Evolve Questions Ch. 42, 43, 45, 46, 47

The nurse assesses a client diagnosed with Sjögren syndrome. The nurse anticipates that the client will also have which symptom? A. Excessive production of saliva in the mouth B. Intermittent episodes of diarrhea C. Abdominal bloating after eating D. Dry eyes

Answer: D Rationale: Clients with Sjögren syndrome experience dry eyes (keratoconjunctivitis sicca), dry mouth, and if female, dry vagina.

The nurse is caring for a client who has an external fixator for an open fracture of the tibia and fibula. What is the nurse's priority for care related to the fixator? A. Inspect the pins to monitor for infection and do not remove crusts. B. Make sure that the wound is managed using a moist wound healing method. C. Keep the leg covered to keep the extremity warm to promote circulation. D. Keep the extremity elevated to three pillows while in bed or in a chair.

Answer: A Rationale: An external fixator is a series of pins attached to a metal frame to hold the bone ends in place while the wound can be managed. The nurse would frequently monitor the pin insertion sites for signs and symptoms of infection. Crusting that occurs at the sites should not be removed because it helps seal the open pin site areas to prevent infection. Leg elevation is important but the client would not necessarily need three pillows.

The nurse is reviewing the laboratory test results of a client with a recently diagnosed osteosarcoma. What abnormal laboratory finding would the nurse expect for this client? A. Elevated alkaline phosphatase B. Decreased hematocrit C. Increased calcium D. Increased white blood cell count

Answer: A Rationale: An osteosarcoma is a type of primary malignant bone tumor. Alkaline phosphatase is an enzyme that is released from the bone when it is diseased or damaged. All of these lab values would be expected in clients who have bone metastasis.

The nurse is preparing to give apixaban for a client who recently had a total knee arthroplasty. What does the nurse recognize as the advantage of this drug over other anticoagulants? A. The client does not need to have labs drawn for PT or INR. B. The client only needs to take the drug while in the hospital. C. The client is not at risk for bleeding or bruising. D. The client does not need to wear sequential compression devices.

Answer: A Rationale: Apixaban is a newer factor Xa inhibitor that helps to prevent venous thromboembolism in clients who have a total knee arthroplasty. The client taking this drug will need to continue for several weeks after surgery and is at risk for bleeding or bruising. However, the drug does not affect PT or INR, so that the client does not need to have labs drawn.

An older adult client has had an open reduction and internal fixation of a fractured right hip. Which intervention does the nurse implement for this client? A. Keep the client's heels off the bed at all times. B. Reposition the client every 3 to 4 hours. C. Avoid the use of antiembolism stockings. D. Administer pain medication before deep-breathing exercises.

Answer: A Rationale: Because the client is an older adult and is more at risk for skin breakdown because of impaired circulation and sensation, the client's heels must be kept off the bed at all times to avoid constant pressure on this sensitive area. Repositioning the older adult client must be done every 2 hours, not every 3 to 4 hours, to prevent skin breakdown and to inspect the skin for any signs of breakdown. Pain medication would not be administered for deep-breathing exercises because this client typically would not experience pain upon breathing. Antiembolic stockings or sequential compression devices are used for older adults to help prevent venous thromboembolism (VTE).

While reading a client's optical chart, the nurse notices that the client has emmetropia. Which assessment findings does the nurse anticipate? A. No corrective lenses; this is a normal finding B. Reading glasses C. Contact lenses D. Bilateral eye patches

Answer: A Rationale: Emmetropia is perfect refraction (bending of light rays from the outside world into the eye) of the eye. Emmetropia is a normal (and ideal) condition that does not require any treatment. Eye patches, contact lenses, and reading glasses are not needed.

The nurse is caring for an older adult client diagnosed with osteomalacia. The nurse anticipates that the primary health care provider will request which supplement? A. Vitamin D3 B. Vitamin C C. Calcium D. Phosphorus

Answer: A Rationale: Osteomalacia is loss of bone related to vitamin D deficiency. The major treatment for osteomalacia is vitamin D in an active form such as ergocalciferol (Calciferol). Vitamin C is not indicated for the treatment of osteomalacia, which is related to vitamin D deficiency. Phosphorus interferes with the absorption of calcium. Calcium is not indicated in the treatment of osteomalacia.

The nurse is caring for a client who is diagnosed with osteopenia. Which T-score will the nurse expect to see for this client after a bone mineral density (BMD) test? A. −2 B. −3 C. 0 to −1 D. +1.5

Answer: A Rationale: The T-score represents the standard deviations above or below the average BMD for young, healthy adults. A T-score of −1 to −2.5 represents osteopenia. The T-score in a young, healthy adult is 0. A normal T-score is between +1 and −1. A score of +1.5 is not a part of the T-score. A T-score of −3 represents osteoporosis.

The nurse is caring for a client who is admitted with mastoiditis. Which nursing action is appropriate? A. Don gloves to examine the pinna. B. Prepare to administer IV antibiotics C. Perform a baseline hearing assessment. D. Teach about Swim-Ear to dry the ears better.

Answer: A Rationale: The appropriate nursing action when a client is admitted for mastoiditis is to prepare to administer IV medication. Mastoiditis can progress to a brain abscess, meningitis, or death if not appropriately managed. Teaching about Swim-Ear, donning gloves to examine the pinna, and performing a baseline hearing assessment are not parts of care associated with mastoiditis. Interventions are focused on halting the infection before it spreads to other structures.

The nurse is caring for a client with osteoarthritis (OA) in the left knee. What factor does the nurse suspect is the most likely cause of this client's OA? A. Trauma to the joint B. Aging C. Osteoporosis D. Familial history

Answer: A Rationale: The client has OA in one knee which suggests that the client has secondary OA rather than primary disease. Secondary OA occurs as a result of joint injury or obesity.

A client with an open fracture of the left femur is admitted to the emergency department after a motorcycle crash. Which action is essential for the nurse to take first? A. Check the dorsalis pedis pulses. B. Administer the prescribed analgesic. C. Place a dressing on the affected area. D. Immobilize the left leg with a splint.

