3 mod 9 msi

The nurse is caring for a 60-year-old female client who sustained a thoracic spinal cord injury 10 years ago. For which potential complication will the nurse assess during this client's care? a. Fracture b. Malabsorption c. Delirium d. Anemia

ANS: A Older adults who have impaired mobility due to a health problem or injury are at risk for complications of immobility, such as osteoporosis (bone loss) which leads to fracture. Being an older woman increases that risk due to loss of estrogen to protect bone loss. The other choices are not problems of immobility. Delirium is possible but is more common in clients over 70 years of age.

A nurse assesses a client who is recovering from an open anterior cervical discectomy and fusion. Which complication would alert the nurse to urgently communicate with the primary health care provider? a. Auscultated stridor b. Weak pedal pulses c. Difficulty swallowing d. Inability to shrug shoulders

ANS: A Postoperative swelling can narrow the trachea, cause a partial airway obstruction, and manifest as stridor. The client may also have trouble swallowing, but maintaining an airway takes priority. Weak pedal pulses and an inability to shrug the shoulders are not complications of this surgery.

ANS: A, B A positive Ortolani test and unequal gluteal folds are clinical manifestations of developmental dysplasia of the hip seen from birth to 2 to 3 months. Unequal gluteal folds, negative Babinski sign, and Trendelenburg sign are signs that appear in older infants and children. Telescoping of the affected limb and lordosis are not clinical manifestations of developmental dysplasia of the hip.

1. The nurse is caring for an infant with developmental dysplasia of the hip. Which clinical manifestations should the nurse expect to observe? (Select all that apply.) a. Positive Ortolani click b. Unequal gluteal folds c. Negative Babinski sign d. Trendelenburg sign e. Telescoping of the affected limb f. Lordosis

ANS: D Wet casts should be handled by the palms of the hands, not the fingers, to avoid creating pressure points. Assessing dryness, facilitating easy turning, and keeping the patient's limb balanced are not reasons for using the palms of the hand rather than the fingers when handling a wet cast.

10. The nurse uses the palms of the hands when handling a wet cast for which reason? a. To assess dryness of the cast b. To facilitate easy turning c. To keep the patient's limb balanced d. To avoid indenting the cast

ANS: D The physiologic effects of immobilization, as a result of decreased muscle contraction, include venous stasis. This can lead to pulmonary emboli or thrombi. The metabolic rate decreases with immobilization. Loss of joint mobility leads to contractures. Bone demineralization with osteoporosis and hypercalcemia occur with immobilization.

1. The nurse is caring for a 4-year-old child immobilized by a fractured hip. Which complication should the nurse monitor related to the child's immobilization status? a. Metabolic rate increases b. Increased joint mobility leading to contractures c. Bone calcium increases, releasing excess calcium into the body (hypercalcemia) d. Venous stasis leading to thrombi or emboli formation

ANS: D If hot spots are felt on the cast surface, they usually indicate infection beneath the area. This should be reported so that a window can be made in the cast to observe the site. The five Ps of ischemia from a vascular injury are pain, pallor, pulselessness, paresthesia, and paralysis. Paresthesia is an indication of vascular injury, not infection. Cold toes may be indicative of too tight a cast and need further evaluation. Increased respirations may be indicative of a respiratory tract infection or pulmonary emboli. This should be reported, and child should be evaluated.

11. Which should cause a nurse to suspect that an infection has developed under a cast? a. Complaint of paresthesia b. Cold toes c. Increased respirations d. "Hot spots" felt on cast surface

ANS: A Simple soaking in the bathtub is usually sufficient for the removal of the desquamated skin and sebaceous secretions. It may take several days to eliminate the accumulation completely. The parents and child should be advised not to scrub the leg vigorously or forcibly remove this material because it may cause excoriation and bleeding. Oil or lotion, but not powder, may provide comfort for the child.

12. A child is upset because when the cast is removed from her leg, the skin surface is caked with desquamated skin and sebaceous secretions. Which should the nurse suggest to remove this material? a. Soak in a bathtub. b. Vigorously scrub leg. c. Apply powder to absorb material. d. Carefully pick material off leg.

ANS: B When the muscles are stretched, muscle spasm ceases and permits realignment of the bone ends. The continued maintenance of traction is important during this phase because releasing the traction allows the muscle's normal contracting ability to again cause malpositioning of the bone ends. Continuous traction must be maintained to keep the bone ends in satisfactory realignment. Releasing at any time, either 1 hour before surgery, once every hour for skin care, or once every 8 hours would not keep the fracture in satisfactory alignment.

13. An adolescent with a fractured femur is in Russell's traction. Surgical intervention to correct the fracture is scheduled for the morning. Nursing actions should include which action? a. Maintaining continuous traction until 1 hour before the scheduled surgery b. Maintaining continuous traction and checking position of traction frequently c. Releasing traction every hour to perform skin care d. Releasing traction once every 8 hours to check circulation

ANS: D Buck extension traction is a type of skin traction with the legs in an extended position. It is used primarily for short-term immobilization, preoperatively with dislocated hips, for correcting contractures, or for bone deformities such as Legg-Calvé-Perthes disease. Dunlop traction is an upper-extremity traction used for fractures of the humerus. Bryant traction is skin traction with the legs flexed at a 90-degree angle at the hip. Russell traction uses skin traction on the lower leg and a padded sling under the knee. The combination of longitudinal and perpendicular traction allows realignment of the lower extremity and immobilizes the hips and knees in a flexed position.

14. Which is a type of skin traction with the legs in an extended position? a. Dunlop b. Bryant c. Russell d. Buck extension

ANS: C Russell traction uses skin traction on the lower leg and a padded sling under the knee. The combination of longitudinal and perpendicular traction allows realignment of the lower extremity and immobilizes the hips and knees in a flexed position. Dunlop traction is an upper-extremity traction used for fractures of the humerus. Bryant traction is skin traction with the legs flexed at a 90-degree angle at the hip. Buck extension traction is a type of skin traction with the legs in an extended position. It is used primarily for short-term immobilization, preoperatively with dislocated hips, for correcting contractures, or for bone deformities such as Legg-Calvé-Perthes disease.

