A male client has undergone spinal surgery, the nurse should:
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Solution
Assess the client’s feet for sensation and circulation
Option C: Alteration in sensation and circulation indicates damage to the spinal cord, if these occur, notify the physician immediately.
Mang Jose with rheumatoid arthritis states, “the only time I am without pain is when I lie in bed perfectly still”. During the convalescent stage, the nurse in charge with Mang Jose should encourage:
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Solution
Active joint flexion and extension
Option A: Active exercises, alternating extension, flexion, abduction, and adduction, mobilize exudates in the joints relieves stiffness and pain.
Nurse Katrina would recognize that the demonstration of crutch walking with tripod gait was understood when the client places weight on the:
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Solution
Palms of the hand
Option B: The palms should bear the client’s weight to avoid damage to the nerves in the axilla.
While performing a physical assessment of a male client with gout of the great toe, Nurse Vivian should assess for additional tophi (urate deposits) on the:
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Solution
Ears
Option B: Uric acid has a low solubility, it tends to precipitate and form deposits at various sites where blood flow is least active, including cartilaginous tissue such as the ears.
After a long leg cast is removed, the male client should:
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Solution
Elevate the leg when sitting for long periods of time.
Option D: Elevation will help control the edema that usually occurs.
A male client’s left tibia was fractured in an automobile accident, and a cast is applied. To assess for damage to major blood vessels from the fracture tibia, the nurse in charge should monitor the client for:
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Solution
Prolonged reperfusion of the toes after blanching
Option C: Damage to blood vessels may decrease the circulatory perfusion of the toes, this would indicate the lack of blood supply to the extremity.
Patricia a 20-year-old college student with diabetes mellitus requests additional information about the advantages of using a pen-like insulin delivery devices. The nurse explains that the advantages of these devices over syringes include:
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Solution
Accurate dose delivery
Option A: These devices are more accurate because they are easy to use and have improved adherence to insulin regimens by young people because the medication can be administered discreetly.
A female client is receiving IV Mannitol. An assessment specific to safe administration of the said drug is:
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Solution
Urine output hourly
Option C: The osmotic diuretic mannitol is contraindicated in the presence of inadequate renal function or heart failure because it increases the intravascular volume that must be filtered and excreted by the kidney.
Karina a client with myasthenia gravis is to receive immunosuppressive therapy. The nurse understands that this therapy is effective because it:
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Solution
Decreases the production of autoantibodies that attack the acetylcholine receptors.
Option C: Steroids decrease the body’s immune response thus decreasing the production of antibodies that attack the acetylcholine receptors at the neuromuscular junction
Which of the following signs and symptoms would Nurse Maureen include in teaching plan as an early manifestation of laryngeal cancer?
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Solution
Hoarseness
Option C: Early warning signs of laryngeal cancer can vary depending on tumor location. Hoarseness lasting 2 weeks should be evaluated because it is one of the most common warning signs.