Answer: A Rationale: The essential nursing action is to check the dorsalis pedis pulses. It is necessary to assess the circulatory status of the leg because the client is at risk for acute compartment syndrome, which can begin as early as 6 to 8 hours after an injury. Severe tissue damage can also occur if neurovascular status is compromised. Immobilization will be needed, but the nurse must assess the client's condition first. Administering an analgesic and placing a dressing on the affected area would both be done after the nurse has assessed the client.

A client sustains a fracture of one arm and the primary health care provider applies a synthetic cast to the extremity. What will the nurse teach the client to do during the first 24 hours after discharge from the emergency department? A. Monitor neuromuscular status for decreased circulation and sensation in the extremity. B. Check the fit of the cast by inserting a tongue blade between the cast and the skin. C. Apply a heating pad for 15 to 20 minutes four times daily to help with pain. D. Keep the cast covered with a soft towel to help it to dry quickly.

Answer: A Rationale: The most important intervention the nurse teaches the client is to monitor the neurovascular status during the first 24 hours after ED discharge. The client should apply ice for discomfort, not heat. The client should not place anything between the cast and the skin. In assessing fit, one finger should easily fit between the cast and the skin. The cast dries quickly because it is made of synthetic materials.

A client who had a right elective above-the-knee amputation reports severe pain in the right lower leg and foot. What is the nurse's best action at this time? A. Assess the level of the client's pain. B. Change the subject and talk about the client's hobbies. C. Distract the client with stories about the nurse's family. D. Remind the client that the lower leg was removed.

Answer: A Rationale: The nurse should recognize that the pain (phantom limb pain) is real to the client and perform a pain assessment in preparation for pain management. The other options are not examples of acknowledging the client's concern or therapeutic responses to the client in this situation.

A young female client whose mother and grandmother have osteoporosis asks whether she needs to take steps to prevent this disease in herself. What will the nurse tell this client? A. "Now is the time to begin building strong bones." B. "Your risk isn't present until age 50; we can talk about it then." C. "You do not have to worry about symptoms at your age." D. "You should begin to take steps to prevent disease at age 30."

Answer: A Rationale: The nurse will tell this client that peak bone mass is achieved by about 30 years of age in most women, so building strong bone as a young person may be the best defense against osteoporosis in later adulthood. She needs to begin getting adequate calcium and vitamin D now as well as exercising to help build strong bones. The nurse will not tell the client not to worry about symptoms at her age. Beginning at age 30 may be too late. By the time symptoms appear in older adulthood, it is too late to build strong bones.

An older adult client who has osteoporosis is discharged from the hospital. What does the nurse include in health teaching related to the client's home safety? A. "Keep walkways free of clutter." B. "Keep light low to prevent glare." C. "Walk slowly on wet floor areas after mopping." D. "Use area rugs on tile floors."

Answer: A Rationale: The nurse teaches the client that walkways in the home must be clear of clutter and obstacles to help prevent falls. Clients with metabolic bone problems should not use area rugs at home because they may cause tripping or falling. Clients with metabolic bone problems must not walk on wet floors because the potential for falling is too great. Keeping the lights low would not allow the client to see adequately to walk safely or avoid an object on the floor.

The nurse is caring for a postoperative client with total hip arthroplasty. What actions would the nurse take to prevent venous thromboembolism (VTE) postoperatively? Select all that apply. A. Apply pneumatic or sequential compression devices. B. Administer anticoagulant therapy. C. Ambulate the client on the day of surgery. D. Elevate the client's legs. E. Keep the legs slightly abducted.

Answer: A, B, C Rationale: Preventive postoperative actions that help prevent VTE include pharmacology (anticoagulants), ambulation, and compression.

A client is admitted to the emergency department following a left severe ankle sprain caused by playing football with friends. What nursing actions will the nurse implement at this time? Select all that apply. A. Elevate the left leg above the level of the heart. B. Tell the client to keep his left leg still. C. Apply an elastic wrap or ankle or compression brace. D. Administer morphine via IV push. E. Apply heat to promote blood flow and healing.

Answer: A, B, C Rationale: The nurse follows the RICE approach to emergency care of clients who experience a sports-related injury, which includes rest, ice, compression, and elevation of the affected part. Heat may be used after 24 hours, but ice is needed now to reduce swelling. The client does not need a strong opioid for this injury.

Which client does the nurse identify that is at high risk for developing hearing problems Select all that apply. A. Teenager listening to music using ear buds B. Airline mechanic C. Drummer in a rock band D. Client with Down syndrome E. Telephone operator

Answer: A, B, C, D Rationale: Clients who are at high risk for hearing problems include an airline mechanic who is exposed to excessive noise, a client with Down syndrome, (a genetic condition associated with frequent hearing problems), a drummer in a rock band due to exposure to loud noise, and a teenager listening to music using ear buds. Ear buds are known risk factors for increasing potential hearing loss among people who use them on a regular basis with elevated noise levels. A telephone operator is not at risk for hearing problems simply because he or she may wear headphones or audio equipment.

The nurse providing education on eye protection suggest protective eyewear for which client? Select all that apply. A. Racquetball player B. Lifeguard C. Cab driver D. Registered nurse E. College student

Answer: A, B, C, D, E Rationale: All clients are in need of eye protection from ultraviolet (UV) A and UVB rays because of exposure to the sun. People who play sports need to wear protective eyewear to prevent possible eye injury. Nurses may need protective eyewear to avoid getting or transmitting infection.

The nurse recognizes that a client who has persistent pain may have difficulty with pain management after a total joint arthroplasty. What collaborative interventions are needed to help the client manage postoperative pain? Select all that apply. A. Establish trust and explain the postoperative pain management plan. B. Consult the pain management team if needed and available. C. Plan continuing pain management after discharge. D. Use multimodal and alternative pain management modalities. E. Identify at-risk clients preoperatively using a comprehensive assessment.

