COHAC Exam Review Questions

•A client is being treated in a substance abuse unit of a local hospital. The nurse understands that when this client has compulsive behavior to use a drug for its psychic effect, the client needs to be monitored for which effect? a) Addiction b) Tolerance c) Placebo d) Dependence

A Addiction is a behavioral pattern of substance use characterized by a compulsion to take the substance primarily to experience its psychic effects. Placebo effect is analgesia that results from the expectation that a substance will work, not from the actual substance itself. Dependence occurs when a client who has been taking opioids experiences a withdrawal syndrome when the opioids are discontinued. Tolerance occurs when a client who has been taking opioids becomes less sensitive to their analgesic properties.

The result of which diagnostic study is decreased in the client diagnosed with rheumatoid arthritis? a. Red blood cell count b. Creatinine c. ESR d. Uric acid

A Rationale: Clients diagnosed with rheumatic diseases have a decreased red blood cell count. ESR is increased in inflammatory connective tissue disease. Uric acid is increased in gout. Increased creatinine may indicate renal damage in SLE, scleroderma, and polyarteritis.

A client with rheumatoid arthritis reports joint pain. What intervention is a priority to assist the client? a. Nonsteroidal anti-inflammatory drugs b. Ice packs c. Opioid therapy d. Surgery

A Rationale: Nonsteroidal anti-inflammatory drugs are the mainstay of treatment for rheumatoid arthritis pain. They help to decrease inflammation in the joints. Heat, rather than ice packs, is used to relieve pain. Paraffin baths may also help. Surgery is reserved for joint replacement when the joint is no longer functional; it is not an intervention specific to relieving pain.

A client is admitted with an acute attack of gout. What interventions are essential for this client? Select all that apply. a. Serum uric acid concentration b. Dietary consult c. Corticosteroid therapy d. Pain medication e. Probenecid

A, B, C, D, E Rationale: Steroids may be used in clients who have not responded to other therapies. They have been shown to decrease inflammation and pain in attacks of gout. Probenecid will assist in the excretion of uric acid, the causative agent. Serum uric acid concentrations will guide therapy and treatment. A dietary consult can wait until the client the acute, painful period is over but will be a necessary nursing intervention for a client experiencing gout.

Prostaglandins are chemical substances with what property? a) Inhibit the transmission of pain b) Increase the sensitivity of pain receptors c) Inhibit the transmission of noxious stimuli d) Reduce the perception of pain

B Prostaglandins are believed to increase sensitivity to pain receptors by enhancing the pain-provoking effect of bradykinin. Endorphins and enkephalins reduce or inhibit transmission or perception of pain. Morphine and other opioid medications inhibit the transmission of noxious stimuli by mimicking enkephalin and endorphin.

Which client(s) is most likely to have compartment syndrome after sustaining a fracture? Select all that apply. a. The client using ice to control pain in the extremity b. The client with a plaster cast applied immediately after injury c. The client with hemorrhage in the site of injury d. The client with elevated pressure within the muscles e. The client who sustained a clavicle fracture

B, C, D Rationale: Compartment syndrome occurs in cases of fracture when the normal pressure of a compartment is altered by the force of the injury itself, by development of edema, or by hemorrhaging at the site of the injury, which increases the contents of the compartment, or from outside pressure caused by constriction from a dressing or cast. A client with elevated muscle pressure is at risk for compartment syndrome. The application of a plaster cast immediately after the injury places the client at risk for compartment syndrome because the cast will not allow for edema and therefore will compress the tissue. Clavicle fractures are not a risk factor for compartment syndrome because of the location of the fracture. Ice will assist in decreasing edema and may help prevent compartment syndrome.

Which finding is consistent with the diagnosis of rheumatoid arthritis? a. Decreased ESR b. Increased red blood cell count c. Cloudy synovial fluid d. Increased C4 complement component

C Rationale: In a client with rheumatoid arthritis, arthrocentesis shows synovial fluid that is cloudy, milky, or dark yellow and contains numerous inflammatory components, such as leukocytes and complement.

