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The nurse teaches a client diagnosed with a spinal cord injury about measures to prevent autonomic hyperreflexia. Which statement by the client indicates the need for additional teaching?
- A. It is best if I avoid tight clothing and lumpy bedclothes.
- B. I should watch for headache, congestion, and flushed skin.
- C. Signs/symptoms I should watch for include fever and chest pain.
- D. I need to pay close attention to how frequently my bowels move.
Correct Answer: C
Rationale: Autonomic hyperreflexia generally occurs in a client with a spinal cord injury after the period of spinal shock resolves. It occurs with injuries above T6 and cervical injuries. Signs/symptoms of autonomic hyperreflexia include headache, congestion, flushed skin above the level of injury and cold skin below it, diaphoresis, nausea, and anxiety. Fever and chest pain are not associated with this condition.
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The nurse is teaching a client how to stand on crutches. What information should the nurse give the client related to placement of the crutches?
- A. Place the crutches 3 inches to the front and side of the toes.
- B. Place the crutches 6 inches to the front and side of the toes.
- C. Place the crutches 15 inches to the front and side of the toes.
- D. Place the crutches 20 inches to the front and side of the toes.
Correct Answer: B
Rationale: The tripod position for crutches involves placing them 6 to 10 inches to the front and side of the toes, depending on body size, to ensure balance and support. Other distances are either too short or too long for effective crutch use.
The nurse is reviewing the assessment data of a client. Which finding is most important for the client to modify to lessen the risk for coronary artery disease (CAD)?
- A. Elevated triglyceride levels
- B. Elevated serum lipase levels
- C. Elevated serum testosterone level
- D. Elevated low-density lipoprotein (LDL) levels
Correct Answer: D
Rationale: Elevated LDL levels are most directly linked to CAD, as they contribute to atherosclerosis. Triglycerides are a risk factor but less predictive, lipase is unrelated to CAD, and low testosterone, not high, may influence CAD risk.
The nurse makes a home care visit to a client diagnosed with Bell's palsy. Which statement by the client indicates a need for further teaching?
- A. I wear an eye patch at night.
- B. I am staying on a liquid diet.
- C. I wear dark glasses when I go out.
- D. I have been gently massaging my face.
Correct Answer: B
Rationale: Bell's palsy is caused by a lower motor neuron lesion of the seventh cranial nerve that may result from infection, trauma, hemorrhage, meningitis, or tumor. It is not necessary for a client diagnosed with Bell's palsy to stay on a liquid diet. The client should be encouraged to chew on the unaffected side. Wearing an eye patch at night, dark glasses for daytime outings, and gently massaging the face identify accurate statements related to the management of Bell's palsy.
The nurse is caring for a client with myasthenia gravis (MG) who is 14 weeks pregnant. Which of the following does the nurse understand about MG in the pregnant client?
- A. Most women with MG tolerate labor poorly unless they are in excellent physical health.
- B. Approximately 25% to 30% of neonates born to women with MG develop neonatal myasthenia.
- C. MG usually goes into remission with younger clients and causes exacerbation in older clients.
- D. Narcotics must be used with caution due to the risk of respiratory depression in clients who are already at risk for respiratory muscle weakness.
Correct Answer: B,D
Rationale: 25-30% of neonates may develop transient myasthenia, and narcotics require caution due to respiratory risks. Labor tolerance varies, and remission isn't age-dependent.
A client weighs 165 pounds (75 kg) at admission. During hospitalization, the nurse determines that the client is maintaining adequate nutritional status if the client's weight is how many pounds?
- A. 153 pounds (69.5 kg)
- B. 155 pounds (70.4 kg)
- C. 157 pounds (71.3 kg)
- D. 160 pounds (72.7 kg)
Correct Answer: D
Rationale: Adequate nutritional status is maintained if the client's weight remains within 5 pounds of the baseline (165 pounds), so 160 to 165 pounds is acceptable. Weights below 160 pounds indicate significant loss, suggesting inadequate nutrition.