Answer: A, B, C, D, E Rationale: All of these interventions are needed to successfully manage pain for clients who have persistent (chronic) pain.

The nurse is teaching a client preparing to have a total knee replacement about interventions to help prevent surgical infection. What interventions would the nurse include in this teaching? Select all that apply. A. Using nasal mupirocin for at least a week before surgery B. Avoiding sleeping with pets in the client's bed C. Showering the night before and the morning of surgery with chlorhexidine D. Giving antibiotics before and after surgery for at least 3 days E. Sleeping on clean linen wearing clean nightwear

Answer: A, B, C, E Rationale: All of these interventions are used to help prevent infection except for the use of long-term antibiotics. Long-term antibiotic therapy is used to treat rather than prevent postoperative infection.

Which systemic disorder may affect vision and require yearly eye examination by an ophthalmologist? Select all that apply. A. Hypertension B. Diabetes mellitus C. Hepatitis D. Anemia E. Multiple sclerosis (MS)

Answer: A, B, E Rationale: Clients who are diabetic are at risk for diabetic retinopathy and are in need of annual eye examinations. Clients with elevated blood pressure need to have annual eye examinations because of the increased risk for retinal damage. Clients with MS should have annual examinations because of changes that occur with the neurologic effects of MS that impact visual acuity. Anemia does not require eye examination on a routine basis. Hepatitis does not increase eye risk and is not indicated as a disorder requiring annual examinations.

The nurse is caring for a client who is at risk for osteoporosis. What lifestyle changes might the client be able to implement to decrease this risk? Select all that apply. A. Avoiding excessive alcohol consumption B. Increasing foods high in phosphorus C. Decreasing consumption of carbonated beverages D. Preventing a sedentary daily lifestyle E. Seeking a smoking cessation program, if needed F. Including more calcium-rich foods into the diet

Answer: A, C, D, E, F Rationale: All of these lifestyle changes are needed to avoid modifiable risk factors that contribute to the development of osteoporosis except that foods high in phosphorus should be avoided. If the serum phosphorous/phosphate level increases, the serum calcium level decreases due to their inverse relationship. Low calcium levels can result in bone loss.

Which risk factors are shared by male clients who have osteoporosis or osteomalcia? Select all that apply. A. High alcohol intake B. Homelessness C. Low BMI D. A history of smoking E. Inadequate exposure to sunlight

Answer: A, D Rationale: High alcohol intake is a risk factor for both osteoporosis and osteomalacia. A history of smoking is a risk factor for osteoporosis only. Inadequate exposure to sunlight and homelessness are risk factors for osteomalacia. A high BMI is a risk factor for both.

The nurse is assessing a client with recent changes in hearing. After taking a medication history, which drug does the nurse identify as a possible cause of the client's hearing change? Select all that apply. A. Furosemide B. Acetaminophen C. Insulin D. Ibuprofen E. Erythromycin F. Atenolol

Answer: A, D, E Rationale: The nurse identifies erythromycin, ibuprofen, and furosemide as medications known to increase the risk for ototoxicity and hearing problems. Acetaminophen, beta blockers, and insulin are not known ototoxic drugs.

A client who uses a computer for hours each day asks the nurse how to help prevent carpal tunnel syndrome (CTS). Which statement by the client indicates a need for further teaching? A. "I need to make sure I have an ergonomically sound computer station." B. "I need to exercise repetitively to strengthen my wrists." C. "I should stretch my fingers and wrists frequently during the day." D. "I may need to wear a wrist splint when my wrist gets inflamed."

Answer: B Rationale: All of these statements are correct except that CTS is caused by repetitive motion such as that caused by working every day on computers. Repetitive exercises would therefore not be appropriate.

An older adult client reports ear pain. Which assessment finding will the nurse report as the priority to the health care provider? A. Pain on movement of the tragus B. Dizziness C. Dry, flaky cerumen D. Ringing in the ears

Answer: B Rationale: Dizziness could be the indication of numerous clinical findings; also, the client's risk for falling (or other safety concerns) is raised when dizziness is present. The nurse will report this symptom as the priority to the health care provider. The other concerns can be reported secondary to dizziness.

Which eye procedure requires the nurse to assure that informed consent has been obtained from the client? A. Ophthalmoscopy B. Fluorescein angiography C. Snellen test D. Eyedrop instillation

Answer: B Rationale: Fluorescein angiography is an invasive test and requires informed consent from the client. Eyedrop instillation, ophthalmoscopy, and the Snellen test are not invasive procedures and do not require informed consent from the client.

The nurse is talking to a client about cerumen removal from the ear canal. Which statement by the client indicates a need for further teaching? A. "I dry my ears using my fingertip and a towel." B. "I use a cotton swab to remove earwax." C. "I use Swim-Ear after I go swimming." D. "I should not use an ear candle to soften the wax."

Answer: B Rationale: Further teaching is needed when the client states, "I use a cotton swab to remove earwax." Nothing smaller than the client's own fingertip should be inserted into the ear canal. Use of a cotton swab or other device like a key can scrape the skin of the canal, push cerumen up against the eardrum, and even puncture the eardrum. Using the fingertip and a towel and irrigating the ear canal with tap water are acceptable. Clients are discouraged from using ear candles. Using a product like Swim-Ear to help the ears dry after swimming is appropriate.

The nurse is caring for a client with osteoarthritis who reports severe pain in both knees. What nonpharmacologic intervention is the most appropriate for the nurse to recommend for this client? A. Massage and hypnosis. B. Hot compresses or moist heating pad. C. Glucosamine and chondroitin combination. D. Ice packs used every 3 to 4 hours during the day.

Answer: B Rationale: Heat sources such as compresses and heating pads cause vasodilation which promotes healing in the affected joints. Ice is best for inflamed joints rather than those that are degenerative. Glucosamine and chondroitin are integrative therapies that help some clients but their effectiveness has not been validated. Massage would be painful and hypnosis may or may not be helpful, depending on the client.

