Crisis 2 Final Exam

Paget's

Abnormal bone breakdown and formation

What medication do you avoid if diagnosed with gout?

Aspirin

Instructions for a client with severe vertigo related to Meniere's disease include:

Avoid sudden head movements

A nurse in a clinic is caring for a client who has frequent migraine headaches. The client asks about foods that can cause headaches. The nurse should recommend that the client avoid which of the following foods? a.) Baked salmon b.) Salted cashews c.) Frozen strawberries d.) Fresh asparagus

B

A nurse is admitting an adult client who has suspected osteoporosis. Which of the following findings are risk factors for osteoporosis? (select all that apply) a.) History of consuming one glass of wine daily b.) Loss in height of 2 in. c.) Body mass index (BMI) of 18 d.) Kyphotic curve at upper thoracic spine e.) History of lactose intolerance

B

A nurse is caring for a client who has SLE and is experiencing an episode of Raynaud's phenomenon. Which of the following findings should the nurse anticipate? a.) Swelling of joints of the fingers b.) Pallor of toes with cold exposure c.) Feet that become reddened with ambulation d.) Client report of intense feeling of heat in the fingers

B

A nurse is caring for a client who has a spinal cord injury who reports a severe headache and is sweating profusely. Vital signs include blood pressure 220/110 mm Hg and apical heart rate 54/min. Which of the following actions should the nurse take first? a.) Examine skin for irritation or pressure b.) Sit the client upright in bed c.) Check the urinary catheter for blockage d.) Administer antihypertensive medication

B

A nurse is caring for a client who has diabetes mellitus and reports a gradual loss of peripheral vision. The nurse should recognize this as a manifestation of which of the following diseases? a.) Cataracts b.) Open-angle glaucoma c.) Macular degeneration d.) Angle-closure glaucoma

B

A nurse is caring for a client who received a lower back injury during a fall and describes sharp pain in the back and down the left leg. In which of the following positions should the nurse plan to place the client to attempt to decrease the pain? a.) Prone without use of pillows b.) Semi-Fowler's with a pillow under the knees c.) High-Fowler's with the knees flat on the bed d.) Supine with the head flat

B

A nurse is providing care for a client who had a vertebroplasty of the thoracic spine. Which of the following actions should the nurse take? a.) Apply heat to the puncture site b.) Place the client in a supine position c.) Turn the client every 1 hour d.) Ambulate the client within the first hour postprocedure

B

A nurse is providing dietary teaching about calcium-rich foods to a client who has osteoporosis. Which of the following foods should the nurse include in the instructions? a.) White bread b.) Kale c.) Apples d.) Brown rice

B

A nurse is providing information about capsaicin cream to a client who reports continuous knee pain from osteoarthritis. Which of the following information should the nurse include in the discussion? a.) Continuous pain relief is provided b.) Put on gloves before applying the cream to other parts of the body c.) Leave cream on the hands for 10 min following application d.) Apply the medication every 2 hr during the day

B

A nurse is caring for a male older adult client who has a new diagnosis of glaucoma. Which of the following should the nurse recognize as risk factors associated with this disease? (select all that apply) a.) Sex b.) Genetic predisposition c.) Hypertension d.) Age e.) Diabetes mellitus

B, C, D, E

A nurse in a provider's office is obtaining a health history from a client who has cluster headaches. Which of the following are expected findings? (select all that apply) a.) Pain is bilateral across the posterior occipital area b.) Client experiences altered sleep-wake cycle c.) Headache occurs approximately 1 to 8 times daily d.) Client describes headache pain as dull and throbbing e.) Nasal congestion and drainage occur

B, C, E

A nurse is completing preoperative teaching for a client who is to undergo an arthroscopy to repair a shoulder injury. Which of the following statements should the nurse include? (select all that apply) a.) "avoid damage or moisture to the cast on your arm" b.) "Inspect your incision daily for indications of infection" c.) "Apply ice packs to the area for the first 24 hours." d.) "Keep your arm in a dependent position" e.) "Preform isometric exercises"

