Musculoskeletal Nclex style, Lewis Chapter 58, Lewis Chapter 56, Ch. 24 Integumentary, Musculoskeletal Practice Problems, Med-Surg: Lewis: Chapter 57: Acute Intracranial Problems, Med-Surg: Lewis: Chapter 59: Chronic Neurologic Problems, Med-Surg: Le...

A patient is seen at the outpatient clinic for a sudden onset of inflammation and severe pain in the great toe. A diagnosis of gout is made on the basis of a. a family history of gout b. elevated urine uric acid levels c. elevated serum uric acid levels d. the presence of sodium urate crystals in synovial fluid

D. the presence of sodium urate cystals in synovial fluid

A patient who is having an acute exacerbation of multiple sclerosis has a prescription for methylprednisolone (Solu-Medrol) 160 mg IV. The label on the vial reads: methylprednisolone 125 mg in 2 mL. How many mL will the nurse administer?

2.56. With a concentration of 125 mg/2 mL, the nurse will need to administer 2.56 mL to obtain 160 mg of methylprednisolone.

The nurse is monitoring a patient for increased ICP following a head injury. Which of the following manifestations indicate an increased ICP (select all that apply) a. fever b. oriented to name only c. narrowing pulse pressure d. dilated right pupil > left pupil e. decorticate posturing to painful stimulus

A, B, D, E- The first sign of increased ICP is a change in LOC. Other manifestations are dilated ipsilateral pupil, changes in motor response such as posturing, and fever, which may indicate pressure on the hypothalamus. Changes in vital signs would be an increased systolic BP with widened pulse pressure and bradycardia

A 27-year-old patient who has been treated for status epilepticus in the emergency department will be transferred to the medical nursing unit. Which equipment should the nurse have available in the patient's assigned room (select all that apply)? a. Side-rail pads b. Tongue blade c. Oxygen mask d. Suction tubing e. Urinary catheter f. Nasogastric tube

A, C, D. The patient is at risk for further seizures, and oxygen and suctioning may be needed after any seizures to clear the airway and maximize oxygenation. The bed's side rails should be padded to minimize the risk for patient injury during a seizure. Use of tongue blades during a seizure is contraindicated. Insertion of a nasogastric (NG) tube is not indicated because the airway problem is not caused by vomiting or abdominal distention. A urinary catheter is not required unless there is urinary retention.

What is a classic manifestation of tetanus infection? A. Rigidity and seizures B. Bloody diarrhea and vomiting C. Pulmonary edema D. Sepsis

A. Rigidity and seizures The manifestations are mainly neurologic. They include stiffness in the jaw (trismus), generalized tonic convulsions, and opisthotonos. Laryngeal and respiratory spasms can also occur. The other options are not related to tetanus.

Teaching that the nurse will plan for the patient with SLE includes a. ways to avoid exposure to sunlight b. increasing dietary protein and carbohydrate intake c. the necessity of genetic counseling before planning a family d. the use of no pharmacologic pain interventions instead of analgesics

A. ways to avoid exposure to sunlight

A newly admitted patient who has suffered a right sided brain stroke has a nursing diagnosis of disturbed visual sensory perception related to homonymous hemianopsia. Early in the care of the patient, the nurse should a. place objects on the right side within the patient's field of vision b. approach the patient from the left side to encourage the patient to turn the head c. place objects on the patient's left side to assess the patient's ability to compensate d. patch the affected eye to encourage the patient to turn the head to scan the environment

A: Place objects on the right side within the patient's field of vision- the presence of homonymous hemianopia in a patient with right-hemisphere brain damage causes a loss of vision in the left field. Early in the care of the patient, objects should be placed on the right side of the patient in the field of vision, and the nurse should approach the patient from the right side. Later in treatment, patients should be taught to turn the head and scan the environment and should be approached from the affected side to encourage head turning. Eye patches are used if patients have diplopia (double vision).

Four days following a stroke, a patient is to start oral fluids and feedings. Before feeding the patient, the nurse should first a. check the patient's gag reflex b. order a soft diet for the patient c. raise the head of the bed to sitting position d. evaluate the patient's ability to swallow small sips of ice water

A: check the patient's gag reflex- the first step in providing oral feedings for a patient with a stroke is ensuring that the patient has an intact gag reflex because oral feedings will not be provided if gag reflex is impaired. The nurse should then evaluate the patient's ability to swallow ice chips or ice water after placing the patient in an upright position

Which menu choice by the patient with diverticulosis is best for preventing diverticulitis? a. Navy bean soup and vegetable salad b. Whole grain pasta with tomato sauce c. Baked potato with low-fat sour cream d. Roast beef sandwich on whole wheat bread

ANS: A A diet high in fiber and low in fats and red meat is recommended to prevent diverticulitis. Although all of the choices have some fiber, the bean soup and salad will be the highest in fiber and the lowest in fat.

The nurse admitting a patient with acute diverticulitis explains that the initial plan of care is to a. administer IV fluids. b. give stool softeners and enemas. c. order a diet high in fiber and fluids. d. prepare the patient for colonoscopy.

ANS: A A patient with acute diverticulitis will be NPO and given parenteral fluids. A diet high in fiber and fluids will be implemented before discharge. Bulk-forming laxatives, rather than stool softeners, are usually given, and these will be implemented later in the hospitalization. The patient with acute diverticulitis will not have enemas or a colonoscopy because of the risk for perforation and peritonitis.

A 28-year-old with psoriatic arthritis and back pain is receiving etanercept (Enbrel). Which finding is most important for the nurse to report to the health care provider? a. Crackles are heard in both lung bases. b. Red, scaly patches are noted on the arms. c. Hemoglobin level is 11.1g/dL and hematocrit is 35%. d. Patient reports continued back pain after a week of etanercept therapy.

ANS: A Because heart failure is a possible adverse effect of etanercept, the medication may need to be discontinued. The other information will also be reported to the health care provider but does not indicate a need for a change in treatment. Red, scaly patches of skin and mild anemia are commonly seen with psoriatic arthritis. Treatment with biologic therapies requires time to improve symptoms.

When a patient's intracranial pressure (ICP) is being monitored with an intraventricular catheter, which information obtained by the nurse is most important to communicate to the health care provider? a. Oral temperature 101.6° F b. Apical pulse 102 beats/min c. Intracranial pressure 15 mm Hg d. Mean arterial pressure 90 mm Hg

ANS: A Infection is a serious consideration with ICP monitoring, especially with intraventricular catheters. The temperature indicates the need for antibiotics or removal of the monitor. The ICP, arterial pressure, and apical pulse are all borderline high but require only ongoing monitoring at this time. DIF: Cognitive Level: Application REF: 1438-1440

While admitting a patient with a basal skull fracture, the nurse notes clear drainage from the patient's nose. Which of these admission orders should the nurse question? a. Insert nasogastric tube. b. Turn patient every 2 hours. c. Keep the head of bed elevated. d. Apply cold packs for facial bruising.

ANS: A Rhinorrhea may indicate a dural tear with cerebrospinal fluid (CSF) leakage, and insertion of a nasogastric tube will increase the risk for infections such as meningitis. Turning the patient, elevating the head, and applying cold pack are appropriate orders. DIF: Cognitive Level: Application REF: 1440

The charge nurse observes an inexperienced staff nurse who is caring for a patient who has had a craniotomy for a brain tumor. Which action by the inexperienced nurse requires the charge nurse to intervene? a. The staff nurse suctions the patient every 2 hours. b. The staff nurse assesses neurologic status every hour. c. The staff nurse elevates the head of the bed to 30 degrees. d. The staff nurse administers a mild analgesic before turning the patient.

ANS: A Suctioning increases intracranial pressure and is done only when the patient's respiratory condition indicates it is needed. The other actions by the staff nurse are appropriate. DIF: Cognitive Level: Application REF: 1430-1431

A patient with a head injury has admission vital signs of blood pressure 128/68, pulse 110, and respirations 26. Which of these vital signs, if taken 1 hour after admission, will be of most concern to the nurse? a. Blood pressure 156/60, pulse 55, respirations 12 b. Blood pressure 130/72, pulse 90, respirations 32 c. Blood pressure 148/78, pulse 112, respirations 28 d. Blood pressure 110/70, pulse 120, respirations 30

ANS: A Systolic hypertension with widening pulse pressure, bradycardia, and respiratory changes represent Cushing's triad and indicate that the intracranial pressure (ICP) has increased, and brain herniation may be imminent unless immediate action is taken to reduce ICP. The other vital signs may indicate the need for changes in treatment, but they are not indicative of an immediately life-threatening process. DIF: Cognitive Level: Application REF: 1429-1430

When admitting a patient who has a tumor of the right frontal lobe, the nurse would expect to find a. judgment changes. b. expressive aphasia. c. right-sided weakness. d. difficulty swallowing.

ANS: A The frontal lobes control intellectual activities such as judgment. Speech is controlled in the parietal lobe. Weakness and hemiplegia occur on the contralateral side from the tumor. Swallowing is controlled by the brainstem. DIF: Cognitive Level: Application REF: 1447 | 1448

The nurse observes a patient ambulating in the hospital hall when the patient's arms and legs suddenly jerk and the patient falls to the floor. The nurse will first a. assess the patient for a possible head injury. b. give the scheduled dose of divalproex (Depakote). c. document the timing and description of the seizure. d. notify the patient's health care provider about the seizure.

ANS: A The patient who has had a myoclonic seizure and fall is at risk for head injury and should first be evaluated and treated for this possible complication. Documentation of the seizure, notification of the seizure, and administration of antiseizure medications are also appropriate actions, but the initial action should be assessment for injury.

A 63-year-old patient hospitalized with polymyositis has joint pain, an erythematosus facial rash, eyelid edema, and a weak, hoarse voice. The priority nursing diagnosis for the patient is a. risk for aspiration related to dysphagia. b. disturbed visual perception related to swelling. c. acute pain related to generalized inflammation. d. risk for impaired skin integrity related to scratching.

ANS: A The patient's vocal weakness and hoarseness indicate weakness of the pharyngeal muscles and a high risk for aspiration. The other nursing diagnoses also are appropriate but are not as high a priority as the maintenance of the patient's airway

A healthy 28-year-old woman patient who weighs 145 pounds (66 kg) asks the nurse about the minimum daily requirement for protein. How many grams of protein will the nurse recommend? a. 53 b. 66 c. 75 d. 98

ANS: A The recommended daily protein intake is 0.8 to 1 g/kg of body weight, which for this patient is 66 kg × 0.8 g = 52.8 or 53 g/day.

To assess the functioning of the trigeminal and facial nerves (CN V and VII), the nurse should a. apply a cotton wisp strand to the cornea. b. have the patient read a magazine or book. c. shine a bright light into the patient's pupil. d. check for unilateral drooping of the eyelids.

ANS: A The trigeminal and facial nerves are responsible for the corneal reflex. The optic nerve is tested by having the patient read a Snellen chart or a newspaper. Assessment of pupil response to light and ptosis are used to check function of the oculomotor nerve. DIF: Cognitive Level: Comprehension REF: 1416-1417

A patient is receiving continuous enteral nutrition through a small-bore silicone feeding tube. What should the nurse plan for when this patient has a computed tomography (CT) scan ordered? a. Shut the feeding off 30 to 60 minutes before the scan. b. Ask the health care provider to reschedule the CT scan. c. Connect the feeding tube to continuous suction during the scan. d. Send the patient to CT scan with oral suction in case of aspiration.

ANS: A The tube feeding should be shut off 30 to 60 minutes before any procedure requiring the patient to lie flat. Because the CT scan is ordered for diagnosis of patient problems, rescheduling is not usually an option. Prevention, rather than treatment, of aspiration is needed. Small-bore feeding tubes are soft and collapse easily with aspiration or suction, making nasogastric suction of gastric contents unreliable.

When admitting an acutely confused patient with a head injury, which action should the nurse take? a. Ask family members about the patient's health history. b. Ask leading questions to assist in obtaining health data. c. Wait until the patient is better oriented to ask questions. d. Obtain only the physiologic neurologic assessment data.

ANS: A When admitting a patient who is likely to be a poor historian, the nurse should obtain health history information from others who have knowledge about the patient's health. Waiting until the patient is oriented or obtaining only physiologic data will result in incomplete assessment data; this could adversely affect decision-making about treatment. Asking leading questions may result in inaccurate or incomplete information. DIF: Cognitive Level: Application REF: 1412-1413

Which of the nurse's assigned patients should be referred to the dietitian for a complete nutritional assessment (select all that apply)? a. A 23-year-old who has a history of fluctuating weight gains and losses b. A 35-year-old who complains of intermittent nausea for the past 2 days c. A 64-year-old who is admitted for débridement of an infected surgical wound d. A 52-year-old admitted with chest pain and possible myocardial infarction (MI) e. A 48-year-old with rheumatoid arthritis who takes prednisone (Deltasone) daily

ANS: A, C, E Weight fluctuations, use of corticosteroids, and draining or infected wounds all suggest that the patient may be at risk for malnutrition. Patients with chest pain or MI are not usually poorly nourished. Although vomiting that lasts 5 days places a patient at risk, nausea that has persisted for 2 days does not always indicate poor nutritional status or risk for health problems caused by poor nutrition.

A 49-year-old man has been admitted with hypotension and dehydration after 3 days of nausea and vomiting. Which order from the health care provider will the nurse implement first? a. Insert a nasogastric (NG) tube. b. Infuse normal saline at 250 mL/hr. c. Administer IV ondansetron (Zofran). d. Provide oral care with moistened swabs.

ANS: B Because the patient has severe dehydration, rehydration with IV fluids is the priority. The other orders should be accomplished as quickly as possible after the IV fluids are initiated.

The nurse will plan to monitor a patient with an obstructed common bile duct for a. melena. b. steatorrhea. c. decreased serum cholesterol levels. d. increased serum indirect bilirubin levels.

ANS: B A common bile duct obstruction will reduce the absorption of fat in the small intestine, leading to fatty stools. Gastrointestinal (GI) bleeding is not caused by common bile duct obstruction. Serum cholesterol levels are increased with biliary obstruction. Direct bilirubin level is increased with biliary obstruction.

A patient being admitted with an acute exacerbation of ulcerative colitis reports crampy abdominal pain and passing 15 or more bloody stools a day. The nurse will plan to a. administer IV metoclopramide (Reglan). b. discontinue the patient's oral food intake. c. administer cobalamin (vitamin B12) injections. d. teach the patient about total colectomy surgery.

ANS: B An initial therapy for an acute exacerbation of inflammatory bowel disease (IBD) is to rest the bowel by making the patient NPO. Metoclopramide increases peristalsis and will worsen symptoms. Cobalamin (vitamin B12) is absorbed in the ileum, which is not affected by ulcerative colitis. Although total colectomy is needed for some patients, there is no indication that this patient is a candidate.

The nurse preparing for the annual physical exam of a 50-year-old man will plan to teach the patient about a. endoscopy. b. colonoscopy. c. computerized tomography screening. d. carcinoembryonic antigen (CEA) testing.

ANS: B At age 50, individuals with an average risk for colorectal cancer (CRC) should begin screening for CRC. Colonoscopy is the gold standard for CRC screening. The other diagnostic tests are not recommended as part of a routine annual physical exam at age 50.

Which information obtained by the nurse interviewing a 30-year-old male patient is most important to communicate to the health care provider? a. The patient has a history of constipation. b. The patient has noticed blood in the stools. c. The patient had an appendectomy at age 27. d. The patient smokes a pack/day of cigarettes.

ANS: B Blood in the stools is a possible clinical manifestation of colorectal cancer and requires further assessment by the health care provider. The other patient information will also be communicated to the health care provider, but does not indicate an urgent need for further testing or intervention.

A family member of a 28-year-old patient who has suffered massive abdominal trauma in an automobile accident asks the nurse why the patient is receiving famotidine (Pepcid). The nurse will explain that the medication will a. decrease nausea and vomiting. b. inhibit development of stress ulcers. c. lower the risk for H. pylori infection. d. prevent aspiration of gastric contents.

ANS: B Famotidine is administered to prevent the development of physiologic stress ulcers, which are associated with a major physiologic insult such as massive trauma. Famotidine does not decrease nausea or vomiting, prevent aspiration, or prevent H. pylori infection.

A 54-year-old critically ill patient with sepsis is frequently incontinent of watery stools. What action by the nurse will prevent complications associated with ongoing incontinence? a. Apply incontinence briefs. b. Use a fecal management system c. Insert a rectal tube with a drainage bag. d. Assist the patient to a commode frequently.

ANS: B Fecal management systems are designed to contain loose stools and can be in place for as long as 4 weeks without causing damage to the rectum or anal sphincters. Although incontinence briefs may be helpful, unless they are changed frequently, they are likely to increase the risk for skin breakdown. Rectal tubes are avoided because of possible damage to the anal sphincter and ulceration of the rectal mucosa. A critically ill patient will not be able to tolerate getting up frequently to use the commode or bathroom.

Which information will the nurse include in teaching a patient who had a proctocolectomy and ileostomy for ulcerative colitis? a. Restrict fluid intake to prevent constant liquid drainage from the stoma. b. Use care when eating high-fiber foods to avoid obstruction of the ileum. c. Irrigate the ileostomy daily to avoid having to wear a drainage appliance. d. Change the pouch every day to prevent leakage of contents onto the skin.

ANS: B High-fiber foods are introduced gradually and should be well chewed to avoid obstruction of the ileostomy. Patients with ileostomies lose the absorption of water in the colon and need to take in increased amounts of fluid. The pouch should be drained frequently but is changed every 5 to 7 days. The drainage from an ileostomy is liquid and continuous, so control by irrigation is not possible.

Which statement by a patient with systemic lupus erythematosus (SLE) indicates that the patient has understood the nurse's teaching about the condition? a. "I will exercise even if I am tired." b. "I will use sunscreen when I am outside." c. "I should take birth control pills to keep from getting pregnant." d. "I should avoid aspirin or nonsteroidal antiinflammatory drugs."

ANS: B Severe skin reactions can occur in patients with SLE who are exposed to the sun. Patients should avoid fatigue by balancing exercise with rest periods as needed. Oral contraceptives can exacerbate lupus. Aspirin and nonsteroidal antiinflammatory drugs are used to treat the musculoskeletal manifestations of SLE.

Which assessments will the nurse make to test a patient's cerebellar function (select all that apply)? a. Assess for graphesthesia. b. Perform the finger-to-nose test. c. Observe arm movement with gait. d. Check ability to push against resistance. e. Determine ability to sense heat and cold.

ANS: B, C The cerebellum is responsible for coordination and is assessed by looking at the patient's gait and the finger-to-nose test. The other assessments will be used for other parts of the neurological assessment. DIF: Cognitive Level: Analysis REF: 1417-1418

The nurse is assessing a patient who had a total gastrectomy 8 hours ago. What information is most important to report to the health care provider? a. Absent bowel sounds b. Complaints of incisional pain c. Temperature 102.1° F (38.9° C) d. Scant nasogastric (NG) tube drainage

ANS: C An elevation in temperature may indicate leakage at the anastomosis, which may require return to surgery or keeping the patient NPO. The other findings are expected in the immediate postoperative period for patients who have this surgery.

Which statement to the nurse from a patient with jaundice indicates a need for teaching? a. "I used cough syrup several times a day last week." b. "I take a baby aspirin every day to prevent strokes." c. "I use acetaminophen (Tylenol) every 4 hours for back pain." d. "I need to take an antacid for indigestion several times a week"

ANS: C Chronic use of high doses of acetaminophen can be hepatotoxic and may have caused the patient's jaundice. The other patient statements require further assessment by the nurse, but do not indicate a need for patient education.

Which action will the nurse include in the plan of care for a 42-year-old patient who is being admitted with Clostridium difficile? a. Educate the patient about proper food storage. b. Order a diet with no dairy products for the patient. c. Place the patient in a private room on contact isolation. d. Teach the patient about why antibiotics will not be used.

ANS: C Because C. difficile is highly contagious, the patient should be placed in a private room and contact precautions should be used. There is no need to restrict dairy products for this type of diarrhea. Metronidazole (Flagyl) is frequently used to treat C. difficile. Improper food handling and storage do not cause C. difficile.

A 68-year-old male patient with a stroke is unconscious and unresponsive to stimuli. After learning that the patient has a history of gastroesophageal reflux disease (GERD), the nurse will plan to do frequent assessments of the patient's a. apical pulse. b. bowel sounds. c. breath sounds. d. abdominal girth.

ANS: C Because GERD may cause aspiration, the unconscious patient is at risk for developing aspiration pneumonia. Bowel sounds, abdominal girth, and apical pulse will not be affected by the patient's stroke or GERD and do not require more frequent monitoring than the routine.

Which assessment is most important for the nurse to make regarding a patient with myasthenia gravis? a. Pupil size b. Grip strength c. Respiratory effort d. Level of consciousness

ANS: C Because respiratory insufficiency may be life threatening, it will be most important to monitor respiratory function. The other data also will be assessed but are not as critical.

An 80-year-old who is hospitalized with peptic ulcer disease develops new-onset auditory hallucinations. Which prescribed medication will the nurse discuss with the health care provider before administration? a. Sucralfate (Carafate) b. Omeprazole (Prilosec) c. Metoclopramide (Reglan) d. Aluminum hydroxide (Amphojel)

ANS: C Metoclopramide can cause central nervous system (CNS) side effects ranging from anxiety to hallucinations. Hallucinations are not a side effect of proton-pump inhibitors, mucosal protectants, or antacids.

Which patient seen by the nurse in the outpatient clinic is most likely to require teaching about ways to reduce risk for osteoarthritis (OA)? a. A 38-year-old man who plays on a summer softball team b. A 56-year-old man who is a member of a construction crew c. A 56-year-old woman who works on an automotive assembly line d. A 49-year-old woman who is newly diagnosed with diabetes mellitus

ANS: C OA is more likely to occur in women as a result of estrogen reduction at menopause and in individuals whose work involves repetitive movements and lifting. Moderate exercise, such as softball, reduces risk for OA. Diabetes is not a risk factor for OA. Working on a construction crew would involve nonrepetitive work and thus would not be as risky.

When caring for a patient who has had cerebral angiography, which nursing action will be included in the plan of care? a. Ask about headache and photophobia. b. Keep patient NPO until gag reflex returns. c. Check pulse and blood pressure frequently. d. Assess orientation to person, place, and time.

ANS: C Since a catheter is inserted into an artery (such as the femoral artery) during cerebral angiography, the nurse should assess for bleeding after this procedure. The other nursing assessments are not necessary after angiography. DIF: Cognitive Level: Application REF: 1418-1419

A 22-year-old female patient with an exacerbation of ulcerative colitis is having 15 to 20 stools daily and has excoriated perianal skin. Which patient behavior indicates that teaching regarding maintenance of skin integrity has been effective? a. The patient uses incontinence briefs to contain loose stools. b. The patient asks for antidiarrheal medication after each stool. c. The patient uses witch hazel compresses to decrease irritation. d. The patient cleans the perianal area with soap after each stool.

ANS: C Witch hazel compresses are suggested to reduce anal irritation and discomfort. Incontinence briefs may trap diarrhea and increase the incidence of skin breakdown. Antidiarrheal medications are not given 15 to 20 times a day. The perianal area should be washed with plain water after each stool.

The nurse will plan to teach a patient with Crohn's disease who has megaloblastic anemia about the need for a. oral ferrous sulfate tablets. b. regular blood transfusions. c. iron dextran (Imferon) infusions. d. cobalamin (B12) spray or injections.

ANS: D Crohn's disease frequently affects the ileum, where absorption of cobalamin occurs. Cobalamin must be administered regularly by nasal spray or IM to correct the anemia. Iron deficiency does not cause megaloblastic anemia. The patient may need occasional transfusions but not regularly scheduled transfusions.

The health care provider prescribes antacids and sucralfate (Carafate) for treatment of a patient's peptic ulcer. The nurse will teach the patient to take a. sucralfate at bedtime and antacids before each meal. b. sucralfate and antacids together 30 minutes before meals. c. antacids 30 minutes before each dose of sucralfate is taken. d. antacids after meals and sucralfate 30 minutes before meals.

ANS: D Sucralfate is most effective when the pH is low and should not be given with or soon after antacids. Antacids are most effective when taken after eating. Administration of sucralfate 30 minutes before eating and antacids just after eating will ensure that both drugs can be most effective. The other regimens will decrease the effectiveness of the medications.

The home health nurse is doing a follow-up visit to a 41-year-old patient with recently diagnosed rheumatoid arthritis (RA). Which assessment made by the nurse indicates that more patient teaching is needed? a. The patient takes a 2-hour nap each day. b. The patient has been taking 16 aspirins daily. c. The patient sits on a stool while preparing meals. d. The patient sleeps with two pillows under the head.

ANS: D The joints should be maintained in an extended position to avoid contractures, so patients should use a small, flat pillow for sleeping. The other information is appropriate for a patient with RA and indicates that teaching has been effective

A patient with gout is treated with drug therapy to prevent future attacks. The nurse teaches the patient that is is the most important to a. avoid all foods high in purine, such as organ meats b. have periodic determination of serum uric acid levels c. perform active ROM of all joints that have been affected by gout d. increase the dosage of medication with the onset of an acute attack

B. have periodic determination of serum uric acid levels

A patient with an intracranial problem does not open his eyes to any stimulus, has no verbal response except moaning and muttering when stimulated, and flexes his arm in response to painful stimuli. The nurse records the patients GCS score as a. 6 b. 7 c. 9 d. 11

B. 7- no opening of eyes = 1; incomprehensible words= 2, flexion withdrawal = 4 Total = 7

Vasogenic cerebral edema increases ICP by a. shifting fluid in gray matter b. altering the endothelial lining of cerebral capillaries c. leaking molecules from the intracellular fluid to the capillaries d. altering the osmotic gradient flow inot the intravascular component

B. Altering the endothelial lining of cerebral capillaries

The nurse will assess a 67-year-old patient who is experiencing a cluster headache for a. nuchal rigidity. b. unilateral ptosis. c. projectile vomiting. d. throbbing, bilateral facial pain.

B. Unilateral eye edema, tearing, and ptosis are characteristic of cluster headaches. Nuchal rigidity suggests meningeal irritation, such as occurs with meningitis. Although nausea and vomiting may occur with migraine headaches, projectile vomiting is more consistent with increased intracranial pressure (ICP). Unilateral sharp, stabbing pain, rather than throbbing pain, is characteristic of cluster headaches.

A diagnosis of a ruptured cerebral aneurysm has been made in a patient with manifestations of a stroke. The nurse anticipates that treatment options that would be evaluated for the patient include a. hyperventilation therapy b. surgical clipping of the aneurysm c. administration of hyperosmotic agents d. administration of thrombolytic therapy

B: Surgical clipping of they aneurysm- Surgical management with clipping of an aneurysm to decrease re bleeding and vasospasm is an option for a stroke cause by rupture of a cerebral aneurysm. Placement of coils into the lumens of the aneurysm by intercentional radiologists is increasing in popularity. Hyperventilation therapy would increase vasodilation and the potential for hemorrhage. Thrombolytic therapy would be absolutely contraindicated, and if a vessel is patent, osmotic diuretics may leak into tissue, pulling fluid out of the vessel and increasing edema.

To promote communication during rehabilitation of the patient with aphasia, an appropriate nursing intervention is to a. use gestures, pictures, and music to stimulate patient responses b. talk about activities of daily living (ADLs) that are familiar to the patient c. structure statements so that patient does not have to respond verbally d. use flashcards with simple words and pictures to promote language recall

B: Talk about ADLs that are familiar to the patient- during rehabilitation, the patient with aphasia needs frequent, meaningful verbal stimulation that has relevance for him. Conversation by the nurse and family should address ADLs that are familiar to the patient. Gestures, pictures, and simple statements are more appropriate in the acute phase, when patients may be overwhelmed with verbal stimuli. Flashcards are often perceived by the patient as childish and meaningless.

Nursing management of a patient with a brain tumor includes (select all that apply) a. discussing with the patient methods to control appropriate behavior b. using diversion techniques to leep the patient stimulated and motivated c. assisting and supporting the family in understanding any changes in behavior d. limiting self care activities until the patient has regained maximal physical functioning e. plan for seizure precautions and teaching the patient and caregiver about antiseizure drugs.

C, E

A 49-year-old patient with multiple sclerosis (MS) is to begin treatment with glatiramer acetate (Copaxone). Which information will the nurse include in patient teaching? a. Recommendation to drink at least 4 L of fluid daily b. Need to avoid driving or operating heavy machinery c. How to draw up and administer injections of the medication d. Use of contraceptive methods other than oral contraceptives

C. Copaxone is administered by self-injection. Oral contraceptives are an appropriate choice for birth control. There is no need to avoid driving or drink large fluid volumes when taking glatiramer.

What is the classic manifestation of a spinal cord tumor? A. Sudden onset of excruciating pain, worse at night B. Radiating pain down one leg C. Gradual onset of radicular pain, worse when lying down D. Positive Brudzinski's sign

C. Gradual onset of radicular pain, worse when lying down Tumors are slow growing. The most common early symptom is pain in the back with radicular pain. The pain worsens with activity, coughing, straining, and lying down. Sudden onset of excruciating pain is not related to spinal cord tumors. Radiating pain down one leg is a classic characteristic of sciatic nerve pathology. A positive Brudzinski's sign is seen in meningitis.

The nurse teaches the patient with RA that one of the most effective methods of aerobic exercise is a. ballet dancing b. casual walking c. aquatic exercises d. low-impact aerobic exercises

C. aquatic exercises

During the physical assessment of the patient with moderate RA, the nurse would expect to find a. hepatomegaly b. Heberden's nodes c. spindle-shaped fingers d. crepitus on joint movement

C. spindle-shaped fingers

The health care provider initially orders bed rest for a patient with an open-book pelvic fracture. Which assessment data obtained by the nurse are most important to report to the health care provider? a. The bowel tones are absent. b. There is an unusual amount of pelvic movement. c. The patient complains of level 4 abdominal pain on a 10-point pain scale. d. There is bruising of the abdomen.

Correct Answer: A Rationale: Absent bowel tones may be due to complications of pelvic fractures such as paralytic ileus, hemorrhage, or trauma to the bladder, urethra, or colon. Unusual pelvic movement, abdominal pain, and abdominal bruising would be expected with this type of injury.

When caring for a patient with systemic sclerosis, the nurse knows it is important to instruct the patient related to (select all that apply) a. avoiding the consumption of high-purine foods b. strategies for good dental hygiene and mouth care c. protecting the extremities from hot and cold temperatures d. maintaining joint function and preserving muscle strength e. performing mouth excursion (yawning) exercises on a daily basis

Correct answers: b, c, d, e Rationale: Systemic sclerosis (SS), or scleroderma, is a disorder of connective tissue characterized by fibrotic, degenerative, and occasionally inflammatory changes in the skin, blood vessels, synovium, skeletal muscle, and internal organs. The nurse should include the following in the teaching plan for a patient with SS: daily oral hygiene (neglect may increase tooth and gingival problems); protection of hands and feet from cold exposure and possible burns or cuts (wounds heal slowly); avoidance of emotional stress and cold ambient temperatures (they aggravate Raynaud's phenomenon); isometric exercises for arthropathy (no joint movement occurs); use of assistive devices as appropriate and organization of activities to preserve strength and reduce disability; and mouth excursion (i.e., yawning with an open mouth) (helps maintain temporomandibular joint function).

Laboratory findings that the nurse would expect to be present in the patient with RA include a. polycythemia b. increased IgG c. decreased WBC d. increased C-reactive protein (CRP)

D. increased C-reactive protein (CRP)

After teaching a patient with RA to use heat and cold therapy to relieve symptoms, the nurse determines that teaching has been effective when the patient says, a. heat treatments should not be used if muscle spasms are present b. cold applications can be applied for 15-20 minutes to relieve joint stiffness c. I should use heat applications for 20 minutes to relieve the symptoms of an acute flare d. when my joints are painful, I can use a bag of frozen corn for 10 to 15 minutes to relieve the pain

D. when my joints are painful, I can use a bag of frozen corn for 10 to 15 minutes to relive the pain

A patient comes to the emergency department immediately after experiencing numbness of the face and an inability to speak, but while the patient awaits examination, the symptoms disappear and the patient request discharge. The nurse stresses that it is important for the patient to be evaluated primarily because a. the patient has probably experienced an asymptomatic lacunar stroke b. the symptoms are likely to return and progress to worsening neurologic deficit in the next 24 hours c. neurologic deficits that are transient occur most often as a result of small hemorrhages that clot off d. the patient has probably experienced a transient ischemic attack (TIA), which is a sign of progressive cerebral vascular disease

D: The patient has probably experienced a transient ischemic attack (TIA), which is a sign of progressive cerebral vascular disease- A TIA is a temporary focal loss of neurologic function caused by ischemia of an area of the brain, usually lasting only about 3 hours. TIAs may be due to microemboli from heart disease or carotid or cerebral thrombi and are a warning of progressive disease. Evaluation is necessary to determine the cause of the neurologic deficit and provide prophylactic treatment if possible.

A nurse caring for a disheveled patient with poor hygiene observes that the patient that small red lesions flush with the skin on the head and body. The patient complains of severe itching at the sites. For what should the nurse further assess the patient? A. Nits on the shaft of his head hair B. A history of sexually transmitted diseases. C. The presence of ticks attached to the scalp D. The presence of burrows in the interdigital webs

Pediculosis (head lice and body lice) causes very small, red, noninflammatory lesions that progress to popular wheal-like lesions and cause severe itching. Lice live on the body as nits (tiny white eggs) that are firmly attached to hair shafts on the head and body. Burrows, especially in interdigital webs, are found with scabies.

The patient has diabetes mellitus and COPD that has been treated with high-dose corticosteroids for the past several years. Which dermatologic manifestations could be related to these systemic problems (select all that apply)? A. Acne B. Increased sweating C. Dry, coarse, brittle hair D. Impaired wound healing E. Erythematous plaques of the shins F. Decreased subcutaneous fat over extremities

a,d,e,f. Glucocorticoid excess can cause acne and decreased subcutaneous fat over the extremities. Diabetes mellitus can cause erythematous plaques of the shins and and both the corticosteroids and diabetes can impair or delay wound healing. Increased sweating is seen with hyperthyroidism and coarse, brittle hair is seen with hypothyroidism.

What is the most common reason elective cosmetic surgery is requested by patients? A. Improve self-image B. Remove deep acne scars C. Lighten the skin in pigmentation problems D. Prevent skin changes associated with aging

a. Improvement of body image is the most common reason for undergoing cosmetic surgery; appearance is an important part of confidence and self-assurance. Acne scars, pigmentation problems, and wrinkling can be treated with cosmetic surgery but the surgery does not prevent the skin changes associated with aging.

To prevent lichenification related to chronic skin problems, what does the nurse encourage the patient to do? A. Use measures to control itching. B. Wear sterile gloves when touching the lesions. C. Use careful hand washing and safe disposal of soiled dressings. D. Use topical antibiotics with wet-to-dry dressings over the lesions.

a. Lichenification is thickening of the skin caused by chronic scratching or rubbing and can be prevented by controlling itching. It is not an infection, nor is it contagious, as the other options indicate.

What is a skin graft that is used to transfer skin and subcutaneous tissue to large areas of deep tissue destruction called? A. Skin flap B. Free graft C. Soft tissue extension D. Free graft with vascular anastomoses

a. Skin flaps as grafts include moving skin and subcutaneous tissue to another part of the body and are used to cover wounds with poor vascular beds, adding padding, and cover wounds over cartilage and bone. Both types of free grafts include just skin and soft tissue extension involves placement of an expander under the skin, which stretches the skin over time to provide extra skin to cover the desired area.

1. A patient who is hospitalized with pneumonia is disoriented and confused 2 days after admission. Which information obtained by the nurse about the patient indicates that the patient is experiencing delirium rather than dementia? a. The patient was oriented and alert when admitted. b. The patient's speech is fragmented and incoherent. c. The patient is disoriented to place and time but oriented to person. d. The patient has a history of increasing confusion over several years.

a. The patient was oriented and alert when admitted. The onset of delirium occurs acutely. The degree of disorientation does not differentiate between delirium and dementia. Increasing confusion for several years is consistent with dementia. Fragmented and incoherent speech may occur with either delirium or dementia.

A patient with osteomyelitis is treated with surgical debridement with implantation of antibiotic beads. When the patient asks why the beads are used, the nurse answers (select all that apply) a."The beads are used to directly deliver antibiotics to the site of the infection." b."There are no effective oral or IV antibiotics to treat most cases of bone infection." c."This is the safest method of delivering long-term antibiotic therapy for a bone infection." d."The beads are an adjunct to debridement and oral and IV antibiotics for deep infections." e."The ischemia and bone death that occur with osteomyelitis are impenetrable to IV antibiotics."

a."The beads are used to directly deliver antibiotics to the site of the infection." d."The beads are an adjunct to debridement and oral and IV antibiotics for deep infections." Treatment of chronic osteomyelitis includes surgical removal of the poorly vascularized tissue and dead bone and the extended use of IV and oral antibiotics. Antibiotic-impregnated polymethylmethacrylate bead chains may be implanted during surgery to aid in combating the infection.

Which statement characterize malignant melanomas (select all that apply)? A. Lesion is keratotic and firm. B. Neoplastic growth of melanocytes. C. Skin cancer with highest mortality rate D. Irregular color and asymmetric shape E. Frequently occurs on previously damaged skin.

b, c, d. Actinic and firm lesions are actinic keratosis and squamous cell carcinoma. Squamous cell carcinoma frequently occurs in previously damaged skin

The nurse plans care for a patient with a newly diagnosed malignant melanoma based on the knowledge that initial treatment may involve (select all that apply) A. Shave biopsy B. Moh's surgery C. Surgical excision D. Localized radiation E. Fluorouracil (5-FU) F. Topical nitrogen mustard

b, c. In the early stages, surgical excision with a margin of normal skin is the initial treatment for malignant melanoma. Mohs' surgery can also be used to treat malignant melanoma. Radiation may be used after excision for malignant melanoma, depending on staging of the disease.

A female patient with chronic skin lesions of the face and arms tells the nurse that she cannot stand to look at herself in the mirror anymore because of her appearance. Based on this information, the nurse identifies which nursing diagnosis. A. Anxiety related to personal appearance B. Disturbed body image related to perception of unsightly lesions C. Social isolation related to decreased activities a s a result of poor self-image D. Ineffective self-health management related to lack of knowledge of cover-up techniques

b. Defining characteristics for body image problems include verbalization of self-disgust and reluctance to look at lesions, as evidenced in this patient. Social isolation is indicated only if there is evidence of decreases social activities and of anxiety by verbalization of anxiety and frustration. Ineffective self-health management is indicated by evidence of a lack of self-care or understanding of the disease process.

Which description characterizes seborrheic keratosis? A. White patchy yeast infection B. Warty, irregular papules or plaques C. Excessive turnover of epithelial cells D. Deep inflammation of subcutaneous tissue

b. Seborrheic keratosis are irregularly round or oval shaped and are often verrucuos papules or plaques. Candidiasis a white patchy yeast infection. Cellulitis is a deep inflammation of subcutaneous tissue. Psoriasis is an excessive turnover of epithelial cells.

What is an appropriate intervention to promote debridement and removal of scales and crusts of skin lesions? A. Warm oatmeal baths B. Warm saline dressings C. Cool sodium bicarbonate baths D. Cool magnesium sulfate dressings

b. Tepid or warm solutions should b e used when the purpose is debridement and saline is a common debridement solution. Baths are appropriate for debridement but sodium bicarbonate and oatmeal are used for pruritus.

Priority Decision: A 46-year-old African American patient is scheduled to have basal cell carcinoma on his cheek excised in the health care provider's office. What factor is most important for the nurse to obtain in the patient's history? A. Protected sun exposure B. Radiation treatment for acne C. Prior treatments for the lesion D. Exposure to harsh irritants such as ammonia

b. Thirty years ago, when the patient was a teenager, radiation therapy was used to treat cystic acne with the result that many of these patients now have developed basal cell carcinoma. For a person with dark skin, radiation therapy is a higher risk factor for skin cancer than exposure to the sun or other irritants.

A patient has been diagnosed with osteosarcoma of the humerus. He shows an understanding of his treatment options when he states a."I accept that I have to lose my arm with surgery." b."The chemotherapy before surgery will shrink the tumor." c."This tumor is related to the melanoma I had 3 years ago." d."I'm glad they can take out the cancer with such a small scar."

b."The chemotherapy before surgery will shrink the tumor." A patient with osteosarcoma usually has preoperative chemotherapy to decrease tumor size before surgery. As a result, limb-salvage procedures, including a wide surgical resection of the tumor, are being used more often. Osteosarcoma is a primary bone tumor that is extremely aggressive and rapidly metastasizes to distant sites.

