Adult Exam 4

A client with multiple sclerosis is being discharged from rehabilitation. Which statement would the nurse include in the client's discharge teaching? a. "Be sure that you use a wheelchair when you go out in public." b. "Wear an undergarment brief at all times in case of incontinence." c. "Avoid overexertion, stress, and extreme temperature if possible." d. "Avoid having sexual intercourse to conserve energy."

"Avoid overexertion, stress, and extreme temperature if possible."

The nurse interviews an older client with moderate osteoarthritis and her husband. What psychosocial assessment question would the nurse include? a. "Do you feel like hurting yourself or others?" b. "Are you planning to retire due to your disease?" c. "Do you ask your husband for assistance?" d. "Do you experience discomfort during sex?"

"Do you experience discomfort during sex?" Although some clients can become depressed and anxious as a result of having OA, suicidal ideation is not common. The nurse should not assume that an older adult will want to retire or that the client will need help from her husband. Many clients avoid sexual intercourse because of joint pain and stiffness

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."

"Ejaculation may not be as predictable as before." "I may urinate with ejaculation but this will not cause infection." "I should be able to have an erection with stimulation."

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?"

"Have you been diagnosed with a mental health problem?"

The nurse assesses a client with diabetes and osteoarthritis (OA) during a checkup. The nurse notes the client's blood glucose readings have been elevated. What question by the nurse is most appropriate? a. "Are you following the prescribed diabetic diet?" b. "Have you been taking glucosamine supplements?" c. "How much exercise do you really get each week?" d. "You're still taking your diabetic medication, right?"

"Have you been taking glucosamine supplements?" All of the topics are appropriate for a client whose blood glucose readings have been higher than usual. However, since this client also has OA, and glucosamine can increase blood glucose levels, the nurse would ask about its use. The other questions all have an element of nontherapeutic communication in them. Asking how much exercise the client "really" gets is or if the diet is being followed is accusatory. Asking if the client takes his or her medications "right?" is patronizing

The nurse is preparing to teach a client recently diagnosed with multiple sclerosis about taking glatiramer acetate. Which statement by the client indicates a need for further teaching? a. "I will rotate injection sites to prevent skin irritation." b. "I need to avoid large crowds and people with infection." c. "I should report any flulike symptoms to my primary health care provider." d. "I will report any signs of infection to my primary health care provider."

"I should report any flulike symptoms to my primary health care provider."

The nurse is teaching a client who is planning to have a total hip arthroplasty. What statement by the client indicates a need for further teaching? a. "I will get an IV antibiotic right before surgery to prevent infection." b. "I may request a regional nerve block as part of the surgical anesthesia." c. "I will receive IV heparin before surgery to decrease the risk of clots." d. "I will receive tranexamic acid to help reduce blood loss during surgery."

"I will receive IV heparin before surgery to decrease the risk of clots." All of the choices are correct except that IV heparin is not given before or after surgery. A different anticoagulant is given after surgery to prevent postoperative venous thromboembolism, such as deep vein thrombosis and pulmonary embolus

The nurse is teaching a client who is prescribed acetaminophen for control of osteoarthritic joint pain. What statement by the client indicates a need for further teaching? a. "I won't take more than 5000 mg of this drug each day." b. "I'll follow up to get my lab tests done to check my liver." c. "I'll check drugs that I take for acetaminophen in them." d. "I can use topical patches and creams to help relieve pain."

"I won't take more than 5000 mg of this drug each day." All of the choices are correct about acetaminophen except that the maximum daily dosage is 4000 mg. For older adults, 3000 mg are recommended due to slower drug metabolism by the liver

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."

"I'll be in the hospital for 2 to 3 days."

A client is prescribed celecoxib for joint pain. What statement by the client indicates a need for further teaching? a. "I'll report any signs of bleeding or bruising to my primary health care provider." b. "I'll take this drug only as prescribed by my primary health care provider." c. "I'll be sure to take this drug three times a day only on an empty stomach." d. "I'll monitor the amount of urine that I excrete every day and report any changes."

"I'll be sure to take this drug three times a day only on an empty stomach." All of the choices are correct for this NSAID except that celecoxib can cause GI distress unless taken with meals or food. The drug should not be taken on an empty stomach and is rarely taken more than twice a day

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."

"I'll use my incentive spirometer every 2 hours while I'm awake."

A client who had a recent total knee arthroplasty will be using a continuous passive motion (CPM) machine after discharge at home. What health teaching about the CPM machine will the nurse include? (Select all that apply.) a. "Keep the machine padded well to prevent skin breakdown." b. "Ensure that your leg is placed properly on the machine." c. "Use the machine as prescribed but not at mealtime." d. "When the machine is not being used, do not store it on the floor." e. "Check that the cycle and range of motion is kept at the level prescribed."

"Keep the machine padded well to prevent skin breakdown." "Ensure that your leg is placed properly on the machine." "Use the machine as prescribed but not at mealtime." "When the machine is not being used, do not store it on the floor." "Check that the cycle and range of motion is kept at the level prescribed." Although not used as often today, some clients are prescribed to use the CPM machine to increase range of motion in the surgical knee. All of these teaching points are important for any client who uses a CPM machine

A client has a left knee arthrocentesis to remove excess joint fluid. What postprocedure health teaching will the nurse include? a. "Take your opioid medication as prescribed by the primary health care provider." b. "Do not bear weight on your left leg for at least a week after you get home." c. "Monitor the site for bleeding or clear fluid leakage when you are home." d. "Tell your employer that you can't come back to work for 2 to 3 weeks."

