NR-325 Adult Health II - Set 4 - Part 1

Correct Answer: Measure vital capacity and inspiratory force every few hours

Ascending weakness threatens the diaphragm next, and neuromuscular respiratory failure keeps oxygen saturation normal until collapse is imminent. Serial bedside vital capacity and inspiratory force detect the decline in time for elective intubation. Option b is incorrect because active exercise is beyond a client whose muscles are failing. Passive range of motion preserves joints during the acute phase, and neither activity protects the airway. Option c is incorrect because reassurance, though genuinely useful, does not rank above breathing. Emotional support belongs in the plan once the nurse has confirmed that ventilatory reserve is still adequate. Option d is incorrect because clot prevention matters for an immobile client but addresses a slower threat. Compression sleeves can be applied after the more urgent respiratory measurement has been obtained.

Correct Answer: Muscle strength that improves after a rest period

Myasthenia gravis damages postsynaptic acetylcholine receptors, so transmission fails with repeated use. Strength therefore fades during sustained activity and returns after rest, which is the fatigable pattern that defines the disorder. Option a is incorrect because sensory pathways are untouched in this disease. The defect sits at the neuromuscular junction, where the motor nerve meets muscle, so the client feels touch, pain, and position normally. Option b is incorrect because reflexes stay intact here. Areflexia points instead toward Guillain Barre syndrome, where the peripheral nerve roots lose myelin and the reflex arc itself is interrupted. Option d is incorrect because pupil size stays normal in myasthenia gravis. Miosis belongs to cholinergic excess from too much anticholinesterase drug, or to botulism, and its presence should redirect the assessment.

Correct Answer: Squeeze the bulb flat before replacing the cap

A bulb that is not compressed exerts no suction, and the drain stops pulling fluid out of the mastectomy space. Recompressing before recapping is the step families most often miss at home. Option b is incorrect because waiting until the bulb fills lets it lose suction long before that point. Teaching is to empty at about half full and at least twice daily, recording each volume. Option c is incorrect because a swinging bulb tugs on the insertion site with every step. The device is secured snugly to clothing or a drain belt so its weight never pulls the tubing. Option d is incorrect because the system stays closed. Rinsing the reservoir opens a sterile drainage path to tap water and organisms, and nothing about rinsing restores the negative pressure the drain needs.

Correct Answer: Infuse isotonic saline at a brisk rate

Volume repletion with isotonic saline restores circulation and lets the kidneys excrete calcium, so it leads. Calcitonin and a bisphosphonate follow, and a diuretic waits until the client is no longer dry. Option a is incorrect because a diuretic given to a dehydrated client deepens the volume deficit and concentrates calcium further. Loop agents have a place only after saline has restored intravascular volume. Option b is incorrect because bisphosphonates need two to three days to lower calcium meaningfully. They are essential to the plan, yet they do nothing for the dehydration and confusion happening right now. Option d is incorrect because withholding fluid worsens the very problem driving this admission. Immobility also pulls more calcium out of bone, so bed rest without mobilization pushes the level higher still.

Correct Answer: Give the ordered antiemetics before the infusion starts

Antiemetics work best when serum levels are already established before the emetogenic stimulus arrives. Scheduled dosing ahead of the infusion also prevents the conditioned anticipatory nausea that follows a badly controlled first cycle. Option b is incorrect because waiting for symptoms surrenders the advantage. Once serotonin has flooded the gut and vomiting has begun, rescue dosing works poorly and the client keeps almost nothing down. Option c is incorrect because a heavy warm meal adds aroma and gastric volume just as emesis risk peaks. Small bland portions and cool foods with little smell are what the nurse offers instead. Option d is incorrect because relaxation techniques are useful adjuncts, not the main defense against a cisplatin regimen. Breathing exercises without drug prophylaxis leave the strongest emetic trigger in oncology completely unopposed.

Correct Answer: Take calcium and vitamin D, and walk regularly

Removing testosterone strips bone of a major protective signal, so mineral density falls and fractures follow. Calcium, vitamin D, and regular weight-bearing activity are the counter-measures taught alongside periodic bone density testing. Option a is incorrect because vasomotor symptoms persist while testosterone stays suppressed. Hot flushes commonly last for the whole course of treatment, and clients are taught layered clothing and cool rooms rather than a quick resolution. Option b is incorrect because inactivity accelerates the very bone loss it claims to prevent. Loading the skeleton is what stimulates bone formation, so walking and resistance work are encouraged within the client's safe limits. Option d is incorrect because loss of libido is an anticipated result of removing testosterone. Stopping treatment without the provider lets the tumor regain its fuel, and sexual effects are managed through discussion and referral.

