A nurse is reviewing discharge instructions with the family of a client who sustained a minor head injury earlier in the day. Which of the following instructions should the nurse include?

Apply heat to the area of swelling for the first 48 hr.

Repeatedly ask the client questions to check for orientation.

Do not let the client engage in strenuous activities for 1 week.

Encourage the client to sleep for the first 24 hr.

Answer and Explanation

The Correct Answer is C

The nurse should instruct the family to not let the client engage in strenuous activities for 1 week following a minor head injury. This can help prevent further injury and allow the client to rest and recover.

Applying heat to the area of swelling for the first 48 hr, repeatedly asking the client questions to check for orientation, and encouraging the client to sleep for the first 24 hr are not appropriate instructions for the nurse to include in this situation. Applying heat can increase swelling and inﬂammation. Repeatedly asking the client questions can be disorienting and confusing. Encouraging the client to sleep for the first 24 hr is not necessary and could interfere with monitoring the client's condition.

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Correct Answer is B

Explanation

The nurse should use the term "postictal phase" when documenting the client's difficulty arousing and sleepiness for several hours following a generalized tonic-clonic seizure. The postictal phase is the period of time immediately following a seizure during which the client may be difficult to arouse and very sleepy.

Presence of absence seizures, presence of automatisms, and aura phase are not appropriate descriptions for the nurse to use when documenting this finding in the medical record. Absence seizures are a type of seizure characterized by brief episodes of staring and unresponsiveness. Automatisms are repetitive, unconscious movements that can occur during a seizure. The aura phase is a warning sign that can occur before a seizure.

A. Position the lower extremities so that they are touching B. Ensure that the client's heels are touching the bed. C. Prevent hip ﬂexion of the aﬀected extremity. D. Instruct the client to avoid movement of the aﬀected leg.

Correct Answer is C

Explanation

When contributing to the plan of care for a client who is postoperative following a total hip arthroplasty, the nurse should include information on preventing hip ﬂexion of the aﬀected extremity. This can help prevent dislocation of the new hip joint and promote healing.

a. Positioning the lower extremities so that they are touching is not necessary for a client who is postoperative following a total hip arthroplasty. The position of the lower extremities should be determined by the surgeon's instructions and the client's comfort.
b. Ensuring that the client's heels are touching the bed is not necessary for a client who is postoperative following a total hip arthroplasty. The position of the heels should be determined by the surgeon's instructions and the client's comfort.

d. Instructing the client to avoid movement of the aﬀected leg is not necessary for a client who is postoperative following a total hip arthroplasty. The client will need to begin moving and exercising the aﬀected leg as part of their rehabilitation and recovery.

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A nurse is reviewing discharge instructions with the family of a client who sustained a minor head injury earlier in the day. Which of the following instructions should the nurse include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is difficult to arouse and very sleepy for several hours following a generalized tonic-clonic seizure. Which of the following descriptions should the nurse use when documenting this finding in the medical record?

Correct Answer is B

Explanation

A nurse is contributing to the plan of care for a client who is postoperative following a total hip arthroplasty. Which of the following information should the nurse include?

Correct Answer is C

Explanation

A nurse is assisting with the development of a plan of care for an older adult who is at risk for falls. Which of the following actions should the nurse contribute to the plan? (Select all that apply)

A nurse is completing a neurovascular check for a client who had an open reduction internal fixation surgery. Which of the following findings should the nurse identify as possible manifestations of compartment syndrome? (Select all that apply)

A nurse is contributing to the plan of care for a client to achieve the outcome of functional healing of a fracture. Which of the following nursing interventions is the highest priority to assist in meeting this outcome?

A nurse is assisting with the care of a newly-admited client who has acute osteomyelitis. Which of the following interventions is the priority for the nurse to implement?

A nurse is caring for a client who is 2 days postoperative following an above-the-knee amputation. Which of the following is an appropriate nursing intervention for the client at this time?

A client returns to the surgical unit from the PACU in skeletal traction. The nurses should take action to correct. Which of the following problems with the traction setup?

A nurse is collecting data from a client who fell at home and reported a brief loss of consciousness. Which of the following findings should the nurse immediately report to the charge nurse?

A nurse in an urgent care centre is caring for a client who fell and injured her ankle. The ankle appears swollen and ecchymotic. Which of the following interventions should the nurse take? (Select all that apply)