A nurse is caring for a client who is postoperative following total hip arthroplasty.
Which of the following actions should the nurse take to prevent dislocation of the prosthesis?

Keep an abduction pillow between the client's legs.

Elevate the client's affected leg on a pillow when in bed.

Position the client's knees slightly higher than the hips when up in a chair.

Raise the head of the client's bed to a high-Fowler's position.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Keeping an abduction pillow between the client's legs is a preventive measure to avoid dislocation of the hip prosthesis. This positioning helps maintain the correct alignment of the hip joint, reducing the risk of dislocation. Abduction pillows are commonly used postoperatively after total hip arthroplasty to support proper hip positioning while the patient is in bed.

Choice B rationale:

Elevating the client's affected leg on a pillow when in bed is not recommended after total hip arthroplasty. This position could lead to hip adduction, increasing the risk of prosthesis dislocation. Maintaining abduction (spreading the legs apart) is the key to preventing dislocation, and elevation should be avoided to maintain proper alignment.

Choice C rationale:

Positioning the client's knees slightly higher than the hips when up in a chair is not an appropriate preventive measure for prosthesis dislocation. Proper alignment is crucial, and the client should avoid sitting in low chairs or on low surfaces that could cause the hips to be lower than the knees, potentially leading to dislocation.

Choice D rationale:

Raising the head of the client's bed to a high-Fowler's position is unrelated to preventing prosthesis dislocation. Fowler's position refers to elevating the head of the bed to assist with breathing and facilitate patient comfort. While this position might be suitable for certain respiratory conditions, it has no direct impact on the stability of a hip prosthesis.

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Correct Answer is B

Explanation

The correct answer is choice B: Axillary.

Choice B rationale: The axillary site, or under the arm, is the preferred site for obtaining the temperature of a newborn. This method is safe and generally well-tolerated by infants. It carries a lower risk of injury or discomfort compared to other methods.

Choice A rationale: Rectal temperature measurement can be accurate but is more invasive and may cause discomfort or injury to the newborn. It is generally not the preferred method for routine temperature checks in newborns.

Choice C rationale: Tympanic temperature measurement, which uses the ear canal, may not be accurate for newborns due to their small ear canal size and the presence of vernix caseosa or amniotic fluid.

Choice D rationale: Oral temperature measurement is not suitable for newborns as they cannot hold the thermometer in their mouth safely or reliably. This method is more appropriate for older children and adults.

A. Client reports auditory hallucinations. B. Client expresses illusions of grandeur. C. Moves quickly from one idea to the next. D. Inability to carry out a simple task.

Correct Answer is D

Explanation

Choice A rationale:

Auditory hallucinations are more commonly associated with conditions like schizophrenia or certain types of psychosis. In bipolar disorder, individuals may experience mood swings between depression and mania, but auditory hallucinations are not a typical symptom during a depressive episode.

Choice B rationale:

Illusions of grandeur involve an exaggerated sense of one's importance, power, knowledge, or identity. This symptom is more commonly associated with manic episodes in bipolar disorder, not depressive episodes.

Choice C rationale:

Rapid speech and moving quickly from one idea to the next are characteristic symptoms of a manic episode in bipolar disorder, not a depressive episode. During depressive episodes, individuals often exhibit symptoms such as low energy, feelings of worthlessness, and difficulty concentrating.

Choice D rationale:

Inability to carry out a simple task is a common symptom of depression. Depressed individuals often struggle with daily activities, lose interest in hobbies, and have difficulty concentrating. This symptom aligns with the depressive episode of bipolar disorder.

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A nurse is caring for a client who is postoperative following total hip arthroplasty.Which of the following actions should the nurse take to prevent dislocation of the prosthesis?

Nursing Test Bank

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A nurse is caring for a client who is postoperative following total hip arthroplasty.
Which of the following actions should the nurse take to prevent dislocation of the prosthesis?