Question

A client's electronic health record notes that the client has hallux valgus. What signs and symptoms should the nurse expect this client to manifest?

Answer 1

Correct Answers:

Deviation of a great toe laterally

Rationale :

🦶Hallux valgus is defined as a lateral deviation of the great toe at the metatarsophalangeal joint, often forming a bunion on the medial side of the foot.

📚This condition commonly results from chronic pressure on the medial aspect of the first metatarsophalangeal joint, such as from ill-fitting or narrow shoes.

🩺The lateral drift of the great toe can cause pain, inflammation, and difficulty with footwear, which are classic clinical manifestations.

👣Recognizing the hallmark feature—great toe deviating laterally toward the other toes—helps distinguish hallux valgus from other toe deformities like hammer toes or claw toes.

📌Core Message

Hallux valgus is characterized by a lateral deviation of the great toe, often associated with bunion formation and discomfort.

Answer 2

Correct Answers:

Daily weights and abdominal girth measurement

Rationale :

🧠Portal hypertension commonly leads to ascites due to increased hydrostatic pressure in the portal venous system and fluid shifts into the peritoneal cavity.

📏Daily weights are a sensitive indicator of fluid retention or loss, helping evaluate changes in total body fluid status.

📐Measuring abdominal girth allows the nurse to monitor changes in ascitic fluid volume, which can increase the risk of respiratory compromise, hernias, and discomfort.

🩺Because complications of portal hypertension largely involve fluid accumulation and volume shifts, tracking weight and abdominal girth directly addresses the primary physiologic problem and its progression.

📌Core Message

For portal hypertension, priority assessments focus on fluid accumulation, so daily weights and abdominal girth are crucial to monitor ascites.

Answer 3

Correct Answers:

0.5

Rationale :

🧮The ordered dose is 20 mg, and the available concentration is 40 mg/mL, so a dose calculation is required.

📏Using the formula (Desired / Have) × Volume = (20 mg ÷ 40 mg) × 1 mL = 0.5 mL.

✏️This shows the nurse must administer half a milliliter to deliver the correct 20 mg dose of Zofran.

✅Rounding to the tenth place keeps the answer as 0.5 mL, which is both accurate and safe for IM administration.

📌Core Message

Correct dose calculations use desired ÷ available strength, giving a final IM volume here of 0.5 mL.

Answer 4

Correct Answers:

Sciatica

Rationale :

🧠Sciatica refers to pain along the distribution of the sciatic nerve, which runs from the lower back through the buttock, down the posterior leg, and may reach the foot.

🦵The description of pain that starts in the back and radiates down the leg to the foot is classic for nerve root compression involving the sciatic nerve, often from lumbar disc herniation.

🩺This type of pain is typically sharp, shooting, or burning and follows a radicular pattern, differentiating it from localized muscle or joint pain.

📚Recognizing the radiating nature of pain along a nerve pathway is key for identifying sciatica and guiding further neurologic and musculoskeletal assessment.

📌Core Message

Pain that radiates from the lower back down the leg to the foot strongly suggests sciatica, involving irritation of the sciatic nerve.

Answer 5

Correct Answers:

To remove atherosclerotic plaques blocking cerebral flow

Rationale :

🧠Transient ischemic attacks (TIAs) are often caused by temporary reductions in cerebral blood flow, frequently due to atherosclerotic plaque in the carotid arteries.

🔪A carotid endarterectomy is a surgical procedure where atherosclerotic plaque is removed from the carotid artery lumen to improve blood flow to the brain.

🛡️By removing these plaques, the procedure aims to decrease the risk of future ischemic strokes, which are a major complication following TIAs.

📚The primary purpose is therefore stroke prevention via restoration of adequate cerebral perfusion, not seizure control or edema reduction.

📌Core Message

A carotid endarterectomy is done mainly to remove atherosclerotic plaque in the carotid artery and thereby reduce stroke risk after TIAs.

Answer 6

Correct Answers:

Two to three soft bowel movements daily

Rationale :

🧪In hepatic encephalopathy, the liver is unable to adequately detoxify ammonia, which accumulates and affects brain function.