•For which reasons are nonpharmacologic pain management techniques used? Select all that apply a) They can successfully replace pain medications for severe pain. b) They lower the risk of clients becoming addicted to pain medications. c) They help decrease the sensation of pain. d) They allow clients to match the technique to their own individual and cultural preferences. e) They help decrease the distress a client experiences as a result of pain.

C, D, E Nonpharmacologic pain management techniques are usually used in conjunction with medications and help to decrease the sensation of pain and the distress the client experiences as a result of pain. Nonpharmacologic methods are used to complement, not replace, pharmacologic methods in cases of severe pain. Many clients find that the use of nonpharmacologic methods helps them cope better with their pain and feel they have greater control over the pain. Nonpharmacologic methods do not have any relation to a client's risk of becoming addicted to pain medications. A variety of techniques allows clients to match the technique to their own individual and cultural preferences.

A client with a severe electrical burn injury is treated in the burn unit. Which laboratory result would cause the nurse the most concern? a) Na+: 145 mEq/L b) K+: 5.0 mEq/L c) Ca: 9 mg/dL d) BUN: 28 mg/dL

D The elevated BUN would cause the nurse the most concern. The nurse should report decreased urine output or increased BUN and creatinine values to the physician. These laboratory values indicate possible renal failure. In addition, myoglobinuria, associated with electrical burns, is common with muscle damage and may also cause kidney failure if not treated. The other values are within normal limits.

TRUE OR FALSE A hallmark of rheumatologic diseases is autoimmunity, where the body mistakenly recognizes its own tissue as a foreign pathogen (antigen).

True

TRUE OR FALSE Alkylating agents and purine analogues are the first line of pharmacologic therapy for people with systemic lupus erythematous because of their effect on overall immune function.

True

TRUE OR FALSE Compartment syndrome---the most serious complication of casting and splinting---occurs when increased pressure within a confined space compromises blood flow.

True

TRUE OR FALSE Gout is the most common form of inflammatory arthritis.

True

TRUE OR FALSE Osteoporosis frequently results in compression fractures of the spine, fractures of the neck or intertrochanteric region of the femur, and Colles fractures of the wrist.

True

TRUE OR FALSE Risk factors for osteoarthritis and its progression include older age, female gender, and obesity.

True

TRUE OR FALSE Risk factors for rheumatoid arthritis and its progression include older age, nulliparity, and obesity.

True

The nurse assesses subtle personality changes, restlessness, irritability, and confusion in a client who has sustained a fracture. The nurse suspects which complication? a. Fat embolism syndrome b. Reflex sympathetic dystrophy syndrome c. Compartment syndrome d. Hypovolemic shock

A Rationale: Cerebral disturbances in the client with fat embolism syndrome include subtle personality changes, restlessness, irritability, and confusion. The client with compartment syndrome reports deep, throbbing, unrelenting pain. The client with hypovolemic shock would have a decreased blood pressure and increased pulse rate. Clinical manifestations of reflex sympathetic dystrophy syndrome include severe, burning pain; local edema; hyperesthesia; muscle spasms; and vasomotor skin changes. Fat embolism syndrome occurs most frequently in young adults and elderly clients who experience fractures of the proximal femur (i.e., hip fracture). Presenting features of fat embolism syndrome include hypoxia, tachypnea, tachycardia, and pyrexia. The respiratory distress response includes tachypnea, dyspnea, wheezes, precordial chest pain, cough, large amounts of thick, white sputum, and tachycardia. Avascular necrosis (AVN) occurs when the bone loses its blood supply and dies. This does not cause coughing. Complex regional pain syndrome does not have cardiopulmonary involvement. Long bone fracture: The nurse should include monitoring for sufficient blood supply by assessing the color, temperature, and pulses of the affected extremity. Weight-bearing exercises are encouraged, but passive ROM exercises have the potential to cause pain and inhibit healing. Corticosteroids, vitamin D, and calcium are not normally given.

