Nokea
When taking Mr. Sands' health history, which question would be especially important to ask?
- A. Do you have any back pain or flank tenderness?
- B. Does cold affect your hands in any way?
- C. Do you have any difficulty chewing or swallowing?
- D. Do you have any joint tenderness or stiffness?
Correct Answer: C
Rationale: Difficulty chewing or swallowing is a key symptom of reflux esophagitis.
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Which of the following would lead the nurse to suspect that a child with meningitis has developed disseminated intravascular coagulation?
- A. Hemorrhagic skin rash
- B. Edema
- C. Cyanosis
- D. Dyspnea on exertion
Correct Answer: A
Rationale: A hemorrhagic skin rash is a hallmark sign of disseminated intravascular coagulation (DIC), a severe complication of meningitis. DIC occurs due to widespread activation of the clotting cascade, leading to microthrombi and subsequent bleeding. This condition requires urgent medical intervention to prevent organ failure and death.
Which myotome is responsible for shoulder abduction
- A. C4
- B. C5
- C. C6
- D. C7
Correct Answer: B
Rationale: The C5 and C6 nerve roots innervate the deltoid and supraspinatus muscles, which are responsible for shoulder abduction. This is important in assessing brachial plexus injuries.
In performing range of motion (ROM) with a patient, the nurse puts each joint through its full movement. Which joints are capable of abduction and adduction (select all that apply)?
- A. Hip
- B. Knee
- C. Wrist
- D. Elbow
Correct Answer: A
Rationale: Hips, thumbs, and shoulders allow abduction/adduction.
Why should clients who take warfarin (Coumadin®) refrain from food items such as green, leafy vegetables and soybeans?
- A. Because the foods contain vitamin K
- B. which reduces the anticoagulant effect of the medication.
- C. Because the foods contain vitamin K
- D. which increases the anticoagulant effect of the medication.
Correct Answer: A
Rationale: Vitamin K counteracts the effects of warfarin.
What would the nurse document if the client is unresponsive except to superficial, relatively mild painful stimuli to which the client makes some purposeful motor response?
- A. Client is somnolent or lethargic.
- B. Client is in a stuporous state.
- C. Client is semicomatose.
- D. Client is comatose.
Correct Answer: B
Rationale: A stuporous state indicates minimal response to stimuli.