Med Surg ll final

A client with hiatal hernia chronically experiences heartburn after meals. Which should the nurse teach the client to avoid?

Lying recumbent after meals

A client has undergone fasciotomy to treat compartment syndrome of the leg. Which type of wound care should the nurse anticipate will be prescribed for the fasciotomy site?

Moist, sterile saline dressings

A nurse is caring for a client who has a femur fracture suspects fat embolism syndrome. Which of the following finding is the nurse's earliest warning that his complication is developing?

Confusion

An older client recently has begun taking cimetidine. The nurse should monitor the client for which most frequent central nervous system side effect of this medication?

Confusion

The nurse is preparing to administer an enteral feeding through a nasogastric tube. The nurse should place the client in which position during and after the feedings?

Fowler's

The nurse is reinforcing discharge instructions to a client following surgical treatment for carpal tunnel syndrome. Which statement by the client would indicate a need for further teaching?

"I should perform pronation and supination exercises of my wrist starting 24 hours after surgery."

The nurse has reinforced instructions to the client returning home after arthroscopy of the knee. The nurse determines that the client understands the instructions if the client makes which statement?

"I'll report fever or site inflammation to the health care provider."

The nurse is collecting data from a client admitted to the hospital with a diagnosis of suspected gastric ulcer and is asking the client questions about pain. Which statement made by the client supports the diagnosis of gastric ulcer?

"My pain comes shortly after I eat, maybe a half hour or so later."

The nurse is reinforcing instructions to a client and his family about alcohol abuse and chronic cirrhosis. The nurse knows to include which essential elements in the discharge teaching guide? Select all that apply.

-Avoid potentially hepatotoxic over-the-counter drugs -Teach symptoms of complications and when to seek prompt medical attention -Explain that cirrhosis of the liver is a chronic illness and the importance of continuous health care. -Avoid spicy and rough foods and activities that increase portal pressure such as straining at stool, coughing, sneezing and vomiting.

Which client is at greatest risk for having a hemolytic transfusion reaction? A 34-year-old client with type O blood A 42-year-old client with allergies A 58-year-old immune-suppressed client A 78-year-old client

34-year-old client with type O blood

The nurse is performing health screening for a client at a health fair. Which of the following client's are at risk for osteoporosis?

40-year-old client who takes prednisone for asthma 45-year-old client who takes phenytoin (dilantin) for seizures 65-year-old client who has a sedentary lifestyle 70-year-old client who has smoked for 50 years

The nurse is planning to reinforce instructions to the client about how to stand on crutches. In the instructions, the nurse should plan to tell the client to place the crutches in which position?

8 inches to the front and side of the client's toes

Nursing interventions for the patient with cholecystitis associated with cholelithiasis are based on the knowledge that:

A heavy meal with a high fat content may precipitate the signs and symptoms of the disease

A nurse is collecting data from a client who has a casted compound fracture of the femur. The nurse nurse should identify which of the following findings as a manifestation of fat emboli?

Altered mental status

The nurse notes that the medical record of a client with cirrhosis states that the client has asterixis. To verify this information the nurse should take which action?

Ask the client to extend the arms.

A nurse is caring for a client who is postprocedure following lumbar puncture and reports a throbbing headache when sitting upright. Which of the following actions should the nurse take? Select all that apply

Assist the client to a supine position Admin an opioid med Encourage the client to increase fluid intake

A client is complaining of low back pain, with radiation down the left posterior thigh. The nurse continues to collect data from the client to see if the pain is worsened or aggravated with which action?

Bending or lifting

A nurse is admitting a client to the orthopedic unit following a total knee arthroplasty. Which of the following actions should the nurse take? Select all that apply

Check continuous passive motion device settings Palpate dorsal pedal pulses Elevate heels off the bed

A client with a possible hiatal hernia complains of difficulty swallowing. Which other sign/symptom is associated with a hiatal hernia?

Heartburn and regurgitation

The nurse is interpreting the laboratory results of a client who has a history of chronic ulcerative colitis. Which result indicates a complication of ulcerative colitis?

Hemoglobin 10.2 g/dL

It has been determined that a client with hepatitis has contracted the infection from contaminated food. Which type of hepatitis is this client most likely experiencing?

