Invasive I - IV Therapy 2

A nurse is preparing to administer amantadine 150 mg PO for a client who is experiencing Parkinsonism due to an antipsychotic medication. Available is amantadine 50 mg/5mL oral solution. How many mL should the nurse administer? Round the answer to the nearest whole number.

15 mL

A nurse is reinforcing teaching with a client who has multiple sclerosis and a new prescription for baclofen. Which of the following instructions should the nurse include? A - "Avoid driving until the medication's effects are evident." ​B - "Take the medication on an empty stomach." ​C - "Stop taking the medication immediately for headache." ​D - "Diarrhea is an adverse effect of this medication."

A - "Avoid driving until the medication's effects are evident." Rational A -Several CNS-related effects are common, including drowsiness, dizziness, headache, and confusion. Therefore, until the client knows how the medication will affect her, she should not drive a vehicle. B- The medication causes nausea and gastrointestinal distress, so the client should take it with milk or meals. C - Abrupt withdrawal of baclofen, a centrally acting muscle relaxant, might cause seizures, fever, and hypotension. The client should notify the provider if headache persists. D - Constipation is an adverse effect of this medication.

A nurse is reinforcing teaching for a female client who has multiple sclerosis and a new prescription for dantrolene. Which of the following client statements indicates an understanding of the teaching? A - "I need to notify my provider if I don't get some relief from my muscle spasms within 3 months." B - "I should return to the clinic to have my calcium level checked every 6 weeks." C - "I should take this medication when my spasms are bad." D - "I am glad this medication is safe to take if I get pregnant."

A - "I need to notify my provider if I don't get some relief from my muscle spasms within 3 months." Rational A - Dantrolene is highly hepatotoxic. If the client does not get relief from muscle spasms within 45 days, the provider should discontinue the medication. B - Dantrolene is highly hepatotoxic. The client should have periodic tests for kidney function, liver function, as well as blood cell counts. C - The client should take dantrolene every day as the prescription indicates, not on a PRN basis for spasticity. D - Dantrolene is pregnancy category C. For this category of medications, animal studies might have demonstrated a risk to the fetus, but studies on women are not available. It is used with caution during pregnancy.

A nurse is caring for an older adult client who has a hip fracture and will require rehabilitative care. The client's family asks the nurse for information about this type of care. Which of the following statements should the nurse make? A - "Rehabilitation began with the client's admission to the hospital." B - "The focus of rehabilitative care is the client's physical injuries." C - "The client will require long-term rehabilitation services." D - "The client will require inpatient rehabilitation services."

A - "Rehabilitation began with the client's admission to the hospital." Rational A - Rehabilitation is a process that assists a client who has an illness, a disability, or an impairment to achieve the best possible level of functioning. The process of rehabilitation begins with the client's acute care hospital admission. B - The rehabilitation process focuses on the client's physical, mental, social, spiritual, and economic abilities. C - Typically, clients who require long-term rehabilitation have more permanent injuries, such as brain or spinal-cord injuries. D - The client is more likely to receive rehabilitation services on an outpatient basis or in the home environment.

A nurse is reinforcing teaching about placement of a prosthesis with a client who is having a below the knee amputation. Which of the following information should the nurse include in the teaching? A - "This will improve your ability to ambulate sooner." B - "This will decrease the chance of you experiencing phantom limb pain." C - "This will help to decrease the frequency of dressing changes." D - "Placing this now will improve the fit of the prosthesis."

A - "This will improve your ability to ambulate sooner." Rational A - The nurse should explain that the purpose of a prosthesis immediately following surgery is to promote postoperative ambulation. B - The nurse should teach that phantom limb pain is a neurological disorder for clients who had an amputation; therefore, the placement of a prosthesis immediately following surgery does not decrease the incidence of phantom limb pain. C - The nurse should reinforce in the teaching to check the dressings when obtaining postoperative vitals; however, the placement of a prosthesis immediately following surgery does not decrease the need for or frequency of dressing changes. D - The placement of a prosthesis immediately following surgery does not improve the fit of the prosthesis.

A nurse is caring for a client who has diabetes mellitus and had a below the knee amputation 2 days ago. Which of the following statements by the client should the nurse identify as an indication that the client has a body image disturbance? A - "When I look in the mirror, all I see is a person without a leg." B- "I have not always made good choices in life. I deserve to lose my leg." C - "If my wife had paid more attention to my blood sugar levels I would not have needed an amputation." D - "No matter how hard I work in physical therapy, I can't seem to make any progress."

A - "When I look in the mirror, all I see is a person without a leg." Rational A - A client who has a body image disturbance may not want to look or touch a body part that has been altered by disease or injury. The client may also express feelings of helplessness, hopelessness and powerlessness. B - The client's statement indicates the client feels guilty and blames himself for needing an amputation. However, this does not indicate that the client has a body image disturbance. C- The client is using rationalization to explain the reason for his amputation. This does not indicate that the client has a body image disturbance. D - The client's statement indicates the client is frustrated with his progress towards recovery. However, this does not indicate that the client has a body image disturbance.

