AH Exam 4 - Practice Assesment
10. A patient is experiencing bilateral symmetrical muscle weakness and sensory changes of both feet and legs. What should the nurse expect to assess that determines the presence of Guillain-Barré syndrome (GBS)? 1) Areflexia 2) Hyporeflexia 3) Hyperreflexia 4) Hyperanalgesia
1
14. A patient with amyotrophic lateral sclerosis is prescribed riluzole (Rilutek). What statement by the patient indicates that further teaching is needed about this treatment? 1) "This medication will cure my disease." 2) "This medication may delay the need to be on a ventilator." 3) "This medication works on nerve conduction." 4) "This medication may decrease the progression of my disease."
1
17. A patient returns to the community clinic after being diagnosed with Parkinson's disease. What should the nurse expect to see documented in the patient's medical record to support this diagnosis? 1) Rigidity with ambulation 2) Unremarkable electroencephalogram 3) Results of serum potassium and calcium levels 4) Integrity of cerebral vessels after a cerebral angiogram
1
2. The nurse is reading the results of a single-fiber electromyography completed on a patient suspected of having myasthenia gravis. Which information would validate this patient's diagnosis? 1) Increased jitter 2) Nerve compression 3) Increased antibodies 4) Decreased muscle response
1
5. The nurse is caring for a patient with myasthenia gravis. Which assessment should the nurse complete to determine respiratory functioning? 1) Vital capacity 2) Pulse oximetry 3) Auscultate lung sounds 4) Arterial blood gas analysis
1
11. A patient is scheduled for a CT scan of the left femur. What should the nurse expect the findings of this diagnostic test to reveal? 1) Fractures 2) Disk disease 3) Osteomyelitis 4) Ligamentous tears
1 - Computed tomography scans are done to diagnose muscle and bone disorders including fractures
A client is diagnosed with myasthenia gravis. What should the nurse explain about this disease process? 1) "Your nerve endings are worn out." 2) "Your body does not recognize the neurotransmitter needed for movement." 3) "Your body does not make enough of the neurotransmitter needed for movement." 4) "Your nerves have lost their protective covering and impulses cannot reach body areas."
2
12. The nurse notes that patient is scheduled for an arthrogram. What is the purpose of this test? 1) Evaluate healing of a bone fracture 2) Visualize joint soft tissue structures 3) Identify the location of a bone tumor 4) Determine the cause for muscle weakness
2 - An arthrogram allows for visualization of soft tissue structures of a joint.
19. An older patient is experiencing arthritis in major joints. What could be the reason for the development of this disorder? 1) Decreased cartilage 2) Decline in muscle mass 3) Less fluid in joint spaces 4) Loss of fluid in ligaments
2 - Muscle fibers gradually decrease in size, number, and contractility starting around age 30. This identified loss of strength places more stress on an individual's joints and predisposes to the development of arthritis.
2. A patient has a muscle that has been torn from the bone. Which structure has been injured in this patient? 1) Fascia 2) Tendon 3) Cartilage 4) Ligament
2 - Skeletal muscle consists of bundles of muscle fibers called fasciculi and are attached to a bone by a fibrous cord known as a tendon.
6. A patient with myasthenia gravis has lost 6 kg of weight over the last two months. What should the nurse suggest to improve this patient's nutritional status? 1) Eat three large meals per day 2) Plan medication doses to occur before meals 3) Restrict drinking fluids prior to and during meals 4) Increase the amount of fat and carbohydrates in meals
2 pyridostigmine
23. During an assessment the nurse suspects that patient should be evaluated for myasthenia gravis. What did the nurse assess to make this clinical determination? Select all that apply. 1) Ptosis 2) Diplopia 3) Abdominal pain 4) Left leg weakness 5) Epigastric burning
1,2
27. The nurse is planning care for a patient with osteoarthritis (OA). On what should the nurse focus when preparing teaching material for this patient? Select all that apply. 1) Weight management 2) Nonsteroidal therapy 3) Activity modification 4) Joint replacement surgery 5) Glucosamine and chondroitin
1,2,3,5 - The initial medical management prior to joint replacement is focused on the use of joint supplements such as glucosamine and chondroitin.
22. The nurse is assessing a patient's musculoskeletal system. Which observation indicates that the muscles are functioning appropriately? Select all that apply. 1) Limb bends at a joint. 2) A body part is raised. 3) Action occurs automatically. 4) Arm moves in a circle around the shoulder. 5) Limb moves away from the midline of the body.
1,2,4,5
24. The nurse notes that a patient with myasthenia gravis is experiencing bulbar manifestations. On what should the nurse focus when assessing this patient? Select all that apply. 1) Swallowing 2) Eye opening 3) Blood pressure 4) Tongue movement 5) Head and neck movement
1,3,4,5
25. A patient is scheduled for electromyography. What teaching should the nurse provide to prepare the patient for this test? Select all that apply. 1) Shower before the test. 2) Apply lotion for better electrode contact. 3) Slight pain might occur with needle insertion. 4) Slight bruising may occur at the site of electrodes. 5) Avoid caffeinated food items two to three hours before the test.
1,3,4,5
6. A patient has a low level of thyroid stimulating hormone (TSH). How will this affect the musculoskeletal system? 1) Reduces bone growth 2) Initiates the growth of bone 3) Slows the rate of bone destruction 4) Promotes the number of osteoblasts
1- TSH inhibits the activity of osteoclasts and reduces bone growth.
