PN2 Final Exam Study

A nurse is completing discharge teaching to a client following middle ear surgery. Which of the following statements by the client indicates understanding of the teaching? A. "I should restrict rapid movements and avoid bending from the waist for several weeks." B. "I should wait until the day after surgery to wash my hair." C. "I will remove the dressing behind my ear in 7 days." D. "My hearing should be back to normal right after my surgery."

A. "I should restrict rapid movements and avoid bending from the waist for several weeks."

A nurse is teaching a group of clients about influenza. Which of the following client statements indicates an understanding of the teaching? A. "I should wash my hands after blowing my nose to prevent spreading the virus." B. "I need to avoid drinking fluids if I develop symptoms." C. "I need a flu shot every 2 years because of the different flu strains." D. "I should cover my mouth with my hand when I sneeze."

A. "I should wash my hands after blowing my nose to prevent spreading the virus"

A nurse is providing discharge teaching for a client who has heart failure and is on a fluid restriction of 2,000 mL/day. The client asks the nurse how to determine the appropriate amount of fluids he is allowed. Which of the following statements is an appropriate response by the nurse? A. "Pour the amount of fluid you drink into an empty 2-liter bottle to keep track of how much you drink." B. "Each glass contains 8 ounces. There are 30 mL per ounce, so you can have a total of 8 glasses or cups of fluid each day." C. "This is the same as 2 quarts, or about the same as two pots of coffee." D. "Take sips of water or ice chips so you will not take in too much fluid."

A. "Pour the amount of fluid you drink into an empty 2-liter bottle to keep track of how much you drink."

A nurse is teaching a client who has a new diagnosis of RA. Which of the following statements should the nurse include in the teaching? A. "You can experience morning stiffness when you get out of bed." B. "You can experience abdominal pain." C. "You can experience weight gain." D. "You can experience low blood sugar."

A. "You can experience morning stiffness when you get out of bed."

A nurse is teaching a client who has heart failure about the need to limit sodium in the diet to 2,000 mg daily. Which of the following foods should the nurse recommend for the client? (select all that apply) A. 1 slice cheddar cheese B. 1 medium beef hot dog C. 3 oz Atlantic salmon D. 3 oz roasted chicken breast E. 2 oz lean baked ham

A. 1 slice cheddar cheese C. 3 oz Atlantic salmon D. 3 oz roasted chicken breast

A nurse is providing information about a new prescription for corticosteroid cream to a client who has mild psoriasis. Which of the following instructions should the nurse include? (Select all that apply) A. Apply an occlusive dressing after application B. Apply three to four times per day C. Wear gloves after application to lesions on the hands D. Avoid applying in skin folds E. Use medication continuously over a period of several months

A. Apply an occlusive dressing after application C. Wear gloves after application to lesions on the hands D. Avoid applying in skin folds

A nurse is providing information to a client who has osteoarthritis of the hip and knee. Which of the following information should the nurse include in the information? (Select all that apply) A. Apply heat to joints to alleviate pain B. Ice inflamed joints following activity C. Install an elevated toilet seat D. Take tub baths E. Complete high-energy activities in the morning

A. Apply heat to joints to alleviate pain B. Ice inflamed joints following activity C. Install an elevated toilet seat E. Complete high-energy activities in the morning

A nurse is teaching a client who has a new prescription for clopidogrel. Which of the following instructions should the nurse include in the teaching? (select all that apply) A. Avoid the consuming of grapefruit while taking this medication. B. Monitor for the presence of black, tarry stools C. Take this medication when you have pain. D. Schedule a weekly PT test E. Limit food sources containing vitamin K while taking this medication

A. Avoid the consuming of grapefruit while taking this medication B. Monitor for the presence of black, tarry stools

A nurse is admitting a client to the orthopedic unit following a total knee arthroplasty. Which of the following actions by the nurse are appropriate? (Select all that apply) A. Check continuous passive motion device settings B. Palpate dorsal pedal pulses C. Place a pillow behind the knee D. Elevate heels off bed E. Apply heat therapy to incision