A nurse is caring for a client following an open reduction and internal fixation of a fractured femur. Which of the following findings is the nurse's priority? A - Altered level of consciousness B - Oral temperature of 37.7° C (100° C) C - Muscle spasms D - Headache

A - Altered level of consciousness Rational A - When using the airway, breathing, circulation approach to client care, the nurse determines that the priority finding is for the nurse to monitor the client's altered level of consciousness. A fracture of one of the long bones of the body places the client is at risk for fat embolism, which causes a decrease in oxygenation and alters the client's level of consciousness. B - The nurse should monitor the client's temperature, as this can be a risk for infection or a fat embolism; however, another action is the priority. C - The nurse should observe the client for muscle spasms as a manifestation following this type of procedure; however, another action is the priority. D - The nurse should observe the client for a headache to address his pain; however, another action is the priority.

A nurse is caring for a client who is postoperative open reduction and internal fixation with placement of a wound drain to repair a hip fracture. Which of the following actions should the nurse take? A - Empty the suction device every 4 hr. B - Monitor circulation on the affected extremity every 2 hr for the first 12 hr. C- Position the client's hip so that it is internally rotated. D - Encourage foot exercises every 4 hr.

A - Empty the suction device every 4 hr. Rational A- The nurse should empty the client's wound drain every 4 hr to monitor for bleeding. B - The nurse should monitor neurovascular status of the operative leg every hour for the first 12 to 24 hr to monitor for changes that can indicate impaired circulation. C - The nurse should position the client's hip so that it is abducted to prevent dislocation. D- The nurse should encourage foot and calf exercises every 2 hr to prevent a deep vein thrombosis.

A nurse is caring for an adolescent following the application of a plaster cast for a fracture right tibia. Which of the following actions should the nurse take? A - Perform a neurovascular check of the lower extremities. B - Keep the client's leg in a dependent position. C - Discourage the client from ambulating. D - Use a hair dryer on a hot setting to dry the cast.

A - Perform a neurovascular check of the lower extremities. Rational A - The client is at risk for compartment syndrome following the application of a cast because the extremity can continue to swell inside the cast resulting in obstruction to circulation. Therefore, the nurse should perform a neurovascular check following cast application to check circulation, motion, and sensation of the lower extremities. B - The nurse should keep the client's leg elevated to promote venous return and minimize swelling. C - After the cast dries, the nurse should assist the client to ambulate using crutches to promote general circulation and prevent complications of immobility. D - The nurse should not expose the cast to heat, such as from a dryer or a fan, because heat conduction can result in skin burns under the cast.

A nurse is collecting data from a client who is postoperative from a below-the-knee amputation and whose residual limb is wrapped with an elastic bandage to shrink the stump. Which of the following findings should alert the nurse to a possible complication? A - Pitting edema above the bandage B - Looseness of the stump dressing C - The dressing forming a cone shape over the stump D - Figure-eight wrapping around the stump

A - Pitting edema above the bandage Rational A - If the elastic bandage is properly applied, it should prevent edema. The nurse should remove the bandage and rewrap the stump. B - The nurse should expect the bandage to become loose as the limb heals and shrinks, so the nurse should rewrap the stump every 4 to 6 hr. C - If the elastic bandage is properly applied, it should form a cone shape over the stump. D - If the elastic bandage is properly applied, it should form figure-eights around the stump.

A nurse is contributing to the plan of care for a client who has a spinal cord injury resulting in paraplegia. Which of the following interventions should the nurse include? A - Provide a high-protein, high-calorie diet. B - Perform passive range of motion exercises daily. C - Use sequential compression devices for 4 hr three times a day. D - Develop a schedule to restrict fluid intake.

A - Provide a high-protein, high-calorie diet. Rational A - Following injury, the client will have increased caloric needs. The nurse should provide a diet high in protein, carbohydrates, and calories to provide proper nutrition. B - The nurse should plan to perform passive range of motion exercises at least two times a day, using all of the client's extremities. C - The nurse should plan to keep sequential compression devices on the client's lower extremities and remove them each shift for 30 to 60 min. D- The nurse should understand the client is at risk for constipation and urinary tract infection and should promote adequate intake of fluids and fiber.

A nurse is reinforcing teaching to the family of a client who has Parkinson's disease. Which of the following instructions should the nurse include? A - Provide the client a cane. B - Limit the client's physical activity. C - Speak loudly to the client. D- Offer the client 3 large meals a day.

A - Provide the client a cane. Rational A - The nurse's instructions should include providing the client with a cane or walker to increase stability and decrease the risk of falls. B - The nurse's instructions should include providing an exercise program to improve mobility, alternated with periods of rest, not limiting activity. C - The nurse's instructions should include speaking clearly and in a normal tone to the client. There is no reason to speak loudly to a client with Parkinson's disease. D - The nurse's instructions should include offering the client six small meals per day to compensate for the need to eat slowly and take small bites to reduce the risk of aspiration.