B, C, E

A nurse is caring for a client who has rheumatoid arthritis. Which of the following laboratory tests are used to diagnose this disease? (select all that apply) a.) Urinalysis b.) Erythrocyte sedimentation rate (ESR) c.) BUN d.) Antinuclear antibody (ANA) titer e.) WBC count

B, D, E

A nurse is educating clients at a health fair about dual-energy x-ray absorptiometry (DXA) scans. Which of the following information should the nurse include? (select all that apply) a.) The test requires the use of contrast materials b.) The hip and spine are the usual areas the device scans c.) The scan detects osteoarthritis d.) Bone pain can indicate a need for a scan e.) Females should have a baseline scan during their 40s

B, D, E

What disorder can cause facial paralysis?

Bell's Palsy

With retinal detachment, areas of detachment appear what color?

Bluish-Gray

What nursing assessment is an expected finding with early stages of cataract formation?

Blurred Vision

A nurse in a clinic is teaching a client who has a history of migraine headaches about a new prescription for zolmitriptan. Which of the following statements by the client indicates understanding of the teaching? a.) "This medication will relieve my symptoms by causing blood vessels to dilate" b.) "I should take this medication daily to prevent the headache from occurring" c.) "I should expect facial flushing when I take this medication" d.) "This medication will lower my sensitivity to food triggers"

C

A nurse is teaching a client who has SLE about self-care. Which of the following statements by the client indicates an understanding of teaching? a.) "I should limit my time to 10 minutes in the tanning bed" b.) "I will apply powder to any skin rash" c.) "I should use a mild hair shampoo" d.) "I will inspect my skin once a month for rashes"

C

A nurse is caring for a client who has a new diagnosis of cataracts. Which of the following manifestations should the nurse expect? (select all that apply) a.) Eye pain b.) Floating spots c.) Blurred vision d.) White pupils e.) Bilateral red reflexes

C, D

A nurse is planning care for a client who will undergo electromyography (EMG). Which of the following actions should the nurse include? (select all that apply) a.) Assess for bruising b.) Administer aspirin prior to the procedure c.) Determine whether the client takes a muscle relaxant d.) Instruct the client to flex muscles during needle insertion e.) Expect swelling, redness, and tenderness at the insertion sites

C, D

Injury to what vertebrae requires vent dependency?

C3 and above

Injury to what vertebrae would cause complete paralysis below the neck?

C4

Injury to what vertebrae indicated respiratory insufficiencies?

C4 and below

Injury to the Lumbar and Sacral nerve roots results in what?

Cauda Equine

A nurse is assessing a client who has a new diagnosis of SLE. Which of the following findings should the nurse expect? a.) Weight gain b.) Petechiae on thighs c.) Systolic murmur d.) Alopecia

D

A nurse is caring for a client who experienced a cervical spine injury 24 hr. ago. Which of the following prescriptions should the nurse clarify with the provider? a.) Anticoagulant b.) Plasma expanders c.) H2 antagonists d.) Muscle relaxants

D

A nurse is caring for a client who has a C4 spinal cord injury. The nurse should recognize the client is at greater risk for which of the following complications? a.) Neurogenic shock b.) Paralytic ileus c.) Stress ulcer d.) Respiratory compromise

D

A nurse is caring for a client who has suspected Menieres disease. Which of the following is an expected finding? a.) Presence of a purulent lesion in the external ear canal b.) Feeling of pressure in the ear c.) Bulging, red, bilateral tympanic membranes d.) Unilateral hearing loss

D

A nurse is obtaining a health history from a client who is being evaluated for the cause of frequent headaches. Which of the following questions should the nurse ask to identify the aura type of migraine headaches? a.) "Do the headaches occur multiple times each day?" b.) "Is your headache accompanied by profuse facial sweating?" c.) "Does your headache occur on one side of your head?" d.) "Do you have the same manifestations each time the headache occurs?"

