Exam 1

When an older woman falls down at church and immediately complains of severe pain in her left hip, the choir director recognizes the cardinal sign of a fractured hip when he sees: 1. the left leg is shorter than the right. 2. downward curled toes. 3. internal rotation of the left leg. 4. hematoma on the left hip.

1

A patient is diagnosed with a small meniscus tear of the right knee. What should the nurse expect to be prescribed for this patient? Select all that apply. 1) Ice 2) Limited rest 3) Physical therapy for a month 4) Total immobility for several weeks 5) Use of nonsteroidal anti-inflammatory drugs (NSAIDs)

1, 2, 5

A hospitals emergency operations plan has been enacted following an industrial accident. While one nurse performs the initial triage, what should other emergency medical services personnel do? A) Perform life-saving measures. B) Classify patients according to acuity. C) Provide health promotion education. D) Modify the emergency operations plan.

A

A nurse is caring for a patient who had a right below-the-knee amputation (BKA). The nurse recognizes the importance of implementing measures that focus on preventing flexion contracture of the hip and maintaining proper positioning. Which of the following measures will best achieve these goals? A) Encouraging the patient to turn from side to side and to assume a prone position B) Initiating ROM exercises of the hip and knee 10 to 12 weeks after the amputation C) Minimizing movement of the flexor muscles of the hip D) Encouraging the patient to sit in a chair for at least 8 hours a day

A

A nurse is caring for a patient who has just had an arthroscopy as an outpatient and is getting ready to go home. The nurse should teach the patient to monitor closely for what postprocedure complication? A) Fever B) Crepitus C) Fasciculations D) Synovial fluid leakage

A

A nurse is caring for a patient who is postoperative day 1 right hip replacement. How should the nurse position the patient? A) Keep the patients hips in abduction at all times. B) Keep hips flexed at no less than 90 degrees. C) Elevate the head of the bed to high Fowlers. D) Seat the patient in a low chair as soon as possible.

A

A nurse is caring for an adult patient diagnosed with a back strain. What health education should the nurse provide to this patient? A) Avoid lifting more than one-third of body weight without assistance. B) Focus on using back muscles efficiently when lifting heavy objects. C) Lift objects while holding the object a safe distance from the body. D) Tighten the abdominal muscles and lock the knees when lifting of an object

A

A nurse is collaborating with the physical therapist to plan the care of a patient with osteomyelitis. What principle should guide the management of activity and mobility in this patient? A.Stress on the weakened bone must be avoided B. Increased heart rate enhances perfusion and bone healing. C.Bed rest results in improved outcomes in patients with osteomyelitis. D.Maintenance of baseline ADLs is the primary goal during osteomyelitis treatment

A

A patient tells the nurse that he has pain and numbness to his thumb, first finger, and second finger of the right hand. The nurse discovers that the patient is employed as an auto mechanic, and that the pain is increased while working. This may indicate that the patient could possibly have what health problem? A) Carpel tunnel syndrome B) Tendonitis C) Impingement syndrome D) Dupuytrens contracture

A

The surgical nurse is admitting a patient from postanesthetic recovery following the patients below-the- knee amputation. The nurse recognizes the patients high risk for postoperative hemorrhage and should keep which of the following at the bedside. A) A tourniquet B) A syringe preloaded with vitamin K C) A unit of packed red blood cells, placed on ice D) A dose of protamine sulfate

A

A nurse suspects an older adult is experiencing heat stroke based on which assessment findings? Select all that apply . A) Temperature 105 degrees F (40.6 degrees B) Lack of sweating C )Increased thirst D) Weakness E) Delirium F) Bradypnea

A) Temperature 105 degrees F (40.6 degrees B) Lack of sweating E) Delirium

A client returns to the nursing unit following an open reduction with internal fixation of the right hip. Which nursing interventions would be appropriate for the prophylactic treatment of deep vein thrombosis? Select all that apply. A) Increasing fluid intake B) Maintaining antiembolic stockings C) Administering enoxaparin D) Encouraging coughing exercises E) Increasing fiber intake

A, B, C

Which of the following assessment findings indicate to the nurse that a client may have peripheral neurovascular dysfunction? A) Absence of feeling B) Capillary refill of 4 to 5 seconds C) Cool skin D) Pain E) Redness of the skin F)Weakness in motion

