MIDTERM CH 43, 44, 48, 49 Review Questions

Which is a true statement regarding angina pectoris? (Select all that apply.) 1. Angina indicates a lack of oxygen and blood supply to the heart. 2. Angina only occurs at rest. 3. Angina may resemble heartburn or indigestion. 4. Angina is usually relieved by nitroglycerin. 5. Angina may appear as jaw pain.

1, 3, 4, 5--Angina indicates a lack of oxygen and blood supply to the coronary arteries, usually as a result of a narrowing of the lumen. When the myocardial oxygen demand exceeds the available supply, ischemia occurs, resulting in chest pain or angina. Angina may resemble heartburn or indigestion in some patients. Patients may not have the "classic" symptom of chest pain, especially older adults and women. Angina is usually relieved by nitroglycerin. This is one way angina is differentiated from a myocardial infarction—pain from the MI is generally not relieved by nitroglycerin. The patient should be instructed to take a nitroglycerin tablet and lie down when experiencing an anginal attack. If the pain is not relieved, the patient may take two more nitroglycerin tablets, 5 minutes apart. If the pain is still unrelieved after the third nitroglycerin, he or she needs to seek emergency medical attention. Although the pain from angina is typically substernal chest pain, it may be present in different ways: it may radiate to the chest, arm, or jaw. Angina may appear as posterior thoracic or jaw pain only. Angina typically occurs with an increased cardiac workload (e.g., exercise, heavy meal, cold, stress) and may disappear at rest and/or with administration of nitroglycerin.

Appropriate nursing care for a patient with pneumonia includes which intervention? (Select all that apply.) 1. Assist the patient to conserve energy. 2. Position the patient with the side of the good lung up. 3. Place the patient in a semi- to high-Fowler's position. 5. Educate the patient about the importance of hand washing. 5. Encourage the patient to limit fluids.

1, 3, 4--Appropriate nursing care for a patient with pneumonia includes assisting the patient to conserve energy, which will decrease oxygen demands. The nurse should allow rest periods and should facilitate optimal air exchange by placing the patient in a high Fowler's position, which allows maximum lung inflation to promote air exchange. Appropriate nursing care for a patient with pneumonia includes implementing interventions to foster the ability to move secretions. This will be tailored to the individual patient and may include coughing, positioning, suctioning, and liquefying secretions. Medications, such as bronchodilators, expectorants, and mucolytic agents, may be prescribed. Appropriate nursing care for a patient with pneumonia includes educating him or her about the importance of hand washing to prevent spread of the disease. The patient with pneumonia should be positioned with the good lung down when lying in the supine position. The good or unaffected side benefits from improved perfusion in the dependent position, and the bad or side of the lung affected by pneumonia will benefit by being in the upright position, which allows for maximal inflation of the alveoli. This position should be alternated with the semi-Fowler's position and should not be used exclusively. Hydration to 3 L/day of fluid may be encouraged, unless contraindicated.

What is an atopic allergic reaction caused by an antigen-antibody reaction that occurs in the conjunctiva, usually resulting from a contact allergen? 1. Allergic conjunctivitis 2. Epistaxis 3. Deviated septum 4. Allergic rhinitis

1--Allergic conjunctivitis is an atopic allergic reaction caused by an antigen-antibody reaction that occurs in the conjunctiva, usually resulting from a contact allergen. In this reaction, mucosal gland secretion increases, eosinophil infiltration occurs, and because of increased capillary permeability and vasodilation, local tissue edema results. Epistaxis is a nosebleed. There is congestion of nasal membranes, leading to capillary rupture. It may be related to injury, hypertension, menstruation, or mucosal irritation. A deviated septum is when the septum deviates from the midline, which can cause a partial obstruction of the nasal passageway. Clinical manifestations of a deviated septum include stertorous respirations, dyspnea, and sometimes postnasal drip. Allergic rhinitis is caused by an antigen-antibody reaction that occurs in the nasal membranes or nasopharynx. In this condition, ciliary action slows, and, similar to allergic conjunctivitis, mucosal gland secretion increases and eosinophil infiltration occurs; because of increased capillary permeability and vasodilation, local tissue edema results.

Which diagnostic test allows observation of real time movement via radiography? 1. Fluoroscopy 2. Angiography 3. Echocardiography 4. Cardiac monitoring

1--Fluoroscopy is the diagnostic test that allows observation of real time movement via radiography. This is invaluable for placement of pacemakers and intracardial catheter placement. Angiography is a series of radiographs taken following administration of contrast dye. This test aids in diagnosis of vessel occlusion, pooling in various heart chambers, and congenital abnormalities. Echocardiography uses high-frequency ultrasound directed at the heart. The reflected sound is recorded, outlining size, shape, and position of cardiac structures. This is useful in detecting pericardial effusion, evaluating ventricular function, cardiac chamber size and contents, ventricular muscle and septal motion and thickness, cardiac output, cardiac tumors, valvular function, and congenital heart disorders. Cardiac monitoring records the cardiac electrical activity of patients. A cardiac monitor displays information transferred via the conductive electrodes, which transfer electrical activity of the heart and relay it to a video display screen. This is useful for patients with known or suspected arrhythmias, or patients who may be likely to develop arrhythmias.

The nurse is caring for a patient with a new pacemaker. Nursing care for this patient would include which aspect of care? 1. Monitoring the heart rate and rhythm by apical pulse and ECG patterns 2. Bed rest for 24 hours 3. Scheduling of an MRI to verify pacemaker placement 4. Performing range-of-motion exercises every 4 hours to the arm on the pacemaker side for the first 2 days

1--Nursing care for a patient with a new pacemaker would include closely monitoring heart rate and rhythm by apical pulse and ECG patterns. Also, vital signs and level of consciousness are checked frequently. The insertion site is observed for erythema, edema, and tenderness, which could be signs of infection. Bed rest for 24 hours is not necessary for a patient with a new pacemaker. Nursing care for a patient with a new pacemaker would include bed rest for the first few hours only, unless unexpected complications occurred. Scheduling of an MRI to verify pacemaker placement would be inappropriate. Performing range of motion every 4 hours to the arm on the pacemaker side would be inappropriate. The arm on the pacemaker side should be immobilized for the first few hours, and the patient should not raise the arm above his or her head for several days. After this time, normal activities can be resumed.

The nurse is assisting a health care provider with placement of a subclavian central line catheter in a patient. While the health care provider is inserting the line, the patient suddenly develops acute dyspnea and tachypnea. The health care provider quickly directs the nurse to "get a chest tube tray, STAT!" What does the nurse suspect may be happening to the patient? 1. Development of a pneumothorax 2. Development of atelectasis 3. Development of a pulmonary embolus 4. Discovery of lung cancer

1--The patient has likely developed a pneumothorax. A pneumothorax is a collection of air or gas in the pleural space, causing the lung to collapse. In this case, it would be secondary to central line placement (i.e., the lung tissue was punctured), which is one of the risks of the procedure. Other causes of pneumothorax include penetrating chest injury, rib fracture, severe coughing episode, and ruptured bleb on the lung surface (e.g., in a patient with emphysema); or it can occur without any obvious cause ("spontaneous pneumothorax). With a pneumothorax, the lung's negative pressure is disrupted, and the lung is unable to inflate fully. A chest tube is inserted to help reestablish negative pressure. Atelectasis is lung tissue collapse due to occlusion of air to a portion of the lung. It does not have a dramatic presentation, as in this scenario, although the patient may complain of dyspnea, air hunger, and other signs and symptoms of hypoxia. Development of a pulmonary embolus (PE) does often have a dramatic presentation; however, because the health care provider was in the process of central line placement, it is more likely to be a pneumothorax. A PE is caused by passage of a foreign substance (blood clot, air, fat, or amniotic fluid) into the pulmonary artery or its branches, with resulting obstruction of blood supply to the lung tissue and subsequent collapse. The patient experiencing a PE may have sudden, sharp, constant pleuritic chest pain that worsens with inspiration, as well as acute, unexplained dyspnea and tachypnea. Other signs and symptoms can include hemoptysis, elevated temperature, elevated WBC count, hypoxia, hypotension, and diaphoresis. It would be extremely unlikely that lung cancer would be discovered during placement of a central line. Typically, lung cancer will be detected on a chest x-ray, with further investigation via MRI or CT scans and tissue cytology or biopsy.

What is the most definitive method of diagnosing a pulmonary embolism? 1. Helical/spinal CT scan 2. A pulmonary angiogram 3. A ventilation-perfusion (V/Q scan) 4. Bronchoscopy

2--A pulmonary angiogram is the most definitive method of diagnosing a pulmonary embolism. Radiographic contrast material is injected into the pulmonary arteries, allowing visualization of the pulmonary vasculature. This test is considered to be the "gold standard" for diagnosing a pulmonary embolism, as false-positive results may influence the results obtained from a V/Q scan. A helical/spinal CT scan images the abdomen and chest within 30 seconds and represents a significant improvement over traditional CT scans. Injection or swallowing of the contrast dye helps the organs or tissues show up more clearly. This test is not used, however, to diagnose a pulmonary embolism. A V/Q scan is used to diagnose a pulmonary embolism, and although it is accurate most of the time, it is not the most definitive method. The V/Q scan has definite advantages over the pulmonary angiogram, however. It is less costly and less invasive. If the scan is normal, then a pulmonary embolism has been ruled out. If the scan is equivocal, the diagnosis of pulmonary embolism is questionable because various lung pathologies also can cause abnormalities on the scan. Bronchoscopy is not a diagnostic tool used to diagnose a pulmonary embolism. In a bronchoscopy, a bronchoscope is inserted into the trachea and bronchi. This is performed to look for abnormalities, obtain tissue biopsy, and obtain secretions for cell or bacteriologic examination.

Which infection is usually bacterial in origin? 1. Pharyngitis 2. Acute follicular tonsillitis 3. Acute rhinitis 4. Laryngitis

2--Acute follicular tonsillitis, or inflammation of the tonsils, is usually the result of an airborne or foodborne bacterial infection, often Streptococcus. It can be viral, but this occurs less often. If caused by group A β-hemolytic streptococci, sequelae such as rheumatic fever, carditis, and nephritis must be considered. Pharyngitis, which frequently accompanies the common cold, is usually viral in origin. Less frequently, it may be bacterial in origin, caused by hemolytic streptococci, staphylococci, or other bacteria. Acute rhinitis, or the common cold, is an inflammatory condition of the mucous membranes of the nose and accessory sinuses. It is usually caused by one or more viruses; however, it may become complicated by a bacterial infection. Laryngitis often occurs secondary to other respiratory (viral or bacterial) infections, although it may be related to voice abuse or inhalation of irritating fumes. When laryngitis occurs in children younger than 5 years old, it can easily lead to airway obstruction because of the small diameter of the larynx.

A patient informs the nurse "I cannot breathe while lying flat and must sleep with two pillows". What word would the nurse use to document this condition? 1. Dyspnea 2. Orthopnea 3. Hypoxia 4. Adventitious lung sounds

2--Orthopnea is a condition in which a patient must sit or stand in order to breathe comfortably. The patient with orthopnea has difficulty breathing while lying flat. Dyspnea is a subjective feeling of shortness of breath experienced by the patient. Hypoxia is oxygen deficiency. Adventitious lung sounds are abnormal breath sounds (superimposed on breath sounds) that are audible when auscultating with a stethoscope.

What is the term that describes the presence of infected fluid that accumulated in the pleural space? 1. Pleural effusion 2. Empyema 3. Pleurisy 4. Atelectasis

2--The presence of infected fluid that has accumulated in the pleural space is called empyema. Empyema can be acute or chronic. In acute empyema, there is inflammation of the affected area with a thin layer of fluid. In chronic empyema, the fluid thickens and the pleura becomes scarred and fibrosed, losing its elasticity. Pleural effusion is the presence of fluid that has accumulated in the pleural space but is not infected. This rarely occurs by itself but is a result of another disease process. Pleurisy is an inflammation of the parietal and visceral pleura. It can be caused by either a bacterial or a viral infection. The underlying pathophysiologic change is an inflammation of any part of the pleura. It may occur spontaneously but is more commonly associated with pneumonia, pulmonary infarction, pleural trauma, early stages of TB, or a lung tumor. Atelectasis is lung tissue collapse due to occlusion of air to a portion of the lung.

Which cardiac marker is specific to the heart, not influenced by skeletal muscle trauma or renal failure, and rises 3 hours following a myocardial infarction? 1. CK-MB 2. Troponin I 3. Homocysteine 4. Myoglobin

2--Troponin I is a myocardial muscle protein released into circulation after myocardial injury. It can identify very small amounts of myocardial injury. It rises 3 hours following a myocardial infarction, peaks at 14 to 18 hours, and may remain elevated for 1 to 2 weeks. Troponin I is specific to the heart, not influenced by skeletal muscle trauma or renal failure, and is very useful in diagnosing a myocardial infarction. CK-MB is a cardiac enzyme that also is elevated following a myocardial infarction; however, it is also elevated by other factors (surgery, muscle trauma). It rises in 2 to 3 hours following a myocardial infarction, peaks at 24 hours, and returns to normal in 24 to 40 hours. Homocysteine is not a cardiac marker. It is an amino acid produced during protein digestion. Elevated levels of homocysteine may act as an independent risk factor for ischemic heart disease, cerebrovascular disease, peripheral arterial disease, and venous thrombosis. It appears to promote the development of atherosclerosis by causing endothelial damage, promoting LDL deposits, and promoting vascular smooth muscle growth. Myoglobin is a cardiac marker that is released into circulation a few hours after a myocardial infarction. Because it is also present in skeletal muscle, it lacks cardiac specificity.

A patient suddenly collapses, and is found to be pulseless. Cardiopulmonary resuscitation (CPR) is in progress. When the cardiac monitor is applied, which arrhythmia is the patient most likely experiencing? 1. Atrial fibrillation 2. Ventricular fibrillation 3. Supraventricular tachycardia 4. Sinus bradycardia

2--Ventricular fibrillation is a medical emergency that will result in death if left untreated. It is a state whereby the ventricles are quivering with disorganized electrical and mechanical activity. Prompt treatment, including CPR and defibrillation, are essential and must be performed promptly (ideally within 20 seconds) to give the patient the best chance of recovery. Atrial fibrillation, although serious, is not as imminently life threatening as ventricular fibrillation. In atrial fibrillation, electrical activity is disorganized, and the atria quiver at a rate of 350 to 600/min rather than contract in an organized manner. Ventricular response may be 100 to 180 beats/min, and the patient experiences decreased cardiac output along with symptoms of palpitations, dyspnea, syncope, light-headedness, decreased level of consciousness, and pulmonary edema. Treatment involves slowing the ventricular rate, treating the atrial irritability, and treating the cause of the arrhythmia. Supraventricular tachycardia is the sudden onset of a rapid heartbeat, originating in the atria. It is characterized by a pulse rate of 150 to 250 beats/min. The patient with supraventricular tachycardia may experience palpitations, light-headedness, dyspnea, and angina. Sinus bradycardia is a slow rhythm that originates in the SA node and is characterized by a rate of less than 60 beats/min. Causes can be sleep, vomiting, intracranial tumors, myocardial infarction, vagal stimulation, endocrine disorders, and hypothermia. It may be completely normal in athletes. Treatment of sinus bradycardia depends on the cause.

Which is the correct impulse pattern of the cardiac conduction system? 1. Pacemaker→Bundle of His→SA node→Bundle branches 2. Purkinje fibers→SA node→Right and left bundle branches→AV node 3. SA node→AV node→Bundle of His→Right and left bundle branches→Purkinje fibers 4. Pacemaker→SA node→Bundle of His→AV node→Purkinje fibers

3--The impulse pattern of the cardiac conduction system is as follows: SA node→AV node→Bundle of His→Right and left bundle branches→Purkinje fibers.

The nurse is caring for a patient who has been diagnosed with severe acute respiratory syndrome (SARS). Which assessment and/or laboratory data would the nurse expect to discover? 1. Positive bacterial cultures indicating a serious bacterial infection 2. Elevated white blood cell count in the early stages of the illness 3. Fever, headache, discomfort, and muscle aches 4. Decreased creatinine phosphokinase (CPK) levels

3--The patient with SARS may experience fever (>100.8°F), headache discomfort, muscle aches, and mild respiratory symptoms. After 2 to 7 days, the patient may develop a dry cough and shortness of breath, difficulty breathing, or hypoxia. About 20% will require endotracheal intubation and mechanical ventilation. The patient with SARS will not have positive bacterial cultures, as SARS is caused by a coronavirus. The patient with SARS will have a WBC count in the early stages that is either normal or low. The patient with SARS will have an elevated CPK level, as high as 3000 U/L (normal being 5 to 200 U/L).

