During the neurologic assessment of a "healthy" 35-year-old patient, the nurse asks him to relax his muscles completely. The nurse then moves each extremity through full range of motion. Which of these results would the nurse expect to find?
a. Firm, rigid resistance to movement
b. Mild, even resistance to movement
c. Hypotonic muscles as a result of total relaxation
d. Slight pain with some directions of movement
ANS: B
Tone is the normal degree of tension (contraction) in voluntarily relaxed muscles. It shows a mild resistance to passive stretching. Normally, the nurse will notice a mild, even resistance to movement. The other responses are not correct.
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a. "Give the baby one serving of fruit per day." b. "Increase the amount and frequency of her feedings." c. "It sounds like the baby is uncomfortable because she is constipated." d. "Newborns might strain with bowel movements because their muscles aren't fully developed."
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The nurse is caring for a client with newly diagnosed atrial fibrillation. Which medication class does the nurse anticipate the client will need to take to prevent the formation of blood clots?
a. Antipyretics b. Anticoagulants c. Analgesics d. Thrombolytics
A patient looks up the drug he is taking in a drug guide. The patient asks the nurse why the physician prescribed a medication that has a lethal dose measure. What is the best response by the nurse?
1. "It just refers to what is done in research; it is not used by doctors prescribing drugs." 2. "It is a value determined during research, which helps to determine the safe dose to give." 3. "All that means is that the drug could be lethal, but I will watch you for side effects." 4. "Don't worry about that, I'll have your doctor explain it to you."