3. A patient is being prepared for a Edrophonium (tensilon) test (rapid-acting AChE inhibitor). What should the nurse ensure is available prior to the beginning of this test? 1) Oxygen 2) Atropine sulfate 3) Intravenous fluids 4) Nasogastric suction
2
4. A patient with myasthenia gravis is experiencing sweating and pallor. After administering edrophonium (Tensilon), which finding suggests the patient is experiencing a cholinergic crisis? 1) Clear vision 2) Fasciculations 3) Strong hand grasps 4) Equal shoulder shrugs
2
6. During morning care a patient with a seizure disorder asks why the room has suddenly turned green. What should the nurse do? 1) Ask the patient to explain 2) Prepare for a seizure to begin 3) Turn on the overhead room lights 4) Document visual hallucinations present
2
7. The nurse provides care for a patient who is 4 hours postoperative after surgery to correct a herniated nucleus pulposus. Which assessment finding causes the nurse to notify the healthcare provider? 1) The patient is drowsy. 2) The patient's respiratory rate is nine breathes per minute. 3) The patient reports pain of 5 on a scale of 1 to 10. 4) The patient's dressing has serosanguinous drainage.
2
15. A patient recently diagnosed with amyotrophic lateral sclerosis is having difficulty with swallowing and has been choking and coughing excessively at mealtimes. The nurse implements which action first? 1) Initiating low-flow oxygen therapy 2) Suctioning the oropharynx 3) Auscultating breath sounds 4) Assessing neurological status
3
5. A patient is prescribed alendronate (Fosamax). What instruction should the nurse provide to the patient about this medication? 1) Take at bedtime 2) Take with a full meal 3) Take on an empty stomach 4) Take two hours after breakfast
3 - Alendronate (Fosamax) should be taken on an empty stomach.
11. A patient with severe hip pain is diagnosed with osteoarthritis (OA). What information should the nurse provide to the patient about this disease process? 1) "OA causes an overgrowth of cartilage in the joints." 2) "OA causes joint fluid to become bluish-white in color." 3) "OA causes a decrease in joint fluid that affects the cartilage." 4) "OA causes a build of fluid in the joints, hindering movement."
3 - In OA, there is a decrease in the proteoglycans, which are responsible for the management of the fluid within the joints. The result is a loss of cartilage strength and functionality
9. The nurse is evaluating dietary teaching provided to a patient recovering from osteomyelitis. Which meal choice indicates that additional teaching is required? 1) Green salad, meat loaf, brown rice, and broccoli 2) Caesar's salad, pork loin slices, sauerkraut, baked potato, and sautéed carrots 3) Tossed salad, spaghetti with marinara sauce, Italian bread, and creamed spinach 4) Iceberg lettuce wedge, baked chicken breast, parsley red potatoes, and green beans
3 - his meal choice has no protein. It may have adequate zinc and folic acid; however, protein is missing, which is required for wound healing.
Which action will the nurse include in the plan of care for a patient with impaired functioning of the left glossopharyngeal nerve (CN IX) and the vagus nerve (CN X)? A. Withhold oral fluid or foods. B. Provide highly seasoned foods. C. Insert an oropharyngeal airway. D. Apply artificial tears every hour.
A The glossopharyngeal and vagus nerves innervate the pharynx and control the gag reflex. A patient with impaired function of these nerves is at risk for aspiration. An oral airway may be needed when a patient is unconscious and unable to maintain the airway, but it will not decrease aspiration risk. Taste and eye blink are controlled by the facial nerve.
7. A patient with a seizure disorder asks the purpose of staying awake all night prior to having an electroencephalogram in the morning. What should the nurse explain to this patient? 1) "You will be expected to sleep during the test." 2) "Most people with seizure disorders receive too much sleep." 3) "This is the only way to prove that you really have a seizure disorder." 4) "Sleep deprivation can cause a seizure, which will be helpful during the test."
4
A client is diagnosed with multiple sclerosis. What should the nurse explain about this disease process? 1) "Your nerve endings are worn out." 2) "Your body does not recognize the neurotransmitter needed for movement." 3) "Your body does not make enough of the neurotransmitter needed for movement." 4) "Your nerves have lost their protective covering and impulses cannot reach body areas."
4
20. An older patient asks what can be done to prevent bone fractures. What should the nurse suggest to this patient? 1) Limit exposure to the sun 2) Increase the intake of water 3) Increase frequency of rest periods 4) Engage in weight-bearing exercise
4 Regular weight-bearing exercise is necessary to maintain a healthy, functional musculoskeletal system.
A 45-year-old patient has a dysfunction of the cerebellum. The nurse will plan interventions to A. prevent falls. B. stabilize mood. C. avoid aspiration. D. improve memory.
A Because functions of the cerebellum include coordination and balance, the patient with dysfunction is at risk for falls. The cerebellum does not affect memory, mood, or swallowing ability.
After change-of-shift report, which patient should the nurse assess first? A. Patient with myasthenia gravis who is reporting increased muscle weakness B .Patient with a bilateral headache described as like a band around my head C. Patient with seizures who is scheduled to receive a dose of phenytoin (Dilantin) D. Patient with Parkinsons disease who has developed cogwheel rigidity of the arms
A Because increased muscle weakness may indicate the onset of a myasthenic crisis, the nurse should assess this patient first. The other patients should also be assessed, but do not appear to need immediate nursing assessments or actions to prevent life-threatening complications.
