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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The client is being seen in the clinic for a second-degree ankle sprain. Which treatments should the nurse plan?
- A. Rest, elevate the extremity, apply ice intermittently, and apply a compression bandage.
- B. Do range of motion to determine the extent of injury, apply heat, and check circulation.
- C. Use moist heat and then apply ice; check circulation, motion, and sensation; and elevate.
- D. Refer to an orthopedic surgeon, apply ice, give an analgesic, elevate, and encourage rest.
Correct Answer: A
Rationale: A. Rest prevents further injury and promotes healing. Ice and elevation control swelling. Compression with an elastic bandage controls bleeding, reduces edema, and provides support for injured tissues.
Which neural tube defect is the nurse describing when stating that the vertebral arch fails to close and the spinal cord and meninges stay within the vertebral canal?
- A. Meningocele
- B. Spina bifida occulta
- C. Spina bifida cystica
- D. Myelomeningocele
Correct Answer: B
Rationale: Spina bifida occulta involves a failure of the vertebral arch to close, with the spinal cord and meninges remaining within the vertebral canal.
The emergency department nurse is caring for a client with a compound fracture of the right ulna. Which interventions should the nurse implement? List in order of priority.
- A. Apply a sterile, normal saline-soaked gauze to the arm.
- B. Send the client to radiology for an x-ray of the arm.
- C. Assess the fingers of the client’s right hand.
- D. Stabilize the arm at the wrist and the elbow.
- E. Administer a tetanus toxoid injection.
Correct Answer: C,A,D,B,E
Rationale: Priority: 1) Assess fingers (neurovascular status); 2) Cover wound with sterile gauze (prevent infection); 3) Stabilize arm (reduce damage); 4) X-ray (confirm fracture); 5) Tetanus (prevent infection).
The 75-year-old client continues to experience phantom limb pain following an AKA, despite being given the prescribed morphine sulfate and using distraction. Which interventions, if prescribed by the HCP, should the nurse plan to implement? Select all that apply.
- A. Apply lidocaine patch 5% to the residual limb
- B. Start transcutaneous electrical nerve stimulation (TENS)
- C. Give atenolol 12.5 mg orally twice daily with food
- D. Give oxcarbazepine 300 mg orally twice daily
- E. Limit the client's activity until the sensations resolve
Correct Answer: A,B,C,D
Rationale: A. A local anesthetic provides pain relief for some with phantom limb pain. B. A TENS unit sends stimulating pulses across the skin surface and along the nerve to help prevent pain signals from reaching the brain. C. Beta blockers such as atenolol (Tenormin) may relieve dull, burning discomfort. D. Antiseizure medication such as oxcarbazepine (Trileptal) has been shown to control stabbing and cramping pain.
During a physical examination of the 1-month-old, the nurse notes that the infant has blue sclerae. The nurse should further assess for signs and symptoms of which disorder?
- A. Juvenile rheumatoid arthritis (JRA)
- B. Tay-Sachs disease
- C. Duchenne muscular dystrophy (DMD)
- D. Osteogenesis imperfecta (OI)
Correct Answer: D
Rationale: Blue sclerae are a hallmark of osteogenesis imperfecta due to thin connective tissue.