EXAM 5 (without perfusion) - third semester

A patient at 32 weeks of gestation reports that she has severe lower back pain. The nurse's assessment should include a. observation of posture and body mechanics. b. palpation of the lumbar spine. c. exercise pattern and duration. d. ability to sleep for at least 6 hours uninterrupted.

ANS: A Correct posture and body mechanics can reduce lower back pain caused by increasing lordosis. Pregnancy should not cause alterations in the spine. Any assessment for malformation should be done early in the pregnancy. Exercise and sleep are not as important to assess as are posture and body mechanics, which can contribute to the pain.

A nurse teaches a client who has a reflex (spastic) bladder after a spinal cord injury. Which bladder training technique would the nurse teach? a. Stroking the medial aspect of the thigh b. Valsalva maneuver c. Self-catheterization d. Frequent toileting

ANS: A If there is an upper motor neuron problem but the reflex arc is intact (reflex bladder pattern), the voiding response can be initiated by any stimulus that sends the message to the spinal cord level S2-4 that the bladder might be full. Such techniques include stroking the medial aspect of the thigh, pinching the area above the groin, massaging the peno-scrotal area, pinching the posterior aspect of the glans penis, and providing digital anal stimulation. The Valsalva maneuver is used for a flaccid bladder. Intermittent catheterization may be necessary if nothing else works. A consistent toileting schedule may be included in the regimen.

A patient taking entacapone (Comtan) for the first time calls the clinic to report a dark discoloration of his urine. After listening to the patient, the nurse realizes that what is happening in this situation? a. This is a harmless effect of the drug. b. The patient has taken this drug along with red wine or cheese. c. The patient is having an allergic reaction to the drug. d. The ordered dose is too high for this patient.

ANS: A COMT inhibitors, including entacapone, may darken a patient's urine and sweat.

A nurse teaches assistive personnel (AP) about how to care for a client with Parkinson disease. Which statement would the nurse include as part of this teaching? a. "Allow the client to be as independent as possible with activities." b. "Assist the client with frequent and meticulous oral care." c. "Assess the client's ability to eat and swallow before each meal." d. "Schedule appointments early in the morning to ensure rest in the afternoon."

ANS: A Clients with Parkinson disease do not move as quickly and can have functional problems. The client would be encouraged to be as independent as possible and provided time to perform activities without rushing. Although oral care is important for all clients, instructing the UAP to provide frequent and meticulous oral is not a priority for this client. This statement would be a priority if the client was immune-compromised or NPO. The nurse would assess the client's ability to eat and swallow; this would not be delegated. Appointments and activities would not be scheduled early in the morning because this may cause the client to be rushed and discourage the client from wanting to participate in activities of daily living.

A client who has rheumatoid arthritis is prescribed etanercept. What health teaching by the nurse about this drug is appropriate? a. Giving subcutaneous injections b. Having a chest x-ray once a year c. Taking the medication with food d. Using heat on the injection site

ANS: A Etanercept is given as a subcutaneous injection twice a week. The nurse would teach the client how to self-administer the medication. The other options are not appropriate for etanercept.

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

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

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

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

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

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

A client with a history of prostate cancer is in the clinic and reports new onset of severe low back pain. What action by the nurse is most important? a. Assess the client's gait and balance. b. Ask the client about the ease of urine flow. c. Document the report completely. d. Inquire about the client's job risks.

ANS: A This client has symptoms of spinal cord compression, which can be seen with prostate cancer. This may affect both gait and balance and urinary function. For client safety, assessing gait and balance is most important. Documentation would be complete. The client may or may not have occupational risks for low back pain, but with his history of prostate cancer, this would not be where the nurse starts investigating.

