142 Final - Part 4 - PRACTICE QUESTIONS

A nurse admits a client who has a fracture of the nose that has resulted in a skin tear and involvement of the mucous membranes of the nasal passages. The orthopedic nurse should plan to care for what type of fracture? A. Compression B. Compound C. Impacted D. Transverse

A compound fracture involves damage to the skin or mucous membranes and is also called an open fracture. A compression fracture involves compression of bone and is seen in vertebral fractures. An impacted fracture occurs when a bone fragment is driven into another bone fragment. A transverse fracture occurs straight across the bone shaft.

A nurse in a dermatology clinic is reading the electronic health record of a new client. The nurse notes that the client has a history of a primary skin lesion. What skin lesion may this client have? A. Crust B. Keloid C. Pustule D. Ulcer

A pustule is an example of a primary skin lesion. Primary skin lesions are original lesions arising from previously normal skin. Crusts, keloids and ulcers are secondary lesions.

A client with a suspected malignant melanoma is referred to the dermatology clinic. The nurse knows to facilitate what diagnostic test to rule out a skin malignancy? A. Tzanck smear B. Skin biopsy C. Patch testing D. Skin scrapings

A skin biopsy is done to rule out malignancies of skin lesions. A Tzanck smear is used to examine cells from blistering skin conditions, such as herpes zoster. Patch testing is performed to identify substances to which the client has developed an allergy. Skin scrapings are done for suspected fungal infections.

A nurse in the preoperative holding area is admitting a woman prior to reduction mammoplasty. What should the nurse include in the care given to this client? Select all that apply. A. Establishing an IV line B. Verifying the surgical site with the client C. Taking measures to ensure the client's comfort D. Applying a grounding device to the client E. Preparing the medications to be given in the OR

A, B, C. In the holding area, the nurse reviews charts, identifies clients, verifies surgical site per institutional policy, establishes IV lines, administers any prescribed medications, and takes measures to ensure each client's comfort. A grounding device is applied in the OR. A nurse in the preoperative holding area does not prepare medications to be given by anyone else.

The PACU nurse is caring for a client who had minimally invasive knee surgery. Which actions are the responsibility of the nurse in the PACU? Select all that apply. A. Monitoring the safe recovery from anesthesia B. Answering family questions about recovery C. Ensuring that informed consent has been signed D. Providing light nourishment E. Assessing the operative site for hemorrhage

A, B, D, E. After surgery, the client is taken to the PACU, where the PACU nurse monitors the client for safe recovery from surgery and anesthesia. The PACU nurse also explains the equipment (such as an IV or sequential compression devices) to the client and family and answers their questions. The nurse brings the client, who has had nothing by mouth for 8 to 10 hours, light nourishment and assesses the client's response to eating. The PACU nurse also assesses the client's postoperative site for hemorrhage. Ensuring informed consent is the role of the nurse in the preoperative area.

The nurse caring for a client in a persistent vegetative state is regularly assessing for potential complications. The nurse should assess for which complications? Select all that apply. A. Contractures B. Hemorrhage C. Pressure ulcers D. Venous thromboembolism E. Pneumonia

A, C, D, E. Based on the assessment data, potential complications (partially based on immobility) may include respiratory distress or failure, pneumonia, aspiration, pressure ulcer, deep vein thrombosis (DVT), and contractures. A persistent vegetative state does not directly create a heightened risk for hemorrhage.. A persistent vegetative state condition is when the client is wakeful but devoid of conscious content, without cognitive or affective mental function

The PACU nurse is caring for an adult client who had a left lobectomy. The nurse is assessing the client frequently for airway patency and cardiovascular status. The nurse should know that the most common cardiovascular complications seen in the PACU include what? Select all that apply. A. Hypotension B. Hypervolemia C. Heart murmurs D. Dysrhythmias E. Hypertension

A, D, E. The primary cardiovascular complications seen in the PACU include hypotension and shock, hemorrhage, hypertension, and dysrhythmias. Heart murmurs are not adverse reactions to surgery. Hypervolemia is not a common cardiovascular complication seen in the PACU, though fluid balance must be vigilantly monitored.

The surgical nurse is preparing to send a client from the presurgical area to the OR and is reviewing the client's informed consent form. What are the criteria for legally valid informed consent? Select all that apply. A. Consent must be freely given. B. Consent must be notarized. C. Consent must be signed on the day of surgery. D. Consent must be obtained by a health care provider. E. Signature must be witnessed by a professional staff member.

A, D, E. Valid consent must be freely given, without coercion. Consent must be obtained by a health care provider, and the client's signature must be witnessed by a professional staff member. It does not need to be signed on the same day as the surgery and it does not need to be notarized.

Which diagnostic test is used to examine cells from herpes zoster? A. Tzanck smear B. Skin biopsy C. Skin scrapings D. Patch testing

A. A Tzanck smear is a test used to examine cells from blistering skin conditions such as herpes zoster, varicella, herpes simplex, and all forms of pemphigus. Biopsies are performed on skin nodules, plaques, blisters, and other lesions to rule out malignancy and to establish an exact diagnosis. Skin scraping is used to diagnose spores and hyphae. A patch test is used to identify substances to which the client has developed an allergy.

While waiting to see the health care provider, a client shows the nurse skin areas that are flat, nonpalpable, and have had a change of color. The nurse recognizes that the client is demonstrating: A. macules. B. papules. C. vesicles. D. pustules.

A. A macule is a flat, non palpable skin color change, while a papule is an elevated, solid, palpable mass. A vesicle is a circumscribed, elevated, palpable mass containing serous fluid, while a pustule is a pus-filled vesicle.

A client has a boil that is located in the left axillary area and is elevated with a raised border, and filled with pus. How would the nurse document this type of lesion? A. Pustule B. Vesicle C. Cyst D. Macule

A. A pustule has an elevated, raised border, filled with pus. A macule is a flat, round, colored lesion such as a freckle or rash. A vesicle is a lesion that is elevated, round, and filled with serum. A cyst is an encapsulated, round, fluid-filled or solid mass beneath the skin.

A client was brought to the emergency department after a fall. The client is taken to the operating room to receive a right hip prosthesis. In the immediate postoperative period, what health education should the nurse emphasize? A. Make sure you don't bring your knees close together. B. Try to lie as still as possible for the first few days. C. Try to avoid bending your knees until next week. D. Keep your legs higher than your chest whenever you can.

A. After receiving a hip prosthesis, the affected leg should be kept abducted. Mobility should be encouraged within safe limits. There is no need to avoid knee flexion and the client's legs do not need to be higher than the level of the chest.

The nurse is caring for a client whose recent health history includes an altered LOC. What should be the nurse's first action when assessing this client? A. Assessing the client's verbal response B. Assessing the client's ability to follow complex commands C. Assessing the client's judgment D. Assessing the client's response to pain

A. Assessment of the client with an altered LOC often starts with assessing the verbal response through determining the client's orientation to time, person, and place. In most cases, this assessment will precede each of the other listed assessments, even though each may be indicated.

The perioperative nurse is providing care for a client who is recovering on the postsurgical unit following a transurethral prostate resection (TUPR). The client is reluctant to ambulate, citing the need to recover in bed. For what complication is the client most at risk? A. Atelectasis B. Anemia C. Dehydration D. Peripheral edema

A. Atelectasis occurs when the postoperative client fails to move, cough, and breathe deeply. With good nursing care, this is an avoidable complication, but reduced mobility greatly increases the risk. Anemia occurs rarely and usually in situations where the client loses a significant amount of blood or continues bleeding postoperatively. Fluid shifts postoperatively may result in dehydration and peripheral edema, but the client is most at risk for atelectasis

An operating room nurse is participating in an interdisciplinary audit of infection control practices in the surgical department. The nurse should know that a basic guideline for maintaining surgical asepsis is which of the following? A. Sterile surfaces or articles may touch other sterile surfaces. B. Sterile supplies can be used on another client if the packages are intact. C. The outer lip of a sterile solution is considered sterile. D. The scrub nurse may pour a sterile solution from a nonsterile bottle.

A. Basic guidelines for maintaining sterile technique include that sterile surfaces or articles may touch other sterile surfaces only. The other options each constitute a break in sterile technique.

A nurse is planning the care of an older adult client with osteomalacia. What action should the nurse recommend in order to promote vitamin D synthesis? A. Ensuring adequate exposure to sunlight B. Eating a low-purine diet C. Performing cardiovascular exercise while avoiding weight-bearing exercises D. Taking thyroid supplements as prescribed

A. Because sunlight is necessary for synthesizing vitamin D, clients should be encouraged to spend some time in the sun. A low-purine diet is not a relevant action, and thyroid supplements do not directly affect bone function. Action must be taken to prevent fractures, but weight-bearing exercise within safe parameters is not necessarily contraindicated.

An older, female client with osteoporosis has been hospitalized. Prior to discharge, when teaching the client, the nurse should include information about which major complication of osteoporosis? A. Bone fracture B. Loss of estrogen C. Negative calcium balance D. Dowager hump

A. Bone fracture is a major complication of osteoporosis that results when loss of calcium and phosphate increases the fragility of bones. Estrogen deficiencies result from menopause, not osteoporosis. Calcium and vitamin D supplements may be used to support normal bone metabolism, but a negative calcium balance is not a complication of osteoporosis. Dowager hump results from bone fractures. It develops when repeated vertebral fractures increase spinal curvature.

The nurse in an ambulatory care center is admitting an older adult client who has bright red moles on the skin. What benign changes in the skin of an older adult appear as bright red moles? A. Cherry angiomas B. Solar lentigines C. Seborrheic keratoses D. Xanthelasmas

A. Cherry angiomas appear as bright red moles, while solar lentigines are commonly called liver spots. Seborrheic keratoses are described as crusty brown stuck on patches, while xanthelasmas appear as yellowish, waxy deposits on the upper eyelids.

The nurse is reviewing the medication administration record of the client. Which medication would lead the nurse to suspect that the client is suffering from an acute attack of gout? A. colchicine B. prednisone C. penicillamine D. methotrexate

A. Colchicine is prescribed for the treatment of an acute attack of gout.

The nurse is conducting an admission history and physical examination of a client with a history of contact dermatitis. The nurse assesses whether the client uses which medication classification? A. Corticosteroids B. Antivirals C. Saline irrigations D. Antifungals

A. Corticosteroids are used for contact dermatitis. Antifungals, antivirals, and saline irrigations are not used in the treatment of contact dermatitis.

An OR nurse will be participating in the intraoperative phase of a client's kidney transplant. What action will the nurse prioritize in this aspect of nursing care? A. Monitoring the client's physiologic status B. Providing emotional support to family C. Maintaining the client's cognitive status D. Maintaining a clean environment

A. During the intraoperative phase, the nurse is responsible for physiologic monitoring. The intraoperative nurse cannot support the family at this time and the nurse is not responsible for maintaining the client's cognitive status. The intraoperative nurse maintains an aseptic, not clean, environment.

A nurse is conducting a health interview and is assessing for integumentary conditions that are known to have a genetic component. What assessment question is most appropriate? A. Does anyone in your family have eczema or psoriasis? B. Have any of your family members been diagnosed with malignant melanoma? C. Do you have a family history of vitiligo or port-wine stains? D. Does any member of your family have a history of keloid scarring?

A. Eczema and psoriasis are known to have a genetic component. This is not true of any of the other listed integumentary disorders.

A nurse in the emergency department (ED) is triaging a 5-year-old who has been brought to the ED by the parents for an outbreak of urticaria. What would be the most appropriate question to ask this client's parents? A. Has your child eaten any new foods today? B. Has your child bathed in the past 24 hours? C. Did your child go to a friend's house today? D. Was your child digging in the dirt today?

A. Foods can cause skin reactions, especially in children. In most cases, this is a more plausible cause of urticaria than bathing, contact with other children, or soil-borne pathogens.

A patient's skin is examined and the nurse notes the presence of herpes simplex/zoster skin lesions. The nurse describes the lesions as: A. Pus-filled vesicles; circumscribed and elevated masses >0.5 cm. B. Palpable, solid tumors >3 cm. C. Flat, mole-like lesions. D. Flat macules with irregular borders.

A. Herpes vesicles are circumscribed, elevated, palpable masses containing serous fluid.

The surgical nurse is admitting a client from postanesthetic recovery following the client's below-the-knee amputation. The nurse recognizes the client's high risk for postoperative hemorrhage and should keep what equipment at the bedside? A. A tourniquet B. A syringe preloaded with vitamin K C. A unit of packed red blood cells, placed on ice D. A dose of protamine sulfate

A. Immediate postoperative bleeding may develop slowly or may take the form of massive hemorrhage resulting from a loosened suture. A large tourniquet should be in plain sight at the client's bedside so that, if severe bleeding occurs, it can be applied to the residual limb to control the hemorrhage. PRBCs cannot be kept at the bedside. Vitamin K and protamine sulfate are antidotes to warfarin and heparin, but are not given to treat active postsurgical bleeding.

A client's decreased mobility has been attributed to an autoimmune reaction originating in the synovial tissue, which caused the formation of pannus. This client has been diagnosed with which health problem? A. Rheumatoid arthritis (RA) B. Systemic lupus erythematosus (SLE) C. Osteoporosis D. Polymyositis

A. In RA, the autoimmune reaction results in phagocytosis, producing enzymes within the joint that break down collagen, cause edema and proliferation of the synovial membrane, and ultimately form pannus. Pannus destroys cartilage and bone. SLE, osteoporosis, and polymyositis do not involve pannus formation.

A patient visits a clinic for assessment of an inflammatory skin disorder. The nurse diagnoses the condition as psoriasis based on the appearance of the skin. Which of the following describes the dermatoses? A. Red, raised patches of skin covered with silvery scales B. Clear vesicles with a dusky base C. Flat, elongated scales, dark in color D. Clusters of pustules with irregular borders

A. Lesions of psoriasis appear as red, raised patches of skin covered with silvery scales. The other choices describe different types of ringworm infections.

Diagnostic tests show that a client's bone density has decreased over the past several years. The client asks the nurse which factors contribute to bone density decreasing. Which response by the nurse would be best? A. For many people, a lack of proper nutrition can cause a loss of bone density. B. Progressive loss of bone density is mostly related to your genes. C. Stress is known to have many unhealthy effects, including reduced bone density. D. Bone density decreases with age, but scientists are not exactly sure why this is the case.