A. Check continuous passive motion device setting B. Palpate dorsal pedal pulses D. Elevate heels off bed

A nurse is planning discharge teaching for a client who had a total hip arthroplasty. Which of the following should the nurse include in the teaching? (Select all that apply) A. Clean the incision daily with soap and water B. Turn the toes inward when sitting or lying C. Sit in a straight-backed armchair D. Bend at the waist when putting on socks E. use a raised toilet seat

A. Clean the incision daily with soap and water C. Sit in a straight-backed armchair E. Use a raised toilet seat

A nurse is monitoring a group of clients for increased risk of developing pneumonia. Which of the following clients should the nurse expect to be at risk? (Select all that apply) A. Client who has dysphagia B. Client who has AIDS C. Client who was vaccinated for pneumococcus and influenza 6 months ago D. Client who is postoperative and has received local anesthesia E. Client who has a closed head injury and is receiving ventilation F. Client who has myasthenia gravis

A. Client who has dysphagia B. Client who has AIDS E. Client who has a closed head injury and is receiving ventilation F. Client who has myasthenia gravis

A nurse is caring for a client who experienced a cervical spine injury 3 months ago. The nurse should plan to implement which of the following types of bladder management methods? A. Condom catheter B. Intermittent urinary catheterization C. Crede's method D. Indwelling urinary catheter

A. Condom catheter

A nurse is discussing gout with a client who is concerned about developing the disorder. Which of the following findings should the nurse identify as risk factors for this disease? (Select all that apply) A. Diuretic use B. Obesity C. Deep sleep deprivation D. Depression E. Cardiovascular disease

A. Diuretic use B. Obesity E. Cardiovascular disease

A nurse is completing a preoperative teaching plan for a client who is scheduled to have a total hip arthroplasty. Which of the following should the nurse include in the teaching plan? (Select all that apply) A. Encourage complete autologous blood donation B. Sit in a low reclining chair C. Instruct the client to roll onto the operative hip D. use an abductor pillow when turning the client E. Perform isometric exercises

A. Encourage complete autologous blood donation D. Use an abductor pillow when turning the client E. Perform isometric exercises

A nurse is reviewing the health record of a client who has severe otitis media. Which of the following are expected findings? (Select all that apply) A. Enlarged adenoids B. Report of recent colds C. Client prescription for daily furosemide D. Light reflex visible on otoscopic exam in the affected ear E. Ear pain relieved by meclizine

A. Enlarged adenoids B. Report of recent colds E. Ear pain relieved by meclizine

What are the manifestations of retinal detachment? (Select all that apply) A. Floaters when eyes and head move B. Sees "halos" around lights C. Flashes of light when eyes and head move D. Clouded vision

A. Floaters when eyes and head move C. Flashes of light when eyes and head move

A nurse is assessing a client who has osteoarthritis of the knees and fingers. Which of the following manifestations should the nurse expect to find? (Select all that apply) A. Heberden's nodes B. Swelling of all joints C. Small body frame D. Enlarged joint size E. Limp when walking

A. Heberden's nodes D. Enlarged joint size E. Limp when walking

A nurse is providing teaching for a client who has a new diagnosis of dry macular degeneration. Which of the following instructions should the nurse include in the teaching? A. Increase intake of deep yellow and orange vegetables. B. Administer eye drops twice daily. C. Avoid bending at the waist. D. Wear an eye patch at night.

A. Increase intake of deep yellow and orange vegetables

A nurse is assessing a client who has splinter hemorrhages in her nail beds and reports a fever. The nurse should identify these findings as manifestations of which of the following disorders? A. Infective endocarditis B. Pericarditis C. Myocarditis D. Rheumatic endocarditis

A. Infective endocarditis

A nurse in a clinic is caring for a client whose partner states the client woke up this morning, didn't recognize him, and did not know where she was. The client reports chills and chest pain that is worse upon inspiration. Which of the following actions is the nursing priority? A. Obtain baseline vital signs and oxygen saturation B. Obtain a sputum culture C. Obtain a complete history from the client D. Provide a pneumococcal vaccine

A. Obtain baseline vital signs and oxygen saturation

A nurse in a clinic is caring for a client who has been on long-term NSAID therapy to treat myocarditis. Which of the following lab findings should the nurse report to the provider? A. Platelets 100,000/mm3 B. Serum glucose 110 mg/dL C. Serum creatinine 0.7 mg/dL D. Amino alanine transferase 30 IU/L