The nurse would perform which nursing intervention for a patient with chronic obstructive pulmonary disease (COPD)? 1. Administering high-flow oxygen, usually 40% or greater 2. Performing physical therapy immediately before meals to stimulate appetite 3. Encouraging a low-calorie, low-protein diet 4. Encouraging the patient to get a flu vaccination each year and a pneumococcal revaccination every 5 years

4--Appropriate nursing interventions for a patient with COPD include encouraging the patient to get a flu vaccination each year and a pneumococcal revaccination every 5 years. These patients are chronically ill and at greater risk of developing complications either from the flu or from pneumonia. Low-flow oxygen (1 to 2 L via nasal cannula) therapy is usually prescribed for the patient with COPD. A higher flow rate of oxygen can be dangerous for the patient with COPD, because it diminishes the brain's respiratory center and can lead to respiratory failure. Physical therapy should not be performed immediately before meals for the patient with COPD; rather, the patient should be encouraged to rest for 30 minutes before a meal. This will conserve energy and decrease dyspnea. The patient with COPD should be encouraged to eat a high-calorie, high-protein diet to maintain adequate nutritional status. This should be divided into six small meals per day, rather than three larger ones. Oral fluids should be maintained at 2 to 3 L/day, unless contraindicated. Consuming fluids in between meals will reduce gastric distention and pressure on the diaphragm.

The nurse is caring for an older woman with cardiac disease. How could aging affect this individual? 1. The cardiac output tends to be increased in the older adult. 2. The younger adult tends to have a more extensive network of collateral circulation than the older adult. 3. Dyspnea is a typical symptom of a myocardial infarction in the younger adult, whereas angina is the more common symptom in the older adult. 4. Even with lower doses of medications, the older adult should be observed for signs and symptoms of toxicity.

4--Even with lower doses of medications, the older adult should be observed for signs and symptoms of toxicity, because the rate of drug metabolism and excretion decreases with age. The older adult should be encouraged to maintain regular contact with the health care provider and to seek care at the first sign of problems. The cardiac output tends to be decreased in the older adult due to changes in cardiac musculature and reduced efficiency and strength. Progressive coronary artery changes can lead to the development of collateral coronary circulation. The older adult tends to have a more extensive network of collateral circulation than the younger adult. Angina is a typical symptom of a myocardial infarction in the younger adult, whereas dyspnea may be a more common symptom in the older adult, owing to the severity of signs and symptoms being modified by the development of collateral circulation.

In evaluating risk factors for cardiovascular disease, which does the nurse identify as a modifiable risk factor? 1. Family history of cardiovascular disease 2. Age 3. Active lifestyle 4. Hyperlipidemia

4--Hyperlipidemia is a risk factor for cardiovascular disease. The ratio of high-density lipoproteins (HDLs) to low-density lipoproteins (LDLs) is the best predictor for cardiovascular disease. A diet high in saturated fat, calories, and cholesterol contributes to hyperlipidemia. Dietary control is an important factor in modifying the risk factor. Family history of cardiovascular disease is a risk factor for cardiovascular disease; however, it is a nonmodifiable risk factor. Advanced age is a risk factor for cardiovascular disease; however, it is a nonmodifiable risk factor. Inactive lifestyle is the modifiable risk factor for cardiovascular disease. Regular exercise can improve the heart's efficiency, lower blood glucose levels, lower blood pressure, help the patient to reduce weight, reduce stress, improve the ratio of HDLs to LDLs, and improve overall feelings of well-being.

Which statement most accurately describes the disease tuberculosis (TB)? 1. TB is easily spread from person to person via respiratory secretions. 2. TB has the highest rates in the white U.S. population. 3. All strains of TB are resistant to antibiotic therapy. 4. Most people who become infected with the TB organism do not progress to the active disease stage.

4--Most people who become infected with the TB organism do not progress to the active disease stage; they remain asymptomatic and noninfectious. These people will have a positive tuberculin skin test, and chest radiograph results will be negative. These people retain a lifelong risk of developing reactivation TB if their immune systems become compromised. A common misconception about TB is that it is easily spread—in fact, most people exposed to TB do not become infected. The body's first line of defense, the upper airway, prevents most inhaled TB organisms from ever reaching the lungs. TB rates in the white population is about half that of the nonwhite population. More than two-thirds of reported cases occur in racial and ethnic minorities, particularly among Hispanic and African American populations. Not all strains of TB are resistant to antibiotic therapy. A growing percentage of new TB cases are resistant to the medications that are traditionally used to fight the disease.

A patient was admitted yesterday for a myocardial infarction. The nurse anticipates which aspect of care will be included in the plan of care? 1. Thrombolytic agents, such as aspirin, are used to minimize infarct size and maximize heart function. 2. Thrombolytic agents must be initiated within 24 hours of the onset of symptoms in order to be effective. 3. Morphine sulfate is contraindicated in a patient with a myocardial infarction due to its effects on the central nervous system. 4. Nitroglycerine is administered intravenously to dilate the coronary arteries to increase oxygen and nutrient flow to the heart to decrease the heart's workload.

4--Nitroglycerine is administered intravenously to dilate the coronary arteries to increase oxygen and nutrient flow to the heart as a way to decrease the heart's workload. Thrombolytic agents are used to minimize infarct size and maximize heart function. Aspirin is an antiplatelet medication, not a thrombolytic agent. Thrombolytic agents must be initiated within 3 to 5 hours of the onset of symptoms to be effective, although it is most effective if administered within 30 minutes to 1 hour. Morphine sulfate is useful for the patient with a myocardial infarction, because it helps with vasodilation of coronary arteries, relief of pain, and reduction of apprehension. It also decreases myocardial oxygen demands, reduces contractility, and slows the heart rate.

Which is important for the nurse to assess when inspecting the skin of a patient? 1. Avoid potentially embarrassing questions about rashes or scars. 2. Wear gloves only if the skin appears broken or inflamed. 3. Have artificial, preferably fluorescent, lighting for proper illumination of the skin. 4. Ask the patient about personal skin care.

4--The patient should be asked about personal skin care. The nurse should ask about recent color changes, sun exposure (with and without sunscreen), and family history of skin cancer. The nurse should establish a professional relationship with the patient and ask questions needed to assist with planning patient care. The nurse should ask the patient about recent skin lesions or rashes, where the lesions first appeared, and how long they have been present. It is important for the nurse to remember to wear gloves when inspecting the skin, mucous membranes, and any involved area. When assessing the skin, the nurse should have natural lighting.

The nurse is assessing the skin of several patients. Which patients have physiologic factors to consider when evaluating the skin color? Select all that apply. 1. Patient has a chronic respiratory condition and lower oxygen saturation. 2. Child has a congenital heart defect that affects blood flow. 3. Patient has unusually heavy menses and untreated anemia. 4. Patient has advanced liver failure. 5. Patient had a magnetic resonance imaging (MRI) 2 hours ago. 6. Patient has hypothermia after prolonged exposure to cold.

Answer 1, 2, 3, 4, 6: Physiologic factors that can affect skin color include oxygenation, pulmonary function, cardiac function, blood count, ambient and physiologic temperature, and elimination of waste byproducts. Occasionally, a patient may have an allergic reaction to the contrast media used during an MRI, but this is not expected.

Which patients are benefiting from the functions of the skeletal system? Select all that apply. 1. Patient sustains a mild concussion after a head injury. 2. Patient ambulates in the hallway at least three times each day. 3. Patient sits upright and dangles legs before attempting to stand. 4. Patient builds calcium storage by including dairy products in diet. 5. Patient drinks 3500 mL of fluid and voids 3375 mL of clear yellow urine. 6. Patient eats protein foods after donating blood to facilitate hemopoiesis.

Answer 1, 2, 3, 4, 6: The five functions of the skeletal system are support, movement, mineral storage, hemopoiesis, and protection. When fluid intake closely approximates urine output, and this is a sign of adequate kidney function.

A 72-year-old man was transferred from a long-term care center to the hospital for viral pneumonia. Which assessments and interventions would be performed for this patient? Select all that apply. 1. Take vital signs and pulse oximeter readings every 2 hours. 2. Monitor level of consciousness and orientation. 3. Auscultate breath sounds and observe respiratory effort. 4. Assess characteristics of sputum. 5. Direct UAP to assist with ambulation several times a day. 6. Administer pneumococcal vaccination, as prescribed.

Answer 1, 2, 3, 4, 6: The nurse would frequently monitor vital signs, level of consciousness, breath sounds, respiratory effort, and characteristics of the sputum. Pneumococcal vaccination would be given. This older patient is at risk for this common bacterial infection because he is recovering from an illness, and he resides in a long-term care facility. Ambulation is generally a good intervention, however, the nurse must assess the patient's strength, energy, and respiratory effort before, during and after exertion, so delegating the task to the UAP would be inappropriate.

During a discharge teaching session, the young patient voices concern about her risk for heart disease because she has diabetes mellitus. Which self-care measures would the nurse teach the patient? Select all that apply. 1. Keep the blood glucose level under control. 2. Monitor blood pressure at home: goal less than 120/80 mm Hg. 3. Eat a low-fat diet rich in fruits and vegetables. 4. Exercise 3-5 times a week for at least 30 minutes. 5. Take low-dose aspirin once a day.

Answer 1, 2, 3, 4: Blood glucose control, monitoring blood pressure, healthy eating, and regular exercise are recommendations for all patients, but persons with diabetes have a higher risk for cardiac problems. The nurse would not recommend aspirin therapy, because prescribing medication is outside the nurse's scope of practice. The nurse could suggest that the patient talk to the HCP about aspirin therapy.

Which people are performing an action that represents a function of muscles when contracted? Select all that apply. 1. Child squats to tie shoelaces and then straightens legs to stand upright. 2. Man briskly walks a block to warm up before beginning his morning run. 3. High-school cheerleaders actively move around to deal with cool fall weather. 4. Soldiers stand at attention and in formation during the morning inspection. 5. Woman gets a black eye after getting hit, but her eyeball is undamaged.

Answer 1, 2, 3, 4: When muscles contract, they produce motion and heat, and allow us to maintain posture and position. The skeletal system, specifically the supraorbital ridge and the zygoma (cheekbone) protect the eyeball.

A patient with a chronic lung disorder says, "I feel like I am getting sick again." Which questions would the nurse ask? Select all that apply. 1. "How's your breathing? Can you describe it? " 2. "Are you coughing? Can you describe the cough? " 3. "When did you first notice the worsening of symptoms? " 4. "What were your last arterial blood gas results? " 5. "Do you use oxygen at home? If so, does it help? " 6. "Have you noticed a change in your ability to do routine activities? "

Answer 1, 2, 3, 5, 6: The nurse would ask the patient to describe symptoms, onset, alleviating factors, and changes in ability to perform activities of daily living (ADLs). Patients with chronic lung disorders can have abnormal blood gas results but past results are less relevant to the current status.

The nurse is planning care for several patients on the orthopedic unit. Which patients will need frequent neurovascular checks during the shift? Select all that apply. 1. Patient has a long leg cast for fracture sustained in an automobile accident. 2. Older patient had elective hip replacement surgery secondary to arthritis. 3. Construction worker sustained a crush injury to the lower leg. 4. Patient has Volkmann's contracture of the right upper extremity. 5. Young athlete sustained a dislocated shoulder during a football game.

Answer 1, 2, 3, 5: Neurovascular assessments are made on patients with musculoskeletal trauma or when there is risk for damage to nerves and blood vessels resulting from surgery, tight bandages, splints, or casts. Volkmann's contracture is a permanent contracture (with clawhand, flexion of wrist and fingers, and atrophy of the forearm) that can occur because of compartment syndrome. Vigilant neurovascular assessment is necessary to prevent this complication.

Which information is likely to be included in the discharge instructions for a patient who was treated for epistaxis? Select all that apply. 1. Use a vaporizer. 2. Use saline nose drops. 3. Apply nasal lubricants. 4. Take aspirin for pain as needed. 5. Vigorously blow to remove clots. 6. Avoid inserting foreign objects into nose.

Answer 1, 2, 3, 6: The goal is to keep the nasal mucous membranes moist, so a vaporizer, saline nose drops, and lubricants are recommended. Nose-picking and putting other objects into the nose should be avoided; this point is emphasized with pediatric patients. Aspirin is considered an anticoagulant. Blowing vigorously can restart bleeding. (Note to student: The HCP may have had the patient blow vigorously just prior to examination, so the patient may assume that the action is okay.)

The nurse is caring for a patient who had unicompartmental knee surgery. Which interventions will the nurse use in the postoperative period? Select all that apply. 1. Encourage deep-breathing and coughing every 2 hours. 2. Begin with a clear liquid diet and advance to regular as tolerated. 3. Inspect the skin at the edge of the cast for erythema. 4. Assess the patient's ability to use an assistive device such as a walker. 5. Monitor IV fluids and effectiveness of antibiotics. 6. Administer intraarticular injections of corticosteroids.

Answer 1, 2, 4, 5: Coughing, deep-breathing, clear liquids with transition to a regular diet, assessing ability to use assistive devices, and monitoring IV fluids and antibiotics would be included in the care of the patient who had unicompartmental knee surgery. The patient would not have a cast and intraarticular injections of corticosteroids would be given by the HCP for rheumatoid arthritis.

Which nonpharmacologic interventions for hypertension would be included in the patient teaching plan? Select all that apply. 1. Encourage including unsalted and unprocessed foods in the diet. 2. Give information about support groups and aids to stop smoking. 3. Advise taking over-the-counter potassium and calcium supplements. 4. Encourage 30-45 minutes of aerobic exercise three or four times a week. 5. Review fat intake; suggest limiting fat to less than 50% of total calories. 6. Advise limiting calories and increasing exercise to lose weight.

Answer 1, 2, 4, 6: Unsalted and unprocessed foods are encouraged to reduce sodium. Smoking cessation, exercise, and weight loss are encouraged. Advising use of over-the-counter supplements is outside the scope of nursing practice; these supplements may interact with prescribed medications such as ACE inhibitors or be contraindicated in some disorders. Fat intake should be less than 30% of total calories.

Which foods would the nurse recommend as good sources of calcium for a 59-year-old woman who is concerned about her risk for osteoporosis? Select all that apply. 1. Milk 2. Spinach 3. Potatoes 4. Sardines 5. Organ meats

Answer 1, 2, 4: Foods that are good sources of calcium include whole and skim milk, yogurt, turnip greens, cottage cheese, ice cream, sardines with bones, spinach, many green vegetables, calcium-fortified orange juice, and soymilk.

Which medical and nursing interventions are used in the care of patients who are hospitalized with COVID-19 and develop adult respiratory distress syndrome? Select all that apply. 1. Use non-invasive, mask-free, high-flow oxygen. 2. Place patients in a semi-Fowler's position. 3. Report all cases to local health department. 4. Don N-95 respirator and eye covering before providing patient care. 5. Gather information about quarantine of close contacts. 6. Obtain a chest radiograph.

Answer 1, 3, 4, 5, 6: Patients with COVID-19 who develop adult respiratory distress (ARDS) are treated with a noninvasive, mask-free, high-flow oxygen delivery device delivering up to 40 L/min (Vapotherm), prone positioning, and mechanical ventilation. Infection control and self-protection include donning N-95 respirator and eye covering before giving care. Chest x-rays are ordered to identify pneumonia and ARDS. Reporting case data to local health departments and gathering information about quarantine and close contacts contribute to the public health measures of prevention and surveillance.

What are the functions of the skin? Select all that apply. 1. Excretion of waste 2. Synthesis of vitamin A 3. Protection from infection 4. Regulation of temperature 5. Prevention of dehydration 6. Support and structure of the body

Answer 1, 3, 4, 5: The primary functions of the integumentary system include protection, temperature regulation, and vitamin D synthesis. The skin also aids in elimination of waste products, prevention of dehydration, and serves as a reservoir for food and water. Support and structure are functions of the musculoskeletal system.

