The following scenario applies to the next 1 items
The nurse in the emergency department (ED) is caring for a 62-year-old female client.
Item 1 of 1
Triage Note
1211: The client was brought to the ED by her neighbor, who was concerned about her increasing pain and immobility. The client's neighbor reported that the client called her a few hours ago, asking her to go to the ED because of increasing pain and the inability to perform her activities of daily living. History of osteoporosis, hypertension, and gout. She reports that she recently started seeing a rheumatologist because of persistent fatigue, low-grade fevers, and lack of appetite. Vital signs: T 99.7° F (37.6° C), P 82, RR 16, BP 134/76, pulse oximetry reading 98% on room air. Pain rated 7/10 on the Numerical Rating Scale, which is described as throbbing of both feet, especially in her toes. She also reports having stiffness in her wrists and fingers that starts in the morning and persists throughout the day. Triage assessment: the client is alert and fully oriented to person, place, and situation. Peripheral pulses 2+. Clear lung sounds bilaterally. Swollen, errythemic toes that are warm and tender to touch. She does not recall her weight but reports significant weight loss over the past three months.
For each assessment finding below, click to specify if the finding is consistent with the disease process of osteoarthritis, acute gout flare, or rheumatoid arthritis. Each finding may support more than 1 disease process.
Your Selected Order (Tap items to remove)
Available Options (Tap to select in order)
A
Low-grade fever
B
Weight loss
C
Redness and warmth of the affected joint
D
Morning joint stiffness in the wrists that lasts throughout the day
E
Pain with movement in the affected joint
F
Reduced range of motion in the affected joint
G
Pain level
Rationale:
A: Rheumatoid Arthritis, Acute Gout Flare. Low-grade fever is often associated with inflammatory conditions like rheumatoid arthritis and acute gout flare, reflecting the body's response to these diseases' processes, indicating active inflammation.
B: Weight loss. Not specific to osteoarthritis, weight loss is more indicative of systemic illnesses, including rheumatoid arthritis, rather than a localized degenerative joint condition like osteoarthritis.
C: Redness and warmth of the affected joint. These signs suggest acute inflammation, characteristic of rheumatoid arthritis and acute gout flare, rather than the chronic, more stable symptoms seen in osteoarthritis.
D: Morning joint stiffness in the wrists that lasts throughout the day. This symptom is particularly indicative of rheumatoid arthritis, where stiffness is prominent, contrasting with osteoarthritis, which typically has less prolonged morning stiffness.
E: Pain with movement in the affected joint. While pain is common in all conditions, osteoarthritis usually exhibits pain with use, unlike rheumatoid arthritis and acute gout, which have different pain characteristics.
F: Reduced range of motion in the affected joint. This finding occurs in osteoarthritis due to joint degeneration, but rheumatoid arthritis and acute gout can also lead to temporary reductions in mobility due to inflammation.
G: Pain level. Pain is a common feature across all conditions mentioned; however, its intensity and characteristics can vary, making it less indicative for distinguishing between them.
The nurse is teaching a client with low back pain. Which of the following statements, if made by the client, would require follow-up?
Rationale:
Sleeping on the stomach can exacerbate low back pain by placing undue stress on the spine and straining the neck. Proper sleeping positions, such as on the back or side, are crucial for spinal alignment and pain relief.
A: I am planning to stop smoking cigarettes. Quitting smoking is beneficial for overall health and can improve circulation, supporting recovery from low back pain.
C: I have decided to purchase a firm mattress. A firm mattress can provide better support for the spine, aiding in pain management and enhancing sleep quality.
D: I will bend my knees when lifting objects. Bending the knees is a proper technique that reduces strain on the back while lifting, promoting safer body mechanics.
The nurse reviews newly prescribed medications from the primary healthcare provider (PHCP). The nurse understands that the prescribed etanercept is intended to treat which condition?
Rationale:
Etanercept is intended to treat rheumatoid arthritis. This medication is a TNF inhibitor, which helps reduce inflammation and halt the progression of joint damage associated with this autoimmune condition, providing relief to patients.
A: Osteoarthritis Etanercept primarily targets autoimmune conditions, while osteoarthritis is a degenerative joint disease not primarily driven by autoimmune processes, making this option unsuitable for etanercept treatment.
B: Diabetes mellitus Diabetes mellitus is a metabolic disorder characterized by high blood sugar levels, which does not involve the inflammatory pathways that etanercept addresses, thus making this option inappropriate.
C: Infective endocarditis (IE) Infective endocarditis is an infection of the heart valves that requires antibiotics, not an immunosuppressive medication like etanercept, which is ineffective for treating infections.
The nurse teaches a client about their newly applied halo fixator device with a vest. Which of the following statements should the nurse make?
Rationale:
You should report any fever or drainage at the pin sites. Monitoring for signs of infection is crucial when using a halo fixator, as it can prevent complications and ensure timely medical intervention.
A: You should ride a bicycle instead of driving a car. Engaging in cycling may pose risks of falls or injuries, making it unsuitable while using a halo fixator.
C: Always keep the wrench taped to the front of the vest. While accessibility is important, this may create unnecessary bulk or discomfort, hindering movement and daily activities for the patient.
D: When getting out of bed, roll to your side and push on the mattress. This technique may not provide the necessary support or stability for safely moving with a halo fixator.
E: Wear a cotton t-shirt under the vest to absorb any moisture. While moisture control is important, this option does not address critical aspects of preventing skin irritation or infection effectively.
The nurse reviews the client's clinical data. Which action should the nurse take based on the clinical data?
Rationale:
Remove the heating pad from the client's lower back. The clinical data likely indicates a risk of burns or skin damage from prolonged heat exposure, necessitating the immediate removal of the heating pad to ensure patient safety and prevent complications.
A: Administer the prescribed ketorolac. This action does not address potential adverse effects or safety concerns highlighted in the clinical data, which may require reevaluation of pain management strategies.
C: Contact the physician to question the prescription of ketorolac. While communication is crucial, this option fails to address immediate patient safety issues indicated by the clinical data that necessitate a more urgent intervention.
D: Reposition the client to the side of the bed and have them twist from side to side. This maneuver may exacerbate discomfort or injury rather than promote healing, contrary to the guidance suggested by the clinical findings.
E: Remove and discard the prescribed fentanyl patch because of its lack of efficacy. This option overlooks potential valid reasons for the patch's application and does not align with the immediate safety considerations presented in the clinical data.
Following the application of a fiberglass cast to treat the client's severe ankle sprain (i.e., Grade 3), a nurse performs client education. During this discussion, the client asks, 'How long will my cast take to dry?' Based on this type of cast, the nurse should respond:
Rationale:
A fiberglass cast typically dries within 30 minutes, allowing for quick immobilization of the ankle after a severe sprain. This rapid drying time is essential for facilitating the client's recovery process.
A: Eight hours This duration vastly exceeds the actual drying time for fiberglass casts, which sets quickly and allows for early mobility and less waiting for the client.
C: At least 24 hours This timeframe is excessive for fiberglass casts, which are designed for rapid drying, enabling the client to begin rehabilitation sooner rather than later.
