Exam 2 med surg chapter level 1-5

CHAPTER 35 LVL 1-5

CHAPTER 35 LVL 1-5

CHAPTER 38 LVL 1-5

CHAPTER 38 LVL 1-5

The nurse is employed at a long-term care facility caring for geriatric clients. Which assessment finding is characteristic of an age-related change? Depressive symptoms Loss of height Cognitive decline Increased muscle mass

answer

Which factor inhibits fracture healing? History of diabetes Age of 35 years Immobilization of the fracture Increased vitamin D and calcium in the diet

answer 1 Factors that inhibit fracture healing include diabetes, smoking, local malignancy, bone loss, extensive local trauma, age greater than 40, and infection. Factors that enhance fracture healing include proper nutrition, vitamin D and calcium, exercise, maximum bone fragment contact, proper alignment, and immobilization of the fracture.

The nurse is providing education to a client with cancer radiation treatment options. The nurse determines that the client understands the teaching when the client states that which type of radiation aims to protect healthy tissue during the treatment? Teletherapy Brachytherapy Proton therapy External

answer 2 In internal radiation, or brachytherapy, a dose of radiation is delivered to a localized area inside the body through the use of an implant. With this type of therapy, the farther the tissue is from the radiation source, the lower the dose. This helps to protect normal tissue from the radiation therapy.

A client asks the nurse how to identify rheumatoid nodules with rheumatoid arthritis. What characteristic will the nurse include? nonmovable located over bony prominence tender to the touch reddened

answer 2 Rheumatoid nodules usually are nontender, movable, and evident over bony prominences, such as the elbow or the base of the spine. The nodules are not reddened.

When obtaining a health history from a patient with possible abnormal immune function, what question would be a priority for the nurse to ask? "Have you ever been treated for a sexually transmitted infection?" "Do you have abdominal pain or discomfort?" "Have you ever received a blood transfusion?" "When was your last menstrual period?"

answer 3 A history of blood transfusions is obtained, because previous exposure to foreign antigens through transfusion may be associated with abnormal immune function.

What food can the nurse suggest to the client at risk for osteoporosis? Bananas Carrots Broccoli Chicken

answer 3 Calcium is important for the prevention of osteoporosis. Broccoli is high in calcium.

What is the function of the thymus gland? Produces stem cells Develops the lymphatic system Programs T lymphocytes to become regulator or effector T cells Programs B lymphocytes to become regulator or effector B cells

answer 3 The thymus gland is located in the neck below the thyroid gland. It extends into the thorax behind the top of the sternum. The thymus gland produces lymphocytes during fetal development. It may be the embryonic origin of other lymphoid structures such as the spleen and lymph nodes. After birth, the thymus gland programs T lymphocytes to become regulator or effector T cells. The thymus gland becomes smaller during adolescence but retains some activity throughout the life cycle. The other options are incorrect.

chapter 15 level 1-5

chapter 15 level 1-5

chapter 39

chapter 39

chapter 40 1-5

chapter 40 1-5

chapter 41 lelvel 1-5

chapter 41 lelvel 1-5

Which client would the nurse identify as having the greatest risk for osteoporosis? A 16-year-old male with a history of asthma A small-framed, thin 45-year-old white woman A 20-year-old male athlete with repeated injuries A 40-year-old overweight African American woman

ANSWER

The nurse is educating the patient with low back pain about the proper way to lift objects. What muscle should the nurse encourage the patient to maximize? Latissimus dorsi Rectus abdominis Gastrocnemius Quadriceps

ANSWER 4

A decrease in circulating white blood cells is granulocytopenia. leukopenia. neutropenia. thrombocytopenia.

answer 2 A decrease in circulating WBCs is referred to as leukopenia. Granulocytopenia is a decrease in neutrophils. Thrombocytopenia is a decrease in the number of platelets. Neutropenia is an abnormally low absolute neutrophil count.

Which medication directly inhibits osteoclasts, thereby reducing bone loss and increasing BMD? Calcitonin (Miacalcin) Teriparatide (Forteo) Raloxifene (Evista) Vitamin D

answer1 Calcitonin directly inhibits osteoclasts, thereby reducing bone loss and increased BMD. Raloxifene reduces the risk of osteoporosis by preserving BMD without estrogenic effects on the uterus. Teriparatide has been recently approved by the FDA for the treatment of osteoporosis.

The nurse is assessing a client with a history of ankylosing spondylitis. What will the nurse most commonly assess? increased urine output low back pain patchy hair loss on the scalp red, butterfly-shaped facial rash

ANSWER 2

The nurse is teaching a newly diagnosed client about systemic lupus erythematosus(SLE). What statement by the client indicates the teaching was successful? "This disorder is more common in men in their thirties and forties than in women." "The symptoms are primarily localized to the skin but may involve the joints." "SLE has very specific manifestations that make diagnosis relatively easy." "The belief is that it is an autoimmune disorder with an unknown trigger."

Answer

CHAPTER 36 LVL 1-5

CHAPTER 36 LVL 1-5

CHAPTER 37 LVL 1-5

CHAPTER 37 LVL 1-5

The health care provider has prescribed plicamycin to control serum calcium levels in a client with Paget's disease. The dose prescribed is 25 micrograms per kg. The client weighs 132 lbs. How many milligrams will the nurse expect the client to receive?

The client weighs 60 kg (132 lbs/2.2 lbs per kg). The client will receive 1500 micrograms (60 kg x 25 micrograms/kg). 1500 micrograms/1000 micrograms per mg = 1.5 mg.

Which statement accurately reflects current stem cell research? Clinical trials are underway only in clients with acquired immune deficiencies. Stem cell transplantation has been performed in the laboratory only. Stem cell transplantation cannot restore immune system functioning. The stem cell is known as a precursor cell that continually replenishes the body's entire supply of both red and white cells.

The stem cell is known as a precursor cell that continually replenishes the body's entire supply of both red and white cells. Stem cells comprise only a small portion of all types of bone marrow cells. Research conducted with mouse models has demonstrated that once the immune system has been destroyed experimentally, it can be completely restored with the implantation of just a few purified stem cells. Stem cell transplantation has been carried out in human subjects with certain types of immune dysfunction, such as severe combined immunodeficiency. Clinical trails are underway in clients with a variety of disorders with an autoimmune component, including systemic lupus erythematosus, rheumatoid arthritis, scleroderma, and multiple sclerosis.

The nurse is assigned to a client admitted with advanced Parkinson's disease. What type of gait correlates with Parkinson's disease? shuffling steppage spastic hemiparesis scissors

answer 1 A variety of neurologic conditions are associated with abnormal gaits, such as spastic hemiparesis gait (stroke), steppage gait (lower motor neuron disease), and shuffling gait (Parkinson's disease). Scissors gait is seen in cerebral palsy.

The nurse is planning teaching for a client with gout. Which topics will the nurse include in the teaching? Select all that apply. Decreasing alcohol intake Limiting exercise Avoiding purine-rich foods Weight loss Restricting the intake of water

answer

The nurse is asked to explain to the client the age-related processes that contribute to bone loss and osteoporosis. What is the nurse's best response? Decrease in estrogen Increase of vitamin D Decrease in parathyroid hormone Increase in calcitonin

ANSWER 1

The nurse tells the client that if exposure to an allergen occurs around 8:00 AM, then the client should expect a mild or moderate reaction by what time? 1:00 PM 10:00 AM 3:00 PM 11:00 AM

ANSWER 2 Mild and moderate reactions begin within 2 hours of exposure.

The nurse is performing a health history with a new client in the clinic. What is the most common reason for a client to seek medical attention for arthritis? weakness stiffness pain joint swelling

answer 3 The symptom that most commonly causes a person to seek medical attention is pain. Other common symptoms include joint swelling, limited movement, stiffness, weakness, and fatigue.

An older adult with rheumatoid arthritis limits going out with others because of the need to use a cane. Which response will the nurse make to this client? "Everyone will get older at some time." "Invite people over to your home instead." "Look at the cane as maintaining your independence." "It must be hard to get older."

ANSWER

Osteoarthritis is known as a disease that affects the cartilaginous joints of the spine and surrounding tissues. affects young males. requires early treatment because most of the damage seems to occur early in the course of the disease. is the most common and frequently disabling of joint disorders.

ANSWER

The nurse is preparing to administer a medication that has an affinity for H1 receptors. Which medication would the nurse administer? Diphenhydramine Omeprazole Cimetidine Nizatidine

ANSWER 1 Certain medications are categorized by their action at these receptors. Diphenhydramine (Benadryl) is an example of an antihistamine, a medication that displays an affinity for H1 receptors. Cimetidine (Tagamet) and nizatidine (Axid) target H2 receptors to inhibit gastric secretions in peptic ulcer disease.

A client has had surgical repair of a hip injury after joint manipulation was unsuccessful. After surgery, the nurse implements measures to prevent complications. Which complications is the nurse seeking to prevent? Select all that apply. wound infection skin breakdown diarrhea pneumonia

ANSWER 1-2-4 After surgery, the nurse implements measures to prevent skin breakdown, wound infection, pneumonia, constipation, urinary retention, muscle atrophy, and contractures.

Which assessment finding would the nurse expect to document for a client with ataxia-telangiectasis? Thrush Vascular lesions Eczema Thrombocytopenia

ANSWER 2 Ataxia-telangiectasis is characterized by loss of muscle coordination and vascular lesions. Thrombocytopenia and eczema are associated with Wiskott-Aldrich syndrome. Thrush is a manifestation associated with severe combined immunodeficiency (SCID).

Which condition is an early manifestation of HIV encephalopathy? Vacant stare Headache Hallucinations Hyperreflexia

ANSWER 2 Early manifestations of HIV encephalopathy include headache, memory deficits, difficulty concentrating, progressive confusion, psychomotor slowing, apathy, and ataxia. Later stages include hyperreflexia, a vacant stare, and hallucinations.

A client with a fracture develops compartment syndrome that requires surgical intervention. What treatment will the nurse would most likely prepare the client for? Bone graft Fasciotomy Amputation Joint replacement

ANSWER 2 Surgical treatment of compartment syndrome is achieved with a fasciotomy, a surgical incision of the fascia and separation of the muscle to relieve pressure and restore tissue perfusion. Bone graft, joint replacement or amputation may be done for a client who experiences avascular necrosis.

Which is usually the most important consideration in the decision to initiate antiretroviral therapy? ELISA CD4+ counts Western blotting assay HIV RNA

ANSWER 2 The most important consideration in decisions to initiate antiretroviral therapy is CD4+ counts.

A nurse is reviewing the dietary history of a client who has experienced anaphylaxis. What would the nurse identify as a common cause of anaphylaxis? Select all that apply. Beef Milk Eggs Chicken Shrimp

ANSWER 2-3-5 Common food causes of anaphylaxis include peanuts, tree nuts, shellfish, fish, milk, eggs, soy, and wheat. Beef and chicken are not common causes.

The nurse is caring for a client with a hip fracture. The physician orders the client to start taking a bisphosphonate. Which medication would the nurse document as given? Denosumab Teriparatide Alendronate Raloxifene

ANSWER 3

The nurse is administering intravenous vancomycin. What will the nurse initially assess the client for if an allergic reaction occurs? hypotension and tachycardia the presence and location of pruritus dyspnea, bronchospasm, and/or laryngeal edema the severity of cutaneous warmth and flushing

ANSWER 3 Initial nursing assessment and intervention needs to be directed toward evaluating breathing and maintaining an open airway, so the initial assessment will be for dyspnea, bronchospasm, and laryngeal edema. Hypotension, pruritis, and flushing may occur, but the airway is most important.

Kaposi sarcoma (KS) is diagnosed through visual assessment. skin scraping. biopsy. computed tomography.

ANSWER 3 KS is diagnosed by biopsy of the suspected lesions. Prognosis depends on the extent of the tumor, the presence of other symptoms of HIV infection, and the CD4+ count.

The inflammatory response needs to be balanced so that what is helpful does not become harmful if mediators are secreted in excess. Which of the following are the primary mediators in an inflammatory response? Macrophages Suppressor T cells T cells and cytokines B lymphocytes

ANSWER 3 T cells and cytokines mediate the inflammatory response and also halt the response through transforming growth factor, which inhibits macrophage activation.

Which area of the spinal column is subject to the greatest mechanical stress and degenerative changes? Thoracic Upper lumbar Lower lumbar Cervical

ANSWER 3 The lower lumbar disks, L4 to L5 and L5 to S1, are subject to the greatest mechanical stress and greatest degenerative changes.

A client with ataxia-telangiectasia approaches the nurse with many questions and concerns. The client asks what the primary cause of death is for this disease. The nurse's best response would be: Acute renal failure Chronic lung disease Overwhelming infection Neurologic dysfunction

ANSWER 3 The primary causes of death in clients with ataxia-telangiectasia are overwhelming infection and lymphoreticular or epithelial cancer.

The nurse is teaching a client with osteoarthritis about the disease. What is the most important client focus for disease management? disease-modifying antirheumatic drug therapy detection of systemic complications strategies for remaining active prevention of joint deformity

ANSWER 3 The goals of osteoarthritis disease management are to decrease pain and stiffness and improve joint mobility. Strategies for remaining active are the most important client focus. The detection of complications, disease-modifying antirheumatic drugs management, and prevention of joint deformity are considerations, but not the most important priorities for the client.

A patient has been diagnosed with an allergy to peanuts. What is a priority for this patient to carry at all times? A medical alert bracelet An oral airway An H1 blocker An EpiPen

ANSWER 4 All patients with food allergies, especially seafood and nuts, should have an EpiPen device prescribed.

Which condition is an early manifestation of HIV encephalopathy? Vacant stare Hallucinations Hyperreflexia Headache

ANSWER 4 Early manifestations of HIV encephalopathy include headache, memory deficits, difficulty concentrating, progressive confusion, psychomotor slowing, apathy, and ataxia. Later stages include hyperreflexia, a vacant stare, and hallucinations.

The nurse completes a history and physical assessment on a client with acquired immune deficiency syndrome (AIDS) who was admitted to the hospital with respiratory complications. The nurse knows to assess for what common infection (80% occurrence) in persons with AIDS? Cytomegalovirus Mycobacterium tuberculosis Legionnaire's disease Pneumocystis pneumonia

ANSWER 4 Pneumocystic pneumonia (PCP) is one of the first and most common opportunistic infections associated with AIDS. It may be present despite the absence of crackles. If untreated, PCP progresses to cause significant pulmonary impairment and respiratory failure.

A client is prescribed an oral corticosteroid for 2 weeks to relieve asthma symptoms. The nurse educates the client about side effects, which include hypotension. diuresis. hypoglycemia. adrenal suppression.

ANSWER 4 The nurse should instruct the client that side effects of oral corticosteroid therapy include adrenal suppression, fluid retention, weight gain, glucose intolerance, hypertension, and gastric irritation.

The nurse explains to a client that immunotherapy initially starts with injections at which interval? Monthly Daily Bi-monthly Weekly

ANSWER 4 Typically, immunotherapy begins with very small amounts and gradually increases, usually at weekly intervals until a maximum tolerated dose is attained. Then maintenance booster injections are administered at 2- to 4-week intervals, frequently for a period of several years.

The client asks the nurse about types of exercise that do not stress the joints. What exercise will the nurse include in the teaching plan? jogging weight lifting t'ai chi running on a treadmill

Answer 3 Heberden nodes are a characteristic finding of osteoarthritis. Swan neck deformity, boutonniere deformity, and ulnar deviation are characteristic of rheumatoid arthritis.

Question 5 of 5 A client was seen in the clinic for musculoskeletal pain, fatigue, mood disorders, and sleep disturbances. The physician has diagnosed fibromyalgia. What would not be a part of teaching plan for this condition? applications of ice avoiding caffeine and alcohol regular exercise and stress reduction encouraging the client to eat a healthy diet

Application of ice is not part of the treatment regimen. Encouraging the client to eat a healthy diet, avoiding caffeine and alcohol, regular exercise, and stress reduction are part of the teaching plan.

Which connective tissue disorder is characterized by insoluble collagen being formed and accumulating excessively in the tissues? Rheumatoid arthritis Systemic lupus erythematosus Scleroderma Polymyalgia rheumatic

Scleroderma occurs initially in the skin but also occurs in blood vessels, major organs, and body systems, potentially resulting in death. Rheumatoid arthritis results from an autoimmune response in the synovial tissue, with damage taking place in body joints. SLE is an immunoregulatory disturbance that results in increased autoantibody production. In polymyalgia rheumatic, immunoglobulin is deposited in the walls of inflamed temporal arteries.

The nurse is caring for a client who has been diagnosed with a "rheumatic disease." What nursing diagnoses will most likely apply to this client's care? Select all that apply. Fluid and electrolyte imbalance Fatigue Alteration of self-concept Fluid volume deficit Pain

answer -2-3-5 Clients with rheumatic diseases, which typically involve joints and muscles, experience problems with mobility, fatigue, and pain. Because of the limitations of the disease, clients often have an altered self-image and self-concept. Fluid and electrolyte imbalances are not typically associated with these types of diseases.

A client with osteoporosis is prescribed a selective estrogen receptor modifier (SERM) as treatment. The nurse would identify which drug as belonging to this class? Raloxifene (Evista) Alendronate (Fosamax) Tamoxifen (Nolvadex) Calcium gluconate

answer 1 An example of a selective estrogen receptor modifier (SERM) is raloxifene (Evista). Alendronate is a bisphosphonate; calcium gluconate is an oral calcium preparation; tamoxifen is an antiestrogen agent.

A nurse is caring for a client with eczema. Which medication would be prescribed when an allergy is a factor causing the skin disorder? Chlorpheniramine Bupivacaine Dicloxacillin Dexamethasone

answer 1 Antihistamines such as chlorpheniramine are frequently prescribed when an allergy is a factor in causing a skin disorder. Antihistamines relieve itching and shorten the duration of allergic reaction. Corticosteroids such as dexamethasone are used to relieve inflammatory or allergic symptoms. Antibiotics such as dicloxacillin are used to treat infectious disorders. Local anesthetics such as bupivacaine are used to relieve minor skin pain and itching.

The nurse is discussing life management with the client with rheumatoid arthritis in a health clinic. What assessment finding indicates the client is having difficulty implementing self-care? increased fatigue a weight gain of 2 pounds ability to perform activities of daily living (ADL) decreased joint pain

answer 1 Fatigue is common with rheumatoid arthritis. Finding a balance between activity and rest is an essential part of the therapeutic regimen. The client is reporting being able to do ADLs and decreased joint pain. The client's weight gain of 2 pounds does not correlate with self-care problems.

The client is receiving a vesicant antineoplastic for treatment of cancer. Which assessment finding would require the nurse to take immediate action? Extravasation Bone pain Nausea and vomiting Stomatitis

answer 1 The nurse needs to monitor IV administration of antineoplastics (especially vesicants) to prevent tissue necrosis to blood vessels, skin, muscles, and nerves. Stomatitis, nausea/vomiting, and bone pain can be symptoms of the disease process or treatment mode but does not require immediate action.

Decades ago, before the role of the tonsils and adenoids was better understood, it was typical after repeated bouts with tonsillitis to have a tonsillectomy and adenoidectomy. Today it is understood that the tonsils and adenoids are lymphoid tissues that: filter bacteria from tissue fluid. program T lymphocytes. increase the efficacy of antibiotics. eliminate cancer cells.

answer 1 The tonsils and adenoids filter bacteria from tissue fluid. Because they are exposed to pathogens in the oral and nasal passages, they can become infected and locally inflamed.

A patient sustains an open fracture with extensive soft tissue damage. The nurse determines that this fracture would be classified as what grade? III IV II I

answer 1 (GRADED 3) Open fractures are graded according to the following criteria (Schaller, 2012): Grade I is a clean wound less than 1 cm long. Grade II is a larger wound without extensive soft tissue damage or avulsions. Grade III is highly contaminated and has extensive soft tissue damage. It may be accompanied by traumatic amputation and is the most severe.

A client has had surgical repair of a hip injury after joint manipulation was unsuccessful. After surgery, the nurse implements measures to prevent complications. Which complications is the nurse seeking to prevent? Select all that apply. skin breakdown diarrhea pneumonia wound infection

answer 1-3-4 After surgery, the nurse implements measures to prevent skin breakdown, wound infection, pneumonia, constipation, urinary retention, muscle atrophy, and contractures.

An x-ray demonstrates a fracture in which a bone has splintered into several pieces. Which type of fracture is this? Depressed Comminuted Impacted Compound

answer 2 A comminuted fracture may require open reduction and internal fixation. A compound fracture is one in which damage also involves the skin or mucous membranes. A depressed fracture is one in which fragments are driven inward. An impacted fracture is one in which a bone fragment is driven into another bone fragment.

Which term refers to moving away from midline? Adduction Abduction Eversion Inversion

answer 2 Abduction is moving away from the midline. Adduction is moving toward the midline. Inversion is turning inward. Eversion is turning outward.

Which medication taken by the client in the previous 24 hours would be of greatest concern to the nurse caring for a client undergoing a bone biopsy? NPH insulin aspirin digoxin furosemide

answer 2 Aspirin has anti-clotting properties, and bone is a very vascular tissue. The client taking aspirin in close proximity to a bone biopsy is at increased risk for excessive bleeding.

Which assessment should be completed if immune dysfunction is suspected in the neurosensory system? Urinary frequency Ataxia Burning upon urination Hematuria

answer 2 Ataxia should be assessed when immune dysfunction in the neurosensory system is suspected. Hematuria, discharge, and frequency of and burning upon urination are associated with the genitourinary system.

A nursing instructor is giving a lecture on the immune system. The instructor's discussion on phagocytosis will include: regulator T cells and helper T cells. neutrophils and monocytes. lymphokines and suppressor T cells. plasma cells and memory cells.

answer 2 Neutrophils and monocytes are phagocytes, cells that perform phagocytosis.

What is the term for a lateral curving of the spine? Diaphysis Scoliosis Lordosis Epiphysis

answer 2 Scoliosis is a lateral curving of the spine. Lordosis is an increase in the lumbar curvature of the spine. Diaphysis is the shaft of a long bone. Epiphysis is the end of a long bone.

A client has been treated for migraine headaches for several months and comes to the clinic reporting no improvement. The nurse is talking with the client and hears an audible click when the client is moving the jaw. What does the nurse suspect may be happening? Trigeminal neuralgia Temporomandibular disorder Loose teeth Dislocated jaw

answer 2 The disorder can be confused with trigeminal neuralgia and migraine headaches. The client experiences clicking of the jaw when moving the joint, or the jaw can lock, which interferes with opening the mouth. Loose teeth will not cause a clicking of the jaw. The client does not have a dislocated jaw.

The nurse is caring for a client with rheumatoid arthritis who suffers with chronic pain in the hands. When would be the best time for the nurse to perform range-of-motion exercises? After the client has a diagnostic test After the client has had a warm paraffin hand bath First thing in the morning when the client wakes After cool compresses have been applied to the hands

answer 2 Whether resting or moving, clients in this stage of the disease have considerable chronic pain, which typically is worse in the morning after a night's rest. Warmth helps decrease the symptoms of pain and will be the best time to perform range of motion exercises.

Which assessment suggests to the nurse that a client with systemic lupus erythematous is having renal involvement? Chest pain Behavioral changes Hypertension Decreased cognitive ability

answer 3 Hypertension is suggestive of renal damage in the client with systemic lupus erythematous.

The client returns to the nursing unit following an open reduction with internal fixation of the right hip. Nursing assessment findings include temperature 100.8 degrees Fahrenheit, heart rate 112 beats per minute, respiratory rate 28 breaths per minute, and blood pressure 86/58. There is no urine in the Foley catheter collection bag. The nurse interprets these findings as indicating which complication? Urinary retention Osteomyelitis Hypovolemic shock Atelectasis

answer 3 Indicators of hypovolemic shock include a heart rate greater than 100 beats per minute, a blood pressure less than 90/60 mm Hg, and urine output less than 30 ml per hour.

The nurse is conducting a medication reconciliation with a client admitted with a fracture. What medication predisposes a client for a risk for fractures? furosemide metoprolol prednisone digoxin

answer 3 Prednisone, a corticosteroid, causes increased bone resorption and decreased bone formation, resulting in increased risk for fractures. Furosemide, digoxin, and metoprolol do not interfere with bone resorption or predispose clients to fractures.

Which of the following is the final stage of fracture repair? Cartilage removal Angiogenesis Remodeling Cartilage calcification

answer 3 The final stage of fracture repair consists of remodeling the new bone into its former structural arrangement. During cartilage calcification, enzymes within the matrix vesicles prepare the cartilage for calcium release and deposit. Cartilage removal occurs when the calcified cartilage is invaded by blood vessels and becomes reabsorbed by chondroblasts and osteoclasts. Angiogenesis occurs when new capillaries infiltrate the hematoma, and fibroblasts from the periosteum, endosteum, and bone marrow produce a bridge between the fractured bones.

After a person experiences a closure of the epiphyses, which statement is true? The bone grows in length but not thickness. The bone increases in thickness and is remodeled. Both bone length and thickness continue to increase. No further increase in bone length occurs.

answer 4

A nurse is caring for a client receiving chemotherapy. Which assessment finding places the client at the greatest risk for an infection? Ate 75% of all meals during the day Temperature of 98.3° F (36.8° C) White blood cell (WBC) count of 9,000 cells/mm3 Stage 3 pressure ulcer on the left heel

answer 4 A stage 3 pressure ulcer is a break in the skin's protective barrier, which could lead to infection in a client who is receiving chemotherapy. The WBC count and temperature are within normal limits. Eating 75% of meals is normal and doesn't increase the client's risk for infection. A client who is malnourished is at a greater risk for infection.

A client is being treated for hyperuricemia. Part of the treatment strategy is for the client to avoid contributing factors whenever possible. Which activities might bring on an acute attack? high carbohydrate intake frequently ingesting salicylates frequently drinking coffee eating organ meats and sardines

answer 4 During an acute attack, high-purine foods are avoided, including organ meats, gravies, meat extracts, anchovies, herring, mackerel, sardines, and scallops. The other listed factors do not worsen attacks.

Decades ago, before the role of the tonsils and adenoids was better understood, it was typical after repeated bouts with tonsillitis to have a tonsillectomy and adenoidectomy. Today it is understood that the tonsils and adenoids are lymphoid tissues that: program T lymphocytes. eliminate cancer cells. increase the efficacy of antibiotics. filter bacteria from tissue fluid.

answer 4 The tonsils and adenoids filter bacteria from tissue fluid. Because they are exposed to pathogens in the oral and nasal passages, they can become infected and locally inflamed.

A client with fibromyalgia asks why physical therapy has been prescribed. Which response will the nurse make? "It will help with the overall deconditioning that has occurred." "It will take your mind off your health problem." "It is used instead of prescribing medications for the condition." "I will ask the health care provider it if is necessary."

ANSWER

The nurse is preparing a client for a surgical procedure that will allow visualization of the extent of joint damage of the knee for a client with rheumatoid arthritis and also obtain a sample of synovial fluid. What procedure will the nurse prepare the client for? Arthroscopy Open reduction Needle aspiration Arthroplasty

ANSWER 1

What food can the nurse suggest to the client at risk for osteoporosis? Broccoli Chicken Bananas Carrots

ANSWER 1 Calcium is important for the prevention of osteoporosis. Broccoli is high in calcium.

The lower the client's viral load, the longer the survival time. the shorter the time to AIDS diagnosis. the longer the time immunity. the shorter the survival time.

ANSWER 1 The lower the client's viral load, the longer the time to AIDS diagnosis and the longer the survival time. The key goal of antiretroviral therapy is to achieve and maintain durable viral suppression.

What types of cells are the primary targets of the healthy immune system? Select all that apply. foreign cells cancerous cells infectious cells typical cells

ANSWER 1-2-3 The immune system's primary targets are infectious, foreign, or cancerous cells.

The nurse is creating a discharge teaching plan for a client with a latex allergy. Which information should be included? Select all that apply. Avoidance of latex-based products Radioallergosorbent testing (RAST) Administration of emergency epinephrine Administration of antihistamines

ANSWER 1-3-4 The nurse should include in the discharge teaching plan avoidance of latex-based products. Additionally, the nurse should include administration of antihistamines and an emergency epinephrine. RAST testing would not be indicated; it is a diagnostic test for allergies, and the client's latex allergy is already diagnosed.

The nurse is gathering a health history for a client with osteoarthritis. What clinical manifestation will the nurse expect to find? early morning stiffness small joint involvement subcutaneous nodules joint pain that increases with rest

ANSWER 2

Which of the following are routes of administration for Calcitonin? Select all that apply. Intravenous Nasal spray Intramuscular injection Oral Subcutaneous

ANSWER 2-3-5

A client with gout has been advised to lose weight. The client informs the nurse of plans to go on a "guaranteed rapid weight loss" plan that involves fasting and heavy exercise. Which response would be most appropriate? "Make sure to eat some fat occasionally with all that exercise." "Try combining the fasting with moderate exercise." "There might be some difficulties with your plan and fasting." "The fasting is okay, but make sure you drink fluids when exercising."

ANSWER 3 Clients should avoid fasting, low-carbohydrate diets, and rapid weight loss because these measures increase the likelihood of ketone formation, which inhibits uric acid excretion. Gradual weight loss helps reduce serum uric acid levels in clients with gout.

