medsurg 2 gold :)

A nurse interprets a Mantoux reaction as "0 millimeters," a negative test for TB. The client tells the nurse, "It's good to know that I definitely don't have TB." The correct response by the nurse should be,

"A negative test does not always mean that TB is not present."

Which statements indicates that a family has a good understanding of the changes in motor movement and the care associated with Parkinson's disease?

"I should offer smaller meals with bite-size portions and a liquid supplement"

1. Client fell at home and enters the ED with injured right knee. The client tells the nurse that he immediately put a hot compress on the injury. The nurse's best response at this time would be

"Let me exchange the hot compress for a cold one. Heat may cause more bleeding and discomfort." (RICE) Rest, ice, Compress, elevation.

The male client diagnosed with a brain tumor is scheduled for a magnetic resonance MRI in the morning. The client tells the nurse that he is scared. Which response by the nurse indicates an appropriate therapeutic response?

"You're scared. Tell me about what is scaring you."

When the nurse is performing oral hygiene for an unconscious client, which intervention is the most important?

- Ensure suction equipment is available.

Person following bed rest after a stroke with hemiparesis (Weakness) the best nursing diagnosis for this patient ?

- Ineffective Tissue Perfusion

The nurse is caring for a client who has expressive aphasia following a stroke. Which nursing intervention would be most helpful?

- Use a picture board

A client who experiences an ischemic stroke arrives in the emergency department. Prior to administering tissue plasminogen activator, t-PA (alteplase), which is the most important question to ask the client?

- What time did the symptoms begin?

When assessing a patient who has compartment syndrome, a nurse should expect the patient to have which of these symptoms? SATA

-Capillary refill of 6 sec -pallor -decreased peripheral pulses on the effected side (Written differently on test)

1. Following a supratentorial craniotomy the nurse establishes a goal to maintain intracranial pressure (ICP) between 10-20 mm/Hg. which interventions should the nurse implement? SATA

-Elevate the head of the bed 15 to 30 degrees - Contact health care provider to report change of level of consciousness - Initiate neurological checks utilizing the Glasgow Coma Scale

. A client in the post-anesthesia care unit (PACU) with a left below the knee amputation complaints of pains her left big toe. Which of the following should the nurse do first? SELECT ALL THAT APPLY:

-Explain to the client that the pain is real -Give the client a prescribed opioid analgesic

A client who has COPD has severe shortness of breath at rest and arterial oxygen tension (PaO2) of 75 mmHg on the most recent ABG. Orders include oxygen via nasal cannula & activity as tolerated. The nurse intervenes when noting:

-Oxygen being delivered at 4 L/min via nasal cannula.

Two days after an accident in which a client sustained multiple injuries, including fractures, the client becomes confused and dyspneic and has a temperature of 102.6F (39.2C). In giving the SBAR report to the primary care provider, the recommendation section would include a suggestion for a stat

-ventilation-perfusion (V-Q) scan.

Pt. post anesthesia care; he undergoing a total hip replacement. The pt. has a hemovac in place. Which devices?

. Abduction pillow.

After receiving a change of shift report at 0700, which of these clients should the nurse assess first?

A 63 y/o with multiple sclerosis (MS) who has an oral temperature of 101.8 F and flank pain

After receiving a change of shift report at 0700, which of these clients should the nurse assess first?

A 63 y/o with multiple sclerosis who has an oral temperature of 101.8 F and flank pain

Two days after an accident in which a client sustained multiple injuries, including fractures, the nurse assesses confusion, dyspnea, temperature of 103.4, respiratory rate of 26, heart rate of 112 minutes and petchiae of the chest. The nurse assesses that the client may have developed

A fat embolism

A home health nurse is conducting an initial visit to a recently discharged client who has osteoporosis, the home health nurse recognizes the need for additional client teaching when finding

A narrow staircase w/no handrail.

Pt has osteoporosis, pt. needs further teaching when:

A narrow staircase w/no handrail.

In the initial visit to a recently discharged client with osteoporosis, the home health nurse recognizes the need for additional client teaching when noticing

A narrow staircase with no handrail

The client admitted with a neurological problem indicates to the nurse that MRI (magnetic resonance imaging) may be performed. The nurse interprets that the client may be ineligible for this diagnostic procedure based on the client history of

A prosthetic heart valve

The nurse assigns the unlicensed assistive personnel (UAP) to position an unconscious client on one side (lateral position). In doing the head to toe assessment, the nurse recognizes that the area most at risk for a pressure ulcer for a client in this position is the

Ankle

1. A client is seen and treated for a severe sprain to the left ankle. When discharging the client home, the nurse recognizes that additional teaching is needed if the client states that once at home they will

Apply a heating pad to the left ankle

Client is seen and treated for a severe sprain to the left ankle. The nurse recognizes additional teaching

Apply a heating pad to the left ankle

Client with osteoporosis the home care nurse recognizes the need for additional teaching when noticing

Area rugs on the floor

A nurse is admitting a client diagnosed with a stroke. Assessment reveals that the client is unconscious and unresponsive to stimuli. The clients wife tells the nurse that he has a history of gastroesophageal reflux disease (GERD). Based on this information the nurse determines that this client would be at increased risk for?

