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The right hand of a client with multiple sclerosis trembles severely whenever she attempts a purposeful act, such as picking up her coffee cup or buttoning her dress. Which is the best legal documentation in nurses' notes of the chart for this client assessment?
- A. "Has an intention tremor of the right hand."
- B. "Right-hand tremor worsens with purposeful acts."
- C. "Needs assistance with dressing and eating due to severe trembling and clumsiness."
- D. "Slight shaking of right hand increases to severe tremor when client tries to button her clothes or drink from a cup."
Correct Answer: D
Rationale: The most detailed and accurate documentation is: "Slight shaking of right hand increases to severe tremor when client tries to button her clothes or drink from a cup," as it describes the intention tremor specifically and legally.
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Alteplase recombinant, or tissue plasminogen activator (t-PA), is administered during the first 6 hours after onset of myocardial infarction (MI) to:
- A. Control chest pain.
- B. Reduce coronary artery vasospasm.
- C. Control the arrhythmias associated with MI.
- D. Revascularize the blocked coronary artery.
Correct Answer: D
Rationale: t-PA dissolves clots in the coronary artery, restoring blood flow (revascularization) to the ischemic myocardium, critical within the first 6 hours of MI.
The nurse is providing education to a client who is prescribed terbinafine for onychomycosis affecting the toenails. Which statements by the client demonstrate understanding regarding the teaching about terbinafine? Select all that apply.
- A. Following a successful course of treatment, my chance of getting cured is 90%.
- B. I will have to take terbinafine for 3 to 6 months.
- C. I will need liver function tests before starting terbinafine.
- D. I will take this on an empty stomach to help improve its absorption.
- E. It may cause taste or vision changes, so I will report vision changes to my doctor.
- F. Dark urine, pale stools, and persistent nausea may indicate a serious side effect.
Correct Answer: B,C,E
Rationale: Choice B is correct; terbinafine treatment for toenail onychomycosis typically lasts 3-6 months. Choice C is correct; liver function tests are required before and during treatment due to the risk of hepatotoxicity. Choice E is correct; terbinafine can cause taste or vision changes, and vision changes should be reported. Choice A is incorrect; the cure rate is approximately 70-80%, not 90%. Choice D is incorrect; terbinafine can be taken with or without food, and an empty stomach is not required. Choice F is correct; dark urine, pale stools, and nausea may indicate liver toxicity, a serious side effect.
Before a client's discharge after mitral valve replacement surgery, the nurse should evaluate the client's understanding of postsurgery activity restrictions. Which of the following should the client not engage in until after the 1-month postdischarge appointment with the surgeon?
- A. Showering.
- B. Lifting anything heavier than 10 lb.
- C. A program of gradually progressive walking.
- D. Light housework.
Correct Answer: B
Rationale: Lifting heavy objects (>10 lb) risks sternal dehiscence post-mitral valve replacement, so it is restricted until surgeon approval.
The nurse is planning a staff development conference about medication reconciliation. Which of the following information should the nurse include?
- A. Obtain a list of the medications instead of reviewing the list with the client
- B. Medication reconciliation should occur just at discharge to prevent omissions.
- C. Prescribed medications should be obtained and omit herbs and supplements.
- D. This process should occur at admission, client transfer, and discharge.
Correct Answer: C
Rationale: Medication reconciliation at admission, transfer, and discharge ensures accuracy and continuity of care.
A client is being admitted with a spinal cord transection at C7. Which of the following assessments take priority upon the client's arrival?
- A. Reflexes.
- B. Bladder function.
- C. Blood pressure.
- D. Temperature.
- E. Respirations.
Correct Answer: C,E
Rationale: Respirations and blood pressure are the priority assessments for a C7 spinal cord injury, as this level can impair diaphragmatic function and cause neurogenic shock, both life-threatening. Reflexes, bladder function, and temperature are important but secondary to airway and circulation stability.