exam 6
Which assessment finding supports the nurse's conclusion that a prosthesis for a client with an above-the-knee amputation fits correctly? 1 Skin that is cool to the touch 2 Shrinking of the residual limb 3 Absence of phantom limb pain 4 Evenly darkened skin of the residual limb
Evenly darkened skin of the residual limb
Which synovial joint movement is described as turning the sole outward away from the midline of the body? 1 Pronation 2 Eversion 3 Adduction 4 Supination
Eversion
Which condition can result from the bone demineralization associated with immobility? a. Osteoporosis c. Pooling of blood b. Urinary retention d. Susceptibility to infection
A
Which term is used to describe a type of fracture that does not produce a break in the skin? a. Simple c. Complicated b. Compound d. Comminuted
A
Upon palpation, the nurse identifies spongy swelling caused by synovial fluid. Which joint was most likely palpated? 1 Biaxial joint 2 Pivotal joint 3 Synovial joint 4 Temporomandibular joint
Temporomandibular joint
Which drug may cause tooth and bone anomalies as a teratogenic effect? 1 Alcohol 2 Estrogen 3 Tetracycline 4 Valproic acid
Tetracycline
...
..
....
..
While performing a musculoskeletal assessment, the nurse notices that the client can complete range of motion with gravity eliminated. Which grade would the nurse assign to the client? 1 2 3 4
2
A child is upset because, when the cast is removed from her leg, the skin surface is caked with desquamated skin and sebaceous secretions. What should the nurse suggest to remove this material? a. Soak in a bathtub. c. Apply powder to absorb material. b. Vigorously scrub the leg. d. Carefully pick material off of the leg.
A
A young girl has just injured her ankle at school. In addition to calling the childs parents, the most appropriate immediate action by the school nurse is to: a. Apply ice. b. Observe for edema and discoloration. c. Encourage child to assume a comfortable position. d. Obtain parental permission for administration of acetaminophen or aspirin.
A
Four-year-old David is placed in Bucks extension traction for Legg-Calv-Perthes disease. He is crying with pain as the nurse assesses that the skin of his right foot is pale with an absence of pulse. What should the nurse do first? a. Notify the practitioner of the changes noted. b. Give the child medication to relieve the pain. c. Reposition the child and notify the physician. d. Chart the observations and check the extremity again in 15 minutes.
A
When assessing the child with osteogenesis imperfecta, the nurse should expect to observe: a. Discolored teeth. c. Increased muscle tone. b. Below-normal intelligence. d. Above-average stature.
A
A 52-year-old client relates to the nurse that she has never had a mammogram because she is terrified that she will have cancer. Which response by the nurse is therapeutic? a. "Don't worry, most lumps are discovered by women during breast self-examination." b. "Does anyone in your family have breast cancer?" c. "Finding a cancer in the early stages increases the chance for cure." d. "Have you noticed a lump or thickening in your breast?"
ANS: C Providing truthful information addresses the client's concerns. Mammography can detect lumps smaller than those discovered by palpation. Asking about family history or symptoms is not therapeutic because it does not address the client's fear of cancer.
22. A clinic patient is experiencing an allergic reaction to an unknown allergen. Which action is appropriate for the registered nurse (RN) to delegate to a licensed practical/vocational nurse (LPN/LVN)? a. Perform a focused physical assessment. b. Obtain the health history from the patient. c. Teach the patient about the various diagnostic studies. d. Administer a skin test by the cutaneous scratch method.
ANS: D LPN/LVNs are educated and licensed to administer medications under the supervision of an RN. RN-level education and the scope of practice include assessment of health history, focused physical assessment, and patient teaching. DIF: Cognitive Level: Apply (application) REF: 200 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment
10. The nurse should assess the patient undergoing plasmapheresis for which clinical manifestation? a. Shortness of breath c. Transfusion reaction b. High blood pressure d. Extremity numbness
ANS: D Numbness and tingling may occur as the result of the hypocalcemia caused by the citrate used to prevent coagulation. The other clinical manifestations are not associated with plasmapheresis. DIF: Cognitive Level: Apply (application) REF: 205 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity
1. Kyle, age 6 months, is brought to the clinic. His parent says, "I think he hurts. He cries and rolls his head from side to side a lot." This most likely suggests which feature of pain? a. Type b. Severity c. Duration d. Location
ANS: D The child is displaying a local sign of pain. Rolling the head from side to side and pulling at ears indicate pain in the ear. The child's behavior indicates the location of the pain. The behavior does not provide information about the type, severity, or duration. PTS: 1 DIF: Cognitive Level: Comprehension OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
A nurse is conducting discharge teaching for parents of an infant with osteogenesis imperfecta (OI). Further teaching is indicated if the parents make which statement? a. We will be very careful handling the baby. b. We will lift the baby by the buttocks when diapering. c. Were glad there is a cure for this disorder. d. We will schedule follow-up appointments as instructed.
C
The primary method of treating osteomyelitis is: a. Joint replacement. c. Intravenous antibiotic therapy. b. Bracing and casting. d. Long-term corticosteroid therapy.
C
When infants are seen for fractures, which nursing intervention is a priority? a. No intervention is necessary. It is not uncommon for infants to fracture bones. b. Assess the familys safety practices. Fractures in infants usually result from falls. c. Assess for child abuse. Fractures in infants are often nonaccidental. d. Assess for genetic factors.
C
A client is experiencing both tingling of the extremities and tetany. What should the nurse anticipate will be prescribed by the healthcare provider? 1 Dialysis 2 Calcium supplements 3 Mechanical ventilation 4 Intravenous fluids with potassium
Calcium supplements
A nurse is caring for a client with scoliosis of the thoracic spine and lumbar spine. Which risk does the nurse suspect in the client? 1 Osteoarthritis 2 Muscle spasticity 3 Intervertebral disc prolapse 4 Cardiac function impairment
Cardiac function impairment
The nurse coordinates postoperative care for a 70-year-old man with osteoarthritis after prostate surgery. Which task is appropriate for the nurse to delegate to a licensed practical/vocational nurse (LPN/LVN)? A. Teach the patient how to perform Kegel exercises. B. Provide instructions to the patient on catheter care. C. Administer oxybutynin (Ditropan) for bladder spasms. D. Manually irrigate the urinary catheter to determine patency.
D. Manually irrigate the urinary catheter to determine patency. The nurse may delegate the following to an LPN/LVN: monitor catheter drainage for increased blood or clots, increase flow of irrigating solution to maintain light pink color in outflow, administer antispasmodics and analgesics as needed. A registered nurse may not delegate teaching, assessments, or clinical judgments to a LPN/LVN.
A nurse is caring for depressed older adults. What precipitating factors for depression are most common in the older adult without cognitive problems? Select all that apply. 1 Dementia 2 Multiple losses 3 Declines in health 4 A milestone birthday 5 An injury requiring hospitalization
Multiple losses Declines in health
A registered nurse is teaching isometric exercises to an 80-year-old client. Which age change in the client necessitates the teaching of this exercise? 1 Kyphotic posture 2 Muscular atrophy 3 Decreased bone density 4 Cartilaginous degeneration
Muscular atrophy
After an above-the-knee amputation of a right leg, a client reports pain in the right foot. The nurse should inform the client that phantom limb pain is the result of what? 1 Tactile illusions associated with severed blood vessels 2 Nerve endings in the limb that are still intact and react to stimuli 3 An unconscious phenomenon to aid with grieving over the lost body part 4 Hallucinations secondary to emotional symptoms associated with the distress of amputation
Nerve endings in the limb that are still intact and react to stimuli
X-ray films reveal that a client has closed fractures of the right femur and tibia. In addition, multiple soft-tissue contusions are present. Which action is most important for the nurse to take? 1 Perform a neurovascular assessment of the extremity. 2 Reassure the client that these injuries are not that serious. 3 Gather equipment needed for the application of skeletal traction. 4 Prepare the client for a surgical reduction of the injured extremity.
Perform a neurovascular assessment of the extremity.
After an amputation, the client's residual limb is bandaged snugly throughout the postoperative period. Which goal should the nurse identify as the primary reason for this intervention? 1 Promoting shrinkage 2 Preventing injury to the area 3 Preventing suture line infection 4 Promoting drainage of secretions
Promoting shrinkage
Which musculoskeletal abnormality does the nurse suspect in a client who exhibits short steps and drags a foot? 1 Torticollis 2 Pes planus 3 Spastic gait 4 Steppage gait
Spastic gait
Which principle should the nurse consider when assisting a client with crutches to learn the four-point gait? 1 Elbows should be kept in rigid extension. 2 Most of the weight should be supported by axillae. 3 The client must be able to bear weight on both legs. 4 The affected extremity should be kept off the ground.
The client must be able to bear weight on both legs.
What is the main reason a nurse raises three of the four side rails on the bed of a 63-year-old client who had surgery for a fractured hip? 1 As a safety measure because of the client's age 2 Because clients older than 60 years of age should use side rails 3 To be used as handholds to facilitate the client's ability to move in bed 4 Because older adults often are disoriented for several days after anesthesia
To be used as handholds to facilitate the client's ability to move in bed
What does the nurse instruct a client to do while performing McMurray's test? 1 To raise the leg to 60 degrees 2 To abduct the arm to 90 degrees 3 To flex, rotate, and extend the knees 4 To flex the knee to 30 degrees and pull the tibia forward
To flex, rotate, and extend the knees
While caring for a client with a second-degree left ankle sprain, a nurse raises the injured part above heart level. What is the reason behind this nursing intervention? 1 To promote bone density 2 To prevent further edema 3 To reduce pain perception 4 To increase muscle strength
To prevent further edema
15. A patient with a right lower leg fracture will be discharged home with an external fixation device in place. Which information will the nurse teach? a. "You will need to check and clean the pin insertion sites daily." b. "The external fixator can be removed for your bath or shower." c. "You will need to remain on bed rest until bone healing is complete." d. "Prophylactic antibiotics are used until the external fixator is removed."
a. "You will need to check and clean the pin insertion sites daily."
12. A 32-year-old patient who has had an open reduction and internal fixation (ORIF) of left lower leg fractures continues to complain of severe pain in the leg 15 minutes after receiving the prescribed IV morphine. Pulses are faintly palpable and the foot is cool. Which action should the nurse take next? a. Notify the health care provider. b. Assess the incision for redness. c. Reposition the left leg on pillows. d. Check the patient's blood pressure.
a. Notify the health care provider.
In providing care for patients with chronic, progressive neurologic disease, what is the major goal of treatment that the nurse works toward? a. Meet the patient's personal care needs. b. Return the patient to normal neurologic function. c. Maximize neurologic functioning for as long as possible. d. Prevent the development of additional chronic diseases.
c. Maximize neurologic functioning for as long as possible. Rationale: Many chronic neurologic diseases involve progressive deterioration in physical or mental capabilities and have no cure, with devastating results for patients and families. Health care providers can only attempt to alleviate physical symptoms, prevent complications, and assist patients in maximizing function and self-care abilities for as long as possible.
44. After change-of-shift report, which patient should the nurse assess first? a. Patient with a Colles' fracture who has right wrist swelling and deformity b. Patient with a intracapsular left hip fracture whose leg is externally rotated c. Patient with a repaired mandibular fracture who is complaining of facial pain d. Patient with right femoral shaft fracture whose thigh is swollen and ecchymotic
d. Patient with right femoral shaft fracture whose thigh is swollen and ecchymotic
On the first postoperative evening after a lumbar laminectomy, a client states, "My feet are as numb as they were before the operation." Which is the nurse's best response? 1 "Let me elevate your feet so the numbness will decrease more quickly." 2 "That's important to know. I will inform your healthcare provider about the numbness." 3 "Continue to let me know how you feel. It often takes time before this feeling subsides." 4 "There is no cause for concern because the numbness will disappear as soon as the anesthesia wears off."
"Continue to let me know how you feel. It often takes time before this feeling subsides."
A client reports mild tenderness and swelling near the ankle while running. Which nursing instruction would best benefit the client? 1 "Do vigorous endurance exercises." 2 "Complete your activity with a balancing exercise." 3 "Perform strengthening exercises in between your activity." 4 "Do warm-up muscle exercises before performing an activity."
"Do warm-up muscle exercises before performing an activity."
A registered nurse teaches a client about magnetic resonance imaging to diagnose osteomyelitis. Which statement made by the client indicates the need for further education? 1 "I expect no pain from the procedure." 2 "I can take an anti-anxiety agent if needed." 3 "I should remain still throughout the procedure." 4 "I will hear loud noises and alarms."
"I will hear loud noises and alarms."
After a cervical neck injury, a client is placed in a halo fixation device with a body cast. Which statement indicates the client's concern about body image has been resolved successfully? 1 "I hate having everyone else do things for me." 2 "I've gotten used to the brace. I may even miss it when it's gone." 3 "I've been keeping my daily calories low in an attempt to lose weight." 4 "I can't get to sleep. However, I make up for it in the morning by sleeping later."
"I've gotten used to the brace. I may even miss it when it's gone."
A client who had a right total hip replacement is progressing from the use of a walker to the use of a cane. In which hand should the nurse teach the client to hold the cane? 1 Left hand 2 Right hand 3 Stronger hand 4 Dominant hand
Left hand
30. Which nursing action for a patient who has had right hip replacement surgery can the nurse delegate to experienced unlicensed assistive personnel (UAP)? a. Reposition the patient every 1 to 2 hours. b. Assess for skin irritation on the patient's back. c. Teach the patient quadriceps-setting exercises. d. Determine the patient's pain level and tolerance.
a. Reposition the patient every 1 to 2 hours
25. A patient who slipped and fell in the shower at home has a proximal humerus fracture immobilized with a left-sided long-arm cast and a sling. Which nursing intervention will be included in the plan of care? a. Use surgical net dressing to hang the arm from an IV pole. b. Immobilize the fingers of the left hand with gauze dressings. c. Assess the left axilla and change absorbent dressings as needed. d. Assist the patient in passive range of motion (ROM) for the right arm.
c. Assess the left axilla and change absorbent dressings as needed.
A client with multiple sclerosis is informed that it is a chronic progressive neurologic condition. The client asks the nurse, "Will I experience pain?" What is the nurse's best response? 1 "Tell me about your fears regarding pain." 2 "Analgesics will be prescribed to control the pain." 3 "Pain is not a characteristic symptom of this condition." 4 "Let's make a list of the things you need to ask your primary healthcare provider."
"Pain is not a characteristic symptom of this condition."
When the nurse is counseling a 60-year-old African-American male client with all of these risk factors for lung cancer, teaching should focus most on which risk factor? a. Tobacco use b. Ethnicity c. Gender d. Increased age
ANS: A Although all of these are risk factors for lung cancer, the client's tobacco use is the only factor that he can change. Ethnicity, gender, and increasing age are associated with lung cancer, but they are not modifiable risks.
The nurse caring for oncology clients knows that which form of metastasis is the most common? a. Bloodborne b. Direct invasion c. Lymphatic spread d. Via bone marrow
ANS: A Bloodborne metastasis is the most common way for cancer to metastasize. Direct invasion and lymphatic spread are other methods. Bone marrow is not a medium in which cancer spreads, although cancer can occur in the bone marrow.
A student nurse asks the nursing instructor what "apoptosis" means. What response by the instructor is best? a. Growth by cells enlarging b. Having the normal number of chromosomes c. Inhibition of cell growth d. Programmed cell death
ANS: D Apoptosis is programmed cell death. With this characteristic, organs and tissues function with cells that are at their peak of performance. Growth by cells enlarging is hyperplasia. Having the normal number of chromosomes is euploidy. Inhibition of cell growth is contact inhibition.
A nurse plans care to prevent deformities in a client with rheumatoid arthritis. Which intervention should be alternated with periods of rest? 1 Active exercises 2 Passive massage 3 Bracing of joints 4 Isometric exercises
Active exercises
Postoperatively, a patient who has had a laser prostatectomy has continuous bladder irrigation with a three-way urinary catheter with a 30-mL balloon. When he complains of bladder spasms with the catheter in place, you should A. deflate the catheter balloon to 10 mL to decrease bulk in the bladder. B. deflate the catheter balloon and then reinflate it to ensure that it is patent. C. encourage the patient to try to have a bowel movement to relieve colon pressure. D. explain that this feeling is normal and that he should not try to urinate around the catheter.
Answer: D Bladder spasms occur as a result of irritation of the bladder mucosa from the insertion of the resectoscope, presence of a catheter, or clots leading to obstruction of the catheter. Instruct the patient not to urinate around the catheter because this increases the likelihood of spasm.
You recognize the need to begin testosterone therapy when testosterone levels drop below A. 750 ng/dL. B. 500 ng/dL. C. 400 ng/dL. D. 250 ng/dL.
Answer: D Normal testosterone levels can range from 280 to 1100 ng/dL. Replacement therapy may be considered when levels are below 250 ng/dL.
Kristin, age 10 years, sustained a fracture in the epiphyseal plate of her right fibula when she fell off of a tree. When discussing this injury with her parents, the nurse should consider which statement? a. Healing is usually delayed in this type of fracture. b. Growth can be affected by this type of fracture. c. This is an unusual fracture site in young children. d. This type of fracture is inconsistent with a fall.
B
The nurse is caring for a 4-year-old child immobilized by a fractured hip. Which complications should the nurse monitor? a. Hypocalcemia b. Decreased metabolic rate c. Positive nitrogen balance d. Increased production of stress hormones
B
Which interaction is part of the discharge plan for a school-age child with osteomyelitis who is receiving home antibiotic therapy? a. Instructions for a low-calorie diet b. Arrangements for tutoring and schoolwork c. Instructions for a high-fat, low-protein diet d. Instructions for the parent to return the child to team sports immediately
B
Which statement is accurate concerning a childs musculoskeletal system and how it may be different from an adults? a. Growth occurs in children as a result of an increase in the number of muscle fibers. b. Infants are at greater risk for fractures because their epiphyseal plates are not fused. c. Because soft tissues are resilient in children, dislocations and sprains are less common than in adults. d. Childrens bones have less blood flow.
C
Which type of traction uses skin traction on the lower leg and a padded sling under the knee? a. Dunlop c. Russell b. Bryants d. Bucks extension
C
The nurse is caring for a preschool child with a cast applied recently for a fractured tibia. Which assessment findings indicate possible compartment syndrome (Select all that apply)? a. Palpable distal pulse b. Capillary refill to extremity of <3 seconds c. Severe pain not relieved by analgesics d. Tingling of extremity e. Inability to move extremity
C,D,E
Some clients self-prescribe over-the-counter glucosamine to help relieve joint pain and stiffness. Which condition should the nurse identify as a reason for a client to reconsider taking this medication? 1 Osteoarthritis 2 Heart disease 3 Hyperthyroidism 4 Diabetes mellitus
Diabetes mellitus
The nurse is teaching the parents of a 7-year-old child who has just had a cast applied for a fractured arm with the wrist and elbow immobilized. Which instructions should be included in the teaching? a. Swelling of the fingers is to be expected for the next 48 hours. b. Immobilize the shoulder to decrease pain in the arm. c. Allow the affected limb to hang down for 1 hour each day. d. Elevate casted arm when resting and when sitting up.
