EAQ #6
A client is undergoing diagnostic testing for myasthenia gravis. Which test would the nurse identify as the most specific for this diagnosis?
edrophonium chloride test- uses a medication that is a cholinergic and an anticholinesterase, it blocks the actins of the cholinesterase at the myoneural junction and inhibits the destruction of acetylcholine; Pyridostigmine is a slower acting anticholinesterase medication that is commonly prescribed to treat myasthenia gravis
Which joint is an example of a gliding joint?
SI- connects the sacrum with the pelvis, one surface of the bone moves over another surface; wrist joint is an example of a condyloid joint, the elbow is an example of a hinge joint, shoulder joint is ball and socket
Which is a component of the primary survey?
disability- assessing disability by conducting a brief neurological examination is a component of the primary survey which aims to identify life threatening conditions so appropriate intervention can be started; assessment of the abdomen, flank, head, neck, face, and HPI are all part of the secondary survey which begins after addressing lifesaving needs
A client with a parotid tumor and enlarged lymph nodes in the neck is undergoing radiation therapy on an outpatient basis. Which condition will the nurse assess the client for during the return visit to the radiology department?
dysphagia- the proximity of the parotid gland to the esophagus necessitates assessment of swallowing because dysphagia may be result of damage to surrounding tissue
For optimum nutrition, which intervention would the nurse implement when determining a client, who sustained a CVA, needs assistance with eating?
encourage the client to participate in the feeding process
Which factor is used to assess the quality of health care provided to a client?
functional health status of the client after discharge
Which type of joint is present in between the client's tarsal bones?
gliding joint; the pivot joint is present in the proximal radioulnar joint, the hinge joint is present in the elbows and knees, the saddle joint is present in between the carpometacarpal joints of the thumb
The nurse is interviewing a client with a tentative diagnosis of Parkinson disease. Which description would the nurse give to a client about the onset of symptoms?
gradually- the disease is insidious, with a prolonged course and gradual progression, onset is slow and gradual, there is a gradual, regular progression of symptoms
Which action would the nurse take for an older client with Alzheimer disease who has laid out several outfits on the bed to wear to a recreational session but is still wearing nightclothes?
help the client select appropriate attire and offer to help the client get dressed
Which type of cast or splint will the nurse expect to see on a child with a fractured femur?
hip spica; cylinder cast is used for knee fractures because it extends from the groin to the malleoli of the ankle, a prefabricated knee splint is a commonly used cast for a lower extremity injuries, a robert jones dressing is composed of bulky padding material, splints, and elastic wrap or stockinette used for lower extremity injuries
The nurse is performing an assessment of fine motor skills on an infant. Which actions would the nurse observe?
holding a rattle, picking up objects, holding a baby bottle
When would the nurse expect the client who has RA to experience the most joint pain and stiffness?
in the morning on awakening- inactivity over an extended time increases stiffness and pain in joints
During the neurological assessment of a client with a tentative diagnosis of Guillaine- Barre syndrome, which clinical finding would the nurse expect the client to manifest?
increased muscular weakness- muscular weakness and paralysis results from impaired nerve conduction because the motor nerve become demyelinated
Which activity will prepare the client who has a new above the knee amputation for crutch walking?
lifting weights- to strengthen arm and shoulder muscles
Which tissue connects the client's tibia to the femur at the knee joint?
ligament- a dense, fibrous connective tissue that connects bone to bone, such as the tibia to the femur at the knee joint, provide stability while permitting controlled movement at the joint; fascia is a connective tissue that can withstand limited stretching- provides strength to muscle and tissues, bursae are small sacs of connective tissue lines with synovial membrane and synovial fluid that are located at bony prominences and joints to relieve pressure, a tendon is a dense, fibrous connective tissue that attaches muscles to bone
A client with Parkinsonism takes an anticholinergic medication for morning stiffness and tremors in the right arm. During a visit to the clinic, the client complained of some numbness in the left hand. Which intervention would the nurse implement for this client?
make immediate arrangements for further medical evaluation by the client's primary health care provider- numbness is inconsistent with Parkinson's, this may be indicative of an impending CVA, seek treatment immediately
Which element would the nurse focus on when teaching crutch-walking to a client who has a casted leg fracture?