Lymphoid tissues, which perform a function within the immune response, are found throughout the body. While the thymus gland, tonsils and adenoids, spleen, and lymph nodes are lymphoid tissues, where else in the body can lymphoid tissues be found? Select all that apply. stomach kidneys lungs intestines brain

ANSWER 3-4 Lymphoid tissue also is found on alveolar membranes in the lungs, mucous membranes of the intestines, and in the lining of the sinusoids of the liver.

What treatment option does the nurse anticipate for the patient with severe combined immunodeficiency disease (SCID)? Radiation therapy Removal of the thymus gland Antibiotics Bone marrow transplantation

ANSWER 4Treatment options for SCID include stem cell and bone marrow transplantation.

A client in the emergency department is being treated for a wrist fracture. The client asks why a splint is being applied instead of a cast. What is the best response by the nurse? "It is best if an orthopedic doctor applies the cast." "A splint is applied when more swelling is expected at the site of injury." "Not all fractures require a cast." "You would have to stay here much longer because it takes a cast longer to dry."

Answer 2

A patient comes to the clinic and informs the nurse of numbness, tingling, and a burning sensation in the arm from the elbow down to the fingers. What type of symptom would this be documented as? Paresthesia Effusion Atonia Flaccidity

answer 1

In which phase of the cell cycle does cell division occur? Mitosis G1 phase S phase G2 phase

answer 1 Cell division occurs in mitosis. RNA and protein synthesis occurs in the G1 phase. DNA synthesis occurs during the S phase. DNA synthesis is complete, and the mitotic spindle forms in the G2 phase.

Which term refers to a disease of a nerve root? Radiculopathy Involucrum Sequestrum Contracture

answer 1 When the client reports radiating pain down the leg, the client is describing radiculopathy. Involucrum refers to new bone growth around the sequestrum. Sequestrum refers to dead bone in an abscess cavity. Contracture refers to abnormal shortening of muscle or fibrosis of joint structures.

The nurse is screening children for scoliosis. What nursing assessment finding is indicative of scoliosis? crepitus of the knee joint lateral curvature of the spine contracture of the wrists loss of 1 inch (2.5 cm) in height

answer 2

In which phase of the cell cycle does cell division occur? S phase Mitosis G1 phase G2 phase

answer 2 Cell division occurs in mitosis. RNA and protein synthesis occurs in the G1 phase. DNA synthesis occurs during the S phase. DNA synthesis is complete, and the mitotic spindle forms in the G2 phase.

What type of cytokine will attract neutrophils and monocytes to remove debris? Cytotoxic T cells Lymphokines Regulator T cells Suppressor T cells

answer 2 Lymphokines, a type of cytokine, attract cells when they detect antigens and direct B-cell lymphocytes to multiply and mature. Cytotoxic T cells bind to invading cells, destroy the targeted invader by altering their cellular membrane and intracellular environment, and stimulate the release of chemicals called lymphokines. Suppressor T cells limit or turn off the immune response in the absence of continued antigenic stimulation. Regulator T cells are made of up of helper and suppressor cells.

A client has Paget's disease. An appropriate nursing diagnosis for this client is: Risk for infection Risk for falls Delayed wound healing Fatigue

answer 2 The client with Paget's disease is at risk for falls secondary to pathological fractures and impaired gait/mobility.

Which area of the spinal column is subject to the greatest mechanical stress and degenerative changes? Thoracic Lower lumbar Upper lumbar Cervical

answer 2 The lower lumbar disks, L4 to L5 and L5 to S1, are subject to the greatest mechanical stress and greatest degenerative changes.

The nurse is caring for a client with an external fixator that requires pin care twice a day. The nurse observes that there is a new purulent drainage around one of the pins. What intervention should the nurse anticipate doing? Applying iodine-based solution Scrubbing the drainage from around the pin site Obtaining a culture Apply ointment to the pin site.

answer 3 A culture should be obtained if purulent drainage is present. Drainage should be gently removed, not scrubbed. Iodine-based products interfere with tissue healing and are not recommended for cleaning pin sites. Ointment should not be applied to the pin site unless specifically ordered.

A client with metastatic pancreatic cancer underwent surgery to remove a malignant tumor in the pancreas. Despite the tumor being removed, the physician informs the client that chemotherapy must be started. Why might the physician opt for chemotherapy? Fatigue Stomatitis To prevent metastasis

answer 3 Chemotherapy treats systemic and metastatic cancer. It can also be used to reduce tumor size preoperatively, or to destroy any remaining tumor cells postoperatively. Angiogenesis is the growth of new capillaries from the tissue of origin. This process helps malignant cells obtain needed nutrients and oxygen to promote growth. Fatigue and stomatitis are side effects of radiation and chemotherapy.

Dupuytren contracture causes flexion of which area(s)? Index and middle fingers Thumb Fourth and fifth fingers Ring finger

answer 3 Dupuytren contracture causes flexion of the fourth and fifth fingers, and frequently the middle finger.

A client has a fracture that is being treated with open rigid compression plate fixation devices. What teaching will the nurse reinforce to the client about how the progress of bone healing will be monitored? An arthroscopy will be performed. The bone will heal on its own without intervention. Serial x-rays will be taken. The plate will be removed to determine if the bone is growing back.

answer 3 Serial x-rays are used to monitor the progress of bone healing. The plate need not be disturbed. An arthroscopy is used to visualize joints. While the bone will heal without interference, monitoring of bone healing is needed to ensure further adjustments are not necessary.

The nurse is conducting a screening for familial predisposition to cancer. Which element should the nurse note as a possible indication of hereditary cancer syndrome? Onset of cancer after age 50 in family member A second cousin diagnosed with cancer An aunt and uncle diagnosed with cancer A first cousin diagnosed with cancer

answer 3 The hallmarks of hereditary cancer syndrome include cancer in two or more first-degree or second-degree relatives, early onset of cancer in family members younger than age 50, the same type of cancer in several family members, individual family members with more than one type of cancer, and a rare cancer in one or more family members.

When obtaining a health history from a patient with possible abnormal immune function, what question would be a priority for the nurse to ask? "Have you ever been treated for a sexually transmitted infection?" "Do you have abdominal pain or discomfort?" "When was your last menstrual period?" "Have you ever received a blood transfusion?"

answer 4 A history of blood transfusions is obtained, because previous exposure to foreign antigens through transfusion may be associated with abnormal immune function.

The nurse is working on an orthopedic floor caring for a client injured in a football game. The nurse is reviewing the client's chart noting that the client has previously had an injured tendon. The nurse anticipates an injury between the periosteum of the bone and which of the following? Ligament Joint Cartilage Muscle

answer 4 Tendons attach muscles to the periosteum of bone. Joints are a junction between two or more bones. Ligaments connect two freely movable bones. Cartilage is a dense connective tissue used to reduce friction between two structures.

While the nurse is performing a physical assessment, the client reports numbness, tingling, and pain when the nurse percusses lightly over the median nerve. What should this assessment indicate to the nurse? Impingement syndrome Morton's neuroma Dupuytren's contracture Carpal tunnel syndrome

answer 4 Tinel's sign (numbness, tingling, and pain in response to light percussion over the median nerve) is a positive finding for carpal tunnel syndrome. Morton's neuroma is assessed as a painful condition that affects the ball of the foot. Dupuytren's contracture is when knots of tissue beneath the skin cause one or more fingers stay bent toward the palm. Impingement syndrome is a shoulder condition.

chapter 42 lvl 1-5

chapter 42 lvl 1-5

Which of the following inhibits bone resorption and promotes bone formation? Calcitonin Estrogen Parathyroid hormone Corticosteroids

ANSWER 1

Which of the following is the most common and most fatal primary malignant bone tumor? Osteogenic sarcoma (osteosarcoma) Enchondroma Rhabdomyoma Osteochondroma

ANSWER 1

Which of the following is a term used to describe a soft tissue injury produced by a blunt force? Contusion Hematoma Strain Sprain

ANSWER 1 A contusion is a soft tissue injury produced by blunt force, such as a blow, kick, or fall, that results in bleeding into soft tissues (ecchymosis, or bruising). A hematoma develops when the bleeding is sufficient to form an appreciable solid swelling. A strain, or a "pulled muscle," is an injury to a musculotendinous unit caused by overuse, overstretching, or excessive stress. A sprain is an injury to the ligaments and supporting muscle fibers that surround a joint often caused by a trauma, wrenching or twisting motion.

In which process is the antigen-antibody molecule coated with a sticky substance that facilitates phagocytosis? Opsonization Immunoregulation Apoptosis Agglutination

ANSWER 1 In the process of opsonization, the antigen-antibody molecule is coated with a sticky substance that facilitates phagocytosis. Apoptosis is programmed cell death that results from the digestion of DNA by endonucleases. Agglutination is the clumping effect that occurs when an antibody acts as a cross-link between two antigens. Immunoregulation is a complex system of checks and balances that regulates or controls immune responses.

A patient sustains an open fracture of the left arm after an accident at the roller skating rink. What does emergency management of this fracture involve? (Select all that apply.) Immobilizing the affected site Asking the patient if he or she is able to move the arm Covering the area with a clean dressing if the fracture is open Splinting the injured limb Wrapping the arm in an ace bandage

ANSWER 1-3-4 Cranial nerve assessment would only be carried out for head-related injuries or diseases. General nursing measures include administering analgesics, providing comfort measures, assisting with ADLs, preventing constipation, promoting physical mobility, preventing infection, maintaining skin integrity, and preparing client for self-care.

Which area of the spinal column is subject to the greatest mechanical stress and degenerative changes? Thoracic Lower lumbar Upper lumbar Cervical

ANSWER 2

The nurse is teaching a client who has been diagnosed with Hashimoto's thyroiditis. Which statement correctly describes the process of autoimmunity? The body produces inappropriate or exaggerated responses to specific antigens. The normal protective immune response attacks the body, damaging tissues. A deficiency results from improper development of immune cells or tissues. The body overproduces immunoglobulins.

ANSWER 2 Autoimmunity happens when the normal protective immune response paradoxically turns against or attacks the body, leading to tissue damage. It is not an immune deficiency. An exaggerated immune response describes a hypersensitivity. An overproduction of immunoglobulins is the definition of gammopathies.

The nurse is teaching a client with allergic rhinitis about medications. What medication is a mast cell stabilizer used in the treatment of allergic rhinitis? tetrahydrozoline hydrochloride intranasal cromolyn sodium oxymetazoline hydrochloride pseudoephedrine hydrochloride

ANSWER 2 Intranasal cromolyn sodium is a mast cell stabilizer. Tetrahydrozoline hydrochloride, oxymetazoline hydrochloride, and pseudoephedrine hydrochloride are adrenergic agents.

What is the most common cause of anaphylaxis? Opioids Penicillin NSAIDs Radiocontrast agent

ANSWER 2 Penicillin is the most common cause of anaphylaxis, accounting for about 75% of fatal anaphylactic reactions in the United States each year. Opioids, NSAIDs, and radiocontrast agents are some of the medications that are frequently reported as causing anaphylaxis.

A client taking fosamprenavir reports "getting fat." What is the nurse's best action? Assess the client's diet. Teach the client about medication side effects. Have the client increase exercise. Arrange for a psychological counseling.

ANSWER 2 The client needs to be aware of the potential for fat redistribution. Exercise, diet, and counseling will not change the outcome of this side effect.

The nurse is teaching the client who has an immunodeficiency disorder how to avoid infection at home. Which statement indicates that additional teaching is needed? "I will make sure to have my own toothbrush and tube of toothpaste at home." "I will be sure to eat lots of fresh fruits and vegetables every day." "I will wash my hands whenever I get home from work." "I will avoid contact with people who are sick or who have recently been vaccinated."

ANSWER 2 The client should avoid eating raw fruits and vegetables. All foods should be cooked thoroughly and all leftover food should be refrigerated immediately to prevent infection.

A client with ataxia-telangiectasia is admitted to the unit. The nurse caring for the client would expect to see what included in the treatment regimen? Platelet administration IV gamma globulin administration Thymus grafting Factor VIII administration

ANSWER 2 Treatment for ataxia-telangiectasia includes IV gamma globulin, antimicrobial therapy, and bone marrow transplantation. It does not include platelet administration, factor VIII administration, or thymus grafting.

What type of immunoglobulin does the nurse recognize that promotes the release of vasoactive chemicals such as histamine when a client is having an allergic reaction? IgA IgG IgE IgM

ANSWER 3 IgE promotes the release of vasoactive chemicals such as histamine and bradykinin in allergic, hypersensitivity, and inflammatory reactions. IgG neutralizes bacterial toxins and accelerates phagocytosis. IgA interferes with the entry of pathogens through exposed structures or pathways. IgM agglutinates antigens and lyses cell walls.

Which immunity type becomes active as a result of infection by a specific microorganism? naturally acquired passive immunity artificially acquired active immunity naturally acquired active immunity artificially acquired passive immunity

ANSWER 3 Naturally acquired active immunity occurs as a direct result of an infection by a specific microorganism.

A nursing instructor is giving a lecture on the immune system. The instructor's discussion on phagocytosis will include: regulator T cells and helper T cells. plasma cells and memory cells. neutrophils and monocytes. lymphokines and suppressor T cells.

ANSWER 3 Neutrophils and monocytes are phagocytes, cells that perform phagocytosis.

A client visits an orthopedic specialist because of pain beginning in the low back and radiating behind the right thigh and down below the right knee. The doctor suspects a diagnosis of sciatica. The nurse knows that the origin of the pain is between which intervertebral disks? C3, C4, and L1 L1, L2, and L4 L2, L3, and L5 L4, L5, and S1

ANSWER 4

What is the most common cause of anaphylaxis? Opioids Radiocontrast agent NSAIDs Penicillin

ANSWER 4 Penicillin is the most common cause of anaphylaxis, accounting for about 75% of fatal anaphylactic reactions in the United States each year. Opioids, NSAIDs, and radiocontrast agents are some of the medications that are frequently reported as causing anaphylaxis.

To reduce the incidence of complications in a client in traction, which intervention should be included in the care plan? Reduce fluid intake. Remove the weights during linen changes. Increase fiber intake. Increase calorie intake.

Answer 3

Which is a benefit of a continuous passive motion (CPM) device when applied after knee surgery? It prevents infection and controls edema and bleeding. It promotes healing by increasing circulation and movement of the knee joint. It provides active range of motion. It promotes healing by immobilizing the knee joint.

answer 2 A CPM device applied after knee surgery promotes healing by increasing circulation and movement of the knee joint.

Which of the following cell types are involved in humoral immunity? Helper T lymphocyte B lymphocytes Memory T lymphocyte Suppressor T lymphocyte

answer 2 B lymphocytes are involved in the humoral immune response. T lymphocytes are involved in cellular immunity.

Which term refers to the failure of fragments of a fractured bone to heal together? Subluxation Nonunion Dislocation Malunion

answer 2 When nonunion occurs, the client reports persistent discomfort and movement at the fracture site. Dislocation refers to the separation of joint surfaces. Subluxation refers to partial separation or dislocation of joint surfaces. Malunion refers to growth of the fragments of a fractured bone in a faulty position, forming an imperfect union.

An x-ray demonstrates a fracture in which a bone has splintered into several pieces. Which type of fracture is this? Compound Comminuted Impacted Depressed

answer 2A comminuted fracture may require open reduction and internal fixation. A compound fracture is one in which damage also involves the skin or mucous membranes. A depressed fracture is one in which fragments are driven inward. An impacted fracture is one in which a bone fragment is driven into another bone fragment.

The nurse is preparing the client for computed tomography. Which information should be given by the nurse? "A small bit of tissue will be removed and sent to the lab." "Fluid will be removed from you affected joint." "You must remain very still during the procedure." "A radioisotope will be given through an IV."

answer 3 In computed tomography, a series of detailed x-rays are taken. The client must lie very still during the procedure. A contrast agent, not a radioisotope, may or may not be injected. Arthrocentesis involves the removal of fluid from a joint. A small bit of tissue is removed with a biopsy.

A client with a recent left above-the-knee amputation states, "I can feel pain in my left toes." Which is the best response by the nurse? "Pain medication usually does not help this type of pain." "Your left toes have been amputated." "Describe the pain and rate it on the pain scale." "The pain is really from the nerves in the upper leg."

answer 3 The nurse should recognize phantom pain as real and complete a pain assessment as if the limb were attached. The client's pain should be address and treated appropriately. By telling the client that the toes have been amputated or the pain is really from the nerves in the upper leg, the nurse is negating the client's pain. Opioid pain medication can be effective with phantom pain.

Which hormone inhibits bone reabsorption and increases calcium deposit in the bone? Vitamin D Growth hormone Sex hormones calcitonin

answer 4

Colles fracture occurs in which area? Clavicle Elbow Humeral shaft Distal radius

answer 4 A Colles fracture is a fracture of the distal radius (wrist). It is usually the result of a fall on an open, dorsiflexed hand.

What term refers to a flexion deformity caused by a slowly progressive contracture of the palmar fascia? Callus Hammertoe Hallux valgus Dupuytren contracture

answer 4 Dupuytren disease results in a slowly progressive contracture of the palmar fascia, called Dupuytren contracture. A callus is a discretely thickened area of skin that has been exposed to persistent pressure or friction. A hammertoe is a flexion deformity of the interphalangeal joint, which may involve several toes. Hallux valgus is a deformity in which the great toe deviates laterally.

Which type of surgery is used in an attempt to relieve complications of cancer? Prophylactic Reconstructive Salvage Palliative

answer 4 Palliative surgery is performed to relieve complications of cancer. Prophylactic surgery involves removing nonvital tissues or organs that are likely to develop cancer. Reconstructive surgery may follow curative or radical surgery and is carried out in an attempt to improve function or to obtain a more desirable cosmetic effect. Salvage surgery is an additional treatment option that uses an extensive surgical approach to treat the local recurrence of a cancer after the use of a less extensive primary approach.

Skull sutures are an example of which type of joint? Diarthrosis Aponeuroses Amphiarthrosis Synarthrosis

answer 4 Skull sutures are considered synarthrosis joints and are immovable. Amphiarthrosis joints allow limited movement, such as a vertebral joint. Diarthrosis joints are freely movable joints such as the hip and shoulder. Aponeuroses are broad, flat sheets of connective tissue.

The nurse is caring for a pregnant patient with pregnancy-induced hypertension. When assessing the reflexes in the ankle, the nurse observes rhythmic contractions of the muscle when dorsiflexing the foot. What would the nurse document this finding as? Hypertrophy Ankle reflex Positive Babinski reflex Clonus

answer 4 The nurse may elicit muscle clonus (rhythmic contractions of a muscle) in the ankle or wrist by sudden, forceful, sustained dorsiflexion of the foot or extension of the wrist.

Which statement describes the clinical manifestations of a delayed hypersensitivity (type IV) allergic reaction to latex? They are localized to the area of exposure, usually the back of the hands. They can be eliminated by changing glove brands or using powder-free gloves. They occur within minutes after exposure to latex. They may worsen when hand lotion is applied before donning latex gloves.

ANSWER 1 Clinical manifestations of a delayed hypersensitivity reaction are localized to the area of exposure. Clinical manifestations of an irritant contact dermatitis can be eliminated by changing glove brands or using powder-free gloves. With an irritant contact dermatitis, avoid use of hand lotion before donning gloves; this may worsen symptoms, as lotions may leach latex proteins from the gloves. Described as a latex allergy, when clinical manifestations occur within minutes after exposure to latex, an immediate hypersensitivity (type I) allergic reaction has occurred.

An important nursing assessment, post fracture, is to evaluate neurovascular status. Therefore, the nurse should check for: Capillary refill. Shortening and deformity. Crepitus. Swelling and discoloration.

ANSWER 1 Assessment for neurovascular impairment includes checking for weak pulses or delayed capillary refill (normal is <2 seconds).

While taking the health history of a newly admitted client, the nurse reviews general lifestyle behaviors. What strategies would have a positive effect on the immune system? Biofeedback, relaxation, and hypnosis Relaxation, intense competitive exercise, and humor Hypnosis, humor, and chronic illness Humor, rigorous physical stress, and biofeedback

ANSWER 1 Growing evidence indicates that strategies such as relaxation, imagery techniques, biofeedback, humor, hypnosis, and conditioning can positively influence a measurable immune system response. Intense or rigorous competitive exercise can cause negative effects on the immune system, especially if the environment is stressful while undergoing exercise.

Which may occur if a client experiences compartment syndrome in an upper extremity? Volkmann's contracture Callus Whiplash injury Subluxation

ANSWER 1 If compartment syndrome occurs in an upper extremity, it may lead to Volkmann's contracture, a claw-like deformity of the hand resulting from obstructed arterial blood flow to the forearm and hand. A whiplash injury is a cervical spine sprain. Callus refers to the healing mass that occurs with true bone formation after a fracture. Subluxation refers to a partial dislocation.

What type of immunoglobulin does the nurse recognize that promotes the release of vasoactive chemicals such as histamine when a client is having an allergic reaction? IgE IgA IgM IgG

ANSWER 1 IgE promotes the release of vasoactive chemicals such as histamine and bradykinin in allergic, hypersensitivity, and inflammatory reactions. IgG neutralizes bacterial toxins and accelerates phagocytosis. IgA interferes with the entry of pathogens through exposed structures or pathways. IgM agglutinates antigens and lyses cell walls.

A nurse is caring for a client with multiple sclerosis. Client education about the disease process includes which explanation about the cause of the disorder? The immune system recognizes one's own tissues as "foreign." The immune system recognizes one's own tissues as "self." Regulatory mechanisms fail to halt the immune response. Excess cytokines cause tissue damage.

ANSWER 1 The immune system's recognition of one's own tissues as "foreign" rather than self is the basis of many autoimmune disorders, including multiple sclerosis. When regulatory mechanisms fail to halt the immune response or excess cytokines are produced, pathology occurs (e.g., allergies, hypersensitivity).

Which term refers to an incomplete antigen? Antibody Hapten Allergen Antigen

ANSWER 2 A hapten is an incomplete antigen. An allergen is a substance that causes manifestations of allergy. An antigen is a substance that induces the production of antibodies. An antibody is a protein substance developed by the body in response to and interacting with a specific antigen.

An infant is born to a mother who had no prenatal care during her pregnancy. What type of hypersensitivity reaction does the nurse understand may have occurred? Bacterial endocarditis Rh-hemolytic disease Rheumatoid arthritis Lupus erythematosus

ANSWER 2 A type II hypersensitivity, or cytotoxic, reaction, which involves binding either the IgG or IgM antibody to a cell-bound antigen, may lead to eventual cell and tissue damage. The reaction is the result of mistaken identity when the system identifies a normal constituent of the body as foreign and activates the complement cascade. Examples of type II reactions are myasthenia gravis, Goodpasture syndrome, pernicious anemia, hemolytic disease of the newborn, transfusion reaction, and thrombocytopenia.

A client with an allergic disorder calls the nurse and asks what treatment is available for allergic disorders. The nurse explains to the client that there is more than one treatment available. What treatments would the nurse tell the client about? Sublingual-swallow immunotherapy (SLIT) Desensitization Sublingual-topical immunotherapy (STIT) Resensitization

ANSWER 2 Desensitization is another option. Desensitization is a form of immunotherapy in which a person receives weekly or twice-weekly injections of dilute but increasingly higher concentrations of an allergen without interruption. SLIT is a form of desensitization therapy. Options C and D are distractors for this question.

A nursing instructor is giving a lecture on the immune system. The instructor's discussion on phagocytosis will include: lymphokines and suppressor T cells. neutrophils and monocytes. regulator T cells and helper T cells. plasma cells and memory cells.

ANSWER 2 Neutrophils and monocytes are phagocytes, cells that perform phagocytosis.

The nurse knows the best strategy for latex allergy is antihistamines. avoidance of latex-based products. epinephrine from an emergency kit. corticosteroids.

ANSWER 2 The best strategy available for latex allergy is to avoid latex-based products, but this is often difficult because of their widespread use. Antihistamines and an emergency kit containing epinephrine should be provided to these clients, along with instructions about emergency management of latex allergy.

Which of the following cell types are involved in humoral immunity? Helper T lymphocyte Memory T lymphocyte B lymphocytes Suppressor T lymphocyte

ANSWER 3 B lymphocytes are involved in the humoral immune response. T lymphocytes are involved in cellular immunity.

What education should the nurse provide to the patient taking long-term corticosteroids? The patient should take the medication only as needed and not take it unnecessarily. The patient should not stop taking the medication abruptly and should be weaned off of the medication. The patient should discontinue using the drug immediately if weight gain is observed. Corticosteroids are relatively safe drugs with very few side effects.

ANSWER 3 Patients who receive high-dose or long-term corticosteroid therapy must be cautioned not to stop taking the medication suddenly. Doses are tapered when discontinuing this medication to avoid adrenal insufficiency.

Which is usually the most important consideration in the decision to initiate antiretroviral therapy? ELISA HIV RNA CD4+ counts Western blotting assay

ANSWER 3 The most important consideration in decisions to initiate antiretroviral therapy is CD4+ counts.

When assessing the skin of a client with allergic contact dermatitis, the nurse would most likely expect to find irritation at which area? Lower arms Plantar aspects of the feet Dorsal aspect of the hand Ankles

ANSWER 3 With allergic contact dermatitis, irritation is most common on the dorsal aspects of the hand. Irritant, phototoxic, and photoallergic types of contact dermatitis are commonly seen on the hands and lower arms.

An important nursing assessment, post fracture, is to evaluate neurovascular status. Therefore, the nurse should check for: Crepitus. Shortening and deformity. Swelling and discoloration. Capillary refill.

ANSWER 4 Assessment for neurovascular impairment includes checking for weak pulses or delayed capillary refill (normal is <2 seconds).

The nurse notes that the client's left great toe deviates laterally. This finding would be recognized as which condition? Hallux valgus Hammertoe Pes cavus Flatfoot

answer 1 Hallux valgus is commonly referred to as a bunion. Hammertoes are usually pulled upward. Pes cavus refers to a foot with an abnormally high arch and a fixed equinus deformity of the forefoot. The client with flatfoot demonstrates a diminished longitudinal arch of the foot.

Which type of hematopoietic stem cell transplantation (HSCT) is characterized by cells from a donor other than the patient? Allogeneic Homogenic Autologous Syngeneic

answer 1 If the source of donor cells is from a donor other than the patient, it is termed allogeneic. Autologous donor cells come from the patient. Syngeneic donor cells are from an identical twin. Homogenic is not a type of stem cell transplant.

Which immunity type becomes active as a result of infection by a specific microorganism? naturally acquired active immunity artificially acquired active immunity naturally acquired passive immunity artificially acquired passive immunity

answer 1 Naturally acquired active immunity occurs as a direct result of an infection by a specific microorganism.

Which is a sign or symptom of septic shock? Altered mental status Increased urine output Warm, moist skin Hypertension

answer 1 Signs of septic shock include altered mental status, cool and clammy skin, decreased urine output, and hypotension.

Which joint is most commonly affected in gout? Metatarsophalangeal Tarsal area Ankle Knee

answer 1 The metatarsophalangeal joint of the big toe is the most commonly affected joint (90% of clients); this is referred to as podagra. The wrists, fingers, and elbows are less commonly affected. The tarsal area, ankle, and knee are not the most commonly affected in gout.

A nurse is caring for a client following foot surgery. Which nursing intervention is most important for the nurse to include in the nursing care plan? Perform neuromuscular assessment every hour. Monitor vital signs every 4 hours. Administer pain medication per client request. Examine the surgical dressing every hour.

answer 1 The priority nursing intervention is to perform a neuromuscular assessment every hour. Early detection of neurological and perfusion problems is important to prevent complications from the surgery. The surgical dressing does not need to be examined hourly. Administering pain medication is important, but assessing the foot color and temperature are most important. Vital sign monitoring is important, but not a priority after foot surgery.

A client undergoes an invasive joint examination of the knee. What will the nurse closely monitor the client for? Serous drainage Signs of shock Lack of sleep and appetite Signs of depression

answer 1 When the client undergoes an invasive knee joint examination, the nurse should inspect the knee area for swelling, bleeding, and serous drainage. An invasive joint examination does not cause lack of sleep or appetite, depression, or shock. The client may be in shock due to the injury itself.

An example of a flat bone is the metacarpals. sternum. vertebra. femur.

answer 2 An example of a flat bone is the sternum. A short bone is a metacarpal. The femur is a long bone. The vertebra is an irregular bone.

Which of the following biologically active vitamin functions to increase the amount of calcium in the blood? A C D E

answer 3

A client reports pain in the right knee, stating, "My knee got twisted when I was going down the stairs." The client was diagnosed with an injury to the ligaments and tendons of the right knee. Which terminology, documented by the nurse, best reflects the injury? Subluxation Strain Sprain Dislocation

answer 3 A sprain is caused by a wrenching or twisting motion. Dislocation refers to the separation of joint surfaces. Subluxation refers to partial separation or dislocation of joint surfaces. Strain refers to a muscle pull or tear.

A patient has stepped in a hole in the yard, causing an ankle injury. The ankle is edematous and painful to palpation. How long should the nurse inform the patient that the acute inflammatory stage will last? Less than 24 hours About 72 hours Between 24 and 48 hours At least 1 week

answer 3 After the acute inflammatory stage (e.g., 24 to 48 hours after injury), intermittent heat application (for 15 to 30 minutes, four times a day) relieves muscle spasm and promotes vasodilation, absorption, and repair.

