Nokea
Which client symptom indicates that the nurse should discontinue the medication and notify the physician even if the client's pain is unrelieved?
- A. Vomiting
- B. Dizziness
- C. Drowsiness
- D. Headache
Correct Answer: A
Rationale: Vomiting is a sign of colchicine toxicity, requiring immediate discontinuation and physician notification, as it can precede serious complications like bone marrow suppression. Other symptoms are less urgent.
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The nurse is assessing the leg of a client in Russell's traction. Which area is it essential to assess?
- A. Pedal area
- B. Femoral area
- C. Popliteal area
- D. Inner aspect of the thigh
Correct Answer: A
Rationale: Assessing the pedal area checks for circulation, sensation, and movement, critical in traction to detect neurovascular compromise.
The client diagnosed with osteoporosis asks the nurse, 'Why does smoking cigarettes cause my bones to be brittle?' Which response by the nurse is most appropriate?
- A. Smoking causes nutritional deficiencies, which contribute to osteoporosis.'
- B. Tobacco causes an increase in blood supply to the bones, causing osteoporosis.'
- C. Smoking low-tar cigarettes will not cause your bones to become brittle.'
- D. Nicotine impairs the absorption of calcium, causing decreased bone strength.'
Correct Answer: D
Rationale: Nicotine reduces calcium absorption, contributing to bone loss in osteoporosis. Nutritional deficiencies are secondary, blood supply does not increase, and low-tar cigarettes still harm bones.
The nurse is preparing the plan of care for the client with a closed fracture of the right arm. Which problem is most appropriate for the nurse to identify?
- A. Risk for ineffective coping related to the inability to perform ADLs.
- B. Risk for compartment syndrome-related injured muscle tissue.
- C. Risk for infection related to exposed bone and tissue.
- D. Risk for complications related to compromised neurovascular status.
Correct Answer: B
Rationale: Compartment syndrome is a critical risk in closed fractures due to swelling, threatening limb viability. Coping, infection (more for open fractures), and general complications are secondary.
Which assessment findings should the nurse associate with the development of hydrocephalus in a 7-year-old child?
- A. Headache
- B. Vomiting
- C. Angioedema
- D. Personality change
- E. Increased head circumference
Correct Answer: A,B,D
Rationale: Headache, vomiting, and personality changes are common symptoms of hydrocephalus due to increased intracranial pressure.
Which type of seizure involves a brief loss of awareness and minor motor movements such as eye blinking?
- A. Myoclonic seizure involves muscle movement and not just loss of awareness.
- B. Febrile seizures occur when the child's temperature is excessively elevated and usually includes tonic-clonic muscle movement.
- C. An absence seizure is a generalized seizure (involving loss of awareness) that might involve minor motor movements (e.g., eye blinking). The child appears to be staring.
- D. Atonic means absence of tone and would involve loss of muscle control and not eye blinking, which requires muscle control.
Correct Answer: C
Rationale: Absence seizures are characterized by brief loss of awareness and minor motor movements like eye blinking, with the child appearing to stare.