves the bone breaking into multiple fragments, often without an open skin break. The description 'no open break in the skin' distinguishes it from a compound fracture, while the other options describe impacted or avulsion fractures.