A client who is treated for a meniscal injury to the knee is advised prolonged immobility. To help prevent skin breakdown and infections, the nurse should instruct the client to increase the intake of which of the following?

Correct Answer: A

Rationale: Rationale: The correct answer is A) Protein. When a client is advised prolonged immobility due to a meniscal injury, there is an increased risk of skin breakdown and infections due to reduced blood flow and pressure on bony prominences. Protein is essential for tissue repair and wound healing, which are crucial in preventing skin breakdown. Adequate protein intake supports the body in maintaining and repairing skin integrity during periods of immobility. Now, let's discuss why the other options are incorrect: - B) Fiber: While fiber is important for digestive health, it does not directly impact skin breakdown or infection prevention in the context of prolonged immobility. - C) Calcium: Calcium is vital for bone health, but it does not directly address the issue of skin breakdown or infection prevention during immobility. - D) Liquid: Staying hydrated is important for overall health, but simply increasing liquid intake alone does not provide the necessary components for skin integrity maintenance during prolonged immobility. Educational Context: Understanding the importance of nutrition in wound healing and skin integrity is crucial for nurses caring for clients with limited mobility. Protein plays a significant role in the healing process, providing the necessary building blocks for tissue repair. By educating clients on the importance of protein intake during periods of immobility, nurses can help prevent complications such as skin breakdown and infections, promoting better outcomes for their patients.

Correct Answer: B

Rationale: In this scenario, the correct answer is B) Assess if the husband had an ischemic or hemorrhagic cerebrovascular accident (CVS). This is the most appropriate action for the physician to take because distinguishing between an ischemic and hemorrhagic stroke is crucial for determining the appropriate treatment and management plan. Ischemic strokes occur due to a blockage in a blood vessel supplying the brain, while hemorrhagic strokes result from a blood vessel rupture. Administering tissue plasminogen activator (TPA) as in option A is only suitable for ischemic strokes and must be done within a specific time frame. Choosing option C and sending the husband home without proper evaluation could be life-threatening if he indeed had a stroke. Option D of admitting the husband and placing him on bed rest without determining the type of stroke would delay potentially life-saving interventions. This question provides valuable educational context by emphasizing the importance of prompt and accurate assessment in cases of suspected cerebrovascular accidents. Understanding the different types of strokes and their management is crucial for healthcare providers to deliver effective care and improve patient outcomes.

Correct Answer: A

Rationale: The correct answer is A) "I take my ibuprofen every morning as soon as I get up." This statement indicates the need for additional teaching because ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that can increase the risk of gastrointestinal issues, such as ulcers or bleeding, especially in individuals with osteoporosis who are already at a higher risk for fractures. It is crucial for patients with osteoporosis to be aware of the potential side effects of medications and to consult their healthcare provider before taking any new medication. Option B) "My daughter removed all of the throw rugs in my home" is a positive statement as removing throw rugs reduces the risk of falls, which is essential for individuals with osteoporosis who are at a higher risk of fractures due to decreased bone density. Option C) "My husband helps me every afternoon with range-of-motion exercises" is also a positive statement as range-of-motion exercises can help improve flexibility, strength, and balance, which are all beneficial for individuals with osteoporosis to maintain bone health and prevent falls. Option D) "I rest in my recliner chair every day for at least an hour" is not necessarily an incorrect statement, but it does not address the management or prevention of osteoporosis. Weight-bearing and muscle-strengthening activities are more critical for individuals with osteoporosis to maintain bone density and overall health. In an educational context, it is important to emphasize to patients with osteoporosis the importance of medication safety, fall prevention strategies, appropriate exercise routines, and a healthy, balanced lifestyle to manage their condition effectively and reduce the risk of complications. Encouraging open communication with healthcare providers for any concerns or questions about their treatment plan is also crucial for optimal management of osteoporosis.

Correct Answer: C

Rationale: In this scenario, the nurse should assess the 28-year-old patient with a fracture complaining that the cast is tight first after change-of-shift report. This patient requires immediate attention because a tight cast can lead to complications such as compromised circulation, nerve damage, and increased pain. Addressing this issue promptly is crucial to prevent further harm and ensure the patient's safety and comfort. Option A: The 42-year-old patient with carpal tunnel syndrome complaining of pain can be assessed after addressing the urgent situation with the patient whose cast is tight. While pain management is important, it is not an immediate threat to the patient's well-being in the same way that a tight cast can be. Option B: The 64-year-old patient with osteoporosis waiting for discharge is not a priority over the patient with a tight cast. Discharge planning can be addressed once the urgent patient needs are met. Option D: The 56-year-old patient with left leg amputation complaining of phantom pain also requires attention, but phantom pain, while distressing, is not a critical issue that necessitates immediate intervention to prevent physical harm like the tight cast does. Educational Context: This question assesses the nurse's ability to prioritize patient care based on the urgency of the situation. Understanding the potential complications of a tight cast and the importance of assessing and addressing it promptly is essential in providing safe and effective nursing care. By choosing the correct answer, nurses learn to prioritize patient needs to ensure the best outcomes for those under their care.

Correct Answer: B

Rationale: The correct answer is B) By moving the head and chin of the client towards the chest. This action is known as the Kernig's sign, a specific test for assessing stiffness and rigidity of the neck, which can indicate conditions such as meningitis or other neurological issues. By flexing the neck in this manner, the nurse can observe the client's response for any resistance or discomfort, providing valuable information about the client's neurological status. Option A is incorrect because positioning the client flat on the bed for hours does not specifically assess stiffness and rigidity of the neck. It may lead to discomfort and immobility-related issues but does not target the neurological assessment needed. Option C is incorrect as asking the client to bend and pick up objects on the floor assesses motor function and flexibility but does not specifically target the stiffness and rigidity of the neck. Option D is incorrect as introducing a painful stimulus on the neck is not a standard or appropriate method for assessing stiffness and rigidity. It can cause unnecessary discomfort and is not a recommended practice in neurological assessments. Understanding how to properly assess neurological signs and symptoms is crucial for nurses to provide accurate care and interventions for clients with neurological conditions. Conducting assessments like Kernig's sign correctly can help in early detection and appropriate management of neurological issues, emphasizing the importance of thorough and accurate assessments in nursing practice.