A client with Alzheimer’s disease is awaiting placement in a skilled nursing facility. Which long-term plans would be most therapeutic for the client?
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Solution
Answer C is correct. Answers A and B are not recommended because placing mirrors and pictures in several locations tends to cause agitation. Answer C is correct because placing simple signs that indicate the location of rooms where the client sleeps, eats, and bathes will help the client be more independent. Answer D is incorrect because alternating healthcare workers also confuses the client and leads to further confusion.
The nurse is preparing a client for cataract surgery. The nurse is aware that the procedure will use:
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Solution
Answer A is correct. Before cataract removal, the client will have Mydriatic drops instilled to dilate the pupil. This will facilitate removal of the lens. Answer B is incorrect because miotics constrict the pupil and are not used in cataract clients. Answer C is incorrect because a laser is not used to smooth and reshape the lens. The diseased lens is removed. Answer D is incorrect because a silicone oil is not injected in this client.
Following a heart transplant, a client is started on medication to prevent organ rejection. Which category of medication prevents the formation of antibodies against the new organ?
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Solution
Answer C is correct. Immunosuppressants are used to prevent antibody formation. Answer A is incorrect because antivirals are not used in this client. Answer B is not correct because antibiotics do not prevent organ rejection. Answer D is incorrect because analgesics do not prevent rejection.
A nurse is performing the Trendelenburg test for the client with multiple sclerosis. The nurse is aware that this test is used to measure:
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Solution
Answer A is correct. A Trendelenburg test is done to determine muscle weakness. The Trendelenburg sign is positive if the client cannot stand on one leg without having pelvic weakness. The test is not done to determine fluid volume, as stated in answer B, or to determine the client’s ability to concentrate, as stated in answer C. Answer D is incorrect because the Trendelenburg test does not check for dexterity.
The nurse is caring for a client admitted to the emergency room after a fall. X-rays reveal that the client has several fractured bones in the foot. Which treatment should the nurse anticipate for the fractured foot?
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Solution
Answer B is correct. A client with a fractured foot often has a short leg cast applied to stabilize the fracture. Answer A is incorrect because a spica cast is used to stabilize a fractured pelvis or vertebral fracture. Answer C is incorrect because Kirschner wires are used to stabilize small bones such as toes. Answer D is incorrect because the client will most likely have a cast application.
The physician has ordered an injection of RhoGam for a client with blood type A negative. The nurse understands that RhoGam is given to:
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Solution
Answer B is correct. RhoGam is used to prevent formation of Rh antibodies. It does not provide immunity to Rh isoenzymes, eliminate circulating Rh antibodies, or convert the Rh factor from negative to positive, so answers A, C, and D are incorrect.
The physician has ordered a liver scan with contrast to confirm the diagnosis. Before the procedure, the nurse should:
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Solution
Answer A is correct. A thyroid scan with contrast uses a dye, so the client should be assessed for allergies to iodine. The client will not have a bolus of fluid, will not be asleep, and will not have a urinary catheter inserted, so answers B, C, and D are incorrect.
The client has an order for Demerol (meperidine) and Phenergan (promethazine) to be given together. The nurse is aware that the purpose of this order is:
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Solution
Answer A is correct. Demerol and Phenergan are given for their synergistic effect. Synergistic means that one drug increases the effectiveness of the other. Demerol is a narcotic analgesic, and Phenergan is an antianxiety, antiemetic medication. Answer B is incorrect because they are not given for the agonist effect; an agonist is a medication that works with chemicals or substances in the blood, such as hormones. Answer C is incorrect because they are not given together to cause extrapyramidal effects. Answer D is incorrect because antagonists work against one another.
An adolescent primigravida who is 10 weeks pregnant attends the antepartal clinic for her first check-up. To develop a teaching plan, the nurse should initially assess:
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Solution
Answer B is correct. The client who is 10 weeks pregnant should be assessed to determine how she feels about the pregnancy. Answer A is incorrect because it is too early to discuss preterm labor. Answer C is incorrect because it is too late to discuss whether she was using a method of birth control. Answer D is incorrect because now is not the time to discuss future children; this can be done after the client delivers.
A client with pancreatic cancer has an infusion of TPN (Total Parenteral Nutrition). The doctor has ordered a sliding scale insulin. The most likely explanation for this order is:
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Solution
Answer C is correct. Total Parenteral Nutrition is a high-glucose solution. This therapy often causes the glucose levels to be elevated. Because this is a common complication, insulin might be ordered. Answer A is incorrect because TPN is used to treat negative nitrogen balance; it will not lead to negative nitrogen balance. Answer B is incorrect because Total Parenteral Nutrition can be managed with oral hypoglycemic drugs, but it is difficult. Answer D is incorrect because Total Parenteral Nutrition will not lead to further pancreatic disease