A nurse is caring for a client who has a femur fracture and, 8 hr after the injury, reports a sudden onset of dyspnea and a sever headache. Which action should the nurse take first? A - ​Administer oxygen. B - ​Prepare for an ICU transfer. C - ​Increase the IV fluid infusion rate. ​D - Administer pain medication.

A - ​Administer oxygen. Rational A- The priority action the nurse should take when using the airway, breathing, and circulation (ABC) approach to client care is to administer oxygen. In addition to placing the client in high-Fowler's position, the nurse should use a non-rebreather's mask and administer oxygen at a high flow rate. B - The nurse should anticipate that the client will require transfer to ICU; however, there is another action that is the priority. C - The nurse should anticipate that the client will likely require increased hydration; however, there is another action that is the priority. D - The nurse should administer pain medication to the client to treat the headache; however, there is another action that is the priority.

A nurse is reinforcing teaching about elimination with an adolescent who is paralyzed from the waist down down following a spinal cord injury. Which of the following statements by the adolescent indicates a need for further teaching? A- "I need to catheterize myself twice a day." B - "I carry a water bottle with me because I drink a lot of water." C - "I use a suppository every night to have a bowel movement." D - "I do my wheelchair exercises sitting in my chair."

A- "I need to catheterize myself twice a day." Rational A - In most cases, paralysis from waist down affects bladder and bowel control. Catheterization should be performed every 4 to 6 hr, and as needed. Infrequent emptying of the bladder can result in urinary tract infections. B - A client who is paralyzed from the waist down is at increased risk for urinary tract infections. Therefore, drinking plenty of water is appropriate. C - Using a suppository to stimulate a bowel movement every 1 to 2 days is appropriate. D- Wheelchair exercises are appropriate to prevent skin breakdown and increase upper body strength.

A nurse is caring for a client who is scheduled for surgical repair of a femur fracture and has a prescription for lorazepam preoperatively. Which of the following statements by the client should indicate to the nurse that the medication has been effective? A - "My mouth is very dry." B - "I feel very sleepy." C - "I am not hungry any longer." D - "My leg feels numb."

B - "I feel very sleepy." Rational A - The nurse should recognize that oral dryness is most likely a result of the client being NPO prior to surgery and not an effect of lorazepam. B - The nurse should recognize that preoperative doses of benzodiazepines such as lorazepam relieve anxiety and promote sedation. C - The nurse should recognize anorexia as an adverse, but unintended, effect of lorazepam. D - The nurse should identify that one of the effects of lorazepam is muscle relaxation, which may decrease the pain experienced with a femur fracture; however, numbness of the extremity is not an effect of lorazepam.

A nurse is reinforcing teaching with a parent of an 8-year-old child who has a fracture of the epiphyseal plate. Which of the following statements should the nurse include in the teaching? A - "Fractures in a child take longer to heal than fractures in an adult." B - "Normal bone growth can be affected by the fracture." C - "Bone marrow can be lost though the fracture." D - "Your child will need to increase his calcium intake to 3,000 milligrams daily."

B - "Normal bone growth can be affected by the fracture." Rational A - Children heal fractures in less time than adults take to heal because of the generous blood supply to the bone and the epiphyseal plate. B - A fracture of the epiphyseal plate can affect growth in a child. Therefore, it needs to be detected and treated rapidly. C - The epiphyseal plate is the cartilage growth plate. Therefore, bone marrow is not lost through this type of fracture. D - Children who have fractures should be monitored for sufficient calcium intake. However, the recommended daily allowance of calcium for this age group is 1,000 mg. A daily allowance of 3,000 mg is too much for a child and places him at risk for calcium toxicity.

A nurse provides a fracture bedpan for a client who has a femur fracture and needs to defecate. When the client ask why the nurse chose that type of bedpan, which of the following responses should the nurse make? A - "This kind of bedpan will help your fracture heal correctly." B - "This kind of bedpan is easier to place under you." C - "With this bedpan, you can keep lying flat." D - "You'll be able to get on and off this kind of bedpan by yourself."

B - "This kind of bedpan is easier to place under you." Rational A - The type of bedpan does not typically affect the healing of a femur fracture. B - A fracture (or slipper) bedpan is smaller and flatter than a regular bedpan. It is easier to place under a client than a regular bedpan is. A client who has difficulty with raising herself onto a regular bedpan, has femur or lower spine fractures, is immobile, or has limited movement should use a fracture bedpan. C - No matter which type of bedpan the nurse uses, the nurse should elevate the head of the bed at least 30°. D - The nurse should always assist a client who has a femur fracture to get on and off the bedpan.

