NM 255 Ati Quiz 4

A nurse is caring for a client who has rheumatoid arthritis and tells the nurse that she wears a copper bracelet to help her feel better. Which of the following response should the nurse make? 1. "Yes, I understand that you feel better wearing your bracelet." 2. "Why d you think the copper helps with your arthritis?" 3. "Believing objects have powers to make you feel better has no scientific basis." 4. "I think you should rely more on your medication therapy than on your bracelet."

1. "Yes, I understand that you feel better wearing your bracelet." The nurse illustrate the therapeutic communication technique of accepting. The nurse demonstrates the knowledge that the bracelet is harmless for the client and shows respect for the client's beliefs.

A nurse in the emergency department is caring for a client who has a compression fracture of a spinal vertebrae. During transport to the family, the client was medicated with intravenous morphine. On arrival, the neurosurgeon determined urgent surgical intervention is indicated for the fracture. Staff members have been unable to reach the clients family. Which of following actions should the nurse anticipate the neurosurgeon taking? 1. Invoking implied consent 2. Delaying the surgery until a member of the clients family is reached 3. Asking the client to sign the surgical consent form 4. Prescribing naloxone to reverse the effects of the morphine

1. Invoking implied consent The client is unable to sign the consent form because he is sedated from the morphine. The neurosurgeon has the legal right to invoke implied consent and proceed with the surgery if it is determined an emergency and surgery is in the clients best interest. The neurosurgeon should document the specifics of the situation in the clients medical record.

A nurse is assessing a client at a follow-up clinic visit for acute low back pain. A goal for this client is to use proper body mechanisms at all times. Which of the following indicates that the client is meeting this goal? 1. The client faces the direction of movement when sliding an object across the floor. 2. When pushing a object, the client moves his front foot backward. 3. When moving an object to one side, the client puts his weight on his heels. 4. The client stands with his feet close together when lifting an object.

1. The client faces the direction of movement when sliding an object across the floor. Sliding an object across the floor rather than lifting it prevents strain on the lower back muscles. Facing the direction of movement prevents twisting his back.

A nurse notes increasing edema in the calf of a client who has multiple fracture of the leg. The nurse should recognize that increasing edema is a manifestation of which of the following complications? 1. Fat embolism syndrome 2. Acute compartment syndrome 3. Pulmonary embolism 4. Malignant hypothermia

2. Acute compartment syndrome Increasing edema is a manifestation os acute compartment syndrome, which is a complication that occurs when excessive pressure reduces circulation.

A nurse is assessing a client who has multiple fractures in his left leg notes increasing edema. The nurse should recognize this finding as an early manifestation of which of the following complications? 1. Fat embolism syndrome 2. Acute compartment syndrome 3. Pulmonary embolism 4. Osteomyelitis

2. Acute compartment syndrome. Edema is an early manifestation of acute compartment syndrome, which is a complication that involves increased pressure within the fascia that leads to reduced circulation to the affected area.

A nurse is caring for a client who has acute osteomyelitis. Which of the following interventions is the nurse's priority? 1. Provide the client with antipyretic therapy. 2. Administer antibiotics to the client. 3. Increase the clients protein intake. 4. Teach relaxation breathing to reduce the clients pain.

2. Administer antibiotics to the client. The greatest risk to the client is bacteremia caused by the infection which can lead to septic shock; therefore, the priority intervention is antibiotic therapy. The client might require multiple antibiotics for a extended time.

A nurse is teaching a client who has rheumatoid arthritis about taking methotrexate. Which of the following information should the nurse include? 1. Take an antiemetic 1 hr following administration 2. Drink 2 to 3 L of water per day 3. Take the medication with an NSAID Rinse mouth 2 times per day with an alcohol based mouthwash

2. Drink 2 to 3 L of water pre day. Methotrexate can cause renal toxicity. The client should drink 2-3L of water per day to promote excretion of the medication.

A nurse is assessing a client who reports numbers and pain in his right palm, index finger, and middle finger. The client reports working with a keyboard most the time while at work. The nurse suspects carpal tunnel syndrome. Which of the following tests should the nurse request that the client perform? 1. Hold the right arm straight 2. Hold the wrist at a 90-degree flexion 3. Flex the right arm at the elbow 4. Extend the right arm upward

2. Hold the wrist at a 90-degree flexion. Carpal tunnel syndrome is the compression of the median nerve at the wrist. The condition is common in people who perform repetitive motions of the handing wrist, such as typing. Tapping over the median nerve at the wrist may cause pain to shoot from the wrist to the hand, and bending the wrist at 90-degree flexion will usually result in numbers, tingling, or weakness.

A nurse is assessing a client who has a puncture wound on his foot. Which of the following findings is a manifestation of acute osteomyelitis? 1. Numbness of toes on the affected foot 2. Hypothermia 3. Localized erythema 4. Bradycardia

3. Localized erythema Swelling and localized erythema are manifestations for acute osteomyelitis.

A nurse is caring for an adolescent who has metastatic osteosarcoma. While the parents are away, the adolescent asked the nurse if she is going to die. Which of the following responses should the nurse make? 1. "Your doctor can tell you about your prognosis." 2. "You should discuss this with your parents when they return." 3. "Tell me more about what you are thinking." 4. "You should use focus on getting better."

3. Tell me more about what you are thinking. This response by the nurse facilities therapeutic communications, and encourages the adolescence to explore her feelings further while in a safe environment.

A nurse at an urgent care center is caring for four clients who all have leg or foot injuries. Which of the following client reports should suggest to the nurse that the client has an ankle sprain? 1. Dropped a 4.5kg (10lb) weight on his leg at health club. 2. Has ankle pain after running a 16km (10mi) race. 3. Twisted his foot while running bases at a baseball game. 4. Was hit by another soccer player on the field.

3. Twisted his foot while running bases at a baseball game. A sprain is a stretching injury to ligaments around a joint. Twisting and wrenching motions cause this type of injury.

A nurse is caring for a client who has fallen while getting out of bed and states,"I'm okay! I guess I should have called for help to the bathroom."After assessing the client, the nurse notifies the provider. Which of the following documentations should the nurse include in the clients medical record? 1. "There were no injuries sustained." 2. "An incident report was completed." 3. "An incident report was forwarded to risk management." 4. "The provider was notified."

4. "The provider was notified." Nursing interventions that supply factual information should be documented in the health record.

A nurse is teaching a client about risk factors for osteoarthritis. Which of the following factors should the nurse include in the teaching? Select all the apply. Bacteria Diuretics Aging Obesity Smoking

Aging- Joints bear the load of the body's weight over time Obesity- Increases the load of the body's weight over time Smoking- Predisposes people to the loss of cartilage in the knees