Which persons should be advised to get pneumococcal vaccination? Select all that apply. 1. 18-month-old child with no known health problems 2. 25-year-old nurse with no known health problems 3. 80-year-old with chronic conditions who lives in a nursing home 4. 35-year-old with diabetes mellitus that is well-controlled with insulin 5. 40-year-old in good general health, who travels outside the United States 6. 19-year-old who smokes two packs of cigarettes per day

Answer 1, 3, 4, 6: Pneumococcal vaccination is recommended for all babies and children younger than 2 years old, all adults 65 years or older, and people 2 through 64 years old with certain medical conditions (e.g., diabetes, chronic obstructive pulmonary disease [COPD]) and adults age 19-64 years old who smoke cigarettes. Occupational exposure and traveling are not currently considered risk factors for healthy adults.

The patient's beta natriuretic peptide (BNP) is greater than 100 pg/mL (11.8245 pmol/L). Which assessment will the nurse perform? 1. Assess for cough and adventitious breath sounds. 2. Assess for radiation of pain into the neck or jaw. 3. Assess capillary refill and peripheral pulses. 4. Assess for pulse deficit and hypotension.

Answer 1: A BNP level above 100 pg/mL indicates heart failure. Congestion of blood in the lungs causes orthopnea; dyspnea on exertion; a dry, hacking cough that becomes moist over time; and crackles auscultated in the lungs. Radiation of pain into the jaw or neck is associated with myocardial infarction. Capillary refill and peripheral pulses are assessed when peripheral vascular disease is a concern. Pulse deficit and hypotension could occur in atrial fibrillation

The nurse is providing care for a patient who has just had a hip replacement. Which comment from the patient indicates the need for further education? 1. "I need to be on bedrest for the first 72 hours." 2. "I need to obtain a seat riser for my toilet at home." 3. "I should never sit with my legs crossed." 4. "I'll have limitations in hip position for 2-3 months."

Answer 1: Bedrest is typically for the first 24 hours. The other comments are correct.

Which instruction would the nurse give to the UAP about assisting the patient who has emphysema to accomplish ADLs? 1. Divide hygienic care into short sessions with 90 minutes of rest between. 2. Defer the hygienic care until the patient has better activity tolerance. 3. Observe the patient's response to ambulating and shorten walks accordingly. 4. Perform range-of-motion exercises, unless the patient declines them.

Answer 1: Care should be divided into short sessions with intermittent periods of rest. Hygienic care should not be completely deferred; the nurse should determine how the care can be abbreviated or adapted and inform the UAP accordingly. The nurse must assess the patient's response to ambulation and patient's ability to participate in range-of-motion exercises and then inform the UAP.

Under which circumstances would the nurse expect to observe sinus tachycardia if the patient were on a cardiac monitor? 1. Patient has an untreated high fever. 2. Patient demonstrates obstructive sleep apnea. 3. Patient faints during a bowel movement. 4. HCP performs carotid massage.

Answer 1: Causes of sinus tachycardia include exercise, anxiety, fever, shock, medications, heart failure, excessive caffeine, recreational drugs, and tobacco use. In the other options, sinus bradycardia is more likely to be observed.

The nurse must assess several patients who have skin disorders. Which disorder can manifest signs/symptoms that could be mistaken for venous thrombosis? 1. Cellulitis 2. Pityriasis rosea 3. Spider angioma 4. Tinea corporis

Answer 1: Cellulitis is an infection of the skin and underlying subcutaneous tissues. The affected areas become erythematous, edematous, tender, and warm to the touch. These signs/ symptoms can also occur with venous thrombosis. Pityriasis rosea begins as a single scaly area up to 4 inches in diameter (10 cm) with a raised border and a pink center that resembles ringworm (a fungal infection). Spider angioma is associated with liver disease. An angioma develops when a group of blood vessels dilate and form a tumor-like mass. Tinea corporis produces flat lesions that are clear in the center with erythematous borders. Scaly appearance also occurs and pruritus is severe.

The nurse notes that the patient has clubbing of the fingertips. Based on this finding, which question would the nurse ask? 1. "Have you been diagnosed with a respiratory disorder?" 2. "Do you take medication for high blood pressure?" 3. "Do you have a family history of diabetes mellitus?" 4. "Are you taking medication for osteoporosis?"

Answer 1: Clubbing of the fingertips indicates chronic hypoxemia, which is associated with conditions such as emphysema.

Which question would the nurse ask to assist the health care provider (HCP) to determine the cause of contact dermatitis? 1. "Have you used any new soaps or detergents?" 2. "Are you currently sexually active?" 3. "Is anyone in the household having similar symptoms?" 4. "Have you had a recent febrile illness?"

Answer 1: Common causes of dermatitis are detergents, soaps, industrial chemicals, and plants such as poison ivy. The other questions would apply to different skin conditions.

For a patient with cor pulmonale, which assessment is the nurse most likely to perform? 1. Check for distended neck veins. 2. Monitor for hoarseness and sore throat. 3. Assess for petechiae over the chest. 4. Palpate for enlarged cervical lymph nodes.

Answer 1: Cor pulmonale is enlargement of the right ventricle, which results in peripheral edema, distended neck veins, and engorgement of the liver with ascites. Hoarseness and sore throat would be observed in laryngitis. Petechiae are usually associated with coagulation problems. Enlarged cervical lymph nodes occur with infections and some cancers.

A patient receives a prescription for anticoagulant medication for treatment of arterial emboli. Which dietary information would the nurse give? 1. Do not increase intake of dark-green vegetables because of vitamin K. 2. Take extra dairy products to ensure calcium intake and vitamin D. 3. Eat fruits such as citrus and bananas that provide potassium. 4. Avoid eating saturated fats by limiting use of butter, oils, and red meats.

Answer 1: Dark-green vegetables contain vitamin K, which counteracts the effect of the anticoagulant drug. The other options are good dietary advice for most patients.

A younger patient has a one-time elevated blood pressure reading of 130/80 mm Hg. Which intervention does the nurse anticipate? 1. Advise repeat blood pressure readings on two or more separate occasions. 2. Modify lifestyle by losing weight, increasing exercise, and decreasing fat intake. 3. Order for diagnostic tests such as complete blood count, electrolytes, and lipid profile. 4. Prescriptions for diuretics, beta-adrenergic blockers, or ACE inhibitors.

Answer 1: Diagnosis for hypertension would not be based on a one-time elevated reading. The patient would be advised of the need to have repeated readings on separate occasions. If elevated blood pressure is confirmed, the other options would be considered.

A patient is prescribed colchicine to treat gout. The nurse would assess for which potential medication side effects? 1. Diarrhea, nausea, and vomiting 2. Seizures and dysrhythmias 3. Fluid retention and sodium retention 4. Hypercalcemia and orthostatic hypotension

Answer 1: Diarrhea, nausea, and vomiting are potential side effects of colchicine. Fluid retention and sodium retention are side effects of adrenocorticosteroids. Seizures and dysrhythmias are side effects of meloxicam, which is a nonsteroidal antiinflammatory drug. Hypercalcemia and orthostatic hypotension are side effects of teriparatide, which is used for postmenopausal women who are at increased risk for osteoporosis fractures or for those who cannot use other treatments.

Which patient will require postprocedural checks for peripheral pulses, color, and sensation of the extremity every 15 minutes for 1 hour? 1. Needs cardiac catheterization to diagnose extent of atherosclerotic heart disease 2. Is scheduled for electrocardiogram to identify specific cardiac dysrhythmias 3. Requires chemically induced stress electrocardiogram for poor exercise tolerance 4. Must have positron emission tomography because of coronary artery disease

Answer 1: During cardiac catheterization, the catheter is inserted into a peripheral vessel (usually the arm or the groin). There is a potential for bleeding or injury to nerves; pulses and sensation distal to the site of insertion must be checked. Electrocardiograms and positron emission tomography are considered noninvasive.

The patient who had a myocardial infarction 2 weeks ago is now having frequent episodes of ventricular tachycardia. For this patient, what is the clinical significance of this dysrhythmia? 1. Warning sign for ventricular fibrillation 2. Expected finding at this stage 3. Reaction to a beta-adrenergic blocker 4. Treatment is given only for symptoms

Answer 1: For this patient, there is an increased risk for ventricular fibrillation. The patient may or may not have symptoms during the episodes, but aggressive treatment is initiated to prevent ventricular fibrillation, which is a lethal dysrhythmia. Beta-adrenergic blockers are used in the ongoing suppression of ventricular tachycardia.

Which disorder of the cardiovascular system places the patient at highest risk for the potentially life-threatening condition of cardiac tamponade? 1. Pericarditis 2. Valvular heart disease 3. Buerger's disease 4. Endocarditis

Answer 1: In pericarditis, the membranous sac that surrounds the heart becomes inflamed. Fluid collects in the sac and the heart becomes compressed by the pressure of the fluid. The effusion restricts the movement of the heart (cardiac tamponade).

The nurse knows that the HCP frequently prescribes isotretinoin for patients with acne. Which question is the most important to routinely ask? 1. "Are you pregnant or contemplating a pregnancy in the near future?" 2. "Do you have a history of kidney problems or frequent urinary tract infections?" 3. "How often do you sunbathe? Are you willing to abstain during treatment?" 4. "Do you have any problems with your liver or a history of hepatitis?"

Answer 1: Isotretinoin is teratogenic; thus, pregnancy is an absolute contraindication and strict contraception is advised for 1 month before starting and 1 month after completing treatment. Avoiding sun exposure is also advised

The patient is admitted for acute osteomyelitis of the left lower extremity. Which instruction would the nurse give to the unlicensed assistive personnel (UAP)? 1. Use drainage and secretion precautions when caring for the patient. 2. Assist the patient to ambulate in the hall every 2-3 hours. 3. Anticipate that movement is more difficult in the morning. 4. Refresh the patient's ice pack every 2 hours or as needed.

Answer 1: Osteomyelitis is an infection of the bone. Drainage precautions are initiated, because the wounds frequently require débridement, irrigation, and sterile dressing changes. Ambulating may be restricted to rest the affected part. Patients with arthritis or fibromyalgia are more likely to have trouble moving in the early morning. Ice packs are more appropriate for patients with sprains or strains; sometimes for patients with arthritis.

The HCP has diagnosed a patient with paronychia. Which assessment is the nurse most likely to perform before administering the ordered therapy? 1. History of allergies to antibiotics 2. Rating of pain on a pain scale 3. Baseline range of motion 4. Feelings about body image

Answer 1: Paronychia is an infection of the nail that spreads around the nail. Topical antibiotics and wet dressings are the usual treatment; sometimes a surgical incision and drainage of the infected area are performed.

Which position would the nurse help the patient to assume for a thoracentesis for therapeutic removal of fluid? 1. Seated on the bed; head and arms resting on a pillow placed on an overbed table 2. Placed in a supine position with the anterior lateral chest draped for ready access 3. Positioned in a recumbent prone position with head resting on forearms and hands 4. Situated in a side-lying position on affected side and uncovered to the waist

Answer 1: Positioning the patient upright will facilitate the drainage and removal of the fluid from the thoracic cavity.

For a patient who is on anticoagulant therapy, which laboratory values are the most important to monitor? 1. Prothrombin time, International Normalized Ratio, and partial thromboplastin time 2. Blood glucose, potassium, sodium, calcium, and magnesium 3. Enzyme creatine kinase, creatine phosphokinase, and myoglobin 4. B-type natriuretic peptide and troponins 1 and 2

Answer 1: Prothrombin time, International Normalized Ratio, and partial thromboplastin time reflect blood clotting, so these laboratory values are the most important to follow up for patients who are on anticoagulant therapy. The electrolytes are important for heart muscle contraction. Enzyme creatine kinase, creatine phosphokinase, and myoglobin can be used to assist with the diagnosis of myocardial infarction, but troponin levels are now more commonly used. B-type natriuretic peptide is used in the diagnosis of heart failure.

Which patient has the highest mortality risk related to acute respiratory distress syndrome (ARDS)? 1. Was diagnosed and treated for sepsis 5 days ago 2. Had direct trauma to chest during a fight 10 days ago 3. Has a history of chronic obstructive pulmonary disease (COPD) 4. Has been treated for asthma since early childhood

Answer 1: Sepsis is the most common precursor of ARDS. The window is 5-10 days after onset of sepsis. The mortality rate is 55%-70% when ARDS is associated with sepsis. ARDS due to injury usually manifests in 12-24 hours. COPD or asthma can be underlying factors, but many patients who have COPD or asthma never develop ARDS.

The nurse is assessing a patient who had a thrombectomy in the right lower extremity. Which assessment finding is cause for greatest concern? 1. Sudden absence of pulse in the affected extremity 2. Capillary refill in extremity is greater than 2 seconds 3. Affected extremity is erythematous and edematous 4. Patient reports a tingling sensation in extremity

Answer 1: Sudden absence of pulse may indicate an arterial occlusion. Permanent tissue damage can occur if blockage persists. Capillary refill can be slower than normal for patients with peripheral vascular disease. Erythema and edema may accompany infection or venous thrombosis. A tingling or burning sensation (paresthesia) should be investigated as an early sign of decreased tissue perfusion.

For a patient with a chest tube, which task could be delegated to the UAP? 1. Assist to ambulate with water-seal below the level of the chest. 2. Check to make sure that all connections are secure and intact. 3. Observe for and report hypoventilation or increased dyspnea. 4. Assess quantity and quality of drainage in the collection chamber.

Answer 1: The UAP can help the patient ambulate, but the nurse must give specific instructions about holding the container below the chest and ensure that the UAP and patient do not place undue pressure on the tubes. The other actions are nursing responsibilities.

Which patient has the greatest need for a helical computed tomography scan? 1. A disoriented older patient who may have a pulmonary embolus 2. A toddler who might have swallowed a metallic foreign body 3. A patient who requires a sample of lymph node tissue for biopsy 4. A patient who was exposed to tuberculosis several decades ago

Answer 1: The advantage of the helical computed tomography scan is that the entire study can be performed in less than 30 seconds. The disoriented patient may have difficulty cooperating for a V-Q scan or pulmonary angiography, as both are much longer procedures. A flat plate of the abdomen is the best exam for ingested metallic foreign bodies. A mediastinoscopy will be performed to obtain lymph tissue. A chest x-ray will be performed for the patient exposed to tuberculosis.

If the epiglottis fails to perform its intended function, how would this affect the patient? 1. Increased risk for aspiration 2. Increased incidence of throat infections 3. Decreased respiratory drive 4. Decreased forced expiratory volume

Answer 1: The epiglottis protects the larynx when swallowing; it covers the larynx tightly to prevent food from entering the trachea (aspiration) and directs the food to the esophagus.

What is the nurse's role in allergy testing? 1. Uses a lancet to prick the skin with different allergens 2. Evaluates the response to different allergens 3. Advises the patient about allergens to avoid 4. Determines schedule for retesting questionable allergens

Answer 1: The nurse can administer the allergens and should mark the sites. The localized reaction should be measured and documented. The HCP is responsible for evaluating the outcomes of the test, discussing allergens to avoid, and instructing the patient about ambiguous results. The nurse can reinforce what the HCP tells the patient.

The patient was in a car accident and reports pain over the pelvic region with difficulty raising legs in a supine position. Ecchymosis is present over the pelvic region. Which laboratory test is the primary concern in the immediate phase of care? 1. Hemoglobin and hematocrit 2. Blood type and Rh 3. Urinalysis 4. Stool for occult blood

Answer 1: The patient has signs and symptoms of a pelvic fracture, and hemorrhage is the most life-threatening complication. Hemoglobin and hematocrit are laboratory indicators of blood loss. Blood type and Rh are important if the patient needs emergency surgery. Urinalysis and stool for occult blood are performed because of the position of the bladder and the colon in the pelvic area.

The patient with mild heart failure says, "Every night I fall sleep in this recliner chair. I sleep better with my head up." Which assessment will the home health nurse perform first? 1. Check for dependent edema in the lower extremities. 2. Look at accessibility to the bedroom and bathroom. 3. Assess ability to independently move and ambulate. 4. Ask about compliance with low-sodium, low-fat diet.

Answer 1: The patient is describing a strategy that he uses to deal with orthopnea. Worsening heart failure is accompanied by fluid retention and it is likely that sleeping in a chair is causing the fluid to collect in the lower extremities. As the edema worsens, the abdominal girth will increase, and the breathing will become more labored as the fluid progresses upwards. The nurse is also likely to assess compliance with diet and medications. The home health nurse has an additional advantage of being able to look at the environment. Climbing stairs or navigating distances between rooms may be an issue as the patient becomes progressively more fatigued.