💊Lactulose is a non-absorbable disaccharide that traps ammonia in the gut and promotes its excretion through increased stool frequency.

🚽The therapeutic goal is two to three soft bowel movements per day, indicating effective removal of ammonia without causing severe diarrhea or dehydration.

🩺Monitoring stool pattern helps the nurse evaluate whether lactulose dosing is appropriate and whether the risk of encephalopathy is being reduced.

📌Core Message

For hepatic encephalopathy, lactulose is effective when it produces about 2–3 soft stools daily, indicating enhanced ammonia excretion.

Answer 7

Correct Answers:

Altered serum calcium levels

Rationale :

🦴Paget disease involves abnormal bone remodeling with periods of excessive bone resorption followed by disorganized bone formation.

⚖️This abnormal bone turnover can cause changes in serum calcium, especially when extensive bone involvement increases release or deposition of calcium.

🩺Clients may show elevated or fluctuating calcium levels, particularly if immobilized, due to increased bone breakdown.

📚Because Paget disease directly affects bone metabolism, monitoring serum calcium is more relevant than sodium, magnesium, or potassium levels.

📌Core Message

Paget disease is a disorder of bone remodeling, so serum calcium levels may be altered due to increased bone turnover.

Answer 8

Correct Answers:

Ensuring that there are no metal objects on or in the client

Rationale :

🧲An MRI uses a powerful magnetic field, which can strongly attract metallic objects, posing serious safety risks.

🚫Metal implants or objects (e.g., pacemakers, aneurysm clips, some prostheses, jewelry) can move, heat, or malfunction in the MRI environment.

🩺The priority safety action is therefore to screen for and remove external metal and verify the safety of any internal metallic devices before the scan.

📚Without confirming the absence or safety of metal, the MRI could cause injury, device failure, or image distortion, making this step critical.

📌Core Message

Before an MRI, the top safety priority is ensuring no unsafe metal is on or in the client due to the strong magnetic field.

Answer 9

Correct Answers:

Activities of daily living

Rationale :

🧍Musculoskeletal disorders primarily affect movement, strength, and coordination, which directly influence the client’s functional ability.

🧴Assessing activities of daily living (ADLs) shows how the condition impacts self-care tasks such as bathing, dressing, feeding, and mobility.

📊This functional assessment helps determine the degree of disability, need for assistive devices, and appropriate rehabilitation plans.

🩺While strength, ROM, and gait are important, evaluating ADLs provides a global picture of how the disorder affects the client’s daily life and independence.

📌Core Message

In musculoskeletal disorders, assessing activities of daily living gives the most meaningful picture of functional impact and independence.

Answer 10

Correct Answers:

Increased warmth of the calf

Rationale :

🩸A deep vein thrombosis (DVT) often presents with localized inflammation, causing warmth, redness, and swelling in the affected limb.

🦵In the calf, increased warmth, sometimes with tenderness and increased circumference, is a key clinical sign suggesting venous clot formation.

🩺Identifying these signs early is critical because a DVT can embolize to the lungs, resulting in a pulmonary embolism, a potentially life-threatening complication.

📚For a client in traction, decreased mobility increases VTE risk, so the nurse must be especially vigilant for calf warmth and other thrombotic signs.

📌Core Message

An early sign of DVT in a limb is increased warmth (often with swelling and tenderness) in the calf, indicating local inflammation and clot formation.

1 :
A client's electronic health record notes that the client has hallux valgus. What signs and symptoms should the nurse expect this client to manifest?

2 :
A client with portal hypertension has been admitted to the medical floor. The nurse should prioritize what assessments?

3 :
A patient has an order for Zofran 20 mg IM BID. You're supplied with a vial that is labeled 40 mg/ml. How many mls will the registered nurse administer per dose? Round to the tenth place

4 :
A client presents at a clinic reporting back pain that goes all the way down the back of the leg to the foot. The nurse should document the presence of what type of pain?

