Tissue Integrity, Perfusion, Mobility
The nurse is discussing medications with a client with hypertension who has a prescription for furosemide daily. The client needs further education when the client states: "I know I should not drive after taking my furosemide." "I need to be sure to also take the potassium supplement that the health care provider prescribed along with my furosemide." "I should be careful not to stand up too quickly when taking furosemide." "I should take the furosemide in the morning instead of before bed."
"I know I should not drive after taking my furosemide." Explanation: Furosemide is a diuretic often prescribed for clients with hypertension or heart failure; the drug should not affect a client's ability to drive safely. Furosemide may cause orthostatic hypotension, and clients should be instructed to be careful when changing from supine to sitting to standing position. Diuretics should be taken in the morning if possible to prevent sleep disturbance due to the need to get up to void. Furosemide is a loop diuretic that is not potassium sparing; clients should take potassium supplements as prescribed and have their serum potassium levels checked at prescribed intervals.
A patient presents to the ED following a burn injury. The patient has burns to the anterior chest and entire left leg. Using the rule of nines, the nurse documents the total body surface area (TBSA) percentage as which of the following? 9% 27% 36% 18%
36% Explanation: The rule-of-nines system is based on dividing anatomic regions, each representing approximately 9% of the TBSA, quickly allowing clinicians to obtain an estimate. If a portion of an anatomic area is burned, the TBSA is calculated accordingly—for example, if approximately half of the anterior leg is burned, the TBSA burned would be 4.5%. More specifically, with an adult who has been burned, the percent of the body involved can be calculated as follows: head = 9%, chest (front) = 9%, abdomen (front) = 9%, upper/mid/low back and buttocks = 18%, each arm = 9% (front = 4.5%, back = 4.5%), groin = 1%, and each leg = 18% total (front = 9%, back = 9%)
A nurse is caring for a client who has had a left-side mastectomy. The nurse notes a Penrose drain intact. Which of the following statements is true about Penrose drains? A Penrose drain is a closed drainage system that is connected to an electronic suction device. A Penrose drain has a small bulblike collection chamber that is kept under negative pressure. A Penrose drain promotes drainage passively into a dressing. A Penrose drain has a round collection chamber with a spring that is kept under negative pressure.
A Penrose drain promotes drainage passively into a dressing. Explanation: A Penrose drain is an open drainage system that promotes drainage of fluid passively into a dressing. Additional drains include the Jackson-Pratt drain that has a small bulb like collection chamber that is kept under negative pressure. A Hemovac is a round collection chamber with a spring inside that must be kept under negative pressure also.
What is the term for a rhythmic contraction of a muscle? Hypertrophy Clonus Atrophy Crepitus
Clonus Explanation: Clonus is a rhythmic contraction of the muscle. Atrophy is a shrinkagelike decrease in the size of a muscle. Hypertrophy is an increase in the size of a muscle. Crepitus is a grating or crackling sound or sensation that may occur with movement of ends of a broken bone or irregular joint surface
Which of the following is the primary lesion associated with acne, caused by sebum blockage in hair follicles? Striae Furuncle Carbuncle Comedone
Comedone Explanation: A comedone is the primary lesion of acne, caused by sebum blockage in the hair follicle. A furuncle is a localized skin infection of a single hair follicle. A carbuncle is a localized skin infection involving several hair follicles. Striae are bandlike streaks on the skin, distinguished by color, texture, depression, or elevation from the tissue in which they are found
Which assessment finding would cause the nurse to suspect compartment syndrome in the client following a bone biopsy? Bounding dorsalis pedis pulses Toes move freely without pain Capillary refill < 3 seconds Increased diameter of the calf
Increased diameter of the calf Explanation: Increasing diameter of the calf can be indicative of bleeding into the muscle. The other findings are within normal limits.
A nurse needs to measure the blood pressure of a client who has just undergone a bilateral mastectomy. How should the nurse measure the blood pressure? Over the client's thigh Radial artery Over the lower arm Brachial artery
Over the client's thigh Explanation: The nurse should measure the blood pressure over the client's thigh or the popliteal artery behind the knee. It is inadvisable post-mastectomy to assess blood pressure at the normal site, which is over the brachial artery at the inner aspect of the elbow. In normal cases, the blood pressure may also be assessed at the lower arm and radial artery.
Which action by the nurse would be inappropriate for the client following casting? Circulate room air with a portable fan. Petal and smooth the edges of the cast. Protect the cast by covering with a sheet. Handle the cast with the palms of hands.
Protect the cast by covering with a sheet. Explanation: The nurse performs actions to facilitate drying of the cast. The cast should be exposed to air. Portable fans can be used to dry the cast. Pressure on the cast should be avoided.
You are caring for a patient who is on bed rest and was just turned to the left side. Which of the following actions should you take next to decrease the risk of impaired skin integrity? Cover the patient with the bed linens. Pull the shoulder blade forward and out from under the patient. Assess for pain. Place the call bell within reach.
Pull the shoulder blade forward and out from under the patient. Explanation: Positioning the shoulder blade in this manner removes pressure from the bony prominence.
