Clinical Scenario:

A nurse is assessing a patient who is 2 plays post-total hip arthroplasty (THA). The patient reports sudden severe hip pain while repositioning in bed. Upon examination, the nurse notes that the affected leg appears shortened and externally rotated.

Which additional finding would confirm that the patient has experienced a hip dislocation?

Increased hip range of motion and absence of pain

Reports of hearing a "pop" at the time of pain onset

Ability to bear weight on the affected leg without discomfort

Symmetric leg length with normal alignment

Answer and Explanation

The Correct Answer is B

A. Increased hip range of motion and absence of pain. A hip dislocation causes severe pain and reduced mobility, not increased range of motion. This option is incorrect.

B. Reports of hearing a "pop" at the time of pain onset. A "popping" sound often occurs when the prosthetic hip dislocates from the joint, making this a key symptom of hip dislocation.

C. Ability to bear weight on the affected leg without discomfort. A hip dislocation causes severe pain and functional impairment, making weight-bearing extremely difficult or impossible.

D. Symmetric leg length with normal alignment. A dislocated hip causes the affected leg to appear shortened and externally rotated, so symmetrical leg length would not be expected.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

A. Tophi deposits and podagra: These findings are associated with gout, not osteoarthritis. Tophi are urate crystal deposits, and podagra refers to gout affecting the big toe.

B. Heberden's nodes and Bouchard's nodes: Heberden’s nodes are bony growths at the distal interphalangeal (DIP) joints, while Bouchard’s nodes affect the proximal interphalangeal (PIP) joints. These are characteristic of osteoarthritis.

C. Ulnar deviation and joint subluxation: Ulnar deviation and joint subluxation are commonly seen in rheumatoid arthritis, not osteoarthritis.

D. Swan-neck deformity and Boutonnière deformity: These deformities are typical of rheumatoid arthritis, not osteoarthritis.

A. Deep Tissue Injury B. Stage III Pressure Ulcer C. Unstageable Pressure Ulcer D. Stage II Pressure Ulcer

Correct Answer is C

Explanation

A. Deep Tissue Injury. Deep tissue injuries appear as intact or discolored skin (purple or maroon) due to underlying soft tissue damage. This wound is already open with slough, so it does not fit this category.

B. Stage III Pressure Ulcer. A Stage III pressure ulcer involves full-thickness skin loss with visible subcutaneous tissue, but the wound depth must be assessable. Since the slough covers the wound, the depth cannot be determined.

C. Unstageable Pressure Ulcer. An unstageable pressure ulcer is one where the base of the wound is covered with slough or eschar, preventing assessment of the full depth of tissue damage. Until the slough is removed, the stage cannot be determined.

D. Stage II Pressure Ulcer. A Stage II ulcer has partial-thickness skin loss with exposed dermis, often appearing as an open blister or shallow wound. The presence of thick slough suggests deeper involvement, making this an incorrect classification.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A nurse is assessing a patient with a pressure ulcer on the heel (as shown in the image). The wound is covered with thick yellow slough, making it difficult to determine the depth of tissue damage. How should the nurse classify this wound?

Correct Answer is C

Explanation

A nurse is reviewing the medical record of a patient diagnosed with Stevens-Johnson Syndrome (SJS). Which of the following findings should the nurse identify as the most likely cause of this condition?

A nurse is assessing a client who has a fracture of the femur. The nurse obtains vital signs on admission and again in 2 hours. Which of the following changes in assessment should indicate to the nurse that the client could be developing a serious complication?

A nurse is caring for a client who has a fractured right femur and is in balanced suspension traction. The client is reporting pain from muscle spasms. Which of the following actions should the nurse take first?

A nurse is assessing a client who reports burning, stabbing pain on their right thorax. The nurse notes the presence of a unilateral vesicular rash following a dermatome. Based on these findings, which of the following is the most likely diagnosis?

A nurse is caring for a client who is scheduled for an arthroplasty. The nurse asks client to state if he understands the procedure that is being performed. Which of the following statements by the client indicates an understanding of the procedure?

A patient with chronic gout is prescribed allopurinol. Which statement by the patient indicates a correct understanding of the medication's purpose?

A nurse is explaining the pathophysiology of pneumonia to a group of nursing students. Which statement by one of the students indicates a correct understanding of the condition?