D: At least 48 hours This lengthy period is not applicable to fiberglass casts, as they typically harden much faster, ensuring timely support for the injured area.
The nurse is assessing a client in skeletal traction, and the findings show a pale and cold foot with an unpalpable pulse. What is the priority nursing intervention?
Rationale:
Notify the primary healthcare provider (PHCP).
This finding indicates potential complications such as compromised circulation or neurovascular impairment, necessitating immediate intervention. Prompt notification of the PHCP ensures timely assessment and intervention to prevent further deterioration of the client's condition.
A: Reassess the foot in twenty minutes. Delaying action for twenty minutes could lead to significant complications, making immediate notification to the PHCP a more appropriate response to the alarming findings.
B: Readjust the traction. Adjusting the traction may not address the underlying issue of compromised circulation, which requires urgent medical evaluation rather than alterations to the existing treatment setup.
C: Administer the ordered PRN medication. While medication may be important, it does not address the critical issue of potential vascular compromise, which demands immediate communication with the healthcare provider for further evaluation.
The nurse is caring for a client following a knee arthroscopy procedure. Which of the following assessments should be the priority?
Rationale:
D: Circulation and sensation
Prioritizing circulation and sensation is vital post-knee arthroscopy, as compromised blood flow or nerve function can lead to serious complications. Ensuring these assessments are conducted promptly helps identify potential issues early, allowing for timely interventions.
A: Wound and skin integrity
While important, wound and skin integrity assessment follows circulation checks, as issues with blood flow or sensation can indicate more urgent underlying problems that must be addressed first.
B: Mobility assessment
Mobility assessment is essential for recovery but does not take precedence over immediate evaluations of circulation and sensation, which are crucial for preventing complications after the procedure.
C: Skin and vascular assessment
Though skin and vascular evaluations are relevant, they are less immediate than circulation and sensation checks, which are critical for early detection of potential complications following surgery.
The nurse is caring for a client on bed rest for a week following a right hip fracture. Which of the following findings, if noted in the client, would indicate signs of complications due to immobility?
Rationale:
An area of the client's sacrum is unable to be blanched. This finding suggests the development of a pressure ulcer, which can occur due to prolonged immobility, indicating tissue ischemia and potential skin breakdown as complications from being on bed rest.
B: The skin and the sclerae are yellow. This symptom typically points to liver dysfunction or hemolysis, rather than complications arising directly from immobility in a client recovering from a fracture.
C: Crackles in the bases of the client's lungs. While this may suggest respiratory issues, it does not directly indicate complications from immobility specifically related to the client's condition following a hip fracture.
D: Swelling and tenderness in the left calf. This symptom could indicate a deep vein thrombosis, a concern in immobile patients, but it is not as definitive as skin changes indicating pressure ulcers.
E: The client is using the bedpan to void. Utilizing a bedpan is a common practice for clients on bed rest and does not inherently signify any complications related to immobility or the client's recovery process.
The nurse is caring for a client two days post-op total knee replacement with a continuous passive motion (CPM) device at the bedside. The nurse would recognize that the primary purpose of this machine is to:
Rationale:
The primary purpose of the continuous passive motion (CPM) device is to promote knee flexion.
The CPM device facilitates gradual movement of the knee, enhancing flexibility and preventing stiffness after surgery, which is crucial for effective rehabilitation and recovery.
A: Stabilize the knee joint during ambulation. Stabilization during movement is not the primary function of the CPM; it focuses on passive motion rather than support during walking.
C: Reduce post-surgical swelling. While some motion might help with circulation, the main intent of a CPM is not to address swelling, but rather to improve joint mobility.
D: Prevent blood clots. The CPM device does not specifically target clot prevention; its primary objective is to enhance range of motion in the knee following surgery.
A nurse is caring for a client admitted to the emergency department with suspected rhabdomyolysis. Which of the following findings would the nurse anticipate in a client with this condition?
Rationale:
Elevated creatinine kinase (CK) levels. Rhabdomyolysis leads to muscle breakdown, resulting in the release of creatinine kinase into the bloodstream, which significantly elevates CK levels as a primary laboratory finding.
B: Decreased serum potassium levels. Rhabdomyolysis often causes an increase in serum potassium due to muscle cell damage, rather than a decrease, which can lead to hyperkalemia.
C: Hypertension and bradycardia. Rhabdomyolysis typically does not present with both hypertension and bradycardia; rather, it may cause tachycardia and fluctuations in blood pressure due to electrolyte imbalances.
D: Clear urine output. Rhabdomyolysis can lead to dark, tea-colored urine due to myoglobinuria, indicating kidney stress and damage, contradicting the presence of clear urine output.
The nurse is caring for a client reporting phantom limb pain after a below-the-knee amputation. The client is experiencing what type of pain?
Rationale:
Phantom limb pain after a below-the-knee amputation is classified as neuropathic pain. This type of pain arises from nerve damage or dysfunction, often resulting in sensations perceived in the absent limb, highlighting the brain's role in pain perception.
A: Perceived pain This term is too vague and does not specifically refer to the nerve-related origins of the pain experienced in phantom limb scenarios.
B: Somatic pain This type of pain originates from body tissues and is typically linked to injury or inflammation, not the neurological phenomena associated with phantom limb sensations.
D: Nociceptive pain Nociceptive pain is related to actual tissue damage and is not applicable here, as phantom limb pain arises from nerve signals rather than direct physical injury.
The nurse is teaching a client with low back pain. Which of the following statements, if made by the client, would require follow-up?
Rationale:
Sleeping on the stomach can exacerbate low back pain by placing undue stress on the spine and neck, thus requiring follow-up to discuss healthier sleeping positions that promote spinal alignment.
A: I am planning to stop smoking cigarettes. Quitting smoking can improve overall health and may alleviate some back pain, making this a positive choice that doesn't necessitate further discussion.
C: I have decided to purchase a firm mattress. A firm mattress can provide adequate support for the back, potentially improving posture and reducing pain, which aligns with therapeutic recommendations.
D: I will bend my knees when lifting objects. Bending the knees while lifting is a recommended technique to prevent back strain and injury, promoting safe and effective body mechanics.
The nurse performs a physical assessment on a client and observes a tremor in the client's hand when their arm is extended. The nurse understands that this finding is consistent with which of the following?
Rationale:
Tremors in the hand when the arm is extended align with Neuroleptic Malignant Syndrome (NMS), a potentially life-threatening condition characterized by muscle rigidity, altered mental status, and autonomic dysfunction.
A: Rheumatic fever. This condition primarily affects the heart, joints, skin, and brain, presenting with different symptoms rather than tremors associated with neurological issues.
B: End-stage renal disease. While it can lead to neurological manifestations, tremors are not a hallmark finding in this stage, which typically presents with more systemic symptoms.
D: Human Immunodeficiency Virus (HIV). HIV primarily affects the immune system and does not directly cause tremors as a prominent physical assessment finding during the disease's progression.