A. Platelets 100,00/mm3

A nurse is reviewing the plan of care for a client who has SLE. The client reports fatigue, joint tenderness, swelling, and difficulty urinating. Which of the following laboratory findings should the nurse anticipate? (Select all that apply) A. Positive ANA titer B. Increased hemoglobin C. 2+ urine protein D. Increased serum C3 and C4 E. Elevated BUN

A. Positive ANA titer C. 2+ urine protein E. Elevated BUN

A nurse is planning care for a client who has a spinal cord injury involving a T12 fracture 1 week ago. The client has no muscle control of the lower limbs, bowel, or bladder. Which of the following should be the nurse's highest priority? A. Prevention of further damage to the spinal cord B. Prevention of contractures of the lower extremities C. Prevention of skin breakdown of areas that lack sensation D. Prevention of postural hypotension when placing the client in a wheelchair

A. Prevention of further damage to the spinal cord

A nurse working in an outpatient clinic is assessing a client who has rheumatoid arthritis. the client reports increased joint tenderness and swelling. Which of the following findings should the nurse expect? (Select all that apply) A. Recent influenza B. Decreased range of motion C. Hypersalivation D. Increased blood pressure E. Pain at rest

A. Recent influenza B. Decreased range of motion E. Pain at rest

A nurse in a clinic is caring for a client who has been experiencing mild to moderate vertigo due to benign paroxysmal vertigo for several weeks. Which of the following actions should the nurse recommend to help control the vertigo? (Select all that apply) A. Reduce exposure to bright lighting B. Move head slowly when changing positions C. Do not eat fruit high in potassium D. Plan evenly spaced daily fluid intake E. Avoid fluids containing caffeine

A. Reduce exposure to bright lighting B. Move head slowly when changing positions D. Plan evenly spaced daily fluid intake E. Avoid fluids containing caffeine

A nurse is caring for a client who is receiving a blood transfusion. Which of the following actions should the nurse expect if an allergic transfusion reaction is suspected? (select all that apply) A. Stop the transfusion B. Monitor for hypertension C. Maintain an IV infusion with 0.9% sodium chloride D. Position the client in an upright position with the feet lower than the heart E. Administer diphenhydramine

A. Stop the transfusion C. Maintain an IV infusion with 0.9% sodium chloride E. Administer diphenhydramine

A nurse is completing the admission assessment of a client who has suspected pulmonary edema. Which of the following manifestations are expected findings? (select all that apply) A. Tachypnea B. Persistent cough C. Increased urinary output D. Thick, yellow sputum E. Orthopnea

A. Tachypnea B. Persistent cough E. Orthopnea

Complications of heart disease

Acute pulmonary edema Cardiogenic shock Pericardial tamponade- results from fluid accumulation in the pericardial sac

If prescribed combination agents, which medication should be used first?

Administer bronchodilator first in order to increase the absorption of the anti-inflammatory agent.

Rheumatic endocarditis

An infection of the endocardium due to a complication of rheumatic fever. Produces lesions in the heart

Medications to treat pneumonia

Antibiotics- penicillins and cephalosporins Bronchodilators- albuterol, ipratropium, theophylline Anti-inflammatories-glucocorticosteroids such as fluticasone, prednisone

Medications for peripheral arterial disease

Antiplatelet Statins

Expected findings of pneumonia

Anxiety Fatigue Weakness Chest discomfort due to coughing Confusion from hypoxia (most common)

Complications of pneumonia

Atelectasis Bacteremia (Sepsis) Acute respiratory distress syndrome

A nurse is reinforcing teaching with a client on the purpose of taking a bronchodilator. Which of the following client statements indicates an understanding of the teaching? A. "This medication can decrease my immune response." B. "I take this medication to prevent asthma attacks." C. "I need to take this medication with food." D. "This medication has a slow onset to treat my symptoms."