Which information about a client who was admitted with a pelvic fracture after being crushed by a tractor is most important for the nurse to assess to monitor for serious complications from this type of injury? A. Lungs for bilateral normal breath sounds B. Urine specimen to assess for the red blood cells C. Pain score and level of alertness D. Skin to evaluate lacerations and abrasions

Answer: B Rationale: It is most important for the nurse to determine the presence of blood in the urine as well as assessing the abdomen for rigidity. Clients with crushing injuries to the pelvis are at increased risk of internal hemorrhage. Pelvic injuries are the second cause of death from trauma after head injuries. Assessing the skin for external trauma and monitoring pain and alertness will be performed as part of the overall assessment but are not critical nursing actions at this time. Assessing lung sounds is more critical with chest injuries and rib fractures.

Which drug does the nurse anticipate will be prescribed for a client with Ménière disease to decrease endolymph volume? A. Atorvastatin B. Furosemide C. Ibuprofen D. Doxazosin

Answer: B Rationale: Mild diuretics are often prescribed to decrease endolymph volume. Ménière disease causes an excess of endolymphatic fluid that distorts the entire inner-canal system. This distortion decreases hearing by dilating the cochlear duct, causes vertigo because of damage to the vestibular system, and stimulates tinnitus. Ibuprofen, atorvastatin, and doxazosin are not indicated for Ménière disease. Ibuprofen should actually be avoided, as it can increase water retention.

A client who has osteopenia is prescribed to begin risedonate. What health teaching would the nurse include about this drug? A. "Take the drug with dinner or other meal or snack every day." B. "Remain in an upright position for 30 minutes after taking the drug." C. "Be sure to follow up with lab work to monitor your liver function." D. "Be sure to report any new bone pain or infection."

Answer: B Rationale: Risedonate is an oral bisphosphonate that can cause esophagitis. Therefore, the nurse would teach the client to take the drug before breakfast on an empty stomach with a glass of water, and stay in an upright position (sitting or standing) for at least 30 minutes after taking the drug.

A client was recently diagnosed with osteoarthritis and asks the nurse which over-the-counter drug would be the best to take? What would the nurse's recommendation be? A. Ibuprofen B. Acetaminophen C. Tramadol D. Gabapentin

Answer: B Rationale: Several major medical organizations, including the American Pain Society and OARSI committee recommend acetaminophen as the primary drug of choice.

The nurse is teaching a postmenopausal client about the need for bone health and screening. What diagnostic test would the nurse recommend? A. Serum Vitamin D B. Dual x-ray absorptiometry (DXA) C. Serum calcium and phosphorus D. Vertebral x-rays

Answer: B Rationale: The DXA scan screens for bone loss and provides a score to indicate the amount of loss, if any. It is a noninvasive test performed every 2 years to monitor for bone loss as one ages.

A client recently diagnosed with Ménière's disease reports ongoing tinnitus, and difficulty coping, despite treatment. How does the nurse provide support to this client? A. Contact the health care provider. B. Refer the client to the American Tinnitus Association. C. Suggest removing ear-mold hearing aids. D. Conduct further assessment.

Answer: B Rationale: The appropriate action by the nurse is to refer the client to the American Tinnitus Association. This group assists clients in coping with tinnitus when other therapy is unsuccessful. Reassessment and contacting the health care provider is not needed since treatment has already been attempted. Ear-mold hearing aids can amplify sounds to drown out tinnitus during the day, so it is inappropriate to suggest that these be removed.

A client is in the immediate postoperative period after tympanoplasty. How will the nurse position the client? A. Supine, with eyes toward the ceiling B. On the affected side C. With the head elevated 60 degrees D. With the affected ear facing up

Answer: D Rationale: The nurse keeps the client flat, with the head turned to the side and the operative ear facing up, for at least 12 hours after surgery. All other choices are incorrect and do not facilitate healing.

The nurse is teaching a client about the use of crutches following a foot fracture. When adjusting the crutches to ensure a correct fit, what action will the nurse take? A. Ensure that each crutch fits firmly into the client's armpit. B. Be sure that the top of each crutch is well padded. C. Use the crutch on the affected side only. D. Check to see how many steps the client can take with the crutches.

Answer: B Rationale: The crutches are used a set and require that the nurse ensure that the client does not develop axillary nerve damage. The tops of the crutches should be well padded and should be at least 2 to 3 finger-breadths below the armpit.

What will the nurse recommend as the most appropriate way to decrease the risk for osteoporosis in a client who has just been determined to be at high risk for the disease? A. Increase nutritional intake of phosphorus. B. Walk for 30 minutes three times a week. C. Increase nutritional intake of calcium. D. Engage in high-impact exercise, such as running.

Answer: B Rationale: Walking for 30 minutes three to five times a week is the best and single most effective exercise for osteoporosis prevention. Osteoporosis occurs most often in older, lean-built Euro-American and Asian women, particularly those who do not exercise regularly. Walking is a safe way to promote weight bearing and muscle strength. A variety of nutrients are needed to maintain bone health, so the promotion of a single nutrient will not prevent or treat osteoporosis. High-impact exercise and overtraining, such as running, may cause vertebral compression fractures and should be avoided. Calcium loss occurs at a more rapid rate when intake of phosphorus is high; people who drink large amounts of carbonated beverages each day (over 40 ounces [1.2 L]) are at high risk for calcium loss and subsequent osteoporosis, regardless of age or gender.

A client had a fractured tibia repair several weeks ago and tells the nurse that she has persistent burning pain, ongoing edema, and muscle spasms in her affected leg. For which chronic complication is the client at risk? A. Chronic osteomyelitis B. Complex regional pain syndrome C. Severe osteoporosis D. Compartment syndrome

Answer: B Rationale: When pain is not managed appropriately or interventions are not implemented to prevent complex regional pain syndrome (CRPS), the client is at risk for developing CRPS, a chronic debilitating complication of traumatic injury.

