Patient Data

Exhibits

Choose the most likely options for the information missing from the statement below by selecting from the lists of options provided. The nurse recognizes that a diagnosis of
dropdown
would be explained by assessment findings of
dropdown
and
dropdown

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A","dropdown-group-3":"E"}

Rationale for correct choices:

• Cellulitis: The client presents with redness, warmth, swelling, and pain in the left lower leg, along with a small preceding cut. These findings are characteristic of cellulitis, a bacterial infection of the dermis and subcutaneous tissue, often following a breach in the skin barrier.

• Break in skin: The small cut noted above the lateral ankle provides an entry point for bacteria, explaining the localized infection. A break in skin is a common precursor to cellulitis, particularly in clients with diabetes or vascular compromise.

• Left lower leg erythema: Erythema indicates inflammation and infection, which are hallmark signs of cellulitis. The presence of erythema, along with swelling and warmth, supports the clinical diagnosis of a bacterial skin infection.

Rationale for incorrect choices:

• Left lower leg erythema (as a diagnosis option): Erythema alone describes a symptom rather than a medical diagnosis. While present, it does not capture the underlying bacterial infection requiring treatment.

• Break in skin (as a diagnosis option): A break in the skin is a risk factor or contributing event, not a formal diagnosis. It explains how infection occurred but does not replace the clinical diagnosis of cellulitis.

• Cool, pale left leg: This finding is more indicative of arterial insufficiency or ischemia rather than infection. The client’s affected leg is warm and erythematous, which contrasts with cool, pale tissue.

• Intact skin: Intact skin would not allow bacterial entry and does not explain the localized infection. The client has a visible small cut that preceded the erythema.

• Dry scaly skin: While common in peripheral vascular disease or chronic dermatologic conditions, dry scaly skin does not explain the acute signs of infection seen in this client.

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Correct Answer is ["C","D","E"]

Explanation

A. Continue PROM if joint's muscle spasms to relax muscle: Continuing to move a joint during muscle spasms can worsen injury or cause pain. PROM should be stopped if spasms occur and reassessed to prevent harm.

B. Slowly stretch the joint's muscles if pain is present: Stretching a joint when pain is present can cause tissue damage or exacerbate injury. Pain indicates that the joint has reached its limit, so exercises should be within a pain-free range.

C. Move the joint slowly until resistance is felt: Moving the joint slowly until resistance allows for safe assessment of mobility and flexibility without overstretching or causing injury. Resistance provides a natural limit to the joint’s passive range of motion.

D. Instruct the client to relax during the exercises: Relaxation reduces muscle tension, allowing for safer and more effective passive movements. Client cooperation helps prevent muscle guarding and ensures proper joint mobilization.

E. Support the extremity of the joint being exercised: Supporting the extremity prevents undue stress on muscles and joints, reduces the risk of injury, and allows controlled movement during PROM exercises. Proper support is essential for safety.

Correct Answer is []

Explanation

Rationale for Correct Choices:

• Extrapyramidal reaction: The client exhibits muscle stiffness, constant leg shaking, forward-backward rocking, and abnormal head positioning, all of which are hallmark signs of extrapyramidal symptoms (EPS) often caused by antipsychotic medications like haloperidol and chlorpromazine. Recognizing EPS early prevents further complications such as severe dystonia or Parkinsonism.

• Initiate one-on-one observation: Continuous observation is essential to ensure client safety, particularly due to agitation, abnormal movements, and risk of injury from dystonia or uncontrolled motor activity, which can be exacerbated in psychiatric patients on antipsychotics.

• Education on administration and side effects of haloperidol: Teaching the client and caregivers about haloperidol’s potential side effects, including EPS, akathisia, and tardive dyskinesia, enhances adherence, promotes early reporting of adverse effects, and supports safe medication management.

• Gait and muscle strength: Monitoring gait and muscle strength allows the nurse to track the severity and progression of extrapyramidal symptoms, assess mobility limitations, and evaluate the effectiveness of interventions like anticholinergic medications or dosage adjustments.

• Improvement in symptoms: Observing improvement in EPS or agitation provides measurable evidence that interventions are effective, guiding ongoing care and any necessary modifications to therapy or dosing.

Rationale for Incorrect Choices:

• Mucositis: Mucositis involves inflammation and ulceration of the mucous membranes, typically related to chemotherapy or radiation therapy, and is not consistent with this client’s current presentation of abnormal motor activity and psychiatric symptoms.

•Hypertensive crisis: The client’s blood pressure is within a normal to mildly elevated range, and there are no signs of acute end-organ damage, so hypertensive crisis is unlikely in this scenario.

• Parkinson’s Disease: Parkinsonism is a chronic neurodegenerative disorder characterized by resting tremor, bradykinesia, and rigidity, not acute onset EPS triggered by antipsychotic use in a young adult with schizophrenia.

• Institute oral hygiene to prevent candidiasis: Oral hygiene is generally important but does not address the acute neurological side effects of antipsychotic medications, making it nonessential for EPS management.

• Immediate dietician consult: While nutrition is important, it is not immediately relevant for extrapyramidal symptoms and does not address the urgent motor complications caused by antipsychotics.

• Administer antihypertensive: The client’s blood pressure is not critically elevated, and there are no indications of hypertensive emergency, so antihypertensive therapy is unnecessary.

• Blood pressure: Monitoring blood pressure is routine but not directly related to tracking extrapyramidal symptoms or response to antipsychotic therapy in this case.

• Swallowing: While dysphagia can occur in severe EPS, this client does not currently present with swallowing difficulties, making it less critical to monitor compared to gait and muscle strength.

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Patient Data Exhibits Choose the most likely options for the information missing from the statement below by selecting from the lists of options provided. The nurse recognizes that a diagnosis ofdropdown would be explained by assessment findings of dropdown anddropdown

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is performing a musculoskeletal assessment with a client. Which action(s) should the nurse implement when performing passive range of motion (PROM) exercises with a client? Select all that apply.

Correct Answer is ["C","D","E"]

Explanation

Correct Answer is []

Explanation

A client who is receiving zidovudine reports the appearance of pinpoint, red, round spots on the skin. Which result should the nurse report to the healthcare provider (HCР)?

The healthcare provider prescribes dalteparin 200 units/kg subcutaneously once day for a client who weighs 154 pounds. The medication is available in 25,000 units/mL vial. How many mL should the nurse administer? (Enter numerical value only. If rounding is required, round to the nearest tenth.)

A client who had bariatric surgery 2 months ago is admitted because of vomiting and inability to tolerate food and liquids. The client is pain free. Which intervention should the nurse include in the client's plan of care?

The nurse is providing teaching to a client newly diagnosed with type 2 diabetes mellitus about disease management. Which response by the client indicates understanding?

Which oral medication can the nurse safely cut in half?

The healthcare provider prescribes the antibiotic cefdinir 300 mg PO every 12 hours for a client with a postoperative wound infection. Which foods should the nurse encourage this client to eat?

Patient Data

Exhibits

Choose the most likely options for the information missing from the statement below by selecting from the lists of options provided. The nurse recognizes that a diagnosis of
dropdown
would be explained by assessment findings of
dropdown
and
dropdown