A nurse is assessing a client who has Paget's disease of the bone. Which of the following findings should the nurse expect? (Select all that apply.)
Cold extremities
Skeletal pain
Visual loss
Cranial enlargement
Abnormal gait
Correct Answer : B,C,D,E
Choice A reason:
Cold extremities are not a typical symptom associated with Paget's disease of the bone. This condition usually does not affect the temperature of the limbs directly.
Choice B reason:
Skeletal pain is a common symptom in Paget's disease due to the abnormal bone remodeling process. The affected bones may become painful, especially in the pelvis, spine, skull, and long bones.
Choice C reason:
Visual loss can occur if Paget's disease affects the skull, leading to increased pressure on the nerves associated with vision. This pressure can result in visual impairment or loss.
Choice D reason:
Cranial enlargement is a possible finding in Paget's disease when the skull is involved. The abnormal bone growth can cause the skull to increase in size.
Choice E reason:
An abnormal gait may develop if Paget's disease affects the legs, causing the bones to bow and leading to difficulty walking.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason:
Clay-colored stools are typically associated with issues in the biliary system, such as bile duct obstruction, and not directly with aspirin use. Aspirin, especially when used in high doses, is more commonly associated with gastrointestinal side effects like bleeding, which would likely cause dark or bloody stools rather than clay-colored ones.
Choice B reason:
Nystagmus, which is a vision condition characterized by repetitive, uncontrolled eye movements, is not a recognized side effect of aspirin. While aspirin can have effects on various systems in the body, it does not typically affect the muscles or nerves controlling eye movements.
Choice C reason:
Tinnitus, or ringing in the ears, is a well-documented adverse effect of aspirin, particularly when taken in high doses or for a prolonged period. It is related to the effect of aspirin on the inner ear structures and is usually reversible once the medication is stopped or the dosage is reduced.
Choice D reason:
Respiratory depression is not a typical side effect of aspirin. Aspirin can cause respiratory alkalosis in cases of overdose due to hyperventilation, but it does not cause respiratory depression. If respiratory depression occurs, it would likely be due to a different cause and not the aspirin itself.
Correct Answer is ["B","C"]
Explanation
Choice A reason:
A temperature of 37.2°C (99°F) is slightly elevated but not necessarily indicative of sepsis. A heart rate of 88/min is within normal limits (60-100/min). This client's signs do not strongly suggest sepsis.
Choice B reason:
A heart rate of 132/min and a respiratory rate of 30/min are both elevated, which can be signs of sepsis. Sepsis can cause an increase in heart rate (tachycardia) and respiratory rate (tachypnea) as the body attempts to maintain adequate blood flow and oxygenation during a systemic infection.
Choice C reason:
A decrease in the level of consciousness combined with a heart rate greater than 130/min could indicate sepsis, as confusion or changes in mental status are common symptoms when the body is fighting a severe infection.
Choice D reason:
Bradypnea, or abnormally slow breathing, is not typically associated with sepsis, which more commonly causes rapid breathing. A WBC count of 10,000/mm³ is at the upper limit of the normal range and does not necessarily indicate sepsis without other symptoms.
Choice E reason:
A temperature of 36°C (96.8°F) is on the lower end of the normal body temperature range and does not suggest fever, which is a common sign of sepsis. A respiratory rate of 16/min is within the normal range (12-20/min) and does not indicate sepsis.
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