The nurse advises a patient with myasthenia gravis (MG) to A. perform physically demanding activities early in the day. B. anticipate the need for weekly plasmapheresis treatments. C. do frequent weight-bearing exercise to prevent muscle atrophy. D. protect the extremities from injury due to poor sensory perception.
A Muscles are generally strongest in the morning, and activities involving muscle activity should be scheduled then. Plasmapheresis is not routinely scheduled, but is used for myasthenia crisis or for situations in which corticosteroid therapy must be avoided. There is no decrease in sensation with MG, and muscle atrophy does not occur because although there is muscle weakness, they are still used
A patient has a new order for magnetic resonance imaging (MRI) to evaluate for left femur osteomyelitis after a hip replacement surgery. Which information indicates that the nurse should consult with the health care provider before scheduling the MRI? A. The patient has a pacemaker. B. The patient is claustrophobic. C. The patient wears a hearing aid. D. The patient is allergic to shellfish.
A Patients with permanent pacemakers cannot have MRI because of the force exerted by the magnetic field on metal objects. An open MRI will not cause claustrophobia. The patient will need to be instructed to remove the hearing aid before the MRI, but this does not require consultation with the health care provider. Because contrast medium will not be used, shellfish allergy is not a contraindication to MRI.
A 64-year-old patient who has amyotrophic lateral sclerosis (ALS) is hospitalized with pneumonia. Which nursing action will be included in the plan of care? A. Assist with active range of motion (ROM). B. Observe for agitation and paranoia. C. Give muscle relaxants as needed to reduce spasms. D. Use simple words and phrases to explain procedures.
A ALS causes progressive muscle weakness, but assisting the patient to perform active ROM will help maintain strength as long as possible. Psychotic manifestations such as agitation and paranoia are not associated with ALS. Cognitive function is not affected by ALS, and the patients ability to understand procedures will not be impaired. Muscle relaxants will further increase muscle weakness and depress respirations.
A patient has been taking phenytoin (Dilantin) for 2 years. Which action will the nurse take when evaluating for adverse effects of the medication? A.Inspect the oral mucosa. B. Listen to the lung sounds. C. Auscultate the bowel tones. D. Check pupil reaction to light.
A Phenytoin can cause gingival hyperplasia, but does not affect bowel tones, lung sounds, or pupil reaction to light.
A patient with a right lower leg fracture will be discharged home with an external fixation device in place. Which information will the nurse teach? A. You will need to check and clean the pin insertion sites daily. B. The external fixator can be removed for your bath or shower. C. You will need to remain on bed rest until bone healing is complete. D. Prophylactic antibiotics are used until the external fixator is removed.
A Pin insertion sites should be cleaned daily to decrease the risk for infection at the site. An external fixator allows the patient to be out of bed and avoid the risks of prolonged immobility. The device is surgically placed and is not removed until the bone is stable. Prophylactic antibiotics are not routinely given when an external fixator is used.
The nurse suggests that a patient recently diagnosed with rheumatoid arthritis (RA) plan to start each day with A. a warm bath followed by a short rest. B. a short routine of isometric exercises. C. active range-of-motion (ROM) exercises. D. stretching exercises to relieve joint stiffness.
A Taking a warm shower or bath is recommended to relieve joint stiffness, which is worse in the morning. Isometric exercises would place stress on joints and would not be recommended. Stretching and ROM should be done later in the day, when joint stiffness is decreased.
A patient who has had an open reduction and internal fixation (ORIF) of a hip fracture tells the nurse that he is ready to get out of bed for the first time. Which action should the nurse take? A. Check the postoperative orders for the patients weight-bearing status. B.Avoid administration of pain medications before getting the patient up. C. Delegate the transfer of the patient to nursing assistive personnel (NAP). D. Use a mechanical lift to transfer the patient from the bed to the chair.
A The nurse should be familiar with the weight-bearing orders for the patient before attempting the transfer. Mechanical lifts are not typically needed after this surgery. Pain medications should be given because the movement is likely to be painful for the patient. The registered nurse (RN) should supervise the patient during the initial transfer to evaluate how well the patient is able to accomplish this skill.
A 27-year-old patient who has been treated for status epilepticus in the emergency department will be transferred to the medical nursing unit. Which equipment should the nurse have available in the patients assigned room (select all that apply)? [Seizure Precautions] A. Side-rail pads B. Tongue blade C. Oxygen mask D. Suction tubing E. Urinary catheter F. Nasogastric tube
A, C, D The patient is at risk for further seizures, and oxygen and suctioning may be needed after any seizures to clear the airway and maximize oxygenation. The beds side rails should be padded to minimize the risk for patient injury during a seizure. Use of tongue blades during a seizure is contraindicated. Insertion of a nasogastric (NG) tube is not indicated because the airway problem is not caused by vomiting or abdominal distention. A urinary catheter is not required unless there is urinary retention.
A 73-year-old patient with Parkinsons disease has a nursing diagnosis of impaired physical mobility related to bradykinesia. Which action will the nurse include in the plan of care? A. Instruct the patient in activities that can be done while lying or sitting. B. Suggest that the patient rock from side to side to initiate leg movement. C. Have the patient take small steps in a straight line directly in front of the feet. D. Teach the patient to keep the feet in contact with the floor and slide them forward.