In caring for a patient after a spinal fusion, the nurse would immediately report to the physician which patient symptom? a.The patient experiences a single episode of emesis. b.The patient is unable to move the lower extremities. c. The patient is nauseated and has not voided in 4 hours. d. The patient complains of pain at the bone graft donor site.

b.The patient is unable to move the lower extremities. After spinal fusion surgery, the nurse should frequently monitor peripheral neurologic signs. Movement of the arms and legs and assessment of sensation should be unchanged in comparison with the preoperative status. These assessments are usually repeated every 2 to 4 hours during the first 48 hours after surgery, and findings are compared with those of the preoperative assessment. Paresthesias, such as numbness and tingling sensation, may not be relieved immediately after surgery. The nurse should document any new muscle weakness or paresthesias and report this to the surgeon immediately.

Which skin condition would be treated with laser surgery? A. Preauricular lesion B. Redundant soft tissue conditions C. Obesity with subcutaneous fat accumulation D. Fine wrinkle reduction or facial lesion removal

d. A facelift is used for preauricular lesions and redundant soft tissue reduction. Liposuction is used for obesity with subcutaneous fat accumulation.

What is the name for papillomavirus infection seen on the skin? A. Furuncle B. Carbuncle C. Erysipelas D. Plantar wart

d. A plantar wart is caused by (HPV). A furuncle is a deep skin infection with staphylococci around the hair follicle. A carbuncle is multiple, interconnecting furuncles. Erysipelas is superficial cellulitis primarily involving the dermis.

A patient with psoriasis is being treated with psoralen plus UVA light phototherapy. During the course of therapy, for what duration should the nurse teach the patient to wear protective eyewear that blocks all UV rays? A. Continuously for 6 hours after taking the medication B. Until the pupils are able to constrict on exposure to light C. For 12 hours following treatment to prevent retinal damage D. For 24 hours following treatment when outdoors or when indoors near a bright window

d. Prosalen is absorbed by the lens of the eye and eyewear that blocks 100% of UV light must be used for 24 hours after taking the medication. Because UVA penetrates glass, the eyewear must also be worn indoors when near a bright window. Psoralen does not affect the accommodative ability of the eye.

4. The nurse's responsibility for a patient with a suspected disc herniation who is experiencing acute pain and muscle spasms is a.encouraging total bed rest for several days. b.teaching the principles of back strengthening exercises. c.stressing the importance of straight-leg raises to decrease pain. d.promoting the use of cold and hot compresses and pain medication.

d.promoting the use of cold and hot compresses and pain medication. If the acute muscle spasms and accompanying pain are not severe and debilitating, the patient may be treated on an outpatient basis with nonsteroidal antiinflammatory drugs (NSAIDs; e.g., acetaminophen) and muscle relaxants (e.g., cyclobenzaprine [Flexeril]). Massage and back manipulation, acupuncture, and the application of cold and hot compresses may help some patients. Severe pain may necessitate a brief course of opioid analgesics. A brief period (1 to 2 days) of rest at home may be necessary for some people; most patients do better with a continuation of their regular activities. Prolonged bed rest should be avoided. All patients during this time should refrain from activities that aggravate the pain, including lifting, bending, twisting, and prolonged sitting.

The health care provider has prescribed the following collaborative interventions for a patient who is taking azathioprine (Imuran) for systemic lupus erythematosus. Which order will the nurse question? a. Draw anti-DNA blood titer. b. Administer varicella vaccine. c. Naproxen (Aleve) 200 mg BID. d. Famotidine (Pepcid) 20 mg daily.

ANS: B Live virus vaccines, such as varicella, are contraindicated in a patient taking immunosuppressive drugs. The other orders are appropriate for the patient

A patient has ICP monitoring with an intraventricular catheter. A priority nursing intervention for the patient is a. aseptic technique to prevent infection b. constant monitoring of ICP waveforms c. removal of CSF to maintain normal ICP d. sampling CSF to determine abnormalities

A. Aseptic technique to prevent infection- An intraventricular catheter is a fluid coupled system that can provide direct access for microorganisms to enter the ventricles of the brain, and aseptic technique is a very high nursing priority to decrease the risk for infection. Constant monitoring of ICP waveforms is not usually necessary, and removal of CSF for sampling or to maintain normal ICP is done only when specifically ordered

Which individuals would be at high risk for low back pain (select all that apply)? a.A 63-year-old man who is a long-distance truck driver b.A 36-year-old 6 ft, 2 in construction worker who weighs 260 lb c.A 28-year-old female yoga instructor who is 5 ft, 6 in and weighs 130 lb d.A 30-year-old male nurse who works on an orthopedic unit and smokes e.A 44-year-old female chef with prior compression fracture of the spine

A, B, D, E Risk factors associated with low back pain include a lack of muscle tone and excess body weight, stress, poor posture, cigarette smoking, pregnancy, prior compression fractures of the spine, spinal problems since birth, and a family history of back pain. Jobs that require repetitive heavy lifting, vibration (such as a jackhammer operator), and prolonged periods of sitting are also associated with low back pain. Low back pain is most often caused by a musculoskeletal problem. The causes of low back pain of musculoskeletal origin include (1) acute lumbosacral strain, (2) instability of the lumbosacral bony mechanism, (3) osteoarthritis of the lumbosacral vertebrae, (4) degenerative disc disease, and (5) herniation of an intervertebral disc. Health care personnel are at high risk for the development of low back pain. Lifting and moving patients, excessive time being stooped over or leaning forward, and frequent twisting can result in low back pain.

A patient with Parkinson's disease is admitted to the hospital for treatment of pneumonia. Which nursing interventions will be included in the plan of care (select all that apply)? a. Use an elevated toilet seat. b. Cut patient's food into small pieces. c. Provide high-protein foods at each meal. d. Place an armchair at the patient's bedside. e. Observe for sudden exacerbation of symptoms.

A, B, D. Because the patient with Parkinson's has difficulty chewing, food should be cut into small pieces. An armchair should be used when the patient is seated so that the patient can use the arms to assist with getting up from the chair. An elevated toilet seat will facilitate getting on and off the toilet. High-protein foods will decrease the effectiveness of L-dopa. Parkinson's is a steadily progressive disease without acute exacerbations.

The nurse provides instructions to a 30-year-old female office worker who has low back pain. Which statement by the patient requires an intervention by the nurse? A. "Acupuncture to the lower back would cause irreparable nerve damage." B. "Smoking may aggravate back pain by decreasing blood flow to the spine." C. "Sleeping on my side with knees and hips bent reduces stress on my back." D. "Switching between hot and cold packs provides relief of pain and stiffness."

A. "Acupuncture to the lower back would cause irreparable nerve damage." Acupuncture is a safe therapy when the practitioner has been appropriately trained. Very fine needles are inserted into the skin to stimulate specific anatomic points in the body for therapeutic purposes.

A 54-year-old patient with acute osteomyelitis asks the nurse how this problem will be treated. Which response by the nurse is most appropriate? A. "IV antibiotics are usually required for several weeks." B. "Oral antibiotics are often required for several months." C. "Surgery is almost always necessary to remove the dead tissue that is likely to be present." D. "Drainage of the foot and instillation of antibiotics into the affected area is the usual therapy."

A. "IV antibiotics are usually required for several weeks." The standard treatment for acute osteomyelitis consists of several weeks of IV antibiotic therapy. This is because bone is denser and less vascular than other tissues, and it takes time for the antibiotic therapy to eradicate all of the microorganisms. Surgery may be used for chronic osteomyelitis, which may include debridement of the devitalized and infected tissue and irrigation of the affected bone with antibiotics.

For a 65-year-old female patient who has lived with a T1 spinal cord injury for 20 years, which health teaching information should you emphasize? A. A mammogram is needed every year. B. Bladder function tends to improve with age. C. Heart disease is not common in persons with spinal cord injury. D. As a person ages, the need to change body position is less important.

A. A mammogram is needed every year. Health promotion and screening are important for the older patient with a spinal cord injury. Older adult women with spinal cord injuries should perform monthly breast examinations and yearly mammograms

A 64-year-old patient who has amyotrophic lateral sclerosis (ALS) is hospitalized with pneumonia. Which nursing action will be included in the plan of care? a. Assist with active range of motion (ROM). b. Observe for agitation and paranoia. c. Give muscle relaxants as needed to reduce spasms. d. Use simple words and phrases to explain procedures.

A. ALS causes progressive muscle weakness, but assisting the patient to perform active ROM will help maintain strength as long as possible. Psychotic manifestations such as agitation and paranoia are not associated with ALS. Cognitive function is not affected by ALS, and the patient's ability to understand procedures will not be impaired. Muscle relaxants will further increase muscle weakness and depress respirations.

A hospitalized 31-year-old patient with a history of cluster headache awakens during the night with a severe stabbing headache. Which action should the nurse take first? a. Start the ordered PRN oxygen at 6 L/min. b. Put a moist hot pack on the patient's neck. c. Give the ordered PRN acetaminophen (Tylenol). d. Notify the patient's health care provider immediately.

A. Acute treatment for cluster headache is administration of 100% oxygen at 6 to 8 L/min. If the patient obtains relief with the oxygen, there is no immediate need to notify the health care provider. Cluster headaches last only 60 to 90 minutes, so oral pain medications have minimal effect. Hot packs are helpful for tension headaches but are not as likely to reduce pain associated with a cluster headache.

What is the best method to assess a patient with trigeminal neuralgia (tic douloureux)? A. Ask the patient what the triggering factors are. B. Have the patient open and close the jaw while palpating the mandible. C. Instruct the patient to touch the examiner's finger and then the patient's nose. D. Look at the optic disk with an ophthalmoscope

A. Ask the patient what the triggering factors are. The main symptom is spasms of severe, unilateral facial pain. Palpating the face may trigger a painful episode; touch is a common trigger. The other options do not reveal information about the trigeminal nerve effect.

A patient has a nursing diagnosis of risk for ineffective cerebral tissue perfusion related to cerebral edema. An appropriate nursing intervention for the patient is a. avoiding positioning the patient with neck and hip flexion b. maintaining hyperventilation to a PaCO2 of 15 to 20 mm Hg c. clustering nursing activities to provide periods of uninterrupted rest d. routine suctioning to prevent accumulation of respiratory secretions

A. Avoiding positioning the patient with neck and hip flexion- Nursing care activities that increase ICP include hip and neck flexion, suctioning, clustering care activities, and noxious stimuli; they should be avoided or performed as little as possible in the patient with increased ICP. Lowering the PaCO2 below 20 mm Hg can cause ischemia and worsening of ICP; the PaCO2 should be maintained at 30 to 35 mm Hg.

After change-of-shift report, which patient should the nurse assess first? a. Patient with myasthenia gravis who is reporting increased muscle weakness b. Patient with a bilateral headache described as "like a band around my head" c. Patient with seizures who is scheduled to receive a dose of phenytoin (Dilantin) d. Patient with Parkinson's disease who has developed cogwheel rigidity of the arms

A. Because increased muscle weakness may indicate the onset of a myasthenic crisis, the nurse should assess this patient first. The other patients should also be assessed, but do not appear to need immediate nursing assessments or actions to prevent life-threatening complications.

The nurse is admitting a patient to the nursing unit with a history of a herniated lumbar disc and low back pain. In completing a more thorough pain assessment, the nurse should ask the patient if which action aggravates the pain? A. Bending or lifting B. Application of warm moist heat C. Sleeping in a side-lying position D. Sitting in a fully extended recliner

A. Bending or lifting Back pain that is related to a herniated lumbar disc often is aggravated by events and activities that increase the stress and strain on the spine, such as bending or lifting, coughing, sneezing, and lifting the leg with the knee straight (straight leg-raising test). Application of moist heat, sleeping position, and ability to sit in a fully extended recliner do not aggravate the pain of a herniated lumbar disc.

Which is most important to respond to in a patient presenting with a T3 spinal injury? A. Blood pressure of 88/60 mm Hg, pulse of 56 beats/minute B. Deep tendon reflexes of 1+, muscle strength of 1+ C. Pain rated at 9 D. Warm, dry skin

A. Blood pressure of 88/60 mm Hg, pulse of 56 beats/minute Neurogenic shock is a loss of vasomotor tone caused by injury, and it is characterized by hypotension and bradycardia. The loss of sympathetic nervous system innervations causes peripheral vasodilation, venous pooling, and a decreased cardiac output. The other options can be expected findings and are not as significant. Patients in neurogenic shock have pink and dry skin, instead of cold and clammy, but this sign is not as important as the vital signs.

Which clinical manifestation do you interpret as representing neurogenic shock in a patient with acute spinal cord injury? A. Bradycardia B. Hypertension C. Neurogenic spasticity D. Bounding pedal pulses

A. Bradycardia Neurogenic shock results from loss of vasomotor tone caused by injury and is characterized by hypotension and bradycardia. Loss of sympathetic innervation causes peripheral vasodilation, venous pooling, and a decreased cardiac output.

The nurse is caring for a patient hospitalized with exacerbation of chronic bronchitis and herniated lumbar disc. Which breakfast choice would be most appropriate for the nurse to encourage the patient to check on the breakfast menu? A. Bran muffin B. Scrambled eggs C. Puffed rice cereal D. Buttered white toast

A. Bran muffin Each meal should contain one or more sources of fiber, which will reduce the risk of constipation and straining with defecation, which increases back pain. Bran is typically a high-fiber food choice and is appropriate for selection from the menu. Scrambled eggs, puffed rice cereal, and buttered white toast do not have as much fiber.

What should the patient with Bell's palsy be cautioned against? A. Cornea dryness B. Driving while experiencing diplopia C. Sudden movement of the head when bending over D. Contamination from the affected eye to the other eye

A. Cornea dryness With Bell's palsy, the eyelid on the affected side often does not close tightly. Eye drops are used during the daytime, and patches are worn at night. The other options are not related to Bell's palsy.

What is the classic presentation of botulism? A. Descending flaccid paralysis B. Ascending bilateral paralysis C. Homonymous hemianopsia D. Vomiting and diarrhea

A. Descending flaccid paralysis Neurologic manifestations can develop rapidly or evolve over several days. They include the development of a descending flaccid paralysis with intact sensation, photophobia, ptosis, paralysis of extraocular muscles, blurred vision, diplopia, dry mouth, sore throat, and difficulty in swallowing. Ascending bilateral paralysis is associated with Guillain-Barré syndrome. Homonymous hemianopsia, the loss of one half of the field of vision, can occur in a stroke

For the patient undergoing a craniotomy, the nurse provides information about the use of wigs and hairpieces or other methods to disguise hair loss a. during pre operative teaching b. in the patient asks about their use c. in the immediate postoperative period d. when the patient expresses negative feelings about his or her appearance

A. During pre operative teaching- The prevent undue concern and anxiety about hair loss and postoperative self-esteem disturbances, a patient undergoing cranial surgery should be informed pre operatively that the head is usually shaved in surgery while the patient is anesthetized and that methods can be used after the dressings are removed postoperatively to disguise the hair loss. In the immediate postoperative period, the patient is very ill, and the focus is on maintaining neurologic function, bur preoperatively the nurse should anticipate the patient's postoperative need for self-esteem and maintenance of appearance.

A 31-year-old woman who has multiple sclerosis (MS) asks the nurse about risks associated with pregnancy. Which response by the nurse is accurate? a. "MS symptoms may be worse after the pregnancy." b. "Women with MS frequently have premature labor." c. "MS is associated with an increased risk for congenital defects." d. "Symptoms of MS are likely to become worse during pregnancy."

A. During the postpartum period, women with MS are at greater risk for exacerbation of symptoms. There is no increased risk for congenital defects in infants born of mothers with MS. Symptoms of MS may improve during pregnancy. Onset of labor is not affected by MS.

A patient is suspected of having a cranial tumor. The signs and symptoms include memory deficits, visual disturbances, weakness of right upper and lower extremities, and personality changes. The nurse recognizes that the tumor is most likely located in the a. frontal lobe b. parietal lobe c. occipital lobe d. temporal lobe

A. Frontal lobe

Which signs and symptoms in a patient with a T4 spinal cord injury should alert you to the possibility of autonomic dysreflexia? A. Headache and rising blood pressure B. Irregular respirations and shortness of breath C. Decreased level of consciousness or hallucinations D. Abdominal distention and absence of bowel sounds

A. Headache and rising blood pressure Among the manifestations of autonomic dysreflexia are hypertension (up to 300 mm Hg systolic) and throbbing headache. Respiratory manifestations, decreased level of consciousness, and gastrointestinal manifestations are not characteristic.

When a patient is admitted to the emergency department following a head injury, the nurse's first priority in management of the patient once a patent airway is confirmed is a. maintaining cervical spine precautions b. determining the presence of increased ICP c. monitoring for changes in neurologic status d. establishing IV access with a large-bore catheter

A. In addition to monitoring for a patent airway during emergency care of the patient with a head injury, the nurse must always assume that a patient with a head injury may have a cervical spine injury. Maintaining cervical spine precautions in all assessment and treatment activities with the patient is essential to prevent additional neurologic damage.

During assessment of the patient with trigeminal neuralgia, what should you do (select all that apply)? A. Inspect all aspects of the mouth and teeth. B. Assess the gag reflex and respiratory rate and depth. C. Lightly palpate the affected side of the face for edema. D. Test for temperature and sensation perception on the face. E. Ask the patient to describe factors that initiate an episode.

A. Inspect all aspects of the mouth and teeth. D. Test for temperature and sensation perception on the face. E. Ask the patient to describe factors that initiate an episode. Assessment of the attacks, including the triggering factors, characteristics, frequency, and pain management techniques, helps you plan patient care. The painful episodes are usually initiated by a triggering mechanism of light cutaneous stimulation at a specific point (trigger zone) along the distribution of the nerve branches. Precipitating stimuli include chewing, tooth brushing, a hot or cold blast of air on the face, washing the face, yawning, and talking. Touch and tickle seem to predominate as causative triggers, rather than pain or changes in temperature.

A patient with gout has a new prescription for losartan (Cozaar) to control the condition. The nurse will plan to monitor a. blood glucose. b. blood pressure. c. erythrocyte count. d. lymphocyte count.

ANS: B Losartan, an angiotensin II receptor antagonist, will lower blood pressure. It does not affect blood glucose, red blood cell (RBC) count, or lymphocytes.

The nurse advises a patient with myasthenia gravis (MG) to a. perform physically demanding activities early in the day. b. anticipate the need for weekly plasmapheresis treatments. c. do frequent weight-bearing exercise to prevent muscle atrophy. d. protect the extremities from injury due to poor sensory perception.

A. Muscles are generally strongest in the morning, and activities involving muscle activity should be scheduled then. Plasmapheresis is not routinely scheduled, but is used for myasthenia crisis or for situations in which corticosteroid therapy must be avoided. There is no decrease in sensation with MG, and muscle atrophy does not occur because although there is muscle weakness, they are still used.

During admission of a patient with a severe head injury to the ED, the nurse places highest priority on assessment for a. patency of of airway b. presence of a neck injury c. neurologic status with Glascow Coma Scale d. CSF leakage from ears and nose

A. Patency of airway is the #1 priority with all head injuries

A patient has been taking phenytoin (Dilantin) for 2 years. Which action will the nurse take when evaluating for adverse effects of the medication? a. Inspect the oral mucosa. b. Listen to the lung sounds. c. Auscultate the bowel tones. d. Check pupil reaction to light.

A. Phenytoin can cause gingival hyperplasia, but does not affect bowel tones, lung sounds, or pupil reaction to light.

Which nursing intervention is most appropriate when turning a patient following spinal surgery? A. Placing a pillow between the patient's legs and turning the body as a unit B. Having the patient turn to the side by grasping the side rails to help turn over C. Elevating the head of bed 30 degrees and having the patient extend the legs while turning D. Turning the patient's head and shoulders and then the hips, keeping the patient's body centered in the bed

A. Placing a pillow between the patient's legs and turning the body as a unit Placing a pillow between the legs and turning the patient as a unit (logrolling) helps to keep the spine in good alignment and reduces pain and discomfort following spinal surgery. Having the patient turn by grasping the side rail to help, elevating the head of the bed, and turning with extended legs or turning the patient's head and shoulders and then the hips will not maintain proper spine alignment and may cause damage.

A patient with OA asks the nurse whether he could try glucosamine and chondroitin for control of his symptoms. The best response by the nurse includes the information that a. some patients find these supplements helpful for relieving arthritis knee pain and improving mobility b. although these substances may not help, there is no evidence that they can cause any untoward effects c. these supplements are a fad that has not been shown to reduce pain or increase joint mobility in patients with OA d. only dosages of these supplements available by prescription are high enough to provide any benefit in treatment of OA

A. Some patients find these supplements helpful for relieving arthritis knee pain and improving mobilitiy

A 46-year-old patient tells the nurse about using acetaminophen (Tylenol) several times every day for recurrent bilateral headaches. Which action will the nurse plan to take first? a. Discuss the need to stop taking the acetaminophen. b. Suggest the use of biofeedback for headache control. c. Describe the use of botulism toxin (Botox) for headaches. d. Teach the patient about magnetic resonance imaging (MRI).

A. The headache description suggests that the patient is experiencing medication overuse headache. The initial action will be withdrawal of the medication. The other actions may be needed if the headaches persist.

A patient reports feeling numbness and tingling of the left arm before experiencing a tonic-clonic seizure. The nurse determines that this history is consistent with what type of seizure? a. Focal b. Atonic c. Absence d. Myoclonic

A. The initial symptoms of a focal seizure involve clinical manifestations that are localized to a particular part of the body or brain. Symptoms of an absence seizure are staring and a brief loss of consciousness. In an atonic seizure, the patient loses muscle tone and (typically) falls to the ground. Myoclonic seizures are characterized by a sudden jerk of the body or extremities.

The nurse observes a patient ambulating in the hospital hall when the patient's arms and legs suddenly jerk and the patient falls to the floor. The nurse will first a. assess the patient for a possible head injury. b. give the scheduled dose of divalproex (Depakote). c. document the timing and description of the seizure. d. notify the patient's health care provider about the seizure.

A. The patient who has had a myoclonic seizure and fall is at risk for head injury and should first be evaluated and treated for this possible complication. Documentation of the seizure, notification of the seizure, and administration of antiseizure medications are also appropriate actions, but the initial action should be assessment for injury.

Which intervention should you perform in the acute care of a patient with autonomic dysreflexia? A. Urinary catheterization B. Administration of benzodiazepines C. Suctioning of the patient's upper airway D. Placement of the patient in the Trendelenburg position

A. Urinary catheterization Because the most common cause of autonomic dysreflexia is bladder irritation, immediate catheterization to relieve bladder distention may be necessary. The patient should be positioned upright. Benzodiazepines are contraindicated, and suctioning is likely unnecessary.

A patient taking ibuprofen (Motrin) for treatment of OA has good pain relief but is experiencing increased dyspepsia and nausea with the drug's use. The nurse consults the patient's primary care provider about a. adding misoprostol (Cytotec) to the patient's drug regimen b. substituting naproxen (Naprosyn) for the ibuprofen (Motrin) c. administering the ibuprofen with antacids to decrease the GI irritation d. returning to the use of acetaminophen, but at a dose of 5 g/day instead of 4 g/day

A. adding misoprostol (Cytotec) to the patient's drug regimen

The pathophysiology of systemic lupus erthematosus (SLE) is characterized by a. destruction of nucleic acids and other self-proteins by autoantibodies b. overproduction of collagen that disrupts the functioning of internal organs c. formation of abnormal IgG that attaches to cellular antigens, activating complement d. increased activity of T-suppressor cells with B-cell hypoactivity, resulting in an immunodeficiency

A. destruction of nucleic acids and other self-proteins by autoantibodies

A patient is admitted to the hospital with a left hemiplegia. To determine the size and location and to ascertain whether a stroke is ischemic or hemorrhagic, the nurse anticipates that the health care provider will request a a. CT scan b. lumbar puncture c. cerebral arteriogram d. positron emission tomography (PET)

A: CT scan- A CT scan is the most commonly used diagnostic test to determine the size and location of the lesion and to differentiate a thrombotic stroke from a hemorrhagic stroke. Positron emission tomography (PET) will show the metabolic activity of the brain and provide a depiction of the extent of tissue damage after a stroke. Lumbar punctures are not performed routinely because of the chance of increased intracranial pressure causing herniation. Cerebral arteriograms are invasive and may dislodge an embolism or cause further hemorrhage; they are performed only when no other test can provide the needed information.

During the acute phase of a stroke, the nurse assesses the patient's vital signs and neurologic status every 4 hours. A cardiovascular sign that the nurse would see as the body attempts to increase cerebral blood flow is a. hypertension b. fluid overload c. cardiac dysrhythmias d. S3 and S4 heart sounds

A: Hypertension- The body responds to the vasopasm and a decreased circulation to the brain that occurs with a stroke by increasing the BP, frequently resulting in hypertension. The other options are important cardiovascular factors to assess, but they do not result from impaired cerebral blood flow.

An unconscious patient with a traumatic head injury has a blood pressure of 126/72 mm Hg, and an intracranial pressure of 18 mm Hg. The nurse will calculate the cerebral perfusion pressure as ____________________.

ANS: 72 mm Hg The formula for calculation of cerebral perfusion pressure is [(Systolic pressure + Diastolic blood pressure 2)/3] = intracranial pressure. DIF: Cognitive Level: Application REF: 1452-1453

The nurse is caring for a 47-year-old female patient who is comatose and is receiving continuous enteral nutrition through a soft nasogastric tube. The nurse notes the presence of new crackles in the patient's lungs. In which order will the nurse take action? (Put a comma and a space between each answer choice [A, B, C, D].) a. Check the patient's oxygen saturation. b. Notify the patient's health care provider. c. Measure the tube feeding residual volume. d. Stop administering the continuous feeding.

ANS: D, A, C, B The assessment data indicate that aspiration may have occurred, and the nurse's first action should be to turn off the tube feeding to avoid further aspiration. The next action should be to check the oxygen saturation because this may indicate the need for immediate respiratory suctioning or oxygen administration. The residual volume should be obtained because it provides data about possible causes of aspiration. Finally, the health care provider should be notified and informed of all the assessment data the nurse has just obtained.

In which order will the nurse take the following actions when caring for a patient who develops watery diarrhea and a fever after prolonged omeprazole (Prilosec) therapy? (Put a comma and a space between each answer choice [A, B, C, D].) a. Contact the health care provider. b. Assess blood pressure and heart rate. c. Give the PRN acetaminophen (Tylenol). d. Place the patient on contact precautions.

ANS: D, B, A, C Proton pump inhibitors including omeprazole (Prilosec) may increase the risk of Clostridium difficile-associated colitis. Because the patient's history and symptoms are consistent with C. difficile infection, the initial action should be initiation of infection control measures to protect other patients. Assessment of blood pressure and pulse is needed to determine whether the patient has symptoms of hypovolemia and/or shock. The health care provider should be notified so that actions such as obtaining stool specimens and antibiotic therapy can be started. Tylenol may be administered, but is the lowest priority of the actions.

A 64-year-old patient who has amyotrophic lateral sclerosis (ALS) is hospitalized with pneumonia. Which nursing action will be included in the plan of care? a. Assist with active range of motion (ROM). b. Observe for agitation and paranoia. c. Give muscle relaxants as needed to reduce spasms. d. Use simple words and phrases to explain procedures.

ANS: A ALS causes progressive muscle weakness, but assisting the patient to perform active ROM will help maintain strength as long as possible. Psychotic manifestations such as agitation and paranoia are not associated with ALS. Cognitive function is not affected by ALS, and the patient's ability to understand procedures will not be impaired. Muscle relaxants will further increase muscle weakness and depress respirations.

A 50-year-old female patient calls the clinic to report a new onset of severe diarrhea. The nurse anticipates that the patient will need to a. collect a stool specimen. b. prepare for colonoscopy. c. schedule a barium enema. d. have blood cultures drawn.

ANS: A Acute diarrhea is usually caused by an infectious process, and stool specimens are obtained for culture and examined for parasites or white blood cells. There is no indication that the patient needs a colonoscopy, blood cultures, or a barium enema.

A hospitalized 31-year-old patient with a history of cluster headache awakens during the night with a severe stabbing headache. Which action should the nurse take first? a. Start the ordered PRN oxygen at 6 L/min. b. Put a moist hot pack on the patient's neck. c. Give the ordered PRN acetaminophen (Tylenol). d. Notify the patient's health care provider immediately.

ANS: A Acute treatment for cluster headache is administration of 100% oxygen at 6 to 8 L/min. If the patient obtains relief with the oxygen, there is no immediate need to notify the health care provider. Cluster headaches last only 60 to 90 minutes, so oral pain medications have minimal effect. Hot packs are helpful for tension headaches but are not as likely to reduce pain associated with a cluster headache.

A 34-year-old female patient with a new ileostomy asks how much drainage to expect. The nurse explains that after the bowel adjusts to the ileostomy, the usual drainage will be about _____ cups. a. 2 b. 3 c. 4 d. 5

ANS: A After the proximal small bowel adapts to reabsorb more fluid, the average amount of ileostomy drainage is about 500 mL daily. One cup is about 240 mL.

A patient is brought to the emergency department (ED) by ambulance after being found unconscious on the bathroom floor by the spouse. Which action will the nurse take first? a. Obtain oxygen saturation. b. Check pupil reaction to light. c. Palpate the head for hematoma. d. Assess Glasgow Coma Scale (GCS).

ANS: A Airway patency and breathing are the most vital functions and should be assessed first. The neurologic assessments should be accomplished next and the health and medication history last. DIF: Cognitive Level: Application REF: 1435-1437

A patient complains of gas pains and abdominal distention two days after a small bowel resection. Which nursing action is best to take? a. Encourage the patient to ambulate. b. Instill a mineral oil retention enema. c. Administer the ordered IV morphine sulfate. d. Offer the ordered promethazine (Phenergan) suppository.

ANS: A Ambulation will improve peristalsis and help the patient eliminate flatus and reduce gas pain. A mineral oil retention enema is helpful for constipation with hard stool. A return-flow enema might be used to relieve persistent gas pains. Morphine will further reduce peristalsis. Promethazine (Phenergan) is used as an antiemetic rather than to decrease gas pains or distention.

Which of these patients is most appropriate for the intensive care unit (ICU) charge nurse to assign to an RN who has floated from the medical unit? a. A 44-year-old receiving IV antibiotics for meningococcal meningitis b. A 23-year-old who had a skull fracture and craniotomy the previous day c. A 30-year-old who has an intracranial pressure (ICP) monitor in place after a head injury a week ago d. A 61-year-old who has increased ICP and is receiving hyperventilation therapy

ANS: A An RN who works on a medical unit will be familiar with administration of IV antibiotics and with meningitis. The postcraniotomy patient, patient with an ICP monitor, and the patient on a ventilator should be assigned to an RN familiar with the care of critically ill patients. DIF: Cognitive Level: Application REF: 1435-1438

Which action will the nurse include in the plan of care for a 40-year-old with newly diagnosed ankylosing spondylitis? a. Advise the patient to sleep on the back with a flat pillow. b. Emphasize that application of heat may worsen symptoms. c. Schedule annual laboratory assessment for the HLA-B27 antigen. d. Assist patient to choose physical activities that allow the spine to flex.

ANS: A Because ankylosing spondylitis results in flexion deformity of the spine, postures that extend the spine (such as sleeping on the back and with a flat pillow) are recommended. HLA-B27 antigen levels are used for initial diagnosis, but are not needed annually. To counteract the development of flexion deformities, the patient should choose activities that extend the spine, such as swimming. Heat application is used to decrease localized pain

When developing a plan of care for a patient with dysfunction of the cerebellum, the nurse will include interventions to a. prevent falls. b. stabilize mood. c. enhance swallowing ability. d. improve short-term memory.

ANS: A Because functions of the cerebellum include coordination and balance, the patient with dysfunction is at risk for falls. The cerebellum does not affect memory, mood, or swallowing ability. DIF: Cognitive Level: Application REF: 1410

After change-of-shift report, which patient should the nurse assess first? a. Patient with myasthenia gravis who is reporting increased muscle weakness b. Patient with a bilateral headache described as "like a band around my head" c. Patient with seizures who is scheduled to receive a dose of phenytoin (Dilantin) d. Patient with Parkinson's disease who has developed cogwheel rigidity of the arms

ANS: A Because increased muscle weakness may indicate the onset of a myasthenic crisis, the nurse should assess this patient first. The other patients should also be assessed, but do not appear to need immediate nursing assessments or actions to prevent life-threatening complications.

Which nursing action will be included in the plan of care for a 27-year-old male patient with bowel irregularity and a new diagnosis of irritable bowel syndrome (IBS)? a. Encourage the patient to express concerns and ask questions about IBS. b. Suggest that the patient increase the intake of milk and other dairy products. c. Educate the patient about the use of alosetron (Lotronex) to reduce symptoms. d. Teach the patient to avoid using nonsteroidal antiinflammatory drugs (NSAIDs).

ANS: A Because psychologic and emotional factors can affect the symptoms for IBS, encouraging the patient to discuss emotions and ask questions is an important intervention. Alosetron has serious side effects, and is used only for female patients who have not responded to other therapies. Although yogurt may be beneficial, milk is avoided because lactose intolerance can contribute to symptoms in some patients. NSAIDs can be used by patients with IBS.

Which finding for a 19-year-old female who is a vegan may indicate the need for cobalamin supplementation? a. Paresthesias b. Ecchymoses c. Dry, scaly skin d. Gingival swelling

ANS: A Cobalamin (vitamin B12) cannot be obtained from foods of plant origin, so the patient will be most at risk for signs of cobalamin deficiency, such as paresthesias, peripheral neuropathy, and anemia. The other symptoms listed are associated with other nutritional deficiencies but would not be associated with a vegan diet.

Which patient statement indicates that the nurse's teaching following a gastroduodenostomy has been effective? a. "Vitamin supplements may prevent anemia." b. "Persistent heartburn is common after surgery." c. "I will try to drink more liquids with my meals." d. "I will need to choose high carbohydrate foods."

ANS: A Cobalamin deficiency may occur after partial gastrectomy, and the patient may need to receive cobalamin via injections or nasal spray. Although peptic ulcer disease may recur, persistent heartburn is not expected after surgery and the patient should call the health care provider if this occurs. Ingestion of liquids with meals is avoided to prevent dumping syndrome. Foods that have moderate fat and low carbohydrate should be chosen to prevent dumping syndrome.

The nurse determines that colchicine has been effective for a patient with an acute attack of gout upon finding a. relief of joint pain. b. increased urine output. c. elevated serum uric acid. d. increased white blood cells (WBC).

ANS: A Colchicine produces pain relief in 24 to 48 hours by decreasing inflammation. The recommended increase in fluid intake of 2 to 3 L/day would increase urine output but would not indicate the effectiveness of colchicine. Elevated uric acid levels would result in increased symptoms. The WBC count might decrease with decreased inflammation, but would not increase.

A 31-year-old woman who has multiple sclerosis (MS) asks the nurse about risks associated with pregnancy. Which response by the nurse is accurate? a. "MS symptoms may be worse after the pregnancy." b. "Women with MS frequently have premature labor." c. "MS is associated with an increased risk for congenital defects." d. "Symptoms of MS are likely to become worse during pregnancy."

ANS: A During the postpartum period, women with MS are at greater risk for exacerbation of symptoms. There is no increased risk for congenital defects in infants born of mothers with MS. Symptoms of MS may improve during pregnancy. Onset of labor is not affected by MS.

The nurse will anticipate preparing a 71-year-old female patient who is vomiting "coffee-ground" emesis for a. endoscopy. b. angiography. c. barium studies. d. gastric analysis.

ANS: A Endoscopy is the primary tool for visualization and diagnosis of upper gastrointestinal (GI) bleeding. Angiography is used only when endoscopy cannot be done because it is more invasive and has more possible complications. Barium studies are helpful in determining the presence of gastric lesions, but not whether the lesions are actively bleeding. Gastric analysis testing may help with determining the cause of gastric irritation, but it is not used for acute GI bleeding.

A 58-year-old woman has just returned to the nursing unit after an esophagogastroduodenoscopy (EGD). Which action by unlicensed assistive personnel (UAP) requires that the registered nurse (RN) intervene? a. Offering the patient a drink of water b. Positioning the patient on the right side c. Checking the vital signs every 30 minutes d. Swabbing the patient's mouth with cold water

ANS: A Immediately after EGD, the patient will have a decreased gag reflex and is at risk for aspiration. Assessment for return of the gag reflex should be done by the RN. The other actions by the UAP are appropriate.

A 50-year-old patient who underwent a gastroduodenostomy (Billroth I) earlier today complains of increasing abdominal pain. The patient has no bowel sounds and 200 mL of bright red nasogastric (NG) drainage in the last hour. The highest priority action by the nurse is to a. contact the surgeon. b. irrigate the NG tube. c. monitor the NG drainage. d. administer the prescribed morphine.

ANS: A Increased pain and 200 mL of bright red NG drainage 12 hours after surgery indicate possible postoperative hemorrhage, and immediate actions such as blood transfusion and/or return to surgery are needed. Because the NG is draining, there is no indication that irrigation is needed. Continuing to monitor the NG drainage is not an adequate response. The patient may need morphine, but this is not the highest priority action.

Which finding will the nurse expect when assessing a 58-year-old patient who has osteoarthritis (OA) of the knee? a. Discomfort with joint movement b. Heberden's and Bouchard's nodes c. Redness and swelling of the knee joint d. Stiffness that increases with movement

ANS: A Initial symptoms of OA include pain with joint movement. Heberden's nodules occur on the fingers. Redness of the joint is more strongly associated with rheumatoid arthritis (RA). Stiffness in OA is worse right after the patient rests and decreases with joint movement.

Which action for a patient receiving tube feedings through a percutaneous endoscopic gastrostomy (PEG) may be delegated to a licensed practical/vocational nurse (LPN/LVN)? a. Providing skin care to the area around the tube site b. Teaching the patient how to administer tube feedings c. Determining the need for adding water to the feedings d. Assessing the patient's nutritional status at least weekly

ANS: A LPN/LVN education and scope of practice include actions such as dressing changes and wound care. Patient teaching and complex assessments (such as patient nutrition and hydration status) require registered nurse (RN)-level education and scope of practice.

A 48-year-old man who has just been started on tube feedings of full-strength formula at 100 mL/hr has 6 diarrhea stools the first day. Which action should the nurse plan to take? a. Slow the infusion rate of the tube feeding. b. Check gastric residual volumes more frequently. c. Change the enteral feeding system and formula every 8 hours. d. Discontinue administration of water through the feeding tube.

ANS: A Loose stools indicate poor absorption of nutrients and indicate a need to slow the feeding rate or decrease the concentration of the feeding. Water should be given when patients receive enteral feedings to prevent dehydration. When a closed enteral feeding system is used, the tubing and formula are changed every 24 hours. High residual volumes do not contribute to diarrhea.

A 51-year-old male patient has a new diagnosis of Crohn's disease after having frequent diarrhea and a weight loss of 10 pounds (4.5 kg) over 2 months. The nurse will plan to teach about a. medication use. b. fluid restriction. c. enteral nutrition. d. activity restrictions.

ANS: A Medications are used to induce and maintain remission in patients with inflammatory bowel disease (IBD). Decreased activity level is indicated only if the patient has severe fatigue and weakness. Fluids are needed to prevent dehydration. There is no advantage to enteral feedings.

The nurse advises a patient with myasthenia gravis (MG) to a. perform physically demanding activities early in the day. b. anticipate the need for weekly plasmapheresis treatments. c. do frequent weight-bearing exercise to prevent muscle atrophy. d. protect the extremities from injury due to poor sensory perception.

ANS: A Muscles are generally strongest in the morning, and activities involving muscle activity should be scheduled then. Plasmapheresis is not routinely scheduled, but is used for myasthenia crisis or for situations in which corticosteroid therapy must be avoided. There is no decrease in sensation with MG, and muscle atrophy does not occur because although there is muscle weakness, they are still used.

Which action should the nurse in the emergency department anticipate for a 23-year-old patient who has had several episodes of bloody diarrhea? a. Obtain a stool specimen for culture. b. Administer antidiarrheal medication. c. Provide teaching about antibiotic therapy. d. Teach about adverse effects of acetaminophen (Tylenol).

ANS: A Patients with bloody diarrhea should have a stool culture for E. coli O157:H7. Antidiarrheal medications are usually avoided for possible infectious diarrhea to avoid prolonging the infection. Antibiotic therapy in the treatment of infectious diarrhea is controversial because it may precipitate kidney complications. Acetaminophen does not cause bloody diarrhea.

A patient who has bacterial meningitis is disoriented and anxious. Which nursing action will be included in the plan of care? a. Encourage family members to remain at the bedside. b. Apply soft restraints to protect the patient from injury. c. Keep the room well-lighted to improve patient orientation. d. Minimize contact with the patient to decrease sensory input.

ANS: A Patients with meningitis and disorientation will be calmed by the presence of someone familiar at the bedside. Restraints should be avoided because they increase agitation and anxiety. The patient requires frequent assessment for complications; the use of touch and a soothing voice will decrease anxiety for most patients. The patient will have photophobia, so the light should be dim. DIF: Cognitive Level: Application REF: 1453-1455

A patient has been taking phenytoin (Dilantin) for 2 years. Which action will the nurse take when evaluating for adverse effects of the medication? a. Inspect the oral mucosa. b. Listen to the lung sounds. c. Auscultate the bowel tones. d. Check pupil reaction to light.

ANS: A Phenytoin can cause gingival hyperplasia, but does not affect bowel tones, lung sounds, or pupil reaction to light.