A. Nutrition has a profound effect on bone density, especially later life. Genetics are also an important factor, but nutrition has a more pronounced effect. The pathophysiology of bone density is well understood and psychosocial stress has a minimal effect.

A client is undergoing diagnostic testing to determine the etiology of recent joint pain. The client asks the nurse about the difference between osteoarthritis (OA) and rheumatoid arthritis (RA). What is the best response by the nurse? A. OA is considered a noninflammatory joint disease. RA is characterized by inflamed, swollen joints. B. OA and RA are very similar. OA affects the smaller joints such as the fingers, and RA affects the larger, weight-bearing joints like the knees. C. OA originates with an infection. RA is a result of your body's cells attacking one another. D. OA is associated with impaired immune function; RA is a consequence of physical damage.

A. OA is a degenerative arthritis with a noninflammatory etiology, characterized by the loss of cartilage on the articular surfaces of weight-bearing joints, with spur development. RA is characterized by inflammation of synovial membranes and surrounding structures. The diseases are not distinguished by the joints affected and neither has an infectious etiology.

A circulating nurse provides care in a surgical department that has multiple surgeries scheduled for the day. The nurse should know to monitor which client most closely during the intraoperative period because of the increased risk for hypothermia? A. A 74-year-old client with a low body mass index B. A 17-year-old client with traumatic injuries C. A 45-year-old client having an abdominal hysterectomy D. A 13-year-old client undergoing craniofacial surgery

A. Older clients are at greatest risk during surgical procedures because they have an impaired ability to increase their metabolic rate and impaired thermoregulatory mechanisms, which increase susceptibility to hypothermia. The other clients are likely at a lower risk.

A nurse is caring for a 78-year-old client with a history of osteoarthritis (OA). When planning the client's care, what goal should the nurse prioritize? A. The client will express satisfaction with the ability to perform ADLs. B. The client will recover from OA within 6 months. C. The client will adhere to the prescribed plan of care. D. The client will deny signs or symptoms of OA.

A. Pain management and optimal functional ability are major goals of nursing interventions for OA. Cure is not a possibility, and it is unrealistic to expect a complete absence of signs and symptoms. Adherence to the plan of care is highly beneficial, but this is not the priority goal of care; adherence is of little benefit if the regimen has no effect on the client's functional status.

The nurse notes several very small, round, red and purple macules on a patient's skin. The patient has a history of anticoagulant use. The nurse records this finding as which of the following? A. Petechiae B. Cherry angiomas C. Telangiectasias D. Ecchymoses

A. Petechiae are small red or purple macules, usually 1 to 2 mm in size, associated with bleeding tendencies. A patient with a history of anticoagulant use would fall in this category. Ecchymoses are round or irregular macular lesions larger than petechiae. Cherry angiomas are papular, round, red or purple lesions that are normal-age related changes. Telangiectasias are spider-like or linear bluish or red lesions associated with varicosities.

A client is undergoing photochemotherapy involving a combination of a photosensitizing chemical and ultraviolet light. What health problem does this client most likely have? A. psoriasis B. undesired tattoo C. dandruff D. plantar warts

A. Photochemotherapy is used to treat psoriasis.

The nurse is caring for an 88-year-old client who is recovering from an iliac-femoral bypass graft. The client is day 2 postoperative and has been mentally intact, as per baseline. When the nurse assesses the client, it is clear that the client is confused and has been experiencing disturbed sleep patterns and impaired psychomotor skills. Which complication should the nurse suspect? A. Postoperative delirium B. Postoperative dementia C. Senile dementia D. Senile confusion

A. Postoperative delirium, characterized by confusion, perceptual and cognitive deficits, altered attention levels, disturbed sleep patterns, and impaired psychomotor skills, is a significant problem for older adults. Dementia does not have a sudden onset. Senile confusion is not a recognized health problem.

A client asks the nurse what psoriasis is. What is the best answer? A. It is characterized by patches of redness covered with silvery scales. B. The onset typically occurs in young children. C. A cure is possible with prompt treatment. D. It is a chronic, infectious inflammatory disease.

A. Psoriasis is characterized by patches of erythema covered with silvery scales, usually on the extensor surfaces of the elbows, knees, trunk, and scalp. It is a chronic non-infectious inflammatory disease. Psoriasis has no cure. The onset is in young and middle adulthood.

A nurse is caring for a client who has been diagnosed with psoriasis. The nurse is creating an education plan for the client. What information should be included in this plan? A. Lifelong management is likely needed. B. Avoid public places until symptoms subside. C. Wash skin frequently to prevent infection. D. Liberally apply corticosteroids as needed.

A. Psoriasis usually requires lifelong management. Psoriasis is not contagious. Many clients need reassurance that the condition is not infectious, not a reflection of poor personal hygiene, and not skin cancer. Excessive frequent washing of skin produces more soreness and scaling. Overuse of topical corticosteroids can result in skin atrophy, striae, and medication resistance.

A client presents to a clinic reporting a leg ulcer that isn't healing; subsequent diagnostic testing suggests osteomyelitis. The nurse is aware that the most common pathogen to cause osteomyelitis is: A. Staphylococcus aureus. B. Proteus. C. Pseudomonas. D. Escherichia coli.

A. S. aureus causes more than half of all bone infections. Proteus, Pseudomonas, and E. coli are also causes, but to a lesser extent.

A 10-year-old child is brought to the office with complaints of severe itching in both hands that's especially annoying at night. On inspection, the nurse notes gray-brown burrows with epidermal curved ridges and follicular papules. The physician performs a lesion scraping to assess this condition. Based on the signs and symptoms, what diagnosis should the nurse expect? A. Scabies B. Contact dermatitis C. Impetigo D. Dermatophytosis

A. Signs and symptoms of scabies include gray-brown burrows, epidermal curved or linear ridges, and follicular papules. Clients complain of severe itching that usually occurs at night. Scabies commonly occurs in school-age children. The most common areas of infestation are the finger webs, flexor surface of the wrists, and antecubital fossa. Impetigo is a contagious, superficial skin infection characterized by a small, red macule that turns into a vesicle, becoming pustular with a honey-colored crust. Contact dermatitis is an inflammation of the skin caused by contact with an irritating chemical or allergen. Dermatophytosis, or ringworm, is a disease that affects the scalp, body, feet, nails, and groin. It's characterized by erythematous patches and scaling.

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)? A. Increased warmth of the calf B. Decreased circumference of the calf C. Loss of sensation to the calf D. Pale-appearing calf

A. Signs of DVT include increased warmth, redness, swelling, and calf tenderness. These findings are promptly reported to the health care provider for definitive evaluation and therapy. Signs and symptoms of a DVT do not include a decreased circumference of the calf, a loss of sensation in the calf, or a pale-appearing calf.

A client with a fracture develops compartment syndrome that requires surgical intervention. What treatment will the nurse would most likely prepare the client for? A. Fasciotomy B. Joint replacement C. Bone graft D. Amputation

A. Surgical treatment of compartment syndrome is achieved with a fasciotomy, a surgical incision of the fascia and separation of the muscle to relieve pressure and restore tissue perfusion. Bone graft, joint replacement or amputation may be done for a client who experiences avascular necrosis.

Which of the following is the most important nursing diagnosis for an elderly patient diagnosed with osteoporosis? A. Risk for injury related to fractures due to osteoporosis B. Risk for constipation related to immobility C. Deficient knowledge about osteoporosis and the treatment regimen D. Acute pain related to fracture and muscle spasm

A. The most important concern for an elderly patient with osteoporosis is prevention of falls and fractures. Pain and constipation can be managed, and knowledge can be reinforced, but fractures can cause significant morbidity and mortality.

The circulating nurse in an outpatient surgery center is assessing a client who is scheduled to receive moderate sedation. Which principle should guide the care of a client receiving this form of anesthesia? A. The client must never be left unattended by the nurse. B. The client should begin a course of antiemetics the day before surgery. C. The client should be informed that the client will remember most of the procedure. D. The client must be able to maintain the client's own airway.

A. The client receiving moderate sedation should never be left unattended. The client's ability to maintain the client's own airway depends on the level of sedation. The administration of moderate sedation is not an indication for giving an antiemetic. The client receiving moderate sedation does not remember most of the procedure.

A client has just been admitted to the postanesthesia care unit following abdominal surgery. As the client begins to awaken, the client is uncharacteristically restless. The nurse checks the skin, and it is cold, moist, and pale. The nurse is concerned the client may be at risk for which condition? A. Hemorrhage and shock B. Aspiration C. Postoperative infection D. Hypertension and dysrhythmias

A. The client with a hemorrhage presents with hypotension; rapid, thready pulse; disorientation; restlessness; oliguria; and cold, pale skin. Aspiration would manifest in airway disturbance. Hypertension or dysrhythmias would be less likely to cause pallor and cool skin. An infection would not be present at this early postoperative stage.

A nurse is collaborating with the physical therapist to plan the care of a client with osteomyelitis. What principle should guide the management of activity and mobility in this client? A. Stress on the weakened bone must be avoided. B. Increased heart rate enhances perfusion and bone healing. C. Bed rest results in improved outcomes in clients with osteomyelitis. D. Maintenance of baseline ADLs is the primary goal during osteomyelitis treatment.

A. The client with osteomyelitis has bone that is weakened by the infective process and must be protected by avoidance of stress on the bone. This risk guides the choice of activity in a client with osteomyelitis. Bed rest is not normally indicated. Maintenance of prediagnosis ADLs may be an unrealistic short-term goal for many clients.

The client with a fractured left humerus reports dyspnea and chest pain. Pulse oximetry is 88%. Temperature is 100.2 degrees Fahrenheit (38.5 degrees Centigrade); heart rate is 110 beats per minute; respiratory rate is 32 breaths per minute. The nurse suspects the client is experiencing: A. Fat embolism syndrome B. Compartment syndrome C. Delayed union D. Complex regional pain syndrome

A. The clinical manifestations described in the scenario are characteristic of fat embolism syndrome.

The nurse is reviewing the diagnostic test findings of a client with rheumatoid arthritis. What would the nurse expect to find? A. Elevated erythrocyte sedimentation rate B. Increased albumin levels C. Increased red blood cell count D. Increased C4 complement

A. The erythrocyte sedimentation rate (ESR) may be elevated, particularly as the disease progresses. ESR shows inflammation associated with RA. Red blood cell count and C4 complement component are decreased. Serum protein electrophoresis may disclose increased levels of gamma and alpha globulin but decreased albumin.

The nurse is teaching a client with osteoarthritis about the disease. What is the most important client focus for disease management? A. strategies for remaining active B. detection of systemic complications C. disease-modifying antirheumatic drug therapy D. prevention of joint deformity

A. The goals of osteoarthritis disease management are to decrease pain and stiffness and improve joint mobility. Strategies for remaining active are the most important client focus. The detection of complications, disease-modifying antirheumatic drugs management, and prevention of joint deformity are considerations, but not the most important priorities for the client.

A nurse is caring for a client who is postoperative day 1 following a total arthroplasty of the right hip. How should the nurse position the client? A. Place a pillow between the legs. B. Turn the client on the surgical side. C. Avoid flexion of the right hip. D. Keep the right hip adducted at all times.

A. The hips should be kept in abduction by a pillow placed between the legs. When positioning the client in bed, the nurse should avoid placing the client on the operated hip. The right hip should not be flexed more than 90 degrees to avoid dislocation. The right hip should be maintained in an abducted position.

An 80-year-old client is brought to the clinic by one of the client's children. The client asks the nurse why the client has gotten so many spots on the skin. What would be an appropriate response by the nurse? A. As people age, they normally develop uneven pigmentation in their skin. B. These 'spots' are called 'liver spots' or 'age spots.' C. Older skin is more apt to break down and tear, causing sores. D. These are usually the result of nutritional deficits earlier in life.

A. The major changes in the skin of older people include dryness, wrinkling, uneven pigmentation, and various proliferative lesions. Stating the names of these spots and identifying older adults' vulnerability to skin damage do not answer the question. These lesions are not normally a result of nutritional imbalances.

One of the things a nurse has taught to a client during preoperative teaching is to have nothing by mouth for a specified time before surgery. The client asks the nurse why this is important. What is the most appropriate response for the client? A. You will need to have food and fluid restricted before surgery so you are not at risk for aspiration. B. The restriction of food or fluid will prevent the development of pneumonia related to decreased lung capacity. C. The presence of food in the stomach interferes with the absorption of anesthetic agents. D. By withholding food for 8 hours before surgery, you will not develop constipation in the postoperative period.

A. The major purpose of withholding food and fluid before surgery is to prevent aspiration. There is no scientific evidence that withholding food prevents the development of pneumonia or that food in the stomach interferes with absorption of anesthetic agents. Constipation in clients in the postoperative period is related to the anesthesia, not to having food within 8 hours before surgery, so withholding food or fluid would not necessarily prevent constipation.

The nurse is performing the shift assessment of a postsurgical client. The nurse finds the client's mental status, level of consciousness, speech, and orientation are intact and at baseline, but the client appears unusually restless. What should the nurse do next? A. Assess the client's oxygen levels. B. Administer antianxiety medications. C. Page the client's health care provider. D. Initiate a social work referral.

A. The nurse assesses the client's mental status and level of consciousness, speech, and orientation and compares them with the preoperative baseline. Although a change in mental status or postoperative restlessness may be related to anxiety, pain, or medications, it may also be a symptom of oxygen deficit or hemorrhage. Antianxiety medications are not given until the cause of the anxiety is known. The health care provider is notified only if the reason for the anxiety is serious or if a prescription for medication is needed. A social work consult is inappropriate for addressing restlessness.

The nurse is differentiating between a macule and a papule when evaluating a client's skin lesion. The nurse determines that the lesion is a papule when which characteristic is noted? A. Elevated and palpable B. Flat with skin color change C. Circumscribed border D. Greater than 1 cm in diameter

A. The nurse determines that the lesion is a papule, and not a macule, when the lesion is noted to be elevated and palpable. Macules are flat, non palpable skin color changes. Both macules and papules have circumscribed borders. Macules are less than 1 cm in diameter and papules are less than 0.5 cm in diameter.

