Acute - Module 8

_____: The state of perfect refraction of the eye; with the lens at rest, light rays from a distant source are focused into a sharp image on the retina.

Emmetropia

Which factors can decrease blood supply to the ear in an older patient? Select all that apply. a. Osteoporosis b. Diabetes c. Smoking d. Heart disease e. Hypertension f. Cerumen

B,C,D,E

The nurse needs to assess the patient for color blindness. Which assessment tool will the nurse use? a. Ishihara chart b. Confrontation test c. Snellen chart d. Rosenberg Pocket Vision Screener

A

_____: The bony socket of the skull that surrounds and protects the eye along with the attached muscles, nerves, vessels, and tear-producing glands.

Orbit

Which hormones affect bone growth? Select all that apply. a. Glucocorticoids b. Renin c. Thyroxine d. Estrogens e. Androgens f. Catecholamines

A,C,D,E

_____: Cell associated with formation of bone.

Osteoblast

_____: The quality of bone that determines bone strength. It peaks between 30 and 35 years of age, when both bone resorption activity and bone-building activity occur at a constant rate. When bone resorption activity exceeds bone-building activity, bone density decreases.

Bone mineral density (BMD)

_____: Cell associated with destruction or resorption of bone.

Osteoclast

_____: Bone cell.

Osteocyte

The nurse is supervising a nursing student who is caring for a patient with a cast to the lower leg who reports pain that is worsening despite medication, with decreased movement and skin sensation. The nurse would intervene if the student performed which action? a. Instructs the patient to move the toes b. Places an extra pillow underneath the cast c. Checks for dorsalis pedis pulse d. Checks agency protocol to see who may cut the cast

B

_____: A radionuclide test in which radioactive material is injected for visualization of the entire skeleton; used to detect tumors, arthritis, osteomyelitis, osteoporosis, vertebral compression fractures, and unexplained bone pain.

Bone scan

A 44-year-old client with diabetes asks how often a visit to the eye care practitioner is recommended. What is the appropriate nursing response? A) "Annually." B) "Every six months." C) "Only if you have vision problems." D) "No examinations are necessary until you are 50 years old."

ANS: A. To provide the earliest detection of concerns such as macular degeneration, retinal detachment, or glaucoma, an annual visit to the eye care practitioner should be recommended.

The nurse is reviewing T-scores for a 68-year- old woman. The patient has a T-score of 2.5. How does the nurse interpret this data? A. The patient has osteopenia. B. The patient has osteoporosis. C. This is a normal score for the patient's age. D. There is osteoblastic activity.

B

The nurse is reviewing the laboratory results and sees that the patient has hypercalcemia. Which laboratory result does the nurse expect because of the inverse relationship to calcium? a. Low level of sodium b. Low level of phosphorus c. High level of thyroxine d. High level of insulin

B

_____: The removal of a limb or other appendage of the body.

Amputation

_____: A term that refers to an abnormality in the stance phase of gait. When part of one leg is painful, the person shortens the stance phase on the affected side.

Antalgic (gait)

_____: An opaque ring within the outer edge of the cornea caused by fat deposits. Its presence does not affect vision.

Arcus senilis

_____: A refractive error caused by unevenly curved surfaces on or in the eye (especially of the cornea) that distort vision.

Astigmatism

The nurse is instructing a teenage patient who has a tibia-fibula fracture that was treated with internal fixation and a long leg cast. He is anxious to know when the cast will be removed so that he can resume football practice. Which statement by the patient indicates a need for additional teaching? a. "There's a possibility that the cast could be removed in 4 weeks." b. "The plates and screws reduce the length of time I'll be in the cast." c. "The cast could remain in place as long as 6 weeks." d. "I'll use crutches for 2 weeks, and then the cast will be removed."

D

Which food would the nurse recommend, that would be particularly good for eye health? a. Whole-grain cereal b. Low-fat milk c. Raw almonds d. Fresh tomatoes

D

_____: A quality of sound that is expressed in decibels; generally, having a high degree of energy or activity.

Intensity

_____: To spread cancer from the main tumor site to many other body sites.

Metastasize

_____: Constriction of the pupil of the eye.

Miosis

_____: A profound hearing loss that results from a combination of both conductive and sensorineural types of hearing loss.

Mixed conductive-sensorineural hearing loss

_____: The junction of a peripheral motor nerve and the muscle cells that it supplies.

Motor end plate

_____: Dilation of the pupil of the eye.

Mydriasis

_____: Irregular bone growth around the ossicles.

Otosclerosis

_____: Drooping of the eyelid.

Ptosis

_____: A piece of necrotic bone that has separated from surrounding bone tissue; a common complication of osteomyelitis.

Sequestrum

_____: Bone that is small and bears little or no weight, such as the phalanges (fingers and toes).

Short bone

_____: Test that confirms a diagnosis of carpal tunnel syndrome; a positive test causes palmar paresthesias when the area of the median nerve is tapped lightly.

Tinel's sign

_____: A continuous ringing or noise perception in the ears.

Tinnitus

_____: The application of a pulling force to a part of the body to provide reduction, alignment, and rest.

Traction

If the superior rectus muscle is damaged or not functioning properly, the patient would have difficulty with which eye movement? a. Looking upwards b. Looking downwards c. Gazing inwards to the nose d. Gazing outwards to the ear

A

_____: A collection of pus that forms in the extradural, subdural, or intracerebral area of the brain as a result of a purulent infection, usually due to bacteria invading the brain directly or indirectly.

Brain abscess

_____: Test that determines the presence of internal bleeding following abdominal trauma.

Diagnostic peritoneal lavage (DPL)

_____: Pertaining to a bruise.

Ecchymotic

_____: A turning outward and sagging of the eyelid, which is caused by relaxation of the orbicular muscle.

Ectropion

_____: An accumulation of fluid, such as in a joint (where it may limit movement).

Effusion

_____: The use of an electronic device (e.g., magnetic coils applied on the skin or over a cast to deliver a pulsed magnetic field) to promote bone union after a fracture. The exact mechanism of action is unknown, but this procedure is based on research showing that bone has inherent electrical properties that are used in healing.

Electrical bone stimulation

_____: Bone that protects vital organs and often contains blood-forming cells, such as the scapula.

Flat bone

_____: An error of refraction that occurs when the eye does not refract light enough, causing images to fall (converge) behind the retina and resulting in poor near vision. Also called farsightedness.

Hyperopia

_____: Inadequate levels of phosphate in the blood (below 3.0 mg/dL).

Hypophosphatemia

_____: A treatment for lower back pain in which a small electrical current and dexamethasone are typically used.

Iontophoresis

_____: The colored portion of the external eye; its center opening is the pupil. Muscles of the iris contract and relax to control pupil size and the amount of light entering the eye.

Iris

_____: Bone that has a unique shape, such as the carpal bones of the wrist.

Irregular bone

_____: The degeneration of the corneal tissue resulting in abnormal corneal shape.

Keratoconus

_____: Corneal transplant. The surgical removal of diseased corneal tissue and replacement with tissue from a human donor cornea.

Keratoplasty

_____: The deterioration of the macula, the area of central vision.

Macular degeneration

_____: An acute or chronic infection of the mastoid air cells caused by untreated or inadequately treated otitis media.

Mastoiditis

_____: A fracture in which the skin surface over the broken bone is disrupted, causing an external wound.

Open (compound) fracture

_____: The reduction of a fracture after surgical incision into the site to allow direct visualization of the fracture.

Open reduction (internal fixation)

_____: The point at the inside back of the eye where the optic nerve enters the eyeball. It appears as a creamy pink to white depressed area in the retina and contains only nerve fibers and no photoreceptor cells.

Optic disc

_____: The area at the inside back of the eye that can be seen with an ophthalmoscope.

Optic fundus

_____: The nerve of sight; connects the optic disc to the brain.

Optic nerve

_____: Replacement of the ossicles within the middle ear.

Ossiculoplasty

_____: Abnormal softening of the bone tissue characterized by inadequate mineralization of osteoid. It is the adult equivalent of rickets (vitamin D deficiency) in children.

Osteomalacia

_____: An inflammation of bone tissue caused by pathogenic microorganisms; produces an increased vascularity and edema often involving the surrounding soft tissues.

Osteomyelitis

_____: The death of bone tissue, usually because the blood supply to the bone is disrupted. Usually a complication of a hip fracture or any fracture in which there is displacement of bone.

Osteonecrosis

_____: A condition of low bone mass that occurs when there is a disruption in the bone remodeling process.

Osteopenia

_____: A metabolic disease in which bone demineralization results in decreased density and subsequent fractures.

Osteoporosis

_____: Surgical resection of bone.

Osteotomy

_____: An instrument used to examine the ear; consists of a light, a handle, a magnifying lens, and a pneumatic bulb for injecting air into the external canal to test mobility of the eardrum.

Otoscope

_____: Having a toxic effect on the inner ear structures.

Ototoxic

_____: Abnormal or unusual nerve sensations of touch, such as tingling and burning.

Paresthesia

_____: A health problem that occurs most often in people who are runners or who overuse their knee joints. For that reason, it is sometimes referred to as "runner's knee." These patients describe pain as being behind or around their patella (knee cap) in one or both knees.

Patellofemoral pain syndrome (PFPS)

_____: A fracture that occurs after minimal trauma to a bone that has been weakened by a disease such as bone cancer or osteoporosis.

Pathologic (spontaneous) fracture

_____: Pinpoint red spots on the mucous membranes, palate, conjunctivae, or skin.

Petechiae

_____: Test to determine the presence of carpal tunnel syndrome (CTS); a positive test for CTS causes paresthesia in the medial nerve distribution of the palm of the hand in 60 seconds.

Phalen's maneuver

_____: A frequent complication of amputation in which the patient perceives sensation in the absent (amputated) foot or hand. This sensation usually diminishes over time.

Phantom limb pain (PLP)

_____: Abnormal sensitivity to light.

Photophobia

_____: The appearance of bright flashes of light due to the onset of retinal detachment.

Photopsia

_____: An inflammation of the plantar fascia, which is located in the area of the arch of the foot. It is often seen in athletes, especially runners.

Plantar fasciitis

_____: The middle layer of the eye, which consists of the choroid, ciliary body, and iris. The choroid has many blood vessels that supply nutrients to the retina.

Uvea

_____: A minimally invasive surgery for managing vertebral fractures in patients with osteoporosis. Bone cement is injected directly into the fracture site to provide immediate pain relief.

Vertebroplasty

_____: A sense of spinning movement that may result from diseases of the inner ear.

Vertigo

_____: A phase lasting 2 to 3 weeks after peripheral nerve trauma resulting in complete denervation; the extremity is warm, and the skin appears flushed or rosy. The warm phase is gradually superseded by a cold phase.

Warm phase

_____: An intolerance for sound levels that do not bother other people.

Hyperacusis

What is an early sign/symptom of macular degeneration? a. Mild blurring b. Decreased tear production c. Loss of central vision d. Difficulty with activities of daily living

A

A patient has an effusion of the right knee. Which assessment finding does the nurse expect to assess in this patient? a. Limitations in movement and accompany- ing pain b. Poor alignment as in genu valgum c. Crepitus and difficulty bearing weight d. Obvious redness and skin breakdown

A

A patient in traction reports severe pain from a muscle spasm. What is the nurse's priority action? a. Assess the patient's body alignment. b. Give the patient a prn pain medication. c. Notify the health care provider. d. Remove some of the traction weights.

A

A patient is being evaluated for bone pain in the lower extremity. Which laboratory result would suggest a malignant bone tumor? a. Elevated serum alkaline phosphatase b. Decreased serum calcium level c. Low vitamin D level d. Decreased erythrocyte sedimentation rate

A

A 40-year-old patient is admitted for acute osteomyelitis of the left lower leg. What does the nurse expect to find documented in the patient's admitting assessment? a. Temperature greater than 101°F, swelling, tenderness, erythema, and warmth of area b. Ulceration resulting with sinus tract formation, localized pain, and drainage c. Aching pain, poorly described, deep, and worsened by pressure and weight bearing d. Shortening of the extremity with pain during weight bearing or palpation

A

A 46-year-old patient calls the clinic and reports sudden "floating dark spots" in her vision. What should the nurse say to the patient? a. Advise the patient to immediately call her ophthalmologist. b. Advise the patient that this is normal for her age. c. Ask the patient if the spots were accom- panied by pain. d. Tell the patient to mention this during her annual eye appointment.

A

A female patient with osteoporosis comes to the emergency department after falling suddenly while opening her car door. She said it felt as though her "leg gave way" and caused her to fall. What type of fracture is this patient most likely to have? a. Pathologic b. Colles' c. Impacted d. Compound

A

A patient is scheduled to have a dual x-ray absorptiometry. What information does the nurse give to the patient about preparing for the test? a. "Leave metallic objects such as jewelry, coins, and belt buckles at home." b. "Have someone come with you to drive you home after the test." c. "You will be asked to give a urine specimen prior to the test." d. "Bring a comfortable loose nightgown without buttons or snaps."

A

A patient tells the nurse that he has "soft bones." What additional information supports the likelihood of osteomalacia in this patient? a. Recent immigration from a country where famine is common b. Taking hormone replacement therapy for a prolonged time c. Unable to perform a prescribed exercise regimen d. History of recent episode of venous thromboembolism

A

A patient underwent electronystagmography, and results showed failure of nystagmus to occur with cerebral stimulation. Which action is the nurse most likely to take because of the test results? a. Initiate fall precautions. b. Use a whiteboard as needed. c. Give an antiemetic medication. d. Speak slowly to patient.

A

A patient with a long leg cast that was applied in the emergency department is being admit- ted to the orthopedic unit. Which task is best for the nurse to delegate to unlicensed assistive personnel? a. Obtain a fracture pan and use caution to prevent spillage on the cast. b. Assist the patient to stand and bear weight when the cast is dry. c. Check flexion/extension and color of the toes. d. Turn the patient every 4-6 hours to allow the cast to dry.

A

A patient with bone sarcoma had surgery to salvage an upper limb. The nurse has identi- fied that the patient has impaired physical mobility related to musculoskeletal impair- ment. Which intervention does the nurse perform in the early postoperative period? a. Encourage the patient to use the opposite hand to achieve forward flexion and abduction of the affected shoulder. b. Encourage the patient to emphasize strengthening the quadriceps muscles by using passive and active motion. c. Instruct unlicensed assistive personnel to perform all hygiene until the patient expresses readiness to do self-care. d. Evaluate the patient's and family's readiness to use the continuous passive motion machine in the home setting.

A

A patient with osteoporosis moves slowly and carefully with voluntary restriction of movement. The lower thoracic area is tender on palpation. How does the nurse interpret this assessment data? a. Vertebral compression fracture b. Kyphosis of the dorsal spine c. Osteopenia related to immobility d. Increased osteoblastic activity

A

An adult patient has otitis media. What does the nurse expect the patient's main concern to be? a. Ear pain b. Rhinitis c. Drainage d. Swelling

A

An older adult patient has skin traction in place for a hip fracture. Which outcome statement reflects that the goal of the therapy is successful? a. Patient reports a decrease in painful muscle spasms. b. X-ray indicates that the fracture shows signs of healing. c. Patient can perform activities of daily living with some assistance. d. There are no signs/symptoms of compression syndrome.

A

An older patient reports a sensation of eye dryness. The nurse would teach the patient to use saline eye drops and to increase the humidity in the house to reduce the risk for which eye disorder? a. Corneal abrasion b. Presbyopia c. Hyperopia d. Yellowing of the sclera

A

An older patient's family is trying to find an appropriate cane for the patient to use because of chronic pain in the right ankle. The nurse instructs the family to purchase which type of cane? a. One with top that is parallel to greater trochanter of the femur b. One that creates about 45 degrees of flexion of the elbow c. One that is adequate to safely support the patient's weight d. One with padding on the handle grip to ensure safety

A

During physical assessment of an older patient, the nurse notes a small, crusted ulceration on the pinna. What should the nurse do first? a. Ask the patient how long the sore has been there. b. Teach the patient how to clean the ears to prevent infection. c. Ask the health care provider to check the ear for cancer. d. Document the finding and mention it at shift change

A

For which circumstance is the nurse or rehabilitation therapist most likely to use a goniometer? a. Older patient had knee surgery and is undergoing physical therapy. b. Older patient is undergoing therapy to correct difficulties with balance and gait. c. Young woman had a wrist cast removed and arm muscles appear atrophied. d. Teenager had surgery for scoliosis and is undergoing physical therapy.

A

The home health nurse reads in the documen- tation that the patient has Volkmann's contrac- ture that occurred several years ago. Which assessment is the nurse most likely to perform to assess this condition? a. Ability to do activities of daily living b. Presence of distal pulses c. Ability to climb the stairs d. Need for pain medication

A

The nurse hears in shift report that the patient will have phacoemulsification for treatment of an eye problem. What does the nurse anticipate in the care of this patient? a. Patient will be discharged within an hour of surgery. b. Patient is likely to mourn the loss of the body part. c. Patient will need opioid medication for severe pain. d. Patient should be closely observed for postoperative bleeding.

A

The nurse immediately stops irrigating the ear if the patient reports which symptom? a. Persistent pain b. Sensation of fullness c. Tingling sensation d. Feelings of fatigue

A

The nurse is assessing a patient's posture and gait and notes that the patient has a lurch and shifts his shoulders from side to side while walking. What is the clinical significance of this finding? A. Muscles in the buttocks and/or legs are too weak to allow weight change from one foot to the other. B. Patient has a prosthetic device, such as an artificial hip that is limiting motion and flexibility. C. Part of one leg is painful, so the patient shortens the stance phase on the affected side. D. One leg is much shorter than the other, and this causes asymmetric body movement.

A

The nurse is assessing an older construction worker who tells the nurse that he developed osteoarthritis as a result of his work duties. Which joints is the nurse most likely to assess to detect this disorder? a. Knees and lumbar spine b. Fingers and toes c. Shoulders and pelvis d. Wrists and thoracic spine

A

The nurse is caring for a patient in Buck's (skin) traction. Which task is best to delegate to unlicensed assistive personnel (with supervision)? a. Turning and repositioning b. Inspecting heels and sacral area c. Asking the patient about muscle spasms d. Adjusting the weights on the apparatus

A

The nurse is caring for a patient with an open fracture. Which intervention does the nurse perform to prevent infection of the fracture? a. Use aseptic technique for dressing changes and wound irrigations. b. Culture the wound and an obtain an order for antibiotics. c. Place the patient in contact isolation and wear sterile gloves. d. Place the patient on neutropenic precau- tions and perform hand hygiene.

A

The nurse is caring for a patient with skeletal pins that have been placed for traction. What does the nurse expect in the first 48 hours? a. Clear fluid drainage weeping from the pin insertion site b. Some bloody drainage at the site but very minimal c. Swelling at the site with tenderness to gentle touch d. Dressings around the pin sites to be dry and intact

A

The nurse is caring for an adult patient with a recent increase in growth hormone that has resulted in acromegaly. In assessing this pa- tient, what does the nurse expect to find? a. Bone and soft-tissue deformities b. Pain that increases when flexing joints c. Unusually tall height for ethnic background d. Marked lateral curvature of the spine

A

The nurse is caring for patients on an orthope- dic unit who are being treated with a variety of therapies, including immobilization with a bandage, a splint, a cast, specialized orthope- dic shoe, and traction. What is the priority nursing concern for all of these patients? a. Assessment and prevention of neurovas- cular dysfunction and compromise b. Assessment and management of pain and discomfort c. Assessment of abilities to do activities of daily living after discharge d. Assessment and intervention for concerns related to disability and immobility

A

The nurse is educating a patient who will have external fixation for treatment of a compound tibial fracture. What information does the nurse include in the teaching session? a. "The device allows for early ambulation." b. "The device is sterile; there is no danger of infection." c. "The device is a substitute therapy for a cast." d. "The advantage of the device is rapid bone healing."

A

The nurse is interviewing a patient to help the health care provider determine the patient's risk for osteomalacia. Which assessment is the nurse most likely to perform? a. Typical 24-hour dietary intake b. Usual patterns for rest and sleep c. Type and frequency of exercise d. Presence of pain and pain management

A

The nurse is on a camping trip, and one of the camper's reports, "I think there is an insect in my ear. I can hear it and feel it moving around inside my ear canal." What should the nurse try first? a. Shine a flashlight in the canal and try to coax the insect to come out. b. Instill cooking oil into the ear to suffocate the insect, then flush the canal with water. c. Apply a thin coating of antibiotic oint- ment to the external canal and pinna. d. Instruct the camper to tilt head down- wards and vigorously shake the head.

A

The nurse observes that an older patient has flexion contractures of the fourth and fifth fingers. The patient reports that he had a similar problem on the other hand and had a fasciectomy, which improved the function. What condition does the patient have? a. Dupuytren's contracture b. Ganglion cyst c. Bunion d. Volkmann's contracture

A

The nurse sees that a patient has an elevated alkaline phosphatase (ALP). What is the clinical significance of this result? a. The concentration of ALP increases with bone or liver damage. b. An increased ALP indicates progressive muscular dystrophy. c. An above normal ALP value suggests pa- tient may have acromegaly. d. An elevated ALP indicates that patient is ingesting too much calcium.

A

The nurse would ask the patient to perform extension and flexion to assess full range of motion for which joint? a. Elbow joint b. Pelvis area c. Hip joint d. Cervical area

A

The patient is being treated for an eye infec- tion. The drug therapy may continue for 3 or more weeks; eye drops are required at night, and the patient is not allowed to wear contact lenses for weeks to months until the infection is completely cleared. Which patient statement indicates that the patient understands the goal of therapy? a. "Stopping the infection can save the vision in my infected eye." b. "I'll never have to worry about cataracts once this infection clears." c. "Antibiotic drops are easier than surgery, so I guess I'll use them." d. "Three weeks is a long time, but I have a spare pair of eyeglasses."

A

Tympanometry is helpful in distinguishing which disorder? a. Middle ear infections b. External ear infections c. Hearing loss for low-pitched tones d. Indurated lesions on the pinna

A

What is the normal response to caloric testing? a. Vertigo and nystagmus within 20-30 seconds b. Vertigo and nystagmus immediately c. Vertigo and nystagmus within 5 minutes d. Nystagmus with no vertigo

A

What is the pathophysiology that underlies the development of glaucoma? a. Pressure on retinal vessels decreases blood flow so photoreceptors and nerve fibers become hypoxic. b. Decreased muscle tone reduces ability to keep the gaze focused on a single object. c. Cornea flattens, and the surface becomes irregular with worsening of astigmatism and blurred vision. d. The lens hardens, shrinks, and loses elasticity, and cataracts begin to form.

A

Which clinical manifestation typifies the priority concept for patients who have disorders of the musculoskeletal system? a. Pain in the knee joint that worsens after jogging b. Mild dehydration and dark urine after being in the sun c. Exertional dyspnea after attempting to climb stairs d. Lightheadedness when standing up too quickly

A

Which disorder of the ear/hearing is more commonly found among men aged 20-50 years old? a. Ménière's disease b. Otosclerosis c. Excessive cerumen d. Labyrinthitis

A

Which ethnic group has the lowest risk for developing osteoporosis? a. African American b. European American c. Asian American d. Hispanic American

A

Which intervention would be best to use for a patient with presbyopia? a. Encouragement to get a prescription for reading glasses b. Administration of the prescribed eye medications c. Reinforcement to wear sunglasses for protection against UV light d. Reminder to have annual examination for early detection of glaucoma

A

Which nursing intervention is best to prevent increased pain in a patient experiencing phan- tom limb pain? a. Handle the residual limb carefully when assessing the site or changing the dressing. b. Advise the patient that the sensation is temporary and will diminish over time. c. Remind the patient that the part is not really there, so the pain is not real. d. Encourage the patient to mourn the loss of the body part and express grief.

A

Which outcome statement indicates that calcitonin is performing its intended function? a. Calcium level is within normal limits. b. Muscle mass is improving with exercise. c. Growth of healthy bone tissue is occurring. d. White cell blood count is within normal range.

A

Which outcome statement indicates that the goal has been achieved in preventing the most common complication of osteoporosis? a. Patient has avoided fractures by preventing falls and managing her risk factors. b. Patient has not developed jaw osteonecrosis secondary to medication therapy. c. Patient has not developed kyphosis of the dorsal spine ("dowager's hump"). d. Patient understands how to avoid esopha- gitis associated with bisphosphonates.

A

Which patient has the greatest risk for acute hematogenous osteomyelitis? A. Older man with a catheter-related urinary tract infection b. Older patient in intensive care with poor dental hygiene c. Older woman with a methicillin-resistant Staphylococcus aureus infection d. Young patient with a leg fracture who has external skeletal pins

A

Which patient is at risk for regional osteoporosis? a. Patient who has been in a long leg cast for 10 weeks b. Patient on long-term corticosteroid therapy c. Patient with a history of hyperparathy- roidism d. Patient in menopause with a history of falls

A

Which patient is most likely to have the low- est threshold for hearing tones and speech? a. 25-year-old patient with no previous hearing problems b. 76-year-old patient with significant hearing loss c. 43-year-old patient who is well adapted to a hearing aid d. 60-year-old patient with no known health problems

A

Which patient is the most likely candidate to benefit from the Rinne tuning fork test? a. Patient requires differentiation of hearing by air conduction versus bone conduction. b. Patient has a mental disability and is unable to follow instructions for audiometry or other tests. c. Patient has a family history of sensorineural hearing loss and genetic mutation in gene GJB2. d. Patient is unable to identify and report which ear has the greater hearing loss.

A

Which person has the greatest risk for developing a soft tissue injury? a. Middle-aged adult runs 5 miles every day. b. Older adult does water aerobics 3 times a week. c. Teenager spends 7 hours a day using a computer. d. College student rides a bicycle 2-3 times every week.

A

Which person is following the recommenda- tions for healthy bones related to alcohol consumption? a. Slender young woman drinks less than 5 ounces per day. b. Obese older woman has 3 drinks on Friday, Saturday, and Sunday. c. Older man has 2 drinks on weekdays and 5-6 on the weekend. d. Young man drinks 60 ounces or more but only on Saturday nights.

A

Which type of benign tumor is commonly located in the hands and feet? a. Chondroma b. Giant cell tumor c. Osteochondroma d. Fibrogenic tumor

A

Why do men develop osteoporosis after the age of 50? a. Older men have decreased testosterone levels. b. Older men are prescribed more medications. c. In older men hyperparathyroidism causes osteoporosis. d. After age 50, men are much less active.

A

the nurse is providing the immediate postop- erative care for a patient who had a keratoplasty. Which assessment will the nurse perform to identify the most likely complication? a. Assess for bleeding. b. Assess for photosensitivity. c. Monitor for respiratory depression. d. Monitor for hypotension.

A

A decrease in the body's vitamin D level can result in which disorder of the musculoskeletal system? f. a. Acromegaly b. Osteomalacia c. Muscular dystrophy d. Polymyositis

B

_____: Located within the joint capsule.

Intracapsular

A patient with a bone tumor is grieving and anxious. The nurse includes which psychosocial interventions? Select all that apply. a. Allow the patient to verbalize feelings. b. Offer to call the patient's spiritual or religious adviser. c. Prepare the patient for death. d. Share stories of personal losses. e. Redirect the patient to more cheerful topics. f. Listen attentively while the patient talks.

A,B,F

According to the clinical guidelines outlined by the National Osteoporosis Foundation, vertebral imaging is indicated for which groups? Select all that apply. a. Women aged 65 to 69 and men aged 70 to 79 if bone mineral density (BMD) is less than or equal to 1.5 b. Women aged 70 and older and men aged 80 and older if BMD is less than or equal to a T-score of 1.0 c. Men aged 50 and older with significant height loss and history of low-trauma fracture or being on long-term corticosteroids d. Postmenopausal women with significant height loss, history of low-trauma fracture, or history of being on long-term cortico- steroids e. Men aged 40 or younger with significant weight gain, history of high-impact trauma fractures, or history of being on long-term steroids for bodybuilding f. Women aged 40 or older who have never been pregnant, history of irregular men- ses, or history of being on long-term oral contraceptives

A,B,C,D

The nurse is reviewing the laboratory results of a patient who may have fat embolism syndrome. Which abnormal laboratory findings accompany this condition? Select all that apply. a. Decreased Pao2 level (often below 60 mm Hg) b. Increased erythrocyte sedimentation rate c. Decreased serum calcium levels d. Decreased red blood cell and platelet counts e. Increased serum level of lipids f. Increased serum potassium levels

A,B,C,D,E

An adult patient has been diagnosed with Ménière's disease. Which points does the nurse include in the teaching plan for this patient? Select all that apply. a. Move or turn head very slowly. b. Reduce the intake of salt. c. Stop smoking. d. Take vitamin supplements. e. Avoid caffeine. f. Irrigate ears frequently to decrease cerumen

A,B,C,E

Which treatments are used for external otitis? Select all that apply. a. Application of heat b. Oral analgesics c. Topical antibiotics d. Myringotomy e. Minimizing he

A,B,C,E

The nurse is reviewing laboratory results for a patient who was involved in an accident. There is no evidence of fracture or bone damage, but multiple soft tissue injuries were sustained. Which muscle enzymes are expected to be elevated because of the injuries? Select all that apply. a. Creatine kinase b. Aspartate aminotransferase c. Alkaline phosphatase d. Lactic dehydrogenase e. Aldolase f. Lipase

A,B,D,E

What interventions can the nurse use to enhance communication with a hearing- impaired patient? Select all that apply. A. Have conversations in a quiet room with minimal distractions. B. Use appropriate hand motions. C. Stand in front of a bright light or a window. D. Get the patient's attention before speaking. E. Face the patient while speaking. F. Sit side by side to access the patient's better ear.

A,B,D,E

Age is important because cataracts are most prevalent in the older adult. In addition, the nurse would ask about which predisposing factors? Select all that apply. A. Exposure to radioactive materials, x-rays, or UV light B. Family history of cataracts C. Family history of rheumatoid arthritis D. Systemic disease (e.g., diabetes mellitus, hypoparathyroidism) E. Recent or past trauma to the eye F. Prolonged use of corticosteroids, chlor- promazine, beta blockers, or miotic drugs

A,B,D,E,F

What questions would the nurse ask to assess auditory sensory perception? Select all that apply. a. "Do you have a hearing problem now?" b. "Have you ever had any ear trauma or surgery?" c. "What kind of music does you like to listen to?" d. "Have you ever been exposed to loud noises?" e. "Have you had problems with excessive earwax?" f. "Are you having any pain or itching in your ears?"

A,B,D,E,F

Which signs and symptoms should a patient who has had cataract surgery report to the health care provider? Select all that apply. a. Sharp, sudden pain in the eye b. Decreased vision c. Mild eye itching d. Green or yellow thick discharge e. Flashes of light f. Lid swelling

A,B,D,E,F

The nurse is caring for a patient who had a kyphoplasty. What is included in the postoper- ative care of this patient? Select all that apply. a. Monitor and record vital signs. b. Perform frequent neurologic assessments. c. Apply a warm pack to the puncture site if needed to relieve pain. d. Assess pain level and compare it to the preoperative level. e. Give opioid analgesics to maintain comfort level. f. Monitor for bleeding at the puncture site.

A,B,D,F

The nurse is caring for several patients on an orthopedic trauma unit. Which conditions pose a high risk for development of acute compartment syndrome? Select all that apply. a. Lower legs caught between the bumpers of two cars b. Massive infiltration of IV fluid into forearm c. Bivalve cast on the lower leg d. Multiple insect bites to lower legs e. Daily use of oral contraceptives f. Severe burns to the upper extremities

A,B,D,F

A patient who has sustained a traumatic amputation of the left leg expresses grief and loss. What resources could the nurse recom- mend to help the patient adjust to his lost limb? Select all that apply. a. Chaplain b. Psychiatric social worker c. Physical therapist d. Orthopedic surgeon e. National Amputation Foundation f. Other spiritual leaders

A,B,E,F

What are the nurse's instructions to a patient after a myringotomy? Select all that apply. a. Report excessive drainage to your health care provider. b. Avoid washing hair for 1 week. c. Use a straw for drinking liquids. d. Leave ear dressing in place until the next office visit. e. Blow the nose gently with the mouth open. f. Stay away from people with respiratory infections.

A,B,E,F

The health care provider tells the nurse that a patient has a mild first-degree sprain to the ankle. What instructions does the nurse give to the patient about the treatment for the injury? Select all that apply. a. Rest the injured part; immobilize the joint above and below the injury by applying a splint if needed. b. Apply ice intermittently for the first 4-6 hours. c. Apply a compression bandage for the first 24-48 hours. d. Elevate the foot to decrease swelling. e. Perform range-of-motion exercises every 4 hours. f. Use crutches until the swelling resolves.

A,C,D

What changes in the ear are related to aging? Select all that apply. a. Tympanic membrane may appear dull and retracted. b. Pinna becomes shorter and thickened. c. Cerumen is drier and impacts more easily. d. Cochlear nerve cells degenerate. e. High-frequency sounds are lost first. f. Hair in the canal is very sparse or absent.

A,C,D,E

What is included in the correct procedure for instilling ophthalmic drops in a patient's eyes? Select all that apply. a. Check the name, strength, and expiration date of the solution. b. Have the patient tilt the head backward and look down. c. Release drops into the conjunctival pocket. d. Avoid contaminating the tip of the bottle. e. Rest the wrist holding the bottle against the patient's cheek. f. After instilling a drop, tell patient to tightly close eyelids.

A,C,D,E

A patient had an arthroscopy in the right leg. In assessing the patient's neurovascular status of the extremity, what does the nurse evaluate? Select all that apply. A. Presence of pain b. Gait and balance c. Distal pulses d. Capillary refill e. Sensation f. Temperature of skin

A,C,D,E,F

Which assessment findings of the eye are normal? Select all that apply. a. Presbyopia in a 45-year-old woman b. Ptosis of the eyelids c. Yellow sclera with small pigmented dots in a dark-skinned person d. Pupil constriction in response to accommodation e. Pupil constriction within 1 minute in response to light f. Nystagmus in the far lateral gaze

A,C,D,F

Which conditions or diseases can adversely affect a patient's eyes and vision? Select all that apply. a. Pregnancy b. Inflammatory bowel disease c. Diabetes d. Hypertension e. Osteoarthritis f. Thyroid problems

A,C,D,F

What are potential adverse reactions of alendronate? Select all that apply. A. Difficulty swallowing b. Drowsiness c. Esophagitis d. Constipation e. Esophageal ulcers f. Gastric ulcers

A,C,E,F

Which patients are at risk for osteoporosis because of nutritional issues? Select all that apply. a. Older female patient who drinks five cups of coffee daily b. Patient who is overweight for height c. Patient who is on the high-protein Atkins diet d. Patient who prefers to drink diluted powdered milk e. Patient who drinks a carbonated soda every day f. Older male patient with chronic alcoholism

A,C,F

Sequentially order the events that allow for hearing. Use 1 for the first step and 6 for the final step. _____ a. Sound waves are transferred to the malleus. _____ b. Sound waves are transferred to the incus and the stapes. ______ c. Vibrations are transmitted to the cochlea. _____ d. Neural impulses are conducted by the auditory nerve. _____ e. Sound waves strike the mastoid and the movable tympanic membrane. _____ f. Sound is processed and interpreted by the brain.

A:2, b:3, C:4, D:5, E:1, F:6

What additional assessment data will the nurse collect from an older Euro-American (white) woman to determine the client's risk for osteoporosis? (Select all that apply.) A) Tobacco use, especially smoking B) Alcohol use each day C) Exercise and activity level D) Dietary intake of Vitamin D E) Use of calcium supplements F) Medication history

ANS: A, B, C, D, E, F. All of the choices are risk factors for developing osteoporosis. Tobacco and frequent alcohol use each day combined with lack of exercise and adequate calcium and Vitamin D make an individual at high risk for osteoporosis. Some medications, especially corticosteroids, also cause bone loss and cause osteopenia and osteoporosis.

Which foods will the nurse recommend to a client who wishes to enhance eye health? (Select all that apply.) A) Kale B) Bananas C) Carrots D) Ground Beef E) Shellfish F) Spinach

ANS: A, B, C, F. Foods richest in lutein include fruits like bananas; vegetables like carrots; and especially leafy, dark green vegetables like kale and spinach.

A nurse is performing a musculoskeletal assessment on an older adult living independently. What normal physiologic changes of aging does the nurse expect? (Select all that apply.) A) Muscle atrophy B) Slowed movement C) Scoliosis D) Arthritis E) Widened gait

ANS: A, B, D, E. Scoliosis occurs in childhood. The correct choices are all associated with aging changes.

A client is being discharged after surgery to correct a retinal detachment. Which symptoms will the nurse teach the client to immediately report to the eye care provider? (Select all that apply.) A) Purulent discharge in the affected eye B) Fever of 102 degrees Fahrenheit (38.9 degrees Centigrade) C) Pupil that constricts in response to light D) Improved visual acuity E) Pain in the eye

ANS: A, B, E. Purulent discharge can be a sign of infection. Fever of 102°F (38.9°C) can be a sign of infection. Pain in the eye should be reported to the eye care provider since this is not a normal side effect of surgery to repair a detached retina. Pupils that constrict in response to light and improved visual acuity are favorable findings.

What is the nurse's priority when doing an admission for a client who returned directly from the operating suite after a carpal tunnel repair? A) Monitor vital signs, including pulse oximetry. B) Check the surgical dressing to ensure it is intact. C) Assess neurovascular assessment in the affected arm. D) Monitor intake and output.

ANS: A. The priority assessment is always ABC to monitor for any potential life-threatening event and establish a baseline for comparison with future assessments; assess vital signs, oxygen saturation via pulse oximetry, and lung and heart sounds. The other choices, B, C, and D, would be performed after the ABC assessment is complete.

A client has a synthetic cast placed for a right wrist fracture in the emergency room. What priority health teaching is important for the nurse to provide for this client before returning home? (Select all that apply.) A) "Keep your right arm below the level of your heart as often as possible." B) "Use an ice pack for the first 24 hours to decrease tissue swelling." C) "Move the fingers of the right hand frequently to promote blood flow." D) "Report coolness or discoloration of your right hand to your doctor." E) "Don't place any device under the case to scratch the skin if it itches."

ANS: B, C, D, E. Rest, ice, and elevation are strategies that help to prevent edema from becoming severe and causing impaired perfusion. Therefore, the arm should be above, not below the level of the heart (A). Using a pen, hanger, or other device to scratch the skin under the cast is discouraged because these devices can cause tissue damage which can worsen under the cast.

The nurse is caring for a client immediately after a bunionectomy. What is the nurse's priority action? A) Relieve or reduce the patient's pain. B) Assess neurovascular status in the affected foot. C) Apply a hot compress to the surgical area. D) Check the surgical dressing for intactness.

ANS: B. Heat is not appropriate for immediate postoperative care because the surgical area will be swollen due to increased blood flow. Heat increases blood flow and contributes to pain. Ice and foot elevation are most appropriate. While reducing pain and checking the dressing are important, the nursing priority is to ensure that the surgical area is being adequately perfused. Perfusion may be impaired if the dressing is too tight or if edema is severe.

The nurse is caring for a client who reports slow onset of a gradual loss of vision in the center of the right eye. The client describes vision as "foggy" and reports concerns of ongoing headaches from "trying to concentrate to see." What condition does the nurse anticipate? A) Cataract B) Glaucoma C) Conjunctivitis D) Retinal detachment

ANS: B. Primary open-angle glaucoma, the most common form of primary glaucoma, may have no symptoms in the early stages. In later stages, the client experiences a gradual loss of central visual field. Vision may be described as "foggy," and the client may have mild eye aching or experience headaches. Late signs and symptoms include halos around lights, loss of peripheral vision, and decreased visual sensory perception that does not improve with eyeglasses.

A client who has a plaster leg splint reports a painful pressure sensation under the elastic wrap that is holding the splint in place. What is the nurse's best initial action? A) Remove the splint to reduce skin pressure. B) Perform a neurovascular assessment. C) Report the client's concern to the primary health care provider. D) Inspect the skin under the elastic bandage.

ANS: B. The first action of the nurse is to check for perfusion compromise by performing a circulation check, or neurovascular assessment. If there is no impairment, the patient may be developing a pressure area under the splint because it may be too tight. The skin cannot be inspected under the elastic bandage (D) because its purpose is to hold the splint in place. The only way to inspect the skin is to remove the splint to inspect it. That action requires direction from the primary health care provider.

The nurse is caring for a client who has experienced an increased frequency in Ménière's disease attacks. When the client asks, "Will I have to have surgery?", what is the appropriate nursing response? (Select all that apply.) A) "If you eat a better balanced diet, you will not need surgery." B) "Surgery is not an option for this type of disorder." C) "You sound like you are concerned about having surgery." D) "It will be essential for you to have surgery if medications don't work." E) "Different types of surgery can be considered with your health care provider." F) "I would not worry about surgery. Let's see how this new medication works for you."

ANS: C, E. Allowing the client to express fear is therapeutic. The health care provider and client can discuss different types of surgery if this seems to be the best option after considering risks and benefits. Other statements are inaccurate and/or nontherapeutic.

The nurse is caring for a client with tinnitus. Which client statement requires nursing teaching? A) "I enjoy eating bananas every day for breakfast." B) "I have found several local support groups for people with tinnitus." C) "I take aspirin every day to help reduce my risk for having a stroke." D) "I am seeing an audiologist who is fitting me for hearing aids."

ANS: C. Aspirin, NSAIDs, high-ceiling diuretics, quinine, and aminoglycoside antibiotics can increase tinnitus symptoms. Other statements are appropriate and do not require nursing teaching.

How should the nurse communicate with a client who is deaf? A) By having the client read your lips B) By talking more loudly to the client C) By using pictures and writing, if the client can see D) By talking exclusively with the client's caregivers

ANS: C. If the client can see, pictures and writing can serve as effective ways of communicating. Do not assume the client can read lips; talking more loudly would be ineffective for a client who is deaf. Talking exclusively with the client's caregivers does not allow client autonomy, and excludes the client from his or her own place of care.

The nurse is teaching a client who must instill multiple types of eye drops before cataract surgery. Which client statement requires further teaching? A) "I will make a schedule for inserting the eye drops." B) "Touching the dropper to my eye could cause contamination and infection." C) "If I can't remember when to take which drops, I'll just take them all at once." D) "If I have trouble instilling the drops, I will have my spouse put them in for me."

ANS: C. Multiple eye drops that are prescribed prior to cataract surgery must be taken on a specific schedule. They should not be mixed together for convenience of administration.

A client recently diagnosed with primary bone cancer states "My life is over. I'll never get married now!" What is the nurse's best action at this time? A) Refer the client to a clergy member or spiritual leader. B) Ask the client what is meant by that statement. C) Listen while the client expresses feelings. D) Provide hope that marriage will happen.

ANS: C. The best action for the nurse at this time is to listen and establish a trusting relationship with the client as he or she expresses emotions and feelings. At some point, the client may request referral to a clergy member or spiritual leader. While it is appropriate to provide hope, stating that the client will marry is unknown as this time.

An adult patient with a history of otitis media states that his left ear pain is better. Now, the patient has noticed some pus with blood in the affected ear. What does the nurse suspect has happened? a. Antibiotics are resolving the infection. b. The eardrum has perforated. c. The infection has worsened. d. The ear is permanently damaged.

B

A client who had an elective below-the-knee amputation (BKA) reports pain in the foot that was amputated last week. What is the nurse's most appropriate response to the client's pain? A) "The pain will go away after the swelling decreases." B) "That's phantom limb pain and every amputee has that." C) "Your foot has been amputated, so it's in your head." D) "On a scale of 0 to 10, how would you rate your pain?"

ANS: D. As stated in Chapter 4 of this text, pain is what the patient says it is. The nurse should acknowledge that the pain is real to the patient and perform an assessment of the pain first. All pain must be managed to prevent long-term chronic pain.