A, B, C, D, F

A nurse is planning the care of an older adult patient who will soon be discharged home after treatment for a fractured hip. In an effort to prevent future fractures, the nurse should encourage which of the following? Select all that apply. A) Regular bone density testing B) A high-calcium diet C) Use of falls prevention precautions D) Use of corticosteroids as ordered E) Weight-bearing exercise

A, B, C, E

A patient with a short arm cast is suspected to have compartment syndrome. What actions should the nurse include in the plan of care? Select all that apply. a) Provide support to the injured extremity. b) Apply ice to extremity. c) Prepare for cast removal. d) Elevate the arm above the heart. e) Assess neurovascular status every 8 hours.

A, C

Which interventions should a nurse implement as part of initial pain relief for the client with a cast? Select all that apply. A) Apply cold packs B) Apply a new cast C) Administer analgesics D) Elevate the involved part E) Provide passive range of motion

A, C, D

A 75-year-old client had surgery for a left hip fracture yesterday. When completing the plan of care, the nurse should include assessment for which complications? Select all that apply. A)Pneumonia B)Necrosis of the humerus C)Skin breakdown D)Sepsis E)Delirium

A, C, D, E

A patient presents to the ED following a motor vehicle collision. The patient is suspected of having internal hemorrhage. The nurse assesses the patient for signs and symptoms of shock. Signs and symptoms of shock include which of the following? Select all that apply. a) Decreasing blood pressure b) Increasing urine volume c) Increasing heart rate d) Delayed capillary refill e) Cool, moist skin

A, C, D, E

A patient admitted to the ED with severe diarrhea and vomiting is subsequently diagnosed with food poisoning. The nurse caring for this patient assesses for signs and symptoms if fluid and electrolyte imbalances. For what signs and symptoms would this nurse assess? SATA A. Dysrhythmias B. Hypothermia C. Hypotension D. Hyperglycemia E. Delirium

A, C, E

A patient admitted to the ED with severe diarrhea and vomiting is subsequently diagnosed with food poisoning. The nurse caring for this patient assesses for signs and symptoms of fluid and electrolyte imbalances. For what signs and symptoms would this nurse assess? Select all that apply A) Dysrhythmias B) Hypothermia C) Hypotension D) Hyperglycemia E) Delirium

A, C, E

A home care nurse assesses for disease complications in a client with bone cancer. Which laboratory value may indicate the presence of a disease complication? a) Sodium level of 110 mEq/L b) Calcium level of 11.6 mg/dl c) Magnesium level of 0.9 mg/dl d) Potassium level of 6.3 mEq/L

B

A nurse is caring for a patient receiving skeletal traction. Due to the patients severe limits on mobility, the nurse has identified a risk for atelectasis or pneumonia. What intervention should the nurse provide in order to prevent these complications? A) Perform chest physiotherapy once per shift and as needed. B) Teach the patient to perform deep breathing and coughing exercises. C) Administer prophylactic antibiotics as ordered. D) Administer nebulized bronchodilators and corticosteroids as ordered.

B

A nurse is caring for an older adult patient who is preparing for discharge following recovery from a total hip replacement. Which of the following outcomes must be met prior to discharge? A) Patient is able to perform ADLs independently. B) Patient is able to perform transfers safely. C) Patient is able to weight-bear equally on both legs. D) Patient is able to demonstrate full ROM of the affected hip.

B

A nurse is performing a nursing assessment of a patient suspected of having a musculoskeletal disorder. What is the primary focus of the nursing assessment with a patient who has a musculoskeletal disorder? A) Range of motion B) Activities of daily living C) Gait D) Strength

B

A nurse is reviewing a patients activities of daily living prior to discharge from total hip replacement. The nurse should identify what activity as posing a potential risk for hip dislocation? A) Straining during a bowel movement B) Bending down to put on socks C) Lifting items above shoulder level D) Transferring from a sitting to standing position

B

A nurse is triaging patients after a chemical leak at a nearby fertilizer factory. The guiding principle of this activity is what? A) Assigning a high priority to the most critical injuries B) Doing the greatest good for the greatest number of people C) Allocating resources to the youngest and most critical D) Allocating resources on a first come, first served basis

B

A patient is being prepared for a total hip arthroplasty, and the nurse is providing relevant education. The patient is concerned about being on bed rest for several days after the surgery. The nurse should explain what expectation for activity following hip replacement? A) Actually, patients are only on bed rest for 2 to 3 days before they begin walking with assistance. B) The physical therapist will likely help you get up using a walker the day after your surgery. C) Our goal will actually be to have you walking normally within 5 days of your surgery. D) For the first two weeks after the surgery, you can use a wheelchair to meet your mobility needs.

