AH2 Practice Exam

A nurse is teaching a client about risk factors for osteoarthritis. Which of the following factors should the nurse include in the teaching? (sata) a) Bacteria b) Diuretics c) Aging d) Obesity e) Smoking

c, d, e -diuretics are a risk factor for gout, but not OA -Infection can lead to infectious arthritis, but not OA

A nurse is conducting a primary survey of a client who has sustained life-threatening injuries due to a MVA. Identify the sequence of actions the nurse should take. 1) Perform GCS assessment 2) Establish IV access 3) Open the airway using jaw-thrust maneuver 4) determine effectiveness of ventilator efforts 5) remove clothing for a thorough assessment

3,4,2,1,5 A (airway), B (breathing), C (circulation), D (disability), E (exposure)

A nurse in a provider's office is assessing a client who reports shoulder pain. Which of the following findings by the nurse indicates rotator cuff injury? a) Alteration in the contour of the joint b) Inability to abduct the arm at the shoulder c) Negative drop arm test d) A positive Tinel's sign

B

A nurse is talking with a young clint who has a family history of osteoporosis. Which health promotion activity should the nurse recommend as a possible preventative measure? a) Increase sodium intake. b) Have a bone-density scan each year. c) Engage in weight-bearing exercise regularly. d) Drink a cup of coffee each morning.

C

A nurse is assessing a client who has a spinal cord injury. Which of the following actions should the nurse take to monitor C4 function? a) Apply downward pressure while the client shrugs his shoulders upward. b) Apply resistance while the client lifts his legs from the bed. c) Ask the client to grasp an object and form a fist. d) Apply resistance while the client flexes his arms.

a-this is for C4-C5 b assesses L2-L4 C assesses C8 d assesses C7

A nurse is providing care for four clients on a med-surge unit. Which of the following clients should the nurse identify as being at risk for the development of pressure ulcers? (sata) a) A client who is ambulatory following a cardiac catheterization 4 hr ago b) A client who has type1 diabetes mellitus and is hyperglycemic c) A client who has protein calorie malnutrition d) A client who has right-sided heart failure and 4+ edema to the lower extremities e) a client with delirium/dementia

c,d,e

A nurse is providing care for four clients on a medical-surgical unit. Which of the following clients should the nurse identify for being at risk for the development of pressure ulcers. (sata) a) A client who is ambulatory following a cardiac catheterization 4 hr ago b) A client who has type1 diabetes mellitus and is hyperglycemic c) A client who has protein calorie malnutrition d) A client who has right-sided heart failure and 4+ edema to the lower extremities e) A client who has postoperative delirium

c,d,e

A nurse is caring for a client who has had a stoke involving the right hemisphere. Which of the following alterations in functions should the nurse expect? a) difficulty reading b) inability to recognize family members c) right hemiparesis d) Aphasia

c-the right hemisphere has to do with visual and spatial awareness

A nurse in a provider's office is assessing a client who has wrist pain. Which of the following findings is a manifestation of carpel tunnel syndrome? a) Decreased radial pulse b) Positive Trousseau's sign c) Cool extremeties d) Positive Phalen's sign

d

A nurse is caring for a client who has parkinson's disease and is taking diphenhydramine 25mg PO TID. Which of the following therapeutic outcomes should the nurse expect to see? a) Delay in disease progression b) Improved bladder function c) Relief of depression d) Decreased tremors

d

A rehabilitation nurse is caring for a client who has had a spinal cord injury that resulted in paraplegia. After a week on the unit, the nurse notes that the client is withdrawn and increasingly resistant to rehabilitation efforts by the staff. Which of the following actions should the nurse take. a)Inform the client that privileges are related to participation in therapy. b) Limit visiting hours until the client begins to participate in therapy. c) Allow the client to control the timing and frequency of the therapy. d) Establish a plan of care with the client that sets attainable goals.

d Client may be feeling discouraged, this will help them feel empowered.

