Health & Illness Exam #1 Review

A nurse believes that patients with the same type of tissue injury should have the same amount of pain. This statement reflects a. a belief that will contribute to appropriate pain management. b. an accurate statement about pain mechanisms and expected goals of pain therapy. c. a belief that will not have any effect on the type of care provided to people in pain. d. a lack of knowledge about pain mechanisms, which is likely to contribute to poor pain management.

D

During routine assessment of a patient with Guillain-Barré syndrome, the nurse finds the patient is short of breath. The patient's respiratory distress is caused by a. elevated protein levels in the CSF. b. immobility resulting from ascending paralysis. c. degeneration of motor neurons in the brainstem and spinal cord. d. paralysis ascending to the nerves that stimulate the thoracic area.

D

Which complication would the nurse monitor for in a client on strict bed rest for 3 days? Select all that apply. One, some, or all responses may be correct. 1-Atelectasis 2-Hypotension 3-Constipation 4-Pressure injuries 5-Urinary tract infection

1-Atelectasis 2-Hypotension 3-Constipation 4-Pressure injuries 5-Urinary tract infection

Which nursing interventions would the nurse avoid when providing care for a client with a fractured extremity? 1-Keeping the client warm and dry 2-Removing the client's shoes or boots immediately 3-Immobilizing the affected extremity 4-Allowing the client to lie in supine position

2-Removing the client's shoes or boots immediately

The effects of immobility on the cardiac system include which of the following? (Select all that apply.) 1. Thrombus formation 2. Increased cardiac workload 3. Weak peripheral pulses 4. Irregular heartbeat 5. Orthostatic hypotension

1,2,5

Which item in the plan of care for a client with paraplegia would the nurse question? 1-Change the client's bed position hourly. 2-Use supportive devices to maintain body alignment. 3-Instruct the client to do active leg exercises. 4-Perform passive leg exercises several times daily.

3-Instruct the client to do active leg exercises.

An older-adult patient has been bedridden for 2 weeks. Which of these complaints by the patient indicates to the nurse that he or she is developing a complication of immobility? 1. Increase of appetite 2. Gum soreness 3. Difficulty in swallowing 4. Left ankle joint stiffness

4

During rehabilitation, a patient with spinal cord injury begins to ambulate with long leg braces. Which level of injury does the nurse associate with this degree of recovery? a. L1-2 b. T6-7 c. T1-2 d. C7-8

A

A nurse is helping a patient perform active assisted range of motion in the right elbow. Which statement describes the correct technique? 1. Support elbow by holding distal part of extremity. 2. Grasp joint with fingers to provide support. 3. Have patient move joint independently. 4. Move the joint past the point of resistance. 5. Perform the exercise a few times only, and gradually build up to more.

1

A patient has been on bed rest for over 5 days. Which of these findings during the nurse's assessment may indicate a complication of immobility? 1. Decreased peristalsis 2. Decreased heart rate 3. Increased blood pressure 4. Increased urinary output

1

An older-adult patient is admitted following a hip fracture and surgical repair. Before ambulating the patient postoperatively on the evening of surgery, which of the following would be most important to assess? (Select all that apply.) 1. Patient's usual dietary intake 2. Time and date of the patient's last bowel movement 3. Preadmission activity tolerance 4. Baseline heart rate 5. Patient's home living situation 856

3,4

During an 8-hour shift, a client has a 6-oz (180-mL) cup of tea and 360 mL of water. The client vomits 100 mL, and the instilled intravenous (IV) fluids equaled the urinary output. What is this client's fluid balance at the end of this 8-hour period that the nurse must document on the client's intake and output record? 1-240 mL 2-340 mL 3-440 mL 4-540 mL

3-440 mL

A patient with a T4 spinal cord injury has neurogenic shock due to sympathetic nervous system dysfunction. What would the nurse recognize as characteristic of this condition? a. Tachycardia b. Hypotension c. Increased cardiac output d. Peripheral vasoconstriction

B

An example of distraction to provide pain relief is a. TENS. b. music. c. exercise. d. biofeedback.

B

An important nursing responsibility related to pain is to a. leave the patient alone to rest. b. help the patient appear to not be in pain. c. believe what the patient says about the pain. d. assume responsibility for eliminating the patient's pain.

C

Giving opioids to an actively dying patient who has moderate to severe pain a. may cause addiction. b. will likely be ineffective. c. is an appropriate nursing action. d. will likely hasten the person's death.

C

Unrelieved pain is a. not expected after major surgery. b. expected in a person with cancer. c. dangerous and can lead to many physical and psychologic complications. d. an annoying sensation, but it is not as important as other physical care needs.

C

A pediatric client with a past history of chicken pox reports a fever and headache. Which medication would the nurse avoid giving to the client? 1-Aspirin 2-Tetracycline 3-Nalidixic acid 4-Chloramphenicol

1-Aspirin

A patient is receiving 40 mg of enoxaparin subcutaneously every 12 hours while on prolonged bed rest to prevent thrombophlebitis. Because bleeding is a potential side effect of this medication, the nurse should continually assess the patient for what signs of bleeding? (Select all that apply.) 1. Bruising 2. Pale yellow urine 3. Bleeding gums 4. Coffee ground-like vomitus 5. Light brown stool

1,3,4

A middle-aged adult patient has limited mobility following a total knee arthroplasty. During assessment, the nurse notes that the patient is having difficulty breathing while lying supine. Which assessment data support a pulmonary issue related to immobility? (Select all that apply.) 1. Oxygen saturation of 89% 2. Irregular radial pulse 3. Diminished breath sounds bilateral bases on auscultation 4. BP: 132/84 5. Pain reported at 3 on scale of 0 to 10 following medication 6. Respiratory rate of 26

1,3,6

Which would the nurse include in the client's medication teaching on the administration of aspirin 650 mg every 6 hours as needed for arthritic pain? Select all that apply. One, some, or all responses may be correct. 1-"Report persistent abdominal pain." 2-"Do not chew enteric-coated tablets." 3-"Take the aspirin with meals or a snack." 4-"See a dentist if bleeding gums develop." 5-"Switch to acetaminophen if tinnitus occurs."

1-"Report persistent abdominal pain." 2-"Do not chew enteric-coated tablets." 3-"Take the aspirin with meals or a snack."

After surgery, a child experiences intense pain and an analgesic is prescribed. Which would the nurse consider when administering the analgesic? 1-Even though children do not like medicine, analgesics will make them more comfortable. 2-Pain is not felt as strongly by children as by adults; therefore analgesics are not needed as frequently. 3-Children should rarely receive analgesics because they could cause addiction or respiratory depression. 4-Children do not need analgesics because they quickly return to playing or sleeping when they are distracted

1-Even though children do not like medicine, analgesics will make them more comfortable.

Which assessment findings alert the nurse that the client who has a spinal cord injury is developing autonomic hyperreflexia (autonomic dysreflexia)? 1-Hypertension and bradycardia 2-Flaccid paralysis and numbness 3-Absence of sweating and pyrexia 4-Escalating tachycardia and shock

1-Hypertension and bradycardia

Which rational supports administering the medication pregabalin to a client with acquired immunodeficiency syndrome (AIDS)? 1-To reduce neuropathic pain 2-To reduce cognitive difficulty 3-To reduce swallowing difficulty 4-To reduce muscle and joint pain

1-To reduce neuropathic pain

A 46-year-old patient is admitted to the emergency department following an automobile accident. The patient has a pelvic fracture and is ordered on bed rest and placed in an immobilization device to limit further injury until the fracture can safely be repaired. Which measures would be appropriate for this patient to prevent complications of bed rest? (Select all that apply.) 1. Administer intravenous analgesic as ordered. 2. Have patient perform incentive spirometry. 3. Support patient in active assistive ROM exercises of upper extremities. 4. Provide patient a low-calorie diet. 5. Apply sequential compression devices to legs.

2,3,5

The health care provider has prescribed enoxaparin 1 mg/kg for a client who had a total knee replacement. The client weighs 85 kg (187 lb). This medication is available in a concentration of 30 mg/0.3 mL. Which dose will the nurse administer in milliliters? 1-0.8 mL 2-0.85 mL 3-0.9 mL 4-0.95 mL

2-0.85 mL

A 9-year-old child has a fractured tibia, and a full leg cast is applied. Which assessment findings would the nurse immediately report to the health care provider? Select all that apply. One, some, or all responses may be correct. 1-Increased urine output 2-Inability to move the toes 3-Pedal pulse of 90 beats per minute 4-Tingling sensation in the foot 5-Fiberglass cast that is damp after 4 hours

2-Inability to move the toes 4-Tingling sensation in the foot 5-Fiberglass cast that is damp after 4 hours

Which client assessment finding would the nurse document as subjective data? 1-Blood pressure 120/82 beats/min 2-Pain rating of 5 3-Potassium 4.0 mEq 4-Pulse oximetry reading of 96%

2-Pain rating of 5

Which intervention would the nurse perform first to manage the condition of a client with autonomic dysreflexia? 1-Cover the client with blanket. 2-Place the client in a sitting position. 3-Assess the client's urinary retention. 4-Administer alpha blockers to the client.

2-Place the client in a sitting position.