Hepatitis A

40. A client had an external fixate on device applied 4 hr ago for a compound fracture of the left wrist. Which of the following data indicates the possibility that compartment syndrome is occurring?

Intense pain when passively move There is an increase in edema of the left finger when compared to the prior assessment Pain is unrelieved by second dose of analgesia Hard swollen muscle in the left leg Burning and tingling of the left foot

The nurse is preparing a list of cast care instruction for a client who just had a plaster cast applied to his right forearm. Which instructions should the nurse include on the list?

Keep the cast and extremity elevated The cast needs to be kept clean and dry Handle a plaster cast with palms until the cast is dry Allow the wet cast to dry.

A client sustains a closed fracture of the tibia and is placed in a long plaster cast. The cast is still damp. Which of the following methods should the nurse use to move the cast without causing complication?

Palm the cast to move it

The nurse is caring for a patient who has closed reduction of the ulna with a cast applied. Later the patient reports left arm pain. Which of the following interventions is the highest priority?

Perform neurovascular check on fingers

A client is complaining of skin irritation from the edges of a cast applied the previous day. The nurse should plan for which intervention?

Petaling the cast edges with adhesive tape

A postgastrectomy client is at high risk for hyperglycemia related to uncontrolled gastric emptying of fluid and food into the small intestine (dumping syndrome). Because of this risk, the nurse plans to monitor which data?

Postprandial blood glucose readings

The nurse is checking the cast extremity of a client. The nurse should check for which sign indicative of infection?

Presence of a hot spot on the cast

A client with a peptic ulcer is scheduled for a vagotomy, and the client asks the nurse about the purpose of this procedure. The nurse tells the client that a vagotomy serves which purpose?

Reduces the stimulation of acid secretions

The client has begun medication therapy with pancrelipase. The nurse evaluates that the medication is having the optimal intended benefit if which effect is observed?

Reduction of steatorrhea

The nurse assesses multiple clients who are receiving transfusions of blood components. Which assessment indicates the need for the nurse's immediate action?

Respiratory rate of 36 breaths/min in a client receiving red blood cells

The nurse assigned to care for a client with cirrhosis reviews the medical record and notes that the client has difficulty maintaining an effective breathing pattern due to pressure on the diaphragm. The nurse plans care knowing that which client position will best assist in facilitating breathing?

Semi-Fowler's

A client with diabetes mellitus has had a right below-knee amputation. The nurse should be especially vigilant in monitoring for which complication related to the client's history?

Separation of wound edges

The nurse is monitoring a client for the early signs and symptoms of dumping syndrome. Which indicates this occurrence?

Sweating and pallor

The nurse is caring for a client with a long bone fracture who is at risk for fat embolism. The nurse specifically monitors for the earliest signs of this complication by checking which criteria? Select all that apply.

The client's mental status The client's respiratory function

The nurse is reviewing information with a client schedule for dual x-ray absorption (DXA) scan. Which of the following should the nurse include?

The hip and the spine are the usual areas to be scanned Bone pain can indicate a need for a scan At age 40 a baseline scan is recommended

A client has a newly fractured fibula that is plaster casted in the emergency department. Because the client will need to use crutches, the nurse plans to teach the client which crutch-walking gait before discharge?

Three-point gait

The patient, age 56, has cirrhosis of the liver with severe ascites. The nurse is assisting the physician in the procedure to remove this fluid from his abdominal cavity. This procedure is called an

abdominal paracentesis.

the nurse is working in the emergency department and he is caring for a client admitted with a small bowel obstruction due to post surgical adhesions. what signs and symptoms would the nurse observe?

profuse projectile vomiting with a fecal odor

The nurse is caring for a client with thrombocytopenia. Which data should the nurse monitor for related to this condition? Select all that apply.

purpura, ecchymoses, platelets less than 150,000 cells/mm3

36. The nurse is contributing to the plan of care for a patient who has a right fracture femur. What intervention would be essential to include in the plan of care to prevent fat emboli?

Maintain immobilization of the right leg until an immobilization procedure performed

38. The nurse is collecting data for a patient suspected of developing a fat embolus from a fracture of the right femur. Which of these manifestations would the nurse expect?

Mental confusion Cutaneous petechia Tachycardia

The nurse has given the client with hepatitis instructions about postdischarge management during convalescence. The nurse determines that the client needs further teaching if the client makes which statement?