A nurse is caring for a client who has limited mobility and requires a wheelchair. The nurse has concern for circulation problems when which device is used? Water bed Specialty mattress Gel flotation pad Ring or donut
Ring or donut Explanation: The nurse should not use rings or donuts with any client because this equipment restricts circulation. Specialty mattresses evenly distribute pressure. Gel pads redistribute the client's weight, and water beds distribute pressure over the entire surface.
Skull sutures are an example of which type of joint? Diarthrosis Amphiarthrosis Aponeuroses Synarthrosis
Synarthrosis Explanation: Skull sutures are considered synarthrosis joints and are immovable. Amphiarthrosis joints allow limited movement, such as a vertebral joint. Diarthrosis joints are freely movable joints such as the hip and shoulder. Aponeuroses are broad, flat sheets of connective tissue
The nurse cares for a group of clients who all need assistance to ambulate. Use of a gait belt is contraindicated for which client? The 52-year-old woman who had hip replacement surgery 3 days ago and uses a walker The 38-year-old man who had a colon resection 2 days ago The 66-year-old woman who is legally blind and has a below-the-knee prosthesis The 87-year-old man who has scoliosis
The 38-year-old man who had a colon resection 2 days ago Explanation: Gait belts should not be used on patients with abdominal or thoracic incisions
The nurse is caring for an infant who has impetigo and is hospitalized. Which nursing intervention is the highest priority for this child? The nurse follows contact precautions. The nurse applies elbow restraints to the infant. The nurse soaks the skin with warm water. The nurse applies topical antibiotics to the lesions.
The nurse follows contact precautions. Explanation: Impetigo is highly contagious and can spread quickly. The nurse should follow contact (skin and wound) precautions, including wearing a cover gown and gloves. The nurse will soak the crusts with warm water, apply topical antibiotics, and apply elbow restraints, but these are not as high a priority as trying to prevent the spread of the infection by following contact precautions.
When planning care for a client with myasthenia gravis, the nurse understands that the client is at highest risk for: sensory loss. hypertension. bladder dysfunction. aspiration.
aspiration. Explanation: Loss of motor function to the face and throat can cause dysphagia and places the client at risk for aspiration. Bladder dysfunction and hypertension are not associated with myasthenia gravis. Myasthenia affects nerve impulses at the neuromuscular junction, causing loss of motor function; there is no sensory deficit
Bone density testing in patients with post-polio syndrome has demonstrated no significant findings. calcification of long bones. osteoarthritis. low bone mass and osteoporosis.
low bone mass and osteoporosis. Explanation: Bone density testing in patients with post-polio syndrome has demonstrated low bone mass and osteoporosis. Thus, the importance of identifying risks, preventing falls, and treating osteoporosis must be discussed with patients and their families.
A client with peripheral vascular disease has poor circulation. The nurse should assess the client for changes in: (Select all that apply.) fluid intake skin temperature nausea pain in extremity nail bed color
nail bed color skin temperature pain in extremity Explanation: Maintaining circulation is critical in individuals with peripheral vascular disease. Skin and nail bed color and temperature will reveal the degree to which the extremity is receiving blood flow. Clients with peripheral vascular disease also usually have a certain amount of pain, especially when the oxygen demand becomes greater than oxygen supply, such as with walking or exercising. Fluid intake and nausea are unrelated to peripheral circulation.
A nursing instructor is discussing the diagnosis of intermittent claudication with students. To determine if the students understand the pathophysiology of the disease, the instructor asks, "What percentage of the arterial lumen must be obstructed before intermittent claudication is experienced?" 30 40 20 50
50 Explanation: Typically, about 50% of the arterial lumen or 75% of the cross-sectional area must be obstructed before intermittent claudication is experienced.
The nurse caring for a client on the medical-surgical unit collects the following data during head-to-toe assessment; mid-sternal chest pain, nausea, and pulse oximetry (SpO2) of 86%. The nurse would next implement which priority nursing intervention for this client who is experiencing these symptoms? Administer sublingual nitroglycerin Administer morphine Administer oxygen Notify health care provider
Administer oxygen Explanation: Myocardial infarction causes a lack of oxygen to the body tissues; therefore, administering oxygen is the first priority. Administering nitroglycerin and morphine and notifying the health care provider can be done after the administration of oxygen.
What scenario demonstrates the nurse's knowledge when using guided imagery to relieve pain in pediatric clients? Leading a 6-year-old female in a fairy princess setting where she is the princess and the nurse is the queen Leading a 4-year-old male to a guided imagery of him being an airplane pilot and flying across the sky After achieving a relaxed state, beginning a guided imagery of walking down a sandy beach and collecting seashells, a favorite activity of the 13-year-old female After achieving a relaxed state, beginning guided imagery of a fun birthday party for a 3-year-old female
After achieving a relaxed state, beginning a guided imagery of walking down a sandy beach and collecting seashells, a favorite activity of the 13-year-old female Explanation: Imagery begins with achieving a relaxed state. Guide the child to choose a favorite place. When using guided imagery, do not lead the child; let the child become immersed in their personal image and take command of the experience. Guided imagery is not appropriate for preschoolers and toddlers.
