Evolve: Neuromusculoskeletal System

A client with rheumatoid arthritis calls the outpatient clinic to report that pain with exercising has increased. To decrease pain, the nurse should suggest: 1 For morning stiffness, take a tub bath rather than a hot shower 2 Apply an ice pack directly to the involved joint for no more than 20 minutes at a time 3 Decrease the number of repetitions of the exercises 4 Cease exercising for a day

3 Decrease the number of repetitions of the exercises

A client develops a seizure disorder as a result of a traumatic fall. When the client returns to the clinic for a routine visit, the client states, "I have not had a seizure in two years. When can I stop taking my anti-seizure medications?" What is the nurse's best response? 1 "A gradual reduction in seizure medication may be considered." 2 "You will require medication for the rest of your life." 3 "Enough time has passed since the last seizure. The medication probably will be discontinued at this visit." 4 "A minimum of 10 years without seizures is necessary before discontinuation of medications is considered."

1 "A gradual reduction in seizure medication may be considered."

A male client with a brain attack (cerebrovascular accident) has regained control of bowel movements but still is incontinent of urine. To help reestablish bladder control, the nurse should encourage the client to: 1 Assume a standing position for voiding 2 Void every four hours and attempt to hold urine between set times 3 Attempt to void more frequently in the afternoon than in the morning 4 Drink a minimum of 4 L of fluid daily and divide it equally among the hours while awake

1 Assume a standing position for voiding

client has a diagnosis of myasthenia gravis. The nurse recalls that associated clinical manifestations include: 1 Blurred vision along with episodes of vertigo 2 Tremors of the hands when attempting to lift objects 3 Partial improvement of muscle strength with mild exercise 4 Involvement of the distal muscles rather than the proximal muscles

1 Blurred vision along with episodes of vertigo

A client has a diagnosis of trigeminal neuralgia. When assessing the client's trigeminal nerve function, the nurse should evaluate: 1 Corneal sensation 2 Facial expressions 3 Ocular muscle movement 4 Shrugging of the shoulders

1 Corneal sensation The afferent sensory branch of the trigeminal nerve (cranial nerve V) innervates the cornea. Facial expressions (e.g., smiling, frowning) reflect the functioning of cranial nerve VII. The ocular muscle movement tests the function of cranial nerves III, IV, and VI. Shrugging of the shoulders tests the function of cranial nerve XI.

A client with rheumatoid arthritis arrives in the clinic stating, "I don't take any medications because they are too expensive." The client reports that family members are arranging for the medications to be obtained from another country. What is the nurse's best response? 1 Discuss alternative solutions with the client 2 Encourage the client to use any method possible to obtain the medications 3 Contact the primary health care provider immediately to discuss the client's plan 4 Explain that medical regimens must be followed to continue to receive care in the clinic

1 Discuss alternative solutions with the client The nurse should discuss alternatives in terms of funding, such as Medicaid, research projects, and special aid.

What instructions should the nurse provide to a client after a long leg cast is removed? 1 Elevate the extremity when sitting. 2 Report discomfort or stiffness of the ankle. 3 Perform full range of motion of the leg once daily. 4 Cleanse the leg by scrubbing with long, brisk motions

1 Elevate the extremity when sitting. Elevation will help to control swelling that occurs after a leg cast is removed. Because the ankle has been immobilized, discomfort and stiffness are expected after cast removal. The leg should be put through full range of motion more often than once daily. Because the skin was not exposed, it needs gentle washing to prevent skin trauma.

During a routine clinic visit, an older adult complains about being unable to sleep well at night and then feeling sleepy throughout the next day. The nurse should advise the client to use what sleep promotion technique? 1 Exercise daily 2 Read in bed before sleeping 3 Avoid naps during the daytime 4 Have a hot cup of tea at bedtime

1 Exercise daily

After a cervical neck injury, a client is placed in a halo fixation device with a body cast. A statement that indicates that the client's concern about body image has been resolved successfully is: 1 "I hate having everyone else do things for me." 2 "I've gotten used to the brace. I may even miss it when it's gone." 3 "I've been keeping my daily calories low in an attempt to lose weight." 4 "I can't get to sleep. However, I make up for it in the morning by sleeping later."

2 "I've gotten used to the brace. I may even miss it when it's gone."

A nurse is caring for a client who had a total hip replacement. What nursing action should be incorporated into the plan of care to prevent thrombus formation? 1 Turning the client from side to side 2 Encouraging the client to perform ankle exercises 3 Getting the client up to sit in a chair for as long as tolerated 4 Ambulating the client when the effects of anesthesia subside

2 Encouraging the client to perform ankle exercises

A client experiences an acute episode of rheumatoid arthritis. The nurse observes that the client's finger joints are swollen. The nurse concludes that this swelling most likely is related to: 1 Urate crystals in the synovial tissue 2 Inflammation in the joint's synovial lining 3 Formation of bony spurs on the joint surfaces 4 Escaped fluid from the capillaries that increases interstitial fluids

2 Inflammation in the joint's synovial lining The pathological process involved with rheumatoid arthritis is accompanied by vascular congestion, fibrin exudate, and cellular infiltrate, causing inflammation of the synovium.

A nurse is providing education to a community group about hospice. The nurse clarifies that the primary goal of hospice is help clients do what? 1 Have the option of assisted suicide 2 Remain comfortable until the end of life 3 Explore the newest treatments for their form of cancer 4 Release family members from participating in care

2 Remain comfortable until the end of life

A client with rheumatoid arthritis has been given a prescription for acetylsalicylic acid. The client asks the nurse, "What kind of drug is acetylsalicylic acid?" The nurse recalls that the classification to which this drug belongs is: 1 Sedatives 2 Hypnotics 3 Analgesics 4 Antibiotics

3 Analgesics Acetylsalicylic acid acts as an analgesic by protecting peripheral pain receptors from bradykinin, a component in the inflammatory process.

A health care provider prescribes mannitol (Osmitrol) for a client with a head injury. The nurse concludes that the purpose of the medication is to relieve cerebral edema by: 1 Decreasing the production of cerebrospinal fluid 2 Limiting the metabolic requirements of the brain 3 Drawing fluid from brain cells into the bloodstream 4 Preventing uncontrolled electrical discharges in the brain

3 Drawing fluid from brain cells into the bloodstream Mannitol, an osmotic diuretic, pulls fluid from the white cells of the brain to relieve cerebral edema. Preventing uncontrolled electrical discharges in the brain is the action of phenytoin sodium (Dilantin), not mannitol.

A nurse obtains the nursing history from a client who has open-angle (chronic) glaucoma. The nurse anticipates that the client will report: 1 Flashes of light 2 Sensitivity to light 3 Seeing floating specks 4 Loss of peripheral vision

4 Loss of peripheral vision

A client sustains a fractured right femur in a fall on the ice and is admitted to the hospital's emergency department. How should the nurse assess this client for signs of circulatory impairment? 1 Turn the client to the side-lying position 2 Ask the client to cough and deep breathe 3 Instruct the client to wiggle the toes of the right foot 4 Take the client's pedal pulse in the affected extremity

4 Take the client's pedal pulse in the affected extremity

A client with osteoarthritis who had a left total hip replacement returns to the unit after surgery. The nurse should place the client in which position? 1 Maintain the left leg in an adduction position. 2 Place the client in a right-lying position. 3 Place the left leg in an internal rotation. 4 Use pillows to keep the client's legs abducted.

4 Use pillows to keep the client's legs abducted.

A client hospitalized with a severe myocardial infarction tells the nurse, "My life is over. I may as well just give up." What is the best response by the nurse? 1 "You feel your life is over?" 2 "Have you nothing to live for?" 3 "We are not going to let you die." 4 "Everything will be fine. Do not worry."

1 "You feel your life is over?"