The nurse is caring for four clients. Which has the highest risk for development of macular degeneration? A) 25 year old, 70 inches tall, with fracture of the right femur B) 38 year old, 71 inches tall, who has just given birth to a healthy baby C) 45 year old, 67 inches tall, who is a vegetarian D) 57 year old, 60 inches tall, with hypertension

ANS: D. Dry AMD is more common and progresses at a faster rate among smokers than among nonsmokers. Other risk factors include hypertension, female gender, short stature, family history, and a long-term diet poor in carotene and vitamin E. The client in choice D is of short status and has a hypertension, increasing the risk for AMD.

Which statement by the client regarding lifestyle changes to prevent osteoporosis indicates a need for further teaching by the nurse? A) "I am going to continue having my DXA scans as my doctor orders." B) "I will drink only a half glass of wine occasionally to help me sleep." C) "I plan to increase calcium and vitamin D foods in my diet." D) "I am going to jog every day for at least 30 minutes."

ANS: D. Eating foods high in calcium and Vitamin D and consuming only a minimal amount of alcohol are strategies that promote bone health. Having regular DXA scans as prescribed are useful in detecting bone loss early so that it can be treated. Jogging is not an appropriate exercise for prevention of bone loss as it can jar the body, especially the vertebral column, and cause compression fractures. Therefore, if the patient thinks that jogging is a good exercise to use, the nurse needs to do further teaching about decreasing the risk for osteoporosis.

For which client will the nurse avoid performing an otoscopic examination? A) 29-year old with abdominal pain B) 37-year old with vertigo C) 45-year old with new diagnosis of diabetes D) 59-year old with confusion

ANS: D. Performing an otoscopic examination on the confused client could result in damage to the ear. If the client becomes combative, it could result in a safety concern for the nurse.

A client returns to the postanesthesia care unit (PACU) after an arthroscopy to prepare a knee injury. What is the nurse's priority when caring for this client? A) Perform passive range-of-motion exercises. B) Keep the affected leg immobilized. C) Ensure that the patient uses the patient-controlled analgesia (PCA) pump. D) Check the neurovascular status of the affected leg and foot.

ANS: D. While all of these nursing interventions are performed after surgery, the most important intervention is to ensure that the client has adequate perfusion to the affected leg and foot. Assessing neurovascular status, or performing "circ check," provides data about distal perfusion.

The nurse is teaching a class to pregnant teenagers. Which information is most important when discussing ways to prevent osteoporosis? 1. Take at least 1,200 mg of calcium supplements a day. 2. Eat foods low in calcium and high in phosphorus. 3. Osteoporosis does not occur until around age 50 years. 4. Remain as active as possible until the baby is born

ANSWER: 1 1. The National Institutes of Health (NIH) recommends a daily calcium intake of 1,200 to 1,500 mg/day for adolescents, young adults, and pregnant and lactating women. 2. The pregnant teenager should eat foods high in calcium. 3. Osteoporosis may not occur before age 50 years, but taking calcium throughout the life span will help prevent it. Remember, teenagers tend to focus on the present, not the future, so the most important intervention to teach them is to take calcium supplements. 4. Activity will not help prevent osteoporosis in the teenager; the teenager must take calcium supplements. TEST-TAKING HINT: The age of the client is important when answering questions; developmental stages will help rule out or help select the correct answer.

Which signs/symptoms indicate to the nurse the client has developed osteoporosis? 1. The client has lost one (1) inch in height. 2. The client has lost 12 pounds in the last year. 3. The client's hands are painful to the touch. 4. The client's serum uric acid level is elevated.

ANSWER: 1. 1. The loss of height occurs as vertebral bodies collapse. 2. Weight loss is not a sign of osteoporosis. 3. This may indicate rheumatoid arthritis but not osteoporosis. 4. This is a sign of gout. TEST-TAKING HINT: If the test taker is not sure of the answer and knows osteo- means "bone," the only answer related to bones is the height of the client, related to the spine.

The nurse writes a concept of "impaired mobility" for a client diagnosed with a fractured right hip. Which would the nurse include in the plan of care? Select all that apply. 1. Request a physical therapy referral. 2. Administer enoxaparin (Lovenox) subcutaneously. 3. Utilize a gait belt when ambulating the client. 4. Assess the client's pain levels on a 1-to10 scale. 5. Provide a high-carbohydrate, high-fat, high-sodium diet.

ANSWER: 1, 2, 3, 4. 1. A physical therapist will assist the client to ambulate safely while protecting the hip from being displaced. 2. The client's mobility is compromised, placing the client at risk for developing a deep vein thrombosis (DVT). Lovenox will assist in preventing a DVT. 3. Health-care workers should use gait belts to provide support and stability when ambulating clients. 4. Fractures of any bone are painful; pain scales are useful in qualifying the amount and type of pain being experienced by the client. 5. The client's diet should be a well-balanced diet with an emphasis on protein for wound healing. TEST-TAKING HINT: Knowledge of basic nursing care is required when answering this question. The use of a gait belt for ambulating and assessing pain are basic nursing skills.

The client who has sustained a left-sided cerebrovascular accident (stroke) has residual right-sided paralysis. The nurse identifies a concept of impaired functional ability. Which should be included in the care map? Select all that apply. 1. Refer to the occupational therapist. 2. Assess the client for neglect of the right side. 3. Place the client in a room where the door is on the left side. 4. Teach the client to call for assistance prior to getting out of bed. 5. Encourage the client to participate in physical therapy daily.

ANSWER: 1, 2, 3, 4. 1. Occupational therapists work on upper body ability and activities of daily living as well as increasing cognitive ability. This is an excellent referral. 2. Clients who no longer have the use of a side of the body will not realize when the arm or leg moves and this can be a safety issue. 3. The client may not realize that one-half of the visual field has been impaired as a result of the stroke. If this has happened the client will not see things in the left visual fields. Remember that the nerve pathways cross over at the base of the skull, so a leftsided stroke produces issues for the body below the neck on the opposite side of the stroke, but in the brain (visual fields) it would be on the side of the stroke. 4. For safety this should be done for all clients. 5. The nurse should encourage the client to participate in activity that increases the client's functional ability. TEST-TAKING HINT: When answering "Select all that apply" questions, each option is read independently of the others. Each option becomes a true/false question.

The 32-year-old male client with a traumatic left AKA is being discharged from the rehabilitation department. Which discharge instructions should be included in the teaching? Select all that apply. 1. Report any pain not relieved with analgesics. 2. Eat a well-balanced diet and increase protein intake. 3. Be sure to attend all outpatient rehabilitation appointments. 4. Encourage the client to attend a support group for amputations. 5. Stay at home as much as possible for the first couple of months.

ANSWER: 1, 2, 3, 4. 1. Pain not relieved with analgesics could indicate complications or could be phantom pain. 2. A well-balanced diet promotes wound healing, especially a diet high in protein. 3. The client must keep appointments in outpatient rehabilitation to continue to improve physically and emotionally. 4. A support group may help the client adjust to life with an amputation. 5. The client should be encouraged to get out as much as possible and live as normal a life as possible. TEST-TAKING HINT: The test taker needs to select all appropriate options.

Which interventions should be included in the discharge teaching for a client who had a total hip replacement? Select all that apply. 1. Discuss the client's weight-bearing limits. 2. Request the client demonstrate use of assistive devices. 3. Explain the importance of increasing activity gradually. 4. Instruct the client not to take medication prior to ambulating. 5. Tell the client to ambulate with open-toed house shoes.

ANSWER: 1, 2, 3. 1. Clients need to understand the amount of weight bearing to prevent injury. 2. Teaching the safe use of assistive devices is necessary prior to discharge. 3. Increases in activity should occur slowly to prevent complications. 4. Using medication therapy, including analgesics, anti-inflammatory agents, or muscle relaxants, should be taught so the client is comfortable while ambulating. 5. The client should ambulate with well-fitted, supported, closed-toed shoes such as a tennis shoe or walking shoe. TEST-TAKING HINT: The test taker should apply basic concepts to all surgeries. Many times the test taker may not be familiar with the specific surgery, but by using discharge teaching applicable to all clients, a choice can be made.

Which risk factors should the nurse discuss with the client concerning reasons for hearing loss? Select all that apply. 1. Perforation of the tympanic membrane. 2. Chronic exposure to loud noises. 3. Recurrent ear infections. 4. Use of nephrotoxic medications. 5. Multiple piercings in the auricle.

ANSWER: 1, 2, 3. 1. The tympanic membrane is the eardrum, and if it is punctured it may lead to hearing loss. 2. Loud persistent noise, such as heavy machinery, engines, and artillery, over time may cause noise-induced hearing loss. 3. Multiple ear infections scar the tympanic membrane, which can lead to hearing loss. 4. Nephrotoxic means harmful to the kidneys; ototoxic is harmful to the ears. 5. Multiple pierced earrings do not lead to hearing loss. The auricle (skin attached to the head) is composed mainly of cartilage, except for the fat and subcutaneous tissue in the earlobe. TEST-TAKING HINT: This alternate-type question requires the test taker to select multiple correct answers. Many options can be eliminated as incorrect answers when the test taker knows medical terminology— nephro- means kidney-related—and normal anatomy of the body—auricle means "skin attached to the head."

The 50-year-old female client is being evaluated for osteoporosis. Which data should the nurse assess? Select all that apply. 1. Family history of osteoporosis. 2. Estrogen or androgen deficit. 3. Exposure to secondhand smoke. 4. Level and amount of exercise. 5. Alcohol intake.

ANSWER: 1, 2, 4, 5. 1. Clients are more prone to have osteoporosis if there is a genetic predisposition. 2. Clients who are deficient in either estrogen or androgen are at risk for osteoporosis. 3. Clients who smoke are more at risk for osteoporosis. Research does not show a correlation between osteoporosis and secondhand smoke. 4. Regular, weight-bearing exercise promotes healthy bones. 5. Clients who consume alcohol and have diets low in calcium are at a higher risk for osteoporosis

The nurse is reviewing the orders for a patient who was admitted for 24-hour observation of a leg fracture. A cast is in place. Which order does the nurse question? a. Elevate lower leg above the level of the heart. b. Perform neurovascular assessments every 8 hours. c. Apply ice pack for 24 hours. d. Provide regular diet as tolerated.

B

The nurse is caring for a client diagnosed with a fracture of the right distal humerus. Which data indicate a complication? Select all that apply. 1. Numbness and mottled cyanosis. 2. Paresthesia and paralysis. 3. Proximal pulses and point tenderness. 4. Coldness of the extremity and crepitus. 5. Palpable radial pulse and functional movement.

ANSWER: 1, 2, 4. 1. The nurse should assess for numbness and mottled cyanosis, which might indicate nerve damage. 2. The presence of paresthesia and paralysis indicates impaired circulation. 3. Pulses should be assessed but not proximal to the fracture. Pulses distal to the fracture should be assessed. Point tenderness should be expected. 4. Coldness indicates decreased blood supply. Crepitus indicates air in subcutaneous tissue and is not expected. 5. Palpable radial pulses and functional movement do not indicate a complication has occurred. TEST-TAKING HINT: This is an alternate-type question in which the test taker must select all options that apply. The test taker should remember the neuromuscular assessment, which includes the 6 Ps—pulse, pain, paresthesia, paralysis, pallor, polar (cold).

The nurse writes the problem of "pain" for a client diagnosed with lumbar strain. Which nursing interventions should be included in the plan of care? Select all that apply. 1. Assess pain on a 1-to-10 scale. 2. Administer pain medication prn. 3. Provide a regular bedpan for elimination. 4. Assess surgical dressing every four (4) hours. 5. Perform a position change by the log roll method every two (2) hours.

ANSWER: 1, 2. 1. An objective method of quantifying the client's pain should be used. 2. Once the nurse has determined the client is stable and not experiencing complications, the nurse can medicate the client. 3. A regular bedpan is high and could cause pain for a client diagnosed with back pain. The client should be given a fracture pan. 4. There is no surgical dressing. 5. The client has not been to surgery, so log rolling is not necessary. TEST-TAKING HINT: Two of the options, "4" and "5," apply to postsurgical cases and could be eliminated

The nurse is administering eyedrops to the client. Which guidelines should the nurse adhere to when instilling the drops into the eye? Select all that apply. 1. Do not touch the tip of the medication container to the eye. 2. Apply gentle pressure on the outer canthus of the eye. 3. Apply sterile gloves prior to instilling eyedrops. 4. Hold the lower lid down and instill drops into the conjunctiva. 5. Gently pat the skin to absorb excess eyedrops on the cheek.

ANSWER: 1, 4, 5. 1. Touching the tip of the container to the eye may cause eye injury or an eye infection. 2. Gentle pressure should be applied on the inner canthus, not outer canthus, near the bridge of the nose for one (1) or two (2) minutes after instilling eyedrops. 3. The nurse should wash hands prior to and after instilling medications; this is not a sterile procedure. 4. Medication should not be placed directly on the eye but in the lower part of the eyelid. 5. Eyedrops are meant to go in the eye, not on the skin, so the nurse should use a clean tissue to remove excess medication. TEST-TAKING HINT: This is an alternate-type question requiring the test taker to select all the correct options. The test taker should not second-guess the question. All five (5) options can be selected or only one (1). The test taker should read each option, and if it is correct, select it.

The nurse is caring for the following clients. After receiving the shift report, which client should the nurse assess first? 1. The client with a total knee replacement who is complaining of a cold foot. 2. The client diagnosed with osteoarthritis who is complaining of stiff joints. 3. The client who needs to receive a scheduled intravenous antibiotic. 4. The client diagnosed with back pain who is scheduled for a lumbar myelogram.

ANSWER: 1. 1. A cold foot in a client who has had surgery may indicate a neurovascular compromise and must be assessed first. 2. A client with osteoarthritis is expected to have stiff joints. 3. A routine medication is not priority over a potential complication of surgery. 4. A routine diagnostic procedure does not have priority over a potential complication of surgery. TEST-TAKING HINT: The test taker must take a systematic approach when answering prioritizing questions. First, the test taker must determine if any client is experiencing a life-threatening or life-altering complication such as loss of a limb. The test taker must determine if the sign/symptom is expected for the disease or condition.

The nurse identifies a concept of impaired mobility for a male client with degenerative disk disease. Which assessment data best support this concept? 1. The client reports a history of chronic back pain and multiple back surgeries. 2. The client reports that taking NSAIDs caused the development of peptic ulcers. 3. The client reports a three (3)-year history of difficulty initiating a urinary stream. 4. The client states he fell a year ago and had to have a cast on the right arm for a month.

ANSWER: 1. 1. A history of low back pain and multiple back surgeries indicates a history of disk and back issues. 2. The use of NSAIDS could have happened for reasons other than degenerative disk disease. 3. Difficulty initiating a urinary stream usually indicates a male client has benign prostatic hypertrophy. The prostate is blocking the urethra. 4. A fall and wearing a cast on the arm do not indicate degenerative disk (vertebra of the back) disease. TEST-TAKING HINT: The test taker could eliminate option "4" if familiar with medical terminology; disks refer to the back, not the arm. Option "2" is nonspecific as to the reason for taking the NSAIDs and could be eliminated.

Which staff nurse should the charge nurse assign to the client recovering from a repair of the hallux valgus? 1. A new graduate nurse. 2. An experienced nurse. 3. A nurse practitioner. 4. An unlicensed assistive personnel.

ANSWER: 1. 1. A new graduate is the best choice for this client. The client's surgery (correction of a hammer toe) is not a high-risk procedure but requires assessment and pain management. 2. This client does not need a more experienced nurse. 3. A nurse practitioner does not need to be assigned to this client. 4. The UAP is not assigned the responsibility of managing the care of a client; the UAP works under the guidance of the nurse.

The nurse is discharge teaching for a client with a short leg cast. Which statement indicates the client understands the discharge teaching? 1. "I need to keep my leg elevated on two pillows for the first 24 hours." 2. "I must wear my sequential compression device all the time." 3. "I can remove the cast for one (1) hour so I can take a shower." 4. "I will be able to walk on my cast and not have to use crutches."

ANSWER: 1. 1. This is a correct intervention. The leg should be elevated for at least the first 24 hours. If edema is present, the client needs to keep it elevated longer. 2. Sequential compression devices work to prevent deep vein thrombosis and the client does not wear one of these at home. 3. The client will not be able to remove the cast for any reason. The cast must be cut off. 4. Clients with casts can only ambulate if they have a walking cast or boot. This information is not in the stem of the question.

The client with a right AKA is being taught how to toughen the residual limb. Which intervention should the nurse implement? 1. Instruct the client to push the residual limb against a pillow. 2. Demonstrate how to apply an elastic bandage around the residual limb. 3. Encourage the client to apply vitamin B12 to the surgical incision. 4. Teach the client to elevate the residual limb at least three (3) times a day

ANSWER: 1. 1. Applying pressure to the end of the residual limb will help toughen the limb. Gradually pushing the residual limb against harder and harder surfaces is done in preparation for prosthesis training. 2. An Ace bandage applied distal to proximal will help decrease edema and help shape the residual limb into a conical shape. 3. Vitamin E oil will help decrease the angriness of the scar, but it will not help with residual limb toughening. 4. Elevating the residual limb will help decrease edema, but it will also cause a contracture if the residual limb is elevated after the first 24 hours. TEST-TAKING HINT: The stem of the question asks the test taker to choose a method of toughening the residual limb. Demonstrating how to apply an elastic bandage or elevating the limb would not accomplish this, so options "2" and "4" could be eliminated from consideration.

The client has undergone a bilateral stapedectomy. Which action by the client warrants immediate intervention by the nurse? 1. The client is ambulating without assistance. 2. The client is sneezing with the mouth open. 3. There is some slight serosanguineous drainage. 4. The client reports hearing popping in the affected ear.

ANSWER: 1. 1. Balance disturbance, or true vertigo, rarely occurs with other middle-ear surgical procedures, but it does occur for a short time after a stapedectomy. Safety is an important issue, and ambulating without assistance requires intervention by the nurse. 2. Pressure changes in the middle ear will be minimal if the client sneezes or blows the nose with the mouth open instead of closed. 3. Slightly bloody or serosanguineous drainage is normal after ear surgery. 4. Popping and crackling in the operative ear is normal for about three (3) to five (5) weeks after surgery

The 62-year-old client diagnosed with type 2 diabetes who has a gangrenous right toe is being admitted for a below-the-knee amputation. Which nursing intervention should the nurse implement? 1. Assess the client's nutritional status. 2. Refer the client to an occupational therapist. 3. Determine if the client is allergic to IVP dye. 4. Start a 22-gauge Angiocath in the right arm.

ANSWER: 1. 1. For wound healing, a balanced diet with adequate protein and vitamins is essential, along with meals appropriate for type 2 diabetes. 2. An occupational therapist addresses activities of daily living and usually addresses upper extremity amputations. A referral to a physical therapist is most appropriate to address ambulating and transfer concerns. 3. There is no type of intravenous dye used in this surgical procedure, so this answer is not appropriate. 4. An 18-gauge catheter should be started because the client is going to surgery; the client may need a blood transfusion, which should be administered through an 18-gauge catheter. TEST-TAKING HINT: The nurse must take into account all the client's comorbid conditions (diabetes type 2) when selecting the correct answer.

The nurse is caring for a client diagnosed with a cerebrovascular accident (CVA). Which assessment information should the nurse determine first when placing the client in the assigned room? 1. Determine if the client has loss of vision in the same half of each visual field. 2. Find out if the client prefers the bed by the window or by the bathroom. 3. Request dietary to place the meat at 1200 on each plate and vegetables at 0900 and 1500. 4. Request a physical therapy consult to assess the client's mobility issues.

ANSWER: 1. 1. Homonymous hemianopsia (blindness in the same half of each visual field) is a common problem after a stroke. Clients disregard objects in that part of the visual field. The nurse would want to place the client in a room with the bed positioned so that the client will know when someone is entering the room. 2. Client preference can be taken into consideration but is not a priority. 3. Requesting dietary to place foods in a certain order will assist the client with visual disturbances to know where to find the food on the plate but is not first. 4. Physical therapy may need to assess the client, but it is not first. TEST-TAKING HINT: The signs/symptoms of CVA vary and some of the clinical manifestations may not be immediately observable. The brain impacts the entire body. The test taker must know which symptoms impact the client's daily life.

The client with a retinal detachment has just undergone a gas tamponade repair. Which discharge instruction should the nurse include in the teaching? 1. The client must lie flat with the face down. 2. The head of the bed must be elevated 45 degrees. 3. The client should wear sunglasses when outside. 4. The client should avoid reading for three (3) weeks

ANSWER: 1. 1. If gas tamponade is used to flatten the retina, the client may have to be specially positioned to make the gas bubble float into the best position; clients must lie face down or on the side for days. 2. The HOB should not be elevated after this surgery. 3. There is no need for the client to wear sunglasses; this surgery does not cause photophobia. 4. The client does not need to avoid reading.

The client is diagnosed with glaucoma. Which symptom should the nurse expect the client to report? 1. Loss of peripheral vision. 2. Floating spots in the vision. 3. A yellow haze around everything. 4. A curtain coming across vision.

ANSWER: 1. 1. In glaucoma, the client is often unaware he or she has the disease until the client experiences blurred vision, halos around lights, difficulty focusing, or loss of peripheral vision. Glaucoma is often called the "silent thief." 2. Floating spots in the vision is a symptom of retinal detachment. 3. A yellow haze around everything is a complaint of clients experiencing digoxin toxicity. 4. The complaint of a curtain coming across vision is a symptom of retinal detachment. TEST-TAKING HINT: The signs/symptoms of eye disorders are confusing. The test taker must know which complaints will be made by the client with a specific eye disorder

The nurse is caring for a client with a right total knee repair. Which intervention should the nurse implement? 1. Monitor the continuous passive motion machine. 2. Apply thigh-high TED hose bilaterally. 3. Place the abductor pillow between the legs. 4. Encourage the family to perform ADLs for the client.

ANSWER: 1. 1. The CPM machine is used to ensure the client has adequate range of motion in the knee postoperatively. 2. The TED hose are only applied to the unaffected leg, not the leg with the incision. 3. Adductor pillows are used in clients with total hip replacements to maintain function hip alignment. 4. The client should perform as many ADLs as possible. The client should maintain independence as much as possible. TEST-TAKING HINT: The test taker should remember to think about basic concepts of surgical care: Would an elastic hose be placed over a new incision? Sometimes trying to imagine what is actually occurring at the bedside helps to eliminate some options.

The employee health nurse is teaching a class on "Preventing Eye Injury." Which information should be discussed in the class? 1. Read instructions thoroughly before using tools and working with chemicals. 2. Wear some type of glasses when working around flying fragments. 3. Always wear a protective helmet with eye shield around dust particles. 4. Pay close attention to the surroundings so eye injuries will be prevented.

ANSWER: 1. 1. Instructions provide precautions and steps to take if eye injuries occur secondary to the use of tools or chemicals. 2. The employee must wear safety glasses, not just any type of glasses and especially not regular prescription glasses. 3. A protective helmet is used to help prevent sports eye injuries, not work-related injuries. 4. Eye injuries will not be prevented by paying close attention to the surroundings. They are prevented by wearing protective glasses or eye shields. TEST-TAKING HINT: The test taker must make sure what the question is asking and must pay close attention to adjectives. An "employee health nurse" is in the workplace. If the test taker is going to select an option with a word such as "always," "never," or "only," he or she must be absolutely sure it is an intervention never questioned. In health care, there are very few absolutes.

Which situation makes the nurse suspect the client has glaucoma? 1. An automobile accident because the client did not see the car in the next lane. 2. The cake tasted funny because the client could not read the recipe. 3. The client has been wearing mismatched clothes and socks. 4. The client ran a stoplight and hit a pedestrian walking in the crosswalk.

ANSWER: 1. 1. Loss of peripheral vision as a result of glaucoma causes the client problems with seeing things on each side, resulting in a "blind spot." This problem can lead to the client having car accidents when switching lanes. 2. This is indicative of cataracts because clients with cataracts have blurred vision and cannot read clearly. 3. This is indicative of cataracts because there is a color shift to yellow-brown and there is reduced light transmission. 4. This is indicative of macular degeneration, in which the central vision is affected.

The client is scheduled for a magnetic resonance imaging (MRI) scan. Which intervention should the nurse delegate to the unlicensed assistive personnel (UAP)? 1. Prepare the client by removing all metal objects. 2. Inject the contrast into the intravenous site. 3. Administer a sedative to the client to decrease anxiety. 4. Explain why the client cannot have any breakfast.

ANSWER: 1. 1. Metal objects such as jewelry and zippers can interfere with the magnetic imaging and pose a danger to the client as a result of the magnetic properties of the equipment. This intervention can be delegated to the UAP. 2. Injection of contrast is given in the radiology department. 3. UAPs are unable to administer medications in hospitals. 4. The nurse cannot delegate teaching to a UAP.

The occupational health nurse is teaching a class on the risk factors for developing osteoarthritis (OA). Which is a modifiable risk factor for developing OA? 1. Being overweight. 2. Increasing age. 3. Previous joint damage. 4. Genetic susceptibility

ANSWER: 1. 1. Obesity is a well-recognized risk factor for the development of OA and it is modifiable because the client can lose weight. 2. Increasing age is a risk factor, but there is nothing the client can do about getting older, except to die. 3. Previous joint damage is a risk factor, but it is not modifiable, which means the client cannot do anything to change it. 4. Genetic susceptibility is a result of family genes, which the client cannot change; it is a nonmodifiable risk factor. TEST-TAKING HINT: The adjective "modifiable" is the key to selecting the correct answer. Only option "1" contains anything the client has control over changing or modifying.

The nurse is caring for a client diagnosed with acute otitis media. Which signs/symptoms support this medical diagnosis? 1. Unilateral pain in the ear. 2. Green, foul-smelling drainage. 3. Sensation of congestion in the ear. 4. Reports of hearing loss.

ANSWER: 1. 1. Otalgia (ear pain) is experienced by clients with otitis media. 2. A green, foul-smelling drainage supports the diagnosis of external otitis, not of acute otitis media. 3. A sensation of congestion in the ear supports serous otitis media. 4. Hearing loss supports a diagnosis of chronic otitis media or serous otitis media. TEST-TAKING HINT: If the test taker were not sure of the answer, the adjective "acute" in the stem should cause the test taker to think "pain," which is included in option "1."

The 34-year-old male client presents to the outpatient clinic complaining of numbness and pain radiating down the left leg. Which further data should the nurse assess? 1. Posture and gait. 2. Bending and stooping. 3. Leg lifts and arm swing. 4. Waist twists and neck mobility

ANSWER: 1. 1. Posture and gait will be affected if the client is experiencing sciatica (pain radiating down a leg resulting from pressure on the sciatic nerve). 2. The client with pain and numbness is not able to bend or stoop and should not be asked to do so. 3. Leg lifts will not give the nurse the needed information and could cause this client pain; also, the lower extremity, not the upper extremity, is being assessed. 4. Waist twists will not assess the mobility of the lower extremity, and neck mobility is assessed if a cervical neck problem is suspected. TEST-TAKING HINT: Anatomical positioning and the function of spinal nerves rule out options "3" and "4."

The nurse is discussing the importance of an exercise program for pain control to a client diagnosed with OA. Which intervention should the nurse include in the teaching? 1. Wear supportive tennis shoes with white socks when walking. 2. Carry a complex carbohydrate while exercising. 3. Alternate walking briskly and jogging when exercising. 4. Walk at least 30 minutes three (3) times a week.

ANSWER: 1. 1. Safety should always be discussed when teaching about exercises. Supportive shoes will prevent shin splints. Colored socks have dye and may cause athlete's foot, which is why white socks are recommended. 2. Clients with diabetes mellitus should carry complex carbohydrates with them. 3. Osteoarthritis occurs most often in weightbearing joints. Exercise is encouraged, but jogging increases stress on these joints. 4. For exercising to help pain control, the client must walk daily, not three (3) times a week. Walking at least 30 minutes three (3) times a week is appropriate for weight loss. TEST-TAKING HINT: The test taker can rule out option "3" as an answer because the stem says "pain control"; option "1" is correct for any exercise program.

The Jewish client with peripheral vascular disease is scheduled for a left AKA. Which question is most important for the operating room nurse to ask the client? 1. "Have you made any special arrangements for your amputated limb?" 2. "What types of food would you like to eat while you're in the hospital?" 3. "Would you like a rabbi to visit you while you are in the recovery room?" 4. "Will you start checking your other foot at least once a day for cuts?"

ANSWER: 1. 1. The Jewish faith believes all body parts must be buried together. Therefore, many synagogues will keep amputated limbs until death occurs. 2. Specific foods are important but not while the client is in the operating room. 3. Spiritual issues are important for the nurse to discuss with the client, but the operating room should be concerned with disposition of the amputated limb. 4. Addressing teaching issues is important, but the most important concern is disposition of the amputated limb. TEST-TAKING HINT: The nurse must always address the cultural needs of the client, and when the test taker sees a specific culture in the stem of a question, it is a prompt indicating this will be important when selecting the answer.

Two unlicensed assistive personnel (UAP) are using the transfer board to move the client from the bed to the wheelchair. Which action should the nursing take? 1. Take no action because this is the correct procedure for transferring a client. 2. Instruct the UAPs not to use a transfer board when moving the client. 3. Tell the UAPs to use the bed scale sling to move the client to the chair. 4. Request the UAPs to stop and come to the nurse's station immediately

ANSWER: 1. 1. The UAPs are transferring the client correctly and safely, so no action should be taken. The UAPs are adhering to the Patient Care Safety Standards by using approved equipment. 2. The nurse should encourage the use of appropriate equipment designed to protect the client and the staff from injury. 3. The bed scale sling is inappropriate to use when moving the client from the bed to a wheelchair. 4. There is no reason for the nurse to stop the UAPs because the task is being performed correctly

The 72-year-old client tells the nurse food does not taste good anymore and he has lost a little weight. Which information should the nurse discuss with the client? 1. Suggest using extra seasoning when cooking. 2. Instruct the client to keep a seven (7)-day food diary. 3. Refer the client to a dietitian immediately. 4. Recommend eating three (3) meals a day

ANSWER: 1. 1. The acuity of taste buds decreases with age, which may cause a decreased appetite and subsequent weight loss. Spices or other seasonings may help the food taste better to the client. 2. This may be an appropriate intervention if excessive weight is lost or if seasoning the food does not increase appetite, but it is not necessary at this time. 3. The client does not need a dietary consult for food not "tasting good." The nurse can address the client's concern. 4. This recommendation does not address the client's comment about food not tasting good.

Which foods should the nurse recommend to a client when discussing sources of dietary calcium? 1. Yogurt and dark-green, leafy vegetables. 2. Oranges and citrus fruits. 3. Bananas and dried apricots. 4. Wheat bread and bran

ANSWER: 1. 1. The best dietary sources of calcium are milk and other dairy products. Other sources include oysters; canned sardines or salmon; beans; cauliflower; and darkgreen, leafy vegetables. 2. These foods are high in vitamin C. 3. These foods are high in potassium. 4. These foods are recommended for a highfiber diet. TEST-TAKING HINT: A question about special diets is a knowledge-based question, and the test taker must know which foods are in which type of diets. Foods high in calcium should be associated with milk products such as yogurt.

The client is prescribed Fosamax, a bisphosphonate. Which information should the nurse teach? 1. Take this medication with a full glass of water. 2. Take with breakfast to prevent gastrointestinal upset. 3. Use sunscreen to prevent sensitivity to sunlight. 4. This medication increases calcium reabsorption.

ANSWER: 1. 1. The client needs to take this medication with a full glass of water and remain upright for at least 30 minutes to reduce the risk of esophagitis. 2. This medication should be taken before breakfast on an empty stomach. 3. This medication does not cause photosensitivity. 4. This medication decreases calcium reabsorption by decreasing the activity of osteoclasts.

The nurse is caring for the client who had a right shoulder replacement. Which data warrant immediate intervention? 1. The client's hemoglobin is 8.1 g/dL. 2. The client's white blood cell count is 9,000/mm3 . 3. The client's creatinine level is 0.8 mg/dL. 4. The client's potassium level is 4.2 mEq/L.

ANSWER: 1. 1. The client's hemoglobin is near 8 g/dL, which indicates the client requires a blood transfusion. This information warrants intervention by the nurse. 2. This white blood cell count is within normal limits, so it does not warrant immediate intervention. 3. The creatinine level is within normal limits and does not warrant intervention. 4. The potassium level is within normal limits and does not require intervention by the nurse. TEST-TAKING HINT: The test taker must be knowledgeable of laboratory values. There is no test-taking hint except memorize the values.

Which recommendation should the nurse suggest to an elderly client who lives alone when discussing normal developmental changes of the olfactory organs? 1. Suggest installing multiple smoke alarms in the home. 2. Recommend using a night-light in the hallway and bathroom. 3. Discuss keeping a high-humidity atmosphere in the bedroom. 4. Encourage the client to smell food prior to eating it

ANSWER: 1. 1. The decreased sense of smell resulting from atrophy of olfactory organs is a safety hazard, and clients may not be able to smell gas leaks or fire, so the nurse should recommend a carbon monoxide detector and a smoke alarm. This safety equipment is critical for the elderly. 2. Night-lights do not address the client's sense of smell. 3. High humidity may help with breathing, but it does not help the sense of smell. 4. The client's sense of smell is decreased; therefore, smelling food before eating is not an appropriate intervention.

The nurse is preparing the care plan for a client with a fractured lower extremity. Which outcome is most appropriate for the client? 1. The client will maintain function of the leg. 2. The client will ambulate with assistance. 3. The client will be turned every two (2) hours. 4. The client will have no infection.

ANSWER: 1. 1. The expected outcome for a client with a fracture is maintaining the function of the extremity. 2. Ambulation with assistance is not the best goal. 3. This is a nursing intervention, not a client goal. 4. Infection is not the highest priority problem for a client with a fracture. TEST-TAKING HINT: The test taker must note the words "most appropriate" and look at the client as a whole entity. With musculoskeletal problems, maintaining normal function or anatomical function is the desired outcome. Remember, independence is priority for the client

The client is 12-hours post-lumbar laminectomy. Which nursing interventions should be implemented? 1. Assess ability to void and log roll the client every two (2) hours. 2. Medicate with IV steroids and keep the bed in a Trendelenburg position. 3. Place sandbags on each side of the head and give cathartic medications. 4. Administer IV anticoagulants and place on O2 at eight (8) L/min

ANSWER: 1. 1. The lumbar nerves innervate the lower abdomen. The bladder is in the lower abdomen. The client will be required to lie flat, and this is a difficult position for many clients, especially males, to be in to void. Clients are log rolled every 2 hours. 2. The client should be receiving IV pain medication, not steroids. A Trendelenburg position is head down. 3. Sandbags keep the neck still, but the surgical area is in the lumbar region, so there is no reason the client cannot turn the head; also, cathartic medications are harsh laxatives. 4. The client will be receiving subcutaneous anticoagulant medications to prevent deep vein thrombosis, but IV anticoagulant therapy is not warranted. Eight (8) L/min of oxygen is high-flow oxygen and is used for a client in respiratory distress who does not have carbon dioxide narcosis. TEST-TAKING HINT: The test taker must note the adjective "lumbar"; this can rule out option "3." Knowledge of medication classifications would rule out options "2" and "4."

The nurse is admitting a female client who is complaining of severe back pain radiating down the left leg whenever she tries to ambulate. The concepts of impaired mobility and comfort are implemented on the care map. Which nursing interventions should the nurse implement? 1. Assist the client when ambulating to the bathroom and administer medications based on the pain scale. 2. Place the client on strict bedrest and have the client use a regular bedpan for elimination of urine and feces. 3. Ambulate the client in the hallway at least four (4) times per day and discourage the use of pharmacological pain relief. 4. Request the health-care provider (HCP) to assist the client in ambulating in the hallway so the HCP can observe the client's pain

ANSWER: 1. 1. The nurse or nursing staff should assist the client to ambulate to the bathroom, and pain medication should be administered using the pain scale to quantify and qualify the pain level. 2. The client should have bathroom privileges; strict bedrest will place the client at risk for pneumonia and DVT development. Movement should be encouraged within safe guidelines. A regular bedpan would place the client's back in an awkward position and increase the pain. 3. Pain is whatever the client says it is and occurs whenever the client says it does. The nurse should not discourage the use of pain medications in the light of "severe" pain. 4. The HCP does not need to assist the client to ambulate in the hallway to observe the effect of ambulation on the client's pain. The HCP can ask the client to ambulate in the room with the assistance of the UAP, nurse, or PT. TEST-TAKING HINT: The test taker should read words in the stem of a question and in the options—words matter. In option "2" "strict" and "regular" make this an incorrect option; in option "3" "discourage" makes it incorrect. In option "4" HCPs do not do the nurse's job of ambulating

The unlicensed assistive personnel (UAP) reports a client with a fractured femur has "fatty globules" floating in the urinal. What intervention should the nurse implement first? 1. Assess the client for dyspnea and altered mental status. 2. Obtain an arterial blood gas and order a portable chest x-ray. 3. Call the HCP for a ventilation/perfusion scan. 4. Instruct the UAP keep the client on strict bedrest.

ANSWER: 1. 1. The nurse should assess the client for signs of hypoxia from a fat embolism, which is what the nurse should anticipate from "fatty globules" in the urine. 2. Arterial blood gases and portable chest x-ray will be done, but they will not be done first. 3. A ventilation/perfusion scan is not the highest priority for the client. Assessment for complications is priority. 4. The UAP should keep the client on strict bedrest, but the nurse's first intervention is to assess the client. The client is unstable and the nurse should assess the client first, then maintain strict bedrest. TEST-TAKING HINT: If the test taker is unsure of the correct answer, always apply the nursing process. Assessment is the first part of the nursing process.

The client is taken to the emergency department with an injury to the left arm. Which intervention should the nurse implement first? 1. Assess the nailbeds for capillary refill time. 2. Remove the client's clothing from the arm. 3. Call radiology for a STAT x-ray of the extremity. 4. Prepare the client for the application of a cast

ANSWER: 1. 1. The nurse should assess the nailbeds for the capillary refill time. A prolonged time (greater than three [3] seconds) indicates impaired circulation to the extremity. 2. Clothing may need to be removed but not before assessment. 3. An x-ray will be done but is not the highest priority action. 4. A cast may or may not be applied, depending on the type and location of the fracture. TEST-TAKING HINT: When the question asks to prioritize nursing care, usually assessment is first. Assessment is an independent nursing intervention.

Which referral is most important for the nurse to implement for the client with permanent hearing loss? 1. Aural rehabilitation. 2. Speech therapist. 3. Social worker. 4. Vocational rehabilitation

ANSWER: 1. 1. The purpose of aural rehabilitation is to maximize the communication skills of the client who is hearing impaired. It includes auditory training, speech reading, speech training, and the use of hearing aids and hearing guide dogs. 2. A speech therapist may be part of the aural rehabilitation team, but the most important referral is aural rehabilitation. 3. The client may or may not need financial assistance, but the most important referral is aural rehabilitation. 4. The client may or may not need assistance with employment because of hearing loss, but the most important referral is the aural rehabilitation.

The nurse is conducting a Weber test on the client who is suspected of having conductive hearing loss in the left ear. Where should the nurse place the tuning fork when conducting this test? 1. Top of head. 2. Forehead. 3. Ear. 4. Chin.

ANSWER: 1. 1. The tuning fork should be struck to produce vibrations and then placed midline between the ears on top of the head. 2. The right temple area is not an appropriate place to assess for conductive hearing loss. 3. The right occipital area is not the appropriate place to place the tuning fork; this is the area behind the ear where the Rinne test is performed. 4. The chin area is not the appropriate area to put the tuning fork.

Which intervention is an example of a secondary nursing intervention when discussing osteoporosis? 1. Obtain a bone density evaluation test. 2. Perform non-weight-bearing exercises regularly. 3. Increase the intake of dietary calcium. 4. Refer clients to a smoking cessation program.

ANSWER: 1. 1. This is an example of a secondary nursing intervention, which includes screening for early detection. 2. The client should perform weight-bearing exercises, which promote osteoblast activity helping to maintain bone strength and integrity. This is a primary nursing intervention. 3. Increasing dietary calcium may be a primary intervention to help prevent osteoporosis or a tertiary intervention, which helps treat osteoporosis. 4. Smoking cessation is a primary intervention, which will help prevent the development of osteoporosis. TEST-TAKING HINT: The nurse must be knowledgeable of primary, secondary, and tertiary nursing interventions. Primary interventions are those which prevent the disease; secondary interventions are interventions such as screening the client for the disease with the goal of detecting it early; and tertiary interventions are interventions implemented when the client has the disease.

Which statement by the client prescribed calcitonin, a thyroid hormone, indicates to the nurse the teaching has been effective? 1. "I should administer the mediation in a different nostril each day." 2. "I need to drink a lot of water when I take my medicine." 3. "I have to dilute the medication with vitamin D before I take it." 4. "This medication will help the calcium leave my bones."

ANSWER: 1. 1. This medication is administered intranasally. Alternating nostrils will decrease the risk of nasal irritation. 2. This intervention should be implemented for Fosamax, a bisphosphonate, not calcitonin, a thyroid hormone. 3. Clients do not dilute their medication. Vitamin D is not used as a diluent for medication. 4. Calcium should be retained in the bone to maintain bone strength; medications are not administered to encourage loss from the bone.

Which behavior by the male client should make the nurse suspect the client has a hearing loss? Select all that apply. 1. The client reports hearing voices in his head. 2. The client becomes irritable very easily. 3. The client has difficulty making decisions. 4. The client's wife reports he ignores her. 5. The client does not dominate a conversation.

ANSWER: 2, 3, 4. 1. Voices in the head may indicate schizophrenia, but it is not a symptom of hearing loss. 2. Fatigue may be the result of straining to hear, and a client may tire easily when listening to a conversation. Under these circumstances, the client may become irritable very easily. 3. Loss of self-confidence makes it increasingly difficult for a person who is hearing impaired to make a decision. 4. Often it is not the person with the hearing loss but a significant other who notices hearing loss; hearing loss is usually gradual. 5. Many clients who are hearing impaired tend to dominate the conversation because, as long as it is centered on the client, they can control it and are not as likely to be embarrassed by some mistake.

The client diagnosed with cervical disk degeneration has undergone a laminectomy. Which interventions should the nurse implement? 1. Position the client prone with the knees slightly elevated. 2. Assess the client for difficulty speaking or breathing. 3. Measure the drainage in the Jackson Pratt bulb every day. 4. Encourage the client to postpone the use of narcotic medications.

ANSWER: 2. 1. "Prone" means on the abdomen. On the abdomen with the knees flexed is an uncomfortable position, placing the spine in an unnatural position. 2. The surgical position of the wound places the client at risk for edema of tissues in the neck. Difficulty speaking or breathing should alert the nurse to a potentially lifethreatening problem. 3. The drainage from a JP drain should be emptied and monitored every shift. 4. The client should be kept as comfortable as possible. TEST-TAKING HINT: The nurse must know the meaning of the common medical term prone and realize this would be uncomfortable for the client, thus eliminating option "1." The time frame of "every day" makes option "3" wrong.

Which break would make the nurse suspect child abuse? 1. Compound fracture. 2. Spiral fracture. 3. Oblique fracture. 4. Greenstick fracture.

ANSWER: 2. 1. A compound fracture is a fracture where the bone protrudes through the skin; it is also called an open fracture, and the nurse would not suspect child abuse based on only the type of fracture. 2. A spiral fracture is a fracture that involves twisting around the shaft of the bone, such as when an adult twists the arm of a child. The nurse should suspect child abuse. 3. An oblique fracture is a fracture that remains contained and does not break the skin. There are many reasons the child could have this type of fracture other than child abuse. 4. A greenstick fracture is a fracture in which one side of the bone is broken and the other side is bent. There are many reasons other than child abuse that could account for this type of fracture

The nurse who is at a local park sees a young man on the ground who has fallen and has a stick lodged in his eye. Which intervention should the nurse implement at the scene? 1. Carefully remove the stick from the eye. 2. Stabilize the stick as best as possible. 3. Flush the eye with water if available. 4. Place the young man in a high-Fowler's position

ANSWER: 2. 1. A foreign object should never be removed at the scene of the accident because this may cause more damage. 2. The foreign object should be stabilized to prevent further movement, which could cause more damage to the eye. 3. Flushing with water may cause further movement of the foreign object and should be avoided. 4. The person should be kept flat and not in a sitting position because it may dislodge or cause movement of the foreign object. TEST-TAKING HINT: In an emergency situation, the first responder should first "do no harm." The test taker should examine each option and decide what will happen if this option is performed—will it help, harm, or stabilize the client? If the test taker determines one (1) action may not help, then stabilization becomes the priority

The nurse is assessing a client who has a "pinpoint" pupil reaction bilaterally and the pupils do not constrict when the light is shown on the eye. Which should the nurse document? 1. Pupillary response poor. 2. Pupils one (1) mm, equal and nonreactive to light. 3. Pupils two (2) to three (3) mm and nonconstrictive to light. 4. Pupils are barely open and don't constrict to light.

