AH2: Exam 4

Which cast care instructions should the nurse provide to a client who just had a plaster cast applied to the right forearm? Select all that apply. 1. Keep the cast clean and dry. 2. Allow the cast 24 to 72 hours to dry. 3. Keep the cast and extremity elevated. 4. Expect tingling and numbness in the extremity. 5. Use a hair dryer set on a warm to hot setting to dry the cast. 6. Use a soft padded object that will fit under the cast to scratch the skin under the cast.

1, 2, 3

The nurse is assessing a client who is experiencing seizure activity. The nurse understands that it is necessary to determine information about which items as part of routine assessment of seizures? Select all that apply. 1. Postictal status 2. Duration of the seizure 3. Changes in pupil size or eye deviation 4. Seizure progression and type of movements 5. What the client ate in the 2 hours preceding seizure activity

1, 2, 3, 4

You delegate the measurement of vital signs to an experienced UAP. Osteomyelitis has been diagnosed in a patient. Which vital sign value would you instruct the UAP to report immediately? 1. Temperature of 101° F (38.3° C) 2. Blood pressure of 136/80 mm Hg 3. Heart rate of 96 beats/min 4. Respiratory rate of 24 breaths/min

1. Temperature of 101° F (38.3° C)

The nurse is assessing a client with a history of absence seizures. Which clinical manifestation does the nurse assess for? a. Automatisms b. Intermittent rigidity c. Sudden loss of muscle tone d. Brief jerking of the extremities

a. Automatisms

While a woman with a fractured femur is being prepared for surgery, she exhibits cyanosis, tachycardia, dyspnea, and restlessness. What should the nurse do first? 1. Call the practitioner 2. Administer oxygen by mask 3. Place her in the high Fowler's position 4. Lower her to the Trendelenburg position

2. Administer oxygen by mask

A patient has a long-arm plaster cast applied for immobilization of a fractured left radius. Until the cast has completely dried, the nurse should a. keep the left arm in dependent position. b. avoid handling the cast using fingertips. c. place gauze around the cast edge to pad any roughness. d. cover the cast with a small blanket to absorb the dampness.

b. avoid handling the cast using fingertips.

A patient, age 27, has been admitted to the neurological department because of seizures of unknown cause. The nurse should take precautions by

being certain padded side rails are present.

A nurse is caring for a client being treated for fat embolus after multiple fractures. Which of the following data would the nurse evaluate as the most favorable indication of resolution of the fat embolus? 1. Minimal dyspnea 2. Clear mentation 3. Oxygen saturation of 85% 4. Arterial oxygen level of 78 mm Hg

2. Clear mentation

A patient has been admitted with meningococcal meningitis. Which observation by the nurse requires action? a. The bedrails at the head and foot of the bed are both elevated. b. The patient receives a regular diet from the dietary department. c. The lights in the patient's room are turned off and the blinds are shut. d. Unlicensed assistive personnel enter the patient's room without a mask.

d. Unlicensed assistive personnel enter the patient's room without a mask.

The nurse is creating a plan of care for a client in skin (external) traction. The nurse should monitor for which priority finding in this client? 1. Urinary incontinence 2. Signs of skin breakdown 3. The presence of bowel sounds 4. Signs of infection around the pin sites

2. Signs of skin breakdown

A 67-year-old woman fen while washing windows in her apartment. X-ray films indicate an intertrochanteric fracture of the left femur. She is to be placed in Buck's traction until surgery is performed the next morning. Nursing care is based on the fact that the primary purpose of Buck's traction is to: 1. Reduce the fracture 2. Immobilize the fracture 3. Maintain abduction of the leg 4. Eliminate rotation of the femur

2. Immobilize the fracture

A client has an open reduction and internal fixation for a fractured hip. Postoperatively the nurse should position the client's affected extremity in: 1. External rotation 2. Slight hip flexion 3. Moderate abduction 4. Anatomical body alignment

3. Moderate abduction

The nurse is caring for a client in skeletal leg traction with an overbed frame. Which nursing intervention will best assist the client with self-positioning in bed? 1. Use the assistance of four nurses to reposition the client. 2. Place a draw sheet on the mattress for pulling the client up in bed. 3. Place a trapeze on the bed frame to provide a means for the client to lift the hips off the bed. 4. Encourage the client to push with the unaffected leg on the bed mattress to help with repositioning.

3. Place a trapeze on the bed frame to provide a means for the client to lift the hips off the bed.

A patient is admitted to the hospital with possible bacterial meningitis. During the initial assessment, the nurse questions the patient about a recent history of a. mosquito or tick bites b. chickenpox or measles c. cold sores or fever blisters d. an upper respiratory infection

d. an upper respiratory infection

The earliest sign of increased intracranial pressure is:

decreasing level of consciousness

A client with diabetes mellitus has had a right below-knee amputation. Given the client's history of diabetes mellitus, which complication is the client at most risk for after surgery? 1. Hemorrhage 2. Edema of the residual limb 3. Slight redness of the incision 4. Separation of the wound edges

4. Separation of the wound edges

You are preparing to admit a client with a seizure disorder. Which actions can you delegate to an LPN? A) Completing the admission assessment. B) Setting up oxygen and suction equipment. C) Placing a padded tongue blade at the bedside. D) Padding the side rails before the client arrives.

