Test 3: Mobility, Tissue Integrity, and Intracranial Regulation

The nurse is caring for a client who is an athlete and has sustained an injury to the anterior cruciate ligament. The nurse is providing education to the client regarding the potential treatment measures for this injury. What should the nurse include in the teaching? Select all that apply. 1.Physical therapy 2.Knee immobilizer 3.Aspiration of joint fluid 4.Ambulation with a walker 5.Antiinflammatory medications

1, 2, 3, and 5

An older client has been lying in a supine position for the past 3 hours. The nurse who is repositioning this client would be most concerned with examining which bony prominences of the client? Select all that apply. 1.Heels 2.Ankles 3.Elbows 4.Sacrum 5.Back of the head 6.Greater trochanter

1, 3, 4, and 5

The community health nurse is providing a teaching session to firefighters in a small community regarding care of a burn victim at the scene of injury. The nurse instructs the firefighters that in the event of a tar burn, which is the immediate action? 1.Cooling the injury with water 2.Removing all clothing immediately 3.Removing the tar from the burn injury 4.Leaving any clothing that is saturated with tar in place

1. Cooling the injury with water

The nurse has admitted a client to the clinical nursing unit after undergoing a right mastectomy. The nurse should plan to place the right arm in which position? 1.Elevated on a pillow 2.Level with the right atrium 3.Dependent to the right atrium 4.Elevated above shoulder level

1. Elevated on a pillow

The emergency department nurse is caring for a client who has sustained chemical burns to the esophagus after ingestion of lye. The nurse reviews the health care provider's prescriptions and should plan to question which prescription? 1.Gastric lavage 2.Intravenous (IV) fluid therapy 3.Nothing by mouth (NPO) status 4.Preparation for laboratory studies

1. Gastric lavage

A 2-year-old child is being transported to the trauma center from a local community hospital for treatment of a burn injury that is estimated as covering more than 40% of the body. The burns are both partial- and full-thickness burns. The nurse is asked to prepare for the arrival of the child and gathers supplies, anticipating that which treatment will be prescribed initially? 1.Insertion of a Foley catheter 2.Insertion of a nasogastric tube 3.Administration of an anesthetic agent for sedation 4.Application of an antimicrobial agent to the burns

1. Insertion of a Foley catheter

Sodium hypochlorite solution is prescribed for a client with a wound on the left foot that is draining purulent material. Which action should the nurse plan to take? 1.Irrigate the wound with the solution. 2.Soak the foot in the solution for 20 minutes daily. 3.Place the solution in the wound, and cover with an occlusive dressing. 4.Soak a sterile dressing with the solution, and pack the dressing into the wound.

1. Irrigate the wound with the solution.

A client with multiple sclerosis tells a home health care nurse that she is having increasing difficulty in transferring from the bed to a chair. What is the initial nursing action? 1.Observe the client demonstrating the transfer technique. 2.Start a restorative nursing program before an injury occurs. 3.Seize the opportunity to discuss potential nursing home placement. 4.Determine the number of falls that the client has had in recent weeks.

1. Observe the client demonstrating the transfer technique.

The nurse is caring for a client after an above-the-knee amputation. The nurse assesses the residual (remaining) limb and expects to note which finding? 1.Pink color to the skin flap 2.Hot feeling on palpation of the skin flap 3.Serous fluid leaking from the skin flap incision 4.Absent pulse at the proximal pulse point site closest to the skin flap

1. Pink color to the skin flap

The nurse is caring for a 1-year-old child after cleft palate repair. On completion of feeding, the nurse should plan for which appropriate nursing action? 1.Rinsing the mouth with water 2.Cleaning the mouth with diluted hydrogen peroxide 3.Using a soft lemon and glycerin swab to clean the mouth 4.Using cotton swabs saturated with half-strength povidone-iodine to clean the mouth

1. Rinsing the mouth with water

Ketoconazole is prescribed for an assigned client. The nurse prepares to administer the medication by which method? 1.With food 2.With an antacid 3.With 8 oz (235 ml) of water 4.On an empty stomach

1. With food

The nurse teaches a client who is going to have a plaster cast applied about the procedure. Which statement by the client indicates a need for further teaching? 1. "The cast will give off heat as it dries." 2."I can bear weight on the cast in one-half hour." 3."The cast edges may be trimmed with a cast knife." 4."A stockinette will be placed over the leg area to be casted."

2. "I can bear weight on the cast in one-half hour."

