Nokea
A 54-year-old female is brought into the ED by her spouse. The client's spouse tells the nurse the client has been experiencing muscle stiffness, increased perspiration, and anxiety. The nurse obtains bloodwork as ordered by the physician, including a complete blood count and a comprehensive metabolic panel. For which result should the nurse immediately notify the physician?
- A. calcium 7.2 mg/dL
- B. alkaline phosphatase 120 IU/L
- C. sodium 143 mEq/L
- D. creatinine 0.8 mg/dL
Correct Answer: A
Rationale: Hypocalcemia (calcium 7.2 mg/dL, normal 8.5–10.2) can cause muscle stiffness and anxiety, requiring immediate notification. Other results are normal.
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An elderly female is admitted with a fractured right femoral neck. Which clinical manifestation would the nurse expect to find?
- A. Free movement of the right leg
- B. Abduction of the right leg
- C. Internal rotation of the right hip
- D. Shortening of the right leg
Correct Answer: D
Rationale: A femoral neck fracture typically causes shortening of the affected leg due to muscle contraction pulling the bone fragments together, along with external rotation and limited movement.
A client with AIDS is admitted with a diagnosis of pneumocystis carinii pneumonia. Shortly after his admission, he becomes confused and disoriented. He attempts to pull out his IV and refuses to wear an O2 mask. Based upon his mental status, the priority nursing diagnosis is:
- A. Social isolation
- B. Risk for injury
- C. Ineffective coping
- D. Anxiety
Correct Answer: B
Rationale: The client's confusion and disorientation pose a risk for injury, such as pulling out the IV or falling, making this the priority nursing diagnosis.
A client with schizophrenia has been taking Clozaril (clozapine) for the past 6 months. This morning the client's temperature was elevated to 102°F. The nurse should give priority to:
- A. Placing a note in the chart for the doctor
- B. Rechecking the temperature in 4 hours
- C. Notifying the physician immediately
- D. Asking the client if he has been feeling sick
Correct Answer: C
Rationale: A fever of 102°F in a client on clozapine may indicate agranulocytosis, a life-threatening side effect, requiring immediate physician notification.
A patient with hypothyroidism states that she takes Synthroid® 0.112 mg daily, but the pharmacy has issued the drug labeled in micrograms. How many micrograms of Synthroid® is equivalent to 0.112 mg? Record your answer using a whole number.
Correct Answer: 112
Rationale: To convert milligrams to micrograms, multiply by 1,000: 0.112 mg X 1,000 = 112 micrograms.
A child with Down syndrome has a developmental age of 4 years. According to the Denver Developmental Assessment, the 4-year-old should be able to:
- A. Draw a man in six parts
- B. Give his first and last name
- C. Dress without supervision
- D. Define a list of words
Correct Answer: B
Rationale: Per the Denver Developmental Screening Test, a 4-year-old should be able to give their first and last name, a milestone achievable despite developmental delays.