Nokea
A client is being evaluated for carpel tunnel syndrome. The nurse is observed tapping over the median nerve in the wrist and asking the client if there is pain or tingling. Which assessment is the nurse performing?
- A. Phalen's maneuver
- B. Tinel's sign
- C. Kernig's sign
- D. Brudzinski's sign
Correct Answer: B
Rationale: Tinel's sign involves tapping over the median nerve to elicit pain or tingling, indicating carpal tunnel syndrome. Phalen's maneuver involves wrist flexion, and the others assess meningitis.
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The nurse is precepting a student nurse who is helping to care for a client with a hip fracture. The client has Buck's traction applied. Which statement by the student nurse indicates a need for further explanation by the primary nurse?
- A. The weight on Buck's traction should be between 5 and 7 pounds.
- B. Buck's traction is a type of skeletal traction that helps in bone realignment.
- C. The weights should hang freely and be checked regularly for correct positioning.
- D. Diligent pin site care is crucial to prevent infection in clients with skeletal traction.
Correct Answer: B
Rationale: Buck’s traction is skin traction, not skeletal traction, which uses pins. The other statements are correct regarding weight, positioning, and pin care (though pin care applies to skeletal traction).
A neonatal nurse assesses a premature newborn baby using the Apgar score. All of the following assessments are given a score EXCEPT
- A. grimace.
- B. pulse.
- C. activity.
- D. rooting.
- E. appearance.
Correct Answer: D
Rationale: The Apgar score evaluates appearance, pulse, grimace, activity, and respiration. Rooting (a feeding reflex) is not part of the Apgar assessment.
As the client reaches 6cm dilation, the nurse notes late decelerations on the fetal monitor. What is the most likely explanation of this pattern?
- A. The baby is sleeping.
- B. The umbilical cord is compressed.
- C. There is head compression.
- D. There is uteroplacental insufficiency.
Correct Answer: D
Rationale: Late decelerations indicate uteroplacental insufficiency, reducing fetal oxygenation during contractions.
The nurse administers ciproflaxin to a client and then realizes that the client is allergic to the medication. What nursing action is the priority for this client?
- A. induce vomiting
- B. obtain the client's vital signs
- C. complete an incident report
- D. notify the health care provider
Correct Answer: D
Rationale: Notifying the health care provider is the priority to initiate immediate management of a potential allergic reaction, followed by monitoring and reporting.
A client has been taking perphenazine (Trilafon) by mouth for two days and now displays the following: head turned to the side, neck arched at an angle, stiffness and muscle spasms in neck. The nurse would expect to give which of the following as a PRN medication?
- A. Promazine (Sparine).
- B. Biperiden (Akineton).
- C. Thiothixene (Navane).
- D. Haloperidol (Haldol).
Correct Answer: B
Rationale: is an antiparkinsonian agent, used to counteract extrapyramidal side effects the client is experiencing