Nokea
A nurse is working in an outpatient orthopedic clinic. During the patient's history the patient reports, 'I tore 3 of my 4 Rotator cuff muscles in the past.' Which of the following muscles cannot be considered as possibly being torn?
- A. Teres minor
- B. Teres major
- C. Supraspinatus
- D. Infraspinatus
Correct Answer: B
Rationale: Teres Minor, Infraspinatus, Supraspinatus, and Subscapularis make up the Rotator Cuff.
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The father of a one-day-old son works the evening shift (3 PM to 11 PM) at another hospital. Which of the following plans would be a priority to meet the needs of this father?
- A. Encourage the father to call his wife after work.
- B. Instruct the father about visiting policy and suggest AM visitation.
- C. Adjust visiting hours to meet the new parents' needs.
- D. Present a change of visiting hours to the appropriate hospital committee.
Correct Answer: C
Rationale: Adjusting visiting hours accommodates the father’s evening shift, enabling bonding with his newborn, a priority for family-centered care. Options A and B are less flexible, and option D is a long-term solution, not immediate.
A client has been taking perphenazine (Trilafon) by mouth for two days and now displays the following: head turned to the side, neck arched at an angle, stiffness and muscle spasms in neck.
- A. Which PRN medication should the nurse expect to give for a client with extrapyramidal side effects from perphenazine?
- B. Promazine (Sparine).
- C. Biperiden (Akineton).
- D. Thiothixene (Navane).
- E. Haloperidol (Haldol).
Correct Answer: B
Rationale: Biperiden, an antiparkinsonian agent, counteracts extrapyramidal side effects (e.g., dystonia, stiffness) caused by antipsychotics like perphenazine. Promazine, thiothixene, and haloperidol are antipsychotics that could worsen these side effects.
A client hospitalized with bipolar disorder, manic phase, begins to talk loudly, pace the floor, and shout commands to others in the day room as he quickly changes the TV channels. The nurse's first action should include:
- A. Checking the client's medication order
- B. Escorting the client from the day room
- C. Placing the client in seclusion
- D. Finding out whether the client's behavior is upsetting others in the day room
Correct Answer: B
Rationale: Escorting the client from the day room de-escalates the situation by removing them from a stimulating environment, reducing agitation.
An adult is being worked up for possible pulmonary tuberculosis. The nurse knows that which test is most conclusive for the diagnosis of tuberculosis?
- A. Intradermal skin test
- B. Chest x-ray
- C. Sputum examination
- D. Computed tomography (CT) scan
Correct Answer: C
Rationale: Sputum examination for acid-fast bacilli is the gold standard for confirming tuberculosis, unlike skin tests (screening), x-rays (supportive), or CT (non-specific).
A 13 year old girl is admitted to the ER with lower right abdominal discomfort. The admitting nursing should take which the following measures first?
- A. Administer Loritab to the patient for pain relief.
- B. Place the patient in right sidelying position for pressure relief.
- C. Start a Central Line.
- D. Provide pain reduction techniques without administering medication.
Correct Answer: D
Rationale: Do not administer pain medication or start a central line without MD orders.