Nokea
The client with MS tells the nurse about extreme fatigue. Which assessment findings should the nurse identify as contributing to the client's fatigue? Select all that apply.
- A. Hemoglobin 9.5 g/dL and hematocrit is 31.8%
- B. Taking baclofen 15 mg 3 times per day
- C. Working 4 to 8 hours per week in the family business
- D. Stopped taking amitriptyline 8 weeks earlier
- E. Presence of a cardiac murmur at the tricuspid valve.
- F. Bilateral leg weakness noted when walking in room
Correct Answer: A,B,D,E,F
Rationale: The lower-than-normal Hgb and Hct indicate anemia. Inadequate cell oxygenation contributes to fatigue. Baclofen (Lioresal), a skeletal muscle relaxant used to relieve spasms, has the adverse effects of drowsiness and fatigue. Working 4 to 8 hours per week is a limited number of hours and should not contribute to the client’s fatigue. The client has stopped amitriptyline (Elavil), an antidepressant, and may be clinically depressed. Fatigue is a major symptom of depression. A tricuspid murmur indicates an incompetent cardiac valve, which will decrease the amount of oxygenated blood reaching the tissues. The increased energy expenditure with ambulation can increase fatigue.
You may also like to solve these questions
Which diagnostic test is used to confirm the diagnosis of Amyotrophic Lateral Sclerosis (ALS)?
- A. Electromyogram (EMG).
- B. Muscle biopsy.
- C. Serum creatine kinase (CK).
- D. Pulmonary function test.
Correct Answer: A
Rationale: EMG (A) detects abnormal muscle electrical activity characteristic of ALS, confirming the diagnosis. Muscle biopsy (B) is less specific, CK (C) may be elevated but isn’t diagnostic, and pulmonary tests (D) assess complications, not diagnosis.
Spinal precautions are ordered for the client who sustained a neck injury during an MVA. The client has yet to be cleared that there is no cervical fracture. Which action is the nurse’s priority when receiving the client in the ED?
- A. Assessing the client using the Glasgow Coma Scale (GCS)
- B. Assessing the level of sensation in the client’s extremities
- C. Checking that the cervical collar was correctly placed by EMS
- D. Applying antiembolism hose to the client’s lower extremities
Correct Answer: C
Rationale: The nurse should determine the neurological status using the GCS, but this is not the priority. The nurse should assess sensation status at intervals to determine neurological injury progression, but this is not the priority. Maintaining the correct placement of the cervical collar will keep the client’s head and neck in a neutral position and prevent further injury if a spinal fracture or SCI is present. Because ensuring that the cervical collar is correctly placed will prevent further injury, it is priority. Applying antiembolism hose is an intervention to prevent thromboembolic complications, but this is not the priority.
The client is at risk for septic emboli after being diagnosed with meningococcal meningitis. Which action by the nurse directly addresses this risk?
- A. Monitoring vital signs and oxygen saturation levels hourly
- B. Planning to give meningococcal polysaccharide vaccine
- C. Assessing neurological function with the Glasgow Coma Scale q2h
- D. Completing a thorough vascular assessment of all extremities q2h
Correct Answer: D
Rationale: Monitoring VS is indicated but does not address the complication of septic emboli. Immunization with the meningococcal polysaccharide vaccine (Menomune) is a preventive measure against meningitis and would not be included in treatment. Frequent neurological assessments are indicated but do not address the complication of septic emboli. Frequent vascular assessments will detect vascular compromise secondary to septic emboli. Early detection allows for interventions that will prevent gangrene and possible loss of limb.
The nurse observes a coworker acting erratically. The clients assigned to this coworker don’t seem to get relief when pain medications are administered. Which action should the nurse implement?
- A. Try to help the coworker by confronting the coworker with the nurse’s suspicions.
- B. Tell the coworker that the nurse will give all narcotic medications from now on.
- C. Report the nurse’s suspicions to the nurse’s supervisor or the facility’s peer review.
- D. Do nothing until the nurse can prove the coworker has been using drugs.
Correct Answer: C
Rationale: Erratic behavior and ineffective pain relief suggest possible drug diversion. Reporting to the supervisor or peer review (C) ensures proper investigation while protecting patients. Confronting (A) may escalate, taking over medications (B) doesn’t address the issue, and waiting for proof (D) risks harm.
Which should be the nurse's first intervention with the client diagnosed with Bell's palsy?
- A. Explain that this disorder will resolve within a month.
- B. Tell the client to apply heat to the involved side of the face.
- C. Encourage the client to eat a soft diet.
- D. Teach the client to protect the affected eye from injury.
Correct Answer: D
Rationale: Bell’s palsy impairs eye closure, risking corneal damage. Teaching eye protection (D) is the priority. Resolution timeline (A), heat (B), and diet (C) are secondary.