Nokea
The nurse is caring for a client with a history of Raynaud’s disease. The nurse should expect the client to have:
- A. Color changes in fingers
- B. Joint swelling
- C. Fever
- D. Chest pain
Correct Answer: A
Rationale: Raynaud’s disease causes vasospasms, leading to color changes (white, blue, red) in the fingers triggered by cold or stress.
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A client is placed on lithium therapy for her manic-depressive illness. When monitoring the client, the nurse assesses the laboratory blood values. Toxicity may occur with lithium therapy when the blood level is above:
- A. 1.0 mEq/L
- B. 2.2 mEq/L
- C. 0.03 mEq/L
- D. 1.5 mEq/L
Correct Answer: D
Rationale: This value is the level at which most clients are maintained, and toxicity may occur if the level increases. The client should be monitored closely for symptoms, because some clients become toxic even at this level.
A client on a mechanical ventilator begins to fight the ventilator. Which medication will be ordered for the client?
- A. Sublimaze (fentanyl)
- B. Pavulon (pancuronium bromide)
- C. Versed (midazolam)
- D. Atarax (hydroxyzine)
Correct Answer: B
Rationale: Pancuronium bromide, a neuromuscular blocker, paralyzes muscles to prevent fighting the ventilator, ensuring effective ventilation. Sedatives like midazolam or fentanyl are secondary.
The nurse is caring for a client with a diagnosis of postpartum endometritis. Which vital sign change is most characteristic?
- A. Fever
- B. Tachycardia
- C. Hypotension
- D. All of the above
Correct Answer: A
Rationale: Fever is the most characteristic vital sign change in postpartum endometritis reflecting the underlying uterine infection. Tachycardia and hypotension occur only in severe cases.
The nurse is caring for a client with a history of a spinal cord injury who is experiencing autonomic dysreflexia. The nurse should:
- A. Place the client in a prone position
- B. Administer a vasodilator
- C. Insert a Foley catheter immediately
- D. Elevate the head of the bed
Correct Answer: C
Rationale: Autonomic dysreflexia is often triggered by bladder distension. Inserting a Foley catheter relieves the trigger. Vasodilators and positioning are secondary, and prone position is unsafe.
A 10-year-old boy has been diagnosed with Legg-Calvé Perthes disease. Which of the client's responses would indicate compliance during initial therapy?
- A. Drinking large amounts of milk
- B. Not bearing weight on affected extremity
- C. Walking short distances 3 times/day
- D. Putting self on weight reduction diet
Correct Answer: B
Rationale: This condition causes aseptic necrosis of the head of the femur in the acetabulum. Drinking large quantities of milk at this time cannot hasten recovery. The aim of treatment is to keep the head of the femur in the acetabulum. Nonweight-bearing is essential. Activity causes microfractures of the epiphysis. In addition to nonweight-bearing, clients are often placed on bedrest, which helps to reduce inflammation. Later, active motion is encouraged. Weight is not generally an issue with this disease. Slipped femoral capital epiphysis, which is most frequently observed in obese pubescent children, usually requires a weight reduction diet.