1. The nurse is providing health education at a
community center. Which instruction does the nurse include as part of client
education for the prevention of low back pain?
a. |
“Participate in a regular exercise program.” |
b. |
“Purchase a soft mattress for sleeping
comfort.” |
c. |
“Wear high-heeled shoes only for special
occasions.” |
d. |
“Keep your weight within 20% of your ideal body
weight.” |
ANS: A
Exercise can strengthen
back muscles, reducing the incidence of low back pain. The other options will
not prevent low back pain.
DIF: Cognitive Level: Application/Applying
or higher REF: N/A
TOP: Client Needs
Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process:
Teaching/Learning
2. The nurse is caring for a client who has low
back pain (LBP) from a work-related injury. Which measures does the nurse
incorporate into the client’s plan of care?
a. |
Apply moist heat
continuously to the affected area. |
b. |
Use ice packs or ice
massage for 1 to 2 hours over the affected area. |
c. |
Apply heat packs for
20 to 30 minutes at least four times daily. |
d. |
Advise the client to
avoid hot baths or showers. |
ANS: C
Heat increases blood
flow to the affected area and promotes healing of injured nerves. However,
continuous application of moist heat can promote skin breakdown.
DIF: Cognitive Level:
Comprehension/Understanding REF: p. 962
TOP: Client Needs
Category: Physiological Integrity (Physiological Adaptation—Illness Management)
MSC: Integrated Process: Nursing Process (Implementation)
3. A client who has a herniated disk is being
discharged after a percutaneous endoscopic discectomy. Which postprocedure
instructions does the nurse provide before discharge?
a. |
“You should begin an exercise routine which
includes walking every day.” |
b. |
“You must sleep in a supine position until the
bandage is removed.” |
c. |
“You may feel numbness or tingling in the legs
for 24 hours.” |
d. |
“You will need to wear a lumbar brace for 1
week.” |
ANS: A
After this minimally
invasive surgery, clients typically go home the same day or the day after
surgery. Clients should be taught to begin the prescribed exercise program
immediately after discharge, which includes walking every day. The client
should not be restricted to one sleeping position. Clients generally have less
pain with this procedure and do not experience numbness or tingling. The client
may have a clear or gauze dressing but will not need to wear a lumbar brace.
DIF: Cognitive Level:
Application/Applying or higher REF: N/A
TOP: Client Needs Category:
Physiological Integrity (Reduction of Risk Potential—Potential for
Complications from Surgical Procedures and Health Alterations)
MSC: Integrated Process:
Teaching/Learning
4. The nurse is assessing a client who had a
discectomy 6 hours ago. Which client complaint requires priority action by the
nurse?
a. |
“I am feeling tired.” |
b. |
“My mouth is so dry.” |
c. |
“I can’t seem to relax and rest.” |
d. |
“I am unable to urinate.” |
ANS: D
Inability to void may
indicate damage to the sacral spinal nerves. The other symptoms require the
nurse to provide care but are not the priority or a complication of the
procedure.
DIF: Cognitive Level:
Application/Applying or higher REF: N/A
TOP: Client Needs
Category: Physiological Integrity (Reduction of Risk Potential—Potential for
Complications from Surgical Procedures and Health Alterations)
MSC: Integrated Process:
Nursing Process (Analysis)
5. The nurse is providing discharge teaching to a
client after a lumbar laminectomy. For which complication does the nurse
instruct the client to return to the hospital?
a. |
Pain at the incision
site |
b. |
Decreased appetite |
c. |
Slight redness and
itching at the incision site |
d. |
Clear drainage from
the incision site |
ANS: D
The finding of clear
fluid on the dressing after a laminectomy strongly suggests a cerebrospinal
fluid leak, which constitutes an emergency. The client has in increased risk of
meningitis with a spinal fluid leak. Pain, redness, and itching at the site are
normal. The client should be encouraged to eat a healthy diet but does not need
to return to the hospital for a decreased appetite.
DIF: Cognitive Level:
Application/Applying or higher REF: N/A
TOP: Client Needs
Category: Physiological Integrity (Reduction of Risk Potential—Potential for
Complications from Surgical Procedures and Health Alterations)
MSC: Integrated Process:
Teaching/Learning
6. The nurse is caring for a client who has
undergone a spinal fusion. Which specific postoperative instructions does the
nurse give this client?
a. |
“You may lift items up to 10 pounds.” |
b. |
“Wear your brace when you are out of bed.” |
c. |
“You must remain on bedrest for 48 hours after
surgery.” |
d. |
“You will need to take steroids to prevent
rejection of the bone graft.” |
ANS: B
Clients who undergo
spinal fusion are fitted with a brace that they need to wear throughout the
healing process (usually 3 to 6 months) whenever they are out of bed. The
client does not need to remain on bedrest for the first 48 hours, should not
lift anything, and will not take steroids for rejection prevention.
DIF: Cognitive Level:
Application/Applying or higher REF: N/A
TOP: Client Needs
Category: Physiological Integrity (Reduction of Risk Potential—Potential for
Complications from Surgical Procedures and Health Alterations)
MSC: Integrated Process:
Teaching/Learning
7. A client who suffered a spinal cord injury at
level T5 several months ago develops a flushed face and blurred vision. On
taking vital signs, the nurse notes the blood pressure to be 184/95 mm Hg.
Which is the nurse’s first action?
a. |
Palpate the area over
the bladder for distention. |
b. |
Place the client in
the Trendelenburg position. |
c. |
Administer oxygen via
a nasal cannula. |
d. |
Perform bilateral
carotid massage. |
ANS: A
The client is
manifesting symptoms of autonomic dysreflexia. Common causes include bladder
distention, tight clothing, increased room temperature, and fecal impaction. If
persistent, the client could experience neurologic injury. Precipitating
conditions should be eliminated and the physician notified. The other actions
would not be appropriate.
DIF: Cognitive Level:
Application/Applying or higher REF: N/A
TOP: Client Needs
Category: Physiological Integrity (Reduction of Risk Potential—Potential for
Complications from Surgical Procedures and Health Alterations)
MSC: Integrated Process:
Nursing Process (Implementation)
8. Emergency medical services arrive to the
emergency department with a client who has a cervical spinal cord injury. Which
priority assessment does the emergency department nurse perform at this time?
a. |
Level of consciousness
and orientation |
b. |
Heart rate and rhythm |
c. |
Muscle strength and
reflexes |
d. |
Respiratory pattern
and airway |
ANS: D
The first priority for a
client with a spinal cord injury is assessment of respiratory status and airway
patency. Clients with cervical spine injuries are particularly prone to
respiratory compromise and may even require intubation. The other assessments
should be performed after airway and breathing are assessed.
DIF: Cognitive Level:
Application/Applying or higher REF: N/A
TOP: Client Needs
Category: Physiological Integrity (Reduction of Risk Potential—Potential for
Complications from Surgical Procedures and Health Alterations)
MSC: Integrated Process:
Nursing Process (Assessment)
9. The nurse is caring for a client who has a
vertebral fracture. Which intervention does the nurse implement to prevent
deterioration of the client’s neurologic status?
a. |
Reorient the client to
time, place, and person. |
b. |
Administer the
Mini-Mental State Examination. |
c. |
Immobilize the
affected portion of the spinal column. |
Category | ATI |
Release date | 2021-09-14 |
Pages | 18 |
Language | English |
Comments | 0 |
Sales | 0 |
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