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

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

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

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

The nurse is assessing a client with long-term rheumatoid arthritis (RA) who has been taking prednisone for 10 years. For which complications of chronic drug therapy would the nurse assess? (Select all that apply.) a. Osteoporosis b. Diabetes mellitus c. Glaucoma d. Hypertension e. Hypokalemia f. Decreased immunity

ANS: A, B, C, D, E, F Prednisone is a corticosteroid that is sometimes used for autoimmune disorders like RA when other drugs are not effective or cannot be tolerated. However, it can cause many complications when used long-term, including all of the health problems listed in the choices.

A client has rheumatoid arthritis (RA) and the nurse is conducting a home assessment. What options can the nurse suggest for the client to maintain independence in activities of daily living (ADLs)? (Select all that apply.) a. Grab bars to reach high items b. Long-handled bath scrub brush c. Soft rocker-recliner chair d. Toothbrush with built-up handle e. Wheelchair cushion for comfort

ANS: A, B, D Grab bars, long-handled bath brushes, and toothbrushes with built-up handles all provide modifications for daily activities, making it easier for the client with RA to complete ADLs independently. The rocker-recliner and wheelchair cushion are comfort measures but do not help increase independence. Most clients who have RA are not wheelchair-bound.

When assessing the medication history of a patient with a new diagnosis of Parkinson's disease, which conditions are contraindications for the patient who will be taking carbidopa-levodopa? (Select all that apply.) a. Angle-closure glaucoma b. History of malignant melanoma c. Hypertension d. Benign prostatic hyperplasia e. Concurrent use of monoamine oxidase inhibitors (MAOIs)

ANS: A, B, E Angle-closure glaucoma, a history of melanoma or other undiagnosed skin conditions, and concurrent use of MAOIs are contraindications to the use of carbidopa-levodopa. The other options are incorrect.

The nurse assesses a client who has Parkinson disease. Which signs and symptoms would the nurse recognize as a key feature of this disease? (Select all that apply.) a. Flexed trunk b. Long, extended steps c. Slow movements d. Uncontrolled drooling e. Tachycardia

ANS: A, C, D Key features of Parkinson disease include a flexed trunk, slow and hesitant steps, bradykinesia, and uncontrolled drooling. Tachycardia is not a key feature of this disease.

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

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

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

ANS: A, C, D, F Information about the client's preinjury psychosocial status, usual methods of coping with illness, difficult situations, and disappointments would be obtained. Determine the client's level of independence or dependence and his or her comfort level in discussing feelings and emotions with family members or close friends. Clients who are emotionally secure and have a positive self-image, a supportive family, and financial and job security often adapt to their injury. Information about the client's spiritual and religious beliefs or cultural background also assists the nurse in developing the plan of care. The other options do not supply as much information about coping.

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

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

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

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

Abatacept (Orencia) is prescribed for a patient with severe rheumatoid arthritis. The nurse checks the patient's medical history, knowing that this medication would need to be used cautiously if which condition is present? a. Coronary artery disease b. Chronic obstructive pulmonary disease c. Diabetes mellitus d. Hypertension

ANS: B Abatacept must be used cautiously in patients with recurrent infections or chronic obstructive pulmonary disease. The other options are incorrect.

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

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

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

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

A nurse assesses a group of clients who have rheumatoid arthritis (RA). Which client would the nurse see first? a. Client who reports jaw pain when eating b. Client with a red, hot, swollen right wrist c. Client who has a puffy-looking area behind the knee d. Client with a worse joint deformity since the last visit

ANS: B All of the options are possible manifestations of RA. However, the presence of one joint that is much redder, hotter, or more swollen that the other joints may indicate infection or an exacerbation of the RA disease process. The nurse needs to see this client first.

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

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

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

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

While a patient is receiving drug therapy for Parkinson's disease, the nurse monitors for dyskinesia, which is manifested by which finding? a. Rigid, tense muscles b. Difficulty in performing voluntary movements c. Limp extremities with weak muscle tone d. Confusion and altered mental status

ANS: B Dyskinesia is the difficulty in performing voluntary movements that is experienced by some patients with Parkinson's disease. The other options are incorrect.

