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The nurse assesses the motor functions during a neurologic examination of a client. Which of the ff steps will help the nurse perform the examination effectively? Choose all that apply
- A. Allow the client to grasp the nurses hand firmly
- B. Check the patient's sensitivity to heat, cold, touch, and pain.
- C. Ask the client to pick up small and large objects between the thumb and forefinger
- D. Ask questions that require cognition and logic
Correct Answer: A
Rationale: A. Allowing the client to grasp the nurse's hand firmly is essential to assess grip strength, coordination, and muscle tone, which are important aspects of motor function evaluation during a neurologic examination.
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For a client with polycythemia vera, how can the nurse help decrease the risk for thrombus formation?
- A. Teach the client how to perform isometric exercises
- B. Help the client don thromboembolic stocking or support hose during waking hours
- C. Advise drinking 3 quarts (L) of fluid per day
- D. Instruct the client to rest immediately if chest pain develops  A1 PASSERS TRAINING, RESEARCH, REVIEW & DEVELOPMENT COMPANY MEDICAL SURGICAL NURSING SET I THE HEMATOLOGIC SYSTEM
Correct Answer: B
Rationale: For a client with polycythemia vera, there is an increased risk for thrombus formation due to the increased viscosity of the blood. Wearing thromboembolic stockings or support hose can help promote circulation, prevent stasis, and reduce the risk of thrombus formation. Compression stockings provide external pressure to the legs, which helps prevent blood from pooling and clotting. This intervention is commonly recommended for patients at risk for thrombus formation to improve blood flow in the lower extremities and reduce the risk of deep vein thrombosis (DVT) and pulmonary embolism.
Before, during and after seizure. The nurse knows that the patient is ALWAYS placed in what position?
- A. Low fowler's
- B. Modified trendelenburg
- C. Side lying
- D. Supine
Correct Answer: C
Rationale: The correct position to place a patient before, during, and after a seizure is on their side, also known as the recovery position. Placing the patient in the side-lying position helps prevent aspiration if the patient vomits and ensures that the airway remains open. This position also helps to prevent choking and allows for drainage of fluids from the mouth. Additionally, it reduces the risk of airway obstruction and helps to maintain proper alignment of the head, neck, and spine. By placing the patient in the side-lying position, the nurse can ensure the patient's safety and well-being during and after a seizure episode.
What is the most important postoperative instruction the nurse must give a client who has just returned from the operating room after receiving a subarachnoid block?
- A. "Avoid drinking liquids until the gag reflex returns."
- B. "Avoid eating milk products for 24 hours."
- C. "Notify a nurse if you experience blood in your urine."
- D. "Remain supine for the time specified by the physician."
Correct Answer: D
Rationale: After receiving a subarachnoid block, the client may experience a sudden drop in blood pressure that can lead to complications such as dizziness or fainting upon standing. Therefore, it is crucial for the client to remain in a supine position for the duration specified by the physician to allow for proper monitoring and management of any potential postoperative complications. This instruction helps prevent the occurrence of hypotension and other adverse effects by allowing adequate time for the block to wear off and for the body to adjust to changes in blood pressure. It also ensures the safety and well-being of the client during the immediate postoperative period.
What might you conclude if you notice a wide perineum and unequal gluteal and thigh folds when assessing a newborn?
- A. Osteogenesis imperfecta
- B. Torticollis
- C. Scoliosis
- D. Hip dysplasia
Correct Answer: D
Rationale: When assessing a newborn and noticing a wide perineum and unequal gluteal and thigh folds, it may signal the possibility of developmental dysplasia of the hip (DDH), also known as hip dysplasia. DDH is a condition where the hip joint does not properly form in newborns, leading to instability and potential dislocation. The wide perineum and unequal gluteal and thigh folds are physical signs that can be indicative of hip dysplasia. It is essential to diagnose and treat hip dysplasia early to prevent long-term complications like difficulty walking and osteoarthritis. Regular screening of newborns for hip dysplasia risk factors and physical exam findings is crucial for early detection and intervention.
A 12-year-old male has short stature because of a constitutional growth delay. What should the nurse be the most concerned about?
- A. Proper administration of thyroid hormone
- B. Proper administration of human growth hormones
- C. Child's self-esteem and sense of competence
- D. Helping child understand that his height is most likely caused by chronic illness and is not his fault
Correct Answer: C
Rationale: The nurse should be most concerned about the child's self-esteem and sense of competence. A 12-year-old male with short stature due to a constitutional growth delay may experience feelings of inadequacy or embarrassment because of his height. It is important for the nurse to address these emotional aspects of the condition and support the child in developing a positive self-image. By promoting the child's self-esteem and sense of competence, the nurse can help the child navigate any challenges associated with his height and build confidence in his abilities and worth as an individual.