ANSWER: 2. 1. Pupil response may be poor but this is not professionally documented for a clear record of the nurse's observation. 2. Pinpoint describes the least amount of dilation noted, which is 1 mm. Bilateral means both sides, so equal describes that one side is the same as the other. Nonreactive describes the pupils not constricting. This is clear and concise. 3. Two to 3 mm is not pinpoint, and nonconstrictive is not describing response to light. 4. This is something a layperson might say but is not in professional terms. TEST-TAKING HINT: The signs/symptoms of eye disorders can be confusing but the nurse must communicate in professional terminology that all medical personnel can interpret consistently.

Which interventions should the nurse implement for the client diagnosed with an open fracture of the left ankle? Select all that apply. 1. Apply an immobilizer snugly to prevent edema. 2. Apply an ice pack for 10 minutes and remove for 20 minutes. 3. Place the extremity in the dependent position to allow drainage. 4. Obtain an x-ray of the ankle after applying the immobilizer. 5. Administer tetanus toxoid, 0.5 mL intramuscularly, in the deltoid.

ANSWER: 2. 1. An immobilizer should not be applied snugly. There should be enough room to allow for edema and adequate perfusion of the tissues. 2. Ice packs should be applied 10 minutes on and 20 minutes off. This allows for vasoconstriction and decreases edema. Ice is a nonpharmacological pain management technique. 3. An injured extremity should be elevated above the level of the heart to decrease edema and pain. 4. An x-ray should be done before the immobilizer is in place, not after. 5. Anytime trauma occurs, tetanus should be considered. In an open fracture, this is an appropriate treatment. TEST-TAKING HINT: This is an alternativetype question. When selecting all that apply, it is important to consider the descriptive words which make the options incorrect. Read adjectives and adverbs carefully. The terms "snugly," "dependent," and "after" make options "1," "3," and "4" incorrect.

Which ototoxic medication should the nurse recognize as potentially life altering or threatening to the client? 1. An oral calcium channel blocker. 2. An intravenous aminoglycoside antibiotic. 3. An intravenous glucocorticoid. 4. An oral loop diuretic.

ANSWER: 2. 1. Calcium channel blockers are not going to affect the client's hearing. 2. Aminoglycoside antibiotics are ototoxic. Overdosage of these medications can cause the client to go deaf, which is why peak and trough serum levels are drawn while the client is taking a medication of this type. These antibiotics are also very nephrotoxic. 3. Steroids cause many adverse effects, but damage to the ear is not one of them. 4. Administering an intravenous push loop diuretic too fast can cause auditory nerve damage, but an oral loop diuretic does not. TEST-TAKING HINT: The test taker must be cautious of adjectives. The word "oral" in option "4" eliminates this option as a possible correct answer.

Which statement indicates to the nurse the client is experiencing some hearing loss? 1. "I clean my ears every day after I take a shower." 2. "I keep turning up the sound on my television." 3. "My ears hurt, especially when I yawn." 4. "I get dizzy when I get up from the chair."

ANSWER: 2. 1. Cleaning the ears daily does not indicate the client has a hearing loss. 2. The need to turn up the volume on the television is an early sign of hearing impairment. 3. Pain in the ears is not a clinical manifestation of hearing loss/impairment. 4. This statement may indicate a balance problem secondary to an ear disorder, but it does not indicate a hearing loss. TEST-TAKING HINT: If the test taker has no idea of the answer, option "2" is the only answer which has anything to do with sound.

The nurse is caring for a client with a right below-the-knee amputation. There is a large amount of bright red blood on the client's residual limb dressing. Which intervention should the nurse implement first? 1. Notify the client's surgeon immediately. 2. Assess the client's blood pressure and pulse. 3. Reinforce the dressing with additional dressing. 4. Check the client's last hemoglobin and hematocrit levels

ANSWER: 2. 1. If the client is hemorrhaging, the surgeon needs to be notified, but hemorrhaging has not been determined. 2. Determining if the client is hemorrhaging is the first intervention. The nurse should check for signs of hypovolemic shock: decreased BP and increased pulse. 3. Reinforcing the dressing helps decrease bleeding, but the nurse must assess first. 4. Checking the client's laboratory results is an appropriate intervention, but it is not the first intervention. TEST-TAKING HINT: Remember, when the stem asks the test taker to identify the first intervention, all four options will be probable interventions but only one is the first intervention. Also, the nurse should always assess first. Remember the nursing process.

The occupational health nurse is preparing an in-service for a group of workers in a warehouse. Which information should be included to help prevent on-the-job injuries? 1. Increase sodium and potassium in the diet during the winter months. 2. Use the large thigh muscles when lifting and hold the weight near the body. 3. Use soft-cushioned chairs when performing desk duties. 4. Have the employee arrange for assistance with household chores

ANSWER: 2. 1. Increased calcium, not potassium or sodium, is helpful in preventing orthopedic injuries. Increasing sodium intake could prevent water loss in a non-air-conditioned warehouse in the summer months, not the winter months. 2. These are instructions to prevent back injuries as a result of poor body mechanics. 3. Soft-cushioned chairs are not ergonomically designed. Soft-cushioned chairs promote poor body posture. 4. This might help the client prevent back injuries at home, but it does not prevent job-related injuries. TEST-TAKING HINT: The question is asking for information which will prevent on-the-job back injuries. Option "4" can be ruled out because of this. The two (2) electrolytes in option "1" are not associated with orthopedic injuries or bones, thus ruling out this option.

The HCP prescribes glucosamine and chondroitin for a client diagnosed with OA. What is the scientific rationale for prescribing this medication? 1. It will help decrease the inflammation in the joints. 2. It improves tissue function and retards breakdown of cartilage. 3. It is a potent medication which decreases the client's joint pain. 4. It increases the production of synovial fluid in the joint.

ANSWER: 2. 1. NSAIDs or glucocorticoids help decrease inflammation of the joints. 2. This is the rationale for administering these medications. 3. Narcotic and nonnarcotic analgesics help decrease the client's pain. 4. There is no medication at this time to help increase synovial fluid production, but surgery can increase the viscosupplementation in the joint. TEST-TAKING HINT: There are some questions requiring the test taker to have the knowledge, and there are no test-taking hints to help with selecting the right answer

The elderly client has undergone a right-eye cataract removal with an intraocular implant. Which discharge instructions should the nurse teach the client? 1. Have the client demonstrate placing the otic drops in the ear. 2. Teach the client to instill the eyedrops as prescribed. 3. Remind the client to keep the lights in the home low at all times. 4. Encourage the client to sleep on two pillows at night

ANSWER: 2. 1. Otic drops go in the ear, not the eye. 2. Postoperatively the client will be prescribed eyedrops for several weeks; the nurse should teach the client to administer as prescribed. 3. The light should be brighter for safety. 4. The client does not need to sleep with the HOB elevated. TEST-TAKING HINT: The test taker must know basic instructions for postoperative clients.

The client is diagnosed with osteoarthritis. Which sign/symptom should the nurse expect the client to exhibit? 1. Severe bone deformity. 2. Joint stiffness. 3. Waddling gait. 4. Swan-neck fingers.

ANSWER: 2. 1. Severe bone deformity is seen in clients diagnosed with rheumatoid arthritis. 2. Pain, stiffness, and functional impairment are the primary clinical manifestations of OA. Stiffness of the joints is commonly experienced after resting but usually lasts less than 30 minutes and decreases with movement. 3. A waddling gait is usually seen in women in their third trimester of pregnancy or in older children with congenital hip dysplasia. 4. Swan-neck fingers are seen in clients with rheumatoid arthritis. TEST-TAKING HINT: The test taker can have difficulty distinguishing clinical manifestations of two similar sounding diseases, osteoarthritis and rheumatoid arthritis. Both diseases involve the joints and cause pain and stiffness. Remember, rheumatoid arthritis can permanently disfigure the client, leading to "bone deformity" and "swan-neck fingers."

The client has had an enucleation of the left eye. Which intervention should the nurse implement? 1. Discuss the need for special eyeglasses. 2. Refer the client for an ocular prosthesis. 3. Help the client obtain a seeing-eye dog. 4. Teach the client how to instill eyedrops.

ANSWER: 2. 1. Special eyeglasses are not needed for an enucleation. 2. An enucleation is the removal of the entire eye and part of the optic nerve. An ocular prosthesis will help maintain the shape of the eye socket after the enucleation. 3. The client had the left eye removed but is not blind because he or she still has the right eye. 4. The eyeball was totally removed and a pressure dressing was applied; therefore, there will be no need to instill eyedrops. TEST-TAKING HINT: In some questions, the test taker must know the definition of the word ("enucleation") to be able to apply it in a clinical situation.

The client diagnosed with glaucoma is prescribed a miotic cholinergic medication. Which data indicate the medication has been effective? 1. No redness or irritation of the eyes. 2. A decrease in intraocular pressure. 3. The pupil reacts briskly to light. 4. The client denies any type of floaters

ANSWER: 2. 1. Steroid medication is administered to decrease inflammation. 2. Both systemic and topical medications are used to decrease the intraocular pressure in the eye, which causes glaucoma. 3. Glaucoma does not affect the pupillary reaction. 4. Floaters are a complaint of clients with retinal detachment. TEST-TAKING HINT: To determine the effectiveness of a medication, the nurse must know the signs/symptoms of the disease process. If the test taker knew glaucoma was the result of an increase in intraocular pressure, then the medication is effective if there was a decrease in intraocular pressure.

The female client diagnosed with osteoporosis tells the nurse she is going to perform swim aerobics for 30 minutes every day. Which response is most appropriate by the nurse? 1. Praise the client for committing to do this activity. 2. Explain to the client walking 30 minutes a day is a better activity. 3. Encourage the client to swim every other day instead of daily. 4. Discuss with the client how sedentary activities help prevent osteoporosis

ANSWER: 2. 1. Swimming is not as beneficial as walking in maintaining bone density because of the lack of weight-bearing activity. 2. Weight-bearing activity, such as walking, is beneficial in preventing or slowing bone loss. The mechanical force of weightbearing exercises promotes bone growth. 3. Swimming is not as beneficial in maintaining bone density because of the lack of weight-bearing activity. 4. A sedentary lifestyle is a risk factor for the development of osteoporosis. TEST-TAKING HINT: Sedentary activities include sitting and very low-activity exercises, which are risk factors in developing many diseases and disorders; therefore, option "4" can be eliminated.

The recovery room nurse is caring for a client who has just had a left BKA. Which intervention should the nurse implement? 1. Assess the client's surgical dressing every two (2) hours. 2. Do not allow the client to see the residual limb. 3. Keep a large tourniquet at the client's bedside. 4. Perform passive range-of-motion exercises to the right leg.

ANSWER: 2. 1. The client is in the recovery room, and the dressing must be assessed more frequently than every two (2) hours. 2. The client must come to terms with the amputation; therefore, the nurse should encourage the client to look at the residual limb. 3. The large tourniquet can be used if the residual limb begins to hemorrhage either internally or externally. 4. The nurse should encourage active, not passive, range-of-motion exercises. TEST-TAKING HINT: Remember to look at the phrases describing the intervention, such as "every two (2) hours" and "passive."

The client is three (3) hours postoperative left AKA. The client tells the nurse, "My left foot is killing me. Please do something." Which intervention should the nurse implement? 1. Explain to the client his left leg has been amputated. 2. Medicate the client with a narcotic analgesic immediately. 3. Instruct the client on how to perform biofeedback exercises. 4. Place the client's residual limb in the dependent position.

ANSWER: 2. 1. The client is three (3) hours postoperative and needs medical intervention. 2. Phantom pain is caused by severing the peripheral nerves. The pain is real to the client, and the nurse needs to medicate the client immediately. 3. Biofeedback exercises will not help address the client's postoperative surgical pain. 4. Placing the residual limb below the heart (dependent) will not help address the client's pain and could actually increase the pain. TEST-TAKING HINT: The test taker needs to be aware of adjectives such as "dependent." The nurse must know medical terms for positioning a client.

Which psychosocial problem should the nurse identify for a client with an external fixator device? 1. Ineffective coping. 2. Alteration in body image. 3. Grieving. 4. Impaired communication.

ANSWER: 2. 1. The client problem of ineffective coping is usually not indicated for a client with an external fixator device, unless the stem provides more information about the client. 2. Many clients with an external fixator have alterations in body image because the large, bulky frame makes dressing difficult and because of scarring, which occurs from the trauma and treatment. The length of healing is prolonged, so returning to the client's normal routine is delayed. 3. The client problem of grieving is usually not indicated for a client with an external fixator device, unless the stem of the question provides more information about the client. 4. The client problem of impaired communication is usually not indicated for a client with an external fixator device, unless the stem provides more information about the client

Which instruction should the nurse discuss with the female client with viral conjunctivitis? 1. Contact the HCP if pain occurs. 2. Do not share towels or linens. 3. Apply warm compresses to the eyes. 4. Apply makeup very lightly

ANSWER: 2. 1. The client should be aware eye pain (a sandy sensation and sensitivity to light) will occur with conjunctivitis. 2. Viral conjunctivitis is a highly contagious eye infection. It is easily spread from one person to another; therefore, the client should not share personal items. 3. Cold compresses should be placed over the eyes for about 10 minutes four (4) to five (5) times a day to soothe the pain. 4. The client must not apply any makeup until the disease is over and should discard all old makeup to help prevent reinfection.

Which instruction should the nurse discuss with the client when completing a sensory assessment regarding proprioception? 1. Instruct the client to lie flat without a pillow during the assessment. 2. Instruct the client to keep both eyes shut during the assessment. 3. During the assessment the client must be in a treatment room. 4. Keep the lights off during the client's sensory assessment.

ANSWER: 2. 1. The client should be in the sitting position during a sensory assessment. 2. The eyes are closed so tactile, superficial pain, vibration, and position sense (proprioception) can be assessed without the client seeing what the nurse is doing. 3. The sensory assessment can be conducted at the bedside; there is no reason to take the client to the treatment room. 4. There is no reason the lights should be off during the sensory assessment; the client should close his or her eyes.

The client admitted with a diagnosis of a fractured hip who is in Buck's traction is complaining of severe pain. Which intervention should the nurse implement? 1. Adjust the patient-controlled analgesia (PCA) machine for a lower dose. 2. Ensure the weights of the Buck's traction are off the floor and hang freely. 3. Raise the head of the bed to 45 degrees and the foot to 15 degrees. 4. Turn the client on the affected leg using pillows to support the other leg.

ANSWER: 2. 1. The health-care provider orders the dosage on a PCA. Unless a range of dosages or a new order is obtained, a lower dose will not help pain. 2. Weights from traction should be off the floor and hanging freely. Buck's traction is used to reduce muscle spasms preoperatively in clients who have fractured hips. 3. Raising the head of the bed or the foot will alter the traction. 4. Turning the client to the affected side could increase pain rather than relieve it. TEST-TAKING HINT: This intervention is a form of assessment, assessing the equipment being used for the client's condition. Remember to apply the nursing process.

The elderly male client tells the nurse, "My wife says her cooking hasn't changed, but it is bland and tasteless." Which response by the nurse is most appropriate? 1. "Would you like me to talk to your wife about her cooking?" 2. "Taste buds change with age, which may be why the food seems bland." 3. "This happens because the medications sometimes cause a change in taste." 4. "Why don't you barbecue food on a grill if you don't like your wife's cooking?"

ANSWER: 2. 1. The nurse needs to discuss possible causes with the client and not talk to the wife. 2. The acuity of the taste buds decreases with age, which could cause regular foods to seem bland and tasteless. 3. Some medications may cause a metallic taste in the mouth, but medication does not cause foods to taste bland. 4. Telling the client to cook if he doesn't like his wife's food is an argumentative and judgmental response.

The client diagnosed with osteomyelitis of the left foot and ankle is being prepared for a below-the-knee amputation. Which intervention to improve the client's functional ability is a priority after rehabilitation? 1. Keep a large tourniquet at the bedside to stop potential bleeding from the amputation site. 2. Place a pillow in the bed for the client to push the stump against many times per day. 3. Take and document the client's vital signs every four (4) hours. 4. Have the dietary department send highprotein, high-carbohydrate meals six (6) times a day.

ANSWER: 2. 1. The tourniquet is used to prevent hemorrhage from the residual limb. It does not improve functional ability. 2. The client should push against a pillow to toughen the stump and prepare it for a prosthesis. This will assist the client in regaining functional ability and mobility. 3. Taking and documenting vital signs provides the nurse with data to determine the stability of the client but does not improve functional ability. 4. A diet high in protein improves wound healing. The client's diet should have sufficient calories for wound healing but not particularly high carbohydrates. These interventions help with tissue integrity and would healing, not functional ability. TEST-TAKING HINT: The test taker should read the question carefully; the question is asking about what helps with functional ability. In this question, the test taker can eliminate the other three (3) options based on the fact that they do not address functional ability. Even if the test taker does not "like" option "2," it is the odd man out so it should be the one chosen

The client with a long arm cast is complaining of unrelenting severe pain and feeling as if the fingers are asleep. Which complication should the nurse suspect the client is experiencing? 1. Fat embolism. 2. Compartment syndrome. 3. Pressure ulcer under the cast. 4. Surgical incision infection

ANSWER: 2. 1. These are not signs/symptoms of a fat embolism. 2. These are the classic signs/symptoms of compartment syndrome. 3. Clients in casts rarely develop pressure ulcers and usually they are not painful. 4. Hot spots on the cast usually indicate an infection of the surgical incision under the cast

The nurse is assessing the client who is postoperative total knee replacement. Which assessment data warrant immediate intervention? 1. T 99˚F, HR 80, RR 20, and BP 128/76. 2. Pain in the unaffected leg during dorsiflexion of the ankle. 3. Bowel sounds heard intermittently in four quadrants. 4. Diffuse, crampy abdominal pain

ANSWER: 2. 1. These vital signs are within normal limits. 2. Pain with dorsiflexion of the ankle indicates deep vein thrombosis. This can be from immobility or surgery; therefore, pain should be assessed in both legs. 3. Bowel sounds are normally intermittent. 4. This type of pain should make the nurse suspect the client has flatus, which is not a life-threatening complication and does not warrant immediate intervention. TEST-TAKING HINT: "Warrant immediate intervention" means life threatening, abnormal, or unexpected for the client's condition. Pain with dorsiflexion of the ankle, the Homans' sign, may be life threatening if not treated immediately

Which assessment technique should the nurse implement when assessing the client's cranial nerves for vibration? 1. Move the big toe up and down and ask in which direction the vibration is felt. 2. Place a tuning fork on the big toe and ask if the vibrations are felt. 3. Tap the client's cheek with the finger and determine if vibrations are felt. 4. Touch the arm with two sharp objects and ask if one (1) vibration or two (2) is felt.

ANSWER: 2. 1. This assesses proprioception, or position sense; direction of the toe must be evaluated. 2. Vibration is assessed by using a lowfrequency tuning fork on a bony prominence and asking the client whether he or she feels the sensation and, if so, when the sensation ceases. 3. Tapping the cheek assesses for tetany, not cranial nerve involvement. 4. A two-point discrimination test evaluates integration of sensation, but it does not assess for vibration.

The nurse is administering 0730 medications to clients on a medical orthopedic unit. Which medication should be administered first? 1. The daily cardiac glycoside to a client diagnosed with back pain and heart failure. 2. The routine insulin to a client diagnosed with neck strain and type 1 diabetes. 3. The oral proton pump inhibitor to a client scheduled for a laminectomy this a.m. 4. The fourth dose of IV antibiotic for a client diagnosed with a surgical infection

ANSWER: 2. 1. This could be administered after breakfast if necessary. There is nothing in the action of the medication requiring before breakfast medication administration. 2. Clients with type 1 diabetes are insulin dependent. This medication should be administered before the client eats. 3. This medication should be held until after surgery. 4. The client has already received three (3) doses of IV antibiotic. This medication could be given after the insulin. TEST-TAKING HINT: The nurse must decide which medication has priority by determining the action of the medication, the route of administration, and the diagnosis of the client.

The nurse is caring for a client with a left fractured humerus. Which data warrant intervention by the nurse? 1. Capillary refill time is less than three (3) seconds. 2. Pain is not relieved by the patient-controlled analgesia. 3. Left fingers are edematous and the left hand is purple. 4. Warm and dry skin on left fingers distal to the elastic bandage.

ANSWER: 2. 1. This is a normal assessment finding and does not require immediate action. 2. Unrelieved pain should warrant intervention by the nurse. Pain may indicate a complication or the need for pain medication, but either way it warrants intervention. 3. Edema and a hematoma as a result of the injury are expected and do not warrant intervention by the nurse. 4. The fingers distal to the Ace bandage indicate adequate circulation and require no intervention.

The nurse is working on an orthopedic floor. Which client should the nurse assess first after the change-of-shift report? 1. The 84-year-old female with a fractured right femoral neck in Buck's traction. 2. The 64-year-old female with a left total knee replacement who has confusion. 3. The 88-year-old male post-right total hip replacement with an abduction pillow. 4. The 50-year-old postop client with a continuous passive motion (CPM) device.

ANSWER: 2. 1. This is a normal treatment of a fractured femoral neck. 2. This is an abnormal occurrence from this information. This client should be seen first because confusion is a symptom of hypoxia. 3. This is a common treatment of a total hip replacement. 4. This is a treatment used for total knee replacement. TEST-TAKING HINT: When deciding the answer for this type of question, the test taker who does not know the answer should realize three (3) choices have normal treatments for the disease process and one (1) option contains different information, such as a symptom, and choose the option that is different.

The elderly client is admitted to the hospital for severe back pain. Which data should the nurse assess first during the admission assessment? 1. The client's use of herbs. 2. The client's current pain level. 3. The client's sexual orientation. 4. The client's ability to care for self.

ANSWER: 2. 1. This is a question the admitting nurse asks all clients, but it is not the most important. 2. Pain assessment and management are the most important issues if the client is breathing and has circulation. Lack of pain management decreases the attention of the client during the admission process. Pain is called the fifth vital sign. 3. Sexual practices are included in the admission forms, but they are not as important as pain management. 4. Assessing the client's ability to perform activities of daily living and self-care is important to prepare this client for discharge, which begins on admission, but this is not the most important at this time.

Which client goal is most appropriate for a client diagnosed with OA? 1. Perform passive range-of-motion exercises. 2. Maintain optimal functional ability. 3. Client will walk three (3) miles every day. 4. Client will join a health club.

ANSWER: 2. 1. This is an intervention, not a goal, and "passive" means the nurse performs the range of motion, which should not be encouraged. 2. The two main goals of treatment for OA are pain management and optimizing functional ability of the joints to ensure movement of the joints. 3. Most clients with OA are elderly, are overweight, and have a sedentary lifestyle, so walking three (3) miles every day is not a realistic or safe goal. 4. Joining a health club is an intervention, and the fact the client joins the health club doesn't mean the client will exercise. TEST-TAKING HINT: The test taker must remember a goal is the measurable outcome of nursing interventions based on the client problem/diagnosis. Interventions are not goals; therefore, the test taker could eliminate options "1" and "4" as possible answers.

The female client tells the clinic nurse she is going on a seven- (7)-day cruise and is worried about getting motion sickness. Which information should the nurse discuss with the client? 1. Make an appointment for the client to see the health-care provider. 2. Recommend getting an over-the-counter scopolamine patch. 3. Discourage the client from taking the trip because she is worried. 4. Instruct the client to lie down and the motion sickness will go away

ANSWER: 2. 1. This is not a condition requiring an appointment with the health-care provider. 2. Anticholinergic medications, such as scopolamine patches, can be recommended by the nurse; this is not prescribing. Motion sickness is a disturbance of equilibrium caused by constant motion. 3. Motion sickness can be controlled with medication and it may not even occur. Therefore, discussing canceling the trip is not providing the client with appropriate information. 4. This is providing the client with false information. Lying down may or may not help motion sickness. To be able to enjoy the cruise, the client needs medication.

The nurse is reviewing the prescriptions for a patient receiving drug therapy for the prevention of osteoporosis. The patient also has hypertension and heart disease. Which prescription order does the nurse question? A. Calcium supplements. B. Hormone replacement therapy. C. Alendronate. D. Zoledronic acid (IV)

B

The nurse is admitting a client with rheumatoid arthritis (RA) and the hands are misshapen and deformed at the finger joints. Which concept would the nurse identify as priority? 1. Mobility. 2. Functional ability. 3. Coping. 4. Rehabilitation.

ANSWER: 2. 1. This picture does not indicate any deformity except the hands. 2. This is a picture of swan neck fingers associated with rheumatoid arthritis. The function of the client's hands is priority. 3. The client may have an issue with coping with the RA, but a psychosocial need is not priority over an actual physiological need. 4. Rehabilitation would be an interrelated concept needed for this client, but determining the extent of functional impairment is priority first. TEST-TAKING HINT: The test taker should not read into the question; in option "1" mobility refers to the ability of the client to move the body, not just the hands. The hands are the only body parts pictured. If an option exists that is more specific to the picture (functional ability) then the test taker should choose the one that is most closely related to the issue.

The nurse instructs the client with a right BKA to lie on the stomach for at least 30 minutes a day. The client asks the nurse, "Why do I need to lie on my stomach?" Which statement is the most appropriate statement by the nurse? 1. "This position will help your lungs expand better." 2. "Lying on your stomach will help prevent contractures." 3. "Many times this will help decrease pain in the limb." 4. "The position will take pressure off your backside."

ANSWER: 2. 1. This position will decrease lung expansion. 2. The prone position will help stretch the hamstring muscles, which will help prevent flexion contractures leading to problems when fitting the client for a prosthesis. 3. Lying on the back will not help decrease actual or phantom pain. 4. This will help take pressure off the client's buttocks area, but it is not why it is recommended for a client with a lower extremity amputation. TEST-TAKING HINT: The test taker can eliminate option "1" if visualizing the client in a prone position. This position will limit expansion of the lung more than increase it. When trying to allow for expansion of the lungs, clients are placed with the head elevated, a position the client in a prone position cannot achieve.

The 27-year-old client has a right above-theelbow amputation secondary to a boating accident. Which statement to the rehabilitation nurse indicates the client has accepted the amputation? 1. "I am going to sue the guy who hit my boat." 2. "The therapist is going to help me get retrained for another job." 3. "I decided not to get a prosthesis. I don't think I need it." 4. "My wife is so worried about me and I wish she weren't."

ANSWER: 2. 1. This statement does not indicate acceptance; the client is still in the anger stage of grieving. 2. Looking toward the future and problemsolving indicate the client is accepting the loss . 3. At this young age, a client with an upper extremity prosthesis needs to be thinking about obtaining employment and living a full life. Getting a prosthesis is important to pursue this goal. 4. This statement does not indicate acceptance; his wife will worry about the client's life, which has been changed dramatically. TEST-TAKING HINT: Always notice when the age is given for the client. This will help guide the test taker to the correct answer

Which intervention should the nurse include for a client diagnosed with carpal tunnel syndrome? 1. Teach hyperextension exercises to increase flexibility. 2. Monitor safety during occupational hazards. 3. Prepare for the insertions of pins or screws. 4. Monitor dressing and drain after the fasciotomy

ANSWER: 2. 1. Treatment for carpal tunnel syndrome does not include hyperextension of the wrist. 2. The nurse should monitor for potential injuries resulting from the alterations in motor, sensory, and autonomic function of the first three (3) digits of the hand and palmar surface of the fourth. 3. Surgery may be needed to release the compression of the medial nerve, but pins and screws are used to hold the position. 4. Fasciotomy refers to the surgical excision of strips of connective tissue. This is not applicable in clients with carpal tunnel syndrome.

The nurse is admitting the client with OA to the medical floor. Which statement by the client indicates an alternative form of treatment for OA? 1. "I take medication every two (2) hours for my pain." 2. "I use a heating pad when I go to bed at night." 3. "I wear a copper bracelet to help with my OA." 4. "I always wear my ankle splints when I sleep."

ANSWER: 3 . 1. Medication is a standard therapy and is not considered an alternative therapy. 2. A heating pad is an accepted medical recommendation for the treatment of pain for clients with OA. 3. Alternative forms of treatment have not been proved efficacious in the treatment of a disease. The nurse should be nonjudgmental and open to discussions about alternative treatment, unless it interferes with the medical regimen. 4. Conservative treatment measures for OA include splints and braces to support inflamed joints. TEST-TAKING HINT: The test taker needs to read the stem carefully to be able to determine what the question is asking. There is only one option with alternative-type treatment, which is option "3"; options "1," "2," and "4" are accepted treatment options listed in a textbook.

A client sustained a fractured femur in a motorvehicle accident. Which data require immediate intervention by the nurse? Select all that apply. 1. The client requests pain medication to sleep. 2. The client has eupnea and normal sinus rhythm. 3. The client has petechiae over the neck and chest. 4. The client has a high arterial oxygen level. 5. The client has yellow globules floating in the urine

ANSWER: 3, 5. 1. The client requesting something for sleep is expected and does not require notifying the HCP. 2. Normal respirations and heart rate do not require notifying the HCP. 3. Petechiae are macular, red-purple pinpoint bleeding under the skin. The appearance of petechiae is a classic sign of fat embolism syndrome. 4. The arterial oxygen level would be low, not elevated. This sign does not warrant immediate intervention. 5. Yellow globules in the urine are fat globules released from the bone as it breaks. This should be reported immediately

To which member of the health-care team should the nurse refer the client diagnosed with OA who is complaining of not being able to get in and out of the bathtub? 1. Physiatrist. 2. Social worker. 3. Physical therapist. 4. Counselor.

ANSWER: 3. 1. A physiatrist is a physician who specializes in physical medicine and rehabilitation, but the nurse should not refer the client to this person just because the client is having difficulty with transfers. 2. The social worker does not address this type of physical problem. Social workers address issues concerning finances, placement, and acquiring assistive devices. 3. The physical therapist is able to help the client with transferring, ambulation, and other lower extremity difficulties. 4. A counselor is not able to help the client learn how to get in and out of the bathtub. TEST-TAKING HINT: The nurse must know the roles of all the health-care team members

Which intervention should the nurse include when conducting an in-service to the ancillary nursing staff on caring for elderly clients addressing normal developmental sensory changes? 1. Ensure curtains are open when having the client read written material. 2. Provide a variety of written material when discussing a procedure. 3. Assist the client when getting out of the bed and sitting in the chair. 4. Request a telephone for the hearing impaired for all elderly clients.

ANSWER: 3. 1. Adequate lighting without a glare should be provided when having the client read written material; therefore, the curtains should be closed, not open. 2. The nurse should provide short, concise, and concrete material, not a variety of material. 3. Because fewer tactile cues are received from the bottom of the feet, the client may get confused as to body position and location. Safety is priority, and assisting the client getting out of bed and sitting in a chair is appropriate. 4. This is making a judgment. Not all elderly clients are hard of hearing, and telephones for the hearing impaired require special training for the user.

The client is diagnosed with Ménière's disease. Which statement indicates the client understands the medical management for this disease? 1. "After intravenous antibiotic therapy, I will be cured." 2. "I will have to use a hearing aid for the rest of my life." 3. "I must adhere to a low-sodium diet, 2,000 mg/day." 4. "I should sleep with the head of my bed elevated."

ANSWER: 3. 1. Antibiotics will not cure this disease. Surgery is the only cure for Ménière's disease, which may result in permanent deafness as a result of the labyrinth being removed in the surgery. 2. Ménière's disease does not lead to deafness unless surgery is performed removing the labyrinth in attempts to eliminate the attacks of vertigo. 3. Sodium regulates the balance of fluid within the body; therefore, a low-sodium diet is prescribed to help control the symptoms of Ménière's disease. 4. Sleeping with the head of the bed elevated will not affect Ménière's disease. TEST-TAKING HINT: Sleeping with the HOB elevated is not a medical treatment; therefore, option "4" can be eliminated as a possible answer. The test taker must read the stem carefully

The nurse identifies the concept of impaired functional ability for a client diagnosed with rheumatoid arthritis. Which intervention should the nurse implement? 1. Teach the client to apply antiembolism (TED) hose. 2. Administer the nonsteroidal medication before the morning meal. 3. Encourage the client to perform low-impact exercises daily. 4. Refer the client to occupational therapy for gait training.

ANSWER: 3. 1. Antiembolism hose are to prevent venous stasis, a circulatory issue, not for functional ability. 2. Nonsteroidal medications (NSAIDs) are given with meals or food to prevent gastric distress and risk of bleeding ulcers. They are not administered on empty stomachs. 3. Low-impact exercises improve the client's range of motion in the joints and help to maintain functional ability. They should be performed on a daily basis. 4. Occupational therapists work on upper body activities and activities of daily living. Physical therapists work on the lower body and gait training as well as large muscle functioning. TEST-TAKING HINT: The test taker could eliminate option "4" by knowing the function of the different therapies, "1" can be eliminated by knowing the purpose of antiembolism hose, and "2" can be eliminated by knowing basic nursing interventions for classifications of medications.

The clinic nurse assesses a client with complaints of pain and numbness in the left hand and fingers. Which question should the nurse ask the client? 1. "Do you smoke or use any type of tobacco products?" 2. "Do you have to wear gloves when you are out in the cold?" 3. "Do you do repetitive movements with your left fingers?" 4. "Do you have tremors or involuntary movements of your hand?"

ANSWER: 3. 1. Assessing for smoking is evaluation for Raynaud's disease. 2. Exposure to cold is appropriate to assess for Raynaud's disease. 3. Repetitive movements are appropriate to assess for carpal tunnel syndrome. Clients with this disorder experience pain and numbness. 4. Tremors or involuntary movements could indicate Parkinson's disease.

The client one (1) day postoperative total hip replacement complains of hearing a "popping sound" when turning. Which assessment data should the nurse report immediately to the surgeon? 1. Dark red-purple discoloration. 2. Equal length of lower extremities. 3. Groin pain in the affected leg. 4. Edema at the incision site.

ANSWER: 3. 1. Bruising is common after a total hip replacement. 2. When a dislocation occurs, the affected extremity will be shorter. 3. Groin pain or increasing discomfort in the affected leg and the "popping sound" indicate the leg has dislocated, which should be reported immediately to the HCP for a possible closed reduction. 4. Edema at the incision site is common, but an increase in edema or redness should be reported. TEST-TAKING HINT: The nurse should notify the surgeon of abnormal, unexpected, or life-threatening assessment data; if the test taker did not have an idea of the answer, pain is always a good choice because pain means something is wrong—it may be expected pain, but it may mean a complication.

The nurse is discussing osteoporosis with a group of women. Which factor will the nurse identify as a nonmodifiable risk factor? 1. Calcium deficiency. 2. Tobacco use. 3. Female gender. 4. High alcohol intake

ANSWER: 3. 1. Calcium deficiency is a modifiable risk factor, which means the client can do something about this factor—namely, increase the intake of calcium—to help prevent the development of osteoporosis. 2. Smoking is a modifiable risk factor because the client can quit smoking. 3. A nonmodifiable risk factor is a factor the client cannot do anything to alter or change. Approximately 50% of all women will experience an osteoporosis-related fracture in their lifetime. 4. The client can quit drinking alcohol; therefore, this is a modifiable risk factor. TEST-TAKING HINT: The key word to answering this question is "nonmodifiable," which means the client cannot do anything to modify or change behavior to help prevent developing osteoporosis.

The client with a cervical neck injury as a result of a motor-vehicle accident is complaining of unrelieved pain after administration of a narcotic analgesic. Which alternative method of pain control is an independent nursing action? 1. Medicate the client with a muscle relaxant. 2. Heat alternating with ice applied by a physical therapist. 3. Watch television or listen to music. 4. Discuss surgical options with the health-care provider

ANSWER: 3. 1. This is an example of collaborative care. 2. This is an example of collaborative care. 3. This is distraction and is an alternative method often recommended for the promotion of client comfort. 4. Surgery is collaborative care. TEST-TAKING HINT: The question asks for an alternative, independent type of care. Options "1," "2," and "4" are all collaborative care. If the test taker can find a common thread among three of the options, then the correct answer will be the other option.

The nurse is working with an unlicensed assistive personnel (UAP). Which action by the UAP warrants immediate intervention? 1. The UAP feeds a client two (2) days postoperative cervical laminectomy a regular diet. 2. The UAP calls for help when turning to the side a client who is post-lumbar laminectomy. 3. The UAP is helping the client who weighs 300 pounds and is diagnosed with back pain to the chair. 4. The UAP places the call light within reach of the client who had a disk fusion.

ANSWER: 3. 1. Clients two (2) days postoperative laminectomy should be eating a regular diet. 2. The client who has undergone a lumbar laminectomy is log rolled. It requires four (4) people or more to log roll a client. 3. The legs of any client diagnosed with back pain can give out and collapse at any time, but a large client diagnosed with back pain is at increased risk of injuring the UAP as well as the client. The nurse should intervene before the client or UAP becomes injured. 4. This action helps ensure safety for the client. TEST-TAKING HINT: This question is an "except" question. All the options but one contain interventions which should be implemented.

The client diagnosed with OA is a resident in a long-term care facility. The resident is refusing to bathe because she is hurting. Which instruction should the nurse give the unlicensed assistive personnel (UAP)? 1. Allow the client to stay in bed until the pain becomes bearable. 2. Tell the UAP to give the client a bed bath this morning. 3. Try to encourage the client to get up and go to the shower. 4. Notify the family the client is refusing to be bathed.

ANSWER: 3. 1. Clients with OA should be encouraged to move, which will decrease the pain. 2. A bed bath does not require as much movement from the client as getting up and walking to the shower. 3. Pain will decrease with movement, and warm or hot water will help decrease the pain. The worst thing the client can do is not move. 4. Notifying the family will not address the client's pain, and the client has a right to refuse a bath, but the nursing staff must explain why moving and bathing will help decrease the pain. TEST-TAKING HINT: Allowing clients to stay in bed only increases complications of immobility and will increase the client's pain secondary to OA. Clients with chronic illnesses should be encouraged to be as independent as possible. The family should only be notified if a significant situation has occurred.

An 88-year-old client is admitted to the orthopedic floor with the diagnosis of fractured pelvis. Which intervention should the nurse implement first? 1. Insert an indwelling catheter. 2. Administer a Fleet's enema. 3. Assess the abdomen for bowel sounds. 4. Apply Buck's traction.

ANSWER: 3. 1. Inserting an indwelling catheter is a good intervention, but it is not the first intervention. A tear or injury to the bladder should be suspected. 2. Administering a Fleet's enema should not be implemented until internal bleeding has been ruled out. 3. Assessing the bowel sounds should be the first intervention to determine if an ileus has occurred. This is a common complication of a fractured pelvis. 4. Buck's traction is not used to treat a fractured pelvis. It is used to treat a fractured hip. TEST-TAKING HINT: When prioritizing two equal options, usually, assessing is the answer.

The nurse is caring for a client with a fractured left tibia and fibula. Which data should the nurse report to the health-care provider immediately? 1. Localized edema and discoloration occurring hours after the injury. 2. Generalized weakness and increasing sensitivity to touch. 3. Dorsalis pedal pulse cannot be located with a Doppler and increasing pain. 4. Pain relieved after taking four (4) mg hydromorphone, a narcotic analgesic.

ANSWER: 3. 1. Localized edema and discoloration hours after the injury are normal occurrences after a fracture. 2. Generalized weakness and increasing tenderness are common and not life threatening. 3. If the nurse cannot hear the pedal pulse with a Doppler and the client's pain is increasing, the nurse should notify the health-care provider. These are signs of neurovascular compromise. 4. Pain management is a desired outcome demonstrated by pain relieved after medication administration. TEST-TAKING HINT: The nurse should notify the health-care provider of abnormal or unexpected assessment data; no pulse indicates a neurovascular complication. All the other options contain normal or expected data.

The client is complaining of joint stiffness, especially in the morning. Which diagnostic tests should the nurse expect the health-care provider to order to R/O osteoarthritis? 1. Full-body magnetic resonance imaging scan. 2. Serum studies for synovial fluid amount. 3. X-ray of the affected joints. 4. Serum erythrocyte sedimentation rate (ESR).

ANSWER: 3. 1. MRIs are not routinely ordered for diagnosing OA. 2. There is no serum laboratory test to measure synovial fluid in the joints. 3. X-rays reveal loss of joint cartilage, which appears as a narrowing of the joint space in clients diagnosed with OA. 4. An ESR is a diagnostic laboratory test for rheumatoid arthritis, not osteoarthritis. TEST-TAKING HINT: If the test taker is guessing which answer is correct and knows osteo- means "bone," the only option with any specific connection to bones is an x-ray. This selection is an educated guess.

The 65-year-old client is diagnosed with macular degeneration. Which statement by the client indicates the client needs more discharge teaching? 1. "I should use magnification devices as much as possible." 2. "I will look at my Amsler grid at least twice a week." 3. "I need to use low-watt light bulbs in my house." 4. "I am going to contact a low-vision center to evaluate my home."

ANSWER: 3. 1. Magnifying devices used with activities such as threading a needle will help the client's vision; therefore, this statement does not indicate the client needs more teaching. 2. An Amsler grid is a tool to assess macular degeneration, often providing the earliest sign of a worsening condition. If the lines of the grid become distorted or faded, the client should call the ophthalmologist. 3. Macular degeneration is the most common cause of visual loss in people older than age 60 years. Any intervention which helps increase vision should be included in the teaching, such as bright lighting, not decreased lighting. 4. Low-vision centers will send representatives to the client's home or work to make recommendations about improving lighting, thereby improving the client's vision and safety. TEST-TAKING HINT: This question is asking which statement indicates more teaching is needed. Therefore, three (3) options will indicate the client understands appropriate discharge teaching and only one (1) will indicate the client does not understand the teaching.

The client comes to the clinic and is diagnosed with otitis media. Which intervention should the clinic nurse include in the discharge teaching? 1. Instruct the client not to take any over-thecounter pain medication. 2. Encourage the client to apply cold packs to the affected ear. 3. Tell the client to call the HCP if an abrupt relief of ear pain occurs. 4. Wear a protective ear plug in the affected ear.

ANSWER: 3. 1. Mild analgesics such as aspirin or acetaminophen every four (4) hours as needed to relieve pain and fever are recommended; aspirin may help decrease inflammation of the ear. 2. Heat applied to the affected ear is recommended because heat dilates blood vessels, promoting the reabsorption of fluid and reducing edema. 3. Pain subsiding abruptly may indicate spontaneous perforation of the tympanic membrane within the middle ear and should be reported to the HCP. 4. Ear plugs should not be used in clients with otitis media, but cotton balls could be used to keep otic antibiotics in the ear canal. TEST-TAKING HINT: The test taker must use basic principles when answering questions. Cold causes constriction and heat dilates. Except for aspirin not being administered to children to prevent Reye's syndrome, mild analgesics can be administered for almost any discomfort.

The nurse is caring for clients on an orthopedic floor. Which client should be assessed first? 1. The client diagnosed with back pain who is complaining of a "4" on a 1-to-10 scale. 2. The client who has undergone a myelogram who is complaining of a slight headache. 3. The client two (2) days post-disk fusion who has T 100.4, P 96, R 24, and BP 138/78. 4. The client diagnosed with back pain who is being discharged and whose ride is here

ANSWER: 3. 1. Mild back pain is expected with this client. 2. Lumbar myelograms require access into the spinal column. A small amount of cerebrospinal fluid may be lost, causing a mild headache. The client should stay flat in bed to prevent this from occurring. 3. This client is postoperative and now has a fever. This client should be assessed and the health-care provider should be notified. 4. A discharged client does not have priority over a surgical infection. TEST-TAKING HINT: Options "1" and "2" contain assessment data expected for the procedure.