The patient has smoked for the past 30 years and was recently diagnosed with emphysema. Which assessment finding is the primary manifestation? 1. Dyspnea on exertion 2. Copious thick sputum 3. Barrel-chest appearance 4. Bulbous, shiny fingernails

Answer 1: The primary symptom of emphysema is dyspnea on exertion, which becomes progressively more severe. The other findings will manifest as the disease progresses.

The patient is a very dark-skinned individual who has low hemoglobin and hematocrit. How would the nurse assess for pallor? 1. Observe mucous membranes, lips, nail beds, and conjunctivae of lower eyelids. 2. Check the palms of the hands, soles of the feet, and the abdomen. 3. Gently push down on the skin and then release and watch for blanching. 4. Assess for clubbing of the fingernails and check capillary refill.

Answer 1: The skin of a very dark-skinned person may appear gray or ashen if hemoglobin and hematocrit are low. The skin is thinner on the mucous membranes, lips, and conjunctivae of lower eyelids, and pallor is easier to detect. Capillary refill can be checked on nailbeds. Baseline skin color would be observed in areas with the least pigmentation such as palms of the hands, soles of the feet, underside of forearms, abdomen, and buttocks. The nurse checks for blanching when assessing for pressure injury or depth of a burn injury. Assessing for clubbing is usually done with patients who have chronic respiratory disease. Capillary refill is used to assess perfusion and oxygenation

Which information about sleep hygiene would be provided for a patient who has fibromyalgia? Select all that apply. 1. Take a long, hot bath just before bedtime. 2. Keep the sleeping environment dark, quiet, and comfortable. 3. Keep a diary of sleep patterns. 4. Exercise regularly every day. 5. Have a protein snack just before going to bed.

Answer 2, 3, 4: Controlling the environment, regular exercise, and a sleep diary are recommended. A hot bath and eating just before going to bed are not recommended.

What are signs/symptoms of cardiac arrest? Select all that apply. 1. Pupil constriction 2. Absence of carotid pulse 3. Gasping respirations followed by apnea 4. Lethargic and difficult to arouse 5. Abrupt loss of consciousness 6. Pallor and cyanosis

Answer 2, 3, 5, 6: Signs and symptoms of cardiac arrest include abrupt loss of consciousness with no response to stimuli, gasping respirations followed by apnea, absence of pulse (radial, carotid, femoral, and apical), absence of blood pressure, pupil dilation, pallor, and cyanosis.

Which people have the greatest risk for serious complications secondary to herpes zoster infection? Select all that apply. 1. Healthy middle-aged adult who never had chickenpox 2. Older adult who takes large doses of prednisone for a chronic condition 3. Middle-aged adult who just started taking chemotherapy 4. Nurse who recently received the first dose of varicella vaccine 5. Young adult who is positive for the human immunodeficiency virus

Answer 2, 3, 5: Persons who are immunocompromised have a greater risk of developing serious complications, including death. Healthy adults usually do not have long-term sequelae from herpes zoster infections.

The nurse is interviewing an older adult. Which statement is cause for the greatest concern? 1. "My toenails are tough and thick." 2. "This black mole on my neck is itching." 3. "My hair is thinning and I have a bald spot." 4. "I have a lot of 'age spots' on my hands."

Answer 2: A raised, black nevus is considered one of the most threatening skin lesions, and removal is recommended to prevent it from becoming malignant. Any change in color, size, or texture or any bleeding or pruritus deserves investigation. The other comments reflect typical changes associated with aging.

The nurse is performing a rapid strep screen. Which rationale supports obtaining two throat swabs? 1. The first swab is likely to be contaminated, so a backup swab is needed. 2. If the rapid strep test is negative, the second swab is sent for culture. 3. The second swab is given to the patient, in case the rapid strep is positive. 4. The first and second swabs are grown in different types of culture media.

Answer 2: A rapid strep test is performed to detect the presence of b-hemolytic streptococci, which is a severe form of acute pharyngitis. If those results are negative, then the second swab is used to culture a medium and is allowed to grow so the infecting organism can be identified.

The nurse hears in report that a young female patient is very upset because of alopecia; she cannot focus on the overall cancer treatment plan. In addition to therapeutic communication, which intervention would the nurse use? 1. Suggest therapeutic baths using colloid solution. 2. Teach the patient about use of scarves or wigs. 3. Suggest shaving, tweezing, or rubbing with pumice. 4. Advise the patient to use lotion immediately after bathing.

Answer 2: Alopecia is hair loss, which is a common side effect of chemotherapy. Use of scarves or wigs could help. Also teach the patient that the hair will grow back. Therapeutic baths and applying lotions after bathing help with pruritus. Shaving, tweezing, or pumice stones can be used for hirsutism (excessive growth of hair in a masculine distribution).

A patient is prescribed oral acyclovir for type 1 herpes simplex virus. What is the expected outcome if the patient is compliant with the medication regimen? 1. Prevents complications, such as meningitis or pneumonitis 2. Shortens the outbreak and lessens the severity of symptoms 3. Eliminates the likelihood of spreading the infection to others 4. Decreases the probability of recurrent outbreaks

Answer 2: Antiviral drugs such as acyclovir can shorten the outbreak and lessen the severity of symptoms.

Which instruction would the nurse give to the patient for self-administration of nitrate medications? 1. Refrigerate the oral tablets and nitroglycerin patches until use. 2. Apply patches in the morning and remove them at bedtime. 3. A burning sensation on the tongue indicates an allergic reaction. 4. Pain relief should occur after taking two tablets. 31. For a patient with myocardial infarction, which symptom is the most

Answer 2: Applying patches in the morning and removing them at bedtime prevents the development of tolerance. Nitroglycerin tablets should always be available in a pocket or purse. A burning sensation under the tongue is expected during activation of the tablet. Up to three tablets should be taken to determine if pain relief is adequate.

A child needs postoperative care following a tonsillectomy. In which circumstance would nurse intervene? 1. Grandmother brings popsicles for the child and nursing staff. 2. Nursing student encourages child to drink orange juice. 3. UAP offers to refresh the ice collar and wraps collar in a cloth. 4. Mother assists child to eat small spoonfuls of custard. about quarantine of close contacts.

Answer 2: Citrus juices are not the best choice, because they cause a burning sensation. Popsicles and custard would be offered to provide fluids and nutrition that is nonirritating to the tissue. An ice collar is a comfort measure and facilitates vasoconstriction. The nurse is responsible to evaluate the response and to inform the UAP about the application time

The patient has pulmonary edema and is prescribed furosemide. Which laboratory result is the most important for the nurse to monitor? 1. Complete blood count 2. Electrolytes 3. Coagulation studies 4. Serum lipids

Answer 2: Diuretics will increase urine output and electrolyte imbalances can occur. Potassium must be monitored because hypokalemia or hyperkalemia can cause cardiac dysrhythmias.

A computer data entry clerk reports paresthesia in the thumb, index finger, and middle finger and pain that increases during the night. The clerk has an appointment with a HCP next week. In the meantime, which self-care measure would the nurse advise? 1. Use warm packs and sleep with hands on a pillow. 2. Frequently change position and stretch hands while working. 3. Use a mild analgesic such as ibuprofen or aspirin. 4. Wrap the wrist snugly with an elastic bandage.

Answer 2: Frequent position changes and stretching hands are preventive measures for carpal tunnel syndrome. Warm packs will worsen the inflammation and edema. Suggesting use of medication, even over-the-counter medications, is outside of the nurse's scope of practice. Wrapping the wrist may help a bit, but the HCP is likely to recommend the use of a commercial splint.

A patient who sustained rib fractures during a car accident reports sudden sharp chest pain over the fracture area with difficulty breathing. Which assessment finding supports the nurse's suspicion of pneumothorax? 1. Bilateral wheeze during inspiration and expiration 2. Decreased breath sounds over the affected area 3. Coarse crackles heard in early inspiration 4. Dry creaking and grating when breath is held

Answer 2: If the patient has a pneumothorax, auscultation of the lungs will reveal bilaterally unequal breath sounds, with no breath sounds over the affected area. See Table 49.1 for additional information about breath sounds.

A neighbor says, "I'm pretty healthy and don't take any medications but I'm having occasional nosebleeds." Which suggestion does the nurse make? 1. "To stop bleeding, hold pressure on the lower nose for 10-15 minutes. " 2. "Let's check your blood pressure (BP) for the next several mornings. " 3. "Make an appointment to have your clotting times checked. " 4. "Have your health care provider (HCP) examine your nasal septum. "

Answer 2: If the person has an episode of epistaxis or reports frequent episodes, check his or her BP. Other causes include dryness, chronic infection, trauma (e.g., injury, vigorous nose blowing, or nose picking), topical corticosteroid use, nasal spray abuse, street drug use, and disorders that prolong bleeding time or reduce platelet counts. Aspirin, nonsteroidal antiinflammatory drugs, and anticoagulants can prolong bleeding times. If the neighbor were having active bleeding, holding pressure is the best advice. If the neighbor gives additional information that suggest problems with clotting (e.g., bleeding from other sites), an appointment for laboratory work would be appropriate. If the neighbor reported an injury to nose/face, then the nasal septum should be examined.

For a patient who has a medical diagnosis of ankylosing spondylitis, what is included in the focused assessment? 1. Perform the seven Ps of orthopedic assessment. 2. Assess for back pain and vision changes. 3. Frequently check for change in mental status. 4. Check for urinary retention and overflow incontinence.

Answer 2: In ankylosing spondylitis, back pain and stiffness, weight loss, vision change, and fatigue are common; the cardiovascular and respiratory systems can be affected. Inflammatory bowel disease occurs in about 3%-10% of patients. The seven Ps could be used but apply more to assessment of extremities. Mental status and urination should not be directly affected.

A fiberglass cast has been applied to the forearm of a 6-year-old child to treat and stabilize a greenstick fracture. Which teaching point is the most important to emphasize with the child? 1. Instructing the child to keep the cast dry 2. Teaching the child to report pain to the parents 3. Showing the child how to test capillary refill 4. Reminding the child to wiggle the fingers

Answer 2: Pain is a primary symptom of compartment syndrome or infection. In addition, pain is a subjective symptom that the child will have to report to parents. Capillary refill and cast care and maintenance are important, but the parents can be given written information about these topics. Fiberglass casts do not degrade if they get wet, but drying them out can be time-consuming.

A young woman is diagnosed with infective endocarditis. Which educational brochure is the nurse most likely to prepare for the patient? 1. "Prosthetic Valve Replacement: Questions to Ask Your Doctor" 2. "Importance of Completing Prescribed Antibiotic Therapy" 3. "Activities and Diversions: Tips for Tolerating Complete Bedrest" 4. "How Anticoagulation Therapy Helps Prevent Blood Clots"

Answer 2: Prompt treatment with intensive antibiotic therapy will now cure most patients with endocarditis. Valve replacement is considered an adjunct procedure. Complete bedrest is usually not prescribed unless there is high fever or signs of heart failure. Anticoagulant therapy is not usually prescribed because of risk for intracranial bleeding.

The patient arrives in the emergency department with severe dyspnea, agitation, cyanosis, audible wheezes, and a cough with blood- tinged sputum. What is the priority action? 1. Obtain a blood sample for arterial blood gases. 2. Administer oxygen. 3. Auscultate lung sounds. 4. Establish a peripheral IV.

Answer 2: Remember the priorities of airway and breathing and give the patient oxygen. Next establish a peripheral IV for morphine and diuretics. Arterial blood gases and auscultating lung sounds will assist in the diagnosis of pulmonary edema, but the patient is in severe distress and the symptoms are attended to first.

A patient, recently diagnosed with peripherally located lung cancer, reports severe chest pain. Based on the pathophysiology of this pain, which therapy does the nurse anticipate? 1. Bronchodilators 2. Thoracentesis 3. Mechanical ventilation 4. Corticosteroids

Answer 2: Severe pain in peripheral lung cancer is likely to be caused by a pleural effusion. The treatment for this is a thoracentesis.

Which recommendations does the nurse make for modifiable risk factors for cardiovascular disease for a 23-year-old patient who is currently asymptomatic.? 1. Find out if any first-degree relatives had cardiovascular problems before the age of 50. 2. Stop smoking or consider greatly reducing the number of cigarettes smoked per day. 3. Ask the HCP for a cholesterol-lowering drug such as simvastatin. 4. Monitor weight and calorie intake to maintain a body mass index of 30.

Answer 2: Smoking cessation or at least reducing the number of cigarettes is a modifiable factor. Heredity plays a role but is considered nonmodifiable. Prophylactic drugs would not be first-line therapy for this healthy patient. Discussions of diet and exercise would be more appropriate. Body mass index of 30 is too high and indicates obesity.

Which data set represents the signs/symp- toms of an exacerbation of systemic lupus erythematosus? 1. Vesicles preceded by pain, generally in the thoracic region 2. Fever, rash, cough, or increasing muscle and joint pain 3. Erythema, pain, and tenderness over an area of skin 4. Vesicles appear, ulcerate, rupture, and encrust

Answer 2: Systemic lupus erythematosus is an autoimmune disorder. It is a chronic, multisystem inflammatory disorder of exacerbations and remissions. Signs/symptoms of exacerbation include fever, rash, cough, or increasing muscle and joint pain. Eruption of vesicles preceded by pain is characteristic of herpes zoster. Erythema, pain, and tenderness over an area of skin are the first signs/symptoms of cellulitis. A vesicle that appears, ulcerates, ruptures, and encrusts is characteristic of type 1 herpes simplex (e.g., cold sore).

A young woman injured her ankle while playing soccer. Which question is most important to ask related to diagnostic testing? 1. "Do you have allergies to seafood or iodine?" 2. "Is there any chance you could be pregnant?" 3. "Are you currently taking any medications?" 4. "Do you have a history of radiation exposure?"

Answer 2: The HCP is most likely to order an x-ray examination of the ankle to rule out fracture. The radiation exposure is minimal; however, female patients of childbearing age should always be asked about pregnancy. Assessment of allergies and medications and past treatments are good general questions for all patients, but in this case are less relevant to the diagnostic test that will most likely be ordered.

For a patient who had a bronchoscopy, which task can be delegated to the unlicensed assistive personnel (UAP)? 1. Give clear fluids after checking for the gag reflex. 2. Assist the patient to a semi-Fowler's position. 3. Report signs of laryngeal edema such as stridor. 4. Check sputum for signs of hemorrhage.

Answer 2: The UAP can assist the patient to move and make position changes. The other tasks are nursing responsibilities. (Note to student: The UAP could ordinarily be expected to watch for and report seeing blood in specimens; however, some blood is an expected finding after biopsy and the nurse should do the assessment to determine if bleeding is excessive.)

The patient's cardiac monitor shows a regular rhythm with a rate of 65 beats/min, P waves precede each QRS complex, QRS complexes are symmetrical and regularly spaced, and a normal T wave shows repolarization. What is the nurse's interpretation of the monitor display? 1. Vital signs should be immediately assessed. 2. The monitor indicates a normal sinus rhythm. 3. The monitor is showing a benign dysrhythmia. 4. The patient should be assessed for chest pain.

Answer 2: The monitor is showing a normal sinus rhythm. (Note to student: If there is ever any doubt about the monitor function or display or if you doubt your interpretation of the electrocardiogram tracing, assess the patient for pain or other signs and symptoms.)

A patient is admitted for venous thrombosis in the left leg. He is in good spirits during the am assessment, but later in day, he reports feeling mildly short of breath with a sense of impending doom. Which action would the nurse take first? 1. Obtain an order for an arterial blood gas. 2. Check the vital signs and pulse oximeter reading. 3. Assess the left leg for warmth, redness, or swelling. 4. Alert the RN about possible pulmonary embolus.

Answer 2: The nurse would first check vital signs and a pulse oximeter reading and assess for other signs of respiratory distress or decreased cardiac output. Notifying the RN and HCP would be the next step. A arterial blood gas analysis is likely to be ordered. Assessing the leg is not helpful once the thrombus becomes an embolus.