A client presents to the emergency department via ambulance with a heart rate of 210 beats/minute and a sawtooth waveform pattern per cardiac monitor. The nurse is most correct to alert the medical team of the presence of a client with which disorder? Premature ventricular contraction Ventricular fibrillation Atrial flutter Asystole
Atrial flutter Explanation: Atrial flutter is a disorder in which a single atrial impulse outside the SA node causes the atria to contract at an exceedingly rapid rate. The atrioventricular (AV) node conducts only some impulses to the ventricle, resulting in a ventricular rate slower than the atrial rate, thus forming a sawtooth pattern on the heart monitor. Asystole is the absence of cardiac function and can indicate death. Premature ventricular contraction indicates an early electric impulse and does not necessarily produce an exceedingly rapid heart rate. Ventricular fibrillation is the inefficient quivering of the ventricles and indicative of a dying heart
A patient tells the nurse "my heart is skipping beats again; I'm having palpitations." After completing a physical assessment, the nurse concludes the patient is experiencing occasional premature atrial complexes (PACs). The nurse should instruct the patient to complete which of the following? Request sublingual nitroglycerin. Lie down and elevate the feet. Avoid caffeinated beverages. Apply supplemental oxygen.
Avoid caffeinated beverages. Explanation: If PACs are infrequent, no medical interventions are necessary. Causes of PACs include caffeine, alcohol, nicotine, stretched atrial myocardium (e.g., as in hypervolemia), anxiety, hypokalemia (low potassium level), hypermetabolic states (e.g., with pregnancy), or atrial ischemia, injury, or infarction. The nurse should instruct the patient to avoid caffeinated beverages.
Which medication is used to control the extrapyramidal effects associated with antipsychotic medications? Haloperidol Thioridazine Benzotropine Chlorpromazine
Benzotropine Explanation: Benzotropine is an anticholinergic drug used to relieve drug-induced extrapyramidal adverse effects, such as muscle weakness, involuntary muscle movement, pseudoparkinsonism, and tardive dyskinesia
An adolescent is to receive topical retinoid therapy for his moderately severe acne. The nurse would instruct the adolescent about which adverse effects? Select all that apply. Headache Flu-like symptoms Dryness Photosensitivity Burning
Burning Photosensitivity Dryness Explanation: Adverse effects associated with topical retinoid therapy include burning, dryness, and photosensitivity. Flu-like symptoms and headache are associated with topical immune modulators
What part of the brain would be responsible for activities such as walking and dancing? Cerebrum Midbrain Brain stem Cerebellum
Cerebellum Explanation: The cerebellum, which is located behind and below the cerebrum, controls and coordinates muscle movement integral to physical activities such as walking and dancing. Cerebrum, midbrain, and brain stem are incorrect.
Which of the following is an age-related change of the hepatobiliary system? Decreased prevalence of gallstones Increased drug clearance capability Liver enlargement Decreased blood flow
Decreased blood flow Explanation: Age-related changes of the hepatobiliary system include decreased blood flow, decreased drug clearance capability, increased presence of gallstones, and a steady decrease in size and weight of the liver.
Which type of benign tumor of the eyelids is characterized by superficial, vascular capillary lesions that are strawberry-red in color? Nevi Xanthelasma Hemangioma Milia
Hemangioma Explanation: Hemangiomas are vascular capillary tumors that may be bright, superficial, strawberry-red lesions or bluish and purplish deeper lesions. Milia are small, white, slightly elevated cysts of the eyelid that may occur in multiples. Xanthelasma are yellowish, lipoid deposits on both lids near the inner angle of the eye that commonly appear as a result of the aging of the skin or a lipid disorder. Nevi are freckles
A client with severe peptic ulcer disease has undergone surgery and is several hours postoperative. During assessment, the nurse notes that the client has developed cool skin, tachycardia, and labored breathing; the client also appears to be confused. Which of the following complications has the client most likely developed? Perforation Hemorrhage Pyloric obstruction Penetration
Hemorrhage Explanation: Signs of hemorrhage following surgery include cool skin, confusion, increased heart rate, labored breathing, and blood in the stool. Signs of penetration and perforation are severe abdominal pain, rigid and tender abdomen, vomiting, elevated temperature, and increased heart rate. Indicators of pyloric obstruction are nausea, vomiting, distended abdomen, and abdominal pain.
The primary care provider has prescribed estrogen replacement therapy (ERT) for a menopausal woman who has been diagnosed with pelvic organ prolapse (POP). The client asks the nurse why she needs to be on hormones. Which would be the nurse's best response? Hormone replacement will increase blood perfusion and the elasticity of the vaginal wall. Hormone replacement will decrease blood perfusion and increase the elasticity of the vaginal wall. Hormone replacement will increase the blood perfusion and decrease the elasticity of the vaginal wall. Hormone replacement will decrease blood perfusion and the elasticity of the vaginal wall.
Hormone replacement will increase blood perfusion and the elasticity of the vaginal wall. Explanation: Hormone replacement therapy may improve the tone and vascularity of the supporting tissue in perimenopausal and menopausal women by increasing blood perfusion and the elasticity of the vaginal wall.
