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 by a progressive lateral deviation of the great toe, which is the hallmark feature of this disorder.

🟦 This deviation occurs as the metatarsophalangeal joint becomes misaligned, shifting the toe toward the second toe.

🟦 The deformity often leads to bunion formation, pain, inflammation, and difficulty wearing shoes.

🟦 Risk factors include genetics, improper footwear, and arthritic changes that disrupt normal foot alignment.

🟦 Because lateral deviation is the primary structural change, it is the expected clinical sign of hallux valgus.

❌ Incorrect Answers

Fusion of the toe joints

❌ Seen in severe arthritis, not hallux valgus.

❌ Does not describe the lateral deformity characteristic of this condition.

An exaggerated arch of the foot

❌ This represents pes cavus, not hallux valgus.

❌ Arch height abnormalities do not produce bunion deformities.

Abnormal flexion of the great toe

❌ Indicates a hammertoe or claw toe deformity.

❌ Flexion deformity does not describe the valgus (lateral) angle.

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Answer 2

Correct Answers:

Daily weights and abdominal girth measurement

Rationale :

🟦 Portal hypertension commonly causes ascites and fluid retention, making fluid monitoring the highest priority.

🟦 Daily weights help detect subtle changes in total body fluid that may signal worsening portal pressure.

🟦 Abdominal girth measurement tracks the accumulation of peritoneal fluid, which can impair breathing and mobility.

🟦 These assessments identify complications early, helping to prevent respiratory distress or circulatory compromise.

🟦 This approach directly targets the most dangerous consequences of portal hypertension.

❌ Incorrect Answers

Assess for venous thromboembolism

❌ Not the primary complication associated with portal hypertension.

❌ Ascites and varices take priority.

Blood glucose monitoring q4h

❌ Relevant in diabetes, not portal hypertension.

❌ Does not address main risks of fluid overload.

Blood pressure, headaches, visual changes

❌ These assess hypertension, not portal hypertension.

❌ Do not monitor liver-related fluid complications.

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Answer 3

Correct Answers:

0.5

Rationale :

Order: 20 mg IM

Supply: 40 mg/mL

20 mg ÷ 40 mg/mL = 0.5 mL

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Answer 4

Correct Answers:

Radiculopathy

Rationale :

🟦 Radiculopathy develops from nerve root compression, typically due to disc herniation or spinal stenosis.

🟦 This condition causes radiating pain from the back down the leg, sometimes reaching the foot.

🟦 Clients often describe sharp, burning, or electric-like pain along the affected nerve pathway.

🟦 Nerve-related pain is distinct from localized joint or tendon inflammation.

🟦 Because the pain radiates in a dermatomal pattern, radiculopathy is the correct identification.

❌ Incorrect Answers

Tendonitis

❌ Causes localized tenderness, not radiating nerve pain.

Sciatica

❌ A specific type of radiculopathy, but the broader diagnosis is radiculopathy.

❌ Sciatica refers only to the sciatic nerve.

Bursitis

❌ Involves joint inflammation and localized pain, not nerve distribution.

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Answer 5

Correct Answers:

To remove atherosclerotic plaques blocking cerebral flow

Rationale :

🟦 Carotid endarterectomy removes obstructive plaque that narrows the carotid artery.

🟦 Clients with TIAs are at high risk for stroke due to reduced cerebral perfusion.

🟦 Clearing the artery improves blood flow and reduces the chance of emboli reaching the brain.

🟦 This surgery is a preventative measure designed to avoid future ischemic events.

🟦 It does not diagnose TIAs or treat seizures or cerebral edema, making plaque removal the correct purpose.

❌ Incorrect Answers

Prevent seizures

❌ TIAs do not routinely cause seizures.

Determine cause of TIA

❌ Diagnostic imaging, not surgery, identifies causes.

Reduce cerebral edema

❌ This surgery does not treat swelling.

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Answer 6

Correct Answers:

Two to three soft bowel movements daily

Rationale :

🟦 Lactulose lowers ammonia levels, which improves cognitive function in hepatic encephalopathy.

🟦 It traps ammonia in the gut and removes it by increasing stool frequency.

🟦 The therapeutic target is 2–3 soft stools per day, which indicates effective ammonia clearance.