Which aspect should a nurse include in the teaching plan for a client with osteomalacia? a. Include calcium, phosphorus, and vitamin D supplements b. Avoid dairy products c. Avoid any activity or exercise d. Avoid green, leafy vegetables

A Rationale: The nurse should encourage clients with osteomalacia to include calcium, phosphorus, and vitamin D supplements; adequate nutrition; exposure to sunlight; and progressive exercise and ambulation. Clients need not avoid dairy products, leafy vegetables, or mild exercise.

The nurse cares for a 30-year-old client who suffered severe head and facial burn injuries. Which action, if completed by the client, indicates the client is adapting to altered body image? Select all that apply. a) Participates actively in daily activities b) Wears hats and wigs c) Covers face with a scarf d) Reports absence of sleep disturbance

A, B The following are indicators that a client is adapting to altered body image: verbalizes accurate description of alterations in body image and accepts physical appearance, demonstrates interest in resources that may improve function and perception of body appearance (e.g., uses cosmetics, wigs, and prostheses, as appropriate); socializes with significant others, peers, and usual social group; and seeks and achieves return to role in family, school, and community as a contributing member. Covering the face with a scarf indicates the client is not adapting to the alteration in body image; absence of sleep disturbances is expected by the burn-injured client but is not related to body image disturbance.

Which type of burn injury involves destruction of the epidermis and upper layers of the dermis as well as injury to the deeper portions of the dermis? a) Full-thickness b) Deep partial-thickness c) Superficial partial thickness d) Fourth degree

B A deep partial-thickness burn involves destruction of the epidermis and upper layers of the dermis as well as injury to deeper portions of the dermis. In a superficial partial-thickness burn, the epidermis is destroyed or injured and a portion of the dermis may be injured. Capillary refill follows tissue blanching. Hair follicles remain intact. A full-thickness burn involves total destruction of epidermis and dermis and, in some cases, destruction of underlying tissue, muscle, and bone. Although the term fourth-degree burn is not used universally, it occurs with prolonged flame contact or high voltage injury that destroys all layers of the skin and damages tendons and muscles.

The nurse needs to carefully monitor a client with traumatic injuries. Which action by the nurse demonstrates understanding of the most essential component of the client's pain assessment? a) The nurse validates the client's report of pain by assessing the client's blood pressure. b) The nurse administers pain medication based on the client's reported pain level. c) The nurse assesses the response to medication after every meal consumed by the client. d) The nurse administers ketorolac upon admission to the unit.

B Clients quickly adapt physiologically despite pain and may have normal or below normal vital signs in the presence of severe pain. The overriding principle is that the absence of an elevated blood pressure or heart rate does not mean the absence of pain. The ability of an individual to give a report of pain, especially its intensity, is the most essential component of pain assessment. Pain does not need to be assessed an hour after analgesics are administered or after every meal consumed by the client. Pain medication should not routinely be administered to a client upon admission to the unit.

Which is a risk-lowering strategy for osteoporosis? a. Increased age b. Smoking cessation c. Diet low in calcium and vitamin D d. Low initial bone mass

B Rationale: Risk-lowering strategies include increased dietary calcium and vitamin D intake, smoking cessation, alcohol and caffeine consumption in moderation, and outdoor activity. Individual risk factors include low initial bone mass and increased age. A lifestyle risk factor is a diet low in calcium and vitamin D.

Most cases of osteomyelitis are caused by which microorganism? a. Proteus species b. Staphylococcus aureus c. Escherichia coli d. Pseudomonas species

B Rationale: Staphylococcus aureus causes 70% to 80% of bone infections. Proteus species, Pseudomonas species, and E. coli are frequently found in osteomyelitis, they do not cause the majority of bone infections.

What pain assessment scale would be best to use with a 5-year-old child? a) The Numeric Rating Scale b) The FACES Scale c) A pain assessment scale is inappropriate for a 5-year-old child. d) A visual analog scale

B Rationale: The FACES scale was developed for use in children. It consists of six pictures depicting faces ranging from np pain to worst pain. The child points to the face that best shows how much he or she hurts. The FACES scale may also be useful for adults who have difficulty with numerical or visual analog scales. Specific pain assessment scales have been tested for use in many patient populations, from neonates to clients who have dementia. The Visual Analog Scale and Numeric Rating Scale are not the best choices for a 5-year-old because they depend on the client being able to read and use numbers.

