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The nurse is caring for a client with a history of multiple sclerosis.
- A. Which symptom is expected in a client with multiple sclerosis?
- B. Chest pain and shortness of breath.
- C. Muscle weakness and spasticity.
- D. Weight gain and edema.
- E. Persistent headaches.
Correct Answer: B
Rationale: Muscle weakness and spasticity are common in multiple sclerosis due to demyelination of nerve fibers. Chest pain, edema, and headaches are not typical symptoms.
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The nurse is caring for a client with a history of type 2 diabetes who is receiving insulin aspart (NovoLog) 10 units subcutaneously before meals. Which of the following findings would be of GREATest concern to the nurse?
- A. Blood glucose of 80 mg/dL.
- B. Heart rate of 90 bpm.
- C. Sweating and shakiness.
- D. Blood pressure of 130/80 mmHg.
Correct Answer: C
Rationale: Sweating and shakiness indicate hypoglycemia, a serious complication of insulin aspart, requiring immediate treatment with carbohydrates. Options A, B, and D are less concerning: glucose 80 mg/dL is normal, heart rate 90 bpm and blood pressure 130/80 mmHg are stable.
The nurse is caring for an adult who had a cervical laminectomy this morning. In addition to routine vital signs, what should the nurse assess because of the location of the surgery?
- A. Pedal pulses
- B. Hand grasps
- C. Radial pulse
- D. Urine output
Correct Answer: B
Rationale: Cervical laminectomy affects the cervical spine, which innervates upper extremities; assessing hand grasps evaluates neurological function. Pedal pulses, radial pulse, and urine output are unrelated.
A woman with chronic obstructive pulmonary disease (COPD) is admitted with an acute exacerbation. Her vital signs are: BP 162/100, pulse 78, respirations 30 and labored with wheezing. The nurse should question which of the following orders?
- A. Theophylline (Somophyllin) 0.7 mg/kg/hr IV.
- B. Tetracycline hydrochloride (Sumycin) 250 mg IM qd.
- C. Ipratropium bromide (Atrovent) inhaler 2 inhalations qid.
- D. Propranolol hydrochloride (Inderal) 40 mg PO bid.
Correct Answer: D
Rationale: Propranolol, a non-selective beta-blocker, can cause bronchoconstriction, worsening COPD. Options A, B, and C are appropriate: theophylline bronchodilates, tetracycline treats infections, and ipratropium reduces bronchospasm.
Which play activity is most appropriate for a 15-month-old with a cyanotic heart defect?
- A. Push-and-pull toy
- B. Mobile
- C. Shape sorter
- D. Pounding board
Correct Answer: B
Rationale: A mobile is a passive activity suitable for a 15-month-old with a cyanotic heart defect, as it avoids exertion, so B is correct. Push-and-pull toys , shape sorters , and pounding boards require more physical effort.
Upon completing the admission documents, the nurse learns that the 87 year-old client does not have an advance directive. What action should the nurse take?
- A. Record the information on the chart
- B. Give information about advance directives
- C. Assume that this client wishes a full code
- D. Refer this issue to the unit secretary
Correct Answer: B
Rationale: For each admission, nurses should request a copy of the current advance directive. If there is none, the nurse must offer information about what an advance directive implies. It is then the client's choice to sign it.