Exam #9

A nursing student asks the nurse why older adults are at risk for falls. The best response by the nurse is: A) "Muscles atrophy with aging." B) "Bones become more fragile." C) "Cartilage deteriorates with age." D) "Ligaments become lax with age."

A) Muscles atrophy with aging Muscle atrophy results in weakness and decreased flexibility, which increases the risk for stumbling and falls.

A client is transported to the emergency department for a femur fracture following a motor vehicle crash. What action by the nurse is the highest priority? A) Assess vital signs and level of consciousness. B) Administer pain medication per orders. C) Assess pedal pulses. D) Assess the diameter of the thigh every 15 minutes.

A) Assess vital signs and LOC

A 13-year-old patient is admitted to the pediatric unit with a suspected brain tumor. The nurse should understand that which diagnostic test is the most helpful in the diagnosis of brain tumors? A) Computed tomography (CT) scan B) Magnetic resonance imaging (MRI) C) Brain biopsy D) Blood work with adrenocorticotropic hormone (ACTH) levels

B) MRI An MRI is the most helpful in the diagnosis of brain tumors. Its use has resulted in the detection of smaller lesions; it is particularly helpful in detecting tumors in the brainstem and pituitary regions, where bone interferes with CT. A brain biopsy or blood work with ACTH levels does not diagnose brain tumo

A nurse who works in a neurological rehabilitation facility is aware of the complex structure and function of the nervous system. Which of the following statements most accurately describes an aspect of the structure of the neurological system? A) The sympathetic nervous system is a component of the peripheral nervous system (PNS). B) The cranial nerves and spinal nerves are components of the central nervous system (CNS). C)The somatic nervous system consists of sympathetic and parasympathetic branches. D) The PNS is a component of the CNS.

A) The sympathetic nervous system is a component of the peripheral nervous system

A primary nursing assessment for a patient who has sustained a fracture involving the basilar skull is inspection for: A) Leakage of CSF from the nose. B) Ecchymosis of the mastoid process of the temporal bone. C)Leakage of CSF from the ear. D)Vomiting and headaches due to increased intracranial pressure.

C) Leakage of CSF from the ear Otorrhea (leakage of CSF via the ear) is suspected with fractures involving the basilar skull. Leakage of CSF places the patient at risk for meningitis. If a CSF leak is suspected, the nurse is aware that nothing is allowed into the patient's nose or ears.

A patient comes to the emergency department with severe pain in the face that was stimulated by brushing the teeth. What cranial nerve does the nurse understand can cause this type of pain? A) III B) IV C) V D) VI

C) V The trigeminal nerve (cranial nerve V) innervates the forehead, cheeks, and jaw, so pain in the face elicited when brushing the teeth would most likely involve this nerve.

A client preparing to undergo a lumbar puncture states he doesn't think he will be able to get comfortable with his knees drawn up to his abdomen and his chin touching his chest. He asks if he can lie on his left side. Which statement is the best response by the nurse? A) "Lying on your left side will be fine during the procedure." B)"There's no other option but to assume the knee-chest position." C)"Although the required position may not be comfortable, it will make the procedure safer and easier to perform." D) "I'll report your concerns to the physician."

C) Although the required position may not be comfortable, it will make the procedure safer and easier to perform The nurse should explain that the knee-chest position is necessary to make the procedure safer and easier to perform. Lying on his left side won't make the procedure easy or safe to perform. The nurse shouldn't simply tell the client there is no other option because the client is entitled to understand the rationale for the required position. Reporting the client's concerns to the physician won't meet the client's needs in this situation.

A client had an above-the-knee amputation of the left leg related to complications from peripheral vascular disease. The nurse enters the client's room and observes the dressing and bed covers saturated with blood. What is the first action by the nurse? A) Notify the health care provider. B)Apply a tourniquet. C) Use skin clips to close the wound. D) Reinforce the dressing.

B) Apply a tourniquet

A nurse understands the influence of hormones on bone maintenance. Therefore, the nurse knows that a patient on long-term cortisol may experience: A) Increased deposits of calcium in the bone. B) Increased bone resorption. C) Accelerated bone modeling. D) Inhibition of osteoclasts.

