Nokea
Which statement indicates that the client understands the restrictions to be followed?
- A. I should avoid pointing my toes.
- B. I shouldn't cross my legs.
- C. I shouldn't lie flat in bed.
- D. I shouldn't stand upright.
Correct Answer: B
Rationale: Avoiding crossing legs prevents adduction of the hip, which could lead to dislocation after total hip replacement. The other restrictions are less critical or inaccurate.
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Which interventions should be included in the discharge teaching for a client who had a total hip replacement? Select all that apply.
- A. Discuss the client’s weight-bearing limits.
- B. Request the client demonstrate use of assistive devices.
- C. Explain the importance of increasing activity gradually.
- D. Instruct the client not to take medication prior to ambulating.
- E. Tell the client to ambulate with open-toed house shoes.
Correct Answer: A,B,C
Rationale: Weight-bearing limits, assistive device use, and gradual activity prevent complications post-THR. Pain medication aids ambulation, and open-toed shoes are unsafe.
Which nursing intervention is most appropriate for preventing a pathological fracture?
- A. Encouraging a high fluid intake
- B. Providing a nutritional diet
- C. Supporting the limb during movement
- D. Relieving pressure on bony prominences
Correct Answer: C
Rationale: Supporting the limb during movement minimizes stress on the necrotic bone, reducing the risk of a pathological fracture in osteomyelitis. Fluid, diet, and pressure relief are less directly preventive.
The nurse identifies the concept of impaired functional ability for a client diagnosed with rheumatoid arthritis. Which intervention should the nurse implement?
- A. Teach the client to apply antiembolism (TED) hose.
- B. Administer the nonsteroidal medication before the morning meal.
- C. Encourage the client to perform low-impact exercises daily.
- D. Refer the client to occupational therapy for gait training.
Correct Answer: C
Rationale: Low-impact exercises maintain joint function in RA, addressing impaired ability. TED hose are for DVT, NSAIDs are for pain, and OT is for specific tasks, not gait.
The client has been diagnosed with OA for the last seven (7) years and has tried multiple medical treatments and alternative treatments but still has significant joint pain. Which psychosocial client problem should the nurse identify?
- A. Severe pain.
- B. Body image disturbance.
- C. Knowledge deficit.
- D. Depression.
Correct Answer: D
Rationale: Chronic OA pain often leads to depression due to persistent discomfort and functional limitations. Pain is physiological, body image is less relevant, and knowledge deficit is not indicated.
The client newly diagnosed with osteoporosis is prescribed calcitonin by nasal spray. Which assessment data indicate to the nurse an adverse effect of the medication?
- A. The client complains of nausea and vomiting.
- B. The client is drinking two (2) glasses of milk a day.
- C. The client has a runny nose and nasal itching.
- D. The client has had numerous episodes of nosebleeds.
Correct Answer: C
Rationale: Runny nose and nasal itching are common adverse effects of nasal calcitonin. Nausea is less common, milk intake is unrelated, and nosebleeds are not typical.