The client comes to the emergency department after splashing chemicals into the eyes. Which intervention should the nurse implement first? 1. Have the client move the eyes in all directions. 2. Administer a broad-spectrum antibiotic. 3. Irrigate the eyes with normal saline solution. 4. Determine when the client had a tetanus shot.

ANSWER: 3. 1. Movement of the eye should be avoided until the client has received general anesthesia; therefore, this is not the first intervention. 2. Parenteral broad-spectrum antibiotics are initiated but not until the eyes are treated first. 3. Before any further evaluation or treatment, the eyes must be thoroughly flushed with sterile normal saline solution. 4. Tetanus prophylaxis is recommended for full-thickness ocular wounds. TEST-TAKING HINT: If the test taker is not sure of the answer, the test taker should select the answer directly addressing the client's condition. Options "1" and "3" directly affect the eyes, but when choosing between these two options, the test taker should ask, "How will moving the eyes help treat the eyes?" and then eliminate option "1."

The client is being evaluated for osteoporosis. Which diagnostic test is the most accurate when diagnosing osteoporosis? 1. X-ray of the femur. 2. Serum alkaline phosphatase. 3. Dual-energy x-ray absorptiometry (DEXA). 4. Serum bone Gla-protein test.

ANSWER: 3. 1. Osteoporotic changes do not occur in the bone until more than 30% of the bone mass has been lost. 2. This serum blood study may be elevated after a fracture, but it does not help diagnose osteoporosis. 3. This test measures bone density in the lumbar spine or hip and is considered to be highly accurate. 4. This test is most useful to evaluate the effects of treatment, rather than as an indicator of the severity of bone disease. TEST-TAKING HINT: Option "2" does not have bone or x-ray in it; therefore, if the test taker did not know the correct answer, eliminating this option is appropriate. If the test taker knew osteoporosis is secondary to poor absorption of calcium, option "3" is an appropriate selection for the correct answer.

Which intervention should the nurse implement for a client with a fractured hip in Buck's traction? 1. Assess the insertion sites for signs and symptoms of infection. 2. Monitor for drainage or odor from under the plaster covering the pins. 3. Check the condition of the skin beneath the Velcro boot frequently. 4. Take weights off for one (1) hour every eight (8) hours and as needed.

ANSWER: 3. 1. Skeletal traction has a pin, screws, tongs, or wires inserted into the bone. There is no insertion site in skin traction. 2. Plaster traction is a combination of skeletal traction using pins and a plaster brace to maintain alignment of any deformities. 3. In Buck's traction, a Velcro boot is used to attach the ropes to weights to maintain alignment. Skin covered by the boot can become irritated and break down. 4. Buck's traction is applied preoperatively to prevent muscle spasms and maintain alignment, and the weights should not be removed unless assessing for skin breakdown.

The occupational health nurse is planning health promotion activities for a group of factory workers. Which activity is an example of primary prevention for clients at risk for low back pain? 1. Teach back exercises to workers after returning from an injury. 2. Place signs in the work area about how to perform first aid. 3. Start a weight-reduction group to meet at lunchtime. 4. Administer a nonnarcotic analgesic to a client complaining of back pain.

ANSWER: 3. 1. Teaching back exercises to a client who has already experienced a problem is tertiary care. 2. Placing signs with instructions about how to render first aid is a secondary intervention, not primary prevention. 3. Excess weight increases the workload on the vertebrae. Weight-loss activities help to prevent back injury. 4. Administering a nonnarcotic analgesic to a client with back pain is an example of secondary or tertiary care, depending on whether the client has a one-time problem or a chronic problem with back pain. TEST-TAKING HINT: Primary care is any activity which will prevent an illness or injury.

The elderly client is complaining of abdominal discomfort. Which scientific rationale should the nurse remember when addressing an elderly client's perception of pain? 1. Elderly clients react to pain the same way any other age group does. 2. The elderly client usually requires more pain medication. 3. Reaction to painful stimuli may be decreased with age. 4. The elderly client should use the Wong scale to assess pain.

ANSWER: 3. 1. This is an inaccurate statement. 2. The elderly client usually requires less pain medication because of the effects of the normal aging process on the liver (metabolism) and renal system (excretion). 3. Decreased reaction to painful stimuli is a normal developmental change; therefore, complaints of pain may be more serious than the client's perception might indicate and thus such complaints require careful evaluation. 4. The Wong scale is used to assess pain for the pediatric client, not the adult client.

The nurse is caring for a client who has sustained a fracture of the right hip. Which data should be reported to the orthopedic surgeon prior to surgery? RBC 4.78 (normal value: Men- 4.5-5.3, Women - 4.1-5.1); Hemoglobin 14 (Normal value: Men - 13-18, Women - 12-16); Hematocrit 42 (Men - 37%-49%, Women - 36%-46%); Platelet 98 (150-400); WBC 7.8 (5-10); ESR 17 (Men - 0-17, Women - 1-25). 1. The red blood cell count of 4.78 equals 4,780,000 when multiplied by 106 . 2. The hemoglobin of 14 g/100 mL of blood. 3. The platelet count of 98. 98,000, when multiplies by 103 . 4. The sedimentation rate of 17 mm/hr.

ANSWER: 3. 1. The RBC is WNL; there is no reason for the nurse to notify the surgeon. 2. The hemoglobin is WNL; there is no reason for the nurse to notify the surgeon. 3. The client is going to surgery and bone surgeries result in blood loss. This client's platelet count is below 100,000, impairing the client's ability to clot. The nurse should immediately notify the surgeon. 4. The sedimentation rate is WNL; there is no reason for the nurse to notify the surgeon. TEST-TAKING HINT: When reading a graph or a laboratory report, the test taker should read the normal ranges carefully in order to identify what is abnormal.

The nurse is providing discharge teaching to the 12-year-old with a fractured humerus and the parents. Which information should the nurse include regarding cast care? 1. Keep the fractured arm at heart level. 2. Use a wire hanger to scratch inside the cast. 3. Apply an ice pack to any itching area. 4. Explain foul smells are expected occurrences.

ANSWER: 3. 1. The arm should be elevated above the heart, not at heart level. 2. The nurse should instruct the child to not insert anything under the cast because it could cause a break in the skin, leading to an infection. 3. Applying ice packs to the cast will relieve itching, and nothing should be placed down a cast to scratch. Skin becomes fragile inside the cast and is torn easily. Alteration in the skin's integrity can become infected. 4. Smells indicate infection and should be reported to the HCP. TEST-TAKING HINT: A concept for any injury is elevating it above the heart to decrease edema. Many times the test taker must apply basic concepts to a variety of client conditions. Any foul smell is not expected in any disease or condition.

The client is scheduled for a computed tomography (CT) scan. Which question is most important for the nurse to ask before the procedure? 1. "On a scale of 1 to 10, how do you rate your pain?" 2. "Do you feel uncomfortable in enclosed spaces?" 3. "Are you allergic to seafood or iodine?" 4. "Have you signed a permit for this procedure?"

ANSWER: 3. 1. The assessment of the pain is important so the client will be able to tolerate the procedure. Pain is not a life-threatening problem but is a quality-of-care issue. 2. This is an appropriate question for a client having a closed MRI, not a CT scan. 3. This is the most important information the nurse should obtain. Any client who is allergic to seafood cannot be injected with the iodine-based contrast. This contrast could cause an allergic response, endangering the client's life. 4. The general consent for admission to the hospital covers this procedure. A separate informed consent is not required.

The 35-year-old client who sustained a crushing injury to the left hand and forearm is being discharged. Which referral should the nurse implement? 1. Refer the client to physical therapy at home. 2. Refer the client to an assistive living facility. 3. Refer the client to a workforce commission for job training. 4. Refer the client to the dietitian

ANSWER: 3. 1. The client should be able at age 35 to perform exercises on his/her own. 2. The client is 35 and should prepare to live life with the new limitations, not go into an assistive living facility. 3. The client needs to gain new skills to become a productive member of society with the new limitations. All states have opportunities for clients who have issues to be able to access training and assistance. 4. The client has a functional disability, not a dietary need. TEST-TAKING HINT: The test taker must read the words in the question and options. Ages matter. This is a 35-year-old client who should be in Erikson's stage of Generativity vs. Stagnation.

The nurse is instilling eye ointment. Which should the nurse perform prior to instilling the medication depicted in the image? 1. Have the client close the eye tightly to rid the eye of tears. 2. Place the nurse's nondominant hand on the client's eyebrow. 3. Discard the first bead of ointment, then instill the ointment. 4. Ask the client to look down toward the floor.

ANSWER: 3. 1. The client should close the eye gently after the ointment is instilled in order for the eyelid to spread the ointment over the eye. 2. The nurse's nondominant thumb or fingers are placed on the cheekbone to pull the lid down to expose the conjunctival sac. 3. The first bead of ointment is considered contaminated and should be discarded. 4. The client should look upward to reduce the amount of blinking during administration. TEST-TAKING HINT: The test taker must remember basics of medication administration.

The client with cataracts who has had intraocular lens implants is being discharged from the day surgery department. Which discharge instructions should the nurse discuss with the client? 1. Do not push or pull objects heavier than 50 pounds. 2. Lie on the affected eye with two pillows at night. 3. Wear glasses or metal eye shields at all times. 4. Bend and stoop carefully for the rest of your life.

ANSWER: 3. 1. The client should not lift, push, or pull objects heavier than 15 pounds; 50 pounds is excessive. 2. The client should avoid lying on the side of the affected eye at night. 3. The eyes must be protected by wearing glasses or metal eye shields at all times following surgery. Very few answer options with "all" will be correct, but if the option involves ensuring safety, it may be the correct option. 4. The client should avoid bending or stooping for an extended period—but not forever.

The emergency department nurse is assessing a client who has a needle in the sclera of the right eyeball just below the iris. Which should the nurse implement first? 1. Remove the needle with tweezers. 2. Notify an ophthalmologist to care for the client. 3. Stabilize the right eye and place a patch over the left eye. 4. Irrigate the right eye to wash the needle out of the eye.

ANSWER: 3. 1. The nurse should leave the needle where it is but try to make sure the client does not move the eye. The HCP will be the one to remove the obstacle. 2. The ophthalmologist will need to be notified after the nurse has made sure that the client will not sustain further damage to the eye. 3. The nurse should try to stabilize the right eye but not do anything that increases the damage to it. The left eye is patched to keep it from moving to see what is going on and the right eye moves with it. 4. The nurse should not do anything, including irrigating the eye, that might move the needle and create more damage. TEST-TAKING HINT: The emergency treatment of eye disorders requires the nurse to stabilize the client until the HCP can take care of the situation.

The nurse working on a medical-surgical floor feels a pulling in the back when lifting a client up in the bed. Which should be the first action taken by the nurse? 1. Continue working until the shift is over and then try to sleep on a heating pad. 2. Go immediately to the emergency department for treatment and muscle relaxants. 3. Inform the charge nurse and nurse manager on duty and document the occurrence. 4. See a private health-care provider on the nurse's off time but charge the hospital.

ANSWER: 3. 1. The nurse should not continue working, and this is self-diagnosing and treating. 2. The nurse may go to the emergency department, but this is not the first action. 3. The first action is to notify the charge nurse so a replacement can be arranged to take over care of the clients. The nurse should notify the nurse manager or house supervisor. An occurrence report should be completed, documenting the situation. This provides the nurse with the required documentation to begin a worker's compensation case for payment of medical bills. 4. The nurse has the right to see a private health-care provider in most states, but this is not the first action. TEST-TAKING HINT: When the test taker is determining a priority, then all of the answers may be appropriate interventions, but only one is implemented first. The test taker should read the full stem, identifying the important words and making sure he or she understands what the question is asking.

Which priority intervention should the day surgery nurse implement for a client who has had right knee arthroscopy? 1. Encourage the client to perform range-ofmotion exercises. 2. Monitor the amount and color of the urine. 3. Check the client's pulses distally and assess the toes. 4. Monitor the client's vital signs

ANSWER: 3. 1. The nurse should not encourage range of motion until the surgeon gives permission for flexion of the knee. 2. Urinary output is important postoperatively, but monitoring is not priority over a neurovascular assessment. 3. Neurovascular assessment is priority because this surgery has two (2) to three (3) small incisions in the knee area. The nurse needs to make sure circulation is getting past the surgical site. 4. Vital signs should be assessed, but the priority is to maintain the neurovascular status of the limb.

The nurse is administering eardrops to a six (6)-year-old client. Which indicates the nurse is aware of the correct method for instilling eardrops to a child? 1. Pull the pinna upward only to instill the eardrops. 2. Pull the pinna to a neutral position to instill the eardrops. 3. Pull the pinna upward and backward prior to instilling the drops. 4. Pull the pinna downward and forward to instill the drops.

ANSWER: 3. 1. The pinna should be pulled upward and backward for all clients three (3) years of age and older. Prior to three (3) years of age the pinna is directed upward only. 2. The pinna should be pulled upward and backward for all clients three (3) years of age and older. Prior to three (3) years of age the pinna is directed upward only. 3. The pinna should be pulled upward and backward for all clients three (3) years of age and older. Prior to three (3) years of age the pinna is directed upward only. 4. The pinna should be pulled upward and backward for all clients three (3) years of age and older. Prior to three (3) years of age the pinna is directed upward only. TEST-TAKING HINT: The test taker must remember basics of medication administration.

The nurse is caring for an 80-year-old client admitted with a fractured right femoral neck who is oriented 3 1. Which intervention should the nurse implement first? 1. Check for a positive Homans' sign. 2. Encourage the client to take deep breaths and cough. 3. Determine the client's normal orientation status. 4. Monitor the client's Buck's traction.

ANSWER: 3. 1. There is controversy over assessing for a positive Homans' sign, but it is not the first intervention for a client who is oriented to person only. 2. Encouraging the client to take deep breaths and cough aids in the exchange of gases. Mental changes are early signs of hypoxia in the elderly client, but the nurse must first determine if mental changes have occurred. 3. The nurse is not aware of the client's usual mental status so, before taking any further action, the nurse should determine what is normal or usual for this client. 4. Checking the client's Buck's traction will not address the problem of confusion. This will not address taking care of the orientation of the client. TEST-TAKING HINT: The test taker needs to understand what the question is asking. Although the client has a fractured hip, the orientation status is the unexpected symptom which requires assessment.

The client is taking calcium carbonate (Tums) to help prevent further development of osteoporosis. Which teaching should the nurse implement? 1. Encourage the client to take Tums with at least eight (8) ounces of water. 2. Teach the client to take Tums with the breakfast meal only. 3. Instruct the client to take Tums 30 to 60 minutes before a meal. 4. Discuss the need to get a monthly serum calcium level

ANSWER: 3. 1. There is no reason to take Tums with eight (8) ounces of water. Tums are usually chewed. 2. Tums should not be taken with meals. 3. Free hydrochloric acid is needed for calcium absorption; therefore, Tums should be taken on an empty stomach. 4. To determine the effectiveness of calcium supplements, the client must have a bone density test, not a serum calcium level measurement. TEST-TAKING HINT: If unsure of the answer, the test taker should not select an option with an absolute-type word such as "only," "always," or "never." There are very few absolutes in health care.

The nurse finds small, fluid-filled lesions on the margins of the client's surgical dressing. Which statement is the most appropriate scientific rationale for this occurrence? 1. These were caused by the cautery unit in the operating room. 2. These are papular wheals from herpes zoster. 3. These are blisters from the tape used to anchor the dressing. 4. These macular lesions are from a latex allergy

ANSWER: 3. 1. These are not burns from the cautery unit. Such burns are located in or near the incision site and are usually black. 2. Herpes simplex lesions occur in a linear pattern along a dermatome. 3. Fluid-filled blisters are from a reaction to the tape and usually occur along the margins of the dressing where the tape was applied. 4. Skin reactions to latex are local irritations or generalized dermatitis, not blisters. TEST-TAKING HINT: If the test taker does not know the answer, the test taker might think about the dressing because the lesions are on the side of the dressing. How is a dressing anchored to the skin? Answer: with tape. The test taker should choose the option having the word "tape."

Which assessment technique should the nurse use to assess the client's optic nerve? 1. Have the client identify different smells. 2. Have the client discriminate between sugar and salt. 3. Have the client read the Snellen chart. 4. Have the client say "ah" to assess the rise of the uvula.

ANSWER: 3. 1. This assesses cranial nerve I, the olfactory nerve. 2. This assesses cranial nerve IX, the glossopharyngeal nerve. 3. This assesses cranial nerve II, the optic nerve, along with visual field testing and ophthalmoscopic examination. 4. This assesses cranial nerve X, the vagus nerve

The nurse writes the diagnosis "risk for injury related to impaired balance" for the client diagnosed with vertigo. Which nursing intervention should be included in the plan of care? 1. Provide information about vertigo and its treatment. 2. Assess for level and type of diversional activity. 3. Assess for visual acuity and proprioceptive deficits. 4. Refer the client to a support group and counseling

ANSWER: 3. 1. This is appropriate for a diagnosis of "knowledge deficit." 2. This is appropriate for a diagnosis of "deficient diversional activity" related to environmental lack of activity. 3. Balance depends on visual, vestibular, and proprioceptive systems; therefore, the nurse should assess these systems for signs/symptoms. 4. This is appropriate for a diagnosis of "ineffective coping."

Which statement best describes the scientific rationale for the nurse holding the otoscope with the hand in a pencil-hold position when examining the client's ear? 1. It is usually the most comfortable position to hold the otoscope. 2. This allows the best visualization of the tympanic membrane. 3. This prevents inserting the otoscope too far into the external ear. 4. It ensures the nurse will not cause pain when examining the ear.

ANSWER: 3. 1. This is not the rationale for holding the otoscope in this manner. 2. Holding the otoscope in this manner does not help visualize the membrane any better than holding the otoscope in other ways. 3. Inserting the speculum of the otoscope into the external ear can cause ear trauma if not done correctly. 4. If the ear is inflamed, it may be impossible to prevent hurting the client on examination. TEST-TAKING HINT: The scientific rationale is the critical-thinking component of nursing; the test taker must understand the "why" of nursing interventions.

The client is postoperative retinal detachment surgery, and gas tamponade was used to flatten the retina. Which intervention should the nurse implement first? 1. Teach the signs of increased intraocular pressure. 2. Position the client as prescribed by the surgeon. 3. Assess the eye for signs/symptoms of complications. 4. Explain the importance of follow-up visits.

ANSWER: 3. 1. This should be done, but it is not the first intervention the nurse should implement. 2. The client will have to be specifically positioned to make the gas bubble float into the best position; some clients must lie face down or on their side for days, but it is not the first intervention. 3. The nurse's priority must be assessment of complications, which include increased intraocular pressure, endophthalmitis, development of another retinal detachment, or loss of turgor in the eye. 4. Follow-up visits are important, but this is not the first intervention the nurse should implement. TEST-TAKING HINT: When the question asks which intervention should be implemented first, all four (4) answer options are possible interventions but only one (1) should be implemented first. Remember to apply the nursing process to help select the correct answer. Assessment is the first part of the nursing process

Which teaching instruction should the nurse discuss with students who are on the high school swim team when discussing how to prevent external otitis? 1. Do not wear tight-fitting swim caps. 2. Avoid using silicone ear plugs while swimming. 3. Use a drying agent in the ear after swimming. 4. Insert a bulb syringe into each ear to remove excess water

ANSWER: 3. 1. Tight-fitting swim caps or wetsuit hoods should be worn because they prevent water from entering the ear canal. 2. Silicone ear plugs should be worn because they keep water from entering the ear canal without reducing hearing significantly. 3. A 2% acetic acid solution or 2% boric acid in ethyl alcohol is effective in drying the canal and restoring its normal acidic environment. 4. A bulb syringe with a Teflon catheter can be used to remove impacted debris from the ear, but it is not used to remove excess water. TEST-TAKING HINT: If the test taker has no idea what the correct answer is, the test taker should evaluate the answer options to see if two are similar. In this question, both options "1" and "2" say to not use ear protectors. Because there cannot be two correct answers, these two could be eliminated as possible correct answers.

The client is complaining of ringing in the ears. Which data are most appropriate for the nurse to document in the client's chart? 1. Complaints of vertigo. 2. Complaints of otorrhea. 3. Complaints of tinnitus. 4. Complaints of presbycusis

ANSWER: 3. 1. Vertigo is an illusion of movement in which the client complains of dizziness. 2. Otorrhea is drainage of the ear. 3. Tinnitus is "ringing of the ears." It is a subjective perception of sound with internal origins. 4. Presbycusis is progressive hearing loss associated with aging. TEST-TAKING HINT: The test taker who is familiar with medical terminology can rule out options based on the understanding of medical terms.

Which statement by the daughter of an 80-year-old female client who lives alone warrants immediate intervention by the nurse? 1. "I put a night-light in my mother's bedroom." 2. "I got carbon monoxide detectors for my mother's house." 3. "I changed my mother's furniture around." 4. "I got my mother large-print books."

ANSWER: 3. 1. With normal aging comes decreased peripheral vision, constricted visual field, and tactile alterations. A night-light addresses safety issues and warrants praise, not intervention. 2. Carbon monoxide detectors help ensure safety in the mother's home, so this comment doesn't warrant intervention. 3. Decreased peripheral vision, constricted visual fields, and tactile alterations are associated with normal aging. The client needs a familiar arrangement of furniture for safety. Moving the furniture may cause the client to trip or fall. The nurse should intervene in this situation. 4. As a result of normal aging, vision may become impaired, and the provision of large-print books warrants praise.

The male nurse is helping his friend cut wood with an electric saw. His friend cuts two fingers of his left hand off with the saw. Which action should the nurse implement first? 1. Wrap the left hand with towels and apply pressure. 2. Instruct the friend to hold his hand above his head. 3. Apply pressure to the radial artery of the left hand. 4. Go into the friend's house and call 911.

ANSWER: 3. 1. Wrapping the hand with towels is appropriate, but it is not the first intervention. 2. Holding the arm above the head will help decrease the bleeding, but it is not the first intervention. 3. Applying direct pressure to the artery above the amputated parts will help decrease the bleeding immediately and is the first intervention the nurse should implement. Then the nurse should instruct the client to hold the hand above the head, apply towels, and call 911. 4. Calling 911 should be done, but it is not the first intervention. TEST-TAKING HINT: Remember, when the stem asks the test taker to identify the first intervention, all four options will be probable interventions, but only one is the first intervention.

Which medication should the nurse question administering to a client diagnosed with rheumatoid arthritis who has a comorbid condition of non-Hodgkin's lymphoma? 1. Celecoxib. 2. Filgrastim. 3. Adalimumab. 4. Acetaminophen.

ANSWER: 3. . 1. Celebrex is approved for the routine treatment of arthritis and bone and joint diseases. The nurse would not question this medication. 2. Clients undergoing treatment for cancer frequently require filgrastim to promote the production of WBCs due to the suppression of the bone marrow. The nurse would not question this medication. 3. An adverse effect of adalimumab is the development of lymphoma. Because this client has a lymphoma, suppressing the immune system even further could have disastrous results for the client. The nurse would question administering this medication. 4. Acetaminophen would not be questioned; the client has pain and the dose is a recommended dose. TEST TAKING HINT: The test taker must know basic medication guidelines.

A client recovering from a total hip replacement has developed a deep vein thrombosis. The health-care provider has ordered a continuous infusion of heparin, an anticoagulant, to infuse at 1,200 units per hour. The bag comes with 20,000 units of heparin in 500 mL of 0.9% normal saline. At what rate should the nurse set the pump? ______

ANSWER: 30 mL/hr. Divide the amount of heparin by the volume of fluid to get the concentration: 20,000 units ÷ 500 mL = 40 units of heparin per 1 mL Divide the dose ordered by the concentration for the amount of milliliters per hour to set the pump: 1,200 units/hr ÷ 40 units/mL = 30 mL/hr

The nurse is caring for an elderly client diagnosed with a herniated nucleus pulposus of L4-5. Which scientific rationale explains the incidence of a ruptured disk in the elderly? 1. The client did not use good body mechanics when lifting an object. 2. There is an increased blood supply to the back as the body ages. 3. Older clients develop atherosclerotic joint disease as a result of fat deposits. 4. Clients develop intervertebral disk degeneration as they age

ANSWER: 4 1. Back pain occurs in 80% to 90% of the population at different times in their lives. Although not using good body mechanics when lifting an object may be a reason for younger clients to develop a herniated disk, it is not the reason most elderly people develop back pain. 2. There is a decreased blood supply as the body ages. 3. Older clients develop degenerative joint disease. Fat does not deposit itself in the nucleus pulposus. 4. Less blood supply, degeneration of the disk, and arthritis are reasons elderly people develop back problems.

The nurse is caring for clients on a surgical unit. Which nursing task is most appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)? 1. Help the client with a two (2)-day postop amputation put on the prosthesis. 2. Request the UAP double-check a unit of blood to be hung. 3. Change the surgical dressing on the client with a Syme's amputation. 4. Ask the UAP to take the client to the physical therapy department.

ANSWER: 4. 1. A client who is only two (2) days postoperative amputation is not putting on a prosthesis. 2. Two (2) registered nurses must double-check a unit of blood prior to infusing the blood. 3. The surgical dressing is changed by the surgeon or the nurse; Syme's amputation is above the ankle, just removing the foot. 4. The unlicensed assistive personnel (UAP) could take a client to another department in the hospital. TEST-TAKING HINT: Remember, teaching, assessing, and evaluating cannot be delegated.

The nurse is preparing to administer subcutaneous Lovenox, a low molecular weight heparin. Which intervention should the nurse implement? 1. Monitor the client's serum aPTT. 2. Encourage oral and intravenous fluids. 3. Do not eat foods high in vitamin K. 4. Administer in the anterolateral upper abdomen.

ANSWER: 4. 1. An aPTT is used to determine therapeutic levels of unfractionated heparin. Laboratory studies such as aPTT are not monitored when administering subcutaneous Lovenox, a low molecular weight heparin. A therapeutic level will not be achieved as a result of a short half-life. 2. Oral fluids do not need to be increased because of this medication. 3. Vitamin K is the antidote for warfarin (Coumadin), an oral anticoagulant. It does not affect Lovenox. 4. Administering the medication in the prescribed areas, the "love handles," ensures safety and decreases the risk of abdominal trauma

The client is two (2) hours postoperative rightear mastoidectomy. Which assessment data should be reported to the health-care provider? 1. Complaints of aural fullness. 2. Hearing loss in the affected ear. 3. No vertigo. 4. Facial drooping.

ANSWER: 4. 1. Aural fullness or pressure after surgery is caused by residual blood or fluid in the middle ear. This is an expected occurrence after surgery, and the nurse should administer the prescribed analgesic. 2. Hearing in the operated ear may be reduced for several weeks because of edema, accumulation of blood and tissue fluid in the middle ear, and dressings or packing, so this does not need to be reported to the health-care provider. 3. Vertigo (dizziness) is uncommon after this surgery, but if it occurs the nurse should administer an antiemetic or antivertigo medication and does not need to report it to the health-care provider. 4. The facial nerve, which runs through the middle ear and mastoid, is at risk for injury during mastoid surgery; therefore, a facial paresis should be reported to the health-care provider.

The charge nurse is admitting a 90-year-old client to a long-term care facility. Which intervention should the nurse implement? 1. Ensure the client's room temperature is cool. 2. Talk louder to make sure the client hears clearly. 3. Complete the admission as fast as possible. 4. Provide extra orientation to the surroundings.

ANSWER: 4. 1. Because of altered temperature regulation, the client usually needs a warmer room temperature, not a cooler room temperature. 2. The nurse should use a low-pitched, normal-volume, clear voice. Talking louder or shouting only makes it harder for the client to understand the nurse. 3. The elderly client requires adequate time to receive and respond to stimuli, to learn, and to react; therefore, the nurse should take time and not rush the admission. 4. Sensory isolation resulting from visual and hearing loss can cause confusion, anxiety, disorientation, and misinterpretation of the new environment; therefore, the nurse should provide extra orientation.

The nurse is assessing the client's cranial nerves. Which assessment data indicate cranial nerve I is intact? 1. The client can identify cold and hot on the face. 2. The client does not have any tongue tremor. 3. The client has no ptosis of the eyelids. 4. The client is able to identify a peppermint smell.

ANSWER: 4. 1. Being able to identify cold and hot on the face indicates an intact trigeminal nerve, cranial nerve V. 2. Not having any tongue tremor indicates an intact hypoglossal nerve, cranial nerve XI. 3. No ptosis of the eyelids indicates an intact oculomotor nerve (cranial nerve III), trochlear nerve (IV), and abducens nerve (VI). Tests also assess for ocular motion, conjugate movements, nystagmus, and papillary reflexes. 4. Cranial nerve I is the olfactory nerve, which involves the sense of smell. With the eyes closed, the client must identify familiar smells to indicate an intact cranial nerve I.

The nurse is discharging a client who had a total hip replacement. Which statement indicates further teaching is needed? 1. "I should not cross my legs because my hip may come out of the socket." 2. "I will call my HCP if I have a sudden increase in pain." 3. "I will sit on a chair with arms and a firm seat." 4. "After three (3) weeks, I don't have to worry about infection."

ANSWER: 4. 1. Clients should not cross their legs because the position increases the risk for dislocation. 2. If the client experiences a sudden increase in pain, redness, edema, or stiffness in the joint or surrounding area, the client should notify the HCP. 3. Clients should sleep on firm mattresses and sit on chairs with firm seats and high arms. These will decrease the risk of dislocating the hip joint. 4. Infections are possible months after surgery. Clients should monitor temperatures and report any signs of infection. TEST-TAKING HINT: Note the stem is asking about the need for "further teaching." This means the test taker is looking for an unexpected option. This is an "except" question. Sometimes, if the test taker will change the question and say "the client understands the teaching," then the option with an incorrect statement is the answer.

The student nurse asks the nurse, "Which type of hearing loss involves damage to the cochlea or vestibulocochlear nerve?" Which statement is the best response of the nurse? 1. "It is called conductive hearing loss." 2. "It is called a functional hearing loss." 3. "It is called a mixed hearing loss." 4. "It is called sensorineural hearing loss."

ANSWER: 4. 1. Conductive hearing loss results from an external ear disorder, such as impacted cerumen, or a middle ear disorder, such as otitis media or otosclerosis. 2. Functional (psychogenic) hearing loss is nonorganic and unrelated to detectable structural changes in the hearing mechanisms. It is usually a manifestation of an emotional disturbance. 3. Mixed hearing loss involves both conductive loss and sensorineural loss. It results from dysfunction of air and bone conduction. 4. Sensorineural hearing loss is described in the stem of the question. It involves damage to the cochlea or vestibulocochlear nerve.

The 65-year-old male client who is complaining of blurred vision reports he thinks his glasses need to be cleaned all the time, and he denies any type of eye pain. Which eye disorder should the nurse suspect the client has? 1. Corneal dystrophy. 2. Conjunctivitis. 3. Diabetic retinopathy. 4. Cataracts.

ANSWER: 4. 1. Corneal dystrophy is an inherited eye disorder occurring at about age 20 and results in decreased vision and the development of blisters; it is usually associated with primary open-angle glaucoma. 2. Conjunctivitis is an inflammation of the conjunctiva, which results in a scratching or burning sensation, itching, and photophobia. 3. Diabetic retinopathy results from deterioration of the small blood vessels nourished by the retina; it leads to blindness. 4. A cataract is a lens opacity or cloudiness, resulting in the signs/symptoms discussed in the stem of the question. TEST-TAKING HINT: The test taker must know the signs/symptoms of eye disorders, especially those commonly occurring in the elderly. Option "2" could be ruled out because -itis means inflammation and none of the signs/symptoms is inflammatory

The client is scheduled for right-eye cataract removal surgery in five (5) days. Which preoperative instruction should be discussed with the client? 1. Administer dilating drops to both eyes for 72 hours prior to surgery. 2. Prior to surgery do not lift or push any objects heavier than 15 pounds. 3. Make arrangements for being in the hospital for at least three (3) days. 4. Avoid taking any type of medication which may cause bleeding, such as aspirin.

ANSWER: 4. 1. Dilating drops are administered every 10 minutes for four (4) doses one (1) hour prior to surgery, not for three (3) days prior to surgery. 2. Lifting and pushing objects should be avoided after surgery, not prior to surgery. 3. All types of cataract removal surgery are usually done in day surgery. 4. To reduce retrobulbar hemorrhage, any anticoagulation therapy is withheld, including aspirin, nonsteroidal antiinflammatory drugs (NSAIDs), and warfarin (Coumadin). TEST-TAKING HINT: The test taker must notice the adjectives; these descriptors are important when selecting a correct answer. The test taker should notice "preoperative" and "prior to surgery."

The nurse is caring for a client six (6) hours postoperative right total knee replacement. Which data should the nurse report to the surgeon? 1. A total of 100 mL of red drainage in the autotransfusion drainage system. 2. Pain relief after using the patient-controlled analgesia (PCA) pump. 3. Cool toes, distal pulses palpable, and pale nailbeds bilaterally. 4. Urinary output of 60 mL of clear yellow urine in three (3) hours

ANSWER: 4. 1. Drainage in the first 24 hours can be expected to be 200 to 400 mL. When using an autotransfusion drainage system, the client's blood will be filtered and returned to the client. 2. Pain relief with the PCA does not require notifying the surgeon. 3. Bilateral coolness of toes is not concerning because both feet are cool. Circulation is not restricted if pulses are present. Seeing pale pink nailbeds indicates blood loss during surgery. 4. The urinary output is not adequate; therefore, the surgeon needs to be notified. This is only 20 mL/hr. The minimum should be 30 mL/hr. TEST-TAKING HINT: A concept the test taker will see throughout testing and throughout the nurse's practice is 30 mL of urine output per hour is necessary to maintain kidney function.

Which information should the nurse teach the client regarding sports injuries? 1. Apply heat intermittently for the first 48 hours. 2. An injury is not serious if the extremity can be moved. 3. Only return to the health-care provider if the foot becomes cold. 4. Keep the injury immobilized and elevated for 24 to 48 hours.

ANSWER: 4. 1. Ice should be applied intermittently for the first 48 hours. Heat can be used later in the recovery process. 2. Severe injury can be present even with some range of motion. 3. The client needs to return if the injury does not improve and if the foot gets cold. 4. The leg should be iced, elevated, and immobilized for 48 hours.

The client is scheduled for ear surgery. Which statement indicates the client needs more preoperative teaching concerning the surgery? 1. "If I have to sneeze or blow my nose, I will do it with my mouth open." 2. "I may get dizzy after the surgery, so I must be careful when walking." 3. "I will probably have some hearing loss after surgery, but hearing will return." 4. "I can shampoo my hair the day after surgery as long as I am careful."

ANSWER: 4. 1. Leaving the mouth open when coughing or sneezing will minimize the pressure changes in the middle ear. 2. Surgery on the ear may disrupt the client's equilibrium, increasing the risk for falling. 3. Hearing loss secondary to postoperative edema is common after surgery, but the hearing will return after the edema subsides. 4. Shampooing, showering, and immersing the head in water are avoided to prevent contamination of the ear canal; therefore, this comment indicates the client does not understand the preoperative teaching. TEST-TAKING HINT: This is an "except" question. The stem states "needs more teaching"; therefore, three (3) of the options reflect an appropriate understanding of the teaching and only one (1) indicates a misunderstanding of the teaching.

The nurse is caring for the client who has had a total hip replacement. Which data indicate the surgical treatment is effective? 1. The client states the pain is at a "3" on a 1-to10 scale. 2. The client has a limited ability to ambulate. 3. The client's left leg is shorter than the right leg. 4. The client ambulates to the bathroom.

ANSWER: 4. 1. Minimal pain is expected in a postoperative client but it does indicate surgical treatment is effective. 2. The client should be able to ambulate with almost full mobility. 3. A shorter leg indicates a dislocation of the hip. 4. The hip should have functional motion and the client should be able to ambulate to the bathroom. This indicates surgical treatment has been effective. TEST-TAKING HINT: With musculoskeletal problems, functional movement is priority. Also note option "2" has the word "limited" and "3" has "one leg shorter than the other," both of which are negative outcomes, so the test taker could eliminate these options.

The client newly diagnosed with osteoporosis is prescribed calcitonin by nasal spray. Which assessment data indicate to the nurse an adverse effect of the medication? 1. The client complains of nausea and vomiting. 2. The client is drinking two (2) glasses of milk a day. 3. The client has a runny nose and nasal itching. 4. The client has had numerous episodes of nosebleeds.

ANSWER: 4. 1. Nausea and vomiting may occur during initial stages of therapy, but they will disappear as treatment continues. 2. The client should be sure to consume adequate amounts of calcium and vitamin D while taking calcitonin. 3. Rhinitis (runny nose) is the most common side effect with calcitonin nasal spray along with itching, sores, and other nasal symptoms. 4. Nosebleeds are adverse effects and should be reported to the client's HCP. TEST-TAKING HINT: If the test taker has no idea of the answer, an appropriate option to select is an option with bleeding in it; bleeding is abnormal and indicates an adverse effect.

The client has been diagnosed with OA for the last seven (7) years and has tried multiple medical treatments and alternative treatments but still has significant joint pain. Which psychosocial client problem should the nurse identify? 1. Severe pain. 2. Body image disturbance. 3. Knowledge deficit. 4. Depression.

ANSWER: 4. 1. Pain is a physiological problem, not a psychosocial problem. 2. A client with OA does not have bone deformities; therefore, body image disturbance is not appropriate. 3. After seven (7) years of OA and multiple treatment modalities, knowledge deficit is not appropriate for this client. 4. The client experiencing chronic pain often experiences depression and hopelessness. TEST-TAKING HINT: The adjective "psychosocial" should help the test taker rule out option "1." The test taker needs to read the stem carefully. This client has had a problem for years, and, therefore, option "3" could be ruled out as a correct answer.

The client who underwent a left above-theknee amputation as a result of uncontrolled diabetes questions the nurse, asking, "Why did this happen to me? I have always been a good person." Which is the nurse's most therapeutic response? 1. "Tell me about how it feels to have caused this to happen to you." 2. "I know how you feel; having your leg cut off is sad." 3. "Why do you think that you had to have your leg amputated?" 4. "I can see you are hurting. Would you like to talk?"

ANSWER: 4. 1. Placing blame is not therapeutic. 2. Unless the nurse has had exactly the same situation happen to him/her, the nurse cannot make this statement. It is not therapeutic. 3. Asking why is not therapeutic; the nurse is requesting the client to defend his/her feeling. 4. This is a broad opening statement and offering self. Both are therapeutic techniques. The client needs an opportunity to verbalize the feeling associated with loss. TEST-TAKING HINT: When a question asks for a therapeutic response by the nurse, the nurse must give a response that does NOT lay blame or advise in any way and MUST encourage the client to discuss feelings.

A person's right thumb was accidentally severed with an axe. The amputated right thumb was recovered. Which action by the nurse preserves the thumb so it could possibly be reattached in surgery? 1. Place the right thumb directly on some ice. 2. Put the right thumb in a glass of warm water. 3. Wrap the thumb in a clean piece of material. 4. Secure the thumb in a plastic bag and place on ice

ANSWER: 4. 1. Placing the amputated part directly on ice will cause vasoconstriction and necrosis of viable tissue. 2. Warm water will cause the amputated part to disintegrate and lose viable tissue. 3. Wrapping the amputated part in a piece of material will not help preserve the thumb so it can be reconnected. 4. Placing the thumb in a plastic bag will protect it and then placing the plastic bag on ice will help preserve the thumb so it may be reconnected in surgery. Do not place the amputated part directly on ice because this will cause necrosis of viable tissue. TEST-TAKING HINT: The test taker should make sure he or she knows what the question is asking before selecting the option. The question is asking "what will help preserve the thumb?"—which is the key to answering this question.

Which statement by the client diagnosed with a fractured ulna indicates to the nurse the client needs further teaching? 1. "I need to eat a high-protein diet to ensure healing." 2. "I need to wiggle my fingers every hour to increase circulation." 3. "I need to take my pain medication before my pain is too bad." 4. "I need to keep this immobilizer on when lying down only."

ANSWER: 4. 1. Protein is necessary for healing. 2. By wiggling the fingers of the affected arm, the client can improve the circulation. 3. Pain medication should be taken prior to perception of severe pain. Pain relief will require more medication if allowed to become severe. 4. The immobilizer should be kept on at all times. This indicates the client does not understand the teaching and needs the nurse to provide more instruction. TEST-TAKING HINT: When selecting an answer for questions such as this, the test taker should remember to look for an untrue statement. This indicates teaching is needed.

The nurse is caring for the client diagnosed with fat embolism syndrome. Which HCP order should the nurse question? 1. Maintain heparin to achieve a therapeutic level. 2. Initiate and monitor intravenous fluids. 3. Keep the O2 saturation higher than 93%. 4. Administer an intravenous loop diuretic.

ANSWER: 4. 1. The HCP should prescribe heparin to treat a fat embolism. 2. The client should be hydrated to prevent platelet aggregation. 3. The nurse should monitor oxygen levels and administer oxygen as needed to prevent further complications. 4. The nurse should question this order. This will decrease the client's hydration and may result in further embolism

The nurse is preparing the preoperative client for a total hip replacement (THR). Which intervention should the nursing implement postoperatively? 1. Keep an abduction pillow in place between the legs at all times. 2. Cough and deep breathe at least every four (4) to five (5) hours. 3. Turn to both sides every two (2) hours to prevent pressure ulcers. 4. Sit in a high-seated chair for a flexion of less than 90 degrees.

ANSWER: 4. 1. The abduction pillow should be kept between the legs while in bed to maintain a neutral position and prevent internal rotation. 2. The client should deep breathe and cough at least every two (2) hours to prevent atelectasis and pneumonia. 3. The client will need to turn every two (2) hours but should not turn to the affected side. 4. Using a high-seated toilet and chair will help prevent dislocation by limiting the flexion to less than 90 degrees. TEST-TAKING HINT: Option "1" has the word "all"; an absolute word such as this usually eliminates the option as a possible correct answer. Nursing usually does not have situations involving absolutes.

The 84-year-old client is a resident in a longterm care facility. Which intervention should be implemented to help prevent complications secondary to osteoporosis? 1. Keep the bed in the high position. 2. Perform passive range-of-motion exercises. 3. Turn the client every two (2) hours. 4. Provide nighttime lights in the room

ANSWER: 4. 1. The bed should be kept in the low position. Preventing falls is a priority for a client diagnosed with osteoporosis. 2. Range-of-motion (ROM) exercises will help prevent deep vein thrombosis or contractures, but they do not help prevent osteoporosis. 3. Turning the client will help prevent pressure ulcers but does not help prevent osteoporosis. 4. Nighttime lights will help prevent the client from falling; fractures are the number one complication of osteoporosis. TEST-TAKING HINT: The test taker should realize the bed should be kept in a low position at all times and should eliminate option "1" as a possible answer; ROM exercises and turning will help prevent complications of immobility, not osteoporosis

The client is scheduled for laser-assisted in situ keratomileusis (LASIK) surgery for severe myopia. Which instruction should the nurse discuss prior to the client's discharge from day surgery? 1. Wear bilateral eye patches for three (3) days. 2. Wear corrective lenses until the follow-up visit. 3. Do not read any material for at least one (1) week. 4. Teach the client how to instill corticosteroid ophthalmic drops.