A client is admitted to the emergency department with head trauma resulting from an accident. The client opens both eyes and withdraws appropriately, but has no verbal response to the stimulus. Using the Glasgow Coma Scale, the nurse determines the client's score is: 1 7 2 9 3 12 4 15

1 7 The Glasgow Coma Scale is a three-part neurological assessment measuring eye opening, response to auditory stimuli, and motor response; the lower the score, the deeper the coma. A score of 8 or less indicates coma.

A spouse spends most of the day with a client who is receiving chemotherapy for inoperable cancer. The spouse asks the nurse, "What can I do to help?" How can the nurse support the client's spouse? 1 Assist the couple to maintain open communication. 2 Offer the couple a description of the disease process. 3 Instruct the spouse about the action of the medications. 4 Meet privately with the spouse to explore personal feelings.

1 Assist the couple to maintain open communication.

The nurse is assisting a client with myasthenia gravis to bathe. The nurse identifies that the client's arms become weaker with sustained movement. What action should the nurse take? 1 Encourage the client to rest for short periods 2 Continue the bath while supporting the client's arms 3 Gradually increase the client's activity level each day 4 Administer a dose of pyridostigmine bromide (Mestinon)

1 Encourage the client to rest for short periods Rest will decrease the demands at the synaptic membrane of the neuromuscular junction, reducing fatigue; activity should be paced to prevent fatigue before it begins.

An older client is treated in the emergency department for soft-tissue injuries that the medical team suspects might be caused by physical abuse. An adult child states that the client is forgetful and confused and falls all the time. A mini-mental examination indicates that the client is oriented to person, place, and time, and the client does not comment when asked directly how the bruises and abrasions occurred. What is the next appropriate nursing action? 1 Interview the client without the presence of family members. 2 Report the abuse to the appropriate state agency for investigation. 3 Accept the adult child's explanation until more data can be collected. 4 Refer the client's clinical record to the hospital ethics committee for review

1 Interview the client without the presence of family members. Privacy may provide an environment that is conducive to the client sharing information about the situation. The client needs to be kept safe; this action ensures additional time for assessment to rule out the possibility of abuse. Reporting the abuse to the appropriate state agency for investigation is premature; further assessment is needed to determine if it is necessary to notify the appropriate agency.

Which medication should the nurse anticipate will be prescribed to relieve anxiety and apprehension in a client with pulmonary edema? 1 Morphine 2 Phenobarbital 3 Hydroxyzine (Atarax) 4 Chloral hydrate

1 Morphine Morphine binds with the same receptors as natural opioids. However, it has a rapid onset, lowers the blood pressure, decreases pulmonary reflexes, and produces sedation. Phenobarbital has a slower onset than morphine and does not affect respirations and blood pressure to the same extent as morphine.

A client who takes four 325-mg tablets of buffered aspirin four times a day for severe arthritis complains of dizziness and ringing in the ears. Which complication does the nurse conclude that the client probably is experiencing? 1 Salicylate toxicity 2 Anaphylactic reaction 3 Withdrawal symptoms 4 Acetaminophen overdose

1 Salicylate toxicity

A client with a history of tuberculosis reports difficulty hearing. Which medication should the nurse consider is related to this response? 1 Streptomycin 2 Pyrazinamide 3 Isoniazid (INH) 4 Ethambutol (Myambutol)

1 Streptomycin

A client has a brain attack (cerebrovascular accident [CVA]) that involves the right cerebral cortex and cranial nerves. What areas of paralysis should the nurse expect the client to exhibit? (Select all that apply.) 1 Left leg 2 Left arm 3 Right leg 4 Right arm 5 Left side of face

1 Left leg 2 Left arm

When a client has gluteal edema, why should the nurse avoid using the gluteus maximus muscle for administration of intramuscular medications? 1 Deposition of an injected drug causes pain. 2 Blood supply is insufficient for adequate absorption. 3 Fluid leaks from the site for a long time after the injection. 4 Tissue fluid dilutes the drug before it enters the circulation.

2 Blood supply is insufficient for adequate absorption. Fluid in interstitial spaces impairs circulation, leading to slowed absorption of drugs, as well as an increased risk for skin breakdown.

A client is receiving furosemide (Lasix). For which sign of hypokalemia should the nurse monitor the client? 1 Chvostek sign 2 Flabby muscles 3 Anxious behavior 4 Abdominal cramping

2 Flabby muscles With hypokalemia, failure occurs in myoneural conduction and smooth muscle functioning, resulting in fatigue, muscle weakness, and soft, flabby muscles. Chvostek sign, the contraction of the facial muscles in response to a light tap over the facial nerve in front of the ear, is associated with hypocalcemia; low calcium levels allow sodium to move into excitable cells, increasing depolarization and nerve excitability. Anxiety and irritability are associated with hyperkalemia. Hyperkalemia affects the nervous and muscular systems; fatigue, weakness, and lethargy are associated with hypokalemia. Decreased gastrointestinal motility occurs with hypokalemia; abdominal cramping is associated with hyperkalemia and is caused by hyperactivity of smooth muscles.

A nurse is interviewing a client with a tentative diagnosis of Parkinson disease. What should the nurse expect the client to report about how the onset of symptoms occurred? 1 Suddenly 2 Gradually 3 Overnight 4 Irregularly

2 Gradually

A nurse is caring for a client with glaucoma. What rationale associated with the need for treatment of this condition should the nurse include in a teaching program? 1 Total blindness is inevitable 2 Lost vision cannot be restored 3 Use of both eyes usually is restricted 4 Surgery will help the problem only temporarily

2 Lost vision cannot be restored Retinal damage caused by the increased intraocular pressure of glaucoma is progressive and permanent if the disease is not controlled. Early treatment may prevent blindness. One eye may be affected, and there is no restriction on the use of either eye. Surgery can open up drainage and permanently reduce pressure.

A client with Ménière disease is advised to eat a sodium-restricted diet to reduce endolymphatic fluid. Which food selection provides evidence that the nurse's teaching was effective? 1 Cake 2 Macaroni 3 Baked clams 4 Grilled cheese

2 Macaroni Macaroni, boiled in unsalted water, has the least sodium of the food choices offered.

A client is recuperating from a spinal cord injury at the T4 level and depends on a wheelchair for mobility. What should the nurse teach the client to prepare for use of a wheelchair? 1 Leg lifts to prevent hip contractures 2 Push-ups to strengthen arm muscles 3 Balancing exercises to promote equilibrium 4 Quadriceps-setting exercises to maintain muscle tone

2 Push-ups to strengthen arm muscles Arm strength is necessary for transfers and activities of daily living and for the use of crutches or a wheelchair.

A nurse is caring for an anxious, fearful client. Which client response indicates sympathetic nervous system control? 1 Dry skin 2 Skin pallor 3 Constriction of pupils 4 Pulse rate of 60 beats/min

2 Skin pallor The sympathetic nervous system constricts the smooth muscle of blood vessels in the skin when a person is under stress, thereby causing skin pallor. The sympathetic system stimulates, rather than inhibits, secretion by the sweat glands. Constriction of pupils is not under sympathetic control; the parasympathetic system constricts the pupils. The parasympathetic system (vagus nerve) slows the pulse, and the sympathetic system increases it.

A client has rotator cuff surgery. What should be included when the nurse performs a neurovascular assessment of the affected extremity immediately after surgery? (Select all that apply.) 1 Pulse rate 2 Skin color 3 Presence of edema 4 Movement of the hand 5 Sensations in the extremity

2 Skin color 4 Movement of the hand 5 Sensations in the extremity

A client arrives at the nursing unit with neurological deficits after a motor vehicle accident. Using the Glasgow Coma Scale, the nurse assesses what client responses? (Select all that apply.) 1 Pupil response to light 2 Verbal response to speech 3 Eye opening in response to speech 4 Deep tendon reflexes in response to percussion 5 Motor activity in response to a verbal command

2 Verbal response to speech 3 Eye opening in response to speech 5 Motor activity in response to a verbal command Assessing a client's verbal response to the nurse's speech is one of the three criteria for determining level of consciousness with the Glasgow Coma Scale. Assessing eye opening in response to the nurse's speech is one of the three criteria for assessing level of consciousness with the Glasgow Coma Scale. Assessing a client's motor response to a verbal command is one of the three criteria for assessing level of consciousness with the Glasgow Coma Scale.