D
Which type of burn/injury may cause a client to have a cervical spine injury? 1 Electrical burns 2 Chemical burns 3 Inhalation injury 4 Cold thermal injury
Electrical burns
A client has a fracture of the tibia, and a cast is applied. Which action will the nurse take? 1 Cover the cast with plastic wrap until dry. 2 Assist with weight bearing when the client ambulates. 3 Elevate the affected leg above the level of the heart. 4 Insert a finger inside the edges of the cast to check for skin abrasions.
Elevate the affected leg above the level of the heart.
A client is admitted to the hospital with a diagnosis of lower extremity arterial disease (LEAD) or peripheral arterial disease. Which is the most beneficial lifestyle modification the nurse should teach this client? 1 Stop smoking 2 Control blood glucose 3 Start a walking program 4 Eat a low-fat, low-cholesterol diet
Stop smoking
The nurse is caring for a client with a long leg cast. Which clinical findings indicate compromised circulation? Select all that apply. 1 Foul odor 2 Swelling of the toes 3 Drainage on the cast 4 Increased temperature 5 Prolonged capillary refill
Swelling of the toes Prolonged capillary refill
A client who had a total hip replacement is receiving continuous regional analgesia. The nurse recognizes what as the benefit of this treatment over conventional methods? 1 It is easy to adjust the dose. 2 Neuropathic pain can be relieved. 3 Systemic side effects are minimal. 4 The need for parenteral medication is prevented.
Systemic side effects are minimal.
Range-of-motion exercises are prescribed for a child with juvenile idiopathic arthritis. What criterion should the nurse use to evaluate the effectiveness of the exercises? 1 The pain is relieved. 2 The affected joints can flex and extend. 3 The pedal and radial pulses are diminished. 4 The subcutaneous nodules at the joints recede.
The affected joints can flex and extend.
Social effects of a chronic neurologic disease include (select all that apply) a. divorce. b. job loss. c. depression. d. role changes. e. loss of self-esteem.
a, b, c, d, e Rationale: Social problems related to chronic neurologic disease may include changes in roles and relationships (e.g., divorce, job loss, role changes); other psychologic problems (e.g., depression, loss of self-esteem) also may have social effects.
When providing teaching regarding potential complications after perineal resection of the prostate, what should you include? A. Deep vein thrombosis B. Pulmonary embolism C. Colonic constipation D. Urinary incontinence
Answer: D The two major complications after a radical prostatectomy are erectile dysfunction and urinary incontinence.
An advantage to using a fiberglass cast instead of a plaster cast is that a fiberglass cast: a. Is less expensive. c. Molds closely to body parts. b. Dries rapidly. d. Has a smooth exterior.
B
The nurse is teaching clinic patients about risk factors for testicular cancer. Which individual is at highest risk for developing testicular cancer? A. A 30-year-old white male with a history of cryptorchidism B. A 48-year-old African American male with erectile dysfunction C. A 19-year-old Asian male who had surgery for testicular torsion D. A 28-year-old Hispanic male with infertility caused by a varicocele
A. A 30-year-old white male with a history of cryptorchidism The incidence of testicular cancer is four times higher in white males than in African American males. Testicular tumors are also more common in males who have had undescended testes (cryptorchidism) or a family history of testicular cancer or anomalies. Other predisposing factors include orchitis, human immunodeficiency virus infection, maternal exposure to DES, and testicular cancer in the contralateral testis.
The nurse is caring for a 62-year-old man after a transurethral resection of the prostate (TURP). Which instructions should the nurse include in the teaching plan? A. Avoid straining during defecation. B. Restrict fluids to prevent incontinence. C. Sexual functioning will not be affected. D. Prostate exams are not needed after surgery.
A. Avoid straining during defecation. Activities that increase abdominal pressure, such as sitting or walking for prolonged periods and straining to have a bowel movement (Valsalva maneuver), should be avoided in the postoperative recovery period to prevent a postoperative hemorrhage. Instruct the patient to drink at least 2 L of fluid every day. Digital rectal examinations should be performed yearly. The prostate gland is not totally removed and may enlarge after a TURP. Sexual functioning may change after prostate surgery. Changes may include retrograde ejaculation, erectile dysfunction, and decreased orgasmic sensation.
The nurse working with oncology clients understands that interacting factors affect cancer development. Which factors does this include? (Select all that apply.) a. Exposure to carcinogens b. Genetic predisposition c. Immune function d. Normal doubling time e. State of euploidy
ANS: A, B, C The three interacting factors needed for cancer development are exposure to carcinogens, genetic predisposition, and immune function.
To decrease the patient's discomfort about care involving his reproductive organs, you should A. relate his sexual concerns to his sexual partner. B. arrange to have male nurses care for the patient. C. maintain a nonjudgmental attitude toward his sexual practices. D. use technical terminology when discussing reproductive function.
Answer: C Conducting routine health assessments on men places you in a unique position. It provides an opportunity to ask the patient questions pertaining to general health and to sexual health and function. Given the opportunity, men are less hesitant to answer these questions when they know that someone cares and can provide them with answers. You must remain nonjudgmental about sexual practices.
You expect which finding in a patient as a complication of prostatic hyperplasia? A. Dysuria B. Hematuria C. Urinary retention D. Urinary frequency
Answer: C Obstructive symptoms caused by prostate enlargement include a decrease in the caliber and force of the urinary stream, difficulty in initiating voiding, intermittency (stopping and starting stream several times while voiding), and dribbling at the end of urination. These symptoms result from urinary retention.
A 45-year-old man asks you if it is advisable to have his prostate-specific antigen (PSA) level tested, because his father and brother have prostate cancer. What is your response? A. "You should wait until you are age 50." B. "You should have a transurethral resection of the prostate as a preventive measure." C. "You should have a voiding cystourethrogram yearly." D. "You should have annual PSA levels assessed and a digital examination of the prostate."
Answer: D The American Cancer Society recommends an annual digital rectal examination (DRE) and a blood test for PSA beginning at age 50 for men who are at average risk for prostate cancer. During DRE, an abnormal prostate may feel hard, nodular, and asymmetric.
A newborn has been diagnosed with developmental dysplasia of the hips and is placed in a Pavlik harness. The parents have been instructed that the infant is to wear the appliance full time except for bathing. What additional instruction should the nurse give the parents about the harness? 1 Avoid undershirts or diapers under the harness. 2 The harness may be adjusted as needed as the baby grows. 3 Apply lotion or baby powder under the harness to prevent skin breakdown. 4 Avoid using the legs to lift the infant's buttocks when changing the diaper at bath time.
Avoid using the legs to lift the infant's buttocks when changing the diaper at bath time.
An appropriate nursing intervention when caring for a child in traction is to: a. Remove adhesive traction straps daily to prevent skin breakdown. b. Assess for tightness, weakness, or contractures in uninvolved joints and muscles. c. Provide active range-of-motion exercises to affected extremity 3 times a day. d. Keep child in one position to maintain good alignment.
B
A male patient complains of fever, dysuria, and cloudy urine. What additional information may indicate that these manifestations may be something other than a urinary tract infection (UTI)? A. E. coli bacteria in his urine B. A very tender prostate gland C. Complaints of chills and rectal pain D. Complaints of urgency and frequency
B. A very tender prostate gland A tender and swollen prostate is indicative of prostatis, which is a more serious male reproductive problem because an acute episode can result in chronic prostatis and lead to epididymitis or cystitis. E. coli in his urine, chills and rectal pain, and urgency and frequency are all present with a UTI and not specifically indicative of prostatis.
The nurse teaches a 30-year-old man with a family history of prostate cancer about dietary factors associated with prostate cancer. The nurse determines that teaching is successful if the patient selects which menu? A. Grilled steak, French fries, and vanilla shake B. Hamburger with cheese, pudding, and coffee C. Baked chicken, peas, apple slices, and skim milk D. Grilled cheese sandwich, onion rings, and hot tea
C. Baked chicken, peas, apple slices, and skim milk A diet high in red meat and high-fat dairy products along with a low intake of vegetables and fruits may increase the risk of prostate cancer.
The patient has a low-grade carcinoma on the left lateral aspect of the prostate gland and has been on "watchful waiting" status for 5 years. Six months ago his last prostate-specific antigen (PSA) level was 5 ng/mL. Which manifestations now indicate that the prostate cancer may be growing and he needs a change in his care (select all that apply)? A. Casts in his urine B. Presence of α-fetoprotein C. Serum PSA level 10 ng/mL D. Onset of erectile dysfunction E. Nodularity of the prostate gland
C. Serum PSA level 10 ng/mL E. Nodularity of the prostate gland The manifestations of increased PSA level along with the new nodularity of the prostate gland potentially indicate that the tumor may be growing. Casts in the urine, presence of α-fetoprotein, and new onset of erectile dysfunction do not indicate prostate cancer growth.
An older client experiences urinary frequency and nocturia. While ambulating, the client develops severe back pain and is found to have a vertebral compression fracture. When planning care, the nurse will focus interventions on which type of fracture? 1 Collapse of vertebral bodies 2 Demineralization of the spinal cord 3 Wear and tear of the spinous processes 4 Bulging of the spinal cord from the vertebra
Collapse of vertebral bodies
A nurse is caring for an older adult who had an open reduction and internal fixation of a fractured hip. What clinical finding requires the nurse to notify the primary healthcare provider? 1 Lack of a productive cough 2 days postoperatively 2 Rectal temperature of 100.2° F (37.9° C) 3 days postoperatively 3 Complaints of right-sided chest pain 6 days postoperatively 4 Fatigue in the leg on the unaffected side 5 days postoperatively
Complaints of right-sided chest pain 6 days postoperatively
The nurse uses the palms of the hands when handling a wet cast to: a. Assess dryness of the cast. c. Keep the patients limb balanced. b. Facilitate easy turning. d. Avoid indenting the cast.
D
17. When doing discharge teaching for a 19-year-old patient who has had a repair of a fractured mandible, the nurse will include information about a. administration of nasogastric tube feedings. b. how and when to cut the immobilizing wires. c. the importance of high-fiber foods in the diet. d. the use of sterile technique for dressing changes.
b. how and when to cut the immobilizing wires.
A nurse is caring for two clients. One has Parkinson disease, and the other has myasthenia gravis. For which common complication associated with both disorders should the nurse assess these clients? 1 Cogwheel gait 2 Impaired cognition 3 Difficulty swallowing 4 Nonintention tremors
Difficulty swallowing
14. Which action will the nurse take in order to evaluate the effectiveness of Buck's traction for a 62-year-old patient who has an intracapsular fracture of the right femur? a. Check peripheral pulses. b. Ask about hip pain level. c. Assess for hip contractures. d. Monitor for hip dislocation.
b. Ask about hip pain level.
8. Which nursing intervention will be included in the plan of care after a patient with a right femur fracture has a hip spica cast applied? a. Avoid placing the patient in prone position. b. Ask the patient about abdominal discomfort. c. Discuss remaining on bed rest for several weeks. d. Use the cast support bar to reposition the patient.
b. Ask the patient about abdominal discomfort.
16. A patient who has had an open reduction and internal fixation (ORIF) of a hip fracture tells the nurse that he is ready to get out of bed for the first time. Which action should the nurse take? a. Use a mechanical lift to transfer the patient from the bed to the chair. b. Check the postoperative orders for the patient's weight-bearing status. c. Avoid administration of pain medications before getting the patient up. d. Delegate the transfer of the patient to nursing assistive personnel (NAP).
b. Check the postoperative orders for the patient's weight-bearing status.
3. The occupational health nurse will teach the patient whose job involves many hours of typing about the need to a. obtain a keyboard pad to support the wrist. b. do stretching exercises before starting work. c. wrap the wrists with compression bandages every morning. d. avoid using nonsteroidal antiinflammatory drugs (NSAIDs) for pain.
a. obtain a keyboard pad to support the wrist.
A nurse is caring for a client who will have a below-the-knee amputation with an immediate postoperative prosthesis. The client asks the nurse the advantage of having an immediate prosthesis. What should the nurse explain is the advantage? 1 Decreases phantom limb sensations 2 Encourages a normal walking pattern 3 Reduces the incidence of wound infection 4 Allows for fitting of the prosthesis before discharge
Encourages a normal walking pattern
27. After being hospitalized for 3 days with a right femur fracture, a 32-year-old patient suddenly develops shortness of breath and tachypnea. The patient tells the nurse, "I feel like I am going to die!" Which action should the nurse take first? a. Stay with the patient and offer reassurance. b. Administer the prescribed PRN oxygen at 4 L/min. c. Check the patient's legs for swelling or tenderness. d. Notify the health care provider about the symptoms.
b. Administer the prescribed PRN oxygen at 4 L/min.
26. A patient is being discharged 4 days after hip replacement surgery using the posterior approach. Which patient action requires immediate intervention by the nurse? a. The patient uses crutches with a swing-to gait. b. The patient leans over to pull shoes and socks on. c. The patient sits straight up on the edge of the bed. d. The patient bends over the sink while brushing teeth.
b. The patient leans over to pull shoes and socks on.
29. A young man arrives in the emergency department with ankle swelling and severe pain after twisting his ankle playing basketball. Which of these prescribed collaborative interventions will the nurse implement first? a. Take the patient to have x-rays. b. Wrap the ankle and apply an ice pack. c. Administer naproxen (Naprosyn) 500 mg PO. d. Give acetaminophen with codeine (Tylenol #3).
b. Wrap the ankle and apply an ice pack.
9. A patient has a long-arm plaster cast applied for immobilization of a fractured left radius. Until the cast has completely dried, the nurse should a. keep the left arm in dependent position. b. avoid handling the cast using fingertips. c. place gauze around the cast edge to pad any roughness. d. cover the cast with a small blanket to absorb the dampness.
b. avoid handling the cast using fingertips.
10. Which statement by the patient indicates a good understanding of the nurse's teaching about a new short-arm plaster cast? a. "I can get the cast wet as long as I dry it right away with a hair dryer." b. "I should avoid moving my fingers and elbow until the cast is removed." c. "I will apply an ice pack to the cast over the fracture site off and on for 24 hours." d. "I can use a cotton-tipped applicator to rub lotion on any dry areas under the cast."
c. "I will apply an ice pack to the cast over the fracture site off and on for 24 hours."
23. A high school teacher with ulnar drift caused by rheumatoid arthritis (RA) is scheduled for a left hand arthroplasty. Which patient statement to the nurse indicates a realistic expectation for the surgery? a. "This procedure will correct the deformities in my fingers." b. "I will not have to do as many hand exercises after the surgery." c. "I will be able to use my fingers with more flexibility to grasp things." d. "My fingers will appear more normal in size and shape after this surgery."
c. "I will be able to use my fingers with more flexibility to grasp things."
18. After the health care provider has recommended amputation for a patient who has nonhealing ischemic foot ulcers, the patient tells the nurse that he would rather die than have an amputation. Which response by the nurse isbest? a. "You are upset, but you may lose the foot anyway." b. "Many people are able to function with a foot prosthesis." c. "Tell me what you know about your options for treatment." d. "If you do not want an amputation, you do not have to have it."
c. "Tell me what you know about your options for treatment."
40. Which action will the urgent care nurse take when caring for a patient who has a possible knee meniscus injury? a. Encourage bed rest for 24 to 48 hours. b. Avoid palpation or movement of the knee. c. Apply a knee immobilizer to the affected leg. d. Administer intravenous narcotics for pain relief.
c. Apply a knee immobilizer to the affected leg.
1. When teaching seniors at a community recreation center, which information will the nurse include about ways to prevent fractures? a. Tack down scatter rugs in the home. b. Most falls happen outside the home. c. Buy shoes that provide good support and are comfortable to wear. d. Range-of-motion exercises should be taught by a physical therapist.
c. Buy shoes that provide good support and are comfortable to wear.
36. A 42-year-old patient is admitted to the emergency department with a left femur fracture. Which information obtained by the nurse is most important to report to the health care provider? a. Ecchymosis of the left thigh b. Complaints of severe thigh pain c. Slow capillary refill of the left foot d. Outward pointing toes on the left foot
c. Slow capillary refill of the left foot
28. A patient arrived at the emergency department after tripping over a rug and falling at home. Which finding is most important for the nurse to communicate to the health care provider? a. There is bruising at the shoulder area. b. The patient reports arm and shoulder pain. c. The right arm appears shorter than the left. d. There is decreased shoulder range of motion.
c. The right arm appears shorter than the left.
43. When a patient arrives in the emergency department with a facial fracture, which action will the nurse take first? a. Assess for nasal bleeding and pain. b. Apply ice to the face to reduce swelling. c. Use a cervical collar to stabilize the spine. d. Check the patient's alertness and orientation.
c. Use a cervical collar to stabilize the spine.
4. Which discharge instruction will the emergency department nurse include for a patient with a sprained ankle? a. Keep the ankle loosely wrapped with gauze. b. Apply a heating pad to reduce muscle spasms. c. Use pillows to elevate the ankle above the heart. d. Gently move the ankle through the range of motion.
c. Use pillows to elevate the ankle above the heart.
33. A pedestrian who was hit by a car is admitted to the emergency department with possible right lower leg fractures. The initial action by the nurse should be to a. elevate the right leg. b. splint the lower leg. c. check the pedal pulses. d. verify tetanus immunizations.
c. check the pedal pulses.
31. A patient who arrives at the emergency department experiencing severe left knee pain is diagnosed with a patellar dislocation. The initial patient teaching by the nurse will focus on the need for a. a knee immobilizer. b. gentle knee flexion. c. monitored anesthesia care. d. physical activity restrictions.
c. monitored anesthesia care.
A 65-year-old woman was just diagnosed with Parkinson's disease. The priority nursing intervention is a. searching the Internet for educational videos. b. evaluating the home for environmental safety. c. promoting physical exercise and a well-balanced diet. d. designing an exercise program to strengthen and stretch specific muscles.
c. promoting physical exercise and a well-balanced diet. Rationale: Promotion of physical exercise and a well-balanced diet are major concerns of nursing care for patients with Parkinson's disease.
21. The nurse is caring for a patient who is to be discharged from the hospital 5 days after insertion of a femoral head prosthesis using a posterior approach. Which statement by the patient indicates a need for additional instruction? a. "I should not cross my legs while sitting." b. "I will use a toilet elevator on the toilet seat." c. "I will have someone else put on my shoes and socks." d. "I can sleep in any position that is comfortable for me."
d. "I can sleep in any position that is comfortable for me."
41. Which finding in a patient with a Colles' fracture of the left wrist is most important to communicate to the health care provider? a. Swelling is noted around the wrist. b. The patient is reporting severe pain. c. The wrist has a deformed appearance. d. Capillary refill to the fingers is prolonged.
d. Capillary refill to the fingers is prolonged.
Which nursing diagnosis is of highest priority for a patient with Parkinson's disease who is unable to move the facial muscles? a. Activity intolerance b. Self-care deficit: toileting c. Ineffective self-health management d. Imbalanced nutrition: less than body requirements
d. Imbalanced nutrition: less than body requirements Rationale: The data about the patient indicate that poor nutrition will be a concern because of decreased swallowing. The other diagnoses may also be appropriate for a patient with Parkinson's disease, but the data do not indicate that they are current problems for this patient.
The classic triad of manifestations associated with Parkinson's disease is tremor, rigidity, and bradykinesia. What is a consequence related to rigidity? a. Shuffling gait b. Impaired handwriting c. Lack of postural stability d. Muscle soreness and pain
d. Muscle soreness and pain Rationale: The degeneration of dopamine-producing neurons in the substantia nigra of midbrain and basal ganglia lead to this triad of signs. Muscle soreness, pain, and slowness of movement are patient function consequences related to rigidity. Shuffling gait, lack of postural stability, absent arm swing while walking, absent blinking, masked facial expression, and difficulty initiating movement are all related to bradykinesia. Impaired handwriting and hand activities are related to the tremor of Parkinson's disease (PD).