A nurse is caring for a client who had a right below-the-knee amputation (BKA). The nurse recognizes the importance of implementing measures that focus on preventing flexion contracture of the hip and maintaining proper positioning. What nursing action will best achieve these goals? A. Encouraging the client to turn from side to side and to assume a prone position B. Initiating ROM exercises of the hip and knee 10 to 12 weeks after the amputation C. Minimizing movement of the flexor muscles of the hip D. Encouraging the client to sit in a chair for at least 8 hours a day

A. The nurse encourages the client to turn from side to side and to assume a prone position, if possible, to stretch the flexor muscles and to prevent flexion contracture of the hip. Postoperative ROM exercises are started early because contracture deformities develop rapidly. ROM exercises include hip and knee exercises for clients with BKAs. The nurse also discourages sitting for prolonged periods of time.

The nurse is working with community groups. At which of the following locations would the nurse anticipate a possible scabies outbreak? A. College dormitory B. Gymnasium C. Swimming pool D. Shopping mall

A. The nurse is correct to anticipate a potential scabies outbreak in a college dormitory. Outbreaks are common where large groups of people are confined or housed. Spread of scabies is from skin-to-skin contact. Although there are groups of people at the shopping mall, swimming pool, and gymnasium, typically, there is no personal contact.

A nurse is providing self-care education to a client who has been receiving treatment for acne vulgaris. What instruction should the nurse provide to the client? A. Wash your face with water and gentle soap each morning and evening. B. Before bedtime, clean your face with rubbing alcohol on a cotton pad. C. Gently burst new pimples before they form a visible 'head'. D. Set aside some time each day to squeeze blackheads and remove the plug.

A. The nurse should inform the client to wash the face and other affected areas with mild soap and water twice each day to remove surface oils and prevent obstruction of the oil glands. Cleansing with rubbing alcohol is not recommended and all forms of manipulation should be avoided.

During a routine physical examination on an older female client, a nurse notes that the client is 5 feet, 3/8 inches (1.6 m) tall. The client states, How is that possible? I was always 5 feet and 1/2? (1.7 m) tall. Which statement is the best response by the nurse? A. After menopause, the body's bone density declines, resulting in a gradual loss of height. B. The posture begins to stoop after middle age. C. After age 40, height may show a gradual decrease as a result of spinal compression D. There may be some slight discrepancy between the measuring tools used.

A. The nurse should tell the client that after menopause, the loss of estrogen leads to a loss in bone density, resulting in a loss of height. This client's history doesn't indicate spinal compression. Telling the client that measuring tools used to obtain the client's height may have a discrepancy or that the posture begins to stoop after middle age doesn't address the client's question.

A nurse is caring for a client who is 12 hours' postoperative following foot surgery. The nurse assesses the presence of edema in the foot. What nursing measure should the nurse implement to control the edema? A. Elevate the foot on several pillows. B. Apply warm compresses intermittently to the surgical area. C. Administer a loop diuretic as prescribed. D. Increase circulation through frequent ambulation.

A. To control the edema in the foot of a client who experienced foot surgery, the nurse will elevate the foot on several pillows when the client is sitting or lying. Diuretic therapy is not an appropriate intervention for edema related to inflammation. Intermittent ice packs should be applied to the surgical area during the first 24 to 48 hours after surgery to control edema and provide some pain relief. Ambulation will gradually be resumed based on the guidelines provided by the surgeon.

A client is admitted with acute osteomyelitis that developed after an open fracture of the right femur. When planning this client's care, the nurse should anticipate which measure? A. Administering large doses of I.V. antibiotics as ordered B. Withholding all oral intake C. Administering large doses of oral antibiotics as ordered D. Instructing the client to ambulate twice daily

A. Treatment of acute osteomyelitis includes large doses of I.V. antibiotics (after blood cultures identify the infecting organism). Surgical drainage may be indicated, and the affected bone is immobilized. The client usually requires I.V. fluids to maintain hydration, but oral intake isn't necessarily prohibited.

To treat a client with acne vulgaris, the physician is most likely to order which topical agent for nightly application? A. Tretinoin (retinoic acid [Retin-A]) B. Fluorouracil (5-fluorouracil, 5-FU [Efudex]) C. Zinc oxide gelatin D. Minoxidil (Rogaine)

A. Tretinoin is a topical agent applied nightly to treat acne vulgaris. Minoxidil promotes hair growth. Zinc oxide gelatin treats stasis dermatitis on the lower legs. Fluorouracil is an antineoplastic topical agent that treats superficial basal cell carcinoma.

An 80-year-old man in a long-term care facility has a chronic leg ulcer and states that the area has become increasingly painful in recent days. The nurse notes that the site is now swollen and warm to the touch. The client should undergo diagnostic testing for what health problem? A. Osteomyelitis B. Osteoporosis C. Osteomalacia D. Septic arthritis

A. When osteomyelitis develops from the spread of an adjacent infection, no signs of septicemia are present, but the area becomes swollen, warm, painful, and tender to touch. Osteoporosis is noninfectious. Osteomalacia is a metabolic bone disease characterized by inadequate mineralization of bone. Septic arthritis occurs when joints become infected through spread of infection from other parts of the body (hematogenous spread) or directly through trauma or surgical instrumentation.

The nurse teaches the client with a high risk for osteoporosis about risk-lowering strategies, including which action? A. Reduce stress B. Walk or perform weight-bearing exercises outdoors C. Decrease the intake of vitamin A and D D. Increase fiber in the diet

B. Risk-lowering strategies for osteoporosis include walking or exercising outdoors, performing a regular weight-bearing exercise regimen, increasing dietary calcium and vitamin D intake, smoking cessation, and consuming alcohol and caffeine in moderation.

The nurse is planning teaching for a client with gout. Which topics will the nurse include in the teaching? Select all that apply. A. Restricting the intake of water B. Weight loss C. Avoiding purine-rich foods D. Limiting exercise E. Decreasing alcohol intake

B, C, E. Management between the attacks of gout include lifestyle changes to include weight loss, decreasing alcohol intake, and avoiding purine-rich foods. Exercise does not need to be limited and water does not need to be restricted.

A surgical client has been in the PACU for the past 3 hours. What are the determining factors for the client to be discharged from the PACU? Select all that apply. A. Absence of pain B. Stable blood pressure C. Ability to tolerate oral fluids D. Sufficient oxygen saturation E. Adequate respiratory function

B, D, E. A client remains in the PACU until fully recovered from the anesthetic agent. Indicators of recovery include stable blood pressure, adequate respiratory function, and adequate oxygen saturation level compared with baseline. Clients can be released from PACU before resuming oral intake. Pain is often present at discharge from the PACU and can be addressed in other inpatient settings.

A nurse is caring for a client who is suspected of having giant cell arteritis (GCA). Which laboratory tests are most useful in diagnosing this rheumatic disorder? Select all that apply. A. Erythrocyte count B. Erythrocyte sedimentation rate C. Creatinine clearance D. C-reactive protein E. D-dimer

B, D. Simultaneous elevation in the erythrocyte sedimentation rate and C-reactive protein has a sensitivity of 98.6% and a specificity of 75.7% in making the diagnosis of GCA when coupled with clinical findings. Erythrocyte counts, creatinine clearance, and D-dimer are not diagnostically useful.

The nurse is completing a health history with a client in a clinic. What assessment finding best correlates with a diagnosis of osteoarthritis? A. fever and malaise B. joint stiffness that increases with activity C. erythema and edema over the affected joint D. anorexia and weight loss

B. A characteristic feature of osteoarthritis (degenerative joint disease) is joint stiffness that increases with activity and movement. Erythema and edema over the affected joint, anorexia, weight loss, and fever and malaise are associated with rheumatoid arthritis, a more severe and destructive form of arthritis.

Radiographs of a client's upper arm shows three fragments of the humeral bone. This diagnostic result suggests what type of fracture? A. Open B. Comminuted C. Intra-articular D. Greenstick

B. A comminuted fracture has more than two bone fragments. An open fracture has a bone end which breaks through the skin surface. An intra-articular fracture extends into the joint surface of a bone. A greenstick fracture refers to a partial break of a bone.

A client has received a diagnosis of irritant contact dermatitis. What action should the nurse prioritize in the client's subsequent care? A. Teaching the client to safely and effectively administer immunosuppressants B. Helping the client identify and avoid the offending agent C. Teaching the client how to maintain meticulous skin hygiene D. Helping the client perform wound care in the home environment

B. A focus of care for clients with irritant contact dermatitis is identifying and avoiding the offending agent. Immunosuppressants are not used to treat eczema and wound care is not normally required, except in cases of open lesions. Poor hygiene has no correlation with contact dermatitis.

A nurse practitioner is seeing a 16-year-old client who has come to the dermatology clinic for treatment of acne. The nurse practitioner would know that the treatment may consist of which of the following medications? A. Acyclovir B. Benzoyl peroxide and erythromycin C. Diphenhydramine D. Triamcinolone

B. A nurse practitioner is seeing a 16-year-old client who has come to the dermatology clinic for treatment of acne. The nurse practitioner would know that the treatment may consist of which of the following medications? A. Acyclovir B. Benzoyl peroxide and erythromycin C. Diphenhydramine D. Triamcinolone

Assessment of a client's leg reveals the presence of a 1.5-cm circular region of necrotic tissue that is deeper than the epidermis. The nurse should document the presence of what type of skin lesion? A. Keloid B. Ulcer C. Fissure D. Erosion

B. A pressure ulcer that is stage 2 or greater is one that extends past the epidermal layer and can develop necrotic tissue. Keloids lack necrosis and consist of scar tissue. A fissure is linear, and erosions do not extend to the dermis.

The nurse is performing a preoperative assessment on a client going to surgery. The client reports to the nurse drinking approximately two bottles of wine each day for the last several years. What postoperative difficulties should the nurse anticipate for this client? A. Nonadherence to prescribed treatment after surgery B. Increased risk for postoperative complications C. Alcohol withdrawal syndrome upon administration of general anesthesia D. Increased risk for allergic reactions

B. Alcohol use increases the risk of complications. Withdrawal does not occur immediately upon administration of anesthesia. Alcohol does not increase the risk of allergies and is not necessarily a risk factor for nonadherence.

A client with rheumatoid arthritis comes to the clinic reporting pain in the joint of his right great toe and is eventually diagnosed with gout. When planning teaching for this client, what management technique should the nurse emphasize? A. Take OTC calcium supplements consistently. B. Restrict consumption of foods high in purines. C. Ensure fluid intake of at least 4 L per day. D. Restrict weight-bearing on right foot.

B. Although severe dietary restriction is not necessary, the nurse should encourage the client to restrict consumption of foods high in purines, especially organ meats. Calcium supplementation is not necessary and activity should be maintained as tolerated. Increased fluid intake is beneficial, but it is not necessary for the client to consume more than 4 L daily.

An important nursing assessment, post fracture, is to evaluate neurovascular status. Therefore, the nurse should check for: A. Shortening and deformity. B. Capillary refill. C. Crepitus. D. Swelling and discoloration.

B. Assessment for neurovascular impairment includes checking for weak pulses or delayed capillary refill (normal is <2 seconds).

A gerontologic nurse is teaching a group of nursing students about integumentary changes that occur in older adults. How should these students best integrate these changes into care planning? A. By avoiding the use of moisturizing lotions on older adults' skin B. By protecting older adults against shearing injuries C. By avoiding the use of ice packs to treat muscle pain D. By protecting older adults against excessive sweat accumulation

B. Cellular changes associated with aging include thinning at the junction of the dermis and epidermis, which creates a risk for shearing injuries. Moisturizing lotions can be safely used to address the increased dryness of older adults' skin. Ice packs can be used, provided skin is assessed regularly and the client possesses normal sensation. Older adults perspire much less than younger adults, thus sweat accumulation is rarely an issue.

Which of the following clients should the nurse recognize as being at the highest risk for the development of osteomyelitis? A. A middle-aged adult who takes ibuprofen daily for rheumatoid arthritis B. An older adult client with an infected pressure ulcer in the sacral area C. A 17-year-old football player who had orthopedic surgery 6 weeks prior D. An infant diagnosed with jaundice

B. Clients who are at high risk of osteomyelitis include those who are poorly nourished, older adults, and clients who are obese. The older adult client with an infected sacral pressure ulcer is at the greatest risk for the development of osteomyelitis, as this client has two risk factors: age and the presence of a soft-tissue infection that has the potential to extend into the bone. The client with rheumatoid arthritis has one risk factor and the infant with jaundice has no identifiable risk factors. The client 6 weeks' postsurgery is beyond the usual window of time for the development of a postoperative surgical wound infection.

A nurse is providing preoperative teaching to a client who will soon undergo a cardiac bypass. The nurse's teaching plan includes exercises of the extremities. What is the purpose of teaching a client leg exercises prior to surgery? A. Leg exercises increase the client's muscle mass postoperatively. B. Leg exercises improve circulation and prevent venous thrombosis. C. Leg exercises help to prevent pressure sores to the sacrum and heels. D. Leg exercise help increase the client's level of consciousness after surgery.

B. Exercise of the extremities includes extension and flexion of the knee and hip joints (similar to bicycle riding while lying on the side) unless contraindicated by type of surgical procedure (e.g., hip replacement). When the client does leg exercises postoperatively, circulation is increased, which helps to prevent blood clots from forming. Leg exercises do not prevent pressure sores to the sacrum or increase the client's level of consciousness. Leg exercises have the potential to increase strength and mobility but are unlikely to make a change to muscle mass in the short term.

Which of the following nonsedating antihistamines is appropriate for daytime pruritus? A. Diphenhydramine (Benadryl) B. Fexofenadine (Allegra) C. Hydroxyzine (Atarax) D. Lorazepam (Ativan)

B. Nonsedating antihistamine medications such as Allegra are more appropriate to relieve daytime pruritus. Benadryl or Atarax, when prescribed in a sedative dose at bedtime, may be beneficial in producing a restful and comfortable sleep. Ativan has sedating properties and is used as an antianxiety medication.

