Exam 2 questions
The nurse is assessing an older adult client in a long-term care facility after a fall. Which finding requires priority action?
The injured leg is shortened and externally rotated.
The nurse is evaluating a client in skin traction. Which observation indicates the traction is applied for maximum effectiveness?
The ropes are in the wheel grooves of the pulleys.
A Pt with Parkinson's is reporting that his gait is more unsteady; there is an increased risk for falls. Which suggestion could the nurse offer to diminish this risk?
Walk by stepping over imaginary lines on the floor
A client has been diagnosed with relapsing-remitting multiple sclerosis (MS). Which statement by the nurse most accurately explains to the client the onset of symptoms with this type of MS?
"Symptoms will flare up at times, with periods of partial or complete remission."
The nurse is caring for an 8-year-old child who sustained a hip fracture from a motor vehicle crash. The parents ask if the child will be scheduled for a hip replacement. How should the nurse respond?
"Treatment for hip fractures in children often involves casting for 4 to 6 weeks."
What is the normal range for CO2 in an ABG
35-45
The order is for D5W 1 liter at 160 mL/hour. The tubing drop factor is 15 gtts/mL.
40
The nurse assesses a child suspected of having autism spectrum disorder (ASD). Which behavior noted in the assessment supports the diagnosis?
An aversion to being touched
The quick and easiest way to help correct respiratory acidosis in a hypoventilating patient is
Arose them and have them take deep breaths
Why do clients with Parkinson disease (PD) nearly always take carbidopa in combination with levodopa?
Carbidopa prevents levodopa from converting to dopamine until it reaches the brain, thus minimizing levodopa's unwanted side effects.
The nurse is caring for a client admitted with an exacerbation of multiple sclerosis (MS). The client is demonstrating frustration with eating because he is experiencing hand and arm spasms that prevent the proper use of utensils. Which intervention should the nurse implement to best assist this client?
Consult with the occupational therapist regarding assistive devices for meals.
The nurse is teaching the parents of a very young client newly diagnosed with attention-deficit/hyperactivity disorder (ADHD) about the newly prescribed medication methylphenidate (Ritalin). Which instruction should the nurse include?
Give the medication first thing in the morning.
Acid-base balance is critical to homeostasis and cellular function. One measurement of acid-base balance is the pH of the blood. Which ion is measured to determine the pH?
H+
An woman planning to get pregnant inquires how best to reduce the risk of her child having CP. What advice is most accurate?
Have prenatal care and take precautions to avoid preterm labor
The nurse is assessing a toddler client for an upper respiratory infection. The nurse suspects the child may have autism spectrum disorder (ASD). Which behavior caused the nurse's suspicion?
Having a tantrum when touched by the nurse
A client with chronic hip pain is diagnosed with osteoarthritis. Which instruction regarding home safety is most appropriate for the nurse to provide to this client?
Install grab bars in the bathroom near the commode and in the shower.
The nurse notes a high level of stress between the parents of a child with cerebral palsy (CP). Which action should the nurse take to support the parents?
Listen to concerns and encourage expression of feelings
The nurse is assessing a 4-month-old infant. Which developmental milestone should the nurse expect the infant to have mastered by this time?
Looks at and plays with own fingers
A client is brought to the emergency department (ED) after a syncopal episode in a local department store. The client has been fasting and has ketones in the urine. Which acid-base imbalance would the nurse expect to assess in this client?
Metabolic acidosis
The nurse is preparing discharge instructions for an older adult client recovering from respiratory acidosis caused by restrictive lung disease and pneumonia. Which topics should the nurse include in the discharge teaching for this client? Select all that apply.
Obtain annual influenza immunization. Avoid crowds. Cover the nose and mouth when coughing. Engage in frequent hand washing.
The nurse caring for a child recently diagnosed with cerebral palsy (CP) is discussing the plan of care with the parents. Which should the nurse identify as a major goal of therapy for this child?
Promoting optimal global development
The nurse is caring for a child diagnosed with autism spectrum disorder (ASD) who is being admitted to the hospital with dehydration. Which action by the nurse is appropriate when the child arrives to the care area?
Quietly orient the child to a single-bed hospital room.
The nurse is caring for a client who has cerebral palsy (CP). Which intervention should the nurse use to promote flexibility and prevent contractures?