The patient had a hip arthroplasty and returned from the postanesthesia care unit several hours ago. The patient is now restless and anxious. Which action is the priority? 1. Decrease anxiety by reassuring the patient that everything is going as expected. 2. Initiate vital signs every 15 minutes, compare to baseline, and monitor trends. 3. Look at the urinary output and compare the total to baseline. 4. Call the patient's family and invite them to spend time at the bedside.

Answer 2: The nurse's first action would be to assess for signs/symptoms of hypovolemic shock. An increase in pulse is an early sign. A decrease in blood pressure comes later. The nurse could also look at the urinary output, but the most useful piece of data is to know output per hour. Reassurance and visitors are appropriate if the patient is physically stable and needs additional emotional support.

To assess the temperature and texture of the patient's skin, which technique would the nurse use? 1. Use the fingertips and gently palpate the affected area. 2. Use the palms of the hands and compare opposite body areas. 3. Use a cotton-tipped applicator and apply gentle pressure. 4. Use a gloved finger to touch skin and ask about sensations.

Answer 2: The palm of the hand supplies more information about temperature and texture than the fingertips, and both sides should be compared. A cotton-tipped applicator can be used to test for sensation. Use of gloves is recommended if the skin is broken or if mucous membranes are being assessed.

A patient who is waiting for diagnostic testing for a possible aortic aneurysm suddenly reports severe chest pain. He becomes pale, weak, and confused. His pulse is 130 beats/ min and blood pressure is 85/50 mm Hg. What would the nurse do first? 1. Call the HCP. 2. Put the patient in a supine position. 3. Assess pain and give opioid medication. 4. Establish a patent peripheral IV.

Answer 2: The patient is showing signs and symptoms of a ruptured aneurysm and hypovolemic shock. The nurse would place the patient in a shock position and immediately call for help. (Note to student: See Chapter 47, Nursing Interventions for Hypovolemic Shock, for additional information. Rapid Response Team, code team, or hospitalist may be available in different facilities.) The patient does need a patent IV. Giving pain medication is not a priority, although oxygen should be started.

The nursing student places an automatic BP cuff on the patient's right arm and puts the pulse oximeter on the right hand. The pulse oximeter reading is below 90%. Which action would the student take first? 1. Report the findings to the nurse or instructor. 2. Redo the pulse oximeter reading on the other hand. 3. Assess the patient for shortness of breath. 4. Document the finding in the patient's record.

Answer 2: The student remembers that the automatic BP cuff occludes blood flow to the distal portions of the extremity, so the first pulse oximeter reading is likely to be falsely low.

Tissue plasminogen activator (TPA) is being considered for a patient with an acute myocardial infarction. Which disclosure is a contraindication for TPA? 1. Patient is a Jehovah's Witness. 2. Patient recently had a head injury. 3. Patient forgot to take insulin this morning. 4. Patient had a small heart attack last year.

Answer 2: Thrombolytics are not used for patients with active internal bleeding, suspected aortic dissecting aneurysm, recent head trauma, history of hemorrhagic stroke within the past year, or surgery within the past 10 days.

A patient who was in a traffic accident shows mild respiratory distress, and during inspiration, the right side of the chest rises less compared to the left. The emergency team initiates care for which disorder? 1. Pleural effusion 2. Pneumothorax 3. Empyema 4. Pulmonary edema

Answer 2: Trauma combined with uneven chest expansion is associated with pneumothorax (collapsed lung).

Which action would be included in "RICE" for the self-care of a sprained ankle? 1. Gently rub the ankle 2-3 times a day to stimulate circulation. 2. Apply an ice pack wrapped in a towel to protect the skin. 3. Use crutches as directed until the next follow-up appointment. 4. Perform active range-of motion exercises three times per day.

Answer 2: Treatment of sprains usually consists of rest, ice, compression, and elevation (RICE) of the affected area.

The patient is on the cardiac monitor while undergoing a diagnostic procedure. Suddenly, the monitor shows ventricular fibrillation. Which piece of equipment is the most vital? 1. Temporary pacemaker 2. Defibrillator 3. Bag-valve-mask 4. Crash cart

Answer 2: Ventricular fibrillation can be reversed if an electrical countershock is applied using the defibrillator. If defibrillation fails to convert the dysrhythmia, a bag-valve-mask with supplemental oxygen and a crash cart will be needed. A temporary pacemaker is not typically used for ventricular fibrillation.

The nurse hears in report that the patient has Volkmann's contracture of the dominant upper extremity. Which intervention would the nurse plan to use? 1. Frequently assess using the seven Ps of orthopedic assessment. 2. Assess the patient's abilities to perform activities of daily living. 3. Teach the patient to report pain, loss of sensation, or swelling. 4. Instruct the UAP on proper position and alignment.

Answer 2: Volkmann's contracture is a permanent contracture that can result from undetected and untreated compartment syndrome. The result is clawhand with flexion of the wrist and hand and atrophy of the forearm. The nurse would assess the patient's abilities to perform activities of daily living. The other options are actions that should have been performed during the patient's initial injury and treatment.

An older neighbor just fell down. He cheerfully says, "I tripped on the carpet and took a spill. No harm done!" Based on mechanism of injury, which assessment is the nurse most likely to perform if the neighbor will allow it? 1. Head-to-toe to detect occult injury 2. Palpation and range of motion for wrist injury 3. Mental status examination for head injury 4. Environmental assessment for other hazards

Answer 2: When a person falls, the natural instinct is to extend the arms out to break the fall. This results in a Colles' fracture, which is a fracture of the distal portion of the radius within 1 inch of the wrist joint. A head-to-toe assessment always gives good information, but the obvious injuries should be addressed first in this "field" situation. Mental status examination would be the priority if the patient could not relate details of the fall (e.g., loss of consciousness because of a cardiac, neurologic, or metabolic event). Based on the patient's current status, the environmental assessment should be performed after other potential injuries are assessed.

The patient is diagnosed with pleurisy. Which adventitious breath sounds is the nurse most likely to hear? 1. Interrupted crackling or bubbling sounds more common on inspiration 2. Deep, loud, low, coarse sound (like a snore) during inspiration or expiration 3. Dry, creaking, grating, with a machinelike quality loudest over anterior chest 4. High-pitched, musical, whistlelike sound during inspiration or expiration

Answer 3: A pleural friction rub is considered diagnostic for pleurisy. The nurse should hear a dry, creaking, grating, low-pitched sound with a machinelike quality during both inspiration and expiration. Crackles are interrupted crackling or bubbling sounds more common on inspiration (e.g., pneumonia). Sonorous wheezes are deep, loud, low, coarse sounds (like a snore) during inspiration or expiration (e.g., secretions, tumor, or spasm). Sibilant wheezes are high-pitched, musical, whistlelike sounds during inspiration or expiration (e.g., foreign matter or tumor compression).

The patient had a permanent tracheostomy 1 month ago. At this point, what is likely to be the patient's priority concern? 1. Breathing independently and safely 2. Secreting adequate amounts of mucus 3. Being unable to produce normal speech 4. Swallowing without choking or gagging

Answer 3: Air cannot pass over the vocal cords, so normal speech is impossible. The patient can breathe through the tracheostomy opening. Secretions will be produced, but interventions relate to keeping the skin around the opening clean and dry. The esophagus and trachea do not communicate, so choking is not anticipated.

The nurse sees that the patient has a new prescription for alendronate. In addition to medication teaching, which self-care measure is the nurse most likely to review with the patient? 1. Fluid intake of at least 2000 mL daily 2. Postural and breathing exercises 3. Weight-bearing exercise, such as walking 4. Application of heat and cold packs for pain

Answer 3: Alendronate is prescribed for osteoporosis. Patients are encouraged to do regular weight-bearing exercise to strengthen muscles, prevent bone loss, and stimulate bone formation. Calcium and vitamin D supplements may be prescribed, and the nurse should review dietary sources for these nutrients.

The nurse hears in report that the patient has anemia. Based on this information, what would the nurse expect to observe when assessing the patient's integumentary system? 1. Cyanosis in the periphery 2. Yellow tinge of conjunctivae 3. Pallor of mucous membranes 4. Brown concentration of melanin

Answer 3: Anemia, (low hemoglobin and hematocrit), causes the skin to appear pale and unhealthy. Yellow discoloration (jaundice) is usually associated with elevated levels of bilirubin (e.g., liver or gallbladder disorders). Cyanosis is caused by decreased oxygenation to the tissues (e.g., chronic obstructive pulmonary disorder). Brown spots, related to concentrations of melanin, are associated with aging.

Which patient should be counseled about the risk of cardiomyopathy related to lifestyle choices? 1. High-risk sexual behavior 2. Poor intake of dietary fiber 3. Use of crack cocaine 4. Social consumption of alcohol

Answer 3: Cardiomyopathy can be caused by cocaine abuse. Cocaine causes intense vasoconstriction of the coronary arteries and peripheral vasoconstriction, resulting in hypertension. Cocaine also causes high circulating levels of catecholamines, which may further damage myocardial cells, leading to ischemic or dilated cardiomyopathy. The prognosis is poor. Excessive alcohol intake over a prolonged period also increases the risk.

A patient who has atrial fibrillation is prescribed dabigatran. Which assessment will the nurse perform related to the prescribed medication? 1. Assess for relief of pain and discomfort. 2. Assess for regularity and strength of pulse. 3. Assess for bruising and bleeding along the gumline. 4. Assess for dependent edema in the lower extremities.

Answer 3: Dabigatran, rivaroxaban, and apixaban are novel oral anticoagulants (NOACs) that are commonly prescribed for atrial fibrillation. The nurse would assess for bruising or other signs of bleeding.

The nurse hears during shift report that the patient was admitted for penicillin-induced dermatitis medicamentosa. Which question is the most important to ask? 1. "Was the affected area immediately washed and rinsed?" 2. "Has the patient been medicated for pain and itching?" 3. "Has the patient had any respiratory distress?" 4. "Does the patient have any fever or other signs of infection?"

Answer 3: Dermatitis medicamentosa can cause patients to have respiratory distress. Dermatitis venenata is caused by contact with plants and the area should be immediately washed. Pain, itching, and infection are possible complications for many skin disorders, but these problems have lower priority than respiratory distress.

For a postsurgical patient, which intervention is the most important in preventing venous thrombosis in the legs? 1. Applying elastic compression stockings 2. Elevating the lower extremities 3. Ensuring early ambulation and mobility 4. Measuring the calf circumference daily

Answer 3: Early ambulation and encouraging mobility, which includes change of position and range-of-motion exercises, are the most important preventive measures. Compression stockings and calf measurements are part of prevention and detection. Elevating the legs may be prescribed as a comfort measure if venous thrombosis occurs.

The nurse is assisting a mother to plan meals for a child who was recently diagnosed with eczema. Which foods would the nurse mention as common allergens associated with eczema? 1. Strawberries and cured meats 2. Eggs, rye, and preservatives 3. Orange juice, wheat, and eggs 4. Wheat, sugar, and bananas

Answer 3: Eczema is associated with allergies to chocolate, wheat, eggs, and orange juice.

Which sign/symptom indicates to the nurse that a patient with endocarditis is experiencing a serious common complication of the disease? 1. Fever and chills 2. Joint pains and aches 3. Sudden shortness of breath 4. Petechiae on neck and chest

Answer 3: Endocarditis puts the patient at risk for emboli that can travel to any organ. Sudden shortness of breath suggest that a large embolus or numerous small emboli have lodged in the lungs. The other signs/symptoms are also clinical manifestations of endocarditis.

A neighbor says, "I had indigestion that has lasted 60 minutes and I took my nitroglycerin, but it didn't help." What would the nurse do first? 1. Tell the neighbor to take an aspirin and then drive to the emergency department. 2. Stay with the neighbor, assist him to remain calm, and call 911. 3. Assess the neighbor's use of nitroglycerin and assess for other symptoms. 4. Phone the neighbor's HCP and ask for recommendations.

Answer 3: First, the nurse would determine if the correct dose and form of the nitroglycerin were taken. If the nitroglycerin was taken correctly, then the nurse may opt to quickly assess for other symptoms that suggest cardiac or digestive problems. Based on the assessment, the nurse may decide to call 911 or the HCP. The neighbor should not drive himself to the hospital.

A patient has peripheral arterial disease with burning pain in the right leg that occurs at rest. Which intervention will the nurse use? 1. Elevate the leg on a pillow. 2. Use a covered ice compress. 3. Place the leg in a dependent position. 4. Encourage aerobic exercise for circulation.

Answer 3: For arterial insufficiency, the leg should be dependent because this will increase the blood flow to the tissues and help decrease the pain. The other options are likely to increase pain. Elevation and ice will decrease the blood flow. Exercise must be balanced with rest.

For a patient with newly diagnosed asthma, what is the best rationale for the home health nurse to assess the home environment? 1. Identify any activity intolerance related to the design of the home. 2. Assess the safety of the environment related to the use of home oxygen. 3. Identify stimulants or allergens that are triggering the asthma attacks. 4. Evaluate the need for a home health aide to accomplish ADLs.

Answer 3: For newly diagnosed asthma patients, identification of allergens in the home environment will help them to control/avoid exposure and will decrease episodes of acute attacks. These patients should be able to resume normal activities after treatment for an acute episode.

The home health aide phones the nurse and says, "Yesterday, I helped the patient bathe. I wore gloves, but afterwards he told me that he has herpes zoster." Which question would the nurse ask first? 1. "Are you having a painful burning rash with itching?" 2. "Did the patient have fluid-filled vesicles on the back or trunk?" 3. "Have you received two doses of varicella vaccine?" 4. "How long were you in contact with the patient?"

Answer 3: Health care staff who have received two doses of the varicella vaccine should be assessed for symptoms 8-21 days after exposure to the patient with shingles. Staff who develop symptoms consistent with herpes zoster should be removed from active duty. Health care staff who have not received the two doses of varicella vaccine may be infective for 8-21 days and should be moved to another duty location away from patient care.

The nurse is reviewing the admission orders for a patient who was diagnosed with pulmonary edema. Which order is the nurse most likely to question? 1. Oxygen 2 L per nasal cannula 2. Notify HCP with all blood gas results 3. IV normal saline at 250 mL per hour 4. Place on telemetry monitor

Answer 3: IV fluids are usually withheld to prevent adding fluids to the overloaded patient. (An IV saline lock would be the expected.) The other options are appropriate for patients with pulmonary edema.

The nurse finds a patient on the bathroom floor. The patient is unresponsive and there is no palpable pulse. Which action will the nurse take first? 1. Notify the supervising RN and health care provider (HCP). 2. Initiate advanced cardiac life support (ACLS). 3. Start cardiopulmonary resuscitation (CPR). 4. Initiate electrocardiogram (ECG) monitoring.

Answer 3: If a patient is discovered unresponsiveness with no palpable pulse, the first person on the scene initiates CPR. CPR is part of basic life support (BCLS), which continues until the Rapid Response Team arrives and starts ACLS. ECG monitoring is part of ACLS. The supervising RN and HCP are notified as soon as possible, but emergency care would not be delayed.

For which dysrhythmia would a pacemaker most likely be necessary? 1. Sinus tachycardia 2. Premature ventricular contractions 3. Third-degree heart block 4. Atrial fibrillation

Answer 3: In third-degree heart block, the impulses to stimulate heart muscle contraction are not being transmitted through the atrioventricular junction. The rate is very slow and hypotension and angina are likely.

What is the common factor for etiology and pathophysiology of folliculitis, furuncles, and carbuncles? 1. Superficial infections are caused by fungus. 2. Parasites get underneath the skin. 3. Hair follicles are infected or inflamed. 4. There is an allergic response to an allergen.

Answer 3: Infected or inflamed hair follicles occur in folliculitis, furuncles, and carbuncles.

The nurse instructs the patient on use of lindane. Which additional instructions will the nurse give? 1. If skin lesion starts to bleed or ooze or feels different (swollen, hard, lumpy, itchy, or tender to the touch), report symptoms to the HCP. 2. Apply broad-spectrum sunscreens with a sun protection factor of 15 or greater approximately 15 minutes before sun exposure and after swimming. 3. Furniture, carpeting, and car interiors must be cleaned. Wash bed linens in hot water; then use dryer. Put stuffed toys in hot dryer for a full cycle. 4. Use neutral soaps and avoid hot water and vigorous rubbing. Skin and hair should be washed to remove excess oil and excretions and to prevent odor.