"I should resume a full activity level within 1 week."

the nurse is caring for a client with hepatitis and is reviewing dietary instructions. the nurse instructs the client to have a diet that is

.high carbohydrate, low fat, and low protein

the nurse is caring for a client who has developed compartment syndrome from a severely fractured arm. The client asks the nurse how this can happen. How should the nurse explain compartment syndrome?

Bleeding and swelling cause increased pressure in a area that cannot expand

The nurse is caring for a client who has developed compartment syndrome from a severely fractured arm. The client asks the nurse how this can happen. How should the nurse explain compartment syndrome?

Bleeding and swelling cause increased pressure in an area that cannot expand

nurse is caring for a client with a suspected diagnosis of aplastic anemia. Which tests should the nurse anticipate to be performed to confirm the diagnosis?

Bone marrow aspiration

A nurse is reviewing the health record of a client who is to undergo total joint arthroplasty. The nurse should recognize which of the following findings as a contraindication to this procedure?

Bronchitis 2 weeks ago

The nurse is reinforcing medication instructions to a client with peptic ulcer disease. Which represents correct information given by the nurse?

Cimetidine (Tagamet) results in decreased secretion of stomach acid

A nurse is assisting with planning discharge teaching for a client who had a total hip arthroplasty. Which of the following instructions should the nurse include? Select all that apply

Clean the incision daily with soap and water Sit in a straight backed armchair Use a raised toilet seat

The nurse is caring for a client being treated for fat embolus after multiple fractures. Which data indicates to the nurse favorable resolution of the fat embolus?

Clear chest x-ray

A client is admitted to the hospital with acute viral hepatitis. Which sign/symptom should the nurse expect to note based on this diagnosis?

Fatigue

A nursing instructor asks a nursing student about the risk factors associated with osteoporosis. The instructor determines that the student needs father teaching if the student states which is an associates risk factor?

High-calcium diet consumption

39. Which of the following client statement indicates an understanding of how to safety manage an external fixation device applied to the distal radius and ulna?

I will clean the pin site 1 to 2 times a day, or a directed by my physician I will use a separated cotton swab to clean each pin I will report loosening of the pins of the provider I will check for drainage and redness around the pin sites

The nurse is reviewing the medication record of a client with acute gastritis. Which medication noted on the client's record should the nurse question?

Ibuprofen (Motrin)

A client is admitted to the hospital with viral hepatitis and is complaining of a loss of appetite. In order to provide adequate nutrition, which action does the nurse encourage the client to take?

Increase intake of fluids.

The nurse is caring for a comatose client at risk for fat embolism because of a fractured femur and pelvis sustained in a fall. Which findings does the nurse identify as early signs of possible fat embolism?

Increased heart rate and adventitious breath sounds

The nurse is infusing platelets to a client who is scheduled for a hematopoietic stem cell transplant. What procedure does the nurse follow for administering this blood product?

Infuse the transfusion over a 15-30 minute period

The nurse performs an assessment on a newly admitted client with thrombocytopenia. Which assessment finding requires immediate intervention by the nurse?

bleeding from the nose

The nurse can prevent the transmission of hepatitis A by avoiding

direct contact through fecal matter, contaminated food, or contaminated water.

The nurse is assigned to care for a client with multiple traumas who is admitted to the hospital. The client has a leg fracture, and a plaster cast has been applied. In positioning the castes leg, the nurse should perform which interventions?

Elevate the leg on pillows continuously for 24 to 48 hours

The nurse is contributing the plan of care for a client who is post-operative following an arthroscopy of the knee. Which of the following should the nurse include in the plan of care.

Inspect color and temperature of the extremity Elevate extremities Administer analgesic medications as prescribe Check pulses and sensation in the foot

A nurse is reinforcing pre-op teaching with a client who is to undergo an arthroscopy to repair a shoulder injury. Which of the following statements should the nurse include? Select all that apply

Inspect your incision daily for indications of infection Apply ice packs to the area for the first 24 hours Perform isometric exercises

The nurse is reinforcing discharge instructions to a client after a gastrectomy. Which measure should the nurse include in client teaching to help prevent dumping syndrome?

Limit the fluids taken with meals.

A nurse is collecting data from a client who has GERD. Which of the following findings should the nurse expect?