D

A nurse is preforming an otoscopic examination of a client. Which of the following is an unexpected finding? a.) Pearly gray tympanic membrane (TM) b.) Malleus visible behind the TM c.) Presence of soft cerumen in the external canal d.) Fluid or bubbles seen behind the TM

D

A nurse is providing discharge instructions to a client who has a new diagnosis of migraine headaches. Which of the following instructions should the nurse include? a.) Use music therapy for relaxation with the onset of the headache b.) Increase physical activity when a headache is present c.) Drink beverages that contain artificial sweeteners to prevent headaches d.) Apply a cool cloth to the face during a headache

D

A nurse is providing postoperative teaching to a client following cataract surgery. Which of the following statements should the nurse include in the teaching? a.) "You can resume playing golf in 2 days" b.) "You need to tilt your head back when washing your hair" c.) "You can get water in your eyes in 1 day" d.) "You need to limit your housekeeping activities"

D

A nurse is teaching a client who is going to have a bone scan. Which of the following statements should the nurse include? a.) "You will receive an injection of a radioactive isotope when the scanning procedure begins." b.) "You will be inside a tube-like structure during the process." c.) "You will need to take a radioactive precautions with your urine for 24 hours after the procedure." d.) "You will have to urinate just before the procedure."

D

Sensorineural Hearing Loss

Damage to cranial nerve VIII

Respiratory Difficulties with Injury to C5-T6

Decreased respiratory reserve

A sense of a curtain falling across the field of vision is a sign of what?

Detached Retina

What is the leading cause of blindness?

Diabetic Retinopathy

Most common precipitating factor of Autonomic Dysreflexia

Distended Bladder or Rectum

Thinning retinal tissue with yellowish spots is called what?

Dry Macular Degeneration

Glaucoma

Excess fluid results in increased pressure on the retina

Loss of peripheral vision is called what?

Glaucoma

Osteomyelitis

Infection of the bone

A client splashes a chemical in his eyes. What is the 1st intervention?

Irrigate eyes with normal saline

Injury to what vertebrae would cause paralysis only below the waist?

L1

How long will a patient with Glaucoma use eye medication?

Lifetime

Loss of central vision is called what?

Macular Degeneration

Herberden's and Bouchard's Nodes are evident in what disease?

Osteoarthritis

Noninflammatory Synovial Joints are present in what?

Osteoarthritis

Stiffness in the morning lasting 30 mins in indicative of what disorder?

Osteoarthritis

Is Glaucoma painful or painless?

Painless

Ripe Cataracts

Poor light penetration

Conductive Hearing Loss

Problem conducting sound waves through the ear

What nutrition category should a patient consume if they have a pressure ulcer?

Protein

Loss of night vision in childhood is an early sign of what?

Retinitis Pigmentosa

Systemic effects are present in what form of Arthritis: Rheumatoid or Osteo?

Rheumatoid

DMARDS are used to treat what?

Rheumatoid Arthritis

Inflammatory Synovial Joints are present in what?

Rheumatoid Arthritis

Sjogren's Syndrome is associated with what disease?

Rheumatoid Arthritis

Stiffness in the morning lasting 60 mins in indicative of what disorder?

Rheumatoid Arthritis

Osetomalacia

Softening of the bone

Immature Cataracts

Some light gets through

Most Common Cause of Osteomyelitis

Staph Aureus

The autoimmune disease in which the body attacks its own tissues is referred to as what?

Systemic Lupus

Injury to what vertebrae would cause paralysis only below the chest?

T6

What vertebrae injury location signifies Neurogenic Shock?

T6 or higher

The most common client complaint with an inner ear disorder is:

Tinnitus

Cluster headaches occur at the same time of day for 4 to 12 weeks True or False?

True

Loss of vision with Glaucoma is permanent True or False?

True

What food can cause migraines?

Tyramine (Nuts)

Autonomic Dysreflexia

Uncompensated cardiovascular reaction due to an irritant below the level of injury

What medication is used to treat HTN during autonomic dysreflexia?

Vasodilators

Domes of fluid on the retina is called what?