22. Which action will the nurse include in the plan of care for a patient who has had a total right knee arthroplasty? a. Avoid extension of the right knee beyond 120 degrees. b. Use a compression bandage to keep the right knee flexed. c. Teach about the need to avoid weight bearing for 4 weeks. d. Start progressive knee exercises to obtain 90-degree flexion.
d. Start progressive knee exercises to obtain 90-degree flexion.
A 62-year-old patient who has Parkinson's disease is taking bromocriptine (Parlodel). Which information obtained by the nurse may indicate a need for a decrease in the dose? a. The patient has a chronic dry cough. b. The patient has four loose stools in a day. c. The patient develops a deep vein thrombosis. d. The patient's blood pressure is 92/52 mm Hg.
d. The patient's blood pressure is 92/52 mm Hg. Rationale: Hypotension is an adverse effect of bromocriptine, and the nurse should check with the health care provider before giving the medication. Diarrhea, cough, and deep vein thrombosis are not associated with bromocriptine use.
A 33-year-old patient noticed a painless lump in his scrotum on self-examination of his testicles and a feeling of heaviness. The nurse should first teach him about what diagnostic test? A. Ultrasound B. Cremasteric reflex C. Doppler ultrasound D. Transillumination with a flashlight
A. Ultrasound When the scrotum has a painless lump, scrotal swelling, and a feeling of heaviness, testicular cancer is suspected, and an ultrasound of the testes is indicated. Blood tests will also be done. The cremasteric reflex and Doppler ultrasound are done to diagnose testicular torsion. Transillumination with a flashlight is done to diagnose a hydrocele.
The nurse explains to a client that which risk factor of those listed most likely contributed to the client's primary liver carcinoma? a. Infection with hepatitis B virus b. Consuming a diet high in animal fat c. Exposure to radon d. Familial polyposis
ANS: A Hepatitis B and C are risk factors for primary liver cancer. Alcohol abuse is also a risk factor for the development of liver cancer. Consuming a diet high in animal fat may predispose a person to colon or breast cancer. Exposure to radon is a risk factor for lung cancer. Familial polyposis is a risk factor for colorectal cancer.
A patient is one day postoperative following a transurethral resection of the prostate (TURP). Which event is not an expected normal finding in the care of this patient? A. The patient requires two tablets of Tylenol #3 during the night. B. The patient complains of fatigue and claims to have minimal appetite. C. The patient has continuous bladder irrigation (CBI) infusing, but output has decreased. D. The patient has expressed anxiety about his planned discharge home the following day.
C. The patient has continuous bladder irrigation (CBI) infusing, but output has decreased. A decrease or cessation of output in a patient with CBI requires immediate intervention. The nurse should temporarily stop the CBI and attempt to resume output by repositioning the patient or irrigating the catheter. Complaints of pain, fatigue, and low appetite at this early postoperative stage are not unexpected. Discharge planning should be addressed, but this should not precede management of the patient's CBI.
A client with extensive bone and soft tissue injuries to the right leg is on bed rest. How should the nurse position the client? 1 Keep the right leg resting straight on the bed, parallel to the left leg. 2 Elevate the entire right leg with pillows, keeping the foot higher than the knee. 3 Maintain both legs on the bed and use an abduction pillow to keep them separated. 4 Attach a padded ankle sling to a Balkan frame to support the right foot and elevate the leg.
Elevate the entire right leg with pillows, keeping the foot higher than the knee.
Which observation of the patient made by the nurse is most indicative of Parkinson's disease? a. Large, embellished handwriting b. Weakness of one leg resulting in a limping walk c. Difficulty rising from a chair and beginning to walk d. Onset of muscle spasms occurring with voluntary movement
c. Difficulty rising from a chair and beginning to walk Rationale: The bradykinesia of PD prevents automatic movements and activities such as beginning to walk, rising from a chair, or even swallowing saliva cannot be executed unless they are consciously willed. Handwriting is affected by the tremor and results in the writing trailing off at the end of words. Specific limb weakness and muscle spasms are not characteristic of PD.
2. A factory line worker has repetitive strain syndrome in the left elbow. The nurse will plan to teach the patient about a. surgical options. b. elbow injections. c. wearing a left wrist splint. d. modifying arm movements.
d. modifying arm movements.
A patient with Parkinson's disease is admitted to the hospital for treatment of pneumonia. Which nursing interventions will be included in the plan of care (select all that apply)? a. Use an elevated toilet seat. b. Cut patient's food into small pieces. c. Provide high-protein foods at each meal. d. Place an armchair at the patient's bedside. e. Observe for sudden exacerbation of symptoms.
A, B, D Rationale: Because the patient with Parkinson's has difficulty chewing, food should be cut into small pieces. An armchair should be used when the patient is seated so that the patient can use the arms to assist with getting up from the chair. An elevated toilet seat will facilitate getting on and off the toilet. High-protein foods will decrease the effectiveness of L-dopa. Parkinson's is a steadily progressive disease without acute exacerbations.
A 71-year-old patient with a diagnosis of benign prostatic hyperplasia (BPH) has been scheduled for a contact laser technique. What is the primary goal of this intervention? A. Resumption of normal urinary drainage B. Maintenance of normal sexual functioning C. Prevention of acute or chronic renal failure D. Prevention of fluid and electrolyte imbalances
A. Resumption of normal urinary drainage The most significant signs and symptoms of BPH relate to the disruption of normal urinary drainage and consequent urine retention, incontinence, and pain. A laser technique vaporizes prostate tissue and cauterizes blood vessels and is used as an effective alternative to a TURP to resolve these problems. Fluid imbalances, sexual functioning, and kidney disease may result from uncontrolled BPH, but the central focus remains urinary drainage.
2. The nurse is using the FLACC scale to evaluate pain in a preverbal child. The nurse makes the following assessment: Face: occasional grimace; Leg: relaxed; Activity: squirming, tense; Cry: no cry; Consolability: content, relaxed. The nurse records the FLACC assessment as ________. (Record your answer as a whole number.)
ANS: 2 The FLACC scale is recorded per the following table: 01 2 Face No particular expression or smile Occasional grimace or frown, withdrawn, disinterested Frequent to constant frown, clenched jaw, quivering chin Legs Normal position or relaxed Uneasy, restless, tense Kicking or legs drawn up Activity Lying quietly, normal position, moves easily Squirming, shifting back and forth, tense Arched, rigid, or jerking Cry No cry (awake or asleep) Moans or whimpers, occasional complaint Crying steadily, screams or sobs, frequent complaints Consolability Content, relaxed Reassured by occasional touching, hugging, or talking to; distractible Difficult to console or comfort PTS: 1 DIF: Cognitive Level: Application OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
What is an erection lasting longer than 6 hours called? A. Priapism B. Peyronie's disease C. Hydrocele D. Hypospadias
Answer: A Priapism is a painful erection lasting longer than 6 hours. It is caused by an obstruction of the venous outflow in the penis. The condition may constitute a medical emergency. Causes of priapism include thrombosis of the corpus cavernosal veins, leukemia, sickle cell anemia, diabetes mellitus, degenerative lesions of the spine, neoplasms of the brain or spinal cord, vasoactive medications injected into the corpus cavernosa, and medications (e.g., sildenafil, cocaine, trazodone).
What is the primary purpose of a three-way urinary catheter after a transurethral resection of the prostate (TURP)? A. Promote hemostasis and drainage of clots B. Relieve bladder spasms C. Reduce edema D. Increase bladder tone
Answer: A A large three-way indwelling catheter with a 30-mL balloon is inserted into the bladder after the procedure to provide hemostasis and to facilitate urinary drainage. The bladder is irrigated, either continuously or intermittently, usually for the first 24 hours to prevent obstruction from mucus and blood clots.
A patient scheduled for a prostatectomy for prostate cancer expresses the fear that he will have erectile dysfunction. In responding to the patient, you should keep in mind that A. erectile dysfunction can occur even with a nerve-sparing procedure. B. retrograde ejaculation affects sexual functioning more frequently than erectile dysfunction. C. the most common complication of this surgery is postoperative bowel incontinence. D. preoperative sexual functioning is the most important factor in determining postoperative erectile dysfunction.
Answer: A A major complication after a prostatectomy (even with nerve-sparing procedures) is erectile dysfunction
An elderly male patient is experiencing difficulty in initiating voiding and a feeling of incomplete bladder emptying. What causes these symptoms in benign prostatic hyperplasia (BPH)? A. Obstruction of the urethra B. Untreated chronic prostatitis C. Decreased bladder compliance D. Excessive secretion of testosterone
Answer: A BPH is a benign enlargement of the prostate gland. The enlargement of the prostate gradually compresses the urethra, eventually causing partial or complete obstruction. Compression of the urethra ultimately leads to the development of clinical symptoms.
Which ethnic group has the highest incidence of prostate cancer? A. African Americans B. Asians C. Whites D. Hispanics
Answer: A The incidence of prostate cancer worldwide is higher among African Americans than in any other ethnic group. The reasons for the higher rate are unknown.
13. A patient with a complex pelvic fracture from a motor vehicle crash is on bed rest. Which nursing assessment finding is important to report to the health care provider? a. The patient states that the pelvis feels unstable. b. Abdomen is distended and bowel sounds are absent. c. There are ecchymoses across the abdomen and hips. d. The patient complains of pelvic pain with palpation.
b. Abdomen is distended and bowel sounds are absent.
When providing patient teaching about medication therapy for BPH with 5α-reductase inhibitors such as finasteride (Proscar), what information should you include? A. Ninety percent of patients show improvement with the drug. B. The drug can be taken periodically as symptoms occur. C. Women who are pregnant should not handle the drug. D. Effects are seen in 1 week.
Answer: C Although more than 50% of men who are treated with the drug show symptom improvement, it takes about 6 months to be effective. The drug must be taken on a continuous basis to maintain therapeutic results. Women who may be or are pregnant should not handle tablets.
During the first 4 hours after TURP, the patient receives 1200 mL of bladder irrigation solution, and his urine output is 1000 mL. What is your priority intervention? A. Slowing the rate of bladder irrigation B. Continuing to observe the patient C. Checking catheter patency D. Encouraging oral fluids
Answer: C You should continuously monitor the inflow and outflow of the irrigant. If outflow is less than inflow, assess the catheter for kinks or clots. If the outflow is blocked and patency cannot be reestablished by manual irrigation, stop the CBI and notify the physician.
In assessing a patient for testicular cancer, you understand that the manifestations of this disease often include A. acute back spasms and testicular pain. B. rapid onset of scrotal swelling and fever. C. fertility problems and bilateral scrotal tenderness. D. painless mass and heaviness sensation in the scrotal area.
Answer: D Clinical manifestations of testicular cancer include a painless lump in the scrotum, scrotal swelling, and a feeling of heaviness. The scrotal mass usually is not tender and is very firm. Some patients complain of a dull ache or heavy sensation in the lower abdomen, perianal area, or scrotum.
A priority nursing diagnosis for the patient with bacterial prostatitis is A. activity intolerance related to fatigue. B. sexual dysfunction related to painful ejaculation. C. deficient fluid volume related to decreased fluid intake. D. impaired urinary elimination related to urethral compression.
Answer: D Acute urinary retention can develop in acute prostatitis, and it requires bladder drainage with suprapubic catheterization. The patient may experience fatigue, but this is not the priority. Sexual dysfunction can occur, but the pain occurs after ejaculation. Fluid volume should be increased.
A 73-year-old male patient admitted for total knee replacement states during the health history interview that he has no problems with urinary elimination except that the "stream is less than it used to be." The nurse should give the patient anticipatory guidance that what condition may be developing? A. A tumor of the prostate B. Benign prostatic hyperplasia C. Bladder atony because of age D. Age-related altered innervation of the bladder
B. Benign prostatic hyperplasia Benign prostatic hyperplasia is an enlarged prostate gland because of an increased number of epithelial cells and stromal tissue. It occurs in about 50% of men over age 50 and 80% of men over age 80. Only about 16% of men develop prostate cancer. Bladder atony and age-related altered innervations of the bladder do not lead to a weakened stream.
A 45-year-old man reports having recent problems attaining an erection. Which medication will the nurse further explore as the possible etiology of this patient's sexual dysfunction? A. Furosemide (Lasix) B. Fluoxetine (Prozac) C. Clopidogrel (Plavix) D. Nitroglycerin (Nitrostat)
B. Fluoxetine (Prozac) Fluoxetine is a selective serotonin reuptake inhibitor used in the treatment of depression. A common adverse effect of this medication is sexual problems (impotence, delayed or absent orgasm, delayed or absent ejaculation, decreased sexual interest) in nearly 70% of men and women.
What would cause a nurse to suspect that an infection has developed under a cast? a. Complaint of paresthesia c. Increased respirations b. Cold toes d. Hot spots felt on cast surface
D
Which term is used to describe an abnormally increased convex angulation in the curvature of the thoracic spine? a. Scoliosis c. Lordosis b. Ankylosis d. Kyphosis
D
hich nursing intervention is appropriate to assess for neurovascular competency in a child who fell off the monkey bars at school and hurt his arm? a. The degree of motion and ability to position the extremity. b. The length, diameter, and shape of the extremity. c. The amount of swelling noted in the extremity and pain intensity. d. The skin color, temperature, movement, sensation, and capillary refill of the extremity.
D
A client had an above-the-knee amputation of the left leg because of trauma from a motor vehicle collision. The primary healthcare provider prescribes ambulation with crutches until the residual limb is healed and the client can be fitted with a prosthesis. What should be the nurse's initial action? 1 Demonstrate the swing-through crutch walking gait. 2 Determine whether the client has ever used crutches before. 3 Introduce the client to another client who is using crutches. 4 Provide a pamphlet that has information about using crutches.
Determine whether the client has ever used crutches before.
The nurse is assisting a client with myasthenia gravis to bathe. The nurse identifies that the client's arms become weaker with sustained movement. What action should the nurse take? 1 Encourage the client to rest for short periods. 2 Continue the bath while supporting the client's arms. 3 Gradually increase the client's activity level each day. 4 Administer a dose of pyridostigmine bromide.
Encourage the client to rest for short periods.
38. Before assisting a patient with ambulation 2 days after a total hip replacement, which action is most important for the nurse to take? a. Observe the status of the incisional drain device. b. Administer the ordered oral opioid pain medication. c. Instruct the patient about the benefits of ambulation. d. Change the hip dressing and document the wound appearance.
b. Administer the ordered oral opioid pain medication.
The nurse observes a 74-year-old man with Parkinson's disease rocking side to side while sitting in the chair. Which action by the nurse is most appropriate? a. Provide the patient with diversional activities. b. Document the activity in the patient's health record. c. Take the patient's blood pressure sitting and standing. c. Ask if the patient is feeling either anxious or depressed.
b. Document the activity in the patient's health record. Rationale: Patients with Parkinson's disease are instructed to rock from side to side to stimulate balance mechanisms and decrease akinesia.
35. The second day after admission with a fractured pelvis, a 64-year-old patient suddenly develops confusion. Which action should the nurse take first? a. Take the blood pressure. b. Assess patient orientation. c. Check the oxygen saturation. d. Observe for facial asymmetry.
c. Check the oxygen saturation.
What should a nurse explains to a client is the best way to achieve stimulation of calcium deposition in the bone after a distal femoral fracture? 1 Resting the extremity 2 Weight-bearing activity 3 Normal aging processes 4 Ingesting foods high in calcium
Weight-bearing activity
20. Which statement by a 62-year-old patient who has had an above-the-knee amputation indicates that the nurse's discharge teaching has been effective? a. "I should elevate my residual limb on a pillow 2 or 3 times a day." b. "I should lay flat on my abdomen for 30 minutes 3 or 4 times a day." c. "I should change the limb sock when it becomes soiled or each week." d. "I should use lotion on the stump to prevent skin drying and cracking."
b. "I should lay flat on my abdomen for 30 minutes 3 or 4 times a day."
To reduce the risk for falls in the patient with Parkinson's disease, what should the nurse teach the patient to do? a. Use an elevated toilet seat. b. Use a walker or cane for support. c. Consciously lift the toes when stepping. d. Rock side to side to initiate leg movements.
c. Consciously lift the toes when stepping. Rationale: The shuffling gait of PD causes the patient to be off balance and at risk for falling. Teaching the patient to use a wide stance with the feet apart, to lift the toes when walking, and to look ahead helps to promote a more balanced gait. Use of an elevated toilet seat and rocking from side to side will enable a patient to initiate movement. Canes and walkers are difficult for patients with PD to maneuver and may make the patient more prone to injury.
A patient receiving an intravenous opioid analgesic has become apneic. Match the nursing interventions with the step numbers in order from the highest priority (first intervention) to the lowest priority (last intervention). a. Initiate resuscitation efforts as appropriate b. Administer the prescribed naloxone (Narcan) dose by slow IV push c. Prepare to administer naloxone (Narcan) as needed every 2 minutes until desired effect 1. Step 1 2. Step 2 3. Step 3
1. ANS: A PTS: 1 DIF: Cognitive Level: Application OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity NOT: Initiate resuscitation efforts as appropriate. Administer naloxone (Narcan). Administer bolus by slow intravenous (IV) push every 2 minutes until effect is obtained. 2. ANS: B PTS: 1 DIF: Cognitive Level: Application OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity NOT: Initiate resuscitation efforts as appropriate. Administer naloxone (Narcan). Administer bolus by slow intravenous (IV) push every 2 minutes until effect is obtained. 3. ANS: C PTS: 1 DIF: Cognitive Level: Application OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity NOT: Initiate resuscitation efforts as appropriate. Administer naloxone (Narcan). Administer bolus by slow intravenous (IV) push every 2
34. The day after a 60-year-old patient has an open reduction and internal fixation (ORIF) for an open, displaced tibial fracture, the priority nursing diagnosis is a. activity intolerance related to deconditioning. b. risk for constipation related to prolonged bed rest. c. risk for impaired skin integrity related to immobility. d. risk for infection related to disruption of skin integrity.
d. risk for infection related to disruption of skin integrity.
1. A dose of oxycodone (OxyContin) 2 mg/kg has been ordered for a child weighing 33 lbs. The nurse should administer ______ mg of OxyContin. (Record your answer as a whole number.)
ANS: 30 The child's weight is divided by 2.2 to obtain the weight in kilograms. Kilograms in weight are then multiplied by the prescribed 2 mg. 33 lbs/2.2 = 15 kg. 15 kg × 2 mg = 30 mg. PTS: 1 DIF: Cognitive Level: Application OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
1. A patient who is receiving an IV antibiotic develops wheezes and dyspnea. In which order should the nurse implement these prescribed actions? (Put a comma and a space between each answer choice [A, B, C, D, E]). a. Discontinue the antibiotic. b. Give diphenhydramine IV. c. Inject epinephrine IM or IV. d. Prepare an infusion of dopamine. e. Provide 100% oxygen using a nonrebreather mask.