Answer 3: Lindane is a treatment for lice. The environment must be treated to prevent reinfection. Bleeding or oozing or a change in a lesion or mole is one of the warning signs of skin cancer that should be reported to the HCP. Use of sunscreen is recommended for protection against skin cancer and for patients that have skin sensitivity (e.g., systemic lupus erythematosus). Patients with acne are advised to use neutral soaps; wash hair and body to remove excess oil and secretions and to prevent odor; and to avoid hot water and vigorous rubbing.

The nurse is assessing a patient who had a myelogram 3 hours ago. Which patient comment causes the greatest concern? 1. "My head hurts. Could I get an aspirin or a Tylenol tablet?" 2. "I am thirsty. Would it be okay if I drank a soda or some juice?" 3. "My foot feels numb and I can't move my toes very well." 4. "I am not used to lying in bed all day long; I'd like to walk around."

Answer 3: Loss of sensation and movement are unexpected complications that should be reported. Headache is the most common symptom, but if correct positioning and prescribed analgesics do not relieve the pain, this should also be reported. Patients are encouraged to take fluids to flush the dye from the body. Patients are usually in a flat or semi-Fowler's position for 8-12 hours; the nurse would explain the purpose of the position and initiate diversion interventions (e.g., television, reading, listening to music).

The HCP informs the nurse that the patient has occasional premature ventricular contractions (PVCs). Which assessment finding would the nurse expect? 1. Shallow, rapid respiration with PVCs 2. Chest pain when the PVCs occur 3. Irregular rate and rhythm when palpating pulse 4. Blood pressure lower than 120/80 mm Hg

Answer 3: PVCs are early abnormal ventricular beats that occur in conjunction with the underlying rhythm; therefore, the nurse will note a change in the rate and rhythm of the palpated pulse. Some patients are asymptomatic; others may experience palpitations, weakness, and lightheadedness.

For a patient with myocardial infarction, which symptom is the most important? 1. Diaphoresis 2. Palpitations 3. Pain 4. Shortness of breath

Answer 3: Pain is the foremost symptom and is the target of immediate therapy, because pain is a signal of ischemia. Diaphoresis is secondary to pain or possibly hypotension. Palpitations could occur, but are not a typical complaint. Shortness of breath is related to the body's attempt to increase oxygen to the tissues.

The patient who had a laminectomy reports abdominal discomfort with a gaseous, bloated feeling and mild nausea. What would the nurse do first? 1. Offer clear liquids. 2. Encourage ambulation. 3. Listen for bowel sounds. 4. Administer an antiemetic.

Answer 3: Patients who have had a laminectomy are at risk for a paralytic ileus; therefore, the nurse would first assess for possible bowel obstruction.

A patient who has rheumatoid arthritis (RA) has been taking aspirin for a long time and she reports feeling a little more tired than usual. Which point of care testing is the HCP most likely to direct the nurse to perform? 1. Blood glucose level 2. Rapid strep test 3. Guaiac test on stool 4. Blood pressure screening

Answer 3: Prolonged use of aspirin can cause gastrointestinal bleeding. Patients with RA frequently suffer fatigue, anemia, and low-grade fever. The HCP is also likely to order a complete blood count and erythrocyte sedimentation rate (ESR).

A patient is diagnosed with viral laryngitis. Which discharge instruction is the most important to relieve the inflammation and edema of the vocal cords? 1. Use a mild analgesic such as acetaminophen for pain. 2. Complete the full course of antibiotics. 3. Rest the voice; communicate with gestures or by writing. 4. Suck on throat lozenges to promote comfort.

Answer 3: Resting the voice is the most important measure to reduce the inflammation of the vocal cords. Mild analgesics and lozenges help to promote comfort. Antibiotics are not prescribed for a diagnosis of viral laryngitis

The patient with heart failure has 4+ pitting edema in the lower extremities. Which assessment is the priority? 1. Check for edema in the sacrum. 2. Weigh the patient. 3. Observe respiratory effort. 4. Observe for jugular vein distention.

Answer 3: Severe pitting edema will progress upward, and it is likely that there is fluid retention throughout the body. The nurse would first observe respiratory effort. If the patient needs immediate intervention for dyspnea or orthopnea, the nurse will intervene (e.g., position change, oxygen, and diuretics as prescribed). The nurse will also make the other assessments.

The nurse is caring for a patient with valvular heart disease. Which task could be assigned to the UAP? 1. Identify activities of daily living that cause fatigue. 2. Check meal trays for high-sodium foods. 3. Weigh the patient at the same time every day. 4. Explain the plan for rest periods.

Answer 3: The UAP can weigh the patient. The other tasks are nursing responsibilities.

During the well-baby physical, a newborn demonstrates a respiratory rate of 50 breaths/ min. How does the nurse interpret this data? 1. Newborn's respiratory rate suggests a hy- permetabolic state, such as fever. 2. Newborn must be immediately taken to resuscitation area for respiratory distress. 3. Newborn's respiratory rate is within the expected range for developmental age. 4. Newborn's respiratory rate is borderline high and should be closely monitored.

Answer 3: The expected respiratory rate is 40- 60 breaths/minute for a newborn.

A patient is admitted for pain and tenderness in his lower right leg. The nurse's assessment reveals that the extremity is warm, swollen, and has a slightly pitted appearance. Which measure would the nurse use to relieve the discomfort? 1. Assist the patient to ambulate as much as possible. 2. Administer cool compresses or a covered ice bag. 3. Elevate the leg with pillows to reduce edema. 4. Assist with a therapeutic bath and gently pat skin to dry.

Answer 3: The most likely diagnosis is cellulitis. The extremity should be immobilized and elevated. Warm, moist dressings are applied to relieve discomfort. Therapeutic baths are usually used for dry or itchy skin.

The school nurse is assessing a 15-year-old girl and notices multiple linear superficial cuts over the girl's anterior forearms. What would the nurse do first? 1. Call child protective services to report possible abuse. 2. Notify the girl's parents about the finding. 3. Ask the girl directly what happened to her arms. 4. Initiate protective measures to prevent self-harm.

Answer 3: The nurse may suspect selfmutilation, but must conduct further assessment. Based on the assessment, the nurse might consider using the other options.

The darker-skinned patient reports an itching sensation, but the nurse cannot detect a rash with visual inspection. Which assessment technique would be the best? 1. Ask the patient if the skin appears different. 2. Compare patient's skin to pictures of rashes. 3. Palpate for warmth and induration. 4. Examine the skin in natural lighting.

Answer 3: The nurse would use touch, rather than visual observation, to detect a rash. The patient's subjective reports and use of natural lighting may be helpful. Use of pictures may be helpful if the nurse could see a rash.

A patient reports decreased appetite, malaise, and a decreased sense of smell. There is pain over the sinus area with gentle palpation. Which equipment would the HCP need to perform diagnostic testing? 1. Tongue blade 2. Percussion hammer 3. Penlight 4. Cotton-tipped applicator

Answer 3: The patient has symptoms of sinusitis. Transillumination involves shining a light in the mouth with the lips closed around it; infected sinuses will look dark, whereas normal sinuses will transilluminate.

The patient says to the nurse, "I have excruciating pain in my big toe at night." Which assessment question is the nurse most likely to ask? 1. "Have you noticed a change in your bowel movements?" 2. "How much exercise would you normally get in a week?" 3. "Do you eat organ meats, yeast, herring, or mackerel?" 4. "Do you notice jaw tension, excessive fatigue, or anxiety?"

Answer 3: The patient is describing the symptoms of gout; thus, the nurse would do a dietary history to include specific questions about alcohol, organ meats, anchovies, yeast, herring, mackerel, or scallops, because foods high in purines worsen gout. Patients with ankylosing spondylitis should be asked about bowel changes. All patients should be asked about exercise routines. Jaw tension, excessive fatigue, or anxiety would be more typical for patients with fibromyalgia.

The home health nurse is reviewing the patient's laboratory results and sees that the overall serum cholesterol level is 230 mg/dL (6.18 mmol/L). Based on the laboratory results, which patient education topic is the nurse most likely to review with the patient? 1. Importance of ambulation and mobility 2. Coping and stress reduction techniques 3. Dietary sources of fat and weight reduction 4. Methods to increase medication compliance

Answer 3: The patient would benefit from any of these topics; however, reducing fat in the diet and reducing weight are the most important topics for lowering cholesterol levels. An overall serum cholesterol level of less than 200 mg/dL (5.172 mmol/L) is desirable, 200- 239 mg/dL (5.172-6.18 mmol/L) is borderline high, and more than 239 mg/dL (6.18 mmol/L) is high.

At a restaurant, several men are talking, laughing, drinking, and eating. Sitting nearby, the nurse hears, "Hey! Are you all right?" Which behavior signals a need to intervene for choking? 1. Vigorous coughing 2. Running from the room 3. Hand over throat 4. Waving hands frantically

Answer 3: The universal sign for choking is hand over the throat. People who are vigorously coughing should be encouraged to continue coughing. While running out of the room is not an obvious signal, people have been known to leave out of embarrassment. Waving hands frantically is a signal, but cause would have to be assessed.

Which intervention is the most important if 1600 mL of fluid were removed during a therapeutic thoracentesis? 1. Perform routine postprocedure assessments. 2. Increase the fluid intake to compensate for the loss. 3. Watch for signs and symptoms of pulmonary edema. 4. Follow up to get the results of the fluid specimen.

Answer 3: Usually no more than 1300 mL of fluid is removed at one time because there is a risk of intravascular fluid shifting that will result in pulmonary edema. Because of the risk for pulmonary edema, the nurse is likely to increase the frequency of assessment. Giving the patient extra fluid could worsen fluid shifting. If the purpose was therapeutic, the fluid may or may not have been sent to the laboratory for analysis.

A patient on the medical-surgical unit is on remote telemetry. Which instruction would the nurse give to the UAP? 1. "Patient is not allowed to ambulate while wearing the telemetry device." 2. "Remove the telemetry device before helping the patient to shower." 3. "When the patient is ready to go for x-rays, alert the charge nurse." 4. "Check the lead wires of the telemetry device and test the battery."

Answer 3: When the patient leaves the unit, the charge nurse should be alerted because the distance to the x-ray department may exceed the range of the monitor. The patient should ambulate with the device in place. This allows the team to monitor heart activity during minor exertion. Removing the monitor to shower is incorrect, unless specifically ordered by the HCP, because a cardiac event could occur. Checking the function of the unit should not be delegated to the UAP. Licensed personnel would assume this responsibility.

A patient was treated for epistaxis with nasal packing saturated with 1: 1000 epinephrine. During the postprocedure assessment, the nurse notices that the patient swallows frequently. Which question would the nurse ask? 1. "Does your throat feel swollen or painful? " 2. "Would you like some cool fluids to drink? " 3. "Is blood running down the back of your throat? " 4. "Are you tasting epinephrine in your throat? "

Answer 3: With epistaxis, frequent swallowing suggests that the blood is running down the back of the throat. This could either be rebleeding or posterior bleeding. Posterior bleeding is not always resolved with anterior packing.

Which findings would be considered early signs/symptoms of a stage 1 pressure injury? 1. Shallow, open, shiny, dry injury; pink-red wound bed without sloughing or bruising 2. Full-thickness tissue loss, subcutaneous fat visible; possible undermining and tunneling 3. Full-thickness tissue loss, slough and black eschar in wound bed with undermining and tunneling 4. Intact skin with nonblanchable redness, painful, warm, soft, localized area over a bony prominence

Answer 4: A stage 1 pressure injury is a localized intact area with nonblanchable redness, typically over a bony prominence. The wound characteristics vary: areas may be painful, firm, soft, warm, or cool compared with adjacent tissue. A stage 2 pressure injury is a partial-thickness loss of dermis. It appears as a shallow open injury, usually shiny or dry, with a red-pink wound bed without slough or bruising. A stage 3 pressure injury involves full-thickness tissue loss; subcutaneous fat is sometimes visible. Possible features are undermining and tunneling. A stage 4 pressure injury involves full-thickness tissue loss with exposed bone, tendon, cartilage, or muscle. Slough or eschar may be present on the wound bed. Undermining or tunneling are frequently present.

A patient being treated for atelectasis has been prescribed acetylcysteine. What is the purpose of this medication? 1. Reduce the risk of infection 2. Dilate the bronchioles 3. Enhance the cough reflex 4. Reduce viscosity of secretions

Answer 4: Acetylcysteine is used to reduce the viscosity of secretions. This makes expectoration easier and more effective.

The patient reports long bone pain that increases with weight bearing. The serum alkaline phosphatase is elevated. The nurse provides emotional support to the patient because the HCP must order additional diagnostic testing to rule out which condition? 1. Phantom limb pain 2. Rheumatoid arthritis 3. Fibromyalgia 4. Osteogenic sarcoma

Answer 4: An elevated serum alkaline phosphatase signals osteogenic sarcoma or other bone disorders (liver disease is also associated with elevated alkaline phosphatase). Phantom limb pain occurs after amputation for some individuals. Fibromyalgia has a variety of symptoms, but the pain tends to be in the muscles and in the low back. Rheumatoid arthritis is a chronic autoimmune disorder that can lead to severe joint deformity.

For a patient with chronic bronchitis, what is the physiologic cause of polycythemia? 1. Medication side effect 2. Dehydration and fluid shifting 3. Nutritional deficiency 4. Compensation for chronic hypoxemia

Answer 4: An increased number of red blood cells (polycythemia) occurs as the body attempts to increase the oxygen to tissue. Dehydration could contribute to an elevated red cell count, but is not directly related to chronic bronchitis.

After reviewing the 12-lead electrocardiogram, the HCP determines that the patient has an ST-elevation myocardial infarction (STEMI). Which intervention is the priority? 1. Administer beta-adrenergic blocker as prescribed. 2. Transfer to the intensive care unit. 3. Prepare patient for thrombolytic therapy. 4. Administer oxygen at 2 L/minute.

Answer 4: Apply oxygen first. The other interventions are also necessary for patients with STEMI (an acute myocardial infarction caused by complete interruption of blood flow which causes ST elevation).

Which physical assessment would the nurse perform to assist the HCP in identifying atrial fibrillation? 1. Take a manual blood pressure on both arms. 2. Compare bilateral peripheral pulses. 3. Count the apical pulse for a full minute. 4. Obtain help and check for a pulse deficit.

Answer 4: Atrial fibrillation is a very rapid chaotic production of atrial impulses. Heart muscle contractions are too weak to reach the periphery and this manifests as a pulse deficit. To assess for a pulse deficit, one person counts the apical pulse while the other person counts a peripheral (radial) pulse. The deficit is the difference between the two.

A patient is diagnosed with acute bronchitis and instructed to increase fluids to 3000-4000 mL per day. Which fluid is specifically avoided because of the respiratory condition? 1. Coffee 2. Soda 3. Orange juice 4. Milk

Answer 4: Dairy products thicken secretions, so they become more tenacious and harder to expectorate. Coffee, soda, and orange juice are not the ideal choices if the patient has comorbid health conditions (e.g., caffeinated drinks and sodas contribute to loss of calcium and orange juice is not recommended during urinary tract infections). Water, diluted juices, and electrolyte solutions are better choices.

Which patient needs to be monitored for shock? 1. Patient reports pain in the muscles, bones, and joints; headaches; altered thought processes; and stiffness. 2. Patient reports chest pain, especially on inspiration; nurse observes irritability, restlessness, and stupor. 3. Patient experiences deep, unrelenting, progressive, and poorly localized pain unrelieved by analgesics. 4. Patient appears anxious, weak, and lethargic; nurse observes hypotension, tachycardia, and diaphoresis.

Answer 4: Early signs of shock are restlessness, anxiety, weakness, change of mental status, and tachycardia. The patient may have cool, moist, pale skin. As shock progresses, hypotension, hypothermia, and oliguria occur. Pain in the muscles, bones, and joints; headaches, altered thought processes, and stiffness are symptoms of fibromyalgia. During fat embolism, the patient may complain of chest pain especially on inspiration, and localized muscle weakness with spasticity or rigidity. Irritability, restlessness, disorientation, and stupor may occur. Deep, unrelenting, progressive, and poorly localized pain unrelieved by analgesics is characteristic of compartment syndrome.

The inner linings of the pharynx and the eustachian tube are continuous. In children, this normal anatomic structure contributes to which common disorder? 1. Asthma 2. Epistaxis 3. Laryngitis 4. Ear infections

Answer 4: Eustachian tubes are on both sides of the nasopharynx and connect to the middle ear. The inner linings of the pharynx and the eustachian tube are continuous, and an infection of the pharynx can spread easily to the ear. This is common in children.