The following scenario applies to the next 1 items
The nurse cares for a client who sustained a femur fracture twelve hours ago
Item 1 of 1
Nurses’ Notes
Client reports shortness of breath and stated, ‘something is not right.’ The client was assessed to have a respiratory rate of 25/min and oxygen saturation of 90% while on room air. Lung sounds had bilateral crackles throughout, and respirations were labored. Chest pain was reported that worsened with breathing. An emergent 12-lead electrocardiogram was obtained, and it was observed that the client had reddish-purple spots on their torso. A rapid response was called.
The client is demonstrating signs and symptoms of
Rationale:
The client is demonstrating signs and symptoms of fat embolism syndrome. The symptoms, including shortness of breath, tachypnea, crackles in lung sounds, and reddish-purple spots on the torso, align with fat embolism syndrome following a femur fracture.
A: Pulmonary embolism presents with sudden onset dyspnea and possible chest pain, but the presence of reddish-purple spots and crackles indicates a different etiology related to fat globules.
B: Myocardial infarction typically involves chest pain and may include shortness of breath; however, the specific skin manifestations and lung findings suggest fat embolism rather than cardiac issues.
D: Compartment syndrome primarily causes pain and swelling in the limb, not respiratory distress or systemic symptoms like those described, which are characteristic of fat embolism syndrome.
The nurse is teaching a client scheduled for a dual-energy x-ray absorptiometry (DEXA) scan. Which of the following information should the nurse include?
Rationale:
D: Please remove all metallic objects before this exam. This information is crucial as metallic objects can interfere with the imaging process of a DEXA scan, potentially compromising the accuracy of the results.
A: Do not eat or drink 6-8 hours prior to your test. This guideline is typically associated with other imaging tests but is not necessary for a DEXA scan preparation.
B: You will feel flushing as you receive the intravenous contrast. DEXA scans do not require any intravenous contrast, making this statement irrelevant to the procedure being discussed.
C: The scan takes several hours to complete. A DEXA scan is a quick procedure, usually lasting only about 10-30 minutes, contradicting the claim of an extended duration.
The nurse is caring for a client who is in Buck traction. Which of the following actions should the nurse take?
Rationale:
Elevating the foot of the bed provides necessary counter traction, which is essential in maintaining proper alignment and reducing muscle spasms in a client using Buck traction. This position enhances the effectiveness of the traction system and promotes optimal healing.
A: Ensure that weight is between 15 to 30 lb (6.8 to 13.6 kg) Weight may vary based on individual needs and conditions; focusing solely on this range overlooks patient-specific adjustments required for effective traction.
B: Turn the client using a foam wedge every two hours Frequent turning may disrupt the traction mechanism; maintaining stability is crucial for the effectiveness of Buck traction and preventing additional injury.
C: Ensure that a client's heels are supported with a pillow While heel support is important for comfort, prioritizing counter traction through bed elevation is vital for the success of Buck traction therapy.
The nurse is assessing a client who reports left knee pain after playing baseball. The nurse should initially
Rationale:
Inspect the knee for any swelling.
Initial assessment of the knee involves visual inspection to identify swelling, which indicates inflammation, injury, or fluid accumulation. This crucial step helps determine the severity of the condition and guides further evaluation and treatment.
A: Feel the knee for warmth. While warmth can indicate inflammation, initial visual inspection for swelling provides more immediate and relevant information about potential injuries or conditions affecting the knee.
C: Palpate for crepitus in the knee. Checking for crepitus is important but follows initial visual assessment; it focuses on joint sounds rather than assessing visible signs of injury or inflammation first.
D: Have the client perform active range of motion in the knee. Assessing range of motion is premature without first evaluating the knee’s condition, as movement could exacerbate potential injuries or inflammation present.
The nurse is caring for a client two days post-op total knee replacement with a continuous passive motion (CPM) device at the bedside. The nurse would recognize that the primary purpose of this machine is to:
Rationale:
Promote knee flexion. The continuous passive motion (CPM) device is specifically designed to enhance joint mobility by encouraging gradual knee flexion, which is crucial for rehabilitation following total knee replacement surgery.
A: Stabilize the knee joint during ambulation. The CPM device is not intended for stabilization; its primary function is to facilitate movement and flexibility rather than support the joint during walking.
C: Reduce post-surgical swelling. While the CPM may indirectly aid in reducing swelling through movement, its main objective is to improve range of motion rather than directly addressing swelling concerns.
D: Prevent blood clots. Although mobility is essential for preventing blood clots, the CPM's primary focus is on promoting flexion and extension of the knee rather than directly combating clot formation.
The following scenario applies to the next 1 items
The nurse in a urgent care facility cares for a 46-year-old male
Item 1 of 1
Triage Note
1400: 46-year-old man reports right ankle pain that started one hour ago while playing soccer with his children. He states that he was getting ready to kick the ball and lost his footing on wet grass. Focused assessment: swelling over the lateral malleolus down to the area of the fourth and fifth metatarsals is present, and pedal pulses are 2+ bilaterally. Pain is endorsed with movement, and the range of motion of the right ankle is very limited. No gross deformity of the ankle was observed. Pain is rated 9 on a scale of 0 (no pain) to 10 (severe pain). T 97.5° F (36.4° C), P 98, RR 18, BP 144/90, pulse oximetry reading 96% on room air. The client reports allergies to erythromycin with an unknown reaction. Medical history included a myocardial infarction 8 months ago, irritable bowel syndrome, and plaque psoriasis. Current medications include clopidogrel and atenolol.
Physician Orders
• Discharge home with an orthopedic referral
• Ketorolac 15 mg intramuscular (IM) x 1 dose
• Apply ace wrap to the right ankle
• Home prescription: Ketorolac 10 mg by mouth twice a day PRN pain for three days
• Home prescription: Oxycodone 5 mg by mouth twice a day PRN pain for three days
• Home prescription: Docusate 50 mg by mouth once a day for three days
• Home prescription: Crutches, no weight bearing to the right lower extremity until seen by orthopedics
Diagnostics
Right Ankle X-Ray
No obvious fracture is seen. Bones show normal alignment and architecture. Joint spaces and articular margins are intact. Soft tissue swelling noted.
The nurse implements the physician's orders. Complete the sentences below by choosing from the list of options. The nurse reviews the prescriptions and should question the prescribed……….. with the physician based on the client's medical history of…….The nurse is gathering the prescribed crutches and plans on teaching the client to ambulate using the……..The nurse should instruct the client that the crutches should be………To promote comfort and to reduce swelling, the nurse should instruct the client to apply…………..compresses to the ankle for no greater than………..
Rationale:
Ketorolac. This nonsteroidal anti-inflammatory drug (NSAID) should be questioned due to the client's medical history of a recent myocardial infarction, which increases the risk of cardiovascular complications when using NSAIDs.
B: Recent myocardial infarction. The history of myocardial infarction emphasizes the need for caution regarding medications that could elevate cardiovascular risks, particularly NSAIDs like Ketorolac.
C: Three point gait. This is a standard technique for using crutches, but it does not directly relate to potential medication complications tied to the client's condition.
