Nokea
What is the nurse's best response to a client with MS experiencing spasticity?
- A. Administer a sedative.
- B. Teach stretching exercises.
- C. Restrict all movement.
- D. Apply cold compresses.
Correct Answer: B
Rationale: Teaching stretching exercises helps manage spasticity in multiple sclerosis.
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A client has just returned from the postanesthesia care unit after undergoing a laryngectomy. Which of the following interventions should the nurse include in the plan of care?
- A. Maintain the head of the bed at 30 to 40 degrees.
- B. Teach the client how to use esophageal speech.
- C. Initiate small feedings of soft goods.
- D. Irrigate drainage tubes as needed.
Correct Answer: A
Rationale: Elevating the head of the bed 30–40 degrees reduces swelling and maintains airway patency post-laryngectomy. Esophageal speech training is premature immediately post-surgery. Feedings are typically delayed until swallowing is safe. Drainage tubes are not routinely irrigated.
For a client who excretes excessive amounts of calcium during the postoperative period after open heart surgery, which of the following measures should the nurse institute to help prevent complications associated with excessive calcium excretion?
- A. Ensure a liberal fluid intake.
- B. Provide an alkaline-ash diet.
- C. Prevent constipation.
- D. Enrich the client's diet with dairy products.
Correct Answer: A
Rationale: Liberal fluid intake promotes calcium excretion through urine, preventing complications like kidney stones or hypercalcemia.
The nurse is observing a student nurse administer eyedrops, as shown in the fi gure. What should the nurse instruct the student to do?
- A. Move the dropper to the inner canthus.
- B. Have the client raise her eyebrows.
- C. Administer the drops in the center of the lower lid.
- D. Have the client squeeze both eyes after administering the drops.
Correct Answer: C
Rationale: The student has positioned the dropper and the client correctly to prevent injury to the client’s eye. The student should administer the drops in the center of the lower lid. Following administration of the eyedrops, the client should blink her eyes to distribute the medication; squeezing or rubbing her eyes might cause the medication to drip out of the eye.
Allopurinol (Zyloprim), 200 mg/day, is prescribed for the client with renal calculi to take at home. The nurse should teach the client about which the following adverse effects of this medication?
- A. Retinopathy.
- B. Maculopapular rash.
- C. Nasal congestion.
- D. Dizziness.
Correct Answer: B
Rationale: Maculopapular rash is a common adverse effect of allopurinol, requiring monitoring due to potential allergic reactions.
Which of the following symptoms might indicate that a client was developing tetany after a subtotal thyroidectomy?
- A. Pains in the joints of the hands and feet.
- B. Tingling in the fingers.
- C. Bleeding on the back of the dressing.
- D. Tension on the suture line.
Correct Answer: B
Rationale: Tetany, caused by hypocalcemia from parathyroid gland damage during thyroidectomy, presents with tingling in the fingers, muscle cramps, or spasms.