Which instruction would the nurse provide to an older client using ice and heat to treat pain from back strain? Select all that apply. One, some, or all responses may be correct. 1-Switch positions every 4 hours. 2-Use a heating pad for the first 24 hours 3-Apply for 30-minute time intervals. 4-Place the ice pack directly to injury site 5-Take ibuprofen every 4 hours PRN.

3-Apply for 30-minute time intervals.

A client who just returned from a cardiac catheterization reports to the nurse that the pressure bandage on the right groin is tight. Which action would the nurse take? 1-Loosen the dressing slightly 2-Notify the primary health care provider. 3-Assess the circulatory status of the extremity. 4-Have the client flex the joints of the right leg.

3-Assess the circulatory status of the extremity.

The nurse finds the client on the floor, crying for help, with signs of a hip fracture. Which action would the nurse take first? 1-Administer pain medication. 2-Place the affected extremity in traction. 3-Immobilize the affected extremity. 4-Notify the primary health care provider on call.

3-Immobilize the affected extremity.

The nurse is providing care to a client. Which nursing action has the highest priority when the nurse is moving a client with a neck and spinal cord injury during the assessment process? 1-Removing the cervical spine collar 2-Monitoring for autonomic dysreflexia 3-Implementing the logrolling technique 4-Administering the prescribed pain medication

3-Implementing the logrolling technique

The nurse educates the nursing student on measures to reduce vaccine-related pain in children. Which statement by the student indicates a need for further teaching? 1-"I should use a microneedle." 2-"I should apply topical anesthetics." 3-"I should provide tactile stimulation." 4-"I should give antipyretics to the child."

4-"I should give antipyretics to the child."

A client who has a ureteral calculus is admitted to the hospital with severe flank pain, nausea, and hematuria. Which intervention would the nurse implement first? 1-Strain all urine output. 2-Increase oral fluid intake. 3-Obtain a urine specimen for culture 4-Administer a prescribed analgesic

4-Administer a prescribed analgesic

A client has an open reduction and internal fixation (ORIF) of a fractured hip. The nurse monitors this client for signs and symptoms of a fat embolism. Which client assessment finding reflects this complication? 1-Fever and chest pain 2-Positive Homans sign 3-Loss of sensation in the operative leg 4-Tachycardia and petechiae over the chest

4-Tachycardia and petechiae over the chest

M.J. calls the clinic and tells the nurse that her 85-yr-old mother has been nauseated all day and has vomited twice. Before the nurse hangs up and calls the HCP, she should tell M.J. to a. administer antiemetic drugs and assess her mother's skin turgor. b. give her mother sips of water and elevate the head of her bed to prevent aspiration. c. offer her mother large quantities of Gatorade to decrease the risk for sodium depletion. d. give her mother a high-protein liquid supplement to drink to maintain her nutritional needs.

B

Pain is best described as a. a creation of a person's imagination. b. an unpleasant, subjective experience. c. a maladaptive response to a stimulus. d. a neurologic event resulting from activation of nociceptors.

B

Which words are most likely to be used to describe neuropathic pain (select all that apply)? a. Dull b. Itching c. Burning d. Shooting e. Shock-like

B,C,D,E

A patient with osteoarthritis is scheduled for total hip arthroplasty. The nurse explains the purpose of this procedure is to (select all that apply) a. fuse the joint. b. replace the joint. c. prevent further damage. d. improve or maintain ROM. e. decrease the amount of destruction in the joint.

B,D

Appropriate nonopioid analgesics for mild pain include (select all that apply) a. oxycodone. b. ibuprofen (Advil). c. lorazepam (Ativan). d. acetaminophen (Tylenol). e. codeine with acetaminophen (Tylenol #3).

B,D

A cancer patient who reports ongoing, constant moderate pain with short periods of severe pain during dressing changes is a. probably exaggerating his pain. b. in need of a referral for surgical treatment of his pain. c. best treated by receiving a long-acting and a short-acting opioid. d. best treated by regularly scheduled short-acting opioids plus acetaminophen.

C

A patient is receiving a PCA infusion after surgery to repair a hip fracture. She is sleeping soundly but awakens when the nurse speaks to her in a normal tone of voice. Her respirations are 8 breaths/min. The most appropriate nursing action in this situation is to a. stop the PCA infusion. b. obtain an oxygen saturation level. c. continue to closely monitor the patient. d. administer naloxone and contact the provider.

C

A patient undergoing rehabilitation for a C7 spinal cord injury tells the nurse he must have the flu because he has a bad headache and nausea. The nurse's first priority is to a. call the health care provider. b. check the patient's temperature. c. measure the patient's blood pressure. d. elevate the head of the bed to 90 degrees.

C

A patient with spinal cord injury has severe neurologic deficits. What is the most likely mechanism of injury for this patient? a. Compression b. Hyperextension c. Flexion-rotation d. Extension-rotation

C