15. Which type of traction uses skin traction on the lower leg and a padded sling under the knee? a. Dunlop b. Bryant c. Russell d. Buck extension

ANS: A The absence of a pulse and change in color of the foot must be reported immediately for evaluation by the practitioner. Pain medication should be given after the practitioner is notified. Legg-Calvé-Perthes disease is an emergency condition; immediate reporting is indicated. The findings should be documented with ongoing assessment.

16. Four-year-old David is placed in Buck extension traction for Legg-Calvé-Perthes disease. He is crying with pain as the nurse assesses that the skin of his right foot is pale with an absence of pulse. Which action should the nurse take first? a. Notify the practitioner of the changes noted. b. Give the child medication to relieve the pain. c. Reposition the child and notify physician. d. Chart the observations and check the extremity again in 15 minutes.

ANS: B Traction places stress on the affected bone, joint, and muscles. The nurse must assess for tightness, weakness, or contractures developing in the uninvolved joints and muscles. The adhesive straps should be released or replaced only when absolutely necessary. Active, passive, or active with resistance exercises should be carried out for the unaffected extremity only. Movement is expected with children. Each time the child moves, the nurse should check to ensure that proper alignment is maintained.

17. Which is an appropriate nursing intervention when caring for a child in traction? a. Remove adhesive traction straps daily to prevent skin breakdown. b. Assess for tightness, weakness, or contractures in uninvolved joints and muscles. c. Provide active range-of-motion exercises to affected extremity three times a day. d. Keep the child in one position to maintain good alignment.

ANS: C Infants have a rapid growth pattern. The child needs to be assessed by the practitioner every 1 to 2 weeks for possible adjustments. Lotions and powders should not be used with the harness. The harness should not be removed, except as directed by the practitioner. A thin disposable diaper can be placed under the harness.

18. The nurse is teaching a family how to care for their infant in a Pavlik harness to treat developmental dysplasia of the hip. Which should be included? a. Apply lotion or powder to minimize skin irritation. b. Remove harness several times a day to prevent contractures. c. Return to clinic every 1 to 2 weeks. d. Place diaper over harness, preferably using a superabsorbent disposable diaper that is relatively thin.

ANS: C Serial casting is begun shortly after birth before discharge from nursery. Successive casts allow for gradual stretching of skin and tight structures on the medial side of the foot. Manipulation and casting of the leg are repeated frequently (every week) to accommodate the rapid growth of early infancy. Serial casting is the preferred treatment. Surgical intervention is done only if serial casting is not successful. Children do not improve without intervention.

19. A neonate is born with bilateral mild talipes equinovarus (clubfoot). When the parents ask the nurse how this will be corrected, the nurse should give which explanation? a. Traction is tried first. b. Surgical intervention is needed. c. Frequent, serial casting is tried first. d. Children outgrow this condition when they learn to walk.

ANS: A, B Abatacept reduces inflammation by inhibiting T cells and is given intravenously every 4 weeks. Possible side effects of biologics include an increased infection risk. Because of the infection risk, children should be evaluated for tuberculosis exposure before starting these medications. Live vaccines should be avoided while taking these agents.

2. An adolescent with juvenile idiopathic arthritis (JIA) is prescribed abatacept (Orencia). Which should the nurse teach the adolescent regarding this medication? (Select all that apply.) a. Avoid receiving live immunizations while taking the medication. b. Before beginning this medication, a tuberculin screening test will be done. c. You will be getting a twice-a-day dose of this medication. d. This medication is taken orally.

ANS: B Immobilization causes a decreased metabolic rate with slowing of all systems and a decreased food intake. Immobilization leads to hypercalcemia and causes a negative nitrogen balance secondary to muscle atrophy. A decreased production of stress hormones occurs with decreased physical and emotional coping capacity.

2. The nurse is caring for a preschool child immobilized by a spica cast. Which effect on metabolism should the nurse monitor on this child related to the immobilized status? a. Hypocalcemia b. Decreased metabolic rate c. Positive nitrogen balance d. Increased production of stress hormones

ANS: D The family needs to learn the purpose, function, application, and care of the corrective device and the importance of compliance to achieve the desired outcome. The initial therapy is rest and non-weight bearing, which helps reduce inflammation and restore motion. Legg-Calvé-Perthes is a disease with an unknown etiology. A disturbance of circulation to the femoral capital epiphysis produces an ischemic aseptic necrosis of the femoral head. The disease is self-limiting, but the ultimate outcome of therapy depends on early and efficient therapy and the child's age at onset.

20. A 4-year-old child is newly diagnosed with Legg-Calvé-Perthes disease. Nursing considerations should include which action? a. Encouraging normal activity for as long as is possible b. Explaining the cause of the disease to the child and family c. Preparing the child and family for long-term, permanent disabilities d. Teaching the family the care and management of the corrective appliance

ANS: D Kyphosis is an abnormally increased convex angulation in the curve of the thoracic spine. Scoliosis is a complex spinal deformity usually involving lateral curvature, spinal rotation causing rib asymmetry, and thoracic hypokyphosis. Ankylosis is the immobility of a joint. Lordosis is an exaggerated concave lumbar curvature of the spine.

21. The nurse is taking care of an adolescent diagnosed with kyphosis. Which describes this condition? a. Lateral curvature of the spine b. Immobility of the shoulder joint c. Exaggerated concave lumbar curvature of the spine d. Increased convex angulation in the curve of the thoracic spine

ANS: C Idiopathic scoliosis is most noticeable during the preadolescent growth spurt. Idiopathic scoliosis is seldom apparent before age 10 years. Diagnosis usually occurs during the preadolescent growth spurt.

22. A school nurse is conducting a staff in-service to other school nurses on idiopathic scoliosis. During which period of child development does idiopathic scoliosis become most noticeable? a. Newborn period b. When child starts to walk c. Preadolescent growth spurt d. Adolescence

ANS: A Surgical spinal instrumentation is a surgical procedure. A chest tube and urinary catheterization may be required. Ambulation is allowed as soon as possible. Depending on the instrumentation used, most patients walk by the second or third postoperative day. Casting and bracing are required postoperatively. The child usually has considerable pain for the first few days after surgery. Intravenous opioids should be administered on a regular basis.