Aspiration Pneumonia

The nurse is caring for a client who has had intracranial surgery. An important nursing intervention when managing pain in the post-intracranial surgical client is to

Assess LOC prior to administering narcotic analgesics.

Preoperative teaching to the pt who goes to hip replacement. Nurse do first

Assess the pt's fears about the procedure.

When a client has a diagnosis of myasthenia gravis, which of these nursing interventions would be most effective to meet the expected outcome of reducing muscle weakness?

Assist with activities of daily living

An older adult in a long term care facility has become agitates and combative toward the unit staff members. Which of the following actions is most appropriate to implement first?

Attempt to calm the client's fear and reorient the client to the surroundings.

A nurse performing an assessment on a client who has fractures of the right femur and a full leg cast. The nurse assesses pallor of the right foot; pain 6-10 of right foot, and diminished pedal pulses. The nurse contacts the health care provider and should include which of the following interventions in the (situation, background, assessment, and recommendation: SBAR) report under recommendations?

Bivalve the cast

A client is scheduled for a CT scanning with contrast medium for a lesion in the brain. Which of the following laboratory results should be reported as a priority to the healthcare provider?

Bun 46 mg/dL (normal volume 8-23)

A nurse is assessing a client with myasthenia gravis. Which statement by the client reflects symptoms of the disease?

By the end of the day my eyelids are usually drooping

Osteoporosis will probably be treated with

Calcium supplement

The nurse assesses the following client and should anticipate this client has damage to the

Cerebral cortex

The nurse receives a client following intracranial surgery for a complex tumor. The surgeon tells the nurse that she is particularly concerned about ICP in this client and wants to be called at the first sign of problem. The nurse knows that they will monitor the client closely for

Change in LOC

1. An assessment finding that alerts the nurse to the presence of osteoporosis in a patient is

Change in height from 5.2 to 5.1 within 5 months

1. An assessment finding that alerts the nurse to the presence of osteoporosis in a pt is:

Change in height from 5.2 to 5.1 within 5 months

The client tell the nurse that he can't feel his fingers (neurological assessment)

Check for capillary refill in the client's fingers

The nurse, in preparing the nurse care plan for a comatose client receiving nasogastric feedings, would include which of the following routine actions as priority?

Check residual volume every 4 hours.

A pt. who is experiencing dyspnea comes to a health clinic, which assessment finding in the client indicates to the nurse that the respiratory problem is chronic?

Clubbed fingers

A nurse is conducting an assessment on a client who comes to the clinic reporting pain and swelling in the right knee. In beginning the assessment of the client's complaint, the nurse would first

Compare the right knee to the left knee

Client fracture right femur the nurse assesses capillary refill 6 seconds, pallor and decreased peripheral pulse

Compartment syndrome

Two days after an accident in which a client sustained a fracture of the right femur the nurse assesses capillary refill of 6 seconds, pallor and decreased peripheral pulses on the right lower extremity. The nurse assesses that the client may have developed

Compartment syndrome

The nurse is caring for a pt. who had total knee replacement surg. Which complications is a priority?

DVT

1. A nurse is working on a neuro unit and is caring for a client with encephalitis. Which assessment finding indicated neuro status is deteriorating?

Decreased LOC

A comatose patient receiving nasogastric feedings is scheduled to have a gastrostomy tube insertion. The nurse informs the family that the advantage of this feeding tube over nasogastric tubes is:

Decreased risk of aspiration

A nurse is teaching a class on osteoarthritis. The nurse should plan to emphasize that this is best described as:

Degeneration of articular cartilage in synovial joints

A nurse is teaching a class on osteoarthritis. The nurse should plan to emphasize that this is best described as:

Degeneration of articular in synovial joints.

1. When obtaining a health history from a client with meningitis what should the nurse ask about?

Do you live in a crowded residence

The nurse assesses moderate amount of serosanguinous drainage. Based on this finding, the nurse should:

Document findings and continue to assess.

An unconscious client is to receive 200 ml of a tube feeding every 4 hours. When the nurse checks for the clients gastric residual before administering the scheduled feeding, 45 ml of gastric residual is obtained. What should the nurse do next?

Document the residual and feed the client as scheduled

An unconscious client is to receive 200 ml of a tube feeding every 4 hours. When the nurse checks for the clients gastric residual before administering the scheduled feeding, 45 ml of gastric residual is obtained. What should the nurse do next?

Document the residual and fees the client as scheduled.

A client who has an above the knee amputation develops a dime-size bright red spot on the dressing after 45 minutes in the post anesthesia care unit. Which of the following should the nurse do first?

Draw a circle around the site

A client has a bone scan performed. The nurse would evaluate that the client understands the follow-up care if the client states that they should

Drink plenty of water for 1 to 2 days following the procedure

Which of the following nursing interventions will assist in the prevention of respiratory complications in the client with Parkinson's disease?

Elevated the head of the bed to at least 30 degrees

Which of the following nursing interventions will assist in the prevention of respiratory complications in the client with Parkinson's disease?

Elevated the head of the bed to at least 30 degrees.

When caring for a pt with meningitis, which action of the student requires immediate intervention from the nurse?