ANS: A, E, C, B, D The nurse should initially discontinue the antibiotic because it is the likely cause of the allergic reaction. Next, oxygen delivery should be maximized, followed by treatment of bronchoconstriction with epinephrine administered IM or IV. Diphenhydramine will work more slowly than epinephrine, but will help prevent progression of the reaction. Because the patient currently does not have evidence of hypotension, the dopamine infusion can be prepared last. DIF: Cognitive Level: Analyze (analysis) REF: 201 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
A female patient complains of a "scab that just won't heal" under her left breast. During your conversation, she also mentions chronic fatigue, loss of appetite, and slight cough, attributed to allergies. What are the nurse's next steps? a. Continue to conduct a symptom analysis to better understand the patient's symptoms and concerns. b. End the appointment and tell the patient to use skin protection during sun exposure. c. Suggest further testing with a cancer specialist and provide the appropriate literature. d. Tell her to put a bandage on the scab and set a follow-up appointment in one week.
ANS: A A comprehensive health history is vital to treating and caring for the patient. Often times, symptoms are vague. The nurse should conduct a symptom analysis to gather as much information as possible. Questions should address the duration of the symptoms and include the location, characteristics, aggravating and relief factors, and any treatments taken thus far.
The nurse is teaching a 47-year-old woman about recommended screening practices for breast cancer. Which statement by the client indicates understanding of the nurse's instructions? a. "My mother and grandmother had breast cancer, so I am at risk." b. "I get a mammogram every 2 years since I turned 30." c. "A clinical breast examination is performed every month since I turned 40." d. "A computed tomography (CT) scan will be done every year after I turn 50."
ANS: A A strong family history of breast cancer indicates a risk for breast cancer. Annual rather than biannual screening may be indicated for a strong family history. The client may perform a self-breast examination monthly; a clinical examination by a health care provider is indicated annually. An annual mammogram is performed after age 40 or in younger clients with a strong family history.
The nurse is teaching the 47-year-old female client about recommended screening practices for breast cancer. Which statement by the client indicates understanding of the nurse's instructions? a. "My mother and grandmother had breast cancer, so I am at risk." b. "I get a mammography every 2 years since I turned 30." c. "A clinical breast examination is performed every month since I turned 40." d. "A CT scan will be done every year after I turn 50."
ANS: A A strong family history of breast cancer indicates a risk for breast cancer. Annual screening may be indicated for a strong family history. The client may perform a self-breast examination monthly; a clinical examination by a health care provider is indicated annually. An annual mammography is performed after age 40 or in younger clients with a strong family history.
A client asks the nurse if eating only preservative- and dye-free foods will decrease cancer risk. What response by the nurse is best? a. "Maybe; preservatives, dyes, and preparation methods may be risk factors." b. "No; research studies have never shown those things to cause cancer." c. "There are other things you can do that will more effectively lower your risk." d. "Yes; preservatives and dyes are well known to be carcinogens."
ANS: A Dietary factors related to cancer development are poorly understood, although dietary practices are suspected to alter cancer risk. Suspected dietary risk factors include low fiber intake and a high intake of red meat or animal fat. Preservatives, preparation methods, and additives (dyes, flavorings, sweeteners) may have cancer-promoting effects. It is correct to say that other things can lower risk more effectively, but this does not give the client concrete information about how to do so, and also does not answer the client's question.
Which description about genetic screening is correct? a. It identifies genetic risk for specific cancers. b. The tests are performed on cerebrospinal fluid samples. c. A positive test diagnoses cancer in the client. d. The test results are shared with the client's family.
ANS: A Genetic screening helps to identify if a client has a genetic risk for specific cancers. The tests are performed only on blood samples. A positive test indicates the presence of a mutated gene that may cause cancer; however, the cancer may never develop. The test result is not shared with the client's family; it is the client's privilege to maintain secrecy or disclose the contents of the test to the family.
While planning care for a patient experiencing fatigue due to chemotherapy, which of the following is the most appropriate nursing intervention? a. Prioritization and administration of nursing care throughout the day b. Completing all nursing care in the morning so the patient can rest the remainder of the day c. Completing all nursing care in the evening when the patient is more rested d. Limiting visitors, thus promoting the maximal amount of hours for sleep
ANS: A Pacing activities throughout the day conserves energy, and nursing care should be paced as well. Fatigue is a common side effect of cancer and treatment; and while adequate sleep is important, an increase in the number of hours slept will not resolve the fatigue. Restriction of visitors does not promote healthy coping and can result in feelings of isolation.
The nurse would incorporate which of the following into the plan of care as a primary prevention strategy for reduction of the risk for cancer? a. Yearly mammography for women aged 40 years and older b. Using skin protection during sun exposure while at the beach c. Colonoscopy at age 50 and every 10 years as follow-up d. Yearly prostate specific antigen (PSA) and digital rectal exam for men aged 50 and over
ANS: B Primary prevention of cancer involves avoidance to known causes of cancer, such as sun exposure. Secondary screening involves physical and diagnostic examination.
The nurse manager in a long-term care facility is developing a plan for primary and secondary prevention of colorectal cancer. Which tasks associated with the screening plan will be delegated to nursing assistants within the facility? a. Testing of stool specimens for occult blood b. Teaching about the importance of dietary fiber c. Referring clients for colonoscopy procedures d. Giving vitamin and mineral supplements
ANS: A Testing of stool specimens for occult blood is done according to a standardized protocol and can be delegated to nursing assistants. Client education is within the scope of practice of the RN, not of the LPN or nursing assistant. Referral for further care is best performed by the RN. Administration of medications is beyond the nursing assistant's scope of practice and should be done by licensed nursing personnel.
A client who has just been notified that the breast biopsy indicates a malignancy tells the nurse, "I just don't know how this could have happened to me." Which of these responses by the nurse will be most appropriate? a. "Tell me what you mean when you say you don't know how this could have happened to you." b. "Do you have a family history that might make you more likely to develop breast cancer?" c. "Would you like me to help you find more information about how breast cancer develops?" d. "Many risk factors for breast cancer have been identified, so it is difficult to determine what might have caused it."
ANS: A The client's statement may indicate shock and denial or a request for more information. To provide appropriate care, further assessment is needed about the client's psychosocial status. The first action by the nurse in this situation is to obtain more data by asking open-ended questions.
Which of the following statements is essential when teaching a patient who has received an injection of iodine-131? a. "Do not share a toilet with anyone else for 3 days." b. "You need to save all your urine for the next 7 days." c. "No special precautions are needed, because this is a weak type of radiation." d. "You need to avoid contact with everyone except family members until the radiation device is removed."
ANS: A The radiation source is an unsealed isotope that is eliminated from the body mainly through urine and feces. This material is radioactive for about 48 hours after instillation. The patient should not share a toilet with others for 3 days to ensure the isotope has been completely eliminated and is no longer radioactive. Saving the urine is not necessary. Contact should be avoided with anyone who may be ill or immunocompromised. Patients are instructed to avoid crowded areas but isolation is not necessary.
What priority intervention will the nurse employ to prevent injury to the patient with bone cancer? a. Using a lift sheet when repositioning the patient b. Positioning the patient so the heels do not touch the mattress c. Providing small, frequent meals rich in calcium and phosphorus d. Applying pressure for a full 5 minutes after intramuscular injections
ANS: A The resultant bone destruction from bone cancer can cause pathological fractures by grasping or pulling on a patient by the extremities or trunk of the body during re-positioning. Use of a lift sheet evenly distributes the patient's weight, lessening the chance of fractures occurring. While safety risks exist, the priority for bone cancer is reducing risk of fractures.
Which information must the organ transplant nurse emphasize before a client is discharged? a. "Taking immunosuppressant medications increases your risk for cancer and the need for screenings." b. "You are at increased risk for cancer when you reach 60 years of age." c. "Immunosuppressant medications will decrease your risk for developing cancers." d. "After 6 months, you may stop immunosuppressant medications, and your risk for cancer will be the same as that of the general population."
ANS: A Use of immunosuppressant medications to prevent organ rejection increases the risk for cancer. Advanced age is a risk factor for all people, not just for organ transplant recipients. Immunosuppressant medications must be taken for the life of the organ; the risk for developing cancer remains.
While collecting a health history on a patient admitted for colon cancer, which of the following questions would be a priority to ask this patient? a. "Have you noticed any blood in your stool?" b. "Have you been experiencing nausea?" c. "Do you have back pain?" d. "Have you noticed any swelling in your abdomen?"
ANS: A Early colon cancer is often asymptomatic, with occult or frank blood in the stool being an assessment finding in a patient diagnosed with colon cancer. If pain is present, it is usually lower abdominal cramping. Constipation and diarrhea are more frequent findings than nausea or ascites.
3. A patient is being evaluated for possible atopic dermatitis. The nurse expects elevation of which laboratory value? a. IgE c. Basophils b. IgA d. Neutrophils
ANS: A Serum IgE is elevated in an allergic response (type 1 hypersensitivity disorders). The eosinophil level will be elevated rather than neutrophil or basophil counts. IgA is located in body secretions and would not be tested when evaluating a patient who has symptoms of atopic dermatitis. DIF: Cognitive Level: Apply (application) REF: 194 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
13. Ten days after receiving a bone marrow transplant, a patient develops a skin rash. What would the nurse suspect is the cause of the rash? a. The donor T cells are attacking the patient's skin cells. b. The patient needs treatment to prevent hyperacute rejection. c. The patient's antibodies are rejecting the donor bone marrow. d. The patient is experiencing a delayed hypersensitivity reaction.
ANS: A The patient's history and symptoms indicate that the patient is experiencing graft-versus-host disease, in which the donated T cells attack the patient's tissues. The history and symptoms are not consistent with rejection or delayed hypersensitivity. DIF: Cognitive Level: Application (apply) REF: 210 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity
4. An older adult patient who is having an annual check-up tells the nurse, "I feel fine, and I don't want to pay for all these unnecessary cancer screening tests!" Which information should the nurse plan to teach this patient? a. Consequences of aging on cell-mediated immunity b. Decrease in antibody production associated with aging c. Impact of poor nutrition on immune function in older people d. Incidence of cancer-associated infections in older individuals
ANS: A The primary impact of aging on immune function is on T cells, which are important for immune surveillance and tumor immunity. Antibody function is not affected as much by aging. Poor nutrition can also contribute to decreased immunity, but there is no evidence that it is a contributing factor for this patient. Although some types of cancer are associated with specific infections, this patient does not have an active infection. DIF: Cognitive Level: Apply (application) REF: 196 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
A client has a diagnosis of lung cancer. To which areas does the nurse anticipate that this client's tumor may metastasize? Select all that apply. a. Brain b. Bone c. Lymph node d. Kidney e. Liver
ANS: A, B, C, E Typical sites of metastasis of lung cancer include the brain, bone, liver, lymph nodes, and pancreas. Kidneys are not a typical site of lung cancer metastasis.
A nurse is providing community education on the seven warning signs of cancer. Which signs are included? (Select all that apply.) a. A sore that does not heal b. Changes in menstrual patterns c. Indigestion or trouble swallowing d. Near-daily abdominal pain e. Obvious change in a mole
ANS: A, B, C, E The seven warning signs for cancer can be remembered with the acronym CAUTION: changes in bowel or bladder habits, a sore that does not heal, unusual bleeding or discharge, thickening or lump in the breast or elsewhere, indigestion or difficulty swallowing, obvious change in a wart or mole, and nagging cough or hoarseness. Abdominal pain is not a warning sign.
The nurse includes which factors in teaching regarding the typical warning signs of cancer? Select all that apply. a. Persistent constipation b. Scab present for 6 months c. Curdlike vaginal discharge d. Axillary swelling e. Headache
ANS: A, B, D Change in bowel habits, a sore throat that does not heal, and a lump or thickening in the breast or elsewhere are all potential warning signs of cancer. Curdlike vaginal discharge represents a yeast infection. Headache is not a warning sign, but may be present with multiple problems.
A client wishes to undergo genetic testing to determine cancer predisposition. What preliminary information does the nurse provide to this client about genetic testing? Select all that apply. a. Genetic testing is expensive. b. The test is performed on saliva. c. The test is performed on blood. d. It is helpful in diagnosing cancer. e. Insurance usually covers the cost.
ANS: A, C Genetic testing is an expensive procedure that uses the client's blood to rule out a person's genetic risk for a few specific cancers. Genetic testing is helpful only in detecting the risk for cancer, not for diagnosing the presence of cancer. Insurance companies generally do not cover the cost of genetic testing.
A patient asks you, "How can I decrease my risk of prostate cancer?" You teach the patient to avoid which foods (select all that apply)? A. Red meat B. High-fat dairy products C. Fruits D. Vegetables E. Chicken
Answer: A, B Dietary factors may be associated with prostate cancer. A diet high in red meat and high-fat dairy products, along with a low intake of vegetables and fruits, may increase the risk of prostate cancer.
What are the features of a normal cell? Select all that apply. a. Low mitotic index b. Anaplastic c. Tight adherence d. Euploidy e. Migratory
ANS: A, C, D At any given time, there are few actively dividing cells. Normal cells have a low mitotic index. Normal cells with the exception of red blood cells produce proteins that protrude from the membranes, allowing the cells to bind tightly together. This results in normal cells being nonmigratory and prevents cells wandering from one tissue to the next. Normal chromosomes or euploidy is a characteristic feature of most normal human cells. These cells have 23 pairs of chromosomes, the correct number for human beings. Malignant cells or cancer cells are anaplastic; they lose the specific appearance of their parent cells. As a cancer cell becomes more malignant, it becomes smaller and rounded. They have large nuclear-to-cytoplasmic ratio. Normal cells have specific morphological features with small nuclear-to-cytoplasmic ratio. Cancer cells migrate because they have many enzymes on their cell surfaces and do not bind tightly to each other.
3. Which dietary recommendations should a nurse make to an adolescent patient to manage constipation related to opioid analgesic administration? (Select all that apply.) a. Bran cereal b. Decrease fluid intake c. Prune juice d. Cheese e. Vegetables
ANS: A, C, E To manage the side effect of constipation caused by opioids, fluids should be increased, and bran cereal and vegetables are recommended to increase fiber. Prune juice can act as a nonpharmacologic laxative. Fluids should be increased, not decreased, and cheese can cause constipation so it should not be recommended. PTS: 1 DIF: Cognitive Level: Application OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity Copyright © 2018, Elsevier Inc. All Rights Reserved. 4
The nurse is planning care for a patient with hypercalcemia secondary to bone metastasis. Which of the following interventions will be included in the plan of care? (Select all that apply.) a. Increasing oral fluids b. Placement of an oral airway at the bedside c. Monitoring for Chvostek's sign d. Implementing seizure precautions e. Hyperactive reflex assessment f. Observation for muscle weakness
ANS: A, D Serious complications of hypercalcemia include severe muscle weakness, dehydration, loss of deep tendon reflexes, paralytic ileus, and electrocardiographic changes. Early manifestations of hypercalcemia include fatigue, loss of appetite, nausea, vomiting, constipation, and polyuria (increased urine output).
The nursing student learning about cancer development remembers characteristics of normal cells. Which characteristics does this include? (Select all that apply.) a. Differentiated function b. Large nucleus-to-cytoplasm ratio c. Loose adherence d. Nonmigratory e. Specific morphology
ANS: A, D, E Normal cells have the characteristics of differentiated function, nonmigratory, specific morphology, a smaller nucleus-to-cytoplasm ratio, tight adherence, and orderly and well-regulated growth.
A client is at risk for developing colon cancer. What are the various preventive interventions that the nurse may plan to implement? Select all that apply. a. Suggest taking aspirin. b. Administer the vaccine Gardasil. c. Encourage a diet rich in fiber and fat. d. Suggest limiting the number of sexual partners. e. Refer for a polypectomy if the client has associated polyps.
ANS: A, E Clients who are at risk for developing colon cancer may begin taking aspirin, and removing at-risk tissues like associated polyps, if present, to reduce their risk. Gardasil is a vaccine effective against cervical cancer. The client should be encouraged to have a diet rich in fiber and low in fat. Limiting sexual partners is a practice helpful in preventing cervical cancer.
A client asks if there are any drugs which help to prevent the development of cancer. How does the nurse respond? Select all that apply. a. Aspirin (acetylsalicylic acid) reduces the risk of colon cancer. b. Lycopene reduces the risk of prostate cancer. c. Tamoxifen (Nalvodex) reduces the risk of breast cancer. d. There are no drugs which prevent the development of cancer. e. Anticancer drugs can be used as preventive therapy.
ANS: A,B,C The drug therapies that have proven preventive roles for various cancers are aspirin for colon cancer, lycopene for prostate cancer, and tamoxifen for breast cancer. The client should not be encouraged to use anti-cancer drugs because they are associated with a higher risk for developing serious toxic effects. At the same time, they increase the risk of developing other cancers.
Which dietary modifications can the nurse recommend to a client for preventing cancer development? Select all that apply. a. Increasing broccoli intake b. Increasing red meat consumption c. Consuming more dietary bran d. Eating more sausage and bacon e. Restricting alcohol consumption to less than 2 drinks per day
ANS: A,C,E The dietary modifications that can help in reducing cancer development include eating broccoli, cauliflower, sprouts, cabbage, and dietary bran. Restricting alcohol consumption to less than 2 drinks per day also reduces the risk of developing cancer. Consuming animal fats like red meat, sausage, and bacon increase the risk for developing cancer, so their consumption should be restricted.
The nurse is assessing a client with lung cancer. Which symptom does the nurse anticipate finding? a. Easy bruising b. Dyspnea c. Night sweats d. Chest wound
ANS: B Dyspnea is a sign of lung cancer, as are cough, hoarseness, shortness of breath (SOB), bloody sputum, arm or chest pain, and dysphagia. Easy bruising is a nonspecific finding. Night sweats is a symptom of the lymphomas. A chest wound is not specific to lung cancer.
The nurse providing care for a patient with suspected cancer recalls that the only diagnostic procedure that is definitive for a diagnosis of cancer is: a. MRI b. Biopsy c. CT scan d. Tumor marker
ANS: B Only a biopsy is a definitive means of diagnosing cancer, because it actually identifies the pathological cells. Many tests, such as MRI, CT scan, and tumor markers, are indicative of cancer, but they do not confirm the presence of cancer cells as examination of a specimen obtained by biopsy does.
Which activity performed by the community health nurse best reflects primary prevention of cancer? a. Assisting women to obtain free mammograms b. Teaching a class on cancer prevention c. Encouraging long-term smokers to get a chest x-ray d. Encouraging sexually active women to get annual Papanicolaou (Pap) smears
ANS: B Primary prevention involves avoiding exposure to known causes of cancer; education assists clients with this strategy. Mammography is part of a secondary level of prevention, defined as screening for early detection. Chest x-ray is a method of detecting a cancer that is present—secondary prevention and early detection. A Pap smear is a means of detecting cervical cancer early—secondary prevention.
The nurse reviews the chart of a client admitted with a diagnosis of glioblastoma with a T1NXM0 classification. Which explanation does the nurse offer when the client asks what the terminology means? a. "Two lymph nodes are involved in this tumor of the glial cells, and another tumor is present." b. "The brain tumor measures about 1 to 2 cm and shows no regional lymph nodes and no distant metastasis." c. "This type of tumor in the brain is small with some lymph node involvement; another tumor is present somewhere else in your body." d. "Glioma means this tumor is benign, so I will have to ask your health care provider the reason for the chemotherapy and radiation."
ANS: B T1 means that the tumor is increasing in size to about 2 cm, and that no regional lymph nodes are present in the brain. M0 means that no distant metastasis has occurred. NX means that no regional lymph nodes can be assessed. A glioma is a benign tumor of the brain, but the client is diagnosed with a glioblastoma, which means a malignant tumor of the glial cells of the brain.