D: 6 inches (15 cm) in front of their feet while standing. While this instruction is relevant for crutch use, it does not address the safety concerns related to prescribed medications.
E: Cold. This treatment option is appropriate for reducing swelling but does not relate to questioning the safety of the prescribed Ketorolac.
F: 20 minutes at a time. This timing guideline is suitable for applying cold therapy, but it does not address the significance of the client's medical history in relation to medications.
A client sustained a right leg fracture after an industrial accident and reports tingling and severe pain inside the newly applied plaster cast. Upon inspection, the nurse noted that the exposed toes were cyanotic. What is the most appropriate nursing intervention?
Rationale:
Contact the physician immediately.
The client exhibits concerning symptoms such as severe pain and cyanosis of the toes, indicating potential compartment syndrome or cast-related complications. Prompt physician notification is essential for timely assessment and intervention to prevent further complications and ensure the patient's safety.
A: Apply heat packs on the leg. Heat may exacerbate swelling and pain, worsening the condition rather than providing relief, especially in the presence of compromised circulation.
B: Elevate the affected extremity. Although elevation can help reduce swelling, it does not address the urgent need for medical evaluation due to the severe symptoms presented.
D: Instruct the client to move or wiggle their toes. Encouraging movement may not be appropriate given the potential for serious underlying issues, and it could lead to increased pain or further injury.
The nurse is conducting a community health fair. Which of the following clients is at the greatest risk of developing osteoporosis?
Rationale:
B: The 60-year-old woman who smokes cigarettes and just recently stopped drinking alcohol is at the greatest risk of developing osteoporosis due to her age, smoking history, and alcohol use, which negatively affect bone density.
A: The 27-year-old woman who jogs regularly and drinks red wine daily maintains a healthier lifestyle. Regular exercise and moderate red wine consumption can contribute positively to bone health.
C: The 51-year-old man who suffers from alcoholism and recently stopped smoking faces risks, but his age and history of alcoholism are countered by cessation of smoking, which can improve bone health.
D: The 25-year-old man with asthma who takes inhaled corticosteroids could be at risk, but his young age typically offers better bone density protection compared to older individuals with significant risk factors.
The nurse teaches a client about their newly applied halo fixator device with a vest. Which of the following statements should the nurse make?
Rationale:
Report any fever or drainage at the pin sites. This statement emphasizes the importance of monitoring for signs of infection or complications related to the halo fixator, which is crucial for the client's health and recovery.
A: You should ride a bicycle instead of driving a car. Riding a bicycle may pose risks due to balance and stability issues associated with the halo fixator, making it inappropriate advice.
C: Always keep the wrench taped to the front of the vest. While having a wrench accessible is important, taping it to the vest may not be practical or safe for the client.
D: When getting out of bed, roll to your side and push on the mattress. This method can increase the risk of injury or strain, as proper techniques must be followed for safety and stability.
E: Wear a cotton t-shirt under the vest to absorb any moisture. Although wearing a t-shirt may provide comfort, it is not directly related to the care of the halo fixator device.
The following scenario applies to the next 1 items
The nurse is caring for an older adult 4 days postoperative hip arthroplasty.
Item 1 of 1
Nurses' Notes
0900: Assessment completed, and the client was in bed alert and oriented to person, place, time, and situation. Clear lung fields bilaterally, with an infrequent dry cough. Heart tones S1 and S2. Peripheral pulses palpable and 2+. Skin was warm and dry. Bowel sounds were normoactive and present in all four quadrants. Incision was pink, approximated with staples, with scant serous drainage. Pain rated 4/10 on the Numerical Pain Rating Scale. Client refused to ambulate to the bedside chair for breakfast.
1159: Client informed nurse of their refusal to participate in physical therapy. Once up with PT, the client reported intense pain. The client reports that they have intense 'heaviness' in their left calf and that she needs a 'water pill' because it is swollen. The client was placed back in bed. She reports dyspnea immediately after failed ambulation attempt.
Vital Signs
0900
Blood pressure 139/88 mm Hg
Heart rate 77/min
Respiratory rate 21/min
Temperature 99°F (37.2°C)
Pulse oximetry 92% on room air
1200
Blood pressure 149/91 mm Hg
Heart rate 87/min
Respiratory rate 24/min
Temperature 99°F (37.2°C)
Pulse oximetry 90% on room air
Medical History
• hyperlipidemia
• generalized anxiety disorder
• irritable bowel syndrome
• chronic obstructive pulmonary disease
• diabetes mellitus (type two)
• osteoarthritis
The nurse should recognize that the client may be experiencing
Rationale:
The client may be experiencing venous thromboembolism. The report of intense heaviness in the left calf, along with swelling and dyspnea after ambulation, suggests a possible thrombus formation, which is a critical condition requiring immediate attention.
A: Wound infection presents with signs like redness or purulent drainage, which are not noted in the assessment. The incision appears pink with scant serous drainage, indicating no infection.
B: Hypoxia typically results in lower oxygen saturation levels. The client's pulse oximetry readings of 90% indicate mild hypoxia, but the heavy feeling in the calf and swelling align more with thromboembolism.
D: Wound dehiscence would show separation or unusual drainage from the surgical site. The client’s incision is intact and healing well, making this option less relevant.
E: Left lower extremity assessment is a necessary action but does not represent a condition the client is experiencing. The symptoms reported indicate a more serious issue, such as a thrombus.
F: Vital signs are important but do not indicate a specific condition. While changes in vital signs are present, they alone do not explain the symptoms of heaviness and dyspnea.
G: Pain at the surgical incision site is rated as 4/10 and does not explain the significant symptoms of heaviness in the calf or dyspnea experienced by the client.
The nurse is caring for a client with myasthenia gravis who is six hours postoperative following a thymectomy. Which item should the nurse have at the bedside?
Rationale:
A: Calcium gluconate This medication is typically used for hypocalcemia or magnesium toxicity, not specifically relevant in the immediate postoperative period for a thymectomy in myasthenia gravis.
B: Bag-valve mask This device is essential for managing potential respiratory complications, as myasthenia gravis patients may have respiratory muscle weakness, necessitating immediate support in case of respiratory distress.
C: Tracheostomy kit This item is generally reserved for emergencies requiring airway management; however, it is not standard immediate postoperative equipment for a client recovering from a thymectomy.
D: Atropine sulfate While atropine can address bradycardia, it is not a routine necessity for a patient recovering from thymectomy, especially in the absence of specific indications for its use.
The nurse is planning a staff development conference regarding contractures. Which of the following information should the nurse include? Select all that apply.
Rationale:
Range-of-motion exercises of the extremities help prevent contractures, too many pillows under the head may cause a neck flexion contracture, and contractures after a hip arthroplasty can be prevented with an abduction pillow.
A: Range-of-motion exercises of the extremities help prevent contractures. This technique actively maintains flexibility, promoting muscle and joint health, thereby significantly reducing the likelihood of developing contractures over time.
B: Splinting the extremities may increase the risk of contractures. Improper splinting techniques can lead to immobility, which may contribute to the formation of contractures due to prolonged fixation in one position.