B) Increased bone resorption

Which anatomic part supplies cerebrospinal fluid to the subarachnoid space and down the spinal cord on the dorsal surface? A) Third ventricle B) Fourth ventricle C) Lateral ventricle D) Arachnoid villus

B) fourth ventricle Cerebrospinal fluid (CSF), produced in the ventricles, is circulated around both the brain and the spinal cord by the ventricular system. The fourth ventricle supplies CSF to the subarachnoid space and down the spinal cord on the dorsal surface. The third and fourth ventricles connect via the aqueduct of Sylvius. The arachnoid villus is the area in the brain where CSF is absorbed.

A client is scheduled for surgery to fuse a joint. The nurse identifies this as which of the following? A) Osteotomy B) Arthrodesis C) Arthroplasty D) Open reduction internal fixation

B) Arthrodesis An arthrodesis is a surgical procedure to fuse a joint. An osteotomy involves cutting and removing a wedge of the bone to change alignment. An arthroplasty is a total reconstruction or replacement of a joint with an artificial joint. Open reduction internal fixation is accomplished with wire, nails, plate and/or an intramedullary rod to hold bone fragments in place until healing is complete.

A client with a brain tumor experiences projectile vomiting. The nurse integrates understanding of this occurrence as resulting from which of the following? A) Edema associated with the tumor B) Irritation of the meduallary vagal centers C) Compression of surrounding structures D) Distortion of pain-sensitive structures

B) Irritation of the meduallary vagal centers

The nurse is performing an initial assessment on a client admitted with a possible brain abscess. Which of the following would the nurse most likely find? A) Headache that is worse in the morning B) Ptosis that is more pronounced at the end of the day C) Diplopia that is constant D) Nuchal rigidity

A) Headache that is worse in the morning The most prevailing symptom of a brain abscess is headache, which is usually worse in the early morning. Ptosis and diplopia are seen in clients with myasthenia gravis. Nuchal rigidity is seen in clients with meningitis.

Which of the following diagnostics are used to evaluate spinal nerve root disorders (radiculopathies)? A) Electromyogram B) Bone scan C) Computed tomography D) Magnetic resonance imaging

A) Electromyogram An electromyogram and nerve conduction studies are used to evaluate spinal nerve toot disorders (radiculopathies) for patients with low back pain. A bone scan may disclose information about infections, tumors, and bone marrow abnormalities. A computed tomography scan is useful in identifying underlying problems, such as obscure soft tissue lesions adjacent to the vertebral column and problems of vertebral disks. Magnetic resonance imaging permits visualization of the nature and location of spinal pathology.

Nursing students are reviewing the various types of brain tumors. The students demonstrate understanding of the material when they identify which of the following as the most common type? A) Gliomas B) Meningiomas C) Acoustic neuromas D) Pituitary adenomas

A) Gilomas Gliomas are the most common type of intracerebral brain tumor. Menigiomas account for approximately 15% of all primary brain tumors. Pituitary adenomas represent approximately 10% to 15% of all brain tumors. Acoustic neuromas are less common.

To help minimize calcium loss from a hospitalized client's bones, the nurse should: A) reposition the client every 2 hours. B) encourage the client to walk in the hall. C) provide the client dairy products at frequent intervals. D) provide supplemental feedings between meals.

B) Encourage the client to walk in the hall. Calcium absorption diminishes with reduced physical activity because of decreased bone stimulation. Therefore, encouraging the client to increase physical activity, such as by walking in the hall, helps minimize calcium loss. Turning or repositioning the client every 2 hours wouldn't increase activity sufficiently to minimize bone loss. Providing dairy products and supplemental feedings wouldn't lessen calcium loss — even if the dairy products and feedings contained extra calcium — because the additional calcium doesn't increase bone stimulation or osteoblast activity.

An 80-year-old female patient has been admitted to the hospital and lives with numerous health problems, which include osteoporosis. The patient's medication regimen includes calcitonin nasal spray, vitamin D and calcium supplements, and a bisphosphonate that is administered weekly. When administering the patient's bisphosphonate, the nurse should: A) Administer the drug with food and encourage fluid intake. B) Position the patient in high Fowler's after giving the drug. C) Administer the drug at bedtime with a snack. D) Combine the drug with a dose of calcium and vitamin D.

