Nokea
An adult client who experienced a fractured left tibia has a long leg cast and is using crutches to ambulate. In caring for the client, the nurse assesses for which sign/symptom that indicates a complication associated with crutch walking?
- A. Left leg discomfort
- B. Weak biceps brachii
- C. Triceps muscle spasms
- D. Forearm muscle weakness
Correct Answer: D
Rationale: Forearm muscle weakness is a sign of radial nerve injury caused by crutch pressure on the axillae. When a client lacks upper body strength, especially in the flexor and extensor muscles of the arms, he or she frequently allows weight to rest on the axillae and on the crutch pads instead of using the arms for support while ambulating with crutches. Leg discomfort is expected as a result of the injury. Weak biceps brachii is not a complication of crutch walking. Triceps muscle spasms may occur as a result of increased muscle use but is not a complication of crutch walking.
You may also like to solve these questions
The nurse is caring for a client scheduled to undergo a renal biopsy. To minimize the risk of postprocedure complications, the nurse reports which laboratory results to the primary health care provider before the procedure?
- A. Prothrombin time: 15 seconds
- B. Potassium: 3.8 mEq/L (3.8 mmol/L)
- C. Serum creatinine: 1.2 mg/dL (106 mcmol/L)
- D. Blood urea nitrogen (BUN): 18 mg/dL (6.48 mmol/L)
Correct Answer: A
Rationale: Postprocedure hemorrhage is a complication after renal biopsy. Because of this, prothrombin time is assessed before the procedure. The normal prothrombin time range is 11 to 12.5 seconds. The nurse ensures that these results are available and reports abnormalities promptly. Options 2, 3, and 4 identify normal values. The normal potassium is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L); the normal serum creatinine is 0.5 to 1.2 mg/dL (44 to 106 mcmol/L); and the normal BUN is 10-20 mg/dL (3.6-7.1 mmol/L).
The nurse is reviewing the laboratory results for a client who is receiving torsemide 5 mg orally daily. What value should indicate to the nurse that the client might be experiencing an adverse effect of the medication?
- A. A chloride level of 98 mEq/L (98 mmol/L)
- B. A sodium level of 135 mEq/L (135 mmol/L)
- C. A potassium level of 3.1 mEq/L (3.1 mmol/L)
- D. A blood urea nitrogen (BUN) level of 15 mg/dL (5.4 mmol/L)
Correct Answer: C
Rationale: Torsemide is a loop diuretic. The medication can produce acute, profound water loss; volume and electrolyte depletion; dehydration; decreased blood volume; and circulatory collapse. Option 3 is the only option that indicates electrolyte depletion because the normal potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). The normal chloride level is 98 to 107 mEq/L (98 to 107 mmol/L). The normal sodium level is 135 to 145 mEq/L (135 to 145 mmol/L). The normal BUN level ranges from 10 to 20 mg/dL (3.6 to 7.1 mmol/L).
A client prescribed prazosin hydrochloride asks the nurse why the first dose must be taken at bedtime. Which response by the nurse is based on the understanding of the first dose use of prazosin hydrochloride?
- A. Treatment with prazosin hydrochloride results in drowsiness.
- B. Treatment with prazosin hydrochloride can cause dependent edema.
- C. Prazosin hydrochloride should be taken when the stomach is empty.
- D. Treatment with prazosin hydrochloride can cause dizziness or possible syncope.
Correct Answer: D
Rationale: Prazosin is an alpha-adrenergic blocking agent. 'First-dose hypotensive reaction' may occur during early therapy, which is characterized by dizziness, lightheadedness, and possible loss of consciousness. The occurrence of these effects is better tolerated if the client is in bed. This also can occur when the dosage is increased. This effect usually disappears with continued use or the dosage is decreased.
A client is diagnosed with hypothyroidism. The nurse performs an assessment on the client, expecting to note which findings? Select all that apply.
- A. Weight loss
- B. Bradycardia
- C. Hypotension
- D. Dry, scaly skin
- E. Heat intolerance
- F. Decreased body temperature
Correct Answer: B,C,D,F
Rationale: The manifestations of hypothyroidism are the result of decreased metabolism from low levels of thyroid hormones. Some of these manifestations are bradycardia; hypotension; cool, dry, scaly skin; decreased body temperature; dry, coarse, brittle hair; decreased hair growth; cold intolerance; slowing of intellectual functioning; lethargy; weight gain; and constipation.
A client is receiving desmopressin intranasally. Which assessment parameters should the nurse monitor to determine the effectiveness of this medication?
- A. Daily weight
- B. Temperature
- C. Apical heart rate
- D. Pupillary response
Correct Answer: A
Rationale: Desmopressin is an analog of vasopressin (antidiuretic hormone). It is used in the management of diabetes insipidus. The nurse monitors the client's fluid balance to determine the effectiveness of the medication. Fluid status can be evaluated by noting intake and urine output, daily weight, and the presence of edema. The measurements in options 2, 3, and 4 are not related to this medication.