Which of these does the nurse recognize as the goal of palliative surgery for the client with cancer? a. Cure of the cancer b. Relief of symptoms or improved quality of life c. Allowing other therapies to be more effective d. Prolonging the client's survival time
ANS: B The focus of palliative surgery is to improve quality of life during the survival time.
The nurse is assessing a client for bladder cancer. About which sign or symptom does the nurse ask the client? a. Unexplained fevers b. Presence of blood in the urine c. History of urinary tract infections d. Change in the size of urine stream
ANS: B The nurse asks the client about presence of blood in the urine which is often found in clients with bladder cancer. Unexplained fevers may be assessed in the client with leukemia. During an assessment for prostate cancer, the nurse would ask the client about a history of urinary tract infections and a change in the size of urine stream because enlargement of the prostate affects the urinary bladder, thereby affecting the size of the urine stream. The client experiences urine retention and has repeated urinary tract infections.
When teaching women about the risk of breast cancer, which risk factor does the nurse know is the most common for the development of the disease? a. Having an aunt with breast cancer b. Being an older adult c. Being a Euro-American d. Consuming a low-fat diet
ANS: B There is no single-known cause for breast cancer. Being an older woman or man is the primary risk factor, although some people are at higher risk than others. Having a first-degree relative (mother, sister, or daughter) with breast cancer can increase the risk; an aunt is not considered a first-degree relative. Although Euro-American women older than 40 years are at a more increased risk than other racial/ethnic groups, the greater risk is being an older adult. Consuming a high-fat diet is considered a risk factor.
The nurse suspects metastasis from left breast cancer to the thoracic spine when the client has which symptom? a. Vomiting b. Back pain c. Frequent urination d. Cyanosis of the toes
ANS: B Typical sites of breast cancer metastasis include bone, manifested by back pain, lung, liver, and brain. Signs of metastasis to the spine may include numbness, pain, paresthesias and tingling, and loss of bowel and bladder control. Although frequent urination may be a sign of bladder cancer, incontinence is more indicative of spinal metastasis. Cyanosis of the toes indicates decreased tissue perfusion, often related to atherosclerotic disease.
17. A patient is admitted to the hospital with acute rejection of a kidney transplant. Which intervention will the nurse prepare for this patient? a. Testing for human leukocyte antigen (HLA) match b. Administration of immunosuppressant medications c. Insertion of an arteriovenous graft for hemodialysis d. Placement of the patient on the transplant waiting list
ANS: B Acute rejection is treated with the administration of additional immunosuppressant drugs such as corticosteroids. Because acute rejection is potentially reversible, there is no indication that the patient will require another transplant or hemodialysis. There is no indication for repeat HLA testing. DIF: Cognitive Level: Apply (application) REF: 208 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
21. Immediately after the nurse administers an intracutaneous injection of an allergen on the forearm, the patient complains of itching at the site, weakness, and dizziness. What action should the nurse take first? a. Apply antiinflammatory cream. b. Place a tourniquet above the site. c. Administer subcutaneous epinephrine. d. Reschedule the patient's other allergen tests.
ANS: B Application of a tourniquet will decrease systemic circulation of the allergen and should be the first reaction. The other actions may occur, but the tourniquet application slows the allergen progress into the patient's system, allowing treatment of the anaphylactic response. A local antiinflammatory cream may be applied to the site of a cutaneous test if the itching persists. Epinephrine will be needed if the allergic reaction progresses to anaphylaxis. Other testing may be delayed and rescheduled after development of anaphylaxis. DIF: Cognitive Level: Analysis (analyze) REF: 201 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
5. A patient who collects honey to earn supplemental income has developed a hypersensitivity to bee stings. Which statement, if made by the patient, would indicate a need for additional teaching? a. "I need to find a different way to earn extra money." b. "I will take oral antihistamines before going to work." c. "I will get a prescription for epinephrine and learn to self-inject it." d. "I should wear a Medic-Alert bracelet indicating my allergy to bee stings."
ANS: B Because the patient is at risk for bee stings and the severity of allergic reactions tends to increase with added exposure to allergen, taking oral antihistamines will not adequately control the patient's hypersensitivity reaction. The other patient statements indicate a good understanding of management of the problem. DIF: Cognitive Level: Apply (application) REF: 197 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity
1. The nurse provides discharge instructions to a patient who has an immune deficiency involving the T lymphocytes. Which health screening should the nurse include in the teaching plan for this patient? a. Screening for allergies b. Screening for malignancies c. Screening for antibody deficiencies d. Screening for autoimmune disorders
ANS: B Cell-mediated immunity is responsible for the recognition and destruction of cancer cells. Allergic reactions, autoimmune disorders, and antibody deficiencies are mediated primarily by B lymphocytes and humoral immunity. DIF: Cognitive Level: Apply (application) REF: 196 TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance
2. Which example should the nurse use to explain an infant's "passive immunity" to a new mother? a.Vaccinations b. Breastfeeding c. Stem cells in peripheral blood d. Exposure to communicable diseases
ANS: B Colostrum in breast milk provides passive immunity through antibodies from the mother. These antibodies protect the infant for a few months. However, memory cells are not retained, so the protection is not permanent. Active immunity is acquired by being immunized with vaccinations or having an infection. Stem cells are unspecialized cells used to repopulate a person's bone marrow after high-dose chemotherapy. DIF: Cognitive Level: Apply (application) REF: 192 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
15. The nurse teaches a patient about drug therapy after a kidney transplant. Which statement by the patient would indicate a need for further instructions? a. "I need to be monitored closely for development of malignant tumors." b. "After a couple of years I will be able to stop taking the cyclosporine." c. "If I develop acute rejection episode, I will need additional types of drugs." d. "The drugs are combined to inhibit different ways the kidney can be rejected."
ANS: B Cyclosporine, a calcineurin inhibitor, will need to be continued for life. The other patient statements are accurate and indicate that no further teaching is necessary about those topics. DIF: Cognitive Level: Apply (application) REF: 209 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity
19. A patient in the health care provider's office for allergen testing using the cutaneous scratch method develops itching and swelling at the skin site. Which action should the nurse take first? a. Monitor the patient's edema. b. Administer a dose of epinephrine. c. Provide a prescription for oral antihistamines d. Ask the patient about the use of new skin products.
ANS: B Rapid administration of epinephrine when excessive itching or swelling at the skin site is observed can prevent the progression to anaphylaxis. The initial symptoms of anaphylaxis are itching and edema at the site of the exposure. The nurse should not wait and assess for development of additional edema. Hypotension, tachycardia, dilated pupils, and wheezes occur later. Exposure to skin products does not address the immediate concern of a possible anaphylactic reaction. DIF: Cognitive Level: Analyze (analysis) REF: 202 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
12. Which patient should the nurse assess first? a. Patient with urticaria after receiving an IV antibiotic b. Patient who is sneezing after subcutaneous immunotherapy c. Patient who has graft-versus-host disease and severe diarrhea d. Patient with multiple chemical sensitivities who has muscle stiffness
ANS: B Sneezing after subcutaneous immunotherapy may indicate impending anaphylaxis and assessment and emergency measures should be initiated. The other patients also have findings that need assessment and intervention by the nurse, but do not have evidence of life-threatening complications. DIF: Cognitive Level: Analyze (analysis) REF: 203 OBJ: Special Questions: Prioritization | Special Questions: Multiple Patients TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment
11. Which statement by a patient would alert the nurse to a risk for decreased immune function? a. "I had a chest x-ray 6 months ago." b. "I had my spleen removed after a car accident." c. "I take one baby aspirin every day to prevent stroke." d. "I usually eat eggs or meat for at least two meals a day."
ANS: B Splenectomy increases the risk for septicemia from bacterial infections. The patient's protein intake is good and should improve immune function. Daily aspirin use does not affect immune function. A chest x-ray does not have enough radiation to suppress immune function. DIF: Cognitive Level: Apply (application) REF: 206 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
14. A patient seeks care in the emergency department after sharing needles for heroin injection with a friend who has hepatitis B. To provide immediate protection from infection, what medication will the nurse expect to administer? a. Corticosteroids c. Hepatitis B vaccine b. Gamma globulin d. Fresh frozen plasma
ANS: B The patient should first receive antibodies for hepatitis B from injection of gamma globulin. The hepatitis B vaccination series should be started to provide active immunity. Fresh frozen plasma and corticosteroids will not be effective in preventing hepatitis B in the patient. DIF: Cognitive Level: Apply (application) REF: 192 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
8. The nurse taking a health history learns that the patient, who has worked in rubber tire manufacturing, has allergic rhinitis and multiple food allergies. Which action by the nurse is correct? a. Recommend that the patient use latex gloves in preventing blood-borne pathogen contact. b. Document the patient's history and teach about clinical manifestations of a type I latex allergy. c. Encourage the patient to carry an epinephrine kit in case a type IV allergic reaction to latex develops. d. Advise the patient to use oil-based hand creams to decrease contact with natural proteins in latex gloves.
ANS: B The patient's allergy history and occupation indicate a risk of developing a latex allergy. The patient should be taught about symptoms that may occur. Epinephrine is not an appropriate treatment for contact dermatitis that is caused by a type IV allergic reaction to latex. Using latex gloves increases the chance of developing latex sensitivity. Oil-based creams will increase the exposure to latex from latex gloves. DIF: Cognitive Level: Apply (application) REF: 203 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
The nurse is conducting a community health education class on diet and cancer risk reduction. What should be included in the discussion? (Select all that apply.) a. Limit sodium intake. b. Avoid beef and processed meats. c. Increase consumption of whole grains. d. Eat "colorful fruits and vegetables," including greens. e. Avoid gas-producing vegetables such as cabbage.
ANS: B, C, D Consuming bran and whole grains and avoiding red meat and processed foods such as lunchmeats can reduce cancer risk. Consuming foods high in vitamin A, including apricots, carrots, and leafy green and yellow vegetables, can also reduce cancer risk. Reducing sodium is helpful in the treatment of hypertension and heart and kidney failure; no evidence suggests that lowering of sodium intake decreases the incidence of cancer. Eating cruciferous vegetables such as broccoli, cauliflower, Brussels sprouts, and cabbage may actually reduce cancer risk.
A client has a very high risk for developing breast cancer. What preventive measures may the nurse recommend? Select all that apply. a. Encourage a diet rich in fiber and fat. b. Discuss the need for a mastectomy. c. Suggest the long-term use of vitamin D. d. Explain the need for long-term use of tamoxifen. e. Recommend limiting the number of sexual partners.
ANS: B, C, D Preventive measures for clients who are at high risk for developing breast cancer include the removal of the breast (mastectomy), and long-term intake of vitamin D and tamoxifen. The client should be encouraged to consume a diet rich in fiber and low in fat. Limiting the number of sexual partners is helpful in preventing cervical cancer, not breast cancer.
A nurse is participating in primary prevention efforts directed against cancer. In which activities is this nurse most likely to engage? (Select all that apply.) a. Demonstrating breast self-examination methods to women b. Instructing people on the use of chemoprevention c. Providing vaccinations against certain cancers d. Screening teenage girls for cervical cancer e. Teaching teens the dangers of tanning booths
ANS: B, C, E Primary prevention aims to prevent the occurrence of a disease or disorder, in this case cancer. Secondary prevention includes screening and early diagnosis. Primary prevention activities include teaching people about chemoprevention, providing approved vaccinations to prevent cancer, and teaching teens the dangers of tanning beds. Breast examinations and screening for cervical cancer are secondary prevention methods.
What are the common cancers related to tobacco use? Select all that apply. a. Cardiac cancer b. Lung cancer c. Cancer of the tongue d. Skin cancer e. Cancer of the larynx
ANS: B, C, E Organs exposed to the carcinogens in tobacco are the most likely to develop cancer. Oral cancer is also a risk with "smokeless" tobacco. The heart does not contain cells that divide; therefore, cardiac cancer is unlikely. Skin cancer generally is related to repeated sun and other UV exposure such as that found with tanning beds.
A client who is hospitalized has been diagnosed with Epstein-Barr viral infection. What are future malignancies that the client is at risk for developing? Select all that apply. a. Cervical cancer b. B-cell lymphoma c. Burkitt's lymphoma d. Primary liver cancer e. Nasopharyngeal carcinoma
ANS: B, C, E The Epstein-Barr virus predisposes the client to developing B-cell lymphoma, Burkitt's lymphoma, and nasopharyngeal carcinoma. Human papilloma viral infection is a risk factor for cervical cancer. Hepatitis B and C infections are risk factors for primary liver cancer.
The nurse is instructing a client on how to perform breast self-examination (BSE). Which techniques will the nurse include in teaching the client about BSE? Select all that apply. a. Instruct the client to keep her arm by her side while performing the examination. b. Ensure that the setting in which BSE is demonstrated is private and comfortable. c. Ask the client to remove her shirt. The bra may be left in place. d. Ask the client to demonstrate her own method of BSE. e. Use the fingertips, which are more sensitive than the finger pads, to palpate the breasts.
ANS: B, D The setting should be private and comfortable to promote an environment conducive to learning and to prevent potential client embarrassment. Before teaching breast palpation, ask the client to demonstrate her own method, so that the nurse can assess the client's understanding of BSE. For better visualization, the arm should be placed over the head.The client should undress from the waist up. The finger pads, which are more sensitive than the fingertips, are used when palpating the breasts.
The TNM classification report of a client with lung cancer is TisN0Mx. How is this classification interpreted? Select all that apply. a. No metastasis. b. Carcinoma in situ. c. No evidence of the primary tumor. d. Involvement of regional lymph nodes. e. Presence of metastasis cannot be assessed.
ANS: B, E Staging determines the exact location of the cancer and its degree of metastasis at diagnosis. The acronym TNM refers to "Tumor, Nodes, Metastasis." Per the TNM classification, Tis stands for carcinoma in situ. Mx means that the presence of distant metastasis cannot be assessed. The absence of regional lymph node metastasis is indicated by N0.
The nurse is teaching a client about cancer warning signs. Which signs/symptoms does the nurse include? Select all that apply. a. A sore that heals quickly b. Unusual bleeding and discharge c. Change in bowel or bladder habits d. Nagging cough or a hoarse voice e. Long-lasting warts without any observable change
ANS: B,C,E Unusual bleeding and discharge can be a warning sign for the onset of cancer. A change in bowel or bladder habits may be indicative of a malignancy in the intestine and urinary bladder, respectively. Nagging cough or hoarseness can indicate a malignancy of the respiratory airways. A sore that heals quickly indicates an effective wound-healing mechanism, while a non-healing sore can be a cancer warning sign. Long-lasting moles or warts with observable changes may be a warning sign for cancer.
Which of the following findings during a female breast examination should the nurse report as suspicious for breast cancer? a. Multiple nodules of round, lumpy, tender tissue in both breasts b. A single soft, mobile, lobular nodule that is nontender c. A poorly defined, firm lump that is nontender and nonmovable d. A single soft lump that is well-defined and tender
ANS: C A poorly defined, firm lump that is nontender, nonmovable, and fixed to the skin is characteristic of breast cancer. All other choices are usually associated with benign processes. All patients should have a diagnosis of cancer based upon physical assessment and tissue pathology.
nurse is learning about the different types of cancers. Which cancer has the highest incidence among men? a. Lung cancer b. Colon cancer c. Prostate cancer d. Thyroid cancer
ANS: C Among all the cancers in men, prostate cancer has the highest incidence (29%). Lung cancer has the highest death rate among men (29%). The incidence of colon cancer in males is 9%. Thyroid cancer is more common in women than men.
A patient with breast cancer asks the nurse why 6 weeks of daily radiation treatments is necessary. What is the nurse's best response? a. "Your cancer is widespread and requires more than the usual amount of radiation treatment." b. "The cost of larger doses of radiation for a shorter period of time is justified by the results." c. "Research has shown more cancer cells are killed if the radiation is given in smaller doses over a longer period of time." d. "It is less likely your hair will fall out or you will become anemic if radiation is given in smaller doses over a longer period of time."
ANS: C Because of the varying responses of all the cancer cells within a given tumor, smaller doses of radiation given on a daily basis for a set period of time provides multiple opportunities for the destruction of cancer cells while minimizing damage to normal tissues.
The nursing instructor explains the difference between normal cells and benign tumor cells. What information does the instructor provide about these cells? a. Benign tumors grow through invasion of other tissue. b. Benign tumors have lost their cellular regulation from contact inhibition. c. Growing in the wrong place or time is typical of benign tumors. d. The loss of characteristics of the parent cells is called anaplasia.
ANS: C Benign tumors are basically normal cells growing in the wrong place or at the wrong time. Benign cells grow through hyperplasia, not invasion. Benign tumor cells retain contact inhibition. Anaplasia is a characteristic of cancer cells.
A patient diagnosed with benign lipoma is concerned about the tumor spreading to other parts of the body. Which facts should the nurse include when teaching the patient about benign tumors? a. Benign tumors are poorly differentiated. b. Benign tumors have high recurrence rate. c. Benign tumors are not capable of metastasis. d. Benign tumors have moderate vascularity.
ANS: C Benign tumors are not metastatic and not capable of spreading from one organ to another. Benign tumors are normally differentiated, have low vascularity, and their recurrence is rare.
How is the migratory feature of cancer cells explained? a. They have a large nuclear-to-cytoplasmic ratio. b. They lose their specific functions. c. They do not make fibronectin. d. They have a short generation time.
ANS: C Fibronectin is a protein that protrudes from the membrane of normal cells, allowing them to bind tightly together. Cancer cells do not make fibronectin; hence they adhere loosely to each other and break off from the main tumor. These cells easily slip through the walls of the blood vessels and migrate to other body sites. Cancer cells have a large nuclear-to-cytoplasmic ratio; they lose their specific functions and have a short generation time. But it is the absence of fibronectin that makes these cells migratory.
The nurse is aware that an abdominal mass found in a 10-month-old infant corresponds with which childhood cancer? a. Osteogenic sarcoma b. Rhabdomyosarcoma c. Neuroblastoma d. Non-Hodgkin lymphoma
ANS: C Neuroblastoma is found exclusively in infants and children. In most cases of neuroblastoma, a primary abdominal mass and protuberant, firm abdomen are present. Osteogenic sarcoma is a bone tumor. Bone tumors typically affect older children. Rhabdomyosarcoma is a malignancy of muscle, or striated tissue. It occurs most often in the periorbital area, in the head and neck in younger children, or in the trunk and extremities in older children. Non-Hodgkin lymphoma is a neoplasm of lymphoid cells. Painless, enlarged lymph nodes are found in the cervical or axillary region. Abdominal signs and symptoms do not include a mass.
A client who is scheduled to undergo radiation for prostate cancer is admitted to the hospital by the nurse. Which statement by the client is most important to communicate to the health care provider? a. "I am allergic to iodine." b. "My urinary stream is very weak." c. "My legs are numb and weak." d. "I am incontinent when I cough."
ANS: C Numbness and weakness should be reported to the physician because paralysis caused by spinal cord compression can occur. Prostate cancer may frequently metastasize to the bone, specifically the spine. Allergy to iodine should be reported when contrast media will be used, but dye is not used in radiation therapy. A weak urinary stream and incontinence are common clinical manifestations of prostate cancer. Incontinence associated with coughing is typical of stress incontinence and is not a complication of cancer.
