431 Final Exam

93. During assessment of the patient with fibromyalgia syndrome (FMS), the nurse would expect the patient to report (Select all that apply.) a. sleep disturbances. b. multiple tender points. c. urinary frequency and urgency. d. cardiac palpitations and dizziness. e. multijoint pain with inflammation and swelling. f. widespread bilateral, burning musculoskeletal pain.

A, B, C, F

21. When administering a mental status examination to a patient, the nurse suspects depression when the patient responds with a. "I don't know." b. "Is that the right answer?" c. "Wait, let me think about that." d. "Who are those people over there?"

A. "I don't know."

14. Which patient statement to the nurse indicates a need for additional instruction about taking oral ferrous sulfate? a. "I will call my health care provider if my stools turn black." b. "I will take a stool softener if I feel constipated occasionally." c. "I should take the iron with orange juice about an hour before eating." d. "I should increase my fluid and fiber intake while I am taking iron tablets."

A. "I will call my health care provider if my stools turn black."

100. The laboratory reports that the cells from the patient's tumor biopsy are Grade II. What should the nurse know about this histologic grading? A. Cells are abnormal and moderately differentiated. B. Cells are very abnormal and poorly differentiated. C. Cells are immature, primitive, and undifferentiated. D. Cells differ slightly from normal cells and are well-differentiated.

A. Cells are abnormal and moderately differentiated.

10. Which menu choice indicates that the patient understands the nurse's teaching about best dietary choices for iron-deficiency anemia? a. Omelet and whole wheat toast b. Cantaloupe and cottage cheese c. Strawberry and banana fruit plate d. Cornmeal muffin and orange juice

A. Omelet and whole wheat toast

17. When developing a plan of care for a hospitalized patient with moderate dementia, which intervention will the nurse include? a. Reminding the patient frequently about being in the hospital b. Placing suction at the bedside to decrease the risk for aspiration c. Providing complete personal hygiene care for the patient d. Repositioning the patient frequently to avoid skin breakdown

A. Reminding the patient frequently about being in the hospital

7. A 19-year-old woman with immune thrombocytopenic purpura (ITP) has an order for a platelet transfusion. Which information indicates that the nurse should consult with the health care provider before obtaining and administering platelets? a. The platelet count is 42,000/L. b. Petechiae are present on the chest. c. Blood pressure (BP) is 94/56 mm Hg. d. Blood is oozing from the venipuncture site.

A. The platelet count is 42, 000/L

24. The nurse has identified the nursing diagnosis of disturbed thought processes related to effects of dementia for a patient with late-stage Alzheimer's disease (AD). An appropriate intervention for this problem is to a. maintain a consistent daily routine for the patient's care. b. encourage the patient to discuss events from the past. c. reorient the patient to the date and time every few hours. d. provide the patient with current newspapers and magazines.

A. maintain a consistent daily routine for the patient's care

23. Risperidone (Risperdal) is prescribed for an outpatient with moderate Alzheimer's disease (AD). Which information obtained by the nurse at the next clinic appointment indicates that the medication is effective? a. The patient has less agitation. b. The patient is dressed appropriately. c. The patient is able to swallow a pill. d. The patient's speech is clearer.

A. the patient has less agitation

67. A patient has manifestations of autonomic dysreflexia. Which of these assessments would indicate a possible cause for this condition? Select all that apply. A. hypertension B. kinked catheter tubing C. respiratory wheezes and stridor D. diarrhea E. fecal impaction

B, E

5. Which intervention will be included in the nursing care plan for a patient with immune thrombocytopenic purpura (ITP)? a. Assign the patient to a private room. b. Avoid intramuscular (IM) injections. c. Use rinses rather than a soft toothbrush for oral care. d. Restrict activity to passive and active range of motion.

B. Avoid intramuscular (IM) injections

11. A patient who is receiving methotrexate for severe rheumatoid arthritis develops a megaloblastic anemia. The nurse will anticipate teaching the patient about increasing oral intake of a. iron. b. folic acid. c. cobalamin (vitamin B12). d. ascorbic acid (vitamin c)

B. Folic Acid

20. A family member of a patient with possible Alzheimer's disease asks the nurse the purpose of the Mini-Mental State Examination (MMSE). Which response by the nurse is appropriate? a. The MMSE helps in establishing the diagnosis of Alzheimer's disease (AD). b. The MMSE is useful in determining the degree of mental impairment. c. The MMSE determines the choice of the most appropriate treatment. d. The MMSE aids in differentiating acute delirium from chronic dementia.