ANSWER: 4. 1. The client does not have to wear eye patches after this surgery. 2. The purpose of this surgery is to ensure the client does not have to wear any type of corrective lens. 3. The client can read immediately after this surgery. 4. LASIK surgery is an effective, safe, predictable surgery performed in day surgery; there is minimal postoperative care. Instilling topical corticosteroid drops helps decrease inflammation and edema of the eye. TEST-TAKING HINT: Option "3" has the absolute word "any," so the test taker could eliminate it. LASIK is a corrective surgery, and if the problem is corrected, then corrective lenses should not be necessary

The nurse is preparing the plan of care for the client with a closed fracture of the right arm. Which problem is most appropriate for the nurse to identify? 1. Risk for ineffective coping related to the inability to perform ADLs. 2. Risk for compartment syndrome-related injured muscle tissue. 3. Risk for infection related to exposed bone and tissue. 4. Risk for complications related to compromised neurovascular status

ANSWER: 4. 1. The client may experience difficulty coping depending on how much mobility the client has after medical treatment, but it is not the most appropriate nursing diagnosis at this time. 2. Compartment syndrome (edema within a muscle compartment) may occur, but there are multiple complications the nurse should be assessing for, so this is not the most appropriate nursing intervention. 3. The client has a closed fracture, so there is no exposed bone or tissue. 4. Assessing and preventing complications related to the neurovascular compromise is the most appropriate intervention because, if there are no complications, a closed fracture should heal without problems. TEST-TAKING HINT: Physiological problems are priority over psychosocial problems, so the test taker could rule out option "1."

The client diagnosed with chronic otitis media is scheduled for a mastoidectomy. Which discharge teaching should the nurse discuss with the client? 1. Instruct the client to blow the nose with the mouth closed. 2. Explain the client will never be able to hear from the ear. 3. Instill ophthalmic drops in both ears and then insert a cotton ball. 4. Do not allow water to enter the ear for six (6) weeks.

ANSWER: 4. 1. The client should blow the nose with the mouth open to prevent pressure in the eustachian tube. 2. There may be temporary deafness as a result of postoperative edema, but the hearing will return as the edema subsides. 3. Ophthalmic drops are used in the eyes, not the ears. Otic drops are used for the ears. 4. Water should be prevented from entering the external auditory canal because it may irritate the surgical incision and is a medium for bacterial growth. TEST-TAKING HINT: The test taker must be aware of adjectives. In option "3," the test taker should know "ophthalmic" refers to the eye, which causes the test taker to eliminate this as a possible answer.

The nurse is caring for a client in a hip spica cast. Which intervention should the nurse include in the plan of care? 1. Assess the client's popliteal pulses every shift. 2. Elevate the leg on pillows and apply ice packs. 3. Teach the client how to ambulate with a tripod walker. 4. Assess the client for distention and vomiting.

ANSWER: 4. 1. The client's popliteal pulse will be under the cast and cannot be assessed by the nurse; circulation is assessed by the 6 Ps of the neurovascular assessment. 2. Elevation should be used with an arm cast or a leg cast, but this is not possible with a spica cast. 3. Clients with spica casts will not be able to ambulate because the cast covers the entire lower half of the body. 4. The nurse should assess the client for signs and symptoms of cast syndrome— vomiting after meals, epigastric pain, and abdominal distention. This is caused by a partial bowel obstruction from compression and can lead to complete obstruction. The client may still have bowel sounds present with this syndrome.

The client in the rehabilitation hospital refuses to participate in physical therapy following surgery for repair of a fractured right femur sustained in a motor-vehicle accident (MVA). The client also fractured the left forearm. Which should the nurse implement first when encouraging the client to participate in therapy? 1. Medicate the client for pain 30 minutes prior to the therapy. 2. Have the health-care provider make the client go to therapy. 3. Explain that insurance will not pay if the client does not participate in therapy daily. 4. Determine why the client refuses to participate in therapy sessions.

ANSWER: 4. 1. The nurse should medicate the client for pain prior to therapy if that is determined to be the cause for the client refusing to participate in therapy. 2. The client can make his/her own decisions. The HCP cannot make the client do anything. 3. The nurse should explain the rules of rehabilitation coverage, but this is not first. 4. The nurse should first assess the situation to determine the reason the client does not wish to participate in therapy. TEST-TAKING HINT: The test taker should remember the first step of the nursing process is assessment. There are many words that can be used to indicate an assessment step.

The client who had a total knee replacement is being discharged home. To which multidisciplinary team member should the nurse refer the client? 1. The occupational therapist. 2. The physiatrist. 3. The recreational therapist. 4. The home health nurse.

ANSWER: 4. 1. The occupational therapist addresses upper extremity activities of daily living, swallowing issues, and cognition. This is not an appropriate referral. 2. The physiatrist is a physician specializing in rehabilitation medicine who practices in a rehabilitation setting. 3. The recreational therapist is used in psychiatric settings, rehabilitation hospitals, and longterm care facilities. The discipline is not seen in the home. 4. The home health-care nurse will be able to assess the client in the home and make further referrals if necessary. TEST-TAKING HINT: The nurse should always think about safety; therefore, the test taker should select options addressing safety issues.

The school nurse is completing spinal screenings. Which data require a referral to an HCP? 1. Bilateral arm lengthening while bending over at the waist. 2. A deformity which resolves when the head is raised. 3. Equal spacing of the arms and body at the waist. 4. A right arm lower than the left while bending over at the waist.

ANSWER: 4. 1. These are normal data and do not require intervention. 2. If the screener suspects the client has scoliosis while the client is bending over, the screener asks the client to raise the head. An abnormality caused by scoliosis will not resolve. 3. This indicates a normal occurrence and does not need to be referred. 4. Unequal arm length may indicate scoliosis, and further assessment is needed by an HCP

The client diagnosed with rule-out osteosarcoma asks the nurse, "Why am I having a bone scan?" Which statement is the nurse's best response? 1. "You seem anxious. Tell me about your anxieties." 2. "Why are you concerned? Your HCP ordered it." 3. "I'll have the radiologist come back to explain it again." 4. "A bone scan looks for cancer or infection inside the bones."

ANSWER: 4. 1. This is a therapeutic technique, but the client is asking for information. When a client seeks information, the nurse should give information first. Discussion of feelings should follow. 2. This nontherapeutic technique blocks communication between the client and the nurse. The nurse should avoid a response with the word "why," which asks the client to explain or justify feelings to the nurse. 3. When the client requests information, the nurse needs to provide accurate information, not pass the buck. 4. This statement answers the client's question.

The nurse is assessing the client's sensory system. Which assessment data indicate an abnormal stereognosis test? 1. The client is unable to identify which way the toe is being moved. 2. The client cannot discriminate between sharp and dull objects. 3. The toes contract and draw together when the sole of the foot is stroked. 4. The client is unable to identify a key in the hand with both eyes closed.

ANSWER: 4. 1. This is an abnormal finding for testing proprioception, or position sense. 2. This is an abnormal finding for assessing superficial pain perception. 3. This is a normal Babinski's reflex in an adult client. 4. Stereognosis is a test evaluating higher cortical sensory ability. The client is instructed to close both eyes and identify a variety of objects (e.g., keys, coins) placed in one hand by the examiner.

The nurse is preparing to administer otic drops into an adult client's right ear. Which intervention should the nurse implement? 1. Grasp the earlobe and pull back and out when putting drops in the ear. 2. Insert the eardrops without touching the outside of the ear. 3. Instruct the client to close the mouth and blow prior to instilling drops. 4. Pull the auricle down and back prior to instilling drops.

ANSWER: 4. 1. This is not the correct way to administer eardrops. 2. The nurse must straighten the ear canal; therefore, the outside of the ear must be moved. 3. This will increase pressure in the ear and should not be done prior to administering eardrops. 4. This will straighten the ear canal so the eardrops will enter the ear canal and drain toward the tympanic membrane (eardrum). TEST-TAKING HINT: The test taker should notice options "1" and "4" are opposite, which should clue the test taker into either eliminating both or deciding one (1) of these two (2) is the correct answer. Either way, the test taker now has a 50/50 chance of selecting the correct answer.

The client diagnosed with osteoporosis asks the nurse, "Why does smoking cigarettes cause my bones to be brittle?" Which response by the nurse is most appropriate? 1. "Smoking causes nutritional deficiencies, which contribute to osteoporosis." 2. "Tobacco causes an increase in blood supply to the bones, causing osteoporosis." 3. "Smoking low-tar cigarettes will not cause your bones to become brittle." 4. "Nicotine impairs the absorption of calcium, causing decreased bone strength."

ANSWER: 4. 1. This is the rationale for heavy alcohol use leading to the development of osteoporosis. 2. Smoking decreases, not increases, blood supply to the bone. 3. Cigarette smoking has long been identified as a risk factor for osteoporosis, and it doesn't matter if the cigarettes are low tar. 4. Nicotine slows the production of osteoblasts and impairs the absorption of calcium, contributing to decreased bone density. TEST-TAKING HINT: The test taker must always be aware of the words "increase" and "decrease" when selecting a correct answer.

The client diagnosed with OA is prescribed a nonsteroidal anti-inflammatory drug (NSAID). Which instruction should the nurse teach the client? 1. Take the medication on an empty stomach. 2. Make sure to taper the medication when discontinuing. 3. Apply the medication topically over the affected joints. 4. Notify the health-care provider if vomiting blood.

ANSWER: 4. 1. This medication should be taken with food to prevent gastrointestinal distress. 2. Glucocorticoids, not NSAIDs, must be tapered when discontinuing. 3. Topical analgesics are applied to the skin; NSAIDs are oral or intravenous medications. 4. NSAIDs are well known for causing gastric upset and increasing the risk for peptic ulcer disease, which could cause the client to vomit blood. TEST-TAKING HINT: The worst-scenario option is "4," which has blood in the answer. If the test taker did not know the answer, then selecting an option with blood in it is most appropriate.

Which signs/symptoms should the nurse expect to find when assessing the client with an acoustic neuroma? 1. Incapacitating vertigo and otorrhea. 2. Nystagmus and complaints of dizziness. 3. Nausea and vomiting. 4. Unilateral hearing loss and tinnitus

ANSWER: 4. 1. Vertigo and otorrhea are not the signs/ symptoms of an acoustic neuroma. 2. Neither nystagmus, an involuntary rhythmic movement of the eyes, nor dizziness is a sign of an acoustic neuroma. 3. Nausea and vomiting are not signs/symptoms of an acoustic neuroma. 4. An acoustic neuroma is a slow-growing, benign tumor of cranial nerve VII. It usually arises from the Schwann cells of the vestibular portion of the nerve and results in unilateral hearing loss and tinnitus with or without vertigo.

The client is postoperative open reduction and internal fixation (ORIF) of a fractured femoral neck. Which long-term goal should the nurse identify for the client? 1. The client will maintain vital signs within normal limits. 2. The client will have a decrease in muscle spasms in the affected leg. 3. The client will have no signs or symptoms of infection. 4. The client will be able to ambulate down to the nurse's station

ANSWER: 4. 1. Vital signs remaining stable is a short-term goal, not a long-term goal. 2. This is an expected short-term outcome for a preoperative client with a fractured femoral neck. 3. No signs/symptoms of infection is a shortterm goal for the nurse to identify in the hospital. 4. The discharge goal or long-term goal for this client is to return the client to ambulatory status.

The nurse is assessing a client and performs a whisper test. Which should the nurse implement? Rank in order of performance. 1. Have the client cover the ear not being tested. 2. Stand 12 to 24 inches to the side of the client. 3. Explain to the client to repeat what the nurse says. 4. Repeat the test for the opposite ear. 5. Ask the client if he/she is willing to participate in the test

ANSWER: In order of performance: 5, 3, 1, 2, 4 5. The client should be offered the opportunity to agree to being tested before any further action is taken. 3. The nurse should give directions as to what the client is expected to do when he/ she hears what the nurse says. 1. The client covers the ear not being tested after the nurse has explained the test. 2. The nurse should stand to the side but not until talking directly to the client. 4. One ear at a time is tested. TEST-TAKING HINT: This is a basic assessment tool to determine sensory perception. The test taker should memorize basic tests and normal results

The male client diagnosed with type 2 diabetes mellitus tells the nurse he has begun to see yellow spots. Which interventions should the nurse implement? List in order of priority. 1. Notify the health-care provider. 2. Check the client's hemoglobin A1c. 3. Assess the client's vision using the Amsler grid. 4. Teach the client about controlling blood glucose levels. 5. Determine where the spots appear to be in the client's field of vision.

ANSWER: In order of priority: 5, 3, 2, 1, 4. 5. The nurse should question the client further to obtain information such as which eye is affected, how long the client has been seeing the spots, and whether this ever occurred before. 3. The Amsler grid is helpful in determining losses occurring in the visual fields. 2. The hemoglobin A1c laboratory tests results indicate glucose control over the past two (2) to three (3) months. Diabetic retinopathy is directly related to poor blood glucose control. 1. The health-care provider should be notified to plan for laser surgery on the eye. 4. The client should be instructed about controlling blood glucose levels, but this can wait until the immediate situation is resolved or at least until measures to address the potential loss of eyesight have been taken.

The client must take three (3) grams of calcium supplement a day. The medication comes in 500-mg tablets. How many tablets will the client need to take daily? _______

ANSWER: Six (6) tablets. 1,000 mg is equal to one (1) gram. Therefore, three (3) grams is equal to 3,000 mg. If one (1) tablet is 500 mg, the client will need six (6) tablets to get the total amount of calcium needed daily: 3,000 ÷ 500 = 6 TEST-TAKING HINT: The test taker must know how to perform math calculations and must be knowledgeable of conversions. Remember to use the drop-down calculator on the NCLEX-RN examination.

The emergency department nurse is caring for a client with a compound fracture of the right ulna. Which interventions should the nurse implement? List in order of priority. 1. Apply a sterile, normal saline-soaked gauze to the arm. 2. Send the client to radiology for an x-ray of the arm. 3. Assess the fingers of the client's right hand. 4. Stabilize the arm at the wrist and the elbow. 5. Administer a tetanus toxoid injection.

ANSWER: The order should be 4, 1, 3, 2, 5. 4. The nurse first should stabilize the arm to prevent further injury. 1. A compound fracture is one in which the bone protrudes through the skin. The nurse should apply sterile, saline-soaked gauze to protect the area from the intrusion of bacteria. 3. The nurse should assess the client's circulation to the part distal to the injury. This is done after the first two interventions because life-threatening complications could occur if stabilization and protection from infection are not addressed first. 2. An x-ray will be needed to determine the extent of the injury. 5. A tetanus toxoid injection should be administered, but this can be done last.

_____: The process of maintaining a clear visual image when the gaze is shifted from a distant object to a near object. The eye adjusts its focus by changing the curvature of the lens.

Accomodation

_____: A benign tumor of cranial nerve VIII; symptoms include damage to hearing, facial movements, and sensation. The tumor can enlarge into the brain, damaging structures in the cerebellum.

Acoustic neuroma

_____: A complication of a fracture characterized by increased pressure within one or more compartments and causing massive compromise of circulation to the area. Compartments are sheaths of inelastic fascia that support and partition muscles, blood vessels, and nerves in the body.

Acute compartment syndrome (ACS)

_____: An infection resulting from bacteremia, disease, or nonpenetrating trauma that is disseminated by the blood through the circulation.

Acute hematogenous infection

_____: A graft of tissue or bone between individuals of the same species but a different genotype; the donor may be a cadaver or a living person, either related or unrelated. Also called homograft.

Allograft

_____: A difference in the size of the pupils.

Anisocoria

_____: A ratio derived by dividing the ankle blood pressure by the brachial blood pressure; this calculation is used to assess the vascular status of the lower extremities. To obtain the ABI, a blood pressure cuff is applied to the lower extremities just above the malleoli. The systolic pressure is measured by Doppler ultrasound at both the dorsalis pedis and posterior tibial pulses. The higher of these two pressures is then divided by the higher of the two brachial pulses.

Ankle-brachial index (ABI)

The client has sustained a traumatic amputation of the left arm after a machine accident. In what order should the following nursing actions be taken? 1. Apply direct pressure to the amputated site. 2. Elevate the extremity above the client's heart. 3. Assess the client for breathing problems. 4. Examine the amputation site.

Answer: 3,4,1,2. First, the airway must be assessed for breathing problems. Second, the nurse should examine the amputation site. Third, the nurse should apply direct pressure to the amputated site. Finally, the extremity should be elevated above the client's heart to decrease bleeding.All of the other sequencing of options is incorrect.

Which clients are at high risk for developing hearing problems? (Select all that apply) A) Airline mechanic. B) Client with Down Syndrome. C) )Drummer in a rock band. D) Teenager listening to music using ear buds E) Telephone operator

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

A bedridden client with reduced vision has been admitted. Which nursing interventions will ease the client's hospital stay? (Select all that apply). A) Announce name and purpose when entering the client's room. B) Explain food positions on the tray using a clock face as the example. C) Orient the client to the location of the call light, and keep it in that place. D) Orient the client to the room surroundings and equipment. E) Speak in a loud, clear voice.

Answer: A, B, C, D. Staff would always introduce themselves to clients, with or without visual issues. Using a standard clock face to explain food locations on the tray will assist the client with self-feeding. Providing room orientation to the client is important to improve his or her ability for self-care. Orienting the client to the room and equipment in the room will allow him or her to have increased comfort with surroundings.This client has visual issues, not hearing issues, so speaking louder is not necessary.

The nurse anticipates providing collaborative care for a client with a traumatic amputation of the right hand with which health care team members? (Select all that apply). A) Occupational therapist. B) Physical therapist. C) Psychologist. D) Respiratory therapist. E) Speech therapist.

Answer: A, B, C. An occupational therapist and a physical therapist will help to enable the client to become more independent in performing activities of daily living. An amputation can be traumatic to the client; loss of a body part should not be underestimated because the client may experience an altered self-concept, so counseling support with a psychologist should be made available to the client.The client does not have a respiratory condition that warrants collaborative care with a respiratory therapist. A speech therapist is not indicated because the client does not have speech impairment.

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

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

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

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

The nurse is providing discharge instructions to a client with glaucoma. Which activities does the nurse instruct the client to avoid? (Select all that apply). A) Bending over to tie shoes B) Sitting with legs elevated C) Sleeping on more than two pillows D) Blowing the nose frequently E) Lifting objects weighing more than 10 pounds (4.5 kg)

Answer: A, D, E. Any action that would increase pressure in the eye needs to be avoided, such as bending over, excessive blowing of the nose, and lifting heavy objects that weigh more than 10 pounds (4.5 kg).Sitting with the legs elevated or sleeping on more than two pillows is not contraindicated in clients with glaucoma.

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

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

A nurse is caring for a client who has a retinal detachment. Which of the following client reports about the affected ey eshould the nurse expect? A) Flashes of bright light. B) Pain. C) Complete blindness. D) Photophobia.

Answer: A. A) During retinal detachment, the client can see flashes of bright light or floating dark spots in the affected eye as the retinal layers separate. B) Clients who have a retinal detachment should not have pain, because there are no pain fibers in the retina. C) Clients who have a retinal detachment can have some visual field loss in the area of the detachment but should not have complete blindness. D) A retinal detachment does not typically cause photophobia. More likely, clients who have this disorder will report a sensation of a curtain or a shade blocking the vision of one eye.

A nurse in an emergency department is assessing a client who has myasthenia gravis. The client reports recent increasing muscle weakness and the nurse suspects the client is having a myasthenic crisis. Which of the following actions is the nurse's priority? A) Assist with a Tensilon test. B) Assist with plasmapheresis. C) Administer immunosuppressants. D) Administer artificial tears.

Answer: A. A) The first action the nurse should take using the nursing process is to assess the client. The Tensilon test will determine whether the client is having a myasthenic crisis or a cholinergic crisis. B) The nurse should assist with plasmapheresis, which removes antibodies from the plasma and reduces the manifestations of a myasthenic crisis. However, there is another action the nurse should take first. C) The nurse should administer immunosuppressants, such as corticosteroids, methotrexate, or rituximab, to reduce the manifestations of myasthenia gravis. However, there is another action the nurse should take first. D) The nurse should administer artificial tears because the client might have dry eyes due to an inability to close her eyes completely. However, there is another action the nurse should take first.

A nurse is caring for a client who is in balanced supsension skeletal traction and reports intermittent muscle spasms. Which of the following actions should the nurse take first? A) Check the position of the weights and ropes. B) Provide distraction. C) Administer a muscle relaxant. D) Reposition the client.

Answer: A. A) The first action the nurse should take when using the nursing process is to assess the client. The nurse should first check the position of the weights and ropes to investigate the cause of the muscle spasms. The weights might be too heavy, or the nurse might need to realign the client. B) The nurse should provide sensory stimulation to help the client keep his focus away from the pain of the spasms. However, there is another action the nurse should take first. C) The nurse should administer a muscle relaxant to minimize the client's muscle spasms. However, there is another action the nurse should take first. D) The nurse should reposition the client to realign him and try to relieve his muscle spasms. However, there is another action the nurse should take first.

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

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

A nurse is caring for a client who is 72 hours postoperative following an above-theknee amputation and reports phantom limb pain. Which of the following ctions should the nurse take? A) Administer a dose of gabapentin to the client.. B) Remind the client that the surgery removed the limb. C) Change the dressing on the client's residual limb. D) Elevate the client's residual limb above heart level.

Answer: A. A) The nurse should administer a nonopioid medication to help minimize phantom limb pain. Gabapentin is an oral antiepileptic medication that is effective for treating sharp, burning, phantom limb pain. B) It is not therapeutic for the nurse to remind the client that the limb is gone because it does not address the client's pain. C) Changing the dressing on the client's residual limb does not address the client's pain. D) The nurse should only elevate the client's residual limb above the heart level within the first 48 hr following the surgery. After that time, doing so can cause a hip or knee flexion contracture.

A nurse in an emergency department is assessing a client who reports sudden, severe eye pain and blurry vision. The provider determines the client has primary a ngle closure glaucoma. Which of the following medications should the nurse administer? A) Osmotic diuretics via IV bolus B) Corticosteroid ophthalmic drops C) Epinephrine via IV bolus D) Mydriatic ophthalmic drops

Answer: A. A) The nurse should administer osmotic diuretics, such as mannitol, to reduce intraocular pressure and prevent damage to the eye. B) Corticosteroid ophthalmic drops are used for inflammatory conditions of the eye, such as conjunctivitis. There is no indication for clients who have primary angle-closure glaucoma to receive corticosteroid ophthalmic drops. Instead, the nurse should administer medications that decrease intraocular pressure by increasing the absorption or decreasing the production of aqueous humor. C) Clients who have primary angle-closure glaucoma should not receive epinephrine-containing medications because they cause vasoconstriction. Instead, the nurse should administer medications that decrease intraocular pressure by increasing the absorption or decreasing the production of aqueous humor. D) Clients who have primary angle-closure glaucoma should not receive mydriatic ophthalmic drops because they cause pupillary dilation. Instead, the nurse should administer medications that decrease intraocular pressure by increasing the absorption or decreasing the production of aqueous humor.

A nurse is assessing a client who had a right hemispheric stroke. Which of the following neurologic deficits should the nurse expect? A) Impulsive behavior. B) Aphasia. C) Right-sided neglect. D) Inability to read.

Answer: A. A) The nurse should expect clients who had a right hemispheric stroke to demonstrate impulsive behavior, poor judgment, and lack of awareness of neurologic deficits. B) Clients who had a left hemispheric stroke are likely to have aphasia. C) Clients who had a right hemispheric stroke are likely to have neurologic deficits on the left side of the body, not the right side. The nurse should expect the client to be unaware of and unable to move the left side of the body. D) Clients who had a left hemispheric stroke are likely to have difficulty reading due to the inability to discriminate different letters and words.

A nurse is caring for a client who has viral meningitis. Which of the following actions should the nurse take? A) Check capillary refill at least every 4 hr. B) Initiate droplet precautions. C) Place the client in a well-lit environment. D) Assess the client's neurologic status every 8 hr.

Answer: A. A) The nurse should perform a complete vascular assessment at least every 4 hr to monitor for vascular compromise. B)The nurse should implement droplet precautions for clients who have bacterial meningitis. Standard precautions are sufficient for clients who have viral meningitis. C) The nurse should minimize the client's exposure to light from windows and overhead lights because photophobia, or light sensitivity, is a manifestation of viral meningitis. D) The nurse should assess the client's vital signs and neurologic status at least every 2 to 4 hr.

A nurse is caring for a client who has a history of status epilepticus and requires seizure precautions. Which of the folllowing actions should the nurse take? A) Establish IV access. B) Keep the client on bed rest. C) Assess hourly for a spike in blood pressure. D) Keep a padded tongue blade at the bedside.

Answer: A. A) The nurse should plan to establish IV access with a large-bore catheter and administer 0.9% sodium chloride if seizures are imminent. If the client is stable, the nurse should initiate a saline lock. B) A client at risk for seizures does not require bed rest. However, if seizures are imminent or frequent, the nurse should institute safety measures, such as placing the mattress on the floor or raising the side rails, according to agency policy. C) The nurse should check the client's vital signs and perform neurological checks after a seizure. However, a change in blood pressure does not correlate with an increased incidence of seizure activity. D) The nurse should not plan to place objects, such as a padded tongue blade, in the client's mouth during a seizure because it can injure her teeth and put her at risk for aspirating tooth fragments. The tongue blade could also obstruct her airway.

A nurse is assessing a client who is quadriplegic following a cervical fracture at vertebral level C5. The client reports a throbbing headache and nausea. The nurse notes facial flushing and a blood pressure of 220/110 mm Hg. Which o f the following actions should the nurse take first? A) Elevate the head of the client's bed. B) Empty the client's bladder. C) Administer hydralazine via IV bolus D) Loosen the client's clothing.

Answer: A. A) These assessment findings indicate that the client is experiencing autonomic dysreflexia and is at greatest risk for possible rupture of a cerebral vessel or increased intracranial pressure. The first action the nurse should take is to move the client from a supine to an upright position, which will result in rapid postural hypotension. B) The nurse should empty the client's bladder because a full bladder or a fecal impaction is a trigger of autonomic dysreflexia. However, there is another action the nurse should take first. C)The nurse should administer hydralazine, a potent vasodilator, to lower the client's blood pressure. However, there is another action the nurse should take first. D) The nurse should loosen the client's clothing because body temperature and tactile stimulation are triggers of autonomic dysreflexia. However, there is another action the nurse should take first.

A nurse is teaching a client who has osteoporosis and a new prescription for alendronate. Which of the following information should the nurse include in the teaching? A) "Remain upright for 30 min after taking this medication." B) "Expect the medication to cause insomnia." C) "Take the medication with 240 mL of milk." D) "Take vitamin C to promote medication absorption."

Answer: A. A) To prevent esophagitis or esophageal ulcers that can result from alendronate therapy, the client should sit up for 30 min after taking this medication. B) Alendronate does not cause insomnia. Headache is a common adverse effect of alendronate. C) The nurse should instruct the client to take alendronate with 240 mL (8 oz) of water, not milk. Foods or beverages containing calcium can reduce medication absorption. D) Vitamin C intake does not increase alendronate absorption and some sources, such as orange juice, decrease absorption. However, the nurse should encourage the client to take vitamin D, which promotes calcium absorption.

Which test best determines hearing acuity? A) Audiometry B) Electronystagmography C) Otoscope D) Snellen test

Answer: A. Audiometry is the best test for determining hearing acuity. Electronystagmography is a test that is sensitive for detecting central and peripheral disease of the vestibular system in the ear. An otoscope is used to inspect the ear canal. The Snellen test is a vision acuity test.

A client is admitted to the emergency department with metal shards in the right eye. Which test is contraindicated for this client? A) Magnetic resonance imaging (MRI) B) Ophthalmoscopy. C) Radioisotope scanning. D) Snellen chart.

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

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

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

The nurse is instructing a client who has been prescribed calcium citrate (Citracal). Which instruction does the nurse include? A) "Take Citracal with food." B) "For best absorption, take Citracal with a carbonated beverage." C) "One-third of the daily dose is best taken during the day." D) "Milk of Magnesia (MOM) should be taken with Citracal."

Answer: A. Calcium supplements can cause gastric upset. Taking Citracal with food can minimize gastric upset.Calcium citrate should be taken with 6 to 8 ounces (180 to 236 mL) of water, not carbonated beverages. One-third of the daily dose is best taken at bedtime. MOM is not indicated and actually may lead to decreased absorption of calcium citrate.

Which type of hearing loss is most likely to be reversible when treated appropriately? A) Conductive hearing loss B) Sensorineural hearing loss C) Mixed conductive-sensorineural hearing loss D) Central hearing loss

Answer: A. Conductive hearing loss is most likely to be reversible when treated appropriately. This type of hearing loss is often the result of an obstruction in the ear canal or a retracted or bulging tympanic membrane.Sensorineural loss is the result of damage to the eighth cranial nerve, a defect in the cochlea, or damage in the brain. Mixed conductive sensorineural hearing loss is the result of both conductive and sensorineural hearing loss. Central hearing loss results when the brain is unable to process signals from the ear. None of these types of hearing loss is likely to be reversible.

The nurse is teaching a client about ear protection. Which statement by the client indicates that teaching was effective? A) "I wear foam ear inserts at works where it is noisy." B) "I listen to music with foam ear inserts." C) "My ears ring after a rock concert, but it goes away." D) "The machinery is loud at work, but I get used to it."

Answer: A. Foam ear inserts or over-the-ear headsets protect against potential ear damage from loud noises.If the client's work environment is noisy, the client will have to turn up the volume significantly to hear music played through ear inserts. A ringing in the ears (tinnitus) may be a sign of injury. Clients should wear earplugs in environments with loud music. Not wearing ear protection around noisy machinery will cause damage to the ear. "Getting used to" the noise is a sign that damage has occurred.

A client has a bilateral corneal disorder and must instill anti-infective eye drops every hour for the first 24 hours. Which comment by the client indicates a need for further instruction by the nurse? A) "I have two bottles of eye drops in case I run out." B) "I won't be able to wear my contacts for a while." C) "I must apply the drops throughout the night." D) "I must wash my hands before, between, and after eye applications."

Answer: A. If both eyes are infected, separate bottles of drugs are needed for each eye. The client must be taught to clearly label the bottles "right eye" and "left eye" and to not switch the drugs from eye to eye.The client would not wear contact lenses during the entire time that these drugs are being used because the eye then has fewer protections against infection or injury. In addition, the drugs can cloud or damage contact lenses. If the drugs are to be instilled every hour for the first 24 hours, the client will have to wake up every hour during the night to apply the drops. The client would completely care for one eye, wash the hands, and by using the drugs for the remaining eye, care for that eye. As always, handwashing must be done before and after eye care.

Which nursing intervention helps to reduce the incidence of osteomyelitis for a client receiving hemodialysis? A) Instructing the client to brush teeth after every meal B) Maintaining clean dressing change technique for long-term IV catheters C) Using clean technique D) Using Standard Precautions

Answer: A. Proper dental hygiene helps prevent periodontal infection, which can be a causative factor in contiguous osteomyelitis in facial bones. Patients undergoing long-term hemodialysis and IV drug users are at risk for osteomyelitis.Long-term IV catheters can be a primary source of infection, so dressing changes are done using sterile not clean technique. All clients undergoing hemodialysis require careful sterile technique before needle cannulation. Standard Precautions must be used for all clients.

A 55 year-old female client has a high familial risk for osteoporosis and tells the nurse that her mother and an older sister both developed spine and hip fractures as a result of the disease. Which diagnostic test will be appropriate to help determine this client's risk for spine and hip fractures? A) CT-based absorptiometry B) Magnetic resonance spectroscopy (MRS) C) Vertebral imaging studies D) Dual x-ray absorptiometry (DXA)

Answer: A. The CT-based absorptiometry test measures the volume of bone density and strength of the vertebral spine and hip and is predictive of spine and/or hip fractures in women.MRS creates a graph for quantifying the amount of bone marrow adipose tissue and is an expensive and less often used test. Vertebral imaging is done to assess for the presence of factors but is not predictive. DXA measures bone mineral density but is not predictive of fracture risk.

An older adult client reports ear pain. Otoscopic examination for otitis media by the nurse practitioner (NP) reveals a dull and retracted membrane. What does the NP do next? A) Continues further assessment B) Irrigates the ear C) Prescribes antibiotics for probable otitis media D) Tests hearing acuity

Answer: A. The NP needs to perform further assessments. A dull and retracted membrane is not the only indication of otitis media for the older adult client. This finding may be a normal age-related change.Irrigating the ear is not indicated for this client. Further assessment is needed to determine whether the client has otitis media; therefore, antibiotics would not be prescribed. Auditory assessment is the last part of an ear examination after the otoscopic examination.

A client with peripheral vascular disease will undergo a Syme amputation. What will the nurse teach this patient when providing education about this procedure? A) "You will be able to bear weight without needing a prosthesis." B) "This type of procedure results in more pain than others." C) "The surgeon will remove both the foot and ankle." D) "This is an above-the-knee type of amputation."

Answer: A. The Syme procedure is commonly used for clients with peripheral vascular disease. The surgery involves only amputation of the foot, making it possible for clients to bear weight without the use of a prosthesis.The Syme procedure involves removal of the foot but not the ankle. There is considerably less pain with this procedure. It is not an above-the-knee procedure.

The nurse is teaching a client who is scheduled for an ultrasonography of the eye. Which statement by the client indicates a need for further instruction? A) "I'll have to wear a bandage over my eye after the test." B) "I will be awake during this test." C) "I won't hear the high-frequency sound waves." D) "This test will help determine whether my retina is detached."

Answer: A. The client does not have to wear a bandage after the test because no special follow-up care is needed after an ultrasonography of the eye. However, the client should be reminded not to rub or touch the eye until the effects of the anesthetic drops have worn off.The test is noninvasive and painless, and the client remains awake during the test. The high-frequency sound waves that are bounced through the eye cannot be heard. Ultrasonography aids in the diagnosis of trauma, intraorbital tumor, proptosis, and choroidal or retinal detachment.

The nurse is preparing a client for electronystagmography. Which statement by the client indicates that teaching was effective? A) "I can't drink caffeine 24 to 48 hours before the test." B) "I should drink more fluids 4 hours before the test." C) "I'll be placed in a soundproof booth for the test." D) "I'll be sedated for the test."

Answer: A. The client must avoid caffeine-containing beverages for 24 to 48 hours before the test. Electronystagmography (ENG) is a test to assess for central and peripheral disease of the vestibular system in the ear by detecting and recording nystagmus (involuntary eye movements). This response is accurate because the eyes and ears depend on each other for balance.The client must fast for several hours before electronystagmography. Fluids are carefully introduced after the test is completed to prevent nausea and vomiting. The client is placed in a soundproof booth for an audiometry test. Sedation is not given for the test. The examiners will ask the client to name names or do simple math problems during the test to ensure that he or she stays alert.

A 65-year-old female client has chronic hip pain and muscle atrophy from an arthritic disorder. Which musculoskeletal assessment finding does the nurse expect to see in the client? A) Antalgic gait. B) Midswing gait. C) Narrow-based stance. D) No lurch in gait.

Answer: A. The client with chronic hip pain and muscle atrophy from an arthritic disorder would likely have a lurch in the gait (antalgic gait).Midswing gait is not a term used to assess a client's gait. This client would likely have a wide-based stance because of the musculoskeletal disorder.

A client has sustained a fracture of the left tibia. The extremity is immobilized using an external fixation device. Which postoperative instruction does the nurse include in this client's teaching plan? A) "Use pain medication as prescribed to control pain." B) "Clean the pin site when any drainage is noticed." C) "Wear the same clothing that is normally worn." D) "Apply bacitracin (Neosporin) if signs or symptoms of infection develop around pin sites."

Answer: A. The client would be taught the correct use of prescribed pain medication to control pain adequately.Pin sites must be cleaned at least every 8 hours and as needed to reduce the risk for infection, not when any drainage is noticed. The client will have to adjust the type of clothing worn while the fixation device is in place. If signs and symptoms of infection develop around the pin sites, the client must notify the health care provider immediately. Infection at the pin sites places the client at risk for osteomyelitis.

When assessing a female client, the nurse learns that the client has several risk factors for osteoporosis. Which risk factor will be the priority for client teaching? A) Low calcium and vitamin D intake B) Postmenopausal status C) Positive family history D) Previous use of steroids

Answer: A. The client's calcium and vitamin D intake is the priority risk factor that the client can change. The nurse will discuss the other risk factors as contributing to osteoporosis, but the teaching will focus on ways to increase calcium intake.Postmenopausal status, positive family history, and previous use of steroids are not risk factors that the client can change. These risk factors should be discussed but are not the priority for this client.

An older adult client with diabetes who had arthroscopic surgery on the right knee the previous day has a red, swollen, and painful right knee. The nurse anticipates that the health care provider will request which type of medication? A) Antibiotic. B) Anticoagulant. C) Opioid analgesic. D) Corticosteroid.

Answer: A. The client's symptoms indicate a possible right knee infection, so the first action will be to start antibiotic therapy, especially because the client is diabetic and is at greater risk for infection.An anticoagulant can increase the risk for postoperative bleeding. The health care provider usually requests an opioid analgesic combination following arthroscopic surgery. An opioid analgesic is used for more invasive surgical procedures and is not indicated for this client. Corticosteroids are used to treat inflammation. They increase blood sugar and increase susceptibility to infection.

A client recently had an amputation of the right hand. Which statement by the client, who was right-handed, indicates that he or she is coping effectively? A) "I can learn to write with my left hand." B) "I'll need help with all of my personal care." C) "Clothing will cover my missing hand." D) "People will look at me differently."

Answer: A. The client's willingness to learn to write with his or her left hand indicates that the client is coping effectively by planning to adapt to the loss of the right hand.The client can adapt to the use of assistive devices to be independent in personal care. The client's desire for help with all personal care indicates lack of willingness or information or both. Wanting to cover the missing hand with clothing indicates that the client is not adjusting to the loss of the hand. Concern over people looking at him or her differently is a realistic concern for the client, but it also indicates that the client is not coping effectively regarding the amputated limb.

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

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

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

Answer: A. The most important intervention the nurse teaches the client is to monitor the neurovascular status during the first 24 hours after ED discharge.The client should apply ice for discomfort, not heat. The client should not place anything between the cast and the skin. In assessing fit, one finger should easily fit between the cast and the skin. To allow the cast to dry, it should remain uncovered.

Which aspect of postoperative management will the nurse plan to discuss with a client about to undergo an arthroscopic repair of the knee? A) Physical therapy for exercises B) Pharmacy for client medications C) Dietitian for nutrition D) Social work for care coordination

Answer: A. The nurse and the physical therapist will discuss postoperative physical therapy with the client and will assess and collaborate on the postoperative exercises which will be necessary to establish ROM after the procedure.It is the nurse's responsibility to assess which medications the client is currently taking. Nutritional assessment is performed by the nurse, but this might also involve a dietitian if special needs exist. Unless there are postoperative complications or if the client has a variety of special needs, care coordination is not necessary.

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

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

The nurse is completing an admission assessment on a client scheduled for arthroscopic knee surgery. Which information will be most essential for the nurse to report to the health care provider? A) Knee pain at a level of 9 (0-to-10 scale) B) Warm, red, and swollen knee C) Allergy to shellfish and iodine D) Previous surgery on the other knee

Answer: B. Findings such as swelling, heat, and redness may indicate infection in the knee joint and is most essential for the nurse to report to the health care provider. These findings will help the health care provider determine whether there may be a need to cancel the procedure.Having knee pain before surgery is not unexpected but will not affect whether the client will have surgery. Allergy to shellfish and iodine will need to be reported, but also will not affect whether the client will have surgery. Having previous surgery on the other knee does not preclude the client from having this surgery.

An older client who lives at home has been receiving intravenous linezolid to treat methicillin-resistant Staphylococcus aureus (MRSA) osteomyelitis for 2 weeks and is ready to be discharged from the hospital to undergo continued treatment. The client does not want to go to a skilled nursing facility (SNF). What will the nurse do? A) Discuss administering oral linezolid at home with the provider. B) Explain to the client that intravenous medications require skilled nursing care. C) Arrange for a home health aide to administer intravenous antibiotics at home. D) Tell the client that the SNF stay will only need to be for one week.

Answer: A. The nurse will discuss administering oral linezolid at home with the provider because it may be possible for the client to use oral linezolid to treat the MRSA infection and thus allow the client to stay at home rather than be admitted to a SNF.While IV medications do require skilled nursing care, IV medications may not be required for this client. Home health care aides do not administer any medications. Most clients require 4 to 6 weeks of antimicrobial therapy.

An older adult client comes in for a routine visit. During the assessment he is irritable and says, "Speak up and quit mumbling!" How will the nurse respond? A) Apologizes and speaks louder and clearer B) Asks whether the client has a hearing loss C) Shout to ensure that the client can hear D) Suggests that the client move to a soundproof examination room to improve his hearing

Answer: A. The nurse would repeat and speak more clearly first and then determine whether further assessment is needed.It would not be assumed that the client has a hearing loss; this suggestion may make the client more irritable, especially if the client is in denial. Shouting is not recommended because it can make understanding more difficult. Soundproof rooms are used for hearing tests, not to improve hearing.

The nurse is performing an otoscopic examination of a client's ear and notes greenish-white drainage. What does the nurse do next? A) Disposes of the otoscope tip and washes the hands before examining the other ear B) Reports the finding to the health care provider immediately C) Sends a specimen for culture D) Suctions out the drainage

Answer: A. The nurse's next step is to dispose of the otoscope tip and wash the hands before examining the other ear. To prevent cross-contamination, Contact Precautions must be used with any client who has drainage from the ear canal.The health care provider will be notified after the ear examination is complete. After an otoscopic examination, the nurse must perform an auditory assessment. A specimen is obtained only if the nurse is examining the external meatus region, but this is not the first step. The nurse must assess the second ear and compare. Suctioning an ear that is infected is not done because this causes trauma to the tissue.

Which is a priority problem for the older adult client diagnosed with bone cancer? A) Potential for injury related to weakness and drug therapy B) Altered self-esteem related to fear of death and dying C) Reduced mobility related to weakness and fatigue D) Pain of a chronic nature related to tumor invasion of other organs

Answer: A. The priority problem for the older adult client with bone cancer is potential for injury related to weakness and prescribed medications, especially analgesics.Client problems of altered self-esteem, reduced mobility, and chronic pain are relevant but are not the priority. The client's safety comes first.

A client with new-onset diminished vision is being discharged and is concerned about living independently. Which nursing technique best facilitates independent self-care for the client? A) Building on the remaining vision B) Keeping the floor free of clutter C) Suggesting a seeing-eye animal companion D) Teaching Braille

Answer: A. Using large-print books, talking clocks, and telephones with large, raised block numbers are examples of building on the client's remaining vision, and best facilitates the client's independent self-care.Keeping the floor free of clutter is important but is too specific. A seeing-eye animal companion may be assigned to those who are legally blind, not to those with diminished vision. Braille is used by clients who are legally blind. This client will still be able to read using a magnification device such as a visualizer.

The nurse is performing preoperative teaching for an older adult client who will be having a cataract removed. Which instructions does the nurse include? (Select all that apply). A) "You will need to wear a patch on your eye for several weeks after the surgery." B) "Several different types of eye drops are requested after surgery, and they have to be taken several times a day for up to 4 weeks." C) "You will receive a medication to help you relax. Then you will receive eye drops to dilate your pupils and paralyze the lens." D) "Bring sunglasses with you on the day of your procedure." E) "You might experience a lot of bruising and swelling around the eye."

Answer: B, C, D. The client will have multiple eye drops to use after surgery and needs to be made aware of this before the procedure to understand the importance. Providing information on what to expect, such as telling the client about the medication that will be administered and the eye drops that will dilate and paralyze the lens, helps the client prepare for the day of surgery. The client will need to have sun protection after the procedure.A patch is required after surgery only if a risk for injury is present. Cataract surgery does not cause bruising and swelling postsurgery.

Which eye procedure requires informed consent from the client? A) Eye drop instillation. B) Fluorescein angiography. C) Opthalmoscopy. D) Snellen test.

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

A nurse is assessing a client who has a new diagnosis of osteoarthritis. Which of the following findings should the nurse expect? (Select all that apply). A) Low-grade fever B) Joint pain that resolves with rest C) Spongy tissue over the joints D) Decreased range of motion of the affected joint E) Crepitus with joint movement

Answer: B, D, E. A) Osteoarthritis does not cause systemic manifestations. Rheumatoid arthritis causes many systemic manifestations, including low-grade fever, weakness, anorexia, and paresthesias. B) The client who has osteoarthritis experiences increased pain with activity and decreased pain with rest. C) Spongy joint tissue is an expected finding with rheumatoid arthritis, which is an inflammatory disease, not a degenerative disease. D) Decreased range of motion is an expected finding with osteoarthritis because the client's pain limits movement. E) Osteoarthritis is a degenerative joint disease. Crepitus, a grating sound, is an expected finding with osteoarthritis as loosened bone and cartilage move around in the fluid inside the joint.