A nurse is reinforcing teaching with a client who is taking benztropine to teat Parkinson's disease. The nurse should instruct the client to report which of the following findings as an adverse effect of the medication? A - Excessive salvation B - Difficulty voiding C - Diarrhea D - Slow pulse

B - Difficulty voiding Rational A - The nurse should instruct the client that an adverse effect of the medication is dry mouth, due to the anticholinergic response of the medication, not excessive salvation. B - The nurse should instruct the client to report difficulty voiding as an adverse effect of benztropine, which may indicate urinary retention. Benztropine is an anticholinergic medication that helps decrease the rigidity and tremors of Parkinson's disease. C - The nurse should instruct the client to report constipation, which is due to the anticholinergic response of the medication that slows peristalsis. D - The nurse should instruct the client to report tachycardia not bradycardia, which is due to the anticholinergic response of the medication.

A nurse is assisting with the care of a client who has femur fracture and is in skeletal traction. Which of the following actions should the nurse take? A - Loosen the knots on the ropes if the client is experiencing pain. B - Ensure the client's weights are hanging freely from the bed. C - Check the client's bony prominences every 12 hr. D - Cleanse the client's pin sites with povidone-iodine.

B - Ensure the client's weights are hanging freely from the bed. Rational A - The knots should never be loosened on the ropes. Doing this will unsecure the traction and possibly injure the client. B - The nurse should ensure that the client's weights are hanging freely from the bed to maintain the client in proper body alignment and should never be removed without a provider prescription or the development of a life-threatening situation that requires removal. C - The client's bony prominences and skin should be checked every 8 hr for skin breakdown, irritation, and inflammation. D - The nurse should cleanse the client's pin sites with chlorhexidine solution to keep the sites clean and free from bacteria.

A nurse is collecting data from a client following the application of a leg cast for the treatment of a fracture. Which of the following findings should the nurse expect to find first if the cast is too tight? A - Toes cool to touch B - Pallor of the toes C - Edema of the toes D - Inability to move toes

B - Pallor of the toes Rational A - The client who has a cast that is too tight may have toes that are cool to the touch, which is called poikilothermia. If a cast is too tight, it will increase pressure on the blood vessels. When this occurs, the temperature of the toes will become cool to the touch; however, there is another manifestation that is the initial finding. B - The client who has a cast that is too tight may have pallor of the toes caused from inflammation and edema that puts pressure on the vascular system, tissues and nerves, which decreases blood flow and can lead to compartment syndrome. When this occurs, pallor of the toes is the initial finding. The nurse should immediately report this finding to the provider. C - The client who has a cast that is too tight may have edema of the toes and should elevate the extremity. If a cast is too tight, it will increase pressure on the blood vessels. When this occurs, edema will become present in the toes; however, there is another manifestation that is the initial finding. D - The client who has a cast that is too tight from inflammation may have an inability to move the toes of the affected extremity. If a cast is too tight, it will increase pressure on the blood vessels. When this occurs, paralysis of the toes and foot will occur; however, there is another manifestation that is the initial finding.

A nurse is collecting data from an older adult client who has a femoral head fracture 24 hr ago and is in a buck's traction. Which of the following findings is an indication of fat embolism syndrome? A - Extremity pain unrelieved by opioid analgesics B - Petechiae on the chest C - Reports of calf pain D- Absent pedal pulse on affected extremity

B - Petechiae on the chest Rational A- Extremity pain unrelieved by opioid analgesics is a manifestation of compartment syndrome. B - A red rash on the client's abdomen, chest, neck or upper arms is a manifestation of fat embolism. C- Reports of calf pain are a manifestation of deep-vein thrombosis. D- Absent pedal pulse is an indication of neurovascular compromise.

A nurse is modifying the diet of a client who has Parkinson's disease and a prescription for selegiline, a monamine oxidase inhibitor (MAOI). Which of the following foods should the nurse eliminate from the client's diet? A - Fresh fish B -Cheddar cheese C - Cherries D - Chicken

B -Cheddar cheese Rational A - The nurse does not need to eliminate fresh fish from the diet of a client who has a prescription for selegiline. Cured meats containing tyramine should be eliminated from the client's diet. B - The nurse should eliminate aged cheeses, such as cheddar cheese, from the diet of a client who has a prescription for selegiline because it contains tyramine, which can cause a hypertensive crisis. C - The nurse does not need to eliminate cherries from the diet of a client who has a prescription for selegiline. Foods containing tyramine should be eliminated from the client's diet. D- The nurse does not need to eliminate chicken from the diet of a client who has a prescription for selegiline. Foods containing tyramine should be eliminated from the client's diet.

A nurse is caring for an older adult client who has a fractured hip. The client says, "I guess I've lived long enough and my time is up." Which of the following responses should the nurse make? A - "You are in really good shape for your age." B - "This is just a minor setback. You will be back on your feet in no time." C - "You feel as though your life is ending?" D - "The doctors are going to take good care of you. There is nothing to worry about.