A rock climber has sustained an open fracture of the right tibia after a 20-foot (6 m) fall 2 days ago. The nurse plans to assess the client for which potential complications? Select all that apply. A. Urinary tract infection (UTI) B. Acute compartment syndrome (ACS) C. Fat embolism syndrome (FES) D. Osteomyelitis E. Heart failure

Answer: B, C, D Rationale: ACS is a serious condition in which increased pressure within one or more compartments reduces circulation to the area. A fat embolus is a serious complication in which fat globules are released from yellow bone marrow into the bloodstream within 12 to 48 hours after the injury. FES usually results from long bone fracture or fracture repair but is occasionally seen in clients who have received a total joint replacement. Bone infection, or osteomyelitis, is most common in open fractures. Heart failure is not a potential complication for this client; pulmonary embolism is a potential complication of venous thromboembolism, which can occur with fracture. The client is at risk for wound infection resulting from orthopedic trauma, not a UTI.

A client has undergone an elective below-the-knee amputation of the right leg as a result of severe peripheral vascular disease. In postoperative care teaching, the nurse would instruct the client to notify the primary health care provider immediately if which change occurs? A. Absence of erythema and tenderness at the surgical site B. Ability to flex and extend the right knee C. Large amount of serosanguineous or bloody drainage D. Mild to moderate pain controlled with prescribed analgesics

Answer: C Rationale: A large amount of serosanguineous or bloody drainage may indicate hemorrhage or, if an incision is present, that the incision has opened. This requires immediate attention. Mild to moderate pain controlled with prescribed analgesics would be a normal finding for this client. Absence of erythema and tenderness of the surgical site would also be normal findings for this client. The client would be able to flex and extend the right knee (limb) after surgery.

The nurse has provided health teaching for a female client starting on methotrexate (MTX) for early rheumatoid arthritis. What statement by the client indicates a need for further teaching? A. "I will try to avoid crowds because I could easily get an infection." B. "I will start folic acid supplements which can help decrease side effects." C. "I can drink alcohol in small amounts at night to help me relax." D. "I will use strict birth control while I am taking this drug."

Answer: C Rationale: All of these statements are correct about MTX except that the client needs to avoid all alcoholic beverages to prevent liver toxicity.

Buck's (skin) traction for a fractured hip is applied to a client while a urinary tract infection is treated before surgery. What instruction will the nurse give assistive personnel (AP) for providing client care related to the traction? A. "Inspect the pins in the traction for signs of infection." B. "Remove the boot every shift to inspect the skin." C. "Do not allow the traction weights to rest on the ground." D. "Remove traction weights when turning the client."

Answer: C Rationale: Although Buck's traction is not used commonly today because clients have surgical hip repairs to reduce pain, for some clients such as this client, it is used short term until surgery can be performed. The AP should allow the weights to hang freely and not remove them. There are no pins and the boot can be removed by the nurse for skin inspection.

The nurse is assessing an older client who has bony nodules on finger joints (Heberden and Bouchard nodes). What priority question would the nurse want to ask as part of the client interview? A. "When did your bony nodules develop?" B. "How do you feel about having these bony nodules?" C. "Are you able to independently perform ADLs?" D. "Are your bony nodules painful or tender?"

Answer: C Rationale: As a result of the client having bony nodules in his or her hands, the most important question for the nurse to ask is to determine if the client is ADL independent. The nurse would also ask the other questions, but they are not the first questions to be asked.

A client is admitted to the emergency department with metal shards in the right eye. Which diagnostic test ordered by the health care provider does the nurse question? A. Radioisotope scanning B. Snellen chart C. Magnetic resonance imaging (MRI) D. Ophthalmoscopy

Answer: C Rationale: Because the client has metal in the eye, MRI is an absolute contraindication. Ophthalmoscopy is used to assess the eye for interior and exterior damage and is not contraindicated for this client. Radioisotope scanning assesses the eye for tumors or lesions and is not contraindicated. The Snellen chart measures distance vision and is not contraindicated.

The nurse is caring for a female client who has a right wrist ganglion which is interfering with her ability to do her job as an administrative assistant. What collaborative treatment would the nurse anticipate for this client? A. Physical therapy B. Occupational therapy C. Removal of the ganglion D. Intravenous antibiotic therapy

Answer: C Rationale: Because the ganglion cyst is interfering with the client's ability to work, the ganglion cyst would likely be removed rather than aspirated. Antibiotics are not appropriate and rehabilitation is not going to help remove her cyst.

The nurse is caring for a client with an inflamed, reddened, and severely painful first metatarsal joint. With what type of arthritis are these signs and symptoms associated? A. Rheumatoid arthritis B. Infectious arthritis C. Gouty arthritis D. Osteoarthritis

Answer: C Rationale: Clients who have gout (also called gouty arthritis) experience severe inflammation in small joints, especially the metatarsal of the great (first) toe. Gout results when urate crystals created by errors in purine metabolism deposit in small synovial joints.

The nurse is reviewing postoperative instructions with a client undergoing stapedectomy. Which client statement indicates a need for further teaching? A. "I should not drink from a straw for several weeks." B. "I may have problems with vertigo after the surgery." C. "I will be able to hear better as soon as my dressing is removed." D. "I will have to take antibiotics after the surgery."

Answer: C Rationale: Further teaching is necessary if the client states that hearing will be better as soon as the dressing is removed. Hearing is initially worse after a stapedectomy. The client would be informed that improvement in hearing may not occur until 6 weeks after surgery. At first, the ear packing interferes with hearing, and swelling in the ear after surgery reduces hearing, but these conditions are temporary. Vertigo, nausea, and vomiting are common after surgery because of the nearness of the surgical site to inner ear structures. Clients must not drink through a straw for 2 to 3 weeks after surgery. Antibiotics are used to reduce the risk for infection.

A client is to undergo gonioscopy. When the client asks what this test is for, what is the appropriate nursing response? A. "This test creates a three-dimensional view of the back of the eye." B. "Retinal circulation is evaluated by this test." C. "The ophthalmologist uses the test to determine if you have open-angular or closed-angle glaucoma." D. "This method of testing will determine if you have blood vessel changes due to disease or drugs."