"Monitor the site for bleeding or clear fluid leakage when you are home." An arthrocentesis is performed as an ambulatory procedure and may require a mild analgesic such as acetaminophen for discomfort. Opioids are not used. The client may bear weight and return to work, but needs to monitor for bleeding or leakage of synovial fluid at the injection site

The nurse is teaching assistive personnel about postoperative care for an older adult who had a posterolateral total hip arthroplasty. What teaching will the nurse include? (Select all that apply.) a. "Move the client slowly to prevent dizziness and a possible fall." b. "Encourage the client to deep breathe and cough at least every 2 hours." c. "Help the client use the incentive spirometer at least every 2 hours." d. "Keep the abduction pillow in place at all times while the client is in bed." e. "Let me know if the client has an elevated temperature or pulse." f. "Keep in mind that the client may be a little confused after surgery." g. "Please let me know if you see any reddened or open skin areas during bathing."

"Move the client slowly to prevent dizziness and a possible fall." "Encourage the client to deep breathe and cough at least every 2 hours." "Help the client use the incentive spirometer at least every 2 hours." "Keep the abduction pillow in place at all times while the client is in bed." "Let me know if the client has an elevated temperature or pulse." "Keep in mind that the client may be a little confused after surgery." Older adults are at risk for complications of decreased mobility after surgery, including atelectasis, pneumonia, pressure injuries, and orthostatic hypotension. Therefore these precautions are to help keep the client safe and avoid complications that could be life threatening.

The nurse teaches assistive personnel (AP) about care of an older adult diagnosed with osteoporosis. What teaching would the nurse include? a. Teach the client to eat high-calcium foods in the diet ." b. "Assist the client with activities of daily living." c. Osteoporosis places the client is at risk for fractures." d. The client should stay in bed to prevent falling .

"Osteoporosis places the client is at risk for fractures." Anyone who has osteoporosis is at risk for fragility fractures even if he or she does not experience trauma like a fall. The client needs to keep active rather than stay in bed where more bone could be lost. High-calcium foods may not be helpful because bone loss is already severe. There is no indication that the client needs assistance with ADLs.

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 body weight." e. "Avoid prolonged standing or sitting, including driving."

"Participate in an exercise program to strengthen back muscles." "Wear flat instead of high-heeled shoes to work each day." "Avoid prolonged standing or sitting, including driving."

What information does the nurse teach a women's group about osteoporosis? a. Primary osteoporosis occurs in postmenopausal women due to lack of estrogen." b. Men actually have higher rates of the disease but are underdiagnosed." c. There is no way to prevent or slow osteoporosis after menopause." d. "Women and men have an equal chance of getting osteoporosis ."

"Primary osteoporosis occurs in postmenopausal women due to lack of estrogen." Women are more at risk of developing primary osteoporosis after menopause due to the lack of estrogen. Men have a slower loss of bone after the age of 75. Many treatments are now available for women to slow osteoporosis after menopause .

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."

"The drug can increase your risk for infection, so you should avoid crowds." 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

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."

"The rehabilitation program will teach you how to maintain the functional ability you have and prevent further disability."

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."

"Try a paraffin wax dip 20 minutes before you quilt." 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

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."

"Use both hands instead of one with holding objects." "When getting out of bed or a chair, use the palms of your hands." "Bend your knees instead of your waist and keep your back straight." "Do not use multiple pillows under your head to prevent neck flexion." "Use a device or rubber grip to open jars or bottle tops." "Use long-handled devices such as a hairbrush with an extended handle." All of these options are part of health teaching for joint protection except that large joints should be used instead of smaller ones

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."

"Wear your neck brace whenever you are out of bed."

A client had a bunionectomy with osteotomy. The client asks why healing may take up to 3 months. What explanation by the nurse is best? a. The bones in your feet are hard to operate on." b. "The surrounding bones and tissue are damaged ." c. "Your feet have less blood flow, so healing is slower ." d. Your feet bear weight so they never really heal."

"Your feet have less blood flow, so healing is slower ." The feet are the most distal to the heart and receive less blood flow than other organs and tissues, prolonging the healing time after surgery . The other explanations are not correct

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

Giving subcutaneous injections 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.

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.

A 65-year-old female with osteoarthritis.

The nurse is caring for a client who has severe osteoarthritis. What primary joint problems will the nurse expect the client to report? a. Crepitus b. Effusions c. Pain d. Deformities

Pain The primary assessment finding typically reported by clients who have osteoarthritis is joint pain, although crepitus, effusions (fluid), and mild deformities may occur.

A nurse is planning postoperative care for a client following a total hip arthroplasty. What nursing interventions would help prevent venous thromboembolism for this client? (Select all that apply.) a. Early ambulation b. Fluid restriction c. Quadriceps-setting exercises d. Compression stockings/devices e. Anticoagulant drug therapy

A, C, D, E Early ambulation Quadriceps-setting exercises Compression stockings/devices Anticoagulant drug therapy Early ambulation, leg exercises, and compression stockings/devices promote venous return and peripheral circulation which helps prevent deep vein thrombi. Anticoagulants such as subcutaneous low-molecular-weight heparin (LMWH) or factor Xa inhibitors are used for all clients who have a total lower extremity joint arthroplasty. The nurse would encourage fluids to expand blood volume and promote circulation; fluids would not be restricted

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.

Palpate the bladder for distention.

A nurse obtains a focused health history for a client who is suspected of having bacterial meningitis. Which question would the nurse ask? a. "Do you live in a crowded residence?" b. "When was your last tetanus vaccination?" c. "Have you had any viral infections recently?" d. "Have you traveled out of the country in the last month?"

