AH2 comprehensive final
answer: Suggest the client take an analgesic ½ hour before walking.
A 66-year-old client has osteoporosis spends most of their day sitting. The client knows that they are supposed to get up, walk, and do some form of exercise, but states that they have pain and fear of falling. What is the most appropriate nursing intervention for this client?
answer: orthostatic hypotension, DVT, and autonomic dysreflexia
A client with spinal cord injury is ready to be discharged home. A family member asks the nurse to review potential complications one more time. What are the potential complications that would be monitored for in this client? Select all that apply.
answer: Give the client extra time to perform activities
A nurse is caring for a client who has Parkinson's disease and is starting to display bradykinesia. Which of the following is an appropriate action by the nurse?
Feeding the patient slowly with small bites while seated at a 90 degree angle Having the client demonstrate how to use a wheelchair. Reposition the client every 4 hours Toileting the client every 2 hours answer: Feeding the patient slowly with small bites while seated at a 90 degree angle
A nurse on the neur unit is providing care for a client who has spinal cord injury at the level of C4. When planning the client's care, what action by the nurse is most appropriate for this client?
answer: CT scan
A patient comes for follow up after a left knee injury. The nurse notes the area to be swollen, warm to touch, and decreased range of motion. The patient is scheduled for an I&D (incision and drainage) procedure. What diagnostic testing is most appropriate to be performed on the patient?
answer: Calcitonin
Age-related bone loss begins soon after the peak bone mass is achieved. Which hormone inhibits resorption and promotes bone formation?
answer: 0.6
ORDERED: Decadron (dexamethasone sodium phosphate) 2.5 mg. IM q. 12hr. AVAILABLE: Multidose vial containing Decadron 20mg/5ml. How many ml of the Decadron should you administer? Round to the nearest tenth.
answer: 6
Order: 40mEq potassium chloride (KCl) in 150ml D5W at 25 ml/hr. How many hours will it take to administer this infusion?
Answer: delayed wound healing
The client has returned to the unit after undergoing limb-sparing surgery to remove a metastatic bone tumor. The nurse providing postoperative care several days after surgery assesses for what complication?
answer: using the incentive spirometer as prescribed
The nurse is developing a plan of care for a client with Guillain--Barré syndrome. Which of the following interventions would the nurse prioritize for this client?
answer: The client performs muscle-strengthening exercises as prescribed by the MD and PT.
The occupational health nurse is teaching self-management techniques to a client with low back pain. The client demonstrates a need for further teaching by which of the following?
answer: decrease in hemoglobin
When monitoring for potential complications after spinal surgery, what finding would cause the nurse to suspect that the patient is experiencing postoperative bleeding?
answer: Blurred vision, intention tremor, and urinary hesitancy
A 33-year-old client presents at the clinic with reports of weakness, incoordination, dizziness, and loss of balance. The client is hospitalized and diagnosed with MS. What sign or symptom, revealed during the initial assessment, is typical of MS?
answer: "My throat burns when I take this medication"
A 53 year old client is taking Alendronate (Fosamax) to help prevent bone loss due to osteoporosis. The nurse becomes concerned after hearing which of the client's complaints?
answer: notify the provider
A client with a history of breast cancer presents to the ED for complaints of low back pain which began about 3 months ago. Upon assessment, the patient reveals recent episodes of incontinence of bowel and bladder. Which of the following interventions is most appropriate?
answer: difficulty in coordination
A middle-aged woman has sought care from her primary provider and undergone diagnostic testing that has resulted in a diagnosis of MS. What sign or symptom is most likely to have prompted the woman to seek care?
answer: adventitious lung sounds
A nurse is assessing a client with Guillain-Barre. What assessment finding would alert the nurse to progression of this condition?
answer: albumin
An elderly client is brought to the emergency department with a fractured tibia. The client appears malnourished, and the nurse is concerned about the client's healing process related to insufficient protein levels. What laboratory finding would the floor nurse prioritize when assessing for protein deficiency?
answer: client
An interdisciplinary team has been working collaboratively to improve the health outcomes of a young adult who suffered a spinal cord injury in a workplace accident. Which member of the rehabilitation team would determine the final outcome of the process?