A 70-year-old retired patent is interested in nondrug, mind-body therapies, self-management, and alternative strategies to deal with joint discomfort from rheumatoid arthritis. What options should the nurse consider in the plan of care considering the patient's expressed wishes? a. Stationary exercise bicycle, free weights, and spinning class b. Mind-body therapies such as music therapy, distraction techniques, meditation, prayer, hypnosis, guided imagery, relaxation techniques, and pet therapy c. Chamomile tea and IcyHot gel d. Acupuncture and attending church services

ANS: B Mind-body therapies are designed to enhance the mind's capacity to affect bodily function and symptoms and include music therapy, distraction techniques, meditation, prayer, hypnosis, guided imagery, relaxation techniques, and pet therapy, among many others. Stationary exercise bicycle, free weights, and spinning are not mind-body therapies. They are classified as exercise therapies. Chamomile tea and IcyHot gel are not mid-body therapies per se. They are classified as herbal and topical thermal treatments. Acupuncture is an ancient Chinese complementary therapy, while attending church services is a religious prayer mind-body therapy capable of enhancing the mind's capacity to affect bodily function and symptoms.

A patient has an order for the monoclonal antibody adalimumab (Humira). The nurse notes that the patient does not have a history of cancer. What is another possible reason for administering this drug? a. Muscular dystrophy b. Rheumatoid arthritis c. Thrombocytopenia d. Spinal cord injury

ANS: B Monoclonal antibodies are used for the treatment of cancer, rheumatoid arthritis and other inflammatory diseases, multiple sclerosis, and organ transplantation.

The nurse is developing a care plan for a patient who is taking an anticholinergic drug. Which nursing diagnosis would be appropriate for this patient? a. Diarrhea b. Urinary retention c. Risk for infection d. Disturbed sleep pattern

ANS: B Patients receiving anticholinergic drugs are at risk for urinary retention and constipation, not diarrhea. The other nursing diagnoses are not applicable to anticholinergic drugs.

A patient has been given a prescription for levodopa-carbidopa (Sinemet) for her newly diagnosed Parkinson's disease. She asks the nurse, "Why are there two drugs in this pill?" The nurse's best response reflects which fact? a. Carbidopa allows for larger doses of levodopa to be given. b. Carbidopa prevents the breakdown of levodopa in the periphery. c. There are concerns about drug-food interactions with levodopa therapy that do not exist with the combination therapy. d. Carbidopa is the biologic precursor of dopamine and can penetrate into the central nervous system.

ANS: B When given in combination with levodopa, carbidopa inhibits the breakdown of levodopa in the periphery and thus allows smaller doses of levodopa to be used. Lesser amounts of levodopa result in fewer unwanted adverse effects. Levodopa, not carbidopa, is the biologic precursor of dopamine and can penetrate into the CNS.

The nurse is teaching a client with mild rheumatoid arthritis (RA) about how to protect synovial joints. Which health teaching will the nurse include? (Select all that apply.) a. "Use small joints rather than larger ones during tasks." b. "Use both hands instead of one with holding objects." c. "When getting out of bed or a chair, use the palms of your hands." d. "Bend your knees instead of your waist and keep your back straight." e. "Do not use multiple pillows under your head to prevent neck flexion." f. "Use a device or rubber grip to open jars or bottle tops." g. "Use long-handled devices such as a hairbrush with an extended handle."

ANS: B, C, D, E, F, G All of these options are part of health teaching for joint protection except that large joints should be used instead of smaller ones.

The nurse assesses a client with long-term rheumatoid arthritis (RA) for late signs and symptoms. Which assessment findings will the nurse document as late signs and symptoms of RA? (Select all that apply.) a. Anorexia b. Felty syndrome c. Joint deformity d. Low-grade fever e. Weight loss

ANS: B, C, E Late signs and symptoms of RA include Felty syndrome, joint deformity, weight loss, organ involvement, osteoporosis, extreme fatigue, and anemia, among others. Anorexia and low-grade fever are both seen early in the course of the disease.

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

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

A woman who is 32 weeks pregnant telephones the nurse at her obstetrician's office and complains of constant backache. She asks what pain reliever is safe for her to take. The best nursing response is a. "Back pain is common at this time during pregnancy due to poor posture." b. "Acetaminophen is acceptable during pregnancy; however, do not take aspirin." c. "You should come into the office and let the doctor check you." d. "Try a warm bath or using a heating pad."

ANS: C A prolonged backache is one of the subtle symptoms of preterm labor. Early intervention may prevent preterm birth. The woman should be assessed before trying any home care measures.

When providing education for the parents of a child with Duchenne muscular dystrophy, the nurse plans to include a. testing all female children for the disease. b. testing the father for the presence of the trait on the Y chromosome. c. genetic counseling for all female children. d. testing the parents to determine the carrier.

ANS: C Duchenne muscular dystrophy is a recessive sex-linked disease carried on the X chromosome, so only males are affected with the disease. Because it is a recessive X-linked disorder, females can only be carriers and do not have the disease. The disease is an X-linked recessive disorder and would not be found on the Y chromosome. The disease is a recessive X-linked disease and is always carried by the mother.

The primary health care provider prescribes methotrexate (MTX) for a client with a new diagnosis of rheumatoid arthritis. The nurse provides health teaching about the drug. What statement by the nurse is appropriate to include about methotrexate? a. "It will take at least 1 to 2 weeks for the drug to help relieve your symptoms." b. "The drug is very expensive but there are pharmacy plans to help pay for it." c. "The drug can increase your risk for infection, so you should avoid crowds." d. "It's OK for you to drink about 2 to 3 glasses of wine each week while taking the drug."

ANS: C MTX takes up to 4 to 6 weeks to begin to help relieve RA symptoms and is very inexpensive. Clients should avoid alcohol due to the potential for liver toxicity. MTX suppresses the immune system which makes clients susceptible to infection. The nurse teaches clients to avoid crowds and anyone with a known infection.

The nurse is preparing to administer medications to a patient with rheumatoid arthritis (RA). The nurse should explain which goal of treatment to the patient? a. Eradicate the disease b. Enhance immune response c. Control inflammation d. Manage pain

ANS: C Medications for RA are intended to control the inflammation that results from the body's hyperimmune response. Autoimmune diseases like RA are chronic and currently have no curative treatments. Autoimmune diseases like RA are caused by hyperimmune response. The immune system needs to be suppressed, not enhanced. While the medications used for RA might help with pain management, the goal of medication intervention is to manage the inflammation.

A client has long-term rheumatoid arthritis that especially affects the hands. The client wants to finish quilting a baby blanket before the birth of her grandchild. What response by the nurse is appropriate? a. "Let's ask your provider about increasing your pain pills." b. "Hold ice bags against your hands before quilting." c. "Try a paraffin wax dip 20 minutes before you quilt." d. "You need to stop quilting before it destroys your fingers."

ANS: C Paraffin wax dips are beneficial for decreasing pain in arthritic hands and lead to increased mobility. Increasing pain pills may not help with movement. Ice has limited use unless the client has a "hot" or exacerbated joint. The client wants to finish the project, so the nurse would not negate its importance by telling the client it is destroying her joints.

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

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

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

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

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

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

When treating patients with medications for Parkinson's disease, the nurse knows that the wearing-off phenomenon occurs for which reason? a. There are rapid swings in the patient's response to levodopa. b. The patient cannot tolerate the medications at times. c. The medications begin to lose effectiveness against Parkinson's disease. d. The patient's liver is no longer able to metabolize the drug.

ANS: C The wearing-off phenomenon occurs when antiparkinson medications begin to lose their effectiveness, despite maximal dosing, as the disease progresses. The other options are incorrect.