modifying the home environment to prevent accidents
Which type of rehabilitation is an essential component to a client's recover from Guillain-Barre syndrome?
physical therapy- and exercise for the lower extremities because of muscle weakness and discomfort
To best address the functional and behavioral changes associated with a client's early Alzheimer disease, which action would the nurse encourage the daughter to do?
post a schedule for the client's daily activities- establishing a daily routine, posting it, and adhering to it provides a concrete, structure approach
Which synovial joint movement is involved in turning a client's pal downward?
pronation; eversion involves turning the sole outward away from the midline of the body, inversion involved turning the sole inward towards the midline of the body, supination involves turning the palm upward
A client is diagnosed with Parkinson disease and receives a prescription for levodopa therapy. Which mechanism of action would the nurse identify for this medication?
restores the dopamine levels in the brain- is a precursor of dopamine, a catecholamine neurotransmitter; blocking the effects of acetylcholine is accomplished by anticholinergic medication
When encouraging a client to seek testing and treatment for streptococcal pharyngitis, which complication will the nurse discuss?
rheumatic fever- caused by abnormal immunological response to group A beta-hemolytic streptococcus which may cause permanent scarring and damage to the hear valves
Which bones are examples of a client's flat bones?
scapula, sternum- compact bones separated by a layer of cancellous bone that contains bone marrow; bones such as the sacrum and mandible are irregular bones- appear in a variety of shapes and sized, the humerus is a long bone with a central shaft and two widened ends
Which function would the nurse consider in the plan of care when a client has dysphagia?
swallowing
Which explanation would the nurse provide to a client about TIAs?
temporary episodes of neurological dysfunction- narrowing of arteries supplying the brain causes temporary neurological deficits that last for a short period, between attacks neurological function is normal; Emboli results in CVA and the damage is usually permanent; ischemic attacks that result in progressive neurological deterioration occur with multiple small brain attacks
Which level of care is the nurse providing when preparing to discharge a client who is learning to walk again after a stroke to a rehabilitation center?
tertiary care- goal of restoring a client back to his or her prior level of functioning; primary care aims to prevent an illness or injury from happening, secondary care is an ongoing process such as assisted living or psychiatric daycare, secondary acute care provides emergency care or acute care after an illness or accident
Which assessment finding is associated with depression?
the client has islands of intact memory- client with depression has selective or patchy memory loss with islands of intact memory; a client with dementia has impaired recent and remote memory, the onset of delirium may be abrupt causing impaired recent and immediate memory- they are forgetful and require step by step instructions to complete simple tasks
An 80 year old client is admitted to the hospital with severe dehydration. The client's daughter asks the nurse how her mother could have become dehydrated. Which response by the nurse is correct?
the thirst reflex diminishes with age, and the recognition of the need for fluid is decreased
Which reason explains why so many psychiatric clients are given benztropine or trihexyphenidly in conjunction with phenothiazine-derivative neuroleptic medications?
they combat the extrapyramidal side effects of the neuroleptic medication- control extrapyramidal (parkinsonian) manifestations
For which purpose is a goniometer used?
to assess range of motion; mirror therapy is used to reduce phantom limb sensation, buck's traction boot is a type of skin traction used to prevent hip flexion contracture, splints are used to immobilize a joint after a fracture
Which activities can a child perform at 3 years of age?
turning doorknobs, holding crayons with fingers, eating with a spoon without rotating it
Which is an example of a condyloid joint?
wrist joint- a joint between the radial and carpals; elbow joint is an example of a hinge joint, shoulder joint is an example of a ball and socket joint, SI joint is an example of a gliding joint
Which physiological changes of the musculoskeletal system would the nurse associate with aging?
slow movement, cartilage degeneration, increased bone prominence
When teaching about aging, the nurse explains that older adults usually have which characteristic?
slower reaction times- due to decrease in neuromuscular function
Which is the correct order of phases a client experiences in the event of a change in body image?
shock, withdrawal, acknowledgement, acceptance, rehabilitation
Which is the correct order of phases a client experiences in the event of a change in body image?
shock, withdrawal, acknowledgment, acceptance, rehabilitation
The RN is giving home care instructions to a client who was treated for injuries due to a fall. Which statement made by the client indicated a need for additional instruction?
