NCLEX Review Quiz 7 Saunder's Questions (Ch. 45, 46, 66-69)

470. The nurse is providing instructions to the parents of a child with scoliosis regarding the use of a brace. Which statement by the parents indicates a need for further instruction? 1. "I will encourage my child to perform prescribed exercises." 2. "I will have my child wear soft fabric clothing under the brace." 3. "I should apply lotion under the brace to prevent skin breakdown." 4. "I should avoid the use of powder because it will cake under the brace."

3 A brace may be prescribed to treat scoliosis. Braces are not curative, but may slow the progression of the curvature to allow skeletal growth and maturity. The use of lotions or powders under a brace should be avoided because they can become sticky and cake under the brace, causing irritation. Options 1, 2, and 4 are appropriate interventions in the care of a child with a brace.

837. The nurse is admitting a client with multiple trauma to the nursing unit. The client has a leg fracture and had a plaster cast applied. Which position would be best for the casted leg? 1. Flat for 12 hours, then elevated for 12 hours. 2. Elevated for 3 hours and then flat for 1 hour. 3. Flat for 3 hours and then elevated for 1 hour. 4. Elevated on pillows continuously for 24 to 48 hours.

4 A casted extremity is elevated continuously for the first 24 to 48 hours to minimize swelling and promote venous drainage. Options 1, 2, and 3 are incorrect.

851. Colchicine is prescribed for a client with a diagnosis of gout. The nurse reviews the client's record, knowing that this medication would be used with caution in which disorder? 1. Myxedema 2. Kidney disease 3. Hypothyroidism 4. Diabetes mellitus

2 Colchicine is used with caution in older clients, debilitated clients, and clients with cardiac, kidney, or gastrointestinal disease. The disorders in options 1, 3, and 4 are not concerns with administration of this medication.

473. Parents bring their 2-week-old infant to a clinic for treatment after a diagnosis of clubfoot made at birth. Which statement by the parents indicates a need for further teaching regarding this disorder? 1. "Treatment needs to be started as soon as possible." 2. "I realize my infant will require follow-up care until fully grown." 3. "I need to bring my infant back to the clinic in 1 month for a new cast." 4. "I need to come to the clinic every week with my infant for the casting."

3 Clubfoot is a complex deformity of the ankle and foot that includes forefoot adduction, midfoot supination, hindfoot varus, and ankle equinus; the defect may be unilateral or bilateral. Treatment for clubfoot is started as soon as possible after birth. Serial manipulation and casting are performed at least weekly. If sufficient correction is not achieved in 3 to 6 months, surgery usually isindicated. Because clubfoot can recur, all children with clubfoot require long-term interval follow-up until they reach skeletal maturity to ensure an optimal outcome.

804. The nurse is evaluating the neurological signs of a client in spinal shock following spinal cord injury. Which observation indicates that spinal shock persists? 1. Hyperreflexia 2. Positive reflexes 3. Flaccid paralysis 4. Reflex emptying of the bladder

3 Resolution of spinal shock is occurring when there is return of reflexes (especially flexors to noxious cutaneous stimuli), a state of hyperreflexia rather than flaccidity, and reflex emptying of the bladder.

801. A client recovering from a head injury is participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure if the nurse observes the client doing which activity? 1. Blowing the nose 2. Isometric exercises 3. Coughing vigorously 4. Exhaling during repositioning

4 Activities that increase intrathoracic and intraabdominal pressures cause an indirect elevation of the intracranial pressure. Some of these activities include isometric exercises, Valsalva's maneuver, coughing, sneezing, and blowing the nose. Exhaling during activities such as repositioning or pulling up in bed, opens the glottis, which prevents intrathoracic pressure from rising.

457. The nurse is assigned to care for an 8-year-old child with a diagnosis of a basilar skull fracture. The nurse reviews the health care provider's (HCPs) prescriptions and should contact the HCP to question which prescription? 1. Suction as needed. 2. Obtain daily weight. 3. Provide clear liquid intake. 4. Maintain a patent intravenous line.

1 A basilar skull fracture is a type of head injury. Nasotracheal suctioning is contraindicated in a child with a basilar skull fracture: Because of the nature of the injury, there is a possibility that the catheter will enter the brain through the fracture, creating a high risk of secondary infection. Fluid balance is monitored closely by daily weight determination, intake and output measurement, and serum osmolality determination to detect early signs of water retention, excessive dehydration, and states of hypertonicity or hypotonicity. The child is maintained on NPO status or restricted to clear liquids until it is determined that vomiting will not occur. An intravenous line is maintained to administer fluids or medications if necessary.

838. A client is being discharged to home after application of a plaster leg cast. Which statement indicates that the client understands proper care of the cast? 1. "I need to avoid getting the cast wet." 2. "I need to cover the casted leg with warm blankets." 3. "I need to use my fingertips to lift and move my leg." 4. "I need to use something like a padded coat hanger end to scratch under the cast if it itches."

1 A plaster cast must remain dry to keep its strength. The cast should be handled with the palms of the hands, not the fingertips, until fully dry. Air should circulate freely around the cast to help it dry; the cast also gives off heat as it dries. The client should never scratch under the cast; the client may use a hair dryer on the cool setting to relieve an itch.

855. Cyclobenzaprine hydrochloride is prescribed for a client for muscle spasms and the nurse is reviewing the client's record. Which disorder, if noted in the record, would indicate a need to contact the health care provider about the administration of this medication? 1. Glaucoma 2. Emphysema 3. Hypothyroidism 4. Diabetes mellitus

1 Because cyclobenzaprine (Flexeril) has anticholinergic effects, it should be used with caution in clients with a history of urinary retention, glaucoma, and increased intraocular pressure. Cyclobenzaprine should be used only for a short time (2 to 3 weeks). The conditions in options 2, 3, and 4 are not a concern with this medication.

850. Allopurinol is prescribed for a client and the nurse provides medication instructions to the client. Which instruction should the nurse provide? 1. Drink 3000 mL of fluid a day. 2. Take the medication on an empty stomach. 3. The effect of the medication will occur immediately. 4. Any swelling of the lips is a normal expected response.

1 Clients taking allopurinol are encouraged to drink 3000 mL of fluid a day. A full therapeutic effect may take 1 week or longer. Allopurinol is to be given with, or immediately after, meals or milk. A client who develops a rash, irritation of the eyes, or swelling of the lips or mouth should contact the health care provider because this may indicate hypersensitivity.

472. A 1-month-old infant is seen in a clinic and is diagnosed with developmental dysplasia of the hip. On assessment, the nurse understands that which finding should be noted in this condition? 1. Limited range of motion in the affected hip 2. An apparent lengthened femur on the affected side 3. Asymmetrical adduction of the affected hip when the infant is placed supine with the knees and hips flexed 4. Symmetry of the gluteal skinfolds when the infant is placed prone and the legs are extended against the examining table

1 In developmental dysplasia of the hip, the head of the femur is seated improperly in the acetabulum or hip socket of the pelvis. Asymmetrical and restricted abduction of the affected hip, when the child is placed supine with the knees and hips flexed, would be an assessment finding in developmental dysplasia of the hip in infants beyond the newborn period. Other findings include an apparent short femur on the affected side, asymmetry of the gluteal skinfolds, and limited range of motion in the affected extremity.