Loss of tooth enamel

Because vitamin K is malabsorbed in the presence of cirrhosis, which laboratory value would be elevated?

Prothrombin time

Alendronate is prescribed for a client with osteoporosis and the nurse is providing instructions on administration on the medication. Which instruction should the nurse reinforce?

Take the medication with a full glass of water after rising in the morning

A nurse planning care for a client with hepatitis plans to meet the client's safety needs by performing which action?

Monitoring prothrombin and partial thromboplastin values

The nurse is caring for a client who has suspected osteoporosis. The nurse anticipates the provider will precise which of the following diagnostic tests?

Dual-energy X-ray absorptiometry (DXA)

The goals of diet management in a patient with inflammatory bowel disease are: (Select all that apply.)

Prevent weight loss. Correct and prevent malnutrition. Provide adequate nutrition. Replace fluid and electrolyte losses.

the nurse is caring for a client admitted with acute pancreatitis. the client exhibits a positive trousseau's sign. muscle cramps. a positive chvostek's sign, and a prolonged QT interval on the ECG. the nurse knows that the most common electrolyte imbalance associated with pancreatitis is?

hypocalcemia

the nurse is caring for a client who has pancreatitis. the client reports a history of alcohol abuse. orders include keeping the client NPO. insertion of a nasogastric tube and applying suction, and IV fluids. which of the following laboratory results should the nurse expect? (select all that apply)

increased serum lipase increased serum amylase increased blood glucose levels

the nurse is participating in a inservice on her unit. the inservice is on hepatitis. which of the following is correct about hepatitis and should be included in the inservice?

individuals with hepatitis are carriers and can spread the disease without showing any symptoms

the nurse is caring for a cleint with cirrhosis. the client had blood work done and the nurse is reviewing the results. the nurse notices that the serum ammonia level is elevated. what should the nurse do?

observe for increasing confusion

the nurse is preparing to administer pancrelipase(viokase) to a client who has pancreatitis. which of the following is an appropriate nursing action?

offer a glass of water following medication administration

A nurse is preparing to care for a client following a lumbar puncture. The nurse plans to place the client in which position immediately after the procedure?

Prone with a pillow under the abdomen

The nurse is caring for client who has seasonal allergy symptoms and had radioallergsorbent (RAST) testing completed during a prvious clinic visit. The recognizes that a positive results is indicated by an elevation of which of the following?

IGE

The nurse is preparing a patient who has suspected allergies for a radioallergosrbent test (RAST) Which of the following patient statements reveal the need for further reinforcement of teaching?

IT TEST MANY MORE ALLERGENS THAN A SCRATCH

A nurse is contributing to the plan of care for a client who has bacterial meningitis. Which of the following interventions should the nurse include? Select all that apply

Provide an emesis basin at the bedside Administer antipyretic medication Perform a skin assessment

A nurse working in a long term care facility is caring for a client who has AD. Which of the following actions should the nurse take?

Provide finger foods for the client's snacks and meals

A patient states that he returned from a 2-week camping trip a few days ago. He complains of nausea and anorexia and dark urine. What additional information would assist in diagnosing hepatitis A?

Recent ingestion of raw fish

A nurse is collecting data on a client suspected of having Alzheimer's disease. The priority data would focus on which of the following characteristic of this disease?

Recent memory loss

A nurse in a provider office is collecting data from a client who has rheumatoid arthritis (RA). The client reports increased joint tenderness and swelling. Which of following findings should the nurse expect?

Recent recovery from Decrease range of motion Pain at rest

An adult client had a cerebrospinal fluid (CSF) analysis after lumbar puncture. The nurse interprets that a negative value of which of the following is consistent with normal findings?

Red blood cells

A nurse is contributing to the plan of care for a client who has meningitis and is at risk for ICP. Which of the following interventions should the nurse recommend? Select all that apply

Implement seizure precautions Turn off room lights and television. Monitor for impaired extraocular movements

The nurse is caring for a Clint with glaucoma. The client has been prescribed Pilocarpine eye drops to both eyes four time perday. The nurse knows that this medication has which expected action?

Increase the outflow of aqueous humor

A nurse is caring for a client with increased intracranial pressure (ICP). The nurse should monitor for which of the following trends in vital signs that would occur if ICP is rising?

Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure (BP)

A nurse is obtaining a health history from a client who is being evaluated for the cause of frequent headaches. Which of the following questions should the nurse ask to identify the findings of migraine headaches?

Is there a pattern of headaches among family members?

A nurse is providing care to a client with increased intracranial pressure (ICP). Which approach(es) may be beneficial in controlling the client's ICP from an environmental viewpoint? Select all that apply.

Reducing environmental noise Maintaining a calm atmosphere Allowing the client uninterrupted time for sleep

The nurse us assisting with the admission of a client with a confusion following a motor vehicle accident. The nurse's observation of this client should include monitoring for early signs od increasing intracranial pressure including:

Restlessness and irritability

What would the nurse note during the clonic phase of a tonic clonic seizure?

Rhythmic jerking of the extremities

A client is having a lumbar puncture (LP) performed. The nurse would place the client in which position for the procedure?

Side-lying, with legs pulled up and head bent down onto the chest

A patient is admitted to the emergency department with first- and second-degree burns after being involved in a house fire. Which assessment findings would alert you to the presence of an inhalation injury? (select all that apply)?

Singed nasal hair Generalized pallor Painful swallowing History of being involved in a large fire

For the osteoporosis patient taking alendronate (fosamax), the nurse would stress that the drug requires that the patient?

Sit or stand for 30 minutes after administration

A nurse is preparing for the admission of a client with a prescription for seizure precautions. Which supplies will the nurse make available to this client? Select all that apply.

Suction machine Oxygen administration Padding for the side rails Prescribed diazepam (Valium)

a 35yo man has been admitted with a diagnosis of peptic ulcers. Which drugs are most commonly used in these patients to decrease acid secretions?

Tagamet and Zantac

A health care provider has given a prescription for dietary iron supplements to the client with osteoporosis who has an iron deficiency anemia. The nurse suggests that the client do which to enhance compliance with therapy?

Take the medication following a meal.

A nurse is caring for a client that is comatose and notes in the client's chart that the client is exhibiting decerebrate posturing. The nurse understands that decerebrate posturing is characterized by:

The extension of the extremities and pronation of the arms

The nirse is assisting to develop a plan of care for a child who is at risk for seizures. Which interventions apply if the child has a seizure? Select all that apply

Time the seizure Stay with the child Move furniture away from the child

In preparing discharge plans ft a patient with SLE, the nurse must include

USE OF DAILY SUNSCREENS WITH A SUN PROTECTANT FACTOR (SPF) HIGHER THAN 15

The nurse is collecting data from a client who is being seen in the health care clinic. The client is complaining of unrelieved back pain that has persisted over the past 3 months. The nurse determines that which harmful effect can occur as a result of uncontrolled muscle pain?

Weakness

The nurse is transfusing a unit of whole blood to a client when the primary health care provider prescribes "Furosemide (Lasix) 20 mg IV push." Which intervention would the nurse perform?

administer the furosemide after completion of the transfusion

the nurse is planning the care for a client who has cirrhosis of the liver. which of the following should the nurse implement? (select all that apply)

administration of furosemide(lasix) implement a low sodium diet measure the abdominal girth

The nurse a caring for a patient with systemic lupus erythematosus.Which of the following should the nurse reinforce when instructing the patient about self care?

avoid sun exposure avoid harsh hair treatments report peripheral edema to the provider avoid crowds and individuals who are sick

the nurse is collecting date for a patient with acute pancreatitis. which laboratory test result should the nurse expect?

elevated serum amylase

Which nursing intervention most effectively protects a client with thrombocytopenia

encourage use of electric razor

The nurse is to administer packed red blood cells to a client. How does the nurse ensure proper client identification?

review all information with another registered nurse (RN)

A client who is receiving a blood transfusion suddenly tells the nurse, "I don't feel right!" What is the nurse's first action?

stop the transfusion

The nurse is mentoring a recent graduate registered nurse (RN) about administering blood and blood products. What action does the nurse perform before starting the transfusion?

very with another RN all of the data on blood products

the nurse caring for a client recently infected with hepatitis A. the nurse is reinforcing teaching on prevention of transmission of the virus. which of the following should be included?