D: Using multiple staff members to reposition a client may prevent a contracture. While teamwork is beneficial, the key factor is not the number of staff but the technique and timing of repositioning that truly prevents contractures.
The nurse is developing a care plan for a client following a lumbar laminectomy. The nurse should plan to
Rationale:
Log roll the client.
Log rolling is a technique used to maintain spinal alignment and prevent strain on the surgical site following a lumbar laminectomy. This method allows safe repositioning while minimizing discomfort and promoting healing for the client.
B: Apply a cervical collar. Cervical collars are utilized for neck injuries or surgeries, not for lumbar procedures, making this option irrelevant to the client's specific needs post-lumbar laminectomy.
C: Place an overhead trapeze on the bed. While helpful for mobility, the trapeze does not directly address the immediate post-operative care requirements following a lumbar laminectomy, which focuses on spinal stability.
D: Keep the client in high-Fowler's position while in bed. High-Fowler's position can increase strain on the lumbar region, which contradicts the care needed for a client recovering from a lumbar laminectomy.
The PACU nurse is caring for a patient who is presenting with agitation following knee replacement surgery. What action should the nurse take first?
Rationale:
B: Assess the patient's respiratory function. Monitoring respiratory function is crucial as agitation may indicate hypoxia or respiratory distress, which can lead to serious complications post-surgery. Ensuring airway safety is the priority.
A: Notify the anesthesiologist of the adverse reaction. While informing the anesthesiologist is important, it should follow an initial assessment of the patient's immediate respiratory status to address urgent needs.
C: Obtain an order for additional sedation to keep the patient safe during agitation. Administering more sedation without assessing the patient first could mask underlying issues, potentially worsening their condition and compromising safety.
D: Administer a benzodiazepine antagonist. Using an antagonist without evaluating the patient's respiratory status could precipitate withdrawal or exacerbate agitation, failing to address the root cause of the agitation effectively.
The following scenario applies to the next 1 items
The nurse in the emergency department (ED) is caring for a 62-year-old female client.
Item 1 of 1
Triage Note
1211: The client was brought to the ED by her neighbor, who was concerned about her increasing pain and immobility. The client's neighbor reported that the client called her a few hours ago, asking her to go to the ED because of increasing pain and the inability to perform her activities of daily living. History of osteoporosis, hypertension, and gout. She reports that she recently started seeing a rheumatologist because of persistent fatigue, low-grade fevers, and lack of appetite. Vital signs: T 99.7° F (37.6° C), P 82, RR 16, BP 134/76, pulse oximetry reading 98% on room air. Pain rated 7/10 on the Numerical Rating Scale, which is described as throbbing of both feet, especially in her toes. She also reports having stiffness in her wrists and fingers that starts in the morning and persists throughout the day. Triage assessment: the client is alert and fully oriented to person, place, and situation. Peripheral pulses 2+. Clear lung sounds bilaterally. Swollen, errythemic toes that are warm and tender to touch. She does not recall her weight but reports significant weight loss over the past three months.
For each assessment finding below, click to specify if the finding is consistent with the disease process of osteoarthritis, acute gout flare, or rheumatoid arthritis. Each finding may support more than 1 disease process.
Your Selected Order (Tap items to remove)
Available Options (Tap to select in order)
A
Low-grade fever
B
Weight loss
C
Redness and warmth of the affected joint
D
Morning joint stiffness in the wrists that lasts throughout the day
E
Pain with movement in the affected joint
F
Reduced range of motion in the affected joint
G
Pain level
Rationale:
A: Low-grade fever is consistent with rheumatoid arthritis and acute gout flare. This symptom indicates inflammation, commonly associated with autoimmune responses in rheumatoid arthritis and the inflammatory response during gout attacks.
B: Weight loss signifies rheumatoid arthritis, which can cause systemic effects leading to decreased appetite and unintended weight loss. This finding is less specific for osteoarthritis or acute gout flare.
C: Redness and warmth of the affected joint aligns with rheumatoid arthritis and acute gout flare, as both conditions involve inflammation that results in these observable symptoms due to increased blood flow.
D: Morning joint stiffness in the wrists that lasts throughout the day is characteristic of rheumatoid arthritis. This symptom highlights the inflammatory nature of this condition, unlike osteoarthritis, which typically improves with movement.
E: Pain with movement in the affected joint can occur in osteoarthritis, rheumatoid arthritis, and acute gout flare, but it is more typical for osteoarthritis, where joint degeneration leads to pain during activity.
F: Reduced range of motion in the affected joint is a feature of osteoarthritis, rheumatoid arthritis, and acute gout flare, but it is primarily associated with osteoarthritis due to joint damage over time.
G: Pain level is relevant to osteoarthritis, rheumatoid arthritis, and acute gout flare. However, it does not specifically indicate the underlying disease process, as pain can arise from various joint conditions.
The nurse in the medical-surgical unit is caring for a newly admitted client.
Item 3 of 6
History and Physical
1930: Client is a 45-year-old male who has a one-and-a-half-week history of pain, redness, and swelling in his right foot. He reported that the symptoms began after he accidentally cut his foot while walking barefoot in his backyard. Over the next few days, he developed pain and swelling around the cut, accompanied by redness and warmth. He went to urgent care two days later and was diagnosed with cellulitis in his right foot. He was prescribed antibiotics but could not afford the treatment. Three days ago, the pain escalated and was described as throbbing and constant, with a severity rating of 7/10 on the Numerical Pain Rating Scale. He states, "the pain is now in the bone of my foot; I don't know how else to describe it." He also noted occasional fever 101°F (38.3°C), chills, and general malaise. On physical examination, his right foot was erythematous, swollen, and warm to the touch. A 3 cm ulcer was noted on the plantar aspect of the right foot, with moderate purulent discharge present. The ulcer appeared deep, and palpation of the surrounding tissue elicited tenderness. There was limited range of motion in the right ankle due to pain. The distal pulses were palpable 2+, and there were signs of neuropathy in the feet (decreased sensation to light touch and pinprick). He has a medical history of uncontrolled diabetes mellitus (type two), obesity, peripheral neuropathy in all extremities, hypertension, hyperlipidemia, and epilepsy.
Consultation
Infectious Disease Consultation
2050: Client was evaluated and I strongly suspect osteomyelitis in his right foot. Labs are pending. Agree with admission and will follow closely.
The nurse reviews the consultation report from the infectious disease physician. Select the complications that the client is at risk for developing? Select all that apply.
Rationale:
C: Avascular necrosis and D: Sepsis. The client’s history of cellulitis and suspected osteomyelitis indicates a high likelihood of serious complications, including sepsis from infection spread and avascular necrosis due to impaired blood flow from diabetes-related vascular issues.
A: Rheumatoid arthritis. This condition is an autoimmune disorder unrelated to the client’s current infections or complications stemming from cellulitis and osteomyelitis.
B: Osteosarcoma. The symptoms and history presented do not indicate malignant bone tumors, as the focus is on infection rather than neoplastic processes.
E: Paget's disease. This disorder involves abnormal bone remodeling and is not linked to the client’s acute infection or diabetic complications.