ROM exercises
The nurse assesses an older adult woman and determines the client is at high risk for osteoporosis and hip fractures. Based on these findings, which test should the nurse request from the healthcare provider?
bone density testing
The nurse performs a focused assessment on a client diagnosed with multiple sclerosis (MS). Which assessment should the nurse perform as a part of the physical examination specific to MS? (Select all that apply.)
clients affect clients visual acuity clients balance clients speech
After performing a physical assessment, the nurse suspects that a client is experiencing manifestations of osteoarthritis (OA). Which finding supports the nurse's suspicion? (Select all that apply.)
crepitation joint tenderness reduced joint flexibility joint stiffness
A client with Parkinson disease (PD) is prescribed an anticholinergic agent to treat tremors and rigidity. The nurse should teach the client about which adverse effect they may experience from this medication? (Select all that apply.)
dry mouth, loss of perspiration
The nurse is caring for a client who recently sustained a blow to the head. Which of the following assessment findings suggest that the client should be more closely evaluated for retinal detachment?
floaters in the visual field
An adult client seeks care for attention-deficit/hyperactivity disorder (ADHD). Which items in the collected history would support this diagnosis.
forgetfulness, anxiety, and trouble multitasking
Serum potassium of 3.25 mEq/L indicates
hypokalemia
The nurse is teaching the parents of a child recently diagnosed with autism spectrum disorder (ASD). Which etiologies should the nurse include? (Select all that apply.)
immunologic factors environmental factors genetics
The nurse is providing teaching about home care for a client with osteoarthritis of the knees. Which information should the nurse include? (Select all that apply.)
installing handrails in bathroom using assistive devices take pain meds as ordered
A mother of a toddler questions what can be done to assist her child's development. All of the following are ways to help except.
limit introduction of solid foods
When considering acid-base balance, health promotion should focus on
maintaining fluid balance
A client is admitted to the hospital with sudden, severe abdominal pain. The client is diagnosed with respiratory alkalosis. Which arterial blood gas value does the nurse document to support this diagnosis?
pH is 7.47 and PaCO2 is 25.
Which arterial blood gas (ABG) result would the nurse anticipate for a client with a 3-day history of vomiting?
pH: 7.55, PaCO2: 60 mm Hg, HCO3-: 28
The nurse is planning care for a client with osteoarthritis (OA). Which nursing diagnosis is a priority for the nurse to address?
pain, Chronic
A client is admitted to the hospital with a diagnosis of a right hip fracture. The client has right hip pain and cannot move the right leg. The nurse should further assess the right leg to determine if the leg is:
shorter than the leg on the unaffected side.
The nurse is assessing an older adult client. Which finding should cause the nurse to suspect the client has Parkinson disease (PD)? (Select all that apply.)
slurred speech, no emotion, cant remember what he ate for breakfast, hand tremors at rest
The nurse is assessing a 3-year-old child with autism spectrum disorder (ASD). In which area should the nurse expect to find impairments? (Select all that apply.)
social adaptability communication ability to organize responses to situations
The nurse is assessing a client suspected of having multiple sclerosis. Which manifestation should the nurse place as the top priority?
vertigo
A middle-aged female client states to the nurse, "I have noticed a slight tremor in my left hand when it's at rest. I think I might have Parkinson disease because my mother had it." Which response by the nurse is the most appropriate?
"Having a close relative with Parkinson disease can increase your chance of developing it as well."
The nurse is teaching older adults with osteoarthritis (OA) actions to effectively manage chronic pain. Which recommendation should the nurse include? (Select all that apply.)
Encourage resting painful joints apply cool compress use firm support in chairs teach proper posture and body mechanics
While assessing a client with eye pain, the nurse finds red, cloudy conjunctiva and swollen eyelids. The nurse should suspect which eye injury?
Chemical burn of the eye
The wife of a client with Parkinson disease (PD) expresses frustration about trying to communicate with her husband. What can the nurse do to facilitate communication between the client and spouse?
Consult with speech therapy for exercises to aid the client with speech and language.
In clients with Parkinson disease, increasing doses of and long-term exposure to levodopa can cause which of the following conditions?
Dyskinesia
A client with a history of relapsing-remitting multiple sclerosis (MS) is expecting her first child. Which of the following nursing interventions would be indicated for this client?
Suggest the client seek reproductive counseling.
The school nurse is helping to create an individualized education plan (IEP) for a young client with attention-deficit/hyperactivity disorder (ADHD). Which behavioral goal should the nurse include in the plan of care?
The client will respect the boundaries of others.
What is an example of an objective family burden?
amount of unsecured financial debt
The most common disorder that increases a client's risk for respiratory alkalosis is:
an anxiety disorder.
During an assessment, the nurse suspects that an 18-month-old client is demonstrating manifestations of cerebral palsy (CP). Which assessment finding should the nurse use to validate this conclusion? (Select all that apply.)
asymmetric crawling arched back head lag
A client diagnosed with localized idiopathic osteoarthritis (OA) asks the nurse what this means. Which response by the nurse provides the most accurate information?
"Idiopathic describes OA overall while localized indicates that it affects one to two body joints only."
