Nokea
A client has been experiencing muscle weakness for a period of several months. The health care provider suspects polymyositis, and the client asks the nurse about the disorder. The nurse explains to the client that which occurs in this disorder?
- A. Increased fibers and tissue
- B. Muscle fibers are inflamed.
- C. Muscle fibers are thickened.
- D. A decrease in elastic tissue
Correct Answer: B
Rationale: Polymyositis is a diffuse inflammatory disorder of skeletal (striated) muscle that is characterized by symmetrical weakness and atrophy. Increased fibrous tissue is seen in clients diagnosed with ankylosis. Thickened muscle fibers describe the opposite of what is noted with this disorder. Decreased elastic tissue, if it occurred in the aorta, would be noted in a client with Marfan's syndrome.
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The nurse prepares a client with a peripheral intravenous (IV) site for home IV therapy for discharge. Which should the nurse teach the client to help prevent phlebitis and infiltration?
- A. Massage the IV site daily.
- B. Immobilize the extremity.
- C. Stabilize the cannula with tape.
- D. Cleanse the site daily with alcohol.
Correct Answer: C
Rationale: Stabilizing the cannula with tape prevents movement, reducing the risk of phlebitis and infiltration. Massaging the site can cause tissue damage, immobilizing the extremity is unnecessary, and alcohol cleansing causes skin drying and discomfort.
A pediatric nurse in an ambulatory care clinic is admitting a neonate for the 2-week office visit. Which comment by the mother should alert the nurse to suspect colic?
- A. My baby looks yellow.
- B. After feedings, my baby pulls his legs up and cries.
- C. My baby is quiet and doesn't cry much.
- D. My baby is alert for brief periods of 10-20 minutes at a time.
Correct Answer: B
Rationale: Pulling legs up and crying after feedings suggests colic. Jaundice, quietness, or brief alertness are not indicative of colic.
The nurse has provided home-care instructions to a client who is taking lithium carbonate. Which client statement indicates that the client understands the prescribed regimen?
- A. I will restrict my water intake.
- B. I will make sure that my diet contains salt.
- C. I will keep my medication in the refrigerator.
- D. I will be careful to avoid eating foods high in potassium.
Correct Answer: B
Rationale: Lithium is a mood stabilizer used to treat bipolar disorder. It replaces sodium ions in the cells and induces the excretion of sodium and potassium from the body. Client teaching includes the maintenance of sodium intake in the daily diet and increased fluid intake (at least 1 to 1½ L per day) during maintenance therapy. Lithium is stored at room temperature and protected from light and moisture.
A client tells the nurse that he gets dizzy and lightheaded with each use of the incentive spirometer. The nurse asks the client to demonstrate the use of the device. Which action should the nurse expect to be a contributing factor in this client's symptoms?
- A. Inhaling too slowly
- B. Exhaling too slowly
- C. Not resting adequately between breaths
- D. Not forming a tight seal around the mouthpiece
Correct Answer: C
Rationale: Hyperventilation, caused by not resting adequately between breaths, is the most common cause of respiratory alkalosis, leading to lightheadedness and dizziness during incentive spirometer use. Inhaling or exhaling too slowly or not forming a tight seal may reduce effectiveness but does not cause these symptoms.
The nurse has completed discharge teaching with a client who has had surgery for lung cancer. The nurse determines that the client needs additional teaching about the elements of home management if the client verbalizes the need to follow which instruction?
- A. Avoid exposure to crowds.
- B. Deal with any increases in pain independently.
- C. Sit up and lean forward to breathe more easily.
- D. Call the primary health care provider if shortness of breath occurs.
Correct Answer: B
Rationale: Clients post-lung cancer surgery should not manage increased pain independently, as it may indicate complications requiring medical attention. Avoiding crowds, sitting up to breathe easier, and reporting shortness of breath are appropriate home management strategies.