PP1 Test 3 EAQs

which change in the joint may result in joint pain for older adults?

increased cartilage erosion

which client condition is an example of cell-mediated immunity?

TB Graft injection contact dermatitis

which physiological change occurs in older adults and warrants the nurse teaching the client about safety tips to prevent falls?

decreased bone density

which nursing intervention would the nurse include in the plan of care for an older adult client with decreased bone density?

demonstrating weight-bearing exercises to the client

which factor explains why a client who experiences an acute episode of RA has swollen finger joints

inflammation in the joint's synovial lining

the nurse teaches a client who is premenopausal and obese about strategies to prevent osteoporosis. which strategy identified by the client indicates that the teaching is effective?

join a tennis league and practice every day

which tissue connects the client's tibia to the femur at the knee joint?

ligaments

the plan of care for a client with osteoporosis includes active and passive exercises, calcium supplement, and daily vitamins. which finding would indicate that the therapy is helping?

mobility increases

the nurse is caring for a client who had an above-the-knee amputation a week ago. which action would the nurse take to control edema of the residual limb?

rewrap the elastic bandage as necessary

which population-level action would the nurse use to support tertiary prevention for clients with osteoporosis?

support development of low-impact physical activity options for those diagnosed with osteoporosis

the nurse provides moist heat for a client with cartilage degeneration. which rational explains the use of this nursing intervention?

to increase blood flow to the area

while assessing a client, the nurse finds inflammation of the skin at the bases of the client's nails. which event or disorder would the nurse associate with the reason behind this condition?

trauma

according to Maslow's hierarchy, which example belongs to the third level of needs?

- a client is depressed bc significant other passed away - a client wants to reconnect with old friends after being diagnosed with cancer - a client never goes to family gatherings bc the family members do not accept the client

a client with a history of cardiac dysrhythmias is admitted to the hospital due to a fluid volume deficit caused by a pulmonary infection. the registered nurse assesses the recorded vitals. which vital sign requires further assessment?

RR of 14 BP of 120/80 O2 of 95

which type of immunity would a 4 y/o child develop during the course of an infection with varicella?

achieve natural immunity

after a below-the-knee amputation, a client is refusing to eat, talk, or perform any rehabilitative activities. which approach would the nurse take when interacting with this client?

acknowledge that the client's withdrawal is an expected and necessary part of initial grieving

which nursing intervention is the priority when a client receiving chemotherapy develops a temperature of 102.2 when the temp 6 hours ago was 99.2?

administer prescribed antipyretic and notify the primary health care provider of this change

a nurse is creating a plan of care for a client with RA who has severe pain and swelling of the hand joints. which details about range-of-motion exercises would the plan include?

apply heat or cold before the exercises

a postmenopausal woman has been administered raloxifene for osteoporosis. which parameter would the nurse assess to ensure the efficacy of the medication and continuation of use?

bone density

which findings are consistent with hypercalcemia after prolonged immobility?

bone pain and depressed deep tendon flexes

a client with a methicillin-resistant Staphylococcus aureus (MRSA) infected wound is scheduled for a CT scan. to ensure client and visitor safety during transport, the nurse would implement which precaution?

cover the infected site with a dressing

which instruction indicates a lack of understanding of a nurse teaching a HIV + client about strategies to prevent opportunistic infections?

purchase organic, unpasteurized apple cider for your vitamin C requirements

the nurse is assessing a client with arthritis. which statement made by the client indicates a precipitating factor?

"i run for 30 minutes every day; this exercise increases my pain."

which function of leukocytes is involved in the inflammation process?

- destruction of bacteria and cellular debris - release of vasoactive amines during allergic reactions

which tasks should the nurse perform to comply with public health laws?

- report cases of communicable diseases - report incidents of domestic violence - ensure that clients in a community have received necessary immunizations

the nurse is collecting a case reports that can be analyzed using the failure mode effective analysis (FMEA) tool. which case files would the nurse collect?

- retained foreign body left during surgery that was removed immediately - wheelchair-bound client rescued from falling in the corridor of the hospital - UTI after 4 days of continuous catheterization

after teaching a male client about measures to maintain sexual health and prevent transmission of STIs, which client statement indicated effective learning?

"i will consult with my primary health care provider when there is a rash or ulcer on my genitalia"

the nurse recommends that, when in bed, a client who has osteoarthritis should lie in the supine or prone position. the client states that these positions are uncomfortable for the knees and hips. which action would the nurse take?

encourage the client to maintain extension for specific periods of time

which position would the nurse utilize to assess the client's hip joint extension and buttocks?

face down

which assessment findings would the nurse identify in a client with clinical manifestations of RA?