Following a total knee replacement, the surgeon orders a continuous passive motion (CPM) device. The client asks about the purpose of this treatment. What is the best response by the nurse? "CPM prevents injury by limiting flexion of the knee." "CPM strengthens the muscles of the leg." "CPM increases range of motion of the joint." "CPM delivers analgesic agents directly into the joint."

answer 3 CPM increases circulation and range of motion of the knee joint.

Which factor inhibits fracture healing? Vitamin D Exercise Local malignancy Maximum bone fragment contact

answer 3 Factors that inhibit fracture healing include local malignancy, bone loss, and extensive local trauma. Factors that enhance fracture healing include proper nutrition, vitamin D, exercise, and maximum bone fragment contact.

The nurse caring for a client, who has been treated for a hip fracture, instructs the client not to cross their legs and to have someone assist with tying their shoes. Which additional instruction should the nurse provide to client? Do not flex the hip more than 30 degrees. Do not flex the hip more than 120 degrees. Do not flex the hip more than 90 degrees. Do not flex the hip more than 60 degrees.

answer 3 Proper alignment and supported abduction are encouraged for hip repairs. Flexion of the hip more than 90 degrees can cause damage to the a repaired hip fracture.

Which of the following is an appropriate priority nursing diagnosis for the client following an arthrocentesis? Activity intolerance Deficient knowledge: procedure Risk for infection Chronic pain

answer 3 The priority nursing diagnosis following an arthrocentesis is risk for infection. The client may experience acute pain. The client needs adequate information before experiencing the procedure. Activity intolerance would not be an expected nursing diagnosis.

A nurse is caring for a client who's experiencing septic arthritis. This client has a history of immunosuppressive therapy and the immune system is currently depressed. Which assignment is the most appropriate for the nurse caring for this client? The nurse caring for this client is also caring for two other immunosuppressed clients on the medical intensive care unit. The nurse caring for this client is also caring for four clients receiving chemotherapy for cancer treatment on the oncology floor. The nurse is caring for this client on the intensive care unit. The nurse caring for this client is also caring for four other immunosuppressed clients on the medical floor.

answer 3 This client is critically ill; the diagnosis and immunosuppression place the client at a high risk for infection. The most appropriate place for this client is in an intensive care unit, where the nurse can focus exclusively on health promotion. This client shouldn't be on the oncology floor. This client requires close monitoring. The nurse caring for this client shouldn't also be caring for other clients who may require frequent interventions.

A decrease in circulating white blood cells is neutropenia. granulocytopenia. thrombocytopenia. leukopenia.

answer 4 A decrease in circulating WBCs is referred to as leukopenia. Granulocytopenia is a decrease in neutrophils. Thrombocytopenia is a decrease in the number of platelets. Neutropenia is an abnormally low absolute neutrophil count.

A client comes to the emergency department and it is found that the client's radial head is partially dislocated. What is this partially dislocated radial head documented as? Volkmann's contracture Sprain Compartment syndrome Subluxation

answer 4 A partial dislocation is referred to as a subluxation. A Volkmann's contracture is a claw like deformity that results from compartment syndrome or obstructed arterial blood flow to the forearm and hand. Compartment syndrome is a condition in which a structure such as a tendon or nerve is constricted in a confined space and affects nerve innervation, leading to subsequent palsy. A sprain is injury to the ligaments surrounding the joint.

The client displays manifestations of compartment syndrome. What treatment will the nurse expect the client to be scheduled for? A total hip replacement A total knee replacement An open reduction A fasciotomy

answer 4 A treatment option for compartment syndrome is fasciotomy.

The nurse is evaluating a client's complete blood cell count and differential along with the serum immunoglobulin E (IgE) concentration. Which result might indicate that the client has an allergic disorder? High IgE concentration High neutrophil count Low white blood cell count Low eosinophil count

ANSWER 1 A high total IgE concentration and/or a high percentage of eosinophils may indicate an allergic disorder. However, normal IgE levels do not exclude the diagnosis of an allergic disorder. The amounts of neutrophils and white blood cells are not affected by allergic disorders.

A patient with a history of allergies comes to the clinic for an evaluation. The following laboratory test findings are recorded in a patient's medical record:Total serum IgE levels: 2.8 mg/mLWhite blood cell count: 5,100/cu mmEosinophil count: 4%Erythrocyte sedimentation rate: 20 mm/hThe nurse identifies which result as suggesting an allergic reaction? Serum IgE level Erythrocyte sedimentation rate White blood cell count Eosinophil count

ANSWER 1 Normally, serum IgE levels are below 1.0 mg/mL. The patient's level is significantly elevated suggesting allergic reaction. The other values are within normal parameters.

Morton neuroma is exhibited by which clinical manifestation? Inflammation of the foot-supporting fascia Diminishment of the longitudinal arch of the foot Swelling of the third (lateral) branch of the median plantar nerve High arm and a fixed equinus deformity

ANSWER 3

A client with osteoarthritis expresses concerns that the disease will prevent the ability to complete daily chores. Which suggestion should the nurse offer? "Do all your chores in the evening, when pain and stiffness are least pronounced." "Do all your chores in the morning, when pain and stiffness are least pronounced." "Do all your chores after performing morning exercises to loosen up." "Pace yourself and rest frequently, especially after activities."

ANSWER 4

A client is suspected of having an immune system disorder. The health care provider wants to perform a diagnostic test to confirm the diagnosis. What test should the nurse prepare the client for? Complete chemistry panel T-and C-cell assays Plasmapheresis Enzyme-linked immunosorbent assay

ANSWER 4 A client is suspected of having an immune system disorder. The health care provider wants to perform a diagnostic test to confirm the diagnosis. What test should the nurse prepare the client for? Complete chemistry panel T-and C-cell assays Plasmapheresis Enzyme-linked immunosorbent assay

Which allergic reaction is potentially life threatening? urticaria contact dermatitis None of the listed allergic reactions is potentially life threatening. angioedema

ANSWER 4 Angioedema is potentially life threatening. Medical management would include intubation, subcutaneous epinephrine, and aminophylline in severe reactions.

When evaluating a client's knowledge about use of antihistamines, what statement indicates further education is required? "Hard candy will relieve my dry mouth." "I should be careful when driving." "This medication may be taken with food." "If I am pregnant, I should take half the dose."

ANSWER 4 Antihistamines are contraindicated during the third trimester of pregnancy, in nursing mothers and newborns, in children and elderly people, and in patients whose conditions may be aggravated by muscarinic blockade (e.g., asthma, urinary retention, open-angle glaucoma, hypertension, prostatic hyperplasia). The major side effect is sedation, although H1 antagonists are less sedating than earlier antihistamines. Additional side effects include nervousness, tremors, dizziness, dry mouth, palpitations, anorexia, nausea, and vomiting.

Two days after application of a cast to treat a fractured femur, the client reports severe, deep, and constant pain in the leg. What will the nurse suspect? Chronic venous insufficiency. Phlebitis. Infection. Compartment syndrome.

ANSWER 4 Compartment syndrome refers to the compression of nerves, blood vessels, and muscle within a closed space. This leads to tissue death from lack of oxygenation.

The nurse is caring for a client recovering from a major burn. Burns affect the immune system by causing a loss of large amounts of which of the following? Serum, which depletes the body's store of glucagon Plasma, which depletes the body's store of calcitonin Plasma, which depletes the body's store of catecholamines Serum, which depletes the body's store of immunoglobulins

ANSWER 4 Major burns cause impaired skin integrity and compromise the body's first line of defense. Loss of large amounts of serum occurs with burn injuries and depletes the body of essential proteins, including immunoglobulins. Loss of serum or plasma does not deplete the body of catecholamines (adrenal gland), calcitonin (thyroid gland), or glucagon (pancreas).

An adult client has had mumps when the client was a child. The client had a titer prior to entering nursing school and shows immunity. What type of immunity does this reflect? Artificially acquired active immunity Naturally acquired active immunity Passive immunity Natural passive immunity

ANSWER 4 Naturally acquired active immunity occurs as a direct result of infection by a specific microorganism. An example is the immunity to measles that develops after the initial infection. Not all invading microorganisms produce a response that gives lifelong immunity. Artificially acquired immunity is obtained by receiving a killed or weakened microorganism or toxoid. Passive immunity is acquired when ready-made antibodies are given to a susceptible person.

A client suspected of having human immunodeficiency virus (HIV) has blood drawn for a screening test. What is the first test generally run to see if a client is, indeed, HIV positive? Complete blood count (CBC) Schick Western Blot Enzyme-linked immunosorbent assay (ELISA)

ANSWER 4 The ELISA test, an initial HIV screening test, is positive when there are sufficient HIV antibodies; it also is positive when there are antibodies from other infectious diseases. If the ELISA is positive twice then the Western Blot test is run. A CBC and a Schick test are not screening tests for HIV.

A client who has injured a hip in a fall cannot place weight on the leg and is in significant pain. After radiographs indicate intact yet malpositioned bones, what repair would the physician perform? analgesia and immobilization heat and immobilization ice and immobilization joint manipulation and immobilization

ANSWER 4 The physician manipulates the joint or reduces the displaced parts until they return to normal position, then immobilizes the joint with an elastic bandage, cast, or splint for several weeks.

A client is experiencing an acute exacerbation of rheumatoid arthritis. What should the nursing priority be? Administering ordered analgesics and monitoring their effects Performing meticulous skin care Providing comprehensive client teaching; including symptoms of the disorder, treatment options, and expected outcomes Supplying adaptive devices, such as a zipper-pull, easy-to-open beverage cartons, lightweight cups, and unpackaged silverware

answer 1 An acute exacerbation of rheumatoid arthritis can be very painful, and the nurse should make pain management her priority. Client teaching, skin care, and supplying adaptive devices are important, but these actions don't not take priority over pain management.

Which of the following procedures involves a surgical fusion of the joint? Arthrodesis Synovectomy Osteotomy Tenorrhaphy

answer 1 An arthrodesis is a surgical fusion of the joint. Synovectomy is the excision of the synovial membrane. Tenorrhaphy is the suturing of a tendon. An osteotomy alters the distribution of the weight within the joint.

Which hormone inhibits bone resorption and increases the deposit of calcium in the bone? Calcitonin Growth hormone Sex hormones Vitamin D

answer 1 Calcitonin, secreted by the thyroid gland in response to elevated blood calcium levels, inhibits bone reabsorption and increases the deposit of calcium in the bone.

A client with a right leg fracture is returning to the orthopedist to have the cast removed. During cast removal, it is important for the nurse to assure: the client that he or she won't be cut. that the leg will be as good as new. that the cast cutter blade is new. that pedal pulses are present.

answer 1 Casts are removed with a mechanical cast cutter. Cast cutters are noisy and frightening but the blade does not penetrate deep enough to cut the client. The client needs reassurance that the machine will not cut into the skin. The other options are either irrelevant or not something the nurse knows for certain at this time.

What intervention is a priority for a client diagnosed with osteoarthritis? Physical therapy and exercise Hydrotherapy Colchicine Allopurinol

answer 1 Clients with osteoarthritis need to maintain joint mobility. To preserve joint function, individuals need to learn appropriate activities. Colchicine and allopurinol are used for gout, not osteoarthritis. Hydrotherapy is not a priority for care.

A client is being treated for hyperuricemia. Part of the treatment strategy is for the client to avoid contributing factors whenever possible. Which activities might bring on an acute attack? eating organ meats and sardines frequently drinking coffee high carbohydrate intake frequently ingesting salicylates

answer 1 During an acute attack, high-purine foods are avoided, including organ meats, gravies, meat extracts, anchovies, herring, mackerel, sardines, and scallops. The other listed factors do not worsen attacks.

The nurse notes that an older adult was treated for a wound infection and pneumonia within the last 6 months. Which factor will the nurse attribute to this client's illnesses? Immunosenescence Decline in self-care activities Reduced vitamin intake Polypharmacy

answer 1 Immunosenescence is the term for age-related changes in the immune system. These changes have been linked to the increased rates of illness and mortality in older adults, and an increased incidence of infections. There is no evidence that polypharmacy has caused an increase in infections in the older adult. The development of infections is not directly linked to vitamin intake or self-care activities.

A client with rheumatoid arthritis arrives at the clinic for a checkup. Which statement by the client refers to the most overt clinical manifestation of rheumatoid arthritis? "My finger joints are oddly shaped." "My legs feel weak." "I have trouble with my balance." "I have pain in my hands."

answer 1 Joint abnormalities are the most obvious manifestations of rheumatoid arthritis. A systemic disease, rheumatoid arthritis attacks all connective tissue. Although muscle weakness may occur from limited use of the joint where the muscle attaches, such weakness isn't the most obvious sign of rheumatoid arthritis; also, it occurs only after joint abnormalities arise. Subcutaneous nodules in the hands, although common in rheumatoid arthritis, are painless. The disease may cause gait disturbances, but these follow joint abnormalities.

A nurse is caring for a client with an undiagnosed bone disease. When instructing on the normal process to maintain bone tissue, which process transforms osteoblasts into mature bone cells? Ossification and calcification Resorption Remodeling Epiphyses and diaphysis formation

answer 1 Ossification and calcifications the body's process to transform osteoblasts into mature bone cells called osteocytes. Osteocytes are involved in maintaining bone tissue. Resorption and remodeling are involved in bone destruction. Epiphyses and diaphyses are bone tissues that provide strength and support to the human skeleton.

According to the TNM classification system, T0 means there is no evidence of primary tumor. no distant metastasis. distant metastasis. no regional lymph node metastasis.

answer 1 T0 means that there is no evidence of primary tumor. N0 means that there is no regional lymph node metastasis. M0 means that there is no distant metastasis. M1 means that there is distant metastasis.

Which statement by a client undergoing external radiation therapy indicates the need for further teaching? "I'm worried I'll expose my family members to radiation." "I'll not use my heating pad during my treatment." "I'll wear protective clothing when outside." "I'll wash my skin with mild soap and water only."

answer 1 The client undergoing external radiation therapy requires further teaching when he voices a concern that he might expose his family to radiation. Internal radiation, not external radiation, poses a risk to the client's family. The client requires no further teaching if he states that he should wash his skin with mild soap and water, wear protective clothing when outside, and avoid using a heating pad.

An instructor is describing the process of bone development. Which of the following would the instructor describe as being responsible for the process of ossification? Osteoblasts Osteoclasts Cortical bone Cancellous bone

answer 1 Osteoblasts secrete bone matrix (mostly collagen), in which inorganic minerals, such as calcium salts, are deposited. This process of ossification and calcification transforms the blast cells into mature bone cells, called osteocytes, which are involved in maintaining bone tissue. Cortical bone is dense hard bone found in the long shafts; cancellous bone is spongy bone found in the irregular rounded edges of bone.

Which type of fracture involves a break through only part of the cross-section of the bone? Open Incomplete Comminuted Oblique

answer 2 An incomplete fracture involves a break through only part of the cross-section of the bone. A comminuted fracture is one that produces several bone fragments. An open fracture is one in which the skin or mucous membrane wound extends to the fractured bone. An oblique fracture runs across the bone at a diagonal angle of 45 to 60 degrees.

Which term refers to fixation or immobility of a joint? Arthroplasty Ankylosis Hemarthrosis Diarthrodial

answer 2 Ankylosis is the fixation or immobility of a joint. It may result from a disease process or from scarring due to trauma. Hemarthrosis refers to bleeding into a joint. Diarthrodial refers to a joint with two freely moving parts. Arthroplasty refers to replacement of a joint.

Nursing care for the client with fibromyalgia should be guided by the assumption that patients with fibromyalgia will eventually lose their ability to walk. may feel as if their symptoms are not taken seriously. rarely respond to treatment. all have the same type of symptoms.

answer 2 Because clients present with widespread symptoms that are often vague in nature, health care providers may misdiagnose them. Clients feel as though people are not listening to them. Nurses need to provide support and encouragement. Symptoms of disease vary from client to client and respond to different treatments. Clients do not lose their ability to walk.

The nurse is performing a neurovascular assessment of a client's injured extremity. Which would the nurse report? Capillary refill of 3 seconds Dusky or mottled skin color Skin warm to touch Positive distal pulses

answer 2 Normally, skin color would be similar to the color in other body areas. Pale or dusky skin color indicates an abnormality that needs to be reported. Presence of pulses, capillary refill of 3 seconds, and warm skin are normal findings.

Following surgery for adenocarcinoma, the client learns the tumor stage is T3,N1,M0. What treatment mode should the nurse anticipate? Palliative care is likely. Adjuvant therapy is likely. Repeat biopsy is needed before treatment begins. No further treatment is indicated.

answer 2 T3 indicates a large tumor size, with N1 indicating regional lymph node involvement so treatment is needed. A T3 tumor must have its size reduced with adjuncts like chemotherapy and radiation. Although M0 suggest no metastasis, following with adjuvant (chemotherapy or radiation therapy) treatment is indicated to prevent the spread of cancer outside the lymph to other organs. The tumor stage IV wound be indicative of palliative care. A repeated biopsy is not needed until after treatment is completed.

Which primary cancer treatment goal is prolonged survival and containment of cancer cell growth? Cure Prevention Control Palliation

answer 3 The range of possible treatment goals may include complete eradication of malignant disease (cure), prolonged survival and containment of cancer cell growth (control), or relief of symptoms associated with the disease (palliation). Prevention is not a treatment goal when the patient has already been diagnosed with cancer. Prevention of metastasis to a secondary site may be a goal.

Which term indicates an accumulation of crystalline depositions in articular surfaces, bones, soft tissue, and cartilage? Pannus Subchondral bone Tophi Joint effusion

answer 3 Tophi, when problematic, are surgically excised. Subchondral bone refers to a bony plate that supports the articular cartilage. Pannus refers to newly formed synovial tissue infiltrated with inflammatory cells. Joint effusion refers to the escape of fluid from the blood vessels or lymphatic vessels into the joint cavity.

A client's left leg is in skeletal traction with a Thomas leg splint and Pearson attachment. Which intervention should the nurse include in this client's care plan? Remove the traction at least every 8 hours. Apply the traction straps snugly. Assess the client's level of consciousness. Teach the client how to prevent problems caused by immobility.

answer 4 By teaching the client about prevention measures, the nurse can help prevent problems caused by immobility, such as hypostatic pneumonia, muscle contracture, and atrophy. The nurse applies traction straps for skin traction — not skeletal traction. For a client in skeletal traction, the nurse should assess the affected limb, rather than assess the level of consciousness. Removing skeletal traction is the physician's responsibility — not the nurse's.

A client presents to the emergency department with fever, chills, restlessness, and limited movement of a fractured jaw. What complication should the nurse interpret as the findings? Fat embolism Compartment syndrome Avascular necrosis Osteomyelitis

answer 4 Clinical manifestations of osteomyelitis include signs and symptoms of sepsis and localized infection. A client with avascular necrosis does not have fever and chills. Clients with fat emboli will have a rash and breathing complications. A client with compartment syndrome will have numbness, not a fever.

A client is diagnosed with a bone tumor. What result would the nurse expect the blood tests to reveal? Decreased serum phosphorus Decreased alkaline phosphatase Decreased red blood cell count Decreased serum calcium level

answer 4 Decreased serum calcium level may indicate osteomalacia, osteoporosis, and bone tumors. With bone tumors, the alkaline phosphatase and serum phosphorus levels would be increased. Decreased red blood cell count may reflect anemia.

Which is not a guideline for avoiding hip dislocation after replacement surgery. Put a pillow between the legs when sleeping. Keep the knees apart at all times. Never cross the legs when seated. The hip may be flexed to put on clothing such as pants, stockings, socks, or shoes.

answer 4 Guidelines for avoiding hip dislocation after replacement surgery specify that the hip should not be flexed to put on clothing such as pants, stockings, socks, or shoes. Clients should keep the knees apart at all times, put a pillow between the legs when sleeping, and never cross the legs when seated.

Which laboratory study indicates the rate of bone turnover? Serum phosphorous Serum calcium Urine calcium Serum osteocalcin

answer 4 Serum osteocalcin (bone GLA protein) indicates the rate of bone turnover. Urine calcium concentration increases with bone destruction. Serum calcium concentration is altered in clients with osteomalacia and parathyroid dysfunction. Serum phosphorous concentration is inversely related to calcium concentration and is diminished in osteomalacia associated with malabsorption syndrome.

Which group is at the greatest risk for osteoporosis? Asian American women African American women Men European American women

answer 4 Small-framed, nonobese European American women are at greatest risk for osteoporosis. Asian American women of slight build are at risk for low peak bone mineral density. African American women, who have a greater bone mass than European American women and Asian American Women, are less susceptible to osteoporosis. Men have a greater peak bone mass and do not experience sudden estrogen reduction.

A nurse is caring for a client with multiple sclerosis. Client education about the disease process includes which explanation about the cause of the disorder? Excess cytokines cause tissue damage. The immune system recognizes one's own tissues as "self." Regulatory mechanisms fail to halt the immune response. The immune system recognizes one's own tissues as "foreign."

answer 4 The immune system's recognition of one's own tissues as "foreign" rather than self is the basis of many autoimmune disorders, including multiple sclerosis. When regulatory mechanisms fail to halt the immune response or excess cytokines are produced, pathology occurs (e.g., allergies, hypersensitivity).

A client asks the nurse what the difference is between osteoarthritis (OA) and rheumatoid arthritis (RA). Which response is correct? "OA is a noninflammatory joint disease. RA is characterized by inflamed, swollen joints." "OA and RA are very similar. OA affects the smaller joints and RA affects the larger, weight-bearing joints." "OA affects joints on both sides of the body. RA is usually unilateral." "OA is more common in women. RA is more common in men."

ANSWER 1

What education should the nurse provide to the patient taking long-term corticosteroids? The patient should not stop taking the medication abruptly and should be weaned off of the medication. The patient should take the medication only as needed and not take it unnecessarily. Corticosteroids are relatively safe drugs with very few side effects. The patient should discontinue using the drug immediately if weight gain is observed.

ANSWER 1 Patients who receive high-dose or long-term corticosteroid therapy must be cautioned not to stop taking the medication suddenly. Doses are tapered when discontinuing this medication to avoid adrenal insufficiency.

When assisting the patient to interpret a negative HIV test result, the nurse informs the patient that the results mean which of the following? He has not been infected with HIV. Antibodies to HIV are not present in his blood. He is immune to HIV. Antibodies to HIV are present in his blood.

ANSWER 2 A negative test result indicates that antibodies to HIV are not present in the blood at the time the blood sample for the test is drawn. A negative test result should be interpreted as demonstrating that if infected, the body has not produced antibodies (which take from 3 weeks to 6 months or longer). Therefore, subsequent testing of an at-risk patient must be encouraged. The test result does not mean that the patient is immune to the virus, nor does it mean that the patient is not infected. It just means that the body may not have produced antibodies yet. When antibodies to HIV are detected in the blood, the test is interpreted as positive.

A client receiving antiretroviral therapy reports "not urinating enough." What is the nurse's best action? Administer fluids 100 mL/hour IV. Assess blood urea nitrogen and creatinine. Assess liver function tests. Encourage the client to drink more fluids.

ANSWER 2 Adverse effects associated with antiretroviral therapy include potential nephrotoxicity. Assessing blood urea nitrogen and creatinine for clients who have decreased urination is appropriate. The other answers will not assist the nurse in determining the client's problem, which should be assessed before intervention are administered.

A client is prescribed antihistamines, and asks the nurse about administration and adverse effects. The nurse should advise the client to avoid: seafood. alcohol. exposure to sunlight. applying skin moisturizers.

ANSWER 2 The nurse should advise a client taking antihistamines not to take it with alcohol or other central nervous system depressants because additive sedative effects can occur.

A client is presenting an anaphylactic response to unknowingly ingesting nuts at a family celebration. What type of hypersensitivity did this client exhibit? type II type I type IV type III

ANSWER 2 There are four types of hypersensitivity responses, three of which are immediate. This is an example of Type I, atopic or anaphylactic, which is mediated by immunoglobulin E (IgE) antibodies.

A client is admitted with acute osteomyelitis that developed after an open fracture of the right femur. When planning this client's care, the nurse should anticipate which measure? Administering large doses of oral antibiotics as ordered Administering large doses of I.V. antibiotics as ordered Instructing the client to ambulate twice daily Withholding all oral intake

ANSWER 2 Treatment of acute osteomyelitis includes large doses of I.V. antibiotics (after blood cultures identify the infecting organism). Surgical drainage may be indicated, and the affected bone is immobilized. The client usually requires I.V. fluids to maintain hydration, but oral intake isn't necessarily prohibited.

A nurse is teaching a community group about healthy lifestyles. A participant asks about how to maintain a healthy immune system. The nurse informs the group that which factor will positively affect the immune system? Rigorous, competitive exercise Strong family and community connections Poor nutritional status Residential exposure to radiation

ANSWER 2Strong family and community ties will have a positive effect on the immune system. Rigorous or competitive exercise, usually considered a positive lifestyle factor, can be a physiologic stressor and cause negative effects on immune response. Any form of radiation can have a negative effect on the immune system, as can poor nutritional status.

A nurse is assessing a client with a primary immunodeficiency. Afterward the nurse documents that the client displayed ataxia. The nurse makes this documentation because the client has an inability to understand the spoken word. vascular lesions caused by dilated blood vessels. uncoordinated muscle movements. difficulty swallowing.

ANSWER 3 Ataxia-telangiectasia is an autosomal recessive neurodegenerative disorder characterized by cerebellar ataxia (loss of muscle coordination).

A nurse is collecting objective data for a client with AIDS. The nurse observes white plaques in the client's oral cavity, on the tongue, and buccal mucosa. What does this finding indicate? coccidioidomycosis hairy leukoplakia candidiasis Kaposi's sarcoma

ANSWER 3 Candidiasis is a yeast infection caused by the Candida albicans microorganisms. It may develop in the oral, pharyngeal, esophageal, or vaginal cavities or in folds of the skin. It is often called thrush when located in the mouth. Inspection of the mouth, throat, or vagina reveals areas of white plaque that may bleed when mobilized with a cotton-tipped swab. Kaposi's sarcoma is a purple lesion and is an opportunistic cancer. Hairy leukoplakia is also an indication of oral cancer. Coccidioidomycosis causes diarrhea in the immunosuppressed client.

In its attempt to suppress allergic responses, the body releases several chemicals which have a role in mediating physical reactions. Epinephrine, which interferes with vasoactive chemical release from mast cells, is instrumental in suppressing which type of hypersensitivity response? type IV type III type I type II

ANSWER 3 Epinephrine interferes with the release of vasoactive chemicals from mast cells which cause vasodilation during anaphylaxis, also known as a Type I response.

An experiment is designed to determine specific cell types involved in cell-mediated immune response. The experimenter is interested in finding cells that attack the antigen directly by altering the cell membrane and causing cell lysis. Which cells should be isolated? Helper T cells Macrophages Cytotoxic T cells B cells

ANSWER 3 Cytotoxic T cells (killer T cells) attack the antigen directly by altering the cell membrane and causing cell lysis (disintegration) and by releasing cytolytic enzymes and cytokines. Lymphokines can recruit, activate, and regulate other lymphocytes and white blood cells. These cells then assist in destroying the invading organism.

HIV is harbored within which type of cell? Platelet Erythrocyte Nerve Lymphocyte

ANSWER 4 Because HIV is harbored within lymphocytes, a type of white blood cell, any exposure to infected blood results in significant risk of infection. HIV infection is not harbored in platelets, erythrocytes, or nerve cells.

Which assessment finding(s) are likely to cause noncompliance with antiretroviral treatment? Select all that apply. Lack of social support Past substance abuse Depression Active substance abuse

ANSWER 4 Psychosocial barriers such as depression and other mental illnesses, neurocognitive impairment, low health literacy, low levels of social support, stressful life events, high levels of alcohol consumption and active substance use, homelessness, poverty, nondisclosure of HIV serostatus, denial, stigma, and inconsistent access to medications affect adherence to ART. Past substance abuse has not been implicated as a factor for noncompliance with antiretroviral treatment.

A variety of complications can occur after a leg amputation. Which is not a possibility in the immediate postoperative period? hematoma infection hemorrhage osteomyelitis

Answer 4

What is the term for a rhythmic contraction of a muscle? Clonus Hypertrophy Crepitus Atrophy

answer 1 Clonus is a rhythmic contraction of the muscle. Atrophy is a shrinkage-like decrease in the size of a muscle. Hypertrophy is an increase in the size of a muscle. Crepitus is a grating or crackling sound or sensation that may occur with movement of ends of a broken bone or irregular joint surface.

The nurse is reviewing the medication administration record of the client. Which medication would lead the nurse to suspect that the client is suffering from an acute attack of gout? methotrexate penicillamine prednisone colchicine

answer 1 Colchicine is prescribed for the treatment of an acute attack of gout.

A client scheduled to undergo an electromyography asks the nurse what this test will evaluate. What is the correct response from the nurse? Muscle weakness Muscle composition Metastatic bone lesions Bone density

answer 1 Electromyography tests the electric potential of the muscles and nerves leading to the muscles. It is done to evaluate muscle weakness or deterioration, pain, disability, and to differentiate muscle and nerve problems. A bone biopsy is done to identify bone composition. Bone densitometry is done to evaluate bone density. A bone scan would be appropriate to detect metastatic bone lesions.

Which of the following is an example of a hinge joint? Knee Carpal bones in the wrist Joint at base of thumb Hip

answer 1 Hinge joints permit bending in one direction only and include the knee and elbow. The hip is a ball-and-socket joint. The joint at the base of the thumb is a saddle joint. Gliding joints allow for limited movement in all directions and are represented by the joints of the carpal bones in the wrist.