23. The nurse is preparing an adolescent with scoliosis for a spinal surgical instrumentation placement procedure. Which consideration should the nurse include? a. A chest tube and urinary catheter may be required. b. Ambulation will not be allowed for up to 3 months. c. Surgery eliminates the need for casting and bracing. d. Discomfort can be controlled with nonpharmacologic methods.

ANS: D NSAIDs are the first drugs used in JIA. Naproxen, ibuprofen, and tolmetin are approved for use in children. Aspirin, once the drug of choice, has been replaced by the NSAIDs because they have fewer side effects and easier administration schedules. Corticosteroids are used for life-threatening complications, incapacitating arthritis, and uveitis. Methotrexate is a second-line therapy for JIA.

24. Which medication is usually tried first when a child is diagnosed with juvenile idiopathic arthritis (JIA)? a. Aspirin b. Corticosteroids c. Cytotoxic drugs such as methotrexate d. Nonsteroidal antiinflammatory drugs (NSAIDs)

ANS: C The management of JIA is primarily pharmacologic. The family should be instructed regarding administration of medications and the value of a regular schedule of administration to maintain a satisfactory blood level in the body. They need to know that NSAIDs should not be given on an empty stomach and to be alert for signs of toxicity. Warm moist heat is best for relieving stiffness and pain. Acetaminophen does not have antiinflammatory effects. Range-of-motion exercises should not be done during periods of inflammation.

25. The nurse is caring for a school-age child diagnosed with juvenile idiopathic arthritis (JIA). Which intervention should be a priority? a. Apply ice packs to relieve stiffness and pain. b. Administer acetaminophen to reduce inflammation. c. Teach the child and family correct administration of medications. d. Encourage range-of-motion exercises during periods of inflammation.

ANS: C Use of the overhead bed trapeze should be encouraged to begin to build up the arm muscles necessary for walking with crutches. Stump elevation may be used during the first 24 hours, but after this time, the extremity should not be left in this position because contractures in the proximal joint will develop and seriously hamper ambulation. Ice would not be an appropriate intervention and would decrease circulation to the stump. Stump shaping is done postoperatively with special elastic bandaging using a figure-eight bandage, which applies pressure in a cone-shaped fashion. This technique decreases stump edema, controls hemorrhage, and aids in developing desired contours so the child will bear weight on the posterior aspect of the skin flap rather than on the end of the stump. This wrap should not be replaced with a gauze dressing.

26. The nurse is caring for a 12-year-old child with a left leg below-the-knee amputation (BKA). The child had the surgery 1 week ago. Which intervention should the nurse plan to implement for this child? a. Elevate the left stump on a pillow. b. Place an ice pack on the stump. c. Encourage the child to use an overhead bed trapeze when repositioning. d. Replace the ace wrap covering the stump with a gauze dressing.

ANS: C The treatment for OI is primarily supportive. Although patients and families are optimistic about new research advances, there is no cure. The use of bisphosphonate therapy with IV pamidronate to promote increased bone density and prevent fractures has become standard therapy for many children with OI; however, long bones are weakened by prolonged treatment. Infants and children with this disorder require careful handling to prevent fractures. They must be supported when they are being turned, positioned, moved, and held. Even changing a diaper may cause a fracture in severely affected infants. These children should never be held by the ankles when being diapered but should be gently lifted by the buttocks or supported with pillows. Follow-up appointments for treatment with bisphosphonate can be expected.

27. A nurse is conducting discharge teaching for parents of an infant with osteogenesis imperfecta (OI). Further teaching is indicated if the parents make which statement? a. "We will be very careful handling the baby." b. "We will lift the baby by the buttocks when diapering." c. "We're glad there is a cure for this disorder." d. "We will schedule follow-up appointments as instructed."

ANS: A Amitriptyline (Elavil) has been used successfully to decrease phantom limb pain. Opioids such as Vicodin or OxyContin would not be prescribed for this pain. A benzodiazepine such as Xanax would not be prescribed for this type of pain.

28. The nurse is caring for an adolescent with osteosarcoma being admitted to undergo chemotherapy. The adolescent had a right above-the-knee amputation 2 months ago and has been experiencing "phantom limb pain." Which prescribed medication is appropriate to administer to relieve phantom limb pain? a. Amitriptyline (Elavil) b. Hydrocodone (Vicodin) c. Oxycodone (OxyContin) d. Alprazolam (Xanax)

ANS: A, B Key issues for a child with SLE include therapy compliance; body-image problems associated with rash, hair loss, and steroid therapy; school attendance; vocational activities; social relationships; sexual activity; and pregnancy. Specific instructions for avoiding exposure to the sun and UVB light, such as using sunscreens, wearing sun-resistant clothing, and altering outdoor activities, must be provided with great sensitivity to ensure compliance while minimizing the associated feeling of being different from peers. The child should continue school attendance in order to gain interaction with peers, and activity should not be restricted but promoted.

3. A school-age child is diagnosed with systemic lupus erythematosus (SLE). The nurse should plan to implement which interventions for this child? (Select all that apply.) a. Instructions to avoid exposure to sunlight b. Teaching about body changes associated with SLE c. Preparation for home schooling d. Restricted activity

ANS: A The physiologic effects of immobilization, as a result of decreased muscle contraction, include venous stasis. This can lead to pulmonary emboli or thrombi. A decreased vasopressor mechanism results in orthostatic hypotension, syncope, hypotension, decreased cerebral blood flow, and tachycardia. An altered distribution of blood volume is found with decreased cardiac workload and exercise tolerance. Immobilization causes a decreased efficiency of orthostatic neurovascular reflexes with an inability to adapt readily to the upright position and with pooling of blood in the extremities in the upright position.

3. The nurse should monitor for which effect on the cardiovascular system when a child is immobilized? a. Venous stasis b. Increased vasopressor mechanism c. Normal distribution of blood volume d. Increased efficiency of orthostatic neurovascular reflexes

ANS: C, D, E Indications of compartment syndrome are severe pain not relieved by analgesics, tingling of extremity, and inability to move extremity. A palpable distal pulse and capillary refill to the extremity less than 3 seconds are expected findings.