The nursing educator has just completed a lecture to a group of nurses regarding care of the client with a burn injury. A major aspect of the lecture was care of the client at the scene of a fire. Which statement, if made by a nurse, indicates a need for further instruction? 1."Flames should be doused with water." 2."The client should be maintained in a standing position." 3."Flames may be extinguished by rolling the client on the ground." 4."Flames may be smothered by the use of a blanket or another cover."

2. "The client should be maintained in a standing position."

The nurse is estimating the body surface area of a child with a burn injury using the West nomogram. After noting the child's height (45 inches [114 cm]) and weight (65 lb [29.5 kg]), the nurse reads the nomogram and determines that the body surface area is approximately which number? 1. 0.2 2. 1.0 3. 1.9 4. 2.0

2. 1.0

The nurse is repositioning a client who has been returned to the nursing unit after internal fixation of a fractured right hip with a femoral head replacement. The nurse should use which method to reposition the client? 1.A trochanter roll to prevent abduction during turning 2.A pillow to keep the right leg abducted during turning 3.A pillow to keep the right leg adducted during turning 4.A trochanter roll to prevent external rotation during turning

2. A pillow to keep the right leg abducted during turning

The nurse is reviewing the record for a client seen in the health care clinic and notes that the health care provider has documented a diagnosis of amyotrophic lateral sclerosis (ALS). Which initial clinical manifestation of this disorder should the nurse expect to see documented in the record? 1.Muscle wasting 2.Mild clumsiness 3.Altered mentation 4.Diminished gag reflex

2. Mild clumsiness

The nurse is caring for a client who sustained an open fracture and is diagnosed with acute osteomyelitis of the right lower extremity. Which intervention should the nurse plan to perform? 1.Apply ice to the affected area. 2.Perform sterile dressing changes. 3.Instruct the client on leg exercises. 4.Measure the leg circumference daily.

2. Perform sterile dressing changes.

The nurse is assessing a client's peripheral intravenous (IV) site after completion of a vancomycin infusion and notes that the area is reddened, warm, painful, and slightly edematous proximal to the insertion point of the IV catheter. At this time, which action by the nurse is best? 1.Check for the presence of blood return. 2.Remove the IV site and restart at another site. 3.Document the findings and continue to monitor the IV site. 4.Call the health care provider (HCP) and request that the vancomycin be given orally.

2. Remove the IV site and restart at another site.

The nurse is creating a plan of care for a client in skin traction. Which frequent assessment should the nurse include in the plan as a priority intervention? 1.Urinary incontinence 2.Signs of skin breakdown 3.The presence of bowel sounds 4.Signs of infection around the pin sites

2. Signs of skin breakdown

The home care nurse has instructed a client how to perform the three-point gait with the use of crutches. The nurse observes the client using this gait to ensure correct performance of the maneuvers. Which observation, if made by the nurse, would indicate that the client understands how to perform this type of gait? 1.The client moves both crutches forward and then swings both feet forward to the crutches. 2.The client moves both crutches forward, along with the affected leg, and then moves the unaffected leg forward. 3.The client moves the right crutch forward, along with the left foot, and then brings the right foot and the left crutch forward. 4.The client moves the left crutch forward, along with the right foot, and then brings the left foot and the right crutch forward.

2. The client moves both crutches forward, along with the affected leg, and then moves the unaffected leg forward.

The nurse is planning to teach the client with below-the-knee amputation about care to prevent skin breakdown. Which point should the nurse include in developing the teaching plan? 1.The residual limb is washed gently and dried every other day. 2.The socket of the prosthesis must be dried carefully before it is used. 3.A residual limb sock must be worn at all times and changed twice a week. 4.The socket of the prosthesis is washed with a harsh bactericidal agent daily.

2. The socket of the prosthesis must be dried carefully before it is used.

The nurse develops a plan of care for a client with a spica cast that covers a lower extremity and documents that the client is at risk for constipation. When planning for bowel elimination needs, the nurse should include which in the plan of care? 1.Administer an enema daily. 2.Use a fracture pan for bowel elimination. 3.Use a bedside commode for all elimination needs. 4.Use a regular bedpan to prevent spilling of contents in the bed.