A nurse is planning to transfer a client who is experiencing pain from the bed to a chair. Place the following steps in the order in which they should be implemented. 1. Explain the steps of the transfer. 2. Verify the client's activity prescription. 3. Ensure that the wheels on the bed are locked. 4. Position the client in functional body alignment before transferring. 5. Identify factors that may impact the ability to transfer.

2. Verify the client's activity prescription. 5. Identify factors that may impact the ability to transfer. 1. Explain the steps of the transfer. 3. Ensure that the wheels on the bed are locked. 4. Position the client in functional body alignment before transferring

A client with multiple sclerosis is informed that this is a chronic, progressive neurological condition. The client asks the nurse, "Will I experience excruciating pain?" What is the nurse's best response? 1 "Tell me about your fears regarding pain." 2 "Analgesics will be prescribed to control the pain." 3 "Pain is not a characteristic symptom of this disease process." 4 "Let's make a list of the things you need to ask your health care provider."

3 "Pain is not a characteristic symptom of this disease process." The response "Pain is not a characteristic symptom of this disease process" is a truthful answer that provides hope for the client. Although neuropathic pain may sometimes occur, it is not a characteristic manifestation of multiple sclerosis . These clients more typically have diminished sensitivity to pain and paresthesias (e.g., tingling, burning, crawling sensations).

A client returns from the post-anesthesia care unit after a right rotator cuff repair. What should the nurse do when performing a neurovascular assessment? 1 Monitor for a pulse deficit. 2 Obtain hourly blood pressure readings. 3 Assess for capillary refill in the nail beds. 4 Place the shoulder through range of motion

3 Assess for capillary refill in the nail beds. Capillary refill and quality of the pulse in the affected arm reflect the status of circulation distal to the operative site.

A client is admitted to the hospital after sustaining a head injury. The nurse monitors for the most reliable sign of increased intracranial pressure, which is a slow: 1 Rise in respiratory rate 2 Narrowing of pulse pressure 3 Decrease in the level of consciousness 4 Increase in the diastolic blood pressure

3 Decrease in the level of consciousness

A nurse uses the Glasgow Coma Scale to assess a client's status after a head injury. When the nurse applies pressure to the nail bed of a finger, which movement of the client's upper arm should cause the most concern? 1 Flexing 2 Localizing 3 Extending 4 Withdrawing

3 Extending

A nurse is caring for a client with a spinal cord injury. Which is the specific reason why fluid intake should be increased for this client? 1 Prevent dehydration 2 Maintain electrolyte balance 3 Prevent a urinary tract infection 4 Limit an increase in temperature

3 Prevent a urinary tract infection Lack of or reduced movement predisposes the client with paraplegia or quadriplegia to urinary stasis, which may result in a urinary tract infection and calculus formation

A nurse is assisting a client with a full leg cast to use crutches. Which clinical manifestations alert the nurse that the client can no longer tolerate the physical exertion of crutch walking? 1 Pulse of 100 and deep respirations 2 Flushed skin and slowed respirations 3 Profuse diaphoresis and rapid respirations 4 Blood pressure of 150/88 mm Hg and shallow respirations

3 Profuse diaphoresis and rapid respirations Diaphoresis and tachypnea indicate that the client has exceeded tolerance for the activity.

A nurse is monitoring a client who is having a computed tomography (CT) scan of the brain with contrast. Which response indicates that the client is having an untoward reaction to the contrast medium? 1 Pelvic warmth 2 Feeling flushed 3 Shortness of breath 4 Salty taste in the mouth

3 Shortness of breath

When providing discharge teaching to a client who had a total hip replacement, the nurse should instruct the client to avoid: 1 Climbing stairs 2 Stretching exercises 3 Sitting in a low chair 4 Lying prone for more than 15 minutes

3 Sitting in a low chair Excessive flexion of the hip can cause dislocation of the femoral head.

A client taking levodopa (L-dopa) is taught about the signs of levodopa toxicity. The nurse instructs the client to contact the primary health care provider if the client develops: 1 Nausea 2 Dizziness 3 Twitching 4 Constipation

3 Twitching Abnormal involuntary movements (dyskinesias), such as muscle twitching, rapid eye blinking, facial grimacing, head bobbing, and an exaggerated protrusion of the tongue, are signs of toxicity; these probably result from the body's failure to readjust properly to the reduction of dopamine

To reduce a fracture of the hip, a client is placed in Buck's traction before surgery. Because the client keeps slipping down in bed, increased countertraction is prescribed. What should the nurse do to increase countertraction? 1 Add more weight to the traction. 2 Elevate the head of the client's bed. 3 Use a slight Trendelenburg position. 4 Apply a chest restraint around the client

3 Use a slight Trendelenburg position.

A hospice client who has severe pain asks for another dose of oxycodone (OxyContin). The nurse's primary consideration when responding to the client's request is to: 1 Prevent addiction 2 Determine why the drug is needed 3 Provide alternate comfort measures 4 Help reduce the client's pain immediately

4 Help reduce the client's pain immediately Hospice clients with severe pain need increasing levels of analgesics and should be maintained at a pain-free level, even if addiction occurs. Pain management, not the prevention of addiction, is the priority. The client has severe pain and the priority is to relieve the pain.

Pyridostigmine (Mestinon) is prescribed for a client with myasthenia gravis. The primary reason that the nurse instructs the client to take pyridostigmine about one hour before meals is to: 1 Limit the appetite 2 Promote absorption 3 Prevent gastric irritation 4 Increase chewing strength

4 Increase chewing strength Peak action of the medication will occur during meals to promote chewing and swallowing and prevent aspiration. It should be given with a small amount of food to prevent gastric irritation. Pyridostigmine improves muscle strength; it does not affect appetite.

On the second day after surgery, a client reports pain in the right calf. What should the nurse do first? 1 Apply a warm soak. 2 Document the symptom. 3 Elevate the leg above the heart. 4 Notify the health care provider

4 Notify the health care provider Calf pain may be a sign of thrombophlebitis, which can lead to pulmonary embolism. A postoperative client with pain in the calf should be confined to bed immediately and the health care provider notified. A prescription for application of heat may be given after a diagnosis is made; application of heat is a dependent nursing function. Documentation is not the priority; this is a potentially serious complication. The leg should not be elevated above heart level without a prescription; gravity may dislodge a thrombus, creating an embolism.