5 :
A client diagnosed with transient ischemic attacks (TIAS) is scheduled for a carotid endarterectomy. The nurse explains that this procedure will be done for which purpose?

6 :
A client has developed hepatic encephalopathy secondary to cirrhosis and is receiving care on the medical unit. The client's current medication regimen includes lactulose four times daily. What desired outcome should the nurse relate to this pharmacologic intervention?

7 :
A client is undergoing diagnostic testing for suspected Paget disease. What assessment finding is most consistent with this diagnosis?

8 :
A nurse is caring for a client who has an MRI scheduled. What is the priority safety action prior to this diagnostic procedure?

9 :
A nurse is performing a nursing assessment of a client suspected of having a musculoskeletal disorder. Which assessment should the nurse prioritize for a client who has a musculoskeletal disorder?

10 :
The nursing care plan for a client in traction specifies regular assessments for venous thromboembolism (VTE). When assessing a client's lower limbs, what sign or symptom is suggestive of deep vein thrombosis (DVT)?

1 : A client's electronic health record notes that the client has hallux valgus. What signs and symptoms should the nurse expect this client to manifest?

2 : A client with portal hypertension has been admitted to the medical floor. The nurse should prioritize what assessments?

3 : A patient has an order for Zofran 20 mg IM BID. You're supplied with a vial that is labeled 40 mg/ml. How many mls will the registered nurse administer per dose? Round to the tenth place

4 : A client presents at a clinic reporting back pain that goes all the way down the back of the leg to the foot. The nurse should document the presence of what type of pain?

5 : A client diagnosed with transient ischemic attacks (TIAS) is scheduled for a carotid endarterectomy. The nurse explains that this procedure will be done for which purpose?

6 : A client has developed hepatic encephalopathy secondary to cirrhosis and is receiving care on the medical unit. The client's current medication regimen includes lactulose four times daily. What desired outcome should the nurse relate to this pharmacologic intervention?

7 : A client is undergoing diagnostic testing for suspected Paget disease. What assessment finding is most consistent with this diagnosis?

8 : A nurse is caring for a client who has an MRI scheduled. What is the priority safety action prior to this diagnostic procedure?

9 : A nurse is performing a nursing assessment of a client suspected of having a musculoskeletal disorder. Which assessment should the nurse prioritize for a client who has a musculoskeletal disorder?

10 : The nursing care plan for a client in traction specifies regular assessments for venous thromboembolism (VTE). When assessing a client's lower limbs, what sign or symptom is suggestive of deep vein thrombosis (DVT)?

1 :
A client's electronic health record notes that the client has hallux valgus. What signs and symptoms should the nurse expect this client to manifest?

2 :
A client with portal hypertension has been admitted to the medical floor. The nurse should prioritize what assessments?

3 :
A patient has an order for Zofran 20 mg IM BID. You're supplied with a vial that is labeled 40 mg/ml. How many mls will the registered nurse administer per dose? Round to the tenth place

4 :
A client presents at a clinic reporting back pain that goes all the way down the back of the leg to the foot. The nurse should document the presence of what type of pain?

5 :
A client diagnosed with transient ischemic attacks (TIAS) is scheduled for a carotid endarterectomy. The nurse explains that this procedure will be done for which purpose?

6 :
A client has developed hepatic encephalopathy secondary to cirrhosis and is receiving care on the medical unit. The client's current medication regimen includes lactulose four times daily. What desired outcome should the nurse relate to this pharmacologic intervention?

7 :
A client is undergoing diagnostic testing for suspected Paget disease. What assessment finding is most consistent with this diagnosis?

8 :
A nurse is caring for a client who has an MRI scheduled. What is the priority safety action prior to this diagnostic procedure?

9 :
A nurse is performing a nursing assessment of a client suspected of having a musculoskeletal disorder. Which assessment should the nurse prioritize for a client who has a musculoskeletal disorder?

10 :
The nursing care plan for a client in traction specifies regular assessments for venous thromboembolism (VTE). When assessing a client's lower limbs, what sign or symptom is suggestive of deep vein thrombosis (DVT)?