Nokea
The nurse is assisting a client with removing shoes prior to an examination and observes that the client has a flexion deformity of several toes on both feet of the proximal interphalangeal (PIP) joints. What can the nurse encourage the client to do?
- A. Bind the toes so that they will straighten.
- B. Do active range of motion on the toes.
- C. Have surgery to fix them.
- D. Wear properly fitting shoes.
Correct Answer: D
Rationale: Hammer toe is a flexion deformity of the PIP joint and may involve several toes and may result from wearing poorly fitting shoes. They will not straighten by binding the toes or doing active range of motion exercises. Surgery is an option but should be discussed with an orthopedic surgeon or podiatrist.
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A client with diabetes punctured the foot with a sharp object. Within a week, the client developed osteomyelitis of the foot. The client was admitted for IV antibiotic therapy. How long does the nurse anticipate the client will receive IV antibiotics?
- A. 6 months
- B. 7 to 10 days
- C. 2 to 3 weeks
- D. At least 4 weeks
Correct Answer: D
Rationale: Identification of the causative organism to initiate appropriate and ongoing antibiotic therapy for infection control. IV antibiotic therapy is administered for at least 4 weeks, followed by another 2 weeks (or more) of IV antibiotics or oral antibiotics.
A client is receiving treatment for an acute episode of gout with colchicine. The nurse is administering the medication every 2 hours. What symptom(s) should the nurse be sure the client communicates so that the drug can be temporarily stopped? Select all that apply.
- A. Diarrhea
- B. Tingling in the arms
- C. Intestinal cramping
- D. Increase in pain in the affected extremity
- E. Nausea and vomiting
Correct Answer: A,C,E
Rationale: Colchicine is administered every 1 or 2 hours until the pain subsides or nausea, vomiting, intestinal cramping, and diarrhea develop. When one or more of these symptoms occurs, the drug should be stopped temporarily. Tingling in the arms and increase in pain are not normal adverse reactions that are seen with this drug.
A client has had several diagnostic tests to determine systemic lupus erythematosus (SLE). What result is very specific indicator of this diagnosis?
- A. Positive Anti-dsDNA antibody test
- B. Positive Anti-Sm antibodies
- C. Positive ANA titer
- D. Elevated ESR
Correct Answer: A
Rationale: Anti-double-stranded DNA (anti-dsDNA) antibody test is a test that shows high titers of antibodies against native DNA. This is very specific for SLE because this test is not positive for other autoimmune disorders. Anti-Smith (anti-Sm) antibodies are specific for SLE, but are found in only 20% to 30% of clients with SLE. ANA titer shows the presence of an autoimmune disease but is not specific to SLE. The other lab studies may also indicate multisystem involvement.
A nurse is monitoring a client diagnosed with Lyme disease. Which finding would suggest that the disease is in the early stages?
- A. Breathlessness
- B. Red macule or papule
- C. Bony nodule
- D. Swollen painful knees
Correct Answer: B
Rationale: Early stage 1 symptoms include a red macule or papule at the site of the tick bite, a typical bull's-eye rash, headache, neck stiffness, and pain. Breathlessness and bony nodules are not associated with Lyme disease. Later stage symptoms include swollen and painful knees.
A client calls the clinic and reports having been bitten by a tick and expresses worry about Lyme disease. How long does the nurse understand that the tick must be attached to transmit infection?
- A. 1 to 2 hours
- B. 12 to 24 hours
- C. 24 to 36 hours
- D. 36 to 48 hours
Correct Answer: D
Rationale: For the client to have Lyme disease, the tick must be attached for 36 to 48 hours. Removing a tick as early as possible may prevent infection. The other times given are not long enough to transmit infection.