ANS: B Rocking the body from side to side stimulates balance and improves mobility. The patient will be encouraged to continue exercising because this will maintain functional abilities. Maintaining a wide base of support will help with balance. The patient should lift the feet and avoid a shuffling gait. Instruct the patient in activities that can be done while lying or sitting.Suggest that the patient rock from side to side to initiate leg movement.Have the patient take small steps in a straight line directly in front of the feet. Teach the patient to keep the feet in contact with the floor and slide them forward
The health care provider has prescribed the following collaborative interventions for a patient who is taking azathioprine (Imuran) for systemic lupus erythematosus. Which order will the nurse question? A. Draw anti-DNA blood titer. B. Administer varicella vaccine. C. Naproxen (Aleve) 200 mg BID. D. Famotidine (Pepcid) 20 mg daily.
B Live virus vaccines, such as varicella, are contraindicated in a patient taking immunosuppressive drugs. The other orders are appropriate for the patient.
Which finding would the nurse expect when assessing the legs of a patient who has a lower motor neuron lesion? A. Spasticity B. Flaccidity C. No sensation D. Hyperactive reflexes
B Because the cell bodies of lower motor neurons are located in the spinal cord, damage to the neuron will decrease motor activity of the affected muscles. Spasticity and hyperactive reflexes are caused by upper motor neuron damage. Sensation is not impacted by motor neuron lesions.
A patient with left knee pain is diagnosed with bursitis. The nurse will explain that bursitis is an inflammation of A. the synovial membrane that lines the joint. B. a small, fluid-filled sac found at some joints. C. the fibrocartilage that acts as a shock absorber in the knee joint. D. any connective tissue that is found supporting the joints of the body.
B Bursae are fluid-filled sacs that cushion joints and bony prominences. Fibrocartilage is a solid tissue that cushions some joints. Bursae are a specific type of connective tissue. The synovial membrane lines many joints but is not a bursa.
Which assessment information obtained by the nurse indicates that a patient with an exacerbation of rheumatoid arthritis (RA) is experiencing a side effect of prednisone (Deltasone)? A. The patient has joint pain and stiffness. B. The patients blood glucose is 165 mg/dL. C. The patient has experienced a recent 5-pound weight loss. D. The patients erythrocyte sedimentation rate (ESR) has increased.
B Corticosteroids have the potential to cause diabetes mellitus. The finding of an elevated blood glucose reflects this side effect of prednisone. Corticosteroids increase appetite and lead to weight gain. An elevated ESR and no improvement in symptoms would indicate that the prednisone was not effective but would not be side effects of the medication.
Which assessment data for a patient who has Guillain-Barr syndrome will require the nurses most immediate action? A. The patients triceps reflexes are absent. B. The patient is continuously drooling saliva. C. The patient complains of severe pain in the feet. D. The patients blood pressure (BP) is 150/82 mm Hg.
B Drooling indicates decreased ability to swallow, which places the patient at risk for aspiration and requires rapid nursing and collaborative actions such as suctioning and possible endotracheal intubation. The foot pain should be treated with appropriate analgesics, and the BP requires ongoing monitoring, but these actions are not as urgently needed as maintenance of respiratory function. Absence of the reflexes should be documented, but this is a common finding in Guillain-Barr syndrome.
A young man arrives in the emergency department with ankle swelling and severe pain after twisting his ankle playing basketball. Which of these prescribed collaborative interventions will the nurse implement first? A. Take the patient to have x-rays. B. Wrap the ankle and apply an ice pack. C. Administer naproxen (Naprosyn) 500 mg PO. D. Give acetaminophen with codeine (Tylenol #3
B Immediate care after a sprain or strain injury includes the application of cold and compression to the injury to minimize swelling. The other actions should be taken after the ankle is wrapped with a compression bandage and ice is applied.
A patient who is to have no weight bearing on the left leg is learning to walk using crutches. Which observation by the nurse indicates that the patient can safely ambulate independently? A. The patient moves the right crutch with the right leg and then the left crutch with the left leg. B. The patient advances the left leg and both crutches together and then advances the right leg. C. The patient uses the bedside chair to assist in balance as needed when ambulating in the room. D. The patient keeps the padded area of the crutch firmly in the axillary area when ambulating.
B Patients are usually taught to move the crutches and the injured leg forward at the same time and then to move the unaffected leg. Patients are discouraged from using furniture to assist with ambulation. The patient is taught to place weight on the hands, not in the axilla, to avoid nerve damage. If the 2- or 4-point gaits are to be used, the crutch and leg on opposite sides move forward, not the crutch and same-side leg.
Which statement by a patient with systemic lupus erythematosus (SLE) indicates that the patient has understood the nurses teaching about the condition? A. I will exercise even if I am tired. B. I will use sunscreen when I am outside. C. I should take birth control pills to keep from getting pregnant. D. I should avoid aspirin or nonsteroidal antiinflammatory drugs.
B Severe skin reactions can occur in patients with SLE who are exposed to the sun. Patients should avoid fatigue by balancing exercise with rest periods as needed. Oral contraceptives can exacerbate lupus. Aspirin and nonsteroidal antiinflammatory drugs are used to treat the musculoskeletal manifestations of SLE.
When a 74-year-old patient is seen in the health clinic with new development of a stooped posture, shuffling gait, and pill rollingtype tremor, the nurse will anticipate teaching the patient about A. oral corticosteroids. B. antiparkinsonian drugs. C. magnetic resonance imaging (MRI). D. electroencephalogram (EEG) testing.
