Nokea
A client with a history of statin use presents to the clinic with complaints of muscle weakness and pain. The nurse suspects myopathy. Which of the following laboratory tests should the nurse prioritize to evaluate for muscle damage?
- A. Electrocardiogram (ECG)
- B. Liver function tests (LFTs)
- C. Creatine kinase (CK)
- D. Complete blood count (CBC)
Correct Answer: C
Rationale: Creatine kinase (CK) levels rise with muscle damage, common in statin-induced myopathy. ECG is for cardiac issues, LFTs monitor liver, and CBC is not specific to muscle damage.
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The nurse in the medical-surgical unit is caring for a newly admitted client.
Item 2 of 6
History and Physical
1930: Client is a 45-year-old male who has a one-and-a-half-week history of pain, redness, and swelling in his right foot. He reported that the symptoms began after he accidentally cut his foot while walking barefoot in his backyard. Over the next few days, he developed pain and swelling around the cut, accompanied by redness and warmth. He went to urgent care two days later and was diagnosed with cellulitis in his right foot. He was prescribed antibiotics but could not afford the treatment. Three days ago, the pain escalated and was described as throbbing and constant, with a severity rating of 7/10 on the Numerical Pain Rating Scale. He states, "the pain is now in the bone of my foot; I don't know how else to describe it." He also noted occasional fever 101°F (38.3°C), chills, and general malaise. On physical examination, his right foot was erythematous, swollen, and warm to the touch. A 3 cm ulcer was noted on the plantar aspect of the right foot, with moderate purulent discharge present. The ulcer appeared deep, and palpation of the surrounding tissue elicited tenderness. There was limited range of motion in the right ankle due to pain. The distal pulses were palpable 2+, and there were signs of neuropathy in the feet (decreased sensation to light touch and pinprick). He has a medical history of uncontrolled diabetes mellitus (type two), obesity, peripheral neuropathy in all extremities, hypertension, hyperlipidemia, and epilepsy.
Which three (3) findings in the history and physical suggest that the client's condition is worsening?
- A. Chills
- B. Sensation in feet
- C. Fever
- D. Erythema
- E. General malaise
Correct Answer: A, C, E
Rationale: Chills, fever, and general malaise indicate systemic infection or worsening, possibly osteomyelitis, especially with a history of untreated cellulitis. Sensation loss is chronic, and erythema is an earlier sign not necessarily worsening.
The nurse educates a client about the application of a plaster cast to a fractured radius. Which of the following statements by the client would require follow-up?
- A. If my arm feels itchy, I can use a hair dryer on the cool setting for relief.'
- B. I can reduce my arm's swelling by elevating it with a pillow.'
- C. I should be okay to shower with my cast.'
- D. It will be normal for me to feel heat after the cast is applied.'
Correct Answer: C
Rationale: Showering with a plaster cast risks wetting it, leading to breakdown or infection, requiring follow-up. Cool air for itching, elevation for swelling, and initial heat from cast setting are appropriate.
The nurse is caring for a client on bed rest for a week following a right hip fracture. Which of the following findings, if noted in the client, would indicate signs of complications due to immobility?
- A. An area of the client's sacrum is unable to be blanched
- B. The skin and the sclerae are yellow
- C. Crackles in the bases of the client's lungs
- D. Swelling and tenderness in the left calf
- E. The client is using the bedpan to void
Correct Answer: A, C, D
Rationale: Non-blanchable sacral skin indicates pressure injury, crackles suggest pneumonia or fluid from immobility, and calf swelling/tenderness may signal deep vein thrombosis. Jaundice and bedpan use are not directly immobility-related.
The nurse teaches a client about their newly applied halo fixator device with a vest. Which of the following statements should the nurse make?
- A. You should ride a bicycle instead of driving a car.'
- B. Report any fever or drainage at the pin sites.'
- C. Always keep the wrench taped to the front of the vest.'
- D. When getting out of bed, roll to your side and push on the mattress.'
- E. Wear a cotton t-shirt under the vest to absorb any moisture.'
Correct Answer: B, C, E
Rationale: Report fever or drainage for infection, keep the wrench taped for emergency adjustments, and wear a cotton t-shirt for comfort. Bicycling risks falls, and rolling to the side is safe but not the only method.
The nurse performs a physical assessment on a client and observes a tremor in the client's hand when their arm is extended. The nurse understands that this finding is consistent with which of the following?
- A. Rheumatic fever
- B. End-stage renal disease
- C. Neuroleptic Malignant Syndrome (NMS)
- D. Human Immunodeficiency Virus (HIV)
Correct Answer: C
Rationale: A tremor with an extended arm (postural tremor) can be consistent with Neuroleptic Malignant Syndrome, a reaction to certain medications causing muscle rigidity and tremors. Other options are less directly linked to this finding.