The nurse is caring for a patient at risk of shock. What physiologic response would the nurse know to look for while assessing for shock? Temperature Hypoperfusion of tissues Increased blood pressure Activation of infectious response
Hypoperfusion of tissues Explanation: Regardless of the initial cause of shock, certain physiologic responses are common to all types of shock. These physiologic responses include hypoperfusion of tissues, hypermetabolism, and activation of the inflammatory response
A mental health nurse is caring for a client with a diagnosis of schizophrenia. The client presents with catatonia. Which clinical manifestations should the nurse expect? Immobility Uninhibited behavior Perseveration Echopraxia
Immobility Explanation: Catatonia is characterized by psychologically induced immobility occasionally marked by periods of agitation or excitement; the client seems motionless as if in a trance
A client has experienced a gradual flattening of affect, confusion, and withdrawal and has been diagnosed with Alzheimer's disease. Which additional findings would the nurse most likely assess? Transient blindness, slurred speech, and weakness Uncharacteristic use of illicit substances and alcohol Tremors, unsteady gait, and transient paresthesias Personality change, wandering, and inability to perform purposeful movements
Ineffective tissue perfusion: Cerebral, cardiopulmonary, GI Explanation: These are all appropriate nursing diagnoses for the client with thrombocytopenia. However, the risk of cerebral and GI hemorrhage and hypotension pose the greatest risk to the physiological integrity of the client.
The nurse is evaluating a client in the intensive care unit to identify improvement in the client's condition. Which outcome does the nurse note as the result of inadequate compensatory mechanisms? Weight loss Unsteady gait Organ damage Liver dysfunction
Organ damage Explanation: When the body is unable to counteract the effects of shock, further system failure occurs, leading to organ damage and ultimately death. Liver dysfunction may occur as one of the organs which fail. Weight fluctuations may occur if the body holds fluid or is administered a diuretic. Large fluctuations are not noted between shifts. The client is not able to ambulate
A nurse is assessing a child diagnosed with Sturge-Weber syndrome. What finding would the nurse expect to find when assessing the skin? Pigmented nevi Tumors Café-au-lait spots Port wine stain
Port wine stain Explanation: Facial nevus or port wine stain is most often seen on the forehead and on one side of the face. Café-au-lait spots are commonly associated with neurofibromatosis. Tumors are associated with tuberous sclerosis and neurofibromatosis. Pigmented nevi are associated with neurofibromatosis
Megan McKenna is a 43-year-old woman who tripped on a toy in her home, fell, and hit her head on the corner of a table. Shortly after her accident, she arrives at the ED, unable to see out of her left eye. She tells the nurse caring for her that her symptoms began with seeing spots or moving particles in her field of vision but she didn't think anything was wrong because she wasn't having any pain in her eye. Now, she is very upset that her vision will not return. What is the most likely cause of Ms. McKenna's symptoms? Eye trauma Angle-closure glaucoma Chalazion Retinal detachment
Retinal detachment Explanation: A detached retina is associated with a hole or tear in the retina caused by stretching or degenerative changes. Retinal detachment may follow a sudden blow, penetrating injury, or eye surgery. Retinal separation is the most likely cause and is associated with a hole or tear in the retina caused by stretching or degenerative changes. Retinal detachment may follow a sudden blow, penetrating injury, or eye surgery.
Which of the following is an inaccurate principle of traction? Skeletal traction is interrupted to turn and reposition the patient. The weights are not removed unless intermittent treatment is prescribed. The patient must be in good alignment in the center of the bed. The weights must hang freely
Skeletal traction is interrupted to turn and reposition the patient. Explanation: Skeletal traction is never interrupted. The weights are not removed unless intermittent treatment is prescribed. The weights must hang freely with the patient in good alignment in the center of the bed.
Parents bring their 9-year-old child to the clinic for a well-child visit. They are concerned because several children in the neighborhood have developed Lyme disease and ask for suggestions on what to do to reduce their child's risk. What would be appropriate for the nurse to suggest? Select all that apply. Removing ticks by rubbing them away from the skin with a credit card. Contacting the health care provider if there is any area of inflammation that might be a bite. Inspecting the skin closely for ticks after the child plays in wooded areas. Dressing the child in dark clothing when going outdoors. Wearing protective clothing when playing in wooded areas
Wearing protective clothing when playing in wooded areas. Inspecting the skin closely for ticks after the child plays in wooded areas. Contacting the health care provider if there is any area of inflammation that might be a bite. Explanation: The nurse should teach the parents to have the child wear protective clothing and dress the child in light clothing when playing in wooded areas or going outdoors. The parents should inspect the child's skin closely for ticks after being outside in wooded areas and if any ticks are found, remove them with a tweezer, not rub them with a credit card. The parents also should be instructed to contact their health care provider if they notice any area of inflammation that might be a tick bite
A nurse is conducting an refresher program for a group of nurses returning to work in the newborn clinic. The nurse nurse is reviewing the protocols for assessing vital signs in healthy newborns and infants. The nurse determines that additional teaching is needed when the group identifies which parameter as being included in the assessment? blood pressure pain temperature pulse respirations
blood pressure Explanation: Because the readings can be inaccurate, blood pressure is not routinely assessed in term, normal healthy newborns with normal Apgar scores. It is assessed if there is a clinical indication such as suspected blood loss or low Apgar scores. Pain is assessed by objective signs of pain such as grimacing and crying in response to certain stimuli.