B. "I take this medication to prevent asthma attacks."

A nurse is completing discharge teaching with a client who has heart failure and is encouraged to increase potassium in his diet. Which of the following food selections should the nurse include as having the highest source of potassium? A. 1 medium apple B. 1 medium baked potato C. 1 slice toast with 1 tbsp of peanut butter D. 1 large scrambled egg

B. 1 medium baked potato

A nurse is teaching a client who has a history of psoriasis about photochemotherapy and ultraviolet light (PUVA) treatments. Which of the following instructions should the nurse include in the teaching? A. Apply vitamin A cream before each treatment B. Administer a psoralem medication before the treatment C. Use this treatment every evening D. Remove the scales gently following each treatment

B. Administer a psoralem medication before the treatment

A nurse is caring for a client who has pneumonia. Assessment findings include temperature 37.8 C (100 F), respirations 30/min, and SaO2 91% on room air. Prioritize the following nursing interventions. A. Administer antibiotics B. Administer oxygen therapy C. Perform a sputum culture D. Administer an antipyretic medication to promote client comfort

B. Administer oxygen therapy C. Perform a sputum culture A. Administer antibiotics D. Administer an antipyretic medication to promote client comfort

A nurse is caring for a client who has chronic venous insufficiency and a prescription for thigh-high compression stockings. Which of the following actions should the nurse take? A. Elevate the legs for 10 mins, two to three times daily while wearing stockings B. Apply the stockings in the morning upon awakening and before getting out of bed C. Roll the stockings down to the knees to relieve discomfort on the legs D. Remove the stockings while out of bed for 1 hour, four times a day, to allow the legs to rest

B. Apply stockings in the morning upon awakening and before getting out of bed

A nurse is preparing to administer packed RBC's to a client who has a Hgb of 8 g/dL. Which of the following actions should the nurse plan to take during the first 15 min of the transfusion? A. Obtain consent from the client for the transfusion B. Assess for an acute hemolytic reaction C. Explain the transfusion procedure to the client D. Obtain blood culture specimens to send to the lab

B. Assess for an acute hemolytic reaction

A nurse is caring for a client who has heart failure and reports increased shortness of breath. The nurse increases the client's oxygen per protocol. Which of the following actions should the nurse take first? A. Obtain the client's weight B. Assist the client into high-Fowler's position C. Auscultate lungs sounds D. Check oxygen saturation with pulse oximeter

B. Assist the client into high-Fowler's position

A nurse is caring for four clients. Which of the following clients should the nurse identify as being at risk of acquiring rheumatic endocarditis? A. Older adult who has COPD B. Child who has streptococcal pharyngitis C. Middle-age adult who has lupus erythematosus D. Young adult who recently received a body tattoo

B. Child who has streptococcal pharyngitis

A nurse is assessing a client who has a history of asthma. Which of the following factors should the nurse identify as a risk for asthma? A. Gender B. Environmental allergies C. Alcohol use D. Race

B. Environmental allergies

A nurse is caring for a client who has RA. Which of the following laboratory tests are used to diagnose this disease? (Select all that apply) A. Urinalysis B. Erythocyte sedimentation rate C. BUN D. Antinuclear antibody E. WBC count

B. Erythocyte sedimentation rate D. Antinuclear antibody E. WBC count

A nurse is educating a female client on the use of calcipotriene topical medication for the treatment of psoriasis. Which of the following information should the nurse include? (Select all that apply) A. Recommended for facial lesions B. Expect a stinging sensation upon application C. Apply to the scalp D. Obtain a pregnancy test E. Limit application to skin folds

B. Expect a stinging sensation upon application C. Apply to the scalp D. Obtain a pregnancy test E. Limit application to skin folds

A nurse is caring for a male older adult client who has a new diagnosis of glaucoma. Which of the following should the nurse recognize as risk factors associated with this disease? (Select all that apply) A. Gender B. Genetic predisposition C. Hypertension D. Age E. Diabetes mellitus

B. Genetic predisposition C. Hypertension D. Age E. Diabetes mellitus

A nurse is reviewing the manifestations of hyperthyroidism with a client. Which of the following findings should the nurse include? (select all that apply) A. Anorexia B. Heat intolerance C. Constipation D. Palpitations E. Weight loss F. Bradycardia

B. Heat intolerance D. Palpitations E. Weight loss

A nurse is providing information about capsaicin cream to a client who reports continuous knee pain from osteoarthritis. Which of the following information should the nurse include in the discussion? A. Continuous pain relief is provided B. Inspect for skin irritation and cuts prior to application C. Cover the area with tight bandages after application D. Apply the medication every 2 hr during the day