471. The nurse is assisting a health care provider (HCP) examining an infant with developmental dysplasia of the hip perform an Ortolani maneuver. The nurse understands that this maneuver is performed for which purpose? 1. To assess for hip instability 2. To assess for movement of the hips 3. To push the femoral head out of the acetabulum 4. To ensure that hyperextension and full range of motion exist

1 In developmental dysplasia of the hip, the head of the femur is seated improperly in the acetabulum or hip socket of the pelvis. Ortolani's maneuver is a test to assess for hip instability. The examiner abducts the thigh and applies gentle pressure forward over the greater trochanter. A "clicking" sensation indicates a dislocated femoral head moving into the acetabulum. This maneuver does not assess for hip movement or ensure that hyperextension and full range of motion exist. Pushing the femoral head out of the acetabulum is not the purpose of Ortolani's maneuver.

824. The client arrives at the emergency department complaining of back spasms. The client states, "I have been taking two to three aspirin every 4 hours for the last week, and it hasn't helped my back." Since aspirin intoxication is suspected, the nurse should assess the client for which manifestation? 1. Tinnitus 2. Diarrhea 3. Constipation 4. Photosensitivity

1 Mild intoxication with acetylsalicylic acid (aspirin) is called salicylism and is experienced commonly when the daily dosage is higher than 4 g. Tinnitus (ringing in the ears) is the most frequent effect noted with intoxication. Hyperventilation may occur because salicylate stimulates the respiratory center. Fever may result, because salicylate interferes with the metabolic pathways coupling oxygen consumption and heat production. Options 2, 3, and 4 are not associated specifically with toxicity.

846. The nurse is caring for a client who has had spinal fusion, with insertion of hardware. The nurse would be most concerned with which assessment finding? 1. Temperature of 101.6° F orally 2. Complaints of discomfort during repositioning 3. Old bloody drainage outlined on the surgical dressing 4. Discomfort during coughing and deep-breathing exercises

1 The nursing assessment conducted after spinal surgery is similar to that done after other surgical procedures. For this specific type of surgery, the nurse assesses the neurovascular status of the lower extremities, watches for signs and symptoms of infection, and inspects the surgical site for evidence of cerebrospinal fluid leakage (drainage is clear and tests positive for glucose). A mild temperature is expected after insertion of hardware, but a temperature of 101.6° F should be reported.

806. The nurse is assigned to care for a client with complete right-sided hemiparesis. Which characteristics are associated with this condition? Select all that apply. 1. The client is aphasic. 2. The client has weakness in the face and tongue. 3. The client has weakness on the right side of the body. 4. The client has complete bilateral paralysis of the arms and legs. 5. The client has lost the ability to move the right arm but is able to walk independently. 6. The client has lost the ability to ambulate independently but is able to feed and bathe himself or herself without assistance.

1, 2, 3 Hemiparesis is a weakness of one side of the body that may occur after a stroke. It involves weakness of the face and tongue, arm, and leg on one side. These clients are also aphasic: unable to discriminate words and letters. They are generally very cautious and get anxious when attempting a new task. Complete bilateral paralysis does not occur in hemiparesis. The client with right-sided hemiparesis has weakness of the right arm and leg and needs assistance with feeding, bathing, and ambulating.

856. In monitoring a client's response to disease-modifying antirheumatic drugs, which assessment findings would the nurse consider acceptable responses? Select all that apply. 1. Symptom control during periods of emotional stress 2. Normal white blood cell, platelet, and neutrophil counts 3. Radiological findings that show no progression of joint degeneration 4. An increased range of motion in the affected joints 3 months into therapy 5. Inflammation and irritation at the injection site 3 days after the injection is given 6. A low-grade temperature on rising in the morning that remains throughout the day

1, 2, 3, 4 Because emotional stress frequently exacerbates the symptoms of rheumatoid arthritis, the absence of symptoms is a positive finding. DMARDs are given to slow the progression of joint degeneration. In addition, an improvement in the range of motion after 3 months of therapy with normal blood work is a positive finding. Temperature elevation and inflammation and irritation at the medication injection site could indicate signs of infection.

840. The nurse has given a client instructions about crutch safety. Which client statement indicates that the client understands the instructions? Select all that apply. 1. "I should not use someone else's crutches." 2. "I need to remove any scatter rugs at home." 3. "I can use crutch tips even when they are wet." 4. "I need to have spare crutches and tips available." 5. "When I'm using the crutches my arms need to be completely straight."

1, 2, 4 The client should use only crutches measured for the client. When assessing for home safety, make sure the client knows to remove any scatter rugs and does not walk on highly waxed floors. The tips should be inspected for wear, and spare crutches and tips should be available if needed. Crutch tips should remain dry. If crutch tips get wet, the client should dry them with a cloth or paper towel. When walking with crutches, both elbows need to be flexed not more than 30 degrees when the palms are on the handle.

815. The nurse is planning to institute seizure precautions for a client who is being admitted from the emergency department. Which measures should the nurse include in planning for the client's safety? Select all that apply. 1. Padding the side rails of the bed 2. Placing an airway at the bedside 3. Placing the bed in the high position 4. Putting a padded tongue blade at the head of the bed 5. Placing oxygen and suction equipment at the bedside 6. Having intravenous equipment ready for insertion of an intravenous catheter

1, 2, 5, 6 Seizure precautions may vary from agency to agency, but they generally have some common features. Usually, an airway, oxygen, and suctioning equipment are kept available at the bedside. The side rails of the bed are padded, and the bed is kept in the lowest position. The client has an intravenous access in place to have a readily accessible route if anticonvulsant medications must be administered. The use of padded tongue blades is highly controversial, and they should not be kept at the bedside. Forcing a tongue blade into the mouth during a seizure more likely will harm the client who bites down during seizure activity. Risks include blocking the airway from improper placement, chipping the client's teeth, and subsequent risk of aspirating tooth fragments. If the client has an aura before the seizure, it may give the nurse enough time to place an oral airway before seizure activity begins.

800. The nurse is caring for the client with increased intracranial pressure. The nurse would note which trend in vital signs if the intracranial pressure is rising? 1. Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure 2. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure 3. Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure 4. Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure

2 A change in vital signs may be a late sign of increased intracranial pressure. Trends include increasing temperature and blood pressure and decreasing pulse and respirations. Respiratory irregularities also may occur.

853. The nurse is preparing discharge instructions for a client receiving baclofen. Which instruction should be included in the teaching plan? 1. Restrict fluid intake. 2. Avoid the use of alcohol. 3. Stop the medication if diarrhea occurs. 4. Notify the health care provider (HCP) if fatigue occurs.

2 Baclofen is a skeletal muscle relaxant. The client should be cautioned against the use of alcohol and other central nervous system depressants because baclofen potentiates the depressant activity of these agents. Constipation rather than diarrhea is a side/adverse effect. Restriction of fluids is not necessary, but the client should be warned that urinary retention can occur. Fatigue is related to a central nervous system effect that is most intense during the early phase of therapy and diminishes with continued medication use. The client does not need to notify the HCP about fatigue.

