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The nurse is teaching a client how to stand on crutches. What information should the nurse give the client related to placement of the crutches?
- A. Place the crutches 3 inches to the front and side of the toes.
- B. Place the crutches 6 inches to the front and side of the toes.
- C. Place the crutches 15 inches to the front and side of the toes.
- D. Place the crutches 20 inches to the front and side of the toes.
Correct Answer: B
Rationale: The tripod position for crutches involves placing them 6 to 10 inches to the front and side of the toes, depending on body size, to ensure balance and support. Other distances are either too short or too long for effective crutch use.
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The nurse is caring for a client with myasthenia gravis (MG) who is 14 weeks pregnant. Which of the following does the nurse understand about MG in the pregnant client?
- A. Most women with MG tolerate labor poorly unless they are in excellent physical health.
- B. Approximately 25% to 30% of neonates born to women with MG develop neonatal myasthenia.
- C. MG usually goes into remission with younger clients and causes exacerbation in older clients.
- D. Narcotics must be used with caution due to the risk of respiratory depression in clients who are already at risk for respiratory muscle weakness.
Correct Answer: B,D
Rationale: 25-30% of neonates may develop transient myasthenia, and narcotics require caution due to respiratory risks. Labor tolerance varies, and remission isn't age-dependent.
The nurse makes a home care visit to a client diagnosed with Bell's palsy. Which statement by the client indicates a need for further teaching?
- A. I wear an eye patch at night.
- B. I am staying on a liquid diet.
- C. I wear dark glasses when I go out.
- D. I have been gently massaging my face.
Correct Answer: B
Rationale: Bell's palsy is caused by a lower motor neuron lesion of the seventh cranial nerve that may result from infection, trauma, hemorrhage, meningitis, or tumor. It is not necessary for a client diagnosed with Bell's palsy to stay on a liquid diet. The client should be encouraged to chew on the unaffected side. Wearing an eye patch at night, dark glasses for daytime outings, and gently massaging the face identify accurate statements related to the management of Bell's palsy.
The nurse provides home care instructions to a client who has been diagnosed with recurrent trichomoniasis. The nurse determines the need for follow-up teaching if the client indicates she should take which action?
- A. Avoid sexual intercourse.
- B. Perform good perineal hygiene.
- C. Use the metronidazole as prescribed.
- D. Discontinue treatment during menstruation.
Correct Answer: D
Rationale: Treatment for a recurrent vaginal trichomoniasis infection continues through the menstrual period because the vagina is more alkaline during menses, and a flare-up is more likely to occur. While the infection remains active, the client should refrain from sexual intercourse or instruct her partner to wear a condom. To help break the chain of infection, the nurse directs the client to perform perineal hygiene after each voiding and each bowel movement. Metronidazole must be taken as prescribed.
The nurse is developing goals for the postpartum client who is at risk for uterine infection. Which goal is most appropriate for this client?
- A. The client will verbalize a reduction of pain.
- B. The client will report how to treat an infection.
- C. The client will be able to identify measures to prevent infection.
- D. The client will identify the presence of Braxton Hicks contractions.
Correct Answer: C
Rationale: The uterus is theoretically sterile during pregnancy until the membranes rupture. However, it is capable of being invaded by pathogens after membrane rupture. The reduction of pain and Braxton Hicks contractions that occur during pregnancy are unrelated to the subject of infection. Reporting the treatment of infection indicates that an infection is present. Preventing an infection is a goal for the client who is at risk for infection.
A client weighs 165 pounds (75 kg) at admission. During hospitalization, the nurse determines that the client is maintaining adequate nutritional status if the client's weight is how many pounds?
- A. 153 pounds (69.5 kg)
- B. 155 pounds (70.4 kg)
- C. 157 pounds (71.3 kg)
- D. 160 pounds (72.7 kg)
Correct Answer: D
Rationale: Adequate nutritional status is maintained if the client's weight remains within 5 pounds of the baseline (165 pounds), so 160 to 165 pounds is acceptable. Weights below 160 pounds indicate significant loss, suggesting inadequate nutrition.