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While caring for a client with amyotrophic lateral sclerosis (ALS), the nurse performs a neurological assessment every four hours. Which assessment finding warrants immediate intervention by the nurse?
- A. Inappropriate laughter.
- B. Asymmetrical weakness.
- C. Increasing anxiety.
- D. Weakened cough effort.
Correct Answer: D
Rationale: Weakened cough risks aspiration pneumonia, a life-threatening ALS complication requiring urgent intervention.
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A client who works as a data entry clerk is concerned as to how a recent diagnosis of Raynaud's syndrome is going to affect the client's job performance. Which instruction should the nurse provide this client?
- A. Use a space heater to keep the workspace warm.
- B. Take a multivitamin that contains vitamin D daily.
- C. Keep both hands elevated during work breaks.
- D. Obtain a keyboard designed to limit wrist flexion.
Correct Answer: A
Rationale: A warm workspace prevents vasospasm, reducing Raynaud's attacks during work.
The nurse is performing a physical assessment of a client. Which finding should the nurse recognize is a result of a compromised peripheral arterial circulation of the lower extremity?
- A. Uneven hair distribution.
- B. Lower leg edema.
- C. Bronze pigmentation.
- D. Bounding peripheral pulse.
Correct Answer: A
Rationale: Uneven hair distribution results from reduced blood flow impairing hair follicle nutrition, a sign of peripheral arterial disease.
Methotrexate is prescribed for a client with rheumatoid arthritis (RA) who is also taking aspirin. Which is the best explanation for the nurse to provide as to why a second medication has been added?
- A. Methotrexate has less harmful side effects than aspirin.
- B. Methotrexate helps to reduce the side effects of the aspirin therapy.
- C. Methotrexate enhances the effectiveness of the aspirin.
- D. Methotrexate slows the disease progression while aspirin controls the symptoms.
Correct Answer: D
Rationale: Methotrexate slows RA progression, while aspirin manages symptoms, addressing both disease and comfort.
A client reports to the clinic nurse of recently experiencing symptoms of frequent urination, hunger, and great thirst. What finding(s) would the nurse consider as most significant to report to the healthcare provider? Select all that apply.
- A. Total cholesterol 180 mg/dL (4.7 mmol/L).
- B. Hematocrit 45% (0.45 volume fraction).
- C. Random plasma glucose level 200 mg/dL (11.1 mmol/L).
- D. Hemoglobin A1C 7%.
- E. Serum potassium of 4.2 mEq/L (4.2 mmol/L).
Correct Answer: C,D
Rationale: Elevated glucose and HbA1C indicate diabetes, correlating with the client's symptoms and requiring urgent management.
The nurse reviews discharge instructions with a client who has gastroesophageal reflux disease (GERD). Which instruction is most important for the nurse to emphasize?
- A. Remain upright following meals.
- B. Avoid wearing tight fitting clothes.
- C. Minimize intake of spicy foods.
- D. Begin a smoking cessation program.
Correct Answer: A
Rationale: Remaining upright prevents gastric reflux by aiding stomach emptying, directly addressing GERD symptoms.