In providing care for the patient, what is most important for the nurse to do?

Correct Answer: C

Rationale: The correct answer is C) Promote the use of assistive devices so the patient can participate in self-care activities. This option is the most appropriate because it focuses on promoting the patient's independence and autonomy, which are crucial for their physical and psychological well-being. By using assistive devices, the patient can engage in self-care tasks, maintain a sense of control, and preserve their dignity. Option A is incorrect because while educating family members is important, the priority should be on empowering the patient themselves. Option B is incorrect as while social interactions are important, the patient's ability to engage in self-care activities takes precedence in this scenario. Option D is incorrect as it promotes dependency rather than independence, which can lead to a decline in the patient's overall functioning and quality of life. In an educational context, it is vital for nurses to prioritize patient-centered care that promotes independence and self-care abilities. By encouraging the use of assistive devices, nurses can support patients in maintaining their functional abilities and enhancing their quality of life. Empowering patients to engage in self-care tasks also fosters a sense of dignity and self-worth, contributing to their overall well-being.

Correct Answer: B

Rationale: In this scenario, the correct answer is B) Obvious deformity, as this is a cardinal sign of a fracture. When a bone is fractured, it can cause a visible deformity or misalignment at the site of the injury. This can be seen as a limb appearing bent in an abnormal way or a part of the bone poking through the skin. The other options are incorrect for the following reasons: A) Muscle spasms: While muscle spasms can sometimes occur as a result of a fracture due to the body's protective response, they are not a definitive sign of a fracture. C) Edema and swelling: Edema and swelling can be present with a fracture due to inflammation and increased blood flow to the area, but they are not specific to fractures and can be present in other types of injuries. D) Pain and tenderness: Pain and tenderness are common symptoms of a fracture, but they are not as specific or definitive as the presence of an obvious deformity. Educationally, understanding the cardinal signs of fractures is crucial for healthcare professionals, especially nurses, as they are often the first point of contact for patients with potential fractures. Recognizing these signs promptly can lead to timely interventions and appropriate management of the injury, ultimately improving patient outcomes. Nurses must be able to differentiate between various signs and symptoms to provide safe and effective care to patients with musculoskeletal injuries.

Correct Answer: C

Rationale: In this question, the correct answer is C) Petechiae around the neck and upper chest. This symptom is indicative of a fat embolism rather than a pulmonary embolism from a venous thrombosis. Petechiae are tiny red or purple spots that appear on the skin when small blood vessels break. They are a result of fat globules entering the circulation and lodging in small blood vessels in the lungs. This situation is commonly seen in patients with long bone fractures, where fat from the bone marrow can enter the bloodstream. Option A) Tachycardia and dyspnea are non-specific symptoms that can be present in both fat embolism and pulmonary embolism, making it a less specific choice. Option B) A sudden onset of chest pain is more commonly associated with a pulmonary embolism rather than a fat embolism. Option D) Electrocardiographic changes and decreased PaO2 are also non-specific and can be seen in various conditions affecting the respiratory and cardiovascular systems. Educational context: Understanding the specific signs and symptoms of fat embolism is crucial for nurses caring for patients with fractures. Recognizing petechiae can aid in early identification and prompt intervention, ultimately improving patient outcomes. It highlights the importance of thorough assessment and critical thinking in clinical practice.

Correct Answer: D

Rationale: In the case of a patient who has undergone a total hip arthroplasty with a cemented prosthesis, the correct activity the nurse anticipates for the patient on the first or second postoperative day is D) Ambulation and weight bearing on the right leg with a walker. The rationale behind this is that early mobilization and weight-bearing on the affected limb help prevent complications such as blood clots, muscle weakness, and joint stiffness. Walking with assistance like a walker promotes circulation, strengthens muscles, and aids in the recovery process. Option A is incorrect because transferring from bed to chair twice a day may not provide sufficient mobilization for the patient's recovery. Option B, turning from back to unaffected side every 2 hours, is important for preventing pressure ulcers but does not address the need for weight-bearing activity. Option C, crutch walking with non-weight bearing on the operative leg, is not appropriate for a patient with a cemented prosthesis as weight-bearing is usually encouraged with this type of surgery. Educationally, it is essential for nurses to understand the rationale behind postoperative activities to provide optimal care for their patients. In the context of the NCLEX exam, understanding the importance of early mobilization and weight-bearing after orthopedic procedures is crucial for selecting the most appropriate nursing interventions.

Correct Answer: A

Rationale: The correct answer is option A) Perform daily exercise as a lifelong routine. This option is the most appropriate because regular exercise plays a crucial role in preventing and managing low back pain. Strengthening exercises help support the spine and improve flexibility, reducing the risk of future episodes of low back pain. Additionally, exercise promotes overall health and well-being, which can positively impact recovery and prevent recurrence of pain. Option B) Sit in a chair with the hips higher than the knees is incorrect because while maintaining proper posture is important for back health, this specific position may not be practical or feasible in all situations. It is essential to promote good posture and body mechanics, but this alone is not sufficient for recovery from acute low back pain. Option C) Avoid occupations in which the use of the body is required is incorrect because it is unrealistic and impractical advice. Most occupations require some level of physical activity, and avoiding them altogether is not a viable solution for managing or recovering from low back pain. Option D) Sleep on the abdomen or on the back with the legs extended is incorrect because there is no one-size-fits-all sleeping position for individuals with low back pain. The best sleeping position varies from person to person based on their specific condition and comfort level. In an educational context, it is crucial for nurses to provide evidence-based education to patients recovering from low back pain. Teaching patients about the benefits of exercise, proper posture, body mechanics, and individualized self-care strategies empowers them to take an active role in their recovery and overall health. Encouraging patients to adopt healthy lifestyle habits, including regular exercise, can lead to better outcomes and improved quality of life.