Nokea
The nurse observes that a child with muscular dystrophy has a positive Gower's sign. The nurse documents that the child:
- A. Has weak deep tendon reflexes
- B. Must use his hands to rise from the floor
- C. Has increased spinal reflexes
- D. Rocks back and forth in rhythmical fashion
Correct Answer: B
Rationale: A positive Gower's sign indicates the child uses their hands to push up from the floor due to muscle weakness, so B is correct. Answers A, C, and D do not describe Gower's sign.
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The nurse is teaching a client with a new diagnosis of osteoarthritis about celecoxib (Celebrex). Which of the following instructions should the nurse include?
- A. Take the medication with grapefruit juice
- B. Report any black, tarry stools
- C. Stop the medication if pain decreases
- D. Avoid regular joint exams
Correct Answer: B
Rationale: Black, tarry stools indicate gastroinTest inal bleeding, a serious celecoxib side effect. Options A, C, and D are incorrect: grapefruit juice is irrelevant, stopping the medication may not be advised, and exams are needed.
Which of these clients would the nurse monitor for the complication of C. difficile diarrhea?
- A. An adolescent taking medications for acne
- B. An elderly client living in a retirement center taking prednisone
- C. A young adult in the second trimester of pregnancy
- D. A middle-aged client receiving radiation for throat cancer
Correct Answer: D
Rationale: A middle-aged client receiving radiation for throat cancer. Radiation therapy, particularly to the abdomen or pelvis, can disrupt the gut microbiota and increase the risk of C. difficile infection, especially if the client is also receiving antibiotics or has a weakened immune system.
An 8-year-old boy falls off the swings at school and hits his head. He is examined by a physician at an urgent care center, diagnosed with a minor head injury, and sent home.
Which of the following statements, if made by the mother to the nurse, would require further teaching by the nurse?
- A. He should avoid blowing his nose or cleaning his ears for two days.'
- B. I should wake him every 3 hours tonight and tomorrow night to check him.'
- C. I can give him Tylenol every 4 hours if he complains of a headache.'
- D. He will be well enough to play in his soccer game tomorrow.'
Correct Answer: D
Rationale: Strategy: 'Further teaching' indicates an incorrect response. (1) prevents increased pressure on area (2) should check level of consciousness and orientation every 3-4 hours (3) avoid use of sedatives, sleeping pills, alcohol with head injuries (4) correct-no strenuous activity for 48 hours
A client with polyuria, polydipsia, and polyphagia is diagnosed with diabetes mellitus. The nurse would expect that these symptoms are related to
- A. Hypoglycemia
- B. Hyperglycemia
- C. Hyperparathyroidism
- D. Hyperthyroidism
Correct Answer: B
Rationale: Polyuria, polydipsia, and polyphagia are classic symptoms of hyperglycemia in diabetes mellitus. Hypoglycemia , hyperparathyroidism , and hyperthyroidism do not typically cause this triad.
An arthritic client must be able to perform tasks to manage at home alone following discharge from the hospital.
The nurse knows that to manage at home alone following discharge from the hospital, an arthritic client must be able to perform which of the following tasks?
- A. Climb up and down stairs.
- B. Lace and tie his/her shoes.
- C. Comb his/her hair and brush his/her teeth.
- D. Walk without assistance.
Correct Answer: C
Rationale: Strategy: Think about the significance of each answer choice and how it relates to arthritis. (1) stairs can be eliminated in the client's environment (2) is a modifiable problem with the use of slip-on shoes (3) correct-is part of basic hygiene and grooming that must be done daily to maintain overall health (4) is not necessary for independence; walker or wheelchair may be used