Answer: C Rationale: Gonioscopy is performed for clients with high IOP to determine whether open-angle or closed-angle glaucoma is present. A three-dimensional view of the back of the eye is created by ultrasonic imaging of the retina and optic nerve (called ocular coherence tomography). Electroretinography helps the eye care provider to determine if a client has blood vessel changes resulting from disease or drugs. Retinal circulation is evaluated by fluorescein angiography.

A client reports "something scratching on the inside of my eyelid." Before examining the eyelid, what is the appropriate nursing action? A. Test the visual field. B. Obtain informed consent. C. Wash the hands. D. Don sterile gloves.

Answer: C Rationale: Hands must always be washed, and clean gloves donned, before touching the external eye structures to prevent infection. The eye care provider will test the visual field. An informed consent or sterile gloves is not needed for the nurse to examine the client's eye.

The nurse is planning health teaching for a client starting hydroxychloroquine for rheumatoid arthritis. What instruction would the nurse include in the teaching? A. "Be aware that the drug may cause secondary types of cancer." B. "Expect nausea and vomiting for the first week after starting the drug." C. "Have eye examinations every 6 months while on the drug." D. "Keep this medication in the refrigerator at all times."

Answer: C Rationale: Hydroxychloroquine is an antimalarial drug with immune modulating and anti-inflammatory properties. Although side effects are usually mild, long-term use of the drug can cause vision problems. The client is taught to have an eye examination prior to starting the drug and every 6 months while on the drug to detect any visual changes.

Which intervention would the nurse suggest to a client who has undergone a leg amputation to help cope with loss of the limb? A. Talking with a psychiatrist about the amputation B. Engaging in diversional activities to avoid focusing on the amputation C. Talking with an amputee close to the client's age who has a similar amputation D. Drawing a picture of how the client sees him- or herself

Answer: C Rationale: Meeting with someone of a comparable age who has gone through a similar experience will help the client cope better with his or her own situation. Drawing a picture is not therapeutic and may cause more harm than good. Unless the client is having serious maladjustment problems or has a coexisting psychological disorder, meeting with a psychiatrist would not be necessary. Diversional activities do not help the client deal with loss of the limb.

The nurse suspects that a client may have plantar fasciitis if the client has which assessment finding? A. Dorsiflexion of any metatarsophalangeal (MTP) joint, with plantar flexion of the adjacent proximal interphalangeal (PIP) joint B. A small tumor in a digital nerve of the foot C. Severe pain in the arch of the foot, especially when getting out of bed D. Lateral deviation of the great toe; first metatarsal head becomes enlarged

Answer: C Rationale: Severe pain in the arch of the foot, especially when getting out of bed, is an indication of plantar fasciitis. Lateral deviation of the great toe with an enlarged first metatarsal head describes a bunion of the foot. Dorsiflexion of any MTP joint with plantar flexion of the adjacent PIP joint is a description of a hallux valgus and hammertoe of the foot. A small tumor in a digital nerve of the foot describes Morton neuroma of the foot.

A client is admitted to the same-day surgical center PACU after a bunionectomy. After assessing the client's ABCs, what is the priority assessment for the client? A. Muscle strength assessment B. Joint assessment C. Neurovascular assessment D. Neurologic assessment

Answer: C Rationale: The client had foot surgery and would have a bulky surgical dressing placed on the area to prevent bleeding. The nurse would want to frequently assess the neurovascular status of the operative foot as the priority.

When preparing to examine an ear with drainage, what is the appropriate nursing action? A. Give the client a gown to wear during the examination. B. Provide reassurance that ear drainage is normal. C. Begin testing at 1000 Hz. D. Don clean gloves.

Answer: D Rationale: The nurse needs to don clean gloves to prevent infection, as Contact Precautions need to be used when assessing drainage from a client's ear canal. Testing for hearing loss (1000 Hz) is not used when examining an ear for drainage. Ear drainage is not normal and must be investigated. The client does not need to wear a gown during an ear examination.

The nurse is teaching a client with vertigo about safety precautions for fall prevention. Which statement by the client indicates a need for further instruction? A. "Moving more slowly may help the vertigo subside." B. "I may need to use a cane to keep my balance." C. "Medication alleviates dizziness, so I can drive." D. "My grandchildren need to keep their toys out of the hallway."

Answer: C Rationale: The client's statement about taking medication and driving a car indicates further teaching is needed. Medications for vertigo usually cause drowsiness, so the client must not drive or operate machinery while taking these drugs. The client with vertigo may need to use a cane for balance. Clients need to maintain a safe, uncluttered environment to prevent accidents during periods of vertigo. Restricting head motion and moving more slowly may help clients reduce occurrences of vertigo.

A client in the emergency department receives moderate sedation while having a closed reduction of a fractured ankle. What is the nurse's priority assessment during this procedure? A. Check the client's blood pressure frequently. B. Monitor the client's pain level. C. Monitor the client's respiratory rate. D. Perform circulation checks before and after the procedure.

Answer: C Rationale: The drugs used for moderate sedation can suppress respiratory rate which requires constant monitoring during the procedure. The client should not feel any pain.

A client has sustained a rotator cuff tear while playing baseball. The nurse anticipates that the client will receive which immediate conservative treatment? A. Surgical repair of the rotator cuff B. Patient-controlled analgesia with morphine C. Activity limitations for the affected arm D. Prescribed exercises of the affected arm

Answer: C Rationale: The immediate conservative treatment for this client is to limit activity in the injured arm. Surgical intervention is not considered immediate conservative treatment. Exercises are prohibited immediately after a rotator cuff injury. The client with a rotator cuff injury is treated primarily with nonsteroidal anti-inflammatory drugs to manage pain.

The nurse is teaching an older adult client about visual changes that occur with age. Which statement does the nurse include? A. "You will have to move reading materials closer to your eyes to focus." B. "When the sclera turns yellow, you have developed liver problems." C. "It may take your eyes longer to adjust in a darkened room." D. "Most visual changes occur before age 40."