Which finding for a patient who is taking hydroxychloroquine (Plaquenil) to treat rheumatoid arthritis is likely to be an adverse effect of the medication? a. Blurred vision b. Joint tenderness c. Abdominal cramping d. Elevated blood pressure

ANS: A Plaquenil can cause retinopathy. The medication should be stopped. The other findings are not related to the medication although they will also be reported.

A 51-year-old woman with Crohn's disease who is taking infliximab (Remicade) calls the nurse in the outpatient clinic about new symptoms. Which symptom is most important to communicate to the health care provider? a. Fever b. Nausea c. Joint pain d. Headache

ANS: A Since infliximab suppresses the immune response, rapid treatment of infection is essential. The other patient complaints are common side effects of the medication, but they do not indicate any potentially life-threatening complications.

The nurse suggests that a patient recently diagnosed with rheumatoid arthritis (RA) plan to start each day with a. a warm bath followed by a short rest. b. a short routine of isometric exercises. c. active range-of-motion (ROM) exercises. d. stretching exercises to relieve joint stiffness.

ANS: A Taking a warm shower or bath is recommended to relieve joint stiffness, which is worse in the morning. Isometric exercises would place stress on joints and would not be recommended. Stretching and ROM should be done later in the day, when joint stiffness is decreased.

When caring for a patient who has had a head injury, which assessment information requires the most rapid action by the nurse? a. The patient is more difficult to arouse. b. The patient's pulse is slightly irregular. c. The patient's blood pressure increases from 120/54 to 136/62 mm Hg. d. The patient complains of a headache at pain level 5 of a 10-point scale.

ANS: A The change in level of consciousness (LOC) is an indicator of increased intracranial pressure (ICP) and suggests that action by the nurse is needed to prevent complications. The change in BP should be monitored but is not an indicator of a need for immediate nursing action. Headache is not unusual in a patient after a head injury. A slightly irregular apical pulse is not unusual. DIF: Cognitive Level: Application REF: 1431-1433

A 46-year-old patient tells the nurse about using acetaminophen (Tylenol) several times every day for recurrent bilateral headaches. Which action will the nurse plan to take first? a. Discuss the need to stop taking the acetaminophen. b. Suggest the use of biofeedback for headache control. c. Describe the use of botulism toxin (Botox) for headaches. d. Teach the patient about magnetic resonance imaging (MRI).

ANS: A The headache description suggests that the patient is experiencing medication overuse headache. The initial action will be withdrawal of the medication. The other actions may be needed if the headaches persist.

The nurse obtains these assessment findings for a patient who has a head injury. Which finding should be reported rapidly to the health care provider? a. Urine output of 800 mL in the last hour b. Intracranial pressure of 16 mm Hg when patient is turned c. Ventriculostomy drains 10 mL of cerebrospinal fluid per hour d. LICOX brain tissue oxygenation catheter shows PbtO2 of 38 mm Hg

ANS: A The high urine output indicates that diabetes insipidus may be developing and interventions to prevent dehydration need to be rapidly implemented. The other data do not indicate a need for any change in therapy. DIF: Cognitive Level: Application REF: 1434-1435

A 37-year-old patient with 2 school-age children who has recently been diagnosed with rheumatoid arthritis (RA) tells the nurse that home life is very stressful. Which response by the nurse is most appropriate? a. "Tell me more about situations that are causing you stress." b. "You need to see a family therapist for some help with stress." c. "Your family should understand the impact of your rheumatoid arthritis." d. "Perhaps it would be helpful for your family to be involved in a support group."

ANS: A The initial action by the nurse should be further assessment. The other three responses might be appropriate based on the information the nurse obtains with further assessment

A patient reports feeling numbness and tingling of the left arm before experiencing a tonic-clonic seizure. The nurse determines that this history is consistent with what type of seizure? a. Focal b. Atonic c. Absence d. Myoclonic

ANS: A The initial symptoms of a focal seizure involve clinical manifestations that are localized to a particular part of the body or brain. Symptoms of an absence seizure are staring and a brief loss of consciousness. In an atonic seizure, the patient loses muscle tone and (typically) falls to the ground. Myoclonic seizures are characterized by a sudden jerk of the body or extremities.

To palpate the liver during a head-to-toe physical assessment, the nurse a. places one hand on the patient's back and presses upward and inward with the other hand below the patient's right costal margin. b. places one hand on top of the other and uses the upper fingers to apply pressure and the bottom fingers to feel for the liver edge. c. presses slowly and firmly over the right costal margin with one hand and withdraws the fingers quickly after the liver edge is felt. d. places one hand under the patient's lower ribs and presses the left lower rib cage forward, palpating below the costal margin with the other hand.

ANS: A The liver is normally not palpable below the costal margin. The nurse needs to push inward below the right costal margin while lifting the patient's back slightly with the left hand. The other methods will not allow palpation of the liver.

A patient who had arthroscopic surgery of the right knee 7 days ago is admitted with a red, swollen, and hot knee. Which assessment finding by the nurse should be reported to the health care provider immediately? a. The blood pressure is 86/50 mm Hg. b. The white blood cell count is 11,500/µL. c. The patient is taking ibuprofen (Motrin). d. The patient says the knee pain is severe.

ANS: A The low blood pressure suggests that the patient may be developing septicemia as a complication of septic arthritis. Immediate blood cultures and initiation of antibiotic therapy are indicated. The other information is typical of septic arthritis and should also be reported to the health care provider, but it does not indicate any immediately life-threatening problems.

A patient is being scheduled for endoscopic retrograde cholangiopancreatography (ERCP) as soon as possible. Which actions from the agency policy for ERCP should the nurse take first? a. Place the patient on NPO status. b. Administer sedative medications. c. Ensure the consent form is signed. d. Teach the patient about the procedure.

ANS: A The patient will need to be NPO for 8 hours before the ERCP is done, so the nurse's initial action should be to place the patient on NPO status. The other actions can be done after the patient is NPO.

An unconscious patient has a nursing diagnosis of ineffective cerebral tissue perfusion related to cerebral tissue swelling. Which nursing intervention will be included in the plan of care? a. Keep the head of the bed elevated to 30 degrees. b. Position the patient with the knees and hips flexed. c. Encourage coughing and deep breathing to improve oxygenation. d. Cluster nursing interventions to provide uninterrupted rest periods.

ANS: A The patient with increased intracranial pressure (ICP) should be maintained in the head-up position to help reduce ICP. Flexion of the hips and knees increases abdominal pressure, which increases ICP. Because the stimulation associated with nursing interventions increases ICP, clustering interventions will progressively elevate ICP. Coughing increases intrathoracic pressure and ICP. DIF: Cognitive Level: Application REF: 1436-1437

A patient is scheduled for a lumbar puncture. The nurse will plan to a. transfer the patient to radiology just before the procedure. b. help the patient to a side lying position before the procedure. c. place the patient on NPO status for 4 hours before the procedure. d. administer a sedative medication 30 minutes before the procedure.

ANS: B For a lumbar puncture, the patient lies in the lateral recumbent position. The procedure does not usually require a sedative, is done in the patient room, and has no risk for aspiration. DIF: Cognitive Level: Application REF: 1418-1419

When admitting a patient with a possible coup-contracoup injury after a car accident to the emergency department, the nurse obtains the following information. Which finding is most important to report to the health care provider? a. The patient takes warfarin (Coumadin) daily. b. The patient's blood pressure is 162/94 mm Hg. c. The patient is unable to remember the accident. d. The patient complains of a severe dull headache.

ANS: A The use of anticoagulants increases the risk for intracranial hemorrhage and should be immediately reported. The other information would not be unusual in a patient with a head injury who had just arrived to the ED. DIF: Cognitive Level: Application REF: 1437-1438

A female patient is awaiting surgery for acute peritonitis. Which action will the nurse include in the plan of care? a. Position patient with the knees flexed. b. Avoid use of opioids or sedative drugs. c. Offer frequent small sips of clear liquids. d. Assist patient to breathe deeply and cough.

ANS: A There is less peritoneal irritation with the knees flexed, which will help decrease pain. Opioids and sedatives are typically given to control pain and anxiety. Preoperative patients with peritonitis are given IV fluids for hydration. Deep breathing and coughing will increase the patient's discomfort.

Which information will the nurse include when teaching adults to decrease the risk for cancers of the tongue and buccal mucosa? a. Avoid use of cigarettes and smokeless tobacco. b. Use sunscreen when outside even on cloudy days. c. Complete antibiotic courses used to treat throat infections. d. Use antivirals to treat herpes simplex virus (HSV) infections.

ANS: A Tobacco use greatly increases the risk for oral cancer. Acute throat infections do not increase the risk for oral cancer, although chronic irritation of the oral mucosa does increase risk. Sun exposure does not increase the risk for cancers of the buccal mucosa. Human papillomavirus (HPV) infection is associated with an increased risk, but HSV infection is not a risk factor for oral cancer.

charge nurse is observing a new staff nurse who is assessing a patient with a possible spinal cord lesion for sensation. Which action indicates a need for further teaching about neurologic assessment? a. The new nurse asks the patient, "Does this feel sharp?" b. The new nurse tests for light touch before testing for pain. c. The new nurse has the patient close the eyes during testing. d. The new nurse uses an irregular pattern to test for intact touch.

ANS: A When performing a sensory assessment, the nurse should not provide verbal clues. The other actions by the new nurse are appropriate. DIF: Cognitive Level: Application REF: 1417-1418

A patient with Parkinson's disease is admitted to the hospital for treatment of pneumonia. Which nursing interventions will be included in the plan of care (select all that apply)? a. Use an elevated toilet seat. b. Cut patient's food into small pieces. c. Provide high-protein foods at each meal. d. Place an armchair at the patient's bedside. e. Observe for sudden exacerbation of symptoms.

ANS: A, B, D Because the patient with Parkinson's has difficulty chewing, food should be cut into small pieces. An armchair should be used when the patient is seated so that the patient can use the arms to assist with getting up from the chair. An elevated toilet seat will facilitate getting on and off the toilet. High-protein foods will decrease the effectiveness of L-dopa. Parkinson's is a steadily progressive disease without acute exacerbations.

A 27-year-old patient who has been treated for status epilepticus in the emergency department will be transferred to the medical nursing unit. Which equipment should the nurse have available in the patient's assigned room (select all that apply)? a. Side-rail pads b. Tongue blade c. Oxygen mask d. Suction tubing e. Urinary catheter f. Nasogastric tube

ANS: A, C, D The patient is at risk for further seizures, and oxygen and suctioning may be needed after any seizures to clear the airway and maximize oxygenation. The bed's side rails should be padded to minimize the risk for patient injury during a seizure. Use of tongue blades during a seizure is contraindicated. Insertion of a nasogastric (NG) tube is not indicated because the airway problem is not caused by vomiting or abdominal distention. A urinary catheter is not required unless there is urinary retention.

Which information will the nurse include when teaching a patient how to avoid chronic constipation (select all that apply)? a. Many over-the-counter (OTC) medications can cause constipation. b. Stimulant and saline laxatives can be used regularly. c. Bulk-forming laxatives are an excellent source of fiber. d. Walking or cycling frequently will help bowel motility. e. A good time for a bowel movement may be after breakfast.

ANS: A, C, D, E Stimulant and saline laxatives should be used infrequently. Use of bulk-forming laxatives, regular early morning timing of defecation, regular exercise, and avoiding many OTC medications will help the patient avoid constipation.

Which information about a 71-year-old patient is most important for the admitting nurse to report to the patient's health care provider? a. Triceps reflex response graded at 1/5 b. Recent unintended weight loss of 20 pounds c. Patient complaint of chronic difficulty in falling asleep d. Orthostatic drop in systolic blood pressure of 10 mm Hg

ANS: B Although changes in appetite are normal with aging, a 20-pound weight loss requires further investigation. Orthostatic drops in blood pressure, changes in sleep patterns, and slowing of reflexes are normal changes in aging. DIF: Cognitive Level: Application REF: 1412-1413 | 1414

A 33-year-old male patient with a gunshot wound to the abdomen undergoes surgery, and a colostomy is formed as shown in the accompanying figure. Which information will be included in patient teaching? a. Stool will be expelled from both stomas. b. This type of colostomy is usually temporary. c. Soft, formed stool can be expected as drainage. d. Irrigations can regulate drainage from the stomas.

ANS: B A loop, or double-barrel stoma, is usually temporary. Stool will be expelled from the proximal stoma only. The stool from the transverse colon will be liquid and regulation through irrigations will not be possible.

A patient who has a head injury is diagnosed with a concussion. Which action will the nurse plan to take? a. Coordinate the transfer of the patient to the operating room. b. Provide discharge instructions about monitoring neurologic status. c. Transport the patient to radiology for magnetic resonance imaging (MRI) of the brain. d. Arrange to admit the patient to the neurologic unit for observation for 24 hours.

ANS: B A patient with a minor head trauma is usually discharged with instructions about neurologic monitoring and the need to return if neurologic status deteriorates. MRI, hospital admission, or surgery are not indicated in a patient with a concussion. DIF: Cognitive Level: Application REF: 1440

The nurse notes in the patient's medical history that the patient has a positive Romberg test. Which nursing diagnosis is appropriate? a. Acute pain related to hyperreflexia and spasm b. Risk for falls related to dizziness or weakness c. Disturbed tactile sensory perception related to spinal cord damage d. Ineffective thermoregulation related to decreased vasomotor response

ANS: B A positive Romberg test indicates that the patient has difficulty maintaining balance with the eyes closed. The Romberg does not test for tactile perception, thermoregulation, or hyperreflexia. DIF: Cognitive Level: Application REF: 1417-1418

Which action will the nurse include in the plan of care for a 33-year-old patient with a new diagnosis of rheumatoid arthritis? a. Instruct the patient to purchase a soft mattress. b. Suggest that the patient take a nap in the afternoon. c. Teach the patient to use lukewarm water when bathing. d. Suggest exercise with light weights several times daily.

ANS: B Adequate rest helps decrease the fatigue and pain that are associated with rheumatoid arthritis. Patients are taught to avoid stressing joints, to use warm baths to relieve stiffness, and to use a firm mattress. When stabilized, a therapeutic exercise program is usually developed by a physical therapist to include exercises that improve the flexibility and strength of the affected joints, and the patient's overall endurance.

The following orders are received for an unconscious patient who has just arrived in the emergency department after a head injury caused by an automobile accident. Which one should the nurse question? a. Obtain x-rays of the skull and spine. b. Prepare the patient for lumbar puncture. c. Send for computed tomography (CT) scan. d. Perform neurologic checks every 15 minutes.

ANS: B After a head injury, the patient may be experiencing intracranial bleeding and increased intracranial pressure, which could lead to herniation of the brain with lumbar puncture. The other orders are appropriate. DIF: Cognitive Level: Application REF: 1418-1419

A malnourished patient is receiving a parenteral nutrition (PN) infusion containing amino acids and dextrose from a bag that was hung 24 hours ago. The nurse observes that about 50 mL remain in the PN container. Which action is best for the nurse to take? a. Ask the health care provider to clarify the written PN order. b. Add a new container of PN using the current tubing and filter. c. Hang a new container of PN and change the IV tubing and filter. d. Infuse the remaining 50 mL and then hang a new container of PN.

ANS: B All PN solutions are changed at 24 hours. PN solutions containing dextrose and amino acids require a change in tubing and filter every 72 hours rather than daily. Infusion of the additional 50 mL will increase patient risk for infection. Changing the IV tubing and filter more frequently than required will unnecessarily increase costs. The nurse (not the health care provider) is responsible for knowing the indicated times for tubing and filter changes.

The nurse is admitting a 67-year-old patient with new-onset steatorrhea. Which question is most important for the nurse to ask? a. "How much milk do you usually drink?" b. "Have you noticed a recent weight loss?" c. "What time of day do your bowels move?" d. "Do you eat meat or other animal products?"

ANS: B Although all of the questions provide useful information, it is most important to determine if the patient has an imbalance in nutrition because of the steatorrhea.

Which nursing action will the nurse include in the plan of care for a 35-year-old male patient admitted with an exacerbation of inflammatory bowel disease (IBD)? a. Restrict oral fluid intake. b. Monitor stools for blood. c. Ambulate four times daily. d. Increase dietary fiber intake.

ANS: B Because anemia or hemorrhage may occur with IBD, stools should be assessed for the presence of blood. The other actions would not be appropriate for the patient with IBD. Because dietary fiber may increase gastrointestinal (GI) motility and exacerbate the diarrhea, severe fatigue is common with IBD exacerbations, and dehydration may occur.

The nurse determines that additional instruction is needed when a patient diagnosed with scleroderma says which of the following? a. "Paraffin baths can be used to help my hands." b. "I should lie down for an hour after each meal." c. "Lotions will help if I rub them in for a long time." d. "I should perform range-of-motion exercises daily."

ANS: B Because of the esophageal scarring, patients should sit up for 2 hours after eating. The other patient statements are correct and indicate that the teaching has been effective.

A patient in the emergency department has just been diagnosed with peritonitis caused by a ruptured diverticulum. Which prescribed intervention will the nurse implement first? a. Insert a urinary catheter to drainage. b. Infuse metronidazole (Flagyl) 500 mg IV. c. Send the patient for a computerized tomography scan. d. Place a nasogastric (NG) tube to intermittent low suction.

ANS: B Because peritonitis can be fatal if treatment is delayed, the initial action should be to start antibiotic therapy (after any ordered cultures are obtained). The other actions can be done after antibiotic therapy is initiated.

A patient has a lesion that affects lower motor neurons. During assessment of the patient's lower extremities, the nurse expects to find a. spasticity. b. flaccidity. c. loss of sensation. d. hyperactive reflexes.

ANS: B Because the cell bodies of lower motor neurons are located in the spinal cord, damage to the neuron will decrease motor activity of the affected muscles. Spasticity and hyperactive reflexes are caused by upper motor neuron damage. Sensation is not impacted by motor neuron lesions. DIF: Cognitive Level: Comprehension REF: 1408-1409

A 74-year-old patient preparing to undergo a colon resection for cancer of the colon asks about the elevated carcinoembryonic antigen (CEA) test result. The nurse explains that the test is used to a. identify any metastasis of the cancer. b. monitor the tumor status after surgery. c. confirm the diagnosis of a specific type of cancer. d. determine the need for postoperative chemotherapy.

ANS: B CEA is used to monitor for cancer recurrence after surgery. CEA levels do not help to determine whether there is metastasis of the cancer. Confirmation of the diagnosis is made on the basis of biopsy. Chemotherapy use is based on factors other than CEA.

Which item should the nurse offer to the patient who is to restart oral intake after being NPO due to nausea and vomiting? a. Glass of orange juice b. Dish of lemon gelatin c. Cup of coffee with cream d. Bowl of hot chicken broth

ANS: B Clear cool liquids are usually the first foods started after a patient has been nauseated. Acidic foods such as orange juice, very hot foods, and coffee are poorly tolerated when patients have been nauseated.

After noting that a patient with a head injury has clear nasal drainage, which action should the nurse take? a. Have the patient blow the nose. b. Check the nasal drainage for glucose. c. Assure the patient that rhinorrhea is normal after a head injury. d. Obtain a specimen of the fluid to send for culture and sensitivity.

ANS: B Clear nasal drainage in a patient with a head injury suggests a dural tear and cerebrospinal fluid (CSF) leakage. If the drainage is CSF, it will test positive for glucose. Fluid leaking from the nose will have normal nasal flora, so culture and sensitivity will not be useful. Blowing the nose is avoided to prevent CSF leakage. DIF: Cognitive Level: Application REF: 1438-1439

The nurse determines that teaching regarding cobalamin injections has been effective when the patient with chronic atrophic gastritis states which of the following? a. "The cobalamin injections will prevent gastric inflammation." b. "The cobalamin injections will prevent me from becoming anemic." c. "These injections will increase the hydrochloric acid in my stomach." d. "These injections will decrease my risk for developing stomach cancer."

ANS: B Cobalamin supplementation prevents the development of pernicious anemia. Chronic gastritis may cause achlorhydria, but cobalamin does not correct this. The loss of intrinsic factor secretion with chronic gastritis is permanent, and the patient will need lifelong supplementation with cobalamin. The incidence of stomach cancer is higher in patients with chronic gastritis, but cobalamin does not reduce the risk for stomach cancer.

Which information will the nurse include when preparing teaching materials for patients with exacerbations of rheumatoid arthritis? a. Affected joints should not be exercised when pain is present. b. Application of cold packs before exercise may decrease joint pain. c. Exercises should be performed passively by someone other than the patient. d. Walking may substitute for range-of-motion (ROM) exercises on some days.

ANS: B Cold application is helpful in reducing pain during periods of exacerbation of RA. Because the joint pain is chronic, patients are instructed to exercise even when joints are painful. ROM exercises are intended to strengthen joints and improve flexibility, so passive ROM alone is not sufficient. Recreational exercise is encouraged but is not a replacement for ROM exercises.

A 46-year-old male patient with dermatomyositis is receiving long-term prednisone (Deltasone) therapy. Which assessment finding by the nurse is most important to report to the health care provider? a. The blood glucose is 112 mg/dL. b. The patient has painful hematuria. c. Acne is noted on the patient's face. d. The patient has an increased appetite.

ANS: B Corticosteroid use is associated with an increased risk for infection, so the nurse should report the urinary tract symptoms immediately to the health care provider. The increase in blood glucose, increased appetite, and acne are also adverse effects of corticosteroid use but do not need diagnosis and treatment as rapidly as the probable urinary tract infection.

Which assessment information obtained by the nurse indicates that a patient with an exacerbation of rheumatoid arthritis (RA) is experiencing a side effect of prednisone (Deltasone)? a. The patient has joint pain and stiffness. b. The patient's blood glucose is 165 mg/dL. c. The patient has experienced a recent 5-pound weight loss. d. The patient's erythrocyte sedimentation rate (ESR) has increased.

ANS: B Corticosteroids have the potential to cause diabetes mellitus. The finding of an elevated blood glucose reflects this side effect of prednisone. Corticosteroids increase appetite and lead to weight gain. An elevated ESR and no improvement in symptoms would indicate that the prednisone was not effective but would not be side effects of the medication

The nurse is assessing a 31-year-old female patient with abdominal pain. Th nurse,who notes that there is ecchymosis around the area of umbilicus, will document this finding as a. Cullen sign. b. Rovsing sign. c. McBurney sign. d. Grey-Turner's signt.

ANS: B Cullen sign is ecchymosis around the umbilicus. Rovsing sign occurs when palpation of the left lower quadrant causes pain in the right lower quadrant. Deep tenderness at McBurney's point (halfway between the umbilicus and the right iliac crest), known as McBurney's sign, is a sign of acute appendicitis.

Which assessment finding about a patient who has been using naproxen (Naprosyn) for 6 weeks to treat osteoarthritis is most important for the nurse to report to the health care provider? a. The patient has gained 3 pounds. b. The patient has dark-colored stools. c. The patient's pain has become more severe. d. The patient is using capsaicin cream (Zostrix).

ANS: B Dark-colored stools may indicate that the patient is experiencing gastrointestinal bleeding caused by the naproxen. The information about the patient's ongoing pain and weight gain also will be reported and may indicate a need for a different treatment and/or counseling about avoiding weight gain, but these are not as large a concern as the possibility of gastrointestinal bleeding. Use of capsaicin cream with oral medications is appropriate.

Which assessment information will the nurse collect to determine whether a patient is developing postconcussion syndrome? a. Muscle resistance b. Short-term memory c. Glasgow coma scale d. Pupil reaction to light

ANS: B Decreased short-term memory is one indication of postconcussion syndrome. The other data may be assessed but are not indications of postconcussion syndrome. DIF: Cognitive Level: Application REF: 1440

Which information will the nurse include when teaching a 38-year-old male patient with newly diagnosed ankylosing spondylitis (AS) about the management of the condition? a. Exercise by taking long walks. b. Do daily deep-breathing exercises. c. Sleep on the side with hips flexed. d. Take frequent naps during the day.

ANS: B Deep-breathing exercises are used to decrease the risk for pulmonary complications that may occur with the reduced chest expansion that can occur with ankylosing spondylitis (AS). Patients should sleep on the back and avoid flexed positions. Prolonged standing and walking should be avoided. There is no need for frequent naps

After the nurse has taught a 28-year-old with fibromyalgia, which statement by the patient indicates a good understanding of effective self-management? a. "I am going to join a soccer team to get more exercise." b. "I will need to stop drinking so much coffee and soda." c. "I will call the doctor every time my symptoms get worse." d. "I should avoid using over-the-counter medications for pain."

ANS: B Dietitians frequently suggest that patients with fibromyalgia limit their intake of caffeine and sugar because these substances are muscle irritants. Mild exercise such as walking is recommended for patients with fibromyalgia, but vigorous exercise is likely to make symptoms worse. Because symptoms may fluctuate from day to day, the patient should be able to adapt the regimen independently, rather than calling the provider whenever symptoms get worse. Over-the-counter medications such as ibuprofen and acetaminophen are frequently used for symptom management

A patient hospitalized with chronic heart failure eats only about 50% of each meal and reports "feeling too tired to eat." Which action should the nurse take first? a. Teach the patient about the importance of good nutrition. b. Serve multiple small feedings of high-calorie, high-protein foods. c. Obtain an order for enteral feedings of liquid nutritional supplements. d. Consult with the health care provider about providing parenteral nutrition (PN).

ANS: B Eating small amounts of food frequently throughout the day is less fatiguing and will improve the patient's ability to take in more nutrients. Teaching the patient may be appropriate, but will not address the patient's inability to eat more because of fatigue. Tube feedings or PN may be needed if the patient is unable to take in enough nutrients orally, but increasing the oral intake should be attempted first.

Which information will the nurse include for a patient with newly diagnosed gastroesophageal reflux disease (GERD)? a. "Peppermint tea may reduce your symptoms." b. "Keep the head of your bed elevated on blocks." c. "You should avoid eating between meals to reduce acid secretion." d. "Vigorous physical activities may increase the incidence of reflux."

ANS: B Elevating the head of the bed will reduce the incidence of reflux while the patient is sleeping. Peppermint will decrease lower esophageal sphincter (LES) pressure and increase the chance for reflux. Small, frequent meals are recommended to avoid abdominal distention. There is no need to make changes in physical activities because of GERD.

Which nursing action should be included in the postoperative plan of care for a patient after a laparoscopic esophagectomy? a. Notify the doctor about bloody nasogastric (NG) drainage. b. Elevate the head of the bed to at least 30 degrees. c. Reposition the NG tube if drainage stops. d. Start oral fluids when the patient has active bowel sounds.

ANS: B Elevation of the head of the bed decreases the risk for reflux and aspiration of gastric secretions. The NG tube should not be repositioned without consulting with the health care provider. Bloody NG drainage is expected for the first 8 to 12 hours. A swallowing study is needed before oral fluids are started.

After a total proctocolectomy and permanent ileostomy, the patient tells the nurse, "I cannot manage all these changes. I don't want to look at the stoma." What is the best action by the nurse? a. Reassure the patient that ileostomy care will become easier. b. Ask the patient about the concerns with stoma management. c. Develop a detailed written list of ostomy care tasks for the patient. d. Postpone any teaching until the patient adjusts to the ileostomy.

ANS: B Encouraging the patient to share concerns assists in helping the patient adjust to the body changes. Acknowledgment of the patient's feelings and concerns is important rather than offering false reassurance. Because the patient indicates that the feelings about the ostomy are the reason for the difficulty with the many changes, development of a detailed ostomy care plan will not improve the patient's ability to manage the ostomy. Although detailed ostomy teaching may be postponed, the nurse should offer teaching about some aspects of living with an ostomy.

A 24-year-old woman with Crohn's disease develops a fever and symptoms of a urinary tract infection (UTI) with tan, fecal-smelling urine. What information will the nurse add to a general teaching plan about UTIs in order to individualize the teaching for this patient? a. Bacteria in the perianal area can enter the urethra. b. Fistulas can form between the bowel and bladder. c. Drink adequate fluids to maintain normal hydration. d. Empty the bladder before and after sexual intercourse.

ANS: B Fistulas between the bowel and bladder occur in Crohn's disease and can lead to UTI. Teaching for UTI prevention in general includes good hygiene, adequate fluid intake, and voiding before and after intercourse.

Which statement by a patient who is being discharged from the emergency department (ED) after a head injury indicates a need for intervention by the nurse? a. "I will return if I feel dizzy or nauseated." b. "I am going to drive home and go to bed." c. "I do not even remember being in an accident." d. "I can take acetaminophen (Tylenol) for my headache."

ANS: B Following a head injury, the patient should avoid operating heavy machinery. Retrograde amnesia is common after a concussion. The patient can take acetaminophen for headache and should return if symptoms of increased intracranial pressure such as dizziness or nausea occur. DIF: Cognitive Level: Application REF: 1444

A patient is scheduled for a myelogram to confirm the presence of a herniated intervertebral disk. Which information obtained when admitting the patient is most important for the nurse to communicate to the health care provider before the procedure? a. The patient is anxious about the test. b. The patient has an allergy to shellfish. c. The patient had 4 ounces of apple juice 4 hours earlier. d. The patient has back pain when lying flat for long periods.

ANS: B Iodine-containing contrast medium is injected into the subarachnoid space during a myelogram. The health care provider may need to modify the postmyelogram orders to prevent back pain, but this can be done after the procedure. Clear liquids are usually considered safe up to 4 hours before a diagnostic or surgical procedure. The patient's anxiety should be addressed, but this is not as important as the iodine allergy. DIF: Cognitive Level: Application REF: 1421-1422

A 40-year-old African American patient has scleroderma manifested by CREST (calcinosis, Raynaud's phenomenon, esophageal dysfunction, sclerodactyly, and telangiectasia) syndrome. Which action will the nurse include in the plan of care? a. Avoid use of capsaicin cream on hands. b. Keep environment warm and draft free. c. Obtain capillary blood glucose before meals. d. Assist to bathroom every 2 hours while awake.

ANS: B Keeping the room warm will decrease the incidence of Raynaud's phenomenon, one aspect of the CREST syndrome. Capsaicin cream may be used to improve circulation and decrease pain. There is no need to obtain blood glucose levels or to assist the patient to the bathroom every 2 hours.

The home health registered nurse (RN) is planning care for a patient with a seizure disorder related to a recent head injury. Which nursing action can be delegated to a licensed practical/vocational nurse (LPN/LVN)? a. Make referrals to appropriate community agencies. b. Place medications in the home medication organizer. c. Teach the patient and family how to manage seizures. d. Assess for use of medications that may precipitate seizures.

ANS: B LPN/LVN education includes administration of medications. The other activities require RN education and scope of practice.

Which information will the nurse teach a 23-year-old patient with lactose intolerance? a. Ice cream is relatively low in lactose. b. Live-culture yogurt is usually tolerated. c. Heating milk will break down the lactose. d. Nonfat milk is a better choice than whole milk.

ANS: B Lactose-intolerant individuals can usually eat yogurt without experiencing discomfort. Ice cream, nonfat milk, and milk that has been heated are all high in lactose.

A 31-year-old woman is taking methotrexate (Rheumatrex) to treat rheumatoid arthritis. Which information from the patient's health history is important for the nurse to report to the health care provider about the methotrexate? a. The patient had a history of infectious mononucleosis as a teenager. b. The patient is trying to get pregnant before her disease becomes more severe. c. The patient has a family history of age-related macular degeneration of the retina. d. The patient has been using large doses of vitamins and health foods to treat the RA.

ANS: B Methotrexate is teratogenic, and the patient should be taking contraceptives during methotrexate therapy. The other information will not impact the choice of methotrexate as therapy.

Which nursing action can the registered nurse (RN) delegate to unlicensed assistive personnel (UAP) who are assisting with the care of a patient with scleroderma? a. Monitor for difficulty in breathing. b. Document the patient's oral intake. c. Check finger strength and movement. d. Apply capsaicin (Zostrix) cream to hands.

ANS: B Monitoring and documenting patients' oral intake is included in UAP education and scope of practice. Assessments for changes in physical status and administration of medications require more education and scope of practice, and should be done by licensed nurses

After the nurse has finished teaching a 68-year-old patient with osteoarthritis (OA) of the right hip about how to manage the OA, which patient statement indicates a need for more teaching? a. "I can take glucosamine to help decrease my knee pain." b. "I will take 1 g of acetaminophen (Tylenol) every 4 hours." c. "I will take a shower in the morning to help relieve stiffness." d. "I can use a cane to decrease the pressure and pain in my hip."

ANS: B No more than 4 g of acetaminophen should be taken daily to avoid liver damage. The other patient statements are correct and indicate good understanding of OA management.

Which intervention will the nurse include in the plan of care for a patient with primary restless legs syndrome (RLS) who is having difficulty sleeping? a. Teach about the use of antihistamines to improve sleep. b. Suggest that the patient exercise regularly during the day. c. Make a referral to a massage therapist for deep massage of the legs. d. Assure the patient that the problem is transient and likely to resolve.

ANS: B Nondrug interventions such as getting regular exercise are initially suggested to improve sleep quality in patients with RLS. Antihistamines may aggravate RLS. Massage does not alleviate RLS symptoms and RLS is likely to progress in most patients.

A 30-year-old man is being admitted to the hospital for elective knee surgery. Which assessment finding is most important to report to the health care provider? a. Tympany on percussion of the abdomen b. Liver edge 3 cm below the costal margin c. Bowel sounds of 20/minute in each quadrant d. Aortic pulsations visible in the epigastric area

ANS: B Normally the lower border of the liver is not palpable below the ribs, so this finding suggests hepatomegaly. The other findings are within normal range for the physical assessment.

After change-of-shift report, which patient should the nurse assess first? a. 40-year-old male with celiac disease who has frequent frothy diarrhea b. 30-year-old female with a femoral hernia who has abdominal pain and vomiting c. 30-year-old male with ulcerative colitis who has severe perianal skin breakdown d. 40-year-old female with a colostomy bag that is pulling away from the adhesive wafer

ANS: B Pain and vomiting with a femoral hernia suggest possible strangulation, which will necessitate emergency surgery. The other patients have less urgent problems.

A new 19-year-old male patient has familial adenomatous polyposis (FAP). Which action will the nurse in the gastrointestinal clinic include in the plan of care? a. Obtain blood samples for DNA analysis. b. Schedule the patient for yearly colonoscopy. c. Provide preoperative teaching about total colectomy. d. Discuss lifestyle modifications to decrease cancer risk.

ANS: B Patients with FAP should have annual colonoscopy starting at age 16 and usually have total colectomy by age 25 to avoid developing colorectal cancer. DNA analysis is used to make the diagnosis, but is not needed now for this patient. Lifestyle modifications will not decrease cancer risk for this patient.

Which prescribed intervention for a 61-year-old female patient with chronic short bowel syndrome will the nurse question? a. Ferrous sulfate (Feosol) 325 mg daily b. Senna (Senokot) 1 tablet every day c. Psyllium (Metamucil) 2.1 grams 3 times daily d. Diphenoxylate with atropine (Lomotil) prn loose stools

ANS: B Patients with short bowel syndrome have diarrhea because of decreased nutrient and fluid absorption and would not need stimulant laxatives. Iron supplements are used to prevent iron-deficiency anemia, bulk-forming laxatives help make stools less watery, and opioid antidiarrheal drugs are helpful in slowing intestinal transit time.

21. Which information will the nurse include when teaching a patient with peptic ulcer disease about the effect of ranitidine (Zantac)? a. "Ranitidine absorbs the gastric acid." b. "Ranitidine decreases gastric acid secretion." c. "Ranitidine constricts the blood vessels near the ulcer." d. "Ranitidine covers the ulcer with a protective material."

ANS: B Ranitidine is a histamine-2 (H2) receptor blocker, which decreases the secretion of gastric acid. The response beginning, "Ranitidine constricts the blood vessels" describes the effect of vasopressin. The response "Ranitidine absorbs the gastric acid" describes the effect of antacids. The response beginning "Ranitidine covers the ulcer" describes the action of sucralfate (Carafate).

A 58-year-old man with blunt abdominal trauma from a motor vehicle crash undergoes peritoneal lavage. If the lavage returns brown fecal drainage, which action will the nurse plan to take next? a. Auscultate the bowel sounds. b. Prepare the patient for surgery. c. Check the patient's oral temperature. d. Obtain information about the accident.

ANS: B Return of brown drainage and fecal material suggests perforation of the bowel and the need for immediate surgery. Auscultation of bowel sounds, checking the temperature, and obtaining information about the accident are appropriate actions, but the priority is to prepare to send the patient for emergency surgery.

A 73-year-old patient with Parkinson's disease has a nursing diagnosis of impaired physical mobility related to bradykinesia. Which action will the nurse include in the plan of care? a. Instruct the patient in activities that can be done while lying or sitting. b. Suggest that the patient rock from side to side to initiate leg movement. c. Have the patient take small steps in a straight line directly in front of the feet. d. Teach the patient to keep the feet in contact with the floor and slide them forward.

ANS: B Rocking the body from side to side stimulates balance and improves mobility. The patient will be encouraged to continue exercising because this will maintain functional abilities. Maintaining a wide base of support will help with balance. The patient should lift the feet and avoid a shuffling gait.

When family members ask the nurse about the purpose of the ventriculostomy system being used for intracranial pressure monitoring for a patient, which response by the nurse is best? a. "This type of monitoring system is complex and highly skilled staff are needed." b. "The monitoring system helps show whether blood flow to the brain is adequate." c. "The ventriculostomy monitoring system helps check for alterations in cerebral perfusion pressure." d. "This monitoring system has multiple benefits including facilitation of cerebrospinal fluid drainage."

ANS: B Short and simple explanations should be given to patients and family members. The other explanations are either too complicated to be easily understood or may increase the family member's anxiety. DIF: Cognitive Level: Application REF: 1438

After suctioning, the nurse notes that the intracranial pressure for a patient with a traumatic head injury has increased from 14 to 16 mm Hg. Which action should the nurse take first? a. Document the increase in intracranial pressure. b. Assure that the patient's neck is not in a flexed position. c. Notify the health care provider about the change in pressure. d. Increase the rate of the prescribed propofol (Diprovan) infusion.

ANS: B Since suctioning will cause a transient increase in intracranial pressure, the nurse should initially check for other factors that might be contributing to the increase and observe the patient for a few minutes. Documentation is needed, but this is not the first action. There is no need to notify the health care provider about this expected reaction to suctioning. Propofol is used to control patient anxiety or agitation; there is no indication that anxiety has contributed to the increase in intracranial pressure. DIF: Cognitive Level: Application REF: 1426 | 1435-1437 | 1436-1437

A 26-year-old patient with a family history of stomach cancer asks the nurse about ways to decrease the risk for developing stomach cancer. The nurse will teach the patient to avoid a. emotionally stressful situations. b. smoked foods such as ham and bacon. c. foods that cause distention or bloating. d. chronic use of H2 blocking medications.

ANS: B Smoked foods such as bacon, ham, and smoked sausage increase the risk for stomach cancer. Stressful situations, abdominal distention, and use of H2 blockers are not associated with an increased incidence of stomach cancer.

Which patient statement indicates that the nurse's teaching about sulfasalazine (Azulfidine) for ulcerative colitis has been effective? a. "The medication will be tapered if I need surgery." b. "I will need to use a sunscreen when I am outdoors." c. "I will need to avoid contact with people who are sick." d. "The medication will prevent infections that cause the diarrhea."

ANS: B Sulfasalazine may cause photosensitivity in some patients. It is not used to treat infections. Sulfasalazine does not reduce immune function. Unlike corticosteroids, tapering of sulfasalazine is not needed.

Which action will the nurse plan to take for a 40-year-old patient with multiple sclerosis (MS) who has urinary retention caused by a flaccid bladder? a. Decrease the patient's evening fluid intake. b. Teach the patient how to use the Credé method. c. Suggest the use of adult incontinence briefs for nighttime only. d. Assist the patient to the commode every 2 hours during the day.

ANS: B The Credé method can be used to improve bladder emptying. Decreasing fluid intake will not improve bladder emptying and may increase risk for urinary tract infection (UTI) and dehydration. The use of incontinence briefs and frequent toileting will not improve bladder emptying.

Which information about dietary management should the nurse include when teaching a patient with peptic ulcer disease (PUD)? a. "You will need to remain on a bland diet." b. "Avoid foods that cause pain after you eat them." c. "High-protein foods are least likely to cause you pain." d. "You should avoid eating any raw fruits and vegetables."

ANS: B The best information is that each individual should choose foods that are not associated with postprandial discomfort. Raw fruits and vegetables may irritate the gastric mucosa, but chewing well seems to decrease this problem and some patients may tolerate these foods well. High-protein foods help neutralize acid, but they also stimulate hydrochloric (HCl) acid secretion and may increase discomfort for some patients. Bland diets may be recommended during an acute exacerbation of PUD, but there is little scientific evidence to support their use.

When a 74-year-old patient is seen in the health clinic with new development of a stooped posture, shuffling gait, and pill rolling-type tremor, the nurse will anticipate teaching the patient about a. oral corticosteroids. b. antiparkinsonian drugs. c. magnetic resonance imaging (MRI). d. electroencephalogram (EEG) testing.

