Nokea
During muscle strength testing, the patient has active movement against gravity and some resistance to pressure. What score should the nurse give this finding?
- A. 2
- B. 3
- C. 4
- D. 5
Correct Answer: C
Rationale: Grade 4 indicates movement against gravity and moderate resistance.
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Within how many hours does tissue plasminogen activator (TPA) need to be given to be most successful for a client with an ischemic stroke?
- A. 6 hours
- B. 3 hours
- C. 8 hours
- D. 10 hours
Correct Answer: B
Rationale: TPA is most effective when administered within 3 hours of stroke onset.
Which statement describes osteosarcoma?
- A. High rate of local recurrence
- B. Very malignant and metastasizes early
- C. Arises in cancellous ends of long bones
- D. Develops in the medullary cavity of long bones
Correct Answer: B
Rationale: Osteosarcoma is highly malignant and metastasizes early.
When is a fat embolism most likely to occur?
- A. 24 to 48 hours following a fractured tibia
- B. 36 to 72 hours following a skull fracture
- C. 4 to 5 days following a fractured femur
- D. 5 to 6 days following a pelvic fracture
Correct Answer: A
Rationale: Fat embolism is most common after tibial fractures within 24-48 hours.
A client with relapsing-remitting multiple sclerosis tells the nurse that even though the primary symptoms of exacerbation are leg spasms and blurred vision, the hardest part is trying to get through the day because of being so tired. Which diagnosis should the nurse identify as a priority for this client?
- A. Fatigue
- B. Disturbed Sensory Perception
- C. Impaired Physical Mobility
- D. Self-Care Deficit
Correct Answer: A
Rationale: Fatigue is one of the most debilitating symptoms of MS and significantly impacts the client's quality of life. Addressing fatigue should be a priority in the care plan.
What should be included in the management during the first 48 hours after an acute soft tissue injury of the ankle (select one that doesn't apply)?
- A. Use of elastic wrap
- B. Initial immobilization and rest
- C. Elevation of ankle above the heart
- D. Alternating the use of heat and cold
Correct Answer: D
Rationale: The initial management includes rest, ice, compression, and elevation (RICE) to reduce swelling and pain.