847. The nurse is caring for a client with a diagnosis of gout. Which laboratory value would the nurse expect to note in the client? 1. Calcium level of 9.0 mg/dL 2. Uric acid level of 8.6 mg/dL 3. Potassium level of 4.1 mEq/L 4. Phosphorus level of 3.1 mg/dL

2 In addition to the presence of clinical manifestations, gout is diagnosed by the presence of persistent hyperuricemia, with a uric acid level higher than 8 mg/dL; a normal value ranges from 2.5 to 8 mg/dL. Options 1, 3, and 4 indicate normal laboratory values. In addition, the presence of uric acid in an aspirated sample of synovial fluid confirms the diagnosis.

849. A client has been on treatment for rheumatoid arthritis for 3 weeks. During the administration of etanercept, which is most important for the nurse to assess? 1. The injection site for itching and edema 2. The white blood cell counts and platelet counts 3. Whether the client is experiencing fatigue and joint pain 4. Whether the client is experiencing a metallic taste in the mouth, and a loss of appetite

2 Infection and pancytopenia are side/adverse effects of etanercept. Laboratory studies are performed prior to and during medication treatment. The appearance of abnormal white blood cell counts and abnormal platelet counts can alert the nurse to a potentially life-threatening infection. Injection site itching is a common occurrence following administration. A metallic taste and loss of appetite are not common signs of side/adverse effects of this medication.

845. A client is complaining of low back pain that radiates down the left posterior thigh. The nurse should ask the client if the pain is worsened or aggravated by which factor? 1. Bed rest 2. Bending or lifting 3. Application of heat 4. Ibuprofen

2 Low back pain that radiates into one leg (sciatica) is consistent with herniated lumbar disk. The nurse assesses the client to see whether the pain is aggravated by events that increase intraspinal pressure, such as bending, lifting, sneezing, and coughing, or by lifting the leg straight up while supine (straight leg-raising test). Bed rest, heat (or sometimes ice), and nonsteroidal antiinflammatory drugs usually relieve back pain.

799. The nurse is assessing the motor function of an unconscious client. The nurse should plan to use which technique to test the client's peripheral response to pain? 1. Sternal rub 2. Nail bed pressure 3. Pressure on the orbital rim 4. Squeezing of the sternocleidomastoid muscle

2 Motor testing in the unconscious client can be done only by testing response to painful stimuli. Nail bed pressure tests a basic peripheral response. Cerebral responses to pain are tested using a sternal rub, placing upward pressure on the orbital rim, or squeezing the clavicle or sternocleidomastoid muscle.

805. The nurse is caring for a client who begins to experience seizure activity while in bed. Which action by the nurse is contraindicated? 1. Loosening restrictive clothing 2. Restraining the client's limbs 3. Removing the pillow and raising padded side rails 4. Positioning the client to the side, if possible, with the head flexed forward

2 Nursing actions during a seizure include providing for privacy, loosening restrictive clothing, removing the pillow and raising padded side rails in the bed, and placing the client on one side with the head flexed forward, if possible, to allow the tongue to fall forward and facilitate drainage. The limbs are never restrained because the strong muscle contractions could cause the client harm. If the client is not in bed when seizure activity begins, the nurse lowers the client to the floor, if possible, protects the head from injury, and moves furniture that may injure the client.

467. A 4-year-old child sustains a fall at home and after an x-ray examination, the child is determined to have a fractured arm and a plaster cast is applied. The nurse provides instructions to the parents regarding care for the child's cast. Which statement by the parents indicates a need for further instruction? 1. "The cast may feel warm as the cast dries." 2. "I can use lotion or powder around the cast edges to relieve itching." 3. "A small amount of white shoe polish can touch up a soiled white cast." 4. "If the cast becomes wet, a blow drier set on the cool setting may be used to dry the cast."

2 Teaching about cast care is essential to prevent complications from the cast. The parents need to be instructed not to use lotion or powders on the skin around the cast edges or inside the cast. Lotions or powders can become sticky or caked and cause skin irritation. Options 1, 3, and 4 are appropriate statements.

842. The nurse has conducted teaching with a client in an arm cast about the signs and symptoms of compartment syndrome. The nurse determines that the client understands the information if the client states that he or she should report which early symptom of compartment syndrome? 1. Cold, bluish-colored fingers 2. Numbness and tingling in the fingers 3. Pain that increases when the arm is dependent 4. Pain that is out of proportion to the severity of the fracture

2 The earliest symptom of compartment syndrome is paresthesia (numbness and tingling in the fingers). Other symptoms include pain unrelieved by opioids, pain that increases with limb elevation, and pallor and coolness to the distal limb. Cyanosis is a late sign. Pain that is out of proportion to the severity of the fracture, along with other symptoms associated with the pain, is not an early manifestation.

817. The nurse has completed discharge instructions for a client with application of a halo device. Which action indicates that the client needs further clarification of the instructions? 1. Uses a straw for drinking. 2. Drives only during the daytime. 3. Uses caution because the device alters balance. 4. Washes the skin daily under the lamb's wool liner of the vest.

2 The halo device alters balance and can cause fatigue because of its weight. The client should cleanse the skin daily under the vest to protect the skin from ulceration and should avoid the use of powder or lotions. The liner should be changed if odor becomes a problem. The client should have food cut into small pieces to facilitate chewing and use a straw for drinking. Pin care is done as instructed. The client cannot drive at all because the device impairs the range of vision.

814. A client has a neurological deficit involving the limbic system. Which assessment finding is specific to this type of deficit? 1. Is disoriented to person, place, and time 2. Affect is flat, with periods of emotional lability 3. Cannot recall what was eaten for breakfast today 4. Demonstrates inability to add and subtract; does not know who is the president of the United States

2 The limbic system is responsible for feelings (affect) and emotions. Calculation ability and knowledge of current events relate to function of the frontal lobe. The cerebral hemispheres, with specific regional functions, control orientation. Recall of recent events is controlled by the hippocampus.

827. The nurse has given medication instructions to a client receiving phenytoin. Which statement indicates that the client has an adequate understanding of the instructions? 1. "Alcohol is not contraindicated while taking this medication." 2. "Good oral hygiene is needed, including brushing and flossing." 3. "The medication dose may be self-adjusted, depending on side effects." 4. "The morning dose of the medication should be taken before a serum drug level is drawn."

2 Typical anticonvulsant medication instructions include taking the prescribed daily dosage to keep the blood level of the drug constant and having a sample drawn for serum drug level determination before taking the morning dose. The client is taught not to stop the medication abruptly, to avoid alcohol, to check with a health care provider before taking over-the-counter medications, to avoid activities in which alertness and coordination are required until medication effects are known, to provide good oral hygiene, and to obtain regular dental care. The client should also wear a Medic-Alert bracelet.

826. The nurse is caring for a client with severe back pain. Codeine sulfate has been prescribed for the client. Specific to this medication, which intervention should the nurse include in the plan of care while the client is taking this medication? 1. Monitor radial pulse. 2. Monitor bowel activity. 3. Monitor apical heart rate. 4. Monitor peripheral pulses.