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

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

A nurse is planning to teach a client who has epilepsy and is to start therapy with phenytoin. Which of the following instructions should the nurse include in the client's medication teaching plan? A) Use an over-the-counter antihistamine if a rash develops. B) Take medications at a consistent time each day to maintain therapeutic blood levels. C) Slowly taper the medication after 6 consecutive months without seizure activity. D) Rinse with antiseptic mouthwash in place of using dental floss.

Answer: B. A) The client should stop taking phenytoin and report the development of a rash to the provider immediately. An adverse effect of phenytoin therapy is the development of a measles-like rash. If left untreated, the rash could progress to Stevens-Johnson syndrome or toxic epidermal necrolysis. B) The client should take antiepileptic medications on a regular schedule to maintain therapeutic blood levels and achieve the maximum effect. C) The client should continue taking antiepileptic medications even in the absence of seizures. Stopping the medication can lead to the return of seizures or the complication of status epilepticus. D) Phenytoin can cause gingival hyperplasia, an overgrowth of gum tissue. To minimize gum injury and discomfort, the client should brush and floss after each meal, massage her gums, and schedule dental examinations regularly.

Which diagnostic test requires the nurse to know whether the client is allergic to iodine-based contrast? A) Arthroscopy. B) Computed tomography (CT). C) Electromyography (EMG). D) Tomography

Answer: B. A CT scan creates three-dimensional images and may be done with iodine-based contrast.Arthroscopy involves inserting a fiber optic tube into a joint for direct visualization of ligaments, menisci, and articular surfaces of the joint. An EMG evaluates diffuse or localized muscle weakness by testing nerve conduction. Tomography identifies locations, or "slices," for focus and blurs the images of other structures. Arthroscopy, EMG, and tomography do not use iodine-based contrast.

The nurse plans to use which tool to measure joint range of motion (ROM)? A) Doppler device. B) Goniometer. C) Reflex hammer. D) Tonometer.

Answer: B. A goniometer provides an exact measurement of flexion and extension or joint ROM.A Doppler device is used to check and find pulses. A reflex hammer is used to test and elicit reflexes and is used in neurologic examinations. A tonometer is used to measure tension or pressure in the eye.

A nurse is assessing a client who has a head injury following a motor-vehicle crash. The nurse should identify that which of the following findings indicates increasing intracranial pressure. A) Fever. B) Restlessness. C) Dizziness. D) Hypotension.

Answer: B. A) Although a client who has head trauma can develop fever, it is either in response to infection or due to hypothalamic damage, not due to increased intracranial pressure. B) Behavioral changes, such as restlessness and irritability, are early manifestations of increased intracranial pressure. C) Although dizziness might be present after head trauma, it is not a manifestation of increased intracranial pressure. D) Although hypotension might be present after head trauma, especially if the client is experiencing hypovolemic or neurogenic shock, it is not a manifestation of increased intracranial pressure. Cushing's triad of hypertension, bradycardia, and a widening pulse pressure is a late manifestation of increased intracranial pressure.

A nurse is assessing a client who has rheumatoid arthritis. Which of the following assessment findings should the nurse expect? A) Fractures of the spine. B) Ulnar deviation. C) Decreased sedimentation rate. D) Unilateral joint involvement.

Answer: B. A) Compression fractures of the spine are more common in clients who have osteoporosis. B) The inflammation that occurs in the hand joints can make them susceptible to deformity from daily use. Ulnar deviation, or lateral deviation of the fingers, can occur from opening jars and other similar motions. C) The client who has rheumatoid arthritis will have an increased sedimentation rate due to the body's response to the inflammatory connective tissue disorder. D) Rheumatoid arthritis usually occurs bilaterally and symmetrically. Osteoarthritis usually occurs unilaterally.

The nurse is attempting to perform a quick assessment of a client's hip discomfort. The client is sitting upright in a wheelchair. What is the nurses initial action? A) Have the client flex and extend the foot on the affected side. B) Flex and extend the client's knee to assess for discomfort. C) Ask the client to stand from the wheelchair and transfer to the bed. D) Perform passive abduction and adduction of the client's hips.

Answer: B. Hip pain can radiate to the groin and knee, so a rapid initial assessment for a client who is sitting with knees flexed may be performed by flexing and extending the client's knee.Flexing and extending the foot does not assess hip pain. If the knee assessment does not yield information about hip discomfort, the client may be transferred to the bed for a more complete examination of the hip. It is not possible to perform abduction and adduction of the client's hips while the client is sitting in a wheelchair.

A nurse is teaching a client and his family about the diagnosis and treatment of Alzheimer's disease. Which of the following statements should the nurse identify as an indication that the family understands the teaching? A) "Early manifestations of Alzheimer's disease include mild tremors and muscular rigidity." B) "The medications that treat Alzheimer's disease can help delay cognitive changes." C) "The goal of medication therapy is to reverse the degenerative changes that can occur in brain tissue." D) "There is a test for Alzheimer's disease that can establish a reliable diagnosis."

Answer: B. A) Early manifestations include short-term memory loss, forgetfulness, and a shortened attention span. Mild tremors and muscular rigidity are manifestations of Parkinson's disease. B) Medications that treat Alzheimer's disease enhance the availability of acetylcholine, which can slow cognitive decline in some clients. C) None of the medications currently available reverse the course of Alzheimer's disease. D) There is no specific test for identifying Alzheimer's disease, except direct examination of the brain on autopsy. Providers diagnose Alzheimer's disease based on manifestations and by ruling out other diseases.

A nurse in an emergency department is caring for a client who suddenly lost consciousness and fell in her home. The provider determines that the client had an embolic stroke. Which of the following medications should the nurse administer? A) Nitroglycerin. B) Tissue plasminogen activator. C) Lidocaine. D) Recombinant factor VIII.

Answer: B. A) Nitroglycerin is a coronary and venous vasodilator that treats angina. B) Tissue plasminogen activator is a thrombolytic agent that should dissolve the blood clot that caused the stroke. C) Lidocaine is an antidysrhythmic agent that treats ventricular dysrhythmias. D) Recombinant factor VIII helps manage the manifestations of hemophilia.

A nurse is reviewing postoperative instructions with a client following cataract surgery. Which of the following statements should the urine identify as an indication that the client understands the instructions? A) "I will take aspirin for eye discomfort." B) "I should call my doctor if my vision gets worse." C) "I can blow my nose to clear out any drainage." D) "I can lift objects up to 20 pounds."

Answer: B. A) The client should avoid aspirin because it can cause bleeding in the eye. B) The client should report negative changes in vision immediately because there should be an improvement in vision after the surgery. C) The client should avoid blowing his nose because it can increase intraocular pressure. D) The client should avoid lifting objects heavier than 4.5 kg (10 lb) because it can increase intraocular pressure.

A nurse is teaching an assistive personnel (AP) about care of a client following a total hip arthroplasty. Which of the following instructions should the nurse include? A) Avoid applying anti-embolism stockings to the affected leg. B) Place an abductor pillow between the client's legs when turning the client. C) Discourage the client from sitting in a wheelchair with the back reclined. D) Have the client lean forward when moving from a sitting to a standing position.

Answer: B. A) The nurse should instruct the AP that a client who had a total hip arthroplasty should wear anti-embolism stockings on both legs postoperatively to prevent the development of emboli in the lower extremities. B) The nurse should inform the AP that a client who had a total hip arthroplasty should maintain the hip in abduction following surgery to reduce the risk of dislocating the surgical hip. The AP should place an abductor pillow between the client's legs when turning the client to keep her hips in abduction. C) The nurse should instruct the AP that a client who had a total hip arthroplasty can sit in either an upright wheelchair or one with a back that reclines to prevent hip flexion greater than 90°. D) The nurse should instruct the AP that a client who had a total hip arthroplasty should use the unaffected leg and arms to push straight up to standing and not flex the affected hip more than 90°.

A client has recently been diagnosed with 20/200 vision bilaterally and tells the nurse he is "legally blind." How does the nurse best offer increased support? A) Provides instructions in a loud, clear voice B) Refers the family to local services for the blind C) Tells the client to find a support group D) Writes instructions down in very large print

Answer: B. Because the client is considered legally blind, referring the family to local services for the blind is the best way for the nurse to offer increased support.Talking in a loud, clear voice demonstrates insensitivity on the part of the nurse because speaking louder does not have any impact on vision. The client needs more specific assistance than just being told to find a support group. The client with 20/200 vision will not be able to distinguish large print.

The nurse admits an older adult client who sustained a left hip fracture and is in considerable pain. The nurse anticipates that the client will be placed in which type of traction prior to surgical repair? A) Balanced skin traction. B) Buck's traction. C) Overhead traction. D) Plaster traction.

Answer: B. Buck's traction may be applied before surgery to help decrease pain associated with muscle spasm.Balanced skin traction is indicated for fracture of the femur or pelvis. Overhead traction is indicated for fracture of the humerus with or without involvement of the shoulder and clavicle. Plaster traction is indicated for wrist fracture.

Care of the older adult may be affected by which physiologic change in the musculoskeletal system? A) Regeneration of cartilage B) Decreased range of motion (ROM) C) Increased bone density D) Narrower gait

Answer: B. Decreased ROM is the physiological change noted that occurs in older adults. This results in a need for assistance with self-care skills.Cartilage degeneration, not regeneration, is an age-related change that occurs in the musculoskeletal system. Decreased, not increased bone density, occurs with musculoskeletal system aging, and porous bones are more likely to fracture. The older adult experiences kyphotic posture, widened, not narrower gait, and a shift in the center of gravity.

A client with visual limitations has been admitted to the intensive care unit (ICU). Which action is most important to implement for this client? A) Allowing the client's seeing-eye dog in the unit B) Making all health care team members aware of the client's visual limitations C) Keeping the client bedridden for safety D) Addressing the client in a loud, clear voice

Answer: B. It is most important to be sure all health care team members are aware of the client's visual limitations and need for assistance.All health care team members must be made aware of the client's visual limitations and need for assistance. Seeing-eye dogs are not usually allowed in the ICU. It is not necessary to keep the client bedridden. The client would be addressed in a normal tone of voice, because the client's hearing is not affected.

What is the action of miotic drugs that constrict the pupils in the client with glaucoma? A) Decrease the inflammatory process B) Enhance aqueous circulation to site of absorption C) Increase the production of vitreous humor D) Vasoconstrict the blood vessels in the eye

Answer: B. Miotics are used to improve the flow of fluid (aqueous humor) and circulation and decrease intraocular pressure in clients with glaucoma.Steroid drops, not miotics, decrease the inflammatory process. Vitreous humor fills the space between the lens and the retina, is stagnant, and is not replenished as the aqueous humor is. Miotics make the pupil smaller, which creates more room between the iris and the lens.

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

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

The nurse is teaching a client about administering eye drops to treat open-angle glaucoma. Which statement by the client indicates a need for further instruction? A) "I must wait 10 to 15 minutes between different eye drop medications." B) "I must press on the inside of my eye to prevent washout." C) "It is important to not skip a dose." D) "These eye drops will not cure my glaucoma."

Answer: B. Pressing on the inside of the eye after instillation of eye medication prevents systemic absorption of the drug.To avoid washout, the client must wait 10 to 15 minutes between eye drop medications. Skipping a dose will not exacerbate the client's glaucoma. Medication will not cure glaucoma, but it will control its progression.

Which client is most in need of immediate examination by an ophthalmologist? A) A 58-year-old with glasses who reports an inability to see colors well and is feeling as though the glasses are always smudged B) A 40-year-old with glasses and a reddened sclera who reports brow pain, headache, and seeing colored halos around lights C) A 76-year-old with seborrhea of the eyebrows and eyelids who reports burning and itching of the eyes D) A 39-year-old with contacts who reports an inability to tolerate bright lights and has visible purulent drainage on eyelids and eyelashes

Answer: B. The 40-year-old client with glasses and a reddened sclera who reports brow pain, headache, and seeing colored halos around lights is most in need of an ophthalmologic examination. This client is exhibiting signs and symptoms of increased intraocular pressure (IOP). This is a priority because the optic nerve can be damaged, which can cause possible blindness. Acute angle-closure glaucoma can occur in people 40 years of age and older.The 58-year-old client reporting an inability to see colors well is exhibiting early signs of cataracts and will need to be seen, but this is not the priority. The 76-year-old with seborrhea of the eyebrows and eyelids is exhibiting signs and symptoms of blepharitis and will need to be seen, but this is also not the priority. The 39-year-old with contacts is exhibiting signs and symptoms of corneal abrasion, possibly from cataracts, and will need to be seen soon, but the client exhibiting increased IOP is still the priority.

A client is suspected of having muscular dystrophy (MD). Which laboratory test result does the nurse anticipate with this disease? A) Decreased serum creatine kinase (CK) level B) Moderately elevated aspartate aminotransferase (AST) C) Decreased alkaline phosphatase (ALP) D) Decreased skeletal muscle creatine kinase (CK-MM) level

Answer: B. The AST level is moderately elevated (three to five times normal) in certain musculoskeletal diseases, such as MD.The CK level is elevated in musculoskeletal diseases such as MD. ALP is an enzyme normally present in blood, and the concentration of ALP increases with bone or liver damage. It is not associated with MD. A decreased CK-MM level is not associated with MD.

Which technique is correct when instilling ear drops? A) Maintain the head in the same position for 2 minutes after instillation. B) Place the medication bottle in a bowl of warm water before instillation. C) Rinse the ear canal with hydrogen peroxide before instillation. D) Check to see whether the eardrum is intact before instillation.

Answer: B. The correct way to instill eardrops is to first place the bottle (with the top on tightly) in a bowl of warm water for 5 minutes. This warms the medication and makes instillation more comfortable for the client.The head would be gently moved back and forth five times after instillation to ensure proper distribution. It is not necessary to rinse the ear canal with hydrogen peroxide or check to see whether the eardrum is intact before instillation.

The nurse is teaching the mother of a teenage client with conjunctivitis how to administer eye ointment. Which statement by the mother indicates a correct understanding of the nurse's instruction? A) "My child should look down at the floor during instillation." B) "I will place the ointment in the lower lid." C) "My child should rub the eye gently after instillation to increase absorption." D) "I will press gently on the inner canthus for 1 minute."

Answer: B. The mother's statement that she will place the ointment in the lower lid indicates that she understands the nurse's instruction correctly. After the lower lid is gently pulled down to form a small pocket, eye ointment would be placed in the lower lid.For instillation of eye ointment, the client would tilt the head backward and look up at the ceiling. After closing the eye, the client may gently wipe away any excess ointment with a tissue, but the eye would never be rubbed. Pressing on the inner canthus is a technique reserved for the instillation of glaucoma drops.

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

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

A client has sustained damage to the optic nerve (cranial nerve II) after a traumatic injury. Which intervention does the nurse anticipate to accommodate for this injury? A) Artificial tears. B) Identifying food on the client's plate using the clock method C) Daily eye assessment of the six cardinal positions of gaze D) Ensuring that the client wears sunglasses when the curtains are open or when the room light is on

Answer: B. The optic nerve (cranial nerve [CN] II) controls sight. Using the clock method helps the client with impaired vision or loss of vision locate food on his or her plate.Artificial tears are used when tear production is decreased due to the aging process. The six cardinal positions of gaze assess CN III, IV, and VI. Sunglasses are used when the pupils are artificially dilated for assessment purposes, or when medications are used that cause dilation of the pupil.

A client has a grade III open fracture of the right tibia. To prevent infection, which intervention does the nurse implement? A) Apply bacitracin (Neosporin) ointment to the site daily with a sterile cotton swab. B) Use strict aseptic technique when cleaning the site. C) Leave the site open to the air to keep it dry. D) Assist the client to shower daily and pat the wound site dry.

Answer: B. Using aseptic technique is the best way to prevent infection.Chlorhexidine (Hibiclens), 2 mg/mL solution, is the better cleansing solution for pin site care, not Neosporin ointment. A wound of this type should be kept covered, not left open to the air. The wound site of an open fracture must not be exposed to a shower because this violates maintaining aseptic technique.

Which statement indicates to the nursing instructor that the nursing student understands the normal healing process of bone after a fracture? A) "A callus is quickly deposited and transformed into bone." B) "A hematoma forms at the site of the fracture." C) "Cellular and vascular proliferation surround the fracture site." D) "Granulation tissue reabsorbs the hematoma and deposits new bone."

Answer: B. With a stage 1 fracture, a hematoma forms at the site of the fracture within 24 to 72 hours, because bone is extremely vascular. This action helps prompt the formation of fibrocartilage, providing the foundation for bone healing.Stage 2 of bone healing occurs within 3 days to 2 weeks after the fracture, when granulation tissue begins to invade the hematoma. Stage 3 of bone healing occurs as a result of vascular and cellular proliferation. In stage 4 of a healing fracture, callus is gradually reabsorbed and transformed into bone.

The nurse is taking the history of an adult female client. Which factor places the client at risk for osteoporosis? A) Consuming 12 ounces (355 mL) of carbonated beverages daily B) Working at a desk and playing the piano for a hobby C) Having a hysterectomy and taking estrogen replacement therapy D) Consuming one alcoholic drink per week

Answer: B. Working at a desk and playing the piano for a hobby places the client at risk for osteoporosis. Sedentary lifestyle and prolonged immobility help to produce rapid bone loss.The client would have to consume large amounts of carbonated beverages daily (over 40 ounces [1.2 liters]) for this to be a risk factor for osteoporosis. Maintaining estrogen levels reduces the risk for osteoporosis. Alcohol has a direct toxic effect on bone tissue, resulting in decreased bone formation and increased bone resorption. For those who have excessive alcohol intake, alcohol calories decrease hunger and the need to take in adequate quantities of nutrients. This client's alcoholic intake is not high, so it is not a risk factor.

The nurse is assessing a client with osteomalacia. Which findings does the nurse expect to observe? (Select all that apply). A) Hyperparathyroidism B) Hyperuricemia C) Hypophosphatemia D) Looser's lines or zones E) Unsteady gait

Answer: C, D, E. The nurse expects to observe hypophosphatemia, Looser's lines or zones and an unsteady gait. Osteomalacia is loss of bone related to vitamin D deficiency, which can lead to bone softening and inadequate deposits of calcium and phosphorus in the bone matrix; this may cause hypophosphatemia. Looser's lines or zones (radiolucent bands) represent stress fractures and are a classic diagnostic finding of osteomalacia. Muscle weakness in the lower extremities may cause waddling and an unsteady gait.Hyperparathyroidism and hyperuricemia may be observed in Paget's disease.

The nurse is assessing a client with recent changes in hearing. After taking a medication history, which drugs does the nurse identify as possible causes of the client's hearing change? (Selct all that apply). A) Acetaminophen (Tylenol) B) Beta blockers. C) Erythromycin. D) Ibuprofen (Advil). E) Insulin. F) Furosemide (Lasix)

Answer: C, D, F. The nurse identifies erythromycin, ibuprofen, and furosemide (Lasix) as medications known to increase the risk for hearing change related to ototoxicity and hearing problems.Acetaminophen, beta blockers, and insulin are not known ototoxic drugs.

The nurse providing education on eye protection suggests the special need for protective eyewear for which clients? (Select all that apply). A) Cab driver. B) College student. C) Lifeguard. D) Racquetball player. E) Registered nurse.

Answer: C, D. Lifeguards are in need of eye protection from ultraviolet (UV) A and UVB rays because of exposure to the sun. People who play racquetball need to wear protective eyewear to prevent possible eye injury.Cab drivers may require eyewear for corrective purposes but are not at high risk and in need of protective eyewear. College students are generally not at high risk. Although an RN would need eye protection at certain times, RNs do not routinely require protective eyewear for general work.

A client has recently had cataract surgery. The nurse will instruct the client to notify the health care provider immediately if which symptom occurs? A) Increased tearing. B) Itching of the eye. C) Reduction in vision. D) Swollen eyelid.

Answer: C. A reduction in vision after cataract surgery indicates a problem, and the client would notify the provider immediately.Increased tearing, itching of the eye, and a swollen eyelid all are expected after cataract surgery.

A nurse is caring for a client who has multiple sclerosis. Which of the following findings hsould the nurse expect? A) Hypoactive deep-tendon reflexes. B) Increased lacrimation. C) Intention tremors. D) Ascending parlysis.

Answer: C. A) Clients who have multiple sclerosis have hyperactive deep-tendon reflexes. B) Increased lacrimation, or tearing of the eyes, is an expected finding of myasthenia gravis during a cholinergic crisis. C) Clients who have multiple sclerosis are at risk for motor dysfunction, with intention tremors, poor coordination, and loss of balance. D) Clients who have Guillain-Barré syndrome are at risk for ascending paralysis.

A nurse is planning care for a client who has a closed head injury from a fall and is receiving mechanical ventilation. Which of the following interventions is the nurse's priority? A) Provide small doses of fentanyl via IV bolus for pain management. B) Reposition the client every 2 hr. C) Maintain a PaCO2 of approximately 35 mm Hg. D) Measure body temperature every 1 to 2 hr.

Answer: C. A) The nurse should administer opiate pain medications to reduce agitation and restlessness during mechanical ventilation and to manage pain. Fentanyl does not affect vital signs as much as morphine does, so it is a safer choice for this client. However, this is not the nurse's priority. B) The nurse should reposition the client at least every 2 hr to help prevent skin breakdown. However, this is not the nurse's priority. C) The greatest risk to this client is injury from increased intracranial pressure. Therefore, the nurse's priority action is to maintain the PaCO2 at 35 to 38 mm Hg to prevent hypercarbia and subsequent vasodilation that can lead to an increase in intracranial pressure. D) The nurse should monitor the client's body temperature because clients who have head injuries commonly develop a fever due to the body's response to the trauma or hypothalamic damage. However, this is not the nurse's priority.

A nurse is teaching a client who has Parkinson's disease about taking carbidopa-levodopa. Which of the following statements should the nurse identify as an indication that the client understands the teaching? A) "I should expect it to take up to a week for this medication to work." B) "I should take my medication with a high-protein food." C) "I should expect my urine to be a darker color." D) "I should expect a slight increase in my blood pressure while taking this medication."

Answer: C. A) The nurse should inform the client that it can take several months for this medication to take effect. B) High-protein foods can reduce the absorption of carbidopa-levodopa and the transportation of the medication to the brain C) Saliva, urine, and sweat can darken in color during carbidopa-levodopa therapy. This is a harmless adverse effect. D) Orthostatic hypotension is an adverse effect of carbidopa-levodopa.

A client reports "something scratching on the inside of my eyelid." Before examining the eyelid, what does the nurse do first? A) Administer a Snellen test. B) Obtain an informed consent. C) Wash the hands. D) Put on sterile gloves.

Answer: C. Always wash hands before touching the external eye structures to prevent infection.A Snellen test may be done but is not the first thing that should be done by the nurse. An informed consent or sterile gloves are not needed for the nurse to examine the client's eye.

Which type of drug therapy does the nurse anticipate giving to a client with Ménière's disease to decrease endolymph volume? A) Antihistamines. B) Antipyretics. C) Diuretics. D) Nicotinic acid.

Answer: C. Mild diuretics are prescribed to decrease endolymph volume. Ménière's disease causes an excess of endolymphatic fluid that distorts the entire inner-canal system. This distortion decreases hearing by dilating the cochlear duct, causes vertigo because of damage to the vestibular system, and stimulates tinnitus.Antihistamines help reduce the severity of or stop an acute attack, and antipyretics control fever and pain, but they do not decrease endolymph volume. Nicotinic acid has been found to be useful because of its vasodilatory effect, but it does not decrease endolymph volume.

The nurse is teaching a client with impaired hearing about audiometric testing. Which statement by the nurse effectively communicates information about the procedure to the client? A) "Here is a picture of how the test is done. See how your bad ear will be tested first? A)You will be alone in the soundproof booth, so you will need to watch for lights flashing on and off as your cues." B) "Here is a video of the procedure. Please watch and feel free to ask me any questions." C) "I will sit right in front of you in the soundproof booth and give you instructions on what types of sounds you will hear and how you'll need to respond." D) "You will be in a soundproof booth and the sounds will be piped in. When you first hear the loudest sound, put your hand down. When you stop hearing the sound, put your hand up to stop."

Answer: C. An effective statement by the nurse regarding audiometric testing involves informing the client that the nurse will be sitting in front of the hearing-impaired client while providing instructions. This allows the client to read lips.Pictures help the client with impaired hearing, but the good ear is tested first. The client wears earphones and listens for sounds, not flashing lights. Showing a hearing-impaired client a video is ineffective because of tone and frequency differences in the video, which make it difficult to read lips and understand the instructions. During the test, earphones are placed on the client. The client will raise her or his hand up when hearing the first sound and will lower the hand when the sound first disappears.

The nurse is providing postmortem care to a client who will donate a cornea. Which action is appropriate for the nurse to implement? A) Apply a warm pack to the eyes. B) Elevate the lower extremities. C) Instill antibiotic drops into the eyes. D) Contact the recipient family.

Answer: C. Antibiotic eye drops, such as Neosporin (polymyxin B, neomycin, bacitracin) or tobramycin, is appropriate to instill into the corneal donor's eyes to prevent infection.Small cold packs, not warm packs, should be applied to the donor's closed eyes. Raising the head of the bed 30 degrees prevents blood from pooling in the eye region of the deceased client. Raising the lower extremities is not appropriate. The nurse is not the person to contact the recipient family. The donor organization will complete all the communication to the parties involved.

A client experiencing kyphosis appears withdrawn and does not initiate any conversation with the nurse when medications are given each day. Which statement by the nurse is most supportive of this client? A) "It is normal to feel depressed at times about your condition. You have my support." B) "You could exercise more often to build up your strength and endurance." C) "How do you feel about the pain in your spine? I am here if you want to talk." D) "What does your family say to you? Try talking to them."

Answer: C. Asking the client about his or her pain and offering to listen is most supportive because it allows the client to discuss his or her feelings and informs the client that the nurse is available to listen.Telling the client that it is normal to feel depressed is a leading statement and is not supportive. The client may not be depressed. Suggesting that the client exercise more often is not a supportive statement and avoids the opportunity to support the client and diverts the subject to exercise. Asking what the client's family has to say is not supportive because it is the nurse's way of avoiding the issue.

While reading a client's optical chart, the nurse notices that the client has emmetropia. Which corrective equipment does the nurse expect to see this client wearing? A) Bilateral eye patches. B) Contact lenses. C) Nothing; this is normal. D) Reading glasses.

Answer: C. Emmetropia is perfect refraction (bending of light rays from the outside world into the eye) of the eye. Emmetropia is a normal (and ideal) condition that does not require any treatment.Bilateral eye patches inhibit the client's vision. Contact lenses are used to correct under refraction of the eye. Reading glasses are used to correct over refraction of the eye.

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

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

Which client information is most essential for the nurse to report to the health care provider before a client with knee pain undergoes magnetic resonance imaging (MRI)? A) Daily use of aspirin B) Swollen and tender knee C) Presence of a permanent pacemaker D) History of claustrophobia

Answer: C. If the client has a permanent pacemaker, this information is most important for the nurse to report to the health care provider. The presence of a permanent pacemaker is a contraindication for MRI because metallic implants are present within the client.Taking a daily dose of aspirin does not affect or interact with the MRI test. A swollen and tender knee does not warrant cancellation of an MRI. A history of claustrophobia should be reported but does not indicate that cancellation of the MRI is necessary because sedatives can be given to manage claustrophobia.

A client undergoes a surgical amputation of a lower extremity after a motor vehicle crash. The client's vital signs are stable. What is a priority nursing action in the early postoperative period to help prevent complications in this client? A) Fitting the client with a prosthetic device B) Inspecting the limb stump daily for signs of skin breakdown C) Positioning and range-of-motion of the affected extremity D) Teaching the client and family how to apply shrinker stockings

Answer: C. In the early postoperative period the nurse would properly position the client and provide range-of-motion exercises to help prevent flexion contractures so that the client can ambulate with a prosthetic device later.Clients are not fitted with prosthetic devices until the limb stump is prepared; this is not done in the early postoperative period. Clients are taught to inspect for skin breakdown when the stump has healed. Clients are also taught to apply shrinker stockings as part of home care, not during the early postoperative period.

Which finding does the nurse expect to observe in a client with suspected common chronic osteomyelitis? A) Erythema of the affected area B) Fever; temperature usually above 101° F (38° C) C) Ulceration of the skin D) Constant, localized, and pulsating bone pain

Answer: C. The nurse expects to observe ulceration of the skin, which is a feature of chronic osteomyelitis.Erythema of the affected area; fever; and constant, localized, pulsating bone pain are features of acute osteomyelitis.

The nurse is caring for a client with prostate cancer who has bone metastasis. The nurse anticipates that the health care provider will prescribe which medication? A) Calcitonin (Calcimar) B) Medroxyprogesterone (Prempro) C) Pamidronate (Aredia) D) Tamsulosin hydrochloride (Flomax)

Answer: C. Pamidronate (Aredia) is a bisphosphonate that is available intravenously and is approved for bone metastasis from the breast, lung, and prostate. Pamidronate protects bones and prevents fractures.Calcitonin (Calcimar) is used for the treatment of postmenopausal osteoporosis, Paget's disease, and hypercalcemia associated with cancer. Medroxyprogesterone (Prempro) is indicated for treating menopausal symptoms and preventing osteoporosis. Tamsulosin hydrochloride (Flomax) is an alpha-adrenergic blocking agent used for the treatment of benign prostatic hyperplasia.

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

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

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

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

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

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

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

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

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

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

The nurse is caring for a client who is admitted with mastoiditis. Which assessment data obtained by the nurse requires the most immediate action? A) The eardrum is red, thick-appearing, and immobile. B) The lymph nodes are swollen and painful to touch. C) The client reports a headache and a stiff neck. D) The client's oral temperature is 100.1° F (37.8° C).

Answer: C. The most immediate action is required when the client reports a headache and a stiff neck. These complaints may indicate meningitis, which is a serious illness requiring further assessment and immediate intervention.The eardrum being red, thick-appearing, and immobile is an expected finding for a client with an ear infection. Lymph nodes that are swollen and painful to touch are an expected finding for a client with an active infection of the mastoid area. An oral temperature of 100.1° F (37.8° C) is also an expected finding for a client with an active infection.

The nurse is using a common scale to grade a client's muscle strength. The client is able to complete range of motion (ROM) only with gravity eliminated. Which grade does the nurse document in this client's record? A) 0. B) 1. C) 2. D) 3.

Answer: C. The nurse documents a grade of two (2) for this client because it indicates poor muscle strength. The client can complete ROM only with gravity eliminated.Grade zero (0) indicates no evidence of muscle contractility. Grade one (1) indicates trace muscle strength and shows that the client has no joint motion and slight evidence of muscle contractility. Grade three (3) indicates fair muscle strength, where the client can complete ROM against gravity.

The nurse is assessing a client with Ewing's sarcoma. Which finding does the nurse expect to observe? A) Bradycardia. B) High fever. C) Leukocytosis D) Migraine headaches.

Answer: C. The nurse expects to observe leukocytosis. Ewing's sarcoma is a malignant tumor, and the client may experience systemic manifestations, including leukocytosis, anemia, and low-grade fever. The progression of Ewing's sarcoma may reveal elevated serum lactic dehydrogenase (LDH) levels.Bradycardia and migraine headache are not symptoms of Ewing's sarcoma. A low-grade and not high fever is a systemic manifestation of Ewing's sarcoma.

A 25-year-old female client whose mother and grandmother have osteoporosis asks whether she needs to take steps to prevent this disease in herself. What will the nurse tell this client? A) "You do not have to worry about symptoms at your age." B) "You should begin to take steps to prevent disease at age 30." C) "Now is the time to begin building strong bones." D) "Your risk isn't present until age 50; we can talk about it then."

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

A client is returning home after cataract surgery with a patch over the affected eye. Which statement by the client's spouse indicates a need for further instruction on providing a safe home environment? A) "I will get some books on tape for entertainment." B) "I will be sure to pick up all clutter and loose carpets from the floor." C) "I will rearrange the furniture for better flow before my spouse gets home." D) "I will place a nonslip mat in the bathtub."

Answer: C. The statement by the spouse that the furniture will be rearranged indicates the need for further instruction. Changes in item location would not be made without input from the client with reduced vision.Books on tape are a good diversion for recuperating clients with reduced vision. Any objects that may present a tripping hazard would be removed at once. A nonslip mat may be used to prevent falls in the bathtub.

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

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

Which proper technique does the nurse use for eye drop instillation? A) Instilling the drops into the inner canthus B) Opening the eye by raising the upper eyelid C) Placing the eye drop in the lower lid pocket D) Touching the bottle tip to the eyeball

Answer: C. To instill eye drops, the lower eyelid is gently pulled down against the cheek to form a pocket, and the medication is instilled.Instilling drops into the inner canthus causes the medication to enter the punctum and be absorbed systemically. The upper eyelid is larger than the lower eyelid and is used to protect the eye and keep the cornea moist; it should not be used to create a pocket to instill medication. Touching the bottle tip to any part of the eye could potentially contaminate the eye.

A nurse is performing a pain assessment for a client who is postoperative. Which of the following findings should the nurse use to determine the severity of the client's pain? A) Client's vital sign changes. B) Client's nonverbal communication. C) Client's report of the type of pain. D) Client's report of pain on a pain scale.

Answer: D. A) A change in vital signs can identify that pain is present, but it does not identify the severity of the pain. B) Facial grimacing can identify that pain is present, but it does not identify the severity of the pain. C)A report of the type of pain identifies the character of the pain, such as sharp or dull, but it does not indicate the severity of the pain. D) The nurse should use a client's report of pain on a standardized pain scale to determine the severity of the client's pain.

A nurse is caring for a client who has a basilar skull fracture following a fall from a ladder. Which of the following assessment findings should the nurse report to the provider? A) Ecchymosis at base of skull B) Glasgow Coma Scale score of 15 C) Intracranial pressure reading of 15 mm Hg D) Clear drainage from nose

Answer: D. A) A client who has a basilar skull fracture is likely to have ecchymosis at the base of the skull from a contusion. B) A Glasgow Coma Scale score of 15 indicates intact neurologic functioning. C) An intracranial pressure reading of 15 mm Hg is at the upper limit of the expected reference range. D) Clear drainage from the nose indicates that cerebrospinal fluid is leaking from the skull fracture. This places the client at risk for meningeal infection because micro-organisms have access to the cranium through the nose and the tear in the dura. The nurse should report this finding to the provider.

When preparing to examine an ear with drainage, what does the nurse do first? A) Begins testing at 1000 Hz B) Reassures the client that the ear drainage is normal C) Tilts the client's head away slightly D) Dons clean gloves

Answer: D. The nurse needs to don clean gloves first to prevent infection, Contact Precautions need to be used when assessing drainage from a client's ear canal.Testing for hearing loss (1000 Hz) is not used when examining an ear for drainage. Ear drainage is not normal and must be investigated. Tilting the client's head is not the first action among the options given that the nurse needs to do.

A nurse is caring for a client who is recovering from a stroke and has right-sided homonymous hemianopsia. TO help the client adapt to the hemianopsia, the nurse should take which of the following actions. A) Provide the client with eating utensils that have large handles. B) Encourage the client to sit upright with his head tilted slightly forward during meals. C) Check the client's cheek on his affected side after he eats to be sure no food remains there. D) Remind the client to look consciously at both sides of his meal tray.

Answer: D. A) Homonymous hemianopsia does not impair the client's fine motor skills. However, as stroke can impair fine motor skills, eating utensils that have a wide grip surface can help compensate for a weak hand grasp. B) Homonymous hemianopsia does not cause dysphagia. However, as stroke can cause dysphagia, positioning the client upright and having him tilt his head forward to swallow can help prevent aspiration. C) Homonymous hemianopsia does not cause the client to pocket food. However, food can accumulate on the affected side of the mouth, so the nurse should place food on the unaffected side of the client's mouth when feeding him. D) Clients who have right-sided homonymous hemianopsia have lost the right visual field of both eyes and might only eat the food he is able to see on the left half of the meal tray. Therefore, the nurse should remind the client to look at both sides of his meal tray to help him compensate for the visual loss.

A nurse is developing a teaching plan for a client who has Meniere's disease. Which of the following instructions should the nurse include? A) "Take corticosteroids during acute attacks." B) "Apply warm packs to the affected ear during acute attacks." C) "Increase your intake of foods and fluids high in salt." D) "Move your head slowly to decrease vertigo."

Answer: D. A) Taking corticosteroids will not relieve the manifestations of Ménière's disease and can actually worsen them because these medications cause fluid retention. The client should take an antihistamine, such as meclizine, to minimize or stop the attack. B) Applying warm packs to the affected ear does not relieve the manifestations of Ménière's disease. Helpful interventions include drinking plenty of water, decreasing salt intake, and not smoking. C) Clients who have Ménière's disease should avoid consuming foods and fluids that have a high sodium content because they cause fluid retention, which exacerbates the manifestations of Ménière's disease. D) The client should use slow head movements to keep from worsening the vertigo.

A nurse is caring for a client who has a spastic bladder following a spinal cord injury. Which of the following actions should the nurse take to help stimulate micturition? A) Perform the Credé maneuver. B) Encourage the client to use the Valsalva maneuver. C) Administer a diuretic. D) Stroke the client's inner thigh.

Answer: D. A) The nurse should apply direct pressure over the client's bladder, also known as the Credé maneuver, to express urine from a flaccid bladder. It is not effective with a spastic bladder due to the spasticity of the external sphincter. B) The nurse should encourage the client to hold his breath and bear down, also known as the Valsalva maneuver, to express urine from a flaccid bladder. It is not effective with a spastic bladder due to the spasticity of the external sphincter. C) Antispasmodics such as oxybutynin, rather than diuretics, can be effective for treating mild spastic bladder problems. D) The nurse should stimulate micturition by stroking the client's inner thigh. Other techniques include pinching the skin above the groin and providing digital anal stimulation.

A nurse is caring for a client who has a full arm cast and reports a pain severity of 8 on a scale from 0 to 10 that pain medication does not relieve. Which of the following actions should the nurse take first? A) Document the findings. B) Reposition the affected extremity. C) Administer additional pain medicaiton. D) Check the circulation of the affected extremity.

Answer: D. A) The nurse should document the findings to maintain professional standards. However, there is another action the nurse should take first. B) The nurse might need to reposition the client's arm to promote venous return and comfort. However, there is another action the nurse should take first. C) The nurse might need to administer additional pain medication to control the client's pain. However, there is another action the nurse should take first. D) The greatest risk to the client is neuromuscular injury resulting from compartment syndrome. The first action the nurse should take is to check for circulation impairment in the affected extremity.

A nurse is caring for a client who has advancing amyotrophic lateral sclerosis. Which of the following interventions is the nurse's priority? A) Provide for frequent rest periods throughout the day. B) Medicate for pain on a regular schedule. C) Administer baclofen for spasticity. D) Monitor pulse oximetry findings.

Answer: D. A) The nurse should provide for frequent rest periods throughout the day because the client's fatigue will increase as the disease progresses. However, this is not the priority intervention. B) The nurse should administer pain medication on a regular schedule to keep the client's pain level under control. However, this is not the priority intervention. C) The nurse should give baclofen to manage spasticity that can interfere with self-care. However, this is not the priority intervention. D) The greatest risk to the client is respiratory compromise due to progressive paralysis of respiratory muscles. Therefore, the priority intervention is to monitor the client's oxygen saturation to identify respiratory compromise as soon as possible.

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

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

Which assessment finding warrants further investigation by the nurse in the ophthalmology clinic? A) Snellen eye examination result is 20/50 for a client who normally wears corrective lenses but does not have them at the time of the examination. B) When six cardinal positions of gaze of the left eye are assessed, the client exhibits nystagmus when looking to the left lower and upper fields. C) The pupil exhibits miosis when exposed to light from the ophthalmoscope during examination and mydriasis when the light is removed from the pupil. D) When assessing the cornea, the nurse notes cloudiness and the client reports pain when the ophthalmoscope light shines into the pupil.

Answer: D. Cloudiness in the cornea and pain from a light shined into the pupil is an abnormal finding that requires further assessment and possible intervention and/or referral.A Snellen eye examination result of 20/50 for the client who normally wears corrective lenses but does not have them at the time of the examination is normal given the client's baseline and considering that he or she wears corrective lenses. It can be a normal finding for the client to exhibit nystagmus when looking to the left lower and upper fields during assessment of the six cardinal positions of gaze of the left eye. It is normal for the pupil to exhibit miosis when exposed to light from the ophthalmoscope during examination and mydriasis when the light is removed from the pupil.

A client has had a sequestrectomy of the right fibula for osteomyelitis 1 day ago. Which assessment finding requires the nurse to immediately contact the surgeon? A) Swelling of the right lower extremity B) 1+ to 2+ bilateral palpable pedal pulses C) Pain of right lower extremity on movement D) Decreased sensation of right lower extremity

Answer: D. Decreased sensation of the right lower extremity indicates a neurovascular compromise that must be reported immediately to the surgeon. A sequestrectomy is performed to remove necrotic bone and allow revascularization of tissue. The excision of dead and infected bone often results in a sizable cavity, or bone defect.The client undergoing a sequestrectomy experiences increased swelling after the procedure, so the affected extremity should be elevated to increase venous return and thus control swelling. Palpable pulses of 1+ to 2+ bilaterally are a sign of adequate blood flow. Pain on movement of the right lower extremity is an expected finding.

An older adult client reports ear pain. To differentiate the cause, which clinical manifestation is more indicative of otitis media? A) Dry, flaky cerumen B) Pain on movement of the tragus C) Ringing in the ears D) Dizziness

Answer: D. Dizziness is more indicative of otitis media due to pressure as the middle ear pushes against the inner ear.Dry, flaky cerumen is normal with aging. Pain on movement of the tragus is indicative of external otitis. Ringing in the ears is more likely with Ménière's disease.

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

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

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

Answer: D. Further teaching is needed when the client states, "I use a cotton swab to remove earwax." Nothing smaller than the client's own fingertip should be inserted into the ear canal. Use of a cotton swab can scrape the skin of the canal, push cerumen up against the eardrum, and even puncture the eardrum.Using the fingertip and a towel and irrigating the ear canal with tap water are acceptable. Clients would be discouraged from using ear candles.

Clients with a family history of which eye disorder may have problems with increased intraocular pressure (IOP), requiring additional assessment? A) Anisocoria. B) Presbyopia. C) Diabetic retinopathy. D) Glaucoma.

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

The nurse is conducting a musculoskeletal history in an older adult client who requires a caregiver to perform all activities of daily living (ADLs). Which level of functioning does the nurse record in the client's history using Gordon's Functional Health Patterns? A) Level 0. B) Level II. C) Level III. D) Level IV.

Answer: D. Gordon's Functional Health Pattern Level IV indicates that the client is dependent and does not participate in ADLs such as dressing him or herself.Level 0 indicates a client who is able to perform full self-care. Level II indicates a client who requires assistance or supervision of another person without assistive equipment or devices. Level III indicates that the client requires the assistance or supervision of another person, as well as assistive equipment or devices.

A client with glaucoma is being assessed for new symptoms. Which symptom indicates a high priority need for reassessment of intraocular pressure? A) Burning in the eye B) Inability to differentiate colors C) Increased sensitivity to light D) Gradual vision changes

Answer: D. Gradual vision changes are an indication of increased intraocular pressure and indicate a high priority for reassessment.A burning sensation in the eye usually indicates inflammation and/or infection. An inability to differentiate colors is an early sign of cataracts. An increased sensitivity to light might be a sign of a corneal abrasion.