A client who is employed as a carpenter has trouble holding tools because of carpal tunnel syndrome but continues to work to meet family financial obligations. Which is the priority concern when health care instructions are discussed with the client? 1 Anxiety 2 Chronic pain 3 Low self-esteem 4 Potential for injury

4 Potential for injury

A client's tibia is fractured in a motor vehicle accident, and a cast is applied. The nurse should assess for which manifestation indicating damage to major blood vessels caused by the fractured tibia? 1 Increased blood pressure 2 Prolonged edema in the thigh 3 Increased skin temperature of the foot 4 Prolonged reperfusion of the toes after blanching

4 Prolonged reperfusion of the toes after blanching

A client falls at home and is brought to the emergency department by family members. The client reports intercostal pain and is confused and disoriented. What is the best way for the nurse to determine whether this behavior is new for the client? 1 Ask the primary health care provider when the confusion was noted first 2 Interview the client to identify when the confusion started 3 Observe the client for a few hours before determining the onset of confusion 4 Question the family members about the client's usual behavior

4 Question the family members about the client's usual behavior

Which health problem does the nurse identify from an older client's history that increases the client's risk factors for a brain attack? 1 Glaucoma 2 Hypothyroidism 3 Continuous nervousness 4 Transient ischemic attacks (TIAs)

4 Transient ischemic attacks (TIAs)

The nurse is caring for an elderly client who has a right hip fracture. What intervention should be included in the plan of care? 1 Nutrition supplements 2 Cardiac monitoring 3 Oxygen therapy 4 Venous thromboembolism prevention (VTE)

4 Venous thromboembolism prevention (VTE) VTE causes most fatalities in elderly clients with hip fractures.

A client who has a long leg cast for a fractured bone is to be discharged from the emergency department. When discussing pain management, the nurse should advise the client to take the prescribed as needed oxycodone and acetaminophen (Percocet): 1 Just as a last resort 2 Before going to sleep 3 As the pain becomes intense 4 When the discomfort begins

4 When the discomfort begins

A client with a head injury is admitted to the hospital. Which client response indicates increasing intracranial pressure? 1 Hypervigalence 2 Constricted pupils 3 Increased heart rate 4 Widening pulse pressure

4 Widening pulse pressure Pressure on the vital centers in the brain causes an increase in the systolic blood pressure, widening the difference between the systolic and diastolic pressures. The client will be lethargic and have a lowered level of consciousness. The pupils will be unequal or dilated, not constricted. Pressure on the vital centers in the brain results in a decreased, not increased, heart rate.

A client expresses concern about insomnia and asks, "What I can do to get better sleep?" What activities should the nurse recommend? (Select all that apply.) 1 Drink a glass of wine 2 Engage in mild exercise before bedtime 3 Eat foods containing lysine 4 Follow the same bedtime ritual each night 5 Perform deep-breathing exercises

4 Follow the same bedtime ritual each night 5 Perform deep-breathing exercises

When a disaster occurs, the nurse may have to first treat mass hysteria that is indicated by what response? 1 Panic 2 Coma 3 Euphoria 4 Depression

1 Panic

Clients who have casts applied to an extremity must be monitored for complications. The most significant complication for which the nurse should assess the client's extremity is: 1 Warmth 2 Numbness 3 Skin desquamation 4 Generalized discomfort

2 Numbness

A client with multiple sclerosis is in remission. Which diversional activity should the nurse encourage that best meets the client's needs while in remission? 1 Hiking 2 Swimming 3 Sewing classes 4 Watching television

2 Swimming Swimming helps keep the muscles supple, without requiring fine motor activity. Hiking might prove too rigorous for the client. Sewing requires fine motor activity and will be difficult for the client. Sedentary activities are not helpful in maintaining muscle tone.

A client is being prepared for discharge from an ambulatory surgical clinic after a cataract extraction and an intraocular lens implant. Which statement indicates to the nurse that the discharge teaching was effective? 1 "I should call the clinic if my eye begins to hurt." 2 "I am so glad that I can take a shower tomorrow." 3 "There will be bright flashes of light for a few days." 4 "My vision should show some improvement by tomorrow."

1 "I should call the clinic if my eye begins to hurt." Pain after a cataract extraction and intraocular lens implant may indicate infection or hemorrhage and should be reported immediately. Soap may irritate the eye, and showers or shampooing of the hair should be avoided as instructed, usually from several days to two weeks. Seeing bright flashes of light is a symptom of retinal detachment and is not expected. Although rapid vision improvement may occur in some people, others may require several weeks to achieve improved visual acuity.

A client exhibits blurred and double vision with muscular weakness, and diagnostic tests are prescribed. The client is informed that a diagnosis of multiple sclerosis (MS) has been made. The client becomes visibly upset. How should the nurse respond? 1 "Don't worry; early treatment often alleviates symptoms of the disease." 2 "You should be glad that we caught it early so it can be cured." 3 "That must have really shocked you. Tell me what the health care provider told you about it." 4 "You should see a psychiatrist who will help you cope with this overwhelming news."

3 "That must have really shocked you. Tell me what the health care provider told you about it."

An 80-year-old client with dementia of the Alzheimer's type is admitted to a nursing home. A family member visits and remarks how thin and wrinkled the client has become. Which response by the nurse will help the family member most to understand the aging process? 1 "Most people at that age should be careful about weight gain." 2 "This is typical of older adults; they really don't eat well." 3 "It looks as though the frequent tanning has taken its toll." 4 "As we age, we lose the tissue that helps puff out the skin."

4 "As we age, we lose the tissue that helps puff out the skin."

The nurse is monitoring a client with a severe head injury for signs and symptoms of increasing intracranial pressure. Which finding is most indicative of increasing intracranial pressure? 1 Polyuria 2 Tachypnea 3 Increased restlessness 4 Intermittent tachycardia

3 Increased restlessness

Three days after a cast is applied to a client's fractured tibia, the client reports that there is a burning pain over the ankle. The cast over the ankle feels warm to the touch, and the pain is not relieved when the client changes position. The nurse's priority action is to: 1 Obtain a prescription for an antibiotic 2 Report the client's concern to the primary health care provider 3 Administer the prescribed medication for pain 4 Explain that this is typical after a cast is applied

2 Report the client's concern to the primary health care provider

A nurse identifies that a client exhibits the characteristic gait associated with Parkinson disease. When recording on the client's record, the nurse documents this gait as: 1 Ataxic 2 Shuffling 3 Scissoring 4 Asymmetric

2 Shuffling

What should the nurse take into consideration when planning nursing care for a client experiencing an acute episode of rheumatoid arthritis? 1 Inflammation of the synovial membrane rarely occurs. 2 Bony ankylosis of a joint is irreversible and causes immobility. 3 Complete immobility is desired during the acute phase of inflammation. 4 Redness and swelling of a joint signify that irreversible damage has occurred.

2 Bony ankylosis of a joint is irreversible and causes immobility.

The spouse of a client with an intracranial hemorrhage asks the nurse, "Why aren't they administering an anticoagulant?" How should the nurse respond? 1 "It is contraindicated because bleeding will increase." 2 "If necessary it will be started to enhance circulation." 3 "If necessary it will be stated to prevent pulmonary thrombosis." 4 "It is inadvisable because it masks the effects of the hemorrhage."

1 "It is contraindicated because bleeding will increase." An anticoagulant should not be administered to a client who is bleeding because it will interfere with clotting and will increase hemorrhage. Anticoagulants are unsafe and will not be used to enhance the circulation or prevent pulmonary thrombosis. The response "It is inadvisable because it masks the effects of the hemorrhage" is not the reason why it is contraindicated; if given, it will increase, not mask, the effects of the hemorrhage.

After an amputation of a limb, a client begins to experience extreme discomfort in the area where the limb once was. The nurse's greatest concern at this time is: 1 Addressing the pain 2 Reversing feelings of hopelessness 3 Promoting mobility in the residual limb 4 Acknowledging the grieving for the lost limb

1 Addressing the pain

Immediately after cataract surgery a client complains of feeling nauseated. The nurse should: 1 Administer the prescribed antiemetic 2 Provide some dry crackers to eat 3 Explain that this is expected after surgery 4 Encourage deep breathing until the nausea subsides

1 Administer the prescribed antiemetic

After cataract surgery, a client reports feeling nauseated. How can the nurse help to relieve the nausea? 1 Administer the prescribed antiemetic drug. 2 Provide some dry crackers for the client to eat. 3 Explain that this is expected following surgery. 4 Teach how to breathe deeply until the nausea subsides

1 Administer the prescribed antiemetic drug.

A client who had a brain attack (CVA) two weeks ago is having problems communicating. The nurse shows the client a picture of a baseball and asks the client to identify it and its characteristics. The client describes its color, size, and purpose but cannot identify it as a ball. The nurse documents this response as: 1 Anomia 2 Apraxia 3 Dysarthria 4 Dysphagia

1 Anomia Clients with anomia cannot remember names of objects. Clients with apraxia cannot use objects properly. Clients with dysarthria know what they want to say but cannot speak clearly because there is motor impairment caused by a central or peripheral nervous system injury. Clients with dysphagia have difficulty swallowing; they do not have a speech problem.