2 While the client is taking codeine sulfate, the nurse would monitor vital signs and assess for hypotension. The nurse also should increase fluid intake, palpate the bladder for urinary retention, auscultate bowel sounds, and monitor the pattern of daily bowel activity and stool consistency because the medication causes constipation. The nurse should monitor respiratory status and initiate deep-breathing and coughing exercises. In addition, the nurse monitors the effectiveness of the pain medication.

822. Meperidine hydrochloride has been prescribed for a client to treat pain. Which are side/adverse effects of this medication? Select all that apply. 1. Diarrhea 2. Tremors 3. Drowsiness 4. Hypotension 5. Urinary frequency 6. Increased respiratory rate

2, 3, 4 Meperidine hydrochloride is an opioid analgesic. Side/adverse effects include respiratory depression, drowsiness, hypotension, constipation, urinary retention, nausea, vomiting, and tremors.

474. The nurse prepares a list of home care instructions for the parents of a child who has a plaster cast applied to the left forearm. Which instructions should be included on the list? Select all that apply. 1. Use the fingertips to lift the cast while it is drying. 2. Keep small toys and sharp objects away from the cast. 3. Use a padded ruler or another padded object to scratch the skin under the cast if it itches. 4. Place a heating pad on the lower end of the cast and over the fingers if the fingers feel cold. 5. Elevate the extremity on pillows for the first 24 to 48 hours after casting to prevent swelling. 6. Contact the health care provider (HCP) if the child complains of numbness or tingling in the extremity.

2, 5, 6 While the cast is drying, the palms of the hands are used to lift the cast. If the fingertips are used, indentations in the cast could occur and cause constant pressure on the underlying skin. Small toys and sharp objects are kept away from the cast, and no objects (including padded objects) are placed inside the cast because of the risk of altered skin integrity. The extremity is elevated to prevent swelling, and the HCP is notified immediately if any signs of neurovascular impairment develop. A heating pad is not applied to the cast or fingers. Cold fingers could indicate neurovascular impairment, and the HCP should be notified.

458. The nurse is reviewing the record of a child with increased intracranial pressure and notes that the child has exhibited signs of decerebrate posturing. On assessment of the child, the nurse expects to note which characteristic of this type of posturing? 1. Flaccid paralysis of all extremities 2. Adduction of the arms at the shoulders 3. Rigid extension and pronation of the arms and legs 4. Abnormal flexion of the upper extremities and extension and adduction of the lower extremities

3 Decerebrate (extension) posturing is characterized by the rigid extension and pronation of the arms and legs. Option 1 is incorrect. Options 2 and 4 describe decorticate (flexion) posturing.

854. The nurse is analyzing the laboratory studies on a client receiving dantrolene sodium. Which laboratory test would identify an adverse effect associated with the administration of this medication? 1. Platelet count 2. Creatinine level 3. Liver function tests 4. Blood urea nitrogen level

3 Dose-related liver damage is the most serious adverse effect of dantrolene. To reduce the risk of liver damage, liver function tests should be performed before treatment and throughout the treatment interval. Dantrolene is administered at the lowest effective dosage for the shortest time necessary.

811. The nurse has given suggestions to a client with trigeminal neuralgia about strategies to minimize episodes of pain. The nurse determines that the client needs further education if the client makes which statement? 1. "I will wash my face with cotton pads." 2. "I'll have to start chewing on my unaffected side." 3. "I'll try to eat my food either very warm or very cold." 4. "I should rinse my mouth if toothbrushing is painful."

3 Facial pain can be minimized by using cotton pads to wash the face and using room temperature water. The client should chew on the unaffected side of the mouth, eat a soft diet, and take in foods and beverages at room temperature. If toothbrushing triggers pain, an oral rinse after meals may be helpful instead.

829. A client with trigeminal neuralgia tells the nurse that acetaminophen is taken daily for the relief of generalized discomfort. Which laboratory value would indicate toxicity associated with the medication? 1. Sodium level of 140 mEq/L 2. Prothrombin time of 12 seconds 3. Direct bilirubin level of 2 mg/dL 4. Platelet count of 400,000 cells/mm3

3 In adults, overdose of acetaminophen causes liver damage. The correct option is an indicator of liver function and is the only option that indicates an abnormal laboratory value. The normal direct bilirubin level is 0 to 0.3 mg/dL. The normal sodium level is 135 to 145 mEq/L. The normal prothrombin time is 10 to 13 seconds. The normal platelet count is 150,000 to 400,000 cells/mm3.

857. The nurse is administering an intravenous dose of methocarbamol to a client with multiple sclerosis. For which side/adverse effects should the nurse monitor? 1. Tachycardia 2. Rapid pulse 3. Bradycardia 4. Hypertension

3 Intravenous administration of methocarbamol can cause hypotension and bradycardia. The nurse needs to monitor for these side/adverse effects. Options 1, 2, and 4 are not effects with administration of this medication.

468. The parents of a child with juvenile idiopathic arthritis call the clinic nurse because the child is experiencing a painful exacerbation of the disease. The parents ask the nurse if the child can perform range-of-motion exercises at this time. The nurse should make which response? 1. "Avoid all exercise during painful periods." 2. "Range-of-motion exercises must be performed every day." 3. "Have the child perform simple isometric exercises during this time." 4. "Administer additional pain medication before performing range-of-motion exercises."

3 Juvenile idiopathic arthritis is an autoimmune inflammatory disease affecting the joints and other tissues, such as articular cartilage. During painful episodes of juvenile idiopathic arthritis, hot or cold packs and splinting and positioning the affected joint in a neutral position help reduce the pain. Although resting the extremity is appropriate, beginning simple isometric or tensing exercises as soon as the child is able is important. These exercises do not involve joint movement.

461. A lumbar puncture is performed on a child suspected to have bacterial meningitis, and cerebrospinal fluid (CSF) is obtained for analysis. The nurse reviews the results of the CSF analysis and determines that which results would verify the diagnosis? 1. Clear CSF, decreased pressure, and elevated protein level 2. Clear CSF, elevated protein, and decreased glucose levels 3. Cloudy CSF, elevated protein, and decreased glucose levels 4. Cloudy CSF, decreased protein, and decreased glucose levels

3 Meningitis is an infectious process of the central nervous system caused by bacteria and viruses; it may be acquired as a primary disease or as a result of complications of neurosurgery, trauma, infection of the sinus or ears, or systemic infections. Meningitis is diagnosed by testing cerebrospinal fluid obtained by lumbar puncture. In the case of bacterial meningitis, findings usually include an elevated pressure; turbid or cloudy cerebrospinal fluid; and elevated leukocyte, elevated protein, and decreased glucose levels.

836. A client has sustained a closed fracture and has just had a cast applied to the affected arm. The client is complaining of intense pain. The nurse elevates the limb, applies an ice bag, and administers an analgesic, with little relief. Which problem may be causing this pain? 1. Infection under the cast 2. The anxiety of the client 3. Impaired tissue perfusion 4. The recent occurrence of the fracture

3 Most pain associated with fractures can be minimized with rest, elevation, application of cold, and administration of analgesics. Pain that is not relieved by these measures should be reported to the health care provider because pain unrelieved by medications and other measures may indicate neurovascular compromise. Because this is a new closed fracture and cast, infection would not have had time to set in. Intense pain after casting is normally not associated with anxiety or the recent occurrence of the injury. Treatment following the fracture should assist in relieving the pain associated with the injury.