Correct Answer: Keeping the client upright for thirty minutes after eating

Maintaining an upright position after meals is a standardized comfort and safety measure with a predictable outcome, so it fits the assistive role. Assessment, screening and teaching stay with the licensed nurse. Option a is incorrect because judging drug effectiveness requires clinical interpretation of fine motor function. The nurse compares buttoning, writing and feeding ability against baseline, a judgment that cannot be handed off. Option b is incorrect because a swallow screen is an assessment with immediate airway consequences. Deciding whether this client may safely receive a tray rests on nursing judgment about aspiration risk. Option c is incorrect because instruction on movement strategies is a teaching function reserved for licensed staff. Assistive personnel may reinforce cues already taught, but the original teaching belongs to the nurse or therapist.

Correct Answer: Preparing to insert a glycerin suppository

Suppositories, enemas, and rectal temperatures tear fragile mucosa and push gut bacteria straight into the bloodstream of a client with no neutrophils. Constipation is managed with oral softeners instead. Option b is incorrect because warm fluids at breakfast support bowel motility and hydration without breaking any barrier. Nothing about that action threatens a client whose counts are low. Option c is incorrect because gentle perineal care lowers infection risk rather than raising it. Skin and mucosal cleanliness is part of daily neutropenic care, and assistive personnel may carry it out. Option d is incorrect because the oral route is the acceptable way to check this client's temperature. Documenting the reading is squarely within the scope of assistive personnel and needs no correction.

Correct Answer: Notify the provider and start intermittent catheterization teaching

Retained urine plus cloudy output signals infection, the most common trigger of clinical worsening in this disease. Emptying the bladder completely through intermittent catheterization removes the reservoir that keeps reinfecting the client. Option a is incorrect because pelvic floor training helps stress leakage, not a bladder that cannot contract. Strengthening the outlet does nothing for urine sitting in a detrusor that fails to empty. Option b is incorrect because cutting fluids makes urine more concentrated and raises infection risk further. Clients with this disease are taught to drink adequately rather than to dehydrate themselves for convenience. Option c is incorrect because containment manages wetness while ignoring the retained urine underneath. Skin stays drier for a while, yet the residual volume climbs and urosepsis remains a real possibility.

Correct Answer: Sensation and thinking stay intact, so speak to the client

Motor neurons degenerate while sensory pathways, cognition and eye movement are largely preserved. The client feels pressure and pain and follows conversation, so the team addresses the client directly and explains every procedure. Option a is incorrect because reflex changes vary with mixed upper and lower motor neuron damage. More importantly, an inability to move never equals an inability to feel, and discomfort must still be treated. Option b is incorrect because thinking is largely spared in most clients with this disease. A minority develop frontotemporal changes, yet assuming confusion in a nonverbal client is both wrong and harmful. Option d is incorrect because sensory nerves are untouched by motor neuron degeneration. Skin over bony prominences hurts exactly as it would in anyone else, so turning schedules cannot be relaxed.

Correct Answer: Blood-streaked sputum with a changed chronic cough

A cough that changes character in a long-term smoker, especially with blood in the sputum, is the presentation of lung cancer that most often precedes diagnosis and needs imaging without delay. Option a is incorrect because dependent swelling after hours of sitting is common and usually venous. It carries none of the weight of hemoptysis, and it does not point toward a lesion in the airway. Option c is incorrect because meal-related burning belongs to reflux. Spicy food loosens the lower sphincter and the discomfort follows eating, a timing pattern that has nothing to do with the bronchial tree. Option d is incorrect because morning stiffness that loosens with movement is a joint pattern. Shoulder pain worth worrying about in a smoker is constant, one-sided, and paired with hand weakness from an apical tumor.

Correct Answer: Symmetric weakness climbing upward with absent reflexes

Immune attack on peripheral nerve myelin follows an infection by one to three weeks. Weakness starts distally in the legs, ascends symmetrically, and deep tendon reflexes disappear because the reflex arc is interrupted. Option a is incorrect because descending weakness that begins with cranial nerves suggests botulism. That illness also constricts the pupils, a feature absent from this syndrome and from myasthenia gravis. Option b is incorrect because brisk reflexes and an upgoing toe mark upper motor neuron injury. The lesion here lies in peripheral nerve roots, which produces the opposite reflex picture entirely. Option d is incorrect because one sided weakness points toward stroke or a focal cord lesion. Asymmetry should make the team question this diagnosis, since the syndrome affects both sides in step.

Correct Answer: Notify the provider and hold the leg still

Unilateral swelling with warmth suggests deep vein thrombosis, and this client cannot feel the leg to warn anyone. The nurse leaves the limb undisturbed and reports the measurement difference at once. Option b is incorrect because rubbing a limb that may hold a clot risks dislodging it toward the lungs. Massage over a swollen calf is contraindicated whenever thrombosis is on the list. Option c is incorrect because sensation below the tenth thoracic level is gone, so waiting for a pain report waits forever. Assessment here depends on measuring both calves and comparing them. Option d is incorrect because heat applied to insensate skin can burn without the client ever knowing, and it does nothing for a suspected clot. Warmth also masks the very sign being tracked.