B. Inspect for skin irritation and cuts prior to application

A nurse is caring for an older adult client who has diabetes mellitus and reports a gradual loss of peripheral vision. The nurse should recognize this as a manifestation of which of the following diseases? A. Cataracts B. Open-angle glaucoma C. Macular degeneration D. Angle-closure glaucoma

B. Open-angle glaucoma

A nurse is assessing a client who is scheduled to undergo a right knee arthroplasty. The nurse should expect which of the following findings? (Select all that apply) A. Skin reddened over the joint B. Pain when bearing weight C. Joint crepitus D. Swelling of the affected joint E. Limited joint motion

B. Pain when bearing weight C. Joint crepitus D. Swelling of the affected joint E. Limited joint motion

A nurse is caring for a client who has SLE and is experiencing Raynaud's phenomenon. Which of the following findings should the nurse anticipate? A. Swelling of joints of the fingers B. Pallor of toes with cold exposure C. Feet that become reddened with ambulation D. Client report of intense feeling of heat in the finger

B. Pallor of toes with cold exposure

A nurse is caring for a client who has a spinal cord injury who reports a severe headache and is sweating profusely. Vital signs include blood pressure 220/110 mm Hg and apical heart rate 54/min. Which of the following actions should the nurse take first? A. Notify the provider B. Sit the client upright in bed C. Check the urinary catheter for blockage D. Administer antihypertensive medication

B. Sit the client upright in bed

A nurse caring for a client who has contact dermatitis and has a new prescription for diphenhydramine. For which of the following adverse effects should the nurse monitor? A. Elevated blood glucose levels B. Urinary retention C. Hyper-pigmentation of the skin D. Insomnia

B. Urinary retention

A nurse in the emergency department is caring for a client who is having an acute asthma attack. Which of the following assessments indicates that the respiratory status is declining? (Select all that apply) A. SaO2 95% B. Wheezing C. Retraction of sternal muscles D. Pink mucous membranes E. Premature ventricular complexes

B. Wheezing C. Retraction of sternal muscles E. Premature ventricular complexes

Causes of anemia

Blood loss Inadequate RBC production (hypoproliferative) Increased RBC destruction (hemolytic) Deficiency of necessary components such as folic acid, iron, erythropoietin, and/or vitamin B12

Medications to treat asthma

Bronchodilators Anti-inflammatory agents Combination agents (bronchodilator and anti-inflammatory)

Expected findings for peripheral arterial disease

Burning, cramping, and pain in the legs during exercise Numbness or burning pain primarily in the feet when in bed Pain that is relieved by placing legs at rest in a dependent position Bruit over femoral and aortic arteries Loss of fair on lower calf, ankle, and foot Dry, scaly, mottled skin Thick toenails Cold and cyanotic extremity Pallor of extremity with elevation

A nurse is teaching a client who has SLE about self-care. Which of the following statements by the client indicates an understanding of the teaching? A. "I should limit my time to 10 minutes in the tanning bed." B. "I will apply powder to any skin rash." C. "I should use a mild hair shampoo." D. "I will inspect my skin once a month for rashes."

C. "I should use a mild hair shampoo"

A nurse is providing discharge teaching to a client who has a new prescription for prednisone for asthma. Which of the following client statements indicates an understanding of the teaching? A. "I will decrease my fluid intake while taking the medication." B. "I will expect to have black, tarry stools." C. "I will take my medication with meals." D. "I will monitor for weight loss while on this medication."

C. "I will take this medication with food."

A nurse is caring for a client who has a DVT and has been taking unfractionated heparin for 1 week. Two days ago, the provider also prescribed warfarin. The client asks the nurse about receiving both heparin and warfarin at the same time. Which of the following statements should the nurse give? A. "I will remind your provider that you are already receiving heparin." B. "Your laboratory findings indicated that two anticoagulants were needed." C. "It takes 3-4 days before the therapeutic effects of warfarin are achieved, and then the heparin can be discontinued." D. "Only one of these medications is being given to treat your DVT."

C. "It takes 3-4 days before the therapeutic effects of warfarin are achieved, and then the heparin can be discontinued."