- development of antinuclear antibodies - inflammatory disease pattern - bilateral involvement of metacarpophalangeal

a pregnant client is prescribed heparin to prevent the risk of thromboembolism. Which is a possible adverse effect of this medication when used during pregnancy?

- osteoporosis - increased risk of serious bleeding - compression fractures of the spine

identify the clinical manifestation associated with the release of histamine during a type 1 rapid hypersensitivity rxn

- pruritus - erythema - nasal mucus secretion - conjunctival mucus secretion

which option is an example of actively acquired specific immunity?

- recovery from measles - recovery from chickenpox - immunization with live or killed vaccines

which intervention would the nurse anticipate incorporating into the plan of care for a client with bursitis of the left knee?

- rest the affected joint - use a compression splint - take a nonsteroidal NSAID as needed for pain

which physiological change f the musculoskeletal system would the nurse associate with aging?

- slowed movement - cartilage degeneration - increased bone prominence

which findings noted during assessment would lead the nurse to determine that a client is at an increased risk for infection?

- surgical incision - catheter - antibiotic therapy - IV access

which example demonstrates clinical decision-making by the nurse?

"I identified impaired skin integrity in a pressure ulcer document finding redness in a client's hip"

when assessing risk factors, which question would the nurse ask a client who has developed pneumonia?

"are you diabetic?"

arrange the pathophysiological events of acne in the correct sequence

1. excessive sebum production 2. alterations in follicular growth and differentiation 3. colonization of Propionibacterium acnes 4. immune response and inflammation

an adult is taken to the emergency department of the local hospital after stepping on a nail. the nurse asks if the client has a tetanus immunization. adult says all immunizations are up to date. a few days later, the client is admitted to the hospital with a diagnosis of tetanus. which statement describes the nurse's responsibility in this situation?

assessment by the nurse was incomplete and, as a a result, the treatment was insufficient

the nurse is changing the dressing of a postoperative client. another client has fallen near the nursing station and is unconscious. which is the priority action in this situation?

attend to unconscious client

which client would the nurse suspect as having a type IV hypersensitive reaction when providing care for 4 clients with hypersensitivity rxns?

client with erythema and edema after 24 hours

the nurse would include which instruction to the parents of a child being treated with oral ampicillin for otitis media?

complete the entire course of antibiotic therapy

the nurse is completing the health history of a client admitted to the hospital with osteoarthritis. which joint would the nurse expect the client to report as having been involved first?

hips and knees

a 5 month old infant is brought to the pediatric clinic b/c of exposure to an adolescent sibling with measles. which factor would the nurse consider when determining the infant's risk of infection?

maternal diseases and immunizations

the health care provider prescribed raloxifene for a client with osteoporosis. which manifestation would the nurse monitor in this client?

monitor liver function tests

which hormone promotes bone resorption in a client and potentially leads to decreased bone densities?

parathyroid hormone (PTH)

the nurse is caring for a client with chronic inflammation of the bowel. for which most serious complication would the nurse monitor in this client?

perforation

which factor in the client's history increases the risk for osteoporosis?

prolonged immobility

which is the correct response to a parent whose child is undergoing chemotherapy and is not up to date on required immunizations for school?

this isn't the best time to finish the immunizations, because your child's immune system is suppressed

which injury would the nurse suspect in a young adult client who reports that a knee occasionally gives way, sometimes lock, and "clicks" when walking?

torn cartilage

which nursing intervention would prevent septic shock in the hospitalized client?

use septic technique during all invasive procedures

a client with a diagnosis of malabsorption syndrome exhibits a symptom of spastic muscle spasms. which electrolyte is responsible for this symptom?

calcium

the nurse is preparing to insert an IV catheter in a thin, emaciated client who is scheduled to begin intravenous fluid therapy. which interventions would the nurse follow to provide high-quality care?

- flush the IV line with normal saline - stop the insertion procedure when there is a break in technique

the nurse is assessing a client with a moon-shaped face and thin arms and legs. the nurse expects which other assessment findings?

- gastric ulcer - pain in bones - muscle weakness

which surgery is used as a prophylactic measure and as a palliative treatment for clients with rheumatoid arthritis (RA)?

synovectomy

which advice will the nurse provide to the client after a health care provider prescribed aspirin for a client with severe arthritis?

take medication with meals

at which joint would the nurse be able to palpate spongy swelling caused by excess synovial fluid?

temporomandibular joint

an assessment of an 89-year-old client yields a history of severe congenital spinal deformity. which condition would describe the nurse'd findings?

kyphosis

which type of synovial joint movement is involved in moving the client's first and fifth metacarpals anteriorly from the flattened palm?

opposition

which disease process places a client at risk for infection?