ANS: A Bacterial meningitis tends to occur in multiple outbreaks. It is most likely to occur in areas of high-density population, such as college dormitories, prisons, and military barracks. A tetanus vaccination would not place the client at increased risk for meningitis or protect the client from meningitis. A viral infection would not lead to bacterial meningitis but could lead to viral meningitis. Simply knowing if the client traveled out of the country does not provide enough information.

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.

the nurse is teaching a family caregiver about how best to communicate with the client who has been diagnosed with Alzheimer disease. Which statement by the caregiver indicates a need for further teaching? a. "I will avoid communicating with the client to prevent agitation." b. "I should use simple, short sentences and one-step instructions." c. "I can try to use gestures or pictures to communicate with the client." d. "I will limit the number of choices I provide for the client."

ANS: A Communication with the client is important to provide cognitive stimulation. Using short simple sentences, using gestures and pictures, and limiting choices provided for the client will help promote communication.

The nurse observes a client with late-stage Alzheimer disease eat breakfast. Afterward the client states, "I am hungry and want breakfast." What is the nurse's best response? a. "I see you are still hungry. I will get you some toast." b. "You ate your breakfast 30 minutes ago." c. "It appears you are confused this morning." d. "Your family will be here soon. Let's get you dressed."

ANS: A Use of validation therapy with clients who have late-stage Alzheimer disease involves acknowledgment of the client's feelings and concerns. This technique has proved more effective in later stages of the disease because reality orientation only increases agitation. The other statements do not validate the client's concerns.

The nurse assesses clients on a medical-surgical unit. Which clients would the nurse identify as at risk for secondary seizures? (Select all that apply.) a. A 26-year-old woman with a left temporal brain tumor b. A 38-year-old male client in an alcohol withdrawal program c. A 42-year-old football player with a traumatic brain injury d. A 66-year-old female client with multiple sclerosis e. A 72-year-old man with chronic obstructive pulmonary disease

ANS: A, B, C Clients at risk for secondary seizures include those with a brain lesion from a tumor or trauma, and those who are experiencing a metabolic disorder, acute alcohol withdrawal, electrolyte disturbances, and high fever. Clients with a history of stroke, heart disease, and substance abuse are also at risk. Clients with multiple sclerosis or chronic obstructive pulmonary disease are not at risk for secondary seizures.

The nurse assesses a client who has meningitis. Which sign(s) and symptom(s) would the nurse anticipate? (Select all that apply.) a. Photophobia b. Decreased level of consciousness c. Severe headache d. Fever and chills e. Bradycardia

ANS: A, B, C, D All of the choices except for bradycardia are key features of meningitis. Tachycardia is more likely than bradycardia due to the infectious process and fever.

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.

Place the client in a flat position. Report the leak to the surgeon.

The nurse assesses a client who is experiencing a common migraine without an aura. Which assessment finding(s) would the nurse expect? (Select all that apply.) a. Headache lasting up to 72 hours b. Unilateral and pulsating headache c. Abrupt loss of consciousness d. Acute confusion e. Pain worsens with physical activities f. Photophobia

ANS: A, B, E, F A common migraine with an aura is usually accompanied by photophobia, phonophobia, unilateral and pulsating pain, and nausea and/or vomiting. These migraines usually last 4 to 72 hours and are aggravated by physical activity. Loss of consciousness and acute confusion are not associated with a common migraine without an aura.

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 teaches the spouse of a client who has Alzheimer disease. Which statements should the nurse include in this teaching related to caregiver stress reduction? (Select all that apply.) a. "Establish advanced directives early." b. "Trust that family and friends will help." c. "Set aside time each day to be away from the client." d. "Use discipline to correct inappropriate behaviors." e. "Seek respite care periodically for longer periods of time."

ANS: A, C, D To reduce caregiver stress, the spouse should be encouraged to establish advanced directives early, set aside time each day for rest or recreation away from the client, seek respite care periodically for longer periods of time, use humor with the client, and explore alternative care settings and resources. Family and friends may not be available to help. A structured environment will assist the client with AD, but discipline will not correct inappropriate behaviors and not reduce caregiver stress.

The nurse is caring for a client who has Alzheimer disease. The client's wife states, "I am having trouble managing his behaviors at home." Which questions would the nurse ask to assess potential causes of the client's behavior problems? (Select all that apply.) a. "Does your husband bathe and dress himself independently?" b. "Do you weigh your husband each morning around the same time?" c. "Does his behavior become worse around large crowds?" d. "Does your husband eat healthy foods including fruits and vegetables?" e. "Do you have a clock and calendar in the bedroom and kitchen?"

ANS: A, C, E To minimize behavior problems, the nurse would encourage the patient to be as independent as possible with ADLs, minimize excessive simulation, and assist the patient to remain orientated. The nurse would assess these activities by asking if the patient is independent with bathing and dressing, if behavior worsens around crowds, and if a clock and single-date calendar are readily available. Diet and weight are not related to the management of behavior problems for a patient who has Alzheimer disease.

The nurse is caring for a client in late-stage Alzheimer disease. Which assessment finding(s) will the nurse anticipate? (Select all that apply.) a. Immobile b. Has difficulty driving c. Wandering d. ADL dependent e. Incontinent f. Possible seizures

ANS: A, D, E, F The client in late-stage Alzheimer disease is totally bedridden and immobile, and therefore, cannot ambulate to wander or drive. The client is incontinent and ADL dependent.