B. The MMSE is useful in determining the degree of mental impairment

6. Which information obtained by the nurse caring for a patient with thrombocytopenia should be immediately communicated to the health care provider? a. The platelet count is 52,000/µL. b. The patient is difficult to arouse. c. There are purpura on the oral mucosa. d. There are large bruises on the patient's back.

B. The patient is difficult to arouse

22. When teaching the spouse of a patient who is being evaluated for Alzheimer's disease (AD) about the disorder, the nurse explains that a. the most important risk factor for AD is a family history of the disorder. b. a diagnosis of AD can be made only when other causes of dementia have been ruled out. c. new drugs have been shown to reverse AD dramatically in some patients. d. the presence of brain atrophy detected by MRI confirms the diagnosis of AD in patients with dementia.

B. a diagnosis of AD can be made only when other causes of dementia have been ruled out

13. An appropriate nursing intervention for a hospitalized patient with severe hemolytic anemia is to a. provide a diet high in vitamin K. b. alternate periods of rest and activity. c. teach the patient how to avoid injury. d. place the patient on protective isolation.

B. alternate periods of rest and activity

19. To protect a patient from injury during an episode of delirium, the most appropriate action by the nurse is to a. have a close family member remain with the patient and provide reassurance. b. assign a staff member to stay with the patient and offer frequent reorientation. c. ask the health care provider about ordering an antipsychotic drug. d. secure the patient in bed with a soft chest restraint.

B. assign a staff member to stay with the patient and offer frequent reorientation

1. It is important for the nurse providing care for a patient with sickle cell crisis to a. limit the patient's intake of oral and IV fluids. b. evaluate the effectiveness of opioid analgesics. c. encourage the patient to ambulate as much as tolerated. d. teach the patient about high-protein, high-calorie foods.

B. evaluate the effectiveness of opioid analgesics

57. 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

8. Which action will the nurse include in the plan of care for a patient who has thalassemia major? a. Teach the patient to use iron supplements. b. Avoid the use of intramuscular injections. c. Administer iron chelation therapy as needed. d. Notify health care provider of hemoglobin 11g/dL.

C. Administer iron chelation therapy as needed

25. A long-term care patient with moderate dementia develops increased restlessness and agitation. The nurse's initial action should be to a. administer the PRN dose of lorazepam (Ativan). b. reorient the patient to time and place. c. assess the patient for anything that might be causing discomfort. d. have a nursing assistant stay with the patient to ensure safety.

C. Assess the patient for anything that might be causing discomfort

3. Which instruction will the nurse plan to include in discharge teaching for the patient admitted with a sickle cell crisis? a. Take a daily multivitamin with iron. b. Limit fluids to 2 to 3 quarts per day. c. Avoid exposure to crowds when possible. d. Drink only two caffeinated beverages daily.

C. Avoid exposure to crowds when possible

18. When administering a mental status examination to a patient with delirium, the nurse should a. give the examination when the patient is well-rested. b. reorient the patient as needed during the examination. c. choose a place without distracting environmental stimuli. d. medicate the patient first to reduce anxiety.

C. Choose a place without distracting environmental stimuli

96. A 33-year-old patient has recently been diagnosed with stage II cervical cancer. What should the nurse understand about the patient's cancer? A. It is in situ. B. It has metastasized. C. It has spread locally. D. It has spread extensively.

C. It has spread locally.

12. A 52-year-old patient has a new diagnosis of pernicious anemia. The nurse determines that the patient understands the teaching about the disorder when the patient states, "I a. need to start eating more red meat and liver." b. will stop having a glass of wine with dinner." c. could choose nasal spray rather than injections of vitamin B12." d. will need to take a proton pump inhibitor like omeprazole (Prilosec)."

C. could use nasal spray rather than injections of vitamin B12

26. When assessing a patient with Alzheimer's disease (AD) who is being admitted to a long-term care facility, the nurse learns that the patient has had several episodes of wandering away from home. Which nursing action will the nurse include in the plan of care? a. Ask the patient why the wandering episodes have occurred. b. Reorient the patient to the new living situation several times daily. c. Place the patient in a room close to the nurses' station. d. Have the family bring in familiar items from the patient's home.