ANS: B The diagnosis of Parkinson's is made when two of the three characteristic manifestations of tremor, rigidity, and bradykinesia are present. The confirmation of the diagnosis is made on the basis of improvement when antiparkinsonian drugs are administered. This patient has symptoms of tremor and bradykinesia. The next anticipated step will be treatment with medications. MRI and EEG are not useful in diagnosing Parkinson's disease, and corticosteroid therapy is not used to treat it.

Which medications will the nurse teach the patient about whose peptic ulcer disease is associated with Helicobacter pylori? a. Sucralfate (Carafate), nystatin (Mycostatin), and bismuth (Pepto-Bismol) b. Amoxicillin (Amoxil), clarithromycin (Biaxin), and omeprazole (Prilosec) c. Famotidine (Pepcid), magnesium hydroxide (Mylanta), and pantoprazole (Protonix) d. Metoclopramide (Reglan), bethanechol (Urecholine), and promethazine (Phenergan)

ANS: B The drugs used in triple drug therapy include a proton pump inhibitor such as omeprazole and the antibiotics amoxicillin and clarithromycin. The other combinations listed are not included in the protocol for H. pylori infection.

Which result for a 30-year-old patient with systemic lupus erythematosus (SLE) is most important for the nurse to communicate to the health care provider? a. Decreased C-reactive protein (CRP) b. Elevated blood urea nitrogen (BUN) c. Positive antinuclear antibodies (ANA) d. Positive lupus erythematosus cell prep

ANS: B The elevated BUN and creatinine levels indicate possible lupus nephritis and a need for a change in therapy to avoid further renal damage. The positive lupus erythematosus (LE) cell prep and ANA would be expected in a patient with SLE. A drop in CRP shows an improvement in the inflammatory process.

Which action should the nurse take first when preparing to teach a frail 79-year-old Hispanic man who lives with an adult daughter about ways to improve nutrition? a. Ask the daughter about the patient's food preferences. b. Determine who shops for groceries and prepares the meals. c. Question the patient about how many meals per day are eaten. d. Assure the patient that culturally preferred foods will be included.

ANS: B The family member who shops for groceries and cooks will be in control of the patient's diet, so the nurse will need to ensure that this family member is involved in any teaching or discussion about the patient's nutritional needs. The other information will also be assessed and used but will not be useful in meeting the patient's nutritional needs unless nutritionally appropriate foods are purchased and prepared.

A 20-year-old man with extensive facial injuries from a motor vehicle crash is receiving tube feedings through a percutaneous endoscopic gastrostomy (PEG). Which action will the nurse include in the plan of care? a. Keep the patient positioned on the left side. b. Check the gastric residual volume every 4 to 6 hours. c. Avoid giving bolus tube feedings through the PEG tube. d. Obtain a daily abdominal x-ray to verify tube placement.

ANS: B The gastric residual volume is assessed every 4 to 6 hours to decrease the risk for aspiration. The patient does not need to be positioned on the left side. Bolus feedings can be administered through a PEG tube. An x-ray is obtained immediately after placement of the PEG tube to check position, but daily x-rays are not needed.

A 62- year-old man reports chronic constipation. To promote bowel evacuation, the nurse will suggest that the patient attempt defecation a. in the mid-afternoon. b. after eating breakfast. c. right after getting up in the morning. d. immediately before the first daily meal.

ANS: B The gastrocolic reflex is most active after the first daily meal. Arising in the morning, the anticipation of eating, and physical exercise do not stimulate these reflexes.

Neurologic testing of the patient indicates impaired functioning of the left glossopharyngeal nerve (CN IX) and the vagus nerve (CN X). Which action will the nurse include in the plan of care? a. Insert an oral airway. b. Withhold oral fluid or foods. c. Provide highly seasoned foods. d. Apply artificial tears every hour.

ANS: B The glossopharyngeal and vagus nerves innervate the pharynx and control the gag reflex; a patient with impaired function of these nerves is at risk for aspiration. An oral airway may be needed when a patient is unconscious and unable to maintain the airway, but it will not decrease aspiration risk. Taste and eye blink are controlled by the facial nerve. DIF: Cognitive Level: Application REF: 1417

A 25-year-old male patient calls the clinic complaining of diarrhea for 24 hours. Which action should the nurse take first? a. Inform the patient that laboratory testing of blood and stools will be necessary. b. Ask the patient to describe the character of the stools and any associated symptoms. c. Suggest that the patient drink clear liquid fluids with electrolytes, such as Gatorade or Pedialyte. d. Advise the patient to use over-the-counter loperamide (Imodium) to slow gastrointestinal (GI) motility.

ANS: B The initial response by the nurse should be further assessment of the patient. The other responses may be appropriate, depending on what is learned in the assessment.

The nurse will determine that teaching a 67-year-old man to irrigate his new colostomy has been effective if the patient a. inserts the irrigation tubing 4 to 6 inches into the stoma. b. hangs the irrigating container 18 inches above the stoma. c. stops the irrigation and removes the irrigating cone if cramping occurs. d. fills the irrigating container with 1000 to 2000 mL of lukewarm tap water.

ANS: B The irrigating container should be hung 18 to 24 inches above the stoma. If cramping occurs, the irrigation should be temporarily stopped and the cone left in place. Five hundred to 1000 mL of water should be used for irrigation. An irrigation cone, rather than tubing, should be inserted into the stoma; 4 to 6 inches would be too far for safe insertion.

Following a head injury, an unconscious 32-year-old patient is admitted to the emergency department (ED). The patient's spouse and children stay at the patient's side and constantly ask about the treatment being given. What action is best for the nurse to take? a. Ask the family to stay in the waiting room until the initial assessment is completed. b. Allow the family to stay with the patient and briefly explain all procedures to them. c. Call the family's pastor or spiritual advisor to support them while initial care is given. d. Refer the family members to the hospital counseling service to deal with their anxiety.

ANS: B The need for information about the diagnosis and care is very high in family members of acutely ill patients, and the nurse should allow the family to observe care and explain the procedures. A pastor or counseling service can offer some support, but research supports information as being more effective. Asking the family to stay in the waiting room will increase their anxiety. DIF: Cognitive Level: Application REF: 1438

A high school teacher who has just been diagnosed with epilepsy after having a generalized tonic-clonic seizure tells the nurse, "I cannot teach anymore, it will be too upsetting if I have a seizure at work." Which response by the nurse is best? a. "You might benefit from some psychologic counseling." b. "Epilepsy usually can be well controlled with medications." c. "You will want to contact the Epilepsy Foundation for assistance." d. "The Department of Vocational Rehabilitation can help with work retraining."

ANS: B The nurse should inform the patient that most patients with seizure disorders are controlled with medication. The other information may be necessary if the seizures persist after treatment with antiseizure medications is implemented.

A severely malnourished patient reports that he is Jewish. The nurse's initial action to meet his nutritional needs will be to a. have family members bring in food. b. ask the patient about food preferences. c. teach the patient about nutritious Kosher foods. d. order nutrition supplements that are manufactured Kosher.

ANS: B The nurse's first action should be further assessment whether or not the patient follows any specific religious guidelines that impact nutrition. The other actions may also be appropriate, based on the information obtained during the assessment.

A 71-year-old male patient tells the nurse that growing old causes constipation so he has been using a suppository for constipation every morning. Which action should the nurse take first? a. Encourage the patient to increase oral fluid intake. b. Assess the patient about risk factors for constipation. c. Suggest that the patient increase intake of high-fiber foods. d. Teach the patient that a daily bowel movement is unnecessary.

ANS: B The nurse's initial action should be further assessment of the patient for risk factors for constipation and for his usual bowel pattern. The other actions may be appropriate but will be based on the assessment.

After change-of-shift report, which patient will the nurse assess first? a. A 40-year-old woman whose parenteral nutrition infusion bag has 30 minutes of solution left b. A 40-year-old man with continuous enteral feedings who has developed pulmonary crackles c. A 30-year-old man with 4+ generalized pitting edema and severe protein-calorie malnutrition d. A 30-year-old woman whose gastrostomy tube is plugged after crushed medications were administered.

ANS: B The patient data suggest aspiration has occurred and rapid assessment and intervention are needed. The other patients should also be assessed as quickly as possible, but the data about them do not suggest any immediately life-threatening complications.

A patient with a head injury opens the eyes to verbal stimulation, curses when stimulated, and does not respond to a verbal command to move but attempts to remove a painful stimulus. The nurse records the patient's Glasgow Coma Scale score as a. 9. b. 11. c. 13. d. 15.

ANS: B The patient has a score of 3 for eye opening, 3 for best verbal response, and 5 for best motor response. DIF: Cognitive Level: Application REF: 1434

A 48-year-old woman has a body mass index (BMI) of 31 kg/m2, a normal C-reactive protein level, and low serum transferrin and albumin levels. The nurse will plan patient teaching to increase the patient's intake of foods that are high in a. iron. b. protein. c. calories. d. carbohydrate.

ANS: B The patient's C-reactive protein and transferrin levels indicate low protein stores. The BMI is in the obese range, so increasing caloric intake is not indicated. The data do not indicate a need for increased carbohydrate or iron intake.

The nurse and a licensed practical/vocational nurse (LPN/LVN) are working together to care for a patient who had an esophagectomy 2 days ago. Which action by the LPN/LVN requires that the nurse intervene? a. The LPN/LVN uses soft swabs to provide for oral care. b. The LPN/LVN positions the head of the bed in the flat position. c. The LPN/LVN encourages the patient to use pain medications before coughing. d. The LPN/LVN includes the enteral feeding volume when calculating intake and output.

ANS: B The patient's bed should be in Fowler's position to prevent reflux and aspiration of gastric contents. The other actions by the LPN/LVN are appropriate.

A patient with rheumatoid arthritis (RA) complains to the clinic nurse about having chronically dry eyes. Which action by the nurse is most appropriate? a. Teach the patient about adverse effects of the RA medications. b. Suggest that the patient use over-the-counter (OTC) artificial tears. c. Reassure the patient that dry eyes are a common problem with RA. d. Ask the health care provider about discontinuing methotrexate (Rheumatrex) .

ANS: B The patient's dry eyes are consistent with Sjögren's syndrome, a common extraarticular manifestation of RA. Symptomatic therapy such as OTC eye drops is recommended. Dry eyes are not a side effect of methotrexate. Although dry eyes are common in RA, it is more helpful to offer a suggestion to relieve these symptoms than to offer reassurance. The dry eyes are not caused by RA treatment, but by the disease itself

Following a thymectomy, a 62-year-old male patient with myasthenia gravis receives the usual dose of pyridostigmine (Mestinon). An hour later, the patient complains of nausea and severe abdominal cramps. Which action should the nurse take first? a. Auscultate the patient's bowel sounds. b. Notify the patient's health care provider. c. Administer the prescribed PRN antiemetic drug. d. Give the scheduled dose of prednisone (Deltasone).

ANS: B The patient's history and symptoms indicate a possible cholinergic crisis. The health care provider should be notified immediately, and it is likely that atropine will be prescribed. The other actions will be appropriate if the patient is not experiencing a cholinergic crisis.

A 19-year-old female admitted with anorexia nervosa is 5 ft 6 in (163 cm) tall and weighs 88 pounds (41 kg). Laboratory tests reveal hypokalemia and iron-deficiency anemia. Which nursing diagnosis has the highest priority? a. Risk for activity intolerance related to anemia b. Risk for electrolyte imbalance related to eating patterns c. Ineffective health maintenance related to body image obsession d. Imbalanced nutrition: less than body requirements related to anorexia

ANS: B The patient's hypokalemia may lead to life-threatening cardiac dysrhythmias. The other diagnoses are also appropriate for this patient but are not associated with immediate risk for fatal complications.

A patient with possible cerebral edema has a serum sodium level of 115 mEq/L (115 mmol/L) and a decreasing level of consciousness (LOC) and complains of a headache. Which of these prescribed interventions should the nurse implement first? a. Draw blood for arterial blood gases (ABGs). b. Administer 5% hypertonic saline intravenously. c. Administer acetaminophen (Tylenol) 650 mg orally. d. Send patient for computed tomography (CT) of the head.

ANS: B The patient's low sodium indicates that hyponatremia may be causing the cerebral edema, and the nurse's first action should be to correct the low sodium level. Acetaminophen (Tylenol) will have minimal effect on the headache because it is caused by cerebral edema and increased intra-cranial pressure (ICP). Drawing ABGs and obtaining a CT scan may add some useful information, but the low sodium level may lead to seizures unless it is addressed quickly. DIF: Cognitive Level: Application REF: 1452-1455

The nurse is administering IV fluid boluses and nasogastric irrigation to a patient with acute gastrointestinal (GI) bleeding. Which assessment finding is most important for the nurse to communicate to the health care provider? a. The bowel sounds are hyperactive in all four quadrants. b. The patient's lungs have crackles audible to the midchest. c. The nasogastric (NG) suction is returning coffee-ground material. d. The patient's blood pressure (BP) has increased to 142/84 mm Hg.

ANS: B The patient's lung sounds indicate that pulmonary edema may be developing as a result of the rapid infusion of IV fluid and that the fluid infusion rate should be slowed. The return of coffee-ground material in an NG tube is expected for a patient with upper GI bleeding. The BP is slightly elevated but would not be an indication to contact the health care provider immediately. Hyperactive bowel sounds are common when a patient has GI bleeding.

A hospitalized patient complains of a bilateral headache, 4/10 on the pain scale, that radiates from the base of the skull. Which prescribed PRN medications should the nurse administer initially? a. Lorazepam (Ativan) b. Acetaminophen (Tylenol) c. Morphine sulfate (Roxanol) d. Butalbital and aspirin (Fiorinal)

ANS: B The patient's symptoms are consistent with a tension headache, and initial therapy usually involves a nonopioid analgesic such as acetaminophen, which is sometimes combined with a sedative or muscle relaxant. Lorazepam may be used in conjunction with acetaminophen but would not be appropriate as the initial monotherapy. Morphine sulfate and butalbital and aspirin would be more appropriate for a headache that did not respond to a nonopioid analgesic.

A 44-year-old man admitted with a peptic ulcer has a nasogastric (NG) tube in place. When the patient develops sudden, severe upper abdominal pain, diaphoresis, and a firm abdomen, which action should the nurse take? a. Irrigate the NG tube. b. Check the vital signs. c. Give the ordered antacid. d. Elevate the foot of the bed.

ANS: B The patient's symptoms suggest acute perforation, and the nurse should assess for signs of hypovolemic shock. Irrigation of the NG tube, administration of antacids, or both would be contraindicated because any material in the stomach will increase the spillage into the peritoneal cavity. Elevating the foot of the bed may increase abdominal pressure and discomfort, as well as making it more difficult for the patient to breathe.

A 68-year-old patient with a bleeding duodenal ulcer has a nasogastric (NG) tube in place, and the health care provider orders 30 mL of aluminum hydroxide/magnesium hydroxide (Maalox) to be instilled through the tube every hour. To evaluate the effectiveness of this treatment, the nurse a. monitors arterial blood gas values daily. b. periodically aspirates and tests gastric pH. c. checks each stool for the presence of occult blood. d. measures the volume of residual stomach contents.

ANS: B The purpose for antacids is to increase gastric pH. Checking gastric pH is the most direct way of evaluating the effectiveness of the medication. Arterial blood gases may change slightly, but this does not directly reflect the effect of antacids on gastric pH. Because the patient has upper gastrointestinal (GI) bleeding, occult blood in the stools will appear even after the acute bleeding has stopped. The amount of residual stomach contents is not a reflection of resolution of bleeding or of gastric pH.

When caring for a 63-year-old woman with a soft, silicone nasogastric tube in place for enteral feedings, the nurse will a. avoid giving medications through the feeding tube. b. flush the tubing after checking for residual volumes. c. administer continuous feedings using an infusion pump. d. replace the tube every 3 days to avoid mucosal damage.

ANS: B The soft silicone feeding tubes are small in diameter and can easily become clogged unless they are flushed after the nurse checks the residual volume. Either intermittent or continuous feedings can be given. The tubes are less likely to cause mucosal damage than the stiffer polyvinyl chloride tubes used for nasogastric suction and do not need to be replaced at certain intervals. Medications can be given through these tubes, but flushing after medication administration is important to avoid clogging.

Which area of the abdomen shown in the accompanying figure will the nurse palpate to assess for splenomegaly? a. 1 b. 2 c. 3 d. 4

ANS: B The spleen is usually not palpable, but when palpated, it is located in left upper quadrant of abdomen.

The health care provider is considering the use of sumatriptan (Imitrex) for a 54-year-old male patient with migraine headaches. Which information obtained by the nurse is most important to report to the health care provider? a. The patient drinks 1 to 2 cups of coffee daily. b. The patient had a recent acute myocardial infarction. c. The patient has had migraine headaches for 30 years. d. The patient has taken topiramate (Topamax) for 2 months.

ANS: B The triptans cause coronary artery vasoconstriction and should be avoided in patients with coronary artery disease. The other information will be reported to the health care provider, but none of it indicates that sumatriptan would be an inappropriate treatment.

The nurse is assessing an alert and independent 78-year-old woman for malnutrition risk. The most appropriate initial question is which of the following? a. "How do you get to the store to buy your food?" b. "Can you tell me the food that you ate yesterday?" c. "Do you have any difficulty in preparing or eating food?" d. "Are you taking any medications that alter your taste for food?"

ANS: B This question is the most open-ended, and will provide the best overall information about the patient's daily intake and risk for poor nutrition. The other questions may be asked, depending on the patient's response to the first question.

The nurse will assess a 67-year-old patient who is experiencing a cluster headache for a. nuchal rigidity. b. unilateral ptosis. c. projectile vomiting. d. throbbing, bilateral facial pain.

ANS: B Unilateral eye edema, tearing, and ptosis are characteristic of cluster headaches. Nuchal rigidity suggests meningeal irritation, such as occurs with meningitis. Although nausea and vomiting may occur with migraine headaches, projectile vomiting is more consistent with increased intracranial pressure (ICP). Unilateral sharp, stabbing pain, rather than throbbing pain, is characteristic of cluster headaches.

Which information about an 80-year-old man at the senior center is of most concern to the nurse? a. Decreased appetite b. Unintended weight loss c. Difficulty chewing food d. Complaints of indigestion

ANS: B Unintentional weight loss is not a normal finding and may indicate a problem such as cancer or depression. Poor appetite, difficulty in chewing, and complaints of indigestion are common in older patients. These will need to be addressed but are not of as much concern as the weight loss.

When obtaining a health history and physical assessment for a 36-year-old female patient with possible multiple sclerosis (MS), the nurse should a. assess for the presence of chest pain. b. inquire about urinary tract problems. c. inspect the skin for rashes or discoloration. d. ask the patient about any increase in libido.

ANS: B Urinary tract problems with incontinence or retention are common symptoms of MS. Chest pain and skin rashes are not symptoms of MS. A decrease in libido is common with MS.

Which equipment will the nurse obtain to assess vibration sense in a patient who has peripheral nerve dysfunction? a. Sharp pin b. Tuning fork c. Reflex hammer d. Calibrated compass

ANS: B Vibration sense is testing by touching the patient with a vibrating tuning fork. The other equipment is needed for testing of pain sensation, reflexes, and two-point discrimination. DIF: Cognitive Level: Comprehension REF: 1417-1419

The nurse is providing preoperative teaching for a 61-year-old man scheduled for an abdominal-perineal resection. Which information will the nurse include? a. Another surgery in 8 to 12 weeks will be used to create an ileal-anal reservoir. b. The patient will begin sitting in a chair at the bedside on the first postoperative day. c. The patient will drink polyethylene glycol lavage solution (GoLYTELY) preoperatively. d. IV antibiotics will be started at least 24 hours before surgery to reduce the bowel bacteria.

ANS: C A bowel-cleansing agent is used to empty the bowel before surgery to reduce the risk for infection. A permanent colostomy is created with this surgery. Sitting is contraindicated after an abdominal-perineal resection. Oral antibiotics (rather than IV antibiotics) are given to reduce colonic and rectal bacteria.

A 26-year-old woman is being evaluated for vomiting and abdominal pain. Which question from the nurse will be most useful in determining the cause of the patient's symptoms? a. "What type of foods do you eat?" b. "Is it possible that you are pregnant?" c. "Can you tell me more about the pain?" d. "What is your usual elimination pattern?"

ANS: C A complete description of the pain provides clues about the cause of the problem. Although the nurse should ask whether the patient is pregnant to determine whether the patient might have an ectopic pregnancy and before any radiology studies are done, this information is not the most useful in determining the cause of the pain. The usual diet and elimination patterns are less helpful in determining the reason for the patient's symptoms.

Which information will the nurse include when teaching a patient with newly diagnosed chronic fatigue syndrome about self-management? a. Avoid use of over-the-counter antihistamines or decongestants. b. A low-residue, low-fiber diet will reduce any abdominal distention. c. A gradual increase in your daily exercise may help decrease fatigue. d. Chronic fatigue syndrome usually progresses as patients become older.

ANS: C A graduated exercise program is recommended to avoid fatigue while encouraging ongoing activity. Because many patients with chronic fatigue syndrome have allergies, antihistamines and decongestants are used to treat allergy symptoms. A high-fiber diet is recommended. Chronic fatigue syndrome usually does not progress

A 58-year-old patient has just been admitted to the emergency department with nausea and vomiting. Which information requires the most rapid intervention by the nurse? a. The patient has been vomiting for 4 days. b. The patient takes antacids 8 to 10 times a day. c. The patient is lethargic and difficult to arouse. d. The patient has undergone a small intestinal resection.

ANS: C A lethargic patient is at risk for aspiration, and the nurse will need to position the patient to decrease aspiration risk. The other information is also important to collect, but it does not require as quick action as the risk for aspiration.

Which finding in the mouth of a patient who uses smokeless tobacco is suggestive of oral cancer? a. Bleeding during tooth brushing b. Painful blisters at the lip border c. Red, velvety patches on the buccal mucosa d. White, curdlike plaques on the posterior tongue

ANS: C A red, velvety patch suggests erythroplasia, which has a high incidence (greater than 50%) of progression to squamous cell carcinoma. The other lesions are suggestive of acute processes (e.g., gingivitis, oral candidiasis, herpes simplex).

A 54-year-old man has just arrived in the recovery area after an upper endoscopy. Which information collected by the nurse is most important to communicate to the health care provider? a. The patient is very drowsy. b. The patient reports a sore throat. c. The oral temperature is 101.6° F. d. The apical pulse is 104 beats/minute.

ANS: C A temperature elevation may indicate that a perforation has occurred. The other assessment data are normal immediately after the procedure.

Which finding by the nurse during abdominal auscultation indicates a need for a focused abdominal assessment? a. Loud gurgles b. High-pitched gurgles c. Absent bowel sounds d. Frequent clicking sounds

ANS: C Absent bowel sounds are abnormal and require further assessment by the nurse. The other sounds may be heard normally.

After assisting with a needle biopsy of the liver at a patient's bedside, the nurse should a. put pressure on the biopsy site using a sandbag. b. elevate the head of the bed to facilitate breathing. c. place the patient on the right side with the bed flat. d. check the patient's postbiopsy coagulation studies.

ANS: C After a biopsy, the patient lies on the right side with the bed flat to splint the biopsy site. Coagulation studies are checked before the biopsy. A sandbag does not exert adequate pressure to splint the site.

Anakinra (Kineret) is prescribed for a 49-year-old patient who has rheumatoid arthritis (RA). When teaching the patient about this drug, the nurse will include information about a. avoiding concurrently taking aspirin. b. symptoms of gastrointestinal (GI) bleeding. c. self-administration of subcutaneous injections. d. taking the medication with at least 8 oz of fluid.

ANS: C Anakinra is administered by subcutaneous injection. GI bleeding is not a side effect of this medication. Because the medication is injected, instructions to take it with 8 oz of fluid would not be appropriate. The patient is likely to be concurrently taking aspirin or nonsteroidal antiinflammatory drugs (NSAIDs), and these should not be discontinued

A patient admitted with bacterial meningitis and a temperature of 102° F (38.8° C) has orders for all of these collaborative interventions. Which action should the nurse take first? a. Administer ceftizoxime (Cefizox) 1 g IV. b. Use a cooling blanket to lower temperature. c. Swap the nasopharyngeal mucosa for cultures. d. Give acetaminophen (Tylenol) 650 mg PO.

ANS: C Antibiotic therapy should be instituted rapidly in bacterial meningitis, but cultures must be done before antibiotics are started. As soon as the cultures are done, the antibiotic should be started. Hypothermia therapy and acetaminophen administration are appropriate but can be started after the other actions are implemented. DIF: Cognitive Level: Application REF: 1440-1441

A patient with an acute attack of gout in the right great toe has a new prescription for probenecid (Benemid). Which information about the patient's home routine indicates a need for teaching regarding gout management? a. The patient sleeps about 8 to 10 hours every night. b. The patient usually eats beef once or twice a week. c. The patient takes one aspirin a day to prevent angina. d. The patient usually drinks about 3 quarts water daily.

ANS: C Aspirin interferes with the effectiveness of probenecid and should not be taken when the patient is taking probenecid. The patient's sleep pattern will not affect gout management. Drinking 3 quarts of water and eating beef only once or twice a week are appropriate for the patient with gout.

The nurse is planning care for a patient with hypertension and gout who has a red and painful right great toe. Which nursing action will be included in the plan of care? a. Gently palpate the toe to assess swelling. b. Use pillows to keep the right foot elevated. c. Use a footboard to hold bedding away from the toe. d. Teach patient to avoid use of acetaminophen (Tylenol).

ANS: C Because any touch on the area of inflammation may increase pain, bedding should be held away from the toe and touching the toe will be avoided. Elevation of the foot will not reduce the pain, which is caused by urate crystals. Acetaminophen can be used for pain relief.

After abdominal surgery, a patient with protein calorie malnutrition is receiving parenteral nutrition (PN). Which is the best indicator that the patient is receiving adequate nutrition? a. Serum albumin level is 3.5 mg/dL. b. Fluid intake and output are balanced. c. Surgical incision is healing normally. d. Blood glucose is less than 110 mg/dL.

ANS: C Because poor wound healing is a possible complication of malnutrition for this patient, normal healing of the incision is an indicator of the effectiveness of the PN in providing adequate nutrition. Blood glucose is monitored to prevent the complications of hyperglycemia and hypoglycemia, but it does not indicate that the patient's nutrition is adequate. The intake and output will be monitored, but do not indicate that the PN is effective. The albumin level is in the low-normal range but does not reflect adequate caloric intake, which is also important for the patient.

While the nurse is transporting a patient on a stretcher to the radiology department, the patient begins having a tonic-clonic seizure. Which action should the nurse take? a. Insert an oral airway during the seizure to maintain a patent airway. b. Restrain the patient's arms and legs to prevent injury during the seizure. c. Time and observe and record the details of the seizure and postictal state. d. Avoid touching the patient to prevent further nervous system stimulation.

ANS: C Because the diagnosis and treatment of seizures frequently are based on the description of the seizure, recording the length and details of the seizure is important. Insertion of an oral airway and restraining the patient during the seizure are contraindicated. The nurse may need to move the patient to decrease the risk of injury during the seizure.

Which order from the health care provider will the nurse implement first for a patient who has vomited 1200 mL of blood? a. Give an IV H2 receptor antagonist. b. Draw blood for typing and crossmatching. c. Administer 1000 mL of lactated Ringer's solution. d. Insert a nasogastric (NG) tube and connect to suction.

ANS: C Because the patient has vomited a large amount of blood, correction of hypovolemia and prevention of hypovolemic shock are the priorities. The other actions also are important to implement quickly but are not the highest priorities.

A 53-year-old male patient with deep partial-thickness burns from a chemical spill in the workplace experiences severe pain followed by nausea during dressing changes. Which action will be most useful in decreasing the patient's nausea? a. Keep the patient NPO for 2 hours before and after dressing changes. b. Avoid performing dressing changes close to the patient's mealtimes. c. Administer the prescribed morphine sulfate before dressing changes. d. Give the ordered prochlorperazine (Compazine) before dressing changes.

ANS: C Because the patient's nausea is associated with severe pain, it is likely that it is precipitated by stress and pain. The best treatment will be to provide adequate pain medication before dressing changes. The nurse should avoid doing painful procedures close to mealtimes, but nausea/vomiting that occur at other times also should be addressed. Keeping the patient NPO does not address the reason for the nausea and vomiting and will have an adverse effect on the patient's nutrition. Administration of antiemetics is not the best choice for a patient with nausea caused by pain.

A 71-year-old patient had an abdominal-perineal resection for colon cancer. Which nursing action is most important to include in the plan of care for the day after surgery? a. Teach about a low-residue diet. b. Monitor output from the stoma. c. Assess the perineal drainage and incision. d. Encourage acceptance of the colostomy stoma.

ANS: C Because the perineal wound is at high risk for infection, the initial care is focused on assessment and care of this wound. Teaching about diet is best done closer to discharge from the hospital. There will be very little drainage into the colostomy until peristalsis returns. The patient will be encouraged to assist with the colostomy, but this is not the highest priority in the immediate postoperative period.

Which laboratory data is important to communicate to the health care provider for a patient who is taking methotrexate (Rheumatrex) to treat rheumatoid arthritis? a. The blood glucose is 90 mg/dL. b. The rheumatoid factor is positive. c. The white blood cell (WBC) count is 1500/µL. d. The erythrocyte sedimentation rate is elevated.

ANS: C Bone marrow suppression is a possible side effect of methotrexate, and the patient's low WBC count places the patient at high risk for infection. The elevated erythrocyte sedimentation rate and positive rheumatoid factor are expected in rheumatoid arthritis. The blood glucose is normal.

A 62-year-old patient has had a hemorrhoidectomy at an outpatient surgical center. Which instructions will the nurse include in discharge teaching? a. Maintain a low-residue diet until the surgical area is healed. b. Use ice packs on the perianal area to relieve pain and swelling. c. Take prescribed pain medications before a bowel movement is expected. d. Delay having a bowel movement for several days until healing has occurred.

ANS: C Bowel movements may be very painful, and patients may avoid defecation unless pain medication is taken before the bowel movement. A high-residue diet will increase stool bulk and prevent constipation. Delay of bowel movements is likely to lead to constipation. Warm sitz baths rather than ice packs are used to relieve pain and keep the surgical area clean

Which laboratory result will the nurse monitor to determine whether prednisone (Deltasone) has been effective for a 30-year-old patient with an acute exacerbation of rheumatoid arthritis? a. Blood glucose test b. Liver function tests c. C-reactive protein level d. Serum electrolyte levels

ANS: C C-reactive protein is a marker for inflammation, and a decrease would indicate that the corticosteroid therapy was effective. Blood glucose and serum electrolyte levels will also be monitored to check for side effects of prednisone. Liver function is not routinely monitored in patients receiving corticosteroids.

A 38-year old woman receiving chemotherapy for breast cancer develops a Candida albicans oral infection. The nurse will anticipate the need for a. hydrogen peroxide rinses. b. the use of antiviral agents. c. administration of nystatin (Mycostatin) tablets. d. referral to a dentist for professional tooth cleaning.

ANS: C Candida albicans is treated with an antifungal such as nystatin. Oral saltwater rinses may be used but will not cure the infection. Antiviral agents are used for viral infections such as herpes simplex. Referral to a dentist is indicated for gingivitis but not for Candida infection.

The nurse will anticipate the need to teach a 57-year-old patient who has osteoarthritis (OA) about which medication? a. Adalimumab (Humira) b. Prednisone (Deltasone) c. Capsaicin cream (Zostrix) d. Sulfasalazine (Azulfidine)

ANS: C Capsaicin cream blocks the transmission of pain impulses and is helpful for some patients in treating OA. The other medications would be used for patients with RA.

A 49-year-old patient with multiple sclerosis (MS) is to begin treatment with glatiramer acetate (Copaxone). Which information will the nurse include in patient teaching? a. Recommendation to drink at least 4 L of fluid daily b. Need to avoid driving or operating heavy machinery c. How to draw up and administer injections of the medication d. Use of contraceptive methods other than oral contraceptives

ANS: C Copaxone is administered by self-injection. Oral contraceptives are an appropriate choice for birth control. There is no need to avoid driving or drink large fluid volumes when taking glatiramer.

A patient returned from a laparoscopic Nissen fundoplication for hiatal hernia 4 hours ago. Which assessment finding is most important for the nurse to address immediately? a. The patient is experiencing intermittent waves of nausea. b. The patient complains of 7/10 (0 to 10 scale) abdominal pain. c. The patient has absent breath sounds in the left anterior chest. d. The patient has hypoactive bowel sounds in all four quadrants.

ANS: C Decreased breath sounds on one side may indicate a pneumothorax, which requires rapid diagnosis and treatment. The nausea and abdominal pain should also be addressed but they are not as high priority as the patient's respiratory status. The patient's decreased bowel sounds are expected after surgery and require ongoing monitoring but no other action.

When the nurse brings medications to a patient with rheumatoid arthritis, the patient refuses the prescribed methotrexate (Rheumatrex). The patient tells the nurse, "My arthritis isn't that bad yet. The side effects of methotrexate are worse than the arthritis." The most appropriate response by the nurse is a. "You have the right to refuse to take the methotrexate." b. "Methotrexate is less expensive than some of the newer drugs." c. "It is important to start methotrexate early to decrease the extent of joint damage." d. "Methotrexate is effective and has fewer side effects than some of the other drugs."

ANS: C Disease-modifying antirheumatic drugs (DMARDs) are prescribed early to prevent the joint degeneration that occurs as soon as the first year with RA. The other statements are accurate, but the most important point for the patient to understand is that it is important to start DMARDs as quickly as possible.

Which activity in the care of a 48-year-old female patient with a new colostomy could the nurse delegate to unlicensed assistive personnel (UAP)? a. Document the appearance of the stoma. b. Place a pouching system over the ostomy. c. Drain and measure the output from the ostomy. d. Check the skin around the stoma for breakdown.

ANS: C Draining and measuring the output from the ostomy is included in UAP education and scope of practice. The other actions should be implemented by LPNs or RNs.

Which diet choice by the patient with an acute exacerbation of inflammatory bowel disease (IBD) indicates a need for more teaching? a. Scrambled eggs b. White toast and jam c. Oatmeal with cream d. Pancakes with syrup

ANS: C During acute exacerbations of IBD, the patient should avoid high-fiber foods such as whole grains. High-fat foods also may cause diarrhea in some patients. The other choices are low residue and would be appropriate for this patient.

A 76-year-old woman with a body mass index (BMI) of 17 kg/m2 and a low serum albumin level is being admitted by the nurse. Which assessment finding will the nurse expect to find? a. Restlessness b. Hypertension c. Pitting edema d. Food allergies

ANS: C Edema occurs when serum albumin levels and plasma oncotic pressure decrease. The blood pressure and level of consciousness are not directly affected by malnutrition. Food allergies are not an indicator of nutritional status.

After the nurse has completed teaching a patient with newly diagnosed eosinophilic esophagitis about the management of the disease, which patient action indicates that the teaching has been effective? a. Patient orders nonfat milk for each meal. b. Patient uses the prescribed corticosteroid inhaler. c. Patient schedules an appointment for allergy testing. d. Patient takes ibuprofen (Advil) to control throat pain.

ANS: C Eosinophilic esophagitis is frequently associated with environmental allergens, so allergy testing is used to determine possible triggers. Corticosteroid therapy may be prescribed, but the medication will be swallowed, not inhaled. Milk is a frequent trigger for attacks. NSAIDs are not used for eosinophilic esophagitis.

While interviewing a 30-year-old man, the nurse learns that the patient has a family history of familial adenomatous polyposis (FAP). The nurse will plan to assess the patient's knowledge about a. preventing noninfectious hepatitis. b. treating inflammatory bowel disease. c. risk for developing colorectal cancer. d. using antacids and proton pump inhibitors.

ANS: C Familial adenomatous polyposis is a genetic condition that greatly increases the risk for colorectal cancer. Noninfectious hepatitis, use of medications that treat increased gastric pH, and inflammatory bowel disease are not related to FAP.

The nurse is planning care for a patient who is chronically malnourished. Which action is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)? a. Assist the patient to choose high-nutrition items from the menu. b. Monitor the patient for skin breakdown over the bony prominences. c. Offer the patient the prescribed nutritional supplement between meals. d. Assess the patient's strength while ambulating the patient in the room.

ANS: C Feeding the patient and assisting with oral intake are included in UAP education and scope of practice. Assessing the patient and assisting the patient in choosing high-nutrition foods require licensed practical/vocational nurse (LPN/LVN)-or registered nurse (RN)-level education and scope of practice.

A 46-year-old female with gastroesophageal reflux disease (GERD) is experiencing increasing discomfort. Which patient statement indicates that additional teaching about GERD is needed? a. "I take antacids between meals and at bedtime each night." b. "I sleep with the head of the bed elevated on 4-inch blocks." c. "I eat small meals during the day and have a bedtime snack." d. "I quit smoking several years ago, but I still chew a lot of gum."

ANS: C GERD is exacerbated by eating late at night, and the nurse should plan to teach the patient to avoid eating at bedtime. The other patient actions are appropriate to control symptoms of GERD.

Which patient choice for a snack 2 hours before bedtime indicates that the nurse's teaching about gastroesophageal reflux disease (GERD) has been effective? a. Chocolate pudding b. Glass of low-fat milk c. Cherry gelatin with fruit d. Peanut butter and jelly sandwich

ANS: C Gelatin and fruit are low fat and will not decrease lower esophageal sphincter (LES) pressure. Foods such as chocolate are avoided because they lower LES pressure. Milk products increase gastric acid secretion. High-fat foods such as peanut butter decrease both gastric emptying and LES pressure.

A 40-year-old patient is diagnosed with early Huntington's disease (HD). When teaching the patient, spouse, and children about this disorder, the nurse will provide information about the a. use of levodopa-carbidopa (Sinemet) to help reduce HD symptoms. b. prophylactic antibiotics to decrease the risk for aspiration pneumonia. c. option of genetic testing for the patient's children to determine their own HD risks. d. lifestyle changes of improved nutrition and exercise that delay disease progression.

ANS: C Genetic testing is available to determine whether an asymptomatic individual has the HD gene. The patient and family should be informed of the benefits and problems associated with genetic testing. Sinemet will increase symptoms of HD because HD involves an increase in dopamine. Antibiotic therapy will not reduce the risk for aspiration. There are no effective treatments or lifestyle changes that delay the progression of symptoms in HD.

A new clinic patient with joint swelling and pain is being tested for systemic lupus erythematosus. Which test will provide the most specific findings for the nurse to review? a. Rheumatoid factor (RF) b. Antinuclear antibody (ANA) c. Anti-Smith antibody (Anti-Sm) d. Lupus erythematosus (LE) cell prep

ANS: C The anti-Sm is antibody found almost exclusively in SLE. The other blood tests are also used in screening but are not as specific to SLE

Propranolol (Inderal), a β-adrenergic blocker that inhibits sympathetic nervous system activity, is prescribed for a patient. The nurse monitors the patient for a. dry mouth. b. constipation. c. slowed pulse. d. urinary retention.

ANS: C Inhibition of the fight or flight response leads to decreased heart rate. Dry mouth, constipation, and urinary retention are associated with peripheral nervous system blockade. DIF: Cognitive Level: Comprehension REF: 1407

When the nurse applies a painful stimulus to the nail beds of an unconscious patient, the patient responds with internal rotation, adduction, and flexion of the arms. The nurse documents this as a. flexion withdrawal. b. localization of pain. c. decorticate posturing. d. decerebrate posturing.

ANS: C Internal rotation, adduction, and flexion of the arms in an unconscious patient is documented as decorticate posturing. Extension of the arms and legs is decerebrate posturing. Because the flexion is generalized, it does not indicate localization of pain or flexion withdrawal. DIF: Cognitive Level: Comprehension REF: 1429-1430

The nurse determines that teaching about management of migraine headaches has been effective when the patient says which of the following? a. "I can take the (Topamax) as soon as a headache starts." b. "A glass of wine might help me relax and prevent a headache." c. "I will lie down someplace dark and quiet when the headaches begin." d. "I should avoid taking aspirin and sumatriptan (Imitrex) at the same time."

ANS: C It is recommended that the patient with a migraine rest in a dark, quiet area. Topiramate (Topamax) is used to prevent migraines and must be taken for several months to determine effectiveness. Aspirin or other nonsteroidal antiinflammatory medications can be taken with the triptans. Alcohol may precipitate migraine headaches.

While caring for a patient who has just been admitted with meningococcal meningitis, the RN observes all of the following. Which one requires action by the RN? a. The bedrails at the head and foot of the bed are both elevated. b. The patient receives a regular diet from the dietary department. c. The nursing assistant goes into the patient's room without a mask. d. The lights in the patient's room are turned off and the blinds are shut.