B) Setting up oxygen and suction equipment.

What instructions should the nurse provide to a client after a long leg cast is removed?

Elevate the extremity when sitting.

A client with an above-the-knee amputation asks why the residual limb needs to be wrapped with an elastic bandage. The nurse explains that it:

Support the soft tissue and minimize swelling

A client has a fractured tibia and is asking the nurse about external fixation. What are some advantages for the use of external fixation for the immobilization of fractures? (Select all that apply.) a. Leads to minimal blood loss b. Allows for early ambulation c. Decreases the risk of infection d. Increases blood supply to tissues e. Provides visualization of bone ends f. Promotes healing

a, b, f

The nurse is assessing the results of diagnostic tests on a client's cerebrospinal fluid (CSF). Which values and observations does the nurse correlate as most indicative of viral meningitis? (Select all that apply.) a. Clear b. Cloudy c. Normal protein level d. Increased protein level e. Normal glucose level f. Decreased glucose level

a, d, e

Which action will the public health nurse take to reduce the incidence of epidemic encephalitis in a community? a. Encourage the use of effective insect repellents during mosquito season. b. Remind patients that most cases of viral encephalitis can be cared for at home. c. Teach about the importance of prophylactic antibiotics after exposure to encephalitis. d. Arrange for screening of school-age children for West Nile virus during the school year.

a. Encourage the use of effective insect repellents during mosquito season.

You are mentoring a student nurse in the intensive care unit (ICU) while caring for a patient with meningococcal meningitis. Which action by the student requires that you intervene immediately? a. The student enters the room without putting on a mask and gown. b. The student instructs the family that visits are restricted to 10 minutes. c. The student gives the patient a warm blanket when he says he feels cold. d. The student checks the patient's pupil response to light every 30 minutes

a. The student enters the room without putting on a mask and gown.

The nurse instructs a patient who has osteosarcoma of the tibia about a scheduled above-the-knee amputation. Which statement by a patient indicates that additional patient teaching is needed? a. "I will need to participate in physical therapy after surgery." b. "I did not have this bone cancer until my leg broke a week ago." c. "I wish that I did not have to have chemotherapy after this surgery." d. "I can use the patient-controlled analgesia (PCA) to control postoperative pain."

b. "I did not have this bone cancer until my leg broke a week ago."

13. A patient with a complex pelvic fracture from a motor vehicle crash is on bed rest. Which nursing assessment finding is important to report to the health care provider? a. The patient states that the pelvis feels unstable. b. Abdomen is distended and bowel sounds are absent. c. There are ecchymoses across the abdomen and hips. d. The patient complains of pelvic pain with palpation.

b. Abdomen is distended and bowel sounds are absent.

A 50-year-old patient is being discharged after a week of IV antibiotic therapy for acute osteomyelitis in the right leg. Which information will be included in the discharge teaching? a. How to apply warm packs to the leg to reduce pain b. How to monitor and care for the long-term IV catheter c. The need for daily aerobic exercise to help maintain muscle strength d. The reason for taking oral antibiotics for 7 to 10 days after discharge

b. How to monitor and care for the long-term IV catheter

A client being measured for crutches asks the nurse why the crutches cannot rest up underneath the arm for extra support. The nurse's response is based on the understanding that this could result in: a. A fall and further injury b. Injury to the brachia plexus nerves c. Skin breakdown in the area of the axilla d. Impaired range of motion while the client ambulates

b. Injury to the brachia plexus nerves

Which drug treatment helps to decrease ICP by expanding plasma and the osmotic effect to move fluid? a. oxygen administration b. pentobarbitol c. Mannitol 25% d. dexamethasone (decadron)

c. Mannitol 25%

A client has been diagnosed with carpal tunnel syndrome. Which intervention does the nurse question in the treatment of this injury? a. Ibuprofen 600 mg three times a day with meals b. Weekly injections of a corticosteroid by the physician c. Morphine 30 mg to be taken orally every 4 hours d. Use of a hand brace or splint during the day

c. Morphine 30 mg to be taken orally every 4 hours

A child is brought to the healthcare provider's office. The child has been receiving phenytoin (Dilantin) for seizure activity. The family reports that despite the child's previously reported controlled seizures, the child has been seizing two or three times a day. The nurse would anticipate that the:

child's phenytoin level will be drawn

A client with new-onset status epilepticus is prescribed phenytoin (Dilantin). After teaching the client about this treatment regimen, the nurse assesses the client's understanding. Which statement indicates that the client understands the teaching? a. "I must drink at least 2 liters of water daily." b. "This will stop me from getting an aura before a seizure." c. "I will not be able to be employed while taking this medication." d. "Even when my seizures stop, I will take this drug."

d. "Even when my seizures stop, I will take this drug."

The nurse assesses for which clinical manifestations in the client with suspected encephalitis? a. Fever of 101° F (38.3° C) b. Nausea and vomiting c. Hypoactive deep tendon reflexes d. Pain on flexion of the neck

d. Pain on flexion of the neck

Glasgow Coma Scale is a screening tool used to asses LOC in three major areas, which are:

eye opening, best motor response, and best verbal response