B) Position the patient in high Fowler's after giving the drug Side effects of bisphosphonates include gastrointestinal symptoms (eg, dyspepsia, nausea, flatulence, diarrhea, constipation), and some patients may develop esophageal ulcers, gastric ulcers, or osteonecrosis of the jaw related to bisphosphonate use. Patients must take these medications on an empty stomach on arising in the morning, with a full glass of water, and must sit upright for 30 to 60 minutes after their administration. They do not need to be given simultaneously with calcium and vitamin D.

A patient has expressive speaking aphasia after having a stroke. Which portion of the brain does the nurse know has been affected? A) Temporal lobe B) Inferior posterior frontal areas C) Posterior frontal area D) Parietal-occipital area

B) inferior posterior frontal areas A deficiency in language function is called aphasia. Expressive speaking aphasia is associated with injury to the inferior posterior frontal areas, auditory receptive aphasia with the temporal lobe, expressive writing aphasia with the posterior frontal area, and visual receptive aphasia with the parietal and occipital areas.

A client is admitted to an acute care facility for treatment of a brain tumor. When reviewing the chart, the nurse notes that the client's extremity muscle strength is rated 1/5. Which assessment finding should the nurse anticipate? A) Normal, full muscle strength is present. B) Muscles move actively against gravity alone. C) Muscle contraction is palpable and visible. D) Muscle contraction or movement is undetectable.

C) Muscle contraction is palpable and visible Muscle strength is assessed and rated on a five-point scale in all four extremities, comparing one side to the other. Palpable, visible muscle contraction on the affected side and normal, full muscle strength on the unaffected side indicate a rating of 1/5. Normal, full muscle strength on both sides is rated 5/5. Active muscle movement against gravity alone on the affected side with normal, full muscle strength on the unaffected side is rated 3/5. Undetectable muscle contraction or movement on the affected side with normal, full muscle strength on the unaffected side is rated 0/5.

The nurse is educating a group of women on the prevention of osteoporosis. The nurse recognizes the education as being effective when the group members make which statement? A) "We need to increase aerobic exercise." B) "We need to consume a low-calcium, high-phosphorus diet." C) "Estrogen deficiency increases bone density." D) "We need an adequate amount of exposure to sunshine."

D) We need an adequate amount of exposure to sunshine. The only accurate statement is related to getting an adequate amount of exposure to sunshine. Aerobic exercise, such as swimming, does not prevent osteoporosis. The exercise needs to be weight bearing. A diet low in calcium and high in phosphorus will increase the risk forosteoporosis. Estrogen deficiency is linked to decreased bone mass.

A client presents to the emergency department status postseizure. The physician wants to know what the pressure is in the client's head. What test might be ordered on this client? A) lumbar puncture B) echoencephalography C) nerve conduction studies

A) Lumbar puncture Changes in CSF occur in many neurologic disorders. A lumbar puncture (spinal tap) is performed to obtain samples of CSF from the subarachnoid space for laboratory examination and to measure CSF pressure. Echoencephalography records the electrical impulses generated by the brain. Nerve conduction studies measure the speed with which the nerve impulse travels along the peripheral nerve. Electromyography studies the changes in the electrical potential of muscles and the nerves supplying the muscles.

A critical care nurse is documenting her assessment of a client she is caring for. The client is status post-resection of a brain tumor. The nurse documents that the client is flaccid on the left. What does this mean? A) The client has an abnormal posture response to stimuli. B) The client is not responding to stimuli. C) The client is hyperresponsive on the left. D) The client is hyporesponsive on the left.

B) The client is not responding to stimuli

Which diagnostic test may be performed to evaluate blood flow within intracranial blood vessels? A) Computed tomography B) Magnetic resonance imaging C) Transcranial Doppler D) Cerebral angiography

C) Transcranial doppler Transcranial Doppler flow studies are used to study a tumor's blood flow within intracranial blood vessels. Cerebral angiography may be used to study a tumor's blood supply or obtain information about vascular lesions. Magnetic resonance imaging (MRI) provides information similar to that provided by computed tomography, with improved tissue contrast, resolution, and anatomic definition; MRI also examines the lesion in multiple planes.

