Questions and Answers36
Deep-tendon reflexes (DTRs) are graded as... - ANSWERS-4+ = ver brisk with clonus
3+ = more brisk than average
2+ = expected
1+ = diminished
0 = no response
When assessing a young adult client's musculoskeletal system as part of a comprehensive
physical examination. Which of the following findings should the nurse expect? (select all that
apply)
a. convex thoracic spine posteriorly
b. exaggerated lumbar curvature
c. concave lumbar spine posteriorly
d. exaggerated thoracic curvature
e. muscles slight larger on the dominant side - ANSWERS-a. convex thoracic spine posteriorly
c. concave lumbar spine posteriorly
e. muscles slight larger on the dominant side
A client who reports pain with internal rotation of the right shoulder can affect the client's
ability to perform which activity?
a. exercising the deltoid muscle when using hand weights
b. brushing the hair not he back of the head
c. fastening or zipping closures in the back while dressing
d. reaching into a cabinet above the sink - ANSWERS-
,A nurse is collecting data from an older adult client as part of a neurological examination. Which
findings should the nurse expect as changeds associated with aging? (select all that apply)
a. slower light touch sensation
b. some vision and hearing decline
c. slower fine finger movement
d. some short-term memory decline
e. decreased risk of depression - ANSWERS-a, b, c, d
What assessments in a neurological examination should the nurse perform to test the client's
balance? (select all that apply)
a. Romberg test
b. Heel-to-toe walk
c. Snellen test
d. Spinal accessory function
e. Rosenbaum test - ANSWERS-a. Romberg test
b. Heel-to-toe walk
Nurse is reviewing lab results of a school age child 1 week postop following an open fracture
repair. Which findings should nurse ID as indication of potential complication?
a. Erythrocyte sedimentation rate 18 mm/hr
b. WBC count 6,200/mm3
c. C-reactive protein 1.4 mg/LRBC count 4.7 million/mm3 - ANSWERS-a. Erythrocyte
sedimentation rate 18 mm/hr
- above the expected reference range of up to 10 mm/hr and is an indication of osteomyelitis.
,Wrong Answers:
b. WBC count 6,200/mm3:- within the expected reference range of 5,000 to 10,000/mm3.
-An elevated WBC count is an indication of osteomyelitis.
c. C-reactive protein 1.4 mg/L:- within the expected reference range of <10.0 mg/L.
-An elevated C-reactive protein level is an indication of osteomyelitis.RBC count 4.7
million/mm3:- within the expected reference range of 4.0 to 5.5 million/mm3. A decreased RBC
count can indicate hemorrhage.
Nurse planning care for school age child with tunneled CVA device. Which interventions should
the nurse include in plan?
a. Use sterile scissors to remove the dressing from the site.
b. Irrigate each lumen weekly with 10 mL of 0.9% sodium chloride solution when not in use
c. Access the site using a noncoring angled needle
d. Use a semipermeable transparent dressing to cover the site - ANSWERS-d. Use a
semipermeable transparent dressing to cover the site
- The nurse should cover the site with a semipermeable transparent dressing to reduce the risk
of infection.
Wrong Answers:
a. Use sterile scissors to remove the dressing from the site
- The nurse should avoid the use of scissors when performing dressing changes because this can
result in accidental cutting of the catheter.
b. Irrigate each lumen weekly with 10 mL of 0.9% sodium chloride solution when not in use
, - The nurse should flush each lumen of the catheter with a heparin solution daily when not in
use.
c. Access the site using a noncoring angled needle
- The nurse should use a noncoring angled or straight needle when accessing an implanted port.
Nurse is planning care to address nutritional needs for preschooler with cystic fibrosis. Which
interventions should the nurse include in plans?
a. Administer pancreatic enzymes 2 hr after meals.
b. Discontinue the use of pancreatic enzymes if steatorrhea develops.
c. Limit fluid intake to 750 mL per day.
d. Increase fat content in the child's diet to 40% of total calories. - ANSWERS-d. Increase fat
content in the child's diet to 40% of total calories
- A child who has cystic fibrosis is unable to properly digest fats due to fibrosis of the pancreas
and limited secretion of pancreatic enzymes. The nurse should increase the child's fat intake to
35% to 40% of total caloric intake.
Wrong Answers:
a. Administer pancreatic enzymes 2 hr after meals
- The nurse should plan to administer pancreatic enzymes within 30 min of meals and snacks to
replace the enzymes lost with cystic fibrosis.
b. Discontinue the use of pancreatic enzymes if steatorrhea develops
- A child who has cystic fibrosis and develops steatorrhea, or fatty stools, might need to have
their dosage of pancreatic enzyme increased by their provider until the steatorrhea resolves.
c. Limit fluid intake to 750 mL per day
- The nurse should encourage fluid intake, rather than restrict it, to prevent dehydration caused
by the loss of sodium and chloride through perspiration.