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: Crossing legs can dislocate the hip prosthesis.
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A person's right thumb was accidentally severed with an axe. The amputated right thumb was recovered. Which action by the nurse preserves the thumb so it could possibly be reattached in surgery?
- A. Place the right thumb directly on ice.
- B. Put the right thumb in a glass of warm water.
- C. Wrap the thumb in a clean piece of material.
- D. Secure the thumb in a plastic bag and place on ice.
Correct Answer: D
Rationale: Wrapping the thumb and placing it in a bag on ice preserves viability for reattachment without freezing tissue. Direct ice causes frostbite, warm water promotes decay, and wrapping alone is insufficient.
After the client's total hip replacement surgery, which nursing actions are essential? Select all that apply.
- A. Keeping the client's knees apart at all times
- B. Avoiding flexing the client's hips more than 90 degrees
- C. Having the client use a raised toilet seat
- D. Raising the head of the client's bed 90 degrees
- E. Placing two pillows beneath the client's knees
- F. Keeping the client's legs internally rotated
Correct Answer: A,B,C
Rationale: To prevent dislocation after total hip replacement, keep knees apart (using an abductor pillow), avoid hip flexion beyond 90 degrees, and use a raised toilet seat to maintain safe hip angles. Raising the bed 90 degrees or placing pillows under knees risks dislocation, and internal rotation is contraindicated.
When planning the client's discharge, the nurse must help the client obtain which essential piece of equipment for home care?
- A. A wheelchair
- B. A hospital bed
- C. A raised toilet seat
- D. A mechanical lift
Correct Answer: C
Rationale: A raised toilet seat maintains hip angles below 90 degrees, preventing dislocation during toileting, which is essential for safe home care post-hip replacement.
The nurse is caring for an elderly client diagnosed with a herniated nucleus pulposus of L4-5. Which scientific rationale explains the incidence of a ruptured disk in the elderly?
- A. The client did not use good body mechanics when lifting an object.
- B. There is an increased blood supply to the back as the body ages.
- C. Older clients develop atherosclerotic joint disease as a result of fat deposits.
- D. Clients develop intervertebral disk degeneration as they age.
Correct Answer: D
Rationale: Intervertebral disk degeneration with aging reduces disk hydration and elasticity, increasing rupture risk. Poor body mechanics is a risk but not the primary cause, blood supply decreases, and atherosclerosis affects joints differently.
The clinic nurse assesses a client with complaints of pain and numbness in the left hand and fingers. Which question should the nurse ask the client?
- A. Do you smoke or use any type of tobacco products?'
- B. Do you have to wear gloves when you are out in the cold?'
- C. Do you do repetitive movements with your left fingers?'
- D. Do you have tremors or involuntary movements of your hand?'
Correct Answer: C
Rationale: Repetitive movements are a primary cause of carpal tunnel syndrome, causing pain and numbness. Smoking, cold sensitivity, and tremors are unrelated.