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A client with paralysis from a cerebrovascular accident (CVA).
Which of the following is a priority nursing goal in the plan of care for a client with paralysis from a cerebrovascular accident (CVA)?
- A. Maintain adduction of the affected shoulder.
- B. Prevent flexion of the affected extremities.
- C. Observe active range of motion (ROM) daily to all extremities.
- D. Maintain external rotation of the affected hip.
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) to prevent deformities, the nurse needs to prevent adduction of the affected shoulder (2) correct-flexor muscles are stronger than extensor muscles (3) client will be unable to perform active ROM, will need assistance from nurse (4) to prevent deformities, the nurse needs to prevent external rotation of the hip joint, prevent foot drop (plantar flexion), and place the hand in slight supination so that the fingers are barely flexed
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The treatment protocol for a client with acute lymphatic leukemia includes Orasone (prednisone), Trexall (methotrexate), and Zantac (ranitidine). The purpose of Zantac is to:
- A. Decrease the secretion of pancreatic enzymes.
- B. Enhance the effectiveness of the methotrexate.
- C. Promote peristalsis.
- D. Prevent a common side effect of prednisone.
Correct Answer: D
Rationale: Zantac (ranitidine) prevents gastric irritation and ulcers, a common side effect of prednisone. It does not affect pancreatic enzymes, methotrexate efficacy, or peristalsis.
The nurse is caring for a client with a pressure ulcer on the heel that is covered with black hard tissue. Which would be an appropriate goal in planning care for this client?
- A. Protection for the granulation tissue
- B. Heal infection
- C. Debride eschar
- D. Keep the tissue intact
Correct Answer: D
Rationale: Keep the tissue intact. Dry, intact eschar requires no intervention unless signs of infection appear.
The nurse is caring for a patient the first day postoperative after a transurethral prostatectomy (TURP). The patient has a continuous bladder irrigation (CBI). The patient's wife asks why he has Vectors are not supported in text mode. Please provide the text content you want to include, and I'll help format it appropriately. to have the CBI. Which of the following responses by the nurse is BEST?
- A. The CBI prevents urinary stasis and infection.
- B. The CBI dilutes the urine to prevent infection.
- C. The CBI enables urine to keep flowing.
- D. The CBI delivers medication to the bladder.
Correct Answer: C
Rationale: continuous bladder irrigation prevents formation of clots that can lead to obstruction and spasm in the postoperative TURP client
An elderly client is oriented during the day but becomes disoriented during the evening.
Which of the following nursing actions is MOST appropriate?
- A. Place a clock where the client can see it.
- B. Restrain all four extremities.
- C. Keep a light on in the client's room.
- D. Place the side rails in an upright position.
Correct Answer: D
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) will provide visual cues, safety is more important (2) inappropriate (3) may be appropriate, but is not priority over answer choice #4 (4) correct-side rails should always be in an upright position for a disoriented client
While explaining an illness to a 10 year-old, what should the nurse keep in mind about the cognitive development at this age?
- A. They are able to make simple association of ideas
- B. They are able to think logically in organizing facts
- C. Interpretation of events originate from their own perspective
- D. Conclusions are based on previous experiences
Correct Answer: B
Rationale: They are able to think logically in organizing facts. The child in the concrete operations stage is capable of mature thought when organizing objects.