C. place the patient in a room close to the nurses' station

2. Which statement by a patient indicates good understanding of the nurse's teaching about prevention of sickle cell crisis? a. "Home oxygen therapy is frequently used to decrease sickling." b. "There are no effective medications that can help prevent sickling." c. "Routine continuous dosage narcotics are prescribed to prevent a crisis." d. "Risk for a crisis is decreased by having an annual influenza vaccination."

D. "Risk for a crisis is decreased by having an annual influenza vaccination."

15. Which laboratory result will the nurse expect to show a decreased value if a patient develops heparin-induced thrombocytopenia (HIT)? a. Prothrombin time b. Erythrocyte count c. Fibrinogen degradation products d. Activated partial thromboplastin time

D. Activated partial thromboplastin time

4. A patient who has been receiving a heparin infusion and warfarin (Coumadin) for a deep vein thrombosis (DVT) is diagnosed with heparin-induced thrombocytopenia (HIT) when her platelet level drops to 110,000/µL. Which action will the nurse include in the plan of care? a. Use low-molecular-weight heparin (LMWH) only. b. Administer the warfarin (Coumadin) at the scheduled time. c. Teach the patient about the purpose of platelet transfusions. d. Discontinue heparin and flush intermittent IV lines using normal saline.

D. Discontinue heparin and flush intermittent IV lines using normal saline

58. A hospitalized patient with a C7 cord injury begins to yell "I can't feel my legs anymore." Which is the most appropriate action by the nurse? A. Remind the patient of her injury and try to comfort her. B. Call the healthcare provider and get an order for radiologic evaluation. C. Prepare the patient for surgery, as her condition is worsening. D. Explain to the patient that this could be a common, temporary problem.

D. Explain to the patient that this could be a common, temporary problem.

80. The teaching plan for the client with rheumatoid arthritis includes rest promotion. Which of the following would the nurse expect to instruct the client to avoid during rest periods? A. Proper body alignment. B. Elevating the part. C. Prone lying positions. D. Positions of flexion.

D. Positions of flexion.

9. A 62-year old man with chronic anemia is experiencing increased fatigue and occasional palpitations at rest. The nurse would expect the patient's laboratory findings to include a. a hematocrit (Hct) of 38%. b. an RBC count of 4,500,000/L. c. normal red blood cell (RBC) indices. d. a hemoglobin (Hgb) of 8.6 g/dL (86 g/L).

D. a hemoglobin (Hgb) of 8.6 g/dL (86 g/L)

16. A 72-year-old patient hospitalized with pneumonia is disoriented and confused 2 days after admission. Which assessment information obtained by the nurse about the patient indicates that the patient is experiencing delirium rather than dementia? a. The patient is disoriented to place and time but oriented to person. b. The patient has a history of increasing confusion over several years. c. The patient's speech is fragmented and incoherent. d. The patient was oriented and alert when admitted.

D. the patient was oriented and alert when admitted

83. A client with osteoporosis needs education about diet and ways to increase bone density. Which of the following should be included in the teaching plan? Select all that apply. a. Maintain a diet with adequate amounts of vitamin D, as found in fortified milk and cereals. b. Choose good calcium sources, such as figs, broccoli, and almonds. c. Use alcohol in moderation because a moderate intake has no known negative effects. d. Try swimming as a good exercise to maintain bone mass. 5. Avoid the use of high-fat foods, such as avocados, salad dressings, and fried foods.

a, b, c

62. Which patient is at highest risk for a spinal cord injury? a. 18-year-old male with a prior arrest for driving while intoxicated (DWI) b. 20-year-old female with a history of substance abuse c. 50-year-old female with osteoporosis d. 35-year-old male who coaches a soccer team

a. 18-year-old male with a prior arrest for driving while intoxicated (DWI)

92. When the nurse is reviewing laboratory results for a patient with systemic lupus erythematosus (SLE), which result is most important to communicate to the health care provider? a. Elevated blood urea nitrogen (BUN) and creatinine b. Positive lupus erythematosus cell prep c. Positive antinuclear antibodies (ANA) d. Decreased C-reactive protein (CRP)

a. Elevated blood urea nitrogen (BUN) and creatinine

40. A 32-year-old patient who has had an open reduction and internal fixation (ORIF) of left lower leg fractures continues to complain of severe pain in the leg 15 minutes after receiving the prescribed IV morphine. Pulses are faintly palpable and the foot is cool. Which action should the nurse take next? a. Notify the health care provider. b. Assess the incision for redness. c. Reposition the left leg on pillows. d. Check the patient's blood pressure.

a. Notify the health care provider.

