Nokea
The client with a pelvic fracture developed a fat embolism. The nurse should assess the client for which specific sign?
- A. Dyspnea
- B. Chest pain
- C. Delirium
- D. Petechiae
Correct Answer: D
Rationale: D. The nurse should assess for petechiae. Petechiae (small purplish hemorrhagic spots on the skin) are thought to be due to transient thrombocytopenia. They can occur over the chest, anterior axillary folds, hard palate, buccal membranes, and conjunctival sacs.
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If the client is allergic to penicillin, the nurse must question a medical order for which type of antibiotic?
- A. An aminoglycoside such as gentamicin sulfate (Garamycin)
- B. A cephalosporin such as cefaclor (Ceclor)
- C. A tetracycline such as doxycycline (Vibramycin)
- D. A sulfonamide such as trimethoprim/sulfamethoxazole (Bactrim)
Correct Answer: B
Rationale: Cephalosporins (e.g., cefaclor) have a cross-sensitivity with penicillin, risking allergic reactions in penicillin-allergic clients. The other antibiotics listed do not share this cross-reactivity.
Which response by the nurse is most appropriate when the mother, concerned about her unborn daughter developing DMD, states that her brother and son have DMD?
- A. "You already have one child with muscular dystrophy; it's unlikely you'll have another."
- B. "Your brother and son have DMD; it's unlikely that you'll have another child with DMD."
- C. "As many as one-third of children born with DMD have no family history of the disease."
- D. "If your unborn child is a girl, she may carry the gene, but she will not develop DMD."
Correct Answer: D
Rationale: DMD is X-linked; females may be carriers but do not develop the disease.
A femoral head replacement was performed on an elderly client. Postoperatively, the nurse positions the client with an abductor pillow between the client's legs. What is the primary reason for this?
- A. This position will promote greater comfort.
- B. Abduction promotes greater circulation to the hip joint.
- C. Abduction will prevent the prosthesis from snapping out of the socket.
- D. This position will help to prevent pressure on the sciatic nerve.
Correct Answer: C
Rationale: An abductor pillow maintains abduction, preventing prosthesis dislocation post-femoral head replacement.
While teaching the client, what can the nurse explain about the purpose for prescribing this medication?
- A. To reduce emotional depression
- B. To relax skeletal muscles
- C. To promote restful sleep
- D. To relieve inflammation
Correct Answer: B
Rationale: Cyclobenzaprine (Flexeril) is a muscle relaxant used to reduce muscle spasms associated with a herniated disk, alleviating pain and improving mobility. It does not primarily address depression, sleep, or inflammation.
Which level of participation should the nurse expect when assessing a 9-year-old who has mental retardation with an IQ level of 45?
- A. Able to communicate verbally only with two-letter words
- B. Able to read and comprehend simple written instructions
- C. Able to walk independently and perform a simple skill
- D. Able to perform tasks that require careful manual dexterity
Correct Answer: C
Rationale: An IQ of 45 indicates moderate intellectual disability, allowing independent walking and simple tasks.