4. The nurse is caring for a preschool child with a cast applied recently for a fractured tibia. Which assessment findings indicate possible compartment syndrome? (Select all that apply.) a. Palpable distal pulse b. Capillary refill to extremity less than 3 seconds c. Severe pain not relieved by analgesics d. Tingling of extremity e. Inability to move extremity

ANS: A Bone demineralization leads to a negative calcium balance, osteoporosis, pathologic fractures, extraosseous bone formation, and renal calculi. Urinary retention is secondary to the effect of immobilization on the urinary tract. Pooling of blood is a result of the cardiovascular effects of immobilization. Susceptibility to infection can result from the effects of immobilization on the respiratory and renal systems.

4. Which can result from the bone demineralization associated with immobility? a. Osteoporosis b. Urinary retention c. Pooling of blood d. Susceptibility to infection

ANS: A Soft-tissue injuries should be iced immediately. In addition to ice, the extremity should be rested, be elevated, and have compression applied. Observing for edema and discoloration, encouraging the child to assume a position of comfort, and obtaining parental permission for administration of acetaminophen or aspirin are not immediate priorities. The application of ice can reduce the severity of the injury.

5. A young girl has just injured her ankle at school. In addition to calling the child's parents, what is the most appropriate immediate action by the school nurse? a. Apply ice. b. Observe for edema and discoloration. c. Encourage child to assume a position of comfort. d. Obtain parental permission for administration of acetaminophen or aspirin.

ANS: A If a fracture does not produce a break in the skin, it is called a simple, or closed, fracture. A compound, or open, fracture is one with an open wound through which the bone protrudes. A complicated fracture is one in which the bone fragments damage other organs or tissues. A comminuted fracture occurs when small fragments of bone are broken from the fractured shaft and lie in the surrounding tissue. These are rare in children.

6. Which term is used to describe a type of fracture that does not produce a break in the skin? a. Simple b. Compound c. Complicated d. Comminuted

ANS: B Detection of epiphyseal injuries is sometimes difficult, but fractures involving the epiphysis or epiphyseal plate present special problems in determining whether bone growth will be affected. Healing of epiphyseal injuries is usually prompt. The epiphysis is the weakest point of the long bones. This is a frequent site of damage during trauma.

7. Kristin, age 10 years, sustained a fracture in the epiphyseal plate of her right fibula when she fell off of a tree. When discussing this injury with her parents, the nurse should consider which statement? a. Healing is usually delayed in this type of fracture. b. Growth can be affected by this type of fracture. c. This is an unusual fracture site in young children. d. This type of fracture is inconsistent with a fall.

ANS: B A synthetic casting material dries in 5 to 30 minutes as compared with a plaster cast, which takes 10 to 72 hours to dry. Synthetic casts are more expensive and have a rough exterior, which may scratch surfaces. Plaster casts mold closer to body parts.

8. The nurse is conducting a staff in-service on casts. Which is an advantage to using a fiberglass cast instead of a plaster of Paris cast? a. Cheaper b. Dries rapidly c. Molds closely to body parts d. Smooth exterior

ANS: D The injured extremity should be kept elevated while resting and in a sling when upright. This will increase venous return. Swelling of the fingers may indicate neurovascular damage and should be reported immediately. Permanent damage can occur within 6 to 8 hours. Joints above and below the cast on the affected extremity should be moved. The affected limb should not hang down for any length of time.

9. The nurse is conducting teaching to parents of a 7-year-old child who fractured an arm and is being discharged with a cast. Which instruction should be included in the teaching? a. Swelling of the fingers is to be expected for the next 48 hours. b. Immobilize the shoulder to decrease pain in the arm. c. Allow the affected limb to hang down for 1 hour each day. d. Elevate casted arm when resting and when sitting up.

A client who has multiple sclerosis reports increased severe muscle spasticity and tremors. What nursing action is most appropriate to manage this client's concern? a. Request a prescription for an antispasmodic drug such as baclofen. b. Prepare the client for deep brain stimulation surgery. c. Refer the client to a massage therapist to relax the muscles. d. Consult with the occupational therapist for self-care assistance.

A

After teaching a client with a high thoracic spinal cord injury, the nurse assesses the client's understanding. Which statement by the client indicates a correct understanding of how to prevent respiratory problems at home? a. "I'll use my incentive spirometer every 2 hours while I'm awake." b. "I'll drink thinned fluids to prevent choking." c. "I'll take cough medicine to prevent excessive coughing." d. "I'll position myself on my right side so I don't aspirate."

ANS: A The client with a cervical or high thoracic spinal cord injury typically has weak intercostal muscles and is at higher risk for developing atelectasis and stasis pneumonia. Using an incentive spirometer every 2 hours helps the client expand the lungs more fully and helps prevent atelectasis and other respiratory problems. Clients should drink fluids that they can tolerate; usually thick fluids are easier to tolerate. The client would be encouraged to cough and clear secretions, and placed in high-Fowler position to prevent aspiration.

9. A nurse plans care for a client who is experiencing dyspnea and must stop multiple times when climbing a flight of stairs. Which intervention would the nurse include in this client's plan of care? a. Assistance with activities of daily living b. Physical therapy activities every day c. Oxygen therapy at 2 L per nasal cannula d. Complete bedrest with frequent repositioning

ANS: A A client with dyspnea and the inability to complete activities such as climbing a flight of stairs without pausing has class IV dyspnea. The nurse would provide assistance with activities of daily living. These clients would be encouraged to participate in activities as tolerated. They would not be on complete bedrest, may not be able to tolerate daily physical therapy, and only need oxygen if hypoxia is present.

