A client has a herniated disk compressing the lumbar spine at L2, L3, and L4 that is impairing deep tendon reflexes. Which response will the nurse expect from the affected deep tendon reflex?
a. Diminished contraction of the gastrocnemius muscle with plantar flexion of the foot
b. Diminished contraction of the quadriceps muscle with extension of the lower leg
c. Diminished plantar flexion of the toes
d. Diminished dorsiflexion of the foot and flexion of the toes
ANS: B
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The clinic nurse provides teaching for a patient prescribed pyrimethamine (Daraprim) to prevent malaria and instructs on the need to notify the prescriber immediately if what signs and symptoms occur?
A) Diarrhea, fatigue, weight loss, and anemia B) Irritation, rash, or inflammation C) Headache, nausea, or constipation D) Anorexia, nausea, or vomiting
What is the most important precaution or action the nurse should teach a client newly diagnosed with systemic lupus erythematosus (SLE)?
A. Monitoring urine output B. Being immunized yearly against influenza C. Assessing skin daily for open areas or rashes D. Avoiding the use of hair dyes and having permanents
You are caring for a middle-aged woman who is suffering from major depression and melancholia. She expresses her "failure as a wife and mother" and that she "deserves to die." Your first priority to this patient is to:
A) Reassure her that she is a very good wife and mother B) Tell her that her illness is not a punishment and she does not deserve to die C) Divert her to other activities to get her mind off herself D) Protect and monitor her for suicidal tendencies
A patient scores positive on the Confusion Assessment Method of the Intensive Care Unit (CAM-ICU). Which nursing diagnosis would have the highest priority based on this positive score?
1. Injury, Risk for 2. Family Processes, Altered 3. Social Interaction, Impaired 4. Memory Impaired