An older female client experiences a musculoskeletal injury to her hip. Which of the following methods would help a nurse identify any swelling in the client?

Correct Answer: B

Rationale: In this scenario, option B, which is palpating the muscles and joints, is the correct method to help a nurse identify swelling in a client who has experienced a musculoskeletal injury to her hip. Palpation involves using touch to feel for abnormalities such as swelling, tenderness, or warmth in the affected area. Swelling is often palpable due to the increase in fluid accumulation in the tissues surrounding the injury site. Option A, asking questions about pain severity, may provide information on the client's subjective experience but may not directly identify swelling. Option C, asking the client to move the injured area, could potentially exacerbate the injury or cause further damage if there is swelling present. Option D, observing for involuntary movements, is more relevant for assessing neurological issues rather than identifying swelling. In an educational context, it is crucial for nurses to understand the proper techniques for assessing musculoskeletal injuries to provide accurate care and treatment. Palpation is a fundamental skill that allows healthcare providers to gather important information about the client's condition, including identifying swelling, tenderness, or other abnormalities. By mastering palpation techniques, nurses can enhance their assessment skills and provide better care for clients with musculoskeletal injuries.

Correct Answer: C

Rationale: In the context of a client with lupus erythematosus, the correct instruction before performing range of motion (ROM) exercises would be to use moist heat (Option C). The rationale behind this is that moist heat helps to increase blood flow, relax muscles, and reduce joint stiffness, making it an ideal preparatory measure for ROM exercises in this population. Prescribed analgesics (Option A) may help manage pain but do not directly facilitate the effectiveness of ROM exercises. Cold packs (Option B) are more commonly used for acute injuries or inflammation, which may not be the case in clients with lupus. Braces or splints (Option D) are typically used for joint support or stabilization and are not directly related to preparing for ROM exercises. Educationally, it is important for nurses to understand the specific needs of clients with lupus when recommending pre-exercise strategies. Providing rationale and evidence-based instructions ensures that clients receive the most appropriate care tailored to their condition, ultimately promoting better outcomes and adherence to therapeutic interventions.

Correct Answer: D

Rationale: In this scenario, delegating the task of assisting the patient with ambulation to the nursing assistant is the most appropriate intervention. The rationale for choosing option D is based on the principle of task delegation according to the nursing scope of practice. Assisting a patient with ambulation involves direct physical support and monitoring for safety, which aligns with the responsibilities and capabilities of a nursing assistant. This task allows the nursing assistant to provide hands-on support to the patient while also freeing up the nurse to focus on other aspects of care. Options A and B involve more complex assessments and decision-making processes that require a higher level of training and expertise, typically performed by licensed healthcare professionals such as nurses or physical therapists. Identifying environmental factors and monitoring gait, balance, and fatigue level require critical thinking skills and specialized knowledge that exceed the scope of practice for a nursing assistant. Option C involves collaborating with physical therapy to provide the patient with a walker, which is also beyond the nursing assistant's role. Physical therapy interventions and equipment prescription are within the domain of physical therapists who have the expertise to assess the patient's needs and recommend appropriate assistive devices. In an educational context, understanding the appropriate delegation of tasks is crucial for providing safe and effective patient care. Nurses must assess the patient's condition, determine the appropriate interventions, and delegate tasks to other healthcare team members based on their scope of practice and level of training. This question highlights the importance of recognizing the roles and responsibilities of different healthcare team members in promoting patient safety and optimal outcomes.

Correct Answer: A

Rationale: The correct response to a patient with a right above-the-knee amputation asking about phantom limb pain is option A) Phantom limb pain is not explained or predicted by any one theory. This response is correct because phantom limb pain is a complex phenomenon that is not fully understood and cannot be definitively explained by any single theory. It is a subjective experience that varies from person to person and can be influenced by various factors, including psychological, neurological, and peripheral factors. Option B is incorrect because it oversimplifies the phenomenon by suggesting that the body thinks the missing limb is still present, which is not a complete or accurate explanation of phantom limb pain. Option C is incorrect because phantom limb pain can indeed interfere with activities of daily living, depending on its severity and impact on the individual. Option D is incorrect because phantom limb pain is a real sensation experienced by amputees, not just remembered pain. In an educational context, it is important for healthcare providers to have a comprehensive understanding of phantom limb pain to effectively support and treat patients experiencing this phenomenon. By acknowledging the complexity and variability of phantom limb pain, healthcare professionals can provide more empathetic and informed care to individuals with amputations.

Correct Answer: C

Rationale: A ketogenic diet, characterized by high fat, moderate protein, and very low carbohydrates, is suggested for children with seizures, especially those with epilepsy. The rationale behind this lies in the metabolic process called ketosis, where the body uses fat for energy instead of carbohydrates. The high fat content in the diet helps in producing ketones, which are believed to have anticonvulsant properties that can help reduce seizure activity. Option A, a high-carbohydrate diet, is incorrect because it would not induce ketosis, which is the primary goal of a ketogenic diet in managing seizures. High protein diets (Option B) are also not ideal as excess protein can be converted into glucose in the body, potentially interfering with the ketogenic process. Option D, a low-fat diet, is not recommended as fats are essential for the production of ketones. In an educational context, understanding the rationale behind a ketogenic diet for children with seizures is crucial for healthcare professionals, particularly those working with pediatric neurology. It is important to be aware of the specific dietary recommendations for managing conditions like epilepsy to provide optimal care and support for these children and their families.