wash your hands after toileting

nurse is reviewing the laboratory results of a client receiving chemotherapy. The nurse prepares to initiate neutropenic precautions when the nurse notes which laboratory result?

white blood cell (WBC) count of 2000 cells/mm3

The nurse is contributing to the plan of care for a client admitted with an open head injury. Which of the following are interventions that should be included to prevent increased intracranial pressure? (select all that apply)

Keep head of bed elevated 30 degrees Administer stool softeners Avoid extreme flexion, extension or rotation of the head Administer oxygen to keep the oxygen saturation above 92%

A patient who has had a generalized tonic-clonic seizure is sound asleep 30 minutes after the seizure. Meals are about to be delivered. Which nursing action is most appropriate?

Let the patient sleep during the postictal state, and keep the meal warm

A nurse is assisting in caring for a client with a suspected diagnosis of meningitis. The nurse reinforces to the client information regarding which diagnostic test that is commonly used to confirm this diagnosis?

Lumbar puncture

. The nurse is helping to prepare a client with SLE for discharge. Which of the following instructions should the nurse include in the client's discharge teaching plan?

MONITOR YOUR BODY TEMPERATURE AND REPORT ANY CLEVATIONS PROMPTLY

A nurse observes that a client with Parkinson's disease has very little facial expression. The nurse attributes this piece of data to which of the following?

Mask-like facies is a component of Parkinson's disease

A nurse is assisting with the plan of care for a client who has a prescription for TPN. Which of the following interventions should the nurse include? Select all that apply

Measure capillary blood glucose four times daily Monitor vital signs three times during the 12 hr shift Change The TPN IV tubing every 24 hr

A nurse develops a plan of care for a client following a lumbar puncture. Which interventions should be included in the plan? Select all that apply.

Monitor the client's ability to void. Maintain the client in a flat position. Monitor the client's ability to move the extremities. Inspect the puncture site for swelling, redness, and drainage.

A histamine (H2) receptor antagonist will be prescribed for a client. The nurse understands that which medications are H2 receptor antagonist?

Nizatidine Ranitidine Famotidine Cimetidine

The nurse is caring for a patient who is undergoing an arthroscopy of the knee with ligament repair. Which of the following would be included in nursing preoperstive care for the patient the morning of surgery? Select all that apply

No food after midnight Reinforcing how to perform coughing and deep breathing exercises

The nurse is caring for a client who is experiencing itching secondary to skin testing for allergens. Which of the following medications would be recommended for the client?

ORAL DIPHENHYDRAMINE (BENEDRYL)

A client with viral hepatitis has no appetite, and food makes the client nauseated. Which nursing intervention should be appropriate?

Offer small, frequent meals.

A nurse is reinforcing discharge teaching to a client who has seizures and received a vagal nerve stimulator to decrease seizure activity. Which of the following statements should the nurse include?

"I can expect to have a temporary voice change"

A nurse is positioning the client with increased intracranial pressure (ICP). Which position should the nurse avoid?

. Head turned to the side

A client reports bilateral pain and swelling in her finger joints with stiffness in morning. The finger joint are erythematous and warm to the touch. The client tells the nurse that she has a long family history of arthritis. To help diagnose the clients condition the nurse anticipates an order for which laboratory study?

. RHEUMATOID FACTOR

A nurse is caring for a patient with second- and third-degree burns to 50% of the body. The nurse prepares fluid resuscitation based on knowledge of the Parkland (Baxter) formula that includes which recommendation?

One half of the total 24-hour fluid requirement should be administered in the first 8 hours.

The nurse us caring for an older client who has diabetes mellitus. The client reports loss of peripheral vision and mild eye pain. For which of the following is the client at risk?

Open-angle glaucoma

A nurse is collecting data from a client who has Parkinson's disease. Which of the following findings should the nurse expect? Select all that apply

Pill-rolling tremor of the fingers Shuffling gait Drooling

A nurse is caring for a client who has AD and falls frequently. Which of the following actions is the priority for the nurse to take to keep the client safe?

Place the client in a room close to the nurses' station

The nurse is caring for a client who has been diagnosed with left homonymous hemianopsia. Which of the following actions by the nurse is appropriate?

Place the client's bedside table on the right side of the bed

The nurse is caring for a client experiencing an acute exacerbation of multiple sclerosis (MS). The nurse recognizes that symptoms of MS are caused by with of the following pathophysiological changes?