A nurse is teaching a client about the causes of osteoporosis. The nurse should include which of the following types of medication therapy as a risk factor for osteoporosis? a) Anticoagulants b) NSAIDs c) Cardiac glycosides d) thyroid hormones

d-long term thyroid hormone usage can result in bone loss

A nurse is caring for a client who is postoperative following knee arthroplasty and has a continuous passive motion (CPM) machine. Which of the following actions should the nurse take? a) Store the CPM machine on the floor when not in use b) Use a special pillow to rotate the affected knee internally c) set the CPM to fully flex the knee joint d) apply ice to the operative knee

d-reduces edema, pain, and bruising

A nurse is developing a plan of care for a client who has a spinal fracture and a complete spinal cord transection at the level of C5. Which of the following rehabilitation goals should the nurse add to the client's plan of care? a) Ability to achieve independent transfer from bed to wheelchair b) Independent control of bowel and bladder function c) Use of a wheelchair with a chin or mouth stick d) Ability to self-feed with the use of adaptive equipment

d-these clients have some issues using their upper extremities and we want to rehabilitate them to feed themselves

A nurse is teaching a client about preventing osteoporosis. Which of the following statements by the client indicates a need for further teaching? a) "I will reduce my intake of sodium." b) "I will decrease my intake of caffeine." c) "I will limit my intake of soft drinks." d) "I will reduce my intake of vitamin K-rich foods."

d-this is not bad

A nurse is caring for a client who is scheduled for an arthroplasty. The nurse asks the client to state if he understands the procedure that is being performed. Which of the following statements by the client indicates an understanding of the procedure? a) "This procedure determines the extent of joint damage." b) "This procedure will fuse my point to reduce my pain." c) "This procedure will prevent further joint damage." d) "This procedure will replace my joint to improve function."

d-this is reconstruction or replacement of a joint

A nurse is caring for a client who has had a SCI at the level of T2-T3. When planning care, the nurse should anticipate which of the following types of disability? a) Paresthesia b) Hemiplegia c) Quadriplegia d) Paraplegia

d-this is seen in SCI below T1

A nurse is assessing a client who has carpal tunnel syndrome. The nurse should expect which of the following findings? a) Decreased radial pulse b) Positive Chvostek's sign c) cool extremities d) positive Phalen's sign

d-this test is specifically for carpal tunnel (positive for tingling and numbness after wrist flexion for 60 seconds)

A nurse is educating coworkers on how to minimize back strain and avoid repeated episodes of low back pain. Which of the following strategies should the nurse include? (sata) a) Avoid prolonged sitting b) apply heat for 10 min every hour c) sleep in a side-lying position with flexed knees d) sleep on a soft mattress e) try padded shoe insoles

a, c, e -apply heat for 20-30 mins qid -we want them on a firm mattress for support

A nurse in the emergency department is monitoring a client who has a cervical spinal cord injury from a fall. The nurse should monitor the client for which of the following complications? (sata) a) Hypotension b) Polyuria c) Hyperthermia d) Absence of bowel sounds e) Weakened gag reflex

a, d, e -hyperthermia isn't a concern for this, but hypothermia would be -polyuria is incorrect, we would look for bladder distention

A nurse is assessing a client who has Paget's disease of the bone. Which of the following should the nurse expect? (sata) a) Cranial enlargement b) Skeletal pain c) Waddling gait d) Cold extremities e) Vision deficits

a,b,c -Paget's disease causes warmth on affected bones and it causes vision loss (not hearing loss)

A nurse in a provider's office is providing teaching to a client about modifiable risk factors for osteoporosis. Which of the following should the nurse include? (sata) a) Sedentary lifestyle b) Obesity c) Carbonated beverages d) Caffeine intake e) Smoking tobacco products

a,c,d,e

A nurse is teaching a client about the risk factors for osteoporosis. Which of the following factors should the nurse include in the teaching? (sata) a) Sedentary lifestyle b) obesity c) aging d) caffeine intake e) secondhand smoke

a,c,d,e

The nurse is assessing a client who has a herniated cerivcal disc. Which of the following findings should the nurse expect? (sata) a) Tingling in the arms b) Low-back pain c) Shoulder pain d) Muscle spasms e) Stiff neck

a,c,e

A nurse at a rehabilitation center is planning care for a client who had a left hemispheric CVA 3 weeks ago. Which of the following goals should the nurse include in the client's rehabilitations program? a) Establish the ability to communicate effectively. b) Compensate for loss of depth perception. c) Learn to control impulsive behavior. d) Improve left-side motor function.