820. The home health nurse visits a client who is taking phenytoin for control of seizures. During the assessment, the nurse notes that the client is taking birth control pills. Which information should the nurse include in the teaching plan? 1. Pregnancy should be avoided while taking phenytoin. 2. The client may stop the medication if it is causing severe gastrointestinal effects. 3. There is the potential of decreased effectiveness of birth control pills while taking phenytoin. 4. There is the increased risk of thrombophlebitis while taking phenytoin and birth control pills together.

3 Phenytoin enhances the rate of estrogen metabolism, which can decrease the effectiveness of some birth control pills. Options 1, 2, and 4 are inappropriate instructions.

835. The nurse is assessing the casted extremity of a client. Which sign is indicative of infection? 1. Dependent edema 2. Diminished distal pulse 3. Presence of a "hot spot" on the cast 4. Coolness and pallor of the extremity

3 Signs and symptoms of infection under a casted area include odor or purulent drainage from the cast or the presence of "hot spots," which are areas of the cast that are warmer than others. The health care provider should be notified if any of these occur. Signs of impaired circulation in the distal limb include coolness and pallor of the skin, diminished distal pulse, and edema.

816. The nurse is evaluating the status of a client who had a craniotomy 3 days ago. Which assessment finding would indicate that the client is developing meningitis as a complication of surgery? 1. A negative Kernig sign 2. Absence of nuchal rigidity 3. A positive Brudzinski sign 4. A Glasgow Coma Scale score of 15

3 Signs of meningeal irritation compatible with meningitis include nuchal rigidity, a positive Brudzinski sign, and positive Kernig sign. Nuchal rigidity is characterized by a stiff neck and soreness, which is especially noticeable when the neck is flexed. Kernig's sign is positive when the client feels pain and spasm of the hamstring muscles when the leg is fully flexed at the knee and hip. Brudzinski's sign is positive when the client flexes the hips and knees in response to the nurse gently flexing the head and neck onto the chest. A Glasgow Coma Scale score of 15 is a perfect score and indicates that the client is awake and alert, with no neurological deficits.

813. A client with Guillain-Barré syndrome has ascending paralysis and is intubated and receiving mechanical ventilation. Which strategy should the nurse incorporate in the plan of care to help the client cope with this illness? 1. Giving client full control over care decisions and restricting visitors 2. Providing positive feedback and encouraging active range of motion 3. Providing information, giving positive feedback, and encouraging relaxation 4. Providing intravenously administered sedatives, reducing distractions, and limiting visitors

3 The client with Guillain-Barré syndrome experiences fear and anxiety from the ascending paralysis and sudden onset of the disorder. The nurse can alleviate these fears by providing accurate information about the client's condition, giving expert care and positive feedback to the client, and encouraging relaxation and distraction. The family can become involved with selected care activities and provide diversion for the client as well.

810. The nurse has given instructions to a client with Parkinson's disease about maintaining mobility. Which action demonstrates that the client understands the directions? 1. Sits in soft, deep chairs to promote comfort. 2. Exercises in the evening to combat fatigue. 3. Rocks back and forth to start movement with bradykinesia. 4. Buys clothes with many buttons to maintain finger dexterity.

3 The client with Parkinson's disease should exercise in the morning when energy levels are highest. The client should avoid sitting in soft deep chairs because they are difficult to get up from. The client can rock back and forth to initiate movement. The client should buy clothes with Velcro fasteners and slide-locking buckles to support the ability to dress self.

460. The nurse develops a plan of care for a child at risk for tonic-clonic seizures. In the plan of care, the nurse identifies seizure precautions and documents that which item(s) need to be placed at the child's bedside? 1. Emergency cart 2. Tracheotomy set 3. Padded tongue blade 4. Suctioning equipment and oxygen

4 A seizure results from the excessive and unorganized neuronal discharges in the brain that activate associated motor and sensory organs. A type of generalized seizure is a tonic-clonic seizure. This type of seizure causes rigidity of all body muscles, followed by intense jerking movements. Because increased oral secretions and apnea can occur during and after the seizure, oxygen and suctioning equipment are placed at the bedside. A tracheotomy is not performed during a seizure. No object, including a padded tongue blade, is placed into the child's mouth during a seizure. An emergency cart would not be left at the bedside, but would be available in the treatment room or nearby on the nursing unit.

825. A client with trigeminal neuralgia is being treated with carbamazepine, 400 mg orally daily. Which value indicates that the client is experiencing an adverse effect to the medication? 1. Uric acid level, 5 mg/dL 2. Sodium level, 140 mEq/L 3. Blood urea nitrogen level, 15 mg/dL 4. White blood cell count, 3000 cells/mm3

4 Adverse effects of carbamazepine appear as blood dyscrasias, including aplastic anemia, agranulocytosis, thrombocytopenia, and leukopenia; cardiovascular disturbances including thrombophlebitis and dysrhythmias; and dermatological effects. The low white blood cell count reflects agranulocytosis. The laboratory values in options 1, 2, and 3 are normal values.

831. The nurse has given instructions to a client returning home after knee arthroscopy. Which statement by the client indicates that the instructions are understood? 1. "I can resume regular exercise tomorrow." 2. "I can't eat food for the remainder of the day." 3. "I need to stay off the leg entirely for the rest of the day." 4. "I need to report a fever or site inflammation to my health care provider."

4 After arthroscopy, the client usually can walk carefully on the leg once sensation has returned. The client is instructed to avoid strenuous exercise for at least a few days. The client may resume the usual diet. Signs and symptoms of infection should be reported to the health care provider (HCP).

465. A child has a right femur fracture caused by a motor vehicle crash and is placed in skin traction temporarily until surgery can be performed. During assessment, the nurse notes that the dorsalis pedis pulse is absent on the right foot. Which action should the nurse take? 1. Administer an analgesic. 2. Release the skin traction. 3. Apply ice to the extremity. 4. Notify the health care provider (HCP).

4 An absent pulse to an extremity of the affected limb after a bone fracture could mean that the child is developing or experiencing compartment syndrome. This is an emergency situation, and the HCP should be notified immediately. Administering analgesics would not improve circulation. The skin traction should not be released without an HCP's prescription. Applying ice to an extremity with absent perfusion is incorrect. Ice may be prescribed when perfusion is adequate to decrease swelling.

828. A client with myasthenia gravis has become increasingly weaker. The health care provider prepares to identify whether the client is reacting to an overdose of the medication (cholinergic crisis) or an increasing severity of the disease (myasthenic crisis). An injection of edrophonium is administered. Which finding would indicate that the client is in cholinergic crisis? 1. No change in the condition 2. Complaints of muscle spasms 3. An improvement of the weakness 4. A temporary worsening of the condition

4 An edrophonium injection makes the client in cholinergic crisis temporarily worse. An improvement in the weakness indicates myasthenia crisis. Muscle spasms are not associated with this test.