A client is admitted to the hospital with a suspected brain tumor. Based on the history of loss of equilibrium and coordination, the nurse suspects the tumor is located in the: 1 Cerebellum 2 Parietal lobe 3 Basal ganglia 4 Occipital lobe

1 Cerebellum The cerebellum is involved in synergistic control of the skeletal muscles and the coordination of voluntary movement. The parietal lobe is concerned with localization and two-point discrimination; tumors here cause motor seizures and sensory function loss. Basal ganglia are concerned with large subconscious movements and muscle tone; damage here may cause paralysis, as in a brain attack, or involuntary movements and uncontrollable shaking, as in Parkinson disease. The occipital lobe is concerned with special sensory perception; tumors here cause visual disturbances, visual agnosia, or hallucinations.

After becoming incontinent of urine, an older client is admitted to a nursing home. The client's rheumatoid arthritis contributes to severely painful joints. The primary consideration in the care of this client is the need for: 1 Control of pain 2 Immobilization of joints 3 Motivation and teaching 4 Bladder training and control

1 Control of pain

A client arrives on the nursing unit unconscious and exhibiting decerebrate posturing. When assessing the client, the nurse expects to observe: 1 Hyperextension of both the upper and lower extremities 2 Spastic paralysis of both the upper and lower extremities 3 Hyperflexion of the upper extremities and hyperextension of the lower extremities 4 Flaccid paralysis of the upper extremities and spastic paralysis of the lower extremities

1 Hyperextension of both the upper and lower extremities Limbs hyperextended and arms hyperpronated (extension posturing, decerebrate posturing) indicate upper brainstem damage; this is a grave sign. Spastic paralysis of both the upper and lower extremities is associated with an upper motor neuron disease or lesion. Hyperflexion of the upper extremities and hyperextension of the lower extremities is associated with flexion posturing (decorticate posturing), which indicates damage to the pyramidal motor tract above the brainstem. Flaccid paralysis of the upper extremities and spastic paralysis of the lower extremities is associated with a lower motor neuron disease or lesion.

After being hospitalized for a transient ischemic attack (TIA) related to hypertension, a client is discharged with a prescription of hydrochlorothiazide (HCTZ). What should the nurse instruct the client to do when taking this medication? 1 Increase the intake of potassium 2 Drink a protein supplement daily 3 Avoid eating foods high in insoluble fiber 4 Resume regular eating habits

1 Increase the intake of potassium The client must increase the dietary intake of potassium because of potassium loss associated with HCTZ.

The nurse considers that sensory restriction in a client who is blind can: 1 Increase the use of daydreaming and fantasy 2 Heighten the client's ability to make decisions 3 Decrease the client's restlessness and lethargy 4 Lead to the use of permanent neurotic behaviors

1 Increase the use of daydreaming and fantasy Internal self-stimulation increases as external stimuli decrease. Blindness is an added stress that can increase anxiety, which impairs decision-making; lack of visual stimuli limits data for decision-making. Lack of visual stimuli can increase restlessness, lethargy, and apathy.

A family member of a client with a hemorrhagic stroke asks about anticoagulant therapy. The nurse explains that anticoagulant therapy for the client: 1 Is contraindicated because it will increase bleeding 2 May be necessary to prevent pulmonary thrombosis 3 Is inadvisable because it may mask signs and symptoms 4 Will be started if necessary to enhance cerebral circulation

1 Is contraindicated because it will increase bleeding Administration of an anticoagulant to a client who is bleeding will interfere with clotting and increase bleeding. Anticoagulants are not used in this situation because they will increase bleeding; they may be used for a client with a cerebral thrombosis.

While walking in the hall, a hospitalized client has a tonic-clonic seizure. To protect the client during the seizure, the nurse should: 1 Hold the client's extremities firmly 2 Protect the client's head from injury 3 Insert an airway between the client's teeth 4 Have several staff members move the client to a soft surface

2 Protect the client's head from injury

A nurse finds a victim under the wreckage of a collapsed building. The individual is conscious, supine, breathing satisfactorily, and reports back pain and an inability to move the legs. Which action should the nurse take first? 1 Leave the individual lying on the back with instructions not to move, and leave to seek additional help. 2 Roll the individual onto the abdomen, place a pad under the head, and cover with any material available. 3 Gently raise the individual to a sitting position to determine whether the pain either diminishes or increases in intensity. 4 Gently lift the individual onto a flat piece of lumber and, using any available transportation, rush to the closest medical institution

1 Leave the individual lying on the back with instructions not to move, and leave to seek additional help.

A nurse finds a victim under the wreckage of a collapsed building. The individual is conscious, supine, breathing satisfactorily, and reports back pain and an inability to move the legs. Which action should the nurse take first? 1 Leave the individual lying on the back with instructions not to move, and leave to seek additional help. 2 Roll the individual onto the abdomen, place a pad under the head, and cover with any material available. 3 Gently raise the individual to a sitting position to determine whether the pain either diminishes or increases in intensity. 4 Gently lift the individual onto a flat piece of lumber and, using any available transportation, rush to the closest medical institution.

1 Leave the individual lying on the back with instructions not to move, and leave to seek additional help.

A client is admitted to the hospital with the diagnosis of Parkinson disease. What medication should the nurse expect the health care provider to prescribe to relieve the client's physiological responses to this disease? 1 Levodopa (l-Dopa) 2 Isocarboxazid (Marplan) 3 Dopamine (Intropin) 4 Pyridoxine (vitamin B6

1 Levodopa (l-Dopa)

X-ray films reveal that a client has sustained an intracapsular fracture of the left hip as a result of a fall. The client is placed temporarily in Buck's traction. When providing care, the nurse should: 1 Monitor for tenderness in the left calf area 2 Turn the client from side to side every two hours 3 Raise the head of the bed to a semi-Fowler position 4 Put the client's lower extremities through passive range-of-motion exercises

1 Monitor for tenderness in the left calf area

An older client with dementia of the Alzheimer's type is residing in a nursing home. When in bed, the client consistently is found sleeping in the semi-Fowler position. What area of the client's body does the nurse determine is at the greatest risk for developing a pressure ulcer? 1 Sacrum 2 Scapulae 3 Ischial spine 4 Greater trochanter

1 Sacrum

The nurse considers that a 70-year-old female can best limit further progression of osteoporosis by: 1 Taking supplemental calcium and vitamin D 2 Increasing the consumption of eggs and cheese 3 Taking supplemental magnesium and vitamin E 4 Increasing the consumption of milk and milk products

1 Taking supplemental calcium and vitamin D

After a short hospitalization for an episode of a transient ischemic attack (TIA) related to hypertension, a client is discharged on a regimen that includes chlorothiazide (Diuril). What should the nurse instruct the client to do regarding nutrition? (Select all that apply.) 1 Eat more citrus fruits 2 Take protein supplements 3 Return to previous eating habits 4 Increase intake of dairy products 5 Increase intake of dried cooked beans

1 Eat more citrus fruits 5 Increase intake of dried cooked beans The client should increase the dietary intake of potassium because of potassium loss associated with chlorothiazide. Citrus fruits are high in potassium and should be encouraged. Legumes, such as dried beans, are high in potassium and low in saturated fats.