The nurse plans care for a client with epilepsy who is admitted to the hospital. Which interventions would the nurse include in this client's plan of care? (Select all that apply.) a. Have suction equipment with an airway at the bedside. b. Place a padded tongue blade at the bedside. c. Permit only clear oral fluids. d. Have oxygen administration set at the bedside. e. Maintain the client on strict bedrest. f. Ensure that the client has IV access.

ANS: A, D, F Oxygen and suctioning equipment with an airway must be readily available. If the client does not have an IV access, insert a saline lock, especially for those clients who are at significant risk for generalized tonic-clonic seizures. The saline lock provides ready access if IV drug therapy must be given to stop the seizure. Padded tongue blades may pose a danger to the client or nurse during a seizure and would not be used. Dietary restrictions and strict bedrest are not interventions associated with epilepsy.

A nurse is teaching a client who experiences migraine headaches and is prescribed propranolol. Which statement would the nurse include in this client's teaching? a. "Take this drug only when you have symptoms indicating the onset of a migraine headache." b. "Take this drug as prescribed, even when feeling well, to prevent vascular changes associated with migraine headaches." c. "This drug will relieve the pain during the aura phase soon after a headache has started." d. "This drug will have no effect on your heart rate or blood pressure because you are taking it for migraines."

ANS: B Propranolol is a beta-adrenergic blocker which is prescribed as prophylactic treatment to prevent the vascular changes that initiate migraine headaches. Heart rate and blood pressure will also be affected, and the client would monitor these side effects. The other responses do not discuss appropriate uses of this drug.

The nurse cares for a client with middle-stage (moderate) Alzheimer disease. The client's caregiver states, "She is always wandering off. What can I do to manage this restless behavior?" What is the nurse's best response? a. "This is a sign of fatigue. The client would benefit from a daily nap." b. "Engage the client in scheduled activities throughout the day." c. "It sounds like this is difficult for you. I will consult the social worker." d. "The provider can prescribe a mild sedative for restlessness."

ANS: B Several strategies may be used to cope with restlessness and wandering. One strategy is to engage the client in structured activities. Another is to take the client for frequent walks. Daily naps and a mild sedative will not be as effective in the management of restless behavior. Consulting the social worker does not address the caregiver's concern.

The nurse obtains a health history on a client prior to administering prescribed sumatriptan succinate for migraine headaches. Which condition would alert the nurse to withhold the medication and contact the primary health care provider? a. Bronchial asthma b. Heart disease c. Diabetes mellitus d. Rheumatoid arthritis

ANS: B Sumatriptan succinate effectively reduces pain and other associated symptoms of migraine headache by binding to serotonin receptors and triggering cranial vasoconstriction. Vasoconstrictive effects are not confined to the cranium and can cause coronary vasospasm in clients with heart disease, hypertension, or Prinzmetal angina. The other conditions would not affect the client's treatment.

A client with early-stage Alzheimer disease is admitted to the hospital with chest pain. Which nursing action is most appropriate to manage this client's dementia? a. Provide animal-assisted therapy as needed. b. Ensure a structured and consistent environment. c. Assist the client with activities of daily living (ADLs). d. Use validation therapy when communicating with the client.

ANS: B The client who has early Alzheimer disease (AD) does not require assistance with ADLs or validation therapy. While animal-assisted therapy may be helpful, some health care agencies do not allow this intervention. Therefore, the most appropriate action is to provide a structured and consistent environment while the client is hospitalized to prevent worsening of the client's symptoms.

The nurse is teaching a group of college students about the importance of preventing meningitis. Which health promotion activity is the most appropriate for preventing this disease? a. Eating a well-balanced diet that is high in protein b. Having an annual physical examination c. Obtaining the recommended meningitis vaccination and boosters d. Identifying signs and symptoms for early treatment

ANS: C CDC-recommended vaccinations and boosters are available for prevention of a number of diseases including meningococcal meningitis. While the other activities are appropriate for general health promotion, they are not specific to meningitis prevention.

The nurse teaches assistive personnel (AP) about how to care for a client with early-stage Alzheimer disease. Which statement would the nurse include? a. "If she is confused, play along and pretend that everything is okay." b. "Remove the clock from her room so that she doesn't get confused." c. "Reorient the client to the day, time, and environment with each contact." d. "Use validation therapy to recognize and acknowledge the client's concerns."

ANS: C Clients who have early-stage Alzheimer disease would be reoriented frequently to person, place, and time. The AP would reorient the client and not encourage the client's delusions. The room would have a clock and white board with the current date written on it. Validation therapy is used with late-stage Alzheimer disease.

The nurse is teaching the daughter of a client who has middle-stage Alzheimer disease. The daughter asks, "Will the sertraline my mother is taking improve her dementia?" How would the nurse respond about the purpose of the drug? a. "It will allow your mother to live independently for several more years." b. "It is used to halt the advancement of Alzheimer disease but will not cure it." c. "It will not improve her dementia but can help control emotional responses." d. "It is used to improve short-term memory but will not improve problem solving."

ANS: C Drug therapy is not effective for treating dementia or halting the advancement of Alzheimer disease. However, certain psychoactive drugs may help suppress emotional disturbances and manage depression, psychoses, or anxiety. Drug therapy will not allow the client with middle-stage dementia to safely live independently.

The nurse assesses a client who has a history of migraines. Which symptom would the nurse identify as an early sign of a migraine with aura? a. Vertigo b. Lethargy c. Visual disturbances d. Numbness of the tongue

ANS: C Early warning of impending migraine with aura usually consists of visual changes, flashing lights, or diplopia. The other symptoms are not associated with an impending migraine with aura.

