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A healthcare professional reviewing the health care record of a client notes documentation of grade 4 muscle strength. The healthcare professional understands that this indicates:
- A. Full ROM with gravity
- B. Full ROM against gravity with full resistance
- C. Full ROM with gravity eliminated (passive motion)
- D. Full ROM against gravity with some resistance
Correct Answer: D
Rationale: Muscle strength is graded on a scale of 0 to 5. A grade of 5 indicates normal strength and is described as full ROM against gravity with full resistance. Grade 4 indicates good strength and full ROM against gravity with some resistance. Grade 3 indicates fair strength and full ROM with gravity. Grade 2 indicates poor strength and full ROM with gravity eliminated (passive motion). Grade 1 indicates trace strength and slight contraction. Grade 0 indicates zero strength and no contraction. Therefore, the correct answer is 'Full ROM against gravity with some resistance.' Choices A, B, and C are incorrect as they do not match the description of muscle strength associated with a grade of 4.
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A nurse is palpating a client's sinus areas. Which sensation does the nurse expect the client to indicate that he or she is feeling during palpation if the sinuses are normal?
- A. Firm pressure
- B. Pain behind the eyes
- C. Pain during palpation
- D. Pressure producing an acute headache
Correct Answer: A
Rationale: The correct answer is A: Firm pressure. When the sinuses are normal, the client is expected to feel firm pressure during palpation. Pain during palpation of the sinuses is indicative of acute sinusitis, not a normal finding. Pain behind the eyes and pressure producing an acute headache are symptoms of acute sinusitis, not sensations felt during sinus palpation in normal sinuses.
A client describes her cervical mucus as clear, thin, and elastic. Upon examination, the nurse demonstrates that the cervical mucus can be stretched 8-10 cm. The nurse correctly documents the finding as:
- A. increased ferning capacity.
- B. lack of ferning.
- C. spinnbarkheit.
- D. inhospitable.
Correct Answer: C
Rationale: The nurse should document the finding as 'spinnbarkheit.' Spinnbarkheit is the term used to describe the clear, thin, and elastic cervical mucus that can be stretched 8-10 cm, indicating ovulation. It helps couples determine the most fertile period for conception. Ferning capacity or crystallization increases as ovulation approaches, but it requires microscopic examination to be confirmed. Lack of ferning cannot be determined without such examination. 'Inhospitable' cervical mucus refers to patterns that prohibit sperm motility, caused by various factors like hormone levels or infection. These conditions cannot be assessed based solely on the description provided in the question.
A chemical reaction between drugs prior to their administration or absorption is known as:
- A. a drug incompatibility
- B. a side effect
- C. an adverse event
- D. an allergic response
Correct Answer: A
Rationale: A drug incompatibility occurs when drugs react chemically before administration, potentially reducing efficacy or causing harm. Side effects and adverse events occur post-administration, and allergic responses are immune-mediated.
The LPN participates in a home visit for a client with Type 2 Diabetes who has been taking Metformin for 3 years. The client states that for the past 3 months, they have been trying a vegan diet and experiencing fatigue, confusion, and mood changes. What is a likely cause of the new symptoms?
- A. vitamin B12 deficiency
- B. chronic hypoglycemia
- C. vitamin D deficiency
- D. increased tolerance to Metformin
Correct Answer: A
Rationale: The correct answer is vitamin B12 deficiency. Long-term use of Metformin can lead to vitamin B12 deficiency, and a vegan diet is low in vitamin B12. Symptoms of vitamin B12 deficiency include anemia, fatigue, confusion, and mood changes. Chronic hypoglycemia is unlikely in a client with Type 2 Diabetes who has been taking Metformin as it typically causes hyperglycemia. Vitamin D deficiency usually presents with symptoms related to bones and muscles, not confusion and mood changes. Increased tolerance to Metformin does not explain the client's new symptoms, which are more indicative of a nutritional deficiency like vitamin B12.
The client has an order for 0.45 mg of Diltiazem. The medication vial has a concentration of 3 mg/mL. How many mL of the drug should be administered?
- A. 0.15 mL
- B. 6.6 mL
- C. 1.5 mL
- D. 0.65 Ml
Correct Answer: A
Rationale: To calculate the amount of drug to be administered, divide the ordered dose by the concentration of the medication in the vial. In this case, 0.45 mg ÷ 3 mg/mL = 0.15 mL. Therefore, the correct answer is 0.15 mL.
Choice B (6.6 mL) is incorrect as it does not result from the correct calculation. Choice C (1.5 mL) is incorrect as it is not the result of dividing the ordered dose by the concentration. Choice D (0.65 mL) is incorrect as it is not the accurate calculation based on the provided information.