A nurse is caring for a client at an outpatient clinic.
Select the 2 diagnostic tests the nurse should anticipate the provider to prescribe.
Cerebrospinal fluid electrophoresis
Paracentesis
Bone marrow biopsy
MRI of brain
X-ray of abdomen
Correct Answer : A,D
Rationale:
A. Cerebrospinal fluid electrophoresis: CSF electrophoresis is used to detect oligoclonal bands, which are indicative of multiple sclerosis (MS). The client’s presentation—fatigue, intermittent muscle weakness, tremors, double vision, and gait disturbances—suggests a demyelinating disorder, making this test appropriate.
B. Paracentesis: Paracentesis is used to evaluate ascites, which is not indicated in this client. There are no signs of abdominal fluid accumulation or liver disease that would warrant this procedure.
C. Bone marrow biopsy: Bone marrow biopsy is used for hematologic disorders such as anemia, leukemia, or other blood dyscrasias. The client’s symptoms do not indicate a primary bone marrow pathology.
D. MRI of brain: MRI is the diagnostic imaging of choice for detecting lesions in the central nervous system consistent with multiple sclerosis. It helps visualize demyelination and correlate it with clinical symptoms.
E. X-ray of abdomen: Abdominal X-ray is not indicated, as the client does not present with abdominal pain, obstruction, or gastrointestinal issues requiring imaging.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Administer a dose of fluoxetine to the client: Fluoxetine is an antidepressant and is not indicated for acute psychotic symptoms such as auditory hallucinations in schizophrenia. Antipsychotic medications, not SSRIs, are the standard treatment for managing hallucinations.
B. Avoid making eye contact with the client: Avoiding eye contact can be perceived as disengagement or disinterest, which may increase the client’s anxiety or mistrust. Therapeutic communication with appropriate eye contact helps establish rapport and conveys presence and support.
C. Request the client to lie down in a quiet room: Forcing the client to lie down may increase distress or feelings of loss of control. While a quiet environment can reduce stimuli, the intervention should be voluntary and focused on coping strategies rather than directives.
D. Encourage the client to listen to music: Listening to music can help distract the client from hallucinations and provide a coping mechanism to reduce distress. This intervention supports safety, comfort, and engagement without confrontation, aligning with therapeutic approaches for managing auditory hallucinations.
Correct Answer is C
Explanation
A. Abdomen: The abdomen is typically used for subcutaneous injections, such as insulin or heparin, due to its fatty tissue. It is not ideal for intradermal injections, which require a thin layer of skin to allow for proper absorption and observation of a wheal.
B. Deltoid: The deltoid muscle is commonly used for intramuscular injections, not intradermal ones. Using this site for intradermal injections could result in the medication being deposited too deeply, affecting absorption and test accuracy.
C. Back of the upper arm: The inner surface of the forearm or the back of the upper arm is the preferred site for intradermal injections, such as tuberculosis or allergy testing. This area has thin skin, minimal subcutaneous fat, and allows for easy visualization of the wheal and monitoring for reactions.
D. Upper back: While the upper back has subcutaneous tissue, it is not commonly used for intradermal injections because it is less accessible for observation and assessment of local reactions. Proper site selection is important for safety and effectiveness.
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