The presence of crystals in synovial fluid obtained from arthrocentesis is indicative of which of the following? a. Infection b. Gout c. Inflammation d. Degeneration

B Rationale: The presence of crystals is indicative of gout, whereas the presence of bacteria is indicative of infective arthritis.

The nurse determines which statement reflects current research regarding the utilization of nonpharmacological measures in the management of burn pain? a) Humor therapy has not proven effective in the management of burn pain. b) Music therapy may provide reality orientation, distraction, and sensory stimulation. c) Music therapy diverts the client's attention toward painful stimulus. d) Pet therapy has proven effective in the management of burn pain.

B Researchers have found that music affects both the physiologic and psychological aspects of the pain experience. Music diverts the client's attention away from the painful stimulus. Music may also provide reality orientation, distraction, and sensory stimulation. It allows for client self-expression. Humor therapy has proven effective in the management of burn pain. Pet therapy has not proven effective in the management of burn pain.

The nurse is caring for a client who has been diagnosed with a "rheumatic disease." What nursing diagnoses will most likely apply to this client's care? Select all that apply. a. Fluid volume deficit b. Alteration of self-concept c. Pain d. Fatigue e. Fluid and electrolyte imbalance

B, C, D Rationale: Clients with rheumatic diseases, which typically involve joints and muscles, experience problems with mobility, fatigue, and pain. Because of the limitations of the disease, clients often have an altered self-image and self-concept. Fluid and electrolyte imbalances are not typically associated with these types of diseases.

The nurse is performing discharge teaching for a client with rheumatoid arthritis. What teachings are priorities for the client? Select all that apply. a. Dressing changes b. Medication dosages and side effects c. Safe exercise d. Assistive devices e. Narcotic safety

B, C, D Rationale: The client with rheumatoid arthritis who is being discharged to home needs information on how to exercise safely to maintain joint mobility. Medication doses and side effects are always an essential part of discharge teaching. Assistive devices, such as splints, walkers, and canes, may assist the client to perform safe self-care. Narcotics are not commonly used, and there would be no reason for dressings.

Which complication is common for victims of electrical burns? a) Hypovolemic shock b) Infection c) Cardiac dysrhythmia d) Inhalation injury

C Cardiac dysrhythmias are common for victims of electrical burns. If the patient has an electrical burn, a baseline electrocardiogram (ECG) is obtained and continuous monitoring is initiated. Any burn injury can lead to complications, such as inhalation injury, infection, and hypovolemic shock.

Which is a true statement regarding placebos? a) A positive response to a placebo indicates that the client's pain is not real. b) A placebo should be used as the first line of treatment for a client. c) Placebos should never be used to test a client's truthfulness about pain. d) A placebo effect is an indication that the client does not have pain.

C Many pain guidelines, position papers, nurse practice acts, and hospital policies nationwide agree that placebos should not be used to assess or manage pain in any client, regardless of age or diagnosis. Perception of pain is highly individualized. A placebo effect is a true physiologic response. A placebo should never be used as a first line of treatment. Reduction in pain as a response to placebo should never be interpreted as an indication that the person's pain is not real.

A client diagnosed with osteoporosis is being discharged home. Which priority education should the nurse should provide? a. Increase calcium and vitamin D in the diet b. Classify medications c. Remove all small rugs from the home d. Participate in weight-bearing exercises

C Rationale: A client with osteoporosis is at risk for fractures related to falls. The home environment needs to be evaluated for safety issues, such as rugs and other objects that could cause a fall. All other education is important in educating the client, but the risk for injury from a fall and potential for a fracture makes safety in the home environment a priority.

