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A client has been diagnosed with temporomandibular disorder and has not been able to eat. What is an appropriate action for the nurse to take?
- A. Have the client's food pureed
- B. Have the client placed on a liquid diet.
- C. Have the client eat soft rather than coarse food.
- D. Give the client clear liquids as well as intravenous fluids.
Correct Answer: C
Rationale: The nurse modifies the diet to include soft rather than coarse food, which is easier to chew. The nurse also provides nutritional liquid supplements and assists the client to acquire skills that control pain, such as using a bite guard during sleep. The client does not require pureed food or clear liquids. Pureed and clear liquids are not warranted because these are too extreme and may interfere with nutrition.
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A client with diabetes punctured the foot with a sharp object. Within a week, the client developed osteomyelitis of the foot. The client was admitted for IV antibiotic therapy. How long does the nurse anticipate the client will receive IV antibiotics?
- A. 6 months
- B. 7 to 10 days
- C. 2 to 3 weeks
- D. At least 4 weeks
Correct Answer: D
Rationale: Identification of the causative organism to initiate appropriate and ongoing antibiotic therapy for infection control. IV antibiotic therapy is administered for at least 4 weeks, followed by another 2 weeks (or more) of IV antibiotics or oral antibiotics.
A client with ankylosing spondylitis has a stooped position and is being positioned in the bed prior to the nurse taking vital signs. The nurse listens to the client's lungs after positioning. What finding related to the client's condition may the nurse hear when listening to lung sounds?
- A. Crackles in the bases
- B. Pericardial friction rub
- C. Lung sounds may be diminished in the apical area.
- D. Rhonchi
Correct Answer: C
Rationale: Lung sounds may be reduced, especially in the apical area. The nurse would not hear rhonchi, crackles, or a pericardial friction rub unless the client had underlying cardiac or respiratory disorders.
The nurse is gathering objective data for a client at the clinic reporting arthritic pain in the hands. The nurse observes that the fingers are hyperextended at the proximal interphalangeal joint with fixed flexion of the distal interphalangeal joint. What does the nurse recognize this deformity as?
- A. Swan neck deformity
- B. Boutonniere deformity
- C. Ulnar deviation
- D. Rheumatoid nodules
Correct Answer: A
Rationale: A swan neck deformity is a hyperextension of the proximal interphalangeal joint with fixed flexion of the distal interphalangeal joint. A Boutonniere deformity is a persistent flexion of the proximal interphalangeal joint with hyperextension of the distal interphalangeal joint. Ulnar deviation is when the fingers are deviating laterally toward the ulna. A rheumatoid nodule is a subcutaneous nodule.
A client is informed of having a benign bone tumor but that this type of tumor may become malignant. The nurse knows that this is characteristic of which type of tumor?
- A. Osteochondroma
- B. Enchondroma
- C. Osteoclastoma
- D. Osteoid osteoma
Correct Answer: C
Rationale: An osteoclastoma is a giant cell tumor that may invade local tissue; usually soft and hemorrhagic and may become malignant. An osteochondroma occurs as a large projection of bone at the ends of long bones, developing during growth periods and then becoming static bone mass. An enchondroma is a hyaline cartilage tumor that develops in the hand, ribs, femur, tibia, humerus, or pelvis. An osteoid osteoma is a painful tumor surrounded by reactive bone tissue.
A client is diagnosed with systemic lupus erythematosus (SLE). Which action would be most appropriate for the nurse to use to evaluate the client's stage of disease?
- A. Observe the client's gait.
- B. Review the client's medical record.
- C. Inspect the client's mouth.
- D. Ausculate the client's lung sounds.
Correct Answer: B
Rationale: The nurse evaluates the stage of SLE and plans appropriate interventions by reviewing the medical record and diagnostic findings of the client. The stage of the disease cannot be established by observing the client's gait, inspecting the client's mouth, or auscultating the client's lung sounds.