The nurse is observing a client's ambulation abilities and notes a scissors gait. The nurse would suspect which of the following disorders in this client?
1. Parkinson's disease
2. Multiple sclerosis
3. Myasthenia gravis
4. Muscular dystrophy
2
Rationale 1: The client with Parkinson's disease displays stooped posture a shuffling gait. This is known as a festination gait.
Rationale 2: A scissors gait is characterized by spastic lower limb movement with stiffness and jerkiness. The knees come together, the legs come in front of each other, and the legs are abducted as short, slow steps are taken. This gait is associated with multiple sclerosis.
Rationale 3: The client with myasthenia gravis has muscle weakness, and facial abnormalities such as ptosis are consistent with the condition. The client with muscular dystrophy has muscle weakness and may present with a waddling gait or walk on the toes to promote balance.
Rationale 4: The client with muscular dystrophy has muscle weakness and may present with a waddling gait or walk on the toes to promote balance.
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a. Going to be discharged b. Feeling overwhelmed c. Becoming emotionally stabilized d. Adapting to the environment
The nurse is appropriately instructing the client regarding the use of herbals when stating:
1. "Echinacea might reduce the effectiveness of the immunosuppressant medications you've been prescribed since your transplant." 2. "Gingko could affect the results of your aspirin therapy." 3. "Ginger could be contraindicated, since you are taking anticoagulant medications." 4. "With your history of glaucoma, I don't believe you should be supplementing with ginseng." 5. "St. John's wort is a safe supplement when being medicated for depression."
The client receives cisplatin (Platinol) as therapy for cancer. Which assessment finding would prompt the nurse to contact the client's physician immediately?
1. A temperature greater than 101°F 2. An elevation in blood glucose 3. Nausea and projectile vomiting 4. A complaint of painful leg cramps
A nurse assesses the neck of an adult and documents that the client's neck muscles are within normal limits if the client:
a. Has a convex contour of the posterior cervical spine. b. Bends the head to the right and left (ear to shoulder) 15 degrees. c. Is able to resist the nurse's attempt to move the head upright. d. Is able to hyperextend the head 30 degrees from midline.