F: Hyperosmolar hyperglycemic nonketotic syndrome. Although the client has uncontrolled diabetes, the symptoms described are more aligned with an acute infection rather than hyperglycemic crises.
The nurse is caring for a client who is bedbound. Which intervention should the nurse implement to reduce this client's risk of developing contractures?
Rationale:
Perform passive range of motion exercises. This intervention helps maintain joint flexibility and muscle function, crucial for bedbound clients to prevent contractures due to prolonged immobility and lack of movement.
A: Apply sequential compression devices to the lower extremities. These devices primarily prevent deep vein thrombosis and do not directly address the issue of joint and muscle contractures.
C: Obtain a specialty low-air loss mattress. While this mattress enhances skin integrity and comfort, it does not actively promote movement or flexibility needed to prevent contractures.
D: Turn the client every two hours. Although repositioning aids in circulation and pressure relief, it does not specifically engage joints or muscles to combat contracture development.
The nurse in the emergency department is presented with two severed fingers from a client who experienced a traumatic amputation. What should the nurse do to properly preserve the severed fingers for possible reattachment?
Rationale:
Wrap the fingers in gauze, put it in a plastic bag, and then place the bag in ice water. This method preserves the severed fingers' viability by keeping them cool while preventing direct contact with ice, which can cause tissue damage. Proper wrapping and containment in a sealed bag also protect the fingers from contamination.
A: Apply direct pressure to the severed fingers and wrap them in gauze. While this may temporarily control bleeding, it does not adequately preserve the fingers for reattachment.
B: Irrigate the amputated fingers with sterile saline. This action could introduce moisture that damages tissue, making it unsuitable for preservation prior to reattachment.
C: Place the amputated fingers directly on ice. Direct contact with ice can result in frostbite and tissue injury, compromising the fingers' potential for successful reattachment.
The nurse performs a physical assessment on a client and observes a tremor in the client's hand when their arm is extended. The nurse understands that this finding is consistent with which of the following?
Rationale:
Tremor in the extended arm is indicative of Neuroleptic Malignant Syndrome (NMS), a serious reaction to antipsychotic medications characterized by muscle rigidity and tremors, reflecting neurological dysfunction.
A: Rheumatic fever involves inflammatory responses affecting the heart and joints, not primarily characterized by tremors, making it an unrelated condition to the observed physical signs in this scenario.
B: End-stage renal disease manifests with symptoms such as fatigue and fluid imbalance, but tremors are not a hallmark feature of this condition, diminishing its relevance to the assessment findings.
D: Human Immunodeficiency Virus (HIV) primarily affects the immune system and does not typically present with tremors, focusing instead on a range of other symptoms related to immune suppression.
The nurse is caring for a client being admitted to the medical-surgical unit with an acute flare of gout. After performing medication reconciliation, which medication does the nurse suspect could have triggered the acute gout flare? See the exhibit.
Rationale:
Hydrochlorothiazide could have triggered the acute gout flare. Thiazide diuretics, such as hydrochlorothiazide, are known to increase uric acid levels in the body, potentially precipitating gout attacks in susceptible individuals.
B: temazepam This medication is a benzodiazepine used for anxiety and sleep disorders, with no known association with increasing uric acid levels or triggering gout flare-ups.
C: rosuvastatin Statins like rosuvastatin primarily lower cholesterol, and while they may have some metabolic effects, they are not directly linked to increasing uric acid or provoking gout attacks.
D: escitalopram As an SSRI for depression and anxiety, escitalopram does not influence uric acid levels, making it unlikely to be a factor in the development of acute gout flare.
The following scenario applies to the next 1 items
Item 1 of 1
History and Physical
17-year-old male arrives at the emergency department following playing baseball. He slid into a base, felt a ‘pop’, and had pain in his right ankle. The client reports pain of 7 out of 10 in his right ankle, which is described as throbbing. Right pedal pulse was 2+, and the sensation was intact. The client had a limited and painful range of motion in his ankle. Significant swelling and bruising in the ankle were observed.
The client does not have a medical or surgical history. He takes no medications.
Diagnostic Results
X-Ray: bimalleolar fracture of the right ankle
Orders
Crutches
Non-weight bearing status
Apply a splint to the ankle
Acetaminophen-Oxycodone 5/325 mg PO
While teaching the client how to use crutches, the nurse should instruct the client to ambulate using the
Rationale:
B: Three-point gait. This method is ideal for a patient in a non-weight bearing status, allowing the client to keep the injured ankle elevated while providing stability and mobility through the use of crutches.
A: Two-point gait. This technique requires some weight on both legs, which is inappropriate for a non-weight bearing situation like that of the client’s bimalleolar fracture.
C: Four-point gait. This gait involves placing weight on both legs alternately, making it unsuitable for someone who cannot bear weight on one ankle due to injury.
D: Ankle having to be splinted. While the ankle requires splinting, it does not pertain to the method of ambulation using crutches, which focuses on weight distribution and mobility techniques.
E: Non-weight bearing status. This status indicates the client should not place weight on the injured ankle but does not specify how to use crutches effectively for ambulation.
F: Prescribed pain medication. Pain management is crucial for comfort but does not influence the ambulation technique with crutches, which primarily concerns the method of movement.
The nurse is caring for a client who has a fiberglass cast that has just been applied to their left arm due to a humerus fracture. Three hours later, the client complains of numbness in his fingers, and says his fingers 'have become pale.' What is the nurse's most appropriate action?
Rationale:
Notify the primary healthcare provider (PHCP).
The client's symptoms of numbness and paleness in the fingers suggest potential complications, such as impaired circulation or increased pressure from the cast. Prompt notification of the PHCP is essential for timely assessment and intervention to prevent further complications and ensure the client’s safety and comfort.
A: Reassure the client that this is just a normal occurrence after having a cast. Dismissing the client’s symptoms undermines the seriousness of potential complications, which require immediate attention rather than mere reassurance.
B: Ask the client to clench his fist frequently. While this may promote circulation, it does not address the underlying issue of potential pressure or impaired blood flow necessitating professional evaluation.
C: Remove the cast immediately. Removing the cast without proper assessment could exacerbate the situation and does not follow the appropriate protocol for addressing possible complications related to circulation.
The nurse is caring for a client with a newly applied plaster cast. The nurse should
Rationale:
D: Handle the cast with the palms of the hands. This method prevents pressure points and damage to the cast material, ensuring proper support and maintaining its integrity while allowing for safe positioning.
A: Use a small object like a pencil or ruler to itch the leg if it becomes uncomfortable. Inserting objects can lead to skin injury, infection, or damage to the cast.
B: Expedite drying by using a hot blow dryer on the cast. Heat can compromise the cast's structure, causing it to warp or weaken, which may lead to inadequate immobilization.
C: Let the cast hang below the heart to promote blood flow. This position can lead to swelling and increased pressure, potentially causing discomfort and impairing circulation in the affected limb.
The nurse is caring for a client with myasthenia gravis who is six hours postoperative following a thymectomy. Which item should the nurse have at the bedside?
