Verified Marking Scheme
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A client has a functional transaction of the spinal cord at C7-8, resulting in spinal shock.
Which clinical indicators does the nurse expect to identify when assessing the client
immediately after the injury? Select all that apply - Answers -✔✔ flaccid paralysis
Lack of reflexes below the injury
Which statement by a client with multiple sclerosis indicates to the nurse that the client
needs further teaching? - Answers -✔✔ I will take a hot bath to help relax my muscles.
Considerations when caring for a client with a total hip replacement should include
which of the following? Select all that apply. - Answers -✔✔ Pain control should include
regularly scheduled analgesics and may necessitate use of as needed medications as
well
Frequent neurovascular assessment should be done distal to the surgical site and
compared with the unaffected side.
When turning, client should be log rolled to prevent leg from falling forward or backward.
The practitioner prescribes no weight-bearing on a leg that has been casted because of
a fracture of the femur. How should the nurse determine the appropriate length of the
crutches for this child? Select all that apply - Answers -✔✔ The crutches should reach
2 inches below the maxillae.
The tips of the crutches should rest 6 inches outside the feet.
A client has a shoulder immobilizer after surgical repair of a fractured humerus. What
should be included in the nurse's instruction to the client about the appropriate use of
the immobilizer? - Answers -✔✔ Release the wristband to exercise the forearm and
hand routinely.
A client who has an above-the-knee amputation is fitted with a prosthesis. The nurse
evaluates the client's response to the prosthesis. Which indicates that the prosthesis fits
the residual limb correctly? - Answers -✔✔ Darkened skin areas surrounding the end of
the residual limb
A client is admitted to the ambulatory care unit for a muscle biopsy. In preparation for
discharge, what should the nurse teach the client to do? - Answers -✔✔ Resume the
usual diet as soon as desired.
, A client has a below-the-knee amputation and asks why the prosthesis is applied
immediately after surgery. The nurse informs the client that the primary reason is to: -
Answers -✔✔ Encourage a normal walking pattern
A client with cholelithiasis has a laser laparoscopic cholecystectomy. Postoperatively it
is most appropriate for the nurse to: - Answers -✔✔ Ambulate the client when the client
is alert and oriented
A woman who has severe rheumatoid arthritis becomes depressed and is admitted to
the psychiatric unit. The nurse begins to work with her in one-on-one sessions to help
her cope with her depressive episode. The best long-term goal for this client is that she
will: - Answers -✔✔ Decrease negative thinking about herself, others, and life.
A client, admitted to the hospital with a fractured hip, is scheduled for surgery for a total
hip replacement. In which position should the nurse place the client's affected limb after
surgery? - Answers -✔✔ Abduction and extension
A client is brought to the emergency department triage by private car with an obvious
compound fracture of the right lower leg. What is the initial assessment the triage nurse
needs to perform? - Answers -✔✔ Distal pulses right leg
Nursing care of a client with a fractured hip should include the assessment of pedal
pulses. The nurse should assess for which important characteristics of the pedal pulses
- Answers -✔✔ Amplitude and symmetry
A high-protein diet is recommended for a client recovering from a fracture. The nurse
recalls that the rationale for a high-protein diet is to: - Answers -✔✔ A high-protein diet
is recommended for a client recovering from a fracture. The nurse recalls that the
rationale for a high-protein diet is to:
A nurse teaches self-care to a client who had a cast applied for a fracture of the right
ulna and radius. The nurse instructs the client to notify the primary health care provider
immediately if the client experiences: - Answers -✔✔ Increasing pain at the injury site
A client who had an open reduction and internal fixation of a fractured ankle is being
discharged. Which behavior indicates the need for further instruction about the use of
crutches? - Answers -✔✔ Leaning axillae on the crutches to support the body's weight
After an above-the-knee amputation of a right leg, a client reports pain in the right foot.
The nurse should inform the client that phantom limb pain is the result of: - Answers -
✔✔ Nerve endings in the limb that are still intact and react to stimuli.
A nurse is assessing an infant with talipes equinovarus (clubfoot) who has had a
corrective boot cast applied. Which peripheral vascular assessment cannot be
performed while the cast is in place? - Answers -✔✔ Pulse