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A nurse is assessing a client who reports numbness and pain in his right palm, index finger, and middle finger. The client reports working with a keyboard most of the time while at work. The nurse suspects carpal tunnel syndrome. Which of the following tests should the nurse request that the client perform?
- A. Hold the wrist at a 90-degree flexion.
- B. Perform a straight leg raise test.
- C. Tap the wrist for tenderness.
- D. Hold the arm in an elevated position.
Correct Answer: A
Rationale: The correct answer is A: Hold the wrist at a 90-degree flexion. This test, known as the Phalen's test, is used to assess for carpal tunnel syndrome. By holding the wrist in a flexed position for about 60 seconds, the test can reproduce symptoms of numbness and tingling in the affected fingers. This occurs due to increased pressure on the median nerve, which is characteristic of carpal tunnel syndrome.
Choices B, C, and D are incorrect:
B: Performing a straight leg raise test is used to assess for sciatic nerve irritation in the lower back, not carpal tunnel syndrome.
C: Tapping the wrist for tenderness is not a specific test for carpal tunnel syndrome.
D: Holding the arm in an elevated position is not a recognized test for carpal tunnel syndrome and would not provide relevant information in this context.
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A nurse is explaining DIC to a client with septic shock. What should the nurse say?
- A. DIC is caused by abnormal coagulation involving fibrinogen.
- B. DIC is due to a vitamin K deficiency.
- C. DIC is caused by bone marrow suppression.
- D. DIC results from an underactive clotting system.
Correct Answer: A
Rationale: The correct answer is A because Disseminated Intravascular Coagulation (DIC) is characterized by abnormal coagulation involving fibrinogen. In DIC, there is widespread activation of the clotting cascade leading to the formation of microthrombi. This process consumes clotting factors like fibrinogen, leading to bleeding tendencies. Vitamin K deficiency (B) primarily affects the production of clotting factors, but it is not the direct cause of DIC. Bone marrow suppression (C) and an underactive clotting system (D) are not accurate explanations for DIC.
A nurse is providing teaching to a client who is postoperative following coronary artery bypass graft (CABG) surgery and is receiving opioid medications to manage discomfort. Aside from managing pain, which of the following desired effects of medications should the nurse identify as most important for the client's recovery?
- A. It facilitates the client's deep breathing
- B. It increases the client's appetite
- C. It promotes wound healing
- D. It decreases the client's anxiety
Correct Answer: A
Rationale: The correct answer is A: It facilitates the client's deep breathing. Postoperative clients following CABG surgery are at risk for developing atelectasis due to decreased lung expansion. Opioid medications can cause respiratory depression, leading to shallow breathing. By facilitating deep breathing, the nurse helps prevent atelectasis and promotes optimal oxygenation, aiding in the client's recovery. Choices B, C, and D are incorrect as they are not directly related to the immediate physiological needs of a postoperative CABG client. Increasing appetite, promoting wound healing, and decreasing anxiety are important aspects of overall recovery but are not as critical as ensuring proper oxygenation and preventing respiratory complications in the immediate postoperative period.
A nurse is providing teaching to a client about the manifestations of uterine prolapse. Which of the following statements by the client should indicate to the nurse a need for further teaching?
- A. I should avoid heavy lifting.
- B. Feces can be present in the vagina.
- C. I might experience urinary incontinence.
- D. Pelvic pressure may occur during intercourse.
Correct Answer: B
Rationale: The correct answer is B. Feces present in the vagina is not a manifestation of uterine prolapse; it is a symptom of rectocele. The other choices are correct for uterine prolapse: A - Heavy lifting can worsen prolapse, C - Urinary incontinence is common due to pelvic floor weakness, D - Pelvic pressure during intercourse is a symptom. Therefore, the client mentioning feces in the vagina indicates a need for further teaching on distinguishing between uterine prolapse and rectocele symptoms.
A nurse is caring for a client who has HIV. Which of the following laboratory values is the nurse's priority?
- A. Hemoglobin of 12 g/dL
- B. Platelet count of 350,000/mm3
- C. CD4-T-cell count 180 cells/mm3
- D. White blood cell count of 10,000/mm3
Correct Answer: C
Rationale: The correct answer is C: CD4-T-cell count 180 cells/mm3. In HIV care, monitoring the CD4-T-cell count is crucial as it reflects the immune system's ability to fight infections. A low CD4 count indicates a weakened immune system, increasing the client's susceptibility to opportunistic infections. This value guides treatment decisions, such as initiating antiretroviral therapy. The other options, while important, do not directly reflect the client's immune status in the context of HIV. Hemoglobin and platelet counts are relevant for assessing anemia and clotting function, respectively. White blood cell count is a general indicator of infection or inflammation. Prioritizing CD4-T-cell count ensures appropriate management of HIV and prevention of complications.
A nurse is preparing a client for radiation after a mastectomy. What adverse effect should be expected?
- A. Alopecia
- B. Diarrhea
- C. Fatigue
- D. Weight gain
Correct Answer: C
Rationale: The correct answer is C: Fatigue. Radiation therapy often causes fatigue due to its impact on healthy cells surrounding the treatment area. This can result in decreased energy levels and overall tiredness. Alopecia (A) is more commonly associated with chemotherapy. Diarrhea (B) is a potential side effect of certain chemotherapy drugs or radiation to the abdominal area. Weight gain (D) is not a typical adverse effect of radiation therapy.