52. Which nursing action for a patient who has had right hip replacement surgery can the nurse delegate to experienced unlicensed assistive personnel (UAP)? a. Reposition the patient every 1 to 2 hours. b. Assess for skin irritation on the patient's back. c. Teach the patient quadriceps-setting exercises. d. Determine the patient's pain level and tolerance.

a. Reposition the patient every 1 to 2 hours.

87. When helping a patient with rheumatoid arthritis (RA) plan a daily routine, the nurse informs the patient that it is most helpful to start the day with a. a warm bath followed by a short rest. b. a 10-minute routine of isometric exercises. c. stretching exercises to relieve joint stiffness. d. active range-of-motion (ROM) exercises.

a. a warm bath followed

64. A patient with a spinal cord injury is recovering from spinal shock. The nurse realizes that the patient should not develop a full bladder because what emergency condition can occur if it is not corrected quickly? a. autonomic dysreflexia b. autonomic crisis c. autonomic shutdown d. autonomic failure

a. autonomic dysreflexia

75. During the patient's process of grieving for the losses resulting from spinal cord injury, the nurse a. helps the patient understand that working through the grief will be a lifelong process b. should assist the patient to move through all stages of the mourning process to acceptance c. lets the patient know that anger directed at the staff or the family is not a positive coping mechanism d. facilitates the grieving process so that it is completed by the time the patient is discharged from rehabilitation

a. helps the patient understand that working through the grief will be a lifelong process

72. A patient is admitted to the emergency department with a possible cervical spinal cord injury following an automobile crash. During the admission of the patient, the nurse places the highest priority on a. maintaining a patent airway b. assessing the patient for head and other injuries c. maintaining immobilization of the cervical spine d. assessing the patient's motor and sensory function

a. maintaining a patent airway

32. The occupational health nurse will teach the patient whose job involves many hours of typing about the need to a. obtain a keyboard pad to support the wrist. b. do stretching exercises before starting work. c. wrap the wrists with compression bandages every morning. d. avoid using nonsteroidal antiinflammatory drugs (NSAIDs) for pain.

a. obtain a keyboard pad to support the wrist.

68. A patient is admitted to the hospital with Guillain-Barre syndrome. She had a weakness in her feet and ankles that has progressed to weakness with numbness and tingling in both legs. During the acute phase of her illness, the nurse recognizes that a. the most important aspect of care is to monitor the patient's respiratory rate and depth and vital capacity b. early treatment with corticosteroids can suppress the immune response and prevent ascending nerve damages c. although voluntary motor neurons are damaged by the inflammatory response, the autonomic nervous system is unaffected by the disease d. the most serious complication of this condition is ascending demyelination of the peripheral nerves of the lower brainstem and cranial nerves

a. the most important aspect of care is to monitor the patient's respiratory rate and depth and vital capacity

78. Goals of rehabilitation for the patient with an injury at the C6 level include (select all that apply) a. stand erect with leg brace b. feed self with hand devices c. drive an electric wheelchair d. assist with transfer activities e. drive adapted van from wheelchair

b, c, d, e

91. Following instruction for a patient with newly diagnosed systemic lupus erythematosus (SLE), the nurse determines that teaching about the disease has been effective when the patient says, a. "I should expect to have a low fever all the time with this disease." b. "I need to restrict my exposure to sunlight to prevent an acute onset of symptoms." c. "I should try to ignore my symptoms as much as possible and have a positive outlook." d. "I can expect a temporary improvement in my symptoms if I become pregnant."

b. "I need to restrict my exposure to sunlight to prevent an acute onset of symptoms."

97. The home health nurse cares for a patient who has been receiving interferon therapy for treatment of cancer. Which statement by the patient indicates a need for further assessment? a. "I have frequent muscle aches and pains." b. "I rarely have the energy to get out of bed." (fatigue can be dose limiting toxicity for use of biologic therapy) c. "I experience chills after I inject the interferon." d. "I take acetaminophen (Tylenol) every 4 hours."

b. "I rarely have the energy to get out of bed." (fatigue can be dose limiting toxicity for use of biologic therapy)

46. Which statement by a 62-year-old patient who has had an above-the-knee amputation indicates that the nurse's 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. "I should lay flat on my abdomen for 30 minutes 3 or 4 times a day."