Entering the room without mask and gown

A nurse is reviewing lab data of a pt. with asthma. Which lab value indicates to the nurse that the pt. may have asthma triggered by allergies?

Eosinophil count of 500 cells/mm (12%)

The pt. is concerned about her risk for osteoporosis b/c her mother has the condition:

Even w/a family hx of osteoporosis, the calcium loss from bones can be slowed by increased calcium intake and exercise.

A female client is diagnosed with osteoporosis following densitometry testing or DXA test (bone density test). The client is concerned about her risk for osteoporosis because her mother has the condition. When teaching the client about her osteoporosis the nurse should explain that

Even with a family history of osteoporosis, the calcium loss form bones can be slowed by increased calcium intake and exercise

1. A female client is diagnosed with osteoporosis following densitometry testing or DEXA test (bone density test). The client is concerned about her risk for osteoporosis because her mother has the condition. When teaching the client about her osteoporosis the nurse should explain that

Even with a family history of osteoporosis, the calcium loss from bones can be slowed by increased calcium intake and exercise

Nurse assesses confusion, dyspnea, temperature of 103.3 f respiratory rate 26 and H/R 112per min and petechiae. The client may have developed

Fat embolism

Potential complications of osteoporosis

Fracture of the hip, wrist, and spine

A nurse is teaching a client regarding the potential complications of osteoporosis should caution the client about

Fractures of the hip, wrist, and spine

The nurse is positioning the client with increased intracranial pressure. Which of the following positions would the nurse avoid?

Head turned to the side

Which statement indicates that a family has a good understanding of the changes in motor movement and the care associated with Parkinson's disease?

I should offer smaller meals with bite-size portions and a liquid supplement

A pt. who has undergone repair of the right knee ligament complains that the use of the continues passive motion CPM machine causes pain and ask how long he is expected to use the machine:

I will give you a pain med to make you comfortable, since you should use the machine at least 8 hrs out of 24.

1. A client diagnosed with Parkinson's disease is being discharged. Which statement made by the significant other indicates an understanding of the discharge instructions?

I will schedule appointments late in the morning after his morning bath

A client diagnosed with Parkinson's disease is being discharged. Which statement made by the significant other indicates an understanding of the discharge instructions?

I will schedule appointments late in the morning after his morning bath.

A nurse is caring for a client with Parkinson's disease who has been hospitalizes with pneumonia. Which of the following interventions is most appropriate for this client?

Implement fall precautions

A nurse on an orthopedic unit is assessing a client for neurologic impairment following a total hip replacement. Which finding would indicate a need for further evaluation?

Inability to move toes

A nurse is preparing to discharge a client recently diagnosed with Alzheimers to home. What safety instructions should be given?

Install secure locks on all outside doors

A client who has an injured right knee falling at home comes to the ED. The client reports that he immediately put a hot compress on the injury. The nurse's best response to this comment should be:

Let me exchange the hot compress for a cold one. Heat may cause more bleeding and discomfort

Client fell and immediately put a hot compress to the injury. Best response by the nurse

Let me exchange the hot compress for a cold one. Heat may cause more bleeding and discomfort.

A nurse is developing a program on the benefits of exercise for a group of older adults who have OA. Which of the following should the nurse plan to include in the program?

Low-impact exercise program

For a pt. diagnosed with osteoarthritis, which of the following should the nurse explain can minimize stress on a painful joint?

Maintaining normal weight

In planning the care for a client with multiple sclerosis, the nurse recognizes the goal that should be the focus in the management of the client's care is

Maximizing/ increasing neuromuscular function

In planning the care for a client with multiple sclerosis, the nurse recognizes the goal that should be the focus in the management of the client's care is

Maximizing/increasing neuromuscular function

A nurse working in a gerontology clinic sees older adult women on along term basis. An assessment finding that alerts the nurse to the presence of osteoporosis in a client is 1. A nurse working in a gerontology clinic sees older adult women on along term basis. An assessment finding that alerts the nurse to the presence of osteoporosis in a client is

Measurable loss of height (Ex: 5.2-5.1 in 5 months)

In monitoring a client following a head trauma, the nurse observes the client's pupils have become increasingly with sluggish response to light. What is the nurse's next best action?

Notify the physician

1. A nurse is caring for a client who has a new cast for a fractured ulna. The client tells the nurse that he cannot feel his fingers. A priority assessment for the nurse would be to

Notify the physician immediately - Assess cap refill

1. When assessing a client who has MS, a nurse would expect to identify which of these early clinical manifestations?

Nystagmus and ataxia

The nurse determines that the client may have pulmonary embolus because the result of the

PO2 58 (Normal is 80-100)

A nurse is teaching a pt. who has bronchial asthma. The nurse understands that which of these is a possible consequence of chronic, poorly controlled asthma resulting from inflammatory processes?

Permanent hyperplasia of bronchial epithelial cells with resultant airway narrowing

Which member of the health care team should the nurse refer the client diagnosed with OA who is complaining of not going able to get in and out of the bathtub?