ANS: C Meningococcal meningitis is spread by respiratory secretions, so it is important to maintain respiratory isolation as well as standard precautions. Because the patient may be confused and weak, bedrails should be elevated at both the food and head of the bed. Low light levels in the room decrease pain caused by photophobia. Nutrition is an important aspect of care in a patient with meningitis. DIF: Cognitive Level: Application REF: 1453-1455

A patient's capillary blood glucose level is 120 mg/dL 6 hours after the nurse initiated a parenteral nutrition (PN) infusion. The most appropriate action by the nurse is to a. obtain a venous blood glucose specimen. b. slow the infusion rate of the PN infusion. c. recheck the capillary blood glucose in 4 to 6 hours. d. notify the health care provider of the glucose level.

ANS: C Mild hyperglycemia is expected during the first few days after PN is started and requires ongoing monitoring. Because the glucose elevation is small and expected, notification of the health care provider is not necessary. There is no need to obtain a venous specimen for comparison. Slowing the rate of the infusion is beyond the nurse's scope of practice and will decrease the patient's nutritional intake.

A 19-year-old patient hospitalized with a fever and red, hot, and painful knees is suspected of having septic arthritis. Information obtained during the nursing history that indicates a risk factor for septic arthritis is that the patient a. had several knee injuries as a teenager. b. recently returned from South America. c. is sexually active with multiple partners. d. has a parent who has rheumatoid arthritis.

ANS: C Neisseria gonorrhoeae is the most common cause for septic arthritis in sexually active young adults. The other information does not point to any risk for septic arthritis.

A 26-year-old woman has been admitted to the emergency department with nausea and vomiting. Which action could the RN delegate to unlicensed assistive personnel (UAP)? a. Auscultate the bowel sounds. b. Assess for signs of dehydration. c. Assist the patient with oral care. d. Ask the patient about the nausea.

ANS: C Oral care is included in UAP education and scope of practice. The other actions are all assessments that require more education and a higher scope of nursing practice.

A 29-year-old patient reporting painful urination and knee pain is diagnosed with reactive arthritis. The nurse will plan to teach the patient about the need for several months of therapy with a. anakinra (Kineret). b. etanercept (Enbrel). c. doxycycline (Vibramycin). d. methotrexate (Rheumatrex).

ANS: C Reactive arthritis associated with urethritis is usually caused by infection with Chlamydia trachomatis and requires 3 months of treatment with doxycycline. The other medications are used for chronic inflammatory problems such as rheumatoid arthritis.

Four hours after a bowel resection, a 74-year-old male patient with a nasogastric tube to suction complains of nausea and abdominal distention. The first action by the nurse should be to a. auscultate for hypotonic bowel sounds. b. notify the patient's health care provider. c. reposition the tube and check for placement. d. remove the tube and replace it with a new one.

ANS: C Repositioning the tube will frequently facilitate drainage. Because this is a common occurrence, it is not appropriate to notify the health care provider unless other interventions do not resolve the problem. Information about the presence or absence of bowel sounds will not be helpful in improving drainage. Removing the tube and replacing it are unnecessarily traumatic to the patient, so that would only be done if the tube was completely occluded.

A patient with rheumatoid arthritis being seen in the clinic has rheumatoid nodules on the elbows. Which action will the nurse take? a. Draw blood for rheumatoid factor analysis. b. Teach the patient about injections for the nodules. c. Assess the nodules for skin breakdown or infection. d. Discuss the need for surgical removal of the nodules.

ANS: C Rheumatoid nodules can break down or become infected. They are not associated with changes in rheumatoid factor, and injection is not needed. Rheumatoid nodules are usually not removed surgically because of a high probability of recurrence.

The community health nurse is developing a program to decrease the incidence of meningitis in adolescents and young adults. Which nursing action is most important? a. Vaccinate 11- and 12-year-old children against Haemophilus influenzae. b. Emphasize the importance of hand washing to prevent spread of infection. c. Immunize adolescents and college freshman against Neisseria meningitides. d. Encourage adolescents and young adults to avoid crowded areas in the winter.

ANS: C The Neisseria meningitides vaccination is recommended for children ages 11 and 12, unvaccinated teens entering high school, and college freshmen. Hand washing may help decrease the spread of bacteria, but it is not as effective as immunization. Vaccination with Haemophilus influenzae is for infants and toddlers. Because adolescents and young adults are in school or the workplace, avoiding crowds is not realistic. DIF: Cognitive Level: Application REF: 1453-1455

Which information about a patient who is hospitalized after a traumatic brain injury requires the most rapid action by the nurse? a. Intracranial pressure of 15 mm Hg b. Cerebrospinal fluid (CSF) drainage of 15 mL/hour c. Pressure of oxygen in brain tissue (PbtO2) is 14 mm Hg d. Cardiac monitor shows sinus tachycardia, with a heart rate of 126 beats/min

ANS: C The PbtO2 should be 20 to 40 mm Hg. Lower levels indicate brain ischemia. An intracranial pressure (ICP) of 15 mm Hg is at the upper limit of normal. CSF is produced at a rate of 20 to 30 mL/hour. The reason for the sinus tachycardia should be investigated, but the elevated heart rate is not as concerning as the decrease in PbtO2. DIF: Cognitive Level: Application REF: 1430-1432

A 76-year-old patient with obstipation has a fecal impaction and is incontinent of liquid stool. Which action should the nurse take first? a. Administer bulk-forming laxatives. b. Assist the patient to sit on the toilet. c. Manually remove the impacted stool. d. Increase the patient's oral fluid intake.

ANS: C The initial action with a fecal impaction is manual disimpaction. The other actions will be used to prevent future constipation and impactions.

A 19-year-old female is brought to the emergency department with a knife handle protruding from the abdomen. During the initial assessment of the patient, the nurse should a. remove the knife and assess the wound. b. determine the presence of Rovsing sign. c. check for circulation and tissue perfusion. d. insert a urinary catheter and assess for hematuria.

ANS: C The initial assessment is focused on determining whether the patient has hypovolemic shock. The knife should not be removed until the patient is in surgery, where bleeding can be controlled. Rovsing sign is assessed in the patient with suspected appendicitis. A patient with a knife in place will be taken to surgery and assessed for bladder trauma there.

A 22-year-old patient seen at the health clinic with a severe migraine headache tells the nurse about having other similar headaches recently. Which initial action should the nurse take? a. Teach about the use of triptan drugs. b. Refer the patient for stress counseling. c. Ask the patient to keep a headache diary. d. Suggest the use of muscle-relaxation techniques.

ANS: C The initial nursing action should be further assessment of the precipitating causes of the headaches, quality, and location of pain, etc. Stress reduction, muscle relaxation, and the triptan drugs may be helpful, but more assessment is needed first.

A 20-year-old female is being admitted for electrolyte disorders of unknown etiology. Which assessment finding is most important to report to the health care provider? a. The patient uses laxatives daily. b. The patient's knuckles are macerated. c. The patient's serum potassium level is 2.9 mEq/L. d. The patient has a history of large weight fluctuations.

ANS: C The low serum potassium level may cause life-threatening cardiac dysrhythmias, and potassium supplementation is needed rapidly. The other information will also be reported because it suggests that bulimia may be the etiology of the patient's electrolyte disturbances, but it does not suggest imminent life-threatening complications.

At his first postoperative checkup appointment after a gastrojejunostomy (Billroth II), a patient reports that dizziness, weakness, and palpitations occur about 20 minutes after each meal. The nurse will teach the patient to a. increase the amount of fluid with meals. b. eat foods that are higher in carbohydrates. c. lie down for about 30 minutes after eating. d. drink sugared fluids or eat candy after meals.

ANS: C The patient is experiencing symptoms of dumping syndrome, which may be reduced by lying down after eating. Increasing fluid intake and choosing high carbohydrate foods will increase the risk for dumping syndrome. Having a sweet drink or hard candy will correct the hypoglycemia that is associated with dumping syndrome but will not prevent dumping syndrome.

A patient has a systemic BP of 108/51 mm Hg and an intracranial pressure (ICP) of 14 mm Hg. Which action should the nurse take first? a. Elevate the head of the patient's bed to 60 degrees. b. Document the BP and ICP in the patient's record. c. Report the BP and ICP to the health care provider. d. Continue to monitor the patient's vital signs and ICP.

ANS: C The patient's cerebral perfusion pressure is 56 mm Hg, below the normal of 60 to 100 mm Hg and approaching the level of ischemia and neuronal death. Immediate changes in the patient's therapy such as fluid infusion or vasopressor administration are needed to improve the cerebral perfusion pressure. Adjustments in the head elevation should only be done after consulting with the health care provider. Continued monitoring and documentation also will be done, but they are not the first actions that the nurse should take. DIF: Cognitive Level: Analysis REF: 1426

The nurse notices a circular lesion with a red border and clear center on the arm of an 18-year-old summer camp counselor who is in the camp clinic complaining of chills and muscle aches. Which action should the nurse take next? a. Palpate the abdomen. b. Auscultate the heart sounds. c. Ask the patient about recent outdoor activities. d. Question the patient about immunization history.

ANS: C The patient's clinical manifestations suggest possible Lyme disease. A history of recent outdoor activities such as hikes will help confirm the diagnosis. The patient's symptoms do not suggest cardiac or abdominal problems or lack of immunization.

Which patient should the nurse assess first after receiving change-of-shift report? a. A patient with nausea who has a dose of metoclopramide (Reglan) due b. A patient who is crying after receiving a diagnosis of esophageal cancer c. A patient with esophageal varices who has a blood pressure of 92/58 mm Hg d. A patient admitted yesterday with gastrointestinal (GI) bleeding who has melena

ANS: C The patient's history and blood pressure indicate possible hemodynamic instability caused by GI bleeding. The data about the other patients do not indicate acutely life-threatening complications.

A 72-year-old male patient with dehydration caused by an exacerbation of ulcerative colitis is receiving 5% dextrose in normal saline at 125 mL/hour. Which assessment finding by the nurse is most important to report to the health care provider? a. Patient has not voided for the last 4 hours. b. Skin is dry with poor turgor on all extremities. c. Crackles are heard halfway up the posterior chest. d. Patient has had 5 loose stools over the last 6 hours.

ANS: C The presence of crackles in an older patient receiving IV fluids at a high rate suggests volume overload and a need to reduce the rate of the IV infusion. The other data will also be reported, but are consistent with the patient's age and diagnosis and do not require a change in the prescribed treatment.

A 58-year-old woman who recently has been diagnosed with esophageal cancer tells the nurse, "I do not feel ready to die yet." Which response by the nurse is most appropriate? a. "You may have quite a few years still left to live." b. "Thinking about dying will only make you feel worse." c. "Having this new diagnosis must be very hard for you." d. "It is important that you be realistic about your prognosis."

ANS: C This response is open-ended and will encourage the patient to further discuss feelings of anxiety or sadness about the diagnosis. Patients with esophageal cancer have only a low survival rate, so the response "You may have quite a few years still left to live" is misleading. The response beginning, "Thinking about dying" indicates that the nurse is not open to discussing the patient's fears of dying. The response beginning, "It is important that you be realistic," discourages the patient from feeling hopeful, which is important to patients with any life-threatening diagnosis.

A patient's peripheral parenteral nutrition (PN) bag is nearly empty and a new PN bag has not arrived yet from the pharmacy. Which intervention is the priority? a. Monitor the patient's capillary blood glucose until a new PN bag is hung. b. Flush the peripheral line with saline and wait until the new PN bag is available. c. Infuse 5% dextrose in water until the new PN bag is delivered from the pharmacy. d. Decrease the rate of the current PN infusion to 10 mL/hr until the new bag arrives.

ANS: C To prevent hypoglycemia, the nurse should infuse a 5% dextrose solution until the next PN bag can be started. Decreasing the rate of the ordered PN infusion is beyond the nurse's scope of practice. Flushing the line and then waiting for the next bag may lead to hypoglycemia. Monitoring the capillary blood glucose is appropriate but is not the priority.

Which care activity for a patient with a paralytic ileus is appropriate for the registered nurse (RN) to delegate to unlicensed assistive personnel (UAP)? a. Auscultation for bowel sounds b. Nasogastric (NG) tube irrigation c. Applying petroleum jelly to the lips d. Assessment of the nares for irritation

ANS: C UAP education and scope of practice include patient hygiene such as oral care. The other actions require education and scope of practice appropriate to the RN.

A 57-year-old man with Escherichia coli O157:H7 food poisoning is admitted to the hospital with bloody diarrhea and dehydration. Which order will the nurse question? a. Infuse lactated Ringer's solution at 250 mL/hr. b. Monitor blood urea nitrogen and creatinine daily. c. Administer loperamide (Imodium) after each stool. d. Provide a clear liquid diet and progress diet as tolerated.

ANS: C Use of antidiarrheal agents is avoided with this type of food poisoning. The other orders are appropriate.

A 64-year-old woman who has chronic constipation asks the nurse about the use of psyllium (Metamucil). Which information will the nurse include in the response? a. Absorption of fat-soluble vitamins may be reduced by fiber-containing laxatives. b. Dietary sources of fiber should be eliminated to prevent excessive gas formation. c. Use of this type of laxative to prevent constipation does not cause adverse effects. d. Large amounts of fluid should be taken to prevent impaction or bowel obstruction.

ANS: D A high fluid intake is needed when patients are using bulk-forming laxatives to avoid worsening constipation. Although bulk-forming laxatives are generally safe, the nurse should emphasize the possibility of constipation or obstipation if inadequate fluid intake occurs. Although increased gas formation is likely to occur with increased dietary fiber, the patient should gradually increase dietary fiber and eventually may not need the psyllium. Fat-soluble vitamin absorption is blocked by stool softeners and lubricants, not by bulk-forming laxatives.

A 42-year-old male patient has had a herniorrhaphy to repair an incarcerated inguinal hernia. Which patient teaching will the nurse provide before discharge? a. Soak in sitz baths several times each day. b. Cough 5 times each hour for the next 48 hours. c. Avoid use of acetaminophen (Tylenol) for pain. d. Apply a scrotal support and ice to reduce swelling.

ANS: D A scrotal support and ice are used to reduce edema and pain. Coughing will increase pressure on the incision. Sitz baths will not relieve pain and would not be of use after this surgery. Acetaminophen can be used for postoperative pain.

A 73-year-old patient with diverticulosis has a large bowel obstruction. The nurse will monitor for a. referred back pain. b. metabolic alkalosis. c. projectile vomiting. d. abdominal distention.

ANS: D Abdominal distention is seen in lower intestinal obstruction. Referred back pain is not a common clinical manifestation of intestinal obstruction. Metabolic alkalosis is common in high intestinal obstruction because of the loss of HCl acid from vomiting. Projectile vomiting is associated with higher intestinal obstruction.

Which medication taken by a patient with restless legs syndrome should the nurse discuss with the patient? a. Multivitamin (Stresstabs) b. Acetaminophen (Tylenol) c. Ibuprofen (Motrin, Advil) d. Diphenhydramine (Benadryl)

ANS: D Antihistamines can aggravate restless legs syndrome. The other medications will not contribute to restless legs syndrome.

Which breakfast choice indicates a patient's good understanding of information about a diet for celiac disease? a. Oatmeal with nonfat milk b. Whole wheat toast with butter c. Bagel with low-fat cream cheese d. Corn tortilla with scrambled eggs

ANS: D Avoidance of gluten-containing foods is the only treatment for celiac disease. Corn does not contain gluten, while oatmeal and wheat do.

The nurse will anticipate teaching a patient experiencing frequent heartburn about a. a barium swallow. b. radionuclide tests. c. endoscopy procedures. d. proton pump inhibitors.

ANS: D Because diagnostic testing for heartburn that is probably caused by gastroesophageal reflux disease (GERD) is expensive and uncomfortable, proton pump inhibitors are frequently used for a short period as the first step in the diagnosis of GERD. The other tests may be used but are not usually the first step in diagnosis.

Which information about a 60-year-old patient with MS indicates that the nurse should consult with the health care provider before giving the prescribed dose of dalfampridine (Ampyra)? a. The patient has relapsing-remitting MS. b. The patient walks a mile a day for exercise. c. The patient complains of pain with neck flexion. d. The patient has an increased serum creatinine level.

ANS: D Dalfampridine should not be given to patients with impaired renal function. The other information will not impact whether the dalfampridine should be administered.

A 71-year-old patient who takes multiple medications develops acute gouty arthritis. The nurse will consult with the health care provider before giving the prescribed dose of a. sertraline (Zoloft). b. famotidine (Pepcid). c. oxycodone (Roxicodone). d. hydrochlorothiazide (HydroDIURIL).

ANS: D Diuretic use increases uric acid levels and can precipitate gout attacks. The other medications are safe to administer

A 76-year-old patient is being treated with carbidopa/levodopa (Sinemet) for Parkinson's disease. Which information is most important for the nurse to report to the health care provider? a. Shuffling gait b. Tremor at rest c. Cogwheel rigidity of limbs d. Uncontrolled head movement

ANS: D Dyskinesia is an adverse effect of the Sinemet, indicating a need for a change in medication or decrease in dose. The other findings are typical with Parkinson's disease.

When a 72-year-old patient is diagnosed with achalasia, the nurse will teach the patient that a. lying down after meals is recommended. b. a liquid or blenderized diet will be necessary. c. drinking fluids with meals should be avoided. d. treatment may include endoscopic procedures.

ANS: D Endoscopic and laparoscopic procedures are the most effective therapy for improving symptoms caused by achalasia. Keeping the head elevated after eating will improve esophageal emptying. A semisoft diet is recommended to improve esophageal emptying. Patients are advised to drink fluid with meals.

The care plan for a patient who has increased intracranial pressure and a ventriculostomy includes the following nursing actions. Which action can the nurse delegate to nursing assistive personnel (NAP) who regularly work in the intensive care unit? a. Monitor cerebrospinal fluid color hourly. b. Document intracranial pressure every hour. c. Turn and reposition the patient every 2 hours. d. Check capillary blood glucose level every 6 hours.

ANS: D Experienced NAP can obtain capillary blood glucose levels when they have been trained and evaluated in the skill. Monitoring and documentation of cerebrospinal fluid (CSF) color and intracranial pressure (ICP) require RN-level education and scope of practice. Although repositioning patients is frequently delegated to NAP, repositioning a patient with a ventriculostomy is complex and should be done by the RN. DIF: Cognitive Level: Application REF: 1442

During the neurologic assessment, the patient cooperates with the nurse's directions to grip with the hands and to move the feet but is unable to respond orally to the nurse's questions. The nurse will suspect a. a brainstem lesion. b. a temporal lobe lesion. c. injury to the cerebellum. d. damage to the frontal lobe.

ANS: D Expressive speech is controlled by Broca's area in the frontal lobe. The temporal lobe contains Wernicke's area, which is responsible for receptive speech. The cerebellum and brainstem do not affect higher cognitive functions such as speech. DIF: Cognitive Level: Application REF: 1408-1409

A 42-year-old woman is admitted to the outpatient testing area for an ultrasound of the gallbladder. Which information obtained by the nurse indicates that the ultrasound may need to be rescheduled? a. The patient took a laxative the previous evening. b. The patient had a high-fat meal the previous evening. c. The patient has a permanent gastrostomy tube in place. d. The patient ate a low-fat bagel 4 hours ago for breakfast.

ANS: D Food intake can cause the gallbladder to contract and result in a suboptimal study. The patient should be NPO for 8 to 12 hours before the test. A high-fat meal the previous evening, laxative use, or a gastrostomy tube will not affect the results of the study.

Which menu choice indicates that the patient is implementing plans to choose high-calorie, high-protein foods? a. Baked fish with applesauce b. Beef noodle soup and canned corn c. Fresh fruit salad with yogurt topping d. Fried chicken with potatoes and gravy

ANS: D Foods that are high in calories include fried foods and those covered with sauces. High protein foods include meat and dairy products. The other choices are lower in calories and protein.

A 62-year-old patient who has Parkinson's disease is taking bromocriptine (Parlodel). Which information obtained by the nurse may indicate a need for a decrease in the dose? a. The patient has a chronic dry cough. b. The patient has four loose stools in a day. c. The patient develops a deep vein thrombosis. d. The patient's blood pressure is 92/52 mm Hg.

ANS: D Hypotension is an adverse effect of bromocriptine, and the nurse should check with the health care provider before giving the medication. Diarrhea, cough, and deep vein thrombosis are not associated with bromocriptine use.

The nurse receives the following information about a 51-year-old woman who is scheduled for a colonoscopy. Which information should be communicated to the health care provider before sending the patient for the procedure? a. The patient has a permanent pacemaker to prevent bradycardia. b. The patient is worried about discomfort during the examination. c. The patient has had an allergic reaction to shellfish and iodine in the past. d. The patient refused to drink the ordered polyethylene glycol (GoLYTELY).

ANS: D If the patient has had inadequate bowel preparation, the colon cannot be visualized and the procedure should be rescheduled. Because contrast solution is not used during colonoscopy, the iodine allergy is not pertinent. A pacemaker is a contraindication to magnetic resonance imaging (MRI), but not to colonoscopy. The nurse should instruct the patient about the sedation used during the examination to decrease the patient's anxiety about discomfort.

Which parameter is best for the nurse to monitor to determine whether the prescribed IV mannitol (Osmitrol) has been effective for an unconscious patient? a. Hematocrit b. Blood pressure c. Oxygen saturation d. Intracranial pressure

ANS: D Mannitol is an osmotic diuretic and will reduce cerebral edema and intracranial pressure. It may initially reduce hematocrit and increase blood pressure, but these are not the best parameters for evaluation of the effectiveness of the drug. Oxygen saturation will not directly improve as a result of mannitol administration. DIF: Cognitive Level: Application REF: 1432-1433

Which information about a 72-year-old patient who has a new prescription for phenytoin (Dilantin) indicates that the nurse should consult with the health care provider before administration of the medication? a. Patient has generalized tonic-clonic seizures. b. Patient experiences an aura before seizures. c. Patient's most recent blood pressure is 156/92 mm Hg. d. Patient has minor elevations in the liver function tests.

ANS: D Many older patients (especially with compromised liver function) may not be able to metabolize phenytoin. The health care provider may need to choose another antiseizure medication. Phenytoin is an appropriate medication for patients with tonic-clonic seizures, with or without an aura. Hypertension is not a contraindication for phenytoin therapy.

A 62-year-old man patient who requires daily use of a nonsteroidal antiinflammatory drug (NSAID) for the management of severe rheumatoid arthritis has recently developed melena. The nurse will anticipate teaching the patient about a. substitution of acetaminophen (Tylenol) for the NSAID. b. use of enteric-coated NSAIDs to reduce gastric irritation. c. reasons for using corticosteroids to treat the rheumatoid arthritis. d. misoprostol (Cytotec) to protect the gastrointestinal (GI) mucosa.

ANS: D Misoprostol, a prostaglandin analog, reduces acid secretion and the incidence of upper GI bleeding associated with NSAID use. Enteric coating of NSAIDs does not reduce the risk for GI bleeding. Corticosteroids increase the risk for ulcer development, and will not be substituted for NSAIDs for this patient. Acetaminophen will not be effective in treating the patient's rheumatoid arthritis.

After the nurse assesses a 78-year-old who uses naproxen (Aleve) daily for hand and knee osteoarthritis management, which information is most important to report to the health care provider? a. Knee crepitation is noted with normal knee range of motion. b. Patient reports embarrassment about having Heberden's nodes. c. Patient's knee pain while golfing has increased over the last year. d. Laboratory results indicate blood urea nitrogen (BUN) is elevated.

ANS: D Older patients are at increased risk for renal toxicity caused by nonsteroidal antiinflammatory drugs (NSAIDs) such as naproxen. The other information will also be reported to the health care provider but is consistent with the patient's diagnosis of osteoarthritis and will not require an immediate change in the patient's treatment plan

Which question from the nurse would help determine if a patient's abdominal pain might indicate irritable bowel syndrome? a. "Have you been passing a lot of gas?" b. "What foods affect your bowel patterns?" c. "Do you have any abdominal distention?" d. "How long have you had abdominal pain?"

ANS: D One criterion for the diagnosis of irritable bowel syndrome (IBS) is the presence of abdominal discomfort or pain for at least 3 months. Abdominal distention, flatulence, and food intolerance are also associated with IBS, but are not diagnostic criteria.

The nurse teaching a support group of women with rheumatoid arthritis (RA) about how to manage activities of daily living suggests that they a. stand rather than sit when performing household and yard chores. b. strengthen small hand muscles by wringing sponges or washcloths. c. protect the knee joints by sleeping with a small pillow under the knees. d. avoid activities that require repetitive use of the same muscles and joints.

ANS: D Patients are advised to avoid repetitious movements. Sitting during household chores is recommended to decrease stress on joints. Wringing water out of sponges would increase the joint stress. Patients are encouraged to position joints in the extended position, and sleeping with a pillow behind the knees would decrease the ability of the knee to extend and also decrease knee range of motion (ROM).

Which assessment finding in a patient who was admitted the previous day with a basilar skull fracture is most important to report to the health care provider? a. Bruising under both eyes b. Complaint of severe headache c. Large ecchymosis behind one ear d. Temperature of 101.5° F (38.6° C)

ANS: D Patients who have basilar skull fractures are at risk for meningitis, so the elevated temperature should be reported to the health care provider. The other findings are typical of a patient with a basilar skull fracture. DIF: Cognitive Level: Application REF: 1440

After having a craniectomy and left anterior fossae incision, a patient has a nursing diagnosis of impaired physical mobility related to decreased level of consciousness and weakness. An appropriate nursing intervention is to a. position the bed flat and log roll the patient. b. cluster nursing activities to allow longer rest periods. c. turn and reposition the patient side to side every 2 hours. d. perform range-of-motion (ROM) exercises every 4 hours.

ANS: D ROM exercises will help to prevent the complications of immobility. Patients with anterior craniotomies are positioned with the head elevated. The patient with a craniectomy should not be turned to the operative side. When the patient is weak, clustering nursing activities may lead to more fatigue and weakness. DIF: Cognitive Level: Application REF: 1450-1451

A patient is hospitalized with a possible seizure disorder. To determine the cause of the patient's symptoms, the nurse will anticipate the need to teach the patient about which of these tests? a. Cerebral angiography b. Evoked potential studies c. Electromyography (EMG) d. Electroencephalography (EEG)

ANS: D Seizure disorders are usually studied using EEG testing. Evoked potential is used for diagnosing problems with the visual or auditory systems. Cerebral angiography is used to diagnose vascular problems. EMG is used to evaluate electrical innervation to skeletal muscle. DIF: Cognitive Level: Comprehension REF: 1419-1423

When assessing a patient with bacterial meningitis, the nurse obtains the following data. Which finding should be reported immediately to the health care provider? a. The patient has a positive Kernig's sign. b. The patient complains of having a stiff neck. c. The patient's temperature is 101° F (38.3° C). d. The patient's blood pressure is 86/42 mm Hg.

ANS: D Shock is a serious complication of meningitis, and the patient's low blood pressure indicates the need for interventions such as fluids or vasopressors. Nuchal rigidity and a positive Kernig's sign are expected with bacterial meningitis. The nurse should intervene to lower the temperature, but this is not as life threatening as the hypotension. DIF: Cognitive Level: Application REF: 1452-1453

Which nursing diagnosis is of highest priority for a patient with Parkinson's disease who is unable to move the facial muscles? a. Activity intolerance b. Self-care deficit: toileting c. Ineffective self-health management d. Imbalanced nutrition: less than body requirements

ANS: D The data about the patient indicate that poor nutrition will be a concern because of decreased swallowing. The other diagnoses may also be appropriate for a patient with Parkinson's disease, but the data do not indicate that they are current problems for this patient.

After the emergency department nurse has received a status report on the following patients who have been admitted with head injuries, which patient should the nurse assess first? a. A patient whose cranial x-ray shows a linear skull fracture b. A patient who has an initial Glasgow Coma Scale score of 13 c. A patient who lost consciousness for a few seconds after a fall d. A patient whose right pupil is 10 mm and unresponsive to light

ANS: D The dilated and nonresponsive pupil may indicate an intracerebral hemorrhage and increased intracranial pressure. The other patients are not at immediate risk for complications such as herniation. DIF: Cognitive Level: Analysis REF: 1432-1433 | 1437-1438

Which assessment should the nurse perform first for a patient who just vomited bright red blood? a. Measuring the quantity of emesis b. Palpating the abdomen for distention c. Auscultating the chest for breath sounds d. Taking the blood pressure (BP) and pulse

ANS: D The nurse is concerned about blood loss and possible hypovolemic shock in a patient with acute gastrointestinal (GI) bleeding. BP and pulse are the best indicators of these complications. The other information is important to obtain, but BP and pulse rate are the best indicators for assessing intravascular volume.

A 73-year-old patient is diagnosed with stomach cancer after an unintended 20-pound weight loss. Which nursing action will be included in the plan of care? a. Refer the patient for hospice services. b. Infuse IV fluids through a central line. c. Teach the patient about antiemetic therapy. d. Offer supplemental feedings between meals.

ANS: D The patient data indicate a poor nutritional state and improvement in nutrition will be helpful in improving the response to therapies such as surgery, chemotherapy, or radiation. Nausea and vomiting are not common clinical manifestations of stomach cancer. There is no indication that the patient requires hospice or IV fluid infusions.

When caring for a patient with a history of a total gastrectomy, the nurse will monitor for a. constipation. b. dehydration. c. elevated total serum cholesterol. d. cobalamin (vitamin B12) deficiency.

ANS: D The patient with a total gastrectomy does not secrete intrinsic factor, which is needed for cobalamin (vitamin B12) absorption. Because the stomach absorbs only small amounts of water and nutrients, the patient is not at higher risk for dehydration, elevated cholesterol, or constipation.

Which patient should the nurse assess first after receiving change-of-shift report? a. 60-year-old patient whose new ileostomy has drained 800 mL over the previous 8 hours b. 50-year-old patient with familial adenomatous polyposis who has occult blood in the stool c. 40-year-old patient with ulcerative colitis who has had six liquid stools in the previous 4 hours d. 30-year-old patient who has abdominal distention and an apical heart rate of 136 beats/minute

ANS: D The patient's abdominal distention and tachycardia suggest hypovolemic shock caused by problems such as peritonitis or intestinal obstruction, which will require rapid intervention. The other patients should also be assessed as quickly as possible, but the data do not indicate any life-threatening complications associated with their diagnoses.

A 27-year-old female patient is admitted to the hospital for evaluation of right lower quadrant abdominal pain with nausea and vomiting. Which action should the nurse take? a. Encourage the patient to sip clear liquids. b. Assess the abdomen for rebound tenderness. c. Assist the patient to cough and deep breathe. d. Apply an ice pack to the right lower quadrant.

ANS: D The patient's clinical manifestations are consistent with appendicitis, and application of an ice pack will decrease inflammation at the area. Checking for rebound tenderness frequently is unnecessary and uncomfortable for the patient. The patient should be NPO in case immediate surgery is needed. The patient will need to know how to cough and deep breathe postoperatively, but coughing will increase pain at this time.

After several days of antibiotic therapy, an older hospitalized patient develops watery diarrhea. Which action should the nurse take first? a. Notify the health care provider. b. Obtain a stool specimen for analysis. c. Teach the patient about handwashing. d. Place the patient on contact precautions.

ANS: D The patient's history and new onset diarrhea suggest a C. difficile infection, which requires implementation of contact precautions to prevent spread of the infection to other patients. The other actions are also appropriate but can be accomplished after contact precautions are implemented.

A 25-year-old female patient with systemic lupus erythematosus (SLE) who has a facial rash and alopecia tells the nurse, "I never leave my house because I hate the way I look." An appropriate nursing diagnosis for the patient is a. activity intolerance related to fatigue and inactivity. b. impaired social interaction related to lack of social skills. c. impaired skin integrity related to itching and skin sloughing. d. social isolation related to embarrassment about the effects of SLE.

ANS: D The patient's statement about not going anywhere because of hating the way he or she looks supports the diagnosis of social isolation because of embarrassment about the effects of the SLE. Activity intolerance is a possible problem for patients with SLE, but the information about this patient does not support this as a diagnosis. The rash with SLE is nonpruritic. There is no evidence of lack of social skills for this patient.

A 60-year-old man who is hospitalized with an abdominal wound infection has only been eating about 50% of meals and states, "Nothing on the menu sounds good." Which action by the nurse will be most effective in improving the patient's oral intake? a. Order six small meals daily. b. Make a referral to the dietitian. c. Teach the patient about high-calorie foods. d. Have family members bring in favorite foods.

ANS: D The patient's statement that the hospital foods are unappealing indicates that favorite home-cooked foods might improve intake. The other interventions may also help improve the patient's intake, but the most effective action will be to offer the patient more appealing foods.

When performing a focused assessment on a patient with a lesion of the left posterior temporal lobe, the nurse will assess for a. sensation on the left side of the body. b. voluntary movement on the right side. c. reasoning and problem-solving abilities. d. understanding of written and oral language.

ANS: D The posterior temporal lobe integrates the visual and auditory input for language comprehension. Reasoning and problem solving are functions of the anterior frontal lobe. Sensation on the left side of the body is located in the right postcentral gyrus. Voluntary movement on the right side is controlled in the left precentral gyrus. DIF: Cognitive Level: Application REF: 1409

A patient who is suspected of having an epidural hematoma is admitted to the emergency department. Which action will the nurse plan to take? a. Administer IV furosemide (Lasix). b. Initiate high-dose barbiturate therapy. c. Type and crossmatch for blood transfusion. d. Prepare the patient for immediate craniotomy.

ANS: D The principal treatment for epidural hematoma is rapid surgery to remove the hematoma and prevent herniation. If intracranial pressure (ICP) is elevated after surgery, furosemide or high-dose barbiturate therapy may be needed, but these will not be of benefit unless the hematoma is removed. Minimal blood loss occurs with head injuries, and transfusion is usually not necessary. DIF: Cognitive Level: Application REF: 1440-1441

37. A 45-year-old patient is admitted to the emergency department with severe abdominal pain and rebound tenderness. Vital signs include temperature 102° F (38.3° C), pulse 120, respirations 32, and blood pressure (BP) 82/54. Which prescribed intervention should the nurse implement first? a. Administer IV ketorolac (Toradol) 15 mg. b. Draw blood for a complete blood count (CBC). c. Obtain a computed tomography (CT) scan of the abdomen. d. Infuse 1 liter of lactated Ringer's solution over 30 minutes.

ANS: D The priority for this patient is to treat the patient's hypovolemic shock with fluid infusion. The other actions should be implemented after starting the fluid infusion.

A 45-year-old patient is admitted to the emergency department with severe abdominal pain and rebound tenderness. Vital signs include temperature 102° F (38.3° C), pulse 120, respirations 32, and blood pressure (BP) 82/54. Which prescribed intervention should the nurse implement first? a. Administer IV ketorolac (Toradol) 15 mg. b. Draw blood for a complete blood count (CBC). c. Obtain a computed tomography (CT) scan of the abdomen. d. Infuse 1 liter of lactated Ringer's solution over 30 minutes.

ANS: D The priority for this patient is to treat the patient's hypovolemic shock with fluid infusion. The other actions should be implemented after starting the fluid infusion.

After reviewing a patient's cerebrospinal fluid analysis, which result will be most important for the nurse to communicate to the health care provider? a. Specific gravity 1.007 b. Protein 65 mg/dL (0.30 g/L) c. White blood cell (WBC) count 4/μL d. Glucose 45 mg/dL (1.7 mmol/L)

ANS: D The protein level is high. The pH, WBCs, and glucose values are normal. DIF: Cognitive Level: Comprehension REF: 1422

The nurse explaining esomeprazole (Nexium) to a patient with recurring heartburn describes that the medication a. reduces gastroesophageal reflux by increasing the rate of gastric emptying. b. neutralizes stomach acid and provides relief of symptoms in a few minutes. c. coats and protects the lining of the stomach and esophagus from gastric acid. d. treats gastroesophageal reflux disease by decreasing stomach acid production.

ANS: D The proton pump inhibitors decrease the rate of gastric acid secretion. Promotility drugs such as metoclopramide (Reglan) increase the rate of gastric emptying. Cryoprotective medications such as sucralfate (Carafate) protect the stomach. Antacids neutralize stomach acid and work rapidly.

A 47-year-old female patient is transferred from the recovery room to a surgical unit after a transverse colostomy. The nurse observes the stoma to be deep pink with edema and a small amount of sanguineous drainage. The nurse should a. place ice packs around the stoma. b. notify the surgeon about the stoma. c. monitor the stoma every 30 minutes. d. document stoma assessment findings.

ANS: D The stoma appearance indicates good circulation to the stoma. There is no indication that surgical intervention is needed or that frequent stoma monitoring is required. Swelling of the stoma is normal for 2 to 3 weeks after surgery, and an ice pack is not needed.

After change-of-shift report, which patient should the nurse assess first? a. 42-year-old who has acute gastritis and ongoing epigastric pain b. 70-year-old with a hiatal hernia who experiences frequent heartburn c. 53-year-old who has dumping syndrome after a recent partial gastrectomy d. 60-year-old with nausea and vomiting who has dry oral mucosa and lethargy

ANS: D This older patient is at high risk for problems such as aspiration, dehydration, and fluid and electrolyte disturbances. The other patients will also need to be assessed, but the information about them indicates symptoms that are typical for their diagnoses and are not life threatening.

Which prescribed intervention will the nurse implement first for a patient in the emergency department who is experiencing continuous tonic-clonic seizures? a. Give phenytoin (Dilantin) 100 mg IV. b. Monitor level of consciousness (LOC). c. Obtain computed tomography (CT) scan. d. Administer lorazepam (Ativan) 4 mg IV.

ANS: D To prevent ongoing seizures, the nurse should administer rapidly acting antiseizure medications such as the benzodiazepines. A CT scan is appropriate, but prevention of any seizure activity during the CT scan is necessary. Phenytoin will also be administered, but it is not rapidly acting. Patients who are experiencing tonic-clonic seizures are nonresponsive, although the nurse should assess LOC after the seizure.

A 50-year-old man vomiting blood-streaked fluid is admitted to the hospital with acute gastritis. To determine possible risk factors for gastritis, the nurse will ask the patient about a. the amount of saturated fat in the diet. b. any family history of gastric or colon cancer. c. a history of a large recent weight gain or loss. d. use of nonsteroidal antiinflammatory drugs (NSAIDs).

ANS: D Use of an NSAID is associated with damage to the gastric mucosa, which can result in acute gastritis. Family history, recent weight gain or loss, and fatty foods are not risk factors for acute gastritis.

A patient with a brainstem infarction is admitted to the nursing unit. The priority nursing assessment for the patient is a. reflex reaction time. b. pupil reaction to light. c. level of consciousness. d. respiratory rate and rhythm.

ANS: D Vital centers that control respiration are located in the medulla, and these are the priority assessments because changes in respiratory function may be life threatening. The other information also will be collected by the nurse, but it is not as urgent. DIF: Cognitive Level: Application REF: 1410

During a health screening event which assessment finding would alert the nurse to the possible presence of osteoporosis in a white 61-year-old female? A. The presence of bowed legs B. A measurable loss of height C. Poor appetite and aversion to dairy products D. Development of unstable, wide-gait ambulation

B. A measurable loss of height A gradual but measurable loss of height and the development of kyphosis or "dowager's hump" are indicative of the presence of osteoporosis in which the rate of bone resorption is greater than bone deposition. Bowed legs may be caused by abnormal bone development or rickets but is not indicative of osteoporosis. Lack of calcium and Vitamin D intake may cause osteoporosis but are not indicative it is present. A wide gait is used to support balance and does not indicate osteoporosis.

Which is a classic presentation of Guillain-Barré syndrome? A. Acute change in level of consciousness B. Ascending, symmetric paralysis C. Acute onset of paralysis in lower extremities D. Paresthesias in legs starting with feet and radiating to groin area

B. Ascending, symmetric paralysis Guillain-Barré syndrome is an acute, rapidly progressing polyneuritis with ascending, symmetric paralysis. The other options are not related to Guillain-Barré syndrome.

What is the most common early symptom of a spinal cord tumor? A. Urinary incontinence B. Back pain that worsens with activity C. Paralysis below the level of involvement D. Impaired sensation of pain, temperature, and light touch

B. Back pain that worsens with activity The most common early symptom of a spinal cord tumor outside the cord is pain in the back, with radicular pain simulating intercostal neuralgia, angina, or herpes zoster infection. The location of the pain depends on the level of compression. The pain worsens with activity, coughing, straining, and lying down.

What is a common treatment for trigeminal neuralgia? A. Warm, moist compressions B. Carbamazepine (Tegretol) C. Ice packs applied intermittently D. Vitamin D

B. Carbamazepine (Tegretol) Carbamazepine (Tegretol) or oxcarbazepine (Trileptal) is the usual first-line therapy for trigeminal neuralgia. By acting on sodium channels, these drugs lengthen the time needed for neuron repolarization and decrease neuron firing. Some patients take megavitamins as an adjunct therapy. Temperature extremes are often a trigger for painful episodes.

The 24-year-old male patient who was successfully treated for Paget's disease has come to the clinic with a gradual onset of pain and swelling around the left knee. The patient is diagnosed with osteosarcoma without metastasis. The patient wants to know why he will be given chemotherapy before the surgery. What is the best rationale the nurse should tell the patient? A. The chemotherapy is being used to save your left leg. B. Chemotherapy is being used to decrease the tumor size. C. The chemotherapy will increase your 5-year survival rate. D. Chemotherapy will help decrease the pain before and after surgery.