The nurse is caring for a client who experienced a crushing injury of the lower extremities. Which of the following symptoms is essential to be reported to the physician? Pulselessness Coolness Pain Ischemia

answer 1 Neurovascular checks (circulation, sensation, motion) are essential with a crushing injury. The absence of a pulse is a critical assessment finding to report to the physician. The other options are symptoms that need regular assessment.

The nurse is invited to present a teaching program to parents of school-age children. Which topic would be of greatest value for decreasing cancer risks? Sun safety and use of sunscreen Breast and testicular self-exams Pool and water safety Hand washing and infection prevention

answer 1 Pool and water safety as well as infection prevention are important teaching topics but will not decrease cancer risk. While performing breast and testicular self-exams may identify cancers in the early stage, this teaching is not usually initiated in school-age children. Severe sunburns that occur in young children can place the child at risk for skin cancers later in life. Because children spend much time out of doors, the use of sunscreen and protective clothing/hats can protect the skin and decrease the risk.

The physician is attending to a 72-year-old client with a malignant brain tumor. The physician recommends immediate radiation therapy. What is a reason for the physician's recommendation? To prevent the formation of new cancer cells To remove the tumor from the brain To destroy marginal tissues To analyze the lymph nodes involved

answer 1 Radiation therapy helps prevent cellular growth. It may be used to cure the cancer or to control malignancy when the tumor cannot be removed or when lymph node involvement is present; also, it can be used prophylactically to prevent spread. Biopsy is used to analyze lymph nodes or to destroy the surrounding tissues around the tumor.

A 14-year-old client is treated in the emergency room for an acute knee sprain sustained during a soccer game. The nurse reviews discharge instructions with the client's parent. The nurse instructs the parent that the acute inflammatory stage will last how long? 24 to 48 hours At least 7 days 4 to 5 days 3 to 4 days

answer 1 Rest and ice applications during the first 24 to 48 hours produce vasoconstriction while decreasing bleeding and edema. After this time, the acute inflammatory stage decreases.

A client asks the nurse how to identify rheumatoid nodules with rheumatoid arthritis. What characteristic will the nurse include? located over bony prominence reddened tender to the touch nonmovable

answer 1 Rheumatoid nodules usually are nontender, movable, and evident over bony prominences, such as the elbow or the base of the spine. The nodules are not reddened.

Conservative treatment of a compressed nerve root is first line treatment. What conservative treatment is used to increase the distance between vertebrae and decrease severe muscle spasm? Skin traction Skeletal traction Sleeping on a hard mattress with a bed board Cool, moist compresses

answer 1 Skin traction, which can be applied in the home, is used to decrease severe muscle spasm as well as increase the distance between adjacent vertebrae, keep the vertebrae correctly aligned, and, in many instances, relieve pain. Treatment relieves symptoms for an extended period.

Which would be contraindicated as a component of self-care activities for the client with a cast? Cover the cast with plastic to insulate it Do not attempt to scratch the skin under a cast Elevate the casted extremity to heart level frequently Cushioning rough edges of the cast with tape

answer 1 The cast should be kept dry, but do not cover it with plastic or rubber because this causes condensation, which dampens the cast and skin. The other activities are consistent with cast care.

Choose the correct statement about the endosteum, a significant component of the skeletal system: Covers the marrow cavity of long bones Supports the attachment of tendons to bones Contains blood vessels and lymphatics Facilitates bone growth

answer 1 The endosteum is a thin vascular membrane that covers the marrow cavity of long bones and the spaces in cancellous bone. Osteoclasts are located near the endosteum.

A client is receiving the cell cycle-nonspecific alkylating agent thiotepa (Thioplex), 60 mg weekly for 4 weeks by bladder instillation as part of chemotherapy regimen to treat bladder cancer. The client asks the nurse how the drug works. How does thiotepa exert its therapeutic effects? It interferes with DNA replication and RNA transcription. It interferes with ribonucleic acid (RNA) transcription only. It destroys the cell membrane, causing lysis. It interferes with deoxyribonucleic acid (DNA) replication only.

answer 1 Thiotepa interferes with DNA replication and RNA transcription. It doesn't destroy the cell membrane.

Which actions by the nurse demonstrate an understanding of caring for a client in traction? Select all that apply. Ensuring that the weights are hanging freely Placing a trapeze on the bed Assessing the client's alignment in the bed Frequently assessing pain level Removing skeletal traction to turn and reposition the client

answer 1-2-3-4 The weights must hang freely, with the client in good alignment in the center of the bed. The nurse should frequently monitor pain, as uncontrolled pain may be a sign of a complication. The client will be able to assist with alignment and bed mobility if a trapeze is placed on the bed. Skeletal traction should never be interrupted.

A client will be receiving a hepatitis B vaccination series prior to employment in a dialysis center. What type of immunity will this provide? Naturally acquired active immunity Artificially acquired active immunity Passive immunity Forced immunity

answer 2 Artificially acquired immunity is obtained by receiving a killed or weakened microorganism or toxoid. Passive immunity develops when ready-made antibodies are given to a susceptible person. The antibodies provide immediate but short-lived protection from the invading antigen. Newborns receive passive immunity to some diseases for which their mothers have manufactured antibodies. Naturally acquired active immunity occurs as a direct result of infection by a specific microorganism. An example is the immunity to measles that develops after the initial infection . Not all invading microorganisms produce a response that gives lifelong immunity. There is not a type of immunity called forced immunity.

Which is not a guideline for avoiding hip dislocation after replacement surgery. Keep the knees apart at all times. The hip may be flexed to put on clothing such as pants, stockings, socks, or shoes. Never cross the legs when seated. Put a pillow between the legs when sleeping.

answer 2 Guidelines for avoiding hip dislocation after replacement surgery specify that the hip should not be flexed to put on clothing such as pants, stockings, socks, or shoes. Clients should keep the knees apart at all times, put a pillow between the legs when sleeping, and never cross the legs when seated.

The nurse is taking the health history of a newly admitted client. Which condition would place the client at risk for impaired immune function? Negative history for radiation therapy Surgical removal of the appendix Surgical history of a partial gastrectomy Previous organ transplantation

answer 2 Organ transplantation requires immunosuppressive drugs, which cause impaired immune function. Removal of the appendix or stomach would have no effect on the immune system. A positive history for radiation therapy would affect the immune system, but not a negative history.

A nurse provides nutritional health teaching to an adult client who had two fractures in 1 year. Besides recommending supplemental calcium, the nurse suggests a high-calcium diet. What would the nurse recommend that the client increase intake of? Almonds and peanuts. Yogurt and cheese. Salmon and sardines. Canned mixed fruit.

answer 2 Yogurt and cheese are excellent sources of calcium. The other choices are low-calcium foods.

The nurse is performing a neurological assessment. What will this assessment include? Observe for capillary refill of the great toe. Inspect the foot for edema. Ask the client to plantar flex the toes. Palpate the dorsalis pedis pulse.

answer 3 A neurological assessment evaluates sensation and motion. Assessing plantar flexion of the toes would be included in a neurological assessment. Capillary refill, palpation of pulses, and inspecting for edema would be included in a vascular assessment.

The clinic nurse is caring for a client with an injured body part that does not require rigid immobilization. What method of immobilization would the nurse expect the health care provider to use on a short-term basis? Skin traction Cast Splint Brace

answer 3 A splint immobilizes and supports an injured body part in a functional position and is used when the condition does not require rigid immobilization, causes a large degree of swelling, or requires special skin treatment. Casts and traction provide rigid immobilization. A brace provides support, controls movement, and prevents additional injury for more long-term use.

A client reports a new onset of sporadic epigastric pain, yellow skin, nausea, vomiting, weight loss, and fatigue. The health care provider orders a diagnostic workup, which reveals end-stage gallbladder cancer. What nursing intervention should be used to facilitate adaptive coping? Provide written education for prescribed treatments. Encourage ventilation of negative feelings. Refer client for professional counseling. Assist with self-care activities of daily living.

answer 3 Referring the client for professional counseling will facilitate adaptive coping. Encouraging ventilation of negative feelings will allow for emotional expression, but may not facilitate coping. Physical well-being will increase self-esteem, but won't necessarily help the patient cope with the diagnosis. Providing written education is for client teaching, not to facilitate coping.

A patient had a total hip replacement. What recommended leg position should the nurse ensure is maintained to prevent prosthesis dislocation? Internal rotation Adduction Abduction Flexion

answer 3 The nurse educates the patient about protective positioning, which includes maintaining abduction and avoiding internal and external rotation, hyperextension, and acute flexion.

A nurse is planning discharge teaching regarding exercise for a client at risk for osteoporosis. Which exercise would the nurse be most likely to suggest? Swimming Bicycling Walking Yoga

answer 3 Weight-bearing exercises should be incorporated into the client's lifestyle activities. Walking is a low-impact method of weight-bearing exercise and would be the most universal or most likely form of exercise for the nurse to recommend. Bicycling, and swimming are not weight-bearing exercise and will not increase bone density. Yoga may or may not be weight-bearing exercise depending on the yoga poses being performed; it is not as likely as walking to be recommended by the nurse.

A client with a fractured ankle is having a fiberglass cast applied. The client starts yelling, "My leg is burning, take it off." What action by the nurse is most appropriate? Remove the cast immediately, notifying the physician. Call for assistance to hold the client in the required position until the cast has dried. Administer antianxiety and pain medication. Explain that the sensation being felt is normal and will not burn the client.

answer 4 A fiberglass cast will give off heat when applied. The reaction is a normal, temporary sensation. Heat given off during the application phase of the cast does not burn the skin. By explaining these principles to the client, the nurse can alleviate any anxiety associated with the application of the cast. Because this is a known reaction to the application of the fiberglass cast, it is not necessary to remove the cast. Holding the client may cause more harm to the injury. Antianxiety medications are generally not needed when applying a cast.

Which drug is not used in the treatment of rheumatoid arthritis? methotrexate etanercept adalimumab allopurinol

answer 4 Allopurinol is used in the treatment of gout. Etanercept, adalimumab, and methotrexate are all used in the treatment of rheumatoid arthritis.

A client is experiencing muscle weakness in the upper extremities. The client raises an arm above the head but then loses the ability to maintain the position. Muscular dystrophy is suspected. Which diagnostic test would evaluate muscle weakness or deterioration? A magnetic resonance imaging (MRI) An arthroscopy A serum calcium test An electromyography

answer 4 An electromyography tests the electrical potential of muscles and nerves leading to the muscles. It is done to evaluate muscle weakness or deterioration. A serum calcium test evaluates the calcium in the blood. An arthroscopy assesses changes in the joint. An MRI identifies abnormalities in the targeted area.

Which medication directly inhibits osteoclasts, thereby reducing bone loss and increasing bone mass density (BMD)? Vitamin D Teriparatide Raloxifene Calcitonin

answer 4 Calcitonin directly inhibits osteoclasts, thereby reducing bone loss and increased BMD. Raloxifene reduces the risk of osteoporosis by preserving BMD without estrogenic effects on the uterus. Teriparatide has been recently approved by the FDA for the treatment of osteoporosis. Vitamin D increases the absorption of calcium.

A client diagnosed with carpal tunnel syndrome (CTS) asks the nurse about numbness in the fingers and pain in the wrist. What is the best response by the nurse? "CTS is a neuropathy that is characterized by pannus formation in the shoulder." "CTS is a neuropathy that is characterized by bursitis and tendinitis." "CTS is a neuropathy that is characterized by flexion contracture of the fourth and fifth fingers." "CTS is a neuropathy that is characterized by compression of the median nerve at the wrist."

answer 4 Carpal tunnel syndrome is an entrapment neuropathy that occurs when the median nerve at the wrist is compressed by a thickened flexor tendon sheath, skeletal encroachment, edema, or a soft tissue mass.

A client is treated in the emergency department for acute muscle strain in the left leg caused by trying a new exercise. During discharge preparation, the nurse should provide which instruction? "Apply ice packs for the first 12 to 18 hours." "Apply heat packs for the first 24 hours, then apply ice packs for the next 48 hours." "Apply heat packs for the first 24 to 48 hours." "Apply ice packs for the first 24 to 48 hours, then apply heat packs."

answer 4 The nurse should instruct the client to apply ice packs to the injured area for the first 24 to 48 hours to reduce swelling and then apply heat to increase comfort, promote reabsorption of blood and fluid, and speed healing. Applying ice for only 12 to 18 hours may not keep swelling from recurring. Applying heat for the first 24 to 48 hours would worsen, not ease, swelling. Applying ice 48 hours after the injury would be less effective because swelling already has occurred by that time.

The nurse is performing a musculoskeletal assessment for a client whose right leg muscles exhibit no tone and are limp. Which descriptor should the nurse use to document this condition? Atonic Atrophic Spastic Flaccid

answer 4 The term flaccid describes muscles that have no tone or are limp. Spastic describes muscles that have greater-than-normal tone. Atonic describes muscles that are not enervated and become soft and flabby. Atrophic describes muscles deterioration that occurs with lack of use and exercise.

A nurse is teaching a client about preventing osteoporosis. Which teaching point is correct? Obtaining an X-ray of the bones every 3 years is recommended to detect bone loss. To prevent fractures, the client should avoid strenuous exercise. The recommended daily allowance of calcium may be found in a wide variety of foods. Obtaining the recommended daily allowance of calcium requires taking a calcium supplement.

ANSWER 1

A client reports pain in the right knee, stating, "My knee got twisted when I was going down the stairs." The client was diagnosed with an injury to the ligaments and tendons of the right knee. Which terminology, documented by the nurse, best reflects the injury? Sprain Subluxation Dislocation Strain

ANSWER 1 A sprain is an injury to the ligaments and tendons surrounding a joint, usually caused by a wrenching or twisting motion. Dislocation refers to the separation of joint surfaces. Subluxation refers to partial separation or dislocation of joint surfaces. Strain refers to a muscle pull or tear.

Which common problem of the upper extremity results from entrapment of the median nerve at the wrist? Carpal tunnel syndrome Dupuytren contracture Impingement syndrome Ganglion

ANSWER 1 Carpal tunnel syndrome is commonly due to repetitive hand activities. A ganglion is a collection of gelatinous material near the tendon sheaths and joints that appears as a round, firm, cystic swelling, usually on the dorsum of the wrist. Dupuytren contracture is a slowly progressive contracture of the palmar fascia. Impingement syndrome is associated with the shoulder and may progress to a rotator cuff tear.

The nurse is taking the health history of a newly admitted client. Which condition would place the client at risk for impaired immune function? Previous organ transplantation Surgical removal of the appendix Negative history for radiation therapy Surgical history of a partial gastrectomy

ANSWER 1 Organ transplantation requires immunosuppressive drugs, which cause impaired immune function. Removal of the appendix or stomach would have no effect on the immune system. A positive history for radiation therapy would affect the immune system, but not a negative history.

Which of the following presents with an onset of heel pain with the first steps of the morning? Plantar fasciitis Hallux valgus Morton's neuroma Ganglion

ANSWER 1 Plantar fasciitis, an inflammation of the foot-supporting fascia, present as an acute onset of heal pain experienced with the first steps in the morning. Hallux valgus (commonly called a bunion) is a deformity in which the great toe deviates laterally. Morton's neuroma is a swelling of the third (lateral) branch of the median plantar nerve. A ganglion, a collection of gelatinous material near the tendon sheaths and joints, appears as a round, firm compressible cystic swelling, usually on the dorsum of the wrist.

This type of T lymphocyte is responsible for altering the cell membrane and initiating cellular lysis. Choose the T lymphocyte. Cytotoxic T cell Helper T cell Suppressor T cell Memory T cell

ANSWER 1 The cytotoxic T cells (also known as killer T cells) attack the antigen directly and release cytotoxic enzymes and cytokines.

A client comes to the clinic and informs the nurse that he feels as though he has allergies. What laboratory test results will be a positive indicator for an allergic disorder? Radioallergosorbent blood test (RAST) of 3 Eosinophils 6% WBC of 7000/mm3 Neutrophils 60%

ANSWER 1 When the RAST, which measures IgE on a scale of 0 to 5, indicates a score of 2 or greater, it is a significant indication for an allergic disorder. The RAST does not identify those, if any, substances to which a person is allergic. It only validates that the person is potentially hypersensitive to antigenic substances. The other test results are all within normal range and are not indicative of a definite allergic disorder.

The nurse is talking with a group of teens about transmission of human immunodeficiency virus (HIV). What body fluids does the nurse inform them will transmit the virus? Select all that apply. blood urine vaginal secretions breast milk semen

ANSWER 1-3-4-5 There are only four known body fluids through which HIV is transmitted: blood, semen, vaginal secretions, and breast milk. HIV may be present in saliva, tears, and conjunctival secretions, but transmission of HIV through these fluids has not been implicated. HIV is not found in urine, stool, vomit, or sweat.

A nurse is teaching a client with immunodeficiency about the signs and symptoms of infection to report. The nurse determines that the teaching was successful when the client makes which statement? "A dry cough is just irritation, but one with mucous means an infection." "Any change, however subtle, might mean that I have an infection." "I might notice a swollen lymph node or two, but this is normal." "A fever over 101 degrees is the most common sign of infection."

ANSWER 2 For clients with immunodeficiencies, subtle changes may indicate an infection. Therefore, the client would contact the health care provider if symptoms develop that are not typical. Fever does not need to be over 101 degrees to indicate an infection. A cough, either dry or wet, or swollen lymph nodes suggest infection.

Which may occur if a client experiences compartment syndrome in an upper extremity? Whiplash injury Volkmann's contracture Subluxation Callus

ANSWER 2 If compartment syndrome occurs in an upper extremity, it may lead to Volkmann's contracture, a claw-like deformity of the hand resulting from obstructed arterial blood flow to the forearm and hand. A whiplash injury is a cervical spine sprain. Callus refers to the healing mass that occurs with true bone formation after a fracture. Subluxation refers to a partial dislocation.

An adult client has had mumps when the client was a child. The client had a titer prior to entering nursing school and shows immunity. What type of immunity does this reflect? Natural passive immunity Artificially acquired active immunity Naturally acquired active immunity Passive immunity

ANSWER 3 Naturally acquired active immunity occurs as a direct result of infection by a specific microorganism. An example is the immunity to measles that develops after the initial infection. Not all invading microorganisms produce a response that gives lifelong immunity. Artificially acquired immunity is obtained by receiving a killed or weakened microorganism or tox

A client with a discoid facial rash caused by systemic lupus erythematosus (SLE) asks why a urine sample is needed. Which response will the nurse make to the client? "The medication you take can affect your bladder." "It is a routine test done on everyone." "The lupus can affect your kidney function." "The test will determine how long you will have the rash."

ANSWER 3 Nephritis as a result of SLE, also referred to as lupus nephritis, occurs due to a buildup of antibodies and immune complexes that cause damage to the nephrons. Early detection allows for prompt treatment so that renal damage can be prevented. Serum creatinine levels and urinalysis are used in screening for renal involvement. Urinalysis is not a routine test done on every client. The urinalysis is not being used to determine if the client's medication is affecting the bladder. The urinalysis will not determine the length of time the client will have the rash.

The nurse is completing the intake assessment of a client new to the allergy clinic. The client states that he was taking nose drops six times a day to relieve his nasal congestion. The nasal congestion increased, causing him to increase his usage of the nasal spray to eight times a day. But again the congestion worsened. The nurse communicates to the health care provider that the client experienced Atopic dermatitis Leukotriene modifier Rhinitis medicamentosa Tolerance to nose drops

ANSWER 3 Rhinitis medicamentosa is a rebound reaction from overuse of sympathomimetic nose drops or sprays that worsen the congestion, causing the client to use more of the medication, thereby leading to more nasal congestion. This differs from tolerance, when more medication is needed to achieve the desired effect. Leukotriene modifiers are a category of medications used to treat allergies. Atopic dermatitis is a type I hypersensitivity involving inflammation of the skin evidenced by itching, erythema, and skin lesions.

A nurse is providing discharge teaching to a client who is immunosuppressed. Which statement by the client indicates the need for additional teaching? "I stopped smoking last year; this year I'll quit drinking alcohol." "I won't go to see my sister while she has a cold." "I can eat whatever I want as long as it's low in fat." "I won't go to see my nephew right after he gets his vaccines."

ANSWER 3 The client requires additional teaching if he states that he can eat whatever he wants. Immunosuppressed clients should avoid raw fruit and vegetables because they may contain bacteria that could increase the risk of infection; foods must be thoroughly cooked. Avoiding people who are sick, products containing alcohol, and people who have just received vaccines are appropriate actions for an immunosuppressed client.

A 38-year-old client has begun to suffer from rheumatoid arthritis and is being assessed for disorders of the immune system. The client works as an aide at a facility that cares for children infected with AIDS. Which is the most important factor related to the client's assessment? Home environment Diet Use of other drugs Age

ANSWER 3 The nurse needs to review the client's drug history. These data will help her to assess the client's susceptibility to illness because certain past illnesses and drug use, such as corticosteroids, suppress the inflammatory and immune responses. The client's age, home environment, and diet do not have any major implications during assessment because they do not indicate the client's susceptibility to illness.

A client who is HIV+ has been diagnosed with Pneumocystis pneumonia caused by P. jiroveci. What medication will the client take for the treatment of this infection? amphotericin B fluconazole trimethoprim-sulfamethoxazole nystatin

ANSWER 3 To prevent and treat Pneumocystis pneumonia, trimethoprim-sulfamethoxazole (Bactrim, Septra) is prescribed. The other medications are antifungals and used to treat candidiasis.

A client received 2 units of packed red blood cells while in the hospital with rectal bleeding. Three days after discharge, the client experienced an allergic response and began to itch and break out with hives. What type of reaction does the nurse understand could be occurring? Anaphylactic reaction An immediate hypersensitivity response Sensitization Delayed hypersensitivity response

ANSWER 4 A delayed hypersensitivity response may develop over several hours or days, or it may reach maximum severity after repeated exposure. Examples of a delayed hypersensitivity response include a blood transfusion reaction that occurs days to weeks after blood administration, rejection of transplanted tissues, and reaction to a tuberculin skin test. Anaphylaxis is a rapid and profound type I hypersensitivity response. Sensitization is the process by which cellular and chemical events occur after a second or subsequent exposure to an allergen. An immediate hypersensitivity response is due to antibodies interacting with allergens and occurs rapidly.

Which is not one of the general nursing measures employed when caring for the client with a fracture? providing comfort measures administering analgesics assisting with ADLs cranial nerve assessment

ANSWER 4 Cranial nerve assessment would only be carried out for head-related injuries or diseases. General nursing measures include administering analgesics, providing comfort measures, assisting with ADLs, preventing constipation, promoting physical mobility, preventing infection, maintaining skin integrity, and preparing client for self-care.

Which condition is the leading cause of disability and pain in the elderly? Osteoarthritis (OA) Systemic lupus erythematous (SLE) Rheumatoid arthritis (RA) Scleroderma

answer 1 OA is the leading cause of disability and pain in the elderly. RA, SLE, and scleroderma are not leading causes of disability and pain in the elderly.

A male client has been unable to return to work for 10 days following chemotherapy as the result of ongoing fatigue and inability to perform usual activities. Laboratory test results are WBCs 2000/mm³, RBCs 3.2 x 10¹²/L, and platelets 85,000/mm³. The nurse notes that the client is anxious. Which of the following is the priority nursing diagnosis? Risk for infection related to inadequate defenses Fatigue related to deficient blood cells Anxiety related to change in role function Activity intolerance related to side effects of chemotherapy

answer 1 Physiological needs, such as risk for infection, take priority over the client's other needs.

A nurse is caring for a client who underwent a total hip replacement. What should the nurse and other caregivers do to prevent dislocation of the new prosthesis? Prevent internal rotation of the affected leg. Use measures other than turning to prevent pressure ulcers. Keep the affected leg in a position of adduction. Keep the hip flexed by placing pillows under the client's knee.

answer 1 The nurse and other caregivers should prevent internal rotation of the affected leg. However, external rotation and abduction of the hip will help prevent dislocation of a new hip joint. Postoperative total hip replacement clients may be turned onto the unaffected side. The hip may be flexed slightly, but it shouldn't exceed 90 degrees. Maintenance of flexion isn't necessary.

A client with a recent left above-the-knee amputation states, "I can feel pain in my left toes." Which is the best response by the nurse? "Describe the pain and rate it on the pain scale." "Pain medication usually does not help this type of pain." "Your left toes have been amputated." "The pain is really from the nerves in the upper leg."

answer 1 The nurse should recognize phantom pain as real and complete a pain assessment as if the limb were attached. The client's pain should be address and treated appropriately. By telling the client that the toes have been amputated or the pain is really from the nerves in the upper leg, the nurse is negating the client's pain. Opioid pain medication can be effective with phantom pain.

Which oncologic emergency involves the accumulation of fluid in the pericardial space? Cardiac tamponade Tumor lysis syndrome Syndrome of inappropriate antidiuretic hormone release (SIADH) Disseminated intravascular coagulation (DIC)

answer 1 Cardiac tamponade is an accumulation of fluid in the pericardial space. DIC is a complex disorder of coagulation and fibrinolysis that results in thrombosis and bleeding. SIADH is a result of the failure in the negative feedback mechanism that normally regulates the release of antidiuretic hormone (ADH). Tumor lysis syndrome is a rapidly developing oncologic emergency that results from the rapid release of intracellular contents as a result of radiation- or chemotherapy-induced cell destruction of large or rapidly growing cancers such as leukemia.

The root cause of cancer is damage to cellular deoxyribonucleic acid (DNA) which can be caused by many factors, or carcinogens. What factors can be carcinogenic? Select all that apply. environmental factors age gender viruses dietary substances

answer 1-4-5 Carcinogens include chemical agents, environmental factors, dietary substances, viruses, lifestyle factors, and medically prescribed interventions. Although age and gender may increase a person's risk for developing certain types of cancer, they are not carcinogens in and of themselves.

A client who has fractured the radial head asks the nurse about factors that will promote bone healing. Which statement should the nurse include when responding to the client? Select all that apply. "Fractured bones require a good blood supply and adequate nutrition for healing." "Corticosteroids will decrease the bone and soft tissue inflammation associated with the fracture." "Adults heal faster than children because adult bodies are physiologically more mature." "Weight bearing stimulates healing of the long bones of the leg, if the fracture is stabilized." "Immobilization of the fracture will promote healing by maximizing contact of bone fragments."

answer 1-4-5 Factors that enhance fracture healing include immobilization of the fracture fragments, sufficient blood supply, proper nutrition, and weight bearing for stabilized long bones of the lower extremities. Older adults heal more slowly. Corticosteroids inhibit the repair rate and can cause osteoporosis.

The nurse is caring for a client with a hip fracture. The physician orders the client to start taking a bisphosphonate. Which medication would the nurse document as given? Teriparatide Alendronate Raloxifene Denosumab

answer 2 Alendronate is a bisphosphonate medication. Raloxifene is a selective estrogen receptor modulator. Teriparatide is an anabolic agent, and denosumab is a monoclonal antibody agent.

A patient had hand surgery to correct a Dupuytren's contracture. What nursing intervention is a priority postoperatively? Applying a cock-up splint and immobilization Performing hourly neurovascular assessments for the first 24 hours Changing the dressing Having the patient exercise the fingers to avoid future contractures

answer 2 Hourly neurovascular assessment of the exposed fingers for the first 24 hours following surgery is essential for monitoring function of the nerves and perfusion.

Which should be included in the teaching plan for a client diagnosed with plantar fasciitis? The pain of plantar fasciitis diminishes with soaking the foot in warm water. Management of plantar fasciitis includes stretching exercises. Complications of plantar fasciitis include neuromuscular damage and decreased ankle range of motion. Plantar fasciitis presents as an acute onset of pain localized to the ball of the foot.

answer 2 Management also includes wearing shoes with support and cushioning to relieve pain, orthotic devices (e.g., heel cups, arch supports), and using nonsteroidal anti-inflammatory drugs. Plantar fasciitis, an inflammation of the foot-supporting fascia, presents as an acute onset of heel pain experienced upon taking the first steps in the morning. The pain is localized to the anterior medial aspect of the heel and diminishes with gentle stretching of the foot and Achilles tendon. Unresolved plantar fasciitis may progress to fascial tears at the heel and eventual development of heel spurs.

A client in the emergency department is being treated for a wrist fracture. The client asks why a splint is being applied instead of a cast. What is the best response by the nurse? "It is best if an orthopedic doctor applies the cast." "A splint is applied when more swelling is expected at the site of injury." "Not all fractures require a cast." "You would have to stay here much longer because it takes a cast longer to dry."

answer 2 Splints are noncircumferential and will not compromise circulation when swelling is expected. A splint is applied to support and immobilize the injured joint. A fracture will swell as part of the inflammation process. The client would not have to stay longer if a fiberglass cast is applied. Fiberglass cast dry in approximately 30 minutes. An orthopedic doctor is not needed to apply the cast. Many nurses and technicians are trained in proper application of a cast. Some fractures may not be treated with a cast but it would not be appropriate to answer with this response because it does not reflect the actual reason for a splint being applied.