B The diagnosis of Parkinsons is made when two of the three characteristic manifestations of tremor, rigidity, and bradykinesia are present. The confirmation of the diagnosis is made on the basis of improvement when antiparkinsonian drugs are administered. This patient has symptoms of tremor and bradykinesia. The next anticipated step will be treatment with medications. MRI and EEG are not useful in diagnosing Parkinsons disease, and corticosteroid therapy is not used to treat it.
Which result for a 30-year-old patient with systemic lupus erythematosus (SLE) is most important for the nurse to communicate to the health care provider? A. Decreased C-reactive protein (CRP) B. Elevated blood urea nitrogen (BUN) C. Positive antinuclear antibodies (ANA) D. Positive lupus erythematosus cell prep
B The elevated BUN and creatinine levels indicate possible lupus nephritis and a need for a change in therapy to avoid further renal damage. The positive lupus erythematosus (LE) cell prep and ANA would be expected in a patient with SLE. A drop in CRP shows an improvement in the inflammatory process.
Which statement by a 62-year-old patient who has had an above-the-knee amputation indicates that the nurses discharge teaching has been effective? A. I should elevate my residual limb on a pillow 2 or 3 times a day. B. I should lay flat on my abdomen for 30 minutes 3 or 4 times a day. C. I should change the limb sock when it becomes soiled or each week. D. I should use lotion on the stump to prevent skin drying and cracking.
B The patient lies in the prone position several times daily to prevent flexion contractures of the hip. The limb sock should be changed daily. Lotion should not be used on the stump. The residual limb should not be elevated because this would encourage flexion contracture.
Before assisting a patient with ambulation 2 days after a total hip replacement, which action is most important for the nurse to take? a. Observe the status of the incisional drain device. b. Administer the ordered oral opioid pain medication. c. Instruct the patient about the benefits of ambulation. d. Change the hip dressing and document the wound appearance.
B The patient should be adequately medicated for pain before any attempt to ambulate. Instructions about the benefits of ambulation may increase the patients willingness to ambulate, but decreasing pain with ambulation is more important. The presence of an incisional drain or timing of dressing change will not affect ambulation.
A 50-year-old patient is being discharged after a week of IV antibiotic therapy for acute osteomyelitis in the right leg. Which information will be included in the discharge teaching? A. How to apply warm packs to the leg to reduce pain B. How to monitor and care for the long-term IV catheter C. The need for daily aerobic exercise to help maintain muscle strength D. The reason for taking oral antibiotics for 7 to 10 days after discharge
B The patient will be on IV antibiotics for several months, and the patient will need to recognize signs of infection at the IV site and how to care for the catheter during daily activities such as bathing. IV antibiotics rather than oral antibiotics are used for acute osteomyelitis. Patients are instructed to avoid exercise and heat application because these will increase swelling and the risk for spreading infection.
After being hospitalized for 3 days with a right femur fracture, a 32-year-old patient suddenly develops shortness of breath and tachypnea. The patient tells the nurse, I feel like I am going to die! Which action should the nurse take first? A. Stay with the patient and offer reassurance. B. Administer the prescribed PRN oxygen at 4 L/min. C. Check the patients legs for swelling or tenderness. D. Notify the health care provider about the symptoms.
B The patients clinical manifestations and history are consistent with a pulmonary embolus, and the nurses first action should be to ensure adequate oxygenation. The nurse should offer reassurance to the patient, but meeting the physiologic need for oxygen is a higher priority. The health care provider should be notified after the oxygen is started and pulse oximetry and assessment for fat embolus or venous thromboembolism (VTE) are obtained.
Following a thymectomy, a 62-year-old male patient with myasthenia gravis receives the usual dose of pyridostigmine (Mestinon). An hour later, the patient complains of nausea and severe abdominal cramps. Which action should the nurse take first? A. Auscultate the patients bowel sounds. B. Notify the patients health care provider. C. Administer the prescribed PRN antiemetic drug. D. Give the scheduled dose of prednisone (Deltasone).
B The patients history and symptoms indicate a possible cholinergic crisis. The health care provider should be notified immediately, and it is likely that atropine will be prescribed. The other actions will be appropriate if the patient is not experiencing a cholinergic crisis.
A patient has a long-arm plaster cast applied for immobilization of a fractured left radius. Until the cast has completely dried, the nurse should A. keep the left arm in dependent position. B. avoid handling the cast using fingertips. C. place gauze around the cast edge to pad any roughness. D. cover the cast with a small blanket to absorb the dampness.
B Until a plaster cast has dried, using the palms rather than the fingertips to handle the cast helps prevent creating protrusions inside the cast that could place pressure on the skin. The left arm should be elevated to prevent swelling. The edges of the cast may be petaled once the cast is dry, but padding the edges before that may cause the cast to be misshapen. The cast should not be covered until it is dry because heat builds up during drying.
When obtaining a health history and physical assessment for a 36-year-old female patient with possible multiple sclerosis (MS), the nurse should A. assess for the presence of chest pain. B. inquire about urinary tract problems. C. inspect the skin for rashes or discoloration. D. ask the patient about any increase in libido.
B Urinary tract problems with incontinence or retention are common symptoms of MS. Chest pain and skin rashes are not symptoms of MS. A decrease in libido is common with MS.
Which action will the nurse include in the plan of care for a 33-year-old patient with a new diagnosis of rheumatoid arthritis? A. Instruct the patient to purchase a soft mattress. B. Suggest that the patient take a nap in the afternoon. C. Teach the patient to use cold water when bathing. D. Suggest exercise with light weights several times daily.