B. Chemotherapy is being used to decrease the tumor size. Preoperative chemotherapy is used to decrease tumor size before surgery. The chemotherapy will not save his leg if the lesion is too big or there is neurovascular or muscle involvement. Adjunct chemotherapy after amputation or limb salvage has increased 5-year survival rate in people without metastasis. Chemotherapy is not used to decrease pain before or after surgery.

During treatment of the patient with an acute attack of gout, the nurse would expect to administer a. aspirin b. colchicine c. allopurinol (Zyloprim) d. probenecid (Benemid)

B. Colchicine

What is the most common cause of botulism? A. Contamination from Escherichia coli from improper hand washing B. Contamination from spores from improper home canning C. Dairy foods kept at room temperature D. Eating undercooked poultry

B. Contamination from spores from improper home canning Botulism is caused by gastrointestinal absorption of the neurotoxin produced by Clostridium botulinum. The organism is found in the soil and can grow in any food contaminated with the spores. Improper home canning of foods is often the cause. The other options are not related to botulism.

A nursing measure that is indicated to reduce the potential for seizures and increased ICP in the patient with bacterial meningitis is a. administering codeine for relief of head and neck pain b. controlling fever with prescribed drugs and cooling techniques c. keeping the room darkened and quiet to minimize environmental stimulation d. maintaining the patient on strict bed rest with the HOB slightly elevated

B. Controlling fever with prescribed drugs and cooling techniques

The nurse recognizes the presence of Cushing's triad in the patient with a. Increased pulse, irregular respiration, increased BP b. decreased pulse, irregular respiration, increased pulse pressure c. increased pulse, decreased respiration, increased pulse pressure d. decreased pulse, increased respiration, decreased systolic BP

B. Cushing's triad consists of three vital sign measures that reflect ICP and its effect on the medulla, the hypothalamus, the pons, and the thalamus. Because these structures are very deep, Cushing's triad is usually a late sign of ICP. The signs include an increasing systolic BP with a widening pulse pressure, a bradycardia with a full and bounding pulse, and irregular respirations.

A 76-year-old patient is being treated with carbidopa/levodopa (Sinemet) for Parkinson's disease. Which information is most important for the nurse to report to the health care provider? a. Shuffling gait b. Tremor at rest c. Cogwheel rigidity of limbs d. Uncontrolled head movement

D. Dyskinesia is an adverse effect of the Sinemet, indicating a need for a change in medication or decrease in dose. The other findings are typical with Parkinson's disease.

What is the main source of tetanus in the U.S. population? A. Tic bites B. Deep, penetrating wounds C. Unprotected sex D. Improperly prepared food

B. Deep, penetrating wounds Tetanus results from a potent neurotoxin released by an anaerobic bacillus, Clostridium tetani. The spores enter the body through a traumatic or suppurative wound. The most common source in the United States is deep, penetrating wounds or intravenous drug use. The other options are not related to tetanus.

The patient is diagnosed with Guillain-Barré syndrome and admitted to the inpatient unit from the emergency department. What is the most important nursing observation? A. Urine output B. Depth of respiration C. Bowel sounds D. Lower extremity strength

B. Depth of respiration The most serious complication is paralysis progressing to the nerves that innervate the thoracic area and causing respiratory failure. You must constantly monitor the respiratory system by checking respiratory rate and depth, forced vital capacity, and negative inspiratory force. The other options may be affected, but respiratory function is most important.

The nurse identifies a nursing diagnosis of pain related to muscle spasms for a 45-year-old patient who has low back pain from a herniated lumbar disc. What would be an appropriate nursing intervention to treat this problem? A. Provide gentle ROM to the lower extremities. B. Elevate the head of the bed 20 degrees and flex the knees. C. Place the bed in reverse Trendelenburg with the feet firmly against the footboard. D. Place a small pillow under the patient's upper back to gently flex the lumbar spine.

B. Elevate the head of the bed 20 degrees and flex the knees. The nurse should elevate the head of the bed 20 degrees and flex the knees to avoid extension of the spine and increasing the pain. The slight flexion provided by this position often is comfortable for a patient with a herniated lumbar disc. ROM to the lower extremities will be limited to prevent extremes of spinal movement. Reverse Trendelenburg and a pillow under the patient's upper back will more likely increase pain.

What are the goals of rehabilitation for the patient with an injury at the C6 level (select all that apply)? A. Stand erect with leg brace B. Feed self with hand devices C. Drive an electric wheelchair D. Assist with transfer activities E. Drive adapted van from wheel chair

B. Feed self with hand devices C. Drive an electric wheelchair D. Assist with transfer activities E. Drive adapted van from wheel chair Rehabilitation goals for a patient with a spinal cord injury at the C6 level include ability to assist with transfer and perform some self-care; feed self with hand devices; push wheelchair on smooth, flat surface; drive adapted van from wheelchair; independent computer use with adaptive equipment; and needing attendant care only for 6 hours per day.

Assisting the family to understand what is happening to the patient is an especially important role of the nurse when the patient has a tumor of the a. ventricles b. frontal lobe c. parietal lobe d. occipital lobe

B. Frontal lobe- frontal lobe tumors often lead to loss of emotional control, confusion, memory loss, disorientation, and personality changes that are very disturbing and frightening to the family. Physical symptoms, such as blindness, disturbances in sensation and perception, and even seizures, that occur with other tumors are more likely to be understood and accepted by the family

Classic symptoms of bacterial meningitis include a. papilledema and psychomotor seizures b. high fever, nuchal rigidity, and severe headache c. behavioral changes with memory loss and lethargy d. positive Kernig's and Brudzinski's signs and hemiparesis

B. High fever, severe headache, nuchal rigidity, and positive Brudzinski's and Kernig's signs are such classic symptoms of meningitis that they are usually considered diagnostic for meningitis. Other symptoms, such as papilledema, generalized seizures, hemiparesis, and decreased LOC, may occur as complications of increased ICP and cranial nerve dysfunction.

After teaching a patient with RA about the prescribed therapeutic regimen, the nurse determines that further instruction is needed when the patient says, a. it is important for me to perform my prescribed exercises every day b. I should perform most of my daily chores in the morning when my energy level is highest c. an ice pack to a joint for 10 minutes may help relieve pain and inflammation when I have an acute flare d. I can use assistive devices such as padded utensils, electric can openers, and elevated toilet seats to protect my joints

B. I should perform most of my daily chores in the morning when my energy level is highest

The home health registered nurse (RN) is planning care for a patient with a seizure disorder related to a recent head injury. Which nursing action can be delegated to a licensed practical/vocational nurse (LPN/LVN)? a. Make referrals to appropriate community agencies. b. Place medications in the home medication organizer. c. Teach the patient and family how to manage seizures. d. Assess for use of medications that may precipitate seizures.

B. LPN/LVN education includes administration of medications. The other activities require RN education and scope of practice.

The nurse is caring for a patient admitted to the nursing unit with osteomyelitis of the tibia. Which symptom will the nurse most likely find on physical examination of the patient? A. Nausea and vomiting B. Localized pain and warmth C. Paresthesia in the affected extremity D. Generalized bone pain throughout the leg

B. Localized pain and warmth Osteomyelitis is an infection of bone and bone marrow that can occur with trauma, surgery, or spread from another part of the body. Because it is an infection, the patient will exhibit typical signs of inflammation and infection, including localized pain and warmth. Nausea and vomiting and paresthesia of the extremity are not expected to occur. Pain occurs, but it is localized, not generalized throughout the leg.

Which intervention will the nurse include in the plan of care for a patient with primary restless legs syndrome (RLS) who is having difficulty sleeping? a. Teach about the use of antihistamines to improve sleep. b. Suggest that the patient exercise regularly during the day. c. Make a referral to a massage therapist for deep massage of the legs. d. Assure the patient that the problem is transient and likely to resolve.

B. Nondrug interventions such as getting regular exercise are initially suggested to improve sleep quality in patients with RLS. Antihistamines may aggravate RLS. Massage does not alleviate RLS symptoms and RLS is likely to progress in most patients.

When a 74-year-old patient is seen in the health clinic with new development of a stooped posture, shuffling gait, and pill rolling-type tremor, the nurse will anticipate teaching the patient about a. oral corticosteroids. b. antiparkinsonian drugs. c. magnetic resonance imaging (MRI). d. electroencephalogram (EEG) testing.

B. The diagnosis of Parkinson's is made when two of the three characteristic manifestations of tremor, rigidity, and bradykinesia are present. The confirmation of the diagnosis is made on the basis of improvement when antiparkinsonian drugs are administered. This patient has symptoms of tremor and bradykinesia. The next anticipated step will be treatment with medications. MRI and EEG are not useful in diagnosing Parkinson's disease, and corticosteroid therapy is not used to treat it.

A 73-year-old patient with Parkinson's disease has a nursing diagnosis of impaired physical mobility related to bradykinesia. Which action will the nurse include in the plan of care? a. Instruct the patient in activities that can be done while lying or sitting. b. Suggest that the patient rock from side to side to initiate leg movement. c. Have the patient take small steps in a straight line directly in front of the feet. d. Teach the patient to keep the feet in contact with the floor and slide them forward.

B. Rocking the body from side to side stimulates balance and improves mobility. The patient will be encouraged to continue exercising because this will maintain functional abilities. Maintaining a wide base of support will help with balance. The patient should lift the feet and avoid a shuffling gait.

You are caring for a patient admitted with a spinal cord injury after a motor vehicle accident. The patient exhibits a complete loss of motor, sensory, and reflex activity below the injury level. What is this condition? A. Central cord syndrome B. Spinal shock syndrome C. Anterior cord syndrome D. Brown-Séquard syndrome

B. Spinal shock syndrome About 50% of people with acute spinal cord injury experience a temporary loss of reflexes, sensation, and motor activity that is known as spinal shock. Central cord syndrome is manifested by motor and sensory loss greater in the upper extremities than the lower extremities. Anterior cord syndrome results in motor and sensory loss but not loss of reflexes. Brown-Séquard syndrome is characterized by ipsilateral loss of motor function and contralateral loss of sensory function.

You suspect Bell's palsy in which patient? A. Unilateral facial droop with contralateral extremity weakness B. Sudden onset one-sided facial weakness with ear pain and vesicles C. Sharp, knife-like facial pain when eating hot or cold foods D. Inability to shrug the shoulders against resistance

B. Sudden onset one-sided facial weakness with ear pain and vesicles Bell's palsy is an acute, peripheral facial paresis of unknown cause without systemic effects. Facial droop is found in stroke. Sharp facial pain occurs with trigeminal neuralgia. An inability to shrug the shoulders describes pathology of cranial nerve XI.

A patient with a head injury has bloody drainage from the ear. To determine whether CSF is present in the drainage, the nurse a. examines the tympanic membrane for a tear b. tests the fluid for a halo sign on a white dressing c. tests the fluid with a glucose identifying strip or stick d. collects 5 mL of fluid in a test tube and sends it to the laboratory for analysis

B. Tests the fluid for a halo sing on a white dressing- Testing clear drainage for CSF in nasal or ear drainage may be done with a Dextrostik or Tes-Tape strip, but if blood is present, the glucose in the blood will produce and unreliable result. To test bloody drainage, the nurse should test the fluid for a halo or ring that occurs when a yellowish ring encircles blood dripped onto a white pad or towel

Which action will the nurse plan to take for a 40-year-old patient with multiple sclerosis (MS) who has urinary retention caused by a flaccid bladder? a. Decrease the patient's evening fluid intake. b. Teach the patient how to use the Credé method. c. Suggest the use of adult incontinence briefs for nighttime only. d. Assist the patient to the commode every 2 hours during the day.

B. The Credé method can be used to improve bladder emptying. Decreasing fluid intake will not improve bladder emptying and may increase risk for urinary tract infection (UTI) and dehydration. The use of incontinence briefs and frequent toileting will not improve bladder emptying.

Characteristics of spondyloarthritides associated with HLA-B27 antigen include a. symmetric polyarticular arthritis b. an absence of extraarticular disease c. presence of rheumatoid factor and autoantibodies d. high level of involvement of sacroiliac joints and the spine

D. high level of involvement is sacroiliac joints and the spine

One month after a spinal cord injury, which finding is most important for you to monitor? A. Bladder scan indicates 100 mL. B. The left calf is 5 cm larger than the right calf. C. The heel has a reddened, nonblanchable area. D. Reflux bowel emptying.

B. The left calf is 5 cm larger than the right calf. Deep vein thrombosis is a common problem accompanying spinal cord injury during the first 3 months. Pulmonary embolism is one of the leading causes of death. Common signs and symptoms are absent. Assessment includes Doppler examination and measurement of leg girth. The other options are not as urgent to deal with as potential deep vein thrombosis.

A high school teacher who has just been diagnosed with epilepsy after having a generalized tonic-clonic seizure tells the nurse, "I cannot teach anymore, it will be too upsetting if I have a seizure at work." Which response by the nurse is best? a. "You might benefit from some psychologic counseling." b. "Epilepsy usually can be well controlled with medications." c. "You will want to contact the Epilepsy Foundation for assistance." d. "The Department of Vocational Rehabilitation can help with work retraining."

B. The nurse should inform the patient that most patients with seizure disorders are controlled with medication. The other information may be necessary if the seizures persist after treatment with antiseizure medications is implemented.

Following a thymectomy, a 62-year-old male patient with myasthenia gravis receives the usual dose of pyridostigmine (Mestinon). An hour later, the patient complains of nausea and severe abdominal cramps. Which action should the nurse take first? a. Auscultate the patient's bowel sounds. b. Notify the patient's health care provider. c. Administer the prescribed PRN antiemetic drug. d. Give the scheduled dose of prednisone (Deltasone).

B. The patient's history and symptoms indicate a possible cholinergic crisis. The health care provider should be notified immediately, and it is likely that atropine will be prescribed. The other actions will be appropriate if the patient is not experiencing a cholinergic crisis.

A hospitalized patient complains of a bilateral headache, 4/10 on the pain scale, that radiates from the base of the skull. Which prescribed PRN medications should the nurse administer initially? a. Lorazepam (Ativan) b. Acetaminophen (Tylenol) c. Morphine sulfate (Roxanol) d. Butalbital and aspirin (Fiorinal)

B. The patient's symptoms are consistent with a tension headache, and initial therapy usually involves a nonopioid analgesic such as acetaminophen, which is sometimes combined with a sedative or muscle relaxant. Lorazepam may be used in conjunction with acetaminophen but would not be appropriate as the initial monotherapy. Morphine sulfate and butalbital and aspirin would be more appropriate for a headache that did not respond to a nonopioid analgesic.

The health care provider is considering the use of sumatriptan (Imitrex) for a 54-year-old male patient with migraine headaches. Which information obtained by the nurse is most important to report to the health care provider? a. The patient drinks 1 to 2 cups of coffee daily. b. The patient had a recent acute myocardial infarction. c. The patient has had migraine headaches for 30 years. d. The patient has taken topiramate (Topamax) for 2 months.

B. The triptans cause coronary artery vasoconstriction and should be avoided in patients with coronary artery disease. The other information will be reported to the health care provider, but none of it indicates that sumatriptan would be an inappropriate treatment.

When obtaining a health history and physical assessment for a 36-year-old female patient with possible multiple sclerosis (MS), the nurse should a. assess for the presence of chest pain. b. inquire about urinary tract problems. c. inspect the skin for rashes or discoloration. d. ask the patient about any increase in libido.

B. Urinary tract problems with incontinence or retention are common symptoms of MS. Chest pain and skin rashes are not symptoms of MS. A decrease in libido is common with MS.

The nurse is planning health promotion teaching for a 45-year-old patient with asthma, low back pain from herniated lumbar disc, and schizophrenia. What does the nurse determine would be the best exercise to include in an individualized exercise plan for the patient? A. Yoga B. Walking C. Calisthenics D. Weight lifting

B. Walking The patient would benefit from an aerobic exercise that takes into account the patient's health status and fits the patient's lifestyle. The best exercise is walking, which builds strength in the back and leg muscles without putting undue pressure or strain on the spine. Yoga, calisthenics, and weight lifting would all put pressure on or strain the spine.

A patient recovering from an acute exacerbation of RA tells the nurse she is too tired to bathe. The nurse should a. give the patient a bed bath to conserve her energy b. allow the patient a rest period before showering with the nurses' help c. tell the patient that she can skip bathing if she will walk in the hall later d. inform the patient that it is important for her to maintain self-care activities

B. allow the patient a rest period before showering with the nurses' help

The nurse plans care for a patient with increased ICP with the knowledge that the best way to position the patient is to a. keep the head of the bed flat b. elevate the head of the bed to 30 degrees c. maintain patient on the left side with the head supported on a pillow d. use a continuous rotation bed to continuously change patient position

B. elevate the head of the bed to 30 degrees

A patient with newly diagnosed SLE asks the nurse how the disease will affect her life. The best response by the nurse is a. You can plan to have a near-normal life since SLE rarely causes death b. it is difficult to tell because to disease is so variable in its severity and progression c. life span is shortened somewhat in people with SLE, but the disease can be controlled with long-term use of corticosteroids d. most people with SLE have alternating periods of remissions and exacerbations with rapid progression to permanent organ damage

B. it is difficult to tell because the disease is so variable in its severity and progression

To preserve function and the ability to perform activities of daily living, the nurse teaches the patient with OA to a. avoid exercise that involves the affected joints b. plan and organize less stressful ways to perform tasks c. maintain normal activities during an acute episode to prevent loss of function d. use mild analgesics to control symptoms when performing tasks that cause pain

B. plan and organize less stressful ways to perform tasks

The nurse is admitting a patient who complains of a new onset of lower back pain. To differentiate between the pain of a lumbar herniated disc and lower back pain from other causes, what would be the best question for the nurse to ask the patient? A. "Is the pain worse in the morning or in the evening?" B. "Is the pain sharp or stabbing or burning or aching?" C. "Does the pain radiate down the buttock or into the leg?" D. "Is the pain totally relieved by analgesics, such as acetaminophen (Tylenol)?"

C. "Does the pain radiate down the buttock or into the leg?" Lower back pain associated with a herniated lumbar disc is accompanied by radiation along the sciatic nerve and can be commonly described as traveling through the buttock, to the posterior thigh, or down the leg. This is because the herniated disc causes compression on spinal nerves as they exit the spinal column. Time of occurrence, type of pain, and pain relief questions do not elicit differentiating data.

The nurse has reviewed proper body mechanics with a patient with a history of low back pain caused by a herniated lumbar disc. Which statement made by the patient indicates a need for further teaching? A. "I should sleep on my side or back with my hips and knees bent." B. "I should exercise at least 15 minutes every morning and evening." C. "I should pick up items by leaning forward without bending my knees." D. "I should try to keep one foot on a stool whenever I have to stand for a period of time."

C. "I should pick up items by leaning forward without bending my knees." The patient should avoid leaning forward without bending the knees. Bending the knees helps to prevent lower back strain and is part of proper body mechanics when lifting. Sleeping on the side or back with hips and knees bent and standing with a foot on a stool will decrease lower back strain. Back strengthening exercises are done twice a day once symptoms subside.

The nurse receives report from the licensed practical nurse about care provided to patients on the orthopedic surgical unit. It is most important for the nurse to follow up on which statement? A. "The patient who had a spinal fusion 12 hours ago has hypoactive bowel sounds and is not passing flatus." B. "The patient who had cervical spine surgery 2 days ago wants to wear her soft cervical collar when out of bed." C. "The patient who had spinal surgery 3 hours ago is complaining of a headache and has clear drainage on the dressing." D. "The patient who had a laminectomy 24 hours ago is using patient-controlled analgesia with morphine for pain management."

C. "The patient who had spinal surgery 3 hours ago is complaining of a headache and has clear drainage on the dressing." After spinal surgery there is potential for cerebrospinal fluid (CSF) leakage. Severe headache or leakage of CSF (clear or slightly yellow) on the dressing should be reported immediately. The drainage is CSF if a dipstick test is positive for glucose. Patients after spinal surgery may experience paralytic ileus and interference with bowel function for several days. Postoperatively most patients require opioids such as morphine IV for 24 to 48 hours. Patient-controlled analgesia is the preferred method for pain management during this time. After cervical spine surgery patients often wear a soft or hard cervical collar to immobilize the neck.

The nurse is caring for patients in a primary care clinic. Which individual is most at risk to develop osteomyelitis caused by Staphylococcus aureus? A. 22-year-old female with gonorrhea who is an IV drug user B. 48-year-old male with muscular dystrophy and acute bronchitis C. 32-year-old male with type 1 diabetes mellitus and a stage IV pressure ulcer D. 68-year-old female with hypertension who had a knee arthroplasty 3 years ago

C. 32-year-old male with type 1 diabetes mellitus and a stage IV pressure ulcer Osteomyelitis caused by Staphylococcus aureus is usually associated with a pressure ulcer or vascular insufficiency related to diabetes mellitus. Osteomyelitis caused by Staphylococcus epidermidis is usually associated with indwelling prosthetic devices such as joint replacements. Osteomyelitis caused by Neisseria gonorrhoeae is usually associated with gonorrhea. Osteomyelitis caused by Pseudomonas is usually associated with IV drug use. Muscular dystrophy is not associated with osteomyelitis.

The nurse determines that dietary teaching for a 75-year-old patient with osteoporosis has been successful when the patient selects which highest-calcium meal? A. Chicken stir-fry with 1 cup each onions and green peas, and 1 cup of steamed rice B. Ham and Swiss cheese sandwich on whole wheat bread, steamed broccoli, and an apple C. A sardine (3 oz) sandwich on whole wheat bread, 1 cup of fruit yogurt, and 1 cup of skim milk D. A two-egg omelet with 2 oz of American cheese, one slice of whole wheat toast, and a half grapefruit

C. A sardine (3 oz) sandwich on whole wheat bread, 1 cup of fruit yogurt, and 1 cup of skim milk The highest calcium content is present in the lunch containing milk and milk products (yogurt) and small fish with bones (sardines). Chicken, onions, green peas, rice, ham, whole wheat bread, broccoli, apple, eggs, and grapefruit each have less than 75 mg of calcium per 100 g of food. Swiss cheese and American cheese have more calcium, but not as much as the sardines, yogurt, and milk.

Which assessment is most important for the nurse to make regarding a patient with myasthenia gravis? a. Pupil size b. Grip strength c. Respiratory effort d. Level of consciousness

C. Because respiratory insufficiency may be life threatening, it will be most important to monitor respiratory function. The other data also will be assessed but are not as critical.

While the nurse is transporting a patient on a stretcher to the radiology department, the patient begins having a tonic-clonic seizure. Which action should the nurse take? a. Insert an oral airway during the seizure to maintain a patent airway. b. Restrain the patient's arms and legs to prevent injury during the seizure. c. Time and observe and record the details of the seizure and postictal state. d. Avoid touching the patient to prevent further nervous system stimulation.

C. Because the diagnosis and treatment of seizures frequently are based on the description of the seizure, recording the length and details of the seizure is important. Insertion of an oral airway and restraining the patient during the seizure are contraindicated. The nurse may need to move the patient to decrease the risk of injury during the seizure.

Increased ICP in the left cerebral cortex, caused by intracranial bleeding causes displacement of brain tissue to the right hemisphere beneath the falx cerebri. The nurse knows that this is referred to as a. uncal herniation b. tentorial herniation c. cingulate herniation d. temporal lobe herniation

C. Cingulate herniation- the dural structures that separate the two hemispheres and the cerebral hemispheres from the cerebellum influence the patterns of cerebral herniation. A cingulated herniation occurs where there is lateral displacement of brain tissue beneath the falx cerebri.

A 50-year-old patient sustained a large, open wound. The patient indicates his last tetanus booster was 3 years earlier. What action do you anticipate? A. Administer tetanus and diphtheria toxoid (Td) booster. B. Administer tetanus immune globulin (TIg). C. Clean the wound with soap and water. D. Clean the wound with hydrogen peroxide.

C. Clean the wound with soap and water. Immediate, thorough cleansing of all wounds with soap and water is important in the prevention of tetanus. After the adult is immunized, a booster is given every 10 years. If an open wound occurs, a booster is given if the last one was 5 or more years earlier. Immune globulin is used if immunization was never provided. Hydrogen peroxide is not ordinarily used for wound cleansing.

What is essential teaching in treating a patient with Bell's palsy? A. Perform eye exercises to maintain strength. B. Obtain a herpes simplex virus (HSV) immunization. C. Do not abruptly stop the corticosteroids. D. Vigorously massage the area to promote circulation.

C. Do not abruptly stop the corticosteroids. Corticosteroids are usually started immediately. After they are no longer necessary, they should be tapered. Other treatment includes moist heat, gentle massage, and antiviral medications, such as acyclovir (Zovirax). Eye exercises are not indicated. HSV is identified in 70% of infections, but immunization is not beneficial at this point. Antiviral drugs may be used. Vigorous massage can break down tissues, but gentle upward massage has psychologic benefits.

A 40-year-old patient is diagnosed with early Huntington's disease (HD). When teaching the patient, spouse, and children about this disorder, the nurse will provide information about the a. use of levodopa-carbidopa (Sinemet) to help reduce HD symptoms. b. prophylactic antibiotics to decrease the risk for aspiration pneumonia. c. option of genetic testing for the patient's children to determine their own HD risks. d. lifestyle changes of improved nutrition and exercise that delay disease progression.

C. Genetic testing is available to determine whether an asymptomatic individual has the HD gene. The patient and family should be informed of the benefits and problems associated with genetic testing. Sinemet will increase symptoms of HD because HD involves an increase in dopamine. Antibiotic therapy will not reduce the risk for aspiration. There are no effective treatments or lifestyle changes that delay the progression of symptoms in HD.

The nurse determines that teaching about management of migraine headaches has been effective when the patient says which of the following? a. "I can take the (Topamax) as soon as a headache starts." b. "A glass of wine might help me relax and prevent a headache." c. "I will lie down someplace dark and quiet when the headaches begin." d. "I should avoid taking aspirin and sumatriptan (Imitrex) at the same time."

C. It is recommended that the patient with a migraine rest in a dark, quiet area. Topiramate (Topamax) is used to prevent migraines and must be taken for several months to determine effectiveness. Aspirin or other nonsteroidal antiinflammatory medications can be taken with the triptans. Alcohol may precipitate migraine headaches.

Which is the correct teaching regarding neurosyphilis (tertiary syphilis)? A. Symptoms appear 7 to 14 days after the initial infection. B. Untreated neurosyphilis is highly contagious. C. It results from an untreated syphilis infection. D. The main symptom is unilateral paralysis.

C. It results from an untreated syphilis infection. Neurosyphilis is an infection of any part of the nervous system by the organism Treponema pallidum, and it results from untreated or inadequately treated syphilis. It invades the central nervous system within a few months, and except for some minor changes, the organism lies dormant for years. It is not contagious but can be fatal. The later signs result from degenerative changes in the spinal cord and brainstem, including ataxia, loss of proprioception and deep tendon reflexes, and zones of hyperesthesia.

The earliest signs of increased ICP the nurse should assess for include a. Cushing's triad b. unexpected vomiting c. decreasing level of consciousness (LOC) d. dilated pupil with sluggish response to light

C. One of the most sensitive signs of increased intracranial pressure (ICP) is a decreasing LOC. A decrease in LOC will occur before changes in vital signs, ocular signs, and projectile vomiting occur

What is characteristic of trigeminal neuralgia (tic douloureux)? A. Unilateral facial drooping B. Inability to hear whispered speech C. One-sided facial stabbing pain D. Attacks of severe dizziness

C. One-sided facial stabbing pain Trigeminal neuralgia is usually unilateral, severe, brief, stabbing, recurrent episodes of pain in the distribution of the trigeminal nerve. Unilateral facial drooping is found in Bell's palsy or facial nerve pathology (cranial nerve [CN] VII). Inability to hear indicates pathology of the acoustic nerve (CN VIII). Attacks of severe dizziness do not occur in trigeminal neuralgia.

An unconscious patient with increased ICP in on ventilatory support. The nurse notifies the health care provider when arterial blood gas measurement results reveal a a. pH of 7.43 b. SaO2 of 94% c. PaO2 of 50 mm Hg d. PaCO2 of 30 mm Hg

C. PaO2 of 50 mm Hg- A PaO2 of 50 mm Hg reflects a hypoxemia that may lead to further decreased cerebral perfusion and hypoxia and must be corrected. The pH of SaO2 are within normal range, and a PaCO2 of 30 mm Hg reflects acceptable value for the patient with increased ICP

While the nurse performs ROM on an unconscious patient with increased ICP, the patient experiences severe decerebrate posturing reflexes. The nurse should a. use restraints to protect the patient from injury b. administer CNS depressants to lightly sedate the patient c. perform the exercises less frequently because posturing can increase ICP d. continue the exercises because they are necessary to maintain musculoskeletal function

C. Perform the exercises less frequently because posturing can increase ICP- If reflex posturing occurs during ROM or positioning of the patient, these activities should be done less frequently until the patient's condition stabilizes, because posturing can case increases in ICP. Neither restraints nor CNS depressants would be indicated.

What is most important action for a patient who has a suspected cervical spinal injury? A. Apply a soft foam cervical collar. B. Perform a neurologic check. C. Place the patient on a firm surface. D. Assess function of cranial nerves IX and X.

C. Place the patient on a firm surface. A patient with a suspected cervical spine injury should be immobilized with a hard collar and placed on a firm surface. This takes priority over any further assessment. A soft foam collar does not provide immobilization.

A 22-year-old patient seen at the health clinic with a severe migraine headache tells the nurse about having other similar headaches recently. Which initial action should the nurse take? a. Teach about the use of triptan drugs. b. Refer the patient for stress counseling. c. Ask the patient to keep a headache diary. d. Suggest the use of muscle-relaxation techniques.

C. The initial nursing action should be further assessment of the precipitating causes of the headaches, quality, and location of pain, etc. Stress reduction, muscle relaxation, and the triptan drugs may be helpful, but more assessment is needed first.

A 54-year old man is recovering from a skull fracture with a subacute subdural hematoma. He has return of motor control and orientation but appears apathetic and has reduced awareness of his environment. When planning discharge or the patient, the nurse explains to the patient and the family that a. continuous improvement in the patient's condition should occur until he has returned to pre trauma status b. the patient's complete recovery may take years, and the family should plan for his long term dependent care c. the patient is likely to have long term emotional and mental changes that may require continued professional help d. role changes in family members will be necessary because the patient will be dependent on his family for care and support

C. Residual mental and emotional changes of brain trauma with personality changes are often the most incapacitating problems following head injury and are common in patients who have been comatose longer than 6 hours. Families must be prepared for changes in the patient's behavior to avoid family-patient friction and maintain family functioning, and professional assistance may be required. There is no indication he will be dependent on others for care, but he likely will not return to pre trauma status

You are providing care for a patient who has been diagnosed with Guillain-Barré syndrome. Which assessment should you prioritize? A. Pain assessment B. Glasgow Coma Scale C. Respiratory assessment D. Musculoskeletal assessment

C. Respiratory assessment Although all of the assessments are necessary in the care of patients with Guillain-Barré syndrome, the acute risk of respiratory failure necessitates vigilant monitoring of the patient's respiratory status.

The nurse prepares to administer IV ibandronate (Boniva) to a 67-year-old woman with osteoporosis. What is a priority laboratory assessment to make before the administration of ibandronate? A. Serum calcium B. Serum creatinine C. Serum phosphate D. Serum alkaline phosphatase

C. Serum phosphate Ibandronate is a bisphosphonate that is administered IV every 3 months and is administered slowly over 15 to 30 seconds to prevent renal damage. Ibandronate should not be used by patients taking other nephrotoxic drugs or by those with severe renal impairment (defined as serum creatinine above 2.3 mg/dL or creatinine clearance less than 30 mL/min).

What is the primary goal of nursing care for the patient with Guillain-Barré syndrome? A. Assist the patient to adapt to their lifelong paralysis. B. Teach the patient to use a communication board. C. Support body systems until the patient recovers. D. Place the patient in contact isolation to prevent spread of the condition.

C. Support body systems until the patient recovers. The objective of therapy is to support body systems until the patient recovers. Respiratory failure and infection are serious threats. Most patients recover eventually. Depending on the progression of the disease, the patient may be incapable of communicating.

A patient with a C7 spinal cord injury undergoing rehabilitation tells you he must have the flu because he has a bad headache and nausea. What is your initial action? A. Call the physician. B. Check the patient's temperature. C. Take the patient's blood pressure. D. Elevate the head of the bed to 90 degrees.

C. Take the patient's blood pressure. Autonomic dysreflexia is a massive, uncompensated cardiovascular reaction mediated by the sympathetic nervous system. Manifestations include hypertension (up to 300 mm Hg systolic), throbbing headache, marked diaphoresis above the level of the lesion, bradycardia (30 to 40 beats/minute), piloerection, flushing of the skin above the level of the lesion, blurred vision or spots in the visual fields, nasal congestion, anxiety, and nausea. It is important to measure blood pressure when a patient with a spinal cord injury complains of a headache.

CN III originating in the midbrain is assessed by the nurse for an early indication of pressure on the brainstem by a. assessing for nystagmus b. testing the corneal reflex c. testing pupillary reaction to light d. testing for oculocephalic (doll's eye) reflex

C. Testing pupillary reaction to light- One of the functions of CN III, the oculomotor nerve, is pupillary constriction, and testing for pupillary constriction is important to identify patients at risk for brainstem herniation caused by increased ICP. The corneal reflex is used to assess the functions of CN V and VII, and the oculocephalic reflex tests all cranial nerves involved with eye movement. Nystagmus is commonly associatted with specific lesions or chemical toxicities and is not a definitive sign of ICP

On physical examination of a patient with headache and fever, the nurse would suspect a brain abscess when the patient has a. seizures b. nuchal rigidity c. focal symptoms d. signs of increased ICP

C. The symptoms of brain abscess closely resemble those of meningitis and encephalitis, including fever, headache, and increased ICP, except the patient also usually has some focal symptoms that reflect the local are of the abscess.

During an acute exacerbation, a patient with SLE is treated with corticosteroids. The nurse would expect the steroids to begin to be tapered when serum laboratory results indicate a. increased RBCs b. decreased ESR c. decreased anti-DNA d. increased complement

C. decreased anti-DNA

The nurse is alerted to possible acute subdural hematoma in the patient who a. has a linear skull fracture crossing a major artery b. has focal symptoms of brain damage with no recollection of a head injury c. develops decreased LOC and a headache within 48 hours of head injury d. has an immediate loss of consciousness with a brief lucid interval followed by decreasing LOC

C. develops decreased LOC and a headache within 48 hours of head injury

A 70-year old patient is being evaluated for symptoms of RA. The nurse recognizes that a major problem in the management of RA in the older adult is that a. RA is usually more severe in older adults b. older patients are not as likely to comply with treatment regimens c. drug interactions and toxicity are more likely to occur with multidrug therapy d. laboratory and other diagnostic tests are not effective in identifying RA in older adults

C. drug interactions and toxicity are more likely to occur with multidrug therapy

The nurse on the clinical unit is assigned to four patients. Which patient should she assess first? a. patient with a skull fracture whose nose is bleeding b. elderly patient with a stroke who is confused and whose daughter is present c. patient with meningitis who is suddenly agitated and reporting a HA of 10 on a 0 to 10 scale d. patient who had a craniotomy for a brain tumor who is now 3 days postoperative and has had continued emesis

C. patient with meningitis who is suddenly agitated and reporting a HA of 10 on a 0 to 10 scale

A patient with OA uses NSAIDs to decrease pain and inflammation. The nurse teaches the patient that common side effects of these drugs include a. allergic reactions, fever, and oral lesions b. fluid retention, hypertension, and bruising c. skin rashes, gastric irritation, and headache d. prolonged bleeding time, blood dyscrasias, and hepatic damage

C. skin rashes, gastric irritation, and headacche

Which intervention should the nurse delegate to the LPN when caring for a patient following an acute stroke? a. assess the patient's neurologic status b. assess the patient's gag reflex before beginning feeding c. administer ordered antihypertensives and platelet inhibitors d. teach the patient's caregivers strategies to minimize unilateral neglect

C: Administer ordered antihypertensives and platelet inhibitors- medication administration is within the scope of practice for an LPN. Assessment and teaching are within the scope of practice for the RN.

A thrombus that develops in a cerebral artery does not always cause a loss of neurologic function because a. the body can dissolve the atherosclerotic plaques as they form b. some tissues of the brain do not require constant blood supply to prevent damage c. circulation through the circle of Willis may provide blood supply to the affected area of the brain d. neurologic deficits occur only when major arteries are occluded by thrombus formation around an atherosclerotic plaque

C: Circulation through the circle of Willis may provide blood supply to the affected area of the brain. The communication between cerebral arteries in the circle of Willing provides a collateral circulation, which may maintain circulation to an area of the brain if its original blood supply is obstructed. ALl areas of the brain require constant blood supply, and atherosclerotic plaques are not readily reversed. Neurologic deficits can result from ischemia cause by many factors.

The incidence of ischemic stroke in patients with TIAs and other risk factors is reduced with administration of a. furosemide (Lasix) b. lovastatin (Mevacor) c. daily low dose aspirin d. nimodipine (Nimotop)

C: Daily low dose aspirin- the administration of antiplatelet agents, such as aspirin, dipyridamole (Persantine), and ticlopdipine (Ticlid), reduces the incidence of stroke in those at risk. Anticoagulants are also used for prevention of embolic strokes but increase the risk for hemorrhage. Diuretics are not indicated for stroke prevention other than for their role in controlling BP, and antilipemic agents have bot been found to have a significant effect on stroke prevention. The calcium channel blocker nimodipine is used in patients with subarachnoid hemorrhage to decrease the effects of vasospasm and minimize tissue damage. P.S. I freaking love you and good luck on the final!!

A patient with a stroke has a right sided hemiplegia. The nurse prepares family members to help control behavior changes seen with this type of stroke by teaching them to a. ignore undesirable behaviors manifested by the patient b. provide directions to the patient verbally in small steps c. distract the patient from inappropriate emotional responses d. supervise all activities before allowing the patient to pursue them independently

C: Distract the patient from inappropriate emotional responses- patients with left-sided brain damage from stroke often experience emotional lability, inappropriate emotional responses, mood swings, and uncontrolled tears or laughter disproportionate or out of context with the situation. The behavior is upsetting and embarrassing to both the patient and the family, and the patient should be distracted to minimize its presence. Patients with right-brain damage often have impulsive, rapid behavior that supervision and direction.

In promoting health maintenance for prevention of strokes, the nurse understands that the highest risk for the most common type of stroke is present in a. African Americans b. women who smoke c.individuals with hypertension and diabetes d. those who are obese with high dietary fat intake

C: Individuals with hypertension and diabetes- The highest risk factors for thrombotic stroke are hypertension and diabetes. African Americans have a higher risk for stroke than do white persons but probably because they have a greater incidence of hypertension. Factors such as obesity, diet high in saturated fats and cholesterol, cigarette smoking, and excessive alcohol use are also risk factors but carry less risk than hypertension.

A carotid endarterectomy is being considered as a treatment for a patient who has had several TIAs. The nurse explains to the patient that this surgery a. is used to restore blood to the brain following an obstruction of a cerebral artery b. involves intracranial surgery to join a superficial extracranial artery to an intracranial artery c. involves removing an atherosclerotic plaque in the carotid artery to prevent an impending stroke d. is sued to open a stenosis in a carotid artery with a balloon and stent to restore cerebral circulation

C: Involves removing an atherosclerotic plaque in the carotid artery to prevent an impending stroke- An endarterectomy is a removal of an atherosclerotic plaque, and plaque in the carotid artery may impair circulation enough to cause a stroke. A carotid endarterectomy is performed to prevent a cerebrovascular accident (CVA), as are most other surgical procedures. An extacranial-intracranial bypass involves cranial surgery to bypass a sclerotic intacranial artery. Percutaneous transluminal angioplasty uses a balloon to compress stenotic areas in the carotid and vertebrobasilar arteries and often includes inserting a stent to hold the artery open.

A patient with right hemisphere stroke has a nursing diagnosis of unilateral neglect related to sensory perceptual deficits. During the patient's rehabilitation, it is important for the nurse to a. avoid positioning the patient on the affected side b. place all objects for care on the patient's unaffected side c. teach the patient to care consciously for the affected side d. protect the affected side from injury with pillows and supports

C: Teach the patient to care consciously for the affected side- unilateral neglect, or neglect syndrome, occurs when the patient with a stroke is unaware of the affected side of the body, which puts the patient at risk for injury. During the acute phase, the affected side is cared for by the nurse with positioning and support, during rehabilitation the patient is taught to care consciously for and attend to the affected side of the body to protect it from injury. Patients may be positioned on the affected side for up to 30 minutes.

The neurologic functions that are affected by a stroke are primarily related to a. the amount of tissue area involved b. the rapidity of onset of symptoms c. the brain area perfused by the affected artery d. the presence or absence of collateral circulation

C: The brain area perfused by the affected artery- clinical manifestation of altered neurologic function differ, depending primarily on the specific cerebral artery involved and the area of the brain that is perfused by the artery. The degree of impairment depends on rapidity of onset, the size of the lesion, and the presence of collateral circulation.