B

A public health nurse is teaching a mother about vaccinations prior to obtaining informed consent for her childs vaccination. What should the nurse cite as the most common adverse effect of vaccinations? A) Temporary sensitivity to the sun B) Allergic reaction to the antigen or carrier solution C) Nausea and vomiting D) Joint pain near the injection site

B

The nurse is providing care for a patient who has had a below-the-knee amputation. The nurse enters the patients room and finds him resting in bed with his residual limb supported on pillow. What is the nurses most appropriate action? A) Inform the surgeon of this finding. B) Explain the risks of flexion contracture to the patient. C) Transfer the patient to a sitting position. D) Encourage the patient to perform active ROM exercises with the residual limb.

B

A nurse is caring for a child who was admitted to the pediatric unit with infectious diarrhea. The nurse should be alert to what assessment finding as an indicator of dehydration? A) Labile BP B) Weak pulse C) Fever D) Diaphoresis

B) Weak pulse, thirst, dry oral mucous membranes, sunken eyes, weakened pulse, loss of skin turgor Assessment of dehydration includes evaluation of thirst, oral mucous membrane dryness, sunken eyes, a weakened pulse, and loss of skin turgor. Diaphoresis, labile BP, and fever are not characteristic signs and symptoms of dehydration.

Which of the following would the nurse identify as indicating that a client is experiencing a complete airway obstruction? Select all that apply. a) Spontaneous coughing b) Stridor c) Clutching of the neck d) Inability to speak e) Cyanosis

B, C, D, E

13. A nurse is reviewing the pathophysiology that may underlie a patients decreased bone density. What hormone should the nurse identify as inhibiting bone resorption and promoting bone formation? A) Estrogen B) Parathyroid hormone (PTH) C) Calcitonin D) Progesterone

C

A nurse is caring for a patient who has suffered a hip fracture and who will require an extended hospital stay. The nurse should ensure that the patient does which of the following in order to prevent common complications associated with a hip fracture? A) Avoid requesting analgesia unless pain becomes unbearable. B) Use supplementary oxygen when transferring or mobilizing. C) Increase fluid intake and perform prescribed foot exercises. D) Remain on bed rest for 14 days or until instructed by the orthopedic surgeon.

C

A nurse is caring for a patient with a bone tumor. The nurse is providing education to help the patient reduce the risk for pathologic fractures. What should the nurse teach the patient? A) Strive to achieve maximum weight-bearing capabilities. B) Gradually strengthen the affected muscles through weight training. C) Support the affected extremity with external supports such as splints. D) Limit reliance on assistive devices in order to build strength.

C

A nurse is performing a shift assessment on an elderly patient who is recovering after surgery for a hip fracture. The nurse notes that the patient is complaining of chest pain, has an increased heart rate, and increased respiratory rate. The nurse further notes that the patient is febrile and hypoxic, coughing, and producing large amounts of thick, white sputum. The nurse recognizes that this is a medical emergency and calls for assistance, recognizing that this patient is likely demonstrating symptoms of what complication? A) Avascular necrosis of bone B) Compartment syndrome C) Fat embolism syndrome D) Complex regional pain syndrome

C

The nurse is caring for a patient who underwent a total hip replacement yesterday. What should the nurse do to prevent dislocation of the new prosthesis? A) Keep the affected leg in a position of adduction. B) Have the patient reposition himself independently. C) Protect the affected leg from internal rotation. D) Keep the hip flexed by placing pillows under the patients knee.

C

The nurse is educating a patient with lower back pain on proper lifting techniques. The nurse would document what behavior as evidence the education was effective? a) The patient used a narrow base of support. b) The patient bent at the hips and tightened the abdominal muscles c) The patient placed the load close to the body. d) The patient reached over head with arms fully extended.