Correct Answer: Transferring independently from bed to wheelchair

The seventh cervical root supplies the triceps, and elbow extension lets the client push the body up. That single muscle turns transfers, bed mobility and manual wheelchair use into independent tasks. Option a is incorrect because bracing the legs for standing requires trunk control from thoracic and lumbar segments that this injury has cut off. Exercise level standing belongs to much lower lesions. Option b is incorrect because a pacer is offered to clients whose lesion sits above the phrenic roots and who cannot breathe on their own. This client has a working diaphragm already. Option c is incorrect because chin and sip controls are designed for injuries in the first four cervical segments, where no arm movement exists. Full arm function makes a manual chair the better fit.

Correct Answer: Explain that the client is not radioactive

With teletherapy the source sits outside the body and the beam stops when the machine turns off. The client emits nothing afterward, so family contact, including holding a child, needs no restriction. Option b is incorrect because timed visits belong to the care of a client with a temporary sealed implant, who truly is a radiation source while the implant remains in place. Option c is incorrect because distance rules exist to protect people near an internal source. External beam leaves nothing behind, and telling grandchildren to keep away adds isolation the family does not need. Option d is incorrect because shielding applies to staff who work close to an active source, not to a household. No apron is required, and suggesting one reinforces a fear that has no basis.

Correct Answer: About seven to fourteen days after the dose

Neutrophils and platelets bottom out roughly a week to two weeks after most agents, matching how long those cells take to mature. Counts generally recover before the next cycle begins. Option a is incorrect because marrow damage does not show up in the peripheral blood that quickly. Cells already circulating finish their normal lifespan first, so counts on day one look deceptively reassuring. Option c is incorrect because counts are usually climbing back toward baseline by then. Recovery within three to four weeks is what allows cycles to be scheduled every twenty one or twenty eight days. Option d is incorrect because suppression starts with the very first dose rather than waiting for repeated exposure. A client is vulnerable to infection during cycle one, which is when teaching must already be complete.

Correct Answer: Flush the toilet with the lid closed

Urine, stool, and other fluids carry drug for about forty eight hours, so closing the lid contains splash and aerosol. Handwashing after toileting and separate laundering of soiled linens complete the plan. Option a is incorrect because excreta remain contaminated for roughly two days after a dose. Household members who empty a basin or handle soiled clothing need gloves during that window, not blanket reassurance. Option b is incorrect because banning the bathroom is neither necessary nor workable for a family. Ordinary cleaning, a closed lid, and hand hygiene reduce exposure without turning the home upside down. Option d is incorrect because clothing or bedding soiled with urine or emesis goes through its own wash cycle. Mixing it with the children's laundry spreads drug residue across items nobody needs to contact.

Correct Answer: Pallor, fever, and scattered pinpoint bruising

Blasts crowd out normal marrow, so red cells, neutrophils, and platelets all fall together. That single mechanism produces pallor from anemia, fever from lost defense against bacteria, and petechiae from low platelets. Option a is incorrect because leukemia lowers the red cell mass rather than raising it. A flushed, plethoric client with a high hematocrit fits polycythemia vera, a different marrow disorder entirely. Option b is incorrect because fluid retention with a slow heart rate describes an endocrine or cardiac problem. Nothing in marrow failure holds sodium and water or slows conduction through the heart. Option c is incorrect because yellow skin, tea-colored urine, and itching follow bilirubin build-up in liver or biliary disease. Leukemia may enlarge the liver, yet it does not obstruct bile drainage.

Correct Answer: A sore on the ankle that has not healed

A sore that fails to heal is one of the classic warning signs and points to tissue that is no longer repairing normally. The nurse tells the participant to schedule an evaluation promptly. Option a is incorrect because heartburn that an antacid settles fits ordinary reflux rather than the persistent indigestion or trouble swallowing that belongs on the warning list. Nothing here suggests an obstructing lesion. Option b is incorrect because aching muscles after unusual physical work have an obvious cause and settle within days. Cancer red flags are findings that persist, change, or arrive without any explanation. Option d is incorrect because a bruise that is fading is resolving as expected. Unexplained bruising that spreads or recurs would raise concern about bleeding, yet this one is already clearing on its own.

Correct Answer: "The spasms are reflexes returning, not movement he controls."

Spasticity emerging weeks after injury marks the end of spinal shock, not neurologic recovery. The reflex arc below the lesion has come back online, and the brain still cannot reach it. Option a is incorrect because a severed cord does not knit itself back together, and reflex activity says nothing about repair. Offering that hope sets the family up for a painful correction later. Option b is incorrect because voluntary use requires an intact pathway from the brain, which a complete lesion has destroyed. The client cannot start or stop these jerks no matter how hard he tries. Option c is incorrect because grading is repeated once spinal shock lifts, yet spasticity by itself does not overturn a complete classification. Sacral sparing on examination, not leg jerking, would change the grade.