When assessing an individual with peripheral vascular disease, which clinical manifestation would indicate complete arterial obstruction in the lower left leg? numbness and tingling in the left leg coldness of the left foot and ankle aching pain in the left calf burning pain in the left calf
coldness of the left foot and ankle Explanation: Coldness in the left foot and ankle is consistent with complete arterial obstruction. Other expected findings would include paralysis and pallor. Aching pain, a burning sensation, or numbness and tingling are earlier signs of tissue hypoxia and ischemia and are commonly associated with incomplete obstruction.
The nurse is caring for an 11-year-old presenting with tenderness in the shoulder. He is the pitcher for his baseball team and reports shoulder pain with active internal rotation but is able to continue past the pain with full range of motion. Based on these reported symptoms, the nurse is aware that the disorder is most likely to be: epiphysiolysis of the proximal humerus. Osgood-Schlatter disease. Sever disease. epiphysiolysis of the distal radius.
epiphysiolysis of the proximal humerus. Explanation: Epiphysiolysis of the proximal humerus is an overuse disorder that occurs with rigorous upper extremity activity such as pitching and causes tenderness in the shoulder. Osgood-Schlatter disease causes knee pain and painful swelling or prominence of the anterior portion of the tibial tubercle. Sever disease causes pain over the posterior aspect of the calcaneus. Epiphysiolysis of the distal radius is an overuse disorder that causes wrist pain. It is common in gymnasts
A client with a sports injury undergoes a diagnostic arthroscopy of the left knee. Which of the following comments by the client following the procedure should the nurse address first? "My foot is swollen." "My knee aches." "My feet are cold." "My toes are numb."
"My toes are numb." Explanation: Numbness would indicate neurological compromise of the extremity and requires immediate intervention to prevent permanent damage.
A client with a history of angina and intermittent claudication reports pain in both legs with a need to stop and rest after ambulating down the hall. Which statement by the nurse best addresses this concern? "You are experiencing leg pain because of venous congestion." "The pain is probably related to inadequately oxygenated blood getting through the arteries into the muscles of your legs." "The pain is related to atherosclerosis that is the same problem causing your angina." "You are experiencing pain due to inadequate removal of carbon dioxide from the tissues in the legs."
"The pain is probably related to inadequately oxygenated blood getting through the arteries into the muscles of your legs." Explanation: When there is a history of atherosclerosis affecting the heart and resulting in intermittent claudication, there is arterial insufficiency. This results in inadequate provision of oxygenated blood to the muscles when there is an increase in muscle demand. This results in the pain of intermittent claudication. The other choices refer to problems with venous congestion rather than arterial perfusion. That the pain is related to atherosclerosis does not explain the specific reason for the pain.
A nurse plans to have an education session with a client with cardiomyopathy and the client's spouse about ways to increase activity tolerance. Which of the following instructions would provide that information? Avoid all physical and emotional stress. Gradually work up to strenuous activity. Alternate active periods with rest periods. Include isometric exercises in the daily routine.
Alternate active periods with rest periods. Explanation: The client should plan activities to occur in cycles, alternating rest with active periods. The client with cardiomyopathy must avoid strenuous activity and isometric exercises. It is impossible to avoid all physical and emotional stress.
A group of nursing students are reviewing information about the older adult and mobility. The students demonstrate a need for additional study when they identify which of the following? Medications in the older adult play a major contributing role to the risk for falling. An older adult experiences numerous factors that increase the risk for falls. Falls are the leading cause of death due to injury in individuals who are over the age of 75 years. Older adults are faced with challenges related to the fear of falling and striving for independence
Falls are the leading cause of death due to injury in individuals who are over the age of 75 years. Explanation: For people over the age of 65 years, falls are the leading cause of injury leading to death, with hip fractures resulting in significant morbidity and mortality. Numerous factors place the older adult at risk for falls, including a history of falls, fear of falling, cognitive and mood impairments, dizziness, and functional impairments and environmental hazards. Older adults are faced with dealing with the fear of falling and striving for independence. Medications often play a major role in contributing to falls and other complications in the older adult.
Which is a potassium-sparing diuretic used in the treatment of heart failure? Ethacrynic acid (Edecrin) Bumetanide (Bumex) Chlorothiazide (Diuril) Spironolactone (Aldactone)
Spironolactone (Aldactone) Explanation: Aldactone is a potassium-sparing diuretic. A Thiazide diuretic is Diuril. Bumex and Edecrin are loop diuretics.