Answer: intravenous administration of antibiotics
An older adult client sought care for the treatment of a swollen, painful knee joint. Diagnostic imaging and culturing of synovial fluid resulted in a diagnosis of septic arthritis. The nurse would prioritize what aspect of care?
answer: call the surgeon or apply a tourniquet
The client has returned to the post surgical unit from the PACU after an above-the-knee amputation of the right leg. The nurse's initial post surgical assessment were unremarkable, the client has called out. The nurse enters the room and observes copious quantities of blood at the surgical site. What would be the nurse's first action?
answer: altered serum calcium levels
The client is undergoing diagnostic testing for Paget disease, a bone disease that causes bones to grow large and weak leading to weakness, pain, arthritis, and potentially fractures. What assessment finding is most consistent with this diagnosis?
Dyskinesia Lactose intolerance Pruritus Diarrhea answer: Dyskinesia
The clinic nurse caring for a client with Parkinson disease notes that the client has been taking Levodopa and Carbidopa for 7 years. For what common side effect would the nurse assess this client?
answer: Elevate the arm above the level of the heart.
The home care nurse is visiting a diabetic client with a new cast to the left arm following surgical management and excision for an olecranon tumor . Upon assessment, the nurse finds the client's fingers to be cool and slightly swollen. What is the best first action for the nurse to take?
Educate the client about the importance of frequent position changes Limit the amount of assistance provided with ADLs Collaborate with the physical therapist and immobilize the client's extremities temporarily Increase the frequency of ROM exercises answer: Increase the frequency of ROM exercises
The nurse caring for a client with a spinal cord injury notes that the client is exhibiting early signs and symptoms of disuse syndrome. Which of the following is the most appropriate nursing action?
answer: appropriate assistive devices
The nurse is admitting a client into the rehabilitation unit after an industrial accident. The client's nursing diagnoses include disturbed sensory perception with decreased strength and dexterity. The nurse would know that this client may need what to accomplish self-care?
answers: absence of feeling, capillary refill 4 to 5 seconds, and cold skin
The nurse is assessing a client who is experiencing peripheral neurovascular dysfunction following an open reduction internal fixatoin of the left hip. What assessment findings are most consistent with this diagnosis?
answer: maintaining spinal alignment
The nurse is caring for a client who has suffered an unstable thoracolumbar fracture. What goal would the nurse prioritize during patient care?
answer: Inform the surgeon of this finding
The nurse is caring for a client who is post op following a debridement of buttocks wound as a result of immobility following a spinal cord injury. The nurse is emptying a client's closed suction drainage at the end of a shift. The nurse notes that the volume is within expected parameters but that the drainage has a foul odor. What is the nurse's best action?
answer: -Docusate Sodium (Colace) Constipation -Cyclobenzaprine (Flexeril) Muscle spasms -Artificial tears Dry eyes
The nurse is caring for a client with Multiple Sclerosis. The client has complaints of constipation, muscle spasms and dry eyes. Which of the following medications are appropriate for this client. Match each medication to the symptom.
answer: High pitched stridor
The nurse is caring for a client with myasthenia gravis who has undergone a thymectomy. Which assessment would prompt immediate intervention by the nurse following the procedure?
answer: sudden onset of shortness of breath
The nurse is caring for a client with myasthenia gravis who has undergone a thymectomy. Which clinical manifestation should alert the nurse to a complication of this procedure?
answer: Client's general condition, balance, and weight-bearing prescription
The nurse is collaborating with the occupational therapist on discharge teaching for a client who underwent foot surgery. The use of assistive devices primarily depend on which variables?
Assess the client's vital signs and correlate these with the client's baselines Assess the client's eye opening and response to stimuli Facilitate diagnostic testing in an effort to obtain objective data Document that the client currently lacks a level of consciousness answer: Assess the client's eye opening and response to stimuli
The nurse is performing a neurologic assessment of a client whose injuries have rendered the client unable to follow verbal commands. How would the nurse proceed with assessing the client's level of consciousness (LOC)?
answer: The client has a compression fracture
The nurse is performing a physical assessment on a client with osteoporosis. The nurse notes that the client changes position slowly and there is tenderness to palpation of the spinal vertebra at T8. What conclusion can the nurse draw from this data?