Physical therapist

. A nurse is caring for a client who had a left above the knee amputation. During the first 24 hours post operatively, the nurse's priority intervention in managing the surgical site should be to

Place the residual limb in an extended position

1. When assessing a client who has Guillen Barre syndrome, a nurse expects find

Progressive ascending weakness and paresthesia

A client with a hip fracture asks the nurse why buck's extension traction is being applied before surgery. The nurse's response is based on the understanding that Buck's extension traction primarily

Provides comfort by reducing muscle spasms and provides fracture immobilization

Buck's extension/traction is primarily

Provides comfort by reducing muscle spasms and provides fracture immobilization

What nursing intervention would be most helpful in the prevention of flexion contractures in a client with a below the knee amputation?

Range of motion exercises

nurse is reading the PPD test on the left arm of an inpatient client who was injected with the test material exactly 48 hours ago. The test area has a 4mm diameter area of induration. What is the nurses best action

Re-examine the test site at 72 hours

1. During pre-op teaching, a patient who is scheduled for amputation tells the nurse: "I can't believe I'm going to spend the rest of my life as an invalid after they cut off my leg". The best action by the nurse:

Remain silent and continue to listen

During pre-op teaching, a pt. who is scheduled for amputation tells the nurse: " I can't believe I'm going to spend the rest of my life as an invalid after they cut off my leg". The best action by the nurse:

Remain silent and continue to listen

1. atient is worried about amputating leg. What should the nurse best action?

Remain silent and listen to the patient

A nurse is caring for an older client with a diagnosis of alzheimer's disease who has just been admitted to the hospital for a knee replacement. Upon admission the client appears increasingly confused and agitated. What action should the nurse take to assist the client during their hospital stay?

Reorient the client frequently to his or her location

A nurse is caring for an older client with a diagnosis of Alzheimer's disease who has just been admitted to the hospital for a knee replacement. Upon admission the client appears increasingly confused and agitated. What action should the nurse take to assist the client during their hospital stay?

Reorient the client frequently to his or her location.

Russell's traction

Rope and pulleys are in straight alignment

A client with end stage renal disease who is on maintenance dialysis and is anuric is scheduled for a CT scan of the spine with contrast. Which of the following instructions should the nurse give the client to prevent complications following this diagnostic test?

Schedule dialysis after the ct scan

A nurse is aware that when a client is admitted to the emergency department with a coma of unknown origin. The most helpful laboratory study that may identify the cause is

Serum glucose of 44 mg/dl

A nurse receives a client in Buck's traction form the ED. The client sustained a fracture of the right femur. In documenting the assessment, which of the following should the nurse focus on as a priority?

Skin status beneath traction and over bony prominence

Client in bucks traction from the emergency department. The nurse should focus on _________________ as a priority.

Skin status beneath traction and over bony prominences.

A nurse is conducting a community health screening for osteoporosis. The nurse recognizes that the individual most susceptible to osteoporosis would be the:

Slender 75 year old woman

Assessing client for osteoporosis. Highest risk for this disorder

Slender 75 year old woman

When a client has multiple sclerosis is concerned about weakness and fluctuating physical status, the care plan should include which of these measures?

Space activates through out day

A client recently hospitalized with multiple sclerosis is concerned about generalized weakness and a fluctuating physical status. Which of the following nursing interventions should be the priority for this client?

Space activities throughout the day

A nurse is assisting with an arthrocentesis. The nurse determines that the fluid withdrawn from the joint is normal because it is

Straw colored

The nurse is formulating a teaching plan for a client who was recently diagnosed with active tuberculosis (TB). What pertinent information should the nurse include?

TB is usually treated with 3 or more medications to prevent organism resistance.

The caregiver of a client with alzheimer's disease asks how to manage the client's restless behaviors. Which of the following is the best response by the nurse?

Take frequent walks throughout the day

The caregiver of a client with Alzheimer's disease asks how to manage the client's restless behaviors. Which of the following is the best response by the nurse?

Take frequent walks throughout the day.

A nurse identifies the nursing diagnosing of impaired physical mobility related to bradykinesias for a client with parkinson's disease. To assist the client to ambulate safely, the nurse should

Teach the client to rock side to side to initiate leg movement

A nurse identifies the nursing diagnosing of impaired physical mobility related to bradykinesias for a client with Parkinson's disease. To assist the client to ambulate safely, the nurse should

Teach the client to rock side to side to initiate leg movement.

1. A client with Parkinson's disease has a nursing diagnosis of impaired physical mobility related to neuromuscular impairment. The nurse observes a UAP performing all of these actions. For which of these actions should the nurse intervene?

The UAP Performs complete bath and oral care

A client with Parkinson's disease has a nursing diagnosis of impaired physical mobility related to neuromuscular impairment. The nurse observes a UAP performing all of these actions. For which of these actions should the nurse intervene?

The UAP Performs complete bath and oral care

A nurse is delegating care of a client who has a fractured femur to a UAP. Which of the following should the nurse tell the UAP to report immediately?

The client appears confused

1. A nurse is delegating care of a client who has a fractured femur to a UAP. Which of the following should the nurse tell the UAP to report immediately? The client

The client appears confused Fist sign of fat embolism

A nurse caring for a client following an above the knee amputation. During the rehabilitation period, the client should be instructed that the residual limb should not be routinely elevated because

The flexed position can promote hip flexion contracture

An older adult client who lives alone. Planning continued care

Transfer to a rehabilitation facility

An older adult nursing home resident has a productive cough, fever, chills, and a history of night sweats. A PPD test is negative. What instructions would be the infectious disease nurse prepared for nursing staff taking care of this client?

