Nokea
Which one of the following statements is correct when measuring the client for crutches?
- A. A distance of five fingerbreadths should exist between the top of the crutch and the axilla.
- B. The nurse should measure three inches between the top of the crutch and the axilla.
- C. The client's elbows should be flexed at a 10° angle.
- D. The crutches should be extended 8 to 10 inches from the side of the foot.
Correct Answer: B
Rationale: Proper crutch fitting requires a gap of about three inches (or two to three fingerbreadths) between the crutch top and the axilla to prevent nerve damage. The elbow should flex at about 30°, and crutches extend about 6 inches laterally from the foot.
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A client is having episodes of hyperventilation related to her surgery that is scheduled tomorrow. Appropriate nursing actions to help control hyperventilating include:
- A. Administering diazepam (Valium) 10-15 mg po q4h and q1h prn for hyperventilating episode
- B. Keeping the temperature in the client's room at a high level to reduce respiratory stimulation
- C. Having the client hold her breath or breathe into a paper bag when hyperventilation episodes occur
- D. Using distraction to help control the client's hyperventilation episodes
Correct Answer: C
Rationale: An adult diazepam dosage for treatment of anxiety is 2-10 mg PO 2-4 times daily. The order as written would place a client at risk for overdose. A high room temperature could increase hyperventilating episodes by stimulating the respiratory system. Breath holding and breathing into a paper bag may be useful in controlling hyperventilation. Both measures increase CO2 retention. Distraction will not prevent or control hyperventilation caused by anxiety or fear.
A client suffering from schizophrenia has been taking chlorpromazine (Thorazine) for 6 months. On one of his follow-up visits to the mental health center, the nurse reports to the physician that he has developed tardive dyskinesia. Which of the following symptoms might she have observed in the client to support this conclusion?
- A. High fever, tachycardia, stupor, renal failure
- B. Lip smacking, chewing, blinking, lateral jaw movements
- C. Photosensitivity, orthostatic hypotension, dry mouth
- D. Constipation, blurred vision, drowsiness
Correct Answer: B
Rationale: These symptoms are found in clients with tardive dyskinesia.
The nurse is caring for a client with a history of congestive heart failure. The nurse should give priority to:
- A. Monitoring for arrhythmias
- B. Administering bronchodilators
- C. Monitoring for hyperglycemia
- D. Assessing for skin breakdown
Correct Answer: A
Rationale: Congestive heart failure increases the risk of arrhythmias due to cardiac strain, making monitoring for arrhythmias a priority to prevent sudden cardiac events.
A two-year-old is hospitalized with suspected intussusception. Which finding is associated with intussusception?
- A. Currant jelly stools
- B. Projectile vomiting
- C. Ribbonlike stools
- D. Palpable mass over the flank
Correct Answer: A
Rationale: Currant jelly stools (bloody, mucousy) are classic in intussusception due to intestinal ischemia. Vomiting and a palpable abdominal mass may occur, but stools and flank masses are less specific.
The predominant purpose of the first Apgar scoring of a newborn is to:
- A. Determine gross abnormal motor function
- B. Obtain a baseline for comparison with the infant's future adaptation to the environment
- C. Evaluate the infant's vital functions
- D. Determine the extent of congenital malformations
Correct Answer: C
Rationale: Apgar scores are not related to the infant's care, but to the infant's physical condition. Apgar scores assess the current physical condition of the infant and are not related to future environmental adaptation. The purpose of the Apgar system is to evaluate the physical condition of the newborn at birth and to determine if there is an immediate need for resuscitation. Congenital malformations are not one of the areas assessed with Apgar scores.