848. A client with a hip fracture asks the nurse why Buck's (extension) traction is being applied before surgery. The nurse provides a response based on which purpose of Buck's (extension) traction? 1. Allows bony healing to begin before surgery 2. Provides rigid immobilization of the fracture site 3. Lengthens the fractured leg to prevent severing of blood vessels 4. Provides comfort by reducing muscle spasms and provides fracture immobilization

4 Buck's (extension) traction is a type of skin traction often applied after hip fracture before the fracture is reduced in surgery. Traction reduces muscle spasms and helps immobilize the fracture. Traction does not allow for bony healing to begin or provide rigid immobilization. Traction does not lengthen the leg for the purpose of preventing blood vessel severance.

808. The nurse is assessing the adaptation of a client to changes in functional status after a stroke (brain attack). Which observation indicates to the nurse that the client is adapting most successfully? 1. Gets angry with family if they interrupt a task 2. Experiences bouts of depression and irritability 3. Has difficulty with using modified feeding utensils 4. Consistently uses adaptive equipment in dressing self

4 Clients are evaluated as coping successfully with lifestyle changes after a brain attack (stroke) if they make appropriate lifestyle alterations, use the assistance of others, and have appropriate social interactions. Options 1 and 2 are not adaptive behaviors; option 3 indicates a not yet successful attempt to adapt.

843. A client with diabetes mellitus has had a right below-knee amputation. Given the client's history of diabetes mellitus, which should the nurse specifically observe in the postoperative period? 1. Hemorrhage 2. Edema of the residual limb 3. Slight redness of the incision 4. Separation of the wound edges

4 Clients with diabetes mellitus are more prone to wound infection and delayed wound healing because of the disease. Postoperative edema of the residual limb and hemorrhage are complications in the immediate postoperative period that apply to any client with an amputation. Slight redness of the incision is considered normal, as long as it is dry and intact.

809. The nurse is teaching a client with myasthenia gravis about the prevention of myasthenic and cholinergic crises. Which client activity suggests that teaching is most effective? 1. Eating large, well-balanced meals 2. Doing muscle-strengthening exercises 3. Doing all chores early in the day while less fatigued 4. Taking medications on time to maintain therapeutic blood levels

4 Clients with myasthenia gravis are taught to space out activities over the day to conserve energy and restore muscle strength. Taking medications correctly to maintain blood levels that are not too low or too high is important. Muscle-strengthening exercises are not helpful and can fatigue the client. Overeating is a cause of exacerbation of symptoms, as is exposure to heat, crowds, erratic sleep habits, and emotional stress.

819. Carbidopa-levodopa is prescribed for a client with Parkinson's disease. The nurse monitors the client for side/adverse effects to the medication. Which finding indicates that the client is experiencing an adverse effect? 1. Pruritus 2. Tachycardia 3. Hypertension 4. Impaired voluntary movements

4 Dyskinesia and impaired voluntary movement may occur with high levodopa dosages. Nausea, anorexia, dizziness, orthostatic hypotension, bradycardia, and akinesia are frequent side effects of the medication.

812. The client is admitted to the hospital with a diagnosis of Guillain-Barré syndrome. Which past medical history finding makes the client most at risk for this disease? 1. Meningitis or encephalitis during the last 5 years 2. Seizures or trauma to the brain within the last year 3. Back injury or trauma to the spinal cord during the last 2 years 4. Respiratory or gastrointestinal infection during the previous month

4 Guillain-Barré syndrome is a clinical syndrome of unknown origin that involves cranial and peripheral nerves. Many clients report a history of respiratory or gastrointestinal infection in the 1 to 4 weeks before the onset of neurological deficits. On occasion, the syndrome can be triggered by vaccination or surgery.

456. A mother arrives at an emergency department with her 5-year-old child and states that the child fell off a bunk bed. A head injury is suspected, and the nurse checks the child's airway status and assesses the child for early and late signs of increased intracranial pressure (ICP). Which is a late sign of increased ICP? 1. Nausea 2. Irritability 3. Headache 4. Bradycardia

4 Head injury is the pathological result of any mechanical force to the skull, scalp, meninges, or brain. A head injury can cause bleeding in the brain and result in increased intracranial pressure (ICP). In a child, early signs include a slight change in level of consciousness, headache, nausea, vomiting, visual disturbances (diplopia), seizures. Late signs of increased ICP include a significant decrease in level of consciousness, bradycardia, decreased motor and sensory responses, alterations in pupil size and reactivity, posturing, Cheyne-Stokes respirations, and coma.

807. The nurse has instructed the family of a client with stroke (brain attack) who has homonymous hemianopsia about measures to help the client overcome the deficit. Which statement suggests that the family understands the measures to use when caring for the client? 1. "We need to discourage him from wearing eyeglasses." 2. "We need to place objects in his impaired field of vision." 3. "We need to approach him from the impaired field of vision." 4. "We need to remind him to turn his head to scan the lost visual field."

4 Homonymous hemianopsia is loss of half of the visual field. The client with homonymous hemianopsia should have objects placed in the intact field of vision, and the nurse also should approach the client from the intact side. The nurse instructs the client to scan the environment to overcome the visual deficit and does client teaching from within the intact field of vision. The nurse encourages the use of personal eyeglasses, if they are available.

844. The nurse is caring for a client who had an above-knee amputation 2 days ago. The residual limb was wrapped with an elastic compression bandage, which has come off. Which immediate action should the nurse take? 1. Apply ice to the site. 2. Call the health care provider (HCP). 3. Apply a dry sterile dressing and elevate it on one pillow. 4. Rewrap the residual limb with an elastic compression bandage.

4 If the client with an amputation has a cast or elastic compression bandage that slips off, the nurse must wrap the residual limb immediately with another elastic compression bandage. Otherwise, excessive edema will form rapidly, which could cause a significant delay in rehabilitation. If the client had a cast that slipped off, the nurse would have to call the HCP so that a new one could be applied. Elevation on one pillow is not going to impede the development of edema greatly once compression is released. Ice would be of limited value in controlling edema from this cause. If the HCP were called, the prescription likely would be to reapply the compression dressing anyway.

802. A client has clear fluid leaking from the nose following a basilar skull fracture. Which finding would alert the nurse that cerebrospinal fluid is present? 1. Fluid is clear and tests negative for glucose. 2. Fluid is grossly bloody in appearance and has a pH of 6. 3. Fluid clumps together on the dressing and has a pH of 7. 4. Fluid separates into concentric rings and tests positive for glucose.

4 Leakage of cerebrospinal fluid (CSF) from the ears or nose may accompany basilar skull fracture. CSF can be distinguished from other body fluids because the drainage will separate into bloody and yellow concentric rings on dressing material, called a halo sign. The fluid also tests positive for glucose.

455. The nurse notes documentation that a child with meningitis is exhibiting a positive Kernig's sign. Which observation is characteristic of this sign? 1. The child complains of muscle and joint pain. 2. Petechial and purpuric rashes are noted on the child's trunk. 3. Neck flexion causes adduction and flexion movements of the lower extremities. 4. The child is not able to extend the leg when the thigh is flexed anteriorly at the hip.