12. A nurse auscultates a harsh hollow sound over a client's trachea and larynx. What action would the nurse take first? a. Document the findings. b. Administer oxygen therapy. c. Position the client in high-Fowler position. d. Administer prescribed albuterol

ANS: A Bronchial breath sounds, including harsh, hollow, tubular, and blowing sounds, are a normal finding over the trachea and larynx. The nurse would document this finding. There is no need to implement oxygen therapy, administer albuterol, or change the client's position because the finding is normal

A nurse is assessing a client's history of particular matter exposure. What questions are consistent with the I PREPARE tool? (Select all that apply.) a. Investigate all history of known exposures. b. Determine if breathing problems are worse at work. c. Ask the client what type of heating is in the home. d. Gather details about the geographic location of the client's home. e. Have client list all previous jobs and work experiences. f. Assess what hobbies the client and family enjoy

ANS: A, B, C, D, E, F All questions are appropriate for the I PREPARE model of particulate matter exposure. The R and final E stands for resources/referrals and educate.

While obtaining a client's health history, the client states, "I am allergic to avocados, molds, and grass." Which responses by the nurse are best? (Select all that apply.) a. "What happens when you are exposed to those things? b. "How do you treat these allergies?" c. "When was the last time you ate foods containing avocados?" d. "I will document this in your record so all so everyone knows." e. "Have you ever been in the hospital after an allergic response?" f. "How do manage to avoid grass and mold?"

ANS: A, B, D, E Nurses would assess clients who have allergies for the specific cause, treatment, and response to treatment. The nurse would also document the allergies in a prominent place in the client's medical record. Asking about the last time the client ate avocados does not provide any pertinent information for the client's plan of care. Asking how a client manages to avoid environmental allergies in this fashion also does not provide any pertinent information.

The nurse is taking a history on an older adult. Which factors would the nurse assess as potential risks for low back pain? (Select all that apply.) a. Scoliosis b. Spinal stenosis c. Hypocalcemia d. Osteoporosis e. Osteoarthritis

ANS: A,B,C,D,E All of these factors place the client at risk for low back pain due to changes in spinal alignment, loss of bone, or joint degeneration. Bone loss worsens if serum calcium levels are below normal.

A nurse assesses a client who is prescribed varenicline for smoking cessation. Which signs or symptoms would the nurse identify as adverse effects of this medication? (Select all that apply.) a. Visual hallucinations b. Tachycardia c. Decreased cravings d. Manic behavior e. Increased thirst f. Orangish urine

ANS: A, D Varenicline has a black box warning stating that the drug can cause manic behavior and hallucinations. The nurse would assess for changes in behavior and thought processes, including manic behaviors and visual hallucinations. Tachycardia, increased thirst, and orange-colored urine are not adverse effects of this medication. Decreased cravings are a therapeutic response to this medication.

3. A nurse collaborates with a respiratory therapist to complete pulmonary function tests (PFTs) for a client. Which statements would the nurse include in communications with the respiratory therapist prior to the tests? (Select all that apply.) a. "I held the client's morning bronchodilator medication." b. "The client is ready to go down to radiology for this examination." c. "Physical therapy states the client can run on a treadmill." d. "I advised the client not to smoke for 6 hours prior to the test." e. "The client is alert and can follow your commands."

ANS: A, D, E To ensure that the PFTs are accurate, the therapist needs to know that no bronchodilators have been administered in the past 4 to 6 hours (depending on the suspected cause), the client did not smoke within 6 to 8 hours prior to the test, and the client can follow basic commands, including different breathing maneuvers. The respiratory therapist can perform PFTs at the bedside or the respiratory lab. A treadmill is not used for this test.

A nurse teaches a client who is interested in smoking cessation. Which statements would the nurse include in this client's teaching? (Select all that apply.) a. "Find an activity that you enjoy and will keep your hands busy." b. "Keep snacks like potato chips on hand to nibble on." c. "Identify a consequence for yourself in case you backslide." d. "Drink at least eight glasses of water each day." e. "Make a list of reasons you want to stop smoking." f. "Set a quit date and stick to it."

ANS: A, D, E, F The nurse would teach a client who is interested in smoking cessation to find an activity that keeps the hands busy, to keep healthy snacks on hand to nibble on, to drink at least eight glasses of water each day, to make a list of reasons for quitting smoking, and to set a firm quit date and stick to it. The nurse would also encourage the client not to be upset if he or she backslides and has a cigarette but to try to determine what conditions caused him or her to smoke.

A nurse assesses a client who is recovering from an open traditional anterior cervical fusion. Which assessment findings would alert the nursing to a complication from this procedure? (Select all that apply.) a. Difficulty swallowing b. Hoarse voice c. Constipation d. Bradycardia e. Hypertension

ANS: A,B Complications of the open traditional anterior cervical discectomy and fusion include dysphagia and hoarseness. Constipation, bradycardia, and hypertension are not complications of this procedure.

A nurse assesses a client who experienced a spinal cord injury at the T5 level 12 hours ago. Which assessment findings would the nurse correlate with neurogenic shock? (Select all that apply.) a. Heart rate of 34 beats/min b. Blood pressure of 185/65 mm Hg c. Urine output less than 30 mL/hr d. Decreased level of consciousness e. Increased oxygen saturation

ANS: A,C,D Neurogenic shock with acute spinal cord injury manifests with decreased oxygen saturation, symptomatic bradycardia, decreased level of consciousness, decreased urine output, and hypotension.

A nurse assesses a client who recently experienced a traumatic spinal cord injury. Which assessment data would the nurse obtain to assess the client's coping strategies? (Select all that apply.) a. Spiritual beliefs b. Level of pain c. Family support d. Level of independence e. Annual income f. Previous coping strategies

ANS: A,C,D,F

A nurse promotes the prevention of lower back pain by teaching clients at a community center. Which statement(s) would the nurse include in this education? (Select all that apply.) a. "Participate in an exercise program to strengthen back muscles." b. "Purchase a mattress that allows you to adjust the firmness." c. "Wear flat instead of high-heeled shoes to work each day." d. "Keep your weight within 20% of your ideal body weight." e. "Avoid prolonged standing or sitting, including driving."

ANS: A,C,E Exercise can strengthen back muscles, reducing the incidence of low back pain. Women should avoid wearing high-heeled shoes because they cause misalignment of the back. Prolonged standing and sitting should also be avoided. The other options will not prevent low back pain.