B Adequate rest helps decrease the fatigue and pain that are associated with rheumatoid arthritis. Patients are taught to avoid stressing joints, to use warm baths to relieve stiffness, and to use a firm mattress. When stabilized, a therapeutic exercise program is usually developed by a physical therapist to include exercises that improve the flexibility and strength of the affected joints, and the patients overall endurance.
Which action will the nurse take in order to evaluate the effectiveness of Bucks traction for a 62-year-old patient who has an intracapsular fracture of the right femur? A. Check peripheral pulses. B. Ask about hip pain level. C. Assess for hip contractures. D. Monitor for hip dislocation.
B Bucks traction keeps the leg immobilized and reduces painful muscle spasm. Hip contractures and dislocation are unlikely to occur in this situation. The peripheral pulses will be assessed, but this does not help in evaluating the effectiveness of Bucks traction.
A patient is being discharged 4 days after hip replacement surgery using the posterior approach. Which patient action requires immediate intervention by the nurse? A. The patient uses crutches with a swing-to gait. B. The patient leans over to pull shoes and socks on. C. The patient sits straight up on the edge of the bed. D. The patient bends over the sink while brushing teeth.
B Leaning over would flex the hip at greater than 90 degrees and predispose the patient to hip dislocation. The other patient actions are appropriate and do not require any immediate action by the nurse to protect the patient.
Which assessment is most important for the nurse to make regarding a patient with myasthenia gravis? A. Pupil size B. Grip strength C. Respiratory effort D. Level of consciousness
C Because respiratory insufficiency may be life threatening, it will be most important to monitor respiratory function. The other data also will be assessed but are not as critical.
Which laboratory result will the nurse monitor to determine whether prednisone (Deltasone) has been effective for a 30-year-old patient with an acute exacerbation of rheumatoid arthritis? A. Blood glucose test B. Liver function tests C. C-reactive protein level D. Serum electrolyte levels
C C-reactive protein is a marker for inflammation, and a decrease would indicate that the corticosteroid therapy was effective. Blood glucose and serum electrolyte levels will also be monitored to check for side effects of prednisone. Liver function is not routinely monitored in patients receiving corticosteroids.
When the nurse brings medications to a patient with rheumatoid arthritis, the patient refuses the prescribed methotrexate (Rheumatrex). The patient tells the nurse, My arthritis isnt that bad yet. The side effects of methotrexate are worse than the arthritis. The most appropriate response by the nurse is A. You have the right to refuse to take the methotrexate. B. Methotrexate is less expensive than some of the newer drugs. C. It is important to start methotrexate early to decrease the extent of joint damage. D. Methotrexate is effective and has fewer side effects than some of the other drugs.
C Disease-modifying antirheumatic drugs (DMARDs) are prescribed early to prevent the joint degeneration that occurs as soon as the first year with RA. The other statements are accurate, but the most important point for the patient to understand is that it is important to start DMARDs as quickly as possible.
Which discharge instruction will the emergency department nurse include for a patient with a sprained ankle? A. Keep the ankle loosely wrapped with gauze. B. Apply a heating pad to reduce muscle spasms. C. Use pillows to elevate the ankle above the heart. D. Gently move the ankle through the range of motion.
C Elevation of the leg will reduce the amount of swelling and pain. Compression bandages are used to decrease swelling. For the first 24 to 48 hours, cold packs are used to reduce swelling. The ankle should be rested and kept immobile to prevent further swelling or injury.
When giving home care instructions to a patient who has comminuted forearm fractures and a long-arm cast on the left arm, which information should the nurse include? A. Keep the left shoulder elevated on a pillow or cushion. B. Keep the hand immobile to prevent soft tissue swelling. C. Call the health care provider for increased swelling or numbness of the hand. D. Avoid nonsteroidal antiinflammatory drugs (NSAIDs) for 24 hours after the injury.
C Increased swelling or numbness may indicate increased pressure at the injury, and the health care provider should be notified immediately to avoid damage to nerves and other tissues. The patient should be encouraged to move the joints above and below the cast to avoid stiffness. There is no need to elevate the shoulder, although the forearm should be elevated to reduce swelling. NSAIDs are appropriate to treat pain after a fracture.
A 42-year-old patient is admitted to the emergency department with a left femur fracture. Which information obtained by the nurse is most important to report to the health care provider? A. Ecchymosis of the left thigh B. Complaints of severe thigh pain C. Slow capillary refill of the left foot D. Outward pointing toes on the left foot
C Prolonged capillary refill may indicate complications such as arterial damage or compartment syndrome. The other findings are typical with a left femur fracture.
An appropriate nursing intervention for a patient who has acute low back pain and muscle spasms is to teach the patient to A. keep both feet flat on the floor when prolonged standing is required. B. twist gently from side to side to maintain range of motion in the spine. C. keep the head elevated slightly and flex the knees when resting in bed. D. avoid the use of cold packs because they will exacerbate the muscle spasms.
C Resting with the head elevated and knees flexed will reduce the strain on the back and decrease muscle spasms. Twisting from side to side will increase tension on the lumbar area. A pillow placed under the upper back will cause strain on the lumbar spine. Alternate application of cold and heat should be used to decrease pain.
A patient who arrives at the emergency department experiencing severe left knee pain is diagnosed with a patellar dislocation. The initial patient teaching by the nurse will focus on the need for A. a knee immobilizer. B. gentle knee flexion. c. monitored anesthesia care. d. physical activity restrictions.