An appropriate food for a patient with a stroke who has mild dysphagia is a. fruit juices b. pureed meat c. scrambled eggs d. fortified milkshakes

C: scrambled eggs- soft foods that provide enough texture, flavor, and bulk to stimulate swallowing should be used for the patient with dysphasia. Thin liquids are difficult to swallow, and patients may not be able to control them in the mouth. Pureed foods are often too bland and to smooth, and milk products should be avoided because they tend to increase the viscosity of mucus and increase salivation.

11. A patient in the emergency department is diagnosed with a patellar dislocation. The initial patient teaching by the nurse will focus on the need for a. conscious sedation. b. a knee immobilizer. c. gentle knee flexion. d. cast application.

Correct Answer: A Rationale: The first goal of collaborative management is realignment of the knee to its original anatomic position, which will require anesthesia or conscious sedation. Immobilization of the joint will be done after realignment. Later, gentle ROM exercises may be started if the joint is stable. Casting is not usually required for dislocations. Cognitive Level: Application Text Reference: p. 1632 Nursing Process: Implementation NCLEX: Physiological Integrity

A patient with polyarthralgia with joint swelling and pain is being evaluated for systemic lupus erythematosus (SLE). The nurse knows that the serum test result that is the most specific for SLE is the presence of a. rheumatoid factor. b. anti-Smith antibody (Anti-Sm). c. antinuclear antibody (ANA). d. lupus erythematosus (LE) cell prep.

Correct Answer: B Rationale: The anti-Sm is antibody found almost exclusively in SLE. The other blood tests are also used in screening but are not as specific to SLE.

An important nursing intervention for the patient with ankylosing spondylitis is to teach the patient to a. wear roomy shoes with good orthotic support b. sleep on the side with the knees and hips flexed c. keep the spine slightly flexed while sitting, standing, or walking d. perform back, neck, and chest stretches and deep breathing exercises

D. perform back, neck and chest stretches and deep breathing exercises

A 20-year-old baseball pitcher has an arthroscopic repair of a rotator cuff injury performed in same-day surgery. When the nurse plans postoperative teaching for the patient, which information will be included? a. "You have an appointment with a physical therapist for tomorrow." b. "Leave the shoulder immobilizer on for the first few days to minimize pain." c. "The doctor will use the drop-arm test to determine the success of the procedure." d. "You should try to find a different position to play on the baseball team."

Correct Answer: A Rationale: Physical therapy after a rotator cuff repair begins on the first postoperative day to prevent "frozen shoulder." A shoulder immobilizer is used immediately after the surgery, but leaving the arm immobilized for several days would lead to loss of ROM. The drop-arm test is used to test for rotator cuff injury, but not after surgery. The patient may be able to return to pitching after rehabilitation.

9. A patient with a fractured radius asks when the cast can be removed. The nurse will instruct the patient that the cast can be removed only after the bone a. is strong enough to stand mild stress. b. union is complete on the x-ray. c. fragments are fully fused. d. healing has started.

Correct Answer: A Rationale: The cast may be removed when callus ossification has occurred. It is not necessary to wait until radiologic union or complete bone fusion occurs. Bone healing starts immediately after the injury, but the cast will need to be worn at least 3 weeks.

On the first postoperative day, a patient with a below-the-knee amputation complains of pain in the amputated limb. An appropriate action by the nurse is to a. administer prescribed opioids to relieve the pain. b. explain the reasons for phantom limb pain. c. loosen the compression bandage to decrease incisional pressure. d. remind the patient that this phantom pain will diminish over time.

Correct Answer: A Rationale: Phantom limb pain is treated like any other type of postoperative pain would be treated. Explanations of the reason for the pain may be given, but the nurse should still medicate the patient. The compression bandage is left in place except during physical therapy or bathing. Although the pain may decrease over time, it still requires treatment now. Cognitive Level: Comprehension Text Reference: pp. 1660-1661 Nursing Process: Implementation NCLEX: Physiological Integrity

A patient with a fractured right hip has an open reduction and internal fixation of the fracture with compression screw and plate. Postoperatively the nurse plans to a. get the patient up in the chair the first postoperative day. b. position the patient only on the back and unoperative side. c. keep leg abductor splints on the patient except when bathing. d. ambulate the patient with partial weight bearing by discharge.

Correct Answer: A Rationale: Because the fracture site is internally fixed with pins or plates, the fracture site is stable, and the patient is moved from the bed to the chair on the first postoperative day, with ambulation beginning on the first or second postoperative day, without weight bearing on the affected leg. Weight bearing on the affected extremity is usually restricted for 6 to 12 weeks until adequate healing is evident on x-ray. The patient may be positioned on the operative side following internal fixation, and abductor pillows are used for patients who have femoral head prosthesis or total hip replacements.

On the first postoperative day, a patient with a below-the-knee amputation complains of pain in the amputated limb. An appropriate action by the nurse is to a. administer prescribed opioids to relieve the pain. b. explain the reasons for phantom limb pain. c. loosen the compression bandage to decrease incisional pressure. d. remind the patient that this phantom pain will diminish over time.

Correct Answer: A Rationale: Phantom limb pain is treated like any other type of postoperative pain would be treated. Explanations of the reason for the pain may be given, but the nurse should still medicate the patient. The compression bandage is left in place except during physical therapy or bathing. Although the pain may decrease over time, it still requires treatment now.

A patient with severe ulnar drift caused by rheumatoid arthritis (RA) is scheduled for an arthroplasty of the right hand and fingers. The nurse determines that the patient has realistic expectations of the outcome of surgery when the patient says, a. "I will be able to use my fingers to grasp objects better." b. "My fingers will appear normal in size and shape after this surgery." c. "This procedure will prevent further deformity in my hands and fingers." d. "I will not have to do as many hand exercises after the surgery."

Correct Answer: A Rationale: The goal of hand surgery in RA is to restore function, not to correct for cosmetic deformity or treat the underlying process. Cognitive Level: Application Text Reference: p. 1664 Nursing Process: Evaluation NCLEX: Physiological Integrity

A patient who has severe peripheral arterial disease and ischemic foot ulcers is upset with the health care provider's recommendation to have an above-the-knee amputation. The patient tells the nurse, "If they want to cut off my leg, they should just shoot me instead." The most appropriate response to the patient's statement is, a. "Let's talk about how you feel this surgery will affect you." b. "If you do not want the surgery, you do not have to have it." c. "I understand why you are upset, but there really is no choice because your leg is so badly diseased." d. "Many people are able to function normally with a prosthesis after amputation, and you can too."

Correct Answer: A Rationale: The initial nursing action should be to assess how the patient feels about the amputation and what the patient knows about the procedure and rehabilitation process. Discussion about the patient's option to not have the procedure, the reason the procedure is needed, or rehabilitation after the procedure may be appropriate after the nurse knows more about the patient's current level of knowledge and emotional state.

A patient who has severe peripheral arterial disease and ischemic foot ulcers is upset with the health care provider's recommendation to have an above-the-knee amputation. The patient tells the nurse, "If they want to cut off my leg, they should just shoot me instead." The most appropriate response to the patient's statement is, a. "Let's talk about how you feel this surgery will affect you." b. "If you do not want the surgery, you do not have to have it." c. "I understand why you are upset, but there really is no choice because your leg is so badly diseased." d. "Many people are able to function normally with a prosthesis after amputation, and you can too."

Correct Answer: A Rationale: The initial nursing action should be to assess how the patient feels about the amputation and what the patient knows about the procedure and rehabilitation process. Discussion about the patient's option to not have the procedure, the reason the procedure is needed, or rehabilitation after the procedure may be appropriate after the nurse knows more about the patient's current level of knowledge and emotional state. Cognitive Level: Application Text Reference: p. 1659 Nursing Process: Implementation NCLEX: Psychosocial Integrity

All these medications are ordered at 9:00 AM for a patient who has had a right-hip replacement the previous day and is scheduled to ambulate with the physical therapist for the first time at 9:45. Which medication should be given first? a. Oxycodone (Roxicodone) 5 mg PO b. Ceftriaxone (Rocephin) 500 mg IV c. Enoxaparin (Lovenox) 30 mg SC d. Psyllium (Metamucil) 1 tsp PO

Correct Answer: A Rationale: The pain medication should be given so that it has time to take effect before the patient is ambulated. The other medications will not affect whether the patient can ambulate or not, although the antibiotic and anticoagulant medications should be given as soon as possible in order to maintain therapeutic blood levels. Cognitive Level: Application Text Reference: p. 1647 Nursing Process: Implementation NCLEX: Physiological Integrity

When positioning the patient with a total hip arthroplasty, it is important that the nurse maintain the affected extremity in a. adduction and flexion. b. extension and abduction. c. abduction and internal rotation. d. adduction and external rotation.

Correct Answer: B Rationale: Following a total hip arthroplasty, extremes of internal rotation, adduction, and 90-degree flexion of the hip must be avoided for 4 to 6 weeks postoperatively to prevent dislocation of the prosthesis. During hospitalization an abduction pillow is placed between the legs to maintain abduction, and the leg is extended.

10. A patient with a comminuted fracture of the right femur has Buck's traction in place while waiting for surgery. To assess for pressure areas on the patient's back and sacral area and to provide skin care, the nurse should a. have the patient lift the buttocks by bending and pushing with the left leg. b. turn the patient partially to each side with the assistance of another nurse. c. place a pillow between the patient's legs and turn gently to each side. d. loosen the traction and have the patient turn onto the unaffected side.

Correct Answer: A Rationale: The patient can lift the buttocks off the bed by using the left leg without changing the right-leg alignment. Turning the patient will tend to move the leg out of alignment. Disconnecting the traction will interrupt the weight needed to immobilize and align the fracture.

31. When preparing a patient to ambulate the day after an ORIF for a hip fracture, which action is most important for the nurse to take? a. Administering the ordered oral opioid pain medication b. Instructing the patient about the benefits of ambulation c. Ensuring that the incisional drain has been discontinued d. Changing the hip dressing and document the appearance of the site

Correct Answer: A Rationale: The patient should be adequately medicated for pain before any attempt to ambulate. Instructions about the benefits of ambulation may increase the patient's willingness to ambulate, but decreasing pain with ambulation is more important. The presence of an incisional drain or timing of dressing change will not impact on ambulation. Cognitive Level: Application Text Reference: pp. 1654, 1647 Nursing Process: Implementation NCLEX: Physiological Integrity

A patient with comminuted fractures of the tibia and fibula is treated with open reduction and application of an external fixator. The next day, the patient complains of severe pain in the leg, which is unrelieved by ordered analgesics. The patient's toes are pink, but the patient complains of numbness and tingling. The most appropriate action by the nurse is to a. notify the patient's health care provider. b. check the patient's blood pressure. c. assess the external fixator pins for redness or drainage. d. elevate the extremity and apply ice over the wound site.

Correct Answer: A Rationale: The patient's clinical manifestations point to compartment syndrome and delay in diagnosis, and treatment may lead to severe functional impairment. There is no reason to suspect that patient's symptoms are caused by hypotension or hypertension or by infection at the pin sites. Elevation of or ice application to the leg will decrease arterial flow and further reduce perfusion. Cognitive Level: Application Text Reference: pp. 1650-1651 Nursing Process: Implementation NCLEX: Physiological Integrity

A 22-year-old patient started an exercise regimen 2 months ago that includes running 3 to 4 miles a day. The patient tells the nurse, "I enjoy my daily runs, but now I have shin splints." Which response by the nurse is appropriate? a. "You may be increasing your running time too quickly and need to cut back a little bit." b. "You need to have x-rays of your lower legs to be sure you do not have stress fractures." c. "You should expect some leg pain while running." d. "You should try speed-walking rather than running."

Correct Answer: A Rationale: The patient's information about running 3 to 4 miles daily after starting an exercise program only 2 months previously suggests that the shin splints are caused by overuse. Radiographs are not indicated for the type of injury described by the patient. Shin splints are not a normal or expected response to running. Because the patient expresses enjoyment of running, it would not be appropriate for the nurse to suggest a different sport.

A patient arrives in the emergency department with ankle swelling and severe pain after twisting the ankle playing soccer. All of the following orders are written by the health care provider. Which one will the nurse act on first? a. Administer naproxen (Naprosyn) 500 mg PO. b. Wrap the ankle and apply an ice pack. c. Give acetaminophen with codeine (Tylenol #3). d. Take the patient to the radiology department for x-rays.

Correct Answer: B Rationale: Immediate care after a sprain or strain injury includes the application of cold and compression to the injury to minimize swelling. The other actions should be taken after the ankle is wrapped with a compression bandage and ice is applied.

7. A 22-year-old patient started an exercise regimen 2 months ago that includes running 3 to 4 miles a day. The patient tells the nurse, "I enjoy my daily runs, but now I have shin splints." Which response by the nurse is appropriate? a. "You may be increasing your running time too quickly and need to cut back a little bit." b. "You need to have x-rays of your lower legs to be sure you do not have stress fractures." c. "You should expect some leg pain while running." d. "You should try speed-walking rather than running."

Correct Answer: A Rationale: The patient's information about running 3 to 4 miles daily after starting an exercise program only 2 months previously suggests that the shin splints are caused by overuse. Radiographs are not indicated for the type of injury described by the patient. Shin splints are not a normal or expected response to running. Because the patient expresses enjoyment of running, it would not be appropriate for the nurse to suggest a different sport. Cognitive Level: Application Text Reference: p. 1630 Nursing Process: Implementation NCLEX: Physiological Integrity

A patient is seen at the urgent care center after falling on the right arm and shoulder. It will be most important for the nurse to determine a. whether there is bruising at the shoulder area. b. whether the right arm is shorter than the left. c. the amount of pain the patient is experiencing. d. how much range of motion (ROM) is present.

Correct Answer: B Rationale: A shorter limb after a fall indicates a possible dislocation, which is an orthopedic emergency. The nurse will expect bruising and pain at the area, even without an injury that requires surgery. The shoulder should be immobilized until it is evaluated by the health care provider.

A patient is seen at the urgent care center after falling on the right arm and shoulder. It will be most important for the nurse to determine a. whether there is bruising at the shoulder area. b. whether the right arm is shorter than the left. c. the amount of pain the patient is experiencing. d. how much range of motion (ROM) is present.

Correct Answer: B Rationale: A shorter limb after a fall indicates a possible dislocation, which is an orthopedic emergency. The nurse will expect bruising and pain at the area, even without an injury that requires surgery. The shoulder should be immobilized until it is evaluated by the health care provider.

13. Following the application of a hip spica cast for a patient with a fracture of the proximal third of the left femur, an appropriate nursing intervention is to a. use the cast support bar to reposition the patient every 2 to 3 hours. b. ask the patient about any abdominal discomfort or nausea. c. discuss the reasons for remaining on bed rest for several weeks. d. promote drying of the cast by placing the patient in a prone position every 4 hours.

Correct Answer: B Rationale: Assessment of bowel tones, abdominal pain, and nausea and vomiting will detect the development of cast syndrome. To avoid breakage, the support bar should not be used for repositioning. After the cast dries, the patient can begin ambulating with the assistance of physical therapy personnel. The patient should not be placed in the prone position until the cast has dried to avoid breaking the cast. Cognitive Level: Application Text Reference: p. 1640 Nursing Process: Implementation NCLEX: Physiological Integrity

Following a knee arthroplasty, a patient has a *continuous passive-motion machine* for the affected joint. The nurse explains to the patient that this device is used to a. relieve edema and pain at the incision site. b. promote early joint mobility and increase knee flexion. c. prevent venous stasis and the formation of a deep venous thrombosis. d. improve arterial circulation to the affected extremity to promote healing.

Correct Answer: B Rationale: Continuous passive motion machines are frequently used following knee surgery to promote earlier joint mobility. Because joint dislocation is not a problem with knee replacements, early exercise with straight leg raises and gentle ROM is also encouraged postoperatively.

A patient arrives in the emergency department with ankle swelling and severe pain after twisting the ankle playing soccer. All of the following orders are written by the health care provider. Which one will the nurse act on first? a. Administer naproxen (Naprosyn) 500 mg PO. b. Wrap the ankle and apply an ice pack. c. Give acetaminophen with codeine (Tylenol #3). d. Take the patient to the radiology department for x-rays.

Correct Answer: B Rationale: Immediate care after a sprain or strain injury includes the application of cold and compression to the injury to minimize swelling. The other actions should be taken after the ankle is wrapped with a compression bandage and ice is applied. Cognitive Level: Application Text Reference: p. 1631 Nursing Process: Implementation NCLEX: Physiological Integrity

When giving home-care instructions to a patient who has multiple forearm fractures and a long-arm cast on the right arm, which information should the nurse include? a. Keep the hand immobile to prevent soft tissue swelling. b. Call the health care provider for increased swelling or numbness. c. Keep the right shoulder elevated on a pillow or cushion. d. Avoid the use of NSAIDs for the first 48 hours after the injury.

Correct Answer: B Rationale: Increased swelling or numbness may indicate increased pressure at the injury, and the health care provider should be notified immediately to avoid damage to nerves and other tissues. The patient should be encouraged to move the joints above and below the cast to avoid stiffness. There is no need to elevate the shoulder, although the forearm should be elevated to reduce swelling. NSAIDs are appropriate to treat pain after a fracture.

35. When giving home-care instructions to a patient who has multiple forearm fractures and a long-arm cast on the right arm, which information should the nurse include? a. Keep the hand immobile to prevent soft tissue swelling. b. Call the health care provider for increased swelling or numbness. c. Keep the right shoulder elevated on a pillow or cushion. d. Avoid the use of NSAIDs for the first 48 hours after the injury.

Correct Answer: B Rationale: Increased swelling or numbness may indicate increased pressure at the injury, and the health care provider should be notified immediately to avoid damage to nerves and other tissues. The patient should be encouraged to move the joints above and below the cast to avoid stiffness. There is no need to elevate the shoulder, although the forearm should be elevated to reduce swelling. NSAIDs are appropriate to treat pain after a fracture. Cognitive Level: Application Text Reference: p. 1646 Nursing Process: Implementation NCLEX: Physiological Integrity

The nurse observes a patient doing all these activities after having a hip-replacement surgery. Which patient action requires that the nurse intervene immediately? a. The patient sits straight up on the edge of the bed. b. The patient leans over to pull shoes and socks on. c. The patient bends over the sink while brushing the teeth. d. The patient uses crutches with a swing-to gait.

Correct Answer: B Rationale: Leaning over would flex the hip at greater than 90 degrees and predispose the patient to hip dislocation. The other patient actions are appropriate and do not require any immediate action by the nurse to protect the patient. Cognitive Level: Application Text Reference: p. 1654 Nursing Process: Assessment NCLEX: Physiological Integrity

Following instruction for a patient with newly diagnosed systemic lupus erythematosus (SLE), the nurse determines that teaching about the disease has been effective when the patient says, a. "I should expect to have a low fever all the time with this disease." b. "I need to restrict my exposure to sunlight to prevent an acute onset of symptoms." c. "I should try to ignore my symptoms as much as possible and have a positive outlook." d. "I can expect a temporary improvement in my symptoms if I become pregnant."

Correct Answer: B Rationale: Sun exposure is associated with SLE exacerbation, and patients should use sunscreen with an SPF of at least 15 and stay out of the sun between 11:00 AM and 3:00 PM. Low-grade fever may occur with an exacerbation but should not be expected all the time. A positive attitude may decrease the incidence of SLE exacerbations, but patients are taught to self-monitor for symptoms that might indicate changes in the disease process. Symptoms may worsen during pregnancy and especially during the postpartum period.

A patient is to be discharged from the hospital 4 days after undergoing a total hip arthroplasty. A statement by the patient that indicates a need for additional discharge instructions is a. "I should not cross my legs while sitting." b. "I can sleep in any position that is comfortable for me." c. "I will use a toilet elevator on the toilet seat." d. "I will have someone else put on my shoes and socks."

Correct Answer: B Rationale: The patient needs to sleep in a position that allows excessive internal rotation or flexion of the hip. The other patient statements indicate that the patient has understood the teaching. Cognitive Level: Application Text Reference: p. 1654 Nursing Process: Evaluation NCLEX: Physiological Integrity

When getting a patient from the bed into the chair for the first time since having an ORIF of a hip fracture, the nurse should a. use a mechanical lift to transfer the patient from the bed to the chair. b. assist the patient to use a walker with partial weight bearing to assist in transfer to the chair. c. have the patient use crutches with a swing-through gait to transfer. d. ask a nursing assistant to help the patient to stand at the bedside and pivot to the chair.

Correct Answer: B Rationale: The patient will use an assistive device such as a walker to help with the initial transfers and ambulation. A mechanical lift is not needed. Crutch walking is taught before discharge but would not be used for the initial transfer. The RN, not a nursing assistant, should supervise the patient during the initial transfer to evaluate how well the patient is able to accomplish this skill.

A patient who has been hospitalized for 3 days with a hip fracture and Buck's traction has sudden onset shortness of breath and tachypnea. The patient tells the nurse, "I feel like I am going to die!" Which action should the nurse take first? a. Stay with the patient and offer reassurance. b. Administer oxygen at 4 L/min by a nasal cannula. c. Notify the health care provider about the patient's symptoms. d. Check the patient's legs for swelling or tenderness.

Correct Answer: B Rationale: The patient's clinical manifestations and history are consistent with a pulmonary embolus, and the nurse's first action should be to ensure adequate oxygenation. The nurse should offer reassurance to the patient, but meeting the physiologic need for oxygen is a higher priority. The health care provider should be notified after the oxygen is started and pulse oximetry and assessment for deep vein thrombosis (DVT) are obtained. Cognitive Level: Application Text Reference: p. 1646 Nursing Process: Implementation NCLEX: Physiological Integrity

A patient undergoes a right below-the-knee amputation with an immediate prosthetic fitting. When the patient is returned to the nursing unit, the nurse should a. check the surgical site for hemorrhage. b. take the patient's vital signs frequently. c. keep the residual leg elevated on a pillow. d. place the patient in a prone position.

Correct Answer: B Rationale: The vital signs should be monitored frequently to assess for hemorrhage because the nurse will not be able to visualize the surgical site. Flexion contracture of the hip would be encouraged by elevating the residual limb on a pillow. The patient is placed in a prone position after amputation to prevent hip flexion, but this would not be done during the immediate postoperative period. Cognitive Level: Application Text Reference: p. 1660 Nursing Process: Implementation NCLEX: Physiological Integrity

A patient hospitalized with multiple fractures has a long-arm plaster cast applied for immobilization of a fractured left radius. Until the cast has completely dried, the nurse should a. keep the left arm in a dependent position. b. handle the cast with the palms of the hands. c. place gauze around the cast edge to pad any roughness. d. cover the cast with a small blanket to absorb the dampness.

Correct Answer: B Rationale: Until a plaster cast has dried, placing pressure on the cast should be avoided to prevent creating areas inside the cast that could place pressure on the arm. The left arm should be elevated to prevent swelling. The edges of the cast may be petaled once the cast is dry, but padding the edges before that may cause the cast to be misshapen. The cast should not be covered until it is dry because heat builds up during drying.

A patient hospitalized with multiple fractures has a long-arm plaster cast applied for immobilization of a fractured left radius. Until the cast has completely dried, the nurse should a. Keep the left arm in a dependent position. b. Handle the cast with the palms of the hands. c. Place gauze around the cast edge to pad any roughness. d. Cover the cast with a small blanket to absorb the dampness.

Correct Answer: B Rationale: Until a plaster cast has dried, placing pressure on the cast should be avoided to prevent creating areas inside the cast that could place pressure on the arm. The left arm should be elevated to prevent swelling. The edges of the cast may be petaled once the cast is dry, but padding the edges before that may cause the cast to be misshapen. The cast should not be covered until it is dry because heat builds up during drying.

in developing a care plan for a patient with an open reduction and internal fixation (ORIF) of an open, displaced fracture of the tibia, the priority nursing diagnosis is a. risk for constipation related to prolonged bed rest. b. activity intolerance related to deconditioning. c. risk for infection related to disruption of skin integrity. d. risk for impaired skin integrity related to immobility.

Correct Answer: C Rationale: A patient having an ORIF is at risk for problems such as wound infection and osteomyelitis. After an ORIF, patients typically are mobilized starting the first postoperative day, so problems caused by immobility are not as likely. Cognitive Level: Application Text Reference: p. 1638 Nursing Process: Diagnosis NCLEX: Physiological Integrity

A patient with severe osteoarthritis of the left knee has undergone left-knee arthroplasty with replacement of the total knee joint with a plastic prosthesis. Postoperatively, the nurse expects care of the leg to include a. bed rest for 3 days with the left leg immobilized in an extended position. b. use of a compression bandage to hold the left knee in a flexed position. c. progressive leg exercises to obtain 90-degree flexion. d. early ambulation with full weight bearing on the left leg.

Correct Answer: C Rationale: After knee arthroplasty, active or passive flexion exercises are used to obtain a 90-degree flexion of the knee. The patient is ambulated the first postoperative day. A compression bandage is used to hold the knee in an extended position after surgery. Full weight bearing is expected before discharge, but it is not started early after surgery. Cognitive Level: Application Text Reference: p. 1664 Nursing Process: Planning NCLEX: Physiological Integrity

A patient with an extracapsular hip fracture is admitted to the orthopedic unit and placed in Buck's traction. The nurse explains to the patient that the purpose of the traction is to a. pull bone fragments back into alignment. b. immobilize the leg until healing is complete. c. reduce pain and muscle spasms before surgery. d. prevent damage to the blood vessels at the fracture site.

Correct Answer: C Rationale: Although surgical repair is the preferred method of managing intracapsular and extracapsular hip fractures, initially patients frequently may be treated with skin traction, such as Buck's extension or Russell's traction, to immobilize the limb temporarily and to relieve the painful muscle spasms before surgery is performed. Prolonged traction would be required to reduce the fracture or immobilize it for healing, creating a very high risk for complications of immobility.

A patient with an intracapsular fracture of the left femur is placed in Buck's traction before surgery for a hip replacement. The patient asks why traction is necessary when surgery is planned. The nurse's response to the patient is based on the knowledge that traction a. will help prevent flexion contractures of the affected hip. b. is necessary to prevent displacement of the fracture. c. will decrease the incidence of painful muscle spasms d. is used to maintain the leg in the external rotation position.

Correct Answer: C Rationale: Buck's traction keeps the leg immobilized and reduces muscle spasm. Flexion contractures are not likely to occur during the short time before surgery. Displacement of the hip is prevented by keeping the patient on bed rest before surgery. The leg is externally rotated because of the hip fracture, not because of traction. Cognitive Level: Comprehension Text Reference: p. 1653 Nursing Process: Implementation NCLEX: Physiological Integrity

Following x-rays of an injured wrist, the patient is informed that it is badly sprained. In teaching the patient to care for the injury, the nurse tells the patient to a. apply a heating pad to reduce muscle spasms. b. wear an elastic compression bandage continuously. c. use pillows to keep the arm elevated above the heart. d. gently exercise the joint to prevent muscle shortening.

Correct Answer: C Rationale: Elevation of the arm will reduce the amount of swelling and pain. For the first 24 to 48 hours, cold packs are used to reduce swelling. Compression bandages are not left on continuously. The wrist should be rested and kept immobile to prevent further swelling or injury.

Following x-rays of an injured wrist, the patient is informed that it is badly sprained. In teaching the patient to care for the injury, the nurse tells the patient to a. apply a heating pad to reduce muscle spasms. b. wear an elastic compression bandage continuously. c. use pillows to keep the arm elevated above the heart. d. gently exercise the joint to prevent muscle shortening.

Correct Answer: C Rationale: Elevation of the arm will reduce the amount of swelling and pain. For the first 24 to 48 hours, cold packs are used to reduce swelling. Compression bandages are not left on continuously. The wrist should be rested and kept immobile to prevent further swelling or injury.

22. After falling at home, a patient is admitted to the emergency department, where x-rays confirm the presence of an extracapsular fracture of the femur. When assessing the patient, the nurse would expect to find a. bruising of the left hip and thigh. b. numbness in the left leg and hip. c. outward pointing toes on the left leg. d. weak or nonpalpable left leg pulses.

Correct Answer: C Rationale: External rotation of the leg is a classic sign associated with a hip fracture. Bruising does not always appear rapidly, and bruising extending to the thigh might indicate hemorrhage. Numbness and decreased pulses are not typical of a hip fracture unless there is associated tissue swelling and trauma to blood vessels.

After falling at home, a patient is admitted to the emergency department, where x-rays confirm the presence of an *extracapsular fracture* of the femur. When assessing the patient, the nurse would expect to find a. bruising of the left hip and thigh. b. numbness in the left leg and hip. c. outward pointing toes on the left leg. d. weak or nonpalpable left leg pulses.

Correct Answer: C Rationale: External rotation of the leg is a classic sign associated with a hip fracture. Bruising does not always appear rapidly, and bruising extending to the thigh might indicate hemorrhage. Numbness and decreased pulses are not typical of a hip fracture unless there is associated tissue swelling and trauma to blood vessels.

A patient has a short-arm plaster cast applied at the outpatient center for a wrist fracture. An understanding of discharge teaching is apparent when the patient says, a. "I can get the cast wet as long as I dry it right away with a hair dryer." b. "I should avoid moving my fingers and elbow until the cast is removed." c. "I will apply an ice pack to the cast over the fracture site for the next 24 hours." d. "I can rub lotion on any itching areas under the cast with a cotton-tipped applicator."

Correct Answer: C Rationale: Ice application for the first 24 hours after a fracture will help to reduce swelling and can be placed over the cast. Plaster casts should not get wet. The patient should be encouraged to move the joints above and below the cast. Patients should not insert objects inside the cast.

A patient with an acute exacerbation of systemic lupus erythematosus (SLE) is hospitalized with incapacitating fatigue, acute hand and wrist pain, and proteinuria. The health care provider prescribes prednisone (Deltasone) 40 mg twice daily. Which nursing action should be included in the plan of care? a. Institute seizure precautions. b. Reorient to time and place PRN. c. Monitor intake and output. d. Place on cardiac monitor.

Correct Answer: C Rationale: Lupus nephritis is a common complication of SLE, and when the patient is taking corticosteroids, it is especially important to monitor renal function. There is no indication that the patient is experiencing any nervous system or cardiac problems with the SLE.

A 26-year-old woman has been diagnosed with early systemic lupus erythematosus (SLE) involving her joints. In teaching the patient about the disease, the nurse includes the information that SLE is a(n) a. hereditary disorder of women but usually does not show clinical symptoms unless a woman becomes pregnant. b. autoimmune disease of women in which antibodies are formed that destroy all nucleated cells in the body. c. disorder of immune function, but it is extremely variable in its course, and there is no way to predict its progression. d. disease that causes production of antibodies that bind with cellular estrogen receptors, causing an inflammatory response.

Correct Answer: C Rationale: SLE has an unpredictable course, even with appropriate treatment. Women are more at risk for SLE, but it is not confined exclusively to women. Clinical symptoms may worsen during pregnancy but are not confined to pregnancy or the perinatal period. All nucleated cells are not destroyed by the antinuclear antibodies. The inflammation in SLE is not caused by antibody binding to cellular estrogen receptors.

A patient who has a proximal humerus fracture that is immobilized with a left-sided long-arm cast, and a sling is admitted to the medical-surgical unit. Which nursing intervention will be included in the plan of care? a. Use surgical net dressing to hang the arm from an IV pole. b. Immobilize the fingers on the left hand with gauze dressings. c. Assess the left axilla and change absorbent dressings as needed. d. Assist the patient in passive range of motion (ROM) for the right arm.

Correct Answer: C Rationale: The axilla can become excoriated when a sling is used to support the arm, and the nurse should check the axilla and apply absorbent dressings to prevent this. A patient with a sling would not have traction applied by hanging. The patient will be encouraged to move the fingers on the injured arm to maintain function and to help decrease swelling. The patient will do active ROM on the uninjured side.

A patient who has a proximal humerus fracture that is immobilized with a left-sided long-arm cast, and a sling is admitted to the medical-surgical unit. Which nursing intervention will be included in the plan of care? a. Use surgical net dressing to hang the arm from an IV pole. b. Immobilize the fingers on the left hand with gauze dressings. c. Assess the left axilla and change absorbent dressings as needed. d. Assist the patient in passive range of motion (ROM) for the right arm.

Correct Answer: C Rationale: The axilla can become excoriated when a sling is used to support the arm, and the nurse should check the axilla and apply absorbent dressings to prevent this. A patient with a sling would not have traction applied by hanging. The patient will be encouraged to move the fingers on the injured arm to maintain function and to help decrease swelling. The patient will do active ROM on the uninjured side. Cognitive Level: Application Text Reference: p. 1640 Nursing Process: Planning NCLEX: Physiological Integrity

A patient is admitted to the emergency department with possible fractures of the bones of the left lower extremity. The initial action by the nurse should be to a. Splint the lower leg. b. Elevate the left leg. c. Check the popliteal, dorsalis pedis, and posterior tibia pulses. d. Obtain information about the patient's tetanus immunization status.

Correct Answer: C Rationale: The initial nursing action should be assessment of the neurovascular status of the injured leg. After assessment, the nurse may need to splint and elevate the leg, based on the assessment data. Information about tetanus immunizations should be done if there is an open wound.

A patient is admitted to the emergency department with possible fractures of the bones of the left lower extremity. The initial action by the nurse should be to a. splint the lower leg. b. elevate the left leg. c. check the popliteal, dorsalis pedis, and posterior tibial pulses. d. obtain information about the patient's tetanus immunization status.

Correct Answer: C Rationale: The initial nursing action should be assessment of the neurovascular status of the injured leg. After assessment, the nurse may need to splint and elevate the leg, based on the assessment data. Information about tetanus immunizations should be done if there is an open wound. Cognitive Level: Application Text Reference: p. 1642 Nursing Process: Assessment NCLEX: Physiological Integrity

A patient is admitted with facial injuries after a bicycle accident and has a repair of a fractured mandible. When doing postoperative teaching, the nurse will include information about a. the use of sterile technique for dressing changes. b. the importance of including high-fiber foods in the diet. c. when the patient may need to cut the immobilizing wires. d. self-administration of nasogastric tube feedings.

Correct Answer: C Rationale: The jaw will be wired for stabilization, and the patient should know what emergency situations require that the wires be cut to protect the airway. There are no dressing changes for this procedure. The diet is liquid, and patients are not able to chew high-fiber foods. Initially, the patient may receive nasogastric tube feedings, but by discharge the patient will swallow liquid through a straw. Cognitive Level: Application Text Reference: p. 1657 Nursing Process: Implementation NCLEX: Physiological Integrity

3. A checkout clerk in a grocery store has muscle and tendon tears that have become inflamed, causing pain and weakness in the left hand and elbow. The nurse identifies these symptoms as related to a. muscle spasms. b. meniscus injury. c. repetitive strain injury. d. carpal tunnel syndrome.

Correct Answer: C Rationale: The patient's occupation and the inflammation, pain, and weakness in the elbow and hand suggest a repetitive strain injury. Muscle spasms would be characterized by a palpable, firm muscle mass during the spasm. Meniscus injury would affect the knee. Carpal tunnel syndrome is characterized by weakness and numbness of the hand.

A patient with systemic lupus erythematosus (SLE) who has a facial rash and alopecia tells the nurse, "I hate the way I look! I never go anyplace except here to the health clinic." An appropriate nursing diagnosis for the patient is a. activity intolerance related to fatigue and inactivity. b. impaired skin integrity related to itching and skin sloughing. c. social isolation related to embarrassment about the effects of SLE. d. impaired social interaction related to lack of social skills.

Correct Answer: C Rationale: The patient's statement about not going anyplace because of hating the way he or she looks supports the diagnosis of social isolation because of embarrassment about the effects of the SLE. Activity intolerance is a possible problem for patients with SLE, but the information about this patient does not support this as a diagnosis. The rash with SLE is nonpruritic. There is no evidence of lack of social skills for this patient.

When evaluating the crutch-walking technique of a patient with a right-leg long-leg cast and no weight bearing on the right leg, the nurse determines that the patient is prepared to ambulate independently with the crutches on observing that the patient a. uses the bedside chair to assist in balance as needed when ambulating in the room. b. keeps the padded area of the crutch firmly in the axillary area when ambulating. c. advances the right leg and both crutches together and then advances the left leg. d. moves the left crutch with the left leg and then the right crutch with the right leg.

Correct Answer: C Rationale: When using crutches, patients are usually taught to move the assistive device and the injured leg forward at the same time and then to move the unaffected leg. Patients are discouraged from using furniture to assist with ambulation. The patient is taught to place weight on the hands, not in the axilla, to avoid nerve damage. If the 2- or 4-point gaits are to be used, the crutch and leg on opposite sides move forward, not the crutch and same-side leg. Cognitive Level: Application Text Reference: p. 1648 Nursing Process: Evaluation NCLEX: Safe and Effective Care Environment

When counseling an older patient about ways to prevent fractures, which information will the nurse include? a. Tacking down scatter rugs in the home is recommended. b. Occasional weight-bearing exercise will improve muscle and bone strength. c. Most falls happen outside the home. d. Buying shoes that provide good support and are comfortable to wear is recommended.

Correct Answer: D Rationale: Comfortable shoes with good support will help to decrease the risk for falls. Scatter rugs should be eliminated, not just tacked down. Regular weight-bearing exercise will improve strength, but occasional exercise is not helpful in improving strength. Falls inside the home are responsible for many injuries.

When counseling an older patient about ways to prevent fractures, which information will the nurse include? a. Tacking down scatter rugs in the home is recommended. b. Occasional weight-bearing exercise will improve muscle and bone strength. c. Most falls happen outside the home. d. Buying shoes that provide good support and are comfortable to wear is recommended.

Correct Answer: D Rationale: Comfortable shoes with good support will help to decrease the risk for falls. Scatter rugs should be eliminated, not just tacked down. Regular weight-bearing exercise will improve strength, but occasional exercise is not helpful in improving strength. Falls inside the home are responsible for many injuries. Cognitive Level: Application Text Reference: p. 1630 Nursing Process: Implementation NCLEX: Health Promotion and Maintenance

Discharge instructions for the patient following a hip fracture with femoral head prosthesis include a. restricting walking for 2 to 3 months. b. taking a bath rather than a shower to prevent falling. c. keeping the leg internally rotated while sitting and standing. d. having a family member put on the patient's shoes and socks.

Correct Answer: D Rationale: Patients with hip prostheses or a total hip arthroplasty must avoid extreme flexion, adduction, or internal rotation for at least 6 weeks to prevent dislocation of the prosthesis. Gradual weight bearing on the limb is allowed, and ambulation should be encouraged.

A 65-year-old patient has undergone a right total hip arthroplasty with a cemented prosthesis for treatment of severe osteoarthritis of the hip. Patient activity that the nurse anticipates on the patient's first or second postoperative day includes a. transfer from bed to chair twice a day only. b. turning from the back to the unaffected side q2hr only. c. crutch walking with non-weight bearing on the operative leg. d. ambulation and weight bearing on the right leg with a walker.

Correct Answer: D Rationale: Physical therapy is initiated 1 day postoperatively with ambulation and weight bearing using a walker for a patient with a cemented prosthesis and non-weight bearing on the operative side for an uncemented prosthesis. In addition, the patient is turned to both sides and back with support of the operative leg and sits in the chair at least twice a day

A patient with lower-leg fractures has an external fixation device in place and is scheduled for discharge. Which information will the nurse include in the discharge teaching? a. "You will need to remain on bed rest until bone healing is complete." b. "The external fixator can be removed during the bath or shower." c. "Prophylactic antibiotics are needed until the external fixator is removed." d. "You will need to assess and clean the pin insertion sites daily."

Correct Answer: D Rationale: Pin insertion sites should be cleaned daily to decrease the risk for infection at the site. An external fixator allows the patient to be out of bed and avoid the risks of prolonged immobility. The device is surgically placed and is not removed until the bone is stable. Prophylactic antibiotics are not routinely given when an external fixator is used. Cognitive Level: Application Text Reference: p. 1641 Nursing Process: Implementation NCLEX: Physiological Integrity

4. When working with a patient whose job involves many hours of word processing, the nurse will teach the patient about the need to a. do stretching and warm-up exercises before starting work. b. wrap the wrists with a compression bandage every morning. c. use acetaminophen (Tylenol) instead of NSAIDs for wrist pain. d. obtain a keyboard pad to support the wrist while word processing.

Correct Answer: D Rationale: Repetitive strain injuries caused by prolonged times working at a keyboard can be prevented by the use of a pad that will keep the wrists in a straight position. Stretching exercises during the day may be helpful, but these would not be needed before starting. Use of a compression bandage is not needed, although a splint may be used for carpal tunnel syndrome. NSAIDs are appropriate to use to decrease swelling. Cognitive Level: Application Text Reference: p. 1633 Nursing Process: Implementation NCLEX: Health Promotion and Maintenance

An older adult woman is admitted to the emergency department after falling at home. The nurse cautions the patient not to put weight on the leg after finding a. inability to move the toes and ankle. b. edema of the thigh extending to the knee. c. internal rotation of the leg with groin pain. d. shortening and external rotation of the leg.