A client diagnosed with bone cancer of the leg will receive radiation therapy as part of the treatment plan. The client has voiced concern about the side effects of the radiation treatments. The nurse will prepare the patient for which major side effects of radiation therapy? (Select all that apply.) 1 Fatigue 2 Alopecia 3 Vomiting 4 Leukopenia 5 Altered taste sensations

1 Fatigue 5 Altered taste sensations Fatigue and altered taste sensations are major systemic problems caused by radiation therapy. Fatigue may be caused by the increased energy demands needed to repair damaged cells; taste changes are thought to be caused by metabolites released from dead and dying cells. Alopecia can occur when the hair on the head is in the field of radiation, but it is not a major side effect. Vomiting is not common unless the stomach or intestine receives radiation. Leukopenia is not a problem unless 25% or more of the bone marrow is in the treatment field.

The nurse is caring for a client with increased intracranial pressure (ICP). What clinical manifestations are associated with increased ICP? (Select all that apply.) 1 Psychotic behaviors 2 Jacksonian seizures 3 Nausea and vomiting 4 Rapid pulse 5 Hypotension

1 Psychotic behaviors 2 Jacksonian seizures 3 Nausea and vomiting

A nurse observes dorsiflexion of the big toe and fanning of other toes when the lateral side of a client's foot is stroked with an applicator stick during a neurological examination. What should the nurse document in the client's medical record? 1 "Has intact plantar reflexes." 2 "Exhibits a positive Babinski sign." 3 "Demonstrates normal sensory function." 4 "Able to perform active range of motion."

2 "Exhibits a positive Babinski sign." This is a positive Babinski sign ; it is expected in infants but suggests upper motor neuron disease of the pyramidal tract in adults.

A client is scheduled for arthroscopy of the knee in the morning and asks the nurse about the procedure. Which statement by the nurse best describes the procedure? 1 "The procedure will determine the types of treatments that will be prescribed." 2 "It is a direct visualization of the joint to diagnose the extent of your knee injury." 3 "You will not remember anything about the procedure because you will be anesthetized." 4 "It is a radiological procedure that will aid in the diagnosis of the extent of your knee injury."

2 "It is a direct visualization of the joint to diagnose the extent of your knee injury."

A client is admitted to the hospital after having a tonic-clonic seizure. The client has a two-year history of a seizure disorder, but the seizures have been well controlled by phenytoin (Dilantin) for the last six months. The client says to the nurse, "I am so upset. I didn't think I was going to have more seizures." Which is the best response by the nurse? 1 "Did you forget to take your medication?" 2 "You are worried about having more seizures?" 3 "You must be under a lot of stress right now." 4 "Don't be too concerned because your medication needs to be increased."

2 "You are worried about having more seizures?"

In the postanesthesia care unit after a below-the-knee amputation, a client begins crying after feeling for the affected lower leg. How should the nurse respond? 1 Administer medication to induce sleep. 2 Allow the client to ventilate feelings of loss. 3 Provide time for privacy by leaving the room. 4 Do not address the behavior until the client is more alert.

2 Allow the client to ventilate feelings of loss.

A nurse uses a dull object to stroke the lateral side of the underside of a client's left foot and moves upward to the great toe. What reflex is the nurse testing? 1 Moro 2 Babinski 3 Stepping 4 Cremasteric

2 Babinski

A client who had a tonic-clonic seizure of unknown etiology is to begin taking phenytoin (Dilantin). The nurse should instruct the client to: 1 Take the medication on an empty stomach 2 Brush the teeth and gums three times daily 3 Stop taking the drug if abdominal pain occurs 4 Note any change in pulse and respiratory rates

2 Brush the teeth and gums three times daily Adequate dental hygiene is essential to control or prevent the common side effect of hypertrophy of the gums. The medication should be taken with food or milk to decrease gastrointestinal side effects. The health care provider should be consulted before the drug is discontinued or the dosage is adjusted; usually in this situation, a gradual dosage reduction is prescribed. Changes in pulse and respiratory rates are unrelated to phenytoin therapy.

A client's leg is placed in Buck's extension to immobilize a fracture until surgery can be performed. When caring for this client, the nurse understands that Buck's extension is a type of: 1 Skeletal traction 2 Cutaneous traction 3 Halter transfixation 4 Balanced suspension

2 Cutaneous traction Buck's extension is an example of traction applied directly to the skin (cutaneous) by tape or by a foam boot. Skeletal traction is applied directly to the bony skeleton. There is no such intervention as halter transfixation. A halter (strap) may be used with cervical or pelvic traction. Balanced suspension traction keeps the affected extremity elevated off the be

A client is admitted to the hospital with weakness in the right extremities and a slight difficulty with speech. Vital signs are within expected limits. What is the priority nursing action during the first 24 hours? 1 Taking the client's temperature. 2 Evaluating the client's motor status. 3 Obtaining the client's urine for a urinalysis. 4 Monitoring the client's blood pressure for hypertension.

2 Evaluating the client's motor status. Evaluating the client's motor status will indicate whether symptoms progress or improve and assist the health care provider in determining the diagnosis. An elevation in temperature is not an early sign of an extension of a brain attack (cerebrovascular accident [CVA]). Obtaining a urine specimen for a urinalysis is not the priority. The data indicate that vital signs are within expected limits and do not reflect hypertension; although the vital signs should be monitored, the client's motor status in this instance is most significant.

The nurse has provided teaching to a client with impaired balance who uses a walker when ambulating. The nurse observes the client transferring from a sitting to a standing position and using the walker. The nurse evaluates that further teaching is required when the client: 1 Slides toward the edge of the seat before standing 2 Holds both handles of the walker while rising to the standing position 3 Moves forward into the walker after transferring from sitting to standing 4 Stands in place holding on to the walker for at least 30 seconds before walking

2 Holds both handles of the walker while rising to the standing position Because of the angle of force applied to a walker when a person uses it to move from a sitting to a standing position, the walker can become unstable and tip over. The arms of the chair should be used for support when rising from a sitting position

A nurse teaches self-care to a client who had a cast applied for a fracture of the right ulna and radius. The nurse instructs the client to notify the primary health care provider immediately if the client experiences: 1 Slight stiffness of the fingers 2 Increasing pain at the injury site 3 Small amount of bloody drainage on the cast 4 Bounding radial pulse in the affected extremity

2 Increasing pain at the injury site

A client experiences a cerebral vascular accident (CVA) and is admitted to the hospital in a coma. What is the priority nursing care for this client? 1 Monitor vital signs. 2 Maintain an open airway. 3 Monitor pupil response and equality. 4 Maintain fluid and electrolyte balance

2 Maintain an open airway.

Which clinical indicator does a nurse identify when assessing a client with hemiplegia? 1 Paresis of both lower extremities 2 Paralysis of one side of the body 3 Paralysis of both lower extremities 4 Paresis of upper and lower extremities

2 Paralysis of one side of the body

A client sustains a complex comminuted fracture of the tibia with soft tissue injuries after being hit by a car while riding a bicycle. Surgical placement of an external fixator is performed to maintain the bone in alignment. Postoperatively it is most essential for the nurse to: 1 Cleanse the pin sites with alcohol several times a day 2 Perform a neurovascular assessment of both lower extremities 3 Ambulate the client with partial weight bearing on the affected leg 4 Maintain placement of an abduction pillow between the client's legs

2 Perform a neurovascular assessment of both lower extremities A neurovascular assessment identifies early signs and symptoms of compartment syndrome. Compartment syndrome is increased pressure within a closed fascial space caused by a fracture or soft tissue damage that compresses circulatory vessels, nerves, and tissues, compromising viability of the limb. The nurse should monitor for the six Ps: unrelenting pain, pallor, paresthesia, pressure, pulselessness, and paralysis. In addition, the circumference of the extremity will increase and the leg will feel hard and firm on palpation. Both legs are assessed for symmetry.