A client who has just had a mastectomy is crying. When the nurse asks about her crying, the client responds, "I know I shouldn't cry because this surgery may well save my life." What is the nurse's best response? a. "It is all right to cry. Mourning this loss will help make you stronger." b. "I know this is hard, but your chances of survival are better now." c. "I can arrange for someone who had a mastectomy to come visit if you like." d. "How have you coped with difficult situations in the past?"
ANS: C Often, cancer surgery involves the loss of a body part or a decrease in function. Mourning or grieving for a body image alteration is a healthy part of adapting or adjusting to a new image. Visiting with someone who has experienced the same situation as the client is very helpful in showing the client that many aspects of life can be the same afterward. If the opportunity to arrange this type of visit is available, this would be the nurse's best response. The other options do not provide any assistance to the client in coping with her new body image and grieving for her loss.
A 33-year-old patient has recently been diagnosed with stage II cervical cancer. The nurse would understand that the patient's cancer a. Is in situ. b. Has metastasized. c. Has spread locally. d. Has spread extensively.
ANS: C Stage II cancer is associated with local spread. Stage 0 denotes cancer in situ; stage III denotes extensive regional spread, and stage V denotes metastasis.
What should the nurse teach parents about oral hygiene for the child receiving chemotherapy? a. Brush the teeth briskly to remove bacteria. b. Use a mouthwash that contains alcohol. c. Inspect the child's mouth daily for ulcers. d. Perform oral hygiene twice a day.
ANS: C The child's mouth is inspected regularly for ulcers. At the first sign of ulceration, an antifungal drug is initiated. The teeth should be brushed with a soft-bristled toothbrush. Excessive force with brushing should be avoided because delicate tissue could be broken, causing infection or bleeding. Mouthwashes containing alcohol may be drying to oral mucosa, thus breaking down the protective barrier of the skin. Oral hygiene should be performed four times a day.
A nurse has taught a client about dietary changes that can reduce the chances of developing cancer. What statement by the client indicates the nurse needs to provide additional teaching? a. "Foods high in vitamin A and vitamin C are important." b. "I'll have to cut down on the amount of bacon I eat." c. "I'm so glad I don't have to give up my juicy steaks." d. "Vegetables, fruit, and high-fiber grains are important."
ANS: C To decrease the risk of developing cancer, one should cut down on the consumption of red meats and animal fat. The other statements are correct.
Which pathologic description of a client's tumor does the nurse interpret as being the "most malignant" or "high grade" cancer? a. poorly differentiated; mitotic index = 20%, euploid b. Moderately differentiated; mitotic index = 50%, euploid c. Undifferentiated; mitotic index = 50%, aneuploid d. Highly differentiated; mitotic index = 10%, aneuploid
ANS: C Tumors that closely resemble normal cells are "less malignant," and those that have few normal cell features are "more malignant." Thus, those that are euploid are less malignant and those that are aneuploid, with abnormal numbers or structures of chromosomes, are more malignant. Less malignant cells are highly differentiated, and more malignant cells are poorly or undifferentiated. Cells that divide faster (have a higher mitotic index) are more malignant.
What is a known cause of skin cancer? a. Intake of nitrites b. Cigarette smoke c. Tanning beds d. Low-fiber diet
ANS: C Ultraviolet radiation from tanning beds, cosmic radiation, germicidal lights, excessive exposure to the sun, and injuries from burns are known to cause skin cancer. Radiation mutates the genes and can cause cancer among non-dividing cells as well. Intake of nitrites from processed foods such as lunch meats, sausages and bacon increases the risk of cancer. Cigarette smoke is known to cause lung cancer. Although dietary factors like a low-fiber diet are suspected to alter cancer risk, their exact contribution is not clear.
6. Which information about intradermal skin testing should the nurse teach to a patient with possible allergies? a. "Do not eat anything for about 6 hours before the testing." b. "Take an oral antihistamine about an hour before the testing." c. "Plan to wait in the clinic for 20 to 30 minutes after the testing." d. "Reaction to the testing will take about 48 to 72 hours to occur."
ANS: C Allergic reactions usually occur within minutes after injection of an allergen, and the patient will be monitored for at least 20 minutes for anaphylactic reactions after the testing. Medications that might modify the response, such as antihistamines, should be avoided before allergy testing. There is no reason to be NPO for skin testing. Results with intradermal testing occur within minutes. DIF: Cognitive Level: Apply (application) REF: 200 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
23. The health care provider asks the nurse whether a patient's angioedema has responded to prescribed therapies. Which assessment should the nurse perform? a. Obtain the patient's blood pressure and heart rate. b. Question the patient about any clear nasal discharge. c. Observe for swelling of the patient's lips and tongue. d. Assess the patient's extremities for wheal and flare lesions.
ANS: C Angioedema is characterized by swelling of the eyelids, lips, and tongue. Wheal and flare lesions, clear nasal drainage, and hypotension and tachycardia are characteristic of other allergic reactions. DIF: Cognitive Level: Apply (application) REF: 199 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity
7. The nurse reviewing a clinic patient's medical record notes that the patient missed the previous appointment for weekly immunotherapy. Which action by the nurse is appropriate? a. Schedule an additional dose the following week. b. Administer the scheduled dosage of the allergen. c. Consult with the health care provider about giving a lower allergen dose. d. Re-evaluate the patient's sensitivity to the allergen with a repeat skin test.
ANS: C Because there is an increased risk for adverse reactions after a patient misses a scheduled dose of allergen, the nurse should check with the health care provider before administration of the injection. A skin test is used to identify the allergen and would not be used at this time. An additional dose for the week may increase the risk for a reaction. DIF: Cognitive Level: Apply (application) REF: 203 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
16. An older adult patient has a prescription for cyclosporine following a kidney transplant. Which information in the patient's health history has implications for planning patient teaching about the medication at this time? a. The patient restricts salt to 2 grams per day. b. The patient eats green leafy vegetables daily. c. The patient drinks grapefruit juice every day. d. The patient drinks 3 to 4 quarts of fluid each day.
ANS: C Grapefruit juice can increase the toxicity of cyclosporine. The patient should be taught to avoid grapefruit juice. Normal fluid and sodium intake or eating green leafy vegetables will not affect cyclosporine levels or renal function. DIF: Cognitive Level: Apply (application) REF: 209 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
9. What instructions about plasmapheresis should the nurse include in the teaching plan for a patient diagnosed with systemic lupus erythematosus (SLE)? a. Plasmapheresis eliminates eosinophils and basophils from blood. b. Plasmapheresis decreases the damage to organs from T lymphocytes. c. Plasmapheresis removes antibody-antigen complexes from circulation. d. Plasmapheresis prevents foreign antibodies from damaging various body tissues.
ANS: C Plasmapheresis is used in SLE to remove antibodies, antibody-antigen complexes, and complement from blood. T lymphocytes, foreign antibodies, eosinophils, and basophils do not directly contribute to the tissue damage in SLE. DIF: Cognitive Level: Understand (comprehension) REF: 205 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
24. A nurse has obtained donor tissue typing information about a patient who is waiting for a kidney transplant. Which results should be reported to the transplant surgeon? a. Patient is Rh positive and donor is Rh negative b. Six antigen matches are present in HLA typing c. Results of patient-donor crossmatching are positive d. Panel of reactive antibodies (PRA) percentage is low
ANS: C Positive crossmatching is an absolute contraindication to kidney transplantation because a hyperacute rejection will occur after the transplant. The other information indicates that the tissue match between the patient and potential donor is acceptable. DIF: Cognitive Level: Apply (application) REF: 208 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
20. A patient is anxious and reports difficulty breathing after being stung by a wasp. What is the nurse's priority action? a. Provide high-flow oxygen. c. Assess the patient's airway. b. Administer antihistamines. d. Remove the stinger from the site.
ANS: C The initial action with any patient with difficulty breathing is to assess and maintain the airway. The patient's symptoms of anxiety and difficulty breathing may have other causes than anaphylaxis, so additional assessment is warranted. The other actions are part of the emergency management protocol for anaphylaxis, but the priority is airway assessment and maintenance. DIF: Cognitive Level: Analysis (analyze) REF: 202 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
18. The charge nurse is assigning semiprivate rooms for new admissions. Which patient could safely be assigned as a roommate for a patient who has acute rejection of an organ transplant? a. A patient who has viral pneumonia b. A patient with second-degree burns c. A patient who is recovering from an anaphylactic reaction to a bee sting d. A patient with graft-versus-host disease after a recent bone marrow transplant
ANS: C There is no increased exposure to infection from a patient who had an anaphylactic reaction. Treatment for a patient with acute rejection includes administration of additional immunosuppressants and the patient should not be exposed to increased risk for infection as would occur from patients with viral pneumonia, graft-versus-host disease, and burns. DIF: Cognitive Level: Apply (application) REF: 201 OBJ: Special Questions: Multiple Patients TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment
What are the features of benign tumor cells? Select all that apply. a. They exhibit aneuploidy. b. They have migratory tendency. c. They have orderly growth patterns. d. They grow by hyperplastic expansion. e. They are encapsulated by fibrous connective tissue.
ANS: C, D, E Benign tumor cells have orderly growth patterns. They grow by hyperplastic expansion, causing the tissue to increase in size by increasing the number of cells. Growth may continue beyond an appropriate time or occur in the wrong place, but the growth rate is normal. They continue to make fibronectin and adhere to each other tightly. They are encapsulated by fibrous connective tissue which prevents them from migrating. Abnormal chromosomes or aneuploidy are common in cancer cells as they become more malignant. Benign cells have normal chromosomes. Cancer cells have a migratory tendency as they are not bound to each other with fibronectin.
While the nurse is obtaining the health history of a 75-year-old female patient, which of the following has the greatest implication for the development of cancer? a. Being a 75-year-old woman b. Family history of hypertension c. Cigarette smoking as a teenager d. Advancing age
ANS: D According to the American Cancer Society, 2007, the most important risk factor for cancer development is advancing age.
A 72-year-old client recovering from lung cancer surgery asks the nurse to explain how she developed cancer when she has never smoked. Which factor may explain the possible cause? a. A diagnosis of diabetes treated with insulin and diet b. An exercise regimen of jogging 3 miles four times a week c. A history of cardiac disease d. Advancing age
ANS: D Advancing age is the single most important risk factor for cancer. As a person ages, immune protection decreases. Diabetes is not known to cause lung cancer. Regular exercise is not a risk factor for lung cancer, nor does having cardiac disease predispose a person to lung cancer.
The nurse presents a cancer prevention program to teens. Which instruction will have the greatest impact in cancer prevention? a. Avoid asbestos. b. Wear sunscreen. c. Get the human papilloma virus (HPV) vaccine. d. Do not smoke cigarettes.
ANS: D All of these actions are part of cancer prevention; however, tobacco is the single most important source of preventable carcinogenesis. Asbestos may be found in older homes and buildings. Most schools have been through an asbestos abatement program so should not pose a risk. It would be important to share with teens who may be involved in the construction industry during the summer to be aware of asbestos risks. Although asbestos may present a risk for lung cancer, it is not a likely exposure for teens. Lifetime exposure to the sun and the use of tanning beds will increase the risk for cancer, but not as much as tobacco use. The HPV vaccine will decrease the risk for cervical cancer, but will not have as much of an impact on cancer prevention as avoiding tobacco.
The home health nurse is caring for a client who has a history of a kidney transplant and takes cyclosporine (Sandimmune) and prednisone (Deltasone) to prevent rejection. Which assessment finding is most important to communicate to the transplant team? a. Temperature of 96.6° F b. Reports of joint pain c. Pink and dry oral mucosa d. Palpable lump in the client's axilla
ANS: D Clients taking immunosuppressive drugs to prevent rejection are at increased risk for the development of cancer; any lump should be reported to the physician. Fever should be reported to the physician, but this client's temperature is normal. It is not necessary to report joint pain to the transplant team; it is not a sign of rejection and is not a complication of transplant. A pink and dry oral mucosa may be a sign of dehydration, but it is not necessary to report this to the transplant team.
A client is diagnosed with familial polyposis. Which cancer may the client be at risk for developing in the future? a. Meningioma b. Breast cancer c. Gonadal cancer d. Colorectal cancer
ANS: D Clients with familial polyposis are at risk for developing colorectal cancer due to a genetic predisposition. Meningioma and gonadal cancer may eventually occur in clients with Turner's syndrome. Breast cancers are often inherited disorders or occur due to familial clustering.
The nurse is caring for a patient who received a bone marrow transplant 10 days ago. The nurse would monitor for which of the following clinical manifestations that could indicate a potentially life-threatening situation? a. Mucositis b. Confusion c. Depression d. Mild temperature elevation
ANS: D During the first 100 days after a bone marrow transplant, patients are at high risk for life-threatening infections. The earliest sign of infection in an immunosuppressed patient can be a mild fever. Mucositis, confusion, and depression are possible clinical manifestations but are representative of less life-threatening complications.
Which type of cancer has been associated with Down syndrome? a. Breast cancer b. Colorectal cancer c. Malignant melanoma d. Leukemia
ANS: D Leukemia is associated with Down syndrome and Turner syndrome. Breast cancer is often found clustered in families, not in association with Down syndrome. Colorectal cancer is associated with familial polyposis. Malignant melanoma is associated with familial clustering and sun exposure.
A 65-year-old client tells the nurse she does not have mammograms because there is no history of breast cancer in her family. What is the nurse's best response? a. "You are correct. Breast cancer is an inherited type of malignancy and your family history indicates a low risk for you." b. "Performing breast self-examination monthly at home is sufficient screening for someone with your family history." c. "Because your breasts are no longer as dense as they were when you were younger, your risk for breast cancer is now decreased." d. "Breast cancer can be found more frequently in families; however, the risk for general, nonfamilial breast cancer increases with age."
ANS: D Only a small percentage of cancers, including breast cancers, are hereditary or familial. The far more critically important risk factor for breast cancer in women is advancing age. Although performance of monthly self-breast examination is good, for a woman of this age, it should be done in conjunction with a yearly mammogram.
The nurse is giving a group presentation on cancer prevention and recognition. Which statement by an older adult client indicates understanding of the nurse's instructions? a. "Cigarette smoking always causes lung cancer." b. "Taking multivitamins will prevent me from developing cancer." c. "If I have only one shot of whiskey a day, I probably will not develop cancer." d. "I need to report the pain going down my legs to my health care provider."
ANS: D Pain in the back of the legs could indicate prostate cancer in an older man. Cigarette smoking is implicated in causing lung cancer and other types of cancer, but it does not always cause cancer. Investigation is ongoing about the efficacy of vitamins A and C in cancer prevention. Limiting alcohol to one drink per day is only one preventive measure.
In caring for a patient following lobectomy for lung cancer, which of the following should the nurse include in the plan of care? a. Position the patient on the operative side only. b. Avoid administering narcotic pain medications. c. Keep the patient on strict bed rest. d. Instruct the patient to cough and deep breathe.
ANS: D Postoperative deep breathing and coughing is important to promote oxygenation and clearing of secretions. Pain medications will be given to lessen pain and allow for deep breathing and coughing. Strict bed rest is not instituted, because early ambulation will help lessen postoperative complications such as deep vein thrombosis. Prolonged lying on the operative side is avoided.
A client is in the oncology clinic for a first visit since being diagnosed with cancer. The nurse reads in the client's chart that the cancer classification is TISN0M0. What does the nurse conclude about this client's cancer? a. The primary site of the cancer cannot be determined. b. Regional lymph nodes could not be assessed. c. There are multiple lymph nodes involved already. d. There are no distant metastases noted in the report.
ANS: D TIS stands for carcinoma in situ; N0 stands for no regional lymph node metastasis; and M0 stands for no distant metastasis.
A client has a glioblastoma. The nurse begins to plan care for this client with which type of cancer? a. Liver b. Smooth muscle c. Fatty tissue d. Brain
ANS: D The prefix "glio-" is used when cancers of the brain are named. The prefix "hepato-" is included when cancers of the liver are named. The prefix "leiomyo-" is included when cancers of smooth muscle are named. The prefix "lipo-" is included when cancers of fat or adipose tissue are named.
Which statement about the process of malignant transformation is correct? a. Mutation of genes is an irreversible event that always leads to cancer development in the initiation phase. b. Insulin and estrogen enhance the division of an initiated cell during the promotion phase. c. Tumors form when carcinogens invade the gene structure of the cell in the latency phase. d. Nutrition of cancer cells is provided by tumor angiogenesis factor (TAF) in the promotion stage.
ANS: D The promotion phase consists of progression when the blood supply changes from diffusion to TAF.Insulin and estrogen increase cell division. If cell division is halted, mutation of genes does not lead to cancer development in the initiation phase. In the initiation phase, carcinogens invade the DNA of the nucleus of a single cell. A 1-cm tumor consists of 1 billion cells. The latency phase occurs between initiation and tumor formation.
Which statement about carcinogenesis is accurate? a. An initiated cell will always become clinical cancer. b. Cancer becomes a health problem once it is 1 cm in size. c. Normal hormones and proteins do not promote cancer growth. d. Tumor cells need to develop their own blood supply.
ANS: D Tumors need to develop their own blood supply through a process called angiogenesis. An initiated cell needs a promoter to continue its malignant path. Normal hormones and proteins in the body can act as promoters. A 1-cm tumor is a detectable size, but other events have to occur for it to become a health problem.
25. A patient who is receiving immunotherapy has just received an allergen injection. Which assessment finding is most important to communicate to the health care provider? a. The patient's IgG level is increased. b. The injection site is red and swollen. c. The patient's symptoms did not improve in 2 months. d. There is a 2-cm wheal at the site of the allergen injection.
ANS: D A local reaction larger than quarter size may indicate that a decrease in the allergen dose is needed. An increase in IgG indicates that the therapy is effective. Redness and swelling at the site are not unusual. Because immunotherapy usually takes 1 to 2 years to achieve an effect, an improvement in the patient's symptoms is not expected after a few months. DIF: Cognitive Level: Analyze (analysis) REF: 203 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
8. The nurse caring for the child in pain understands that distraction: a. can give total pain relief to the child. b. is effective when the child is in severe pain. c. is the best method for pain relief. d. must be developmentally appropriate to refocus attention.
ANS: D Distraction can be very effective in helping to control pain; however, it must be appropriate to the child's developmental level. Distraction can help control pain, but it is rarely able to provide total pain relief. Children in severe pain are not distractible. Children may use distraction to help control pain, although it is not the best method for pain relief. PTS: 1 DIF: Cognitive Level: Comprehension OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity
A patient with benign prostatic hyperplasia is scheduled for TURP. After you assess the patient's knowledge of the procedure and its effects on reproductive function, you determine a need for further teaching when the patient says, A. "It is possible that I'll be sterile after this procedure." B. "I understand that some retrograde ejaculation may occur." C. "I will have a catheter for several days to keep my urinary system open." D. "It is unlikely that I would become impotent from this procedure."
Answer: A The patient will not be sterile; he may experience retrograde ejaculation and some erectile dysfunction. It is unlikely he will become impotent. He will need a catheter.
You notice that the patient's urinary drainage 4 hours after TURP is redder than 1 hour ago. What is your priority intervention? A. To increase the rate of bladder irrigation B. To manually irrigate the urinary catheter C. To notify the physician D. To obtain vital signs
Answer: A With CBI, irrigating solution is continuously infused and drained from the bladder. The rate of infusion is based on the color of drainage. Ideally, urine drainage should be light pink without clots. Continuously monitor the inflow and outflow of the irrigant.