Rationale:
A: Calcium gluconate This option is unnecessary as myasthenia gravis primarily affects neuromuscular transmission rather than calcium levels. The immediate postoperative concern revolves around respiratory function, not electrolyte management.
B: Bag-valve mask Following a thymectomy, patients risk respiratory complications due to weakened respiratory muscles. A bag-valve mask is essential for providing ventilation support should respiratory distress occur, ensuring prompt intervention.
C: Tracheostomy kit Although a tracheostomy kit can be vital in emergencies, it is not the immediate priority for a postoperative myasthenia gravis patient unless severe airway obstruction is anticipated.
D: Atropine sulfate This medication addresses bradycardia but does not directly relate to myasthenia gravis management. The primary concern after a thymectomy is respiratory support rather than heart rate issues.
The nurse is teaching a client scheduled for a dual-energy x-ray absorptiometry (DEXA) scan. Which of the following information should the nurse include?
Rationale:
D: Please remove all metallic objects before this exam. This instruction is crucial as metallic items can interfere with the DEXA scan's accuracy and may affect the results, compromising the assessment of bone density.
A: Do not eat or drink 6-8 hours prior to your test. This guideline is not applicable for a DEXA scan, which does not require fasting beforehand for accurate results.
B: You will feel flushing as you receive the intravenous contrast. A DEXA scan does not utilize intravenous contrast, making this information irrelevant and misleading for the procedure.
C: The scan takes several hours to complete. A DEXA scan is a quick procedure, typically lasting only about 15 to 30 minutes, making this statement inaccurate.
The nurse in the medical-surgical unit is caring for a newly admitted client.
Item 6 of 6
History and Physical
1930: Client is a 45-year-old male who has a one-and-a-half-week history of pain, redness, and swelling in his right foot. He reported that the symptoms began after he accidentally cut his foot while walking barefoot in his backyard. Over the next few days, he developed pain and swelling around the cut, accompanied by redness and warmth. He went to urgent care two days later and was diagnosed with cellulitis in his right foot. He was prescribed antibiotics but could not afford the treatment. Three days ago, the pain escalated and was described as throbbing and constant, with a severity rating of 7/10 on the Numerical Pain Rating Scale. He states, "the pain is now in the bone of my foot; I don't know how else to describe it." He also noted occasional fever 101°F (38.3°C), chills, and general malaise. On physical examination, his right foot was erythematous, swollen, and warm to the touch. A 3 cm ulcer was noted on the plantar aspect of the right foot, with moderate purulent discharge present. The ulcer appeared deep, and palpation of the surrounding tissue elicited tenderness. There was limited range of motion in the right ankle due to pain. The distal pulses were palpable 2+, and there were signs of neuropathy in the feet (decreased sensation to light touch and pinprick). He has a medical history of uncontrolled diabetes mellitus (type two), obesity, peripheral neuropathy in all extremities, hypertension, hyperlipidemia, and epilepsy.
Orders
2100:
Magnetic resonance imaging of the right foot without contrast
Insert peripheral vascular access device
Laboratory tests: blood culture and sensitivity (C & S), complete blood count (CBC), complete metabolic panel (CMP), lactic acid
vancomycin 1 g, IV, every 12 hours
Wound culture
fentanyl 50 mcg IV, every 5 hours PRN pain
Consultation
Infectious Disease Consultation
2050: Client was evaluated and I strongly suspect osteomyelitis in his right foot. Labs are pending. Agree with admission and will follow closely.
Nurses' Notes
2110: Orders received and reviewed. Vital signs: T 103° F (39.4° C), P 92, RR 18, BP 141/87, pulse oximetry reading 98% on room air. Client reports pain '8' on the Numerical Pain Scale.
For each of the statements made by the client, click to specify whether the statement indicates an understanding or requires follow-up of the discharge teaching provided.
Your Selected Order (Tap items to remove)
Available Options (Tap to select in order)
A
I should wash my feet daily with warm water and mild soap, then dry thoroughly, especially between the toes.'
B
I should inspect my feet bi-weekly for any injuries.'
C
I should use a corn/callus remover on my feet.'
D
I should wear compression socks with well-fitting shoes.'
E
Controlling my blood sugar levels can help reduce my risk of developing foot complications.'
Rationale:
A: I should wash my feet daily with warm water and mild soap, then dry thoroughly, especially between the toes. This statement reflects an understanding of proper foot hygiene, crucial for preventing infections, particularly given the client's history of diabetes and recent cellulitis diagnosis. Regular cleaning and drying can help reduce the risk of further complications.
B: I should inspect my feet bi-weekly for any injuries. Inspecting feet bi-weekly does not indicate sufficient frequency; daily inspections are essential for early detection of injuries, especially in diabetic patients.
C: I should use a corn/callus remover on my feet. Using a corn or callus remover can pose risks of injury or infection, particularly for someone with diabetes, thus requiring further clarification on safer foot care methods.
D: I should wear compression socks with well-fitting shoes. This statement indicates understanding, as proper footwear and compression can improve circulation and prevent complications, which is vital for diabetic patients.
E: Controlling my blood sugar levels can help reduce my risk of developing foot complications. This statement shows understanding since maintaining optimal blood sugar levels is critical in preventing diabetes-related foot issues and promoting overall foot health.
The nurse is developing a plan of care for a patient who has a halo vest immobilizer (halo brace) following a cervical spine fracture. Which of the following should the nurse include in the patient's plan of care?
Rationale:
Pin care every shift. This is essential for preventing infection and ensuring the integrity of the halo vest immobilizer. Regular pin care helps maintain skin integrity around the pins and supports overall patient safety.
B: Neck flexion and extension exercises could jeopardize spinal stability and worsen the fracture. These movements are contraindicated while using a halo vest, which aims to immobilize the cervical spine.
C: Taping the wrench to the vest does not address any clinical need and could hinder emergency access to the pins. Proper protocol requires that the wrench be easily accessible for quick adjustments.
D: Reporting loosening of the pins is vital to ensure prompt intervention and prevent complications such as infection or additional injury. This action directly relates to the patient's safety and care plan.
E: Using straws when providing liquids facilitates safer swallowing and reduces the risk of aspiration for patients with restricted neck movement. This practice supports hydration without compromising the patient's safety.
While reviewing a client's medical record who has fallen twice in the past month, which medications should the nurse recommend be discontinued to lower the client's risk for future falls?
Rationale:
B, E, F. Discontinuing temazepam, hydrocodone-acetaminophen, and hydroxyzine is essential as these medications can cause sedation, dizziness, and impaired coordination, significantly increasing the risk of falls in vulnerable clients.
A: Fluoxetine This selective serotonin reuptake inhibitor typically has a lower risk of sedation and falls compared to other medications, making it less concerning for fall prevention.
C: Bupropion Although it may cause some side effects, bupropion is generally not associated with a significant risk of falls, particularly in comparison to other sedating medications.
D: Ferrous sulfate This iron supplement does not contribute to sedation or dizziness, thus not impacting the client's balance or coordination, which are critical factors in fall prevention.