A nursing student is studying the skeletal system. Which statement best indicates to the nursing instructor that the student understands a normal physiologic function of the skeletal system? A) "Volkmann's canals connect osteoblasts and osteoclasts." B) "In the deepest layer of the periosteum is the cortex, which consists of dense, compact bone tissue." C) "The matrix of the bone is where deposits of calcium and magnesium are present." D) "Hematopoiesis occurs in the red marrow, which is where blood cells are produced."

Answer: D. Hematopoiesis is the production of blood cells in the red marrow and is the statement that best indicates that the student understands a normal physiologic function of the skeletal system.Volkmann's canals connect bone marrow vessels with the haversian system. In the deepest layer of the periosteum are osteogenic cells that differentiate into osteoblasts and osteoclasts. The cortex is the outer layer of the bone that consists of dense, compact bone tissue. Deposits of inorganic calcium salts (carbonate and phosphate) in the matrix of the bone are what provide the hardness of bone.

What is the proper technique for assessing an adult client's ear with an otoscope? A) Hold the otoscope right side up when inserting it into the ear canal. B) Maintain distance between the otoscope and the client's head. C) Place the otoscope in the nondominant hand. D) Pull the pinna up and back with the nondominant hand.

Answer: D. In the adult, pulling the pinna up and back with the nondominant hand allows the ear canal to straighten. The otoscope should be held upside down, like a large pen.The otoscope would not be held right side up. Holding the otoscope upside down permits the hand to lie against the client's head for support. The otoscope would not be held in the nondominant hand.

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

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

The nurse is reviewing the medication history for a client scheduled for a left total hip replacement. The nurse plans to contact the health care provider if the client is taking which medication? A) Acetaminophen (Tylenol) for pain relief B) Bupropion (Wellbutrin) for smoking cessation C) Magnesium hydroxide (Milk of Magnesia) to treat heartburn D) Prednisone (Deltasone) to treat asthma

Answer: D. Long-term use of steroids such as prednisone is strongly associated with osteoporosis and will increase the risk for prolonged recovery after the hip replacement.Taking acetaminophen for pain relief, bupropion for smoking cessation, or magnesium hydroxide to treat heartburn will not influence the potential success of the surgery.

An older adult client has multiple tibia and fibula fractures of the left extremity after a motor vehicle crash. Which pain medication does the nurse anticipate will be requested for this client? A) Cyclobenzaprine (Flexeril) B) Ibuprofen (Advil) C) Meperidine (Demerol) D) Patient-controlled analgesia (PCA) with morphine

Answer: D. Morphine is an opioid narcotic analgesic and is given through PCA. It is the most appropriate mode of pain management for this type of acute pain associated with multiple injuries.Muscle relaxants such as cyclobenzaprine are effective for treating pain related to muscle spasms, but they are not adequate for this type of acute pain. Ibuprofen is a nonsteroidal anti-inflammatory drug that is used to treat mild to moderate pain. This bone pain is very acute, so ibuprofen would not be sufficient. Meperidine should never be used for older adults because it has toxic metabolites that can cause seizures.

The nurse performs a neurovascular assessment on a client with closed multiple fractures of the right humerus who is experiencing increased pain even with maximum ordered doses of morphine. The nurse notes distal capillary refill of 3 seconds and coolness of the hand and fingers. The client reports numbness of the hand and is unable to wiggle the thumb. Which nursing action is indicated? A) Elevate the extremity. B) Apply an ice pack to the extremity. C) Reposition the extremity and recheck in 15-20 minutes. D) Notify the provider of these findings.

Answer: D. Pain unrelieved by narcotic analgesics and numbness of the affected extremity are signs of neurovascular compromise and should be reported immediately to the provider.Elevating the extremity and applying ice may further compromise blood flow and should be avoided. Compartment syndrome may develop quickly, so the provider should be notified immediately and not in 15 to 20 minutes.

The nurse is teaching a client who will soon be fitted for a hearing aid about proper care and use. Which statement by the client indicates that teaching was effective? A) "Background noises will be difficult for me to hear." B) "I should wear my hearing aid only to work at first." C) "I should just get a smaller hearing aid because I don't have much money." D) "Listening to the radio and television will help me get used to new sounds."

Answer: D. Teaching was effective if the client states that listening to television and the radio and reading aloud will help the client to get used to new sounds.With hearing aids, background noises are amplified, so the client must learn to concentrate and filter out background noises. The client would start using the hearing aid slowly, at first wearing it only at home and only during part of the day. The cost of smaller hearing aids is actually greater than for larger ones.

A client says, "I have problems reading signs when I am driving." Which test does the nurse use to best assess this client's problem? A) Confrontation test. B) Ishihara chart. C) Rosenbaum Pocket Vision Screener or a Jaeger card D) Snellen chart.

Answer: D. The Snellen chart test best assesses the client's distance vision, which is the type of vision used while driving.The confrontation test assesses the client's visual field. The Ishihara chart assesses the client's color vision. The Rosenbaum Pocket Vision Screener or Jaeger card assesses the client's near vision.

A client recently diagnosed with Ménière's disease is struggling with tinnitus. How does the nurse provide support to this client? A) Provide further assessment. B) Suggest a quiet environment. C) Suggest temporary removal of a hearing aid. D) Refer the client to the American Tinnitus Association.

Answer: D. The best action by the nurse is to refer the client to the American Tinnitus Association. This group assists clients in coping with tinnitus when other therapy is unsuccessful.Reassessment of the client's diagnosis is not needed; this will only waste the client's and the nurse's time. A quiet environment and removal of the hearing aid will not be helpful. Background noise masks the tinnitus while quiet conditions exacerbate it. Ear-mold hearing aids can amplify sounds to drown out tinnitus during the day.

A client who is using eye drops in both eyes develops a viral infection in one eye and asks the nurse what to do. What is the nurse's best response? A) "As long as you don't touch the eyes with the dropper, it will be OK." B) "Just wash your hands between eyes and put drops in the uninfected eye first." C) "The other eye will probably get infected anyway." D) "You will need to use a separate bottle of drops for each eye."

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

The ambulatory surgery post anesthesia care unit (PACU) nurse has just received report about clients who had arthroscopic surgery. Which client will the nurse plan to assess first? A) Young adult client who has been in the PACU for 30 minutes after left knee arthroscopy under local anesthesia B) Adult client who had a synovial biopsy of the right knee under local anesthesia and has been in the PACU for 20 minutes C) Adult client who has multiple right knee incisions for repair of torn cartilage and arrived in the PACU an hour ago D) Middle-aged adult client who returned to the PACU 25 minutes ago after left knee arthroscopic surgery under epidural anesthesia

Answer: D. The client who had knee arthroscopic surgery under epidural anesthesia is at greatest risk for complications and should be assessed first. After epidural anesthesia, frequent assessments for the return of sensation and movement of the leg will be important.The clients who had local anesthesia for knee arthroscopy, the client who had a synovial biopsy of the right knee, and the client who had multiple right knee incisions are all at less risk for developing complications.

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

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

The nurse is teaching a client with vertigo about safety precautions for fall prevention. Which statement by the client indicates a need for further instruction? A) "I may need to use a cane." B) "I should keep my grandkids' toys out of the hallway." C) "Moving more slowly may help the vertigo subside." D) "Taking my medication will allow me to drive my car again."

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

A client with a fracture asks the nurse about the difference between an open fracture and a simple fracture. Which statement by the nurse is correct? A) "Simple fracture involves a break in the bone, with skin contusions." B) "An open fracture does not extend through the skin." C) "Simple fracture has an increased risk for infection and emboli." D) "An open fracture involves a break in the bone, with damage to the skin."

Answer: D. The correct statement made by the nurse states that an open fracture involves a break in the bone with damage to the skin.A simple fracture does not extend through the skin. An open fracture, not a simple fracture, has an increased risk for infection.

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

Answer: D. The nurse keeps the client flat, with the head turned to the side and the operative ear facing up, for at least 12 hours after surgery.Laying the client on the affected side is the opposite side of where the client should be placed. Laying the client in a supine position is incorrect. Raising the head places undue pressure on the surgical site.

A client has purulent drainage in the inner canthus of the eye. Before examining the eye, what must the nurse do first? A) Administer a Snellen test. B) Obtain an informed consent. C) Instill antibiotic drops. D) Put on gloves.

Answer: D. The nurse must first put on gloves. Gloves must be worn in the presence of drainage and would be put on before examining the eye. Administering a Snellen test or instilling antibiotic eye drops is not the first thing that the nurse should do before examining the client's eye. Obtaining informed consent is not necessary for an eye examination.Administering a Snellen test or instilling antibiotic eye drops is not the first thing that the nurse would do before examining the client's eye. Obtaining informed consent is not necessary for an eye examination.

A client is scheduled to undergo closed magnetic resonance imaging (MRI) without contrast medium. Which information does the nurse give to the client before the test? A) "It will be important to lie still in a reclined position for 20 minutes." B) "Do not eat or drink for 8 hours before the test." C) "You can have the MRI if you have an internal pacemaker." D) "All jewelry and clothing with zippers or metal fasteners must be removed."

Answer: D. The nurse tells the client that all clothing with zippers or metal fasteners and all jewelry must be removed before undergoing MRI.The client having a closed MRI will lie still in a supine position for 45 to 60 minutes, not 20 minutes, and may require sedation. It is not necessary for the client to be NPO before an MRI. The client cannot undergo MRI when an internal pacemaker or any other metal object is present in the body.

The nurse plans to refer a client diagnosed with osteoporosis to which community resource? A) American Bone Society. B) CanSurmount. C) I Can Cope. D) National Osteoporosis Foundation.

Answer: D. The nurse will refer this client with osteoporosis to an appropriate community resource, such as the National Osteoporosis Foundation, for help and support.There is no organization known as the American Bone Society. CanSurmount is a cancer support group geared toward client and family education. I Can Cope is also a support group for clients with cancer.

The charge nurse in the hospital-based day surgery center is making client assignments for the staff. Which client is most appropriate to assign to a nurse who has floated from the general surgical unit? A) Young adult who has just been admitted for surgery after sustaining an ankle fracture B) Adult who needs teaching about quadriceps-setting exercises after knee arthroscopy C) Middle-aged adult who will require a pneumatic tourniquet applied before knee surgery D) Older adult who has undergone arthroscopic surgery of the shoulder under local anesthesia

Answer: D. The postoperative older client who had arthroscopic surgery is most appropriate for the surgical floor nurse to care for. Arthroscopic surgery and local anesthesia have low complication rates. The float nurse would be expected to know how to assess neurovascular status.The young, newly admitted client requires assessment that will be best performed by nurses with more experience in day surgery. Client teaching for the adult client who has had arthroscopic knee surgery is best completed by nurses with more experience in day surgery. The middle-aged adult who needs a pneumatic tourniquet requires an intervention that is best performed by nurses with more experience in day surgery.

Which nursing action does the nurse on the orthopedic unit plan to delegate to unlicensed assistive personnel (UAP)? A) Removing the wound drain for a client who had an open reduction of a hip fracture 3 days ago. B) Assessing for bruising on a client who is receiving warfarin (Coumadin) to prevent deep vein thrombosis. C) Teaching a client with a right ankle fracture how to use crutches when transferring and ambulating. D) Checking the vital signs for a client who was admitted after a total knee replacement 3 hours ago.

Answer: D. Vital sign review is a skill that is within the role of the UAP.Removing a wound drain, assessment, and client teaching are nursing actions that require broader education and are within the scope of practice of licensed nursing staff.

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

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

A client is having a stapedectomy. Which form of postoperative communication is most effective for the nurse to use? A) Gesturing. B) Sign language. C) Speaking. D) Writing.

Answer: D. Writing is the most effective way to communicate with the client who has undergone a stapedectomy.Gesturing can be vague and imprecise. Sign language requires training. It is hoped that the client will not be hearing-impaired long enough for this to be a viable option. The client will not be able to hear for the first 6 weeks after surgery.

A 50-year-old woman has osteoporosis and is at risk for developing vertebral fractures. She asks the nurse about exercises to help minimize this risk. Which exercise will the nurse recommend? A) Cycling. B) Running. C) Walking. D) Yoga.

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

_____: The clear, watery fluid that is continually produced by the ciliary processes and fills the anterior and posterior chambers of the eye. This fluid drains through the canal of Schlemm into the blood to maintain balanced intraocular pressure (pressure within the eye).

Aqueous humor

_____: Pain in a joint.

Arthralgia

_____: An x-ray study of a joint after contrast medium (air or solution) has been injected to enhance its visualization.

Arthrogram

_____: Procedure in which a fiberoptic tube is inserted into a joint for direct visualization of the ligaments, menisci, and articular surfaces of the joint.

Arthroscopy

A 30-year-old patient has cerumen in the left ear. When irrigating the ear, the nurse uses which amount of fluid? a. 10-30 mL b. 50-70 mL c. 60-100 mL d. 150-200 mL

B

A 30-year-old patient who is hospitalized for repair of a fractured tibia and fibula reports shortness of breath. Which complication related to the injury might the patient be experiencing? a. Acute renal failure b. Fat embolism c. Acute compartment syndrome d. Pneumonia

B

A neighbor calls the nurse for advice because he thinks he may have got some metal shavings in his eye while working on a home improvement project. What advice should the nurse give? a. Rinse the eye with water and then don protective eyewear. b. Immediately notify his health care provider or ophthalmologist. c. Mention the incident during the annual eye examination. d. Resting the eye is sufficient unless there is pain or loss of vision.

B

A patient arrives in the emergency department reporting pain and immobility of the right shoulder. The patient reports a history of recurrent dislocations of the same shoulder. Which additional sign/symptom would the nurse assess for a dislocation injury? A. Bone fragments protruding from skin b. Deviation in length of the extremity c. Muscle atrophy with weakness d. Mottled skin discoloration

B

A patient comes into the emergency depart- ment after falling off his four-wheeler. Assess- ment of his lower leg reveals bleeding and bone fragments protruding from the skin. What type of fracture does this patient most likely have? a. Impacted b. Open c. Pathologic d. Displaced

B

A patient comes to the emergency department after accidentally puncturing his hand with an automatic nail gun. Which disorder is this patient primarily at risk for? A. Osteoporosis b. Osteomyelitis c. Osteomalcia d. Dupuytren's contracture

B

A patient has had cataract surgery and is ready to go home. During the discharge education, what does the nurse tell the patient about activities? a. Driving in the daylight is okay, but do not drive at night. b. Meal preparation and doing dishes are acceptable activities. c. Vacuuming and mopping are okay, but do not bend over to scrub. d. Exercises, such as jogging or swimming, can be done at a slow pace.

B

A patient is at risk for a parathyroid hormone imbalance related to a recent surgical proce- dure. Based on this information, which blood level must the nurse monitor? a. Blood glucose b. Serum calcium c. Serum potassium d. Serum magnesium

B

A patient is being seen in the clinic for dull pain and swelling of the proximal femur over 2-3 months. Which type of malignant bone tumor is associated with these symptoms? a. Ewing's sarcoma b. Chondrosarcoma c. Fibrosarcoma d. Osteosarcoma

B

A patient is informed by the health care pro- vider that a fiberglass cast must be applied to the lower extremity. What does the nurse teach the patient about the procedure before the cast is applied? a. "The stockinette should be changed once a week." b. "The cast material will dry and become rigid in a few minutes." c. "The cast will increase your risk for skin breakdown." d. "The fiberglass is not waterproof, so avoiding getting it wet."

B

A patient is receiving scheduled and prn opioids for severe pain related to a musculo- skeletal injury. The nurse finds that the patient's abdomen is distended and bowel sounds are hypoactive. Because the nurse suspects that the patient is having a medication side effect, which question does the nurse ask the patient?" a. "Are you having nausea and vomiting?" b. "When was your last bowel movement?" c. "Does your abdomen hurt?" d. "Are you having diarrhea or loose stool?"

B

A patient who is a long-distance runner reports severe pain in the arch of the foot, especially when getting out of bed and with weight bearing. What does the nurse suspect in this patient? a. Hypertrophic ungual labium b. Plantar fasciitis c. Hammertoe d. Hallux valgus deformity

B

After a scleral buckling procedure, which aspect of postoperative care is affected if gas or oil has been placed in the eye? a. Type of eye patch b. Position of the head c. Eye drop schedule d. Effects of anesthesia

B

Although the older patient denies any problems with his vision, the nurse frequently observes that he closes one eye when trying to look at his meal tray or personal items on the bedside table. What does the nurse suspect? a. Patient has arcus senilis. b. Patient has double vision. c. Patient has dry eye syndrome. d. Patient has a small cataract.

B

An older adult patient has a fractured humerus. The health care provider is consider- ing the use of electrical bone stimulation and asks the nurse to obtain a medical history on the patient. Which question does the nurse ask to identify if the patient has a contraindication for this therapy? a. "Are you taking any medication for seizures?" b. "Do you have a cardiac pacemaker?" c. "Have you ever been treated for a stroke?" d. "Do you have a surgically implanted metallic device?"

B

During physical assessment, the nurse notes that the patient has kyphosis. Which question is the nurse most likely to ask? a. "Have you had any pain in your lower extremities?" b. "Have you ever had any diagnostic testing for osteoporosis?" c. "Lately, have you had a fever or any signs of infection?" d. "Are you having any discomfort associated with your shoes?"

B

In assessing a patient's functional ability and range of motion (ROM), the patient is unable to actively move a joint through the expected ROM. Which technique does the nurse use to assess joint mobility? A. Patient relaxes the muscles while the nurse moves the joint through ROM. B. Nurse holds one hand above and one hand below the joint and allows passive ROM. C. Patient moves the joint through ROM while the nurse applies gentle resistance. D. Patient moves the joint to the best of ability while the nurse palpates for crepitus.

B

In assessing the corneal light reflex of the older patient's eye, the nurse notes an asym- metric reflex. What is the clinical significance of this assessment finding? a. This is a normal finding for an older adult. b. Eye is deviating because of possible muscle weakness. c. The reflex is asymmetrical because of a cataract. d. Eye strain and eye fatigue can alter the reflex.

B

In caring for a patient who was recently diagnosed with dry age-related macular degeneration, which teaching point would the nurse emphasize? a. Importance of adhering to the exact schedule for eye drops b. Dietary modifications to slow progression of vision loss c. Avoiding activities that cause rapid or jerking head movements d. Good handwashing and keeping the tip of the eyedropper clean

B

In older adults, what is the most common cause of contiguous osteomyelitis? a. Malignant external otitis media b. Slow-healing foot ulcers c. Periodontal infections d. Gastrointestinal salmonella infections

B

In the emergency care of a patient with a fracture, which action does the nurse implement first? a. Check the neurovascular status of the area distal to the injury: temperature, color, sensation, movement, and distal pulses. Compare affected and unaffected limbs. b. Remove or cut the patient's clothing to inspect the affected area while supporting the injured area above and below the injury. c. Elevate the affected area on pillows, apply an ice pack that is wrapped to protect the skin, and obtain an order for pain medication. d. Immobilize the extremity by splinting; in- clude joints above and below the fracture site. Recheck circulation after splinting.

B

Lymph node tenderness is most likely to be a symptom of which disorder? a. Ménière's disease b. Mastoiditis c. Otosclerosis d. Cerumen impaction

B

The home health nurse is visiting the patient for the first time. The nurse notices that the patient frequently tilts his head and gives odd answers to simple questions. The nurse has a stethoscope, a digital watch, a pen, and a blood pressure cuff in her supply bag. Which method would the nurse use to test hearing during this visit? a. Hold the watch about 5 inches from each ear and ask the patient what he hears. b. Stand 2 feet away, have patient block one ear, whisper a sentence, and ask patient to repeat it. c. Apply the blood pressure cuff and ask if patient can hear the separation of the Velcro fastener. d. Have the patient don the stethoscope and listen to and count his own heartbeat.

B

The nurse is assessing a patient for severe pain in the right wrist after falling off a step stool. How does the nurse assess this patient's motor function? a. Performs passive range of motion for the wrist. b. Asks the patient to move the fingers. c. Has the patient flex and extend the elbow. d. Instructs the patient to rotate the wrist.

B

The nurse is assessing a patient who is unable to see the 20/400 characters on the Snellen chart. Which assessment will the nurse try first? a. Ask the patient to detect stationary, left- right, or up-down hand movements. b. Ask the patient to count the number of fingers held up in front of the eyes. c. Ask the patient to report "on" or "off " when detecting light in a darkened room. d. Ask the patient to self-select a distance from Snellen chart where 20/400 is visible.

B

The nurse is assessing a patient who was admitted to the unit after undergoing a stape- dectomy. The patient's face has an asymmetric appearance, and there is drooping of features on the affected side. What should the nurse do first? a. Tell the patient that this is a temporary condition related to anesthesia. b. Ask the patient about sensations of taste and touch on the affected side. c. Notify the surgeon because it is likely that there is cranial nerve damage. d. Call the Rapid Response Team because the patient may be having a stroke.

B

The nurse is assessing a patient's shoulder joint. What would be considered a normal finding? a. Patient can perform slight rotation and full flexion and extension. b. Patient can freely move the joint in any direction. c. Patient has motion in one plane of flexion and extension. d. Patient demonstrates rotation only without discomfort.

B

The nurse is assessing an older adult patient at risk for osteoporosis. Which task can be delegated to unlicensed assistive personnel? a. Inspect the vertebral column. b. Take height and weight measurements. c. Compare observations to previous findings. D. Ask if the patient has gained or lost weight

B

The nurse is caring for a patient who just had a bone biopsy. What is the priority nursing action? a. Administer pain medication b. Assess for bleeding c. Review test results d. Assess for infection

B

The nurse is caring for a patient with an above-the-knee amputation. To prevent hip flexion contractures, how does the nurse position the patient? a. Supine position with the residual limb elevated on a pillow b. Prone position every 3-4 hours for 20- to 30-minute periods c. Supine position with an abduction pillow placed between the legs d. Head of the bed elevated 30 degrees with bandage snug around the limb

B

The nurse is caring for several patients on an orthopedic unit. Which patient is most likely to need blood cultures? a. Patient is 2 days postop for limb salvage surgery. b. Patient is admitted for acute osteomyelitis of right leg. c. Patient has osteoporosis and sustained a left hip fracture. d. Patient has osteosarcoma that has metasta- sized to the lungs.

B

The nurse is helping to evaluate several patients to determine candidacy for the Ilizarov external fixation device. Which patient is the best candidate? a. Older woman who lives alone with a fracture of nonunion b. Child with a congenital bone deformity whose mother is a nurse c. Teenager with an open fracture and bone loss of the left lower leg d. Middle-aged man with a new comminuted fracture of the dominant forearm

B

The nurse is planning interventions for a patient with a family history of osteoporosis. What action does the nurse take? a. Ask the patient's age and assess for weight loss. b. Review the patient's dietary intake of calcium. c. Assess the patient for kyphoscoliosis or other deformities. d. Assess the patient for occult fractures of the long bones.

B

_____: To cut a cast lengthwise into two equal pieces.

Bivalve

The nurse is teaching a community group about osteoporosis. What information would the nurse give about routine laboratory testing? A. Serum calcium and phosphorus levels should be routinely monitored biannually for postmenopausal women who are at a high risk for the disease. B. Serum calcium and vitamin D3 levels should be routinely monitored annually for all women and for men older than 50 years who are at a high risk for the disease. C. Serum calcium and estrogen levels should be routinely monitored every 5 years for younger women and annually for women over the age of 50. D. Serum calcium and vitamin D3 levels should be routinely monitored every 2-3 years for all women and for men older than 50 years who are at a high risk for the disease.

B

The nurse is teaching a patient about self- medication with eye drops for glaucoma. Which intervention does the nurse suggest to prevent systemic absorption of the medication? a. Wait 15 minutes between instilling different eye drops. b. Place pressure on the corner of the eye near the nose. c. Place all eye medications in one eye and then the other. d. Blink rapidly after instilling drops and keep head upright.

B

The nurse is volunteering at a community health fair. A 56-year-old woman has just had a peripheral dual-energy x-ray absorptiometry (pDXA) and comments to the nurse, "I'm happy with these results. I guess I won't have to worry about my bones for the next few years." What is the nurse's best response? a. "Yep, you're good to go! Thanks for taking the time to stop and have the pDXA." b. "Your results are good, but the pDXA is not as precise as the tests that your doctor can order." c. "You should have the peripheral quantita- tive ultrasound densitometry (pQUS) to verify results." d. "We are offering the pDXA at next year's health fair. Be sure to stop by to have it repeated."

B

The nurse is working at an ophthalmology specialty center and has just received a handoff report. Which patient needs to be assessed and managed first? a. Patient needs postprocedural care after phacoemulsification. b. Patient was just diagnosed with primary angle-closure glaucoma. c. Patient requires therapy for exudative macular degeneration. d. Patient is resting quietly, with probable retinal detachment.

B

The nurse notices that an older patient has gait changes with decreased coordination and muscle strength. What is the priority goal for the shift? a. Encourage mobility. b. Prevent falls. c. Increase strength. d. Avoid worsening.

B

The nurse sees that the patient has been prescribed raloxifene. Which information, specific to the medication, should be brought to the attention of the prescribing health care provider? a. Patient has a family history of osteoporosis. b. Patient has had recurrent venous thromboembolism. c. Patient has had previous episodes of hypoglycemia. d. Patient has a history of iron deficiency anemia.

B

The nurse uses irrigating fluid that is 98.6°F (37°C) to irrigate a patient's ear to remove cerumen. What is the best rationale for using fluid at this temperature? a. Evidence-based practice guides the selection of temperature. b. It reduces the chance of stimulating the vestibular sense. c. It is less painful than hotter or colder temperatures. d. It potentiates the melting and mobilization of cerumen.

B

The nurse's neighbor comes running over because her husband "cut his finger off with a power saw." What is the priority nursing action? a. Examine the amputation site. b. Assess for airway or breathing problems. c. Elevate the hand above the heart. d. Assess the severed finger.

B

The patient has a low-grade fever. How is this fact sometimes misinterpreted by the health care team in trying to evaluate muscu- loskeletal disorders? A. Osteoporosis is misdiagnosed for osteomalacia. B. Ewing's sarcoma is thought to be osteomyelitis. C. Osteoporosis is thought to be osteopenia. D. Osteosarcoma is mistaken for secondary metastasis.

B

The patient has an intraocular pressure greater than 21 mm Hg. The patient's use of which over-the-counter product should be brought to the immediate attention of the ophthalmologist? a. Aspirin b. Antihistamine c. Vitamin supplement d. Artificial tear eye drops

B

The patient is a middle-aged man with a his- tory of uncontrolled diabetes. His right foot is a dark brownish-purple color, and there is no palpable dorsalis pedis or posterior tibial pulse. The nurse prepares the patient for which diagnostic test? a. X-ray of the foot and ankle b. Doppler ultrasound c. Electromyelogram d. Arthrogram

B

The patient is taking meclizine. Which ques- tion will the nurse ask to determine if the medication is having the desired therapeutic effect? a. "On a scale of 1 to10, which number represents your current level of pain?" b. "Do you feel the medication helped to relieve the dizziness and nausea?" c. "Do you feel the medication decreased the buzzing sound that you reported?" d. "Do you think that your hearing has im- proved after completing the medication?"

B

The patient tells the nurse that he had LASIK (laser in-situ keratomileusis) surgery several years ago. Which question is the nurse most likely to ask? a. "What was the intraocular pressure prior to having LASIK performed?" b. "Did you have LASIK for nearsightedness, farsightedness, or astigmatism?" c. "In addition to LASIK, are you getting sufficient antioxidants, vitamin B12, and carotenoids?" d. "After LASIK, did you see 'shooting stars' or thin 'lightning streaks' or 'floaters'?"

B

The patient tells the nurse that he has unpre- dictable episodes of vertigo. What instructions are the most important to give to the unlicensed assistive personnel who is assisting the patient with activities of daily living? a. "Face the patient directly whenever speaking to him." b. "There is a high risk for falls, so use a gait belt during ambulation." c. "Noise from the television or hallway should be minimized." d. "Patient's pain is likely to escalate, so report any discomfort."

B

What is an early sign of primary open-angle glaucoma? a. Sudden severe pain around the eyes b. Gradual loss of visual fields c. Seeing halos around lights d. Brow pain with nausea and vomiting

B

What is an example of a pivot joint? a. Knee joint b. Radioulnar area c. Shoulder joint d. Cranial area

B

What is the nursing care priority for a deceased patient who is a corneal donor? a. Instill saline solution into the eyes. b. Instill antibiotic drops into the eyes. c. Lay the deceased in a flat supine position. d. Apply loose patches moistened with saline.

B

Which action could prevent ear trauma? a. Holding the nose when sneezing to reduce pressure b. Not using small objects to clean the external ear canal c. Occluding one nostril when blowing the nose d. Not using soap or water around the external ear and canal

B

Which activity is most likely to be very difficult for the patient if the visual function of accommodation is not working correctly? a. Reading a newspaper b. Playing tennis c. Watching a sunset d. Walking in a dark hallway

B

Which clinical finding most strongly suggests that the patient is having a dysfunction of the musculoskeletal system? a. Oxygen saturation is low. B. Red cell count is low. C. Temperature is elevated. D. Blood pressure is elevated.

B

Which group has the greatest risk for trauma resulting in injuries to muscles and bones? a. Older adult men as a result of occupational injuries. B. Young men as a result of motor vehicle accidents. C. Young women as a result of sports injuries. D. Children who are not supervised during play.

B

Which lunch tray contains the most nutri- tional elements required for healthy bones? a. Processed lunch meat on whole-grain bread, apple juice, chips, and salsa b. Green leafy vegetable salad with cheese wedges and low-fat milk c. Fruit salad, iced tea, and a whole-grain muffin with butter and jam d. Pasta with red tomato sauce, garlic toast, seltzer water, and ice cream

B

Which member of the health care team is responsible for teaching the patient about proper use of the cane? a. Occupational therapist b. Physical therapist c. Orthopedic surgeon d. Home health aide

B

Which method is used to measure intraocular pressure? a. Corneal staining b. Tonometry c. Slit lamp examination d. Electroretinography

B

Which patient has sustained a fracture of a bone that would normally function to protect vital organs? a. Has tibia-fibula fracture that occurred during a skateboarding accident b. Has sternal fracture secondary to being thrown from a motorcycle c. Has spiral fracture of the wrist that happened during a climbing accident d. Has compound femur fracture related to falling from a roof

B

Which patient has the greatest risk for devel- oping chronic osteomyelitis? a. Stepped on a rusty nail 30 years ago b. Has recurrent diabetic foot ulcer c. Has osteopenia and is noncompliant with therapy d. Performs heavy manual labor

B

Which patient has the greatest risk for potential life-threatening complications? a. Patient with diabetes mellitus needs treatment for external otitis. b. Patient who is immunosuppressed develops necrotizing otitis. c. Patient who is homeless has limited opportunities for hygiene and has tinnitus. d. Patient who works as a lifeguard frequently has problems with "swimmer's ear."

B

Which patient has the most risk factors associated with osteoporosis? a. Male over 50 years of age, European heritage b. Female, white, menopausal, thin, lean, immobilized c. Older adult with vitamin B deficiency, insufficient exposure to sunlight d. Adult who usually exercises and has moderate alcohol intake

B

Which patient is most likely to be at risk for osteoporosis related to cultural differences and nutritional intake? a. Older African-American male who is a vegetarian b. Young Chinese American female who has anorexia nervosa c. Middle-aged Native American female who has type 2 diabetes d. Young white Irish American male who is overweight

B

Which sign/symptom is the most common early clinical manifestation of retinitis pigmentosa? a. Cataracts b. Night blindness c. Headache d. Vitamin A deficiency

B

Which technique would the nurse use to perform otoscopic assessment? a. The patient's head should be tilted slightly toward the nurse. b. The nurse holds the otoscope upside down, like a large pen. c. The pinna is pulled downwards and backwards. d. The internal ear is visualized while the speculum is slowly inserted.

B

_____: Procedure in which the physician extracts a specimen of bone tissue for microscopic examination to confirm the presence of infection or neoplasm; not commonly done today.

Bone biopsy

_____: Realignment of fractured bone ends for proper healing.

Bone reduction

_____: A process in which bone is constantly undergoing changes.

Bone remodeling

The nurse is caring for a patient who had an allograft for a large bone defect that resulted from tumor removal. Which findings need to be reported immediately to the health care provider? Select all that apply. a. Pain at the surgical site b. Signs of infection c. Hemorrhage d. Fracture e. Difficulty ambulating f. Loss of muscle tone

B,C,D

The nurse is caring for several orthopedic patients who are in different types of traction. What should the nurse do to assess the traction equipment? Select all that apply. a. Inspect all ropes, knots, and pulleys once every 24 hours. b. Inspect ropes and knots for fraying or loosening every 8 to 12 hours. c. Check the amount of weight being used against the prescribed weight. d. Observe the traction equipment for proper functioning. e. Check if the ropes have been changed or cleaned within the past 48 hours. f. Reduce or adjust the weights if the patient is having excessive pain.

B,C,D

The nurse is conducting an assessment on a patient with osteoporosis. Which factors and/or patient data may be associated with osteoporosis? Select all that apply. A. Muscle cramps b. Sedentary lifestyle c. Back pain relieved by rest d. Fracture e. Urinary or renal stones f. High cholesterol diet

B,C,D

Tinnitus may be caused by which factors? Select all that apply. a. Tophi of the pinna b. Otosclerosis c. Continuous exposure to loud noise d. Medications e. Ménière's disease f. Excessive cleaning of ears

B,C,D,E

Which precautions does the nurse instruct a patient to take after having ear surgery? Select all that apply. a. Avoid air travel for 5-7 days. b. Stay away from people with colds. c. Do not drink through a straw for 2-3 weeks. d. Keep your ear dry for 6 weeks. e. Avoid straining when having a bowel movement. f. Avoid rapidly moving head, bouncing, or bending over for 2-3 days.

B,C,D,E

Which substances affect bone growth and metabolism? Select all that apply. A. Chloride b. Calcium c. Vitamin C d. Phosphorus e. Vitamin D f. Sodium

B,C,D,E

Which patients with fractures have factors that put them at risk for developing venous thromboembolism? Select all that apply. a. Has type 2 diabetes mellitus b. Had hip surgery that took several hours c. Is obese and smokes 2 packs per day d. Takes oral contraceptives e. Takes steroid medication f. Was bedridden prior to sustaining fracture

B,C,D,F

A patient reports pain in the left lower ankle. Which questions does the nurse ask to elicit relevant information about this patient's musculoskeletal problem? Select all that apply. a. "Do you eat foods that supply iron and protein?" b. "What seems to make the pain worse?" c. "What measures help alleviate the symptoms?" d. "What did your family doctor tell you?" e. "When did your pain start?" f. "Do you have a history of diabetes mellitus?"

B,C,E

Which medications can adversely affect the eyes and vision? Select all that apply. a. Heparin b. Decongestants c. Oral contraceptives d. Acetaminophen e. Corticosteroids f. Antibiotics

B,C,E,F

The nurse is assessing an older woman who has osteoporosis. Which assessment findings would the nurse expect? Select all that apply. A. Swelling in the finger joints. B. Postural changes. C. Gait changes. D. Inability to bear weight. E. Muscle atrophy. F. History of fractures

B,C,F

A patient who was involved in a motor vehicle accident is brought to the emergency depart- ment by emergency medical services. He is on a backboard, C-collar is in place, and there is a splint on the left leg. Place the assessment steps in the order of priority. A. Assess mental status and orientation. B. Determine if the airway is clear. C. Check for signs of bleeding. D. Observe respiratory effort. E. Make bilateral comparison of legs for the 6 Ps.

B,D,C,A,E

Before performing a physical examination, what assessments related to the patient's hearing can be done while observing the patient? Select all that apply. a. Observe the patient's clothes and hygiene. b. Observe the patient's body posture and position. c. Observe if the patient is anxious or overly talkative. d. Notice if the patient asks for questions to be repeated. e. Notice whether the patient tilts the head toward the examiner. f. Notice patient's response when not looking in direction of sound.

B,D,E,F

_____: Hallux valgus deformity of the foot in which lateral deviation of the great toe causes the first metatarsal head to become enlarged.

Bunion

_____: Surgical removal of the hallux valgus deformity (bunion) of the foot.

Bunionectomy

A 29-year-old patient tells the nurse that he spends a great deal of time in the sun and rarely wears sunglasses. The patient's behavior increases the risk for which eye disorder? a. Hyperopia b. Ptosis c. Ocular melanoma d. Exophthalmos

C

A 49-year-old man comes to the clinic for left mid-tibia tenderness for the past 3 months. The nurse notes a small palpable mass. What type of malignant bone tumor is associated with these signs/symptoms? a. Chondrosarcoma b. Ewing's sarcoma c. Fibrosarcoma d. Osteosarcoma

C

A 55-year-old woman with a small frame is aware of her increased risk for osteoporosis and loss of bone mass. She currently has no pain or loss of function. She asks the nurse to recommend an exercise designed to counter- act the risk. What does the nurse suggest? a. Swimming and water aerobics b. Deep-breathing and isometric exercise c. Walking with arm weights d. Meditation and yoga

C

A man who severed a finger while working on his car comes to the emergency department. The bleeding from the site is well controlled, and the patient is alert and stable. What does the nurse do with the severed finger? a. Place it directly into a bag of ice and then put the bag into a refrigerator. b. Wrap it in moist sterile gauze and ensure that it stays with the patient. c. Wrap it in dry gauze, place it in a water- proof bag, and put the bag in ice water. d. Carefully clean it with sterile saline, and then place it in a sterile container.

C

A patient in a cast reports a painful "hot spot" underneath the cast, and the nurse notices an unpleasant odor. Which intervention is the nurse most likely to perform first? a. Offer the patient a prn pain medication. b. Help the patient with hygiene around the cast. c. Take the patient's temperature and other vital signs. d. Call the orthopedic technician to change the cast.

C

A patient is at high risk for a vertebral compression fracture. Which activity should the patient be instructed to avoid? A. Walking b. Climbing stairs c. Jogging d. Swimming

C

A patient is diagnosed with arcus senilis. Which intervention will the nurse use in caring for this patient? A. Assist the patient in activities that require near vision. B. Teach the patient how to instill the prescribed eye drops. C. Reassure the patient that the vision is not affected. D. Instruct that consistent use of sunglasses prevents worsening.

C

A patient is diagnosed with plantar fasciitis. What instruction does the nurse give to the patient about self-care for this condition? a. Use rest, elevation, and warm packs. b. Perform gentle jogging exercises. c. Strap the foot to maintain the arch. d. Wear loose or open shoes, such as sandals.

C

A patient is lactose intolerant and would like suggestions about food sources that supply adequate calcium and vitamin D. In addition to a generally well-balanced diet, what foods does the nurse suggest? A. Fresh apples and pears. B. Whole-grain bread and pasta. C. Fortified soy or rice products. D. Prune or cranberry juice.

C

A patient reports dramatic changes in color and temperature of the skin over the left foot with intense burning pain, sensitive skin, excessive sweating, and edema. The health care provider makes a preliminary medical diagnosis of complex regional pain syndrome. What is the priority for nursing care? a. Patient education b. Prevention of skin breakdown c. Management of pain d. Assessment of circulation

C

A patient reports not being able to see objects in his peripheral vision. Which method is used to evaluate this symptom? a. Jaeger card b. Six cardinal positions of gaze c. Confrontation test d. Corneal light reflex test

C

A patient was put into traction at 0800 hours. Hourly neurovascular checks were ordered for the first 24 hours and then every 4 hours thereafter. At what time can the nursing staff start performing the 4-hour checks? a. 2000 hours same day b. 0000 hours next day c. 0800 hours next day d. 1200 hours next day

C

A patient who works in a machine shop has a suspected metal foreign body in the eye. Which test is contraindicated for this patient? a. Corneal staining b. Computed tomography scan c. Magnetic resonance imaging d. Ultrasonography

C

What is the most common musculoskeletal assessment finding in patients who have abdominal obesity? a. Scoliosis b. Crepitus c. Lordosis d. Kyphosis

C

A patient with a leg cast denies pain; toes are pink, capillary refill is brisk and toes move freely, and the leg is elevated with an ice pack. Six hours later, the patient reports worsening pain unrelieved by medication. The patient's toes are cool, and pulse is difficult to detect. What does the nurse suspect is occurring with this patient? a. Crush syndrome b. Fat embolism syndrome c. Acute compartment syndrome d. Fasciitis

C

A patient with bone cancer has had the right lower leg surgically removed. The patient has been brave and uncomplaining, but the nurse recognizes that the patient is likely to experience grieving. What is the nurse's most important role? a. Act as a patient advocate to promote the surgeon-patient relationship. b. Encourage the patient to talk to the family and complete an advance directive. c. Be an active listener and encourage the patient and family to verbalize feelings. d. Help the patient and family cope with and resolve grief and loss issues.

C

A young high school athlete had a great toe amputated because of severe injury. The patient is depressed and withdrawn after the health care provider tells him that the amputa- tion will affect balance and gait. What should the nurse do first? a. Explain the role of physical therapy exercises that help with balance and gait. b. Involve the parents and patient in a discussion about rehabilitation programs. c. Encourage verbalization of feelings and thoughts related to the situation. d. Explore how the patient has coped and handled stressful situations in the past.

C

A young patient was hit in the left eye with a baseball. There is discoloration around the eye. Which treatment does the nurse expect to give this patient? a. Eye patch to rest the eye b. Warm, moist compresses c. Small ice application to area d. Bedrest in semi-Fowler's position

C

After a scleral buckling procedure, the patient is advised to avoid reading, writing, or close work, such as sewing. What is the rationale for avoiding these activities? a. They cause increased intraocular pressure. b. Close, fine work is likely to cause pain. c. They cause rapid eye movement. d. Close work or fine print will be blurry.

C

An adult patient has external otitis. After the inflammation resolves, which action should the patient avoid? a. Using earplugs during swimming or other water sports b. Dropping diluted alcohol in the ear to prevent recurrence c. Inserting cotton-tipped applicator into ears after bathing d. Using analgesics and warm compresses for pain relief

C

An adult patient is having problems with hearing. Which of the patient's medications is ototoxic? a. Vitamin B12 b. Digoxin c. Furosemide d. Levothyroxine

C

An older adult has been admitted with a hip fracture. Approximately 20 hours after injury, the patient develops a sign/symptom that the nurse recognizes as an early indicator of fat embolism syndrome. Which sign/symptom is the patient displaying? a. Severe respiratory distress b. Significantly increased pulse rate c. Change in mental status d. Petechial rash over the neck

C

An older patient is discharged to home follow- ing an orthopedic injury. Which mobilization device would be preferred if the patient is having trouble with balance? a. Crutches b. Cane c. Walker d. Wheelchair

C

During the physical assessment, the nurse identifies a defect of the patient's external ear. Based on knowledge of embryonic develop- ment, which question will the nurse ask to identify potential problems in a body system that developed concurrently with the external ear? a. "Have you ever had problems with your heart?" b. "Do you notice shortness of breath with minor exertion?" c. "Have you had any problems with your kidneys or urination?" d. "Do you have episodes of headaches with confusion?"

C

For a patient who had a keratoplasty, which discharge instruction will the nurse give? a. Sleep on the operative side to reduce intraocular pressure. b. Keep eye covered for 1 week with the initial dressing and shield. c. Wear the shield at night for the first month after surgery. d. Apply a small cloth-covered ice pack to reduce swelling.

C

For a person who is just beginning to notice some hearing loss, which sounds would be the most difficult to clearly hear? a. Woman singing in the soprano range b. Toddler who is angry and screaming c. Cell phone ringing with low-frequency tones d. Gunfire shots on a television show

C

For which circumstance is the nurse most likely to use a Doppler during patient assessment? a. Patient has progressive decreased flexion and extension of the wrist related to a contracture. b. Blood pressure cannot be obtained because patient has bilateral arm casts. c. Distal peripheral pulses of the affected extremity are difficult to locate and palpate. d. Patient refuses to do active range of motion (ROM) or allow passive ROM because of pain.