Wet Macular Degeneration

Glaucoma Risk Factors

- African Americans - HTN - Diabetes - Age - Tumors - Infection

Respiratory Difficulties with Injury to C1-3

- Apnea - Inability to cough

Cauda Equine Characteristics

- Asymmetrical distal weakness - Flaccid lower extremity paralysis - Flaccid bladder and bowel

Tension Headache

- Bilateral - Tightening

What vital signs characterize Neurogenic Shock?

- Bradycardia - Hypotension

Vital Signs with Injury above T5

- Bradycardia - Hypotension

Systemic Lupus S/S

- Butterfly Rash - Photosensitivity - HTN - Alopecia

2 Types of Hearing Loss

- Conductive - Sensorineural

Nursing Care after Post Op Cataracts

- Do not lift more than 5 lbs - Do not rub eye - No aspirin

Autonomic Dysreflexia Nursing Interventions

- Elevate HOB - Notify HCP - Monitor & Treat BP - Assess & Remove Cause

Stage 4 Pressure Ulcer

- Full Thickness - Visible Bone, Tendon or Muscle

Stage 3 Pressure Ulcer

- Full Thickness - Visible Fat

Autonomic Dysreflexia Manifestations

- HTN (up to 300 systolic) - Bradycardia - Marked diaphoresis above of injury - Throbbing Headache

Post Op Carpal Tunnel Care

- Hourly circulation checks - Hand on pillow

Cardiac Response to Neurogenic Shock

- Hypotension - Bradycardia

Nursing Care for Cataracts

- Increase the light in the room - Large print - Magnifying lens

Stage 1 Pressure Ulcer

- Intact Skin - Redness

Osteoarthriris S/S

- Joint Stiffness - Asymmetric - Crepitation - Herberden's and Bouchard's

Precipitating Factors of Systemic Lupus

- Meds - Stress - Sunlight - Pregnancy - Genetics

Nursing Management of Systemic Lupus

- Monitor for seizures - Manage Stress - Avoid Infections

What class of drugs are used to help treat Paget's?

- NSAIDS - Bisphosphonates

Cluster Headache

- Pain in and around one eye - Sharp, stabbing, penetrating

Stage 2 Pressure Ulcer

- Partial Thickness - Skin loss

Respiratory Difficulties with Injury to C4

- Poor Cough - Hypoventilation - Diaphragmatic Breathing

Rheumatoid Arthritis S/S

- Symmetric - Stiffness - Limited Movement

Autonomic Dysreflexia Irritants

- UTI - Constipation - Distended Bowel

Migraine

- Unilateral/Bilateral - Throbbing - Manifestations of neurologic and autonomic dysfunction

Osteomalacia Nursing Interventions

- Vitamin D - Calcium - Protein - Sunlight

Normal Uric Acid Level

2.5-8

A nurse is caring for a client who experienced a cervical spine injury 3 months ago. The nurse should plan to implement which of the following types of bladder management methods? a.) Condom catheter b.) Intermittent urinary catheterization c.) Crede's method d.) Indwelling urinary catheter

A

A nurse is completing discharge teaching to a client following middle ear surgery. Which of the following statements by the client indicates understanding of the teaching? a.) "I should restrict rapid movements and avoid bending from the waist for several weeks" b.) "I should wait until the day after surgery to wash my hair" c.) "I will remove the dressing behind my ear in 7 days" d.) "My hearing should be back to normal right after my surgery"

A

A nurse is planning care for a client who has a spinal cord injury involving a T12 fracture 1 week ago. The client has no muscle control of the lower limbs, bowel, or bladder. Which of the following should be the nurses highest priority? a.) Prevention of further damage to the spinal cord b.) Prevention of contractures of the lower extremities c.) Prevention of skin breakdown of areas that lack sensation d.) Prevention of postural hypotension when placing the client in a wheelchair

A

A nurse is providing teaching for a client who has a new diagnosis of dry macular degeneration. Which of the following instructions should the nurse include in the teaching? a.) Increase intake of deep yellow and orange vegetables b.) Administer eye drops twice daily c.) Avoid bending at the waist d.) Wear an eye patch at night

