Nokea
While the client is waiting for the ankle to be X-rayed, which nursing measure is most helpful for relieving the soft-tissue swelling?
- A. Place a heating pad on the ankle.
- B. Apply ice to the ankle.
- C. Exercise the client's foot.
- D. Immobilize the client's foot.
Correct Answer: B
Rationale: Applying ice is the most effective initial measure to reduce soft-tissue swelling by causing vasoconstriction, which decreases blood flow and fluid accumulation in the injured area. Heat may increase swelling, exercise could exacerbate the injury, and immobilization alone does not address swelling as directly.
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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.
Which assessment findings should the nurse associate with the development of hydrocephalus in a 7-year-old child?
- A. Headache
- B. Vomiting
- C. Angioedema
- D. Personality change
- E. Increased head circumference
Correct Answer: A,B,D
Rationale: Headache, vomiting, and personality changes are common symptoms of hydrocephalus due to increased intracranial pressure.
When preparing the client for cast application, which statement by the nurse is most accurate?
- A. The cast will feel tight as it's applied.
- B. Your arm will feel warm as the wet plaster sets.
- C. You can expect a foul odor until the cast is dry.
- D. You may feel itchy while the cast is wet.
Correct Answer: B
Rationale: Wet plaster generates heat as it sets, causing a warm sensation, which is a normal part of the process. Tightness may indicate a problem, odors are not typical, and itching is more common as the cast dries.
Which area of health teaching is essential to include in the discharge instructions for a client who has undergone a total hip replacement?
- A. Modifying ways of donning clothing
- B. Using special equipment for bathing
- C. Taking vigorous daily walks
- D. Receiving a daily stool softener
Correct Answer: A
Rationale: Modifying clothing application (e.g., avoiding bending or crossing legs) prevents hip dislocation, making it essential for discharge teaching. Vigorous walks are contraindicated, and the other options are less critical.
The nurse is caring for a client prior to surgery to repair a broken right hip. Which nursing care measure is essential?
- A. Get the client out of bed twice a day to maintain mobility
- B. Use pillows to maintain the right hip in a state of abduction
- C. Elevate the foot of the bed to 25 degrees
- D. Feed the client to conserve her energy
Correct Answer: B
Rationale: Maintaining abduction with pillows prevents dislocation and aligns the hip pre-surgery.