C

For which ear condition might a myringotomy be recommended? a. Labyrinthitis b. Acoustic neuroma c. Otitis media d. Presbycusis

C

How would the nurse use body position and the surrounding environment when conduct- ing an interview with a patient who may have a hearing problem? a. Conduct the interview in a quiet, dark- ened room without distractions. b. Sit beside the patient and speak directly into the patient's ear. c. Sit directly in front of the patient in a room with adequate lighting. d. Stand over the patient and use hand motions for emphasis.

C

Magnetic resonance imaging and magnetic resonance spectroscopy are more reliable and offer more information about bone change than bone mineral density measure- ments alone. What is the current barrier for using these tests to diagnose and evaluate osteoporosis? a. Many health care providers are not aware of the value of these procedures. b. Radiation exposure is excessive for the purpose of annual screening. c. These tests are expensive, and third parties do not recognize the value to reimburse costs. d. Many facilities do not have the specialized equipment to perform these tests

C

The health care provider asks the nurse to obtain a pneumatic otoscope so that the exter- nal canal can be inspected. What specific assessment finding is this instrument used for? a. To detect infection or inflammation b. To gently elicit pain or discomfort c. To detect mobility of the eardrum d. To verify the patency of the eardrum

C

The health care provider is considering calci- tonin for a patient to treat her osteoporosis. Which information should be relayed to the health care provider prior to the prescription of calcitonin? a. Patient hesitates over periodic subcutaneous injections. B. Patient is 5 years postmenopausal. C. Patient has a history of allergy to salmon. D. Patient has a T-score lower than 22.5.

C

The health care provider tells the nurse that the patient was informed about the diagnosis of acoustic neuroma and was also given information about the prognosis, treatment, and possible complications. Which patient statement indicates that the patient under- stood the information? a. "The tumor is benign, so I am not going to worry about it." b. "I am not sure if I want chemotherapy and radiation." c. "The tumor is benign, but neurologic damage sounds scary." d. "Hearing loss in one ear is not too bad, if that's the worst complication."

C

The home health nurse is reviewing environ- mental safety of an older patient who was discharged to her own home after surgery for a hip fracture. Which observation indicates a need for additional teaching? a. Patient's bed has been moved to the ground floor level. b. There are handlebars around the toilet and tub. c. Floors are clean and shiny and covered with throw rugs. d. Patient's walker is close to the patient's bedside.

C

The home health nurse is visiting an older adult patient with osteoporosis and severe kyphosis. When the nurse asks about activities she has been doing, the patient replies, "I used to be very active and beautiful when I was younger." What is the nurse's best response? a. "You are still very beautiful." b. "Activity can help to prevent fractures." c. "Tell me what you used to do." d. "Let's discuss age-appropriate exercises."

C

The nurse hears in report that the patient has chronic muscle weakness in the upper extrem- ities. Which question is the nurse most likely to ask the off-going nurse? a. "How often did the patient ask for prn pain medication?" b. "Do they know what is causing the weakness?" c. "How much assistance is required for activities of daily living?" d. "Is the family going to come in and bathe the patient?"

C

The nurse hears in shift report that a patient suffers from hyperacusis. Which intervention is the nurse most likely to use in the care of this patient? a. Supply a writing tablet and pen. b. Speak loudly and carefully enunciate. c. Control or reduce environmental noise. d. Instruct the patient to sit up slowly.

C

The nurse is assessing an adolescent patient with an injury to the shoulder and upper arm that occurred during wrestling practice. What is the best position for this patient's assessment? a. Supine so that the extremity can be elevated b. Low Fowler's on an exam table for patient comfort c. Sitting to observe for shoulder droop d. Slow ambulation to observe for natural arm movement

C

The nurse is assisting an inexperienced health care provider who is trying to perform an otoscopic examination on an older patient who is being treated for delirium caused by infection. What should the nurse do? A. Quietly talk to the patient to distract him as the provider inserts the speculum. B. Gently hold the patient's head to prevent movement during the examination. C. Suggest that the otoscopic examination be deferred until the delirium resolves. D. Suggest using a Rinne tuning fork test instead of the otoscopic examination.

C

The nurse is caring for a patient who had hemiarthroplasty and is at risk for hip disloca- tion. The nurse ensures that the hip is main- tained in which position? a. Adduction b. Anatomically neutral c. Abduction d. Extended

C

The nurse is caring for a patient with a plaster splint applied to the ankle. The patient re- ceived oral pain medication at 0900. At 1100, the patient reports that the pain is getting worse, not better. What is the nurse's priority action? a. Give the patient IV pain medication. b. Reposition the extremity on a pillow and place an ice pack. c. Assess the pulses and skin temperature distal to the splint. d. Call the health care provider to report the increasing pain.

C

The nurse is caring for a patient with osteomy- elitis. Which laboratory results are of primary concern for this disorder? a. Bone-specific alkaline phosphatase and osteocalcin. B. Serum calcium level and alkaline phosphatase. C. White blood cell count and erythrocyte sedimentation rate. D. Thyroid function tests and uric acid levels.

C

The nurse is palpating the back and spinal area of a patient who has advanced osteoporosis. The nurse is especially gentle at which area of the spine because it is the most common site for vertebral compression fractures? a. Between C1 and C5 b. Between T1 and T5 c. Between T8 and L3 d. Between L4 and L5

C

The nurse is providing teaching for a patient with a forearm cast. What information does the nurse give to the patient? a. "Forearm should be in an anatomical position when resting." b. "Use an ice pack for the first 6-8 hours, and cover the pack with a towel." c. "Sling should distribute weight over a large area of the shoulders and trunk." d. "Limit movement of the fingers or wrist joints to prevent pain."

C

The nurse is working in a clinic that uses serum and urinary bone turnover markers in the care of patients with osteoporosis. Which outcome statement reflects the purpose of using these markers? a. Patient is noncompliant with medications. b. Patient is able to walk without discomfort. c. Patient's bone density is maintained. d. Patient's height and weight are maintained.

C

The nurse must adjust a pair of crutches to properly fit a patient. Which description illustrates correct crutch adjustment? a. Axilla rests lightly on the top of the crutch when the crutch is moved forward. b. Patient can easily use the crutch without subjective complaints. c. Elbow is flexed no more than 30 degrees when the palm is on the handle. d. Adult patient is of average height, and the crutches are medium-sized.

C

The nurse observes that the older adult has kyphosis. Which topic does the nurse select to address this assessment finding? a. Isometric exercises b. Weight-bearing exercises c. Proper body mechanics d. Use of warm, moist heat

C

The nurse reads PERRLA in the patient's chart as noted by the nurse who worked the previous shift. What does the nurse do to determine if the patient still displays PERRLA or if the patient's status has changed? a. Assesses for presence, relief, or reduction of pain b. Checks pupils, retina, and light refraction c. Assesses the size, shape, and reactivity of pupils d. Checks for signs of presbyopia or retinal detachment

C

The nurse reads in the patient's chart that he has anisocoria. Which assessment of the eye will reveal this variation that is considered normal in 5% of the population? a. Corneal assessment b. Scleral assessment c. Pupillary assessment d. Eye movement assessment

C

The nurse reads in the patient's chart that the Weber tuning fork test showed that the patient had lateralization to the right. Based on this information, what would the nurse do while caring for the patient? a. Instruct the patient to turn his head to the right if he is having trouble hearing. b. Ask the patient in which ear the sound is louder, because the test is inconclusive. c. Position self to the patient's right, so that voice travels directly to the right ear. d. Lateralization indicates normal hearing, so the nurse would perform routine care.

C

The nurse reads in the patient's chart that the patient's visual acuity is 20/40. What is the correct interpretation of this documentation? a. Patient has 50% of the ideal 20/20 visual acuity. b. Patient stood 40 feet from the chart rather than 20 feet from the chart. c. Patient sees at 20 feet from the chart what a healthy eye sees at 40 feet. d. Patient stood 20 feet from the chart and sees 40% of the letters.

C

The nursing student is assisting with the care of a patient with musculoskeletal pain related to soft tissue injury and bone disruption. The student sees that the patient has a prn (as-needed) order for pain medication. What does the student do first to decide when to give the pain medication? a. Ask the health care provider to give specific parameters. b. Ask the primary nurse or the charge nurse for advice. c. Ask the patient about types of activities that increase the pain. d. Ask the nursing instructor for help interpreting the order.

C

The older patient has a fracture that has failed to heal. Which fracture complication best describes this situation? a. Malunion b. Avascular necrosis c. Nonunion d. Crush syndrome

C

The patient admits to drinking excessive alcohol. What additional assessment should the nurse perform to identify how the patient's intake of alcohol may be interfering with musculoskeletal health? a. Perform a neurologic assessment. b. Assess muscle strength against resistance. c. Perform a dietary assessment. d. Assess mobility of weight-bearing joints.

C

The patient has a musculoskeletal injury that resulted from excessive stretching of a muscle or tendon. Which type of injury has this patient sustained? a. Dislocation b. Sprain c. Strain d. Subluxation

C

The patient is admitted for acute osteomyelitis of the right lower leg with severe vascular compromise. Upon assessment, the patient denies pain or discomfort in the leg. Based on the concept of perfusion, how does the nurse interpret the patient's response? a. Vascular compromise may be severe, but the distal tissue is still being perfused. b. An order for Doppler flow studies should be obtained to validate lack of perfusion. c. Patient has sustained extensive nerve damage because of inadequate perfusion. d. Patient's current position in bed is allow- ing for adequate perfusion to distal tissues.

C

The patient is diagnosed with bilateral eye infection and receives a prescription for two bottles of the same antibiotic solution. What instructions should the nurse give to the patient? a. Obtain one bottle from the pharmacy and return for the second if the infection does not clear. b. Obtain and use one bottle for both eyes; the second bottle is not necessary. c. Obtain both bottles and label one for the right eye and the other for the left eye. d. Obtain both bottles but save the second one because the infection will probably recur.

C

The patient underwent a fluorescein angiogra- phy. What postprocedure instructions will the nurse give the patient? A. You may see a yellow haze for several days. B. Use over-the-counter artificial tears to flush the eye. C. Drink fluids to help eliminate the dye from the body. D. Wear bilateral eye patches for 24 hours to rest eyes.

C

The results of an audiometry test indicate that the patient hears about 50% of the time at 0 decibels. Based on these results, which action is the nurse most likely to take? a. Prepare a brochure about different types of hearing aids. b. Explain the purpose and procedure of caloric testing. c. Use normal conversation speech when speaking to the patient. d. Ask the patient which ear is better and direct voice toward that side.

C

What instructions would the home health nurse give to the home health aide about assist- ing an older patient who has a shoulder injury? A. Feed the patient b. Select clothing for the patient c. Wash the patient's hair d. Brush the patient's teeth

C

What is the nurse most likely to notice if the patient has problems with auditory sensory perception? a. Patient frequently looks away when being spoken to. b. Patient feigns disinterest or annoyance when spoken to. c. Patient frequently asks speaker to repeat statements. d. Patient often seeks out others for assistance.

C

What should the nurse teach a patient who is learning to use a hearing aid? a. Soak the hearing aid in a solution of mild soap and water. b. Plug the hearing aid into an electrical source when not in use. c. Avoid exposing the hearing aid to extreme temperatures. d. Adjust volume to the highest setting to maximize hearing.

C

What would be an important point to include in the documentation of a patient's intraocular pressure (IOP)? a. Patient's body position during the IOP measurement b. IOP measurement performed in a darkened room c. Type and time of IOP measurement d. Time of mydriatic drops and response to IOP measurement

C

Which assessment finding in a patient who has undergone a bone graft for a tumor does the nurse report to the health care provider immediately? a. Skin distal to the operative site is warm and pink. b. Cast over the operative site is cool to the touch. c. Distal pulses are decreased and difficult to palpate. d. Pain is present in the operative extremity.

C

Which child is most likely to develop hearing loss in adulthood? A. 1-year-old with ear infections related to "night bottles". B. 2-year-old who stumbles and bumps his head on a table. C. 5-year-old who is diagnosed with Down syndrome. D. 10-year-old with a grandparent who has hearing problems.

C

Which condition requires extra caution when patients are prescribed ototoxic drugs? a. Chronic heart failure b. Chronic pancreatitis c. Chronic glomerulonephritis d. Chronic obstructive pulmonary disease

C

Which cranial nerve is the nurse testing when performing a bedside hearing test? a. V b. VI c. VIII d. IX

C

Which factor presents the greatest risk for hip fracture? a. Decreased visual acuity b. Joint stiffness c. Osteoporosis d. Cardiac drug regimen

C

Which food would be the best choice to supply a vitamin that plays a key role in bone health? a. Carrots b. Apples c. Milk d. Whole grain bread

C

Which method would the nurse use to perform a corneal assessment? a. Inspect the corneas to determine if they are equal distance from the nose. b. Quickly and unexpectedly bring a hand toward the patient's cornea. c. Use a penlight and direct the light on the cornea from the side. d. Ask the patient to open and close eyelids, and observe the cornea.

C

Which patient behavior would prompt the nurse to suggest that the patient should see an ophthalmologist about the possible development of a cataract? a. Patient frequently wipes a creamy white, dry, crusty drainage from the eyelids. b. Patient has tearing and a reddened sclera after instilling prescribed eye drops. c. Patient frequently removes eyeglasses and repeatedly cleans the lenses. d. Patient rubs eyelids because of itching, mild swelling, and irritation.

C

Which patient has the greatest risk for cata- racts and needs an annual eye examination? a. 25-year-old who was treated for an episode of eye infection b. 16-year-old who was struck in the face by a basketball c. 57-year-old with no history of eye problems or vision changes d. 35-year-old who is pregnant with her first child

C

Which patient has the greatest risk for developing avascular necrosis? a. "Little person" with a congenital bone deformity b. Woman with osteoporosis and a Colles' fracture c. Older adult with a hip fracture d. Teenager with a dislocated shoulder

C

Which patient is the most likely to be a candidate for hyperbaric oxygen therapy? a. Patient with osteomalacia related to poverty b. Patient with an advanced case of osteosarcoma c. Patient with chronic, unremitting osteomyelitis d. Patient with osteoporosis and recurrent fractures

C

Which signs/symptoms represent the priority concepts for musculoskeletal trauma? a. Patient notes mild shortness of breath and palpitations with minor exertion. b. Patient describes discomfort in knee and hip joints that is worse in the morning. c. Patient reports decreased range of motion and pain in leg that is unrelieved by medication. d. Patient has problems getting adequate calcium and vitamin D because of lactose intolerance.

C

Which step is a correct part of the procedure for instilling eardrops? a. Gently irrigate the ear if the membrane is not intact. b. Place the bottle of eardrops in a bowl of hot water for 10 minutes. c. Tilt the patient's head in the opposite direction of the affected ear. d. Perform hand hygiene and use sterile gloves during the procedure.

C

_____: Backward displacement of the eyeball into the orbit so that the eye appears sunken.

Enophthalmos

_____: A rigid device that immobilizes the affected body part while allowing other body parts to move. It is most commonly used for fractures but may also be applied to correct deformities (e.g., clubfoot) or to prevent deformities (e.g., those seen in some patients with rheumatoid arthritis).

Cast

_____: A lens opacity that distorts the image projected onto the retina.

Cataract

_____: The loose, fibrous vascular tissue that forms at the site of a fracture as the first phase of healing and is normally replaced by hard bone as healing continues.

Callus

_____: The softer tissue inside bones that contains large spaces, or trabeculae, that are filled with red and yellow marrow.

Cancellous

_____: The place where the upper and lower eyelids meet at the corner of either side of the eye.

Canthus

_____: A common condition in which the median nerve in the wrist becomes compressed, causing pain and numbness.

Carpal tunnel syndrome (CTS)

_____: The wax produced by glands within the external ear canal; helps protect and lubricate the ear canal.

Cerumen

_____: Bone infection that persists over a long time due to misdiagnosis or inadequate treatment. Also called subchronic osteomyelitis.

Chronic osteomyelitis

_____: A fracture that does not extend through the skin and therefore has no visible wound.

Closed (simple) fracture

_____: A member of the rehabilitative health care team, usually a neuropsychologist, who works primarily with patients who have experienced head injuries and have cognitive impairments.

Cognitive therapist

_____: A phase after peripheral nerve trauma resulting in complete denervation in which the skin appears cyanotic, mottled, or reddish blue and feels cool compared with the contralateral unaffected extremity. The cold phase follows the warm phase, which lasts 2 to 3 weeks after injury.

Cold phase

_____: A complex disorder that includes debilitating pain, atrophy, autonomic dysfunction (excessive sweating, vascular changes), and motor impairment (most notably muscle paresis), probably caused by an abnormally hyperactive sympathetic nervous system. This syndrome most often results from traumatic injury and commonly occurs in the feet and hands; formerly called reflex sympathetic dystrophy (RSD).

Complex regional pain syndrome (CRPS)(Reflex sympathetic dystrophy, RSD)

_____: A fracture that is produced by a loading force applied to the long axis of cancellous bone. These fractures commonly occur in the vertebrae of patients with osteoporosis.

Compression fracture

_____: Hearing loss that results from any physical obstruction of sound wave transmission (e.g., a foreign body in the external canal, a retracted or bulging tympanic membrane, or fused bony ossicles).

Conductive hearing loss

_____: The mucous membranes of the eye that line the undersurface of the eyelids (palpebral conjunctiva) and cover the sclera (bulbar conjunctiva).

Conjunctivae

_____: In assessing pupillary reaction to light, a slight constriction of the pupil of the eye not being tested when a penlight is brought in from the side of the patient's head and shined into the eye being tested as soon as the patient opens his or her eyes.

Consensual response

_____: Something in direct contact with, or adjacent to, another area or structure.

Contiguous

_____: The clear layer that forms the external coat on the front of the eye.

Cornea

_____: Scrape or scratch of the cornea that disrupts its integrity.

Corneal abrasion

_____: Deep disruption of the corneal epithelium that extends into the stromal layer and is caused by bacteria, protozoa, or fungi.

Corneal ulceration

A 23-year-old athlete suffered a traumatic eye injury and enucleation was required. The nurse is trying to do discharge teaching, but the patient verbalizes anger and hopelessness, saying, "What's the point of learning about how to take care of this stupid empty hole in my face?" What is the nurse's first response? a. "Let's just take things one step at a time. I'll come back later." b. "Would you like information about joining a support group?" c. "Preventing infection will prevent further disfigurement and problems." d. "You are frustrated. Tell me how this accident will affect your life."

D

A 25-year-old patient sustained a crush injury to his right upper extremity and right lower extremity when heavy equipment fell on him. Signs and symptoms of hypovolemia and compartment syndrome are present. Manage- ment of care for this patient will focus on preventing which complication? a. Acute liver failure b. Ischemic heart failure c. Respiratory failure d. Myoglobinuric renal failure

D

A 45-year-old patient has diabetes mellitus. Which information about vision protection does the nurse include in the teaching plan? a. People with diabetes mellitus have an increased incidence of ocular melanoma. b. Fluctuating blood glucose levels are unde- sirable but do not cause vision problems. c. Use over-the-counter eye drops every day to flush potential infective organisms. d. Annual eye examinations are recommended for patients with diabetes mellitus.

D

A patient comes to the emergency department after slipping on some chalk in her classroom. She "did not have a hard fall" and was able to walk with the assistance of one of her students. What type of fracture is this patient most likely to have? a. Compression b. Displaced c. Impacted d. Incomplete

D

A patient has a fracture of the right wrist. What is an early sign that indicates this patient may be having a complication? a. Patient loses ability to wiggle fingers without pain. b. Fingers are cold and pale; pulses are impalpable. c. Pain is severe and seems out of proportion to injury. d. Patient reports a subjective numbness and tingling.

D

A patient has been advised by the health care provider that exercising may help prevent osteoporosis. Which exercise does the nurse recommend to the patient? a. Swimming 10-15 laps 3-5 times a week b. Running for 20 minutes 4 times a week c. Bowling for 60 minutes 3 times a week d. Walking for 30 minutes 3-5 times a week

D

A patient injured a lower extremity and has been placed in running traction. What instructions does the nurse give to unlicensed assistive personnel? a. Support the weights when turning the patient every 2 hours. b. Ask the patient to turn and move himself, so that he is in control of painful stimuli. c. Defer hygienic care and moving the patient until traction is removed. d. Do not move the patient or the bed because the countertraction can be altered.

D

A patient is experiencing inflammatory arthri- tis accompanied by synovitis. Based on the nurse's knowledge of anatomy and physiology, which diarthrodial joint is involved? a. Vertebral joint b. Cranial joint c. Pelvis joint d. Elbow joint

D

A patient is having problems with speech discrimination. What is the nurse most likely to observe? a. Patient speaks very loudly during a conversation. b. Patient can hear high tones but not low tones. c. Patient cannot accurately repeat two-syllable words. d. Patient repeats back "say" when the nurse says "stay."

D

A patient is prescribed low-intensity pulsed ultrasound treatments for a very slow-healing fracture of the right lower leg. What informa- tion does the nurse give this patient related to the treatment? a. Test for pregnancy before the therapy, and use birth control until treatment is complete. b. The treatment is experimental, but there are no known adverse effects. c. The device is implanted directly into the fracture site, and there is no external apparatus. d. Expect to dedicate approximately 20 minutes each day for a treatment.

D

A patient who tripped and fell down several stairs reports hearing a popping sound and fears that she has broken her ankle. How does the nurse initially assess for fracture in this patient? a. Measures the circumference of the distal leg b. Gently moves the ankle through full range of motion c. Inspects for crepitus and skin color d. Observes for deformity or misalignment

D

A patient who works on the tarmac at a busy airport is being seen for a routine examina- tion. What protection measures for hearing does the nurse suggest to the patient? a. Wear cotton ball ear inserts. b. Listen to music to mask noise. c. Wear a hat with ear covers. d. Wear an over-the-ear headset.

D

A patient with a lower extremity injury is being treated with external fixation. Which nursing assessment is of particular concern in the care of a patient with this type of system? a. Maintaining a 30-degree flexed position of the knee b. Measuring the weights used for counter- traction c. Observing the patient's ability to adjust the clickers d. Observing the points of entry of the pins and wires

D

A patient with myopia tells the nurse that he forgot to bring his glasses to the hospital and that his wife will bring them later when she comes to see him. Which activity is the patient most likely to have difficulty with while he is waiting for his glasses? a. Eating his lunch b. Looking at a brochure c. Using his cell phone d. Watching television

D

A sensorineural hearing loss results from impairment of which structure? A. Mobility of bony ossicles b. First cranial nerve c. Patency of external canal d. Eighth cranial nerve

D

A teenager is brought to the emergency department by a group of excited friends. He is dazed and unable to answer questions. The nurse observes deformity to the right forearm and ecchymosis over the right lateral chest and abdomen. What is the most important reason to ask the friends about mechanism of injury? a. To determine if the teenagers were using drugs or alcohol b. To make a judgment about whether to call the police c. To assist the health care provider to complete the history d. To aid in making the diagnosis of other types of injuries

D

Although any person can develop fallophobia, which person is most likely to have this condition? A. Toddler who has fallen several times and bumped her head b. Woman who recently had a fasciectomy for Dupuytren's contracture c. Man who has severe pain in the foot arch when getting out of bed d. Postmenopausal woman who fell recently and broke her wrist

D

An athletic young adult man broke his leg several weeks ago and is now having his cast removed for the first time. Upon seeing the appearance of the leg, he is stunned. What is the nurse's best response to this patient's surprise? a. "Don't worry; it looks crusty and withered, but the strength and function are normal." b. "The cast compresses the tissue, but your leg will look normal in a couple of days." c. "Let's just wash off the dead skin, and you will see that it is not as bad as it seems." d. "Without regular exercise, muscles atrophy; strength can be restored with use."

D

An older patient with a hip fracture has pro- longed immobility related to difficulties in performing the prescribed weight-bearing exercises. Based on fracture pathophysiology and the patient's abilities, which condition could the patient develop? a. Osteomyelitis b. Internal derangement c. Neuroma d. Pulmonary embolism

D

Compared to acute osteomyelitis, which characteristic is more associated with chronic osteomyelitis? a. Fever b. Swelling c. Erythema d. Sinus tract formation

D

During mealtimes, the nursing student is assisting an older patient who has reduced vision. When would the nursing instructor intervene to help the student to improve the quality of care? a. Student opens sealed packages and removes lids from cups and bowls. b. Student describes food placement on the plate in terms of a clock face. c. Student asks the charge nurse how much assistance the patient needs during meals. d. Student places meal tray on a table and tells the patient to call for help as needed.

D

For a patient with Ménière's disease, what is the purpose of the recommended nutrition therapy? a. To ensure an adequate intake of nutrients to slow progression of the disease b. To reduce harmful lipid accumulation in the acoustic-vestibular system c. To improve general overall health and strengthen the immune system d. To stabilize body fluid and prevent excess endolymph accumulation

D

In older adults, what potential adverse effect can occur with the use of meperidine? a. Hypertension b. Angina c. Kidney failure d. Seizures

D

One of the expected changes of the eyes asso- ciated with aging is the decreased ability of the iris to dilate. How will this affect the patient's eyes or vision? a. Difficulty with tear production resulting in dry eyes b. Decreased ability to see objects that are close c. Difficulty distinguishing blues, greens, or violets d. Increased difficulty seeing in dark environments

D

The home health nurse is interviewing a patient and discovers that there may be a previously undiagnosed vision problem. The nurse does not have a Jaeger card available at the patient's house to assess the suspected problem. Which item would serve as the best temporary substitute for a Jaeger card? a. Flashlight b. Ophthalmoscope c. Snellen chart d. Newspaper

D

The home health nurse is visiting an older patient who was discharged to home yesterday after cataract surgery. The patient reports pain during the evening with nausea and vomiting that started this morning. The home health nurse decides to contact the health care provider for suspicion of which complication? a. Dry eye syndrome b. Tissue graft rejection c. Corneal infection d. Increased intraocular pressure

D

The nurse applies bandages to a patient's residual limb to help shape and shrink the limb for a prosthesis. What is the proper technique for the nurse to use? a. Reapply the bandages every 8 hours or more often if they become loose. b. Use a proximal-to-distal direction when wrapping. c. Use soft, flexible bandage material and pad the area with gauze. d. Use a figure-eight wrapping method to prevent restriction of blood flow.

D

The nurse asks the patient to open and close his eyelids. Which cranial nerve is the nurse assessing? A) Cranial nerve II (optic). B) Cranial nerve III (oculomotor). C) Cranial nerve V (trigeminal). D) Cranial nerve VII (facial).

D

The nurse gently taps over the patient's mastoid process, and the patient reports tenderness. This finding may indicate which condition? a. Excessive cerumen b. Hyperacusis c. Ruptured eardrum d. Inflammatory process

D

The nurse is interviewing an older adult with a history of osteoporosis who reports falling and catching her weight on her outstretched domi- nant hand. This patient is most likely to have sustained what type of fracture? a. Carpal scaphoid fracture b. Phalanges fracture c. Humeral fracture d. Colles' wrist fracture

D

The nurse is reviewing the laboratory results of a patient who was beaten into unconscious- ness by an unknown assailant. Which labora- tory result would accompany extensive tissue damage and the expected inflammatory response? a. Decreased hemoglobin and hematocrit b. Increased serum calcium level c. Increased serum phosphorus level d. Elevated erythrocyte sedimentation rate

D

The nurse is teaching a patient about antibiotic therapy for osteomyelitis. What information does the nurse give to the patient? A. Single-agent therapy is the most effective treatment for acute infections. B. Chronic osteomyelitis may require 1 month of antibiotic therapy. C. Patients usually remain hospitalized to complete the full course of antibiotic therapy. D. The infected wound may be irrigated with one or more types of antibiotic solutions.

D

The nurse is using an ophthalmoscope to examine the lens of a patient with a mature cataract. Which finding does the nurse expect to see? a. Dilated pupil b. Yellow tinge to sclera c. Enlarged retina d. Bluish-white pupiL

D

The older patient has reduced visual sensory perception and is newly admitted to the medical-surgical unit. What instructions should the nurse give to unlicensed assistive personnel about assisting the patient with activities of daily living? a. "When entering and exiting the room, be very quiet so the patient is not disturbed." b. "Put personal belongings in the closet so the patient knows where they are." c. "During mealtimes, sit with the patient and explain how he should eat and drink." d. "When walking with the patient, offer your arm and walk a step ahead."

D

The patient is a construction worker in his early 30s who was treated with oral antibiotics after stepping on a nail. The wound does not appear to be responding to antibiotic treatment as expected, despite the patient's compliance. The nurse suspects the patient may have a family history of which disorder? a. Nephritis b. Crohn's disease c. Skin cancer d. Diabetes mellitus

D

The physical therapist has instructed the patient about several exercises to perform for the prevention and management of osteo- porosis. Which exercise is most directly related to the concept of mobility? A. Abdominal muscle tightening. B. Focused deep-breathing exercise. C. Pectoral muscle tightening. D. Range-of-motion exercise.

D

The student nurse is assessing a patient with a probable fractured tibia-fibula. What assess- ment technique used by the student nurse causes the nursing instructor to intervene? a. Inspects the fracture site for swelling or deformity. b. Instructs the patient to wiggle the toes. c. Assesses bilateral dorsalis pedis pulses. d. Pushes on the leg to elicit pain response.

D

The unlicensed assistive personnel (UAP) is assisting the orthopedic cast technician to cut a window in a patient's cast. What does the nurse instruct the UAP to do? a. Check the distal pulses after the window is cut. b. Clean up and dispose of all casting debris. c. Inform the patient that the procedure is painless. d. Save the cutout cast piece so it can be taped in place.

D

What is a contraindication for a patient having electronystagmography (ENG)? a. Dental problems b. Previous ENG c. Prosthetic hip d. Pacemaker

D

What is an early sign/symptom of a cataract? a. Double vision b. Photophobia c. Decreased depth perception d. Decreased color perception

D

What is the most common type of malignant bone tumor? a. Ewing's sarcoma b. Chondrosarcoma c. Fibrosarcoma d. Osteosarcoma

D

What is the priority concept related to changes that occur during the ischemia-edema cycle? a. Comfort b. Mobility 12. c. Tissue integrity d. Perfusion

D

What is the priority for a patient with impaired vision? a. Self-care b. Communication c. Mobility d. Safety

D

What would be included in the procedure for using an ophthalmoscope? A. The nurse comes toward the patient's eye from 6 inches away. B. The test should be done in a brightly lit room to enhance visibility. C. Have an assistant firmly hold a confused patient during the examination. D. The nurse stands on the same side as the eye being examined.

D

Which activity does the nurse ask a patient to perform when assessing range of motion in the patient's hands? a. Wave the hand as though waving goodbye. b. Grip the nurse's hand as hard as possible. c. Rapidly move hands from palm up to palm down. d. Make a fist and then appose each finger to thumb.

D

Which assessment finding of the musculoskel- etal system indicates an abnormality? A. Symmetry in the upper extremities and equal muscle mass. B. Gait balance and a smooth and regular stride. C. Flexion, extension, and rotation of the neck. D. Opposition of three or four fingers to the thumb.

D

Which laboratory result may indicate liver damage or metastatic cancer of the bone? a. Serum calcium 9.5 mg/dL b. Aspartate aminotransferase 15 units/L c. Lactate dehydrogenase 185 units/L d. Alkaline phosphatase 140 units/L

D

Which patient is most likely to benefit by having music playing during sleeping hours? a. Patient has frequent episodes of acute otitis media. b. Patient reports an odd sensation of "whirling in space." c. Patient has a hearing aid and reports excessive background noise. d. Patient reports tinnitus that contributes to emotional disturbance.

D

Which person has the highest risk for devel- oping hearing problems related to occupation? a. Nurse who works night shift in an emergency department b. Coach who instructs a high school swim team c. Bus driver who picks up elementary school children d. Bartender who works in a nightclub with live music

D

Which traumatic injury is most likely to cause loss of vision in the injured eye? a. Metal shavings on the cornea b. Contusion to periorbital soft tissue c. Laceration to the margin of the eyelid d. Wood splinter embedded in eyeball

D

Why might the health care provider order a computed tomography scan to examine the eye? a. To validate the function of extraocular muscles b. To verify intraocular pressure c. To determine the degree of peripheral vision d. To detect an ocular tumor in the orbital space

D

_____: Bone that is cylindric with rounded ends and often bears weight, such as the femur.

Long bone

Light waves pass through each of the eye structures listed below to reach the retina. Place them in sequence using the numbers 1 through 5, with number 1 being the outermost structure and number 5 being the innermost structure. _____ a. Vitreous humor _____ b. Aqueous humor _____ c. Lens _____ d. Cornea _____ e. Retina

D,B,C,A,E

_____: Term describing a fracture that has not healed within 6 months of injury.

Delayed union

_____: A description of a light reflex that is spotty or multiple because of a changed eardrum shape from either retraction or bulging.

Diffuse light reflex

_____: The placement of an implantable device to promote bone fusion; used as an adjunct for patients for whom spinal fusion may be difficult.

Direct current stimulation (DCS)

_____: Occurrence of the articulating surfaces of two or more bones moving away from each other.

Dislocation of a joint

_____: A type of radiographic scan that measures bone mineral density in the hip, wrist, or vertebral column; used as a screening and diagnostic tool for diagnosis and for follow-up evaluation of treatment of osteoporosis.

Dual x-ray absorptiometry (DXA)

_____: A slowly progressive contracture of the palmar fascia that results in flexion of the fourth or fifth digit of the hand and occasionally affects the third digit. Although a fairly common problem, the cause is unknown. It usually occurs in older men, tends to occur in families, and can be bilateral.

Dupuytren's contracture

_____: An infection in which organisms are carried by the bloodstream from other areas of infection in the body.

Endogenous

_____: A tube used for patients who need long-term enteral feeding; the physician directly accesses the gastrointestinal tract using surgical, endoscopic, or laparoscopic techniques.

Enucleation

_____: Abnormal protrusion of the eyeball (proptosis).

Exophthalmos

_____: A system in which pins or wires are passed through skin and bone and connected to a rigid external frame to immobilize a fracture during healing.

External fixation (external fixator)

_____: A painful irritation or infection of the skin of the external ear, with resulting allergic response or inflammation. When it occurs in patients who participate in water sports, external otitis is called swimmer's ear.

External otitis

_____: Located outside the joint capsule.

Extracapsular

_____: The farthest point at which the eye can see an object.

Far point (of vision)

_____: An inelastic tissue that surrounds groups of muscles, blood vessels, and nerves in the body.

Fascia

_____: A surgical procedure in which an incision is made through the skin and subcutaneous tissues into the fascia of the affected compartment to relieve the pressure in and restore circulation to the affected area in the patient with acute compartment syndrome.

Fasciotomy

_____: A serious complication, usually resulting from a fracture, in which fat globules are released from the yellow bone marrow into the bloodstream. This syndrome usually occurs within 48 hours of the fracture and can result in respiratory failure or death, often from pulmonary edema.

Fat embolism syndrome (FES)

_____: A fracture that results from excessive or repeated strain and stress on a bone.

Fatige (stress) fracture

_____: A break or disruption in the continuity of a bone.

Fracture

_____: (1) The highness or lowness of tones (expressed in hertz). The greater the number of vibrations per second, the higher the frequency (pitch) of the sound; the fewer the number of vibrations per second, the lower the pitch; (2) an urge to urinate frequently in small amounts.

Frequency

_____: A test that is similar to a bone scan but that uses the radioisotope gallium citrate and is more specific and sensitive in detecting bone problems. This substance also migrates to brain, liver, and breast tissue and therefore is used to examine these structures when disease is suspected.

Gallium scan

_____: A round, cystlike lesion, often overlying a wrist joint or tendon.

Ganglion

_____: A deformity in which the knees are abnormally close together and the space between the ankles is increased. Also called knock-knee.

Genu valgum

_____: A deformity in which the knees are abnormally separated and the lower extremities are bowed inward. Also called bowleg.

Genu varum

_____: A group of ocular diseases resulting in increased intraocular pressure, causing reduced blood flow to the optic nerve and retina and followed by tissue damage.

Glaucoma

_____: An instrument for measuring angles; also refers to a tool used to measure joint range of motion.

Goniometer

_____: A polyethylene tube that is surgically placed through the tympanic membrane to allow continuous drainage of middle-ear fluids in the patient with otitis media.

Grommet

_____: A common deformity of the foot that occurs when the great toe deviates laterally at the metatarsophalangeal joint; sometimes referred to as a bunion.

Hallux valgus

_____: The dorsiflexion of any metatarsophalangeal joint with plantar flexion of the adjacent proximal interphalangeal joint. The second toe is most often affected.

Hammertoe

_____: A form of tuberculosis that spreads throughout the body when a large number of organisms enter the blood. Also called miliary tuberculosis.

Hematogenous TB (miliary tuberculosis)

_____: The production of blood cells, which occurs in the red marrow of bones.

Hematopoiesis

_____: A drug that has an increased risk for causing patient harm if given in error.

High-alert drug

_____: Pressure of the fluid within the eye; may be measured by methods that involve direct contact with the eye or by noncontact techniques.

Intraocular pressure (IOP)

_____: A broad term for disturbances of an injured knee joint.

Internal derangement

_____: The use of metal pins, screws, rods, plates, or prostheses to immobilize a fracture during healing. The surgeon makes an incision (open reduction) to gain access to the broken bone and implants one or more devices.

Internal fixation

_____: The place at which two or more bones come together. Also referred to as "articulation" of the joint. The primary function is to provide movement and flexibility in the body.

Joint

_____: A minimally invasive surgery for managing vertebral fractures in patients with osteoporosis. Bone cement is injected into the fracture site to provide pain relief, and an inflated balloon is used to restore height to the vertebra.

Kyphoplasty

_____: Surgical removal of the labyrinth; used as a radical treatment of Ménière's disease when medical therapy is ineffective and the patient already has significant hearing loss.

Labyrinthectomy

_____: An infection of the labyrinth of the ear; may occur as a complication of acute or chronic otitis media.

Labyrinthitis

_____: A small gland that produces tears; located in the upper outer part of each ocular orbit.

Lacrimal gland

_____: The circular, convex structure of the eye that lies behind the iris and in front of the vitreous body. Normally transparent, the lens bends the rays of light entering through the pupil so that they focus on the retina. The curve of the lens changes to focus on near or distant objects.

Lens

_____: Connective tissue that attaches bones to other bones at joints.

Ligament

_____: The reflection of the otoscope's light off the eardrum in the form of a clearly demarcated triangle of light in the normal ear.

Light reflex

_____: The anterior concavity in the curvature of the lumbar and cervical spine when viewed from the side; a common finding in pregnancy and abdominal obesity.

Lordosis

_____: A method using ultrasonic waves to promote bone union in slow-healing fractures or for new fractures as an alternative to surgery.

Low-intensity pulsed ultrasound

_____: An abnormality in the swing phase of gait; occurs when the muscles in the buttocks or legs are too weak to allow the person to change weight from one foot to the other.

Lurch

_____: The extraction of a muscle specimen for the diagnosis of atrophy (as in muscular dystrophy) and inflammation (as in polymyositis).

Muscle biopsy

_____: A group of degenerative myopathies characterized by weakness and atrophy of muscle without nervous system involvement. At least nine types have been clinically identified and can be broadly categorized as slowly progressive or rapidly progressive.

Muscular dystrophy (MD)

_____: A problem in muscle tissue.

Myopathy

_____: An error of refraction that occurs when the eye over-refracts or over-bends the light and focuses images in front of the retina; this results in normal near vision but poor distance vision. Also called nearsightedness.

Myopia

_____: Surgical reconstruction of the eardrum.

Myringoplasty

_____: The surgical creation of a hole in the eardrum; performed to drain middle-ear fluids and relieve pain in the patient with otitis media (middle-ear infection).

Myringotomy

_____: The closest distance at which the eye can see an object clearly.

Near point of vision

_____: A sensitive tumor consisting of nerve cells and nerve fibers.

Neuroma

_____: A problem in nerve tissue that can cause muscle weakness.

Neuropathy

_____: Assessment of the neuromuscular system that includes inspection of skin color, temperature, and capillary refill distal to an injury, surgical procedure, or cast. Palpation of pulses in the extremities below level of injury and assessment of sensation, movement, and pain in the injured part give a complete assessment.

Neurovascular assessment

_____: Involuntary rapid eye movements.

Nystagmus

_____: A metabolic disorder of bone remodeling, or turnover, in which increased resorption or loss results in bone deposits that are weak, enlarged, and disorganized.

Paget's disease (osteitis deformans)

_____: A person's body build and alignment when standing and walking.

Posture

_____: The loss of hearing, especially for high-pitched sounds; occurs as a result of aging.

Presbycusis

_____: An age-related impairment of vision characterized by a loss of lens elasticity and the ability of the eye to accommodate. The near point of vision increases, and near objects must be placed farther from the eye to be seen clearly.

Presbyopia

_____: A form of glaucoma characterized by a narrowed angle and forward displacement of the iris so that movement of the iris against the cornea narrows or closes the chamber angle, obstructing the outflow of aqueous humor. It can have a sudden onset and is an emergency. Also called closed-angle glaucoma, narrow-angle glaucoma, or acute glaucoma.

Primary angle-closure glaucoma (PACG or acute glaucoma)

_____: The most common form of primary glaucoma; characterized by reduced outflow of aqueous humor through the chamber angle. Because the fluid cannot leave the eye at the same rate it is produced, intraocular pressure gradually increases.

Primary open-angle glaucoma (POAG)

_____: The opening through which tears drain; located at the nasal side of the eyelid edges.

Punctum

_____: The opening through which light enters the eye; located in the center of the iris of the eye.

Pupil

_____: A reflection of light on the retina seen as a red glare during ophthalmoscopic examination. An absent red reflex may indicate a lens opacity or cloudiness of the vitreous.

Red reflex

_____: Excessive stretching of a ligament.

Sprain

_____: The bending of light rays.

Refraction

_____: Injury caused by repeated movements of the same part of the body (e.g., carpal tunnel syndrome).

Repetitive stress injury (RSI)

_____: In referring to bone, the loss of bone minerals and density; the release of free calcium from bone storage sites directly into the extracellular fluid.

Resorption

_____: The innermost layer of the eye, made up of sensory receptors that transmit impulses to the optic nerve. It contains blood vessels and two types of photoreceptors called rods and cones. Rods work at low light levels and provide peripheral vision; cones are active at bright light levels and provide color and central vision.

Retina

_____: Separation of the retina from the epithelium.

Retinal detachment

_____: A break in the retina; can be caused by trauma or can occur with aging.

Retinal hole

_____: Jagged and irregularly shaped break in the retina resulting from traction on the retina.

Retinal tear

_____: A granulomatous disorder of unknown cause that can affect any organ but most often involves the lung.

Sarcoidosis

_____: The external white layer of the eye.

Sclera

_____: An abnormal lateral curve in the spine, which normally should be a straight vertical line.

Scoliosis

_____: Hearing loss that results from a defect in the cochlea, the eighth cranial nerve, or the brain itself. Exposure to loud noises and music may cause this type of hearing loss as a result of damage to the cochlear hair cells.

Sensorineural hearing loss

_____: Two-syllable words in which there is generally equal stress on each syllable, such as airplane, railroad, and cowboy; used in testing speech reception threshold.

Spondee

_____: Excessive stretching of a muscle or tendon when it is weak or unstable; sometimes referred to as "muscle pulls."

Strain

_____: The presence of bubbles under the skin because of air trapping; an uncommon late complication of fracture.

Subcutaneous emphysema

_____: Surgical cutting of the sympathetic nerve branches via endoscopy through a small axillary incision.

Sympathectomy

_____: Type of joint lined with synovium, a membrane that secretes synovial fluid for lubrication and shock absorption.

Synovial joint

_____: Inflammation of synovial membrane.

Synovitis

_____: Any one of many bands of tough, fibrous tissue that attach muscles to bones.

Tendon

_____: A test that is similar to a bone scan but uses the radioisotope thallium and is more sensitive in diagnosing the extent of disease in patients with osteosarcoma.

Thallium scans

_____: In evaluating hearing, the lowest level of intensity at which pure tones and speech are heard by a patient; in general, the lowest level at which a stimulus is perceived.

Threshold

_____: The clear, thick gel that fills the vitreous chamber of the eye (the space between the lens and the retina). This gel transmits light and shapes the eye.

Vitreous body