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The nurse is observing a client who sustained a left ankle sprain ascending the stairs using a modified 3-point gait. The nurse should intervene if the client is observed
- A. bearing weight on the right leg
- B. realigning the crutches between each step
- C. assuming the tripod position before ascending the stairs
- D. using the right crutch to support the weight while advancing the left leg onto the next step
Correct Answer: D
Rationale: In a modified 3-point gait, the injured leg (left) should not bear weight, and the right crutch with the left leg should not be used alone to advance. The other actions are consistent with proper crutch use.
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The nurse is talking with a client with rheumatoid arthritis who has a new prescription for adalimumab. Which of the following statements by the client would require follow-up?
- A. I usually take naproxen for pain twice a week
- B. I received my annual influenza vaccine injection 3 weeks ago.
- C. I received a negative test result for my tuberculin skin test one week ago.
- D. I started a course of antibiotic therapy to treat a urinary tract infection 2 days ago.
Correct Answer: D
Rationale: Adalimumab, an immunosuppressant, increases infection risk. Starting antibiotics for an active infection requires follow-up to ensure the infection is resolved before initiating adalimumab. The other statements are not concerning.
The client has a cast applied following a fracture of the femur. The doctor tells the nurse to petal the cast. The nurse is aware that he intends for her to:
- A. Cut the cast down both sides.
- B. Cut a window in the cast.
- C. Cover the edges with cast batting.
- D. Cut the cast down one side.
Correct Answer: C
Rationale: Petaling a cast involves covering the rough edges with adhesive tape or cast batting to prevent skin irritation. Cutting the cast or creating a window is a different procedure.
The nurse is monitoring a newborn with skin discoloration in the buttock and lumbar area. Which action by the nurse is appropriate?
Click the exhibit button for additional information.
- A. Check the newborn's hemoglobin, hematocrit, and platelet levels
- B. Measure and document the size and location of the markings
- C. Notify the registered nurse of the markings immediately
- D. Review the delivery record for evidence of a traumatic birth
Correct Answer: B
Rationale: Skin discoloration in the buttock and lumbar area of a newborn is often due to Mongolian spots (also called congenital dermal melanocytosis). These are benign, flat, bluish-gray patches typically found on the lower back or buttocks. They are more common in infants with darker skin tones and are not harmful, but they can be mistaken for bruises, which raises concern for abuse later on.
The appropriate nursing action is to measure and document the size, shape, and location of the spots in the medical record. This ensures that there is a clear, dated record of the findings to avoid confusion in the future.
The nurse is caring for a client with Cushing syndrome. Which of the following clinical manifestations should the nurse expect? Select all that apply.
- A. Hyperglycemia
- B. Hypertension
- C. Hyponatremia
- D. Truncal obesity
- E. Weight loss
Correct Answer: A,B,D
Rationale: Cushing syndrome causes hyperglycemia, hypertension, and truncal obesity due to excess cortisol. Hyponatremia and weight loss are not typical.
A newly admitted client describes symptoms of dizziness and feeling faint on standing. The client has a history of type 2 diabetes, coronary artery disease, and bipolar disorder. Which medications may be contributing to the client's symptoms? Select all that apply.
- A. Atorvastatin
- B. Metformin
- C. Metoprolol
- D. Olanzapine
- E. Omeprazole
Correct Answer: C,D
Rationale: Metoprolol, a beta-blocker, can cause orthostatic hypotension, leading to dizziness on standing. Olanzapine, an antipsychotic, is associated with orthostatic hypotension as a side effect. A, B, and E are not commonly linked to orthostatic symptoms; atorvastatin manages cholesterol, metformin controls blood sugar, and omeprazole reduces stomach acid.