C The first goal of collaborative management is realignment of the knee to its original anatomic position, which will require anesthesia or monitored anesthesia care (MAC), formerly called conscious sedation. Immobilization, gentle range-of-motion (ROM) exercises, and discussion about activity restrictions will be implemented after the knee is realigned.
Following a motorcycle accident, a 58-year-old patient arrives in the emergency department with massive left lower leg swelling. Which action will the nurse take first? A. Elevate the leg on 2 pillows. B. Apply a compression bandage. C. Check leg pulses and sensation. D. Place ice packs on the lower leg.
C The initial action by the nurse will be to assess the circulation to the leg and to observe for any evidence of injury such as fractures or dislocations. After the initial assessment, the other actions may be appropriate, based on what is observed during the assessment.
A 27-year-old patient is hospitalized with new onset of Guillain-Barr syndrome. The most essential assessment for the nurse to carry out is A. determining level of consciousness. B. checking strength of the extremities. C. observing respiratory rate and effort. D. monitoring the cardiac rate and rhythm.
C The most serious complication of Guillain-Barr syndrome is respiratory failure, and the nurse should monitor respiratory function continuously. The other assessments will also be included in nursing care, but they are not as important as respiratory assessment.
The second day after admission with a fractured pelvis, a 64-year-old patient suddenly develops confusion. Which action should the nurse take first? A. Take the blood pressure. B. Assess patient orientation. C. Check the oxygen saturation. D. Observe for facial asymmetry.
C The patients history and clinical manifestations suggest a fat embolus. The most important assessment is oxygenation. The other actions are also appropriate but will be done after the nurse assesses gas exchange
Which laboratory data is important to communicate to the health care provider for a patient who is taking methotrexate (Rheumatrex) to treat rheumatoid arthritis? A. The blood glucose is 90 mg/dL. B. The rheumatoid factor is positive. C. The white blood cell (WBC) count is 1500/L. D. The erythrocyte sedimentation rate is elevated.
C Bone marrow suppression is a possible side effect of methotrexate, and the patients low WBC count places the patient at high risk for infection. The elevated erythrocyte sedimentation rate and positive rheumatoid factor are expected in rheumatoid arthritis. The blood glucose is normal.
Which medication information will the nurse identify as a concern for a patients musculoskeletal status? A. The patient takes a daily multivitamin and calcium supplement. B. The patient takes hormone therapy (HT) to prevent hot flashes. C. The patient has severe asthma and requires frequent therapy with oral corticosteroids. D. The patient has migraine headaches treated with nonsteroidal antiinflammatory drugs (NSAIDs)
C Frequent or chronic corticosteroid use may lead to skeletal problems such as avascular necrosis and osteoporosis. The use of HT and calcium supplements will help prevent osteoporosis. NSAID use does not increase the risk for musculoskeletal problems.
12. Which menu choice by a patient with osteoporosis indicates that the nurses teaching about appropriate diet has been effective? A. Pancakes with syrup and bacon B. Whole wheat toast and fresh fruit C. Egg-white omelet and a half grapefruit D. Oatmeal with skim milk and fruit yogurt
D Skim milk and yogurt are high in calcium. The other choices do not contain any high-calcium foods.
In which order will the nurse take these actions when caring for a patient in the emergency department with a right leg fracture after a motor vehicle accident? (Put a comma and a space between each answer choice [A, B, C, D, E, F].) a. Obtain x-rays. b. Check pedal pulses. c. Assess lung sounds. d. Take blood pressure. e. Apply splint to the leg. f. Administer tetanus prophylaxis.
C, D, B, E, A, F The initial actions should be to ensure that airway, breathing, and circulation are intact. This should be followed by checking the neurovascular status of the leg (before and after splint application). Application of a splint to immobilize the leg should be done before sending the patient for x-rays. The tetanus prophylaxis is the least urgent of the actions.
While the nurse is transporting a patient on a stretcher to the radiology department, the patient begins having a tonic-clonic seizure. Which action should the nurse take? A. Insert an oral airway during the seizure to maintain a patent airway. B. Restrain the patients arms and legs to prevent injury during the seizure. C. Time and observe and record the details of the seizure and postictal state. D. Avoid touching the patient to prevent further nervous system stimulation.
C. Because the diagnosis and treatment of seizures frequently are based on the description of the seizure, recording the length and details of the seizure is important. Insertion of an oral airway and restraining the patient during the seizure are contraindicated. The nurse may need to move the patient to decrease the risk of injury during the seizure.
The nurse who notes that a 59-year-old female patient has lost 2-3 inch in height over the past 2 years will plan to teach the patient about: A. discography studies. B. myelographic testing. C. magnetic resonance imaging (MRI). D. dual-energy x-ray absorptiometry (DEXA).
D
The day after a 60-year-old patient has an open reduction and internal fixation (ORIF) for an open, displaced tibial fracture, the priority nursing diagnosis is A. activity intolerance related to deconditioning. B. risk for constipation related to prolonged bed rest. C. risk for impaired skin integrity related to immobility. D. risk for infection related to disruption of skin integrity.
D A patient having an ORIF is at risk for problems such as wound infection and osteomyelitis. After an ORIF, patients typically are mobilized starting the first postoperative day, so problems caused by immobility are not as likely.