63. The nurse understands that when the spinal cord is injured, ischemia results and edema occurs. How should the nurse explain to the patient the reason that the extent of injury cannot be determined for several days to a week? a. "Tissue repair does not begin for 72 hours." b. "The edema extends the level of injury for two cord segments above and below the affected level." c. "Neurons need time to regenerate so stating the injury early is not predictive of how the patient progresses." d. "Necrosis of gray and white matter does not occur until days after the injury."

b. "The edema extends the level of injury for two cord segments above and below the affected level."

59. The nurse is educating a patient and the family about different types of stabilization devices. Which statement by the patient indicates that the patient understands the benefit of using a halo fixation device instead of Gardner-Wells tongs? a. "I will have less pain if I use the halo device." b. "The halo device will allow me to get out of bed." c. "I am less likely to get an infection with the halo device." d. "The halo device does not have to stay in place as long."

b. "The halo device will allow me to get out of bed."

35. A 22-year-old tennis player has an arthroscopic repair of a rotator cuff injury performed in same-day surgery. When the nurse plans postoperative teaching for the patient, which information will be included? a. "You will not be able to serve a tennis ball again." b. "You will work with a physical therapist tomorrow." c. "The doctor will use the drop-arm test to determine the success of surgery." d. "Leave the shoulder immobilizer on for the first 4 days to minimize pain."

b. "You will work with a physical therapist tomorrow."

41. A patient with a complex pelvic fracture from a motor vehicle crash is on bed rest. Which nursing assessment finding is important to report to the health care provider? a. The patient states that the pelvis feels unstable. b. Abdomen is distended and bowel sounds are absent. c. There are ecchymoses across the abdomen and hips. d. The patient complains of pelvic pain with palpation.

b. Abdomen is distended and bowel sounds are absent.

45. The day after a having a right below-the-knee amputation, a patient complains of pain in the right foot. Which action is best for the nurse to take? a. Explain the reasons for the phantom limb pain. b. Administer prescribed analgesics to relieve the pain. c. Loosen the compression bandage to decrease incisional pressure. d. Inform the patient that this phantom pain will diminish over time.

b. Administer prescribed analgesics to relieve the pain.

55. 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. Administer the ordered oral opioid pain medication.

49. 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 patient's legs for swelling or tenderness. d. Notify the health care provider about the symptoms.

b. Administer the prescribed PRN oxygen at 4 L/min.

37. Which nursing intervention will be included in the plan of care after a patient with a right femur fracture has a hip spica cast applied? a. Avoid placing the patient in prone position. b. Ask the patient about abdominal discomfort. c. Discuss remaining on bed rest for several weeks. d. Use the cast support bar to reposition the patient.

b. Ask the patient about abdominal discomfort.

42. 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. Use a mechanical lift to transfer the patient from the bed to the chair. b. Check the postoperative orders for the patient's weight-bearing status. c. Avoid administration of pain medications before getting the patient up. d. Delegate the transfer of the patient to nursing assistive personnel (NAP).

b. Check the postoperative orders for the patient's weight-bearing status.

98. 10. A chemotherapy drug that causes alopecia is prescribed for a patient. Which action should the nurse take to maintain the patient's self-esteem? a. Tell the patient to limit social contacts until regrowth of the hair occurs. b. Encourage the patient to purchase a wig or hat and wear it once hair loss begins. c. Teach the patient to gently wash hair with a mild shampoo to minimize hair loss. d. Inform the patient that hair usually grows back once the chemotherapy is complete.

b. Encourage the patient to purchase a wig or hat and wear it once hair loss begins.

71. A patient is admitted to the emergency department with a spinal cord injury at the level of T2. Which of the following findings is of most concern to the nurse? a. SpO2 of 92% b. HR of 42 beats/min c. BP of 88/60 d. loss of motor and sensory function in arms and legs

b. HR of 42 beats/min

27. During the morning change-of-shift report at the long-term care facility, the nurse learns that the patient with dementia has had sundowning. Which nursing action should the nurse take while caring for the patient? a. Move the patient to a quieter room at night. b. Open the blinds in the patient's room and provide frequent activities. c. Have the patient take a brief mid-morning nap. d. Provide hourly orientation to time of day.

b. Open the blinds in the patient's room and provide frequent activities.