The patient displays significant respiratory distress. Which objective finding is generally regarded as a late sign of respiratory distress? 1. Shows increased respiratory rate 2. Has adventitious breath sounds 3. Assumes orthopneic position 4. Demonstrates flaring of nostrils

Answer 4: Flaring of the nostrils is usually considered a late sign. Increased respiratory rate is associated with many conditions. Some are serious (e.g., pulmonary edema), and others are benign (aerobic exercise). Adventitious breath sounds can be present, and the patient may not be aware that there is a problem (e.g., immobile patients can have crackles). The orthopneic position does signal respiratory distress but is also used by many patients who have chronic respiratory disorders.

A 63-year-old patient presents with fever, increased pulse, epistaxis, and joint involvement. Heart murmurs are auscultated. The patient has a history of inadequately treated childhood group A β-hemolytic streptococcus pharyngitis. These findings and history are consistent with which medical diagnosis? 1. Cardiomyopathy 2. Angina 3. Left-sided heart failure 4. Rheumatic heart disease

Answer 4: Fortunately, rheumatic fever now occurs less frequently in the United States, because treatment for group A b-hemolytic streptococci infections has improved. For older patients or for patients who have emigrated from undeveloped countries, the possibility for rheumatic heart disease still exists.

Which electrolyte abnormality would prompt the nurse to assess the patient for airway obstruction secondary to laryngeal spasm? 1. Blood glucose: 350 mg/dL (19.4 mmol/L) 2. Potassium: 6.0 mEq/L (6.0 mmol/L) 3. Sodium: 130 mEq/L (130 mmol/L) 4. Calcium: 7.5 mg/dL (1.87 mmol/L)

Answer 4: Hypocalcemia or calcium that is below 9.0 mg/dL (2.25 mmol/L) can cause laryngeal spasm, which would block the airway. All of the electrolyte levels are abnormal and need to be immediately reported to the HCP. Normal ranges: calcium 9.0-10.5 mg/dL (2.25- 2.75 mmol/L); sodium 136-145 mEq/L (136-145 mmol/L); potassium 3.5-5.0 mEq/L (3.5-5.0 mmol/L); blood glucose 70-110 mg/dL (<6.1 mmol/L)

For a child who is "having an asthma attack," which assessment finding is cause for greatest concern? 1. Audible wheezing on expiration 2. Subjective sensation of chest tightness 3. Substernal and clavicular retractions 4. Symptoms fail to respond to usual treatment

Answer 4: If symptoms continue and fail to respond to usual treatment (status asthmaticus), the patient is at risk for respiratory failure. All of the signs/symptoms can manifest during an acute asthma episode, but retractions are considered a late stage of respiratory distress.

Which patient is the most likely candidate to meet the criteria for a cardiac transplant? 1. Has type 1 diabetes with end-organ damage 2. Has mild heart disease stabilized by medication 3. Has a history of mental illness 4. Has inoperable coronary artery disease

Answer 4: Inoperable coronary artery disease is an indication for transplant. Diabetes with organ damage and mental illness are contraindications. A patient with mild heart disease that is responsive to medications would not be eligible for the transplant list. See Box 48.7 for additional information.

The medication reconciliation list for a patient who has osteoarthritis includes tramadol, acetaminophen, lisinopril, cortisone, and ibuprofen. Which drug-drug combination is cause for greatest concern? 1. Lisinopril and tramadol 2. Lisinopril and acetaminophen 3. Lisinopril and cortisone 4. Lisinopril and ibuprofen

Answer 4: Lisinopril is an antihypertensive medication and the combination of lisinopril and ibuprofen can cause a hypertensive response.

Laboratory results show a low hemoglobin for a patient diagnosed with myocardial infarction. Which intervention would the nurse perform first to address this laboratory result? 1. Obtain an order for an intramuscular iron supplement. 2. Help the patient to order an iron-rich meal tray. 3. Obtain an order for type and cross for blood transfusion. 4. Check to see that oxygen is delivered as prescribed.

Answer 4: Low hemoglobin indicates decreased ability to carry oxygen to the body cells and anemia, so the first action is to make sure that the patient is getting supplemental oxygen. (Oxygen is likely to have been previously prescribed for a diagnosis of myocardial infarction; if not, the nurse should start oxygen and then obtain a prescription.) The other options could also be included to correct low hemoglobin.

The patient has progressive hypoxia that is affecting the medulla oblongata and pons of the brain. Which outcome would occur if hypoxia is left untreated? 1. Pneumonia and lung consolidation 2. Tachycardia with respiratory alkalosis 3. Brain herniation and respiratory arrest 4. Bradycardia with slow, shallow respirations

Answer 4: Medulla oblongata and pons of the brain (brain stem) are responsible for the basic rhythm and depth of respiration. Progressive hypoxia causes respiratory depression, with bradycardia and slow, shallow respirations. Uncontrolled and excessive intracranial pressure can cause brain herniation, which will result in respiratory arrest.

Which symptom would be an early warning of cancer of the larynx? 1. Pain radiating to the ear 2. Difficulty swallowing 3. Feeling of a lump in the throat 4. Progressive or persistent hoarseness

Answer 4: Progressive or persistent hoarseness is an early sign of laryngeal cancer. Signs of metastasis to other areas include pain in the larynx radiating to the ear, difficulty swallowing, a feeling of a lump in the throat, and enlarged cervical lymph nodes.

The patient experiences dizziness and lightheadedness while trying to pass a bowel movement. An immediate pulse check shows 45 beats/min that rapidly recovers to a regular rate of 70. What is the most probable cause of this episode of sinus bradycardia? 1. Digitalis toxicity 2. Endocrine disturbance 3. Intracranial tumor 4. Vagal stimulation

Answer 4: Recall that bearing down is one way to cause vagal stimulation. The other options can also cause sinus bradycardia but are less likely to have such a rapid recovery to a regular rate.

Which psychosocial behaviors are more likely to be associated with increased cardiovascular symptoms? 1. Frequently in a hurry and generally impatient 2. Easygoing and usually enjoys life 3. Neat, organized, and pays attention to detail 4. Pessimistic and generally expresses negativity

Answer 4: Recent studies indicate that type D personality has the highest risk for cardiovascular problems because of increased anxiety and depression. The type A personality who is in a hurry and often angry or irritated was formerly believed to have the highest risk.

A patient reports hair loss (hypotrichosis). Which assessment is the nurse most likely to conduct to assist the HCP to determine the etiology of hypotrichosis? 1. Type of hair-care products 2. Use of herbal supplements 3. Smoking history 4. Dietary assessment

Answer 4: Skin disease, endocrine problems, and malnutrition are associated factors for hypotrichosis.

The patient had a percutaneous transluminal coronary angioplasty with stent placement. Which type of medication is the patient most likely to be prescribed for at least 3 months? 1. Digitalis preparation 2. Diuretic 3. Opioid pain medication 4. Anticoagulant

Answer 4: Stents are thrombogenic; thus, the patient is likely to be prescribed an anticoagulant

What is the best method to help a patient comply with dietary restrictions associated with atherosclerotic heart disease? 1. Tell him to avoid all foods that are high in fats. 2. Remind him that total fat intake is a percentage of total caloric intake. 3. Tell him to eat the recommended amount of soluble fiber every day. 4. Teach him how to read the nutritional labels on food products.

Answer 4: Teaching him how to read the labels gives him a practical skill that he can use at the grocery store. The other options are vague and therefore less helpful. Patients may not be aware of fat within foods, such as mayonnaise or prepackaged meals. Healthy fats that do not exceed 30% of the total calories are part of good nutrition. Fiber intake should be 20-30 g.

The nurse is caring for a patient with a long bone fracture. The laboratory reports the following arterial blood gas (ABG) results. What would the nurse do first? pH 7.4 Paco2 40 mm Hg Pao2 95 mm Hg HCO3 26 mEq/L Sao2 98% 1. Assess the patient for signs of fat embolism and respiratory distress. 2. Continue to monitor the patient and obtain order for repeat ABG. 3. Place the patient in high-Fowler's position to ease respirations. 4. Check vital signs and report ABG results to health care provider (HCP).

Answer 4: The ABG results are within normal limits. However, respiratory failure is the most common cause of death associated with fat embolism, so the nurse would obtain current vital signs and report ABG results to the HCP. Although the occurrence of fat embolism secondary to long bone fracture is relatively rare, patients with risk for life-threatening conditions are always monitored. A repeat ABG is not needed unless respiratory distress or other symptoms of fat embolism are observed.

A patient is being discharged after receiving a permanent pacemaker. What is the best rationale to give to the patient about refraining from sports such as tennis, swimming, golf, and weight-lifting for the first 6-8 weeks? 1. "First, you have to be able to climb at least two flights of stairs." 2. "Active sports will interfere with the pacemaker's fixed mode." 3. "These sports are too strenuous and rapidly increase the heart rate." 4. "The arm on the pacemaker side should not be lifted over the head."

Answer 4: The arm on the pacemaker side should be immobilized for the first several hours; then for 6-8 weeks, the patient must refrain from lifting the arm over the head. Climbing stairs and participation in active sports are more related to recovery during cardiac rehabilitation. Electrical sources may interfere with the pacemaker's fixed mode.

What is the concern for patients who are being treated for tuberculosis? 1. All the patient's contacts must be identified and treated. 2. Infection control measures are complex and expensive. 3. Many have rapid disease progression with mortality rates up to 89%. 4. Drug therapy lasts 6-9 months and about 50% of patients are noncompliant.

Answer 4: The drug regimen is prolonged and for various reasons, many will fail to complete the therapy. This has contributed to multidrugresistant tuberculosis (TB) strains. Family and friends are generally not at high risk for contracting TB. Hand hygiene and covering the mouth while coughing are encouraged as the main infection control measures.

The nurse is assessing a patient who was recently transferred from home to a skilled nursing facility. The nurse sees a pressure injury with full-thickness tissue loss, which is covered by a thick, black layer of eschar. What would the nurse do first? 1. Gently remove the eschar and check for tunneling and depth. 2. Document the size, depth, and location of this Stage IV injury. 3. Contact the wound care specialist for wound management. 4. Leave eschar intact; collaborate with RN to develop care plan.

Answer 4: The eschar provides protection, so at this point, it is left intact. The RN and LPN/LVN would collaborate to develop a comprehensive, long-term care plan, which may include the wound care specialist. The pressure injury is currently unstageable because it can't be fully assessed.

The nurse is supervising a nursing student in caring for a patient who had internal fixation for a hip fracture. The nurse would intervene if the student performed which action? 1. Assessed the amount of drainage in the Jackson-Pratt drain 2. Encouraged coughing and the use of the incentive spirometer 3. Removed the antiembolism stocking to assess the skin 4. Placed the patient in high-Fowler's position prior to eating

Answer 4: The head of the bed should not be elevated past 45 degrees to a avoid acute flexion on the device. The other actions are part of the postoperative care.

A patient comes to the walk-in clinic and reports retrosternal chest pain that radiates down the left arm. He is anxious, diaphoretic, short of breath, and has vomit on his clothes. Which task is the priority to delegate to the unlicensed assistive personnel (UAP)? 1. Assist the patient to undress and don a patient examination gown. 2. Take, report, and record vital signs and pulse oximeter readings. 3. Take the patient to the bathroom and assist to clean face and rinse mouth. 4. Assist the patient onto stretcher and raise the head to at least 30 degrees.

Answer 4: The initial goal is to conserve oxygen for the heart. Elevating the head of the bed at 30 degrees facilitates breathing. The other actions are within the scope of practice for UAPs and can be accomplished after therapies to increase oxygenation are initiated. Vital signs and pulse oximeter reading are essential for monitoring and to measure physical status but recall that in crisis situations, life-saving actions are prioritized over assessment and monitoring.

The patient with a cast on the lower extremity reports pain at 7/10. What would the nurse do first? 1. Reposition the leg so that elevation is maintained. 2. Administer pain medication as prescribed. 3. Report potential compartment syndrome to RN. 4. Perform the seven Ps of orthopedic assessment.

Answer 4: The nurse performs the assessment first. Based on the assessment findings, the nurse may decide to use the other options.

What is the primary problem in identifying life-threatening respiratory disorders such as Legionnaires' disease, severe acute respiratory syndrome, COVID-19, and anthrax? 1. They are agents used in global germ warfare. 2. The percentage of morbidity and mortality is high. 3. They require isolation because transmission is airborne. 4. At first, symptoms are similar to other respiratory disorders.

Answer 4: The symptoms will mimic other respiratory disorders (e.g., influenza); thus, diagnosis is delayed because more common causes will be investigated first. During this delay, the infection will become more entrenched. Legionnaires' and severe acute respiratory syndrome (SARS) and COVID-19 can be transmitted via droplets in air, so many people could be exposed before the diagnosis is made. Anthrax has been identified as a possible bioterrorism agent. Morbidity and mortality is high for all disorders. For Legionnaires' disease, 1 in 10 will die. For SARS, 10%-20% require intubation and risk for death is high. Anthrax responds to antibiotics once the diagnosis is made. The symptoms of COVID-19 can range from mild to severe. Patients may also be asymptomatic with COVID-19 and infect others.

Which neonate has the greatest risk of being infected by herpes virus during childbirth? 1. Mother has chronic genital herpes, but was never treated. 2. Mother contracted genital herpes during first half of pregnancy. 3. Mother previously had severe genital herpes outbreaks. 4. Mother acquired genital herpes near the time of delivery.

Answer 4: Transmission rate of the herpes virus from an infected mother to a newborn is approximately 30%-50% among women who acquire genital herpes near the time of delivery

The HCP instructs the nurse to immediately report laboratory results to confirm the diagnosis of myocardial infarction. Which laboratory result would the nurse seek first? 1. Creatine phosphokinase 2. Creatine kinase 3. Troponin T 4. Troponin I

Answer 4: Troponin I is the most useful in diagnosing a myocardial infarction because it is cardiac muscle-specific. The other cardiac markers would also be reported; however, those values can be affected by skeletal muscle damage, other muscle disorders, or renal problems

When an arterial blood gas is obtained from a patient who is taking warfarin, which special consideration is needed? 1. The dietary therapy associated with the drug is likely to alter the results. 2. The drug increases fragility of the vessels, so the specimen is hard to obtain. 3. The drug alters the amount of oxygen that hemoglobin can carry. 4. The clotting time is prolonged; pressure is held for 20 minutes on the puncture site.

Answer 4: Warfarin is an anticoagulant, so the nurse would hold pressure on the puncture wound for 20 minutes to prevent a hematoma.

The patient comes to the walk-in clinic and reports itching that started shortly after eating shrimp. The nurse observes that the patient has wheals over the anterior neck and chest. Which assessment would the nurse perform first? 1. Check orientation and observe for change in mental status. 2. Auscultate heart sounds for pericardial friction rub. 3. Take vital signs and observe for hypovolemic shock. 4. Count respiratory rate and auscultate breath sounds.

Answer 4: Wheals (hives) signal an allergic reaction. Respiratory rate and effort should be monitored.

The nurse would be prepared to administer epinephrine as needed for which patient? 1. Has burning sensation and a dry crusty lesion on the lip 2. Has a single pink, scaly patch that resembles a large ringworm 3. Has skin maceration, fissures, and vesicles around the toes 4. Has raised red wheals and hives and an expiratory wheeze

Answer 4: Wheals and hives after exposure to foods, insect bites, drugs, and other allergens can lead to anaphylactic shock. Epinephrine would be given to this patient for respiratory symptoms or if rapid worsening occurs. Herpes simplex is accompanied by burning sensation and a dry, crusty lesions. Single pink, scaly patch that resembles a large ringworm occurs with pityriasis rosea. Skin maceration, fissures, and vesicles around the toes is typical of tinea pedis.

