Nokea
The nurse is to give the client with gout one tablet of colchicine every hour until relief or toxicity occurs. Which of the following is an indication for stopping the colchicine?
- A. Ringing in the ears
- B. Nausea and vomiting
- C. A rash on the client's hips
- D. A temperature of 101°F
Correct Answer: B
Rationale: Nausea and vomiting are signs of colchicine toxicity, indicating the need to stop the medication.
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The client is being seen in the clinic for a second-degree ankle sprain. Which treatments should the nurse plan?
- A. Rest, elevate the extremity, apply ice intermittently, and apply a compression bandage.
- B. Do range of motion to determine the extent of injury, apply heat, and check circulation.
- C. Use moist heat and then apply ice; check circulation, motion, and sensation; and elevate.
- D. Refer to an orthopedic surgeon, apply ice, give an analgesic, elevate, and encourage rest.
Correct Answer: A
Rationale: A. Rest prevents further injury and promotes healing. Ice and elevation control swelling. Compression with an elastic bandage controls bleeding, reduces edema, and provides support for injured tissues.
If the client is typical of others with a herniated disk, the nurse would expect the client to report which additional symptom?
- A. Pain radiating into the buttocks and leg
- B. Tenderness over one or both iliac crests
- C. Diminished sensation in one or both knees
- D. Brief periods when the toes feel quite cold
Correct Answer: A
Rationale: A herniated lumbar disk commonly causes sciatica, with pain radiating into the buttocks and leg due to nerve root compression. Other symptoms are less typical or specific.
During a physical examination of the 1-month-old, the nurse notes that the infant has blue sclerae. The nurse should further assess for signs and symptoms of which disorder?
- A. Juvenile rheumatoid arthritis (JRA)
- B. Tay-Sachs disease
- C. Duchenne muscular dystrophy (DMD)
- D. Osteogenesis imperfecta (OI)
Correct Answer: D
Rationale: Blue sclerae are a hallmark of osteogenesis imperfecta due to thin connective tissue.
The client tells the nurse, 'My father is furious with me. He does not want me to ride a motorcycle.' Which response by the nurse is most appropriate?
- A. As they say, 'Father knows best.''
- B. I'll be sure it is a safe.'
- C. It can be frustrating when you disagree with your father.'
- D. I think you should obey your father's wishes.'
Correct Answer: C
Rationale: Acknowledging the client's frustration validates their feelings without judgment, fostering therapeutic communication. The other responses either dismiss the client's emotions or impose the nurse's opinion, which is inappropriate.
The 84-year-old client is a resident in a long-term care facility. Which intervention should be implemented to help prevent complications secondary to osteoporosis?
- A. Keep the bed in the high position.
- B. Perform passive range-of-motion exercises.
- C. Turn the client every two (2) hours.
- D. Provide nighttime lights in the room.
Correct Answer: D
Rationale: Nighttime lights reduce fall risk, a major osteoporosis complication causing fractures. High beds increase fall risk, ROM does not prevent falls, and turning addresses skin integrity, not fractures.