A client asks the nurse about what medications may be included for nonopioid multimodal analgesia following a total knee arthroplasty. What medications may be given to the client? (Select all that apply.) a. Gabapentin b. Ketorolac c. Hydrocodone d. Ketamine e. Morphine f. Bupivacaine

Gabapentin Ketorolac Ketamine Bupivacaine All of the choices are appropriate to use for nonopioid multimodal analgesia except for the two opioid drugs—hydrocodone and morphine. The nonopioid medications are used to decrease inflammation and pain.

The nurse witnesses a client begin to experience a tonic-clonic seizure and loss of consciousness. What action would the nurse take first? a. Start fluids via a large-bore catheter. b. Administer IV push diazepam. c. Turn the client's head to the side. d. Prepare to intubate the client.

ANS: C The nurse would turn the client's head to the side to prevent aspiration and allow drainage of secretions. Anticonvulsants are administered on a routine basis if a seizure is sustained. If the seizure is sustained (status epilepticus), the client must be intubated and would be administered oxygen, 0.9% sodium chloride, and IV push lorazepam or diazepam.

A nurse assesses a client who is recovering from the implantation of a vagal nerve-stimulation device. For which signs and symptoms would the nurse assess as common complications of this procedure? (Select all that apply.) a. Bleeding b. Infection c. Hoarseness d. Dysphagia e. Seizures

ANS: C, D Complications of surgery to implant a vagal nerve-stimulation device include hoarseness (most common), dyspnea, neck pain, and dysphagia. The device is tunneled under the skin with an electrode connected to the vagus nerve to control simple or complex partial seizures. Bleeding is not a common complication of this procedure, and infection would not occur during the recovery period.

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 make 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 a client who is diagnosed with new-onset epilepsy and prescribed phenytoin, the nurse assesses the client's understanding. Which statement by the client indicates a correct understanding of the teaching? a. "To prevent complications, I will drink at least 2 L of water daily." b. "This medication will stop me from getting an aura before a seizure." c. "I will not drive a motor vehicle while taking this medication." d. "Even when my seizures stop, I will continue to take this drug."

ANS: D Discontinuing antiepileptic drugs can lead to the recurrence of seizures or status epilepticus. The client does not need to drink more water and can drive while taking this medication. The drug will not stop an aura before a seizure.

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 white board." 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.

The nurse prepares to discharge a client with early to moderate Alzheimer disease. Which statement to maintain client safety would the nurse include in the discharge teaching for the caregiver? a. "Provide periods of exercise and rest for the client." b. "Place a padded throw rug at the bedside." c. "Provide a highly stimulating environment." d. "Install safety locks on all outside doors."

ANS: D Clients with early to moderate Alzheimer disease have a tendency to wander, especially at night. If possible, alarms would be installed on all outside doors to alert family members if the client leaves. At a minimum, all outside doors should have safety locks installed to prevent the client from going outdoors unsupervised. The client would be allowed to exercise within his or her limits, but this action does not ensure his or her safety. Throw rugs are a slip and fall hazard and would be removed. A highly stimulating environment would likely increase the client's confusion.

The primary health care provider prescribes donepezil for a client diagnosed with early-stage Alzheimer disease. What teaching about this drug will the nurse provide for the client's family caregiver? a. "Monitor the client's temperature because the drug can cause a low grade fever." b. "Observe the client for nausea and vomiting to determine drug tolerance." c. "Donepezil will prevent the client's dementia from progressing as usual." d. "Report any client dizziness or falls because the drug can cause bradycardia."

ANS: D Donepezil is a cholinesterase inhibitor that may temporarily slow cognitive decline for some clients but does not alter the course of the disease. The family caregiver would want to monitor the client's heart rate and report any incidence of dizziness or falls because the drug can cause bradycardia. It does not typically cause fever or nausea/vomiting.

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.

The nurse assesses a client with a history of epilepsy who experiences stiffening of the muscles of the arms and legs, followed by an immediate loss of consciousness and jerking of all extremities. How would the nurse document this type of seizure? a. Atonic b. Myoclonic c. Absence d. Tonic-clonic

ANS: D Seizure activity that begins with stiffening of the arms and legs, followed by loss of consciousness and jerking of all extremities, is characteristic of a tonic-clonic seizure. An atonic seizure presents as a sudden loss of muscle tone followed by postictal confusion. A myoclonic seizure presents with a brief jerking or stiffening of extremities that may occur singly or in groups. Absence seizures present with automatisms, and the client is unaware of his or her environment.

After teaching a client newly diagnosed with epilepsy, the nurse assesses the client's understanding. Which statement by the client indicates a need for additional teaching? a. "I will wear my medical alert bracelet at all times." b. "While taking my medications, I will not drink any alcoholic beverages." c. "I will tell my doctor about my prescription and over-the-counter medications." d. "If I am nauseated, I will not take my epilepsy medication."

ANS: D The nurse must emphasize that antiepileptic drugs must be taken even if the client is nauseated. Discontinuing the medication can predispose the client to seizure activity and status epilepticus. The client should not drink alcohol while taking seizure medications. The client should wear a medical alert bracelet and should make the primary health care provider aware of all drugs he or she is taking to prevent complications of polypharmacy.

