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A nurse in a provider's office is preparing to assess a young adult male client's musculoskeletal system as part of a comprehensive physical examination. Which of the following findings should the nurse expect? Select all.
- A. A concave thoracic spine posteriorly
- B. An exaggerated lumbar curvature
- C. A concave lumbar spine posteriorly
- D. An exaggerated thoracic curvature
- E. Muscles slightly larger on his dominant side
Correct Answer: C, E
Rationale: Correct Answer: C, E
Rationale:
C: A concave lumbar spine posteriorly is expected in a young adult male due to the normal lordotic curve in the lumbar region for weight-bearing support.
E: Muscles slightly larger on his dominant side is an expected finding as asymmetry in muscle size and strength is common due to dominant limb use.
Incorrect Choices:
A: A concave thoracic spine posteriorly is not a normal finding and may indicate poor posture or spinal deformity.
B: An exaggerated lumbar curvature is not expected in a young adult male and may suggest a potential spinal issue.
D: An exaggerated thoracic curvature is not typical in a young adult male and may indicate abnormal spinal curvature.
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A nurse enters a client's room & finds him sitting in his chair. He states, 'I fell in the shower, but I got myself back up & into my chair.' How should the nurse document this in the client's chart?
- A. The client fell in the shower.
- B. The client states he fell in the shower & was able to get himself back into his chair.
- C. The nurse should not document this info because she did not witness the fall.
- D. The client fell in the shower & is now resting comfortably.
Correct Answer: B
Rationale: Correct Answer: B. The client states he fell in the shower & was able to get himself back into his chair.
Rationale: This answer accurately reflects the client's own account of the events without making any assumptions. It documents both the fall and the client's ability to self-recover, which are essential details for the client's care plan.
Summary of Incorrect Choices:
A: This option only mentions the fall without acknowledging the client's ability to get back up, which is crucial information.
C: It is important to document the client's report even if the nurse did not witness the fall, as it provides valuable insight into the client's condition.
D: This option adds unnecessary information about the client's current state that is not directly related to the fall incident.
A nurse is caring for a client who presents with linear clusters of fluid-containing vesicles with some crusting. Which of the following should the nurse suspect?
- A. Allergic reaction
- B. Ringworm
- C. Systemic lupus erythematosus
- D. Herpes zoster
Correct Answer: D
Rationale: The correct answer is D: Herpes zoster. The presentation of linear clusters of fluid-containing vesicles with crusting is characteristic of herpes zoster, also known as shingles. This viral infection is caused by the reactivation of the varicella-zoster virus, which initially causes chickenpox. The linear distribution of the vesicles along a dermatome is a key feature of herpes zoster. The other choices are incorrect because: A: Allergic reactions typically present with hives or itching, not vesicles with crusting. B: Ringworm presents as circular, red, scaly patches, not linear clusters of vesicles. C: Systemic lupus erythematosus is an autoimmune disease that manifests with a butterfly rash on the face, joint pain, and other systemic symptoms, not vesicles. Therefore, the nurse should suspect herpes zoster based on the presentation described.
A nurse is obtaining history from a client who has pain. The nurse's guiding principle throughout this process should be that:
- A. Some clients exaggerate their level of pain
- B. Pain must have an identifiable source to justify the use of opioids.
- C. Objective data are essential in assessing pain
- D. Pain is whatever the client says it is.
Correct Answer: D
Rationale: Step-by-step rationale for why answer D is correct:
1. Pain is a subjective experience: Pain perception varies among individuals, making it crucial to consider the client's own description.
2. Client-centered care: Acknowledging the client's self-report of pain is essential in providing effective and compassionate care.
3. Holistic approach: Recognizing the client's perspective on pain helps in addressing their physical, emotional, and psychological needs.
4. Trust and rapport: Valuing the client's self-assessment of pain fosters a trusting relationship between the nurse and the client.
5. Evidence-based practice: Research supports that self-reporting of pain is the most reliable indicator of pain intensity.
Summary:
- Choice A is incorrect as assuming clients exaggerate pain undermines their credibility and may lead to inadequate pain management.
- Choice B is incorrect as pain is not always identifiable, and opioids may be justified based on the client's report.
- Choice C is incorrect as relying solely on objective data overlooks the
A nurse is receiving a provider's prescription by telephone for morphine for a client who is reporting moderate to severe pain. Which of the following nursing actions are appropriate? Select all.
- A. Repeat the details of the prescription back to the provider
- B. Have another nurse listen to the telephone prescription
- C. Obtain the prescriber's signature on the prescription within 24hrs
- D. Decline the verbal prescription because it is not an emergency situation
- E. Tell the charge nurse that the provider has prescribed morphine by telephone
Correct Answer: A, B, C
Rationale: The correct choices are A, B, and C. A nurse should repeat the prescription back to the provider to ensure accurate communication and prevent errors. Having another nurse listen to the prescription can provide an additional check for accuracy and clarity. Obtaining the prescriber's signature on the prescription within 24 hours is necessary for documentation and legal purposes. Choice D should be ruled out as it is not appropriate to decline a valid prescription for pain medication in a timely manner. Choice E does not address the immediate need to confirm and document the prescription accurately.
A nurse is assessing a client who reports pain when the nurse evaluates the internal rotation of her right shoulder. Which of the following activities is this problem likely to affect?
- A. Mopping her floors
- B. Brushing the back of her hair
- C. Fastening her bra behind her back
- D. Reaching into a cabinet above her sink
Correct Answer: C
Rationale: The correct answer is C. Fastening her bra behind her back. Internal rotation of the shoulder is necessary for this activity as it involves reaching the arm behind the body. Mopping the floors (A) and brushing the back of her hair (B) primarily require shoulder abduction and flexion. Reaching into a cabinet above the sink (D) involves shoulder flexion and abduction, not internal rotation.