Plaque damages the myelin sheath and interferes with impulse transmission

A client has been seen in the ER and has been diagnosed with RA (rheumatiod arthritis) Which f the following findings a would you except?

Positive ANA titer Positive C-Reactive protein Subcutaneous nodules Positive Anti-CCP antibodies Morning stiffness

The nurse is caring for a client admitted with an acute exacerbation pf her multiple sclerosis. Which drug therapy does the nurse anticipate administering to help resolve an exacerbation?

Prednisone

The nurse is providing an in-service for a new group of nurses. The nurse is reviewing clinical findings that could indicate an increased ICP from a closed head injury. Which would she include in the discussion? (select all that apply)

Disorientation to time and place Restlessness and irritability Unequal pupils Severe headache

The nurse is caring for a client in an extended care facility who has macular degeneration. Which of the following ADLs will the client required the greatest amount of assistance?

Eating

The nurse is caring for a client with Rheumatiod Arthritis (RA) and is reviewing the lab results. Which would be an expected findings ?

ANTI-CCP ANTIBODY TEST IS POSITIVE

The nurse is helping to administer a scratch test to a client who has suspected food and enviromental allergies. Which of the following actions should the nurse perform perform prior to the procedure?

ASK THE CLIENT'S SKIN WITH POVIDINE-IODINE (BETADINE) ASK THE CLIENT ABOUT MEDICATIONS TAKEN OVER THE PAST SEVERAL DAYS INFORM THE CLIENT TO EXPECT ITCHING AT LEAST AT THE CONTROL SITE OBTAIN EMERGENCY RESUSCITATION EQUIPMENT

The patient has cirrhosis of the liver and an albumin/globulin ratio of 0.9 g/dL. The normal ratio is 1.2 to 2.2 g/dL. In collecting objective data for her, the nurse would probably note which outstanding clinical sign?

Edema

The nurse is caring for a patient who has a newly casted, fractured wrist. Data collection reveals slightly puffy fingers with good capillary refill. What should the nurse do now to prevent complications?

Elevate the cast on pillow

The nurse is caring for a client with fresh application of a plaster leg cast. The nurse should plan to prevent the development of compartment Syndrome by which action?

Elevating the limb and applying ice to the affected leg

A nurse is assisting with the plan care for a client who has acute gastritis. Which of the following nursing actions should the nurse recommend for the plan of care? Select all that apply

Evaluate I&O Monitor electrolytes Observe stool characteristics

Which clinical manifestation is observed in the clonic phase of a seizure?

Extension spasms of the body

A nurse is preparing for the admission of a client with a diagnosis of early stage Alzheimer's disease. The nurse assists in developing a plan of care, knowing that which of the following is a characteristic of early Alzheimer's disease?

Forgetfulness

The nurse is providing post-procedure care for a patient who has had a lumbar puncture. Which order does the nurse anticipate?

Have patient lay flat for several hours.

A nurse is collecting data from a client who has a gastric ulcer. Which of the following findings should the nurse expect? Select all that apply

Client reports a sensation of bloating Client states that pain occurs after meals Client experiences pain upon palpating of the epigastic region

Which laboratory result would verify the diagnosis of bacterial meningitis?

Cloudy CSF with high protein and low glucose levels

The nurse is giving the client a left cast crutch-walking instruction using the three-point gait. How should the nurse teach the client to use crutches?

Crutches and the left leg, then advance the right leg

e nurse is giving the client with a left leg cast crutch-walking instructions using the three-point gait. The client is allowed to touch down the affected leg. How should the nurse teach the client to use the crutches?

Crutches and the left leg, then advance the right leg

A client is admitted to the ER with complications of RA and is diagnosed with Sjogrens syndrome The nurse understands that this diagnosis presents with which of the following triad of symptoms?

DRY EYES, DRY MOUTH, AND DRY VAGINA

A client with suspected meningitis had a lumbar puncture. What is indicative of bacterial

Decreased glucose

Which of the following is a symptom of ICP that should be reported immediately to the primary care provider?

Decreasing LOC

A client with possible hiatal hernia complains of frequent heartburn and regurgitation. The nurse should gather further information about the presence of which sign or symptom?

Difficulty swallowing