C - "You feel as though your life is ending?" Rational A - This response does not address the client's concerns, devalues the client's feelings, and inhibits effective communication. B - This response devalues the client's feelings. It uses a cliché and provides false reassurance, both of which inhibit therapeutic communication. C - This response uses restatement and clarification of the client's feelings to promote therapeutic communication. It addresses the client's immediate concerns. D - This response focuses on the doctors and not on the client. This is inappropriate when promoting therapeutic communication

A nurse is reinforcing teaching with a client who has Parkinson's disease. The client tells the nurse that he gets nausea when he takes his prescribed levodopa/carbidopa. Which of the following foods should the nurse recommend the client take with this medication? A- 1 cup (8oz) plain low-fat yogurt B - 1 oz of cheddar cheese C - 1 cup (8oz) of applesauce D - 1 cup (8 oz) cooked spinach

C - 1 cup (8oz) of applesauce Rational A - The client should avoid taking levodopa/carbidopa with food that is high in protein because it interferes with absorption and decreases the therapeutic response. 1 cup of plain, low-fat yogurt contains approximately 12 g of protein. B - The client should avoid taking levodopa/carbidopa with food that is high in protein because it interferes with absorption and decreases the therapeutic response. 1 ounce of cheddar cheese contains approximately 7 g of protein. C - The client should take levodopa/carbidopa with food to decrease nausea and vomiting but should avoid food high in protein because it interferes with absorption and decreases the therapeutic response. 1 cup of applesauce contains less than one-half a gram of protein. D - The client should avoid taking levodopa/carbidopa with food that is high because it interferes with absorption and decreases the therapeutic response. 1 cup of cooked spinach contains approximately 5 g of protein.

A nurse is caring for a client who has a fractured tibia as a result of a fall. The x-ray shows that the bone is splintered into several pieces around the shaft. The nurse should recognize this is a finding for which of the following types of fractures? A - Impacted B - Transverse C - Comminuted D - Oblique

C - Comminuted Rational A - An impacted fracture is an injury in which broken ends of bone are forced together, and does not result in bone splintering. B - A transverse fracture is an injury that goes straight across the bone shaft, and does not result in bone splintering. C - A comminuted fracture is an injury in which the bone is broken and splintered into several pieces. D - An oblique fracture is an injury that occurs at an angle across the bone shaft, and does not result in bone splintering.

A nurse is reinforcing teaching to a client who has a fractured ulna and is to start taking cyclobenzaprine. The nurse should instruct the client to expect which of the following therapeutic effects? A- Increased energy level B - Decreased itching C - Decreased muscle spasms D - Decreased dry mouth

C - Decreased muscle spasms Rational A- Drowsiness weakness and fatigue are adverse effects of cyclobenzaprine. B - Pruritus is an adverse effect of cyclobenzaprine. C - Cyclobenzaprine is a centrally acting muscle relaxant that relieves painful muscle spasms due to acute musculoskeletal injury. D- Dry mouth is an adverse effect of cyclobenzaprine.

A nurse is caring for a client who has Parkinson's disease and is taking selegiline 5 mg by mouth twice daily. Which of the following therapeutic outcomes should the nurse monitor for with a client who is taking this medication? A - Improved speech patterns B - Increased bladder function C - Decreased tremors D - Diminished drooling

C - Decreased tremors Rational A - Selegiline preserves dopamine in the brain and is considered a first line medication for the treatment of Parkinson's disease; however, it will not improve speech patterns. B - Selegiline slows the progress of Parkinson's disease; however, it will not increase bladder function. C - Selegiline, an MAO-B inhibitor, improves motor function by decreasing tremors, rigidity and bradykinesia in the client who has Parkinson's disease. D - Selegiline delays the progression of Parkinson's disease by preserving motor function; however, it will not have an effect on drooling.

A nurse is collecting data from a client who has osteomyelitis following a compound fracture of the right lower leg. Which of the following findings should the nurse expect? A - Low erythrocyte sedimentation rate (ESR) B - Pallor of the extremity C - High white blood cell count (WBC) D - Extremity is cool to the touch

C - High white blood cell count (WBC) Rational A - The ESR measures the weight of the erythrocytes circulating within the blood stream. Certain conditions such as infection, inflammation, cancer, or cell death cause an increase in the fibrinogen content of the plasma and, ultimately, cause the RBCs to weigh more and settle faster. The client who has osteomyelitis will have an elevated sedimentation rate. B - The client who has compartment syndrome following a fracture may develop a manifestation of pallor. However, the client who has osteomyelitis would have redness, swelling, and heat at the site. C - Osteomyelitis is an infectious process involving a bacterial infection of the bone. The causative organism is frequently Staphylococcus aureus. The body's response to the bacterial infection is to increase WBCs in order to fight the infection. D - The client who has compartment syndrome following a fracture may develop a manifestation of poikilothermia (taking on the temperature of the environment), or coolness to the touch. However, the client who has osteomyelitis would have redness, swelling, and heat at the site.