The nurse is caring for a patient who has right ventricular heart failure. After therapy, the nurse sees that the patient has lost 5 pounds of weight. Assuming that all the weight represents fluid loss, how much fluid has the patient lost? ____________ L

Answer: 2.27 rounded to 2.3 liters One liter of fluid equals 1 kg (2.2 pounds) 2.2 pounds : 5 pounds = 2.272 1 liter x

Which is a true statement regarding cellulitis? (Select all that apply.) a. The bacteria that cause cellulitis can be spread by direct contact with an open area on a person who has an infection. b. Cellulitis occurs when bacteria enter the body through a break in the skin. c. The primary treatment for cellulitis includes analgesics, dressing changes, and warm compresses. d. Complications from cellulitis can include sepsis.

a, b, d--Bacteria that cause cellulitis can be spread by direct contact with an open area on a person who has an infection. Cellulitis occurs when bacteria enter the body through a break in the skin, such as a cut, scratch, or insect bite after the injury occurs and is not cleansed with soap and water. Complications from cellulitis can include sepsis, meningitis, and lymphangitis. The primary treatment for cellulitis includes prompt administration of antibiotics. If the cellulitis is mild, oral antibiotics may be prescribed; if the cellulitis is rapidly spreading or the patient has evidence of a serious infection, intravenous antibiotics may be required.

Which skin disorder is the most serious due to the possibility of an acute respiratory reaction? (Select all that apply.) a. Contact dermatitis b. Urticaria c. Eczema d. Psoriasis

a, b--Contact dermatitis is caused by direct contact with an irritant to which an individual is hypersensitive, such as soap, chemicals, or plants. A patient with a history of asthmamay experience an acute asthmatic episode. Urticaria is an allergic reaction commonly caused by drugs, food, insect bites, inhalants, emotional stress, or exposure to heat or cold. It is caused by the release of histamine in an antigen-antibody reaction. Capillaries dilate, resulting in increased permeability; respiratory involvement may occur. Eczema, or atopic dermatitis, is a skin disorder primarily occurring in infants and children, associated with allergies to chocolate, eggs, wheat, and orange juice. Papular and vesicular lesions appear, which are surrounded by erythema. Psoriasis is a chronic, noninfectious skin disorder characterized by rapid skin cell division and scaling. Lesions are raised, erythematous, circumscribed plaques on the scalp, elbows, chin, and trunk.

Which is a risk factor for osteoporosis? (Select all that apply.) a. White or Asian woman b. Active lifestyle including weight-bearing exercise three times per week c. High intake of caffeine d. Steroid use e. Postmenopausal female f. Anticonvulsant therapy for seizure disorder g. Overweight African American woman

a, c, d, e, f--White and Asian women have a higher incidence of osteoporosis than do African American women. High intake of caffeine has been found to be a risk factor for the development of osteoporosis. Steroid use has been found to be a risk factor for the development of osteoporosis. Women between the ages of 55 and 65 are identified as a high-risk group for the development of postmenopausal osteoporosis, and many researchers believe that this is related to the loss of estrogen. Anticonvulsant therapy has been found to be a risk factor for the development of osteoporosis. Inactive lifestyle or immobilization has been found to be a risk factor for the development of osteoporosis. Neither being overweight nor being of African American descent has been found to be a risk factor for osteoporosis.

Which is the term for an infection of a hair follicle? a. Folliculitis b. A furuncle c. A carbuncle d. A felon

a--Folliculitis is an infection of a hair follicle, usually from Staphylococcus aureus bacteria. The infection may involve one or several follicles. It often occurs after shaving. A furuncle, also known as a boil, is an inflammation that begins deep in the hair follicles and spreads to the surrounding skin, and is often located in the posterior area of the neck, the forearm, buttocks, and the axillae. A carbuncle is a cluster of furuncles. It is an infection of several hair follicles that spreads to surrounding tissue. A felon occurs when the soft tissue under and around an area, such as the fingernail, becomes infected. The involved finger becomes erythematous, edematous, and tender.

A patient diagnosed with osteoarthritis has numerous questions for the nurse about the disorder. In answering the patient's questions, which does the nurse relay regarding osteoarthritis? a. Considered to be a consequence of aging b. A chronic, progressive disorder of the sacroiliac and hip joints most commonly seen in young men c. A metabolic disease resulting from an accumulation of uric acid in the blood d. Usually treated with high-dose steroids

a--Osteoarthritis is so common with age that it is considered to be a consequence of aging. It is a major cause of severe chronic disability and affects joints of the hand, knee, hip, and cervical and lumbar vertebrae. Ankylosing spondylitis is a chronic, progressive disorder of the sacroiliac and hip joints most commonly seen in young men. It is sometimes referred to as rheumatoid spondylitis. Gout is a metabolic disease resulting from an accumulation of uric acid in the blood. It is an acute inflammatory condition associated with ineffective metabolism of purines. Osteoarthritis is usually treated with large doses of salicylates or NSAIDs. Steroids are sometimes used in low doses or are injected into joints to produce immediate pain relief and temporarily halt the destructive process.

The nurse is caring for a recently admitted patient who has suffered a pelvic fracture. Which is the most serious physical assessment finding for the nurse to report? a. Patient's complaints of pain when being turned in bed b. Hypotension, tachycardia, and hematuria c. Normoactive bowel sounds d. Headache

b--Hypotension, tachycardia, and hematuria are signs of possible shock from hemorrhage. Hemorrhage is by far the most life-threatening complication to a patient with a pelvic fracture. A patient's complaints of pain when being turned in bed would be considered typical for someone who has experienced a pelvic fracture. Although pain management is an important issue, this is not the most serious physical assessment finding of those listed. Normoactive bowel sounds would not be a serious physical assessment finding in this patient. Headache would probably not be related to the pelvic fracture, although it could be a sign that the patient is dehydrated.

A nine year old patient is being evaluated for a skin rash. The preliminary diagnosis is impetigo contagiosa. The nurse assists with planning care with which fact about impetigo contagiosa in mind? a. Is a viral skin infection b. Is a highly contagious inflammatory disorder c. Usually presents with a rash on the patient's back d. Is present in all age-groups, but especially older adults

b--Impetigo contagiosa is a highly contagious inflammatory disorder. It is highly contagious to a person who directly contacts the exudate of a lesion. Impetigo contagiosa is a bacterial skin infection, usually caused by Staphylococcus aureus, streptococci, or mixed bacteria. Impetigo contagiosa usually presents with a rash on the patient's face, hands, arms, and legs. Impetigo contagiosa is present in all age-groups, but especially children.

The patient with herpes zoster virus is asking the nurse about this condition. Which knowledge does the nurse use to base patient teaching on? a. The pain experienced by most patients is typically described as "dull and aching." b. There is usually a rash that occurs in the thoracic region. c. Herpes zoster virus usually is permanently disabling to healthy adults. d. Analgesics are often prescribed for pain; however, steroids are usually avoided because of the immune system suppression.

b--The rash usually occurs in the thorax region; vesicles erupt in a line along the involved nerve. The pain experienced by most patients is typically described as burning and knifelike. Herpes zoster virus usually is not permanently disabling to healthy adults. The greatest risk occurs to patients who have had a lower resistance to infection, such as those on chemotherapy or patients receiving large doses of prednisone, in whom the disease could be fatal due to the patient's compromised immune system. Analgesics are often prescribed for pain, including opioid analgesics. Steroids may be given to decrease inflammation and edema. Lotions may be used to relieve pruritus, and corticosteroids may be used to relieve pruritus and inflammation.

After which diagnostic study is it important that the patient lie quietly in a semi-Fowler's position for approximately 8 hours (12 hours if oil-based dye is used)? a. CT scan b. MRI c. Myelogram d. Bone scan

c--After a myelogram, it is important that the patient lie quietly in a semi-Fowler's position for approximately 8 hours (12 hours if oil-based dye is used) to keep the dye in the lower spine. Encouraging fluids will also help the body absorb the dye from the spinal column. After a CT scan, pretest diet and activity can usually be resumed. Fluids are encouraged (unless contraindicated), and the patient must be observed for a delayed allergic reaction if contrast dye is used. After an MRI, routine vital sign measurements are taken. Pretest diet and activity can be resumed. There are no activity restrictions after a bone scan. The patient should be encouraged to drink water over the next 1 to 3 hours to aid renal clearance of the isotope.

What is fibromyalgia syndrome? a. Psychiatric disorder b. Syndrome of depression, irritability, and hostility c. Musculoskeletal chronic pain syndrome of unknown etiology d. Disorder that usually affects men between the ages of 20 and 50

c--Fibromyalgia syndrome is a musculoskeletal chronic pain syndrome of unknown etiology that causes pain in the muscles, bones, or joints. It is associated with soft tissue tenderness at multiple characteristic sites. Fibromyalgia syndrome is not a psychiatric disorder. Tricyclic antidepressants are used in treating this disorder because they can help with antidepressive effects, decrease inflammation, relax skeletal muscles, and control pain. Fibromyalgia syndrome is not a psychiatric disorder, nor is it a psychosomatic disturbance. Fibromyalgia syndrome is a disorder that usually affects women between the ages of 20 and 50.

A young adult patient has come into a dermatology clinic and reports having had a single 1-in lesion that was scaly with a raised border and a pink center on the chest. Now, a little more than a week later, there are smaller matching spots of the rash on both sides of the chest. The nurse observes pink, oval-shaped spots that are ¼ to ½ in across. What condition does the nurse suspect the health care provider will diagnose? a. Herpes zoster virus b. Herpes simplex type 1 c. Pityriasis rosea d. Impetigo contagiosa

c--Pityriasis rosea begins with a single lesion, up to 4 in in diameter, known as a herald patch. This lesion is scaly with a raised border and a pink center, and is typically found on the patient's chest, abdomen, back, groin, or axillae. Seven to fourteen days after the initial eruption, smaller matching spots of the rash become widespread on both sides of the body. Herpes zoster virus, commonly known as shingles, causes inflammation of the spinal ganglia, and then advances to the skin by way of the peripheral nerves when a patient's resistance to infection has been lowered. Herpes simplex type 1, commonly known as a cold sore, is characterized by a vesicle at the corner of the mouth, on the lips, or on the nose. Impetigo contagiosa consists of macular lesions that rupture and form a dried exudate on the face, hands, arms, and legs.

A patient with rheumatoid arthritis asks the nurse about the condition. On which knowledge does the nurse base patient teaching? a. Most patients affected by rheumatoid arthritis are women older than age 65 years. b. Rheumatoid arthritis is an acute inflammatory condition that usually resolves in 2 to 4 weeks. c. Rheumatoid arthritis is thought to be an autoimmune disorder. d. Exercise is discouraged for the patient with rheumatoid arthritis because the muscles and joints must rest.

c--Rheumatoid arthritis is thought to be an autoimmune disorder, although there is evidence of genetic predisposition. Most patients affected by rheumatoid arthritis are women aged 30 to 69 years old. Rheumatoid arthritis is a chronic systemic inflammatory autoimmune disease. It can affect many organ systems and is characterized by chronic inflammation of the synovial membrane of the diarthrodial joints (freely moveable joints in which continuous bony surfaces are covered by cartilage and connected by ligaments lined with synovial membrane). Exercise is encouraged for the patient with rheumatoid arthritis to prevent the joints from "freezing" and the muscles from weakening.

Tinea capitis, Microsporum audouinii, Tinea corporis, and Tinea pedis are examples of which type of infection a. bacterial skin infections. b. viral skin infections. c. fungal skin infections. d. infections commonly acquired in health clubs.

c--T. capitis, M. audouinii, T. corporis, and T. pedis are all examples of fungal skin infections. These dermatophytoses are superficial infections. These are not bacterial in origin. An example of a bacterial skin infection is cellulitis. These are not viral in nature. An example of a viral skin infection is herpes zoster virus. Not all of these fungal infections are commonly acquired at health clubs. T. pedis, or athlete's foot, can be found between the toes of a person whose feet perspire heavily; it also can be spread from contaminated public bathroom facilities and swimming pools.

Cultural and ethnic considerations for skin assessment include which aspect?? a. Baseline skin color should be assessed in areas with the most pigmentation. b. Pallor in black-skinned individuals will appear as a pale pink color. c. To assess rashes and skin inflammation in dark-skinned individuals, the nurse should rely on palpation. d. The darker the patient's skin, the easier it is to assess for color change.

c--To assess rashes and skin inflammation in dark-skinned individuals, the nurse should rely on palpation for warmth and induration rather than observation. Baseline skin color should be assessed in areas with the least pigmentation. Examples are the palms of the hands, soles of the feet, undersides of the forearms, abdomen, and buttocks. Pallor in black-skinned individuals will appear as ashen or gray. The darker the patient's skin, the more difficult it is to assess for color change. A baseline needs to be established in natural lighting, if possible, or with at least a 60-watt light bulb.

A patient is undergoing a diagnostic procedure in which needle electrodes are inserted into skeletal muscles to record electrical activity. What is this test called? a. Arthroscopy b. Endoscopic spinal microsurgery c. Aspiration of fluid d. Electromyogram (EMG)

d--During an electromyogram (EMG), needle electrodes are inserted into skeletal muscles to record electrical activity. This electrical activity can be heard, seen on an oscilloscope, and recorded on paper simultaneously. Arthroscopy is an endoscopic examination that enables direct visualization of a joint. Endoscopic spinal microsurgery is when surgery to the spine is performed using endoscopic equipment through small incisions. Aspiration of fluid is performed using a needle that is inserted into a body cavity after administration of a local anesthetic.

Which is an example of a flat bone? a. Vertebrae b. Extremities c. Hands d. Skull and sternum

d--Flat bones, one of the four bone types, are commonly found in the skull and sternum. The vertebrae are examples of irregular bones. Long bones are found in the extremities. The hands and feet contain what are known as short bones.

A patient with a chronic musculoskeletal disorder is asking the nurse about alternative therapies for her condition. On which knowledge does the nurse base the response? a. Alternative therapies are unproven and should not be used under any circumstances. b. Long-term studies of glucosamine and chondroitin show that they are completely safe and effective. c. Chiropractic adjustment is dangerous and should not be recommended. d. Glucosamine supplements have been linked with reduced articular pain, lessened joint tenderness, and less restricted joint movement in persons with arthritis.

d--Glucosamine supplements have been linked with reduced articular pain, lessened joint tenderness, and less restricted joint movement in persons suffering from arthritis. Supplemental glucosamine acts like glucosamine found naturally in cartilage, working as a lubricant and shock absorber. Although one must be careful of spending large amounts of money on unproven "therapies," many complementary and alternative therapies can be effective in reducing discomfort and decreasing the need for pain medications for patients with chronic musculoskeletal disorders. It is important, however, to research the various therapies and discuss them with your health care provider as part of a comprehensive wellness program. There are no long-term studies of glucosamine and chondroitin at this point. Short-term studies, however, appear promising and suggest that they provide pain relief and may slow the disease process. Chiropractic adjustment has been shown to be effective in patients with some types of back pain. Like many therapies, it is not without risk; however, choosing a skilled health care provider and careful patient selection can minimize many risks.

What is herpes simplex type 2? a. Is commonly known as a cold sore b. Usually affects the labia in women c. Is characterized by a vesicle at the corner of the mouth, lips, or nose d. Is often associated with lesions in the genital area

d--Herpes simplex type 2 causes lesions in the genital area and is commonly known as genital herpes. Herpes simplex type 1 is commonly known as a cold sore. Herpes simplex type 2 usually affects the cervix in women and the penis in men. The primary mode of transmission is through sexual contact. Herpes simplex type 1 is characterized by a vesicle at the corner of the mouth, lips, or nose.

Which instruction will the nurse include in postoperative nursing care for a patient who has undergone a hip fracture repair? a. Maintaining adduction of the legs b. Turning the patient onto the operative side every 4 hours c. Encouraging the use of chairs that are low to the ground once the patient is out of bed and ambulating d. Wound assessment with special attention paid to color, amount, and odor of exudate; frequent monitoring of vital signs; suture line assessment; and accurate intake and output recording

d--Postoperative nursing care for a patient who has undergone a hip fracture repair includes wound assessment with special attention paid to color, amount, and odor of exudate; frequent monitoring of vital signs; suture line assessment; and accurate intake and output recording. JP drains and Hemovac drains must also be assessed for amount and color of drainage every 4 hours. Abduction of the legs is an important postoperative nursing consideration. This can be accomplished via an abduction pillow. The patient who has undergone a hip fracture repair usually is to be turned onto the nonoperated side, but it is important to check health care provider orders carefully and comply with the ordered positioning. The patient who has undergone a hip fracture repair requires an elevated sitting surface (e.g., raised toilet seat) to keep the angle of the hip within the prescribed limits when the patient is sitting.