a-left sided, so nurse should anticipate some aphasia and communication issues

A nurse is caring for a client taking aspirin for arthritis. The nurse should identify which of the following findings as an adverse effect of this medication? a) Tinnitus b) Clay colored stools c) Nystagmus d) Respiratory depression

a-ringing of them ears is one of the first signs of toxicity

A nurse is providing teaching for a family of a client who has parkinson's disease. Which of the following information should the nurse include in the teaching? a) provide client supervision b) limit client physical activity c) speak loudly to the client d) leave the television on continuously

a-their motor controls are very lackluster. They have problems ambulating and moving, so we don't want them doing physical activities alone

A nurse is caring for a client who has right-sided acoustic neuroma resulting in impairment of cranial nerves IX and X. Which of the following actions should the nurse take? a) place suction equipment at the client's bedside b) apply an eye patch at the client's right eye c) avoid the use of warm water to wash the client's face d) provide ROM exercises to the client's neck and shoulders

a-these are the glossopharyngeal and vagus nerves. this client is an aspiration risk so we may need some good ol sucky suck for them

A nurse is caring for a client with a new medical dx of Paget's disease. The nurse anticipates the provider will prescribe which of the following medications for this client? a) Alendronate b) Colchicine c) Prednisone d) Allopurinol

a-this is a bisphosphate, so it decreases bone resorption and minimizes loss of bone density -calchicine treats gout -Prednisone treats gout and RA -Allopurinol treats gout

A nurse in a long-term care facility is caring for an older adult client who had a stroke 4 weeks ago and who is unable to move independently. The nurse should monitor for which of the following complications of mobility? a) a reddened area over the sacrum b) Stiffness in the lower extremities c) difficulty moving the upper extremities d) difficulty hearing some types of sounds

a-this is a complication of immobility

A nurse is teaching a client who is starting to take alendronate effervescent tablets to treat osteoporosis. Which of the following information would the nurse include? a) "Sit upright or stand for at least 30 minutes after taking this medication." b) "Take this medication with food." c) "Take this medication with orange juice." d) "Chew or suck on the tablet."

a-this reduces medication contact with the esophagus and reduces the likelihood of esophagitis

A nurse is teaching a client at high risk for osteoporosis about dietary measures she can take to increase her calcium level. Which of the following foods should the nurse advise the client to increase in her diet? a) Carrots b) Broccoli c) Cabbage d) Potatoes

b

A nurse is teaching a client who will receive a prosthetic leg. Which of the following statements should the nurse identify as an indication that the client needs further instruction? a) "I will need to wear a sock over the residual portion of the leg." b) "The technician will complete the prosthesis fitting at the time the surgeon removes the staples." c) "I'll need to wear a sturdy pair of shoes for the prosthesis fitting." d) "I can apply elastic bandages to help shrink my residual leg."

b-The surgeon will remove the staples before the shrinking and shaping of the residual leg is complete. If the technician did the fitting before shrinkage and shaping, the prothesis would not fit later.

A nurse is providing nutritional teaching to a client who has osteoporosis. Which of the following foods should the nurse recommend as being highest in Ca? a) 1 cup of carrot strips b) 3 oz of canned salmon c) 1 cup of chopped chicken breast d) 1 plain baked potato

b-fish contains lots of Ca

A nurse is caring for a client who has paraplegia following an MVA. The client is on an intermittent urinary catheterization program. Which of the following findings indicates the need for catheterization? a) Urge incontinence b) Dribbling of urine c) Weight gain d) Rectal distention

b-overflow incontinence and therefore bladder distention

A nurse is modifying the diet of a client who has Parkinson's and is prescribed selegiline, an MAOI. Which of the following should the nurse eliminate? a) Fresh fish b) Cheddar cheese c) Cherries d) Chicken

b-this contains tyramine, which can cause a hypertensive crisis

The nurse is teaching a client who is taking benzotropine to treat Parkinson's. The nurse should instruct the client to report which of the following adverse effects? a) Excess salivation b) Difficulty voiding c) Diarrhea d) Slow pulse

b-this drug is a muscle relaxer and may cause the client to experience trouble flexing their detrusor muscle