A nurse prepares to provide perineal care to a client with meningococcal meningitis. Which personal protective equipment would the nurse wear? (Select all that apply.) a. Particulate respirator b. Isolation gown c. Shoe covers d. Surgical mask e. Gloves

ANS: D, E Meningococcal meningitis is spread via saliva and droplets, and Droplet Precautions are necessary. Caregivers would wear a surgical mask when within 6 feet (1.8 m) of the client and would continue to use Standard Precautions, including gloves. A particulate respirator, an isolation gown, and shoe covers are not necessary for Droplet Precautions.

A nurse is teaching a client newly diagnosed with osteoarthritis (OA) about drugs used to treat the disease. For which drug does the nurse plan health teaching? a. Acetaminophen b. Cyclobenzaprine hydrochloride c. Hyaluronate d. Ibuprofen

Acetaminophen All of these drugs may be appropriate to treat OA. However, the first-line drug is acetaminophen. Cyclobenzaprine is a muscle relaxant given to treat muscle spasms. Hyaluronate is a synthetic joint fluid implant. Ibuprofen is a nonsteroidal anti-inflammatory drug

A client with chronic osteomyelitis is being discharged from the hospital. What information is important for the nurse to teach this client and family? (Select all that apply) a. Adherence to the antibiotic regimen b. Correct intramuscular injection technique c. Eating high-protein and high-carbohydrate foods d. Keeping daily follow-up appointments e. Proper use of the intravenous equipment

Adherence to the antibiotic regimen Eating high-protein and high-carbohydrate foods d. Keeping daily follow-up appointments Proper use of the intravenous equipment The client going home with chronic osteomyelitis will need long-term antibiotic therapyfirst intravenous, and then oral. The client needs education on how to properly to encourage wound healing. The antibiotics are not given by IM injection. The client does not need daily follow -up.

A client has a metastatic bone tumor in the left leg. What action by the nurse is appropriate? a. Administer pain medication as prescribed. b. Elevate the extremity and apply moist heat. c. Teach the client about amputation care . d. Place the client on protective precautions

Administer pain medication as prescribed. Pain medication should be given to control metastatic bone pain. Elevation and heat may or may not be helpful. Protective precautions are not needed for this client.

A nurse is assessing a community group for dietary factors that contribute to osteoporosis. In addition to inquiring about calcium, the nurse also assesses for which other dietary components? (Select all that apply.) a Alcohol b. Caffeine c. Fat d. Carbonated beverages e. Vitamin D

Alcohol Caffeine Carbonated beverages Vitamin D Dietary components that affect the development of osteoporosis include alcohol, caffeine, high phosphorus intake, carbonated beverages, and vitamin D. Tobacco is also a contributing lifestyle factor. Fat intake does not contribute to osteoporosis .

A client with osteoporosis is going home where the client lives alone. What action by the nurse is best? a. Refer the client to Meals on Wheels b . Arrange a home safety evaluation. c. Ensure that the client has a walker at home d. Help the client look into assisted living

Arrange a home safety evaluation. This client has several risk factors that place him or her at a high risk for falling. The nurse should consult social work or home health care to conduct a home safety evaluation. The other options may or may not be needed based upon the client's condition at discharge .

A client has been advised to perform weight-bearing exercises to help slow bone loss, but has not followed this advice. What response by the nurse is appropriate at this time? a. Ask the client about fear of falling. b. Instruct the client to increase calcium.m c. Suggest other exercises the client can do. d. Tell the client to try weight lifting.

Ask the client about fear of falling. Fear of falling can limit participation in activity. The nurse would first assess if the client has this fear and then offer suggestions for dealing with it. The client may or may not need extra calcium, other exercises , or weight lifting

The nurse assesses a client after a total hip arthroplasty. The client's surgical leg is visibly shorter than the other one and the client reports extreme pain. While a co-worker calls the surgeon, what action by the nurse is appropriate? a. Assess neurovascular status in both legs. b. Elevate the surgical leg and apply ice. c. Prepare to administer pain medication. d. Try to place the surgical leg in abduction.

Assess neurovascular status in both legs. This client has signs and symptoms of hip dislocation, a potential complication of this surgery. Hip dislocation can cause neurovascular compromise. The nurse would assess neurovascular status while comparing both legs. The nurse would not try to move the extremity to elevate or abduct it. Pain medication may be administered if possible, but first the nurse would thoroughly assess the client.

A client with bone cancer is hospitalized for a limb salvage procedure. How can the nurse best address the client's psychosocial needs? a. Assess the client's coping skills and support systems b. Explain that the surgery leads to a longer life expectancy c. Refer the client to the social worker or hospital chaplain d. Reinforce physical therapy to aid with ambulating normally

Assess the client's coping skills and support systems The first step in the nursing process is assessment. The nurse would assess coping skills and possible support systems that will be helpful in this client's treatment . Explaining that a limb salvage procedure will extend life does not address the client's psychosocial needs. Referrals may be necessary, but the nurse should assess first. Reinforcing physical therapy is also helpful but again does not address the psychosocial needs of the client.

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.

Assess the pin sites for signs of infection. Assess the chest and back for skin breakdown.

