Nokea
The nurse assesses a client and notes that he has a weak, irregular pulse, as well as soft, flabby muscles. The nurse should assess the client further for:
- A. Hypercalcemia.
- B. Hypernatremia.
- C. Hypokalemia.
- D. Hypomagnesemia.
Correct Answer: C
Rationale: Weak, irregular pulse and flabby muscles are signs of hypokalemia, which affects muscle and cardiac function. The other conditions present differently.
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The nurse caring for a client after shoulder arthroplasty for rheumatoid arthritis monitors the client for brachial plexus compromise. To assess the status of the median nerve, which action would the nurse perform?
- A. Have the client spread all of the fingers wide and resist pressure.
- B. Monitor for flexion of the biceps by having the client raise the forearm.
- C. Have the client move the thumb toward the palm and back to the neutral position.
- D. While grasping the nurse's hand, note the strength of the client's first and second fingers.
Correct Answer: D
Rationale: To assess the median nerve status, the client should be instructed to grasp the nurse's hand. The nurse should note the strength of the client's first and second fingers. A weak grip may indicate compromise of the median nerve. Asking the client to spread all fingers wide and resist pressure assesses the ulnar nerve status. Monitoring for flexion of the biceps by raising the forearm assesses the cutaneous nerve status. Asking the client to move the thumb toward the palm and back to neutral position assesses the radial nerve status.
The nurse is caring for a client with a history of osteoarthritis. Which of the following non-pharmacologic interventions should be included in the plan of care?
- A. Apply heat to affected joints.
- B. Restrict weight-bearing activities.
- C. Encourage a low-protein diet.
- D. Limit range-of-motion exercises.
Correct Answer: A
Rationale: Heat therapy reduces stiffness and pain in osteoarthritis.
You are working in a community pediatric health clinic. Which developmental task should you apply into your practice?
- A. You should apply the principles of initiative when caring for preschool children.
- B. You should apply the principles of sensorimotor thought when caring for preschool children.
- C. You should apply the principles of intimacy when caring for the adolescent.
- D. You should apply the principles of concrete operations when caring for the adolescent.
Correct Answer: A
Rationale: According to Erikson's developmental stages, preschool children (ages 3-5) are in the stage of Initiative vs. Guilt, where they develop a sense of purpose through exploration and play. This is the appropriate developmental task to apply in a pediatric clinic for this age group.
The mother of a child with bronchial asthma tells the nurse that the child wants a pet. Which of the following pets is most appropriate?
- A. Fish
- B. Dog
- C. Cat
- D. Bird
Correct Answer: A
Rationale: Pets are discouraged when parents are trying to allergy-proof a home for a child with bronchial asthma, unless the pets are kept outside. Pets with hair or feathers are especially likely to trigger asthma attacks. A fish is a satisfactory pet for this child, but the parents should be taught to keep the fish tank clean to prevent it from harboring mold.
The nurse teaches a client scheduled for an I.V. pyelogram what to expect when the dye is injected. The nurse knows that the client has correctly understood what was taught when he states that he may experience which of the following sensations when the dye is injected?
- A. A metallic taste.
- B. Flushing of the face.
- C. Cold chills.
- D. Chest pain.
Correct Answer: B
Rationale: Flushing is a common sensation during I.V. pyelogram dye injection due to vasodilation caused by the contrast medium.