An older adult client has fallen in the home and is brought to the emergency department by ambulance with a suspected fractured hip. X-rays confirm a fracture of the left femoral neck. When planning assessments during the client's presurgical care, the nurse should be aware of the client's heightened risk of what complication? A. Osteomyelitis B. Avascular necrosis C. Phantom pain D. Septicemia

B. Fractures of the neck of the femur may damage the vascular system that supplies blood to the head and the neck of the femur, and the bone may become ischemic. For this reason, AVN is common in clients with femoral neck fractures. Infections are not immediate complications and phantom pain applies to clients with amputations, not hip fractures.

A client is taking ibuprofen for the treatment of osteoarthritis. What education will the nurse give the client about the medication? A. Take the medication on an empty stomach in order to increase effectiveness. B. Take the medication with food to avoid stomach upset. C. Since the medication is able to be obtained over the counter, it has few side effects. D. Inform the health care provider if there is ringing in the ears.

B. Ibuprofen is a nonsteroidal anti-inflammatory drug. The nurse should advise the patient to take NSAIDs with food to avoid stomach upset. Ibuprofen is available over the counter, but it still has side effects. Aspirin is known to cause ringing in the ears, not NSAIDs.

During the care of a preoperative client, the nurse has given the client a preoperative benzodiazepine. The client is now requesting to void. What action should the nurse take? A. Assist the client to the bathroom. B. Offer the client a bedpan or urinal. C. Wait until the client gets to the operating room and is catheterized. D. Have the client go to the bathroom.

B. If a preanesthetic medication is given, the client is kept in bed with the side rails raised because the medication can cause lightheadedness or drowsiness. If a client needs to void following administration of a sedative, the nurse should offer the client a bedpan. The client should not get out of bed because of the potential for lightheadedness.

A client exhibiting an altered level of consciousness (LOC) due to blunt force trauma to the head is admitted to the emergency department (ED). The nurse should first gauge the client's LOC on the results of what diagnostic tool? A. Monro-Kellie hypothesis B. Glasgow Coma scale C. Cranial nerve function D. Mental status examination

B. LOC, a sensitive indicator of neurologic function, is assessed based on the criteria in the Glasgow Coma scale: eye opening, verbal response, and motor response. The Monro-Kellie hypothesis states that because of the limited space for expansion within the skull, an increase in any one of the components (blood, brain tissue, cerebrospinal fluid) causes a change in the volume of the others. Cranial nerve function and the mental status examination would be part of the neurologic examination for this client, but would not be the priority in evaluating LOC. Glasgow coma scale can be done quickly and establishes a baseline of neurologic function.

The nurse is providing care for a client who is unconscious. What nursing intervention takes highest priority? A. Maintaining accurate records of intake and output B. Maintaining a patent airway C. Inserting a nasogastric (NG) tube as prescribed D. Providing appropriate pain control

B. Maintaining a patent airway always takes top priority, even though each of the other listed actions is necessary and appropriate.

The nurse is taking the client into the operating room (OR) when the client informs the nurse that the client's grandparent spiked a very high temperature in the OR and nearly died 15 years ago. What relevance does this information have regarding the client? A. The client may be experiencing presurgical anxiety. B. The client may be at risk for malignant hyperthermia. C. The grandparent's surgery has minimal relevance to the client's surgery. D. The client may be at risk for a sudden onset of postsurgical infection.

B. Malignant hyperthermia is an inherited muscle disorder chemically induced by anesthetic agents. Identifying clients at risk is imperative because the mortality rate is 50%. The client's anxiety is not relevant, the grandparent's surgery is very relevant, and all clients are at risk for postsurgical infections.

The nurse is providing preoperative teaching to a client scheduled for surgery. The nurse is instructing the client on the use of deep breathing, coughing, and the use of incentive spirometry when the client states, I don't know why you're focusing on my breathing. My surgery is on my hip, not my chest. What rationale for these instructions should the nurse provide? A. To prevent chronic obstructive pulmonary disease (COPD) B. To promote optimal lung expansion C. To enhance peripheral circulation D. To prevent pneumothorax

B. One goal of preoperative nursing care is to teach the client how to promote optimal lung expansion and consequent blood oxygenation after anesthesia. COPD is not a realistic risk and pneumothorax is also unlikely. Breathing exercises do not primarily affect peripheral circulation.

The nurse is gathering a health history for a client with osteoarthritis. What clinical manifestation will the nurse expect to find? A. joint pain that increases with rest B. early morning stiffness C. subcutaneous nodules D. small joint involvement

B. Osteoarthritis is characterized by early morning stiffness that decreases with activity. Large joints are usually involved with osteoarthritis. Joint pain is a constant with osteoarthritis. Clients with rheumatoid arthritis have subcutaneous nodules.

A client with diabetes has been diagnosed with osteomyelitis. The nurse observes that the client's right foot is pale and mottled, cool to touch, with a capillary refill of greater than 3 seconds. The nurse should suspect what type of osteomyelitis? A. Hematogenous osteomyelitis B. Osteomyelitis with vascular insufficiency C. Contiguous focus osteomyelitis D. Osteomyelitis with muscular deterioration

B. Osteomyelitis is classified as hematogenous osteomyelitis (i.e., due to bloodborne spread of infection); contiguous-focus osteomyelitis, from contamination from bone surgery, open fracture, or traumatic injury (e.g., gunshot wound); and osteomyelitis with vascular insufficiency, seen most commonly among clients with diabetes and peripheral vascular disease, most commonly affecting the feet. Osteomyelitis with muscular deterioration does not exist.

What nursing intervention should the nurse prioritize to facilitate healing in a client who has suffered a hip fracture? A. Administer analgesics as required. B. Place a pillow between the client's legs when turning. C. Maintain prone positioning at all times. D. Encourage internal and external rotation of the affected leg.

B. Placing a pillow between the client's legs when turning prevents adduction and supports the client's legs. Administering analgesics addresses pain but does not directly protect bone remodeling and promote healing. Rotation of the affected leg can cause dislocation and must be avoided. Prone positioning does not need to be maintained at all times.

Primary prevention of osteoporosis includes: A. installing grab bars in the bathroom to prevent falls. B. optimal calcium intake and estrogen replacement therapy. C. placing items within the client's reach. D. using a professional alert system in the home in case a client falls when she's alone.

B. Primary prevention of osteoporosis includes maintaining optimal calcium intake and using estrogen replacement therapy. Placing items within a client's reach, using a professional alert system in the home, and installing grab bars in bathrooms to prevent falls are secondary and tertiary prevention methods.

A nurse assesses a client with dry, rough, scaly skin without lesions on the legs. The client reports itching in the affected area. What skin assessment would the nurse document? A. Seborrhea B. Pruritus C. Candidiasis D. Shingles

B. Pruritus (itching) is one of the most common symptoms of patients with dermatologic disorders. Itch receptors are unmyelinated, penicillate (brush-like) nerve endings that are found exclusively in the skin, mucous membranes, and cornea. Shingles presents with lesions. Candidiasis presents with reddened skin and is often found in the folds of skin. Seborrhea refers to dry, scaly patches usually located on the scalp.

A nurse is assessing a client for risk factors known to contribute to osteoarthritis. What assessment finding should the nurse interpret as a risk factor? A. The client has a 30 pack-year smoking history. B. The client's body mass index is 34 (obese). C. The client has primary hypertension. D. The client is 58 years old.

B. Risk factors for osteoarthritis include obesity and previous joint damage. Risk factors of OA do not include smoking or hypertension. Incidence increases with age, but a client who is 58 years old would not yet face a significantly heightened risk.

A client with diabetes is attending a class on the prevention of associated diseases. What action should the nurse teach the client to reduce the risk of osteomyelitis? A. Increase calcium and vitamin intake. B. Monitor and control blood glucose levels. C. Exercise 3 to 4 times weekly for at least 30 minutes. D. Take corticosteroids as prescribed.

B. Since poor glycemic control can exacerbate the spread of infection from other sources, the client with diabetes should maintain blood glucose levels within a desired range. Corticosteroids can exacerbate the risk of osteomyelitis. Increased intake of calcium and vitamins as well as regular exercise are beneficial health promotion exercises, but they do not directly reduce the risk of osteomyelitis.

A nurse is explaining the importance of sunlight on the skin to a client with decreased mobility who rarely leaves the house. The nurse would emphasize that ultraviolet light helps to synthesize what vitamin? A. E B. D C. A D. C

B. Skin exposed to ultraviolet light can convert substances necessary for synthesizing vitamin D (cholecalciferol). Vitamin D is essential for preventing rickets, a condition that causes bone deformities and results from a deficiency of vitamin D, calcium, and phosphorus.

While performing an assessment, the nurse notes that a client has soft subcutaneous nodules along the extensor tendons of the fingers. Which disorder does this client most likely have? A. Osteoarthritis B. Rheumatoid arthritis C. Gout D. Paget disease

B. Soft nodules that occur within or along tendons that provide extensor function to joints are characteristic of rheumatoid arthritis. The nodules of osteoarthritis are hard and painless and consist of bony overgrowth. The nodules of gout are hard and lie within and immediately adjacent to the joint capsule. Nodules are not characteristic of gout.

A young student is brought to the school nurse after falling off a swing. The nurse is documenting that the child has bruising on the lateral aspect of the right arm. What term will the nurse use to describe bruising on the skin in documentation? A. Telangiectasias B. Ecchymoses C. Purpura D. Urticaria

B. Telangiectasias consist of red marks on the skin caused by stretching of superficial blood vessels. Ecchymoses are bruises, and purpura consists of pinpoint hemorrhages into the skin. Urticaria is wheals or hives.

A presurgical client asks, Why will I go to the postanesthesia care unit (PACU) instead of just going straight up to the postsurgical unit? Which response by the nurse would be best? A. It allows recovery from anesthesia in a stimulating environment to facilitate awakening and reorientation. B. It allows us to observe you until you're oriented and have stable vital signs and no complications. C. The medical-surgical unit is short of beds, and the PACU is an excellent place to triage clients. D. The surgeon likely will need to reinforce or alter the your incision in the hours following surgery.

B. The PACU provides care for the client while the client recovers from the effects of anesthesia. The client must be oriented, have stable vital signs, and show no evidence of hemorrhage or other complications. The PACU does allow the client to recover from anesthesia, but the environment is calm and quiet, as clients are initially disoriented and confused as they begin to awaken and reorient. Clients are not usually placed in the medical-surgical unit for recovery and, although hospitals are occasionally short of beds, the PACU is not used for client triage. Incisions are very rarely modified in the immediate postoperative period.

The surgeon's preoperative assessment of a client finds that the client is at a high risk for venous thromboembolism. Once the client is admitted to the postsurgical unit, what intervention should the nurse prioritize to reduce the client's risk of this complication? A. Maintain the head of the bed at 45 degrees or higher. B. Encourage early ambulation. C. Encourage oral fluid intake. D. Perform passive range-of-motion exercises every 8 hours.

B. The benefits of early ambulation and leg exercises in preventing DVT cannot be overemphasized, and these activities are recommended for all clients, regardless of their risk. Increasing the head of the bed is not effective. Ambulation is superior to passive range-of-motion exercises. Fluid intake is important, but is less protective than early ambulation.

A client recently received lip and tongue piercings and subsequently developed a superinfection of candidiasis from the antibacterial mouthwash. What would the nurse recommend for this client? A. Move the piercing back and forth during washing. B. Use an antifungal mouthwash or salt water. C. Use a soft-bristled toothbrush. D. Rinse the mouth after eating food.

B. The client can substitute an antifungal mouthwash or salt water if a superinfection of candidiasis develops from the antibacterial mouthwash. A soft-bristled toothbrush should be used to avoid additional oral injury, but it is not the recommended solution for this problem. After eating, the client should rinse the mouth for 30 to 60 seconds with an antifungal mouthwash or salt water. Moving the jewelry at the piercing area back and forth during washing helps clean the pierced tract but does not solve the problem.

A client has just been told that he has deep malignant melanoma. The nurse caring for this client should anticipate that the client will undergo what treatment? A. Chemotherapy B. Immunotherapy C. Wide excision D. Radiation therapy

C. Wide excision is the primary treatment for malignant melanoma, which removes the entire lesion and determines the level and staging. Chemotherapy may be used after the melanoma is excised. Immunotherapy is experimental and radiation therapy is palliative.

The nurse admits a client to the postanesthesia care unit with a blood pressure of 132/90 mm Hg and a pulse of 68 beats per minute. After 30 minutes, the client's blood pressure is 94/47 mm Hg, and the pulse is 110. The nurse documents that the client's skin is cold, moist, and pale. This client is showing signs of what potential issue? A. Hypothermia B. Hypovolemic shock C. Neurogenic shock D. Malignant hyperthermia

B. The client is exhibiting symptoms of hypovolemic shock; therefore, the nurse should notify the client's health care provider and anticipate orders for fluid and/or blood product replacement. Neurogenic shock does not normally result in tachycardia, and malignant hyperthermia would rarely present at this stage in the operative experience. Hypothermia does not cause hypotension and tachycardia.

The nurse is caring for an unconscious trauma client who needs emergency surgery. The client has an adult child, is legally divorced, and is planning to marry a partner in a few weeks. The client's parents are at the hospital with the other family members. The health care provider has explained the need for surgery, the procedure to be done, and the risks to the child, the parents, and the partner. Who should be asked to sign the surgery consent form? A. The partner B. The child C. The health care provider, acting as a surrogate D. The client's father

B. The client personally signs the consent if of legal age and mentally capable. Permission is otherwise obtained from a surrogate, who most often is a responsible family member (preferably next of kin) or legal guardian. In this instance, the child would be the appropriate person to ask to sign the consent form as the child is the closest relative at the hospital. The partner is not legally related to the client as the marriage has not yet taken place. The father would only be asked to sign the consent if no children were present to sign. The health care provider would not sign if family members were available.

The nurse is caring for a client who lives alone and had a total knee replacement. An appropriate nursing diagnosis for the client is: A. Risk for avascular necrosis of the joint B. Risk for ineffective therapeutic regimen management C. Disturbed body image D. Situational low self-esteem

B. The client without adequate support and resources is at risk for ineffective therapeutic regimen management. A total knee replacement may be used to treat avascular necrosis. While an orthopedic client is at risk for disturbed body image and situational low self-esteem, there is no evidence that these exist for this client.