Which finding would the nurse expect when assessing the breasts of a client with fibrocystic breast disease? nipple retraction soft mass enlarged lymph nodes skin dimpling
soft mass Explanation: The characteristic breast mass of fibrocystic disease is soft to firm, movable, and unlikely to cause nipple retraction. Nipple retraction, enlarged lymph nodes, and skin dimpling are more commonly associated with breast cancer
The nurse has been teaching the client about how to use a walker safely. The nurse knows the teaching has been effective when the client: leans over the walker when walking uses the sides of the walker to rise up out of a chair. places the walker far in front when walking. steps into the walker when walking.
steps into the walker when walking. Explanation: A walker is mechanical aide that enhances the client's balance and ability to bear weight. Teaching is usually done by physical medicine or physical therapy, but the nurse should continue to assess the client?s ability to use it properly. The client should step into the walker when walking, rather than walking behind it. When rising from a seated position, the arms of the chair should be used for support, not the walker. The client should be cautioned to avoid pushing the walker out too far in front. Also, the client should avoid leaning over the walker, but should stay upright as he/she moves.
Which finding would lead the nurse to suspect that a large-for-gestational-age newborn is developing hyperbilirubinemia? tea-colored urine seizures feeble sucking temperature instability
tea-colored urine Explanation: Hyperbilirubinemia is associated with jaundice and tea-colored urine. Temperature instability, seizures, and feeble sucking suggest hypoglycemia
While an adolescent wears a body brace for scoliosis, the nurse would teach her: to stand absolutely still whenever she is out of the brace. that secondary sex changes will stop until the brace is removed. to wear the brace a maximum of 20 hours each day. to continue with age-appropriate activities.
to continue with age-appropriate activities. Explanation: Wearing a body brace should not interfere with normal activities, which are necessary to maintain adolescent self-esteem. Sex changes continue with or without bracing; the provider will determine the length of time for wearing the brace each day.
A nurse is preparing to help a client with weakness in his or her right leg move from the bed to a chair. Where should the nurse place the chair? Perpendicular to the bed on the left side Perpendicular to the bed on the right side 45 degrees to the bed on the right side 45 degrees to the bed on the left side
45 degrees to the bed on the left side Explanation: The nurse should place the wheelchair at a 45 degree angle or parallel to the bed on the client's strong side to help prevent a fall. The nurse should not place the chair perpendicular to the bed because the client won't be able to support his weight on his right leg
A woman is to undergo labor induction. The nurse determines that the woman requires cervical ripening if her Bishop score is: 6. 9. 7. 5.
5. Explanation: A Bishop score less than 6 usually indicates that a cervical ripening method should be used before labor induction
A client's risk for the development of a pressure ulcer is most likely due to which lab result? Sodium 135 mEq/L Hemoglobin A1C 7% Albumin 2.5 mg/dL Glucose 110 mg/dL
Albumin 2.5 mg/dL Explanation: An albumin level of less than 3.2 mg/dL indicates the client is nutritionally at risk for the development of a pressure ulcer. Hemoglobin A1C levels greater than 8% place the client at risk for the development of pressure ulcers due to prolonged high glucose levels. Glucose levels greater than 120 mg/dL are a risk factor for the development of pressure ulcers. Sodium of 135 mEq/L is normal and would not place the client at risk for the development of a pressure ulcer
When caring for a client who is on intravenous therapy, the nurse observes that the client has developed redness, warmth, and discomfort along the vein. Which of the following interventions should the nurse perform for this complication? Position the client on the left side Apply antiseptic and a dressing Apply a warm compress Elevate the client's head
Apply a warm compress Explanation: Prolonged use of the same vein can cause phlebitis; the nurse should apply warm compress after restarting the IV. The nurse need not elevate the client's head, position the client on the left side, or apply antiseptic and a dressing. The client's head is elevated if the client exhibits symptoms of circulatory overload. The client is positioned on the left side if the client exhibits signs of air embolism. The nurse applies antiseptic and a dressing to an IV site in the event of an infection
The nurse completing a plan of care for a patient with cirrhosis who has ascites and 4+ pitting edema of the feet and legs identifies a nursing diagnosis of risk for impaired skin integrity. Which of the following is an appropriate nursing intervention for this problem? Reposition the patient every 4 hours. Restrict dietary protein intake. Arrange for a low air loss bed. Perform passive range-of-motion exercises four times a day.
Arrange for a low air loss bed. Explanation: Initiating the use of an alternating-pressure mattress or low air loss bed decreases the risk for skin breakdown due to prolonged pressure on bony prominences. The other answers do not apply.
Primary or essential hypertension accounts for about 95% of all hypertension diagnoses—with an unknown etiology. Secondary hypertension accompanies specific conditions that create hypertension as a result of tissue damage. Which of the following conditions contribute to secondary hypertension? Hepatic function Calcium deficit Arterial vasoconstriction Acid-base imbalance
Arterial vasoconstriction Explanation: Secondary hypertension may accompany any primary condition that affects fluid volume or renal function or causes arterial vasoconstriction.