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

Auscultated stridor

The nurse reviews a list of drugs that can cause secondary osteoporosis. Which drugs are most commonly associated with this health problem? select all that apply A. Anti anxiety agents B. Antibiotics C. Barbiturates D. Corticosteroids E. Loop diuretics

Barbiturates Corticosteroids Loop diuretics Several classes of drugs can cause secondary osteoporosis, including barbiturates, corticosteroids, and loop diuretics. Antianxiety agents in antibiotics are not associated with the formation of osteoporosis

A nurse is visiting a client discharged home after a total hip arthroplasty. What safety precautions would the nurse recommend to the client and family? (Select all that apply.) a. Buy and install an elevated toilet seat. b. Install grab bars in the shower and by the toilet. c. Step into the bathtub with the affected leg first. d. Remove all throw rugs throughout the house. e. Use a shower chair while taking a shower

Buy and install an elevated toilet seat. Install grab bars in the shower and by the toilet. Remove all throw rugs throughout the house. Use a shower chair while taking a shower

The nurse is caring for an older client who had a total knee arthroplasty. Prior to surgery, the client lived alone independently. With which interprofessional health care team members will the nurse collaborate to ensure positive client outcomes? (Select all that apply.) a. Case manager b. Mental health counselor c. Physical therapist d. Occupational therapist e. Speech-language pathologist f. Clergy/Spiritual leader

Case manager Physical therapist The client was independent and living alone prior to surgery but will likely need help for a short time at home. However, if the client was ADL independent, he or she will not need referral to an occupational therapist. Therefore, a case manager can assess the living situation and identify any special needs to be addressed. The physical therapist will help the client learn to ambulate independently with a walker. There is no indication that the client needs referral for mental, spiritual, or speech-language services

A nurse assesses clients in an osteoporosis clinic. Which client with a nurse assess first? A. Client taking calcium with vitamin D who reports flank pain two weeks ago B. Client taking ibandronate Who cannot remember when the last dose was C. Client taking raloxifene Who reports unilateral calf swelling D. Client taking risedronate who reports occasional dyspepsia

Client taking raloxifene who reports unilateral calf swelling The client on raloxifene needs to be assessed first because of the potential for deep vein thrombosis, which is an adverse effect

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

Client with a red, hot, swollen right wrist 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

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 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

Client with a spinal cord injury who cannot tolerate sitting up 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 0.8mg / d * L (61 1 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 .

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

Difficulty swallowing Hoarse voice

The nurse is assessing a client for chronic osteomyelitis . Which features distinguish this from the acute form of the disease ? ( Select all that apply .) a. Draining sinus tracts b. High fevers c. Presence of foot ulcers d. Swelling and redness e. Tenderness or pain

Draining sinus tracts Presence of foot ulcers Draining sinus tracts and foot ulcers are seen in chronic osteomyelitis . High fever , swelling, and redness are more often seen in acute osteomyelitis . Pain or tenderness can be in either abirb.com/test case.

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.

Evaluate respiratory status.

A nurse assesses a client with multiple sclerosis after administering prescribed fingolimod. For which common side effect would the nurse monitor? a. Peripheral edema b. Facial flushing c. Tachycardia d. Fever

Facial flushing

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

Felty syndrome Joint deformity Weight loss 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 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

Flaccid bowel

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

Fracture

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

Grab bars to reach high items Long-handled bath scrub brush Toothbrush with built-up handle 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.

A client is getting out of bed into the chair for the first time after an uncemented total hip arthroplasty. What action by the nurse is appropriate? a. Have adequate help to transfer the patient. b. Provide socks so the patient can slide easier. c. Tell the patient full weight bearing is allowed. d. Use a footstool to elevate the patient's leg

Have adequate help to transfer the patient. The client with an uncemented hip will be on toe-touch only after surgery. The nurse would ensure there is adequate help to transfer the patient while preventing falls. Slippery socks may cause a fall. Elevating the leg is not going to assist with the client's transfer

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

Heart rate of 34 beats/min Urine output less than 30 mL/hr Decreased level of consciousness

A client with rheumatoid arthritis (RA) has an acutely swollen, red, and painful joint. What nonpharmacologic intervention does the nurse recommend? a. Heating pad b. Ice packs c. Splint d. Paraffin dip

Ice packs Ice is best for acute inflammation. Heat often helps with joint stiffness. Splinting helps preserve joint function. A paraffin dip is used to provide warmth to the joint which is more appropriate for chronic pain and stiffness.

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

Incisional bulging Clear drainage on the dressing Sudden and severe headache

A client has been prescribed denosumab. What health teaching about this drug is most appropriate for the nurse to include? a . Drink at least 8 ounces (240 mL) of water with it." b. Make appointments to come get your injection." c. Sit upright for 30 to 60 minutes after taking it." d. Take the drug on an empty stomach."

Make appointments to come get your injection." Denosumab is given by subcutaneous injection twice a year. The client does not need to drink 8 ounces (240 mL ) of water with this medication as it is not taken orally. The client does not need to remain upright for 30 to 60 minutes after taking this medication, nor does the client need to take the drug on an empty stomach.

A nurse cares for a client who is experiencing status epilepticus. Which prescribed medication would the nurse anticipate to prepare for administration? a. Atenolol b. Lorazepam c. Phenytoin d. Lisinopril

NS: B Initially, intravenous lorazepam or diazepam is administered to stop motor movements. This is followed by the administration of phenytoin. Atenolol, a beta blocker, and lisinopril, an angiotensin-converting enzyme inhibitor, are not administered for seizure activity. These drugs are typically administered for hypertension and heart failure.

After a total knee arthroplasty, a client is on the postoperative nursing unit with a continuous femoral nerve blockade. On assessment, the nurse notes the skin of both legs is pale pink, warm, and dry, but the client is unable to dorsiflex or plantarflex the surgical foot. What action would the nurse take next? a. Document the findings and monitor as prescribed. b. Increase the frequency of monitoring the client. c. Notify the surgeon or anesthesia provider immediately. d. Palpate the client's bladder or perform a bladder scan

Notify the surgeon or anesthesia provider immediately. With the femoral nerve block, the client would still be able to dorsiflex and plantarflex the affected surgical foot. Since this client has an abnormal finding, the nurse would notify either the surgeon or the anesthesia provider immediately. Documentation is the last priority. Increasing the frequency of assessment may be appropriate, but first the nurse must notify the appropriate provider. Palpating the bladder is not related

A client asks the nurse about having a total knee arthroplasty to relieve joint pain. Which factor would place the client at the highest risk for impaired postoperative healing? a. Controlled hypertension b. Obesity c. Osteoarthritis d. Mild osteopenia

Obesity Obesity places a client at high risk for many postoperative complications including slower wound and bone healing. The other factors usually do not affect healing after surgery.