Use standard precautions and airborne precautions until a chest x-ray shows the client does not have TB

When positioning an unconscious client, in order to prevent external rotation of the lower extremities the nurse should?

Use trochanter rolls

Device is usually preferred for older client diagnosed with OA to maintain balance and promote mobility?

Walker

What device is usually preferred for older client diagnosed with osteoarthritis to maintain balance and promote mobility?

Walker

Which physical assessment finding would the nurse expect to observe in a client with myasthenia gravis?

Weakness in proximal muscles

1. A nurse monitors the Russell's traction a client with fractured hip who is being prepared for surgery. The nurse evaluates that balanced traction is being maintained upon finding that the?

Weights are off the floor and ropes are in straight alignment

Russell's traction. Balanced traction is being maintained upon finding that the

Weights are off the floor and ropes are in straight alignment

A nurse evaluates the effectiveness of therapy for a pt. with acute asthma exacerbation and severely diminished sounds. This finding indicates that the pt.'s respiratory function is beginning to improve:

Wheezing becomes audible

A registered nurse on an ortho/neuro unit is assigned four clients. In delegating care, which client is best assigned to the licensed practical nurse? The client who is

With a fracture of the right femur complaining of pain

Which of the following statements indicates correct understanding by the client who is scheduled to undergo MRI/MRA of the brain? SELECT ALL OF THE ABOVE.

a) "A huge magnet is used to line up the atom in my body. Then the MRI can detect increased water content, indicative of disease, in tissues". b) "I'm glad you brought extra tubing for my oxygen tank". (Because you don't know how the test going to be) c) "The MRI can give detailed views of the blood flow in my head, unlike the CT scan I had in the emergency Department

Which of the following statements indicates correct understanding by the client who is scheduled to undergo MRI/MRA of the brain? SELECT ALL OF THE ABOVE.

a) "A huge magnet is used to line up the atom in my body. Then the MRI can detect increased water content, indicative of disease, in tissues". b) "I'm glad you brought extra tubing for my oxygen tank". (Because you don't know how the test going to be) c) "The MRI can give detailed views of the blood flow in my head, unlike the CT scan I had in the emergency Department."

While caring for a client diagnosed with a fracture of the right distal humerus, what data should the nurse assess that would indicate a complication?

a) Numbness and mottled cyanosis. b) Paresthesia and paralysis. c) Coldness of the extremity and crepitus.

The nurse teaches the client to with COPD how to perform pursed lip breathing, explaining that this technique will assist respiration by:

a) Preventing collapse of small airways in the lungs during expiration b) Slowing the respiratory rate and giving the client control of resp. patterns

A nurse is preparing to deliver a community presentation regarding stroke prevention. What are modifiable factors?

a. -HTN b. -Diabetes c. -Diet

When teaching a pt. about phantom sensations, the nurse would explain that: SATA

a. -It's not possible to have pain in an amputated limb. b. -The client may feel warmth, cold, itching, or pain

A nurse is discharging a pt. with osteoarthritis to home. When developing a discharge teaching plan for this pt., the nurse should include information regarding to: SELECT ALL THAT APPLY:

a. -Pain management b. -Nutrition and weight loss c. -Self-care strategies

A nurse is reviewing the care plan for a client with severe osteoporosis. Which of the following would be included in the care plan? SELECT ALL THAT APPLY

a. -Provide a safe and hazard free environment in the room. b. -Encourage ambulation with assistance if gait unsteady. c. -Move the client gently when turning or getting out of bed.

. A nurse caring for a client with an external fixation device. The client asks the nurse the reason for the use of this device. The nurse bases the response on the understanding that the advantages of using external fixation for immobilization of fractures of: SELECT ALL THAT THE APPLY

a. Allows for early ambulation b. Promotes healing

Client comes to the clinic reporting pain and swelling in the right Knee. The nurse should first

a. Compare the right Knee to the left knee

Following a supratentorial craniotomy the nurse establishes a goal to maintain intracranial pressure (ICP) between 10-20 mm/Hg. which interventions should the nurse implement? Select all that the apply:

a. Elevate the head of the bed 15 to 30 degrees b. Contact health care provider to report change of level of consciousness c. Initiate neurological checks utilizing the Glasgow Coma Scale

Severe Osteoporosis. Care plan. Select all that apply

a. Provide a safe and hazard free environment in the room b. Encourage ambulation with assistance if gait unsteady c. Move the client gently when turning or getting out of bed.

External fixation device attached to Steinman pins. Advantages for the use of external fixation. Select all that apply

a. There is minimal blood loss b. Allows for early ambulation c. Promotes healing

When teaching a client about phantom sensations, the nurse would explain that SELECT ALL OF THE ABOVE.

a. b) The client may feel warmth, cold, itching, or pain, which is cause by intact, which is cause by b. peripheral nerve above the amputation site c. Most phantom pain occurs in client prior to amputation

A nurse is caring for a patient who has sustained a compound fracture of the lower extremity. Which of these clinical manifestation is consistent with this type of fracture?

protruding through the skin

A nurse is writing an infection control policy for a home healthcare agency. The nurse should include the information that the rise in TB cases in recent years is related to the

rise in HIV infection.