C

A patient is admitted to the orthopedic unit with a fractured femur after a motorcycle accident. The patient has been placed in traction until his femur can be rodded in surgery. For what early complications should the nurse monitor this patient? Select all that apply. A) Systemic infection B) Complex regional pain syndrome C) Deep vein thrombosis D) Compartment syndrome E) Fat embolism

C,D,E

A patient has been witness to a disaster involving a large number of injuries. The patient appears upset, but states that he feels capable of dealing with his emotions. What is the nurses most appropriate intervention? A) Educate the patient about the potential harm in denying his emotions. B) Refer the patient to social work or spiritual care. C) Encourage the patient to take a leave of absence from his job to facilitate emotional healing. D) Encourage the patient to return to normal social roles when appropriate.

D

A patient who has had an amputation is being cared for by a multidisciplinary rehabilitation team. What is the primary goal of this multidisciplinary team? A) Maximize the efficiency of care B) Ensure that the patients health care is holistic C) Facilitate the patients adjustment to a new body image D) Promote the patients highest possible level of function

D

An older adult patient has come to the clinic for a regular check-up. The nurses initial inspection reveals an increased thoracic curvature of the patients spine. The nurse should document the presence of which of the following? A) Scoliosis B) Epiphyses C) Lordosis D) Kyphosis

D

A nurse is providing an educational class to a group of older adults at a community senior center. In an effort to prevent osteoporosis, the nurse should encourage participants to ensure that they consume the recommended adequate intake of what nutrients? Select all that apply. A) Vitamin B12 B) Potassium C) Calcitonin D) Calcium E) Vitamin D

D,E

A nurse is performing discharge teaching for an elderly client with osteoporosis. Which instruction about taking a calcium supplement should the nurse include? a) Take weekly on the same day and at the same time .b) Remain in an upright position 30 minutes after taking the supplement .c) Take the supplement on an empty stomach with a full glass of water. d) Take the supplement with meals or with orange juice.

D.

When performing a physical assessment of a client, the client reports numbness, tingling, and pain when the nurse percusses lightly over the median nerve. The nurse recognizes that this finding is consistent with: a) Dupuytren's contracture b) Impingement syndrome c) Morton's neuroma d) Carpal tunnel syndrome

D. Carpel Tunnel Syndrome

Hypercalcemia is a dangerous complication of bone cancer. Therefore, nursing assessment includes evaluation of symptoms that require immediate treatment. Which of the following are signs/symptoms that are indictors of an elevated serum calcium? Select all that apply.

Muscle weakness Shortened QT interval Lack of muscle coordination Anorexia and constipation

An 80-year-old man in a long-term care facility has a chronic leg ulcer and states that the area has become increasingly painful in recent days. The nurse notes that the site is now swollen and warm to the touch. The patient should undergo diagnostic testing for what health problem? Osteomyelitis Osteoporosis Osteomalacia Septic arthritis

Osteomyelitis

A nurse is caring for a patient with a bone tumor. The nurse is providing education to help the patient reduce the risk for pathologic fractures. What should the nurse teach the patient?

Support the affected extremity with external supports such as splints.

The nurse is scheduled to administer tetanus, diphtheria, and pertussis (Tdap) vaccine to a patient at the clinic. The patient states, "I had a reaction the last time I got an immunization." What action should the nurse take first? a) Withhold the immunization. b) Document the reaction to the previous immunization. c) Administer the Tdap as ordered. d) Obtain further history regarding the reaction and immunization.

a

Which intervention should the nurse implement with the client who has an external fixator? Select all that apply. a- Supervise the client during transfers. b- Turn the clamps by one-half every day. c- Perform neurovascular assessment. d- Perform pin care as ordered. e- Inspect pin sites for signs of infection.

a- Supervise the client during transfers. c- Perform neurovascular assessment. d- Perform pin care as ordered. e- Inspect pin sites for signs of infection.

You are teaching a pathophysiology class to pre-nursing students. Today you are teaching about infection. What groups of people would you tell the students are at increased risk for infection? (Mark all that apply.) a) Adolescents b) Clients with impaired skin c) Debilitated clients d) Older adults e) Clients with pancreatic disease

c) Debilitated clients d) Older adults b) Clients with impaired skin