The nurse is assessing the medication history of a patient with a new diagnosis of Parkinson's disease. Which condition is a contraindication for the patient, who will be taking tolcapone (Tasmar)? a. Glaucoma b. Seizure disorder c. Liver failure d. Benign prostatic hyperplasia

ANS: C Tolcapone is contraindicated in patients who have shown a hypersensitivity reaction to it, and it should be used with caution in patients with pre-existing liver disease. The other conditions listed are not contraindications.

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

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

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

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

The nurse is reviewing the laboratory profile for a client who has muscular dystrophy. Which laboratory value(s) would the nurse expect to be elevated? (Select all that apply.) a. Calcium (Ca) b. Phosphate (PO4) c. Creatine kinase (CK) d. Lactic dehydrogenase (LDH) e. Aspartate aminotransferase (AST) f. Aldolase (ALD)

ANS: C, D, E, F Muscular dystrophy causes elevations in muscle enzymes and does not affect minerals like calcium and phosphorus.

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

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

A 75-year-old woman has been given a nonsteroidal anti-inflammatory drug (an NSAID for the treatment of rheumatoid arthritis. The nurse is reviewing the patient's medication history and notes that which types of medications could have an interaction with the NSAID? (Select all that apply.) a. Antibiotics b. Decongestants c. Anticoagulants d. Beta blockers e. Diuretics f. Corticosteroids

ANS: C, E, F Anticoagulants taken with NSAIDs may cause increased bleeding tendencies because of platelet inhibition and hypoprothrombinemia. NSAIDs taken with diuretics may cause reduced hypotensive and diuretic effects. NSAIDs taken with corticosteroids may cause increased ulcerogenic effects. The other options are incorrect.

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

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

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

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

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

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

A client diagnosed with Parkinson disease will be starting ropinirole for symptom control. Which statement by the client indicates a need for further teaching? a. "This drug should help decrease my tremors and help me move better." b. "I need to change positions slowly to prevent dizziness or falls." c. "I should take the drug at the same time each day for the best effect." d. "I know the drug will probably help me prevent constipation."

ANS: D Although ropinirole is a dopamine agonist and mimics dopamine to promote movement, it does not work to prevent constipation. This class of drugs can cause orthostatic hypotension and should be taken at the same time every day.

After teaching the wife of a client who has Parkinson disease, the nurse assesses the wife's understanding. Which statement by the client's wife indicates that she correctly understands changes associated with this disease? a. "His masklike face makes it difficult to communicate, so I will use a whiteboard." b. "He should not socialize outside of the house due to uncontrollable drooling." c. "This disease is associated with anxiety causing increased perspiration." d. "He may have trouble chewing, so I will offer bite-sized portions."

ANS: D Because chewing and swallowing can be problematic, small frequent meals and a supplement are better for meeting the client's nutritional needs. A masklike face and drooling are common in clients with Parkinson disease. The client would be encouraged to continue to socialize and communicate as normally as possible. The wife should understand that the client's masklike face can be misinterpreted and additional time may be needed for the client to communicate with her or others. Excessive perspiration is also common in clients with Parkinson disease and is associated with the autonomic nervous system's response.

A patient has a new order for a catechol ortho-methyltransferase (COMT) inhibitor as part of treatment for Parkinson's disease. The nurse recognizes that which of these is an advantage of this drug class? a. It has a shorter duration of action. b. It causes less gastrointestinal distress. c. It has a slower onset than traditional Parkinson's disease drugs. d. It is associated with fewer wearing-off effects.

ANS: D COMT inhibitors are associated with fewer wearing-off effects and have prolonged therapeutic benefits. They have a quicker onset, and they prolong the duration of action of levodopa

The nurse is caring for several clients with osteoporosis. For which client would bisphosphonates not be a good option? a. Client with diabetes who has a serum creatinine of 0.8 mg/dL (61mcmol/L). b. Client who recently fell and has vertebral compression fractures. c. Hypertensive client who takes calcium channel blockers. d. Client with a spinal cord injury who cannot tolerate sitting up.