🟦 More stools can cause dehydration; fewer stools allow ammonia to accumulate.

🟦 Monitoring stool frequency ensures dosage effectiveness and prevents complications.

❌ Incorrect Answers

Increased appetite

❌ Not an expected effect of lactulose.

Absence of blood or mucus

❌ Not related to hepatic encephalopathy treatment.

No nausea/vomiting

❌ GI symptoms may persist; not the primary goal.

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Answer 7

Correct Answers:

Altered serum calcium levels

Rationale :

🔶Paget disease causes excessive bone resorption, leading to the rapid breakdown of bone tissue and the release of stored calcium into the bloodstream.

🔶As bone turnover becomes disorganized, periods of hypercalcemia develop, especially when the client is immobilized or the disease becomes active.

🔶High calcium levels can produce symptoms such as muscle weakness, fatigue, poor concentration, and bone pain, which align with Paget pathology.

🔶Because calcium is the primary mineral regulated during bone formation and destruction, alterations in serum calcium are the most consistent laboratory result associated with Paget disease.

❌ Incorrect Answers :

❌ Altered sodium: Sodium regulation is controlled by fluid balance, not bone metabolism, and is not affected by Paget disease.

❌ Altered magnesium: Magnesium levels remain stable unless kidney or GI disease exists; Paget disease does not influence magnesium absorption or bone storage.

❌ Altered potassium: Potassium is a cellular electrolyte unrelated to bone remodeling, so Paget disease would not change potassium levels.

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Answer 8

Correct Answers:

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

Rationale :

🌟MRI scanners generate a strong magnetic field capable of pulling or accelerating metal objects, making metal screening the first and most critical safety check.

🌟Any internal metal, such as aneurysm clips, pacemakers, orthopedic implants, or shrapnel, may shift position, heat up, or malfunction, causing severe injury.

🌟External metal objects, such as jewelry or hairpins, can become dangerous projectiles or distort the MRI images, degrading diagnostic accuracy.

🌟Because these risks are immediate and potentially life-threatening, verifying the absence of metal is the highest priority action before MRI.

❌ Incorrect Answers :

❌ Checking for infection: MRI is safe during infection and is not contraindicated by fever or inflammation.

❌ Assessing nut allergies: MRI contrast (gadolinium) does not contain nut components, so allergies to nuts are irrelevant.

❌ Ensuring immobility: Important for image clarity, but not a safety priority compared with metal precautions.

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Answer 9

Correct Answers:

Gait

Rationale :

💠Gait assessment provides an integrated analysis of muscle strength, balance, coordination, and joint function, offering a comprehensive view of musculoskeletal health.

💠Many musculoskeletal disorders—such as arthritis, muscle weakness, or neurological involvement—first appear as subtle gait abnormalities.

💠Observing how the client walks reveals compensatory behaviors like limping, short strides, or uneven weight-bearing, which help identify underlying pathology.

💠Because gait reflects real-world functional mobility and safety, especially fall risk, it takes priority over isolated assessments such as strength or ROM.

❌ Incorrect Answers

❌ Strength: Reveals muscle power but does not capture dynamic movement or functional stability.

❌ Range of motion: Measures joint mobility but cannot identify coordination or balance deficits.

❌ Activities of daily living: Evaluated later; gait must first establish whether functional movement is safe and possible.

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Answer 10

Correct Answers:

Increased warmth of the calf

Rationale :

🔷Increased warmth indicates localized inflammation, a key physiologic response to a developing blood clot in the deep veins.

🔷Clients in traction have reduced mobility, causing venous stasis, which promotes clot formation and subsequent inflammatory heat in the affected limb.

🔷Additional signs such as swelling, redness, and tenderness reinforce the suspicion of DVT, but warmth is often one of the earliest detectable findings.

🔷Early recognition is essential to prevent pulmonary embolism, a life-threatening complication of untreated DVT.

❌ Incorrect Answers

❌ Pale appearance: Suggests lack of arterial blood flow, not venous clotting.

❌ Loss of sensation: Indicates neurological compromise, not venous inflammation.

❌ Decreased calf circumference: DVT causes swelling, making this option physiologically inconsistent.

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Examplify Exam IV Fall 25

No.

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 1

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)?

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Examplify Exam IV Fall 25

No.

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 1

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 1

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)?