Nokea
A client diagnosed with multiple sclerosis is prescribed baclofen. Which assessment finding would indicate to the nurse that the client is experiencing a therapeutic response from the medication?
- A. Decreased nausea
- B. Decreased muscle spasms
- C. Increased muscle tone and strength
- D. Increased range of motion of all extremities
Correct Answer: B
Rationale: Baclofen is a skeletal muscle relaxant and acts at the spinal cord level to decrease the frequency and amplitude of muscle spasms in clients with spinal cord injuries or diseases, or multiple sclerosis. None of the other options are related to the effects of this medication.
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Betamethasone (Celestone) syrup 0.9 mg has been ordered. It is available in a 0.6 mg/5 mL solution. How many milliliters should the nurse administer?
- A. 5 mL
- B. 7.5 mL
- C. 10 mL
- D. 2.5 mL
Correct Answer: B
Rationale: To calculate: (0.9 mg / 0.6 mg) × 5 mL = 7.5 mL.
A newborn diagnosed with respiratory distress syndrome (RDS) is prescribed surfactant replacement therapy. The nurse evaluates the infant 1 hour after the therapy and determines that the infant's condition has improved somewhat. Which finding indicates improvement?
- A. An audible respiratory grunt
- B. Slight increase in the respiratory rate
- C. Arterial blood pH increases to ≥ 7.35
- D. Fine inspiratory crackles heard over both lungs
Correct Answer: C
Rationale: RDS causes hypoperfusion with hypoxemia that results in tissue hypoxia and metabolic acidosis. If the arterial blood pH increases to ≥ 7.35, the metabolic acidosis is resolving and the newborn's condition is improving. Within a few hours, respiratory distress becomes more obvious in RDS. The respiratory rate continues to increase (to 80 to 120 breaths/min), so a gradual increase in rate does not mean that the condition is improving. Also, an audible respiratory grunt and fine inspiratory crackles heard over both lungs are not signs the condition is improving.
A nurse who fails to check a client's armband before administering his medications is:
- A. Negligent.
- B. Following standard procedure.
- C. Acting within their scope of practice.
- D. Exercising professional judgment.
Correct Answer: A
Rationale: Failing to check a client's armband before administering medications is negligent, as it violates patient safety protocols for verifying identity.
The nurse is reviewing the laboratory results of a client with hypothyroidism. An expected finding is:
- A. Decreased thyroxine (T4) and increased thyroid-stimulating hormone (TSH) levels
- B. Decreased TSH and increased T4 levels
- C. Decreased creatine phosphokinase levels
- D. Absence of antithyroid antibodies
Correct Answer: A
Rationale: Hypothyroidism is characterized by decreased thyroxine (T4) and increased TSH as the pituitary attempts to stimulate the thyroid. Other options are inconsistent with hypothyroidism.
A client who underwent cardiac surgery 2 days ago is recovering well. His wife, who is assisting with his care, says, 'He is doing too much. I told him to let me help, but he won't let me.' The nurse says to the wife, 'It sounds like you need to feel you can be more helpful to him.' In order to make her nonverbal behavior complement her words, the nurse should:
- A. Direct the eyes at the client.
- B. Direct the body and eyes at the wife and client.
- C. Avoid direct eye contact with the client and wife.
- D. Shift the eyes back and forth between the client and wife.
Correct Answer: B
Rationale: Directing body and eyes to both the wife and client shows engagement and inclusivity, complementing the empathetic verbal response.