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If a patient comes into facility with muscle weakness, where should you focus your physical assessment?
If a patient comes into facility with muscle weakness, where should you focus your physical assessment?
- A. Muscle tone
- B. Muscle strength
- C. ROM
- D. Sensory function
Correct Answer: B
Rationale: Muscle strength assessment directly evaluates the extent and distribution of weakness.
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A nurse's neighbor complains of severe right flank pain. She explains that it began during the night, but she was able to take acetaminophen (Tylenol) and return to bed. When she awoke, the pain increased in intensity. How should the nurse intervene?
- A. Explain that she can't give medical advice
- B. Inform the neighbor that she might require surgery
- C. Advise the neighbor to seek medical attention
- D. Tell the neighbor that she'll be fine because she was able to get through the night
Correct Answer: C
Rationale: The nurse should advise the neighbor to seek medical attention. Explaining that she can't give medical advice might cause a delay in treatment. It's beyond the nurse's scope of practice to suggest that the neighbor might need surgery. Telling the neighbor she'll be fine might also delay treatment, and it isn't a professional response.
The nurse is teaching a client and family about phenelzine (Nardil).
Which of the following foods would the nurse urge the client to avoid?
- A. Eggs
- B. Vegetables
- C. American cheese
- D. Fruits
Correct Answer: C
Rationale: Cheese is one of the foods that may cause a hypertensive crisis when taken with Nardil, a monoamine oxidase inhibitor (MAOI).
The nurse is assessing a client with suspected rheumatoid arthritis. Which of the following findings would support this diagnosis?
- A. Morning stiffness lasting over 30 minutes.
- B. Heberden’s nodes on the fingers.
- C. Pain in a single joint after exercise.
- D. Fever and weight loss without joint pain.
Correct Answer: A
Rationale: Morning stiffness lasting over 30 minutes is a hallmark of rheumatoid arthritis due to synovial inflammation. Heberden’s nodes (B) indicate osteoarthritis, single-joint pain (C) suggests injury, and fever/weight loss (D) are nonspecific without joint involvement.
The nurse is teaching a client about the healthy use of ego defense mechanisms. An appropriate goal for this client would be
- A. Reduce fear and protect self-esteem
- B. Minimize anxiety and delay apprehension
- C. Avoid conflict and leave unpleasant situations
- D. Increase independence and communicate more often
Correct Answer: A
Rationale: Reduce fear and protect self-esteem. Ego defense mechanisms are unconscious proactive barriers that are used to manage instinct and affect in the presence of stressful situations. Healthy reactions are those in which the client admits that they are feeling various emotions.
The patient is admitted to the emergency department and was brought to the unit due to poor diabetic management. The wife asks how they can learn better. They have previously been to a diabetic class without much success.
Which of the following nursing strategy will be appropriate for the client?
- A. Arrange a meeting with the health care team.
- B. Have a one-on-one diabetic teaching with the client.
- C. Refer the client and wife to group diabetic teaching class.
- D. Discuss the possibility of having to stay longer in the unit to manage the blood sugar.
Correct Answer: B
Rationale: One-on-one teaching allows tailored education to address specific learning needs.