2. Use a fracture pan for bowel elimination.

The nurse is developing a plan of care for a client in Buck's traction. The plan of care should include assessing the client for which finding indicating a complication associated with the use of this type of traction? 1.Hypotension 2.Weak pedal pulses 3.Redness at the pin sites 4.Drainage at the pin sites

2. Weak pedal pulses

A client is taking lansoprazole. The nurse anticipates that the health care provider will advise the client to take which product if needed for a headache? 1. Naproxen 2. Ibuprofen 3. Acetaminophen 3. Acetylsalicylic acid

3. Acetaminophen

A home care nurse is visiting a client to provide follow-up evaluation and care of a leg ulcer. On removing the dressing from the leg ulcer, the nurse notes that the ulcer is pale and deep and that the surrounding tissue is cool to the touch. The nurse should document that these findings identify which type of ulcer? 1.A stage 1 ulcer 2.A vascular ulcer 3.An arterial ulcer 4.A venous stasis ulcer

3. An arterial ulcer

The nurse is caring for a client with a hip fracture who has just been placed in Buck's traction. What intervention is most important for the nurse to perform? 1.Ensure that the weight used as a pulling force is at least 20 lb (9 kg). 2.Ensure that the weights rest on the floor and are not freely hanging. 3.Inspect the skin at least every 8 hours for signs of irritation or inflammation. 4.Remove the weights for at least 5 minutes every hour to give the client a rest.

3. Inspect the skin at least every 8 hours for signs of irritation or inflammation.

The home care nurse visits a client who has a cast applied to the left lower leg. On assessment of the client, the nurse notes the presence of skin irritation from the edges of the cast. Which nursing intervention is most appropriate? 1.Contact the health care provider. 2.Massage the skin at the edges of the cast. 3.Petal the cast edges with appropriate material. 4.Place a small facecloth in the cast around the edges of the cast.

3. Petal the cast edges with appropriate material.

The nurse has given a client with a leg cast instructions on cast care at home. The nurse determines that the client needs further instruction if the client makes which statement? 1."I should avoid walking on wet, slippery floors." 2."I'm not supposed to scratch the skin underneath the cast." 3."It's okay to wipe dirt off the top of the cast with a damp cloth." 4."If the cast gets wet, I can dry it with a hair dryer turned to the warmest setting."

4. "If the cast gets wet, I can dry it with a hair dryer turned to the warmest setting."

A client is being admitted to the hospital for treatment of acute cellulitis of the lower left leg, and a nursing student is assigned to provide care for the client. The nursing instructor asks the student to describe this diagnosis. Which answer demonstrates the student's understanding of the diagnosis? 1."It is an acute superficial infection." 2."It is an inflammation of the epidermis." 3."Staphylococcus is the cause of this epidermal infection." 4."This skin infection involves the deep dermis and subcutaneous fat."

4. "This skin infection involves the deep dermis and subcutaneous fat."

A client with chloasma is extremely stressed about the change in her facial appearance. Which integumentary change observed by the nurse is consistent with this problem? 1.Skin that is uniformly dark 2.Very pale skin with little pigmentation 3.Patches of skin with loss of pigmentation 4.Blotchy brown macules across the cheeks and forehead

4. Blotchy brown macules across the cheeks and forehead

A client exhibits a purplish bruise to the skin after a fall. The nurse would document this finding in the health record most accurately using which term? 1.Purpura 2.Petechiae 3.Erythema 4.Ecchymosis

4. Ecchymosis

A client is seen in the clinic for complaints of skin itchiness that has persisted for several weeks. After an assessment, the client is determined to have scabies. Lindane is prescribed, and the nurse provides instructions to the client regarding the use of the medication. Which action should the nurse tell the client to take? 1.Apply the cream for 2 days in a row. 2.Apply a thick layer of cream to the entire body. 3.Apply the cream to the entire body and scalp, excluding the face. 4.Leave the cream on for 8 to 12 hours, and then remove it by washing.

4. Leave the cream on for 8 to 12 hours, and then remove it by washing.

The nurse is monitoring a wound in a dark-skinned client for signs of erythema. How should the nurse best determine the presence of erythema? 1.Assess for drainage from the wound. 2.Assess for redness around the wound edges. 3.Palpate for swelling around the wound edges. 4.Palpate for increased skin temperature around the wound edges.

4. Palpate for increased skin temperature around the wound edges.

A 9-year-old child fractures the left tibia along an epiphyseal line while using a skateboard. What is the nurse's priority concern during future growth? 1.Infection 2.Paralysis 3.Pressure ulcer 4.Uneven leg growth

4. Uneven leg growth