A client is receiving radiation therapy and asks the nurse about oral hygiene. What teaching specific to the client's situation should the nurse include? Treat cavities immediately. Use a soft toothbrush and allow it to air dry before storing. Gargle after each meal. Floss before going to bed.

answer 2 The nurse advises the client undergoing radiation therapy to use a soft toothbrush to avoid gum lacerations and allow the toothbrush to air dry before storing. Gargling after each meal, flossing before going to bed, and treating cavities immediately are general oral hygiene instructions.

Which of the following is an example of a hinge joint? Hip Carpal bones in the wrist Knee Joint at base of thumb

answer 3

The health care provider is preparing to bivalve the client's cast. Which supplies should the nurse assemble? Stockinette and cotton padding Gauze bandages and tape Elastic compression bandages Sterile saline and basin

answer 3 Bivalving of a cast involves splitting the cast longitudinally and spreading the cast apart to relieve pressure. The fractured extremity is immobilized by securing the two parts of the cast together with an elastic compression bandage.

The nurse is evaluating the client's risk for cancer. The nurse should recommend the client change which lifestyle choice? works as a secretary at a medical radiation treatment center uses the treadmill for 30 minutes on 5 days each week eats red meat such as steaks or hamburgers every day drinks one glass of wine at dinner each night

answer 3 Dietary substances such as nitrate-containing and red meats appear to increase the risk of cancer. Exercising 30 minutes on 5 days or more is recommended for adults. Measures are taken to protect those people who work around radiation. Alcohol consumption recommendations include drink no more than one drink per day for women or two per day for men.

The nurse is performing a musculoskeletal assessment of a client in a nursing home who had a stroke 2 years ago and who has right-sided hemiplegia. The nurse notes that the girth of the client's right calf is 2 inches less in diameter than the left calf. The nurse attributes the decreased girth to increased use of left calf muscle. edema in left lower extremity. atrophy of right calf muscle. bruising in right lower extremity.

answer 3 Girth of an extremity may increase as a result of exercise, edema, or bleeding into the muscle. However, a client with right-sided hemiplegia is unable to use the right lower extremity. This client may experience atrophy of the muscles from lack of use, which results in a subsequent decrease in the girth of the calf muscle.

A client who was in a motor vehicle crash is diagnosed with a stable T7 spinal fracture with no neurologic deficits. Which nursing intervention should the nurse implement? Withhold opioid pain medication to prevent ileus. Sit the client upright in a padded chair for meals. Maintain bed rest with the head of the bed at 20 degrees. Maintain NPO (nothing by mouth) status for surgical repair.

answer 3 The client should maintain limited bed rest with the head of the bed lower than 30 degrees. If the client's pain is not controlled with a lower form of pain medication, then an opioid may be used to treat the pain. The nurse should monitor for an ileus. Stable spinal fractures are treated conservatively and not with surgical repair. The client should avoid sitting until the pain eases.

During a routine physical examination on an older female client, a nurse notes that the client is 5 feet, 3/8 inches (1.6 m) tall. The client states, "How is that possible? I was always 5 feet and 1/2? (1.7 m) tall." Which statement is the best response by the nurse? "There may be some slight discrepancy between the measuring tools used." "The posture begins to stoop after middle age." "After menopause, the body's bone density declines, resulting in a gradual loss of height." "After age 40, height may show a gradual decrease as a result of spinal compression"

answer 3 The nurse should tell the client that after menopause, the loss of estrogen leads to a loss in bone density, resulting in a loss of height. This client's history doesn't indicate spinal compression. Telling the client that measuring tools used to obtain the client's height may have a discrepancy or that the posture begins to stoop after middle age doesn't address the client's question.

The nurse is performing an assessment on an older adult patient and observes the patient has an increased forward curvature of the thoracic spine. What does the nurse understand this common finding is known as? Osteoporosis Lordosis Scoliosis Kyphosis

answer 4 Common deformities of the spine include kyphosis, which is an increased forward curvature of the thoracic spine that causes a bowing or rounding of the back, leading to a hunchback or slouching posture. The second deformity of the spine is referred to as lordosis, or swayback, an exaggerated curvature of the lumbar spine. A third deformity is scoliosis, which is a lateral curving deviation of the spine (Fig. 40-4). Osteoporosis is abnormal excessive bone loss.

The nurse is caring for a client who sustained rib fractures in an automobile accident. What symptoms does the nurse recognize as a complication of rib fractures and should immediately be reported to the physician? Client complains of pain in the affected rib area when taking a deep breath Heart rate of 94 beats/minute Blood pressure of 140/90 mm Hg Crackles in the lung bases

answer 4 Crackles in the lung bases can be an indicator that the client has developed pneumonia from shallow respirations. The blood pressure is high but may be due to pain. It is expected that the client will have pain in the rib area when taking deep breaths. A heart rate of 94 beats/minute is within normal range.

A client with severe combined immunodeficiency is to receive a hematopoietic stem cell transplant. What would the nurse expect to be started? Anticoagulation Immunosuppressive agents Antibiotic therapy Chest physiotherapy

ANSWER 2 For a client undergoing a hematopoietic stem cell transplant, immunosuppression is started to ensure engraftment of depleted bone marrow. Antibiotic therapy may or may not be indicated. Chest physiotherapy would be appropriate for clients with ataxia-telangiectasis who have chronic lung disease. Anticoagulation would not be used.

The nurse is working with a colleague who has a delayed hypersensitivity (type IV) allergic reaction to latex. Which statement describes the clinical manifestations of this reaction? Symptoms worsen when hand lotion is applied before donning latex gloves. Symptoms can be eliminated by changing glove brands. Symptoms are localized to the area of exposure, usually the back of the hands. Symptoms occur within minutes after exposure to latex.

ANSWER 3 Clinical manifestations of a delayed hypersensitivity reaction are localized to the area of exposure. Clinical manifestations of an irritant contact dermatitis can be eliminated by changing glove brands or using powder-free gloves. With an irritant contact dermatitis, avoid use of hand lotion before donning gloves; this may worsen symptoms, as lotions may leach latex proteins from the gloves. When clinical manifestations occur within minutes after exposure to latex, which is described as a latex allergy, an immediate hypersensitivity (type I) allergic reaction has occurred.

An older adult with rheumatoid arthritis says exercise was not effective. Which response will the nurse make to learn the reason for the failure of this treatment approach? "Do you think you are too old to exercise?" "What types of exercise were you doing?" "Does exercise usually work for you?" "Why do you think the exercise didn't work?"

ANSWER 4

The nurse notes that an older adult was treated for a wound infection and pneumonia within the last 6 months. Which factor will the nurse attribute to this client's illnesses? Reduced vitamin intake Decline in self-care activities Polypharmacy Immunosenescence

ANSWER 4 Immunosenescence is the term for age-related changes in the immune system. These changes have been linked to the increased rates of illness and mortality in older adults, and an increased incidence of infections. There is no evidence that polypharmacy has caused an increase in infections in the older adult. The development of infections is not directly linked to vitamin intake or self-care activities.

A client has a cast applied to the leg for treatment of a tibia fracture and also has a wound on the leg that requires dressing changes due to drainage. For what should the nurse prepare the client? Insertion of an external fixator Cutting of a bivalve cast Cutting a cast window Removal of the cast

Answer 3 After the cast dries, a cast window, or opening, may be cut. This usually is done when the client reports discomfort under the cast or has a wound that requires a dressing change. The window permits direct inspection of the skin, a means to check the pulse in a casted arm or leg, or a way to change a dressing. A bivalve cast is when the cast is cut in two if the leg swells or if the client is being weaned from a cast, when a sharp x-ray is needed, or as a splint for immobilizing painful joints when a client has arthritis. The cast should not be removed due to the instability of a fracture. The client's condition does not indicate an external fixator is required

Which nursing diagnosis takes highest priority for a client with a compound fracture? Infection related to effects of trauma Impaired physical mobility related to trauma Activity intolerance related to weight-bearing limitations Imbalanced nutrition: Less than body requirements related to immobility

answer 1 A compound fracture involves an opening in the skin at the fracture site. Because the skin is the body's first line of defense against infection, any skin opening places the client at risk for infection. Imbalanced nutrition: Less than body requirements is rarely associated with fractures. Although Impaired physical mobility and Activity intolerance may be associated with any fracture, these nursing diagnoses don't take precedence because they aren't as life-threatening as infection.

Which is useful in identifying acute or chronic tears of the joint capsule or supporting ligaments of the knee, shoulder, ankle, hip, or wrist? Arthrography Meniscography EMG Bone densitometry

answer 1 Arthrography is useful in identifying acute or chronic tears of the joint capsule or supporting ligaments of the knee, shoulder, ankle, hip, or waist. Meniscography is a distractor for this question. Bone densitometry is used to estimate bone mineral density. An EMG provides information about the electrical potential of the muscles and nerves leading to them.

Which oncologic emergency involves the accumulation of fluid in the pericardial space? Cardiac tamponade Tumor lysis syndrome Syndrome of inappropriate antidiuretic hormone release (SIADH) Disseminated intravascular coagulation (DIC)

answer 1 Cardiac tamponade is an accumulation of fluid in the pericardial space. DIC is a complex disorder of coagulation and fibrinolysis that results in thrombosis and bleeding. SIADH is a result of the failure in the negative feedback mechanism that normally regulates the release of antidiuretic hormone (ADH). Tumor lysis syndrome is a rapidly developing oncologic emergency that results from the rapid release of intracellular contents as a result of radiation- or chemotherapy-induced cell destruction of large or rapidly growing cancers such as leukemia.

A client is receiving chemotherapy to treat breast cancer. Which assessment finding indicates a chemotherapy-induced complication? Serum potassium level of 2.6 mEq/L Urine output of 400 ml in 8 hours Sodium level of 142 mEq/L Blood pressure of 120/64 to 130/72 mm Hg

answer 1 Chemotherapy commonly causes nausea and vomiting, which may lead to fluid and electrolyte imbalances. Signs of fluid loss include a serum potassium level below 3.5 mEq/L, decreased urine output (less than 40 ml/hour), and abnormally low blood pressure. Urine output of 400 ml in 8 hours, serum sodium level of 142 mEq/L, and a blood pressure of 120/64 to 130/72 mm Hg aren't abnormal findings.

A healthcare provider asks a nurse to test a client for Tinel's sign to diagnose carpal tunnel syndrome. What should the nurse do to perform this assessment? Have the client hold the palm of the hand up while the nurse percusses over the median nerve. Have the client make a fist and open the hand against resistance. Have the client stretch the fingers around a ball and squeeze with force. Have the client pronate the hand while the nurse palpates the radial nerve.

answer 1 If tingling, numbness, or pain is felt when the median nerve is percussed, then Tinel's sign is considered positive. To test for Tinel's sign have the client hold the palm of the hand up while the nurse percusses over the median nerve. The client making a fist and pushing will test strength resistance. The client stretching fingers around a ball will not test for Tinel's sign. Having the client pronate the hand and palpating the radial nerve is not Tinel's sign used for carpal tunnel syndrome diagnosis.

The nurse notes that an older adult was treated for a wound infection and pneumonia within the last 6 months. Which factor will the nurse attribute to this client's illnesses? Immunosenescence Reduced vitamin intake Decline in self-care activities Polypharmacy

answer 1 Immunosenescence is the term for age-related changes in the immune system. These changes have been linked to the increased rates of illness and mortality in older adults, and an increased incidence of infections. There is no evidence that polypharmacy has caused an increase in infections in the older adult. The development of infections is not directly linked to vitamin intake or self-care activities.

A client in the emergency department is being treated for a wrist fracture. The client asks why a splint is being applied instead of a cast. What is the best response by the nurse? "A splint is applied when more swelling is expected at the site of injury." "It is best if an orthopedic doctor applies the cast." "Not all fractures require a cast." "You would have to stay here much longer because it takes a cast longer to dry."

answer 1 Splints are noncircumferential and will not compromise circulation when swelling is expected. A splint is applied to support and immobilize the injured joint. A fracture will swell as part of the inflammation process. The client would not have to stay longer if a fiberglass cast is applied. Fiberglass cast dry in approximately 30 minutes. An orthopedic doctor is not needed to apply the cast. Many nurses and technicians are trained in proper application of a cast. Some fractures may not be treated with a cast but it would not be appropriate to answer with this response because it does not reflect the actual reason for a splint being applied.

A client with a musculoskeletal injury is instructed to increase dietary calcium. Which statement by the nurse is appropriate? "You need to increase the amount of vitamin D in your diet." "You need to increase the amount of phosphorus in your diet." "You need to increase the amount of red meat in your diet." "You need to increase the amount of non-citrus fruits in your diet."

answer 1 Vitamin D is needed for the absorption of calcium. Although fruits containing vitamin C assist in the absorption of calcium, non-citrus fruits are of little benefit for calcium absorption. Increasing phosphorus in the diet can cause calcium to be lost from the bone, decreasing bone density. Red meat does not facilitate calcium absorption.

Red bone marrow produces which of the following? Select all that apply. Red blood cells (RBCs) Platelets Estrogen White blood cells (WBCs) Corticosteroids

answer 1-2-4 The red bone marrow located within the bone cavities produces RBC, WBCs, and platelets through the process of hematopoiesis. The red bone marrow does not produce estrogen or corticosteroids.

Two days after surgery to amputate the left lower leg, a client reports pain in the missing extremity. Which action by the nurse is most appropriate? Contact the health care provider. Administer medication, as ordered, for the reported discomfort. Initiate a consult with a psychologist. Do nothing because it isn't possible to have pain in a missing limb.

answer 2 The sensation of pain and discomfort in an amputated extremity is known as phantom pain. Phantom pain is a normal occurrence after an amputation. It should be treated with medication. The nurse doesn't need to contact the health care provider at this time. Consultation with the psychologist isn't indicated, and the nurse shouldn't take this action without consulting the health care provider.

While reading a client's chart, the nurse notices that the client is documented to have paresthesia. The nurse plans care for a client with absence of muscle movement suggesting nerve damage. absence of muscle tone. abnormal sensations. involuntary twitch of muscle fibers.

answer 3

Telangiectasia is the term that refers to Vascular lesions caused by dilated blood vessels Inability to understand the spoken word Difficulty swallowing Uncoordinated muscle movement

ANSWER 1 Telangiectasia is the term that refers to vascular lesions caused by dilated blood vessels. Ataxia-telangiectasia is an autosomal-recessive disorder affecting both T-cell and B-cell immunity. Receptive aphasia is an inability to understand the spoken word. Dysphagia refers to difficulty swallowing.

The nurse is administering a skin test for detection of exposure to tuberculosis. How would the nurse determine if the client was exposed to tuberculosis? The injection area swells if the client has developed antibodies against the antigen. The injection area will break out in a fine macular rash. The injection area will become painful with in duration if the client has antibodies against the antigen. The client will have a productive cough.

ANSWER 1 The injection area swells if the client has developed antibodies against the antigen. The client is not necessarily actively infectious if the test results are positive. Although a productive cough is one of the symptoms of active tuberculosis, it may also indicate other diseases and disorders. The area should not be painful, and the client should not break out with a rash.

A client has been in a motor vehicle collision. Radiographs indicate a fractured humerus; the client is awaiting the casting of the upper extremity and admission to the orthopedic unit. What is the primary treatment for musculoskeletal trauma? external rotation surgical repair immobilization enhancing complications

ANSWER 3 Treatment of musculoskeletal trauma involves immobilization of the injured area until it has healed.

A client is beginning highly active antiretroviral therapy (HAART). The client demonstrates an understanding of the need for follow up when scheduling a return visit for viral load testing at which time? 12 weeks 18 weeks 6 weeks 24 weeks

ANSWER 3 Viral load tests are measured immediately before initiating antiretroviral therapy and then again in 2 to 8 weeks. In most clients, adherence to a regimen of potent antiretroviral agents should result in a large decrease in the viral load by 2 to 8 weeks. Therefore, a return visit at 6 weeks would be in this time frame. By 16 to 20 weeks, the viral load should continue to decline, dropping below detectable levels.

A client is diagnosed with human immunodeficiency virus (HIV). After recovering from the initial shock of the diagnosis, the client expresses a desire to learn as much as possible about HIV and acquired immunodeficiency syndrome (AIDS). When teaching the client about the immune system, the nurse states that humoral immunity is provided by which type of white blood cell? Basophil Neutrophil Monocyte Lymphocyte

ANSWER 4 The lymphocyte provides humoral immunity — recognition of a foreign antigen and formation of memory cells against the antigen. Humoral immunity is mediated by B and T lymphocytes and can be acquired actively or passively. The neutrophil is crucial to phagocytosis. The basophil plays an important role in the release of inflammatory mediators. The monocyte functions in phagocytosis and monokine production.

The nurse is caring for a client is scheduled for chemotherapy followed by autologous stem cell transplant. Which of the following statements by the client indicates a need for further teaching? "I hope they find a bone marrow donor who matches." "The doctor will remove cells from my bone marrow before beginning chemotherapy." "I will need to attend follow-up visits for up to 3 months after treatment." "I will receive chemotherapy until most of the cancer is gone, and then I will get my own stem cells back."

answer 1 An autologous stem cell transplant comes from the client not from a donor. The doctor will remove the stem cells from the bone marrow before beginning chemotherapy and treat the client until most if not all the cancer is eliminated before reinfusing the stem cells. Clients are at risk for infection and will be closely monitored for at least 3 months, but not in protective isolation.

A client's left leg is in skeletal traction with a Thomas leg splint and Pearson attachment. Which intervention should the nurse include in this client's care plan? Teach the client how to prevent problems caused by immobility. Apply the traction straps snugly. Remove the traction at least every 8 hours. Assess the client's level of consciousness.

answer 1 By teaching the client about prevention measures, the nurse can help prevent problems caused by immobility, such as hypostatic pneumonia, muscle contracture, and atrophy. The nurse applies traction straps for skin traction — not skeletal traction. For a client in skeletal traction, the nurse should assess the affected limb, rather than assess the level of consciousness. Removing skeletal traction is the physician's responsibility — not the nurse's.

The client with a fractured left humerus reports dyspnea and chest pain. Pulse oximetry is 88%. Temperature is 100.2 degrees Fahrenheit (38.5 degrees Centigrade); heart rate is 110 beats per minute; respiratory rate is 32 breaths per minute. The nurse suspects the client is experiencing: Fat embolism syndrome Complex regional pain syndrome Delayed union Compartment syndrome

answer 1 The clinical manifestations described in the scenario are characteristic of fat embolism syndrome.

In which deformity does the great toe deviate laterally? Pes cavus Hallux valgus Plantar fasciitis Hammertoe

answer 2 Hallux valgus is a deformity in which the great toe deviates laterally. A hammertoe is a flexion deformity of the interphalangeal joint, which may involve several toes. Pes cavus refers to a foot with an abnormally high arch and a fixed equines deformity of the forefoot. Plantar fasciitis is an inflammation of the foot-supporting fascia.

A health care provider orders tests to determine if a client has systemic lupus erythematosus (SLE). Which test result helps to confirm an SLE diagnosis? Increased total serum complement levels Negative lupus erythematosus cell test An above-normal anti-deoxyribonucleic acid (DNA) test Negative antinuclear antibody test

answer 3 Laboratory results specific for SLE include an above-normal anti-DNA test, a positive antinuclear antibody test, and a positive lupus erythematosus cell test. Because the anti-DNA test rarely is positive in other diseases, this test is important in diagnosing SLE. (The anti-DNA antibody level may be depressed in clients who are in remission from SLE.) Decreased total serum complement levels indicate active SLE.

A client visits an orthopedic specialist because of pain beginning in the low back and radiating behind the right thigh and down below the right knee. The doctor suspects a diagnosis of sciatica. The nurse knows that the origin of the pain is between which intervertebral disks? L1, L2, and L4 C3, C4, and L1 L2, L3, and L5 L4, L5, and S1

answer 4

The nurse is caring for a client with a spica cast. What is the nurse's priority intervention? Keep the legs in abduction. Position the client on the affected side. Promote elimination with a regular bedpan. Keep the cast clean and dry.

answer 4 Keeping the cast clean and dry around the perineal opening is a priority. A spica cast has a built-in abduction bar. The client should be positioned on the unaffected side every 2 hours and prone twice a day. A fracture bedpan is easier to use for the client with a spica cast.

A client is prescribed antihistamines, and asks the nurse about administration and adverse effects. The nurse should advise the client to avoid: alcohol. seafood. exposure to sunlight. applying skin moisturizers.

ANSWER 1 The nurse should advise a client taking antihistamines not to take it with alcohol or other central nervous system depressants because additive sedative effects can occur.

The nurse intervenes to assist the client with fibromyalgia to cope with which symptoms? Chronic fatigue, generalized muscle aching, and stiffness Pain, viral infection, and tremors Generalized muscle aching, mood swings, and loss of balance Diminished vision, chronic fatigue, and reduced appetite

ANSWER 1 Fibromyalgia is a common condition that involves chronic fatigue, generalized muscle aching, and stiffness. The cause is unknown, and no pathologic characteristics specific for the condition have been identified. Treatment consists of attention to the specific symptoms reported by the client. NSAIDs may be used to treat the diffuse muscle aching and stiffness. Tricyclic antidepressants are used to improve or restore normal sleep patterns, and individualized programs of exercise are used to decrease muscle weakness and discomfort and to improve the general deconditioning that occurs in these individuals.

The nurse is teaching a client about allergic rhinitis and its triggers. What is the most common trigger for the respiratory allergic response? animal dander plant pollen dust mites mold spores

ANSWER 2 Plant pollen (from trees, grass, and other plants) causes the most common form of allergic rhinitis, which is known as hay fever. Animal dander, dust mites, and mold spores can be triggers, but are not the most common causes.

The nurse is working with a client with allergies. What will the nurse use to confirm allergies and decrease the risk of anaphylaxis? punch biopsy intradermal testing peripheral blood smears nasal smear

ANSWER 2 The diagnosis of anaphylaxis risk is determined by prick and intradermal skin testing. Skin testing of patients who have clinical symptoms consistent with a type I, IgE-mediated reaction has been recommended. A nasal smear, punch biopsy, and peripheral blood smear would not be used for allergy testing.

After teaching a client how to self-administer epinephrine, the nurse determines that the teaching plan has been successful when the client demonstrates which action? Pushes down on the grey release cap to administer the medication Jabs the autoinjector into the outer thigh at a 90-degree angle Avoids massaging the injection site after administration Maintains pressure on the auto-injector for about 30 seconds after insertion

ANSWER 2 To self-administer epinephrine, the client should remove the autoinjector from its carrying tube, grasp the unit with the black tip (injecting end) pointed downward, form a fist around the device, and remove the gray safety release cap. Then the client should hold the black tip near the outer thigh and swing and jab firmly into the outer thigh at a 90-degree angle until a click is heard. Next, the client should hold the device firmly in place for about 10 seconds, remove the device, and massage the site for about 10 seconds.

Which type of fracture involves a break through only part of the cross-section of the bone? Open Oblique Incomplete Comminuted

ANSWER 3 An incomplete fracture involves a break through only part of the cross-section of the bone. A comminuted fracture is one that produces several bone fragments. An open fracture is one in which the skin or mucous membrane wound extends to the fractured bone. An oblique fracture runs across the bone at a diagonal angle of 45 to 60 degrees.

The nurse has educated a patient with low back pain about techniques to relieve the back pain and prevent further complications. What statement by the patient shows understanding of the education the nurse provided? "I will bend at the waist when I am lifting objects from the floor." "I will lie prone with my legs slightly elevated." "Instead of turning around to grasp an object, I will twist at the waist." "I will avoid prolonged sitting or walking."

ANSWER 4

A client with AIDS has become forgetful with a limited attention span, decreased ability to concentrate, and delusional thinking. What condition is represented by these symptoms? cytomegalovirus (CMV) distal sensory polyneuropathy (DSP) candidiasis AIDS dementia complex (ADC)

ANSWER 4 ADC, a neurologic condition, causes the degeneration of the brain, especially in areas that affect mood, cognition, and motor functions. Such clients exhibit forgetfulness, limited attention span, decreased ability to concentrate, and delusional thinking. DSP is characterized by abnormal sensations, such as burning and numbness in the feet and later in the hands. Candidiasis is a yeast infection that may develop in the oral, pharyngeal, esophageal, or vaginal cavities or in the folds of the skin. CMV infects the choroid and retinal layers of the eye, leading to blindness, and can also cause ulcers in the esophagus, colitis, diarrhea, pneumonia, and encephalitis.

A client with suspected exposure to HIV has been tested with the enzyme-linked immunosorbent assay (ELISA) with positive results twice. The next step for the nurse to explain to the client for confirmation of the diagnosis is to perform a: polymerase chain reaction test for confirmation of diagnosis. T4-cell count for confirmation of diagnosis. p24 antigen test for confirmation of diagnosis. Western blot test for confirmation of diagnosis.

ANSWER 4 The enzyme-linked immunosorbent assay (ELISA) test, an initial HIV screening test, is positive when there are sufficient HIV antibodies; it also is positive when there are antibodies from other infectious diseases. The test is repeated if results are positive. If results of a second ELISA test are positive, the Western blot is performed. The p24 antigen test and the polymerase chain reaction test determine the viral load, and the T4-cell count is not used for diagnostic confirmation of the presence of HIV in the blood.

A client is experiencing an acute attack of gout. Which medications will the nurse anticipate being prescribed for this client? Select all that apply. Colchicine Allopurinol Ibuprofen Febuxostat Prednisone

answer 1-3-5 Acute attacks of gout are managed with colchicine, corticosteroids, or a nonsteroidal anti-inflammatory drug. Once the acute attack has subsided, uric acid lowering therapy should be considered. Xanthine oxidase inhibitors, such as allopurinol and febuxostat, are the agents of choice.

A patient is scheduled for cryoablation for cervical cancer and tells the nurse, "I am not exactly sure what the surgeon is going to do." What is the best response by the nurse? "The surgeon is going to use radiofrequency to ablate the area." "The surgeon is going to use liquid nitrogen to freeze the area." "The surgeon is going to use a laser to remove the area." "The surgeon is going to use medication to inject the area."

answer 2 Cryoablation is the use of liquid nitrogen or a very cold probe to freeze tissue and cause cell destruction. It is used for cervical, prostate, and rectal cancers. Chemosurgery is the use of medication. Laser surgery is the use of a laser. Radiofrequency ablation is the use of thermal energy.

The client is diagnosed with a benign brain tumor. Which of the following features of a benign tumor is of most concern to the nurse? Emission of abnormal proteins Random, rapid growth of the tumor Tumor pressure against normal tissues Cells colonizing to distant body parts

answer 3 Benign tumors grow more slowly than malignant tumors and do not emit tumor-specific antigens or proteins. Benign tumors do not metastasize to distant sites. Benign tumors can compress tissues as it grows, which can result in impaired organ functioning.

The nurse in an orthopedic clinic is caring for a new client. What sign or symptom would lead a nurse to suspect that a client has a rotator cuff tear? Pain worse in the morning Ability to stretch arm over the head Difficulty lying on affected side Minimal pain with movement

answer 3 Clients with a rotator cuff tear experience pain with movement and limited mobility of the shoulder and arm. They especially have difficulty with activities that involve stretching their arm above their head. Many clients find that the pain is worse at night and that they are unable to sleep on the affected side.

Which term indicates an accumulation of crystalline depositions in articular surfaces, bones, soft tissue, and cartilage? Subchondral bone Pannus Tophi Joint effusion

answer 3 Tophi, when problematic, are surgically excised. Subchondral bone refers to a bony plate that supports the articular cartilage. Pannus refers to newly formed synovial tissue infiltrated with inflammatory cells. Joint effusion refers to the escape of fluid from the blood vessels or lymphatic vessels into the joint cavity.

A client is receiving external radiation to the left thorax to treat lung cancer. Which intervention should be part of this client's care plan? Removing thoracic skin markings after each radiation treatment Wearing a lead apron during direct contact with the client Applying talcum powder to the irradiated areas daily after bathing Avoiding using soap on the irradiated areas

answer 4 Because external radiation commonly causes skin irritation, the nurse should wash the irradiated area with water only and leave the area open to air. No soaps, deodorants, lotions, or powders should be applied. A lead apron is unnecessary because no radiation source is present in the client's body or room. Skin in the area to be irradiated is marked to position the radiation beam as precisely as possible; skin markings must not be removed.

Which medication directly inhibits osteoclasts, thereby reducing bone loss and increasing bone mass density (BMD)? Raloxifene Vitamin D Teriparatide Calcitonin

answer 4 Calcitonin directly inhibits osteoclasts, thereby reducing bone loss and increased BMD. Raloxifene reduces the risk of osteoporosis by preserving BMD without estrogenic effects on the uterus. Teriparatide has been recently approved by the FDA for the treatment of osteoporosis. Vitamin D increases the absorption of calcium.

A client who is HIV positive is receiving highly active antiretroviral therapy (HAART) that includes a protease inhibitor (PI). The client comes to the clinic for a follow-up visit. Assessment reveals lipoatrophy of the face and arms. The client states, "I'm thinking the side effects of the drug are worse than the disease. Look what's happening to me." The nurse would most likely identify which nursing diagnosis as the priority? Disturbed body image related to loss of fat in the face and arms Risk for impaired liver function related to drug therapy effects Risk for infection related to the immune system dysfunction Deficient knowledge related to the effects of the disease

ANSWER 1

The client with a fractured left humerus reports dyspnea and chest pain. Pulse oximetry is 88%. Temperature is 100.2 degrees Fahrenheit (38.5 degrees Centigrade); heart rate is 110 beats per minute; respiratory rate is 32 breaths per minute. The nurse suspects the client is experiencing: Delayed union Fat embolism syndrome Complex regional pain syndrome Compartment syndrome

ANSWER 2 The clinical manifestations described in the scenario are characteristic of fat embolism syndrome.