The nurse of a medical-surgical unit is working with an UAP. The nurse should intervene if the UAP

wears a standard surgical mask when entering the room of a client with tuberculosis

In planning for a client diagnosed with TB who is being admitted to the nursing unit, the nurse should the client in a room:

with negative airflow.

1. Client with osteoporosis states that will increase intake of

yogurt

. The nurse, in preparing the nurse care plan for a comatose client receiving nasogastric feedings, would include which of the following routine actions as priority?

- Check residual volume every 4 hours.

1. A nurse is caring for a client who had total knee replacement surgery two days ago. The nurse should plan to monitor this client for which of the following potential complications as a priority?

- Deep vein thrombosis

Nurse is educating student being discharged home with a left leg fracture. When should the Patient call the physician?

- Pallor toes and decreased sensation

1. A nurse is caring for a patient who had a left above the knee amputation. During the 24 hrs post-op, the nurse's priority intervention in managing the surgical site should be to:

- Place the residual limb in an extended position

1. The nurse is caring for a client two days after a closed reduction of a fractured left humerus. In preparing to discharge this client to home, the nurse monitors the client for which of the following findings which could delay discharge?

- Coolness and pallor in the left fingers and hand

1. A nurse is preparing to administer medications to a client who has undergone open reduction of fractured femur. The client asks, "Why am I receiving Lovenox (enoxaparin sodium)?" The nurse explains that the rationale for anticoagulant therapy is to

- Decrease the threat of thrombus

A home care nurse is visiting a client with an above the knee amputation who is scheduled to be fitted with a prosthesis when healing is complete. Which of the following statements, if made by the client indicates a correct understanding of teaching?

- "I should lie on my abdomen for 30 minutes 3 or 4 times per day."

A nurse in the emergency department is admitting a client who has an ischemic stroke. The client is being evaluated from thrombolytic therapy. The nurse works quickly to provide care, knowing that for this therapy to be effective, it must be administered within a post-stroke time window of

- 3 hours

A nurse is caring for a client admitted following a closed head injury. In applying the Monroe-Kellie hypothesis to this client, the nurse should recognize that an increase cerebral edema would probably result in

- A decrease in cerebral blood volume

Which assessment finding, if identified in a client who had intracranial surgery to remove a complex tumor, would require immediate follow up by a nurse?

- A decrease in the Glasgow coma scale from 14 to 12

Two days after an accident in which a client sustained multiple injuries, including fractures, the nurse assesses confusion, dyspnea, temperature of 103.4, respiratory rate of 26, heart rate of 112 minutes and petechiae of the chest. The nurse assesses that the client may have developed

- A fat embolism

A home health nurse is visiting a client who experienced a stroke and was recently discharged from a rehab facility. The nurse concludes that additional teaching is necessary upon observing?

- A fluid restriction chart on the refrigerator

A client returns from PACU to the unit after undergoing a total hip replacement. The client has a hemovac in place. Which of the following devices would be a priority to have available when the client returns to the nursing unit.

- Abduction pillow

On the first post-op day, a pt. with a right below knee amputation complains of pain in the right foot. The nurse performs a full pain assessment & notes a pain level of 7/10 described as stabbing pain. The most appropriate action for the nurse is to:

- Administer prescribed analgesic medication

. The nurse assigns the unlicensed assistive personnel (UAP) to position an unconscious client on one side (lateral position). In doing the head to toe assessment, the nurse recognizes that the area most at risk for a pressure ulcer for a client in this position is the

- Ankle

In the initial visit to a recently discharged client with osteoporosis, the home health nurse recognizes the need for additional client teaching when noting

- Area rugs on the floors

The nurse is caring for a client who has had intracranial surgery. An important nursing intervention when managing pain in the post-intracranial surgical client is to

- Assess LOC prior to administering narcotic analgesics.

1. The nurse is preparing a pre-op teaching plan for a client who is undergoing a total hip replacement. Which of the following should the nurse do first?

- Assess the patient's fears about the procedure.

When a client who had a stroke is being discharged, the care plan should include (Select All That Apply):

- Assist caregiver to plan for respite care - Evaluate the home for potential safety risks - Have family do return demonstration of transfer techniques

A client who has a left hemiparesis due to a stroke is getting out of bed to the chair for the first time. The nurse should position the chair

- At a right angle to the client's right side

1. The nurse is developing a teaching plan for a client who has newly diagnosed migraine headaches. Which of these should the nurse include in teaching plan SATA

- Avoid foods that contain tyramine, such as alcohol and aged cheese - Abortive therapy is aimed at eliminating the pain during the aura - Complementary therapies such as relaxation may be helpful

1. The nurse is caring for the client with increased intracranial pressure. Which of the following findings indicates to the nurse that ICP is worsening? Baseline vital signs are: BP- 135/70, HR- 88, and RR-14

- BP- 155/85, HR- 68, RR-8 = Cushing's Triad

Nursing intervention for a patient admitted who has a seizure disorder

- Bed rails up

During a lumbar puncture on a client in the lateral recumbent position, the physician remarks that the opening pressure is normal. The nurse should interpret this to mean that the pressure is

- Between 6 and 15 mm Hg

1. A nurse performing an assessment on a client who has fractures of the right femur and a full leg cast. The nurse assesses pallor of the right foot; pain 6-10 of right foot, and diminished pedal pulses. The nurse contacts the health care provider and should include which of the following interventions in the (situation, background, assessment, and recommendation: SBAR) report under recommendations?

- Bivalving the cast

1. The nurse receives a client following intracranial surgery for a complex tumor. The surgeon tells the nurse that she is particularly concerned about ICP in this client and wants to be called at the first sign of problem. The nurse knows that they will monitor the client closely for

- Change in LOC

A client who has increased intracranial pressure (ICP) is admitted following a motor vehicle accident. The following morning the client asks to watch a football game that he insists begins in five minutes what is the appropriate action by the nurse would be to

- Determine if the client's pupils are equal and reactive to light =ASSESS

A nurse is caring for a client who had a right above the knee open amputation two days ago. The nurse assesses moderate amount of serosanguinous (normal, purulent is bad) drainage. Based on this finding the nurse should

- Document findings and continue to assess

A client has a tonic-clonic seizure while the nurse is in the client's room. During the seizure it is a priority for the nurse to?

- Document the details of the seizure and the postictal phase

For a client who had a hemorrhagic stroke, which of these drugs should a nurse expect to give to a client to prevent additional bleeding?

- Docusate sodium (Colace)

1. A client who has an above-the-knee amputation develops a dime-size bright red spot on the dressing after 45 min in the (PACU). Which of the following should the nurse do FIRST?

- Draw a circle around the site

When a client has impaired swallowing following a stroke, the care plan should include?

- Ensuring the client is in semi-fowlers position for all meals

1. A client in the PACU with left below the knee amputation complains of pain her left big toe. Which of the following should the nurse do FIRST? SATA

- Explain to the client that the pain is real - Give the client a prescribed opioid analgesic

A family member of a client who experiences a stroke is visiting during the afternoon meal. The nurse should intervene if

- Feeds the client only clear liquid. (Should be fed thick)

To prevent the complication of atelectasis in an older adult client who has a hip fracture, the nurse should

- Frequently reposition the client

A nurse is preparing to deliver a community presentation regarding stroke prevention. What are modifiable factors?

- HTN - Diabetes - Diet

1. When a client is scheduled for a lumbar puncture, which of these should be reported to the health care provider as a priority? The client

- Has signs of increased intracranial pressure

The nurse is positioning the client with increased intracranial pressure. Which of the following positions would the nurse avoid?

- Head turned to the side

1. When caring for a client with a seizure disorder, the teaching plan should include which of these instructions?

- How anticonvulsants prevent seizures - The importance of taking medications regularly - Care during a seizure

An arthroscopic repair of a torn meniscus in the knee was performed on a client with a knee injury. Following the procedure, the nurse advised the client that rehab following the knee should begin

- Immediately

A client sustains a closed fracture and has just had a cast applied to the affected arm. The client is complaining of intense pain. The nurse has elevated the limb, applied an iced bag, and administered analgesic with little relief. The nurse interprets that this pain may be due to?

- Impaired tissue perfusion

. A nurse on an orthopedic unit is assessing a client for neurologic impairment following a total hip replacement. Which of the following findings would indicate a need for further evaluation by the nurse?

- Inability to move the toes

A carotid endaterectomy is being considered as treatment for a client who has a history of two TIA's. The nurse explains to the client this surgery

- Involves removing an atherosclerotic plaque in the carotid artery to prevent an impending stroke

1. When teaching a patient about phantom sensations, the nurse would explain that: SATA

- It's not possible to have pain in an amputated limb?? - The client may feel warmth, cold, itching, or pain

A nurse is caring for a pt. with osteoarthritis. The nurse performs an assessment knowing that which of the following is a clinical manifestation associated with this disorder:

- Joint pain that diminishes after rest

A client describes a throbbing bifrontal and suboccipital headache after a lumbar puncture. The nurse explains that the discomfort is most likely to be relieved by?

- Laying supine in bed

In considering the treatment plan for a client who experience a transient ischemic attack (TIA), the nurse should educate the client that the incidence of recurring TIA's may be reduced with the administration of

- Low-dose aspirin

. Which action is most important in the emergency care of a client with a stroke?

- Maintain respiratory function with patent airway and O2

A nurse is caring for a client who suddenly develops a seizure. During the actual seizure, which of these priorities should the care include? SATA

- Maintaining an airway - Protecting the client from injury - Observing the seizure - Administering anticonvulsant medications if ordered

1. For a pt. diagnosed with osteoarthritis, which of the following should the nurse explain can minimize stress on a painful joint?

- Maintaining normal weight

A patient with a seizure disorder is taught that anti-seizure medication

- Needs to be taken throughout his/her entire life.

In monitoring a client following a head trauma, the nurse observes the client's pupils have become increasingly with sluggish response to light. What is the nurse's next best action?

- Notify the physician

Patient with extensive bone fractures. How do you know nerve damage?