ANS: D Clients on bisphosphonates must be able to sit upright for 30 to 60 minutes after taking them. The client who cannot tolerate sitting up is not a good candidate for this class of drug. Poor renal function also makes clients poor candidates for this drug, but the client with a creatinine of 0.8 mg/dL (61 mcmol/L) is within normal range. Diabetes and hypertension are not related unless the client also has renal disease. The client who recently fell and sustained fractures is a good candidate for this drug if the fractures are related to osteoporosis.

Carbidopa-levodopa (Sinemet) is prescribed for a patient with Parkinson's disease. The nurse informs the patient that which common adverse effects can occur with this medication? a. Drowsiness, headache, weight loss b. Dizziness, insomnia, nausea c. Peripheral edema, fatigue, syncope d. Heart palpitations, hypotension, urinary retention

ANS: D Common adverse reactions associated with carbidopa-levodopa include palpitations, hypotension, urinary retention, dyskinesia, and depression. The other effects may occur with other antiparkinson drugs.

When a patient is taking an anticholinergic such as benztropine (Cogentin) as part of the treatment for Parkinson's disease, the nurse should include which information in the teaching plan? a. Minimize the amount of fluid taken while on this drug. b. Discontinue the medication if adverse effects occur. c. Take the medication on an empty stomach to enhance absorption. d. Use artificial saliva, sugarless gum, or hard candy to counteract dry mouth.

ANS: D Dry mouth can be managed with artificial saliva through drops or gum, frequent mouth care, forced fluids, and sucking on sugar-free hard candy. Anticholinergics should be taken with or after meals to minimize GI upset and must not be discontinued suddenly. The patient must drink at least 3000 mL/day unless contraindicated. Drinking water is important, even if the patient is not thirsty or in need of hydration, to prevent and manage the adverse effect of constipation.

The nurse plans care for a client with Parkinson disease. Which intervention would the nurse include in this client's plan of care? a. Restrain the client to prevent falling. b. Ensure that the client uses incentive spirometry. c. Teach the client pursed-lip breathing techniques. d. Keep the head of the bed at 30 degrees or greater.

ANS: D Elevation of the head of the bed will help prevent aspiration. The other options will not prevent aspiration, which is the greatest respiratory complication of Parkinson disease, nor do these interventions address any of the complications of Parkinson disease. Pursed-lip breathing increases exhalation of carbon dioxide; incentive spirometry expands the lungs. The client should not be restrained to prevent falls. Other less restrictive interventions should be used to maintain client safety.

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

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

The nurse is caring for a young client who has been diagnosed with osteopenia. Which risk factor in the client's history most likely contributed to the bone loss? a. Osteoarthritis b. Hypothyroidism c. Addison disease d. Rheumatoid arthritis

ANS: D Rheumatoid arthritis often occurs in young female adults and can lead to osteoporosis as a common complication. Cushing disease (rather than Addison disease) and hyperthyroidism (rather than hypothyroidism) are also risk factors. Osteoarthritis is a joint disease.

The nurse assesses a client with rheumatoid arthritis (RA) and Sjögren syndrome. What assessment would be most important for this client? a. Abdominal assessment b. Oxygen saturation c. Breath sounds d. Visual acuity

ANS: D Sjögren syndrome may be seen in clients with RA and manifests with dryness of the eyes, mouth, and vagina in females. Visual disturbances can occur. The other assessments are not related to Sjögren syndrome.

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

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

A patient has been treated with antiparkinson medications for 3 months. What therapeutic responses should the nurse look for when assessing this patient? a. Decreased appetite b. Gradual development of cogwheel rigidity c. Newly developed dyskinesias d. Improved ability to perform activities of daily living

ANS: D Therapeutic responses to antiparkinson agents include an improved sense of well-being, improved mental status, increased appetite, increased ability to perform activities of daily living and to concentrate and think clearly, and less intense parkinsonian manifestations.