Nokea
The nurse monitors a client for brachial plexus compromise after shoulder arthroplasty and is checking the status of the ulnar nerve. Which technique should the nurse use to assess the status of this nerve?
- A. Ask the client to raise the forearm above the head.
- B. Have the client spread all of the fingers wide and resist pressure.
- C. Ask the client to move the thumb toward the palm and then back to the neutral position.
- D. Have the client grasp the nurse's hand, and note the strength of the client's first and second fingers.
Correct Answer: B
Rationale: So that the nurse may assess the ulnar nerve status, the client is asked to spread all of the fingers wide and resist pressure. Weakness against pressure may indicate compromise of the ulnar nerve. Raising the forearm above the head assesses the flexion of the biceps and determines the status of the cutaneous nerve. Moving the thumb toward the palm and back describes the assessment of the status of the radial nerve. Having the client grasp the nurse's hand and assessing the strength of the first 2 fingers describes the assessment of the status of the medial nerve.
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Which of the following situations warrants a measurement for orthostatic hypotension?
- A. A 36-year-old male with a spinal injury
- B. An 86-year-old female with significantly altered mental status
- C. A 58-year-old female with near-syncope
- D. A 41-year-old male with acute deep vein thrombosis
Correct Answer: C
Rationale: The correct answer is a 58-year-old female with near-syncope. Orthostatic hypotension is a drop in blood pressure of greater than 20 mmHg systolic when moving from a sitting or lying position to standing. Patients at higher risk include those with syncope or near-syncope, symptomatic hypovolemia, and those prone to falls. The other choices are less likely to present with orthostatic hypotension. A spinal injury, altered mental status, and acute deep vein thrombosis are not directly associated with the immediate need for orthostatic hypotension measurement.
When a blood pressure cuff is too wide for a client's arm, what type of reading might this blood pressure cuff produce?
- A. A normal reading
- B. An abnormally low reading
- C. An abnormally high reading
- D. A fluctuating reading
Correct Answer: B
Rationale: When a blood pressure cuff is too wide for a client's arm, it may produce an abnormally low blood pressure reading. This occurs because the oversized cuff can lead to an underestimation of blood pressure. It is essential to ensure that the cuff fits appropriately to obtain an accurate reading. An abnormally high reading (Choice C) is less likely with an oversized cuff, as it generally leads to lower readings. A normal reading (Choice A) is unlikely due to the inaccuracies caused by the oversized cuff. A fluctuating reading (Choice D) is not a typical result of using a cuff that is too wide; instead, it usually leads to consistently low readings.
The nurse has conducted a class for pregnant clients diagnosed with diabetes mellitus about the signs/symptoms of potential complications. The nurse determines that the teaching was effective if a client makes which statement?
- A. I should not have ultrasounds done because I am diabetic.
- B. I'm glad I don't have to worry about developing hypoglycemia while I am pregnant.
- C. I need to watch my weight for any sudden gains because I could develop what they call gestational hypertension.
- D. My insulin needs should decrease during the last 2 months because I will be using some of the baby's insulin supply.
Correct Answer: C
Rationale: A diabetic pregnant client has a higher incidence of developing gestational hypertension than the nondiabetic pregnant client does. Ultrasounds are done frequently during a diabetic pregnancy to check for congenital anomalies and to determine appropriate growth patterns. Hypoglycemia is a problem during pregnancy in the client diagnosed with diabetes mellitus and needs to be assessed throughout the pregnancy. Insulin needs will increase during the last trimester because of increased hormone levels that destroy circulating insulin.
The nurse is instructing a pregnant client regarding measures to prevent a recurrent episode of preterm labor. Which statement by the client indicates the need for further teaching?
- A. I will report any feeling of pelvic pressure.
- B. I will not engage in sexual intercourse at this time.
- C. I will adhere to the limitations in activity and stay off my feet.
- D. I will limit my fluid intake to three 8-ounce glasses of fluid per day.
Correct Answer: D
Rationale: Risks for preterm labor include dehydration. A client should not restrict fluids (except for those containing alcohol and caffeine). A sign of preterm labor may be pelvic pressure without the perception of a contraction. Mechanical stimulation of the cervix during intercourse can stimulate contractions. A decrease in activity and bed rest are often prescribed in an attempt to decrease pressure on the cervix and to increase uterine blood flow.
The nurse is teaching a client about dietary modifications to control hypertension. Which statement by the client indicates a need for further teaching?
- A. I can have a cup of fresh fruit as a snack.
- B. Baked ham is a good dinner choice for me.
- C. I need to check the label for sodium in ketchup.
- D. I need to cut out frozen pizza as a fast meal option.
Correct Answer: B
Rationale: Baked ham is high in sodium, which is unsuitable for hypertension. Other choices align with low-sodium dietary recommendations.