Which factors place a patient at high risk for prostate cancer (select all that apply)? A. Age older than 65 years B. Asian or Native American ethnicity C. Personal history of BPH D. Brother diagnosed and treated for prostate cancer E. History of undescended testicle and testicular cancer
Answer: A,D Age, ethnicity, and family history are known risk factors for prostate cancer. The incidence of prostate cancer rises markedly after age 50, and more than 66% of men diagnosed are older than 65 years. The incidence of prostate cancer worldwide is higher among African Americans than in any other ethnic group. A family history of prostate cancer, especially first-degree relatives (fathers, brothers), is associated with an increased risk.
Which diagnostic evaluation is used for a patient with a suspected testicular cancer? A. Prostate-specific antigen (PSA) B. α-Fetoprotein (AFP) C. Complete blood cell count D. Urine and semen analyses
Answer: B Palpation of the scrotal contents is the first step in diagnosing testicular cancer. A cancerous mass is firm and does not transilluminate. Ultrasound of the testes is indicated when testicular cancer (e.g., palpable mass) is suspected or when persistent or painful testicular swelling is present. If testicular cancer is suspected, blood is obtained to determine the serum levels of AFP, lactate dehydrogenase (LDH), and human chorionic gonadotropin (hCG).
For the patient with inoperable prostate cancer, you expect the physician to order which type of hormone? A. Gonadotropin-releasing hormone B. Androgen deprivation C. Luteinizing hormone D. Estrogen
Answer: B Prostate cancer growth largely depends on androgens, and androgen deprivation is a primary therapeutic approach for some men with prostatic cancer. Hormone therapy, also known as androgen-deprivation therapy (ADT), focuses on reducing the levels of circulating androgens to diminish tumor growth.
Which fact in the patient's history could be related to the presence of testicular cancer? A. Epispadias B. Cryptorchidism C. Hernia repair D. Uncircumcised penis
Answer: B The incidence of testicular cancer is four times higher among white men (especially those of Scandinavian descent) than African American males. It occurs more commonly in the right testicle than the left. Testicular tumors are also more common in men who have had undescended testes (cryptorchidism) or have a family history of testicular cancer or anomalies. Epispadias and lack of circumcision are not related to testicular cancer. Hernia repair is related to future hernias, but not testicular cancer.
A 73-year-old man admitted for total knee replacement states during the health history interview that he has no problems with urinary elimination except that the "stream is less than it used to be." You would give the patient anticipatory guidance that which condition is likely to be developing? A. A tumor of the prostate B. Benign prostatic hyperplasia C. Bladder atony because of age D. Age-related altered innervation of the bladder
Answer: B BPH is an enlarged prostate gland caused by an increased number of epithelial cells and stromal tissue. It occurs in about 50% of men older than 50 years and 80% of men older than 80 years.
You are teaching the patient with BPH about interventions that can assist in alleviating symptoms. Which behavior in the patient indicates successful teaching? A. The patient increases use of decongestants. B. The patient decreases intake of caffeinated beverages and artificial sweeteners. C. The patient increases activities such as walking. D. The patient voids every 30 minutes.
Answer: B In some patients who have symptoms that appear and then disappear, a conservative treatment approach has value. Dietary changes (decreasing intake of caffeine and artificial sweeteners, limiting spicy or acidic foods), avoiding medications such as decongestants and anticholinergics, and restricting evening fluid intake may result in improvement of symptoms. A timed voiding schedule may reduce or eliminate symptoms, negating the need for further intervention, but 30 minutes is too frequent.
Which best indicates that treatment for cancer of the prostate is effective? A. Increase in urinary stream B. Decrease of PSA to 2 ng/mL C. Decreased blood in the urine D. White blood cell (WBC) count of 10,000/μL
Answer: B The PSA value is used to detect prostate cancer and to monitor the success of treatment. When treatment has been successful in removing prostate cancer, PSA levels should decrease and reach normal levels (less than 4 ng/mL). The regular measurement of PSA levels after treatment is important to evaluate the effectiveness of treatment and possible recurrence of prostate cancer.
What is the most significant factor in the development of clinical symptoms associated with BPH? A. Size of the prostate B. Location of the enlargement C. Age of the patient D. Length of the urethra
Answer: B There is no direct relationship between the size of the prostate and degree of obstruction. The location of the enlargement significantly affects development of obstructive symptoms. For example, it is possible for mild hyperplasia to cause severe obstruction, and it is possible for extreme hyperplasia to cause few obstructive symptoms.
A nurse is caring for a client with compartment syndrome. Which nursing actions are appropriate? Select all that apply. 1 Assisting with splitting the cast 2 Assessing urine output 3 Evaluating the pain on a scale 4 Applying splints to the injured part 5 Placing cold compresses to the affected area
Assisting with splitting the cast Assessing urine output Evaluating the pain on a scale
To accurately monitor progression of a symptom of decreased urinary stream, the nurse should encourage the patient to have which primary screening measure done on a regular basis? A. Uroflowmetry B. Transrectal ultrasound C. Digital rectal examination (DRE) D. Prostate-specific antigen (PSA) monitoring
C. Digital rectal examination (DRE) Digital rectal examination is part of a regular physical examination and is a primary means of assessing symptoms of decreased urinary stream, which is often caused by benign prostatic hyperplasia in men over 50 years of age. The uroflowmetry helps determine the extent of urethral blockage and the type of treatment needed but is not done on a regular basis. Transrectal ultrasound is indicated with an abnormal DRE and elevated PSA to differentiate between BPH and prostate cancer. The PSA monitoring is done to rule out prostate cancer, although levels may be slightly elevated in patients with BPH.
Which statements are true regarding chondrosarcoma? Select all that apply. 1 Chondrosarcoma can arise from benign bone tumors. 2 Chondrosarcoma develops in the medullary cavity of long bones. 3 Chondrosarcoma is mostly treated by radiation and chemotherapy. 4 Chondrosarcoma occurs mostly in young males between ages 10 and 25 years. 5 Chondrosarcoma most commonly occurs in cartilage in the arm, leg, and pelvic bones.
Chondrosarcoma can arise from benign bone tumors. Chondrosarcoma most commonly occurs in cartilage in the arm, leg, and pelvic bones.
7. A 48-year-old patient with a comminuted fracture of the left femur has Buck's traction in place while waiting for surgery. To assess for pressure areas on the patient's back and sacral area and to provide skin care, the nurse should a. loosen the traction and help the patient turn onto the unaffected side. b. place a pillow between the patient's legs and turn gently to each side. c. turn the patient partially to each side with the assistance of another nurse. d. have the patient lift the buttocks by bending and pushing with the right leg.
d. have the patient lift the buttocks by bending and pushing with the right leg.
5. A 22-year-old tennis player has an arthroscopic repair of a rotator cuff injury performed in same-day surgery. When the nurse plans postoperative teaching for the patient, which information will be included? a. "You will not be able to serve a tennis ball again." b. "You will work with a physical therapist tomorrow." c. "The doctor will use the drop-arm test to determine the success of surgery." d. "Leave the shoulder immobilizer on for the first 4 days to minimize pain."
b. "You will work with a physical therapist tomorrow."
19. The day after a having a right below-the-knee amputation, a patient complains of pain in the right foot. Which action is best for the nurse to take? a. Explain the reasons for the phantom limb pain. b. Administer prescribed analgesics to relieve the pain. c. Loosen the compression bandage to decrease incisional pressure. d. Inform the patient that this phantom pain will diminish over time.
b. Administer prescribed analgesics to relieve the pain.
45. When caring for a patient who is using Buck's traction after a hip fracture, which action can the nurse delegate to unlicensed assistive personnel (UAP)? a. Monitor the skin under the traction boot for redness. b. Ensure that the weight for the traction is off the floor. c. Check for intact sensation and movement in the affected leg. d. Offer reassurance that hip and leg pain are normal after hip fracture.
b. Ensure that the weight for the traction is off the floor.
42. Which information obtained by the nurse about a 29-year-old patient with a lumbar vertebral compression fracture is most important to report to the health care provider? a. Patient refuses to be turned due to back pain. b. Patient has been incontinent of urine and stool. c. Patient reports lumbar area tenderness to palpation. d. Patient frequently uses oral corticosteroids to treat asthma.
b. Patient has been incontinent of urine and stool.
A 73-year-old patient with Parkinson's disease has a nursing diagnosis of impaired physical mobility related to bradykinesia. Which action will the nurse include in the plan of care? a. Instruct the patient in activities that can be done while lying or sitting. b. Suggest that the patient rock from side to side to initiate leg movement. c. Have the patient take small steps in a straight line directly in front of the feet. d. Teach the patient to keep the feet in contact with the floor and slide them forward.
b. Suggest that the patient rock from side to side to initiate leg movement. Rationale: Rocking the body from side to side stimulates balance and improves mobility. The patient will be encouraged to continue exercising because this will maintain functional abilities. Maintaining a wide base of support will help with balance. The patient should lift the feet and avoid a shuffling gait.
A patient with Parkinson's disease has bradykinesia. Which action should the nurse include in the plan of care? a. Instruct the patient in activities that can be done while lying or sitting. b. Suggest that the patient rock from side to side to initiate leg movement. c. Have the patient take small steps in a straight line directly in front of the feet. d. Teach the patient to keep the feet in contact with the floor and slide them forward.
b. Suggest that the patient rock from side to side to initiate leg movement. Rationale:Rocking the body from side to side stimulates balance and improves mobility. The patient will be encouraged to continue exercising because this will maintain functional abilities. Maintaining a wide base of support will help with balance. The patient should lift the feet and avoid a shuffling gait.
11. A patient who is to have no weight bearing on the left leg is learning to walk using crutches. Which observation by the nurse indicates that the patient can safely ambulate independently? a. The patient moves the right crutch with the right leg and then the left crutch with the left leg. b. The patient advances the left leg and both crutches together and then advances the right leg. c. The patient uses the bedside chair to assist in balance as needed when ambulating in the room. d. The patient keeps the padded area of the crutch firmly in the axillary area when ambulating.
b. The patient advances the left leg and both crutches together and then advances the right leg.
When a 74-year-old patient is seen in the health clinic with new development of a stooped posture, shuffling gait, and pill rolling-type tremor, the nurse will anticipate teaching the patient about a. oral corticosteroids. b. antiparkinsonian drugs. c. magnetic resonance imaging (MRI). d. electroencephalogram (EEG) testing.
b. antiparkinsonian drugs. Rationale: The diagnosis of Parkinson's is made when two of the three characteristic manifestations of tremor, rigidity, and bradykinesia are present. The confirmation of the diagnosis is made on the basis of improvement when antiparkinsonian drugs are administered. This patient has symptoms of tremor and bradykinesia. The next anticipated step will be treatment with medications. MRI and EEG are not useful in diagnosing Parkinson's disease, and corticosteroid therapy is not used to treat it.
37. A patient undergoes a left above-the-knee amputation with an immediate prosthetic fitting. When the patient arrives on the orthopedic unit after surgery, the nurse should a. place the patient in a prone position. b. check the surgical site for hemorrhage. c. remove the prosthesis and wrap the site. d. keep the residual leg elevated on a pillow.
b. check the surgical site for hemorrhage.
6. The nurse will instruct the patient with a fractured left radius that the cast will need to remain in place a. for several months. b. for at least 3 weeks. c. until swelling of the wrist has resolved. d. until x-rays show complete bony union.
b. for at least 3 weeks.
A patient with a tremor is being evaluated for Parkinson's disease. The nurse explains to the patient that Parkinson's disease can be confirmed by a. CT and MRI scans. b. relief of symptoms with administration of dopaminergic agents. c. the presence of tremors that increase during voluntary movement. d. cerebral angiogram that reveals the presence of cerebral atherosclerosis.
b. relief of symptoms with administration of dopaminergic agents. Rationale: Although clinical manifestations are characteristic in PD, no laboratory or diagnostic tests are specific for the condition. A diagnosis is made when at least two of the three signs of the classic triad are present and it is confirmed with a positive response to antiparkinsonian medication. Research regarding the role of genetic testing and MRI to diagnose PD is ongoing. Essential tremors increase during voluntary movement whereas the tremors of PD are more prominent at rest.
39. When assessing for Tinel's sign in a patient with possible right-sided carpal tunnel syndrome, the nurse will ask the patient about a. weakness in the right little finger. b. tingling in the right thumb and fingers. c. burning in the right elbow and forearm. d. tremor when gripping with the right hand.
b. tingling in the right thumb and fingers.
24. When giving home care instructions to a patient who has comminuted forearm fractures and a long-arm cast on the left arm, which information should the nurse include? a. Keep the left shoulder elevated on a pillow or cushion. b. Keep the hand immobile to prevent soft tissue swelling. c. Call the health care provider for increased swelling or numbness of the hand. d. Avoid nonsteroidal antiinflammatory drugs (NSAIDs) for 24 hours after the injury.
c. Call the health care provider for increased swelling or numbness of the hand.
32. Following a motorcycle accident, a 58-year-old patient arrives in the emergency department with massive left lower leg swelling. Which action will the nurse take first? a. Elevate the leg on 2 pillows. b. Apply a compression bandage. c. Check leg pulses and sensation. d. Place ice packs on the lower leg.
c. Check leg pulses and sensation.
46. Based on the information shown in the accompanying figure and obtained for a patient in the emergency room, which action will the nurse take first? a. Administer the prescribed morphine 4 mg IV. b. Contact the operating room to schedule surgery. c. Check the patient's oxygen saturation using pulse oximetry. d. Ask the patient about the date of the last tetanus immunization.
c. Check the patient's oxygen saturation using pulse oximetry.
A patient with Parkinson's disease is started on levodopa. What should the nurse explain about this drug? a. It stimulates dopamine receptors in the basal ganglia. b. It promotes the release of dopamine from brain neurons. c. It is a precursor of dopamine that is converted to dopamine in the brain. d. It prevents the excessive breakdown of dopamine in the peripheral tissues.
c. It is a precursor of dopamine that is converted to dopamine in the brain. Rationale: Peripheral dopamine does not cross the blood-brain barrier but its precursor, levodopa, is able to enter the brain, where it is converted to dopamine, increasing the supply that is deficient in PD. Other drugs used to treat PD include bromocriptine, which stimulates dopamine receptors in the basal ganglia, and amantadine, which blocks the reuptake of dopamine into presynaptic neurons. Carbidopa is an agent that is usually administered with levodopa to prevent the levodopa from being metabolized in peripheral tissues before it can reach the brain.
A male patient with a diagnosis of Parkinson's disease (PD) has been admitted recently to a long-term care facility. Which action should the health care team take in order to promote adequate nutrition for this patient? a. Provide multivitamins with each meal. b. Provide a diet that is low in complex carbohydrates and high in protein. c. Provide small, frequent meals throughout the day that are easy to chew and swallow. d. Provide the patient with a minced or pureed diet that is high in potassium and low in sodium.
c. Provide small, frequent meals throughout the day that are easy to chew and swallow. Rationale: Nutritional support is a priority in the care of individuals with PD. Such patients may benefit from meals that are smaller and more frequent than normal and that are easy to chew and swallow. Multivitamins are not necessary at each meal, and vitamin intake, along with protein intake, must be monitored to prevent contraindications with medications. It is likely premature to introduce a minced or pureed diet, and a low carbohydrate diet is not indicated.
A 76-year-old patient is being treated with carbidopa/levodopa (Sinemet) for Parkinson's disease. Which information is most important for the nurse to report to the health care provider? a. Shuffling gait b. Tremor at rest c. Cogwheel rigidity of limbs d. Uncontrolled head movement
d. Uncontrolled head movement Rationale: Dyskinesia is an adverse effect of the Sinemet, indicating a need for a change in medication or decrease in dose. The other findings are typical with Parkinson's disease.
A nurse reviews the prescribed treatment with the parents of an infant born with bilateral clubfeet. Which parental statement indicates to the nurse that further education is required? 1 "We'll have to start serial casting right away." 2 "The casts will have to be changed every week." 3 "The baby may have to have surgery if the problem is not fixed in a few months." 4 "We'll have to have the baby fitted with prosthetic devices before he'll be able to walk."
"We'll have to start serial casting right away."
A nurse provides education to a client with myasthenia gravis about how to prevent myasthenic crisis. The nurse evaluates that the teaching is effective when the client makes which statement? 1 "I'll take an antihistamine at the first sign of a cold." 2 "I should skip a dose of pyridostigmine bromide (Mestinon) if it upsets my stomach." 3 "We've told our daughter not to let her cold keep her from visiting us." 4 "The healthcare provider may need to adjust the dosage of my medication if I'm more active."
"The healthcare provider may need to adjust the dosage of my medication if I'm more active."
According to the common scale for grading muscle strength, what rating will be given to a client who can complete range of motion with some resistance? 1 2 3 4
4
The nurse is caring for a client who has sustained blunt trauma to the forearm. The nurse assesses the client for which early sign of compartment syndrome? 1 Warm skin at the site of injury 2 Escalating pain in the fingers 3 Rapid capillary refill in affected hand 4 Bounding radial pulse in the injured arm
Escalating pain in the fingers
10. Which assessment indicates to a nurse that a school-aged child is in need of pain medication? a. The child is lying rigidly in bed and not moving. b. The child's current vital signs are consistent with vital signs over the past 4 hours. c. The child becomes quiet when held and cuddled. d. The child has just returned from the recovery room.
ANS: A Behaviors such as crying, distressed facial expressions, certain motor responses such as lying rigidly in bed and not moving, and interrupted sleep patterns are indicative of pain in children. Current vital signs that are consistent with earlier vital signs do not indicate that the child is feeling pain. Response to comforting behaviors does not suggest that the child is feeling pain. A child who is returning from the recovery room may or may not be in pain. Most times the child's pain is under adequate control at this time. The child may be fearful or having anxiety because of the strange surroundings and having just completed surgery. PTS: 1 DIF: Cognitive Level: Application OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity Copyright © 2018, Elsevier Inc. All Rights Reserved. 3
3. The pediatric nurse understands that nonpharmacologic strategies for pain management: a. may reduce pain perception. b. make pharmacologic strategies unnecessary. c. usually take too long to implement. d. trick children into believing they do not have pain.
ANS: A Nonpharmacologic techniques provide coping strategies that may help reduce pain perception, make the pain more tolerable, decrease anxiety, and enhance the effectiveness of analgesics. Nonpharmacologic techniques should be learned before the pain occurs. With severe pain it is best to use both pharmacologic and nonpharmacologic measures for pain control. The nonpharmacologic strategy should be matched with the child's pain severity and taught to the child before the onset of the painful experience. Some of the techniques may facilitate the child's experience with mild pain, but the child will still know that discomfort is present. PTS: 1 DIF: Cognitive Level: Analysis OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity
7. When pain is assessed in an infant, it is inappropriate for the nurse to assess for: a. facial expressions of pain. b. localization of pain. c. crying. d. thrashing of extremities.