The nurse is collecting data on a client who has multiple sclerosis. Which of the following findings should the nurse expect? A - Bulging of the eyeball B - Shuffling gate C - Involuntary movement of the eyes D - Facial grimacing

C - Involuntary movement of the eyes Rational A - Exophthalmos is a manifestation of hyperthyroidism. B - A shuffling gait is a manifestation of Parkinson disease. C - Nystagmus, or involuntary movement of the eyes, is a manifestation of multiple sclerosis. D - Facial grimacing is a manifestation of Huntington's disease.

A nurse is caring for a client who has balanced skeletal traction with a Thomas splint for the treatment of a fracture of the femur. Which of the following actions should the nurse take to prevent skin breakdown? A - Apply lotion to the skin around the edges of the splint. B -Turn the client every 4 hr. C - Pad the top of the splint with protective dressings. D - The nurse should apply a footplate to the bed.

C - Pad the top of the splint with protective dressings. Rational A - The nurse should avoid applying lotion under or around the edges of the splint due to the risk of skin breakdown from moisture. B - The nurse should properly position the client in bed every 2 hr and use a low-air-loss mattress to prevent skin breakdown because the client is unable to turn in bed. C - The nurse should pad the top of the splint with protective dressings or soft cotton padding to prevent skin breakdown at the splint edge. D - The nurse should apply a footplate to the bed if the client is at risk for foot drop.

A nurse is collecting data from a client who has Parkinson's disease and is experiencing bradykinesia. Which of the following findings should the nurse expect? A - Increased blinking B - States of euphoria C - Slurred speech D - Decreased respiratory rate

C - Slurred speech Rational A - The nurse should expect to observe a decrease in blinking in a client who is experiencing bradykinesia. B - The nurse should expect to observe an expressionless, masklike face in a client who is experiencing bradykinesia. C- The nurse should expect to observe slowed, slurred speech in a client who is experiencing bradykinesia. D - A decreased respiratory rate is not an expected finding in a client who is experiencing bradykinesia.

A nurse is caring for a client who has a spinal cord injury at T-4. The nurse should recognize that the client is at risk for autonomic dysreflexia. Which of the following interventions should the nurse take to prevent autonomic dysreflexia? A - Monitor for elevated blood pressure. B- Provide analgesia for headaches. C- Prevent bladder distention. D - Elevate the client's head.

C- Prevent bladder distention. Rational A - Elevated blood pressure is a serious manifestation of autonomic dysreflexia. However, it is not a causative agent. B- A severe headache is one of the manifestations of autonomic dysreflexia. However, it is not a causative agent. C - Autonomic dysreflexia can occur in clients who have a spinal cord injury at or above the T-6 level. Autonomic dysreflexia can occur as a result of an irritation, or stimulus to the nervous system below the level of injury. Triggers of autonomic dysreflexia include bladder distention, insertion of rectal suppository, enemas, or a sudden change in position D - A sudden change in position can trigger autonomic dysreflexia.

A nurse is reinforcing discharge instructions with a client who has multiple sclerosis (MS). Which of the following instructions should the nurse include? A - "Wait to perform difficult tasks until later in the day." B - "Plan to relax in a hot tub spa each day." C - "Limit your intake of dairy products." D - "Implement a schedule to include periods of rest."

D - "Implement a schedule to include periods of rest." Rational A- The nurse should instruct the client to perform difficult tasks early in the day because fatigue worsens in the afternoon. B - The nurse should instruct the client to avoid extreme temperature changes, which may exacerbate the symptoms of MS. C - The nurse should instruct the client to consume dairy products as well as foods containing calcium and vitamin D to help prevent osteoporosis, which can develop as a result of IV steroid treatments. D - The nurse should instruct the client to implement a schedule with periods of exercise followed by periods of rest to maintain muscle strength and coordination.

A nurse is caring for a client who has skeletal traction for treatment of a femur fracture. Which of the following actions should the nurse take? A - Assist the client to shift position every 4 hr. B - Position the weights on the traction so they are touching the head of the client's bed. C - Encourage isometric exercises every 8 hr. D - Administer pain medication to the client before performing pin care.

D - Administer pain medication to the client before performing pin care. Rational ​A - The nurse should assist the client to shift positions every 2 hr to prevent skin breakdown. B - The weights on the traction should hang free to provide balance. C - The nurse should encourage the client to perform isometric exercises every 4 hr to prevent muscle atrophy. D - The nurse should administer pain medications to the client 30 minutes prior to performing pin care to reduce the client's discomfort.

A nurse is reinforcing teaching with a client who has multiple sclerosis and is learning how to use the four-point alternate gait with crutches. Identify the order of the steps the nurse should give to the client. A - Move the right foot forward B - Move the left foot forward to the level of the left crutch C -Move the left crutch forward D - Move the right crutch about 10 to 15 cm (4 to 6 in)

D - B - C - A D - Move the right crutch about 10 to 15 cm (4 to 6 in) B - Move the left foot forward to the level of the left crutch C -Move the left crutch forward A - Move the right foot forward Rational The nurse should reinforce teaching to a client who can bear weight on both legs but requires crutches for balance and support. The nurse should instruct the client to first move the right crutch about 10 to 15 cm (4 to 6 in). Next the nurse should instruct the client to move the left foot forward to the level of the left crutch. Next, the nurse should instruct the client to move the left crutch forward, and lastly to move the right foot forward.