A nurse assesses cerebrospinal fluid leaking onto a client's surgical dressing. What actions would the nurse take? (Select all that apply.) a. Place the client in a flat position. b. Monitor vital signs for hypotension. c. Utilize a bedside commode. d. Assess for abdominal distension. e. Report the leak to the surgeon.

ANS: A,E If cerebrospinal fluid (CSF) is leaking from a surgical wound, the nurse would place the client in a flat position and contact the surgeon for repair of the leak. Hypotension and abdominal distension are not complications of CSF leakage.

A client who had a complete spinal cord injury at level L5-S1 is admitted with a sacral pressure injury. What other assessment finding will the nurse anticipate for this client? a. Quadriplegia b. Flaccid bowel c. Spastic bladder d. Tetraparesis

ANS: B A low-level complete spinal cord injury (SCI) is a lower motor neuron injury because the reflect arc is damaged. Therefore, the client would be expected to have paraplegia and a flaccid bowel and bladder. Quadriplegia and tetraparesis are seen in clients with cervical or high thoracic SCIs.

A nurse assesses the health history of a client who is prescribed ziconotide for chronic low back pain. Which assessment question would the nurse ask? a. "Are you taking a nonsteroidal anti-inflammatory drug?" b. "Have you been diagnosed with a mental health problem?" c. "Are you able to swallow oral medications?" d. "Do you smoke cigarettes or any illegal drugs?"

ANS: B Clients who have a severe mental health or behavioral health problem would not take ziconotide because the drug can cause psychotic symptoms such as hallucinations. The other questions do not identify a contraindication for this medication.

A nurse teaches a client who is recovering from an open traditional cervical spinal fusion. Which statement would the nurse include in this client's postoperative instructions? a. "Only lift items that are 10 lb (4.5 kg) or less." b. "Wear your neck brace whenever you are out of bed." c. "You must remain in bed for 3 weeks after surgery." d. "You will be prescribed medications to prevent graft rejection."

ANS: B Clients who undergo spinal fusion are fitted with a neck brace that they must wear throughout GRADESLAB.COM the healing process whenever they are out of bed. The client should not lift anything more than 10 lb (4.5 kg). The client does not need to remain in bed. Medications for rejection prevention are not necessary for this procedure.

A client is scheduled for a percutaneous endoscopic lumbar discectomy. Which statement by the client indicates a need for further teaching? a. "I should have a lot less pain after surgery." b. "I'll be in the hospital for 2 to 3 days." c. "I should not have any major surgical complications." d. "I could possibly get an infection after surgery."

ANS: B Percutaneous endoscopic discectomy is a minimally invasive surgical procedure that requires a shorter hospital stay (23 hours or less) when compared to open traditional surgery. The risk for surgical complications is very low and clients experience less far pain from this procedure. However, due to interrupting skin integrity, infection may occur at the surgical site.

5. A nurse is assessing a client who is recovering from a lung biopsy. The client's breath sounds are absent. While another nurse calls the Rapid Response Team, what action by the nurse takes is most important? a. Take a full set of vital signs. b. Obtain pulse oximetry reading. c. Ask the patient about hemoptysis. d. Inspect the biopsy site.

ANS: B Absent breath sounds may indicate that the client has a pneumothorax, a serious complication after a needle biopsy or open lung biopsy. The nurse would first obtain a pulse oximetry reading and perform other respiratory assessments. Temperature is not a priority. The nurse can ask about other symptoms while conducting the assessment. The nurse would assess the biopsy site and/or dressings, but this is not the first action.

11. A nurse is caring for a client who received benzocaine spray prior to a recent bronchoscopy. The client presents with continuous cyanosis even with oxygen therapy. What action would the nurse take next? a. Administer an albuterol treatment. b. Notify the Rapid Response Team. c. Assess the client's peripheral pulses. d. Obtain blood and sputum cultures

ANS: B Cyanosis unresponsive to oxygen therapy is a sign of methemoglobinemia, which is an adverse effect of benzocaine spray. This condition can lead to death. The nurse would notify the Rapid Response Team to provide advanced care. An albuterol treatment would not address the client's oxygenation problem. Assessment of pulses and cultures will not provide data necessary to treat the client.

4. A nurse observes that a client's anteroposterior (AP) chest diameter is the same as the lateral chest diameter. Which question would the nurse ask the client in response to this finding? a. "Are you taking any medications or herbal supplements?" b. "Do you have any chronic breathing problems?" c. "How often do you perform aerobic exercise?" d. "What is your occupation and what are your hobbies?"

ANS: B The normal chest has an anteroposterior (AP or front-to-back) diameter ratio with the lateral (side-to-side) diameter. This ratio normally is about 1:1.5. When the AP diameter approaches the lateral diameter, and the ratio is 1:1, the client is said to have a barrel chest. Most commonly, barrel chest occurs as a result of a long-term chronic airflow limitation problem, such as chronic emphysema. It can also be seen in people who have lived at a high altitude for many years. Medications, herbal supplements, and aerobic exercise are not associated with a barrel chest. Although occupation and hobbies may expose a client to irritants that can cause chronic lung disorders and barrel chest, asking about chronic breathing problems is more direct and would be asked first

19. A nurse prepares a client who is scheduled for a bronchoscopy with transbronchial biopsy procedure at 9:00 AM (0900). What actions would the nurse take? (Select all that apply.) a. Provide a clear liquid breakfast. b. Verify that the informed consent was obtained. c. Document the client's allergies. d. Review laboratory results. e. Hold the client's bronchodilator. f. Monitor the client for at least 24 hours afterwards

ANS: B, C, D, F Prior to a bronchoscopy, the nurse would verify that the informed consent was obtained, keep the client NPO for 4 to 8 hours prior to the procedure or per agency policy to prevent aspiration, document allergies, and review laboratory results including complete blood count and bleeding times. There is no reason to hold the client's bronchodilator prior to this procedure. The nurse will monitor the client at least every 4 hours for 24 hours

A nurse assesses a client who is recovering from a thoracentesis. Which assessment findings would alert the nurse to a potential pneumothorax? (Select all that apply.) a. Bradycardia b. New-onset cough c. Purulent sputum d. Tachypnea e. Pain with respirations f. Rapid, shallow respirations

ANS: B, D, E Symptoms of a pneumothorax include tachycardia, tachypnea, new-onset "nagging" cough, and pain that is worse at the end of inhalation and the end of exhalation on the affected side. Additional symptoms include trachea slanted to the unaffected side, cyanosis, and the affected side of the chest that does not move in and out with respirations. Purulent sputum is a symptom of infection.

