Nokea
During you musculoskeletal assessment of the client, you determine that the client has muscular strength against gravity but not against resistance. You would document this assessment as:
- A. 1 on the scale of 1 to 3
- B. 2 on the scale of 1 to 5
- C. 3 on the scale of 0 to 5
- D. 4 on the scale of 0 to 5
Correct Answer: C
Rationale: Muscular strength against gravity but not resistance is graded as 3 on the 0-5 scale, indicating fair strength.
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The nurse notes that the client admitted after fainting is receiving olanzapine. Which disorder or condition should the nurse suspect the client is experiencing?
- A. Schizophrenia
- B. Dementia disorder
- C. Personality disorder
- D. Major depressive disorder
Correct Answer: A
Rationale: Olanzapine is an atypical antipsychotic medication used in the management of manifestations associated with psychotic disorders. It is the first-line treatment for schizophrenia, targeting both the positive and the negative symptoms. None of the remaining options are indicated uses for this medication.
An infant with increased intracranial pressure (ICP) on a regular diet vomits while eating dinner. Which of the following should the nurse do next?
- A. Put the child on nothing-by-mouth (NPO) status.
- B. Call to report this event to the physician.
- C. Wait a few minutes, then refeed the child.
- D. Administer the prescribed antiemetic.
Correct Answer: B
Rationale: Vomiting in an infant with increased ICP may indicate worsening pressure, requiring immediate physician notification.
The nurse walks into a client's room to administer the 9:00 a.m. medications and notices that the client is in an awkward position in bed. What is the nurse's first action?
- A. Ask the client his name.
- B. Check the client's name band.
- C. Straighten the client's pillow behind his back.
- D. Give the client his medications.
Correct Answer: C
Rationale: Repositioning the client first ensures comfort and safety, addressing the immediate issue of the awkward position before administering medications.
The nurse is caring for a client with a history of burns. Which of the following nutritional interventions should be included in the plan of care?
- A. High-protein, high-calorie diet.
- B. Low-sodium diet.
- C. Low-fat diet.
- D. High-fiber diet.
Correct Answer: A
Rationale: A high-protein, high-calorie diet supports tissue repair and energy needs in burn recovery.
A client experiencing a mild panic attack has the following arterial blood gas (ABG) results: pH 7.49, PCO2 31 mm Hg, PaO2 97 mm Hg, HCO3 22 mEq/L. The nurse reviews the results and determines that the client has which acid-base disturbance?
- A. Metabolic acidosis
- B. Metabolic alkalosis
- C. Respiratory acidosis
- D. Respiratory alkalosis
Correct Answer: D
Rationale: Acidosis is defined as a pH of less than 7.35, whereas alkalosis is defined as a pH of greater than 7.45. Respiratory alkalosis is present when the PCO2 is less than 35, whereas respiratory acidosis is present when the PCO2 is greater than 45. Metabolic acidosis is present when the HCO3 is less than 22 mEq/L, whereas metabolic alkalosis is present when the HCO3 is greater than 26 mEq/L. This client's ABGs are consistent with respiratory alkalosis.