Answer: C Rationale: The nurse teaches the client that, "It may take your eyes longer to adjust in a dark room." With increasing age, the iris has less ability to dilate, which leads to difficulty in adapting to dark environments. Adults older than 40 years are at increased risk for both glaucoma and cataract formation. Presbyopia is also commonly beings in the 40s. The sclera appears yellow or blue as a process of aging, and this condition should not be used to assess for jaundice in the older adult. The near-point of vision (the closest distance at which the eye can see an object clearly) increases with aging. Near objects (especially reading material) must be placed farther from the eye to be seen clearly.

The nurse is instructing a local community group about ways to reduce the risk for musculoskeletal injury. What information will the nurse include in the teaching plan? A. "Avoid rigorous exercise." B. "Avoid contact sports." C. "Wear helmets when riding a motorcycle." D. "Avoid driving in inclement weather."

Answer: C Rationale: Those who ride motorcycles or bicycles should wear helmets to prevent head injury. Telling the general public to avoid contact sports or to avoid driving in inclement weather is not realistic. Telling the general public to avoid rigorous exercise is not only unrealistic, but it is also opposed to what many health care professionals recommend to maintain health.

The nurse is caring for a client who has a continuous femoral nerve blockade following a total knee arthroplasty. What nursing assessment does the nurse need to perform to ensure client safety? A. Monitor vital signs frequently to detect early complications. B. Perform focused cardiovascular and respiratory assessments. C. Check that the client can dorsiflex and plantar flex the foot on the operative leg. D. Monitor for excessive blooding and bruising during the infusion.

Answer: C Rationale: To ensure that the client is not receiving excessive anesthesia, the client should be able to dorsiflex and plantar flex the foot on the operative leg. The purpose of the continuous femoral nerve blockade is to help control postoperative pain.

The nurse is developing a health teaching plan for a client diagnosed with osteoarthritis (OA). The nurse includes which instruction in the teaching plan? A. Take up knitting to slow down joint degeneration. B. Eat at least 2 yogurts every day. C. Wear supportive shoes at all times. D. Begin a jogging or running program.

Answer: C Rationale: Wearing supportive shoes will help prevent falls and damage to foot joints, especially metatarsal joints. Running and running promotes stress on joints and should be avoided. Repetitive stress activities such as knitting or typing should be avoided for prolonged periods. No single food can cure OA; a well-balanced diet should be recommended.

A client is recovering from an above-the-knee amputation resulting from peripheral vascular disease. Which statement indicates that the client is coping well after the procedure? A. "I can't believe that this has happened to me. I can't stand to look at it." B. "I do not want any visitors while I'm in the hospital." C. "My spouse will be the only person to change my dressing." D. "It will take me some time to get used to this."

Answer: D Rationale: Acknowledging that it will take time to get used to the amputation indicates that the client is expressing acceptance and effective coping. Stating that the spouse will change the dressing indicates the client does not want to participate in self-care. Expressing disbelief and disgust over the amputation indicates the client is unwilling to address what has happened. The client who does not want to receive visitors is having difficulty coping with the change in body image.

The nurse is preparing a client for a total hip arthroplasty today. What IV antibiotic would the nurse likely administer if the client has no drug allergies? A. Penicillin B. Clindamycin C. Vancomycin D. Cefazolin

Answer: D Rationale: Cephalosporins are the drug class of choice for clients without allergies who are having a total joint arthroplasty.

The nurse is assessing an older adult client who has severe kyphosis. What psychosocial client problem would the nurse anticipate? A. Dementia B. Bipolar disorder C. Psychosis D. Depression

Answer: D Rationale: Clients who have severe kyphosis often have poor self-esteem and body image. Many clients are afraid to go out of their homes and socially interact and are concerned about possible falls. As a result, depression can occur.

The nurse is caring for a client who has been treated for osteoporosis for 15 years and is starting on denosumab. What health teaching is appropriate for the nurse to include about this drug? A. "You will receive an IV infusion once a year by your provider." B. "Take the drug every morning with a glass of water." C. "Have a dental examination prior to beginning the drug." D. "See your primary health care provider for twice yearly injections."

Answer: D Rationale: Denosumab is a RANKL inhibitor drug administered subcutaneously by a health care professional twice a year. Dental examinations are recommended for clients who are preparing to take bisphosphates.

The nurse is caring for four clients with eye concerns. Which client, who has a family history of an eye disorder, does the nurse identify at risk for increased intraocular pressure (IOP)? A. Client with family history of diabetic retinopathy B. Client with family history of anisocoria C. Client with family history of presbyopia D. Client with family history of glaucoma

Answer: D Rationale: Glaucoma can be caused by increased IOP, which reduces blood flow to the eyes. Adults with a family history of glaucoma should have their IOP measured once or twice a year. Anisocoria is characterized by unequal pupil size, which normally affects about 5% of the population. This condition is not a sign of increased IOP. Presbyopia is a condition related to aging with a progressive loss of the ability to focus on near object. Increased IOP is not a factor. Diabetic retinopathy is microvascular damage by uncontrolled diabetes, not by increased IOP.

The nurse is caring for an older, alert adult client diagnosed with osteoarthritis. Which client statement indicates to the nurse that the client is using effective coping strategies? A. "I do not know how long my wife will be able to take care of me at home." B. "I am helping with the dishes and laundry, but I hurt so badly when I am doing it." C. "I do not know how much longer my neighbor can continue to help clean my house." D. "The bus is coming to pick me up from the senior center three times a week so I can play cards."

Answer: D Rationale: Participation in diversional activities is a way to cope with daily stressors of osteoarthritis and shows good use of available resources for support. Caregiving responsibilities can be a source of stress; the client worrying about his wife's caregiving abilities does not indicate that the client is effectively coping. Routine tasks, such as doing dishes and laundry, need to be reassigned or effective pain management should be instituted before activities are undertaken to demonstrate effective coping. Neighbors are not reliable resources for in-home needs, and asking a neighbor to help does not indicate that the client is coping effectively.