"I should walk on soft scatter rugs at home"
A health care provider prescribed a diagnostic workup for a client who may have myasthenia gravis. Which initial objective would the nurse establish with the client?
"The client will maintain present muscle strength"- until confirming the dx. the primary goal should be to maintain appropriate activity and prevent muscle atrophy
Which muscle- strength rating would the nurse record for a client who can complete range of motion with some resistance?
4; rating 1= given to a client with no joint motion and slight evidence of muscle contractility, rating 2= client who can complete ROM with gravity eliminated, 3= a client who can complete ROM against gravity
Which range of heart rate is acceptable for a preschooler?
80-110bpm; adults range 60-100, school age children range 75-100, toddler is 90-140
Which term describes synovial joint movement away from the midline of the body?
abduction- movement away from the midline of the body; inversion is turning of the sole inward toward the midline of the body, pronation is a synovial joint movement that involves the turning of the palm downward, extension is a synovial joint movement that involves a straightening of a joint that increases the angle between two bones
Which client action would the nurse score as 3 on the muscle strength scale?
active movement against gravity only and not against resistance
Which type of joint permits movement in any direction?
ball and socket; pivot joints permit rotation, hinge joints allow motion in one plan, biaxial joints permit gliding movement
Which structures protect a client's internal organs, support blood cell production, and store minerals?
bones- support and protect internal organs, help in stem cell production from bone marrow, store miners; joints (articulations) help articulate the bones, muscles are the bundles of fibrous tissue that contract to produce movement and maintain body, cartilage is a hyaline, elastic, and fibrous tissues that often functions as a shock absorber
When assessing a client with heart failure for activity tolerance, which activity would the nurse expect to cause the most distress for the client?
climbing a flight of stairs to the bedroom- stair climbing increases oxygen consumption and increases the workload of the heart resulting in dyspnea and fatigue
Which type of treatment is the Buck extension?
cutaneous traction - applied directly to the skin by tape of by a foam boot; skeletal traction applied directly to the bony skeleton, halter strap used with cervical or pelvic traction, balances suspension traction keeps the affected extremity elevated off the bed
Which finding in older adult clients is associated with aging?
decreased in height; loss of heigh, deformity, and shortening of the trunk are common
Which principles of body mechanics would the nurse use when providing care for an immobilized client?
placing the feet apart to increase the stability of the body
Which term would the nurse use to document observing the characteristic gait associated with Parkinson disease?
shuffling; ataxia is staggering gait often associated with cerebellar damage, scissoring is associated with bilateral spastic paresis of the legs, asymmetric gait is associated with weakness of or pain in one lower extremity
A health care provider prescribed daily docusate sodium for a client. The nurse explains to the client that this medication has which action?
softens the feces- promotes the drawing of fluid into the stool, which softens the feces; lubricating the feces in the GI tract is the action of lubricant laxatives such as mineral oil, creating an osmotic effect in the GI tract is the action of saline laxatives such as lactulose, stimulating motor activity of the GI tract is the action of peristaltic stimulants such as cascara
Which type of joint is present in the client's shoulder?
spheroidal joint- ball and socket joint that provides flexion, extension, adduction, abduction, and circumduction in shoulders and hips; saddle joint= carpometacarpal joint of the thumb provides flexion, extension, abduction, adduction, and circumduction of the thumb; the condyloids joint is a wrist joint between the radial and carpals- provides felzion, extension, abduction, adduction, and circumduction
Which observation would correspond to a muscle strength rating of 3?
can complete ROM against gravity
Which bursae are between the client's elbow and the skin?
olecranon; prepatellar bursae are found between the patella and the skin, subacromial bursae are found between the head of the humerus and the acromion process of the scapula, trochanteric bursae are found between the greater trochanter of the proximal femur and the skin
Which term would the nurse use to document a client experiencing urinary incontinence via involuntary loss of small amounts (25-35mL) of urine from an over distended bladder?
