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The nurse is assessing the deep tendon reflexes of a client with preeclampsia. Which method is used to elicit the biceps reflex?
- A. The nurse places her thumb on the muscle inset in the antecubital space and taps the thumb briskly with the reflex hammer.
- B. The nurse loosely suspends the client's arm in an open hand while tapping the back of the client's elbow.
- C. The nurse instructs the client to dangle her legs as the nurse strikes the area below the patella with the blunt side of the reflex hammer.
- D. The nurse instructs the client to place her arms loosely at her side as the nurse strikes the muscle insert just above the wrist.
Correct Answer: A
Rationale: To elicit the biceps reflex, the nurse places her thumb on the biceps tendon in the antecubital space and taps it with a reflex hammer, so A is correct. Answer B is incorrect as it describes a different technique. Answer C refers to the patellar reflex, and Answer D is not a standard method for the biceps reflex.
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The nurse assists with data collection during a screening event at a gastroenterology clinic. Which of the following client statements include risk factors for esophageal cancer? Select all that apply.
- A. A few years ago, I switched from smoking cigarettes to smoking cigars 1 or 2 times a week.
- B. I am proud that I was able to lose 10 lb, but I'm still considered obese for my height.
- C. I drink 3 or 4 beers nightly to relax, but I did switch to light beer recently.
- D. I have struggled with daily episodes of acid reflux for years, especially at nighttime.
- E. I snack on a lot of salted foods like popcorn and peanuts.
Correct Answer: A,C,D
Rationale: Smoking cigars (A), heavy alcohol use (C), and chronic acid reflux (D) are established risk factors for esophageal cancer. Obesity (B) is a weaker risk, and salted foods (E) are not directly linked.
The nurse is caring for a toddler with atopic dermatitis. The nurse should instruct the parents to
- A. Dress the child warmly to avoid chilling
- B. Keep the child away from other children for the duration of the rash
- C. Clean the affected areas with tepid water and detergent
- D. Wrap the child's hand in mittens or socks to prevent scratching
Correct Answer: D
Rationale: Wrap the child's hand in mittens or socks to prevent scratching. This prevents worsening of lesions and secondary infections.
The nurse is caring for a client who has acute pericarditis. Which of the following findings would be a priority to follow up?
- A. chest pain that is worse with deep inspiration
- B. muffled heart tones and jugular venous distension
- C. pericardial friction rub auscultated at the left sternal border
- D. temperature of 100.7 F (38.2 C) and a nonproductive cough
Correct Answer: B
Rationale: Muffled heart tones and jugular venous distension (B) suggest pericardial effusion or tamponade, a life-threatening complication requiring urgent follow-up. Chest pain (A) and friction rub (C) are expected, and mild fever (D) is less urgent.
The clinic nurse is reinforcing client teaching about the tiotropium that has been prescribed for chronic obstructive pulmonary disease (COPD). Which statement indicates that the client has a correct understanding of this medication?
- A. A capsule holds the powdered medication that I put in a special inhaler.
- B. I do not need to rinse my mouth out with water after taking tiotropium.
- C. I have been taking tiotropium every time I have difficulty breathing.
- D. Tiotropium helps control my COPD by reducing inflammation in my airway.
Correct Answer: A
Rationale: Tiotropium is a powder in a capsule used with an inhaler (A). Rinsing the mouth (B) is unnecessary, but it's taken daily, not PRN (C), and it's a bronchodilator, not anti-inflammatory (D).
The nurse has taught the parents of a 6-year-old client with nephrotic syndrome. Which of the following statements by the parents would require follow-up?
- A. I will encourage my child to play with other children.
- B. I will monitor my child's urine for protein every day.
- C. I will provide a healthy diet without added salt for my child.
- D. I will report swelling or rapid weight gain to the health care provider.
Correct Answer: A
Rationale: Encouraging play with others (A) may expose the child to infections, risky in nephrotic syndrome due to immunosuppression. Monitoring urine (B), low-salt diet (C), and reporting swelling (D) are correct.