4 Meningitis is an infectious process of the central nervous system caused by bacteria and viruses. The inability to extend the leg when the thigh is flexed anteriorly at the hip is a positive Kernig's sign, noted in meningitis. Muscle and joint pain is characteristic of meningococcal infection and H. influenzae infection. A petechial or purpuric rash is characteristic of meningococcal infection. A positive Brudzinski's sign is noted when neck flexion causes adduction and flexion movements of the lower extremities in children and adolescents. This is also a characteristic of meningitis.

462. The nurse is planning care for a child with acute bacterial meningitis. Based on the mode of transmission of this infection, which precautionary intervention should be included in the plan of care? 1. Maintain enteric precautions. 2. Maintain neutropenic precautions. 3. No precautions are required as long as antibiotics have been started. 4. Maintain respiratory isolation precautions for at least 24 hours after the initiation of antibiotics.

4 Meningitis is an infectious process of the central nervous system caused by bacteria and viruses; it may be acquired as a primary disease or as a result of complications of neurosurgery, trauma, infection of the sinus or ears, or systemic infections. A major priority of nursing care for a child suspected to have meningitis is to administer the antibiotic as soon as it is prescribed. The child also is placed on respiratory isolation precautions for at least 24 hours while culture results are obtained and the antibiotic is having an effect. Enteric precautions and neutropenic precautions are not associated with the mode of transmission of meningitis. Enteric precautions are instituted when the mode of transmission is through the gastrointestinal tract. Neutropenic precautions are instituted when a child has a low neutrophil count.

852. Alendronate is prescribed for a client with osteoporosis and the nurse is providing instructions on administration of the medication. Which instruction should the nurse provide? 1. Take the medication at bedtime. 2. Take the medication in the morning with breakfast. 3. Lie down for 30 minutes after taking the medication. 4. Take the medication with a full glass of water after rising in the morning.

4 Precautions need to be taken with the administration of alendronate to prevent gastrointestinal side/adverse effects (especially esophageal irritation) and to increase absorption of the medication. The medication needs to be taken with a full glass of water after rising in the morning. The client should not eat or drink anything for 30 minutes following administration and should not lie down after taking the medication.

459. A child is diagnosed with Reye's syndrome. The nurse develops a nursing care plan for the child and should include which intervention in the plan? 1. Assessing hearing loss 2. Monitoring urine output 3. Changing body position every 2 hours 4. Providing a quiet atmosphere with dimmed lighting

4 Reye's syndrome is an acute encephalopathy that follows a viral illness and is characterized pathologically by cerebral edema and fatty changes in the liver. A definitive diagnosis is made by liver biopsy. In Reye's syndrome, supportive care is directed toward monitoring and managing cerebral edema. Decreasing stimuli in the environment by providing a quiet environment with dimmed lighting would decrease the stress on the cerebral tissue and neuron responses. Hearing loss and urine output are not affected. Changing the body position every 2 hours would not affect the cerebral edema directly. The child should be positioned with the head elevated to decrease the progression of the cerebral edema and promote drainage of cerebrospinal fluid.

469. A child who has undergone spinal fusion for scoliosis complains of abdominal discomfort and begins to have episodes of vomiting. On further assessment, the nurse notes abdominal distention. On the basis of these findings, the nurse should take which action? 1. Administer an antiemetic. 2. Increase the intravenous fluids. 3. Place the child in a Sims's position. 4. Notify the health care provider (HCP).

4 Scoliosis is a three-dimensional spinal deformity that usually involves lateral curvature, spinal rotation resulting in rib asymmetry, and hypokyphosis of the thorax. A complication after surgical treatment of scoliosis is superior mesenteric artery syndrome. This disorder is caused by mechanical changes in the position of the child's abdominal contents, resulting from lengthening of the child's body. The disorder results in a syndrome of emesis and abdominal distention similar to that which occurs with intestinal obstruction or paralytic ileus. Postoperative vomiting in children with body casts or children who have undergone spinal fusion warrants attention because of the possibility of superior mesenteric artery syndrome. Options 1, 2, and 3 are incorrect.

818. The nurse is admitting a client with Guillain-Barré syndrome to the nursing unit. The client has ascending paralysis to the level of the waist. Knowing the complications of the disorder, the nurse should bring which most essential items into the client's room? 1. Nebulizer and pulse oximeter 2. Blood pressure cuff and flashlight 3. Flashlight and incentive spirometer 4. Electrocardiographic monitoring electrodes and intubation tray

4 The client with Guillain-Barré syndrome is at risk for respiratory failure because of ascending paralysis. An intubation tray should be available for use. Another complication of this syndrome is cardiac dysrhythmias, which necessitates the use of electrocardiographic monitoring. Because the client is immobilized, the nurse should assess for deep vein thrombosis and pulmonary embolism routinely. Although items in the incorrect options may be used in care, they are not the most essential items from the options provided.

803. A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse should avoid which measure to minimize the risk of occurrence? 1. Strict adherence to a bowel retraining program 2. Keeping the linen wrinkle-free under the client 3. Preventing unnecessary pressure on the lower limbs 4. Limiting bladder catheterization to once every 12 hours

4 The most frequent cause of autonomic dysreflexia is a distended bladder. Straight catheterization should be done every 4 to 6 hours (catheterization every 12 hours is too infrequent), and Foley catheters should be checked frequently to prevent kinks in the tubing. Constipation and fecal impaction are other causes, so maintaining bowel regularity is important. Other causes include stimulation of the skin from tactile, thermal, or painful stimuli. The nurse administers care to minimize risk in these areas.

466. A child is placed in skeletal traction for treatment of a fractured femur. The nurse develops a plan of care and includes which intervention? 1. Ensure that all ropes are outside the pulleys. 2. Ensure that the weights are resting lightly on the floor. 3. Restrict diversional and play activities until the child is out of traction. 4. Check the health care provider's (HCP's) prescriptions for the amount of weight to be applied.

4 When a child is in traction, the nurse would check the HCP's prescription to verify the prescribed amount of traction weight. The nurse would maintain the correct amount of weight as prescribed, ensure that the weights hang freely, check the ropes for fraying and ensure that they are on the pulleys appropriately, monitor the neurovascular status of the involved extremity, and monitor for signs and symptoms of immobilization. The nurse would provide therapeutic and diversional play activities for the child.

832. The nurse is one of several persons who witnessed a vehicle hit a pedestrian at fairly low speed on a small street. The victim is dazed and tries to get up. The leg appears fractured. Which intervention should the nurse take? 1. Try to reduce the fracture manually. 2. Assist the victim to get up and walk to the sidewalk. 3. Leave the victim for a few moments to call an ambulance. 4. Stay with the victim and encourage the person to remain still.

4 With a suspected fracture, the victim is not moved unless it is dangerous to remain in that spot. The nurse should remain with the victim and have someone else call for emergency help. A fracture is not reduced at the scene. Before the victim is moved, the site of fracture is immobilized to prevent further injury.