A

A nurse is teaching a client who has a new diagnosis of rheumatoid arthritis. Which of the following statements should the nurse include in the teaching? a.) "You can experience morning stiffness when you get out of bed" b.) "You can experience abdominal pain" c.) "You can experience weight gain" d.) "You can experience low blood sugar"

A

A nurse is reviewing the health record of a client who has severe otitis media. Which of the following are expected findings? a.) Enlarged adenoids b.) Report of recent colds c.) Client prescription for daily furosemide d.) Light reflex visible on otoscopic exam in the affected ear e.) Ear pain relieved by medicine

A, B

A nurse is planning discharge teaching on home safety for an adult client who has osteoporosis. Which of the following information should the nurse include in the teaching? (select all that apply) a.) Remove throw rugs in walkways b.) Use prescribed assistive devices c.) Remove clutter from the environment d.) Wear soft-bottomed shoes e.) Maintain lighting of doorway areas

A, B, C, E

A nurse in a clinic is caring for a client who has been experiencing mild to moderate vertigo due to benign paroxysmal vertigo for several weeks. Which of the following actions should the nurse recommend to help control the vertigo? (select all that apply) a.) Reduce exposure to bright lighting b.) Move head slowly when changing positions c.) Do not eat fruit high in potassium d.) Plan evenly spaced daily fluid intake e.) Avoid fluids containing caffeine

A, B, D

A nurse is discussing gout with a client who is concerned about developing the disorder. which of the following findings should the nurse identify as risk factors for this disease? (select all that apply) a.) Diuretic use b.) Obesity c.) Deep sleep deprivation d.) Depression e.) Cardiovascular disease

A, B, E

A nurse working in an outpatient clinic is assessing a client who has rheumatoid arthritis (RA). The client reports increased joint tenderness and swelling. Which of the following findings should the nurse expect? (select all that apply) a.) Recent influenza b.) Decreased range of motion c.) Hypersalivation d.) Increased blood pressure e.) Pain at rest

A, B, E

A nurse is planning care for a client who is postoperative following an arthroscopy of the knee. Which of the following actions should the nurse take? (select all that apply) a.) Assess color and temperature of the extremity b.) Apply warm compresses to the incision sites c.) Place pillows under the extremities d.) Administer analgesic medication e.) Assess pulse and sensation in the foot

A, C, D, E

A nurse is providing information to a client who has osteoarthritis of the hip and knee. Which of the following information should the nurse include in the information? (select all that apply) a.) Apply heat to joints to alleviate pain b.) Ice inflamed joints for 30 min after activity c.) Reduce the amount of exercise done on days with increased pain d.) Prop the knees with a pillow while in bed e.) Active range of motion is more effective than passive

A, C, E

A nurse is reviewing the plan of care for a client who has systemic lupus erythematosus (SLE). The client reports fatigue, joint tenderness, swelling, and difficulty urinating. Which of the following laboratory findings should the nurse anticipate? (select all that apply) a.) Positive ANA titer b.) Increased hemoglobin c.) 2+ urine protein d.) Increased serum C3 and C4 e.) Elevated BUN

A, C, E

A nurse is assessing a client who has osteoarthritis of the knees and fingers. Which of the following manifestations should the nurse expect to find? (select all that apply) a.) Heberden's nodes b.) Swelling of all joints c.) Small body frame d.) Enlarged joint size e.) Limp when walking

A, D, E

A nurse is preforming health screenings at a health fair. Which of the following clients have a risk factor for osteoporosis? (select all that apply) a.) A 40-year-old client who has been taking prednisone for 4 months b.) A 30-year-old client who jogs 3 miles a day c.) A 45-year-old client who take phenytoin for seizures d.) A 65-year-old client who has a sedentary lifestyle e.) A 70-year-old client who has smoked for 50 years

A, D, E

A nurse is providing teaching for a client who has a history of low back injury. Which of the following instructions should the nurse give the client to prevent future problems with low back pain? (select all that apply) a.) Engage in regular exercise including walking b.) Sit up for 10 hr each day to rest the back c.) Maintain weight within 25% of ideal body weight d.) Create a smoking cessation plan e.) Wear low-heeled shoes

A, D, E