Correct Answer: D Rationale: The classic signs of a hip fracture are shortening of the leg and external rotation accompanied by severe pain at the fracture site, and additional injury could be caused by weight bearing on the extremity. The patient may not be able to move the hip or the knee, but movement in the ankle and toes is not affected.

12. Following a motor-vehicle accident, a patient arrives in the emergency department with massive right lower-leg swelling. Which action will the nurse take first? a. Elevate the leg on pillows. b. Apply a compression bandage. c. Place ice packs on the lower leg. d. Check leg pulses and sensation.

Correct Answer: D Rationale: The initial action by the nurse will be to assess the circulation to the leg and to observe for any evidence of injury such as fractures or dislocations. After the initial assessment, the other actions may be appropriate based on what is observed during the assessment.

The nurse provides discharge instructions to a patient with an above-the-knee amputation who will be fitted with a prosthesis when healing is complete and the residual limb is well molded. The nurse determines that teaching has been effective when the patient says, a. "I should change the limb sock when it becomes soiled or stretched out." b. "I should use lotion on the stump to prevent drying and cracking of the skin." c. "I should elevate my residual limb on a pillow 2 or 3 times a day." d. "I should lay on my abdomen for 30 minutes 3 or 4 times a day."

Correct Answer: D Rationale: The patient lies in the prone position several times daily to prevent flexion contractures of the hip. The limp sock should be changed daily. Lotion should not be used on the stump. The residual limb should not be elevated because this would encourage flexion contracture.

The nurse provides discharge instructions to a patient with an above-the-knee amputation who will be fitted with a prosthesis when healing is complete and the residual limb is well molded. The nurse determines that teaching has been effective when the patient says, a. "I should change the limb sock when it becomes soiled or stretched out." b. "I should use lotion on the stump to prevent drying and cracking of the skin." c. "I should elevate my residual limb on a pillow 2 or 3 times a day." d. "I should lay on my abdomen for 30 minutes 3 or 4 times a day."

Correct Answer: D Rationale: The patient lies in the prone position several times daily to prevent flexion contractures of the hip. The limp sock should be changed daily. Lotion should not be used on the stump. The residual limb should not be elevated because this would encourage flexion contracture. Cognitive Level: Application Text Reference: p. 1661 Nursing Process: Evaluation NCLEX: Physiological Integrity

Priority Decision: Following change-of-shift handoff, which patient should the nurse assess first? a. a 58-year-old male experiencing phantom pain and requesting analgesic b. a 72-year-old male being transferred to a skilled nursing unit following repair of a hip fracture c. a 25-year-old female in left leg skeletal traction asking for the weights to be lifted for a few minutes d. a 68-year-old male with a new lower leg cast complaining that the cast is too tight and he can't feel his toes

Correct Answer: D Rationale: The patient with a tight cast may be at risk for neurovascular compromise (impaired circulation and peripheral nerve damage) and should be assessed first. The other patients should be seen as soon as possible. Providing analgesia for the patient with phantom pain would be the next priority. The patient in skeletal traction needs explanation of the purpose and functioning of the traction. She may need analgesia or muscle relaxants to help tolerate the traction.

A patient with a fractured pelvis is initially treated with bed rest with no turning from side to side permitted. The second day after admission, the patient develops chest pain, tachypnea, and tachycardia. The nurse determines that the patient's symptoms are most likely related to fat embolism when assessment of the patient reveals a. a blood pressure of 100/65 mm Hg. b. anxiety, restlessness, and confusion. c. warm, reddened areas in the calf. d. pinpoint red areas on the upper chest.

Correct Answer: D Rationale: The presence of petechiae helps distinguish fat embolism from other problems. The other symptoms might occur with fat embolism but could also occur with other postoperative complications such as bleeding, myocardial infarction, venous thrombosis, or hypoxemia.

A patient with a fractured pelvis is initially treated with bed rest with no turning from side to side permitted. The second day after admission, the patient develops chest pain, tachypnea, and tachycardia. The nurse determines that the patient's symptoms are most likely related to fat embolism when assessment of the patient reveals a. a blood pressure of 100/65 mm Hg. b. anxiety, restlessness, and confusion. c. warm, reddened areas in the calf. d. pinpoint red areas on the upper chest.

Correct Answer: D Rationale: The presence of petechiae helps distinguish fat embolism from other problems. The other symptoms might occur with fat embolism but could also occur with other postoperative complications such as bleeding, myocardial infarction, venous thrombosis, or hypoxemia.

The nurse is caring for a patient who has osteoarthritis (OA) of the knees. The nurse teaches the patient that the most beneficial measure to protect the joints is to do which of the following? A. Use a wheelchair to avoid walking as much as possible. B. Eat a well-balanced diet to maintain a healthy body weight. C. Incorrect Use a walker for ambulation to relieve the pressure on her hips. D. Sit in chairs that do not cause her hips to be lower than her knees.

Correct answer: B. Eat a well-balanced diet to maintain a healthy body weight. Rationale: Because maintaining an appropriate load on the joints is essential to the preservation of articular cartilage integrity, the patient should maintain an optimal overall body weight or lose weight if overweight.

The nurse is admitting a patient who is scheduled for knee arthroscopy related to osteoarthritis (OA). Which of the following findings would the nurse expect to be present on examination of the patient's knees? A. Ulnar drift B. Pain with joint movement C. Reddened, swollen affected joints D. Stiffness that increases with movement

Correct answer: B. Pain with joint movement Rationale: OA is characterized predominantly by joint pain upon movement and is a classic feature of the disease.

When reinforcing health teaching about the management of osteoarthritis (OA), the nurse determines that the patient needs additional instruction after making which of the following statements? A. "I should take the Celebrex as prescribed to help control the pain." B. "I should try to stay standing all day to keep my joints from becoming stiff." C. "I can use a cane if I find it helpful in relieving the pressure on my back and hip." D. "A warm shower in the morning will help relieve the stiffness I have when I get up."

Correct answer: B. "I should try to stay standing all day to keep my joints from becoming stiff." Rationale: It is important to maintain a balance between rest and activity to prevent overstressing the joints with OA.

The nurse is working with a 73-year-old patient with osteoarthritis (OA). In assessing the patient's understanding of this disorder, the nurse concludes teaching has been effective when the patient describes the condition as which of the following? A. Joint destruction caused by an autoimmune process B. Degeneration of articular cartilage in synovial joints C. Overproduction of synovial fluid resulting in joint destruction D. Breakdown of tissue in non-weight-bearing joints by enzymes

Correct answer: B. Degeneration of articular cartilage in synovial joints Rationale: OA is a degeneration or breakdown of the articular cartilage in synovial joints. The condition has also been referred to as degenerative joint disease.

A female patient's complex symptomatology over the past year has culminated in a diagnosis of systemic lupus erythematosus (SLE). Which of the patient's following statements demonstrates the need for further teaching about the disease? A. "I'll try my best to stay out of the sun this summer." B. "I know that I probably have a high chance of getting arthritis." C. "I'm hoping that surgery will be an option for me in the future." D. "I understand that I'm going to be vulnerable to getting infections."

Correct answer: C. "I'm hoping that surgery will be an option for me in the future." Rationale: SLE carries an increased risk of infection, sun damage, and arthritis. Surgery is not a key treatment modality for SLE.

The nurse is assessing the recent health history of a 63-year-old patient with osteoarthritis (OA). The nurse determines that the patient is trying to manage the condition appropriately when the patient describes which of the following activity patterns? A. Bed rest with bathroom privileges B. Daily high-impact aerobic exercise C.A regular exercise program of walking D. Frequent rest periods with minimal exercise

Correct answer: C. A regular exercise program of walking Rationale: A regular low-impact exercise, such as walking, is important in helping to maintain joint mobility in the patient with osteoarthritis.

Which of the following patient statements most clearly suggests a need to assess the patient for ankylosing spondylitis (AS)? A. "My right elbow has become red and swollen over the last few days." B. "I wake up stiff every morning and my knees just don't want to bend." C. "My husband tells me that my posture has become so stooped this winter." D. "My lower back pain seems to be getting worse all the time and nothing seems to help."

Correct answer: D. "My lower back pain seems to be getting worse all the time and nothing seems to help." Rationale: AS primarily affects the axial skeleton. Based on this, symptoms of inflammatory spine pain are often the first clues to a diagnosis of AS. Knee or elbow involvement is not consistent with the typical course of AS. Back pain is likely to precede the development of kyphosis.

The nurse is reinforcing general health teaching with a 64-year-old patient with osteoarthritis (OA) of the hip. Which of the following points would the nurse include in this review of the disorder (select all that apply)? A. OA cannot be successfully treated with any current therapy options. B. OA is an inflammatory disease of the joints that may present symptoms at any age. C.Joint degeneration with pain and disability occurs in the majority of people by the age of 60. D. OA is more common with aging, but usually it remains confined to a few joints and does not cause crippling. E.OA can be prevented from progressing when well controlled with a regimen of exercise, diet, and medication.

Correct answer: D. OA is more common with aging, but usually it remains confined to a few joints and does not cause crippling. E.OA can be prevented from progressing when well controlled with a regimen of exercise, diet, and medication. Rationale: OA occurs with greater frequency with increasing age, but it usually remains confined to a few joints and can be managed with a combination of exercise, diet, and medication. OA can lead to significant disability.

Teach the patient with ankylosing spondylitis the importance of a. regular exercise and maintaining proper posture b. continuing with physical activity during flare-ups c. avoiding extremes in environmental temperatures d. applying cool compresses for relief of local symptoms

Correct answer: a Rationale: Patients with ankylosing spondylitis (AS) should exercise after pain and stiffness are managed. Postural control is important to minimize spinal deformity. The exercise regimen should include back, neck, and chest stretches. The nurse should educate the patient with AS about regular exercise and attention to posture, local moist-heat applications, and knowledgeable use of drugs. The nurse should discourage excessive physical exertion during periods of active flare-up of the disease. Proper positioning at rest is essential. The mattress should be firm, and the patient should sleep on the back with a flat pillow, avoiding positions that encourage flexion deformity. Postural training emphasizes avoiding spinal flexion (e.g., leaning over a desk), heavy lifting, and prolonged walking, standing, or sitting.

When administering medications to the patient with gout, the nurse would recognize which of the following as a treatment for chronic disease? a. Colchicine b. Febuxostat c. Sulfasalazine d. Cyclosporine

Correct answer: b Rationale: Febuxostat (Uloric), a selective inhibitor of xanthine oxidase, is given for long-term management of hyperuricemia in persons with chronic gout. Acute gouty arthritis is treated with colchicine and nonsteroidal antiinflammatory drugs (NSAIDs).

In teaching a patient with chronic fatigue syndrome (CFS) about this disorder, the nurse understands that a. palpating tender points is an indicator of CFS severity b. many symptoms are similar to fibromyalgia syndrome c. definitive treatment includes low-dose hydrocortisone d. CFS is characterized by progressive memory impairment

Correct answer: b Rationale: Fibromyalgia syndrome (FS) and chronic fatigue syndrome (CFS) have several commonalities. Both occur in previously healthy, young, and middle-aged women; the cause of both includes an infectious trigger, dysfunction of the hypothalamic-pituitary-adrenal axis or an alteration in central nervous system; and common clinical manifestations are malaise and fatigue, cognitive dysfunction, headaches, sleep disturbances, depression, anxiety, fever, and generalized musculoskeletal pain. Both diseases have symptoms that fluctuate over time, and both disorders have no definitive laboratory tests or joint and muscle examinations. They remain diagnoses of exclusion. Treatment for both disorders is symptomatic and may include antidepressant drugs. Other measures are heat, massage, regular stretching, biofeedback, stress management, and relaxation training.

Assessment data in the patient with osteoarthritis commonly include a. gradual weight loss b. elevated WBC count c. joint pain that worsens with use d. straw-colored synovial fluid

Correct answer: c Rationale: Osteoarthritis pain ranges from mild discomfort to significant disability. Joint pain is the predominant symptom, and the pain generally worsens with joint use.

In teaching a patient with SLE about the disorder, the nurse knows that the pathophysiology of SLE includes a. circulating immune complexes formed from IgG autoantibodies reacting with IgG b. an autoimmune T-cell reaction that results in destruction of the deep dermal skin layer c. immunologic dysfunction leading to chronic inflammation in the cartilage and muscles d. the production of a variety of autoantibodies directed against components of the cell nucleus

Correct answer: d Rationale: Systemic lupus erythematosus (SLE) is characterized by the production of many autoantibodies against nucleic acids (e.g., single-and double-stranded DNA), erythrocytes, coagulation proteins, lymphocytes, platelets, and many other self-proteins. Autoimmune reactions characteristically are directed against constituents of the cell nucleus (e.g., antinuclear antibodies [ANAs]), particularly DNA. Circulating immune complexes containing antibody against DNA are deposited in the basement membranes of capillaries in the kidneys, heart, skin, brain, and joints. Complement is activated, and inflammation occurs. The overaggressive antibody response is also related to activation of B and T cells. The specific manifestations of SLE depend on which cell types or organs are involved. SLE is a type III hypersensitivity response.

In assessing the joints of a patient with rheumatoid arthritis, the nurse understands that the joints are damaged by (select all that apply) a. bony ankylosis following inflammation of the joints b. the deterioration of cartilage by proteolytic enzymes c. the development of Heberden's nodes in the joint capsule d.. increased cartilage and bony growth at the joint margins e. invasion of pannus into the joint causing a loss of cartilage

Correct answers: a, e Rationale: Bony ankylosis is the union of the bones of a joint by proliferation of bone cells, resulting in complete immobility. Bony ankylosis occurs with advanced rheumatoid arthritis. Joint changes from chronic inflammation begin when the hypertrophied synovial membrane invades the surrounding cartilage, ligaments, tendons, and joint capsule. Pannus (i.e., highly vascular granulation tissue) forms within the joint. It eventually covers and erodes the entire surface of the articular cartilage. The production of inflammatory cytokines at the pannus-cartilage junction further contributes to cartilage destruction. The pannus scars and shortens supporting structures such as tendons and ligaments, ultimately causing joint laxity, subluxation, and contracture.

Successful achievement of patient outcomes for the patient with cranial surgery would be best indicated by the a. ability to return home in 6 days b. ability to meet all self-care needs c. acceptance of residual neurologic deficits d. absence of signs and symptoms of increased ICP

D. Absence of signs and symptoms of increased ICP- The primary goal after cranial surgery is prevention of increased ICP, and interventions to prevent ICP and infection postoperatively are nursing priorities. The residual deficits, rehabilitation potential, and ultimate function of the patient depend on the reason for surgery, the postoperative course, and the patient's general state of health

A patient with ICP monitoring has pressure of 12 mm Hg. The nurse understand that this pressure reflects a. a severe decrease in cerebral perfusion pressure b. an alteration in the production of CSF c. the loss of autoregulatory control of ICP d. a normal balance between brain tissue, blood, and CSF

D. A normal balance between brain tissue, blood, and CSF- normal is 10- 15 mm Hg

The nurse suspects the presence of an arterial epidural hematoma in the patient who experiences a. failure to regain consciousness following a head injury b. a rapid deterioration of neurologic function within 24 to 48 hours following a head injury c. nonspecific, nonlocalizing progression of alteration in LOC occurring over weeks or months d. unconsciousness at the time of a head injury with a brief period of consciousness followed by a decrease in LOC

D. An arterial epidural hematoma is the most acute neurologic emergency, and the typical symptoms include unconsciousness at the scene, with a brief lucid interval followed by a decrease in LOC. An acute subdural hematoma manifests signs within 48 hours of an injury; a chronic subdural hematoma develops over weeks or months

A patient is admitted to the hospital with possible bacterial meningitis. During the initial assessment, the nurse questions the patient about a recent history of a. mosquito or tick bites b. chickenpox or measles c. cold sores or fever blisters d. an upper respiratory infection

D. An upper respiratory infection- Meningitis is often a result of an upper respiratory infection or middle ear infection, where organisms gain entry to the CNS. Epidemic encephalitis is transmitted by ticks and mosquitoes, and nonepidemic encephalitis may occur as a complication of measles, chickenpox, or mumps. Encephalitis caused by the herpes simplex virus carries a high fatality rate

Which medication taken by a patient with restless legs syndrome should the nurse discuss with the patient? a. Multivitamin (Stresstabs) b. Acetaminophen (Tylenol) c. Ibuprofen (Motrin, Advil) d. Diphenhydramine (Benadryl)

D. Antihistamines can aggravate restless legs syndrome. The other medications will not contribute to restless legs syndrome.

Metabolic and nutritional needs of the patient with increased ICP are best met with a. enteral feedings that are low in sodium b. the simple glucose available in D5W IV solutions c. a fluid restriction that promotes a moderate dehydration d. balanced, essential nutrition in a form that the patient can tolerate

D. Balanced, essential nutrition in a form that the patient can tolerate= A patient with increased ICP is in a hypermetabolic and hypercatabolic state and needs adequate glucose to maintain fuel for the brain and other nutrients to meet metabolic needs. Malnutrition promotes cerebral edema, and if a patient cannot take oral nutrition, other means of providing nutrition should be used, such as tube feedings or parenteral nutrition. Glucose alone is not adequate to meet nutritional requirements, and 5% dextrose solutions may increase cerebral edema by lowering serum osmolarity. Patients should remain in a normovolemic fluid state with close monitoring of clinical factors such as urine output, fluid intake, serum and urine osmolality, serum electrolytes, and insensible losses.

When assessing the body function of a patient with increased ICP, the nurse should initially assess a. corneal reflex testing b. extremity strength testing c. pupillary reaction to light d. circulatory and respiratory status

D. Circulatory and respiratory status- Of the body functions that should be assessed in an unconscious patient, cardiopulmonary status is the most vital function and gives priorities to the ABCs (airway, breathing, and circulation)

Which information about a 60-year-old patient with MS indicates that the nurse should consult with the health care provider before giving the prescribed dose of dalfampridine (Ampyra)? a. The patient has relapsing-remitting MS. b. The patient walks a mile a day for exercise. c. The patient complains of pain with neck flexion. d. The patient has an increased serum creatinine level.

D. Dalfampridine should not be given to patients with impaired renal function. The other information will not impact whether the dalfampridine should be administered.

Which teaching helps to prevent botulism? A. Do not eat raw shellfish from contaminated water. B. Avoid consuming raw or undercooked eggs. C. Boil water for 10 minutes if unsure of the source. D. Discard any canned food with a swollen end.

D. Discard any canned food with a swollen end. A can's swollen ends may be caused by gases from C. botulinum and should be discarded. Improper food canning is a major cause of botulism. The other options are not related to botulism.

The nurse is reinforcing health teaching about osteoporosis with a 72-year-old patient admitted to the hospital. In reviewing this disorder, what should the nurse explain to the patient? A. With a family history of osteoporosis, there is no way to prevent or slow bone resorption. B. Continuous, low-dose corticosteroid treatment is effective in stopping the course of osteoporosis. C. Estrogen therapy must be maintained to prevent rapid progression of the osteoporosis. D. Even with a family history of osteoporosis, the calcium loss from bones can be slowed by increased calcium intake and exercise.

D. Even with a family history of osteoporosis, the calcium loss from bones can be slowed by increased calcium intake and exercise. The rate of progression of osteoporosis can be slowed if the patient takes calcium supplements and/or foods high in calcium and engages in regular weight-bearing exercise. Corticosteroids interfere with bone metabolism. Estrogen therapy is no longer used to prevent osteoporosis because of the associated increased risk of heart disease and breast and uterine cancer.

A 62-year-old patient who has Parkinson's disease is taking bromocriptine (Parlodel). Which information obtained by the nurse may indicate a need for a decrease in the dose? a. The patient has a chronic dry cough. b. The patient has four loose stools in a day. c. The patient develops a deep vein thrombosis. d. The patient's blood pressure is 92/52 mm Hg.

D. Hypotension is an adverse effect of bromocriptine, and the nurse should check with the health care provider before giving the medication. Diarrhea, cough, and deep vein thrombosis are not associated with bromocriptine use.

When planning care for a patient with a C5 spinal cord injury, which nursing diagnosis is the highest priority? A. Impaired tissue integrity due to paralysis B. Impaired urinary elimination due to quadriplegia C. Ineffective coping due to the extent of trauma D. Ineffective airway clearance due to high cervical spinal cord injury

D. Ineffective airway clearance due to high cervical spinal cord injury Maintaining a patent airway is the most important goal for a patient with a high cervical fracture. Although all of these options are appropriate nursing diagnoses for a patient with a spinal cord injury, respiratory needs are always the highest priority. Remember the ABCs.

A patient is admitted to the intensive care unit (ICU) with a C7 spinal cord injury and diagnosed with Brown-Séquard syndrome. What would you most likely find on physical examination? A. Upper extremity weakness only B. Complete motor and sensory loss below C7 C. Loss of position sense and vibration in both lower extremities D. Ipsilateral motor loss and contralateral sensory loss below C7

D. Ipsilateral motor loss and contralateral sensory loss below C7 Brown-Séquard syndrome is a result of damage to one half of the spinal cord. This syndrome is characterized by a loss of motor function and position and vibratory sense, as well as vasomotor paralysis on the same side (ipsilateral) as the lesion. The opposite (contralateral) side has loss of pain and temperature sensation below the level of the lesion.

A patient is admitted to the hospital with a C4 spinal cord injury after a motorcycle collision. The patient's blood pressure is 83/49 mm Hg and pulse is 39 beats/minute. He remains orally intubated. What is the cause of this pathophysiologic response? A. Increased vasomotor tone after the injury B. A temporary loss of sensation and flaccid paralysis below the level of injury C. Loss of parasympathetic nervous system innervation resulting in vasoconstriction D. Loss of sympathetic nervous system innervation resulting in peripheral vasodilation

D. Loss of sympathetic nervous system innervation resulting in peripheral vasodilation eurogenic shock results from loss of vasomotor tone caused by injury, and it is characterized by hypotension and bradycardia. Loss of sympathetic nervous system innervation causes peripheral vasodilation, venous pooling, and a decreased cardiac output. These effects usually are associated with a cervical or high thoracic injury (T6 or higher).

Which information about a 72-year-old patient who has a new prescription for phenytoin (Dilantin) indicates that the nurse should consult with the health care provider before administration of the medication? a. Patient has generalized tonic-clonic seizures. b. Patient experiences an aura before seizures. c. Patient's most recent blood pressure is 156/92 mm Hg. d. Patient has minor elevations in the liver function tests.

D. Many older patients (especially with compromised liver function) may not be able to metabolize phenytoin. The health care provider may need to choose another antiseizure medication. Phenytoin is an appropriate medication for patients with tonic-clonic seizures, with or without an aura. Hypertension is not a contraindication for phenytoin therapy.

The nurse cares for a 58-year-old woman with breast cancer who is admitted for severe back pain related to a compression fracture. The patient's laboratory values include serum potassium of 4.5 mEq/L, serum sodium of 144 mEq/L, and serum calcium of 14.3 mg/dL. Which signs and symptoms will the nurse expect the patient to exhibit? A. Anxiety, irregular pulse, and weakness B. Muscle stiffness, dysphagia, and dyspnea C. Hyperactive reflexes, tremors, and seizures D. Nausea, vomiting, and altered mental status

D. Nausea, vomiting, and altered mental status Breast cancer can metastasize to the bone. Vertebrae are a common site. Pathologic fractures at the site of metastasis are common because of a weakening of the involved bone. High serum calcium levels result as calcium is released from damaged bones. Normal serum calcium is between 8.6 to 10.2 mg/dL. Clinical manifestations of hypercalcemia include nausea, vomiting, and altered mental status (e.g., lethargy, decreased memory, confusion, personality changes, psychosis, stupor, coma). Other manifestations include weakness, depressed reflexes, anorexia, bone pain, fractures, polyuria, dehydration, and nephrolithiasis. Manifestations of hypomagnesemia include hyperactive reflexes, tremors, and seizures. Symptoms of hyperkalemia include anxiety, irregular pulse, and weakness. Symptoms of hypocalcemia include muscle stiffness, dysphagia, and dyspnea.

During routine assessment of a patient with Guillain-Barré syndrome, you find the patient is short of breath. What is causing the patient's respiratory distress? A. Elevated protein levels in the cerebrospinal fluid (CSF) B. Immobility resulting from ascending paralysis C. Degeneration of motor neurons in the brainstem and spinal cord D. Paralysis ascending to the nerves that stimulate the thoracic area

D. Paralysis ascending to the nerves that stimulate the thoracic area Guillain-Barré syndrome is characterized by ascending, symmetric paralysis that usually affects cranial nerves and the peripheral nervous system. The most serious complication of this syndrome is respiratory failure, which occurs as the paralysis progresses to the nerves that innervate the thoracic area.

Which patient should be assigned to the experienced registered nurse on a neurologic floor? A. Patient with trigeminal neuralgia reporting facial pain rated at 10 B. Patient with Bell's palsy with unilateral facial droop C. Patient after surgical removal of a spinal cord tumor who is scheduled for discharge tomorrow D. Patient with traumatic injury to the cervical spinal cord who was admitted today from the emergency department

D. Patient with traumatic injury to the cervical spinal cord who was admitted today from the emergency department The patient with the cervical spinal cord injury is potentially the most unstable and needs an experienced, professional nurse.

A 67-year-old patient hospitalized with osteomyelitis has an order for bed rest with bathroom privileges with the affected foot elevated on two pillows. The nurse would place highest priority on which intervention? A. Ambulate the patient to the bathroom every 2 hours. B. Ask the patient about preferred activities to relieve boredom. C. Allow the patient to dangle legs at the bedside every 2 to 4 hours. D. Perform frequent position changes and range-of-motion exercises.

D. Perform frequent position changes and range-of-motion exercises. The patient is at risk for atelectasis of the lungs and for contractures because of prescribed bed rest. For this reason, the nurse should place the priority on changing the patient's position frequently to promote lung expansion and performing range-of-motion (ROM) exercises to prevent contractures. Assisting the patient to the bathroom will keep the patient safe as the patient is in pain, but it may not be needed every 2 hours. Providing activities to relieve boredom will assist the patient to cope with the bed rest, and dangling the legs every 2 to 4 hours may be too painful. The priority is position changes and ROM exercises.

When the patient is diagnosed with muscular dystrophy, what information should the nurse include in the teaching about this disorder? A. Prolonged bed rest will be used to decrease fatigue. B. An orthotic jacket will limit mobility and may contribute to deformity. C. Continuous positive airway pressure will be used to facilitate sleeping. D. Remain active to prevent skin breakdown and respiratory complications.

D. Remain active to prevent skin breakdown and respiratory complications. With muscular dystrophy, it is important for the patient to remain active for as long as possible. Prolonged bed rest should be avoided because immobility leads to further muscle wasting. An orthotic jacket may be used to provide stability and prevent further deformity. Continuous positive airway pressure (CPAP) is used as respiratory function decreases, before mechanical ventilation is needed to sustain respiratory function.

What is the primary treatment for a primary neoplasm on the spine? A. High-dose oral corticosteroids B. Methylprednisolone IV C. Chemotherapy D. Surgery

D. Surgery Treatment for most spinal cord tumors is surgical removal. Because autodestruction does not occur, recovery without residual problems is possible after the physical compression is relieved.

Which nursing diagnosis is of highest priority for a patient with Parkinson's disease who is unable to move the facial muscles? a. Activity intolerance b. Self-care deficit: toileting c. Ineffective self-health management d. Imbalanced nutrition: less than body requirements

D. The data about the patient indicate that poor nutrition will be a concern because of decreased swallowing. The other diagnoses may also be appropriate for a patient with Parkinson's disease, but the data do not indicate that they are current problems for this patient.

You are caring for a patient admitted 1 week earlier with an acute spinal cord injury. Which assessment finding alerts you to the presence of autonomic dysreflexia? A. Tachycardia B. Hypotension C. Hot, dry skin D. Throbbing headache

D. Throbbing headache Autonomic dysreflexia is related to reflex stimulation of the sympathetic nervous system, which is reflected by hypertension, bradycardia, throbbing headache, and diaphoresis.

Which prescribed intervention will the nurse implement first for a patient in the emergency department who is experiencing continuous tonic-clonic seizures? a. Give phenytoin (Dilantin) 100 mg IV. b. Monitor level of consciousness (LOC). c. Obtain computed tomography (CT) scan. d. Administer lorazepam (Ativan) 4 mg IV.

D. To prevent ongoing seizures, the nurse should administer rapidly acting antiseizure medications such as the benzodiazepines. A CT scan is appropriate, but prevention of any seizure activity during the CT scan is necessary. Phenytoin will also be administered, but it is not rapidly acting. Patients who are experiencing tonic-clonic seizures are nonresponsive, although the nurse should assess LOC after the seizure.

What is a predominant causative trigger for the painful episodes in trigeminal neuralgia? A. Staphylococcus aureus cellulitis B. Misaligned bite of molar teeth C. Direct trauma to transmandibular joint D. Touching along the lower jaw

D. Touching along the lower jaw Touch and tickle predominate as causative triggers. Others include chewing, tooth brushing, hot or cold blast of air on the face, washing the face, yawning, or talking. The other options are not significant causative factors.

The patient arrives in the emergency department from a motor vehicle accident, during which the car ran into a tree. The patient was not wearing a seat belt, and the windshield is shattered. What action is most important for you to do? A. Determine if the patient lost consciousness. B. Assess the Glasgow Coma Scale (GCS) score. C. Obtain a set of vital signs. D. Use a logroll technique when moving the patient.

D. Use a logroll technique when moving the patient. When the head hits the windshield with enough force to shatter it, you must assume neck or cervical spine trauma occurred and you need to maintain spinal precautions. This includes moving the patient in alignment as a unit or using a logroll technique during transfers. The other options are important and are done after spinal precautions are applied.

What is the most common cause of Guillain-Barré syndrome? A. Parasite infestation causing demyelinization. B. Brain neuron damage from plaques. C. Systemic sepsis from a bacterial infection. D. Viral infection or immunization.

D. Viral infection or immunization. The syndrome is often preceded by immune system stimulation by a viral infection, trauma, surgery, viral immunization, or human immunodeficiency virus (HIV). The other options are not related to Guillain-Barré syndrome.

Skull radiographs and a computed tomography (CT) scan provide evidence of a depressed parietal fracture with a subdural hematoma in a patient admitted to the emergency department following an automobile accident. In planning care for the patient, the nurse anticipates that a. the patient will receive life-support measures until the condition stabilizes b. immediate burr holes will be made to rapidly decompress the intracranial activity c. the patient will be treated conservatively with close monitoring for changes in neurologic condition d. the patient will be taken to surgery for a craniotomy for evacuation of blood and decompression of the cranium

D. When there is a depressed fracture and fractures with loose fragments, a craniotomy is indicated to elevate the depressed bone and remove free fragments. A craniotomy is also indicated in cases of acute subdural and epidural hematomas to remove the blood and control the bleeding. Burr holes may be used in an extreme emergency for rapid decompression, but with a depressed fracture, surgery would be the treatment of choice

The basic pathophysiologic process of rheumatoid arthritis (RA) is a. destruction of joint cartilage and bones by an autoimmune process b. initiated by a viral infection that destroys the synovial membranes of joints c. the presence of HLA-DR4 antigen that causes inflammatory responses throughout the body d. an immune response that activates complement and produces inflammation of joints and other organ systems

D. an immune response that activates complement and produces inflammation of joints and other organ systems

A 60-year-old woman has pain on motion in her fingers and asks the nurse whether this is just a result of aging. The best response by the nurse includes the information that a. joint pain with functional limitation is a normal change that affects all people to some extent b. joint pain that develops with age is usually related to previous trauma or infection of the joints c. this is a symptom of a systemic arthritis that eventually affects all joints as the disease progresses d. changes in the cartilage and bones of joints may cause symptoms of pain and loss of function in some people as they age

D. changes in the cartilage and bones of joints may cause symptoms of pain and loss of function in some people as they age.

A nursing intervention is indicated for the patient with hemiplegia is a. the use of a footboard to prevent plantar flexion b. immobilization of the affected arm against the chest with a sling c. positioning the patient in bed with each joint lower than the joint proximal to it d. having the patient perform passive ROM of the affected limb with the unaffected limb

D: Having the patient perform passive ROM of the affected limb with the unaffected limb- active ROM should be initiated on the unaffected side as soon as possible, and passive ROM of the affected side should be started on the first day. Having the patient actively exercise the unaffected side provides the patient with active and passive ROM as needed. Use of footboards is controversial because they stimulate plantar flexion. The unaffected arm should be supported, but immobilization may precipitate a painful shoulder-hand syndrome. The patient should be positioned with each joint higher than the joint proximal to it to prevent dependent edema.

The nurse can assist the patient and the family in coping with the long term effects of a stroke by a. informing family members that the patient will need assistance with almost all ADLs b. explaining that the patient's prestroke behavior will return as improvement progresses c. encouraging the patient and family members to seek assistance from family therapy or stroke support groups d. helping the patient and family understand the significance of residual stroke damage to promote problem solving and planning

D: Helping the patient and family understand the significance of residual stroke damage to promote problem solving and planning- the patient and family need accurate and complete information about the effects of the stroke to problem solve and make plans for chronic care of the patient. It is uncommon for patients with major strokes to return completely to pre stroke function, behaviors, and role, and both the patient and family will mourn these losses. The patient's specific needs for care must be identified, and rehabilitation efforts should be continued at home. Family therapy and support groups may be helpful for some patients and families.

The priority intervention in the emergency department for the patient with a stroke is a. intravenous fluid replacement b. administration of osmotic diuretics to reduce cerebral edema c. initiation of hypothermia to decrease the oxygen needs of the brain d. maintenance of respiratory function with a patent airway and oxygen administration

D: Maintenance of respiratory function with a patent airway and oxygen administration- the first priority in acute management of the patient with a stroke is preservation of life. Because the patient with a stroke may be unconscious or have a reduced gag reflex, it is most important to maintain a patent airway for the patient and provide oxygen if respiratory effort is impaired. IV fluid replacement, treatment with osmotic diuretics, and perhaps hypothermia may be used for further treatment.

A patient's wife asks the nurse why her husband did not receive the clot busting medication (tPA) she has been reading about. Her husband is diagnosed with a hemorrhagic stroke. What should the nurse respond? a. He didn't arrive within the time frame for that therapy b. Not every is eligible for this drug. Has he had surgery lately? c. You should discuss the treatment of your husband with your doctor d. The medication you are talking about dissolves clots and could cause more bleeding in your husband's head

D: The medication you are talking about dissolves clots and could cause more bleeding in your husband's head- tPA dissolves clots and increases the risk for bleeding. It is not used with hemorrhagic strokes. If the patient had a thrombotic/embolic stroke the time frame would be important as well as a history of surgery. The nurse should answer the question as accurately as possible and then encourage the individual to talk with the primary care physician if he or she has further questions.

Which statements are true about the skin and skin care(select all that apply)? A. One of the detrimental effects of obesity on the skin is increased sweating. B. The nutrient that is critical in maintaining and repairing the structure of epithelial cells is vitamin C. C. Exposure to UVA rays is believed to be the most important factor in the development of skin cancer. D. The photosensitivity caused by various drugs can be blocked by the use of topical hydrocortisone. E. Photosensitivity results when certain chemicals in body cells and tissues absorb light from the sun and release energy that harms the tissues and cells. F. When teaching a patient about the use of sunscreens that protect against exposure to both UVA and UVB rays, the nurse advises the patient to look for inclusion of benzophenones.

a, e, f. Vitamin A, not vitamin C, is critical in maintaining and repairing the structure of epithelial cells. Exposure of UVB rays, not UVA rays, is believed to be the most important factor in the development of skin cancer. Sunscreen, not topical hydrocortisone, can block the photosensitivity caused by various drugs.

What skin condition has keratotic and firm lesions, is a precursor of squamous cell carcinoma, and is treated with topical fluorouracil (5-FU)? a. Actinic keratosis B. Basal cell carcinoma C. Malignant melanoma D. Squamous cell carcinoma

a. Basal cell carcinoma is noduloulcerative with pearly borders. Malignant melanomas tumors arise in melanocytes. Malignant melanoma is the deadliest skin cancer and has an increased risk in people with dysplastic nevus syndrome. Squamous cell carcinoma is a malignant neoplasm of keratinizing epidermal cells.

What are the most appropriate dressings to use to promote comfort for a patient with inflamed, pruritic dermatitis? A. Cool tap water dressings B. Cool acetic acid dressings C. Warm sterile saline dressings D. Warm potassium permanganate dressings

a. Dressings used to treat pruritic lesions should be cool to cause vasoconstriction and to have an anti-inflammatory effect. Water is most commonly used and it does not need to be sterile. Acetic acid solutions are bactericidal and are used to treat skin infections.

Identify two ways the following three-volume components of intracranial pressure (ICP) can be changed to adapt to small increases in intracranial pressure. a. Cerebrospinal fluid (CSF) b. Brain Tissue c. Blood tissue

a. Increased absorption, decreased production, displacement into spinal canal b. herniation, lesion, edema, collapse of veins and dural sinuses, increased venous outflow and decreased blood flow c. distention of dura, slight compression of tissue

Before discharge from the same-day surgery unit, instruct the patient who has had a surgical correction of bilateral hallux valgus to a.rest frequently with the feet elevated. b.soak the feet in warm water several times a day. c.expect the feet to be numb for the next few days. d.expect continued pain in the feet, since this is not uncommon.

a.rest frequently with the feet elevated. After surgical correction of bilateral hallux valgus, the feet should be elevated with the heel off the bed to help reduce discomfort and prevent edema.

What is the most common skin cancer and causes pearly borders? A. Actinic keratosis B. Basal cell carcinoma C. Malignant melanoma D. Squamous cell carcinoma

b. Actinic keratosis is an irregularly shaped, flat, slightly erythematous papule with indistinct borders and an overlying hard keratotic scale or horn. Malignant melanoma tumors arise in melanocytes. Malignant melanoma is the deadliest skin cancer and has an increased risk in people with dysplastic nevus syndrome. Squamous cell carcinoma is a malignant neoplasm of keratinizing epidermal cells.

Priority Decision: A patient is receiving chemotherapy. She calls the physician's office and says she is experiencing itching in her groin and under her breasts. What is the first nursing assessment that would be done before the nurse makes an appointment for the patient with the physician to determine the treatment? A. Her height and weight B. What the areas look like C. If chemotherapy was completed D. Culture and sensitivity of the areas

b. The appearance of candidiasis on the skin shows diffuse popular erythematous rash with pinpoint satellites around the affected area. Height and weight could show if the patient is obese but it would be better to ask if the areas affected are moist. The chemotherapy could contribute to candidiasis but it does not matter if the chemotherapy treatments are finished. Culture and sensitivity of the area may be ordered by the physician at the patient's appointment.

What should the nurse include in the instructions for a patient with urticarial? A. Apply topical benzene hexachloride. B. Avoid contact with the causative agent. C. Gradually expose the area to increasing amounts of sunlight D. Use over-the-counter antihistamines routinely to prevent the condition.

b. Uticaria is inflammation and edema in the upper dermis, most commonly caused by histamine released during an antibody-allergen reaction. The best treatment for all types of allergic dermatitis is avoidance of the allergen. Sunlight and warmth would increase the edema and inflammation. Antihistamines may be used for an acute outbreak but not to prevent the dermatitis.

You are teaching a patient with osteopenia. What is important to include in the teaching plan? a.Lose weight. b.Stop smoking. c.Eat a high-protein diet. d.Start swimming for exercise

b.Stop smoking. Patients with osteopenia should be instructed to quit smoking in order to decrease loss of bone mass.

Which skin conditions are more common in immunosuppressed patients (select all that apply)? A. Acne B. Lentigo C. Candidiasis D. Herpes Zoster E. Herpes simplex 1 F. Kaposi sarcoma

c,e,f. Patients who are immunocompromised are at an increased risk for candidiasis (a fungal infection), herpes simplex 1 (caused by a virus), and Kaposi sarcoma(vascular lesions on the skin, mucous membranes, and viscera with wide range presentation). The other options are not at increased risk with immunosuppression. Acne is caused by inflammation of sebaceous glands. lentigo (also called "liver spots" or "age spots") is caused by increased number of normal melanocytes in the basal layer of epidermis. Hepres zoster virus, which is a group of vesicles and pustules resembling chickenpox located in linear distribution along dermatome.

A patient with contact dermatitis is treated with calamine lotion. What is the rationale for using this base for a topical preparation. A. A suspension of oil and water to lubricate and prevent drying B. An emulsion of oil and water used for lubrication and protection C. Insoluble powders suspended in water that leave a residual powder on the skin D. A mixture of a powder and ointment that causes drying when moisture is absorbed.

c. A lotion with a suspension of insoluble powders in water, which has cooling and drying properties, useful when itching is present. Creams and ointments have an oil and water base that lubricates and protects skin whereas a paste is a mixture of powder and ointment.

What characteristic is commonly seen with dysplastic nevus syndrome? A. Associated with sun exposure B. Precursor of squamous cell carcinoma C. Slow-growing tumor with rare metastasis D. Lesion has irregular color and asymmetric shape

d. Dysplastic nevus syndrome involves atypical moles with irregular borders and various shades of color.