A client has paraplegia as a result of a motorcycle accident. What is the reason the nursing care plan should include turning the client every one to two hours? 1 Maintain comfort 2 Prevent pressure ulcers 3 Prevent flexion contractures of the extremities 4 Improve venous circulation in the lower extremities

2 Prevent pressure ulcers

An x-ray film of a client's arm reveals a comminuted fracture of the radial bone. When determining an appropriate plan of care, the nurse recalls that with a comminuted fracture: 1 Bone protrudes through a break in the skin 2 The bone has broken into several fragments and the skin is intact 3 The bone is broken into two parts and the skin may or may not be broken 4 Splintering has occurred on one side of the bone and bending on the other

2 The bone has broken into several fragments and the skin is intact In a comminuted fracture, the bone is splintered or crushed.

An adult client is brought to the emergency department after an accident. The client has limitations in mental functioning related to Down Syndrome. The nurse can best assess the client's pain level by: 1 Asking the client's parent 2 Using Wong's "Pain Faces" 3 Observing the client's body language 4 Explaining the use of a 0 to 10 pain scale

2 Using Wong's "Pain Faces" An adult client with limited mental capacity may not understand the concept of numbers as an indicator of levels of pain; Wong's "Pain Faces" uses pictures to which the individual can relate. The client, irrespective of mental capacity, is the primary source from whom to obtain information about pain because it is a personal experience. Body language provides some information, but may not accurately reflect the client's level of pain. A client with limitations in mental functioning may not understand the concept of numbers.

A nurse provides discharge teaching for a client who had a total hip replacement. Which statements made by the client indicate an understanding of the education? (Select all that apply.) 1 I should not climb any stairs. 2 I should not cross my legs. 3 I should avoid stretching exercises. 4 I should not sit in a low chair. 5 I should avoid lying prone for longer than 30 minutes.

2 I should not cross my legs. 4 I should not sit in a low chair.

A client receiving morphine is being monitored by the nurse for signs and symptoms of overdose. Which clinical findings support a conclusion of overdose? (Select all that apply.) 1 Polyuria 2 Lethargy 3 Bradycardia 4 Dilated pupils 5 Slow respirations

2 Lethargy 3 Bradycardia 5 Slow respirations

To reduce the risk of recurrent painful gout attacks, the nurse teaches the client to avoid which foods? (Select all that apply.) 1 Eggs 2 Liver 3 Cheese 4 Salmon 5 Shellfish

2 Liver 5 Shellfish Like other organ meats, liver is a high-purine food (range of 150 to 1000 mg/100 g) and should be avoided. Shellfish (e.g., shrimp, lobster) are high-purine foods and should be avoided. Eggs have insignificant amounts of purine and are unrestricted. Cheese has insignificant amounts of purine and is unrestricted. Foods that contain a moderate amount of purine (50 to 150 mg/dL), such as salmon, may be eaten four times a week.

The nurse is caring for a client who has undergone a total hip replacement. The nurse recognizes which clinical manifestations indicate a pulmonary embolism. (Select all that apply.) 1 Flushing of the face 2 Unilateral chest pain 3 Elevation of temperature 4 Sudden onset of shortness of breath 5 Pain rating increase from 2 to 8 in the hip

2 Unilateral chest pain 4 Sudden onset of shortness of breath

A client arrives at the nursing unit with neurological deficits after a motor vehicle accident. Using the Glasgow Coma Scale, the nurse assesses what client responses? (Select all that apply.) 1 Pupil response to light 2 Verbal response to speech 3 Eye opening in response to speech 4 Deep tendon reflexes in response to percussion 5 Motor activity in response to a verbal command

2 Verbal response to speech 3 Eye opening in response to speech 5 Motor activity in response to a verbal command

During a home visit a nurse discovers that a child in the household has a disability and has been experiencing seizures. In addition, the child's parent is unresponsive to the child's physical, emotional, or medical needs and seems to provoke seizure episodes by harsh verbal exchanges with the child. The nurse believes that intervention by an appropriate community resource is indicated. The nurse should make a referral to the: 1 Outpatient clinic 2 Hospital pediatric unit 3 Child Protective Services 4 Bureau of the handicapped

3 Child Protective Services

A nurse is caring for a client who is hospitalized because of injuries sustained in a major automobile collision. As the client is describing the accident to a friend, the client becomes very restless, and his pulse and respirations increase sharply. Which factor probably is related to the client's physical responses? 1 Client's method of seeking sympathy 2 Bleeding from an undiscovered injury 3 Delayed psychological response to trauma 4 Parasympathetic nervous system response to anxiety

3 Delayed psychological response to trauma

A client returns to work as a carpenter after surgery for carpal tunnel syndrome of the right hand. What instructions should the nurse give to help prevent further problems with the hands when the client returns to work? 1 Avoid carrying tools with the arms 2 Learn to hammer with the left hand 3 Do stretching exercises during breaks 4 Avoid power tools such as cordless screwdrivers

3 Do stretching exercises during breaks

After cataract surgery the nurse teaches a client how to self-administer eye drops. The nurse reinforces the use of what technique? 1 Placing the drops on the cornea of the eye 2 Raising the upper eyelid with gentle traction 3 Holding the dropper tip above the conjunctival sac 4 Squeezing the eye shut after instilling the medication

3 Holding the dropper tip above the conjunctival sac

The nurse is caring for a client with rheumatoid arthritis. When should the nurse expect the client to experience increased pain and limited movement of the joints? 1 After assistive exercise 2 When the room is cool 3 In the morning on awakening 4 When the latex fixation test is positive

3 In the morning on awakening nactivity over an extended time increases stiffness and pain in joints. Assistive exercises help maintain joint mobility. Whether the room is cool is not a factor; cold applications may decrease joint discomfort. The latex fixation test is positive when the rheumatoid factor is found in blood serum

A client who is receiving radiation therapy for bone cancer lives alone and works full time. What should the nurse encourage this client to do? 1 Perform regularly scheduled aerobic activity daily. 2 Take a leave of absence from work when receiving therapy. 3 Include rest periods during the day while receiving radiation. 4 Continue the activities usually performed before becoming ill.

3 Include rest periods during the day while receiving radiation.

To what does the nurse attribute the increased risk of respiratory complications in clients with myasthenia gravis? 1 Narrowed airways 2 Impaired immunity 3 Ineffective coughing 4 Viscosity of secretions

3 Ineffective coughing Weakened muscles result in ineffective coughing; secretions are retained and provide a medium for bacterial growth. The airways are not narrowed. Immune mechanisms are not impaired directly. Viscosity of secretions depends on fluid intake and humidity.

The nurse is caring for a client with arthritis. The client asks, "Can I take Tylenol instead of aspirin? Aspirin irritates my stomach." The nurse explains that acetaminophen (Tylenol): 1 Lacks anticoagulant action 2 Has the same action as aspirin 3 Lacks an anti-inflammatory action 4 Has more severe side effects than aspirin Although acetaminophen (Tylenol) reduces pain,

3 Lacks an anti-inflammatory action

A client who had a recent brain attack (CVA) has not had a bowel movement for five days. After addressing this problem, what does the nurse anticipate will be prescribed daily to prevent this from occurring in the future? 1 Fleet enema to stimulate peristalsis 2 Tap-water enema to evacuate the bowel 3 Mild stool softener to make stool easier to pass 4 Lubricant laxative to create more bulk in the intestines

3 Mild stool softener to make stool easier to pass

A client with pain and paresthesia of the left leg is scheduled for an electromyogram. What should the nurse discuss with the client before the test is performed? 1 Bed rest must be maintained after the procedure. 2 The involved area will be shaved before the procedure. 3 Needles will be inserted into the affected muscles during the test. 4 Monitoring of the heart rate and rhythm will be done throughout the test.