While assessing a client who has had knee replacement surgery, the nurse notes that the client has developed a hematoma at the surgical site. The affected leg has a decreased pedal pulse. What would be the priority nursing diagnosis for this client? A. Unilateral Neglect Related to Hematoma B. Risk for Ineffective Peripheral Tissue Perfusion C. Risk for Infection D. Disturbed Kinesthetic Sensory Perception

B. The hematoma may cause an interruption of tissue perfusion. There is also an associated risk for infection because of the hematoma, but impaired perfusion is a more acute threat. Unilateral neglect and impaired sensation are lower priorities than tissue perfusion

A client with a right tibial fracture is being discharged home after having a cast applied. What instruction should the nurse provide in relationship to the client's cast care? A. Cover the cast with a blanket until the cast dries. B. Keep your right leg elevated above heart level. C. Use a clean object to scratch itches inside the cast. D. A foul smell from the cast is normal after the first few days.

B. The leg should be elevated to promote venous return and prevent edema. The cast shouldn't be covered while drying because this will cause heat buildup and prevent air circulation. No foreign object should be inserted inside the cast because of the risk of cutting the skin and causing an infection. A foul smell from a cast is never normal and may indicate an infection.

The nurse is caring for a client who is postoperative day 2 following a colon resection. While turning the client, wound dehiscence with evisceration occurs. What should be the nurse's first response? A. Return the client to the previous position and call the health care provider. B. Place saline-soaked sterile dressings on the wound. C. Assess the client's blood pressure and pulse. D. Pull the dehiscence closed using gloved hands.

B. The nurse should first place saline-soaked sterile dressings on the open wound to prevent tissue drying and possible infection. Then the nurse should call the health care provider and take the client's vital signs. The dehiscence needs to be surgically closed, so the nurse should never try to close it.

A nurse is doing a shift assessment on a group of clients after first taking report. An older adult client is having the second dose of IV antibiotics for a diagnosis of pneumonia. The nurse notices a new rash on the client's chest. The nurse should ask what priority question regarding the presence of a reddened rash? A. Is the rash worse at a particular time or season? B. Are you allergic to any foods or medication? C. Are you having any loss of sensation in that area? D. Is your rash painful?

B. The nurse should suspect an allergic reaction to the antibiotic therapy. Allergies can be a significant threat to the client's immediate health, thus questions addressing this possibility would be prioritized over those addressing sensation. Asking about previous rashes is important, but this should likely be framed in the context of an allergy assessment.

A client is being treated for acne vulgaris. What contributes to follicular irritation? A. stress B. overproduction of sebum C. chocolate D. potato chips

B. The overproduction of sebum provides an ideal environment for bacterial growth within the irritated follicle. The follicle becomes further distended and irritated, causing a raised papule in the skin.

A client's coronary artery bypass graft has been successful, and discharge planning is underway. When planning the client's subsequent care, the nurse should know that the postoperative phase of perioperative nursing ends at what time? A. When the client is returned to the room after surgery B. When a follow-up evaluation in the clinical or home setting is done C. When the client is fully recovered from all effects of the surgery D. When the family becomes partly responsible for the client's care

B. The postoperative phase begins with the admission of the client to the PACU and ends with a follow-up evaluation in the clinical setting or home.

The nurse is providing care for a client who has had a below-the-knee amputation. The nurse enters the client's room and finds the client resting in bed with the residual limb supported on a pillow. What is the nurse's most appropriate action? A. Inform the surgeon of this finding. B. Explain the risks of flexion contracture to the client. C. Transfer the client to a sitting position. D. Encourage the client to perform active ROM exercises with the residual limb.

B. The residual limb should not be placed on a pillow because a flexion contracture of the hip may result. There is no acute need to contact the client's surgeon. Encouraging exercise or transferring the client does not address the risk of flexion contracture.

A client has just begun been receiving skeletal traction and the nurse is aware that muscles in the client's affected limb are spastic. How does this change in muscle tone affect the client's traction prescription? A. Traction must temporarily be aligned in a slightly different direction. B. Extra weight is needed initially to keep the limb in proper alignment. C. A lighter weight should be initially used. D. Weight will temporarily alternate between heavier and lighter weights.

B. The traction weights applied initially must overcome the shortening spasms of the affected muscles. As the muscles relax, the traction weight is reduced to prevent fracture dislocation and to promote healing. Weights never alternate between heavy and light.

A school nurse has sent home four children who show evidence of pediculosis capitis. What is an important instruction the nurse should include in the note being sent home to parents? A. The child's scalp should be monitored for 48 to 72 hours before starting treatment. B. Nits may have to be manually removed from the child's hair shafts. C. The disease is self-limiting and symptoms will abate within 1 week. D. Efforts should be made to improve the child's level of hygiene.

B. Treatment for head lice should begin promptly and may require manual removal of nits following medicating shampoo. Head lice are not related to a lack of hygiene. Treatment is necessary because the condition will not likely resolve spontaneously within 1 week.

Which is an appropriate nursing intervention in the care of the client with osteoarthritis? A. Avoid the use of topical analgesics B. Encourage weight loss and an increase in aerobic activity C. Assess for gastrointestinal complications associated with COX-2 inhibitors D. Provide an analgesic after exercise

B. Weight loss and an increase in aerobic activity such as walking, with special attention to quadriceps strengthening, are important approaches to pain management. Clients should be assisted to plan their daily exercise at a time when the pain is least severe, or plan to use an analgesic, if appropriate, before an exercise session. Gastrointestinal complications, especially bleeding, are associated with the use of nonsteroidal anti-inflammatory drugs. Topical analgesics such as capsaicin and methyl salicylate may be used for pain management.

The nurse is preparing a client for surgery. The client reports being nervous and not really understanding the surgical procedure or its purpose. What is the most appropriate action for the nurse to take? A. Have the client sign the informed consent and place it in the chart. B. Call the health care provider to review the procedure with the client. C. Explain the procedure clearly to the client and the family. D. Provide the client with a pamphlet explaining the procedure.

B. While the nurse may ask the client to sign the consent form and witness the signature, it is the surgeon's responsibility to provide a clear and simple explanation of what the surgery will entail prior to the client giving consent. The surgeon must also inform the client of the benefits, alternatives, possible risks, complications, disfigurement, disability, and removal of body parts as well as what to expect in the early and late postoperative periods. The nurse clarifies the information provided, and, if the client requests additional information, the nurse notifies the health care provider. The consent form should not be signed until the client understands the procedure that has been explained by the surgeon. The provision of a pamphlet will benefit teaching the client about the surgical procedure, but will not substitute for the information provided by the health care provider.

A client is admitted to the orthopedic unit with a fractured femur after a motorcycle accident. The client has been placed in traction until the femur can be rodded in surgery. For what early complication(s) should the nurse monitor this client? Select all that apply. A. Systemic infection B. Complex regional pain syndrome C. Deep vein thrombosis D. Compartment syndrome E. Fat embolism

C, D, E. Early complications include shock, fat embolism, compartment syndrome, and venous thromboemboli (deep vein thrombosis [DVT], pulmonary embolism [PE]). Infection and complex regional pain syndrome are later complications of fractures.

Nursing students are reviewing information about various types of skin lesions. The students demonstrate understanding of the information when they identify which of the following as a vascular lesion? A. Pustule B. Cyst C. Spider angioma D. Erosion

C. A spider angioma is a vascular lesion. Erosion is a secondary lesion. Pustules and cysts are classified as primary skin lesions.

The clinic nurse is caring for a client with an injured body part that does not require rigid immobilization. What method of immobilization would the nurse expect the health care provider to use on a short-term basis? A. Brace B. Skin traction C. Splint D. Cast

C. A splint immobilizes and supports an injured body part in a functional position and is used when the condition does not require rigid immobilization, causes a large degree of swelling, or requires special skin treatment. Casts and traction provide rigid immobilization. A brace provides support, controls movement, and prevents additional injury for more long-term use.

A nurse is educating a client with gout about lifestyle modifications that can help control the signs and symptoms of the disease. What recommendation should the nurse make? A. Ensuring adequate rest B. Limiting exposure to sunlight C. Limiting intake of alcohol D. Smoking cessation

C. Alcohol and red meat can precipitate an acute exacerbation of gout. Each of the other listed actions is consistent with good health, but none directly addresses the factors that exacerbate gout.

Which orthopedic surgery is done to correct and align a fracture after surgical dissection and exposure of the fracture? A. Arthrodesis B. Joint arthroplasty C. Open reduction D. Total joint arthroplasty

C. An open reduction is the correction and alignment of the fracture after surgical dissection and exposure of the fracture. Arthrodesis is immobilizing fusion of a joint. A joint arthroplasty or replacement is the replacement of joint surfaces with metal or synthetic materials. A total joint arthroplasty is the replacement of both the articular surfaces within a joint with metal or synthetic materials.

A nurse is providing care for a client who has psoriasis. Following the appearance of skin lesions, the nurse should prioritize what assessment? A. Assessment of the client's stool for evidence of intestinal sloughing B. Assessment of the client's apical heart rate for dysrhythmias C. Assessment of the client's joints for pain and decreased range of motion D. Assessment for cognitive changes resulting from neurologic lesions

C. Asymmetric rheumatoid factor-negative arthritis of multiple joints occurs in up to 42% of people with psoriasis, most typically after the skin lesions appear. The most typical joints affected include those in the hands or feet, although sometimes larger joints such as the elbow, knees, or hips may be affected. As such, the nurse should assess for this musculoskeletal complication. GI, cardiovascular, and neurologic function are not affected by psoriasis.

The clinic nurse is doing a preoperative assessment of a client who will be undergoing outpatient cataract surgery with lens implantation in 1 week. While taking the client's medical history, the nurse notes that this client had a kidney transplant 8 years ago and that the client is taking immunosuppressive drugs. For what is this client at increased risk when having surgery? A. Rejection of the kidney B. Rejection of the implanted lens C. Infection D. Adrenal storm

C. Because clients who are immunosuppressed are highly susceptible to infection, great care is taken to ensure strict asepsis. The client is unlikely to experience rejection or adrenal storm.

The intraoperative nurse knows that the client's emotional state can influence the outcome of the surgical procedure. How should the nurse best address this? A. Teach the client strategies for distraction. B. Pair the client with another client who has better coping strategies. C. Incorporate cultural and religious considerations, as appropriate. D. Give the client antianxiety medication.

C. Because the client's emotional state remains a concern, the care initiated by preoperative nurses is continued by the intraoperative nursing staff that provides the client with information and reassurance. The nurse supports coping strategies and reinforces the client's ability to influence outcomes by encouraging active participation in the plan of care incorporating cultural, ethnic, and religious considerations, as appropriate. Buddying a client is normally inappropriate and distraction may or may not be effective. Nonpharmacologic measures should be prioritized.

A clinic nurse is caring for a client with a history of osteoporosis. What diagnostic test will best allow the care team to assess the client's risk of fracture? A. Arthrography B. Bone scan C. Bone densitometry D. Arthroscopy

C. Bone densitometry is used to detect bone density and can be used to assess the risk of fracture in osteoporosis. Arthrography is used to detect acute or chronic tears of joint capsule or supporting ligaments. Bone scans can be used to detect metastatic and primary bone tumors, osteomyelitis, certain fractures, and aseptic necrosis. Arthroscopy is used to visualize a joint.

A nurse is reviewing the pathophysiology that may underlie a client's decreased bone density. What hormone should the nurse identify as inhibiting bone resorption and promoting bone formation? A. Estrogen B. Parathyroid hormone (PTH) C. Calcitonin D. Progesterone

C. Calcitonin inhibits bone resorption and promotes bone formation, estrogen inhibits bone breakdown, and parathyroid increases bone resorption. Estrogen, which inhibits bone breakdown, decreases with aging. Parathyroid hormone (PTH) increases with aging, increasing bone turnover and resorption. Progesterone is the major naturally occurring human progestogen and plays a role in the female menstrual cycle.

The nurse is caring for a client who has returned to the postsurgical unit following abdominal surgery. The client is unable to ambulate and is now refusing to wear external pneumatic compression stockings. The nurse should explain that refusing to wear external pneumatic compression stockings increases the risk of which postsurgical complication? A. Sepsis B. Infection C. Pulmonary embolism D. Hematoma

C. Clients who have surgery that limits mobility are at an increased risk for pulmonary embolism secondary to deep vein thrombosis. The use of external pneumatic compression stockings significantly reduces the risk by increasing venous return to the heart and limiting blood stasis. The risk of infection or sepsis would not be affected by external pneumatic compression stockings. A hematoma or bruise would not be affected by external pneumatic compression stockings unless the stockings were placed directly over the hematoma.

A patient is hospitalized with a severe case of gout. The patient has gross swelling of the large toe and rates pain a 10 out of 10. With a diagnosis of gout, what should the laboratory results reveal? A. Glucosuria B. Hyperproteinuria C. Hyperuricemia D. Ketonuria

C. Gout is caused by hyperuricemia (increased serum uric acid).

A clinic nurse is caring for a client with suspected gout. While describing the pathophysiology of gout to the client, what should the nurse explain? A. Autoimmune processes in the joints B. Chronic metabolic acidosis C. Increased uric acid levels D. Unstable serum calcium levels

C. Gout is caused by hyperuricemia (increased serum uric acid). Gout is not categorized as an autoimmune disease and it does not result from metabolic acidosis or unstable serum calcium levels.

An older adult resident of a long-term care facility has been experiencing generalized pruritus that has become more severe in recent weeks. What intervention should the nurse add to this resident's plan of care? A. Avoid the application of skin emollients B. Apply antibiotic ointment, as prescribed, following baths C. Avoid using hot water during the client's baths D. Administer acetaminophen four times daily as prescribed

C. If baths have been prescribed, the client is reminded to use tepid (not hot) water and to shake off the excess water and blot between intertriginous areas (body folds) with a towel. Skin emollients should be applied to reduce pruritus. Acetaminophen and antibiotics do not reduce pruritus.

A nurse is working with a family whose 5-year-old child has been diagnosed with impetigo. What educational intervention should the nurse include in this family's care? A. Ensuring that the family knows that impetigo is not contagious B. Teaching about the safe and effective use of topical corticosteroids C. Teaching about the importance of maintaining high standards of hygiene D. Ensuring that the family knows how to safely burst the child's vesicles

C. Impetigo is associated with unhygienic conditions; educational interventions to address this are appropriate. The disease is contagious, thus vesicles should not be manually burst. Because of the bacterial etiology, corticosteroids are ineffective.