95. The nurse administers an IV vesicant chemotherapeutic agent to a patient. Which action is most important for the nurse to take? a. Infuse the medication over a short period of time. b. Stop the infusion if swelling is observed at the site. c. Administer the chemotherapy through a small-bore catheter. d. Hold the medication unless a central venous line is available. (although a central line is preferred it can be given via peripheral IV)

b. Stop the infusion if swelling is observed at the site.

39. 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. The patient advances the left leg and both crutches together and then advances the right leg.

48. 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. The patient leans over to pull shoes and socks on.

51. 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. Wrap the ankle and apply an ice pack.

90. A patient with polyarthralgia with joint swelling and pain is being evaluated for systemic lupus erythematosus (SLE). The nurse knows that the serum test result that is the most specific for SLE is the presence of a. rheumatoid factor. b. anti-Smith antibody (Anti-Sm). c. antinuclear antibody (ANA). d. lupus erythematosus (LE) cell prep.

b. anti-Smith antibody (Anti-Sm).

86. When teaching a patient who has rheumatoid arthritis (RA) about how to manage activities of daily living, the nurse instructs the patient to a. stand rather than sit when performing household chores. b. avoid activities that require continuous use of the same muscles. c. strengthen small hand muscles by wringing sponges or washcloths. d. protect the knee joints by sleeping with a small pillow under the knees.

b. avoid activities that require continuous use of the same muscles.

38. 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. avoid handling the cast using fingertips.

85. When teaching range-of-motion exercises to a patient who is having an acute exacerbation of rheumatoid arthritis (RA) with joint pain and swelling in both hands, the nurse teaches the patient that a. affected joints should not be exercised when pain is present. b. cold applications before exercise will decrease joint pain. c. exercises should be performed passively by someone other than the patient. d. regular walking may substitute for range-of-motion (ROM) exercises on some days.

b. cold applications before exercise will decrease joint pain.

34. The nurse will instruct the patient with a fractured left radius that the cast will need to remain in place a. for several months. b. for at least 3 weeks. c. until swelling of the wrist has resolved. d. until x-rays show complete bony union.

b. for at least 3 weeks.

43. When doing discharge teaching for a 19-year-old patient who has had a repair of a fractured mandible, the nurse will include information about a. administration of nasogastric tube feedings. b. how and when to cut the immobilizing wires. c. the importance of high-fiber foods in the diet. d. the use of sterile technique for dressing changes.

b. how and when to cut the immobilizing wires.

74. Urinary function during the acute phase of spinal cord injury is maintained with a. an indwelling catheter b. intermittent catheterization c. insertion of a suprapubic catheter d. use of incontinent pads to protect the skin

b. intermittent catheterization

76. A nurse is caring for a client with a spinal cord injury who reports a severe headache and is sweating profusely. vital signs include BP 220/110, apical heart rate of 54/min. Which of the following acctions should the nurse take first? a. notify the provider b. sit the client upright in bed c. check the client's urinary catheter for blockage d. administer antihypertensive medication

b. sit the client upright in bed

66. The patient is admitted with injuries that were sustained in a fall. During the nurse's first assessment upon admission, the findings are: blood pressure 90/60 (as compared to 136/66 in the emergency department), flaccid paralysis on the right, absent bowel sounds, zero urine output, and palpation of a distended bladder. These signs are consistent with which of the following? a. paralysis b. spinal shock c. high cervical injury d. temporary hypovolemia

b. spinal shock

56. When assessing for Tinel's sign in a patient with possible right-sided carpal tunnel syndrome, the nurse will ask the patient about a. weakness in the right little finger. b. tingling in the right thumb and fingers. c. burning in the right elbow and forearm. d. tremor when gripping with the right hand.

b. tingling in the right thumb and fingers.

44. After the health care provider has recommended amputation for a patient who has nonhealing ischemic foot ulcers, the patient tells the nurse that he would rather die than have an amputation. Which response by the nurse is best? a. "You are upset, but you may lose the foot anyway." b. "Many people are able to function with a foot prosthesis." c. "Tell me what you know about your options for treatment." d. "If you do not want an amputation, you do not have to have it."

c. "Tell me what you know about your options for treatment."