A 68-year-old patient hospitalized with a new diagnosis of Guillain-Barr syndrome has numbness and weakness of both feet. The nurse will anticipate teaching the patient about A. intubation and mechanical ventilation. B. administration of corticosteroid drugs. C. insertion of a nasogastric (NG) feeding tube. D. infusion of immunoglobulin (Sandoglobulin).
D Because the Guillain-Barr syndrome is in the earliest stages (as evidenced by the symptoms), use of high-dose immunoglobulin is appropriate to reduce the extent and length of symptoms. Mechanical ventilation and tube feedings may be used later in the progression of the syndrome but are not needed now. Corticosteroid use is not helpful in reducing the duration or symptoms of the syndrome.
A 76-year-old patient is being treated with carbidopa/levodopa (Sinemet) for Parkinsons disease. Which information is most important for the nurse to report to the health care provider? A. Shuffling gait B. Tremor at rest C. Cogwheel rigidity of limbs D. Uncontrolled head movement
D Dyskinesia is an adverse effect of the Sinemet, indicating a need for a change in medication or decrease in dose. The other findings are typical with Parkinsons disease.
The nurse will anticipate teaching a patient with a possible seizure disorder about which test? A. Cerebral angiography B. Evoked potential studies C. Electromyography (EMG) D. Electroencephalography (EEG)
D Seizure disorders are usually assessed using EEG testing. Evoked potential is used for diagnosing problems with the visual or auditory systems. Cerebral angiography is used to diagnose vascular problems. EMG is used to evaluate electrical innervation to skeletal muscle.
A 48-year-old patient with a comminuted fracture of the left femur has Bucks traction in place while waiting for surgery. To assess for pressure areas on the patients back and sacral area and to provide skin care, the nurse should A. loosen the traction and help the patient turn onto the unaffected side. B. place a pillow between the patients legs and turn gently to each side. C. turn the patient partially to each side with the assistance of another nurse. D. have the patient lift the buttocks by bending and pushing with the right leg.
D The patient can lift the buttocks off the bed by using the left leg without changing the right-leg alignment. Turning the patient will tend to move the leg out of alignment. Disconnecting the traction will interrupt the weight needed to immobilize and align the fracture.
Which prescribed intervention will the nurse implement first for a patient in the emergency department who is experiencing continuous tonic-clonic seizures? A. Give phenytoin (Dilantin) 100 mg IV. B. Monitor level of consciousness (LOC). C. Obtain computed tomography (CT) scan. D. Administer lorazepam (Ativan) 4 mg IV.
D To prevent ongoing seizures, the nurse should administer rapidly acting antiseizure medications such as the benzodiazepines. A CT scan is appropriate, but prevention of any seizure activity during the CT scan is necessary. Phenytoin will also be administered, but it is not rapidly acting. Patients who are experiencing tonic-clonic seizures are nonresponsive, although the nurse should assess LOC after the seizure.
The nurse finds that a patient can flex the arms when no resistance is applied but is unable to flex when the nurse applies light resistance. The nurse should document the patients muscle strength as level A. 0. B. 1. C. 2. D. 3.
D A level 3 indicates that the patient is unable to move against resistance but can move against gravity. Level 1 indicates minimal muscle contraction, level 2 indicates that the arm can move when gravity is eliminated, and level 4 indicates active movement with some resistance.
Which action will the nurse include in the plan of care for a patient who has had a total right knee arthroplasty? A. Avoid extension of the right knee beyond 120 degrees. B. Use a compression bandage to keep the right knee flexed. C. Teach about the need to avoid weight bearing for 4 weeks. D. Start progressive knee exercises to obtain 90-degree flexion.
D After knee arthroplasty, active or passive flexion exercises are used to obtain a 90-degree flexion of the knee. The goal for extension of the knee will be 180 degrees. A compression bandage is used to hold the knee in an extended position after surgery. Full weight bearing is expected before discharge.
After the nurse assesses a 78-year-old who uses naproxen (Aleve) daily for hand and knee osteoarthritis management, which information is most important to report to the health care provider? a. Knee crepitation is noted with normal knee range of motion. b. Patient reports embarrassment about having Heberdens nodes. c. Patients knee pain while golfing has increased over the last year. d. Laboratory results indicate blood urea nitrogen (BUN) is elevated.
D Older patients are at increased risk for renal toxicity caused by nonsteroidal antiinflammatory drugs (NSAIDs) such as naproxen. The other information will also be reported to the health care provider but is consistent with the patients diagnosis of osteoarthritis and will not require an immediate change in the patients treatment plan.
A 54-year-old woman who recently reached menopause and has a family history of osteoporosis is diagnosed with osteopenia following densitometry testing. In teaching the woman about her osteoporosis, the nurse explains that A. estrogen replacement therapy must be started to prevent rapid progression to osteoporosis. B. continuous, low-dose corticosteroid treatment is effective in stopping the course of osteoporosis. C. with a family history of osteoporosis, there is no way to prevent or slow gradual bone resorption. D. calcium loss from bones can be slowed by increasing calcium intake and weight-bearing exercise.
D Progression of osteoporosis can be slowed by increasing calcium intake and weight-bearing exercise. Estrogen replacement therapy does help prevent osteoporosis, but it is not the only treatment and is not appropriate for some patients. Corticosteroid therapy increases the risk for osteoporosis
9. A patient with multiple sclerosis experiences exacerbations of new symptoms that last a few days and then disappear. The nurse correlates these clinical manifestations to which type of multiple sclerosis? 1) Relapsing-remitting 2) Primary progressive 3) Progressive relapsing 4) Secondary progressive
a?
