Nokea
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.
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A client has been treated for migraine headaches for several months and comes to the clinic reporting no improvement. The nurse is talking with the client and hears an audible click when the client is moving the jaw. What does the nurse suspect may be happening?
- A. Trigeminal neuralgia
- B. Temporomandibular disorder
- C. Loose teeth
- D. Dislocated jaw
Correct Answer: B
Rationale: The disorder can be confused with trigeminal neuralgia and migraine headaches. The client experiences clicking of the jaw when moving the joint, or the jaw can lock, which interferes with opening the mouth. Loose teeth will not cause a clicking of the jaw. The client does not have a dislocated jaw.
A client with osteoporosis is prescribed a selective estrogen receptor modifier (SERM) as treatment. The nurse would identify which drug as belonging to this class?
- A. Alendronate (Fosamax)
- B. Calcium gluconate
- C. Tamoxifen (Nolvadex)
- D. Raloxifene (Evista)
Correct Answer: D
Rationale: An example of a selective estrogen receptor modifier (SERM) is raloxifene (Evista). Alendronate is a bisphosphonate; calcium gluconate is an oral calcium preparation; tamoxifen is an antiestrogen agent.
The nurse is providing teaching to a client with a mild case of bunions. Which suggestion would be most important for the nurse to give this client?
- A. Avoid strenuous exercise.
- B. Avoid foot creams.
- C. Don proper footwear.
- D. Regularly use analgesics.
Correct Answer: C
Rationale: The most important instruction a nurse should give clients with bunions or hammer toe is to don proper footwear. Low-heeled, well-fitted shoes are recommended. Regular use of analgesics is not necessary for bunions if pain is not severe and the client has little or no difficulty. The client need not avoid strenuous exercise, running, or foot creams if the footwear is appropriate.
A client is receiving treatment for an acute episode of gout with colchicine. The nurse is administering the medication every 2 hours. What symptom(s) should the nurse be sure the client communicates so that the drug can be temporarily stopped? Select all that apply.
- A. Diarrhea
- B. Tingling in the arms
- C. Intestinal cramping
- D. Increase in pain in the affected extremity
- E. Nausea and vomiting
Correct Answer: A,C,E
Rationale: Colchicine is administered every 1 or 2 hours until the pain subsides or nausea, vomiting, intestinal cramping, and diarrhea develop. When one or more of these symptoms occurs, the drug should be stopped temporarily. Tingling in the arms and increase in pain are not normal adverse reactions that are seen with this drug.
The nurse is assisting a client with removing shoes prior to an examination and observes that the client has a flexion deformity of several toes on both feet of the proximal interphalangeal (PIP) joints. What can the nurse encourage the client to do?
- A. Bind the toes so that they will straighten.
- B. Do active range of motion on the toes.
- C. Have surgery to fix them.
- D. Wear properly fitting shoes.
Correct Answer: D
Rationale: Hammer toe is a flexion deformity of the PIP joint and may involve several toes and may result from wearing poorly fitting shoes. They will not straighten by binding the toes or doing active range of motion exercises. Surgery is an option but should be discussed with an orthopedic surgeon or podiatrist.