A client is admitted with a possible diagnosis of osteomyelitis. Based on the documentation below, which laboratory result is the priority for the nurse to report to the physician? Rheumatoid factor ESR Blood culture Alkaline phosphatase
Blood culture Explanation: Osteomyelitis is a bacterial infection of the bone and soft tissue that occurs by extension of soft tissue infection, direct bone contamination following surgery, or spreading from other infection sites in the body. A positive blood culture would be reported immediately to the physician so that specific antibiotic therapy can begin or be adjusted based on the positive culture. A negative rheumatoid factor would be expected in a possible diagnosis of osteomyelitis. An alkaline phosphatase level of 60 IU/L (1.0 nkat/L) is within the normal range, and an ESR of 10 mm/hour is also within the normal range
Which type of scale is used for systematic assessment and quantification of a patient's risk for pressure ulcer? Barthel index Braden scale PULSES profile FIM
Braden scale Explanation: The Braden scale may be used to facilitate systematic assessment and quantification of a patient's risk for pressure ulcer, although the nurse should recognize that the reliability of these scales is not well established for all patient populations. PULSES profile is used to assess physical condition, upper extremity functions, and lower extremity functions. The Barthel index is used to measure the patient's level of independence in ADLs. The Functional Independence Measure (FIM) is a minimum data set, measuring 18 items. The FIM addresses transfers and the ability to ambulate and climb stairs and also includes communication and social cognition items.
A client is receiving chemotherapy for cancer. The nurse reviews the client's laboratory report and notes that he has thrombocytopenia. To which nursing diagnosis should the nurse give the highest priority? Impaired oral mucous membranes Activity intolerance Ineffective tissue perfusion: Cerebral, cardiopulmonary, GI Impaired tissue integrity
Ineffective tissue perfusion: Cerebral, cardiopulmonary, GI Explanation: These are all appropriate nursing diagnoses for the client with thrombocytopenia. However, the risk of cerebral and GI hemorrhage and hypotension pose the greatest risk to the physiological integrity of the client.
A client is being discharged following an open reduction and internal fixation of the left ankle, and is to wear a non-weight-bearing cast for 2 weeks. What should the nurse teach the client to do when using crutches? Maintain two to three finger widths between the axillary fold and underarm piece grip. Maintain balance by supporting body's weight on the axillae. Use a four-point gait. Keep leg dependent when sitting.
Maintain two to three finger widths between the axillary fold and underarm piece grip. Explanation: The nurse instructs the client to maintain two finger widths between the axillary fold and the underarm piece grip of the crutches to prevent pressure on the brachial plexus. The client is advised to use the three-point gait; in the four-point and two point-gait there is partial weight bearing of both feet. The client is also advised to keep the affected leg elevated when sitting to prevent swelling, and to use the arms, not the axillae, to maintain balance and support.
After positioning a patient to move from the bed into a wheelchair, how would the nurse stand when helping the patient to sit up on the side of the bed? Near the patient's hip, with legs shoulder-width apart and one foot near the head of the bed. Near the patient's hip, with legs together. To the dominant side of the patient, with legs together and one foot near the head of the bed. To the nondominant side of the patient, with legs together and one foot near the head of the bed.
Near the patient's hip, with legs shoulder-width apart and one foot near the head of the bed. Explanation: When assisting the patient from the bed into a wheelchair, the nurse would take position near the patient's hip, with legs shoulder-width apart and one foot near the head of the bed. This ensures that the nurse's center of gravity is placed near the patient's greatest weight to assist the patient to a sitting position safely.
A nursing class is practicing the measurement of blood pressure. The finding in one otherwise healthy man, 36 years old, is 130/88. This man requires follow-up for prehypertension. Which of the following lifestyle factors would the nurse discuss with the client? Weight reduction, the DASH diet, and physical activity Physical activity, needed medication, and the DASH diet Physical activity, dietary sodium, and the DASH diet The DASH diet, sexual dysfunction related to required medications, and physical activity
Physical activity, dietary sodium, and the DASH diet Explanation: Lifestyle modifications to prevent and mange hypertension include weight reduction, adoption of the DASH diet, reduction of dietary sodium, physical activity, and moderation of alcohol consumption. It is not within the nursing scope of practice to decide what medications are needed. There is no evidence that this man is overweight.
A patient who was admitted to the hospital with a diagnosis of thrombophlebitis 1 day ago suddenly develops complaints of chest pain and shortness of breath and is visibly anxious. The nurse immediately assesses the patient for other signs and symptoms of which of the following problems? Pulmonary embolism Myocardial infarction Pneumonia Pulmonary edema
Pulmonary embolism Explanation: Pulmonary embolism is a potentially life-threatening disorder typically caused by blood clots in the lungs. This disorder poses a particular threat to people with cardiovascular disease. Blood clots that form in the deep veins of the legs and embolize to the lungs can cause a pulmonary infarction where emboli mechanically obstruct the pulmonary vessels, cutting off the blood supply to sections of the lung. Clinical indicators of pulmonary embolism can vary but typically include dyspnea, pleuritic chest pain, and tachypnea
A client is scheduled to undergo transurethral resection of the prostate. The procedure is to be done under spinal anesthesia. Postoperatively, the nurse should assess the client for: seizures. cardiac arrest. respiratory paralysis. renal shutdown
respiratory paralysis. Explanation: If paralysis of vasomotor nerves in the upper spinal cord occurs when spinal anesthesia is used, the client is likely to develop respiratory paralysis. Artificial ventilation is required until the effects of the anesthesia subside. Seizures, cardiac arrest, and renal shutdown are not likely results of spinal anesthesia.