A client who is using eyedrops in both eyes develops a viral infection in one eye. What teaching will the nurse provide? A. "Wash your hands between eyes and put drops in the uninfected eye first." B. "Don't touch the eyes with the dropper, and you can still use the drops in both eyes." C. "The other eye has already likely been infected with the virus." D. "You will need to use a separate bottle of drops for each eye."

Answer: D Rationale: The appropriate nursing response is that the client will need a separate bottle of eyedrops for each eye. Because of the risk of transmitting the infection to the uninfected eye, clients would receive two bottles of drops labeled "right" and "left" to use in the correct eyes. There is still a risk of transmitting the infection when the dropper is kept from contacting the eye or when hands are washed. With proper technique, transmission of infection to the other eye can be prevented.

When performing an eye or vision assessment, which comment by the client alerts the nurse that immediate care by an ophthalmologist is needed? A. "My vision has been getting worse gradually." B. "One of my eyes is green and the other is blue." C. "My eyes are red and itchy due to allergies." D. "Something hit my eye while I was cutting grass."

Answer: D Rationale: The client who is experiencing trauma, a foreign body in the eye, sudden ocular pain, or sudden redness should be seen immediately by an ophthalmologist. All other reports will be communicated to the ophthalmologist, but do not require immediate intervention. Heterochromia is an ocular condition, usually genetically inherited, that causes the iris to vary in color. This is not an emergency. Itching and redness can be caused by allergies, irritation, or ocular drug effects but do not require immediate attention. Gradual vision loss could be caused by uncontrolled hypertension and diabetes, or other eye changes, but this does not require immediate care by an ophthalmologist.

The nurse has just received change-of-shift report about these clients. Which client will the oncoming nurse assess first? A. Client who has had removal of an acoustic neuroma and has complete hearing loss on the surgical side. B. Client with Ménière's disease who is reporting severe nausea and is requesting an antiemetic. C. Client who has acute otitis media and is reporting drainage from the affected ear. D. Client with labyrinthitis who has a temperature of 102.4° F (39.1° C) and a headache

Answer: D Rationale: The client with an elevated temperature and headache with labyrinthitis must be assessed first. These findings may indicate that the client has developed meningitis requiring immediate intervention. Severe nausea is an expected finding with Ménière's disease. Complete hearing loss on the surgical side is an expected postoperative finding after an acoustic neuroma. Drainage from the affected ear can be an expected finding with otitis media.

A client is in skeletal traction for a complex femoral fracture. Which nursing intervention ensures proper care of this client? A. Ensure that weights are placed on the floor. B. Remove the traction weights only for bathing. C. Ensure that pins are not loose and tighten as needed. D. Inspect the skin at least every 8 hours.

Answer: D Rationale: The client's skin should be inspected at least every 8 hours for signs of irritation, inflammation, or actual skin breakdown. Weights must never rest on the floor because they will not be effective. They must hang freely at all times. Pin sites would be checked for signs and symptoms of infection and for security in their position to the fixation and the client's extremity. However, the nurse does not adjust the pins. Any loose pin site or alteration must be reported to the health care provider. Traction weights are not removed for bathing.

The nurse is caring for a client immediately after a vertebroplasty. In what position would the nurse most likely place the client? A. Prone for the first 1 to 2 hours B. High-Fowler for the first hour C. Side-lying for the first 2 hours D. Flat supine for the first 1 to 2 hours

Answer: D Rationale: The flat supine position provides support for the percutaneous or minimally invasive surgical procedure.

An older adult client comes in for a routine visit. During the assessment he appears frustrated and says, "Speak up and quit mumbling!" What is the appropriate nursing response? A. Suggests moving to a soundproof examination room. B. Shout to ensure that the client can hear. C. Ask if the client has hearing loss. D. Apologize and speak louder and clearer.

Answer: D Rationale: The nurse would repeat and speak more clearly first and then determine whether further assessment is needed. It would not be assumed that the client has a hearing loss; this suggestion may frustrate the client, especially if he is in denial. Shouting is not recommended because it can make understanding more difficult; this is also considered rude and nontherapeutic. Soundproof rooms are used for hearing tests, not for routine assessments.

The nurse is caring for an older client who has a large bulky lower leg dressing with posterior splint to maintain alignment after closed reduction for an ankle fracture. Which client assessment finding would the nurse report to the primary health care provider or Rapid Response Team immediately? A. Affected foot slightly cooler than the other foot. B. Reports pain level is 4 on a 0-10 pain intensity scale. C. Pedal pulse on affected foot is 1+ and regular. D. Reports tingling and numbness in affected foot.

Answer: D Rationale: This client is at risk for neurovascular compromise or compartment syndrome from the external dressing. Pain and a slightly cooler foot is to be expected. However, the client should not have tingling and numbness suggesting that arterial blood flow is diminished.

A middle-age female client has osteoporosis and is at risk for developing vertebral fractures. She asks the nurse about exercises to help minimize this risk. Which exercise will the nurse recommend? A. Cycling B. Running C. Walking D. Yoga

Answer: D Rationale: Yoga helps to strengthen abdominal and back muscles which improves posture and support for the spine. Cycling, running, and walking help to develop range of motion and muscle strengthening but do not have specific effects on posture and spinal stability.

An older adult client reports nausea during irrigation of the ear canal to remove impacted cerumen. What is the appropriate nursing action? A. Administer an antiemetic. B. Use less water to irrigate. C. Call the health care provider. D. Stop irrigation immediately.

Answer: D Rationale: If nausea, vomiting, or dizziness develops in the client, the nurse needs to stop the irrigation immediately. The client's nausea may be a sign of vertigo. Antiemetics would not be administered immediately in this case. The client's nausea may be a symptom of vertigo, and further assessment is required first. The health care provider would not be notified before further assessment of the client is done by the nurse. Using less water will not alleviate the client's nausea.