- leukemia - lymphoma - emphysema

which information is appropriate for the nurse to include in the education for a group of nursing students regarding near-miss events?

- no actual harm is caused to clients - they are caused by variation in standard care - the cause may be analyzed by a failure modes effects analysis (FMEA)

a client who has RA participates in an individualized exercise program daily. which statement from the client indicated to the nurse that the client understands the purpose of the program?

"i do one set of exercises slowly after breakfast, then i space the rest of them throughout the day."

arrange the steps involved in skin testing for an allergen causing a type 1 allergic reaction in their correct sequence

1. discontinue corticosteroid meds 2. clean the inner side of the forearm with soap and water 3. place drops of sera containing the known allergen on skin 4. use skin testing needle to scratch the surface of the skin 5. observe for a wheal formation on the skin 6. apply topical steroid on the skin

steps required to stimulate antibody-mediated immunity in the correct sequence

1. invasion of new antigens in the body 2. interaction of the macrophage and helper T cells to recognize the antigen 3. sensitization of B lymphocyte to the new antigen 4. production of antibodies by B lymphocytes 5. binding of antibodies to the antigen and formation of immune complex 6. neutralization or elimination of the antigen

the nurse teaches a client about wearing thigh-high antiembolism elastic stockings. which instruction would be correct to include?

"you will need to apply them in the morning before you lowers your legs from the bed to the floor"

you should remain upright 30 minutes after receiving this medication

alendronate

which diagnostic test would be used for the direct visualization of ligaments, menisci, and articular surfaces of joints?

arthroscopy

after teaching a client about the use of calcitonin (nasal route) as treatment for osteoporosis, which client statement indicates effective learning?

"I should not spray the medication into the same nostril on 2 consecutive days"

which response would the nurse provide during an eduction session at the local community center to a question asking why influenza vaccines are needed annually?

"The nature of the virus changes every year; the vaccine is developed based on the most prevalent type and variant being seen."

which response would the nurse give to a client taking ibuprofen for RA who asks the nurse if the acetaminophen can be substituted?

"ibuprofen has anti-inflammatory properties, and acetaminophen does not."

the parent of a newborn asks the nurse why, except for Hep B vax, the immunization schedule does not start until the infant is 2 months old. which response would the nurse provide?

"maternal antibodies interfere with the development of active antibodies by the infant when immunized"

steps to developing protocol in the electric health record for clients with indwelling urinary catheters to decrease risk of UTIs

1. meet with nursing staff 2. selects an assessment tool 3. interviews the nursing staff 4. designs the assessment screens 5. evaluate and determines data 6. selects a standardized language 7. adds a decision support rule

the nurses in a health care facility have developed a new care plan to prevent the risk of infection in clients with an indwelling urinary catheter in place. to determine if the changes prevent infection, the nurse manager uses the plan-of-do-study-act (PDSA). place in order the steps that the nurse manager would follow to evaluate the changes.

1. plan to test change 2. try out change 3. analyze what happened from the change 4. determine what was learned

which recommendation would the nurse make to the family of a child with juvenile idiopathic arthritis who has difficulty getting ready for school due to joint pain and stiffness?

Provide warm, moist heat to the affected joints before arising

which structure protects a client's internal organs, supports blood cell production, and stores minerals?

bones

which finding in older adult client is associated with aging?

decrease in height

to prevent thrombophlebitis in the immediate postoperative period, which action is important for the nurse to include in the client's plan of care?

encourage early mobility

which meal is most appropriate for a client with a large pressure injury?

grilled chicken, steamed spinach, and a side of orange slices

the nurse is teaching unlicensed assistant personnel about ways to prevent the spread of infection. the nurse decides to emphasize the need to break the cycle of infection. which teaching would be priority?

hand washing before and after providing client care

the nurse caring for a client postsurgery takes necessary steps to achieve quality client care. which nursing action satisfies the Quality and Safety Education for Nurses (QSEN) competency called informatics?

- documenting in the EHR after performing would debridement - locking the EHR after every entrance of necessary information - using a computer-assisted instruction program to provide better quality of care to the client

a client arrived at a health clinic reports "I am here to have my TB skin test read." the nurse notes a 7mm indurated area at injection site. which nurse's statement describes this result?

"the result indicates you are infected with TB organism."

the nurse is preparing discharge instructions for a client who acquired a nosocomial C-diff infection. which would the nurse include in the instructions?