A client is brought to the emergency department after injuring the right arm in a bicycle accident. The orthopedic surgeon tells the nurse that the client has a greenstick fracture of the arm. What does this mean? A. Bone fragments are separated at the fracture line. B. The fracture results from an underlying bone disorder. C. One side of the bone is broken and the other side is bent. D. The fracture line extends through the entire bone substance.

C. In a greenstick fracture, one side of the bone is broken and the other side is bent. A greenstick fracture also may refer to an incomplete fracture in which the fracture line extends only partially through the bone substance and doesn't disrupt bone continuity completely. (Other terms for greenstick fracture are willow fracture and hickory-stick fracture.) The fracture line extends through the entire bone substance in a complete fracture. A fracture that results from an underlying bone disorder, such as osteoporosis or a tumor, is a pathologic fracture, which typically occurs with minimal trauma. Bone fragments are separated at the fracture line in a displaced fracture.

A nurse is performing the health history and physical assessment of a client who has a diagnosis of rheumatoid arthritis (RA). What assessment finding is most consistent with the clinical presentation of RA? A. Cool joints with decreased range of motion B. Signs of systemic infection C. Joint stiffness lasting longer than 1 hour, especially in the morning D. Visible atrophy of the knee and shoulder joints

C. In addition to joint pain and swelling, another classic sign of RA is joint stiffness lasting longer than 1 hour, especially in the morning. Joints are typically swollen, not atrophied, and systemic infection does not accompany the disease. Joints are often warm rather than cool.

The ED nurse is caring for an 11-year-old brought in by ambulance after having been hit by a car. The child's parents are thought to be en route to the hospital but have not yet arrived. No other family members are present, and attempts to contact the parents have been unsuccessful. The child needs emergency surgery to survive. How should the need for informed consent be addressed? A. A social worker should temporarily sign the informed consent. B. Consent should be obtained from the hospital's ethics committee. C. Surgery should be done without informed consent. D. Surgery should be delayed until the parents arrive.

C. In an emergency, it may be necessary for the surgeon to operate as a lifesaving measure without the client's informed consent. However, every effort must be made to contact the client's family. In such a situation, contact can be made by electronic means. In this scenario, the surgery is considered lifesaving, and the parents are on their way to the hospital and not available. A delay would be unacceptable. Neither a social worker nor a member of the ethics committee may sign.

A client with chronic osteomyelitis has undergone 6 weeks of antibiotic therapy. The wound appearance has not improved. What action would the nurse anticipate to promote healing? A. Wound irrigation B. Wound packing C. Surgical debridement D. Vitamin supplements

C. In chronic osteomyelitis, surgical debridement is used when the wound fails to respond to antibiotic therapy. Wound packing, vitamin supplements, and wound irrigation are not the standard of care when treating chronic osteomyelitis.

A client is admitted to the orthopedic unit in skeletal traction for a fractured proximal femur. Which explanation should the nurse give the client about skeletal traction? A. Skeletal traction temporarily stabilizes the fracture before surgery. B. Weights are attached to the leg using a boot. C. Traction involves passing a pin through the bone. D. Light weights must be used with skeletal traction.

C. In skeletal traction, a metal pin or wire is passed through the bone and traction is then applied using ropes and weights attached to the pins. Skin traction, not skeletal traction, stabilizes the fracture until surgery is performed and uses a boot or Velcro to attach the ropes and weights to the leg. Skeletal traction is used when greater weight (11 to 18 kg [25 to 40 lb]) is needed to achieve the therapeutic effect.

A 68-year-old client with a history of rheumatic disease has persistent swelling, no stiffness, and full range of motion to his left knee after an injury sustained several months ago. X-rays reveal no fracture of the extremity. Which factor is the most likely cause of the client's continued swelling? A. Degradation of cartilage B. Aging C. An inflammation process D. Reinjury not seen on x-ray results

C. Inflammation is a complex physiologic process mediated by the immune system that occurs in response to harmful stimuli such as damaged cells. Inflammation is meant to protect the body from insult by removing the triggering antigen or event. But sometimes the immune system deviates from a normal response. Instead of a resolution of swelling after the triggering event has subsided, a proliferation of newly formed synovial tissue infiltrated with inflammatory cells (pannus) occurs. Degradation in rheumatic diseases causes inflammation, bone stiffening, and cartilage failure. Degradation may be the result of genetic or hormonal influences, mechanical factors, or prior joint damage. For this client, because of the full range of motion (ROM), no reported prior joint damage, and no stiffness, degradation is less likely. Swelling is not a normal process of aging. Reinjury not seen on x-ray is a possibility but unlikely because the client has full ROM.

The nurse teaches the client who demonstrates herpes zoster (shingles) that A. no known medications affect the course of shingles. B. once a client has had shingles, they will not have it a second time. C. the infection results from reactivation of the chickenpox virus. D. a person who has had chickenpox can contract it again upon exposure to a person with shingles.

C. It is assumed that herpes zoster represents a reactivation of the latent varicella (chickenpox) virus and reflects lowered immunity. It is believed that the varicella zoster virus lies dormant inside nerve cells near the brain and spinal cord and is reactivated with weakened immune systems and cancers. A person who has had chickenpox is immune and therefore not at risk of infection after exposure to clients with herpes zoster. Some evidence shows that infection is arrested if oral antiviral agents are administered within 24 hours of the initial eruption.

The nurse is checking the informed consent for an older adult client who requires surgery and who has recently been diagnosed with Alzheimer disease. When obtaining informed consent, who is legally responsible for signing? A. The client's next of kin B. The client's spouse C. The client D. The surgeon

C. Just because a client has been diagnosed with Alzheimer disease does not mean that the client is not competent to provide informed consent, although many Alzheimer clients are ultimately declared to be legally incompetent. Because there is no evidence that this client is legally incompetent, the client would be required to personally provide informed consent.

The nurse is caring for a 78-year-old client who has had an outpatient cholecystectomy. The nurse is getting the client up for the first walk postoperatively. To decrease the potential for orthostatic hypotension and consequent falls, what should the nurse have the client do? A. Sit in a chair for 10 minutes prior to ambulating. B. Drink plenty of fluids to increase circulating blood volume. C. Stand upright for 2 to 3 minutes prior to ambulating. D. Perform range-of-motion exercises for each joint.

C. Older adults are at an increased risk for orthostatic hypotension secondary to age-related changes in vascular tone. The client should sit up and then stand for 2 to 3 minutes before ambulating to alleviate orthostatic hypotension. The nurse should assess the client's ability to mobilize safely, but full assessment of range of motion in all joints is not normally necessary. Sitting in a chair and increasing fluid intake are insufficient to prevent orthostatic hypotension and consequent falls.

A client has been diagnosed with shingles. Which of the following medication classifications will reduce the severity and prevent development of new lesions? A. Antipyretics B. Analgesics C. Antiviral D. Corticosteroids

C. Oral acyclovir (Zovirax), when taken within 48 hours of the appearance of symptoms, reduces their severity, and prevents the development of additional lesions. Corticosteroids, analgesics,, and antipyretics are not used for this purpose.

A new client has come to the dermatology clinic to be assessed for a reddened rash on the abdomen. For what diagnostic test should the nurse prepare the client to identify the causative allergen? A. Skin scrapings B. Skin biopsy C. Patch testing D. Tzanck smear

C. Patch testing is performed to identify substances to which the client has developed an allergy. Skin scrapings are done for suspected fungal lesions. A skin biopsy is completed to rule out malignancy and to establish an exact diagnosis of skin lesions. A Tzanck smear is used to examine cells from blistering skin conditions, such as herpes zoster.

The nurse recognizes which condition is associated with emboli to the skin? A. Telangiectasia B. Spider angioma C. Petechiae D. Ecchymosis

C. Petechiae are small, round red or purple macules and are associated with bleeding tendencies or emboli to the skin. Spider angioma is associated with liver disease, pregnancy, and vitamin B deficiency. Ecchymosis is associated with trauma and bleeding tendencies. Telangiectasia is associated with venous pressure states.

A new client presents at the clinic and the nurse performs a comprehensive health assessment. The nurse notes that the client's fingernail surfaces are pitted. The nurse should suspect the presence of what health problem? A. Eczema B. Systemic lupus erythematosus (SLE) C. Psoriasis D. Chronic obstructive pulmonary disease (COPD)

C. Pitted surface of the nails is a definite indication of psoriasis. Pitting of the nails does not indicate eczema, SLE, or COPD.

The nurse is caring for an older adult client in the postanesthesia care unit. The client begins to awaken and responds to their name, but is confused, restless, and agitated. Which principle should guide the nurse's subsequent assessment? A. Postoperative confusion in older adults is an indication of impaired oxygenation or possibly a stroke during surgery. B. Confusion, restlessness, and agitation are expected postoperative findings in older adults, and they will diminish in time. C. Postoperative confusion is common in the older adult client, but it could also indicate a significant blood loss. D. Confusion, restlessness, and agitation indicate an underlying cognitive deficit such as dementia.

C. Postoperative confusion is common in the older adult client, but it could also indicate blood loss and the potential for hypovolemic shock; it is a critical symptom for the nurse to identify. Despite being common, it is not considered to be an expected finding. Postoperative confusion is an indication of an oxygen problem or possibly a stroke during surgery, but blood loss is more likely. A new onset of confusion, restlessness, and agitation does not necessarily suggest an underlying cognitive disorder.

The nurse is caring for a client on the medical-surgical unit postoperative day 5. During each client assessment, the nurse evaluates the client for infection. Which of the following would be most indicative of infection? A. Presence of an indwelling urinary catheter B. Oral temperature of 99.5°F (37.5°C) C. Red, warm, tender incision D. White blood cell (WBC) count of 8,000/mL

C. Redness, warmth, and tenderness in the incision area should lead the nurse to suspect a postoperative infection. The presence of any invasive device predisposes a client to infection, but by itself does not indicate infection. An oral temperature of 99.5°F may not signal infection in a postoperative client because of the inflammatory process. A normal WBC count ranges from 4,000 to 10,000/mL.

A nurse's assessment reveals that a client has shoulders that are not level and one prominent scapula that is accentuated by bending forward. The nurse should expect to read about which health problem in the client's electronic health record? A. Lordosis B. Kyphosis C. Scoliosis D. Muscular dystrophy

C. Scoliosis is evidenced by an abnormal lateral curve in the spine, shoulders that are not level, an asymmetric waistline, and a prominent scapula, accentuated by bending forward. Lordosis is the curvature in the lower back; kyphosis is an exaggerated curvature of the upper back. This finding is not suggestive of muscular dystrophy.

A nurse is leading a health promotion workshop that is focusing on cancer prevention. What action is most likely to reduce participants' risks of basal cell carcinoma (BCC)? A. Teaching participants to improve their overall health through nutrition B. Encouraging participants to identify their family history of cancer C. Teaching participants to limit their sun exposure D. Teaching participants to control exposure to environmental and occupational radiation

C. Sun exposure is the best known and most common cause of BCC. BCC is not commonly linked to general health debilitation, family history, or radiation exposure.

A client presents at the dermatology clinic with suspected herpes simplex. The nurse knows to prepare what diagnostic test for this condition? A. Skin biopsy B. Patch test C. Tzanck smear D. Examination with a Wood light

C. The Tzanck smear is a test used to examine cells from blistering skin conditions, such as herpes zoster, varicella, herpes simplex, and all forms of pemphigus. The secretions from a suspected lesion are applied to a glass slide, stained, and examined. This is not accomplished by biopsy, patch test, or Wood light.

A public health nurse is participating in a health promotion campaign that has the goal of improving outcomes related to skin cancer in the community. What action has the greatest potential to achieve this goal? A. Educating participants about the relationship between general health and the risk of skin cancer B. Educating participants about treatment options for skin cancer C. Educating participants about the early signs and symptoms of skin cancer D. Educating participants about the health risks associated with smoking and assisting with smoking cessation

C. The best hope of decreasing the incidence of skin cancer lies in educating clients about the early signs. There is a relationship between general health and skin cancer, but teaching individuals to identify the early signs and symptoms is more likely to benefit overall outcomes related to skin cancer. Teaching about treatment options is not likely to have a major effect on outcomes of the disease. Smoking is not among the major risk factors for skin cancer.

The classic lesions of impetigo manifest as A. comedones in the facial area. B. patches of grouped vesicles on red and swollen skin. C. honey-yellow crusted lesions on an erythematous base. D. abscess of skin and subcutaneous tissue.

C. The classic lesions of impetigo are honey-crusted lesions on an erythematous base. Comedones in the facial area are representative of acne. A carbuncle is an abscess of skin and subcutaneous tissue. Herpes zoster is exhibited by patches of grouped vesicles on red and swollen skin.

In anticipation of a client's scheduled surgery, the nurse is teaching the client to perform deep breathing and coughing to use postoperatively. What action should the nurse teach the client? A. The client should take three deep breaths and cough hard three times, at least every 15 minutes for the immediate postoperative period. B. The client should take three deep breaths and exhale forcefully and then take a quick short breath and cough from deep in the lungs. C. The client should take a deep breath in through the mouth and exhale through the mouth, take a short breath, and cough from deep in the lungs. D. The client should rapidly inhale, hold for 30 seconds or as long as possible, and exhale slowly.

C. The client assumes a sitting position to enhance lung expansion. The nurse then demonstrates how to take a deep, slow breath and exhale slowly. After the client practices deep breathing several times, the nurse instructs the client to breathe deeply, exhale through the mouth, take a short breath, and cough from deep in the lungs.

Osteoarthritis is known as a disease that A. requires early treatment because most of the damage seems to occur early in the course of the disease. B. affects the cartilaginous joints of the spine and surrounding tissues. C. is the most common and frequently disabling of joint disorders. D. affects young males.

C. The functional impact of osteoarthritis on quality of life, especially for elderly clients, is often ignored. Reiter syndrome is a spondyloarthropathy that affects young adult males and is characterized primarily by urethritis, arthritis, and conjunctivitis. Psoriatic arthritis, characterized by synovitis, polyarthritis, and spondylitis, requires early treatment because of early damage caused by disease. Ankylosing spondylitis affects the cartilaginous joints of the spine and surrounding tissues, making them rigid and decreasing mobility; it is usually diagnosed in the second or third decade of life.

