Nokea
In planning discharge teaching for a client after a lumbar laminectomy, the nurse would instruct the client to exercise regularly to strengthen which muscles?
- A. Anal sphincter.
- B. Abdominal.
- C. Trapezius.
- D. Rectus femoris.
Correct Answer: B
Rationale: strengthening the abdominal muscles adds support for the muscles supporting the lumbar spine
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Which diagnosis for the client with tuberculosis would have the greatest impact on public health?
- A. Ineffective breathing pattern
- B. Deficient knowledge
- C. Fatigue
- D. Ineffective family therapeutic regimen management
Correct Answer: B
Rationale: Deficient knowledge about TB transmission risks public health by increasing spread, requiring education to ensure compliance with treatment and precautions.
A nine-month-old child with complaints of a fever of 102.2°F (39°C) and frequent vomiting.
The nurse would expect which of the following reflexes to still be present?
- A. Babinski's reflex.
- B. Moro's reflex.
- C. Tonic neck reflex.
- D. Grasp reflex.
Correct Answer: A
Rationale: Strategy: Think about growth and development. (1) correct-stroking outer sole of foot upward causes toes to hyperextend and fan and great toe to dorsiflex, disappears after one year of age (2) sudden jarring causes extension and abduction of extremities and fanning of fingers with index finger and thumb forming a C shape, disappears after 3-4 months (3) when head is turned to side, arm and leg extend on that side, and opposite arm and leg flex, disappears by age 3-4 months (4) touching palms of hands or soles of feet causes flexion of hands and toes, palmar grasp disappears after 3 months of age, plantar grasp lessened by 8 months of age
The nurse is caring for a client who is receiving a continuous IV infusion of furosemide (Lasix) for heart failure. Which of the following laboratory results would be of GREATest concern to the nurse?
- A. Potassium 3.0 mEq/L.
- B. Sodium 138 mEq/L.
- C. Creatinine 1.2 mg/dL.
- D. Calcium 9.0 mg/dL.
Correct Answer: A
Rationale: Hypokalemia (potassium 3.0 mEq/L) is a serious complication of furosemide, increasing the risk of arrhythmias in heart failure. Options B, C, and D are normal: sodium 138 mEq/L, creatinine 1.2 mg/dL, and calcium 9.0 mg/dL do not indicate complications.
A client with posttraumatic stress disorder (PTSD).
One of the goals the nurse and a client with posttraumatic stress disorder (PTSD) mutually agreed upon is that he will increase his participation in out-of-the apartment activities. Which of the following recommendations, if made by the nurse, will be MOST therapeutic to achieve this goal?
- A. Take a day trip with a friend.
- B. Take an eleven-minute bus ride alone.
- C. Join a support group and participate in a victim assistance organization.
- D. Take a ten-minute walk with his wife around the block.
Correct Answer: C
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) reasonable recommendation to begin using in a systematic desensitization program after the crisis is alleviated (2) reasonable recommendation to begin using in a systematic desensitization program after the crisis is alleviated (3) correct-support groups of people who have suffered similar acts of violence can be helpful and supportive to teach clients how to deal with the traumatizing situation and the emotional aftermath (4) reasonable recommendation to begin using in a systematic desensitization program after the crisis is alleviated
The nurse has identified what appears to be ventricular tachycardia on the cardiac monitor of a client being evaluated for possible myocardial infarction. The first action the nurse would perform is to
- A. Begin cardiopulmonary resuscitation
- B. Prepare for immediate defibrillation
- C. Notify the 'Code' team and provider
- D. Assess airway breathing and circulation
Correct Answer: D
Rationale: Assess airway breathing and circulation. The nurse must first assess the client to determine the appropriate next step. In this case the first step the nurse must take is to evaluate the A, B, C’s.