The nurse is conducting a health assessment of an older adult. The client tells the nurse about cramping leg pain that occurs when walking for 15 minutes; the pain is relieved with rest. The lower extremities are slightly cool to touch and pedal pulses are palpable +1. The nurse should instruct the client to: include more potassium in the diet. increase the length of time for walking. seek consultation from the health care provider (HCP). perform leg circles and ankle pumps.
seek consultation from the health care provider (HCP). Explanation: This client has indications of peripheral artery disease (PAD) and needs additional follow-up. Increasing walking or exercising the legs and feet likely will not be sufficient to improve peripheral circulation. Muscle cramping is a result of inadequate arterial circulation. Increasing potassium will not decrease the cramping.
Which skin condition would be most likely to cause increased systemic absorption of a topical medication? port wine stain of the face severe sunburn rosacea multiple nevi
severe sunburn Explanation: Systemic absorption from the skin is minimal but may be increased when the skin is inflamed or damaged. Severe sunburn would be an example of inflamed skin. Multiple nevi (moles) and a port wine stain of the face are not examples of skin disorders that would increase absorption of topical medication. Rosacea is an example of an inflammatory skin condition of the face, but it rarely causes systemic absorption because most of the medications prescribed to treat it are topical.
A client is hospitalized for repair of an abdominal aortic aneurysm. The nurse must be alert for signs and symptoms of aneurysm rupture and thus looks for which of the following? Constant, intense headache and falling blood pressure Constant, intense back pain and falling blood pressure Slow heart rate and high blood pressure Higher than normal blood pressure and falling hematocrit
Constant, intense back pain and falling blood pressure Explanation: Indications of a rupturing abdominal aortic aneurysm include constant, intense back pain; falling blood pressure; and decreasing hematocrit.
A client's family member asks the nurse, "What is a conversion disorder?" Which is the best response by the nurse? It is a preoccupation with an imagined or exaggerated defect in physical appearance. It is a preoccupation with the fear that one has a serious disease. It is characterized by multiple physical symptoms. It involves unexplained, usually sudden, deficits in sensory or motor function
It involves unexplained, usually sudden, deficits in sensory or motor function. Explanation: A conversion disorder involves an unexplained, usually sudden, deficit in sensory or motor function.
The nurse is assessing a patient who is bedridden. For which condition would the nurse consider this patient to be at risk? Increased metabolic rate Increase in the movement of secretions in the respiratory tract Predisposition to renal calculi Increase in circulating fibrinolysin
Predisposition to renal calculi Explanation: In a bedridden client, the kidneys and ureters are level, and urine remains in the renal pelvis for a longer period of time before gravity causes it to move into the ureters and bladder. Urinary stasis favors the growth of bacteria that, when present in sufficient quantities, may cause urinary tract infections. Poor perineal hygiene, incontinence, decreased fluid intake, or an indwelling urinary catheter can increase the risk for urinary tract infection in an immobile patient. Immobility also predisposes the patient to renal calculi, or kidney stones, which are a consequence of high levels of urinary calcium; urinary retention and incontinence resulting from decreased bladder muscle tone; the formation of alkaline urine, which facilitates growth of urinary bacteria; and decreased urine volume. The client would be at risk for decreased movement of secretion in the respiratory tract, due to lack of lung expansion. The client would suffer from decreased metabolic rate due to being bedridden. The client would not have an increase in circulating fibrinolysin
A nurse is preparing an in-service presentation that focuses on promoting pressure ulcer healing. The nurse is planning to include information about appropriate nutrition. Which of the following would the nurse include as important for overall tissue repair? Protein Zinc sulfate Water Vitamin C
Protein Explanation: Protein is the nutrient important for overall tissue repair. Vitamin C promotes collagen synthesis and supports the integrity of the capillary wall. Water is important to maintain homeostasis. Zinc sulfate acts as a cofactor for collagen formation
When describing the functions of the skin to a group of nursing students, which skin layer would the instructor include as having the capacity to absorb water? Stratum lucidium Stratum corneum Stratum germinativum Stratum granulosum
Stratum corneum Explanation: The stratum corneum, the outermost layer of the epidermis, has the capacity to absorb water, thereby preventing an excessive loss of water and electrolytes from the internal body and retaining moisture in the subcutaneous tissues. The other layers do not have this capacity.
A client experiencing contractions presents at a health care facility. Assessment conducted by the nurse reveals that the client has been experiencing Braxton Hicks contractions. The nurse has to educate the client on the usefulness of Braxton Hicks contractions. Which role do Braxton Hicks contractions play in aiding labor? These contractions help in softening and ripening the cervix. These contractions increase oxytocin sensitivity. These contractions make maternal breathing easier. These contractions increase the release of prostaglandins
These contractions help in softening and ripening the cervix. Explanation: Braxton Hicks contractions assist in labor by ripening and softening the cervix and moving the cervix from a posterior position to an anterior position. Prostaglandin levels increase late in pregnancy secondary to elevated estrogen levels; this is not due to the occurrence of Braxton Hicks contractions. Braxton Hicks contractions do not help in bringing about oxytocin sensitivity. Occurrence of lightening, not Braxton Hicks contractions, makes maternal breathing easier.