A client is transported to the emergency department for a femur fracture following a motor vehicle crash. What action by the nurse is the highest priority? a. Administer pain medication per orders. b. Assess pedal pulses. c. Assess vital signs and level of consciousness. d. Assess the diameter of the thigh every 15 minutes

C Rationale: Femur fractures can lead to hypovolemic shock due to blood loss in the tissue. By assessing the vital signs and level of consciousness, the nurse can assess for shock. Assessing the pedal pulses and measuring the diameter of the thigh are appropriate interventions for someone with a femur fracture, but assessing for hypovolemic shock would be a priority. Pain medication should be safely administered per orders to help control pain. Many pain medications lower blood pressure (BP). If the client is in shock, BP may be too low to administer the pain medication safely.

Which is the leading cause of disability and pain in the elderly? a. Scleroderma b. Rheumatoid arthritis (RA) c. Osteoarthritis (OA) d. Systemic lupus erythematosus (SLE)

C Rationale: Osteoarthritis is the leading cause of disability and pain in the elderly. RA, SLE, and scleroderma are not leading causes of disability and pain in the elderly.

Pulselessness, a very late sign of compartment syndrome, may signify a. Venous congestion b. Nerve involvement c. Lack of distal tissue perfusion d. Diminished arterial perfusion

C Rationale: Pulselessness is a very late sign that may signify lack of distal tissue perfusion. The other answers do not apply.

A nurse is educating a client diagnosed with osteomalacia. Which statement by the nurse is appropriate? a. "You will need to engage in vigorous exercise three times a week for 30 minutes." b. "You will need to decrease the amount of dairy products you consume." c. "You may need to be evaluated for an underlying cause, such as renal failure." d. "You will need to avoid foods high in phosphorus and vitamin D."

C Rationale: The client may need to be evaluated for an underlying cause. If an underlying cause is discovered, that will guide the medical treatment. The client needs to maintain an adequate to increased supply of calcium, phosphorus, and vitamin D. Dairy products are a good source of calcium. The client is at risk for pathological fractures and therefore should not engage in vigorous exercise.

The most important intervention in the nutritional support of a client with a burn injury is to provide adequate nutrition and calories. The nurse recognizes this intervention is to promote a) increased glucose demands. b) increased metabolic rate. c) increased skeletal muscle breakdown. d) decreased catabolism.

D Burn injuries produce profound metabolic abnormalities fueled by the exaggerated stress response to the injury. The body's response has been classified as hyperdynamic, hypermetabolic, and hypercatabolic. The most important intervention in the nutritional support of a client with a burn injury is to provide adequate nutrition and calories to decrease catabolism. Nutritional support with optimized protein intake can decrease the protein losses by approximately 50%. A marked increase in metabolic rate is seen after a burn injury and interventions are instituted to decrease metabolic rate and catabolism. A marked increase in glucose demand is seen after a burn injury and interventions are instituted to decrease glucose demands and catabolism. Rapid skeletal muscle breakdown with amino acids serving as the energy source is seen after a burn injury and interventions are instituted to decrease catabolism.

An x-ray demonstrates a fracture in which a bone has splintered into several pieces. Which type of fracture is this? a. Compound b. Impacted c. Depressed d. Comminuted

D Rationale: A comminuted fracture may require open reduction and internal fixation. A compound fracture is one in which damage also involves the skin or mucous membranes. A depressed fracture is one in which fragments are driven inward. An impacted fracture is one in which a bone fragment is driven into another bone fragment.

What is the priority intervention for a client who has been admitted repeatedly with attacks of gout? a. Insert a Foley catheter b. Place client on bed rest c. Increase fluids d. Assess diet and activity at home

D Rationale: Clients with gout need to be educated about dietary restrictions in order to prevent repeated attacks. Foods high in purine need to be avoided, and alcohol intake has to be limited. Stressful activities should also be avoided. The nurse should assess to determine what is stimulating the repeated attacks of gout. The other interventions are not appropriate for a client with this problem.

•A client asks the nurse why his residual limb cannot be elevated on a pillow. What is the best response by the nurse? a. "Elevating the extremity may increase your chances of compartment syndrome." b. "I am sorry. We ran out of pillows. I can elevate it on a few blankets." c. "You need to turn yourself side to side. If your leg is on a pillow, you would not be able to do that." d. "Elevating the leg might lead to a flexion contracture."