G: Docusate As a stool softener, it does not have sedative properties or impact balance, making it unrelated to fall risk concerns in this context.
The following scenario applies to the next 6 items
The nurse in the medical-surgical unit is caring for a newly admitted client.
Item 1 of 6
History and Physical
1930: Client is a 45-year-old male who has a one-and-a-half-week history of pain, redness, and swelling in his right foot. He reported that the symptoms began after he accidentally cut his foot while walking barefoot in his backyard. Over the next few days, he developed pain and swelling around the cut, accompanied by redness and warmth. He went to urgent care two days later and was diagnosed with cellulitis in his right foot. He was prescribed antibiotics but could not afford the treatment. Three days ago, the pain escalated and was described as throbbing and constant, with a severity rating of 7/10 on the Numerical Pain Rating Scale. He states, "the pain is now in the bone of my foot; I don't know how else to describe it." He also noted occasional fever 101°F (38.3°C), chills, and general malaise. On physical examination, his right foot was erythematous, swollen, and warm to the touch. A 3 cm ulcer was noted on the plantar aspect of the right foot, with moderate purulent discharge present. The ulcer appeared deep, and palpation of the surrounding tissue elicited tenderness. There was limited range of motion in the right ankle due to pain. The distal pulses were palpable 2+, and there were signs of neuropathy in the feet (decreased sensation to light touch and pinprick). He has a medical history of uncontrolled diabetes mellitus (type two), obesity, peripheral neuropathy in all extremities, hypertension, hyperlipidemia, and epilepsy.
Which of the following findings in the history and physical requires follow-up?
Rationale:
The client’s decreased sensation in the feet indicates potential neuropathy, which necessitates immediate follow-up to prevent further complications and ensure appropriate management of his uncontrolled diabetes and cellulitis.
B: Drainage from wound The presence of moderate purulent discharge from the ulcer suggests infection; however, it does not inherently require follow-up beyond ongoing management of the cellulitis.
C: Peripheral pulses While palpable distal pulses indicate some circulation, they do not require urgent follow-up as they are still present and suggest adequate blood flow to the extremities.
D: Pain characteristics Although the client describes significant pain, the characteristics do not point to an immediate need for follow-up, given the overall context of his cellulitis and medical history.
E: Medical history While important for context, the medical history does not require follow-up unless specific concerns arise during treatment; it primarily informs ongoing care strategies.
The nurse is caring for a client following a knee arthroscopy procedure. Which of the following assessments should be the priority?
Rationale:
D: Circulation and sensation. After a knee arthroscopy, assessing circulation and sensation is crucial to identify any potential complications, such as nerve damage or impaired blood flow, ensuring prompt intervention if needed.
A: Wound and skin integrity. While important, evaluating the wound comes after confirming that circulation and sensation are intact to prevent serious complications related to vascular or nerve issues.
B: Mobility assessment. Mobility is significant for recovery, but it follows the priority of ensuring circulation and sensation are stable to prevent further injury or complications during movement.
C: Skin and vascular assessment. Although skin integrity is relevant, the priority lies in assessing circulation and sensation to address any immediate risks that could lead to serious complications.
The nurse is teaching a client with osteomalacia regarding ways to strengthen their bones. Which statement by the client would necessitate further teaching by the nurse?
Rationale:
B: I don't like dairy products so I've stopped eating them. This statement indicates a lack of calcium intake, crucial for bone health, especially in osteomalacia, which can worsen bone weakening.
A: I've started to walk more frequently under the sun. Increased sun exposure is beneficial for vitamin D synthesis, which is essential for strengthening bones and counteracting osteomalacia.
C: I've enrolled myself in an exercise program for seniors at the community center. Participating in exercise programs promotes mobility and strengthens bones, aligning with effective management strategies for osteomalacia.
D: I've been taking Vitamin D supplements lately. Taking vitamin D supplements supports calcium absorption and bone health, making it a positive action for someone with osteomalacia.
Which of the following best describes an appropriate outcome for a 75-yr-old patient with a history of Huntington's disease, which has developed contractures?
Rationale:
The patient will participate in range of motion exercises to reduce the effects of contractures. Engaging in these exercises is vital as they can help maintain mobility, alleviate stiffness, and enhance overall function despite the progression of Huntington's disease and associated contractures.
A: The patient will monitor for signs of skin breakdown as a result of the contractures. While monitoring skin integrity is important, it does not address the active management of contractures themselves.
B: The patient will learn to reposition himself in bed and in his chair without assistance. Gaining independence in repositioning is beneficial but may not directly counteract the physical limitations imposed by contractures.
D: The patient will verbalize the effects of contractures on activities of daily living. Although understanding the impact of contractures is significant, it does not contribute to the physical management or reduction of the contractures.
The nurse is developing a self-management teaching plan for a client with low back pain. Which of the following should the nurse include?
Rationale:
Avoiding bending at the waist and lifting heavy objects is essential for managing low back pain. This practice helps prevent further strain on the lumbar region and supports proper posture during daily activities.
B: Weight-bearing exercises are recommended. While exercise is beneficial, weight-bearing activities can exacerbate low back pain if not approached with caution and proper technique.
C: Wear shoes with a higher heel. High-heeled shoes can alter body mechanics and increase pressure on the spine, potentially worsening low back pain instead of alleviating it.
D: Lay on your stomach four times daily and flex your legs. This position may not provide relief for low back pain and can lead to discomfort or strain in other areas of the body.
The nurse is caring for a client who is in Buck traction. Which of the following actions should the nurse take?
Rationale:
Elevating the foot of the bed provides essential counter traction in Buck traction, ensuring proper alignment and reducing strain on the affected limb. This action enhances the effectiveness of the traction by stabilizing the patient's position.
A: Ensure that weight is between 15 to 30 lb (6.8 to 13.6 kg) This action does not directly address the importance of counter traction, which is crucial for maintaining proper alignment in Buck traction.
B: Turn the client using a foam wedge every two hours Frequent turning may disrupt the traction setup, potentially compromising the alignment and effectiveness of the Buck traction method being utilized for the client's condition.
C: Ensure that a client's heels are supported with a pillow While heel support is important for comfort, it does not contribute to the necessary counter traction provided by elevating the foot of the bed.
A client with a history of statin use presents to the clinic with complaints of muscle weakness and pain. The nurse suspects myopathy. Which of the following laboratory tests should the nurse prioritize to evaluate for muscle damage?
Rationale:
Creatine kinase (CK) should be prioritized to evaluate for muscle damage. CK is an enzyme that indicates muscle injury, making it essential in diagnosing myopathy, especially in patients with statin use.
A: Electrocardiogram (ECG) An ECG assesses heart rhythm and electrical activity, not muscle damage. It is not relevant for evaluating muscle weakness or pain associated with statin use.
B: Liver function tests (LFTs) LFTs measure liver health and function, which may be affected by statins. However, they do not provide information regarding muscle damage and myopathy evaluation.
D: Complete blood count (CBC) A CBC evaluates overall health and detects various disorders, but it does not specifically assess muscle damage. It is not useful in diagnosing myopathy in this context.