An older adult client on an orthopedic unit has an intracapsular fracture of the right hip following a fall. The client is in Buck's traction and will have hip prosthesis surgery in the morning. The nurse should reinforce with the client that this type of traction promotes which of the following outcomes?

Reduction of the fracture

Support for moving the extremity

Alignment of the pins

Relief from muscle spasms

Answer and Explanation

The Correct Answer is D

The nurse should reinforce to the client that Buck's traction promotes relief from muscle spasms. Buck's traction is a type of skin traction that is widely used for fractures of the femur and hip². It uses splints, bandages, and adhesive tapes to position a limb near the fracture and then applies pressure using weights and pulleys. One of the goals of Buck's traction is to lessen or eliminate muscular spasms.

a. Reduction of the fracture is not the primary purpose of Buck's traction.
b. Support for moving the extremity is not a primary outcome of Buck's traction.
c. Alignment of the pins is not applicable to Buck's traction as it does not involve inserting pins into the
bone.

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Correct Answer is D

Explanation

An appropriate conclusion based on this data is that the client opens his eyes when spoken to. A GCS score of 3 for eye opening indicates that the client opens his eyes in response to voice.

The client is not unconscious, as a GCS score of 3 for eye opening indicates that the client is able to open his eyes in response to voice. The client is not unable to make vocal sound, as a GCS score of 5 for best verbal response indicates that the client is able to make vocal sounds. The client may or may not be able to follow simple motor commands, as a GCS score of 5 for best motor response indicates that the client is able to localize pain.

A. Taking too much prescribed medication B. Developing a respiratory infection C. Insufficient sleep D. Insufficient exercise

Correct Answer is B

Explanation

The nurse should identify that developing a respiratory infection can cause a myasthenic crisis in a client who has myasthenia gravis. A myasthenic crisis is a sudden worsening of myasthenia gravis symptoms, which can include difficulty breathing and swallowing. Respiratory infections can exacerbate these symptoms and trigger a myasthenic crisis.

Taking too much-prescribed medication, insufficient exercise, and insufficient sleep are not factors that can cause a myasthenic crisis. Taking too much-prescribed medication can cause side eﬀects but would not directly cause a myasthenic crisis. Insufficient exercise and insufficient sleep can worsen overall health but would not directly cause a myasthenic crisis.

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Naxlex Comprehensive Predictor Exams

A nurse is receiving a transfer report for a client who has a head injury. The client has a Glasgow Coma Scale (GCS) score of 3 for eye opening, 5 for best verbal response, and 5 for best motor response. Which of the following is an appropriate conclusion based on this data?

Correct Answer is D

Explanation

A nurse in the emergency department is assisting with the care of a client who has myasthenia gravis and is in crisis. The nurse should identify that which of the following factors can cause a myasthenic crisis?

Correct Answer is B

Explanation

A nurse is caring for a client who has a spinal cord injury at T-4. The nurse should recognize that the client is at risk for autonomic dysreﬂexia. Which of the following interventions should the nurse take to prevent autonomic dysreﬂexia?

A nurse enters a client's room and finds the client on the ﬂoor in the clonic phase of a tonic-clonic seizure. Which of the following interventions should the nurse take?

A nurse is caring for a client who is 2 days postoperative following an above-the-knee amputation. Which of the following is an appropriate nursing intervention for the client at this time?

A nurse is collecting data from a client who has an exacerbation of gout. Which of the following findings should the nurse expect? (Select all that apply.)

A nurse is collecting data from a client who has a score of 8 using the Glasgow Coma Scale. Which of the following findings should the nurse expect?

A nurse is assisting a client who is postoperative following a total hip arthroplasty into a supine position. Which of the following actions is appropriate to prevent hip dislocation?

A nurse is assisting with the plan of care for an older adult client who is 4 hr postoperative following an open reduction and internal fixation of a fractured femur. Which of the following interventions should the nurse include in the plan of care?

A nurse is collecting data from a client who has increased intracranial pressure and is informed by the charge nurse that the client demonstrates decorticate posturing. Which of the following findings should the nurse expect to observe?