A nurse is assessing a client who reports numbness and pain in his right paln, index finger, and middle finger. The client reports working with a keyboard most of the time while at work. The nurse suspects carpal tunnel syndrome. Which of the following tests should the nurse request the client to perform? a) hold the arm straight b) hold wrist at a 90-degree flexion c) flex the arm at the elbow d) extend the right arm upward

b-this is phalen's sign

A nurse is teaching an older client who has osteoporosis about beginning a program of regular physical activity. Which of the following recommendations should the nurse make? a) High-impact aerobics b) Walking briskly c) Riding a bicycle d) stretching exercises

b-this provides some mild weight-bearing for them, which strengthens they bones

A nurse is caring for an older client who has dementia and handles anxiety by confabulating. The nurse should recognize confabulation when the client... a) displays compulsive and ritualistic behaviors. b) reminisces about the past. c) makes up stories when he is unable to remember actual events. d) refuses to leave home to see a provider.

c

A nurse is planning care for a female client who has a T4 SCI and is at risk for acquiring a UTI. Which of the following actions should the nurse include in the client's plan of care? a) Cleanse the perineum from back to front. b) Obtain a prescription for an indwelling urinary catheter. c) Encourage fluid intake at and between meals. d) Offer the client the bedpan every 2 hr.

c

A nurse is teaching a client about medications that prevent osteoporosis. The nurse should instruct the client that which of the following medications is prescribed to prevent osteoporosis? a) Levothyroxine b) Calcitonin c) Raloxifene d) Allopurinol

c -levothyroxine is for hypothyroidism -calcitonin is for those who already have it -raloxifene is for prevention -allopurinol is for gout and hyperuricemia

A nurse is caring for a client who had a right-sided stroke and is exhibiting homonymous hemianopsia when eating. Which of the following actions should the nurse take? a) Provide nonskid mat t alleviate plate movement b) Encourage the client to use his right hand when feeding himself c) Remind the client to look for food on the left side of the tray d) Encourage the use of wide grip utensils

c This is a condition where the client can only see only one side. Since this is right-side-affected, then the left eye will be the problem eye. We will want to train the client to utilize this eye as much as possible until the condition resolves.

A nurse is developing a plan of care to prevent skin breakdown for a client with a SCI and paralysis. Which of the following nursing actions are appropriate? (sata) a) massage over erythematous bony prominances b) implement a turning schedule every 4 hours c) use pillows to keep heals off the bed surface d) keep the client's skin dry with powder e) minimize skin exposure to moisture

c,e -turn schedule every 2 hours -powder is bad for skin-use lotion instead -dont ****ing massage bony prominances ya hooligans

A nurse is assessing a client who has Parkinson's. Which of the following manifestations should the nurse expect? a) Pruritus b) Hypertension c) Bradykinesia d) Xerostomia

c-this is difficulty moving d refers to dry mouth, but these patients have excessive drooling

A nurse is preparing to administer a PO medication to a client who has myasthenia gravis. Which of the following actions should the nurse take prior to administering the client medications? a) Have the client empty his bladder. b) Put up the side rails on the client's bed. c) Ask the client to take a few sips of water. d) Place the client in low Fowler's position.

c-we want to make sure they can swallow and will not aspirate the medication

A nurse is teaching a client who has a prosthetic limb d/t a right below-the-knee amputation about prosthesis and stump care. Which of the following instructions should the nurse include in the teaching? a) Keep the prosthesis in direct contact with the residual limb. b) Apply a moisturizing lotion or oil to the stump daily. c) Dry the prosthesis socket completely before applying it to the limb. d) Expect some skin irritation from the prosthesis.

c-yo we dont want no skin breakdowm mannnnn, keep that shit dry