Nokea
Which statement made by the family member indicates the need for further teaching?
- A. The hand should be elevated higher than the elbow.
- B. The knot should be tied at the back of the neck.
- C. The elbow should be flexed within the sling.
- D. The sling is used to elevate and support the arm.
Correct Answer: B
Rationale: Tying the knot at the back of the neck may cause discomfort or pressure on the cervical spine. The knot should be tied to the side to avoid this. The other statements correctly describe the proper use of a triangular sling for shoulder immobilization.
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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.
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.
When the nurse examines the client, which body part is usually affected by gout?
- A. Great toe
- B. Index finger
- C. Sacrococcygeal vertebrae
- D. Temporomandibular joint
Correct Answer: A
Rationale: The great toe is commonly affected in gout due to uric acid crystal deposition.
With the assistance of the translator, the nurse correctly instructs the client to use which technique when picking something up?
- A. Squat with the knees bent.
- B. Keep both feet together.
- C. Lift with the arms extended.
- D. Bend from the waist.
Correct Answer: A
Rationale: Squatting with knees bent uses leg muscles to lift, reducing spinal strain and protecting the surgical site post-laminectomy. Bending from the waist or other techniques risks reinjury.
The nurse is caring for the following clients. After receiving the shift report, which client should the nurse assess first?
- A. The client with a total knee replacement who is complaining of a cold foot.
- B. The client diagnosed with osteoarthritis who is complaining of stiff joints.
- C. The client who needs to receive a scheduled intravenous antibiotic.
- D. The client diagnosed with back pain who is scheduled for a lumbar myelogram.
Correct Answer: A
Rationale: A cold foot post-knee replacement suggests vascular compromise, requiring urgent assessment to prevent tissue damage. Stiff joints, antibiotics, and myelogram prep are lower priority.