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After assessment and diagnostic evaluation, it has been determined that the client has a diagnosis of Lyme disease, stage II. The nurse assesses the client for which manifestation that is most indicative of this stage?
- A. Lethargy
- B. Headache
- C. Erythematous rash
- D. Cardiac dysrhythmias
Correct Answer: D
Rationale: Stage II of Lyme disease develops within 1 to 3 months in most untreated individuals. The most serious problems in this stage include cardiac dysrhythmias, dyspnea, dizziness, and neurological disorders such as Bell's palsy and paralysis. These problems are not usually permanent. Flulike symptoms (headache and lethargy), muscle pain and stiffness, and a rash appear in stage I.
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Which conditions place the client receiving enteral nutrition at increased risk for aspiration? Select all that apply.
- A. Sedation
- B. Coughing
- C. An artificial airway
- D. Head-elevated position
- E. Nasotracheal suctioning
- F. Decreased level of consciousness
Correct Answer: A,B,C,E,F
Rationale: A serious complication associated with enteral feedings is aspiration of formula into the tracheobronchial tree. Some common conditions that increase the risk of aspiration include sedation, coughing, an artificial airway, nasotracheal suctioning, decreased level of consciousness, and lying flat. A head-elevated position does not increase the risk of aspiration.
After a cervical spine fracture, this device (refer to figure) is placed on the client. The nurse creates a discharge plan for the client to ensure safety and includes which measures? Select all that apply.
- A. Teach the client how to ambulate with a walker.
- B. Instruct the client to bend at the waist to pick up needed items.
- C. Demonstrate the procedure for scanning the environment for vision.
- D. Inform the client about the importance of wearing rubber-soled shoes.
- E. Teach the spouse to use the metal frame to assist the client to turn in bed.
Correct Answer: A,C,D
Rationale: The client with a halo fixation device should be taught that the use of a walker and rubber-soled shoes may help prevent falls and injury and are therefore also helpful. It is helpful for the client to scan the environment visually because the client's peripheral vision is diminished from keeping the neck in a stationary position. The client with a halo fixation device should avoid bending at the waist because the halo vest is heavy, and the client's trunk is limited in flexibility. The nurse instructs the client and family that the metal frame on the device is never used to move or lift the client because this will disrupt the attachment to the client's skull, which is stabilizing the fracture.
The nurse in the newborn nursery is planning for the admission of a large for gestational age (LGA) infant. In preparing to care for this infant, the nurse should obtain equipment to perform which diagnostic test?
- A. Serum insulin level
- B. Heel stick blood glucose
- C. Rh and ABO blood typing
- D. Indirect and direct bilirubin levels
Correct Answer: B
Rationale: After birth, the most common problem in the LGA infant is hypoglycemia, especially if the mother is diabetic. At delivery when the umbilical cord is clamped and cut, maternal blood glucose supply is lost. The newborn continues to produce large amounts of insulin, which depletes the infant's blood glucose within the first hours after birth.
The nurse provides information to a client diagnosed with gastroesophageal reflux disease (GERD). What information should the nurse include when discussing foods that contribute to decreased lower esophageal sphincter (LES) pressure and thus worsen the condition? Select all that apply.
- A. Alcohol
- B. Fatty foods
- C. Citrus fruits
- D. Baked potatoes
- E. Caffeinated beverages
- F. Tomatoes and tomato products
Correct Answer: A,B,C,E,F
Rationale: GERD occurs as a result of the backward flow (reflux) of gastrointestinal contents into the esophagus. The most common cause of GERD is inappropriate relaxation of the LES, which allows the reflux of gastric contents into the esophagus and exposes the esophageal mucosa to gastric contents. Factors that influence the tone and contractility of the LES and lower LES pressure include alcohol; fatty foods; citrus fruits; caffeinated beverages such as coffee, tea, and cola; tomatoes and tomato products; chocolate; nicotine in cigarette smoke; calcium channel blockers; nitrates; anticholinergics; high levels of estrogen and progesterone; peppermint and spearmint; and nasogastric tube placement. Baked potatoes would not contribute to worsening the problem.
The nurse is analyzing an electrocardiogram (ECG) rhythm strip on an assigned client. What should the nurse record as the client's PR interval?
- A. 0.12 second
- B. 0.20 second
- C. 0.24 second
- D. 0.40 second
Correct Answer: A
Rationale: Standard ECG graph paper measurements are 0.04 second for each small box on the horizontal axis (measuring time) and 1 mm (measuring voltage) for each small box on the vertical axis.