Delayed reuptake of serotonin Decreased availability of dopamine Premature degradation of acetylcholine Insufficient synthesis of epinephrine answer: Decreased availability of dopamine
The nurse is planning the care of a client with Parkinson disease recently. The client is scheduled to receive Sinemet (Carbidopa-Levadopa) at 1600. The nurse would be aware that treatment will focus on what pathophysiologic phenomenon?
answer: Maintenance of adequate levels of activated vitamin D
The nurse is providing education to a client who has a family history of osteoporosis. What primary goal would guide the choice of nursing interventions?
answer: 30
The nurse practitioner has ordered 1 fluid ounce of Milk of Magnesia to prevent constipation following orthopedic surgery. How many milliliters will the nurse administer?
answer: 4
The physician has ordered Penicillin for a client admitted for management of a septic joint. Order: 500mg PO q4 hours. Available: 750 mg tablets. How many tablets will the client receive in a 24 hour period?
answer: change positions slowly
Which of the following instructions would be included in a teaching plan for a client experiencing orthostatic hypotension from Carbidopa/Levodopa (Sinemet) administration?
Reinforce the dressing and reassess in 1 to 2 hours Inform the surgeon of the possibility of a dural leak Page the health care provider and report this sign of infection Obtain a Type and Screen to prepare for a blood transfusion answer: Reinforce the dressing and reassess in 1 to 2 hours
While assessing the client at the beginning of the shift, the nurse inspects a surgical dressing covering the operative site after the client's cervical discectomy this afternoon. The nurse notes that the drainage is 75% saturated with serosanguineous discharge. What would the nurse do first?
answer: Palpate the amplitude of the pedal pulse.
A client who has sustained a crush injury to the right lower leg resulting in a hip fracture complains of numbness and tingling in that leg. The skin of the right leg appears pale. Which is the nurse's first intervention?
answer: Obtain the client's temperature and vital signs.
A client who is 2 weeks post op following a Left below the knee amputation (BKA) presents to the clinic for a follow-up visit. He reports malaise and fatigue. In reviewing the client's lab data, the nurse notes the client's CBC reveals an elevated WBC. What would be the nurse's best action?
answer: Raise HOB and palpate the bladder for distention.
A client who suffered a spinal cord injury at level T-5 several months ago develops a flushed face, and blurred vision. Upon taking vital signs, the nurse notes a blood pressure of 184/95. Which of the following would the nurse do first?
Administer an analgesics as ordered. Assess the client's urinary catheter for patency. Raise the HOB to high-fowlers to improve perfusion. Place the client on 2L/NC. answer: Assess the client's urinary catheter for patency.
A client who suffered a spinal cord injury is experiencing an exaggerated autonomic response. The client is sweating profusely, complaining of a severe throbbing headache, and nasal congestion. What action by the nurse is most appropriate?
answer: increased bone mass
An older adult woman's current medication regimen includes Alondronate (Fosamx) for osteoporosis. What outcome would indicate successful therapy?
answer: Bone density
An older female adult client has symptoms of osteoporosis the client will require further testing related to a possible exacerbation of her osteoporosis. The nurse would anticipate what diagnostic test?
answer: Palpating the dorsalis pedis and popliteal pulses in the affected extremity
The nurse completes the preoperative assessment for a client scheduled for a total knee replacement today. When the client returns to the from surgery, what priority act would nurse to perform first?
answer: "There is nothing that can be done anyway, because chronic diseases like diabetes cannot be prevented."
The nurse is presenting health education to a 48-year-old man who was just diagnosed with type 2 diabetes. The client has a BMI of 35 and leads a sedentary lifestyle. The nurse gives the client information on the risk factors for his diagnosis and begins talking with him about changing behaviors around diet and exercise. The nurse knows that further client teaching is necessary when the client tells you what?
answer: Cereal with milk, a scrambled egg, and grapefruit
The nurse is providing teaching to a group of clients about the role of diet and bone health. Of the following, what would be the best choice for breakfast?
answer: Evaluating the effects of the musculoskeletal disorder on the client's function
The nurse is taking a health history on a client with musculoskeletal dysfunction. Which evaluation would the nurse prioritize during this phase of the assessment?
answer: How does the feeling in the affected extremity compare with the feeling in the unaffected extremity?
The nurse is taking a health history on a new client who has been experiencing unexplained paresthesia. What question would be most helpful to guide the nurse's assessment of the client's altered sensations?
answer: Cereal with milk, a scrambled egg, and kiwi fruit
The nurse is teaching a client with osteomalacia about the role of diet. What would be the best choice for breakfast for a client with osteomalacia?
Ensure that the player is not moved Perform a rapid assessment of the player's range of motion Assess the player's reflexes Obtain the player's vital signs, if possible answer: Ensure that the player is not moved
The school nurse has been called to the football field where a player is immobile on the field after landing awkwardly on their head during a play. While awaiting an ambulance, what action would the nurse perform first?