The home health nurse is visiting an 18-year-old with osteogenesis imperfecta. Which information obtained on the visit would cause the most concern? The client:
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Solution
Likes to play football
The client with osteogenesis imperfecta is at risk for pathological fractures and is likely to experience these fractures if he participates in contact sports. The client might experience symptoms of hypoxia if he becomes dehydrated or deoxygenated; extreme exercise, especially in warm weather, can exacerbate the condition.
Options B, C, and D are not factors for concern.
The client arrives in the emergency department after a motor vehicle accident. Nursing assessment findings include BP 80/34, pulse rate 120, and respirations 20. Which is the client’s most appropriate priority nursing diagnosis?
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Solution
Fluid volume deficit
The vital signs indicate hypovolemic shock.
Options A, C, and D: They do not indicate cerebral tissue perfusion, airway clearance, or sensory perception alterations.
The nurse is caring for a client with ascites. Which is the best method to use for determining early ascites?
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Solution
Daily measurement of abdominal girth
Measuring with a paper tape measure and marking the area that is measured is the most objective method of estimating ascites.
Options A and D: Inspecting and checking for fluid waves are more subjective.
Option B: Palpation of the liver will not determine the amount of ascites.
A client has cancer of the pancreas. The nurse should be most concerned about which nursing diagnosis?
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Solution
Alteration in nutrition
Cancer of the pancreas frequently leads to severe nausea and vomiting and altered nutrition.
Options B, C, and D: The other problems are of lesser concern.
The client has elected to have epidural anesthesia to relieve labor pain. If the client experiences hypotension, the nurse would:
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Solution
Increase the rate of the IV infusion
If the client experiences hypotension after an injection of epidural anesthetic, the nurse should turn her to the left side, apply oxygen by mask, and speed the IV infusion. If the blood pressure does not return to normal, the physician should be contacted. Epinephrine should be kept for emergency administration.
Option A: Placing the client in Trendelenburg position (head down) will allow the anesthesia to move up above the respiratory center, thereby decreasing the diaphragm’s ability to move up and down and ventilate the client.
Option B: The IV rate should be increased, not decreased.
Option C: the oxygen should be applied by mask, not cannula.
The nurse caring for a client receiving intravenous magnesium sulfate must closely observe for side effects associated with drug therapy. An expected side effect of magnesium sulfate is:
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Solution
Hypersomnolence
The client is expected to become sleepy, have hot flashes, and be lethargic. A decreasing urinary output,
Options A, C, and D: A decreasing urinary output, absence of the knee-jerk reflex, and decreased respirations indicate a magnesium sulfate toxicity.
Which observation in the newborn of a diabetic mother would require immediate nursing intervention?
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Solution
Jitteriness
Jitteriness is a sign of seizure in the neonate.
Options A, B, and D: Crying, wakefulness, and yawning are expected in the newborn.
A diabetic multigravida is scheduled for an amniocentesis at 32 weeks gestation to determine the L/S ratio and phosphatidyl glycerol level. The L/S ratio is 1:1 and the presence of phosphatidylglycerol is noted. The nurse’s assessment of this data is:
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Solution
The infant is at high risk for respiratory distress syndrome.
When the L/S ratio reaches 2:1, the lungs are considered to be mature.
Option A: The L/S ratio does not indicate congenital anomalies.
Option B: The infant is not at risk for intrauterine growth retardation.
Option D: The infant will most likely be small for gestational age and will not be at risk for birth trauma.
A primigravida with diabetes is admitted to the labor and delivery unit at 34 weeks gestation. Which doctor’s order should the nurse question?
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Solution
Brethine 10 mcg IV
Brethine is used cautiously because it raises the blood glucose levels.
Options A, C, and D: Magnesium sulfate, Stadol, and Ancef are all medications that are commonly used in the diabetic client.
The nurse is assessing the deep tendon reflexes of a client with preeclampsia. Which method is used to elicit the biceps reflex?
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Solution
The nurse places her thumb on the muscle inset in the antecubital space and taps the thumb briskly with the reflex hammer.
Option B elicits the triceps reflex.
Option C elicits the patellar reflex.
Option D elicits the radial nerve.