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A client with a diagnosis of a ruptured lumbar disc.
The nurse should anticipate which of the following in assessing a client with a diagnosis of a ruptured lumbar disc?
- A. Sensation loss in an upper extremity.
- B. Clonic jerks in the affected foot.
- C. Paresthesia in the affected leg.
- D. Chorea in the upper and lower extremities.
Correct Answer: C
Rationale: Strategy: Think about each answer choice. (1) results from cervical lesions (2) can occur in a person who has been paralyzed from a spinal cord injury (3) correct-lumbar lesions can cause paresthesia, pain, muscle weakness, and atrophy in the lower extremities (4) is a sign of Huntington chorea, resulting from atrophy of parts of the brain
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A client with hyperthyroidism.
Which of the following actions, if taken by the nurse, is BEST?
- A. Provide the client with extra blankets.
- B. Instill artificial tears prn.
- C. Offer the client reading material.
- D. Offer frequent low-calorie snacks.
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) client is usually sensitive to heat (2) correct-clients with hyperthyroidism frequently exhibit exophthalmos, which requires ophthalmic drops on a regular basis (3) should provide a calm, restful environment with low levels of sensory stimulation, protecting eyes from injury takes priority (4) frequent snacks should be high-calorie
The nurse is caring for a client who had a subtotal thyroidectomy yesterday. Which of the following client statements would be of GREATest concern to the nurse?
- A. I have a sore throat when I swallow.
- B. My legs feel cramped and tingly.
- C. I feel like my heart is skipping beats.
- D. I feel sleepy all the time.
Correct Answer: B
Rationale: Muscle cramps and tingling in the legs post-thyroidectomy suggest hypocalcemia, a serious complication due to possible parathyroid gland damage, which regulates calcium. This requires immediate assessment and intervention. Options A, C, and D are less urgent: sore throat is expected, palpitations may indicate hyperthyroidism, and sleepiness is nonspecific.
A spansule is ordered twice a day for a client in the outpatient clinic. What should the nurse teach the client about taking a spansule?
- A. Take the spansule before breakfast and dinner.
- B. If the spansule is difficult to swallow, open it up and put the contents in food.
- C. Spansules should be taken at 12-hour intervals.
- D. Spansules can safely be cut for partial doses.
Correct Answer: C
Rationale: Spansules are time-release capsules, requiring 12-hour intervals for consistent drug release. Opening, cutting, or meal-based timing disrupts their mechanism.
An adult is admitted with probable pulmonary tuberculosis. Which findings would the nurse expect to be present in this client? Select all that apply.
- A. High fevers in the morning
- B. Cough
- C. Bloody sputum
- D. Night sweats
- E. Weight gain
- F. Malaise
Correct Answer: B,C,D,F
Rationale: Tuberculosis causes chronic cough, hemoptysis (bloody sputum), night sweats, and malaise due to systemic infection. Fevers are typically low-grade and nocturnal, and weight loss, not gain, is common.
What is the most important consideration when teaching parents how to reduce risks in the home?
- A. Age and knowledge level of the parents
- B. Proximity to emergency services
- C. Number of children in the home
- D. Age of children in the home
Correct Answer: D
Rationale: Age of children in the home. Safety measures must be tailored to the developmental stage of the children.