Nokea
If the nurse is unable to elicit the deep tendon reflexes of the patella, the nurse should ask the client to:
- A. Pull against the palms
- B. Grimace the facial muscles
- C. Cross the legs at the ankles
- D. Perform Valsalva maneuver
Correct Answer: A
Rationale: Pulling against the palms enhances reflex response by increasing muscle tone, aiding in eliciting the patellar reflex.
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The nurse is preparing a client with an axillo-popliteal bypass graft for discharge. The client should be taught to avoid:
- A. Using a recliner to rest
- B. Resting in supine position
- C. Sitting in a straight chair
- D. Sleeping in right Sim's position
Correct Answer: C
Rationale: Sitting in a straight chair can compress the graft, impairing blood flow, and should be avoided to promote graft patency.
A client with diabetes asks the nurse for advice regarding methods of birth control. Which method of birth control is most suitable for the client with diabetes?
- A. Intrauterine device
- B. Oral contraceptives
- C. Diaphragm
- D. Contraceptive sponge
Correct Answer: C
Rationale: The diaphragm is suitable for diabetic clients as it avoids hormonal effects that could impact glucose control.
The nurse is on a memory care unit. A client insists on leaving to go home. Which of the following should the nurse do?
- A. review the reality orientation board in the client's room
- B. take the client to the activity room to interact with others
- C. contact the client's primary health care provider for a medication order
- D. provide the client with a glass of milk and a sandwich
Correct Answer: B
Rationale: Redirecting the client to a social activity can help distract from the desire to leave and promote engagement, which is appropriate for a client with memory issues.
A 32-year-old woman comes into the clinic for a well-woman exam and asks for information on an intrauterine device (IUD) for contraception. The nurse should explain that all of the following are potential risks EXCEPT
- A. stroke.
- B. pelvic infections.
- C. abnormal menstrual bleeding.
- D. ectopic pregnancy.
Correct Answer: A
Rationale: IUD risks include pelvic infections, abnormal bleeding, and ectopic pregnancy. Stroke is not a recognized risk associated with IUD use.
A client with acute alcohol intoxication is being treated for hypomagnesemia. During assessment of the client, the nurse would expect to find:
- A. Bradycardia
- B. Negative Chvostek's sign
- C. Hypertension
- D. Positive Trousseau's sign
Correct Answer: D
Rationale: Hypomagnesemia can cause a positive Trousseau's sign, indicating neuromuscular irritability due to low magnesium levels.