3 Needles will be inserted into the affected muscles during the test. Needles will be inserted into the affected muscles during the test to assess electrical activity and to determine whether symptoms are primarily musculoskeletal or neurological

A client has a compound fracture of the femur. The nurse should assess the client for the typical signs and symptoms of a fat embolus. In comparison to thromboembolism, which clinical indicator is unique to a fat embolus? 1 Anxiety 2 Restlessness 3 Pinpoint red spots on the chest 4 Decreased arterial oxygen level

3 Pinpoint red spots on the chest Fat emboli cause capillary fragility; rupture of capillary walls results in pinpoint red spots (petechiae). Anxiety occurs in both fat embolism and thromboembolism. There often is a feeling of dread or impending doom. Restlessness and confusion due to cerebral hypoxia occur in both fat embolism and thromboembolism. The Po2 may be decreased in both fat embolism and thromboembolism.

A nurse begins planning for the discharge of a client who had a brain attack (CVA) with residual hemiparesis and hemianopsia. What information should the nurse include in the discharge teaching plan for this client? 1 Necessity for bed rest at home 2 Use of oxygen therapy at home 3 Significance of a safe environment 4 Need for decreased protein in the diet

3 Significance of a safe environment

A client who has been immobile for a prolonged time develops hypercalcemia. Which findings are consistent with this condition? (Select all that apply.) 1 Convulsions 2 Muscle spasms 3 Deep bone pain 4 Tingling of extremities 5 Depressed deep tendon reflexes

3 Deep bone pain 5 Depressed deep tendon reflexes Increased serum calcium comes from bone demineralization, which results in pain. Depressed or absent deep tendon reflexes are associated with hypercalcemia. The body's excitable tissues are affected most (e.g., nerves, muscles, heart, intestinal smooth muscles).

A client signs a legal consent for hip replacement surgery. Shortly before surgery, the client states, "I decided not to go through with the surgery." What is the best initial response by the nurse? 1 "Then you shouldn't have signed the consent." 2 "I can understand why you changed your mind." 3 "Tell me why you decided to refuse the operation." 4 "Let's talk about your concerns regarding the procedure.

4 "Let's talk about your concerns regarding the procedure.

An x-ray film indicates that an older client has a fractured femur. The client asks the nurse, "Will I be able to walk again?" What is the best response by the nurse? 1 "I have no idea because only time will tell." 2 "You only broke a bone. It could have been worse." 3 "You'll walk again. This is a common issue in older people." 4 "Tell me more about your concerns about being able to walk."

4 "Tell me more about your concerns about being able to walk."

A 50-year-old male client has difficulty communicating because of expressive aphasia after a brain attack (CVA). When the nurse asks the client how he is feeling, his wife answers for him. How should the nurse address this behavior? 1 Ask the wife how she knows how the client feels. 2 Instruct the wife to let the client answer for himself. 3 When the wife leaves return to speak with the client. 4 Acknowledge the wife but look at the client for a response.

4 Acknowledge the wife but look at the client for a response.

Building confidence in one's worth is important for a client who is scheduled for a below-the-knee amputation (BKA) because an amputation: 1 Alters a person's sexuality 2 Implies a lack of wholeness 3 Increases dependency needs 4 Affects an idealized self-image

4 Affects an idealized self-image

A client with expressive aphasia becomes agitated and upset when attempting to communicate with the nurse. To help reduce the client's frustration, the nurse should: 1 Limit the client's contact with others to minimize communication attempts 2 Anticipate needs so the client does not need to ask for help 3 Face the client while speaking loudly 4 Allow the client adequate time to speak

4 Allow the client adequate time to speak

A client with a fractured head of the right femur and osteoporosis is placed in Buck's extension before surgical repair. What should the nurse do when caring for this client until surgery is performed? 1 Remove the weights from the traction every two hours to promote comfort. 2 Turn the client from side to side every two hours to prevent pressure on the coccyx. 3 Raise the knee gatch on the bed every two hours to limit the shearing force of traction. 4 Assess the circulation of the affected leg every two hours to ensure adequate tissue perfusion.

4 Assess the circulation of the affected leg every two hours to ensure adequate tissue perfusion.

A nurse is caring for a client who sustained a transection of the spinal cord. The nurse continually monitors this client for what medical emergency? 1 Pressure ulcer 2 Gastrointestinal atony 3 Urinary tract infection 4 Autonomic hyperreflexia

4 Autonomic hyperreflexia Autonomic hyperreflexia, an uninhibited and exaggerated response of the autonomic nervous system to stimulation, results in a blood pressure greater than 200 mm Hg systolic and 100 mm Hg diastolic; it is a medical emergency. Although a pressure ulcer can result from prolonged immobility, it is not an emergency.

A client experiences a traumatic brain injury. Which finding identified by the nurse indicates damage to the upper motor neurons? 1 Absent reflexes 2 Flaccid muscles 3 Trousseau sign 4 Babinski response

4 Babinski response A Babinski response (dorsiflexion of the first toe and fanning of the other toes) is a reaction to stroking the lateral sole of the foot with a blunt object; it is indicative of damage to the corticospinal tract when seen in adults. Hyperreflexia is associated with upper motor neuron damage. Increased muscle tone (spasticity) is associated with upper motor neuron damage. The Trousseau sign is indicative of hypocalcemia.

A client is admitted to the hospital with a tentative diagnosis of a brain tumor. The nurse recalls that the diagnostic test conducted to confirm this diagnosis is: 1 Myelography 2 Lumbar puncture 3 Electromyography 4 Computed tomography

4 Computed tomography

Which desired effect of therapy should the nurse explain to the client who has primary angle-closure glaucoma? 1 Dilating the pupil 2 Resting the eye muscles 3 Preventing secondary infection 4 Controlling intraocular pressure

4 Controlling intraocular pressure

A client has expressive aphasia. The client's family members ask how they can help the client regain as much speech function as possible. The nurse instructs them to: 1 Speak louder than usual during visits while looking directly at the client 2 Tell the client to use the correct words when speaking 3 Give positive reinforcement for correct communication 4 Encourage the client to speak while being patient with each attempt

4 Encourage the client to speak while being patient with each attempt

Initially after a brain attack (cerebrovascular accident), a client's pupils are equal and reactive to light. Later, the nurse assesses that the right pupil is reacting more slowly than the left and that the systolic blood pressure is beginning to rise. What complication should the nurse consider that the client is developing? 1 Spinal shock 2 Hypovolemic shock 3 Transtentorial herniation 4 Increasing intracranial pressure

4 Increasing intracranial pressure

A client with Parkinsonism is taking an anticholinergic medication for morning stiffness and tremors in the right arm. During a visit to the clinic the client complains of some numbness in the left hand. What is the nurse's priority intervention? 1 Refer the client to the primary health care provider only if other neurological deficits are present 2 Ask the primary health care provider to increase the client's dosage of the anticholinergic medication 3 Stress the importance of having the client call the primary health care provider as soon as possible 4 Make arrangements immediately for further medical evaluation by the client's primary health care provider

4 Make arrangements immediately for further medical evaluation by the client's primary health care provider

A client with a brain attack (cerebrovascular accident) is admitted to the hospital. What is the priority nursing intervention for this client? 1 Changing position every two hours 2 Keeping a serial record of the pulse 3 Performing range-of-motion exercises 4 Monitoring for increased intracranial pressure

4 Monitoring for increased intracranial pressure

After an automobile collision, a client who sustained multiple injuries is oriented to person and place but is confused as to time. The client complains of a headache and drowsiness, but assessment reveals that the pupils are equal and reactive. Which nursing action takes priority? 1 Moving the client as little as possible 2 Preparing the client for mannitol administration 3 Stimulating the client to maintain responsiveness 4 Monitoring the client for increasing intracranial pressure

4 Monitoring the client for increasing intracranial pressure