The perioperative nurse is constantly assessing the surgical client for signs and symptoms of complications of surgery. Which symptom should first signal to the nurse the possibility that the client is developing malignant hyperthermia? A. Increased temperature B. Oliguria C. Tachycardia D. Hypotension

C. The initial symptoms of malignant hyperthermia are related to cardiovascular and musculoskeletal activity. Tachycardia (heart rate greater than 150 beats per minute) is often the earliest sign. Oliguria, hypotension, and increased temperature are later signs of malignant hyperthermia.

Which joint is most commonly affected in gout? A. Tarsal area B. Ankle C. Metatarsophalangeal D. Knee

C. The metatarsophalangeal joint of the big toe is the most commonly affected joint (90% of clients); this is referred to as podagra. The wrists, fingers, and elbows are less commonly affected. The tarsal area, ankle, and knee are not the most commonly affected in gout.

A client diagnosed with a stasis ulcer has been hospitalized. There is an order to change the dressing and provide wound care. Which activity should the nurse first perform when providing wound care? A. Assess the drainage in the dressing. B. Slowly remove the soiled dressing. C. Perform hand hygiene. D. Don nonlatex gloves.

C. The nurse and health care provider must adhere to standard precautions and wear gloves when inspecting the skin or changing a dressing. Use of standard precautions and proper disposal of any contaminated dressing is carried out according to Occupational Safety and Health Administration (OSHA) regulations. Hand hygiene must precede other aspects of wound care.

A nurse is caring for a client who underwent a total hip replacement. What should the nurse and other caregivers do to prevent dislocation of the new prosthesis? A. Use measures other than turning to prevent pressure ulcers. B. Keep the affected leg in a position of adduction. C. Prevent internal rotation of the affected leg. D. Keep the hip flexed by placing pillows under the client's knee.

C. The nurse and other caregivers should prevent internal rotation of the affected leg. However, external rotation and abduction of the hip will help prevent dislocation of a new hip joint. Postoperative total hip replacement clients may be turned onto the unaffected side. The hip may be flexed slightly, but it shouldn't exceed 90 degrees. Maintenance of flexion isn't necessary.

The results of a nurse's musculoskeletal examination show an increase in the lumbar curvature of the spine. The nurse should recognize the presence of what health problem? A. Osteoporosis B. Kyphosis C. Lordosis D. Scoliosis

C. The nurse documents the spinal abnormality as lordosis. Lordosis is an increase in lumbar curvature of the spine. Kyphosis is an increase in the convex curvature of the spine. Scoliosis is a lateral curvature of the spine. Osteoporosis is the significant loss of bone mass and strength with an increased risk for fracture.

Which of the following information regarding the transmission of lice would the nurse identify as a myth? A. Lice need to be removed from the hair with a fine comb. B. Lice can be spread by sharing of hats, caps, and combs. C. Lice can jump from one individual to another. D. Lice can be seen without magnification.

C. The nurse is correct to identify that lice cannot jump from one individual to another. Direct contact is needed for transmission. The other options are correct.

The nurse is assisting an older adult client with performing activities of daily living (ADL) and is brushing her hair. What does the nurse document as an abnormal finding? A. Dry, brittle hair B. Sparse hair, white in color C. Pearly white substance that is attached to the hair shaft that is not removed with brushing D. Knots in hair when brushed

C. The pearly white substance that is attached to the hair shaft is indicative of nits or head lice and should be reported to the physician so treatment can be administered. The other findings are not abnormal in the older adult client

The presence of crystals in synovial fluid obtained from arthrocentesis is indicative of A. degeneration. B. inflammation. C. gout. D. infection.

C. The presence of crystals is indicative of gout, whereas the presence of bacteria is indicative of infective arthritis.

A client with squamous cell carcinoma has been scheduled for treatment of this malignancy. The nurse should anticipate that treatment for this type of cancer will primarily consist of what intervention? A. Chemotherapy B. Radiation therapy C. Surgical excision D. Biopsy of sample tissue

C. The primary goal of surgical management of squamous cell carcinoma is to remove the tumor entirely. Radiation therapy is reserved for older clients, because x-ray changes may be seen after 5 to 10 years, and malignant changes in scars may be induced by irradiation 15 to 30 years later. Obtaining a biopsy would not be a goal of treatment; it may be an assessment. Chemotherapy and radiation therapy are generally reserved for clients who are not surgical candidates.

The nurse is preparing a client for surgery prior to her hysterectomy without oophorectomy. The nurse is witnessing the client's signature on a consent form. Which comment by the client would best indicate informed consent? A. I know I'll be fine because the health care provider has done this procedure hundreds of times. B. I know I'll have pain after the surgery but they'll do their best to keep it to a minimum. C. The health care provider is going to remove my uterus and told me about the risk of bleeding. D. Because the health care provider isn't taking my ovaries, I'll still be able to have children.

C. The surgeon must explain the procedure and inform the client of the benefits, alternatives, possible risks, complications, disfigurement, disability, and removal of body parts as well as what to expect in the early and late postoperative periods. The nurse clarifies the information provided, and, if the client requests additional information, the nurse notifies the health care provider. In the correct response, the client is able to tell the nurse what will occur during the procedure and the associated risks. This indicates the client has a sufficient understanding of the procedure to provide informed consent. Clarification of information given may be necessary, but no additional information should be given. Confidence in the health care provider's experience is good, but does not indicate an understanding of the procedure or its risks. Also, the client's statement, I know I'll be fine, indicates a lack of understanding of the risks of the procedure. Knowledge that the client will experience postoperative pain is good, but the client also needs to understand the procedure itself. Understanding that this procedure will not involve removal of the ovaries is good, but the client's belief that childbearing will still be possible is incorrect.

The circulating nurse will be participating in a 78-year-old client's total hip replacement. Which consideration should the nurse prioritize during the preparation of the client in the operating room? A. The client should be placed in Trendelenburg position. B. The client must be firmly restrained at all times. C. Pressure points should be assessed and well padded. D. The preoperative shave should be done by the circulating nurse.

C. The vascular supply should not be obstructed nor nerves damaged by an awkward position or undue pressure on a body part. During surgical procedures, the client is at risk for impairment of skin integrity due to a stationary position and immobility. An older client is at an increased risk of injury and impaired skin integrity. Therefore, pressure points should be assessed and well padded. A Trendelenburg position is not indicated for this client. Once anesthetized for a total hip replacement, the client cannot move; restraints are not necessary. A preoperative shave is not performed; excess hair is removed by means of a clipper.

A nurse is teaching an educational class to a group of older adults at a community center. In an effort to prevent osteoporosis, the nurse should encourage participants to ensure that they consume the recommended intake of what nutrients? Select all that apply. A. Vitamin B12 B. Potassium C. Calcitonin D. Calcium E. Vitamin D

D, E. A diet rich in calcium and vitamin D protects against skeletal demineralization. Intake of vitamin B12 and potassium does not directly influence the risk for osteoporosis. Calcitonin is not considered to be a dietary nutrient.

A client has a rash on the arm that has been treated with an antibiotic without eradicating the rash. What type of examination can be used to determine if the rash is a fungal rash using ultraviolet light? A. Fungal culture B. Skin biopsy C. Potassium hydroxide test D. A Wood's light examination

D. A Wood's light is also known as a black light and is a handheld device that can identify certain fungal infections that fluoresce under long-wave ultraviolet light. In a darkened room, when a physician or nurse aims the light at a lesion caused by a fungus that fluoresces, the lesion emits a blue-green color. It is the only test that uses a light, the others use skin scrapings.

The nurse is caring for a hospice client who is scheduled for a surgical procedure to reduce the size of a spinal tumor in an effort to relieve pain. The nurse should plan this client care with the knowledge that this surgical procedure is classified as which of the following? A. Diagnostic B. Laparoscopic C. Curative D. Palliative

D. A client on hospice will undergo a surgical procedure only for palliative care, which means to reduce pain or provide comfort, not to cure disease (curative). The reduction of tumor size to relieve pain is considered a palliative procedure. A laparoscopic procedure is a type of surgery that is utilized for diagnostic purposes or for repair. Diagnostic procedures are performed to help diagnose a condition. The excision of a tumor is classified as curative. This client is not having the tumor removed, only the size reduced.

While performing an initial assessment of a client admitted with appendicitis, the nurse observes an elevated blue-black lesion on the client's ear. The nurse knows that this lesion is consistent with what type of skin cancer? A. Basal cell carcinoma B. Squamous cell carcinoma C. Dermatofibroma D. Malignant melanoma

D. A malignant melanoma presents itself as a superficial spreading melanoma which may appear in a combination of colors, with hues of tan, brown, and black mixed with gray, blue-black, or white. The lesion tends to be circular, with irregular outer portions. BCC usually begins as a small, waxy nodule with rolled, translucent, pearly borders; telangiectatic vessels may be present. SCC appears as a rough, thickened, scaly tumor that may be asymptomatic or may involve bleeding. A dermatofibroma presents as a firm, dome-shaped papule or nodule that may be skin colored or pinkish brown.

A client with psoriasis visits the dermatology clinic. When inspecting the affected areas, the nurse expects to see which type of secondary lesion? A. Scar B. Crust C. Ulcer D. Scale

D. A scale is the characteristic secondary lesion occurring in psoriasis. Although crusts, ulcers, and scars also are secondary lesions in skin disorders, they don't occur with psoriasis.

A nurse is planning the care of a client with herpes zoster. What medication, if given within the first 24 hours of the initial eruption, can arrest herpes zoster? A. Prednisone B. Azathioprine C. Triamcinolone D. Acyclovir

D. Acyclovir, if started early, is effective in significantly reducing the pain and halting the progression of the disease. There is evidence that infection is arrested if oral antiviral agents are given within the first 24 hours. Prednisone is an anti-inflammatory agent used in a variety of skin disorders, but not in the treatment of herpes. Azathioprine is an immunosuppressive agent used in the treatment of pemphigus. Triamcinolone is utilized in the treatment of psoriasis.

The nurse is asked to explain to the client the age-related processes that contribute to bone loss and osteoporosis. What is the nurse's best response? A. Increase of vitamin D B. Decrease in parathyroid hormone C. Increase in calcitonin D. Decrease in estrogen

D. Age related processes that contribute to loss of bone mass and osteoporosis are decreases in estrogen, calcitonin, and vitamin D and an increase in parathyroid hormone.

There are a variety of problems that can become complications after a fracture. Which is described as a condition that occurs from interruption of the blood supply to the fracture fragments after which the bone tissue dies, most commonly in the femoral head? A. fat embolism B. pulmonary embolism C. shock D. avascular necrosis

D. Avascular necrosis is described as a condition that occurs from interruption of the blood supply to the fracture fragments after which the bone tissue dies, most commonly in the femoral head.

A nurse is assessing the skin of a client who has been diagnosed with bacterial cellulitis on the dorsal portion of the great toe. When reviewing the client's health history, the nurse should identify what comorbidity as increasing the client's vulnerability to skin infections? A. Chronic obstructive pulmonary disease B. Rheumatoid arthritis C. Gout D. Diabetes

D. Clients with diabetes are particularly susceptible to skin infections. COPD, RA, and gout are less commonly associated with integumentary manifestations.

A nurse is providing a class on osteoporosis at the local center for older adults. Which statement related to osteoporosis is most accurate? A. High levels of vitamin D can cause osteoporosis. B. A nonmodifiable risk factor for osteoporosis is a person's level of activity. C. Secondary osteoporosis occurs in women after menopause. D. The use of corticosteroids increases the risk of osteoporosis.

D. Corticosteroid therapy is a secondary cause of osteoporosis when taken for long-term use. Adequate levels of vitamin D are needed for absorption of calcium. A person's level of physical activity is a modifiable factor that influences peak bone mass. Lack of activity increases the risk for the development of osteoporosis. Primary osteoporosis occurs in women after menopause.

Which medication classification may be used for contact dermatitis? A. Antifungals B. Saline irrigations C. Antivirals D. Corticosteroids

D. Corticosteroids are used for contact dermatitis. Antifungals, antivirals, and saline irrigations are not used in the treatment of contact dermatitis.

A client's rheumatoid arthritis (RA) has failed to respond appreciably to first-line treatments and the primary provider has added prednisone to the client's drug regimen. What principle will guide this aspect of the client's treatment? A. The client will need daily blood testing for the duration of treatment. B. The client must stop all other drugs 72 hours before starting prednisone. C. The drug should be used at the highest dose the client can tolerate. D. The drug should be used for as short a time as possible.

D. Corticosteroids are used for shortest duration and at lowest dose possible to minimize adverse effects. Daily blood work is not necessary and the client does not need to stop other drugs prior to using corticosteroids.

A nurse is performing a musculoskeletal assessment of a client with arthritis. During passive range-of-motion exercises, the nurse hears an audible grating sound. The nurse should document the presence of what assessment finding? A. Fasciculations B. Clonus C. Effusion D. Crepitus

D. Crepitus is a grating, crackling sound or sensation that occurs as the irregular joint surfaces move across one another, as in arthritic conditions. Fasciculations are involuntary twitching of muscle fiber groups. Clonus is the rhythmic contractions of a muscle. Effusion is the collection of excessive fluid within the capsule of a joint.

A nurse is assessing a teenage client with acne vulgaris. The client's mother states, I keep telling him that this is what happens when you eat as many french fries as he does. What aspect of the pathophysiology of acne should inform the nurse's response? A. A sudden change in client's diet may exacerbate, rather than alleviate, the client's symptoms. B. French fries are one of the foods that are known to directly cause acne. C. Elimination of fried foods from the client's diet will likely lead to resolution within several months. D. Diet is thought to play a minimal role in the development of acne.

D. Diet is not believed to play a major role in acne therapy. A change in diet is not known to exacerbate symptoms. However, there does appear to be a correlation between foods high in refined sugars and acne; therefore, these foods should be avoided.

A nurse's plan of care for a client with rheumatoid arthritis includes several exercise-based interventions. What goal should the nurse prioritize? A. Maximize range of motion while minimizing exertion. B. Increase joint size and strength. C. Limit energy output in order to preserve strength for healing. D. Preserve or increase range of motion while limiting joint stress.