A nurse plans care for a client with a halo fixator. Which interventions would the nurse include in this client's plan of care? (Select all that apply.) a. Remove the vest for client bathing. b. Assess the pin sites for signs of infection. c. Loosen the pins when sleeping. d. Decrease the patient's oral fluid intake. e. Assess the chest and back for skin breakdown.

ANS: B,E The nurse would assess the pin sites for signs of infection or loose pins. The nurse would also assess the client's chest and back for skin breakdown from the halo vest. The vest is not removed for bathing and the pins are not intentionally loosened.

A nurse assesses a client with a spinal cord injury at level T5. The client's blood pressure is 184/95 mm Hg, and the client presents with a flushed face and blurred vision. After raising the head of the bed, what action would the nurse take next? a. Initiate oxygen via a nasal cannula. b. Recheck the client's blood pressure. c. Palpate the bladder for distention. d. Administer a prescribed beta blocker.

ANS: C The client is manifesting symptoms of autonomic dysreflexia. Common causes include bladder distention, tight clothing, increased room temperature, and fecal impaction. If persistent, the client could experience neurologic injury such as s stroke. The other actions are not appropriate for this complication.

A nurse cares for a client with a spinal cord injury. With which interprofessional health team member would the nurse collaborate to assist the client with activities of daily living? a. Social worker b. Physical therapist c. Occupational therapist d. Case manager

ANS: C The occupational therapist instructs the patient in the correct use of all adaptive equipment. In collaboration with the therapist, the nurse instructs family members or the caregiver about transfer skills, feeding, bathing, dressing, positioning, and skin care. The other team members are consulted to assist the client with other issues.

2. A nurse assesses a client after an open lung biopsy. Which assessment finding is matched with the correct intervention? a. Client reports being dizzy—nurse calls the Rapid Response Team. b. Client's heart rate is 55 beats/min—nurse withholds pain medication. c. Client has reduced breath sounds—nurse calls primary health care provider immediately. d. Client's respiratory rate is 18 breaths/min—nurse decreases oxygen flow rate.

ANS: C A potentially serious complication after biopsy is pneumothorax, which is indicated by decreased or absent breath sounds. The primary health care provider needs to be notified immediately. Dizziness without other data would not lead the nurse to call the RRT. If the client's heart rate is 55 beats/min, no reason is known to withhold pain medication. A respiratory rate of 18 breaths/min is a normal finding and would not warrant changing the oxygen flow rate.

10. A nurse teaches a client who is prescribed nicotine replacement therapy. Which statement would the nurse include in this client's teaching? a. "Make a list of reasons why smoking is a bad habit." b. "Rise slowly when getting out of bed in the morning." c. "Smoking while taking this medication will increase your risk of a stroke." d. "Stopping this medication suddenly increases your risk for a heart attack."

ANS: C Clients who smoke while using drugs for nicotine replacement therapy increase the risk of stroke and heart attack. Nurses would teach clients not to smoke while taking these drugs. The nurse would encourage the client to make a list of reasons for stopping the habit but would not phrase it so judgmentally. Orthostatic hypotension is not a risk with nicotine replacement therapy. Stopping suddenly does not increase the risk of heart attack.

A nurse is caring for a client with paraplegia who is scheduled to participate in a rehabilitation program. The client states, "I don't understand the need for rehabilitation; the paralysis will not go away and it will not get better." How would the nurse respond? a. "If you don't want to participate in the rehabilitation program, I'll let your primary health care provider know." b. "Rehabilitation programs have helped many patients with your injury. You should give it a chance." c. "The rehabilitation program will teach you how to maintain the functional ability you have and prevent further disability." d. "When new discoveries are made regarding paraplegia, people in rehabilitation programs will benefit first."

ANS: C Participation in rehabilitation programs has many purposes, including prevention of disability, maintenance of functional ability, and restoration of function. The other responses do not meet this client's needs.

1. A nurse obtains the health history of a client who is recently diagnosed with lung cancer and identifies that the client has a 60-pack-year smoking history. Which action is most important for the nurse to take when interviewing this client? a. Tell the client that he or she needs to quit smoking to stop further cancer development. b. Encourage the client to be completely honest about both tobacco and marijuana use. c. Maintain a nonjudgmental attitude to avoid causing the client to feel guilty. d. Avoid giving the client false hope regarding cancer treatment and prognosis

ANS: C Smoking assessments and cessation information can be an uncomfortable and sensitive topic among both clients and health care providers. The nurse would maintain a nonjudgmental attitude in order to foster trust with the client. Telling the client he or she needs to quit smoking is paternalistic and threatening. Assessing exposure to smoke includes more than tobacco and marijuana. The nurse would avoid giving the client false hope but when taking a history, it is most important to get accurate information.

8. A nurse cares for a client who had a bronchoscopy 2 hours ago. The client asks for a drink of water. What action would the nurse take next? a. Call the primary health care provider and request food and water for the client. b. Provide the client with ice chips instead of a drink of water. c. Assess the client's gag reflex before giving any food or water. d. Let the client have a small sip to see whether he or she can swallow.

ANS: C The topical anesthetic used during the procedure will have affected the client's gag reflex. Before allowing the client anything to eat or drink, the nurse must check for the return of this reflex

A nurse assesses a client who is recovering from an open traditional lumbar laminectomy with fusion. Which complications would the nurse report to the primary health care provider? (Select all that apply.) a. Surgical discomfort b. Redness and itching at the incision site c. Incisional bulging d. Clear drainage on the dressing e. Sudden and severe headache

ANS: C,D,E Bulging at the incision site or clear fluid on the dressing after open back surgery strongly suggests a cerebrospinal fluid leak, which constitutes an emergency. Loss of cerebrospinal fluid may cause a sudden and severe headache. Pain, redness, and itching at the site are normal.