454. The parents of a child recently diagnosed with cerebral palsy ask the nurse about the disorder. The nurse bases the response on the understanding that cerebral palsy is which type of condition? 1. An infectious disease of the central nervous system 2. An inflammation of the brain as a result of a viral illness 3. A congenital condition that results in moderate to severe retardation 4. A chronic disability characterized by impaired muscle movement and posture

4 Cerebral palsy is a chronic disability characterized by impaired movement and posture resulting from an abnormality in the extrapyramidal or pyramidal motor system. Meningitis is an infectious process of the central nervous system. Encephalitis is an inflammation of the brain that occurs as a result of viral illness or central nervous system infection. Down syndrome is an example of a congenital condition that results in moderate to severe retardation.

830. The nurse is conducting health screening for osteoporosis. Which client is at greatest risk of developing this disorder? 1. A 25-year-old woman who jogs 2. A 36-year-old man who has asthma 3. A 70-year-old man who consumes excess alcohol 4. A sedentary 65-year-old woman who smokes cigarettes

4 Risk factors for osteoporosis include female gender, being postmenopausal, advanced age, a low-calcium diet, excessive alcohol intake, being sedentary, and smoking cigarettes. Long-term use of corticosteroids, anticonvulsants, and/or furosemide (Lasix) also increases the risk.

841. The nurse is caring for a client being treated for fat embolus after multiple fractures. Which data would the nurse evaluate as the most favorable indication of resolution of the fat embolus? 1. Clear mentation 2. Minimal dyspnea 3. Oxygen saturation of 85% 4. Arterial oxygen level of 78 mm Hg

1 An altered mental state is an early indication of fat emboli; therefore, clear mentation is a good indicator that a fat embolus is resolving. Eupnea, not minimal dyspnea, is a normal sign. Arterial oxygen levels should be 80 to 100 mm Hg. Oxygen saturation should be higher than 95%.

464. The nurse is developing a plan of care for a child who is at risk for seizures. Which interventions apply if the child has a seizure? Select all that apply. 1. Time the seizure. 2. Restrain the child. 3. Stay with the child. 4. Place the child in a prone position. 5. Move furniture away from the child. 6. Insert a padded tongue blade in the child's mouth.

1, 3, 5 A seizure is a disorder that occurs as a result of excessive and unorganized neuronal discharges in the brain that activate associated motor and sensory organs. During a seizure, the child is placed on his or her side in a lateral position. Positioning on the side prevents aspiration because saliva drains out the corner of the child's mouth. The child is not restrained because this could cause injury to the child. The nurse would loosen clothing around the child's neck and ensure a patent airway. Nothing is placed into the child's mouth during a seizure because this action may cause injury to the child's mouth, gums, or teeth. The nurse would stay with the child to reduce the risk of injury and allow for observation and timing of the seizure.

839. A client being measured for crutches asks the nurse why the crutches cannot rest up underneath the arm for extra support. The nurse responds knowing that which would most likely result from this improper crutch measurement? 1. A fall and further injury 2. Injury to the brachial plexus nerves 3. Skin breakdown in the area of the axilla 4. Impaired range of motion while the client ambulates

2 Crutches are measured so that the tops are two to three fingerwidths from the axillae. This ensures that the client's axillae are not resting on the crutch or bearing the weight of the crutch, which could result in injury to the nerves of the brachial plexus. Although the conditions in options 1, 3, and 4 can occur, they are not the most likely result from resting the axilla directly on the crutches.

834. The nurse is evaluating the pin sites of a client in skeletal traction. The nurse would be least concerned with which finding? 1. Inflammation 2. Serous drainage 3. Pain at a pin site 4. Purulent drainage

2 A small amount of serous oozing is expected at pin insertion sites. Signs of infection such as inflammation, purulent drainage, and pain at the pin site are not expected findings and should be reported to the health care provider.

821. The nurse is caring for a client in the emergency department who has been diagnosed with Bell's palsy. The client has been taking acetaminophen, and acetaminophen overdose is suspected. Which antidote should the nurse anticipate to be prescribed? 1. Pentostatin 2. Auranofin 3. Fludarabine 4. Acetylcysteine

4 The antidote for acetaminophen is acetylcysteine (Mucomyst). The normal therapeutic serum level of acetaminophen is 10 to 20 mcg/mL. A toxic level is higher than 50 mcg/mL, and levels higher than 200 mcg/mL could indicate hepatotoxicity. Auranofin (Ridaura) is a gold preparation used to treat rheumatoid arthritis. Pentostatin (Nipent) and fludarabine (Fludara) are antineoplastic agents.

833. Which cast care instructions should the nurse provide to a client who just had a plaster cast applied to the right forearm? Select all that apply. 1. Keep the cast clean and dry. 2. Allow the cast 24 to 72 hours to dry. 3. Keep the cast and extremity elevated. 4. Expect tingling and numbness in the extremity. 5. Use a hair dryer set on a warm to hot setting to dry the cast. 6. Use a soft padded object that will fit under the cast to scratch the skin under the cast.

1, 2, 3 A plaster cast takes 24 to 72 hours to dry (synthetic casts dry in 20 minutes). The cast and extremity should be elevated to reduce edema if prescribed. A wet cast is handled with the palms of the hand until it is dry, and the extremity is turned (unless contraindicated) so that all sides of the wet cast will dry. A cool setting on the hair dryer can be used to dry a plaster cast (heat cannot be used on a plaster cast because the cast heats up and burns the skin). The cast needs to be kept clean and dry, and the client is instructed not to stick anything under the cast because of the risk of breaking skin integrity. The client is instructed to monitor the extremity for circulatory impairment, such as pain, swelling, discoloration, tingling, numbness, coolness, or diminished pulse. The health care provider is notified immediately if circulatory impairment occurs.

463. An infant with a diagnosis of hydrocephalus is scheduled for surgery. Which is the priority nursing intervention in the preoperative period? 1. Test the urine for protein. 2. Reposition the infant frequently. 3. Provide a stimulating environment. 4. Assess blood pressure every 15 minutes.

2 Hydrocephalus occurs as a result of an imbalance of cerebrospinal fluid absorption or production that is caused by malformations, tumors, hemorrhage, infections, or trauma. It results in head enlargement and increased intracranial pressure. In infants with hydrocephalus, the head grows at an abnormal rate, and if the infant is not repositioned frequently, pressure ulcers can occur on the back and side of the head. An egg crate mattress under the head is also a nursing intervention that can help prevent skin breakdown. Proteinuria is not specific to hydrocephalus. Stimulus should be kept at a minimum because of the increase in intracranial pressure. It is not necessary to check the blood pressure every 15 minutes.

823. A client is taking the prescribed dose of phenytoin to control seizures. Results of a phenytoin blood level study reveal a level of 35 mcg/mL. Which finding would be expected as a result of this laboratory result? 1. Hypotension 2. Tachycardia 3. Slurred speech 4. No abnormal finding

3 The therapeutic phenytoin level is 10 to 20 mcg/mL. At a level higher than 20 mcg/mL, involuntary movements of the eyeballs (nystagmus) occur. At a level higher than 30 mcg/mL, ataxia and slurred speech occur.