A nurse is providing preoperative teaching for a client who requests autologous donation in preparation for a scheduled orthopedic surgical procedure. Which of the following statements should the nurse include in the teaching? A. "You should make an appointment to donate blood 8 weeks prior to the surgery." B. "If you need an autologous transfusion, the blood your brother donates can be used." C. "You can donate blood each week if your hemoglobin is stable." D. "Any unused blood that is donated can be used for other clients."

C. "You can donate blood each week if your hemoglobin is stable."

A nurse is caring for a client who has a new diagnosis of cataracts. Which of the following manifestations should the nurse expect? (Select all that apply) A. Eye pain B. Floating spots C. Blurred vision D. White pupils E. Bilateral red reflexes

C. Blurred vision D. White pupils

A nurse is monitoring a client who began receiving a unit of packed RBC's 10 min ago. Which of the following findings should the nurse identify as an indication of a febrile transfusion reaction? (select all that apply) A. Temperature change from 37 C pre-transfusion to 37.2 C B. Current blood pressure 178/90 C. Heart rate change from 88/min pre-transfusion to 120/min D. Client report of itching E. Client appears flushed

C. Heart rate change from 88/min pre-transfusion to 120/min E. Client appears flushed

A nurse is providing teaching to the parent of a child who has contact dermatitis. Which of the following information should the nurse include? A. Use fabric softener dryer sheets when drying the child's clothing B. Apply a warm, dry compress to the rash area C. Place the child in a bath with colloidal oatmeal D. Leave the child's hands uncovered during the night.

C. Place the child in a bath with colloidal oatmeal

Physical findings of VTE

Calf or groin pain, tenderness, and a sudden onset of edema of the extremity. Warmth, edema, and induration and hardness over the involved blood vessel. *Shortness of breath and chest pain can indicate pulmonary embolism*

Expected findings of pericarditis

Chest pressure/pain aggravated by breathing, coughing, and swallowing; pericardial friction rub auscultated at left lower sternal border; shortness of breath; and relief of pain when sitting and leaning forward.

Neurogenic shock

Complication of spinal trauma, causes a sudden loss of communication within the sympathetic nervous system that maintains the normal muscle tone in blood vessel walls.

A nurse is providing postoperative teaching to a client following cataract surgery. Which of the following statements should the nurse include in the teaching? A. "You can resume playing golf in 2 days." B. "You need to tilt your head back when washing your hair." C. "You can get water in your eyes in 1 day." D. "You need to limit your housekeeping activities."

D. "You need to limit your housekeeping activities."

A nurse is assessing a client who has a new diagnosis of SLE. Which of the following findings should the nurse expect? A. Weight gain B. Petechiae on thighs C. Systolic murmur D. Alopecia

D. Alopecia

A nurse is caring for a client 2 hours after admission. The client has an SaO2 of 91%, exhibits audible wheezes, and is using accessory muscles when breathing. Which of the following classes of medications should the nurse expect to administer? A. Antibiotic B. Beta-blocker C. Antiviral D. Beta2 agonist

D. Beta2 agonist

A nurse is reviewing the health record of a client who is to undergo total joint arthroplasty. The nurse should recognize which of the following findings as a contraindication to this procedure? A. Age 78 years B. History of cancer C. Previous joint replacement D. Bronchitis 2 weeks ago

D. Bronchitis 2 weeks ago

A nurse is performing an otoscopic examination of a client. Which of the following is an unexpected finding? A. Pearly, gray tympanic membrane B. Malleus visible behind tympanic membrane C. Presence of soft cerumen in the external canal D. Fluid bubble seen behind tympanic membrane

D. Fluid bubble seen behind tympanic membrane

A nurse is caring for a client who has pericarditis. Which of the following findings should the nurse expect? A. Petechiae B. Murmur C. Rash D. Friction rub

D. Friction rub

A nurse is caring for a client who experienced a cervical spine injury 24 hours ago. Which of the following types of prescribed medications should the nurse clarify with the provider? A. Glucocorticoids B. Plasma expanders C. H2 antagonists D. Muscle relaxants

D. Muscle relaxants

A nurse preceptor is observing a newly licensed nurse on the unit who is preparing to administer a blood transfusion to an older client. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure? A. