A male client in the emergency department has a suspected neurologic disorder. To assess gait, the nurse asks the client to take a few steps; with each step, the client’s feet make a half circle. To document the client’s gait, the nurse should use which term?
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Solution
Helicopod
A helicopod gait is an abnormal gait in which the client’s feet make a half circle with each step.
Option A: An ataxic gait is staggering and unsteady.
Option B: In a dystrophic gait, the client waddles with the legs far apart.
Option D: In a steppage gait, the feet, and toes raise high off the floor and the heel comes down heavily with each step.
A female client who’s paralyzed on the left side has been receiving physical therapy and attending teaching sessions about safety. Which behavior indicates that the client accurately understands safety measures related to paralysis?
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Solution
The client uses a mirror to inspect the skin.
Using a mirror enables the client to inspect all areas of the skin for signs of breakdown without the help of staff or family members.
Option A: The client should keep the side rails up to help with repositioning and to prevent falls.
Option C: The paralyzed client should take responsibility for repositioning or for reminding the staff to assist with it if needed.
Option D: A client with left-side paralysis may not realize that the left arm is hanging over the side of the wheelchair. However, the nurse should call this to the client’s attention because the arm can get caught in the wheel spokes or develop impaired circulation from being in a dependent position for too long.
After an eye examination, a male client is diagnosed with open-angle glaucoma. The physician prescribes Pilocarpine ophthalmic solution (Pilocar), 0.25% gtt i, OU q.i.D. Based on this prescription, the nurse should teach the client or a family member to administer the drug by:
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Solution
Instilling one drop of pilocarpine 0.25% into both eyes four times daily.
The abbreviation “gtt” stands for drop, “i” is the apothecary symbol for the number 1, OU signifies both eyes, and “q.i.d.” means four times a day. Therefore, one drop of pilocarpine 0.25% should be instilled into both eyes four times daily.
Nurse Amber is caring for a client who underwent a lumbar laminectomy two (2) days ago. Which of the following findings should the nurse consider abnormal?
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Solution
Urine retention or incontinence
Urine retention or incontinence may indicate cauda equina syndrome, which requires immediate surgery.
Option A: An increase in pain on the second postoperative day is common because the long-acting local anesthetic, which may have been injected during surgery, will wear off.
Option B: While paresthesia is common after surgery, progressive weakness or paralysis may indicate spinal nerve compression.
Option D: A mild fever is also common after surgery but is considered significant only if it reaches 101° F (38.3° C).
An auto mechanic accidentally has battery acid splashed in his eyes. His coworkers irrigate his eyes with water for 20 minutes, and then take him to the emergency department of a nearby hospital, where he receives emergency care for the corneal injury. The physician prescribes dexamethasone (Maxidex Ophthalmic Suspension), two drops of 0.1% solution to be instilled initially into the conjunctival sacs of both eyes every hour; and polymyxin B sulfate (Neosporin Ophthalmic), 0.5% ointment to be placed in the conjunctival sacs of both eyes every 3 hours. Dexamethasone exerts its therapeutic effect by:
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Solution
Decreasing leukocyte infiltration at the site of ocular inflammation.
Dexamethasone exerts its therapeutic effect by decreasing leukocyte infiltration at the site of ocular inflammation. This reduces the exudative reaction of diseased tissue, lessening edema, redness, and scarring.
Options C and D: Dexamethasone and other anti-inflammatory agents don’t inhibit the action of carbonic anhydrase or produce any type of miotic reaction.
Emergency medical technicians transport a 27-year-old iron worker to the emergency department. They tell the nurse, “He fell from a two-story building. He has a large contusion on his left chest and a hematoma in the left parietal area. He has a compound fracture of his left femur and he’s comatose. We intubated him and he’s maintaining an arterial oxygen saturation of 92% by pulse oximeter with a manual resuscitation bag.” Which intervention by the nurse has the highest priority?
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Solution
Assessing the left leg
In the scenario, airway and breathing are established so the nurse’s next priority should be circulation. With a compound fracture of the femur, there is a high risk of profuse bleeding; therefore, the nurse should assess the site.
Option B and D: Neurologic assessment is a secondary concern to airway, breathing, and circulation.
Option C: The nurse doesn’t have enough data to warrant putting the client in Trendelenburg’s position.
A female client complains of periorbital aching, tearing, blurred vision, and photophobia in her right eye. Ophthalmologic examination reveals a small, irregular, nonreactive pupil — a condition resulting from acute iris inflammation (iritis). As part of the client’s therapeutic regimen, the physician prescribes atropine sulfate (Atropisol), two drops of 0.5% solution in the right eye twice daily. Atropine sulfate belongs to which drug classification?
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Solution
Cholinergic blocker
Atropine sulfate is a cholinergic blocker. It isn’t a parasympathomimetic agent, a sympatholytic agent, or an adrenergic blocker.
Shortly after admission to an acute care facility, a male client with a seizure disorder develops status epilepticus. The physician orders diazepam (Valium) 10 mg I.V. stat. How soon can the nurse administer the second dose of diazepam, if needed and prescribed?
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Solution
In 10 to 15 minutes
When used to treat status epilepticus, diazepam may be given every 10 to 15 minutes, as needed, to a maximum dose of 30 mg. The nurse can repeat the regimen in 2 to 4 hours, if necessary, but the total dose shouldn’t exceed 100 mg in 24 hours.
Option A: The nurse must not administer I.V. diazepam faster than 5 mg/minute. Therefore, the dose can’t be repeated in 30 to 45 seconds because the first dose wouldn’t have been administered completely by that time.
Option B: Waiting longer than 15 minutes to repeat the dose would increase the client’s risk of complications associated with status epilepticus.
The nurse is performing a mental status examination on a male client diagnosed with a subdural hematoma. This test assesses which of the following?
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Solution
Cerebral function
The mental status examination assesses functions governed by the cerebrum. Some of these are orientation, attention span, judgment, and abstract reasoning.
Option A: Cerebellar function testing assesses coordination, equilibrium, and fine motor movement.
Option B: Intellectual functioning isn’t the only cerebral activity.
Option D: Sensory function testing involves assessment of pain, light-touch sensation, and temperature discrimination.
To encourage adequate nutritional intake for a female client with Alzheimer’s disease, the nurse should:
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Solution
Stay with the client and encourage him to eat.
Staying with the client and encouraging him to feed himself will ensure adequate food intake. A client with Alzheimer’s disease can forget how to eat.
Options B, C, and D: Allowing privacy during meals, filling out the menu, or helping the client to complete the menu doesn’t ensure adequate nutritional intake.