60. A hospitalized patient has become unresponsive. The left side of the body is flaccid. The attending physician believes the patient may have had a stroke (CVA). What is the nurse's priority intervention? a. Move the patient to the critical care unit. b. Assess blood pressure. c. Assess the airway and breathing. d. Observe urinary output.

c. Assess the airway and breathing.

99. A patient with cancer has a nursing diagnosis of imbalanced nutrition: less than body requirements related to altered taste sensation. Which nursing action is most appropriate? a. Add strained baby meats to foods such as casseroles. b. Teach the patient about foods that are high in nutrition. c. Avoid giving the patient foods that are strongly disliked. d. Add extra spice to enhance the flavor of foods that are served.

c. Avoid giving the patient foods that are strongly disliked.

53. 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. Check leg pulses and sensation.

54. 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. Check the oxygen saturation.

79. On a visit to the clinic, a client reports the onset of early symptoms of rheumatoid arthritis. The nurse should conduct a focused assessment for: a. Limited motion of joints. b. Deformed joints of the hands. c. Early morning stiffness. d. Rheumatoid nodules.

c. Early morning stiffness.

30. Which of these nursing actions included in the care of a patient after laminectomy can the nurse delegate to an experienced nursing assistant? a. Evaluation of the effectiveness of the PCA b. Monitoring plantar and dorsiflexion of the feet c. Logrolling the patient from side to side every 2 hours d. Determining the patient's readiness to ambulate

c. Logrolling the patient from side to side every 2 hours

50. A patient arrived at the emergency department after tripping over a rug and falling at home. Which finding is most important for the nurse to communicate to the health care provider? a. There is bruising at the shoulder area. b. The patient reports arm and shoulder pain. c. The right arm appears shorter than the left. d. There is decreased shoulder range of motion.

c. The right arm appears shorter than the left. (dislocation - deformity)

33. 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. Use pillows to elevate the ankle above the heart.

73. During assessment of a patient with a spinal cord injury, the nurse determines that the patient has a poor cough with diaphragmatic breathing. Based on this finding, the nurses' first action should be to a. initiate frequent turning and repositioning b. use tracheal suctioning to remove secretions c. assess lung sounds and respiratory rate and depth d. prepare the patient for endotracheal intubation and mechanical ventilation

c. assess lung sounds and respiratory rate and depth

89. A 26-year-old woman has been diagnosed with early systemic lupus erythematosus (SLE) involving her joints. In teaching the patient about the disease, the nurse includes the information that SLE is a(n) a. hereditary disorder of women but usually does not show clinical symptoms unless a woman becomes pregnant. b. autoimmune disease of women in which antibodies are formed that destroy all nucleated cells in the body. c. disorder of immune function, but it is extremely variable in its course, and there is no way to predict its progression. d. disease that causes production of antibodies that bind with cellular estrogen receptors, causing an inflammatory response.

c. disorder of immune function, but it is extremely variable in its course, and there is no way to predict its progression.

65. While caring for the patient with spinal cord injury (SCI), the nurse elevates the head of the bed, removes compression stockings, and continues to assess vital signs every two to three minutes while searching for the cause in order to prevent loss of consciousness or death. By practicing these interventions, the nurse is avoiding the most dangerous complication of autonomic dysreflexia, which is which of the following? a. hypoxia b. bradycardia c. elevated blood pressure d. tachycardia

c. elevated blood pressure

88. A patient is hospitalized with an acute attack of primary gout, which is affecting the left great toe and ankle. The outcome that the nurse determines as most important is that the patient a. maintains a purine-free diet. b. experiences no evidence of tophi. c. expresses satisfactory pain relief. d. has minimal functional loss in joints.

c. expresses satisfactory pain relief.