A client comes to the emergency department complaining of localized pain and swelling of the lower leg. Ecchymotic areas are noted. History reveals that the client got hit in the leg with a baseball bat. Which of the following would the nurse suspect as most likely? Strain Fracture Sprain Contusion

ANSWER 4 The client's description of blunt trauma by a baseball bat and localized pain in conjunction with swelling and ecchymosis would most likely suggest a contusion. A fracture would be manifested by pain, loss of function, deformity, swelling, and spasm. A sprain would be manifested by pain and swelling; ecchymosis may appear later. A strain is characterized by inflammation, local tenderness, and muscle spasms.

A client with advanced cancer makes the following comment to the nurse: "Why are you bathing me? I am going to die no matter what." What is the most appropriate response of the nurse? "A bath will make you feel better." "Do you want to skip the bath today?" "Would you like to talk about what you are feeling?" "I can give you some medicine to make you feel better."

answer 3 By asking the client talk may open the door for further discussion and sharing of feelings, fears, etc. A bath will make the client feel better and asking if the client wishes to skip the bath today are matter-of-fact comments and disconnect, resulting in a shutdown to further communication. The nurse stating that medication could be given is a quick fix and demonstrates a nontherapeutic

A client is experiencing painful joints and changes in the lungs, heart, and kidneys. For which condition will the nurse schedule this client for diagnostic tests? Vascular diseases Metabolic disorders Autoimmune disorders Heart disease

answer 3 A hallmark of inflammatory rheumatic diseases is autoimmunity, where the body mistakenly recognizes its own tissue as a foreign antigen. Although focused in the joints, inflammation and autoimmunity also involve other areas. The blood vessels (vasculitis and arteritis), lungs, heart, and kidneys may be affected by the autoimmunity and inflammation. It is unlikely that the client's array of symptoms is being caused by heart disease, vascular diseases, or metabolic disorders.

A nurse is administering daunorubicin (DaunoXome) to a patient with lung cancer. Which situation requires immediate intervention? The client states he is nauseous. The laboratory reports a white blood cell (WBC) count of 1,000/mm3. The I.V. site is red and swollen. The client begins to shiver.

answer 3 A red, swollen I.V. site indicates possible infiltration. Daunorubicin is a vesicant chemotherapeutic agent and can be very damaging to tissue if it infiltrates. The nurse should immediately stop the medication, apply ice to the site, and notify the physician. Although nausea, WBC count of 1,000/mm3, and shivering require interventions, these findings aren't a high priority at this time.

for a client newly diagnosed with radiation-induced thrombocytopenia, the nurse should include which intervention in the care plan? Administering aspirin if the temperature exceeds 102° F (38.8° C) Providing for frequent rest periods Inspecting the skin for petechiae once every shift Placing the client in strict isolation

answer 3 Because thrombocytopenia impairs blood clotting, the nurse should inspect the client regularly for signs of bleeding, such as petechiae, purpura, epistaxis, and bleeding gums. The nurse should avoid administering aspirin because it may increase the risk of bleeding. Frequent rest periods are indicated for clients with anemia, not thrombocytopenia. Strict isolation is indicated only for clients who have highly contagious or virulent infections that are spread by air or physical contact.

A client diagnosed with acute myelocytic leukemia has been receiving chemotherapy. During the last 2 cycles of chemotherapy, the client developed severe thrombocytopenia requiring multiple platelet transfusions. The client is now scheduled to receive a third cycle. How can the nurse best detect early signs and symptoms of thrombocytopenia? Monitor daily platelet counts. Perform a cardiovascular assessment every 4 hours. Check the client's history for a congenital link to thrombocytopenia. Closely observe the client's skin for petechiae and bruising.

answer 4 The nurse should closely observe the client's skin for petechiae and bruising. Daily laboratory testing may not reflect the client's condition as quickly as subtle changes in the client's skin. Performing a cardiovascular assessment every 4 hours and checking the clients history for a congenital link to thrombocytopenia don't help detect early signs and symptoms of thrombocytopenia.

A client has been treated for migraine headaches for several months and comes to the clinic reporting no improvement. The nurse is talking with the client and hears an audible click when the client is moving the jaw. What does the nurse suspect may be happening? Temporomandibular disorder Loose teeth Trigeminal neuralgia Dislocated jaw

ANSWER 1 The disorder can be confused with trigeminal neuralgia and migraine headaches. The client experiences clicking of the jaw when moving the joint, or the jaw can lock, which interferes with opening the mouth. Loose teeth will not cause a clicking of the jaw. The client does not have a dislocated jaw.

A nurse is preparing a discharge teaching plan for a client with atopic dermatitis. Which instruction should the nurse include in the teaching plan? Use a topical skin moisturizer daily. Bathe only three times per week. Wear only synthetic fabrics. Keep the thermostat above 75° F (23.9° C).

ANSWER 1 The nurse should instruct the client to use a topical skin moisturizer daily to help keep the skin hydrated. Likewise, the client should be encouraged to bathe daily. To minimize irritation, the client should wear only cotton fabrics. The client should maintain a room temperature between 68° F (20° C) and 72° F (22.2° C).

The nurse is caring for a 24-year-old female client with a right tibial fracture treated with a cast 2 hours ago. The client now reports unrelenting pain, rated as 7/10, despite taking oxycodone, and decreased sensation in the right foot. A nursing assessment reveals the right foot is cooler and paler than the left foot, with delayed capillary refill and a weak pulse. Based on the nursing assessment, the priority action the nurse should take is to_______________ and prepare the client for ____________________

ANSWER 1.notify the orthopedic health care provider immediately 2.bivalving of the cast R:A client in a cast is at risk for compartment syndrome, a sudden and severe buildup of pressure in an enclosed space, that can lead to tissue ischemia and loss of limb, if not promptly treated. Clinical manifestations of compartment syndrome include loss of sensation, pale and cool skin, delayed capillary refill, weak pulses, and paresthesia in the affected limb as well as pain that is unrelieved by position change, ice, or increasing doses of analgesia. Because of the risk for permanent neurovascular impairment, the nurse needs to notify the health care provider immediately so that measures can be taken to relieve pressure within the cast. To relieve pressure within the confined right lower leg, the nurse should anticipate that the cast will need to be bivalved (cut in half longitudinally). If compartment syndrome is suspected, the nurse should not delay measures to relieve pressure within the confined space of the cast by administering an analgesic and waiting 30 minutes to determine the outcome. The nurse may elevate the right leg to reduce swelling, but it is not the priority action. The nurse should not prepare the client for discharge until after pressure has been relieved from the right lower leg. If pressure is not relieved through bivalving the cast, a fasciotomy may be needed to relieve pressure within the muscle compartment.

A client is infected with human immunodeficiency virus (HIV) after sharing needles with another intravenous (IV) drug abuser. Upon infection with HIV, the immune system responds by making antibodies against the virus, usually within how many weeks after infection? 3 to 6 weeks 3 to 12 weeks 1 to 2 weeks 6 to 18 weeks

ANSWER 2 When a person is infected with HIV, the immune system responds by producing antibodies against the virus, usually within 3 to 12 weeks after infection.

Which body substance causes increased gastric secretion, dilation of capillaries, and constriction of the bronchial smooth muscle? Bradykinin Prostaglandin Histamine Serotonin

ANSWER 3 When cells are damaged, histamine is released. Bradykinin is a polypeptide that stimulates nerve fibers and causes pain. Serotonin is a chemical mediator that acts as a potent vasoconstrictor and bronchoconstrictor. Prostaglandins are unsaturated fatty acids that have a wide assortment of biologic activities.

A client who has fallen and injured a hip cannot place weight on the leg and is in significant pain. After radiographs indicate intact but malpositioned bones, what would the physician diagnose? strain fracture sprain dislocation

ANSWER 4 In joint dislocation, radiographic films show intact yet malpositioned bones. Arthrography or arthroscopy may reveal damage to other structures in the joint capsule. A strain is an injury to a muscle when it is stretched or pulled beyond its capacity. Sprains are injuries to the ligaments surrounding a joint. A fracture is a break in the continuity of a bone.

A client has been prescribed alendronate for the prevention of osteoporosis. Which is the highest priority nursing intervention associated with the administration of the medication? Have the client sit upright for at least 30 minutes following administration Encourage the client to get yearly dental exams Assess for the use of corticosteroids Ensure adequate intake of vitamin D in the diet

answer 1 While all interventions are appropriate, the highest priority is having the client sit upright for 60 minutes following administration of the medication. This will prevent irritation and potential ulceration of the esophagus. The client should have adequate intake of vitamin D and obtain yearly dental exams. The concurrent use of corticosteroids and alendronate is link to a complication of osteonecrosis.

A nurse is administering daunorubicin (DaunoXome) to a patient with lung cancer. Which situation requires immediate intervention? The client begins to shiver. The I.V. site is red and swollen. The laboratory reports a white blood cell (WBC) count of 1,000/mm3. The client states he is nauseous.

answer 2 A red, swollen I.V. site indicates possible infiltration. Daunorubicin is a vesicant chemotherapeutic agent and can be very damaging to tissue if it infiltrates. The nurse should immediately stop the medication, apply ice to the site, and notify the physician. Although nausea, WBC count of 1,000/mm3, and shivering require interventions, these findings aren't a high priority at this time.

Which action would be most important postoperatively for a client who has had a knee or hip replacement? Encouraging expressions of anxiety. Assisting in early ambulation. Using a continuous passive motion (CPM) machine. Providing crutches to the client.

answer 2 An anticoagulant therapy and early ambulation are important for clients who undergo a knee or hip replacement. A CPM machine or crutches may be provided when prescribed. It is important to encourage clients to express their feelings of anxiety or depression. This is more crucial for clients who undergo an amputation rather than for clients who undergo a replacement surgery.

Which of the following would lead a nurse to suspect that a client has a rotator cuff tear? Minimal pain with movement Difficulty lying on affected side Increased ability to stretch arm over the head Pain worse in the morning

answer 2 Clients with a rotator cuff tear experience pain with movement and limited mobility of the shoulder and arm. They especially have difficulty with activities that involve stretching their arm above their head. Many clients find that the pain is worse at night and that they are unable to sleep on the affected side.

The nurse notes that the client's left great toe deviates laterally. This finding would be recognized as which condition? Pes cavus Hallux valgus Hammertoe Flatfoot

answer 2 Hallux valgus is commonly referred to as a bunion. Hammertoes are usually pulled upward. Pes cavus refers to a foot with an abnormally high arch and a fixed equinus deformity of the forefoot. The client with flatfoot demonstrates a diminished longitudinal arch of the foot.

A patient had hand surgery to correct a Dupuytren's contracture. What nursing intervention is a priority postoperatively? Having the patient exercise the fingers to avoid future contractures Performing hourly neurovascular assessments for the first 24 hours Applying a cock-up splint and immobilization Changing the dressing

answer 2 Hourly neurovascular assessment of the exposed fingers for the first 24 hours following surgery is essential for monitoring function of the nerves and perfusion.

A client has a cast applied to the leg for treatment of a tibia fracture and also has a wound on the leg that requires dressing changes due to drainage. For what should the nurse prepare the client? Cutting of a bivalve cast Removal of the cast Cutting a cast window Insertion of an external fixator

answer 3 After the cast dries, a cast window, or opening, may be cut. This usually is done when the client reports discomfort under the cast or has a wound that requires a dressing change. The window permits direct inspection of the skin, a means to check the pulse in a casted arm or leg, or a way to change a dressing. A bivalve cast is when the cast is cut in two if the leg swells or if the client is being weaned from a cast, when a sharp x-ray is needed, or as a splint for immobilizing painful joints when a client has arthritis. The cast should not be removed due to the instability of a fracture. The client's condition does not indicate an external fixator is required.

Which intervention should the nurse implement with the client who has undergone a hip replacement? Adduct the legs by placing a pillow between the legs. Have the client bend forward to rise from the chair. Instruct the client to avoid internal rotation of the leg. Place the client in high Fowler's position for meals.

answer 3 The client should avoid all activities that can result in dislocation of the hip. The affected leg should not cross midline or be turned inward. A pillow is used to keep the legs in abduction. The hip should not bend more than 90 degrees when seated. The head of bed should be kept at 60 degrees or less.

A client is brought to the emergency department by a softball team member who states the client and another player ran into each other, and the client is having severe pain in the right shoulder. What symptoms of a fractured clavicle does the nurse recognize? Client complains of tingling and numbness in the right shoulder. Right shoulder is elevated above the left. Right shoulder slopes downward and droops inward. Client complains of pain in the unaffected shoulder.

answer 3 The client with a fractured clavicle has restricted motion, and the affected shoulder appears to slope downward and droop inward. The client will have pain, not typically tingling and numbness in the right shoulder. Pain is not felt in the unaffected shoulder.

A client with chronic renal failure has begun treatment with a colony-stimulating factor. What medication does the nurse anticipate administering to the client that will promote the production of blood cells? infliximab (Remicade) Adalimumab (Humira) Etanercept (Enbrel) Epoetin alfa (Epogen)

answer 4 Colony-stimulating factors are cytokines that prompt the bone marrow to produce, mature, and promote the functions of blood cells. CSFs enable stem cells in bone marrow to differentiate into specific types of cells such as leukocytes, erythrocytes, and platelets. Pharmacologic preparation of CSFs, such as epoetin alfa (Epogen), is used to promote the natural production of blood cells in people whose own hematopoietic functions have become compromised. The other medications in A, B, and D are tumor necrosis factor inhibitors.

The client has finished the first round of chemotherapy. Which statement made by the client indicates a need for further teaching by the nurse? "Hair loss may not occur until after the second round of therapy." "I will eat clear liquids for the next 24 hours." "I will use birth control measures until after all treatment is completed." "I can continue taking my vitamins and herbs because they make me feel better."

answer 4 Herbal products are not regulated by the U.S. Food and Drug Administration (FDA);although some can decrease the risk of cancer, others can have serious side effects and liver toxicity. Use of vitamins and herbals should be reviewed with the oncologist. Use of clear liquids is recommended for the client experiencing nausea and vomiting. Because hair follicles are sensitive to chemotherapy drugs, it is likely for alopecia to occur especially with consecutive treatments. Chemotherapy includes cytotoxic drugs that are harmful to rapid dividing cells such as cell development in the fetus. To prevent damage to the fetus, birth control is recommended during treatment.

An older adult with rheumatoid arthritis says exercise was not effective. Which response will the nurse make to learn the reason for the failure of this treatment approach? "Why do you think the exercise didn't work?" "Do you think you are too old to exercise?" "Does exercise usually work for you?" "What types of exercise were you doing?"

answer 4 In an older adult with rheumatoid arthritis, exercise programs may not be instituted or may be ineffective because the client expects results too quickly or fails to appreciate the effectiveness of a program of exercise. Strength training is encouraged in the older adult with chronic diseases. The other questions will not help the nurse understand what type of exercise was used and what it was not effective for the client.

The nurse is caring for a client with palindromic rheumatism. The nurse knows that this type of rheumatism can lead to which diagnosis? Systemic lupus erythematosus Fibromyalgia Scleroderma Rheumatoid arthritis

answer 4 Palindromic rheumatism is an uncommon variety of recurring and acute arthritis and periarthritis that in some may progress to rheumatoid arthritis (RA) but is characterized by symptom-free periods of days to months. Because of this, the nurse should plan care that would be similar to the client with RA. The symptoms of palindromic rheumatism are not similar to those of scleroderma, fibromyalgia, or systemic lupus erythematosus.-

Which is an inaccurate principle of traction? The weights are not removed unless intermittent treatment is prescribed. The client must be in good alignment in the center of the bed. The weights must hang freely. Skeletal traction is interrupted to turn and reposition the client.

answer 4 Skeletal traction is never interrupted. The weights are not removed unless intermittent treatment is prescribed. The weights must hang freely, with the client in good alignment in the center of the bed.

The community health nurse is assessing the risk factors for osteoporosis in a female client at a health fair. For each assessment finding, click to specify if the finding is a risk factor for osteoporosis or is not a risk factor for osteoporosis.

After the identification of a client's risk factors for osteoporosis, the nurse can develop a plan of care to reduce or prevent osteoporosis. Risk factors for osteoporosis include older age (for women, the risk increases after age 50), Asian heritage, being a postmenopausal woman, and long-term corticosteroid use (such as fluticasone for the treatment of asthma). A small frame, not a large frame, increases the risk for osteoporosis. Being a nonsmoker does not increase the risk for osteoporosis. An alcohol intake of 3 or more drinks/day is a risk factor for osteoporosis; an intake of 3 alcoholic beverages/week does not increase the risk. A sedentary lifestyle also increases the risk for osteoporosis; however, walking 2 miles, 3 days/week is not considered sedentary.

A client with arterial insufficiency undergoes below-knee amputation of the right leg. Which action should the nurse include in the postoperative care plan? Maintaining the client on complete bed rest Applying heat to the stump as the client desires Removing the pressure dressing after the first 8 hours Elevating the stump for the first 24 hours

answer 4 Stump elevation for the first 24 hours after surgery helps reduce edema and pain by increasing venous return and decreasing venous pooling at the distal portion of the extremity. Bed rest isn't indicated and could predispose the client to complications of immobility. Heat application would be inappropriate because it promotes vasodilation, which may cause hemorrhage and increase pain. The initial pressure dressing usually remains in place for 48 to 72 hours after surgery.

Which statement is accurate regarding care of a plaster cast? A dry plaster cast is dull and gray. The cast will dry in about 12 hours. The cast must be covered with a blanket to keep it moist during the first 24 hours. The cast can be dented while it is damp.

answer 4 The cast can be dented while it is damp. A dry plaster case is white and shiny. The cast will dry in 24 to 72 hours. A freshly applied cast should be exposed to circulating air to dry and should not be covered with clothing or bed linens or placed on plastic-coated mats or bedding.

In chronic osteomyelitis, antibiotics are adjunctive therapy in which situation? Wound packing Vitamin supplements Wound irrigation Surgical debridement

answer 4 The disorder can be confused with trigeminal neuralgia and migraine headaches. The client experiences clicking of the jaw when moving the joint, or the jaw can lock, which interferes with opening the mouth. Loose teeth will not cause a clicking of the jaw. The client does not have a dislocated jaw.

The nursing instructor is discussing hypersensitivity responses with a clinical group. What allergic reaction(s) would the nursing instructor talk about? Select all that apply. Cytotoxic Unmediated Typical Immune complex Atopic

ANSWER 1-4-5 Once sensitization occurs, one of four types of hypersensitivity responses can occur. These may be immediate or delayed depending on the time it takes for the immune system to mount a response. An immediate hypersensitivity response is due to antibodies interacting with allergens and occurs rapidly. There are three types of immediate hypersensitivity responses: type I, atopic or anaphylactic, which is mediated by immunoglobulin E (IgE) antibodies; type II, cytotoxic, which is mediated by immunoglobulin M or G (IgM or IgG) antibodies; and type III, immune complex, which is mediated by IgG antibodies. The first two types of responses occur within minutes; type III responses reach a peak within 6 hours after exposure to an allergen. The nurse would not discuss atypical and unmediated hypersensitivity responses in this scenario.

A client with HIV will be started on a medication regimen of three medications. What class of drugs will the nurse instruct the client about? Anticholinergics Reverse transcriptase inhibitors Hydroxyurea Disinhibitors

ANSWER 2 Reverse transcriptase inhibitors are drugs that interfere with the virus' ability to make a genetic blueprint. A protease inhibitor is a drug that inhibits the ability of virus particles to leave the host cell. The integrase inhibitors are a class of drug that prevents the incorporation of viral DNA into the host cell's DNA. Hydroxyurea is a drug that is used as an adjunct therapy that tries to halt the progression of AIDS.

A patient is experiencing an allergic reaction to a dose of penicillin. What should the nurse look for in the patient's initial assessment? The presence and location of pruritus Dyspnea, bronchospasm, and/or laryngeal edema. Hypotension and tachycardia The severity of cutaneous warmth and flushing

ANSWER 2 Severe systemic, anaphylactic reactions have an abrupt onset with the same signs and symptoms described previously. These symptoms progress rapidly to bronchospasm, laryngeal edema, severe dyspnea, cyanosis, and hypotension. Dysphagia (difficulty swallowing), abdominal cramping, vomiting, diarrhea, and seizures can also occur. Cardiac arrest and coma may follow.

A client with AIDS is admitted to the hospital with severe diarrhea and dehydration. The physician suspects an infection with Cryptosporidium. What type of specimen should be collected to confirm this diagnosis? Stool specimen for ova and parasites Blood specimen for electrolyte studies Urine specimen for culture and sensitivity Sputum specimen for acid fast bacillus

ANSWER 1 A stool specimen for ova and parasites will give a definitive diagnosis. The organism is spread by the fecal-oral route from contaminated water, food, or human or animal waste. Those infected can lose from 10 to 20 L of fluid per day. Losing this magnitude of fluid quickly leads to dehydration and electrolyte imbalances.

A client with lupus has had antineoplastic drugs prescribed. Why would the physician prescribe antineoplastic drugs for an autoimmune disorder? To decrease the body's risk of infection For their immunosuppressant effects Because an autoimmune disease is a neoplastic disease So the client has strong drug therapy

ANSWER 2 Drug therapy using anti-inflammatory and immunosuppressive agents is the mainstay for alleviating symptoms. Some antineoplastic (cancer) drugs also are used for their immunosuppressant effects. Antineoplastic drugs do not decrease the body's risk of infection; an autoimmune disease is not a neoplastic disease. Drugs are not ordered just so the client has strong drug therapy.

What intervention is a priority when treating a client with HIV/AIDS? Monitoring skin integrity Assessing fluid and electrolyte balance Assessing neurologic status Monitoring psychological status

ANSWER 2 Fluid and electrolyte deficits are a priority in monitoring clients with HIV/AIDS, and assessment of fluid loss and electrolyte imbalance is essential. Skin integrity should be monitored but is a lower priority. Neurologic and psychological status should also be monitored, but this is not as high a priority as fluid and electrolyte imbalance.

A nurse notices a client lying on the floor at the bottom of the stairs. The client is alert and oriented and denies pain other than in the arm, which is swollen and appears deformed. After calling for help, what should the nurse do? Place the client in a sitting position. Immobilize the client's arm. Raise the client's arm above the heart. Help the client walk to the nearest nurses' station.

ANSWER 2 Signs of a fracture in an extremity include pain, deformity, swelling, discoloration, and loss of function. When a nurse suspects a fracture, the extremity should be immobilized before moving the body part. It isn't appropriate for the nurse to move the client into a sitting position without further assessment. The client shouldn't walk to the nurses' station; the client should wait for help to arrive.

The nurse is teaching the client who has an immunodeficiency disorder how to avoid infection at home. Which statement indicates that additional teaching is needed? "I will make sure to have my own toothbrush and tube of toothpaste at home." "I will be sure to eat lots of fresh fruits and vegetables every day." "I will avoid contact with people who are sick or who have recently been vaccinated." "I will wash my hands whenever I get home from work."

ANSWER 2 The client should avoid eating raw fruits and vegetables. All foods should be cooked thoroughly and all leftover food should be refrigerated immediately to prevent infection.

A client with a history of gout experiences an attack every 2 to 3 months despite losing weight and stopping all alcohol intake. Which question will the nurse ask when assessing this client? "Are you taking frequent rest periods throughout the day?" "Have you increased your intake of fat-soluble vitamins?" "Have you reduced the amount of daily exercise?" "Are you taking the medication as prescribed?"

ANSWER 3

The nurse is caring for a client who was involved in an automobile accident and sustained multiple trauma. The client has a Volkmann's contracture to the right hand. What objective data does the nurse document related to this finding? Dislocation of the fingers Extension of the fingers of the right hand Claw-like deformity of the right hand without ability to extend fingers Nodules on the knuckles of the third and fourth finger

ANSWER 3 A Volkmann's contracture is a claw like deformity of the hand resulting from obstructed arterial blood flow to the forearm and hand. The client is unable to extend the fingers and complains of unrelenting pain, particularly if attempting to stretch the hand. Nodule on the knuckles and dislocation are not indicative of Volkmann's contracture.

A client has been involved in a motor vehicle collision. Radiographs indicate a fractured humerus; the client is awaiting the casting of the upper extremity and admission to the orthopedic unit. Other than the bone, what physical structures could be affected by this injury? nerves blood vessels All options are correct. muscles

ANSWER 3 A fractured bone or other injury can potentially cause dysfunction to the surrounding muscle and injury to the blood vessels and nerves.

A client with suspected exposure to HIV has been tested with the enzyme-linked immunosorbent assay (ELISA) with positive results twice. The next step for the nurse to explain to the client for confirmation of the diagnosis is to perform a: T4-cell count for confirmation of diagnosis. polymerase chain reaction test for confirmation of diagnosis. Western blot test for confirmation of diagnosis. p24 antigen test for confirmation of diagnosis.

ANSWER 3 The enzyme-linked immunosorbent assay (ELISA) test, an initial HIV screening test, is positive when there are sufficient HIV antibodies; it also is positive when there are antibodies from other infectious diseases. The test is repeated if results are positive. If results of a second ELISA test are positive, the Western blot is performed. The p24 antigen test and the polymerase chain reaction test determine the viral load, and the T4-cell count is not used for diagnostic confirmation of the presence of HIV in the blood.

A nurse is administering a chemotherapeutic medication to a client, who reports generalized itching and then chest tightness and shortness of breath. The nurse immediately Administers diphenhydramine Gives prednisolone IV Places the client on oxygen by nasal cannula Stops the chemotherapeutic infusion

answer 4 The client may be experiencing a type I hypersensitivity reaction, which may progress to systemic anaphylaxis. The most immediate action of the nurse is to discontinue the medication followed by initiating emergency protocols.

A client has had a "stuffy nose" and obtained an oxymetazoline nasal spray. What education should the nurse provide to the client in order to prevent "rebound congestion"? Only use the nasal spray for 3 to 4 days once every 12 hours. Be sure to use the nasal spray for at least 10 days to ensure the stuffiness is gone. Use the medication every 4 hours to prevent congestion from recurring. Drink plenty of fluids.

ANSWER 1 Adrenergic agents, which are vasoconstrictors of mucosal vessels, are used topically in nasal (oxymetazoline [Afrin]) and ophthalmic (brimonidine [Alphagan P]) formulations in addition to the oral route (pseudoephedrine [Sudafed]). The topical route (drops and sprays) causes fewer side effects than oral administration; however, the use of drops and sprays should be limited to a few days to avoid rebound congestion.

The nurse is preparing a teaching plan for a client with an immunodeficiency. What aspect would the nurse emphasize as most important? Frequent and thorough handwashing Identifying the signs and symptoms of infection Incorporation of treatment regimens into daily patterns Adherence to prophylactic medication administration

ANSWER 1 Although identifying the signs and symptoms of infection, adherence to medication prophylaxis, and incorporation of treatment regimens into daily patterns are important, the most important aspect is frequent and thorough handwashing to prevent infection. If infection is prevented, signs and symptoms will not develop and medications would not necessarily be needed.

A child is brought to the clinic with a rash and is subsequently diagnosed with measles. The parent reports also having had measles as a young child. What type of immunity to measles develops after the initial infection? Naturally acquired active immunity Artificially acquired passive immunity Artificially acquired active immunity Naturally acquired passive immunity

ANSWER 1 Immunity to measles that develops after the initial infection is an example of naturally acquired active immunity. Artificially acquired active immunity results from the administration of a killed or weakened microorganism or toxoid (attenuated toxin), whereas passive immunity develops when ready-made antibodies are given to a susceptible client.

A nurse is teaching a client who was recently diagnosed with carpal tunnel syndrome. Which statement should the nurse include? "Surgery is the only sure way to manage this condition." "Using arm splints will prevent hyperflexion of the wrist." "This condition is associated with various sports." "Ergonomic changes can be incorporated into your workday to reduce stress on your wrist."

ANSWER 4

After a fracture, during which stage or phase of bone healing is devitalized tissue removed and new bone reorganized into its former structural arrangement? Remodeling Inflammation Reparative Revascularization

answer 1 Remodeling is the final stage of fracture repair. During inflammation, macrophages invade and debride the fracture area. Revascularization occurs within about 5 days after a fracture. Callus forms during the reparative stage but is disrupted by excessive motion at the fracture site.

A nurse assesses a client in the health care provider's office. Which assessment findings support a suspicion of systemic lupus erythematosus (SLE)? Weight gain, hypervigilance, hypothermia, and edema of the legs Photosensitivity, polyarthralgia, and painful mucous membrane ulcers Hypothermia, weight gain, lethargy, and edema of the arms Facial erythema, pericarditis, pleuritis, fever, and weight loss

answer 4 An autoimmune disorder characterized by chronic inflammation of the connective tissues, SLE causes fever, weight loss, malaise, fatigue, skin rashes, and polyarthralgia. Nearly half of clients with SLE have facial erythema, (the classic butterfly rash). SLE also may cause profuse proteinuria (excretion of more than 0.5 g/day of protein), pleuritis, pericarditis, photosensitivity, and painless mucous membrane ulcers. Weight gain, hypervigilance, hypothermia, and edema of the legs and arms don't suggest SLE.