overflow incontinence- occurs when the pressure in the bladder overcomes sphincter control; urge incontinence describes a strong need to void that leads to involuntary urination regardless of the amount in bladder; stress incontinence occurs when the client expels a small amount of urine because of an increase intra-abdominal pressure that occurs with coughing, lifting, or sneezing; functional incontinence occurs from other issues rather than the bladder such as cognitive (dementia) or environmental (no toileting facilities)
A client with myasthenia gravis experiences generalized weakness. Which nursing intervention would the nurse integrate into the client's plan of care>?
provide the client frequent rest periods
A client who has a spinal cord injury at the T4 level wants to use a wheelchair. What exercise would the nurse teach the client to do in preparation for this activity?
pushups to strengthen arm muscles
Which happens during the transition from infanthood to toddlerhood?
reduced need for sleep- and activity level increases; toddlers need less fat and more protein, children establish lifetime eating habits during toddlerhood, and there is an increased emphasis on food choices
Which nursing intervention prevents footdrop in a client with osteomyelitis?
neutral positioning of the foot with the use of a splint; elevating the foot reduces edema, asking client to flex foot can result in flexion contracture, encouraging to change positions helps prevent complications associated with immobility and promotes comfort
A 90 year old resident fell and fracture the proximal end of the right femur. The surgeon plans to reduce the fracture with an internal fixation device. Which general fact about the older adult would the nurse consider when caring for this client?
aging reduces the physiological coping defenses; pain threshold increases with age, older adults become more entrenched in ideas environment, and objects that are familiar, and thus do not tolerate change well
A client is undergoing diagnostic testing for myasthenia gravis. Which test would the nurse identify as the most specific for this diagnosis?
edrophonium chloride test- uses a medication that is a cholinergic and anticholinerase, it blocks the action of the cholinesterase at the myoneural junction and inhibits the destruction of acetylcholine, increases muscle strength immediately for a short period of time
For optimum nutrition, which intervention would the nurse implement when determining a client, who sustained a CVA, needs assistance with eating?
encourage the client to participate in the feeding process- clients should be encouraged to participate in their own care to the extent they are able and extend their abilities by establishing short term goals
While providing care for a client with a second-degree left ankle sprain, the nurse raises the injured part above the heart level. Which statement provides the reason behind this nursing intervention?
to prevent further edema- helps mobilization of the excess fluid fro the area and prevents further edema; strength exercises help build bone density and muscle strength and significantly reduce risk of sprains and strains, cryotherapy and adequate rest help reduce pain by reducing the transmission and perception of pain impulses
The nurse prepares to administer extended- release metformin to an older adult who has asked that it be crushed because it is difficult to swallow. Which rationale will prompt the nurse to ask the provider for a different form of metformin?
extended- release formulations are designed to be released slowly and crushing the tablet will prevent this from occurring
Which organ is commonly affected in children with juvenile idiopathic arthritis (JIA)?
eyes- can cause inflammation of the iris and ciliary body of the eyes, which may lead to blindness; liver may become enlarges but not as frequently as visual problems do
Which action would the nurse take for an older client with Alzheimer disease who has laid out several outfits on the bed to wear to a recreational session but is still wearing nightclothes?
help the client select appropriate attire and offer to help the client get dressed- aids the client in decision making
Which phrase describes a greenstick fracture?
incomplete with one side bent- one side splintered and the other side bent; fracture with more than two fragments that appear to be floating is known as a commuted fracture, a pathologic fracture is a spontaneous fracture that found at the site of bone disease, a transverse racture extends across the longitudinal axis of the bone shaft
Which goal would be the priority for the child with autism spectrum disorder who has frequent episodes of self-biting and head-banging and needs help with feeding and toileting?
remaining safe from self-inflicted injury
Which clinical manifestation would best indicate to the nurse that the mental status of a client with schizophrenia and paranoid delusions is improving?
ability to function effectively in activities of daily living- if they can do this and function in society they are considered mentally stable
A client is likely to undergo reconstructive surgery for which purpose?
to restore function and/or appearance- type of surgery includes plastic surgery, a term that is interchangeable with reconstructive surgery, in reconstructive surgery repairs are made and malformations corrected that are congenital, a result of disease processes, or from traumatic injury; replacement of a tissue or organ is known as transplant, surgery to relive or reduce symptoms is known as palliative, and surgery ot remove or excise an organ or tissue is known as a resection