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

Occupational therapist

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

Osteoporosis Diabetes mellitus Glaucoma Hypertension Hypokalemia Decreased immunity 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

An older client with diabetes is admitted with a heavily draining leg wound. The client's white blood cell count is 38, 000 / m * m ^ 3; ^ 3 (38*10^ 9 /L) but the client is afebrile. Which nursing action is most appropriate at this time? a. Administer acetaminophen as needed . b. Educate the client on amputation . c. Place the client on Contact Precautions. d. Refer the client to the wound care nurse.

Place the client on Contact Precautions. In the presence of a heavily draining wound, the nurse would place the client on Contact Precautions. If the client has discomfort, acetaminophen can be used, but this client has not reported pain and is afebrile . The client may or may not need an amputation in the future. The wound care nurse may be consulted but not as the most appropriate action.

A client has a bone density score of -2.8. What intervention would the nurse anticipate based on this assessment? a Asking the client to complete a food diary test b. Planning to teach about bisphosphonates c. Scheduling another scan in 2 years d. Scheduling another scan in 6 months test

Planning to teach about bisphosphonates A T-score from a bone density scan at or lower than -2.5 indicates osteoporosis. The nurse would plan to teach about medications used to treat this disease, such as the bisphosphonates. A food diary is helpful to determine if the client gets adequate calcium and vitamin D, but at this point, dietary changes will not prevent the disease. Simply scheduling another scan will not help treat the disease either. birb.com/test

A nurse is caring for four clients. After the hand-off report, which client would the nurse see first? a. Client with osteoporosis and a white blood cell count of 27.000 / m * m ^ 3 * (27 * 10 ^ 9 / L) b. Client with osteoporosis and a bone fracture who requests pain medication c. Post-microvascular bone transfer client whose distal leg is cool and pale d. Client with suspected bone tumor who just returned from having a spinal CT

Post-microvascular bone transfer client whose distal leg is cool and pale This client is the priority because the assessment findings indicate a critical lack of perfusion. A high white blood cell count is an expected finding for the client with osteoporosis. The client requesting pain medication should be seen second. The client who just returned from a CT scan is stable and needs no specific postprocedure care.

A client is scheduled to have a total hip arthroplasty. What preoperative teaching by the nurse is most important? a. Teach the need to discontinue all medications for 5 days before surgery. b. Teach the patient about foods high in protein, Vitamin C, and iron. c. Explain to the client the possible need for blood transfusions postoperatively. d. Remind the client to have all dental procedures completed at least 2 weeks prior to surgery.

Remind the client to have all dental procedures completed at least 2 weeks prior to surgery. The nurse would include teaching about dental procedures to avoid infection after new joint has been inserted. Planned procedures would be completed at least 2 weeks before surgery and the client will need to tell any future primary health care providers about having a total joint arthroplasty. Only home medications prescribed that increase the risk for bleeding or clotting need to be discontinued 5 to 10 days before surgery. Clients need to be aware that any postoperative anemia may need to be treated with a blood transfusion, but it is not the most important. Diets high in protein, Vitamin C, and iron help with tissue repair, but are not the most important.

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.

Reposition the client off of the reddened areas. Apply a pressure-reducing mattress.

A client who has multiple sclerosis reports increased severe muscle spasticity and tremors. What nursing action is most appropriate to manage this client's concern? a. Request a prescription for an antispasmodic drug such as baclofen. b. Prepare the client for deep brain stimulation surgery. c. Refer the client to a massage therapist to relax the muscles. d. Consult with the occupational therapist for self-care assistance.

Request a prescription for an antispasmodic drug such as baclofen.

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

Rheumatoid arthritis 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 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

Scoliosis Spinal stenosis Hypocalcemia Osteoporosis Osteoarthritis

The nurse is performing an assessment of a client with possible plantar fasciitis in the right foot. What assessment finding would the nurse expect in the right foot? a. Multiple toe deformities b. Numbness and paresthesias c. Severe pain in the arch of the foot d. Redness and severe swelling

Severe pain in the arch of the foot The most common assessment finding is the client's report of severe pain in the arch of the foot, especially when walking. The other findings are not typical in clients with this health problem.

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

Sliding board

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

Spiritual beliefs Family support Level of independence Previous coping strategies

A nurse is providing education to a community women's group about lifestyle changes helpful in preventing osteoporosis. What topics does the nurse cover? (Select all that apply.) a. Cut down on tobacco product use b. Limit alcohol to two drinks a day c. Strengthening exercises are important test d. Take recommended calcium and vitamin D. e. Walk for 30 minutes at least three times a week.

Strengthening exercises are important test Take recommended calcium and vitamin D. Walk for 30 minutes at least three times a week. Lifestyle changes can be made to decrease the occurrence of osteoporosis and include strengthening and weight-bearing exercises and getting the recommended amounts of both calcium and vitamin D. Tobacco should be totally avoided. Women should not have more than one drink per day.

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

Tramadol

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

Visual acuity 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