After teaching a male client with a spinal cord injury at the T4 level, the nurse assesses the his understanding. Which client statements indicate a correct understanding of the teaching related to sexual effects of his injury? (Select all that apply.) a. "I will explore other ways besides intercourse to please my partner." b. "I will not be able to have an erection because of my injury." c. "Ejaculation may not be as predictable as before." d. "I may urinate with ejaculation but this will not cause infection." e. "I should be able to have an erection with stimulation."

ANS: C,D,E Men with injuries above T6 often are able to have erections by stimulating reflex activity. For example, stroking the penis will cause an erection. Ejaculation is less predictable and may be mixed with urine. However, urine is sterile, so the client's partner will not get an infection.

A nurse assesses a client with paraplegia from a spinal cord injury and notes reddened areas over the client's hips and sacrum. What actions would the nurse take? (Select all that apply.) a. Apply a barrier cream to protect the skin from excoriation. b. Perform range-of-motion (ROM) exercises for the hip joint. c. Reposition the client off of the reddened areas. d. Get the client out of bed and into a chair several times a day. e. Apply a pressure-reducing mattress.

ANS: C,E Appropriate interventions to relieve pressure on the reddened areas include frequent repositioning, using a pressure-reducing mattress, and having the client sit in a chair to remove pressure from the hips and sacrum. Correct sitting position would allow the pressure to be on both ischial tuberosities. ROM exercises are used to prevent contractures.

The nurse is collaborating with the occupational therapist to assist a client with a complete cervical spinal cord injury to transfer from the bed to the wheelchair. What ambulatory aid would be most appropriate for the client to meet this outcome? a. Rolling walker b. Quad cane c. Adjustable crutches d. Sliding board

ANS: D A client who has a complete cervical spinal cord injury is unable to use any extremity except for parts of the hands and possibly the lower arms. Therefore, the client would be unable to use any of these ambulatory aids except for a sliding board, also known as a slider, which provides a "bridge" between the bed and a chair. The client uses his or her arms in a locked position to support the body while moving slowly across the board.

A nurse assesses clients at a community center. Which client is at greatest risk for low back pain? a. A 24-year-old female who is 25 weeks pregnant. b. A 36-year-old male who uses ergonomic techniques. c. A 53-year-old female who uses a walker. d. A 65-year-old female with osteoarthritis.

ANS: D Osteoarthritis causes changes to support structures, increasing the client's risk for low back pain. The other clients are not at high risk.

The nurse initiates care for a client with a cervical spinal cord injury who arrives via emergency medical services. What action would the nurse take first? a. Assess level of consciousness. b. Obtain vital signs. c. Administer oxygen therapy. d. Evaluate respiratory status.

ANS: D The first priority for a client with a spinal cord injury is assessment of respiratory status and airway patency. Clients with cervical spine injuries are particularly prone to respiratory compromise due to interference with diaphragmatic innervation. The other actions would be performed after airway and breathing are assessed.

A nurse assesses a client with multiple sclerosis after administering prescribed fingolimod. For which common side effect would the nurse monitor? a. Peripheral edema b. Facial flushing c. Tachycardia d. Fever

B

A client continues to have persistent low back pain even after using a number of nonpharmacologic pain management strategies. Which prescribed drug would the nurse anticipate that the client might need to manage the pain? a. Oxycontin b. Gabapentin c. Lorazepam d. Tramadol

ANS: D When nonpharmacologic strategies, including physical therapy, are not effective in managing pain, current standards recommend a mild opioid such as tramadol or serotonin-norepinephrine reuptake inhibitor. Strong opioids such as oxycontin and benzodiazepines such as lorazepam are not considered best practice.

7. A nurse assesses a client after a thoracentesis. Which assessment finding warrants immediate action? a. The client rates pain as a 5/10 at the site of the procedure. b. A small amount of drainage from the site is noted. c. Pulse oximetry is 93% on 2 L of oxygen. d. The trachea is shifted toward the opposite side of the neck.

ANS: D A shift of central thoracic structures toward one side is a sign of a tension pneumothorax, which is a medical emergency. The other findings are normal or near normal. The nurse would report this finding immediately or call the Rapid Response Team

6. A nurse is caring for a client who is scheduled to undergo a thoracentesis. Which intervention would the nurse complete prior to the procedure? a. Measure oxygen saturation before and after a 12-minute walk. b. Verify that the client understands all possible complications. c. Explain the procedure in detail to the client and the family. d. Validate that informed consent has been given by the client.

ANS: D A thoracentesis is an invasive procedure with many potentially serious complications. The nurse would ensure signed informed consent has been obtained. Verifying that the client understands complications and explaining the procedure to be performed will be done by the primary health care provider, not the nurse. Measurement of oxygen saturation before and after a 12-minute walk is not a procedure unique to a thoracentesis

3. A nurse assesses a client's respiratory status. Which information is most important for the nurse to obtain? a. Average daily fluid intake. b. Neck circumference. c. Height and weight. d. Occupation and hobbies.

ANS: D Many respiratory problems occur as a result of chronic exposure to inhalation irritants used in a client's occupation and hobbies. Although it will be important for the nurse to assess the client's fluid intake, height, and weight, these will not be as important as determining his occupation and hobbies. This is part of the I-PREPARE assessment model for particulate matter exposure. Determining the client's neck circumference will not be an important part of a respiratory assessment.

A client with multiple sclerosis is being discharged from rehabilitation. Which statement would the nurse include in the client's discharge teaching? a. "Be sure that you use a wheelchair when you go out in public." b. "Wear an undergarment brief at all times in case of incontinence." c. "Avoid overexertion, stress, and extreme temperature if possible." d. "Avoid having sexual intercourse to conserve energy."

C

The nurse is preparing to teach a client recently diagnosed with multiple sclerosis about taking glatiramer acetate. Which statement by the client indicates a need for further teaching? a. "I will rotate injection sites to prevent skin irritation." b. "I need to avoid large crowds and people with infection." c. "I should report any flulike symptoms to my primary health care provider." d. "I will report any signs of infection to my primary health care provider."

C