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Which option below is considered a positive Homan's Sign for the assessment of a deep vein thrombosis (DVT)?
- A. The patient reports pain when the foot is manually dorsiflexed.
- B. The patient reports pain when the foot is manually plantarflexed.
- C. The patient experiences pain when the leg is extended.
- D. the patient experiences pain when the leg is flexed.
Correct Answer: A
Rationale: Homan's Sign is NOT reliable because of false positives, but know for exams how to elicit a response. It done by manually (forced) dorsiflexing the patient's foot (bending it up towards the shin) and if it causes the patient pain it considered a positive Homan's Sign. However, the MD must further investigate if the patient has a DVT.
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When the nurse is instructing the client on the effectiveness of oseltamivir (Tamiflu), which of the following instruction points is essential?
- A. Tamiflu must be started within 12 to 24 hours of the first symptoms.
- B. Tamiflu must be taken on an empty stomach to aid in absorption.
- C. Tamiflu affects the liver; liver enzymes are assessed before administration.
- D. Tamiflu is most effective when administered intranasally.
Correct Answer: A
Rationale: Oseltamivir is most effective when started within 12 to 24 hours of symptom onset, as it inhibits viral replication early.
The nurse is discussing the results of a tuberculosis skin test. Which explanation should the nurse provide the client?
- A. A red area is a positive reading that means the client has tuberculosis.
- B. The skin test is the only procedure needed to diagnose tuberculosis.
- C. A positive reading means exposure to the tuberculosis bacilli.
- D. Do not get another skin test for one (1) year if the skin test is positive.
Correct Answer: C
Rationale: A positive TB skin test (C) indicates exposure to TB bacilli, not active disease, requiring further testing (e.g., chest X-ray). Redness alone (A) is not diagnostic; induration is measured. The skin test (B) is not definitive for diagnosis. Annual testing (D) may be needed in high-risk groups.
Which client problems are appropriate for the nurse to include in the plan of care for the client diagnosed with COPD? Select all that apply.
- A. Impaired gas exchange.
- B. Inability to tolerate temperature extremes.
- C. Activity intolerance.
- D. Inability to cope with changes in roles.
- E. Alteration in nutrition.
Correct Answer: A,C,D,E
Rationale: COPD causes impaired gas exchange (A), activity intolerance (C), role changes (D), and nutritional issues (E) from energy demands. Temperature intolerance (B) is not primary.
Which medication below blocks the function of Leukotriene for the treatment of asthma?
- A. Salmeterol
- B. Theophylline
- C. Tiotropim
- D. Montelukast
Correct Answer: D
Rationale: Montelukast is a leukotriene receptor antagonist that blocks leukotrienes, reducing asthma symptoms.
Which information should the nurse teach the client diagnosed with acute sinusitis?
- A. Instruct the client to complete all the ordered antibiotics.
- B. Teach the client how to irrigate the nasal passages.
- C. Have the client demonstrate how to blow the nose.
- D. Give the client samples of a narcotic analgesic for the headache.
Correct Answer: A
Rationale: Completing antibiotics (A) ensures treatment of bacterial sinusitis, preventing resistance. Irrigation (B) is supportive, nose-blowing (C) is routine, and narcotics (D) are excessive for sinus headaches.