Which laboratory study is most relevant to treating a client who has sustained a pelvic fracture? A) Urine myoglobin B)Urinalysis C)Type and crossmatch D)Serum ethanol

C) Type and crossmatch Because of the rich blood supply to the pelvis, fractures to this area can result in significant blood loss. Type and crossmatch is a priority laboratory test in preparing for fluid replacement. Urine isn't commonly analyzed for myoglobin with this injury unless the mechanism was a crush injury; even then, urinalysis isn't as high a priority as type and crossmatch. Urinalysis and serum ethanol, although part of a trauma workup, aren't relevant to treatment of a pelvic fracture.

A patient falls while skiing and sustains a supracondylar fracture. What does the nurse know is the most serious complication of a supracondylar fracture of the humerus? A) Hemarthrosis B) Paresthesia C) Malunion D) Volkmann's ischemic contracture

D) Volkmann's ischemic contracture The most serious complication of a supracondylar fracture of the humerus is Volkmann contracture (an acute compartment syndrome), which results from antecubital swelling or damage to the brachial artery (Chart 43-3).

Six weeks after an above-the-knee (AKA) amputation, a patient returns to the outpatient office for a routine postoperative checkup. During the nurse's assessment, the patient reports symptoms of phantom pain. To reduce the discomfort of the phantom pain, the nurse should tell the patient to: A) Apply hot compresses to the area of the amputation. B) Avoid rehabilitation exercises until the pain subsides. C) Comfortably increase his level of activity. D) Assess for a pulse in the extremity of the amputation every 4 to 6 hours.

C) Comfortably increase his level of activity

A group of students are reviewing information about osteoporosis in preparation for a class discussion. The students demonstrate a need for additional review when they state which of the following as a risk factor? A) Excess caffeine intake B) Prolonged corticosteroid use C) Hypothyroidism D) Prolonged immobility

C) Hypothyroidism Factors associated with an increased risk for osteoporosis include: family history of osteoporosis, chronic low calcium intake, excessive intake of caffeine, tobacco use, Cushing's syndrome, prolonged use of high doses of corticosteroids, prolonged periods of immobility, hyperthyroidism, hyperparathyroidism, eating disorders, malabsorption syndromes, breast cancer (especially if treated with chemotherapy that suppresses estrogen, excluding Tamoxifen, which may reduce the risk of fractures), renal or liver failure, alcoholism, lactose intolerance, and dietary deficiency of vitamin D and calcium.

The nurse is caring for a client in the hospital emergency department who reports recent muscle weakness, sensory loss, aphasia, and visual changes accompanied by a suddent onset of complex partial seizures. The nurse anticipates which diagnostic test will be prescribed to rule out or confirm with high certainty the presence of a brain tumor? A) Magnetic resonance imaging (MRI) B) Computed tomography (CT) C)Positron emission tomography (PET) D) Cranial x-ray

A) MRI MRI is the gold standard for detecting brain tumors. If a brain tumor is suspected, the MRI will provide a high degree of certainty for ruling out or confirming this diagnosis. Although CT scanning is also used in the diagnostic workup of brain tumors, this test would be prescribed to provide additional diagnostic information about the tumor. A CT scan can give specific information concerning the number, size, and density of the lesions and the extent of secondary cerebral edema. CT can also provide information about the ventricular system (the communicating network of cavities filled with cerebrospinal fluid and located within the brain parenchyma). PET, which measures the brain's activity rather than simply its structure, is useful in differentiating tumor from scar tissue or radiation necrosis. The PET may be useful during or after completion of treatment to determine the progress of the tumor. A cranial x-ray would not provide detailed imaging of the brain and would be best suited to determine any pathology related to the bone surface of the cranium. A cranial fracture could be detected using the x-ray but not a brain tumor.

A client has undergone surgery for a spinal cord tumor that was located in the cervical area. The nurse would be especially alert for which of the following? A) Hemorrhage B) Bowel incontinence C) Respiratory dysfunction D) Skin breakdown

C) Respiratory dysfunction When a spinal tumor is located in the cervical area, respiratory compromise may occur from postoperative edema. Hemorrhage would be a concern with any surgery. Bowel incontinence and skin breakdown are possible but not specific to cervical spinal tumors.