A female client comes to the clinic and tells the nurse, "I think I have another vaginal infection and I also have some wart-like lesions on my vagina. This is happening quite often." Which nursing action is the priority for this client? Recommend abstinence or safer-sex practices. Offer information on human immunodeficiency virus (HIV) testing. Provide a prescribed topical antifungal agent to treat the client's vaginal infection. Refer the client to a support group with others experiencing the same symptoms.

ANSWER 1 In women, gynecologic problems may be the focus of the chief complaint for clients who are HIV positive but not yet diagnosed. Abnormal results of Papanicolaou tests, genital warts, pelvic inflammatory disease, and persistent vaginitis may also correlate with HIV infection. Based on this information, the priority nursing action is to offer information on HIV testing to the client. Although recommending abstinence or safer-sex practices, providing a prescribed topical antifungal agent to treat the client's vaginal infection, and referring to a support group may be appropriate, the priority is to determine the source of the client's symptoms.

A laboring mother asks the nurse if the baby will have immunity to some illnesses when born. What type of immunity does the nurse understand that the newborn will have? Passive immunity transferred by the mother Naturally acquired active immunity There is no immunity passed down from mother to child. Artificially acquired active immunity

ANSWER 1 Passive immunity develops when ready-made antibodies are given to a susceptible person. The antibodies provide immediate but short-lived protection from the invading antigen. Newborns receive passive immunity to some diseases for which their mothers have manufactured antibodies. Naturally acquired active immunity occurs as a direct result of infection by a specific micro organism. An example is the immunity to measles that develops after the initial infection. Not all invading microorganisms produce a response that gives lifelong immunity. Artificially acquired immunity is obtained by receiving a killed or weakened microorganism or toxoid.

A nurse is explaining treatment options to a client diagnosed with an immune dysfunction. Which statement by the client accurately reflects the teaching about current stem cell research? "Stem cell transplantation has been carried out in humans with certain types of immune dysfunction, and clinical trials using stem cells are underway in clients with a variety of disorders with an autoimmune component." "Stem cell transplantation has been discontinued based on concerns about safety, efficacy, resource allocation, and human cloning." "Currently, stem cell transplantation has only been performed in the laboratory, but future research with embryonic stem cell transplants for humans with immune dysfunction has been promising." "Stem cell clinical trials have only been attempted in clients with acquired immune deficiencies, but plans are underway to begin human cloning using embryonic stem cells."

ANSWER 1 Research has shown that stem cells can restore an immune system that has been destroyed (Ko, 2012). Stem cell transplantation has been carried out in humans with certain types of immune dysfunction, such as severe combined immunodeficiency; clinical trials using stem cells are underway in clients with a variety of disorders having an autoimmune component, including systemic lupus erythematosus, rheumatoid arthritis, scleroderma, and multiple sclerosis. Research with embryonic stem cells has enabled investigators to make substantial gains in developmental biology, gene therapy, therapeutic tissue engineering, and the treatment of a variety of diseases (Ko, 2012). However, along with these remarkable opportunities, many ethical challenges arise, which are largely based on concerns about safety, efficacy, resource allocation, and human cloning.

The nurse is completing the intake assessment of a client new to the allergy clinic. The client states that he was taking nose drops six times a day to relieve his nasal congestion. The nasal congestion increased, causing him to increase his usage of the nasal spray to eight times a day. But again the congestion worsened. The nurse communicates to the health care provider that the client experienced Rhinitis medicamentosa Atopic dermatitis Tolerance to nose drops Leukotriene modifier

ANSWER 1 Rhinitis medicamentosa is a rebound reaction from overuse of sympathomimetic nose drops or sprays that worsen the congestion, causing the client to use more of the medication, thereby leading to more nasal congestion. This differs from tolerance, when more medication is needed to achieve the desired effect. Leukotriene modifiers are a category of medications used to treat allergies. Atopic dermatitis is a type I hypersensitivity involving inflammation of the skin evidenced by itching, erythema, and skin lesions.

A nurse is teaching a client about allergic rhinitis. What client statements indicate teaching has been effective? Select all that apply. "I should use my medication for allergy exacerbation only when my allergy is apparent." "I will remove as much carpet from my house as I can." "I can only have one alcoholic drink while I am taking my antihistamine." "I am allowed to miss only one desensitization appointment before my treatment is affected." "I need to reduce my exposure to people that have upper respiratory infections."

ANSWER 1-2-5 The client should only use their medication when allergy is apparent so they do not develop a tolerance, which can occur when the medication is used all the time. The client should reduce their exposure to people that have upper respiratory infections because they are more susceptible to getting sick. Removing as much carpet from the house as possible will help reduce allergens. The client cannot miss any desensitization appointments because it will interfere with dosage adjustments. While taking an antihistamine, alcohol cannot be consumed at all, as antihistamines can exaggerate the effects of alcohol.

A client is diagnosed with severe combined immunodeficiency (SCID). What would the nurse expect to integrate into the client's plan of care? Administration of granulocyte colony-stimulating factors Preparation for bone marrow transplantation Preparation for a thymus graft Administration of antifungal agents

ANSWER 2 For a client with severe combined immunodeficiency (SCID), the nurse would include in the plan of care preparing the client for a bone transplant. Antifungal agents are used to treat chronic mucocutaneous candidiasis. Granulocyte-stimulating factors would be used to treat immunodeficiency related to phagocytic dysfunction. A thymus graft would be used to treat DiGeorge syndrome.

The nurse is obtaining an assessment and health history from the parents of a 6-month-old infant with an elevated temperature. Which statement by the parents alerts the nurse to a possible immunodeficiency disorder? "I usually feed the baby a bottle every 4 to 6 hours during the day." "This is the third infection with a high fever the baby has had in the past month." "My husband's family has a history of hemophilia; could this be the problem?" "I had a good prenatal care and vaginal birth, although they had to use forceps."

ANSWER 2 Infants with X-linked agammaglobulinemia usually become symptomatic after the natural loss of maternally transmitted immunoglobulins, which occurs at about 5 to 6 months of age. Symptoms of recurrent pyogenic infections usually occur by that time.

The nurse is administering intravenous vancomycin. What will the nurse initially assess the client for if an allergic reaction occurs? hypotension and tachycardia dyspnea, bronchospasm, and/or laryngeal edema the presence and location of pruritus the severity of cutaneous warmth and flushing

ANSWER 2 Initial nursing assessment and intervention needs to be directed toward evaluating breathing and maintaining an open airway, so the initial assessment will be for dyspnea, bronchospasm, and laryngeal edema. Hypotension, pruritis, and flushing may occur, but the airway is most important.

The nurse is teaching a client about allergic rhinitis and its triggers. What is the most common trigger for the respiratory allergic response? dust mites plant pollen mold spores animal dander

ANSWER 2 Plant pollen (from trees, grass, and other plants) causes the most common form of allergic rhinitis, which is known as hay fever. Animal dander, dust mites, and mold spores can be triggers, but are not the most common causes.

Which adverse effect(s) should the nurse closely monitor in a client who has secondary immunodeficiencies due to immunosuppressive therapy? Rheumatoid arthritis Respiratory or urinary system infections Depression, memory impairment, and coma Cardiac dysrhythmias and heart failure

ANSWER 2 Secondary immunodeficiencies occur as a result of underlying disease processes or the treatment of these disorders, including administration of immunosuppressive agents. Abnormalities of the immune system affect both natural and acquired immunity. Because immunodeficiencies result in a compromised immune system and pose a high risk for infection, careful assessment of the client's immune status is essential. The nurse assesses and monitors the client for signs and symptoms of infection.

The nurse observes diffuse swelling involving the deeper skin layers in a client who has experienced an allergic reaction. The nurse would correctly document this finding as contact dermatitis. angioneurotic edema. pitting edema. urticaria.

ANSWER 2 The area of skin demonstrating angioneurotic edema may appear normal but often has a reddish hue and does not pit. Urticaria (hives) is characterized as edematous skin elevations that vary in size and shape, itch, and cause local discomfort. Contact dermatitis refers to inflammation of the skin caused by contact with an allergenic substance such as poison ivy. Pitting edema is the result of increased interstitial fluid and associated with disorders such as congestive heart failure.

A client reports to a health care provider's office for intradermal allergy testing. Before testing, the nurse provides client teaching. Which client statement indicates a need for further education? "The test may be mildly uncomfortable." "If I notice tingling in my lips or mouth, gargling may help the symptoms." "I may experience itching and irritation at the site of the testing." "I'll go directly to the pharmacy with my EpiPen prescription."

ANSWER 2 The client requires further teaching if the client states, "I will gargle to help alleviate tingling in the lips or mouth." Allergy testing introduces potentially irritating substances to the client. Tingling in the mouth, lips, or throat indicates the onset of a severe reaction and the need for immediate medical intervention. The testing may cause irritation and itching at the test site. The health care provider may order an epinephrine pen (EpiPen) for the client to self-administer epinephrine if the client experiences an allergic reaction away from the office setting.

A 38-year-old client has been diagnosed with rheumatoid arthritis, an autoimmune disease. During the health history assessment. the nurse learns that the client works as an aide at a facility that cares for children infected with AIDS, does moderate cardiovascular exercises every other day, takes no medication, has no allergies, and eats mainly a vegetarian diet with fish and chicken one to two times each week. Which factor is the most important consideration in determining the status of the client's immune system? Environment Gender Age Diet

ANSWER 2 The immune system functions of men and women differ. For example, many autoimmune diseases have a higher incidence in females than in males, a phenomenon believed to be correlated with sex hormones. Autoimmune diseases tend to be more common in women because estrogen tends to enhance immunity. Androgen, on the other hand, tends to be immunosuppressive. Autoimmune diseases are a leading cause of death by disease in females of reproductive age.

The nurse is teaching a group of health care workers about latex allergies. What reaction will the nurse teach the workers to be most concerned about with laryngeal edema? irritant contact IgG antibodies IgE-mediated hypersensitivity allergic contact

ANSWER 3 A type I, IgE-mediated hypersensitivity can cause severe reaction symptoms such as laryngeal edema and bronchospasm. Irritant and allergic contact dermatitis result in more localized skin reactions. IgG antibodies are important in fighting viral and bacterial infections.

An infant is born to a mother who had no prenatal care during her pregnancy. What type of hypersensitivity reaction does the nurse understand may have occurred? Bacterial endocarditis Rheumatoid arthritis Rh-hemolytic disease Lupus erythematosus

ANSWER 3 A type II hypersensitivity, or cytotoxic, reaction, which involves binding either the IgG or IgM antibody to a cell-bound antigen, may lead to eventual cell and tissue damage. The reaction is the result of mistaken identity when the system identifies a normal constituent of the body as foreign and activates the complement cascade. Examples of type II reactions are myasthenia gravis, Goodpasture syndrome, pernicious anemia, hemolytic disease of the newborn, transfusion reaction, and thrombocytopenia.

A patient asks the nurse if it would be all right to take an over-the-counter antihistamine for the treatment of a rash. What should the nurse educate the patient is a major side effect of antihistamines? Palpitations Anorexia Sedation Diarrhea

ANSWER 3 Antihistamines are the major class of medications prescribed for the symptomatic relief of allergic rhinitis. The major side effect is sedation, although H1 antagonists are less sedating than earlier antihistamines.

The nurse is caring for a client who has a diagnosis of human immunodeficiency virus (HIV). Part of this client's teaching plan is educating the client about his or her medications. What is essential for the nurse to include in the teaching of this client regarding medications? What vaccinations to have The action of each antiretroviral drug Side effects of drug therapy The use of condoms

ANSWER 3 Describing the side effects of drug therapy is essential, with the admonition to refrain from discontinuing any of the prescribed drugs without first consulting the prescribing physician. Although the client may want to know how the drugs work in general, the specific action of each antiretroviral drug is not essential information. Teaching about condoms and vaccinations may be appropriate, but these topics are not directly related to the client's HIV medications.

The nurse is caring for a young client who has agammaglobulinemia. The nurse is teaching the family how to avoid infection at home. Which statement by the family indicates that additional teaching is needed? "I will let my neighbor have my pet iguana." "I will apply lotion following every bath to prevent dry skin." "I can take my child to the beach, as long as we play in the sand rather than swim in the water." "I will avoid letting my child drink any juice that has been sitting out for more than an hour."

ANSWER 3 Parents should verbalize ways to plan for regular exercise and activity that does not pose a risk of infections. Immunocompromised clients should avoid touching sand or soil because of the high level of bacteria and increased risk of diseases such as toxoplasmosis.

A laboring mother asks the nurse if the baby will have immunity to some illnesses when born. What type of immunity does the nurse understand that the newborn will have? Naturally acquired active immunity Artificially acquired active immunity Passive immunity transferred by the mother There is no immunity passed down from mother to child.

ANSWER 3 Passive immunity develops when ready-made antibodies are given to a susceptible person. The antibodies provide immediate but short-lived protection from the invading antigen. Newborns receive passive immunity to some diseases for which their mothers have manufactured antibodies. Naturally acquired active immunity occurs as a direct result of infection by a specific micro organism. An example is the immunity to measles that develops after the initial infection. Not all invading microorganisms produce a response that gives lifelong immunity. Artificially acquired immunity is obtained by receiving a killed or weakened microorganism or toxoid.

A client with a musculoskeletal injury is instructed to alter the diet. The objective of altering the diet is to facilitate the absorption of calcium from food and supplements. Considering the food intake objective, which food item should the nurse encourage the client to include in the diet? Bananas Red meat Vitamin D-fortified milk Green vegetables

ANSWER 3 The nurse should advise the client to include dietary sources of vitamin D, such as fatty fish, vitamin D-fortified milk, and cereals. These foods protect against bone loss and decrease the risk of fracture by facilitating the absorption of calcium from food and supplements. Red meat, bananas, and green vegetables do not facilitate calcium absorption from food and supplements

A client undergoing a skin test has been intradermally injected with a disease-specific antigen on the inner forearm. The client becomes anxious because the area begins to swell. Which technique may be used to decrease anxiety in this client? Apply ice packs to reduce the swelling Gently rub the swollen area to accelerate blood flow Assure the client that this is a normal reaction Advise the client to use prescribed analgesics

ANSWER 3 The nurse should assure the client that this is a normal reaction. When disease-specific antigens are injected, the injection area swells as a result of the client developing antibodies against the antigen that is introduced. The nurse should also keep in mind that the client is not necessarily actively infectious if the test result is positive. Rubbing the area gently or even applying ice packs may only aggravate the swelling. The swollen area should be left open to heal by itself. The nurse should await the physician's instructions before advising the client to use any prescribed analgesics.

The client presents to the emergency department with a suspected allergic reaction to the antibiotic they were given at the quick care clinic to treat their pneumonia. What are the priority actions the nurse should take? Select all that apply. Administer Vitamin K. Evaluate for hypertension. Place oxygen on the client. Insert an intravenous line. Take vital signs. Check for diplopia.

ANSWER 3-4-5 Hypertension is seen in clients with cardiac and stroke. The nurse would see hypotension caused by dilation of blood vessels. Inserting an intravenous line should be done in case the client needs to be given medications or fluids. Vitamin K is administered to reverse the effects of Coumadin, not for an allergic reaction. Taking vital signs is important to determine if they are normal or require treatment. Placing oxygen on a client will help relieve dyspnea caused by constriction of airways, and swollen tongue and throat. Diplopia would be seen in clients with muscular disorders, neurological disorders, and migraines.

The nurse receives a phone call at the clinic from the family of a client with AIDS. They state that the client started "acting funny" and reported headache, tiredness, and a stiff neck. Checking the temperature resulted in a fever of 103.2°F. What should the nurse inform the family member? "The client probably has a case of the flu and you should give acetaminophen." "This is one of the side effects from antiretroviral therapy and will require changing the medication." "The client probably has pneumocystis pneumonia and will need to be evaluated by the health care provider." "The client may have cryptococcal meningitis and will need to be evaluated by the health care provider."

ANSWER 4 A fungal infection, Cryptococcus neoformans is another common opportunistic infection among clients with AIDS, and it causes neurologic disease. Cryptococcal meningitis is characterized by symptoms such as fever, headache, malaise, stiff neck, nausea, vomiting, mental status changes, and seizures.

A client is admitted to the hospital with a diagnosis of pneumonia. The client informs the nurse of having several drug allergies. The physician has ordered an antibiotic as well as several other medications for cough and fever. What should the nurse do prior to administering the medications? Give the client one medicine at a time and observe for allergic reactions. Call the pharmacy and let them know the client has several drug allergies. Administer the medications that the physician ordered. Consult drug references to make sure the medicines do not contain substances which the client is hypersensitive.

ANSWER 4 Clear identification of any substances to which the client is allergic is essential. The nurse must consult drug references to verify that prescribed medications do not contain substances to which the client is hypersensitive. Administering the medications or giving one at a time may cause the client to have an allergic reaction. The nurse may call the pharmacy but still maintains responsibility for the medications administered.

Morton neuroma is exhibited by which clinical manifestation? Inflammation of the foot-supporting fascia Longitudinal arch of the foot is diminished High arm and a fixed equinus deformity Swelling of the third (lateral) branch of the median plantar nerve

ANSWER 4 Morton neuroma is swelling of the third branch of the median plantar nerve. Pes cavus refers to a foot with an abnormally high arch and a fixed equinus deformity of the forefoot. Flatfoot is a common disorder in which the longitudinal arch of the foot is diminished. Plantar fasciitis is an inflammation of the foot-supporting fascia.

A client has had a splenectomy after sustaining serious internal injuries in a motorcycle accident, including a ruptured spleen. Following removal of the spleen, the client will be susceptible to: bleeding because the spleen synthesizes vitamin K. anemia because the spleen produces red blood cells. acidosis because the spleen maintains acid-base balance. infection because the spleen removes bacteria from the blood.

ANSWER 4 One function of the spleen is to remove bacteria from circulation; therefore, the client will be more susceptible to infection.

The nurse is taking the health history of a newly admitted client. Which condition would place the client at risk for impaired immune function? Negative history for radiation therapy Surgical removal of the appendix Surgical history of a partial gastrectomy Previous organ transplantation

ANSWER 4 Organ transplantation requires immunosuppressive drugs, which cause impaired immune function. Removal of the appendix or stomach would have no effect on the immune system. A positive history for radiation therapy would affect the immune system, but not a negative history.

An older adult client slipped on an area rug at home and fractured the left hip. The client is unable to have surgery immediately and is having severe pain. What interventions should the nurse provide for the patient to minimize energy loss in response to pain? Avoid administering too much medication because the client is older. Give pain medication to the client after providing care. Administer prescribed pain medication only when the client requests it. Administer prescribed analgesics around-the-clock.

ANSWER 4 Pain associated with hip fracture is severe and must be carefully managed with around-the-clock dosing of pain medication to minimize energy loss in response to pain. The client may not request the medication even if they are in pain, and it should be offered at the prescribed time. Give pain medication prior to providing any type of care involved in moving the client.

The nurse is caring for a young client who has agammaglobulinemia. The nurse is teaching the family how to avoid infection at home. Which statement by the family indicates that additional teaching is needed? "I will apply lotion following every bath to prevent dry skin." "I will avoid letting my child drink any juice that has been sitting out for more than an hour." "I will let my neighbor have my pet iguana." "I can take my child to the beach, as long as we play in the sand rather than swim in the water."

ANSWER 4 Parents should verbalize ways to plan for regular exercise and activity that does not pose a risk of infections. Immunocompromised clients should avoid touching sand or soil because of the high level of bacteria and increased risk of diseases such as toxoplasmosis.

Which statement accurately reflects current stem cell research? Stem cell transplantation cannot restore immune system functioning. Stem cell transplantation has been performed in the laboratory only. Clinical trials are underway only in clients with acquired immune deficiencies. The stem cell is known as a precursor cell that continually replenishes the body's entire supply of both red and white cells.

ANSWER 4 The stem cell is known as a precursor cell that continually replenishes the body's entire supply of both red and white cells. Stem cells comprise only a small portion of all types of bone marrow cells. Research conducted with mouse models has demonstrated that once the immune system has been destroyed experimentally, it can be completely restored with the implantation of just a few purified stem cells. Stem cell transplantation has been carried out in human subjects with certain types of immune dysfunction, such as severe combined immunodeficiency. Clinical trails are underway in clients with a variety of disorders with an autoimmune component, including systemic lupus erythematosus, rheumatoid arthritis, scleroderma, and multiple sclerosis.

A client has had a "stuffy nose" and obtained an oxymetazoline nasal spray. What education should the nurse provide to the client in order to prevent "rebound congestion"? Drink plenty of fluids. Use the medication every 4 hours to prevent congestion from recurring. Be sure to use the nasal spray for at least 10 days to ensure the stuffiness is gone. Only use the nasal spray for 3 to 4 days once every 12 hours.

ANSWER 4 Adrenergic agents, which are vasoconstrictors of mucosal vessels, are used topically in nasal (oxymetazoline [Afrin]) and ophthalmic (brimonidine [Alphagan P]) formulations in addition to the oral route (pseudoephedrine [Sudafed]). The topical route (drops and sprays) causes fewer side effects than oral administration; however, the use of drops and sprays should be limited to a few days to avoid rebound congestion.

The nurse suspects "compartment syndrome" for a casted extremity. What characteristic symptoms would the nurse assess that would confirm these suspicions? (Select all that apply.) Capillary refill less than 3 seconds Decreased sensory function Excruciating pain 2+ peripheral pulses in the affected distal pulse Loss of motion

Answer 2-3-5

A client is admitted to the emergency room after being hit by a car while riding a bicycle. The client sustained a fracture of the left femur, and the bone is protruding through the skin. What type of fracture does the nurse recognize requires emergency intervention? Compound Oblique Spiral Greenstick

answer 1 A compound fracture is a fracture in which damage also involves the skin or mucous membranes with the risk of infection great. A greenstick fracture is where one side of the bone is broken and the other side is bent; it does not protrude through the skin. An oblique fracture occurs at an angle across the bone but does not protrude through the skin. A spiral fracture twists around the shaft of the bone but does not protrude through the skin.

After undergoing surgery the previous day for a total knee replacement, a client states, "I am not ready to ambulate yet." What should the nurse do? Discuss the complications that the client may experience if there is lack of cooperation with the care plan. Tell the client that this noncompliance will be reported to the health care provider. Do nothing because the client has the ultimate right to determine the degree of participation. Document the client's refusal to ambulate.

answer 1 A culture should be obtained if purulent drainage is present. Drainage should be gently removed, not scrubbed. Iodine-based products interfere with tissue healing and are not recommended for cleaning pin sites. Ointment should not be applied to the pin site unless specifically ordered.

The nurse is caring for a client with an external fixator that requires pin care twice a day. The nurse observes that there is a new purulent drainage around one of the pins. What intervention should the nurse anticipate doing? Obtaining a culture Apply ointment to the pin site. Applying iodine-based solution Scrubbing the drainage from around the pin site

answer 1 A culture should be obtained if purulent drainage is present. Drainage should be gently removed, not scrubbed. Iodine-based products interfere with tissue healing and are not recommended for cleaning pin sites. Ointment should not be applied to the pin site unless specifically ordered.

A patient will be having an endoscopic procedure with a diagnostic biopsy. What type of biopsy does the nurse explain will remove an entire piece of suspicious tissue? Excisional biopsy Incisional biopsy Punch biopsy Needle biopsy

answer 1 Excisional biopsy is most frequently used for small, easily accessible tumors of the skin, breast, and upper or lower gastrointestinal and upper respiratory tracts. In many cases, the surgeon can remove the entire tumor as well as the surrounding marginal tissues. The removal of normal tissue beyond the tumor area decreases the possibility that residual microscopic malignant cells may lead to a recurrence of the tumor. Incisional biopsy is performed if the tumor mass is too large to be removed. In this case, a wedge of tissue from the tumor is removed for analysis. Needle biopsy is performed to sample suspicious masses that are easily and safely accessible, such as some masses in the breasts, thyroid, lung, liver, and kidney. A core needle biopsy uses a specially designed needle to obtain a small core of tissue that permits histologic analysis.

A client is to have an amputation. The client is acutely ill and diagnosed with a gangrenous limb and related fever, disorientation, and electrolyte imbalances. Which of the following would be most important for the nurse to monitor in this client? Signs of sepsis Reduced urine output Occurrence of allergic reactions Signs of nausea and vomiting

answer 1 If the client is acutely ill with a gangrenous limb, related fever, disorientation, and electrolyte imbalances, the nurse should monitor for signs of sepsis and circulation in the limb for any changes such as severe pain, color changes, and lack of peripheral pulses. It is crucial for the nurse to inform the physician about the problems as they occur or else the surgery may become an emergency. Monitoring for signs of nausea and vomiting, occurrence of allergic reactions, and reduced urine output, although necessary, is not as crucial for the client.

The nurse is teaching a client about rheumatic disease. What statement best helps to explain autoimmunity? "Your symptoms are a result of your body attacking itself." "You have antigens to the disease, but they do not prevent the disease." "You have inherited your parent's immunity to the disease." "You are not immune to the disease causing the symptoms."

answer 1 In autoimmunity, the body mistakes its own tissue for foreign tissue and begins to attack it. Symptoms develop as the body destroys tissue. The body is in effect attacking itself. The other statements do not explain autoimmunity.

A patient sustains a fracture of the arm. When does the nurse anticipate pendulum exercise should begin? As soon as tolerated, after a reasonable period of immobilization In 2 to 3 weeks, when callus ossification prevents easy movements of bony fragments In 2 to 3 months, after normal activities are resumed In about 4 to 5 weeks, after new bone is well established

answer 1 Many impacted fractures of the surgical neck of the humerus are not displaced and do not require reduction. The arm is supported and immobilized by a sling and swathe that secure the supported arm to the trunk (Fig. 43-10). Limitation of motion and stiffness of the shoulder occur with disuse. Therefore, pendulum exercises begin as soon as tolerated by the patient. In pendulum or circumduction exercises, the physical therapist instructs the patient to lean forward and allow the affected arm to hang in abduction and rotate. These fractures require approximately 4 to 10 weeks to heal, and the patient should avoid vigorous arm activity for an additional 4 weeks. Residual stiffness, aching, and some limitation of ROM may persist for 6 months or longer (NAON,

A patient is admitted for an excisional biopsy of a breast lesion. What intervention should the nurse provide for the care of this patient? Provide time for the patient to discuss her concerns. Counsel the patient about the possibility of losing her breast. Provide aseptic care to the incision postoperatively. Clarify information provided by the physician.

answer 1 Patients who are undergoing surgery for the diagnosis or treatment of cancer may be anxious about the surgical procedure, possible findings, postoperative limitations, changes in normal body functions, and prognosis. The patient and family require time and assistance to process the possible changes and outcomes resulting from the surgery. The nurse serves as the patient advocate and liaison and encourages the patient and family to take an active role in decision making when possible. If the patient or family asks about the results of diagnostic testing and surgical procedures, the nurse's response is guided by the information that was conveyed previously. The nurse may be asked to explain and clarify information for patients and families that was provided initially but was not grasped because of anxiety and overwhelming feelings. It is important that the nurse, as well as other members of the health care team, provide information that is consistent from one clinician to another.

A client with arterial insufficiency undergoes below-knee amputation of the right leg. Which action should the nurse include in the postoperative care plan? Elevating the stump for the first 24 hours Maintaining the client on complete bed rest Applying heat to the stump as the client desires Removing the pressure dressing after the first 8 hours

answer 1 Stump elevation for the first 24 hours after surgery helps reduce edema and pain by increasing venous return and decreasing venous pooling at the distal portion of the extremity. Bed rest isn't indicated and could predispose the client to complications of immobility. Heat application would be inappropriate because it promotes vasodilation, which may cause hemorrhage and increase pain. The initial pressure dressing usually remains in place for 48 to 72 hours after surgery.

The nurse is performing a health history with a new client with fibromyalgia. What will the nurse expect to assess as the most common finding associated with fibromyalgia? widespread chronic pain jaw locking butterfly facial rash Heberden nodes

answer 1 The most common finding associated with fibromyalgia is widespread and chronic pain. Heberden nodes are associated with osteoarthritis. Jaw locking is a manifestation of temporomandibular joint dislocation. A butterfly facial rash is associated with systemic lupus erythematosus.

Two days after surgery to amputate the left lower leg, a client reports pain in the missing extremity. Which action by the nurse is most appropriate? Administer medication, as ordered, for the reported discomfort. Do nothing because it isn't possible to have pain in a missing limb. Initiate a consult with a psychologist. Contact the health care provider.

answer 1 The sensation of pain and discomfort in an amputated extremity is known as phantom pain. Phantom pain is a normal occurrence after an amputation. It should be treated with medication. The nurse doesn't need to contact the health care provider at this time. Consultation with the psychologist isn't indicated, and the nurse shouldn't take this action without consulting the health care provider.

A client with an autoimmune disorder asks, "Why is autoimmune disease more prevalent in the women in my family?" Which response will the nurse make to this client? "It's believed to be caused by the differences in the sex hormones." "It's because you take better care of your family than yourself." "There is not enough evidence to prove this." "Women have more stress than men and it weakens immunity."

answer 1 There are differences in the immune system functions of men and women. Research has revealed that sex hormones are integral signaling modulators of the immune system and the presence of autoimmune disease. Sex hormones play definitive roles in lymphocyte maturation, activation, and synthesis of antibodies and cytokines. Even though some autoimmune diseases are genetically linked, overall men do not have stronger genes than women. There is no evidence that the client relinquishes self-care for family care. Even though stress influences immunity, there is no evidence that women have more stress than men.

