Nokea
The nurse on the medical/surgical unit cares for a client with a diagnosis of cerebrovascular accident (CVA). The nursing assessment of the client's neurological status should include which of the following? (Select all that apply)
- A. Obtain the pulses in all four extremities
- B. Ask the client to grasp and squeeze two fingers on each of the nurse's hands
- C. Determine the client's orientation to person, place, and time
- D. B, C
Correct Answer: D
Rationale: The correct choices are B and C. Assessing grasp strength and orientation to person, place, and time are essential components of a neurological assessment after a CVA. Pulse assessment in all four extremities is more relevant to circulatory assessment rather than neurological status. Therefore, option A is incorrect.
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The hypertonicity of the muscles in an infant with cerebral palsy causes scissoring of the legs. The nurse teaches the mother that the preferred way to carry the infant is in a sitting position:
- A. Astride one of her hips
- B. Strapped in an infant seat
- C. Wrapped tightly in a blanket
- D. Under the arm using a football hold
Correct Answer: A
Rationale: The correct way to carry an infant with cerebral palsy experiencing muscle hypertonicity and scissoring of the legs is astride one of the mother's hips. This position helps keep the infant's legs apart, reducing muscle tightness. Strapping the infant in an infant seat, wrapping tightly in a blanket, or using the football hold under the arm does not address the specific needs related to muscle hypertonicity and scissoring of the legs in cerebral palsy.
A client has been given instructions about ferrous sulfate. Which statement made by the client would indicate the client needs further education?
- A. "I will take this medication with a full glass of milk."
- B. "I will take the morning dose 1 hour before breakfast."
- C. "I will need to avoid taking this medication with coffee."
- D. "I will take antacids if needed, 2 hours after I take ferrous sulfate."
Correct Answer: A
Rationale: The correct answer is A. Ferrous sulfate should not be taken with milk as it can impair iron absorption. Choice B is correct as taking the morning dose 1 hour before breakfast is appropriate. Choice C is correct as coffee can interfere with iron absorption. Choice D is correct as antacids should be taken 2 hours after ferrous sulfate to avoid interference with its absorption.
The nurse is preparing a teaching care plan for the client diagnosed with nephritic syndrome. Which intervention should the nurse include?
- A. Discontinue the use of steroid therapy immediately if symptoms develop.
- B. Take diuretics as needed to treat the dependent edema in ankles.
- C. Increase the intake of dietary sodium every day to decrease fluid retention.
- D. Report any decrease in daily weight during treatment to the healthcare provider.
Correct Answer: D
Rationale: The correct intervention for the nurse to include in the care plan for a client diagnosed with nephritic syndrome is to instruct the client to report any decrease in daily weight during treatment to the healthcare provider. A decrease in weight could indicate worsening of the nephritic syndrome or dehydration, making it crucial information for the healthcare provider to assess the client's condition. Option A is incorrect because discontinuing steroid therapy should be done under medical guidance rather than immediately if symptoms develop. Option B is incorrect because diuretics should not be taken without healthcare provider's guidance due to the risk of electrolyte imbalances. Option C is incorrect as increasing dietary sodium would exacerbate fluid retention, which is undesirable in nephritic syndrome.
A patient with a history of peptic ulcer disease should avoid which medication?
- A. Acetaminophen
- B. Antacids
- C. Nonsteroidal anti-inflammatory drugs
- D. Antihistamines
Correct Answer: C
Rationale: Patients with a history of peptic ulcer disease should avoid nonsteroidal anti-inflammatory drugs (NSAIDs) because they can worsen peptic ulcers. NSAIDs inhibit the production of prostaglandins, which help protect the stomach lining. Acetaminophen (Choice A) is a safer alternative for pain relief in patients with peptic ulcers. Antacids (Choice B) can actually help in symptom relief by neutralizing stomach acid. Antihistamines (Choice D) are not known to worsen peptic ulcers and are generally safe for use in patients with this condition.
Which of the following statements does NOT apply to a nursing plan of care?
- A. It contains short-term goals
- B. It is developed by the patient's physician
- C. It must be continually evaluated
- D. It contains long-range goals
Correct Answer: B
Rationale: The correct answer is B. A nursing plan of care is developed by the nursing staff, not the patient's physician. Choice A is correct as nursing plans of care typically include short-term goals to address immediate needs. Choice C is also accurate as nursing plans of care need to be continually evaluated and updated to ensure they are effective. Choice D is incorrect as nursing plans of care can contain long-range goals to provide a roadmap for the patient's overall care and recovery.