69. A patient with Guillain-Barre syndrome asks whether he is going to die as the paralysis spreads toward his chest. In responding to the patient, the nurse knows that a. patient who require ventilatory support almost always die b. death occurs when nerve damage affects the brain and meninges c. most patient with Guillain-Barre syndrome make a complete recovery d. if death can be prevented, residual paralysis and sensory impairment are usually permanent

c. most patient with Guillain-Barre syndrome make a complete recovery

70. A patient with a spinal cord injury has spinal shock. The nurse plans care for the patient based on the knowledge that a. rehabilitation measures cannot be initiated until spinal shock has resolved b. the patient will need continuous monitoring for hypotension, tachycardia, and hypoxemia c. resolution of spinal shock is manifested by spasticity, hyperreflexia, and reflex emptying of the bladder d. the patient will have complete loss of motor and sensory functions below the level of the injury, but autonomic functions are not affected

c. resolution of spinal shock is manifested by spasticity, hyperreflexia, and reflex emptying of the bladder

47. The nurse is caring for a patient who is to be discharged from the hospital 5 days after insertion of a femoral head prosthesis using a posterior approach. Which statement by the patient indicates a need for additional instruction? a. "I should not cross my legs while sitting." b. "I will use a toilet elevator on the toilet seat." c. "I will have someone else put on my shoes and socks." d. "I can sleep in any position that is comfortable for me."

d. "I can sleep in any position that is comfortable for me."

81. A client with rheumatoid arthritis tells the nurse, "I know it is important to exercise my joints so that I won't lose mobility, but my joints are so stiff and painful that exercising is difficult." Which of the following responses by the nurse would be most appropriate? a. "You are probably exercising too much. Decrease your exercise to every other day." b. "Tell the physician about your symptoms. Maybe your analgesic medication can be increased." c. "Stiffness and pain are part of the disease. Learn to cope by focusing on activities you enjoy." d. "Take a warm tub bath or shower before exercising. This may help with your discomfort."

d. "Take a warm tub bath or shower before exercising. This may help with your discomfort."

82. Which of the following should the nurse assess when completing the history and physical examination of a client diagnosed with osteoarthritis? a. Anemia. b. Osteoporosis. c. Weight loss. d. Local joint pain.

d. Local joint pain.

94. A patient with a large stomach tumor that is attached to the liver is scheduled to have a debulking procedure. Which information should the nurse teach the patient about the outcome of this procedure? a. Pain will be relieved by cutting sensory nerves in the stomach. b. Relief of pressure in the stomach will promote better nutrition. c. Tumor growth will be controlled by the removal of malignant tissue. d. Tumor size will decrease and this will improve the effects of other therapy.

d. Tumor size will decrease and this will improve the effects of other therapy.

29. Following a laminectomy with a spinal fusion, a patient reports numbness and tingling of the right lower leg. The first action indicated by the nurse is to a. report the patient's complaint to the surgeon. b. check the vital signs for indications of hemorrhage. c. turn the patient to the side to relieve pressure on the operative area. d. check the chart for preoperative neuromuscular assessment data.

d. check the chart for preoperative neuromuscular assessment data.

36. A 48-year-old patient with a comminuted fracture of the left femur has Buck's traction in place while waiting for surgery. To assess for pressure areas on the patient's 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 patient's 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. have the patient lift the buttocks by bending and pushing with the right leg.

61. The nurse is teaching regarding risk factors for stroke (CVA). The greatest risk factor is which of the following? a. diabetes b. heart disease c. renal insufficiency d. hypertension

d. hypertension

31. A factory line worker has repetitive strain syndrome in the left elbow. The nurse will plan to teach the patient about a. surgical options. b. elbow injections. c. wearing a left wrist splint. d. modifying arm movements.

d. modifying arm movements

28. A patient with a herniated intravertebral disk undergoes a laminectomy and diskectomy. Following the surgery, the nurse should position the patient on the side by a. elevating the head of the bed 30 degrees and having the patient extend the legs while turning to the side. b. turning the patient's head and shoulders and then the hips, keeping the patient centered in the bed. c. having the patient turn by grasping the side rails and pulling the shoulders over. d. placing a pillow between the patient's legs and turning the entire body as a unit.

d. placing a pillow between the patient's legs and turning the entire body as a unit.

77. A nurse is caring for a client who has a C4 spinal cord injury. which of the following should the nurse recognize the client as being at the greatest risk for? a. neurogenic shock b. paralytic ileus c. stress ulcer d. respiratory compromise

d. respiratory compromise

84. A 60-year-old patient has osteoarthritis (OA) of the left knee. A finding that the nurse would expect to be present on examination of the patient's knee is a. Heberden's nodules. b. redness and swelling of the knee joint. c. pain upon joint movement. d. stiffness that increases with movement.

d. stiffness that increases with movement.