The infection causes diarrhea accompanied by flatus and abdominal discomfort

which education would the nurse provide the parent of a 2-month-old infant about home care in the event of an immunization rxn?

give acetaminophen for fever; call health care provider if child exhibits marked drowsiness or seizures

which strategies would the nurse apply when vaccinating a child to decrease pain and anxiety?

- apply a topical anesthetic - injecting the most painful vaccine last - holding the child upright during the vaccination - administering intramuscular injections rapidly without prior aspiration

which finding during a home health visit would prompt the nurse to provide a client with home safety instructions?

- area rugs - clogged fireplace - electrical cords - multiple prescribed meds - wheeled walker with uneven legs

the nurse is caring for a client whose mobility is restricted to a wheelchair after. motor vehicle accident. the client has been prescribed physiotherapy as a part of rehabilitation care. which interventions would the nurse consider when the client is discharged from the health care facility?

- assist family in identifying community support systems - encourage the primary caregiver to set a routine time for respite - consider the primary caregiver's experience in the discharge plan

which complication would the nurse monitor for in a client on strict bed rest for 3 days?

- atlectasis - hypotension - constipation - pressure injuries - urinary tract infection

which condition triggers humoral immunity?

- atopic diseases - bacterial infection - anaphylactic shock

the nurse is interviewing a client who was diagnosed with systemic lupus erythematosus. which clinical findings of this disease would the nurse expect the client to exhibit?

- butterfly facial rash - inflammation of the joints

which infection would the nurse monitor for in the toddler based on structural characteristics at this age?

- ear infection - acute sinusitis -laryngotracheobronchitis - inflammation of the tonsils

a client is admitted to the hospital with severe diarrhea, abdominal cramps, and vomiting for 5 days. upon further assessment, the primary health care provider finds the symptoms occurred after the client ate eggs, salad dressings, and sandwich fillings. which food-borne disease would the provider suspect in this client?

salmonellosis

which synovial joint movement is involved in turning a client's palm downward?

pronation

while assessing an immobilized client, the nurse notes that the client has shortened muscles over a joint, preventing full extension. which is this condition known as?

contracture

for which physiological condition would the nurse teach an older adult client about the isometric exercises?

muscle atrophy

the nurse creates a plan of care for a client with a risk of infection. which is the desirable expected outcome for the client?

the client will be free of signs and symptoms of infection by discharge

which describes the purpose of postoperative antibiotics for a client scheduled for a surgical resection of the colon and the creation of a colostomy?

to decrease bacteria in the intestines

which rationale describes why the nurse would advise a client to have a dental examination before beginning prescribed therapy with zoledronic acid?

to prevent maxillary osteonecrosis

the client is on neutropenic precautions. from which direction does the protective environment isolation help prevent the spread of infection?

to the client from outside sources

how does the skeletal system of a toddler differ from that of an older adult?

toddlers' bones can withstand falls better than the bones of older adults

which activities would be encouraged of a child with juvenile idiopathic arthritis to prevent loss of joint function?

- riding a bike - walking to school - swimming in the community pool

after instructing an older client's adult child about age-related immune system changes and associated care measures, which statement indicated a need for further instruction?

"my parent comes in for check ups only when experiencing a fever"

which information will the nurse consider when planning care for a client with HIV who has been diagnosed with class 3 tuberculosis?

- class 3 tuberculosis is a clinically active disease, which is contagious - tuberculosis is the leading cause of mortality in clients infected with HIV - persons with active tuberculosis are usually treated on an outpatient basis

after a client experiences a cardiac arrest, the client is transferred to the ICU. which nursing intervention is the major attribute that affects the quality of care provided to the client?

- coordinate with the members of the ICU while transferring the client - provide cardiopulmonary resuscitation before transferring the client - administer digoxin to the client according to the prescription

which leukocyte would the nurse include when teaching about antibody-mediated immunity>

- memory cell - b lymphocyte

which action would the nurse instruct an older client to implement to ensure antibody-mediated immunity?

- obtain a shingles vax - receive a tetanus booster injection - obtain the pneumococcal vax - receive an annual flu shot

which therapeutic outcome is expected after administering ibuprofen?

- pain relief - temp reduction - reduced inflammation

which condition is consistent with a client's report of posterior leg pain while walking that worsens upon rest?

tendonitis

a primary health care provider schedules a bone scan for a client with osteoporosis. which nursing action is beneficial for the client?

- placing the client in supine position - instructing the client to empty their bladder before the scan

which scenario would the nurse consider an output component of the nursing process?

- the nurse notices the client's wounds healed after performing regular would debridement - when changing the surgical site dressing, the nurse notices the client developed an infection - the nurse finds the client's blood pressure increased, even with timely medication administration

which synovial joint movement is described as turning the stole away from the midline of the body?

eversion