A client suspected of having systemic lupus erythematosus (SLE) is being scheduled for testing. The client asks which of the tests ordered will determine positivity for the disorder. Which statement by the nurse is most accurate? "The diagnosis won't be based on the findings of a single test but by combining all data found." "Tell me more about your concerns about this potential diagnosis." "SLE is a very serious systemic disorder." "You should discuss that matter with your health care provider."

answer 1 There is no single test available to diagnose SLE. Therefore, the nurse should inform the client that diagnosis is based on combining the findings from the physical assessment and the laboratory tests results. Advising the client to speak with the health care provider, stating that SLE is a serious systemic disorder, and asking the client to express feelings about the potential diagnosis do not answer the client's question.

A nurse assesses an oncology client with stomatitis during a chemotherapy session. Which nursing intervention would most likely decrease the pain associated with stomatitis? Provide a solution of viscous lidocaine for use as a mouth rinse. Recommend that the client discontinue chemotherapy. Check regularly for signs and symptoms of stomatitis. Monitor the client's platelet and leukocyte counts.

answer 1 To decrease the pain of stomatitis, the nurse should provide a solution of viscous lidocaine for the client to use as a mouth rinse. (Commercially prepared mouthwashes contain alcohol and may cause dryness and irritation of the oral mucosa.) The nurse also may administer systemic analgesics as ordered. Stomatitis occurs 7 to 10 days after chemotherapy begins; thus, stopping chemotherapy wouldn't be helpful or practical. Instead, the nurse should stay alert for this potential problem to ensure prompt treatment. Monitoring platelet and leukocyte counts may help prevent bleeding and infection, but wouldn't decrease pain in this highly susceptible client. Checking for signs and symptoms of stomatitis also wouldn't decrease the pain.

The nurse is caring for the client with chronic osteomyelitis of the jaw with a draining wound. Which client goal is a priority for the client? Select all that apply. The client will experience a tolerable level of pain. The client will demonstrate wound care. The client will maintain adequate nutritional intake. The client will maintain effective airway clearance. The client will remain free from injury.

answer 1-2-3 Pain is a priority problem for the client with osteomyelitis, and it can interfere with mobility of joint. In this situation, the client's jaw is the site of infection. Pain in this location can interfere with nutritional intake of the individual. Chronic osteomyelitis presents with a nonhealing ulcer over the infected bone with a connecting sinus that will intermittently and spontaneously drain pus. The client will need to be able to provide wound care in the home setting. Remaining free from injury and maintaining an effective airway clearance are not priority goals for the client.

A client with an arm cast reports pain. What nursing interventions should the nurse provide in order to reduce the incidence of complications? Select all that apply. Determine the exact site of the pain. Assess for a pressure sore Administer a prescribed analgesic to promote comfort and allay anxiety. Cut the cast with a cast saw Assess the fingers for color and temperature.

answer 1-2-5 Neurovascular assessment includes the assessment of peripheral circulation, motion, and sensation of the affected extremity, assessing the fingers or toes of the affected extremity, and comparing them with those of the opposite extremity. When assessing peripheral circulation, the nurse must check peripheral pulses as well as capillary refill response (within 3 seconds), edema, and the color and temperature of the skin. The nurse must carefully evaluate pain associated with the musculoskeletal condition, asking the client to indicate the exact site and to describe the character and intensity of the pain using a pain rating scale. Severe burning pain over bony prominences, especially the heels, anterior ankles, and elbows, warns of an impending pressure ulcer.

A nurse is caring for a client who is receiving chemotherapy and has a platelet count of 30,000/mm3. Which statement by the client indicates a need for additional teaching? "I take a stool softener every morning." "I floss my teeth every morning." "I removed all the throw rugs from the house." "I use an electric razor to shave."

answer 2 A client with a platelet count of 30,000/mm3 is at risk for bleeding and shouldn't floss his teeth. Flossing may increase the risk of bleeding in a client with a platelet count less than 40,000/mm3. Using an electric razor is appropriate because doing so helps minimize the risk of cutting when shaving. Taking a stool softener helps decrease potential trauma to the GI tract that may cause bleeding. Removing throw rugs from the house helps prevent falls, which could lead to uncontrolled bleeding.

A patient is having low back pain. What position can the nurse suggest to relieve this discomfort? Supine, with the bed flat and a firm mattress in place Supine, with the knees slightly flexed and the head of the bed elevated 30 degrees High-Fowler's to allow for maximum hip flexion Prone, with a pillow under the shoulders

answer 2 A medium to firm, not sagging mattress (a bed board may be used) is recommended; there is no evidence to support the use of a firm mattress (National Guideline Clearinghouse, 2010). Lumbar flexion is increased by elevating the head and thorax 30 degrees by using pillows or a foam wedge and slightly flexing the knees supported on a pillow. Alternatively, the patient can assume a lateral position with knees and hips flexed (curled position) with a pillow between the knees and legs and a pillow supporting the head (Fig. 42-1). A prone position should be avoided because it accentuates lordosis.

A client comes to the emergency department and it is found that the client's radial head is partially dislocated. What is this partially dislocated radial head documented as? Volkmann's contracture Subluxation Sprain Compartment syndrome

answer 2 A partial dislocation is referred to as a subluxation. A Volkmann's contracture is a claw like deformity that results from compartment syndrome or obstructed arterial blood flow to the forearm and hand. Compartment syndrome is a condition in which a structure such as a tendon or nerve is constricted in a confined space and affects nerve innervation, leading to subsequent palsy. A sprain is injury to the ligaments surrounding the joint.

For a client newly diagnosed with radiation-induced thrombocytopenia, the nurse should include which intervention in the care plan? Placing the client in strict isolation Inspecting the skin for petechiae once every shift Providing for frequent rest periods Administering aspirin if the temperature exceeds 102° F (38.8° C)

answer 2 Because thrombocytopenia impairs blood clotting, the nurse should inspect the client regularly for signs of bleeding, such as petechiae, purpura, epistaxis, and bleeding gums. The nurse should avoid administering aspirin because it may increase the risk of bleeding. Frequent rest periods are indicated for clients with anemia, not thrombocytopenia. Strict isolation is indicated only for clients who have highly contagious or virulent infections that are spread by air or physical contact.

A client with a right leg fracture is returning to the orthopedist to have the cast removed. During cast removal, it is important for the nurse to assure: that pedal pulses are present. the client that he or she won't be cut. that the leg will be as good as new. that the cast cutter blade is new.

answer 2 Casts are removed with a mechanical cast cutter. Cast cutters are noisy and frightening but the blade does not penetrate deep enough to cut the client. The client needs reassurance that the machine will not cut into the skin. The other options are either irrelevant or not something the nurse knows for certain at this time.

A client diagnosed with cancer makes the following statement to the nurse: "I guess I will tell my health care provider to forego the chemotherapy. I do not want to be throwing up all the time. I would rather die." Which of the following facts supports the use of chemotherapy for this client? Nausea and vomiting are only a factor for the first 24 hours after treatment. Chemotherapy treatment can be adjusted to optimize effects while limiting adverse effects. Clinical trials are opening up new cancer treatments all the time. Most clients believe the discomfort is well worth the cure for cancer.

answer 2 Chemotherapy is not one drug for all clients. The therapy can be specifically designed to optimize effects while limiting adverse effects with supplemental anti emetics to control the nausea and vomiting. It is true that nausea and vomiting are most prevalent in the first 24 hours after each chemotherapy treatment but this does not eliminate the fears expressed by this client. No one can state the worth of any treatment, and a cure is never promised. Clinical trials open up new options for treatment, but the process is lengthy and is not a certainty for a client in need of immediate treatment.

The oncology nurse is giving chemotherapy to a client in a short stay area. The client confides that they are very depressed. The nurse recognizes depression as which of the following? An aberrant psychologic reaction to the chemotherapy. A normal reaction to the diagnosis of cancer. A side effect of the neoplastic drugs. A psychiatric diagnosis everyone has at one time or another.

answer 2 Clients have many reactions, ranging from anxiety, fear, and depression to feelings of guilt related to viewing cancer as a punishment for past actions or failure to practice a healthy lifestyle. They also may express anger related to the diagnosis and their inability to be in control. While depression is understandable, it also needs to be acknowledged and treated if necessary. Depression is not a side effect of the neoplastic drugs nor is it an aberrant psychologic reaction to the chemotherapy.

A client is seen in the orthopedic clinic for complaints of severe pain in the left hip. After a series of diagnostic tests, the client is diagnosed with severe degenerative joint disease of the left hip and suggested to have the hip reconstructed. What procedure will the nurse schedule the client for? Left hip arthroscopy Left hip arthroplasty Closed reduction of the left hip. Open reduction and internal fixation of the left hip.

answer 2 Clients with arthritis, trauma, hip fracture, or a congenital deformity may have an arthroplasty, or reconstruction of the joint. This procedure uses an artificial joint that restores previously lost function and relieves pain. An arthroscopy is not used to reconstruct a diseased hip. A closed reduction is not an invasive surgical procedure and would not be used to reconstruct the hip. An open reduction and internal fixation is not the treatment for reconstruction of the hip related to a diseased hip.

You are the nurse caring for a client with cancer. The client complains of pain and nausea. When assessed, you note that the client appears fearful. What other factor must you consider when a client with cancer indicates signs of pain, nausea, and fear? High cholesterol levels Fatigue Ulceration Infection

answer 2 Clients with cancer experience fatigue, which is a side effect of cancer treatments that rest fails to relieve. The nurse must assess the client for other stressors that contribute to fatigue such as pain, nausea, fear, and lack of adequate support. The nurse works with other healthcare team members to treat the client's fatigue. The above indications do not contribute to infections, ulcerations, or high cholesterol levels.

A client with carpal tunnel syndrome has had limited improvement with the use of a wrist splint. The nurse knows that which procedure will show the greatest improvement in treatment for this client? Injection of lidocaine Open nerve release Laser therapy Ultrasound therapy

answer 2 Evidence-based treatment of acute carpal tunnel syndrome includes the application of splints to prevent hyperextension and prolonged flexion of the wrist. Should this treatment fail, open nerve release is a common surgical management option. A variety of treatments may be tried by the client, however, they may fail to improve the condition. These treatments include laser therapy, ultrasound therapy, and the injection of substances such as lidocaine. Though these can be used, surgery to release nerves is the best option.

Which nursing intervention is appropriate for a client with a closed-reduction extremity fracture? Use frequent dependent positioning to prevent edema Encourage participation in ADLs Promote intake of omega-3 fatty acids Administer prescribed enema to prevent constipation

answer 2 General nursing measures for a client with a fracture reduction include administering analgesics, providing comfort measures, encouraging participation with ADLs, promoting physical mobility, preventing infection, maintaining skin integrity, and preparing the client for self-care. Omega-3 fatty acids have no implications on the diet of a client with a fracture reduction. Dependent positioning may increase edema because the extremity is below the level of the heart. While some pain medications may contribute to constipation, this intervention would be reserved for a client experiencing constipation and not as a preventative measure.

A client's fracture was reduced by surgically exposing the bone and realigning it. What type of treatment does the nurse identity this as? Internal fixation Open reduction Skeletal traction Buck's traction

answer 2 In an open reduction, the bone is surgically exposed and realigned. Buck's traction is a type of skin traction that provides pulling on the structures. Skeletal traction is applied directly to the bone using a wire, pin, or cranial tongs. Internal fixation involves the use of metal screws, plates, rods, nails or pins to stabilize a reduced fracture.

A client with rheumatoid arthritis arrives at the clinic for a checkup. Which statement by the client refers to the most overt clinical manifestation of rheumatoid arthritis? "My legs feel weak." "My finger joints are oddly shaped." "I have trouble with my balance." "I have pain in my hands."

answer 2 Joint abnormalities are the most obvious manifestations of rheumatoid arthritis. A systemic disease, rheumatoid arthritis attacks all connective tissue. Although muscle weakness may occur from limited use of the joint where the muscle attaches, such weakness isn't the most obvious sign of rheumatoid arthritis; also, it occurs only after joint abnormalities arise. Subcutaneous nodules in the hands, although common in rheumatoid arthritis, are painless. The disease may cause gait disturbances, but these follow joint abnormalities.

After being seen in the oncology clinic, a client with severe bone marrow suppression is admitted to the hospital. The client's cancer therapy consisted of radiation and chemotherapy. When developing the care plan for this client, which nursing diagnosis takes priority? Imbalanced nutrition: Less than body requirements Risk for infection Risk for injury Anxiety

answer 2 Risk for infection takes highest priority in clients with severe bone marrow depression because they have a decrease in the number of white blood cells, the cells that fight infection. Making clients aware that they are at risk for injuries can help prevent such injuries as falls. The nurse should institute the facility's falls prevention protocol and supply assistive devices, such as a walker, cane, or wheelchair, when needed. Imbalanced nutrition: Less than body requirements is also of concern but doesn't take priority over preventing infection. Anxiety is likely present in clients with severe bone marrow depression; however, anxiety doesn't take priority over preventing infection.

A client sustains a fractured right humerus in an automobile accident. The arm is edematous, the client states not being able to move or feel the fingers, and the nurse does not feel a pulse. What condition should the nurse be concerned about that requires emergency measures? Dislocation Compartment syndrome Muscle spasms Subluxation

answer 2 Separation of adjacent bones from their articulating joint interferes with normal use and produces a distorted appearance. The injury may disrupt local blood supply to structures such as the joint cartilage, causing degeneration, chronic pain, and restricted movement. Compartment syndrome is a condition in which a structure such as a tendon or nerve is constricted in a confined space. The fractured humerus may also be dislocated but is not the result of the impaired circulatory status. Muscle spasms may occur around the fracture site but are not the cause of circulatory impairment. Subluxation is a partial dislocation.

A client with a right below-the-knee amputation is being transferred from the postanesthesia care unit to a medical-surgical unit. What is the highest priority nursing intervention by the receiving nurse? Document the receiving report from the transferring nurse. Ensure that a large tourniquet is in the room. Delegate the gathering of enough pillows for proper positioning and comfort. Review the physician's orders for type and frequency of pain medication.

answer 2 The client with an amputation is at risk for hemorrhage. A tourniquet should be placed in plain sight for use if the client hemorrhages. Documenting the receiving report is important but is not the highest priority. The nurse may delegate to unlicensed assistive personnel (UAP) the job of gathering more pillows for positioning, but this is not the highest priority. The nurse will need to review the physician's orders for pain medication, but again, this is not the highest priority, because any hemorrhaging by the client needs to be addressed first.

A client is treated in the clinic for a sexually transmitted infection, and the nurse suspects that the client is at risk for HIV. The physician determines that the client should be tested for the virus. What responsibility does the nurse have? The nurse should send the client to have the blood drawn without informing him about the specific screening test. The nurse ensures a written consent is obtained prior to testing. The nurse will call the client with the results of the test. The nurse will inform the client that the results will have to be reported to the Centers for Disease Control and Prevention (CDC).

answer 2 The nurse ensures that a written consent is obtained before testing for human immunodeficiency virus (HIV) and keeps the results of HIV testing confidential. The client should never be tested without his knowledge. The physician will review the results when the client comes in for a follow-up visit. It is not necessary for the nurse to report results to the CDC.

The nurse is preparing the client with a right neck mass for magnetic resonance imaging (MRI). Which question should the nurse ask? Select all that apply. "When is the last time you had food or drink?" "Have you removed your hearing aid?" "Do you have a pacemaker?" "Did you take your medicatioAn electromyography tests the electrical potential of muscles and nerves leading to the muscles. It is done to evaluate muscle weakness or deterioration. A serum calcium test evaluates the calcium in the blood. An arthroscopy assesses changes in the joint. An MRI identifies abnormalities in the targeted area.ns this morning?" "Are you wearing any jewelry?"

answer 2-3-5 Magnetic resonance imaging (MRI) is a noninvasive imaging technique that uses magnetic fields, radio waves, and computers to demonstrate abnormalities of soft tissue. Individuals with any metal implants, clips, or pacemakers are not candidates for MRI. Individuals do not need to be NPO and can take usual medications.

A nurse is caring for a client who is receiving chemotherapy and has a platelet count of 30,000/mm3. Which statement by the client indicates a need for additional teaching? "I use an electric razor to shave." "I removed all the throw rugs from the house." "I floss my teeth every morning." "I take a stool softener every morning."

answer 3 A client with a platelet count of 30,000/mm3 is at risk for bleeding and shouldn't floss his teeth. Flossing may increase the risk of bleeding in a client with a platelet count less than 40,000/mm3. Using an electric razor is appropriate because doing so helps minimize the risk of cutting when shaving. Taking a stool softener helps decrease potential trauma to the GI tract that may cause bleeding. Removing throw rugs from the house helps prevent falls, which could lead to uncontrolled bleeding.

A client is experiencing painful joints and changes in the lungs, heart, and kidneys. For which condition will the nurse schedule this client for diagnostic tests? Vascular diseases Heart disease Autoimmune disorders Metabolic disorders

answer 3 A hallmark of inflammatory rheumatic diseases is autoimmunity, where the body mistakenly recognizes its own tissue as a foreign antigen. Although focused in the joints, inflammation and autoimmunity also involve other areas. The blood vessels (vasculitis and arteritis), lungs, heart, and kidneys may be affected by the autoimmunity and inflammation. It is unlikely that the client's array of symptoms is being caused by heart disease, vascular diseases, or metabolic disorders.

A patient is admitted for an excisional biopsy of a breast lesion. What intervention should the nurse provide for the care of this patient? Clarify information provided by the physician. Provide aseptic care to the incision postoperatively. Provide time for the patient to discuss her concerns. Counsel the patient about the possibility of losing her breast.

answer 3 Patients who are undergoing surgery for the diagnosis or treatment of cancer may be anxious about the surgical procedure, possible findings, postoperative limitations, changes in normal body functions, and prognosis. The patient and family require time and assistance to process the possible changes and outcomes resulting from the surgery. The nurse serves as the patient advocate and liaison and encourages the patient and family to take an active role in decision making when possible. If the patient or family asks about the results of diagnostic testing and surgical procedures, the nurse's response is guided by the information that was conveyed previously. The nurse may be asked to explain and clarify information for patients and families that was provided initially but was not grasped because of anxiety and overwhelming feelings. It is important that the nurse, as well as other members of the health care team, provide information that is consistent from one clinician to another.

A nurse is taking the health history of a newly admitted client. Which of the following conditions would NOT place the client at risk for impaired immune function? History of radiation therapy Surgical history of a splenectomy Surgical removal of the appendix Previous organ transplantation

answer 3 Removal of the appendix would have no direct effect on the immune system. Organ transplantation requires immunosuppressive drugs, which cause impaired immune function. Radiation therapy destroys lymphocytes. The spleen is an important part of the immune system, and removal of it increases the client's risk for poor immune function.

A client with a tibia fracture was placed in an external fixator 24 hours ago. The nurse is completing pin care and notices redness at the pin site and a small amount of serous drainage. What action by the nurse is appropriate? Prepare for surgical removal of the fixator. Notify the physician. Document the findings. Assess the client's hemoglobin and hematocrit.

answer 3 Serous drainage and redness at the pin site is an expected finding for 48 to 72 hours after insertion. The nurse should document the findings and continue to monitor the site. The physician does not need to be notified unless other signs and symptoms are present. The fixator does not need to be removed at this time. The greatest concern is infection; assessing the hemoglobin and hematocrit are not relevant to assessing for infection.

The nurse is teaching a newly diagnosed client about systemic lupus erythematosus(SLE). What statement by the client indicates the teaching was successful? "The symptoms are primarily localized to the skin but may involve the joints." "This disorder is more common in men in their thirties and forties than in women." "The belief is that it is an autoimmune disorder with an unknown trigger." "SLE has very specific manifestations that make diagnosis relatively easy."

answer 3 Systemic lupus erythematosus is believed to be an autoimmune disorder but the triggering mechanism is not known. The disorder is more common in women than in men, most with the disorder in the 3rd or 4th decade of life. The disease is considered the "great imitator" because the clinical signs resemble many other conditions. SLE is a diffuse connective tissue disease that affects multiple body systems.

An older adult with rheumatoid arthritis limits going out with others because of the need to use a cane. Which response will the nurse make to this client? "Invite people over to your home instead." "It must be hard to get older." "Look at the cane as maintaining your independence." "Everyone will get older at some time."

answer 3 The body image and self-esteem of the older adult with rheumatic disease, combined with underlying depression, may interfere with the use of assistive devices such as canes. The use of adaptive equipment may be viewed by the older adult as evidence of aging rather than as a means of increasing independence. The nurse should focus on the cane as a method to increase independence rather than a sign of approaching old age. Reminding the client of aging are inappropriate responses. Inviting people to visit will not help improve the client's feelings about needing to use a cane for safe ambulation.

A client arrives in the emergency department with a suspected bone fracture of the right arm. How does the nurse expect the client to describe the pain? A dull, deep, boring ache Similar to "muscle cramps" Sharp and piercing Sore and aching

answer 3 The nurse must carefully evaluate pain associated with the musculoskeletal condition, asking the client to indicate the exact site and to describe the character and intensity of the pain using a pain rating scale. Most pain can be relieved by elevating the involved part, applying ice or cold packs, and administering analgesic agents as prescribed. Pain associated with the underlying condition (e.g., fracture, which is sharp and piercing) is frequently controlled by immobilization. Pain due to edema that is associated with trauma, surgery, or bleeding into the tissues can frequently be controlled by elevation and, if prescribed, intermittent application of ice or cold packs. Ice bags (one third to one half full) or cold application devices are placed on each side of the cast, if prescribed, making sure not to indent or wet the cast. Unrelieved or disproportionate pain may indicate complications. Pain associated with compartment syndrome is relentless and is not controlled by modalities such as elevation, application of ice or cold, and usual dosages of analgesic agents. Severe burning pain over bony prominences, especially the heels, anterior ankles, and elbows, warns of an impending pressure ulcer. This may also occur from too-tight elastic wraps used to hold splints in place.

A client who has suffered a compound fracture is preparing for discharge to home. During the teaching session, the client asks why he needs antibiotics for a broken bone. Which response by the nurse is most appropriate? "If your temperature is normal for 48 hours, you may discontinue the medication." "You may discuss your prescriptions with your physician at your follow-up appointment." "Antibiotic therapy has been prescribed as a precaution because your bone was exposed to the environment at the time of your injury." "The antibiotics will help the bone to heal."

answer 3 The nurse should tell the client that antibiotics are prescribed as a preventive measure for a client with a compound fracture because such fractures expose the bone to the environment and possible infection. Telling the client to discuss his medications with the physician at his follow-up appointment doesn't address the client's questions or immediate needs. The client needs this medication regardless of his body temperature. Antibiotics don't help a bone fracture to heal.

A nurse is caring for a recently married, 29-year-old female client, who was diagnosed with acute lymphocytic leukemia. The client is preparing for an allogeneic bone marrow transplant. Which statement by the client demonstrates she understands the informed consent she gave about the diagnosis and treatment? "I should be able to finally start a family after I'm finished with the chemo." "I'll have to remain in the hospital for about 3 months after my transplant." "I'll only need chemotherapy treatment before receiving my bone marrow transplant." "I always had a good appetite. Even with chemo I shouldn't have to make any changes to my diet."

answer 3 This client demonstrates understanding about treatment when she states that she'll need chemotherapy before receiving a bone marrow transplant. Most clients receive chemotherapy before undergoing bone marrow transplantation. Most women older than age 26 can't bear children after undergoing treatment because they experience the early onset of menopause. Clients who undergo chemotherapy or radiation must avoid all fresh fruits and vegetables, and all foods should be cooked to avoid bacterial contamination. Clients who undergo bone marrow transplantation typically remain hospitalized for 20 to 25 days.

A client with fibromyalgia asks why physical therapy has been prescribed. Which response will the nurse make? "I will ask the health care provider it if is necessary." "It will take your mind off your health problem." "It will help with the overall deconditioning that has occurred." "It is used instead of prescribing medications for the condition."

answer 3 Treatment of fibromyalgia consists of attention to the specific symptoms that the client is experiencing. An individualized program of exercise is used to decrease muscle weakness and discomfort and improve the general deconditioning that occurs in clients with the condition. Physical therapy is not used to take the health problem off of the client's mind. The health care provider is treating the client's symptoms and has determined that physical therapy would be helpful. There are a variety of medications available to treat the symptoms of fibromyalgia.

A nurse is planning discharge instructions for the client with osteomyelitis. What instructions should the nurse include in the discharge teaching? "You need to limit the amount of protein and calcium in your diet." "You need to perform weight-bearing exercises twice a week." "You will receive IV antibiotics for 3 to 6 weeks." "Use your continuous passive motion machine for 2 hours each day."

answer 3 Treatment of osteomyelitis requires IV antibiotics for 3 to 6 weeks. Continuous passive range of motion is used for clients with osteoarthritis. Weight-bearing exercises are used with clients who have osteoporosis. Limiting protein and calcium is not part of the plan of care for clients with osteomyelitis.

A client has sustained a right tibial fracture and has just had a cast applied. Which instruction should the nurse provide in client cast care? "Use a knitting needle to scratch itches inside the cast." "A foul smell from the cast is normal." "Cover the cast with a blanket until the cast dries." "Keep your right leg elevated above heart level."

answer 4 The nurse should instruct the client to elevate the leg to promote venous return and prevent edema. The cast shouldn't be covered while drying. Covering the cast will cause heat buildup and prevent air circulation. The client should be instructed not to insert foreign objects into the cast because of the risk of cutting the skin and causing an infection. A foul smell from a cast is never normal and may indicate an infection.

A client is admitted to the hospital with a diagnosis of pneumonia. The client informs the nurse of having several drug allergies. The physician has ordered an antibiotic as well as several other medications for cough and fever. What should the nurse do prior to administering the medications? Administer the medications that the physician ordered. Give the client one medicine at a time and observe for allergic reactions. Call the pharmacy and let them know the client has several drug allergies. Consult drug references to make sure the medicines do not contain substances which the client is hypersensitive.

answer 4 Clear identification of any substances to which the client is allergic is essential. The nurse must consult drug references to verify that prescribed medications do not contain substances to which the client is hypersensitive. Administering the medications or giving one at a time may cause the client to have an allergic reaction. The nurse may call the pharmacy but still maintains responsibility for the medications administered.

The nurse is evaluating the client's risk for cancer. The nurse should recommend the client change which lifestyle choice? drinks one glass of wine at dinner each night works as a secretary at a medical radiation treatment center uses the treadmill for 30 minutes on 5 days each week eats red meat such as steaks or hamburgers every day

answer 4 Dietary substances such as nitrate-containing and red meats appear to increase the risk of cancer. Exercising 30 minutes on 5 days or more is recommended for adults. Measures are taken to protect those people who work around radiation. Alcohol consumption recommendations include drink no more than one drink per day for women or two per day for men.

An older female client who had a total hip replacement is to be discharged because her healing is almost complete. What would be most important for this client? Advising the client to avoid red meat. Educating the client about the effects of menopause. Urging her to keep the affected limb in an elevated position. Exploring factors related to the client's home environment.

answer 4 Exploring factors related to the older adult client's home environment and determining a plan for continued rehabilitation before discharge is most important. The client should be encouraged to eat foods rich in protein, calcium, and vitamin D. Since the healing is almost complete, the client need not always keep the affected limb elevated unless prescribed to do so. Since the client is in her late 60s, she is most likely to have already undergone menopause. Therefore, educating her about the effects of menopause is not as important.

Which of the following was formerly called a bunion? Ganglion Morton's neuroma Plantar fasciitis Hallux valgus

answer 4 Hallux valgus (commonly called a bunion) is a deformity in which the great toe deviates laterally. Plantar fasciitis, an inflammation of the foot-supporting fascia, present as an acute onset of heel pain experienced with the first steps in the morning. Morton's neuroma is a swelling of the third (lateral) branch of the median plantar nerve. A ganglion, a collection of gelatinous material near the tendon sheaths and joints, appears as a round, firm compressible cystic swelling, usually on the dorsum of the wrist.

On a visit to the family health care provider, a client is diagnosed with a bunion on the lateral side of the great toe at the metatarsophalangeal joint. Which statement should the nurse include in the teaching session? "Bunions are caused by a metabolic condition called gout." "Bunions are congenital and can't be prevented." "Bunions may result from wearing shoes that are too big, causing friction when the shoes slip back and forth." "Some bunions are congenital; others are caused by wearing shoes that are too short or narrow."

answer 4 Bunions may be congenital or may be acquired by wearing shoes that are too short or narrow, which increases pressure on the bursa at the metatarsophalangeal joint. Acquired bunions can be prevented. Wearing shoes that are too big may cause other types of foot trauma but not bunions. Gout doesn't cause bunions. Although a client with gout may have pain in the big toe, such pain doesn't result from a bunion.

Which of the following is the final stage of fracture repair? Cartilage removal Cartilage calcification Angiogenesis Remodeling

answer 4The final stage of fracture repair consists of remodeling the new bone into its former structural arrangement. During cartilage calcification, enzymes within the matrix vesicles prepare the cartilage for calcium release and deposit. Cartilage removal occurs when the calcified cartilage is invaded by blood vessels and becomes reabsorbed by chondroblasts and osteoclasts. Angiogenesis occurs when new capillaries infiltrate the hematoma, and fibroblasts from the periosteum, endosteum, and bone marrow produce a bridge between the fractured bones.