- Numbness

A client is admitted to the hospital who has right-sided hemiplegia as a result of a stroke. To help prevent contractures, the nurse should position the client?

- On the left side with brief periods on the back and right side

A nurse is reviewing the care plan for a client with severe osteoporosis. Which of the following would be included in the care plan? SATA

- Provide a safe and hazard free environment in the room - Encourage ambulation with assistance if gait unsteady - Move the client gently when turning or getting out of bed

1. A client with a hip fracture asks the nurse why buck's extension traction is being applied before surgery. The nurse's response is based on the understanding that Buck's extension traction primarily

- Provides comfort by reducing muscle spasms and provides fracture immobilization (also relives pain).

What nursing intervention would be most helpful in the prevention of flexion contractures in a client with a below the knee amputation?

- Range of motion exercises

A nurse is aware that when a client is admitted to the emergency department with a coma of unknown origin. The most helpful laboratory study that may identify the cause is:

- Serum glucose of 44 mg/dL

A nurse is preparing to admit a client who has seizures. Which of these functions can the nurse delegate to the LPN

- Set up oxygen and suction equipment.

1. A nurse receives a client in Buck's traction form the ED. The client sustained a fracture of the right femur. In documenting the assessment, which of the following should the nurse focus on as a priority?

- Skin status beneath traction and over bony prominence

A nurse is caring for a client following head injury sustained in a motor vehicle accident. Initial assessment indicates that the client is alert and oriented to surroundings. One hour later, the nurse finds the client to be unresponsive upon entering the room. To best assess the client's level of consciousness, the nurse should next?

- Speak to the client and call them by name

A client who has a severe migraine headache is seen at the health clinic. The client tells the nurse she is afraid to make social plans because she never knows when she will be incapacitated with the pain. The most appropriate nursing intervention in response to the client's comments should be to

- Suggest that the client keep a diary of headache episodes to identify precipitating factors

13- 5cm bright red 1st day post op from amputation

- Take the vital signs

1. A nurse caring for a client following an above the knee amputation. During the rehabilitation period, the client should be instructed that the residual limb should not be routinely elevated because

- The flexed position can promote hip flexion contracture

1. External fixation device attached to Steinman pins. Advantages for the use of external fixation. SATA

- There is minimal blood loss - Allows for early ambulation - Promotes healing

1. To prevent external hip rotation, nurse should instruct the UAP to use a

- Trochanter roll

A UAP informs a nurse that a client is experiencing a seizure and is not responsive. What is the nurse's best action when arriving to the room?

- Turn the client to the side

A nurse is assigned to care for a client who has a seizure disorder. Which of these nursing actions would the nurse implement first if the client has a seizure?

- Turn the client to the side and protect the airway

1. A registered nurse on an ortho/neuro unit is assigned four clients. In delegating care, which client is best assigned to the licensed practical nurse (LPN)? The client who is

- With a fracture of the right femur complaining of pain

Degenerative joint disease. Nurse expects the patient to state that the pain is

- Worse at end of day

A client is regaining consciousness after a craniotomy and becomes restless and attempts to pull out the IV Line. Which nursing intervention is most appropriate and will provide protection while not placing this client at risk for increased intracranial pressure?

- Wrap the client's hands in soft "mitten" restrains.

Nurse is giving dietary instructions to a client to minimize the risk for osteoporosis. The nurse evaluates that the client understands the recommended dietary changes if the client states they will increase intake of

- Yogurt

A client is admitted to the nursing unit after a left below-the-knee amputation following the injury to the foot and lower leg. The client tells the nurse "I think I'm going crazy, I can feel my left foot itching." The nurse interprets the client's statement that

The client's response indicates the presence of phantom limb sensation

When positioning an unconscious client, in order to prevent external rotation of the lower extremities the nurse should

Use trochanter rolls

An older adult client who has a fractured hip secondary to osteoporosis asks the nurse about the probable medical protocol for her condition. The nurse responds that the osteoporosis will probably be treated with?

Calcium supplement

While caring for a client diagnosed with a fracture of the right distal humerus, what data should the nurse assess that would indicate a complication?

Numbness and mottled cyanosis. - Paresthesia and paralysis. - Coldness of the extremity and crepitus.

Which member of the health care team should the nurse refer the client diagnosed with osteoarthritis who is complaining of not being able to get in and out of the bathtub?

Physical therapist

When teaching a client about phantom sensations, the nurse would explain that SATA:

The client may feel warmth, cold, itching, or pain, which is cause by intact, which is cause by peripheral nerve above the amputation site - Most phantom pain occurs in client prior to amputation??

A client presents to the emergency department after falling at home and hitting their head. The client is alert and oriented upon their arrival to the ED with a Glascow coma scale score of 15. The nurse should monitor this client for symptoms of ICP which include (Select all that apply):

Headache - Nausea - Vomiting

1. A nurse is developing a program on the benefits of exercise for a group of older adults who have osteoarthritis. Which of the following should the nurse plan to include in the program?

Low-impact exercise program

A nurse working in a gerontology clinic sees older adult women on along term basis. An assessment finding that alerts the nurse to the presence of osteoporosis in a client is

Measurable loss of height (Ex: 5.2-5.1 in 5 months