D. Exercise is vital to the management of rheumatic disorders. Goals should be preserving and promoting mobility and joint function while limiting stress on the joint and possible damage. Cardiovascular exertion should remain within age-based limits and individual ability, but it is not a goal to minimize exertion. Increasing joint size is not a valid goal.

A diet plan is developed for a client with gouty arthritis. What should the nurse advise the client to limit the intake of? A. fresh fish B. citrus fruits C. green vegetables D. organ meats

D. Gouty arthritis is a disorder of purine metabolism. High-purine foods include organ meats, anchovies, sardines, shellfish, chocolate, and meat extracts. Citrus fruits, green vegetables, and fresh fish are appropriate foods for a client with gouty arthritis.

Which is not a guideline for avoiding hip dislocation after replacement surgery. A. Keep the knees apart at all times. B. Put a pillow between the legs when sleeping. C. Never cross the legs when seated. D. The hip may be flexed to put on clothing such as pants, stockings, socks, or shoes.

D. Guidelines for avoiding hip dislocation after replacement surgery specify that the hip should not be flexed to put on clothing such as pants, stockings, socks, or shoes. Clients should keep the knees apart at all times, put a pillow between the legs when sleeping, and never cross the legs when seated.

A client comes to the clinic reporting a red rash of small, fluid-filled blisters and is suspected of having herpes zoster. What presentation is most consistent with this diagnosis? A. Grouped vesicles occurring on lips and oral mucous membranes B. Grouped vesicles occurring on the genitalia C. Rough, fresh, or gray skin protrusions D. Grouped vesicles in linear patches along a dermatome

D. Herpes zoster, or shingles, is an acute inflammation of the dorsal root ganglia, causing localized, vesicular skin lesions following a dermatome. Herpes simplex type 1 is a viral infection affecting the skin and mucous membranes, usually producing cold sores or fever blisters. Herpes simplex type 2 primarily affects the genital area, causing painful clusters of small ulcerations. Warts appear as rough, fresh, or gray skin protrusions.

Which skin condition is caused by staphylococci, streptococci, or multiple bacteria? A. Scabies B. Pediculosis capitis C. Poison ivy D. Impetigo

D. Impetigo is seen at all ages but is particularly common among children living under poor hygienic conditions. Scabies is caused by the itch mite. Pediculosis capitis is caused by head lice. Poison ivy is a contact dermatitis caused by the oleoresin given off by a particular form of ivy.

A client has come to the clinic for a regular check-up. The nurse's initial inspection reveals an increased thoracic curvature of the client's spine. The nurse should document the presence of which condition? A. Scoliosis B. Epiphyses C. Lordosis D. Kyphosis

D. Kyphosis is the increase in thoracic curvature of the spine. Scoliosis is a deviation in the lateral curvature of the spine. Epiphyses are the ends of the long bones. Lordosis is the exaggerated curvature of the lumbar spine.

The nurse is caring for a client who may have a lice infestation. The nurse is using a bright light focused on an area of the head to confirm the presence of lice. In which manner is it easiest to differentiate nits from dandruff? A. Nits are located near the scalp. B. Dandruff is throughout the hair. C. Dandruff looks white and flaky. D. Nits are difficult to move from hair shafts.

D. Lice eggs, or nits, can be confused with dandruff. However, dandruff consists of fine, white particles of dead, dry scalp cells that can be easily picked from the hair. Nits, on the other hand, look like small, yellowish-white ovals and are quite firmly fixed to the hair shaft. The nurse is correct to use the difference of the nits being securely attached to the hair shaft as a guide to confirmation of lice infestation.

The nurse is creating the care plan for a 70-year-old obese client who has been admitted to the postsurgical unit following a colon resection. This client's age and body mass index increase the risk for what complication in the postoperative period? A. Hyperglycemia B. Azotemia C. Falls D. Infection

D. Like age, obesity increases the risk and severity of complications associated with surgery. During surgery, fatty tissues are especially susceptible to infection. In addition, obesity increases technical and mechanical problems related to surgery. Therefore, dehiscence (wound separation) and wound infections are more common. A postoperative client who is obese will not likely be at greater risk for hyperglycemia, azotemia, or falls.

A nurse is caring for a client following knee surgery that was performed under a spinal anesthetic. What intervention should the nurse implement to prevent a spinal headache? A. Seat the client in a chair and have them perform deep breathing exercises. B. Ambulate the client as early as possible. C. Limit the client's fluid intake for the first 24 hours' postoperatively. D. Keep the client positioned supine.

D. Measures that increase cerebrospinal pressure are helpful in relieving headache. These include maintaining a quiet environment, keeping the client lying flat, and keeping the client well hydrated. Having the client sit or stand up decreases cerebrospinal pressure and would not relieve a spinal headache. Limiting fluids is incorrect because it also decreases cerebrospinal pressure and would not relieve a spinal headache.

A client has just undergone surgery for malignant melanoma. Which of the following nursing actions should be prioritized? A. Maintain the client on bed rest for the first 24 hours postoperative. B. Apply distraction techniques to relieve pain. C. Provide soft or liquid diet that is high in protein to assist with healing. D. Anticipate the need for, and administer, appropriate analgesic medications.

D. Nursing interventions after surgery for a malignant melanoma center on promoting comfort, because wide excision surgery may be necessary. Anticipating the need for and administering appropriate analgesic medications are important. Distraction techniques may be appropriate for some clients, but these are not a substitute for analgesia. Bed rest and a modified diet are not necessary.

A patient is complaining of severe itching that intensifies at night. The nurse decides to assess the skin using a magnifying glass and penlight to look for the itch mite. What skin condition does the nurse anticipate finding? A. Tinea corporis B. Contact dermatitis C. Pediculosis D. Scabies

D. Scabies is an infestation of the skin by the itch mite Sarcoptes scabiei. The patient complains of severe itching caused by a delayed type of immunologic reaction to the mite or its fecal pellets. During examination, the patient is asked where the pruritus is most severe. A magnifying glass and a penlight are held at an oblique angle to the skin while a search is made for the small, raised burrows created by the mites. One classic sign of scabies is the increased itching that occurs during the overnight hours, perhaps because the increased warmth of the skin has a stimulating effect on the parasite.

A nurse is assessing the neurovascular status of a client who has had a leg cast recently applied. The nurse is unable to palpate the client's dorsalis pedis or posterior tibial pulse and the client's foot is pale. What is the nurse's most appropriate action? A. Warm the client's foot and determine whether circulation improves. B. Reposition the client with the affected foot dependent. C. Reassess the client's neurovascular status in 15 minutes. D. Promptly inform the primary care provider.

D. Signs of neurovascular dysfunction warrant immediate medical follow-up. It would be unsafe to delay. Warming the foot or repositioning the client may be of some benefit, but the care provider should be informed first.

A client who had a total hip replacement two days ago reports new onset calf tenderness to the nurse. Which action should the nurse take? A. Administer pain medication. B. Massage the client's calf. C. Apply antiembolic stockings. D. Notify the health care provider.

D. Since calf tenderness may be a sign of deep vein thrombosis (DVT), the nurse should notify the health care provider about this finding. The nurse should not administer pain medication since it is prescribed for surgical pain and this tenderness in the calf should not be masked until it is evaluated. The nurse should not massage the client's calf as this may dislodge a thrombus. Antiembolic stockings should be worn prophylactically to prevent DVT but are not applied to treat DVT.

The nurse is doing preoperative client education with a client who has a 40 pack-year history of cigarette smoking. The client will undergo an elective bunionectomy at a time that fits his work schedule in a few months. What would be the best instruction to give to this client? A. Reduce smoking by 50% to prevent the development of pneumonia. B. Continue smoking so as to help manage stress levels before and after surgery. C. Aim to quit smoking in the postoperative period to reduce the chance of surgical complications. D. Stop smoking as soon as possible before the scheduled surgery to enhance pulmonary function and decrease infection.

D. Stopping smoking before the surgery will enhance pulmonary function and reduce the risk of infection in the postoperative period. Merely reducing smoking by 50% would not be as effective as stopping, nor would waiting until after the surgery to stop smoking. Although smoking may help the client manage stress, the pulmonary function and infection risks that it poses far outweigh any benefit it may offer related to stress reduction.

The nurse is planning teaching for a client who is scheduled for an open hemicolectomy. The nurse intends to address the topics of incision splinting and leg exercises during this teaching session. When is the best time for the nurse to provide teaching? A. Upon the client's admission to the postanesthesia care unit (PACU) B. When the client returns from the PACU C. During the intraoperative period D. As soon as possible, and before the surgical procedure

D. Teaching is most effective when provided before surgery. Preoperative teaching is initiated as soon as possible, beginning in the health care provider's office, clinic, or at the time of preadmission testing when diagnostic tests are performed. Upon admission to the PACU, the client is usually drowsy, making this an inopportune time for teaching. Upon the client's return from the PACU, the client may remain drowsy. During the intraoperative period, anesthesia alters the client's mental status, rendering teaching ineffective.

A nurse is teaching a client about rheumatoid arthritis. Which statement by the client indicates understanding of the disease process? A. I'll definitely need surgery for this. B. It will never get any better than it is right now. C. When it clears up, it will never come back. D. It will get better and worse again.

D. The client demonstrates understanding of rheumatoid arthritis if he expresses that it's an unpredictable disease characterized by periods of exacerbation and remission. There's no cure for rheumatoid arthritis, but symptoms can be managed. Surgery may be indicated in some cases.

A community health nurse is performing a visit to the home of a client who has a history of rheumatoid arthritis (RA). On which aspect of the client's health should the nurse focus most closely during the visit? A. Understanding of rheumatoid arthritis B. Risk for cardiopulmonary complications C. Social support system D. Functional status

D. The client's functional status is a central focus of home assessment of the client with RA. The nurse may also address the client's understanding of the disease, complications, and social support, but the client's level of function and quality of life are a primary concern.

A nurse is admitting a client with toxic epidermal necrolysis. What is the nursing priority in preventing sepsis? A. Limiting protein to limit liver failure B. Hydrating to prevent renal failure C. Assessing for hemorrhage D. Preventing infection

D. The major cause of death from toxic epidermal necrolysis is from sepsis. Monitoring vital signs closely and noticing changes in respiratory, kidney, and gastrointestinal function may help the nurse to quickly detect the beginning of an infection. Strict asepsis is always maintained during routine skin care measures. Hand hygiene and wearing sterile gloves when carrying out procedures are essential. Visitors should wear protective garments and wash their hands before and after coming into contact with the patient. People with any infections or infectious disease should not visit the patient until they are no longer a danger to the patient. The nurse is critical in identifying early signs and symptoms of infection and notifying the primary provider. Antibiotic agents are not generally begun until there is an indication for the use. Hemorrhage, renal failure, and liver failure are not the major causes of toxic epidermal necrolysis.

The recovery room nurse is admitting a client from the OR following the client's successful splenectomy. What is the first assessment that the nurse should perform on this newly admitted client? A. Heart rate and rhythm B. Skin integrity C. Core body temperature D. Airway patency

D. The primary objective in the immediate postoperative period is to maintain ventilation and, thus, prevent hypoxemia and hypercapnia. Both can occur if the airway is obstructed and ventilation is reduced. This assessment is followed by cardiovascular status and the condition of the surgical site. The core temperature would be assessed after the airway, cardiovascular status, and wound (skin integrity).

A client has had a cast placed for the treatment of a humeral fracture. The nurse's most recent assessment shows signs and symptoms of compartment syndrome. What is the nurse's most appropriate action? A. Arrange for a STAT assessment of the client's serum calcium levels. B. Perform active range of motion exercises. C. Assess the client's joint function symmetrically. D. Contact the primary provider immediately.

D. This major neurovascular problem is caused by pressure within a muscle compartment that increases to such an extent that microcirculation diminishes, leading to nerve and muscle anoxia and necrosis. Function can be permanently lost if the anoxic situation continues for longer than 6 hours. Therefore, immediate medical care is a priority over further nursing assessment. Assessment of calcium levels is unnecessary.

Allopurinol has been prescribed for a client receiving treatment for gout. The nurse caring for this client knows to assess the client for bone marrow suppression, which may be manifested by what diagnostic finding? A. Hyperuricemia B. Increased erythrocyte sedimentation rate C. Elevated serum creatinine D. Decreased platelets

D. Thrombocytopenia occurs in bone marrow suppression. Hyperuricemia occurs in gout, but is not caused by bone marrow suppression. Increased erythrocyte sedimentation rate may occur from inflammation associated with gout, but is not related to bone marrow suppression. An elevated serum creatinine level may indicate renal damage, but this is not associated with the use of allopurinol.

The nurse is admitting a client to the medical-surgical unit from the PACU. In order to help the client clear secretions and help prevent pneumonia, the nurse should encourage the client to: A. eat a balanced diet that is high in protein. B. limit activity for the first 72 hours. C. take medications as prescribed. D. use the incentive spirometer every 2 hours.

D. To clear secretions and prevent pneumonia, the nurse encourages the client to turn frequently, take deep breaths, cough, and use the incentive spirometer at least every 2 hours. These pulmonary exercises should begin as soon as the client arrives on the clinical unit and continue until the client is discharged. A balanced, high protein diet; visiting family in the waiting room; or taking medications as prescribed would not help to clear secretions or prevent pneumonia.

An 82-year-old client is being treated in the hospital for a sacral pressure ulcer. What age-related change is most likely to affect the client's course of treatment? A. Increased thickness of the subcutaneous skin layer B. Increased vascular supply to superficial skin layers C. Changes in the character and quantity of bacterial skin flora D. Increased time required for wound healing

D. Wound healing becomes slower with age, requiring more time for older adults to recover from surgical and traumatic wounds. There are no changes in skin flora with increased age. Vascular supply and skin thickness both decrease with age.

A nurse is writing a care plan for a client admitted to the emergency department (ED) with an open fracture. The nurse will assign priority to what nursing diagnosis for a client with an open fracture of the radius? A. Risk for infection B. Risk for ineffective role performance C. Risk for perioperative positioning injury D. Risk for powerlessness

The client has a significant risk for osteomyelitis and tetanus due to the fact that the fracture is open. Powerlessness and ineffective role performance are psychosocial diagnoses that may or may not apply, and which would be superseded by immediate physiologic threats such as infection. Surgical positioning injury is not plausible, since surgery is not likely indicated.