A client is about to undergo a closed reduction of a fracture. In addition to analgesia, the nurse suggests that the client listen to an audiotape of music. Which of the following nonpharmacologic interventions for pain management is the nurse using? A - Meditation B - Guided imagery C - Biofeedback D - Distraction

D - Distraction Rational A - Meditation is the use of focused awareness to quiet the mind. Unless the audiotape is a guided meditation, the nurse is not using this technique. B - Depending on the content of the audiotape, there may be some imagery involved as the client processes the tape's content, but this is not specifically a guided imagery technique. C - Biofeedback uses an electronic monitoring device to facilitate learned self-control of physiological responses. An audiotape cannot accomplish this. D - Distraction is focusing attention on stimuli other than pain. Listening to music or a book on tape is a type of auditory distraction that can effectively reduce the client's perception and awareness of pain.

A nurse is caring for a client who is 2 days postoperative following an above-the-knee amputation. Which of the following is an appropriate intervention for this client at this time? A - Elevate the foot of the bed. B - Encourage sitting up as much as possible. C - Elevate the stump on a pillow. D - Have the client lie prone several times each day.

D - Have the client lie prone several times each day. Rational A - The nurse should elevate the foot of the bed and keep the knee extended for a client who has had a below-the-knee amputation, not an above-the-knee amputation. B - For an above-the-knee amputation, the client should avoid prolonged sitting. C - The client may have his stump elevated during the initial 24 hr following surgery. However, he should not elevate the stump on a pillow after the initial postoperative period. D - The nurse should encourage the client to lie prone for 20 to 30 min every 3 to 4 hr to help prevent hip flexion contractures.

A nurse is caring for a client who is 2 days postoperative following an above-the-knee amputation. Which of the following is an appropriate nursing intervention for the client at this time? A - Elevate the foot of the bed. ​B - Encourage sitting up as much as possible. ​C - Elevate the stump on a pillow. D - Have the client lie prone several times each day.

D - Have the client lie prone several times each day. Rational A - The nurse should elevate the foot of the bed and keep the knee extended for a client who has had a below-the-knee amputation, not an above-the-knee amputation. B - The nurse should discourage the client from prolonged sitting to prevent joint deformity. C - After the first 24 hr following an above-the-knee amputation, the client should not elevate the stump on a pillow to prevent joint deformity. D - The nurse should encourage the client to lie prone for 20 to 30 min every 3 to 4 hr to help prevent hip flexion contractures.

A nurse is caring for a child following an open reduction and internal fixation of a fractured femur and application of a cast. The cast has a window cut in it for viewing of the incision. Which of the following actions should the nurse take first? A - Remove the window and view the incision. B - Turn the client so the cast will dry on all sides. C- Medicate the client for pain. D - Perform neurovascular checks of the affected extremity.

D - Perform neurovascular checks of the affected extremity. Rational A - The incision should be viewed regularly for signs of infection; however, this is not the first action the nurse should take. B - The client should be turned regularly to ensure that all sides of the cast are allowed to dry; however, this is not the first action the nurse should take C - Medicating the client for pain is an important nursing action; however, this is not the first action the nurse should take. D - The greatest risk to this client is injury from impaired circulation due to constriction. Therefore, the first action the nurse should take is to perform neurovascular checks.

A nurse is contributing to the plan of care for a client who has spinal cord injury at level C8 who is admitted for comprehensive rehabilitation. Which of the following long-term goals is appropriate with regard to the client's mobility? A - Walk with leg braces and crutches. B - Drive an electric wheelchair with a hand-control device. C - Drive an electric wheelchair equipped with a chin-control device. D - Propel a wheelchair equipped with knobs on the wheels.

D - Propel a wheelchair equipped with knobs on the wheels. Rational A - Crutch walking, even with supportive braces, is an unrealistic goal for this client. A client who has an injury at T1 to T10 may be able to walk with braces. B - A client who has an injury at C5 would require an electric wheelchair with a hand control device. A client who has a C8 spinal cord injury should have a greater degree of mobility. C - A client who has an injury at C1 to C3 would require an electric wheelchair with a chin-control device. A client who has a C8 spinal cord injury should have a greater degree of mobility. D - A client who has an injury at C8 has full use of the shoulders and arms but will likely experience hand weakness. The addition of knobs on the wheels will help the client use the wheelchair more effectively.