D Rationale: Elevating the residual limb on a pillow may lead to a flexion contracture; this could jeopardize the client's ability to use a prosthesis. The client does need to turn to both sides but might still be able to do it with the extremity elevated. Elevating the extremity would not increase the risk for compartment syndrome. The limb should not be elevated on pillows or blankets. The nurse encourages the client to turn from side to side and to assume a prone position, if possible, to stretch the flexor muscles and to prevent flexion contracture of the hip. Postoperative ROM exercises are started early, because contracture deformities develop rapidly. ROM exercises include hip and knee exercises for clients with BKAs. The nurse also discourages sitting for prolonged periods of time. Syme amputation (modified ankle disarticulation amputation) is performed most frequently for extensive foot trauma and produces a painless, durable extremity end that can withstand full weight-bearing. Therefore, each of the other teaching statements is incorrect.

A client with chronic osteomyelitis has undergone 6 weeks of antibiotic therapy. The wound appearance has not improved. What action would the nurse anticipate to promote healing? a. Wound irrigation b. Wound packing c. Vitamin supplements d. Surgical debridement

D Rationale: In chronic osteomyelitis, surgical debridement is used when the wound fails to respond to antibiotic therapy. Wound packing, vitamin supplements, and wound irrigation are not the standard of care when treating chronic osteomyelitis.

The nurse teaches the client with a high risk for osteoporosis about risk-lowering strategies, including which action? a. Increase fiber in the diet b. Reduce stress c. Decrease the intake of vitamins A and D d. Walk or perform weight-bearing exercises

D Rationale: Risk-lowering strategies for osteoporosis include walking or exercising outdoors, performing a regular weight-bearing exercise regimen, increasing dietary calcium and vitamin D intake, quitting smoking, and consuming alcohol and caffeine in moderation.

Which disorder is characterized by a butterfly-shaped rash across the bridge of the nose and cheeks? a. Scleroderma b. Polymyositis c. Rheumatoid arthritis (RA) d. Systemic lupus erythematous (SLE)

D Rationale: The most familiar manifestation of SLE is an acute cutaneous lesion consisting of a butterfly-shaped rash across the bridge of the nose and the cheeks. This type of rash does not characterize RA, scleroderma, or polymyositis.

The nurse is educating a group of women on the prevention of osteoporosis. The nurse recognizes the education as being effective when the group members make which statement? a. "Estrogen deficiency increases bone density." b. "We need to consume a low-calcium, high-phosphorus diet." c. "We need to increase aerobic exercise." d. "We need an adequate amount of exposure to sunshine."

D Rationale: The only accurate statement is related to getting an adequate amount of exposure to sunshine. Aerobic exercise, such as swimming, does not prevent osteoporosis. The exercise needs to be weight bearing. A diet low in calcium and high in phosphorus will increase the risk for osteoporosis. Estrogen deficiency is linked to decreased bone mass.

Nociception includes four specific processes: transduction, transmission, perception, and modulation. Which action illustrates the nociception process of pain transmission? a) A mother in labor utilizing imagery to reduce pain b) A patient taking tramadol to enhance pain management c) A surgeon making an incision to perform surgery d) A child quickly removing a hand when touching a hot object

D Rationale: Transduction, the first process involved in nociception, refers to the processes by which a noxious stimulus, such as a burn, releases of a number of excitatory compounds, which move pain along the pain pathway. Transmission, the second process involved in nociception, is responsible for a rapid reflex withdrawal from painful stimulus. The third process involved in nociception is perception. Imagery is based on the belief that the brain processes can strongly influence pain perception. A dual-mechanism analgesic agent, such as tramadol, involves many different neurochemicals as in the process of modulation.

TRUE OR FALSE The most definitive indicator of rheumatoid arthritis is the rheumatoid factor which is present in 100% of all diagnosed patients.

False

TRUE OR FALSE The nurse should recommend short periods of bed rest, in a prone position, for patients experiencing back pain resulting from a compression fracture.

False