Nokea
Which nursing instruction about heating pads is essential to include in the client's teaching plan?
- A. Set the heating pad to the highest setting.
- B. Place the heating pad directly on the skin.
- C. Cover the heating pad with plastic during use.
- D. Apply the heating pad for 2 hours at a time.
Correct Answer: A
Rationale: A low setting prevents burns while providing therapeutic heat.
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The client has been flat in bed in traction for two weeks, and she is to be allowed out of bed for the first time today. What must the nurse be particularly alert for when getting the client out of bed?
- A. Renal complications
- B. Depression
- C. Orthostatic hypotension
- D. Skin breakdown
Correct Answer: C
Rationale: Prolonged bed rest increases the risk of orthostatic hypotension when first mobilizing, requiring careful monitoring.
Which statements made by a parent indicate that appropriate care is being provided for a 4-year-old with spastic-type CP?
- A. "I perform range of motion (ROM) exercises every 4 hours to help prevent contractures."
- B. "I give my child a therapeutic massage after the stretching exercises to help manage pain."
- C. "I minimize the calories I provide with meals because my child is more prone to obesity."
- D. "I have my child wear a helmet during the day because of chronic tonic-clonic seizures."
- E. "Using utensils with large, padded handles makes it easier for my child to feed himself."
Correct Answer: A,B,D,E
Rationale: ROM exercises, therapeutic massage, helmet use for seizures, and adaptive utensils indicate appropriate care for spastic CP.
Which information is most appropriate to teach the client before the arthroscopy procedure?
- A. Signs and symptoms of arthritis
- B. Technique for using crutches
- C. Adverse effects of drug therapy
- D. The need to balance rest and exercise
Correct Answer: B
Rationale: Crutch use is critical post-arthroscopy for safe ambulation.
The client is admitted to the ED after a sports injury. The client verbalizes extreme shoulder pain, and the nurse sees that the client's right arm is shorter than the left. What should the nurse do initially? Select all that apply.
- A. Lift the right arm to support it with a pillow.
- B. Apply a covered ice pack to the left shoulder.
- C. Prepare the client for immediate surgical repair.
- D. Check the pulses and sensation of the right arm.
- E. Prepare to administer an analgesic as prescribed
- F. Inspect the left shoulder for swelling and bruising.
Correct Answer: D,E
Rationale: D. Assessment of pulses and sensation is important because compression of nerves and blood vessels can occur with shoulder dislocation. A shortened arm on the right indicates that the right shoulder is affected. E. The client is in severe pain and requires pain control.
The nurse correctly instructs the client to avoid which type of fluid?
- A. Milk
- B. Alcohol
- C. Cranberry juice
- D. Carbonated drinks
Correct Answer: B
Rationale: Alcohol, especially beer, increases uric acid production and reduces its excretion, worsening gout. Milk, cranberry juice, and carbonated drinks are generally safe unless otherwise contraindicated.