A nurse is administering meperidine 100 mg IM for a client who is admitted with a pelvic fracture. Following the injection, which of the following data is the priority for the nurse to check? A - Apical pulse rate B - Blood pressure C - Level of consciousness D - Respiratory rate

D - Respiratory rate Rational A - Meperidine might affect the client's apical pulse rate; however, it is not the priority data for the nurse to check. B - Meperidine might lower the client's blood pressure; however, it is not the priority data for the nurse to check. C - Meperidine might affect the client's level of consciousness by causing sedation; however, it is not the priority data for the nurse to check. D- Meperidine, an opioid, can cause respiratory depression. The nurse should apply the ABC priority-setting framework. This framework emphasizes the basic core of human functioning—having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these can indicate a threat to life, and is therefore the nurse's priority concern. When applying the ABC priority setting framework, airway is always the highest priority because the airway must be clear and open for oxygen exchange to occur. Breathing is the second-highest priority in the ABC priority setting framework because adequate ventilator effort is essential in order for oxygen exchange to occur. Circulation is the third-highest priority in the ABC priority setting framework because delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them.

A nurse in a community clinic is caring for a 20-month-old toddler who has spiral fractures of the right ulna and radius. Which fo the following findings should the nurse recognize as a potential indication of abuse? A - The child begins to cry when her arm is examined by the provider. B - The child's examination shows a single injury. C - The child was brought to the facility 30 min after the injury occurred. D - The parents report that the child injured herself by falling off the couch.

D - The parents report that the child injured herself by falling off the couch. Rational A - Children who have been abused might not cry when faced with a painful examination or procedure because they are not used to receiving comfort following pain. B - Children who have been abused should be examined carefully for old injuries as well as current ones. The child might have bruises at varying stages of healing or signs of old fractures or burns, indicating an ongoing pattern of abuse. C - An unexplained delay in seeking treatment, such as several hours or days is a warning sign of abuse. Bringing the child to the facility 30 min after the injury occurred is not a warning sign of abuse. D - Spiral fractures occur due to the twisting of a limb; a simple fall from a couch should not cause a spiral fracture to occur. An indication of abuse is present when the parent's report of the injury does not match the type of injury incurred or if the developmental age of a child makes certain types of injury impossible.

A nurse is caring for a client who reports shortness of breath and chest pain the first day following multiple long bone fractures. The nurse should consider which of the following client complications first? A - Pneumonia ​B - Fat emboli ​C - Cardiac dysrhythmia ​D - Hypoxic condition

​B - Fat emboli Rational A - The nurse should consider pneumonia as a complication when a client has a compound long bone fracture due to immobility; however, evidence-based practice indicates the nurse should consider another complication first. B - According to evidenced-based practice the nurse should first consider a fat emboli, which can occur from a rupture of small venules allowing fat globules into the circulatory system that occludes a blood vessel. The client who has a compound long bone fracture is at high risk for developing a fat embolus within 24 to 96 hr. C - The nurse should consider cardiac dysrhythmia as a complication, which may indicate a pulmonary emboli from a fat embolism, when a client has a compound long bone fracture; however, evidence-based practice indicates the nurse should consider another complication first. D - The nurse should consider hypoxic condition as a complication, which may indicate a pulmonary emboli from a fat embolism, when a client has a compound long bone fracture; however, evidence-based practice indicates the nurse should consider another complication first.

A nurse is collecting data from a client who has a hip fracture. Which of the following findings should the nurse expect when checking the extremity? A - ​Leg lengthening B - Hip pallor ​C - Muscle spasms ​D - Leg abduction

​C - Muscle spasms Rational A - The nurse should expect leg shortening following a hip fracture. B - The nurse should expect ecchymosis at the fracture site from bleeding into the tissues following a hip fracture. C - The nurse should expect muscle spasms following a hip fracture. D - The nurse should expect internal rotation of the leg following a hip fracture.

A nurse is contributing to the plan of care for a client who has a spinal cord injury and paralysis. Which of the following actions should the nurse include in the plan to decrease the client's risk of skin breakdown? Select all A - Massage erythematous bony prominences. ​B - Implement turning schedule every 4 hr. ​C - Use pillows to keep heels off the bed surface. D- Keep environmental humidity less than 30%. ​E - Minimize skin exposure to moisture.

​C - Use pillows to keep heels off the bed surface. ​E - Minimize skin exposure to moisture Rational Massage erythematous bony prominences is incorrect. The nurse should avoid massaging erythematous bony prominences, which would cause further skin breakdown. Implement turning schedule every 4 hr is incorrect. The nurse should implement a turning schedule to prevent skin breakdown. This includes turning the client every 2 hr while in bed and repositioning hourly if the client is up in a chair. Use pillows to keep heels off the bed surface is correct. The nurse should pad all bony prominences and use devices such as pillows to keep the heels off the bed surface and prevent skin breakdown. Keep environmental humidity less than 30% is incorrect. The nurse should manage humidity in the client's room and keep the humidity above 40%. Humidity less than 40% is drying to the skin and increases the risk of skin breakdown. Minimize skin exposure to moisture is correct. The nurse should include actions to minimize exposure of the skin to moisture from sweating, wound drainage or incontinence as this causes maceration of the skin which leads to skin breakdown.