ANS: B Infants are unable to localize pain. Frowning, grimacing, and facial flinching in an infant may indicate pain. Infants often exhibit high-pitched, tense, harsh crying to express pain. Infants may exhibit thrashing of extremities in response to a painful stimulus. PTS: 1 DIF: Cognitive Level: Comprehension OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
4. Which drug is usually the best choice for patient-controlled analgesia (PCA) for a child in the immediate postoperative period? a. Codeine b. Morphine c. Methadone d. Meperidine
ANS: B The most commonly prescribed medications for PCA are morphine, hydromorphone, and fentanyl. Parenteral use of codeine is not recommended. Methadone is not available in parenteral form in the United States. Meperidine is not used for continuous and extended pain relief. PTS: 1 DIF: Cognitive Level: Analysis OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
2. The nurse is monitoring a patient for side effects associated with opioid analgesics. Which side effects should the nurse expect to monitor for? (Select all that apply.) a. Diarrhea b. Respiratory depression c. Hypertension d. Pruritus e. Sweating
ANS: B, D, E Side effects of opioids include respiratory depression, pruritus, and sweating. Constipation may occur, not diarrhea, and orthostatic hypotension may occur but not hypertension. PTS: 1 DIF: Cognitive Level: Comprehension OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
5. A lumbar puncture is needed on a school-age child. The most appropriate action to provide analgesia during this procedure is to apply: a. 4% Liposomal Lidocaine (LMX) 15 minutes before the procedure. b. a transdermal fentanyl (Duragesic) patch immediately before the procedure. c. eutectic mixture of local anesthetics (EMLA) 1 hour before the procedure. d. EMLA 30 minutes before the procedure.
ANS: C EMLA is an effective analgesic agent when applied to the skin 60 minutes before a procedure. It eliminates or reduces the pain from most procedures involving skin puncture. LMX must be applied 30 minutes before the procedure. Transdermal fentanyl patches are useful for continuous pain control, not rapid pain control. For maximal effectiveness, EMLA must be applied approximately 60 minutes in advance. PTS: 1 DIF: Cognitive Level: Analysis OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity Copyright © 2018, Elsevier Inc. All Rights Reserved. 2
12. A nurse is gathering a history on a school-age child admitted for a migraine headache. The child states, "I have been getting a migraine every 2 or 3 months for the last year." The nurse documents this as which type of pain? a. Acute b. Chronic c. Recurrent d. Subacute
ANS: C Pain that is episodic and that recurs is defined as recurrent pain. The time frame within which episodes of pain recur is at least 3 months. Recurrent pain in children includes migraine headache, episodic sickle cell pain, recurrent abdominal pain (RAP), and recurrent limb pain. Acute pain is pain that lasts for less than 3 months. Chronic pain is pain that lasts, on a daily basis, for more than 3 months. Subacute is not a term for documenting type of pain. PTS: 1 DIF: Cognitive Level: Comprehension OBJ: Nursing Process: Communication, Documentation MSC: Client Needs: Physiologic Integrity
1. An appropriate tool to assess pain in a 3-year-old child is the: (Select all that apply.) a. Visual Analog Scale (VAS) b. Adolescent and pediatric pain tool c. Oucher tool d. FACES pain-rating scale
ANS: C, D The Oucher tool can be used to assess pain in children 3 to 12 years of age. The FACES pain-rating scale can be used to assess pain for children 3 years of age and older. The VAS is indicated for use with older school-age children and adolescents. It can be used with younger school-age children, although less abstract tools are more appropriate. The adolescent and pediatric pain tool is indicated for use with children 8 to 17 years of age. PTS: 1 DIF: Cognitive Level: Comprehension OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
11. A 2-year-old child has been returned to the nursing unit after an inguinal hernia repair. Which pain assessment tool should the nurse use to assess this child for the presence of pain? a. FACES pain rating tool b. Numeric scale c. Oucher scale d. FLACC tool
ANS: D A behavioral pain tool should be used when the child is preverbal or does not have the language skills to express pain. The FLACC (face, legs, activity, cry, consolability) tool should be used with a 2-year-old child. The FACES, numeric, and Oucher scales are all self-report pain rating tools. Self-report measures are not sufficiently valid for children younger than 3 years of age because many children are not able to self-report their pain accurately. PTS: 1 DIF: Cognitive Level: Application OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
2. Physiologic measurements in children's pain assessment are: a. the best indicator of pain in children of all ages. b. essential to determine whether a child is telling the truth about pain. c. of most value when children also report having pain. d. of limited value as sole indicator of pain.
ANS: D Physiologic manifestations of pain may vary considerably and may not provide a consistent measure of pain. Heart rate may increase or decrease. The same signs that may suggest fear, anxiety, or anger also indicate pain. In chronic pain the body adapts, and these signs decrease or stabilize. These signs are of limited value and must be viewed in the context of a pain-rating scale, behavioral assessment, and parental report. When the child states that pain exists, it does. That is the truth. PTS: 1 DIF: Cognitive Level: Application OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
The healthcare provider prescribes enoxaparin to be administered subcutaneously daily to a client who had a total knee replacement. To ensure client safety, which measure would the nurse take when administering this medication? 1 Remove air pocket from prepackaged syringe before administration. 2 Rub the injection site after administration for 30 seconds. 3 Administer medication over 2 minutes. 4 Administer in the abdomen area only.
Administer in the abdomen area only.
A back brace is prescribed for a client who had a laminectomy. What should the nurse include in the client's teaching plan? 1 Use the brace when the back feels tired. 2 Apply the brace before getting out of bed. 3 Put the brace on while in the sitting position. 4 Wear the brace when performing twisting exercises.
Apply the brace before getting out of bed.
A client returns from the postanesthesia care unit after a right rotator cuff repair. What should the nurse do when performing a neurovascular assessment? 1 Monitor for a pulse deficit. 2 Obtain hourly blood pressure readings. 3 Assess for capillary refill in the nail beds. 4 Place the shoulder through range-of-motion exercises.
Assess for capillary refill in the nail beds.
An infant with talipes equinovarus has a plaster cast applied to the involved foot. How should the nurse move the infant while the cast is wet? 1 By handling the cast with just the palms 2 By touching the cast with just the fingertips 3 By turning the infant without touching the cast 4 By moving the infant's body while sliding the cast
By handling the cast with just the palms
A nurse is teaching members of a health care team how to help disabled clients stand and transfer from the bed to a chair. To protect the caregivers from injury, the nurse teaches them to lift the client by first placing their arms under the client's axillae and doing what next? 1 Bending and then straightening their knees 2 Bending at the waist and then straightening the back 3 Placing one foot in front of the other and then leaning back 4 Placing pressure against the client's axillae and then raising their arms
Bending and then straightening their knees
The nurse is caring for a client with a spinal cord injury who has paraplegia. The nurse can expect which major problem early in the recovery period? 1 Bladder control 2 Nutritional intake 3 Quadriceps setting 4 Use of aids for ambulation
Bladder control
How would the nurse explain that the skeletal system of toddlers differs from older adults? 1 Bones of toddlers are less pliable than those of older persons. 2 Bones of toddlers can withstand falls better than those of older adults. 3 Bones of toddlers are more susceptible to osteoporosis than those of older adults. 4 Bones of toddlers are more susceptible to bone loss than the bones of older persons.
Bones of toddlers can withstand falls better than those of older adults.
A client is suspected of having myasthenia gravis. What are the most significant initial nursing assessments that should be performed? 1 Ability to chew and speak distinctly 2 Capacity to smile and close the eyelids 3 Effectiveness of respiratory exchange and ability to swallow 4 Degree of anxiety and concern about the suspected diagnosis
Effectiveness of respiratory exchange and ability to swallow
A client admitted to the hospital has edematous ankles. What should the nurse do to best reduce edema of the lower extremities? 1 Restrict fluids. 2 Elevate the legs. 3 Apply elastic bandages. 4 Do range-of-motion exercises.
Elevate the legs.
A young man who sustained a spinal cord injury at the cervical level expresses concern about sexual functioning. What should the nurse do when counseling this client? 1 Consider that the client most likely will be able to have reflex penile erections. 2 Arrange for the client to see the healthcare provider because sexual performance is unlikely. 3 Discourage the client from forming sexual relationships because little pleasure will be possible. 4 Reassure the client that he will be able to have sexual relationships with the ability to reproduce.
Consider that the client most likely will be able to have reflex penile erections.
Which nursing intervention is indicated for aging clients with decreased bone density? 1 Teaching the client isometric exercises 2 Advising the client to take a moist heat shower 3 Providing supportive armchairs to the client 4 Demonstrating weight-bearing exercises to the client
Demonstrating weight-bearing exercises to the client
What should a nurse assess after applying a body jacket brace to a client with severe spine injuries following a car accident? Select all that apply. 1 Pin sites 2 Development of cast syndrome 3 Signs of compartment syndrome 4 Abdomen for decreased bowel sounds 5 Areas of pressure over the bony prominences
Development of cast syndrome Abdomen for decreased bowel sounds Areas of pressure over the bony prominences
A client has an open reduction and internal fixation of the hip. The client is to be transferred to a chair for a half hour on the second postoperative day. Before transferring the client, what should the nurse do? 1 Assess the strength of the affected leg. 2 Explain the transfer procedure step by step. 3 Instruct the client to bear weight evenly on both legs. 4 Encourage the client to keep the affected leg elevated.
Explain the transfer procedure step by step.
After an open reduction and internal fixation of a fractured hip, what assessments of the client's affected leg should the nurse make? Select all that apply. 1 Skin temperature 2 Mobility of the hip 3 Sensation in the toes 4 Condition of the pins 5 Presence of pedal pulse
Skin temperature Sensation in the toes Presence of pedal pulse
A nurse is caring for a client who developed aseptic necrosis after a fracture of the head of the femur. The nurse prepares to administer care based on which factor? 1 Infection at the site of the wound 2 Weight-bearing before the fracture is healed 3 Immobilization after reduction of the fracture 4 Loss of blood supply to the head of the femur
Loss of blood supply to the head of the femur
A client with a chest tube is to be transported via a stretcher. When transporting the client, what should the nurse do? 1 Keep collection device attached to mechanical suction 2 Keep chest tube clamped distal to the water-seal chamber 3 Keep collection device below the level of the client's chest 4 Keep chest tube end covered with sterile gauze pads taped to the client
Keep collection device below the level of the client's chest
A nurse provides discharge instructions to a client who had surgery for a left total hip replacement. Which should the nurse include when teaching the client about how to protect the affected hip when in the sitting position? 1 "When sitting in a soft chair, the left leg should be elevated in a straight-out position." 2 "When sitting in a firm armchair, the left foot should be flat on the floor's surface." 3 "Sit in a firm armchair with the left leg elevated on a high stool." 4 "Sit in a soft chair with pillows tucked under the left hip."
"When sitting in a firm armchair, the left foot should be flat on the floor's surface."
9. Which medication is the most effective choice for treating pain associated with sickle cell crisis in a newly admitted 5-year-old child? a. Morphine b. Acetaminophen c. Ibuprofen d. Midazolam
ANS: A Opioids, such as morphine, are the preferred drugs for the management of acute, severe pain, including postoperative pain, posttraumatic pain, pain from vaso-occlusive crisis, and chronic cancer pain. Acetaminophen provides only mild analgesic relief and is not appropriate for a newly admitted child with sickle cell crisis. Ibuprofen is a type of nonsteroidal anti-inflammatory drug (NSAID) that is used primarily for pain associated with inflammation. It is appropriate for mild to moderate pain, but it is not adequate for this patient. Midazolam (Versed) is a short-acting drug used for conscious sedation, for preoperative sedation, and as an induction agent for general anesthesia. PTS: 1 DIF: Cognitive Level: Application OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
The nurse is caring for a client who is admitted with a crushing injury to the spinal cord above the level of phrenic nerve origin. What should the nurse consider about this type of injury when planning care? 1 Ventricular fibrillation 2 Vagus nerve dysfunction 3 Retention of sensation and paralysis of lower extremities 4 Lack of diaphragmatic contractions and respiratory paralysis
Lack of diaphragmatic contractions and respiratory paralysis
6. The nurse is caring for a child receiving intravenous (IV) morphine for severe postoperative pain. The nurse observes a slower respiratory rate, and the child cannot be aroused. The most appropriate management of this child is for the nurse to: a. administer naloxone (Narcan). b. discontinue the IV infusion. c. discontinue morphine until the child is fully awake. d. stimulate the child by calling his or her name, shaking gently, and asking the child to breathe deeply.
ANS: A The management of opioid-induced respiratory depression includes lowering the rate of infusion and stimulating the child. If the respiratory rate is depressed and the child cannot be aroused, IV naloxone should be administered. The child will be in pain because of the reversal of the morphine. The morphine should be discontinued, but naloxone is indicated if the child is unresponsive. PTS: 1 DIF: Cognitive Level: Analysis OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
A nurse assesses a client who is suspected of being in myasthenic crisis. Which assessment finding is most definitive in support of this conclusion? 1 Difficulty breathing 2 Decline in physical mobility 3 Disturbed sensory perception 4 Decreased tolerance to activity
Difficulty breathing
What clinical finding does the nurse expect when assessing a client with myasthenia gravis? 1 Partial improvement of muscle strength with mild exercise 2 Fluctuating weakness of muscles innervated by the cranial nerves 3 Dramatic worsening in muscle strength with anticholinesterase drugs 4 Minimal changes in muscle strength regardless of the therapy initiated
Fluctuating weakness of muscles innervated by the cranial nerves
Which type of joint is present in between the client's tarsal bones? 1 Pivot joint 2 Hinge joint 3 Saddle joint 4 Gliding joint
Gliding joint
A client is admitted after a motor vehicle crash. The primary healthcare provider has diagnosed the presence of pelvic fractures and bilateral femur fractures. The client's blood pressure has fallen from 120/76 to 60/40, and the heart rate has risen from 82 to 121. Which does the nurse recognize as the most likely reason for the assessment findings? 1 Cardiogenic shock 2 Hypervolemic shock 3 Hemorrhagic shock 4 Septic shock
Hemorrhagic shock
During the neurologic assessment of a client with a tentative diagnosis of Guillain-Barré syndrome, what does the nurse expect the client to manifest? 1 Diminished visual acuity 2 Increased muscular weakness 3 Pronounced muscular atrophy 4 Impairment in cognitive reasoning
Increased muscular weakness
A client sustains a complex comminuted fracture of the tibia with soft tissue injuries after being hit by a car while riding a bicycle. Surgical placement of an external fixator is performed to maintain the bone in alignment. Postoperatively it is most essential for the nurse to do what? 1 Cleanse the pin sites with alcohol several times a day. 2 Perform a neurovascular assessment of both lower extremities. 3 Ambulate the client with partial weight bearing on the affected leg. 4 Maintain placement of an abduction pillow between the client's legs.
Perform a neurovascular assessment of both lower extremities.
A nurse assists a client who had bariatric surgery to be more mobile. What complication is the nurse attempting to prevent? 1 Incisional pain 2 Wound dehiscence 3 Anastomosis leakage 4 Pulmonary embolism
Pulmonary embolism
A nurse is assessing an infant with talipes equinovarus (clubfoot) who has had a corrective boot cast applied. Which peripheral vascular assessment cannot be performed while the cast is in place? 1 Color 2 Pulse 3 Warmth 4 Blanching
Pulse
A client who is recuperating from a spinal cord injury at the T4 level wants to use a wheelchair. What should the nurse teach the client to do in preparation for this activity? 1 Push-ups to strengthen arm muscles 2 Leg lifts to prevent hip contractures 3 Balancing exercises to promote equilibrium 4 Quadriceps-setting exercises to maintain muscle tone
Push-ups to strengthen arm muscles
To reduce a hip fracture, the client is placed in traction before surgery for an open reduction and internal fixation. Because the client keeps slipping down in bed, increased countertraction is prescribed. How does the nurse increase the countertraction? 1 Elevate the head of the bed. 2 Add more weight to the traction. 3 Raise the foot of the bed slightly. 4 Tie a chest restraint around the client.
Raise the foot of the bed slightly.
A client sustains a crushing injury to the lower left leg, and a below-the-knee amputation is performed. For which common clinical manifestations of a pulmonary embolus should the nurse assess this client? Select all that apply. 1 Sharp chest pain 2 Acute onset of dyspnea 3 Pain in the residual limb 4 Absence of the popliteal pulse 5 Blanching of the affected extremity
Sharp chest pain Acute onset of dyspnea
Which information indicates a nurse has a correct understanding about skeletal muscles? 1 Skeletal muscle accounts for about half of a human being's body weight. 2 Skeletal muscle contraction propels blood through the circulatory system. 3 Skeletal muscle contraction is modulated by neuronal and hormonal influences. 4 Skeletal muscle occurs in the walls of hollow structures such as airways and arteries.
Skeletal muscle accounts for about half of a human being's body weight.
Which physiologic changes of the musculoskeletal system are related to aging? Select all that apply. 1 Slowed movement 2 Cartilage degeneration 3 Increased bone density 4 Increased range of motion 5 Increased bone prominence
Slowed movement Cartilage degeneration Increased bone prominence
A client had a cerebrovascular accident (also known as a "brain attack"), and bed rest is prescribed. What can the nurse use to best prevent footdrop in this client? 1 Splints 2 Blocks 3 Cradles 4 Sandbags
Splints
A nurse is assessing an 18-month-old toddler with suspected developmental dysplasia of the left hip. In what position should the nurse place the toddler to elicit the Trendelenburg sign? 1 Standing on the affected leg 2 Supine with the back arched 3 Side-lying on the unaffected side 4 Sitting upright with the legs separated
Standing on the affected leg
The healthcare provider prescribes a progressive exercise program that includes walking for a client with a history of diminished arterial perfusion to the lower extremities. The nurse explains to the client what to do if leg cramps occur while walking. Which instruction did the nurse give the client? 1 Chew one aspirin twice a day. 2 Stop to rest until the pain resolves. 3 Walk more slowly while pain is present. 4 Take one nitroglycerin tablet sublingually.
Stop to rest until the pain resolves.
A client with severe varicose veins has surgery that involves ligation, dissection, and removal of incompetent vessels. In which position should the nurse place the client after surgery? 1 Supine with the knee support of the bed raised 2 In a semi-Fowler position with the knees flexed 3 Supine with the legs elevated at a 15-degree angle 4 In a semi-Fowler position with the feet against a footboard
Supine with the legs elevated at a 15-degree angle
A client with multiple sclerosis is in remission. Which diversional activity should the nurse encourage that best meets the client's needs while in remission? 1 Hiking 2 Swimming 3 Sewing classes 4 Watching television
Swimming
Which joint surgery is used as a prophylactic measure and as a palliative treatment for clients with rheumatoid arthritis (RA)? 1 Osteotomy 2 Arthrodesis 3 Synovectomy 4 Debridement
Synovectomy
While assessing a client, the nurse suspects that the client has acute osteomyelitis. Which symptoms in the client support the nurse's suspicion? Select all that apply. 1 Foot ulcer 2 Temperature of 102° F 3 Erythema of the affected area 4 Tenderness of the affected area 5 Drainage from the affected area
Temperature of 102° F Erythema of the affected area Tenderness of the affected area
A client has corrective surgery for a bladder laceration. What nursing intervention takes priority during this client's postoperative period? 1 Turning frequently 2 Raising side rails on the bed 3 Providing range-of-motion exercises 4 Massaging the back three times a day
Turning frequently
A client has a total hip arthroplasty. What should the nurse do when caring for this client after surgery? 1 Use a pillow to keep the legs abducted. 2 Elevate the client's affected limb on a pillow. 3 Turn the client using the log-rolling technique. 4 Place a trochanter roll along the entire extremity.
Use a pillow to keep the legs abducted.
