Nokea
The nurse is monitoring an unconscious client who sustained a head injury. Which observed positioning supports the suspicion that the client sustained an upper brainstem injury?
- A. Abnormal involuntary flexion of the extremities
- B. Abnormal involuntary extension of the extremities
- C. Upper extremity extension with lower extremity flexion
- D. Upper extremity flexion with lower extremity extension
Correct Answer: B
Rationale: Decerebrate posturing, which can occur with upper brainstem injury, is characterized by abnormal involuntary extension of the extremities. Options 1, 3, and 4 are incorrect descriptions of this type of posturing.
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A child hospitalized with a diagnosis of lead poisoning is prescribed chelation therapy. The nurse caring for the child should prepare to administer which medication?
- A. Ipecac syrup
- B. Activated charcoal
- C. Sodium bicarbonate
- D. Calcium disodium edetate (EDTA)
Correct Answer: D
Rationale: EDTA is a chelating agent that is used to treat lead poisoning. Ipecac syrup may be prescribed by the primary health care provider for use in the hospital setting but would not be used to treat lead poisoning. Activated charcoal is used to decrease absorption in certain poisoning situations. Sodium bicarbonate may be used in salicylate poisoning.
A client diagnosed with multiple myeloma is receiving intravenous hydration at 100 mL per hour. Which finding indicates to the nurse that the client is experiencing a positive response to the treatment plan?
- A. Weight increase of 1 kilogram
- B. Respirations of 18 breaths per minute
- C. Creatinine of 1.0 mg/dL (88 mcmol/L)
- D. White blood cell count of 6000 mm3 (6 × 109/L)
Correct Answer: C
Rationale: Multiple myeloma is a malignant proliferation of plasma cells within the bone. Renal failure is a concern in the client with multiple myeloma. In multiple myeloma, hydration is essential to prevent renal damage resulting from precipitation of protein in the renal tubules and excessive calcium and uric acid in the blood. Creatinine is the most accurate measure of renal function. Options 2 and 4 are unrelated to the subject of hydration. Weight gain is not a positive sign when concerned with renal status.
A client is receiving desmopressin intranasally. Which assessment parameters should the nurse monitor to determine the effectiveness of this medication?
- A. Daily weight
- B. Temperature
- C. Apical heart rate
- D. Pupillary response
Correct Answer: A
Rationale: Desmopressin is an analog of vasopressin (antidiuretic hormone). It is used in the management of diabetes insipidus. The nurse monitors the client's fluid balance to determine the effectiveness of the medication. Fluid status can be evaluated by noting intake and urine output, daily weight, and the presence of edema. The measurements in options 2, 3, and 4 are not related to this medication.
An adult client who experienced a fractured left tibia has a long leg cast and is using crutches to ambulate. In caring for the client, the nurse assesses for which sign/symptom that indicates a complication associated with crutch walking?
- A. Left leg discomfort
- B. Weak biceps brachii
- C. Triceps muscle spasms
- D. Forearm muscle weakness
Correct Answer: D
Rationale: Forearm muscle weakness is a sign of radial nerve injury caused by crutch pressure on the axillae. When a client lacks upper body strength, especially in the flexor and extensor muscles of the arms, he or she frequently allows weight to rest on the axillae and on the crutch pads instead of using the arms for support while ambulating with crutches. Leg discomfort is expected as a result of the injury. Weak biceps brachii is not a complication of crutch walking. Triceps muscle spasms may occur as a result of increased muscle use but is not a complication of crutch walking.
A client prescribed warfarin sodium has been instructed to limit the intake of foods high in vitamin K. The nurse determines that the client understands the instructions if the client indicates that which food items need to be avoided? Select all that apply.
- A. Tea
- B. Turnips
- C. Oranges
- D. Cabbage
- E. Broccoli
- F. Strawberries
Correct Answer: A,B,D,E
Rationale: Warfarin sodium is an anticoagulant that interferes with the hepatic synthesis of vitamin K-dependent clotting factors. The client is instructed to limit the intake of foods high in vitamin K while taking this medication. These foods include coffee or tea (caffeine), turnips, cabbage, broccoli, greens, fish, and liver.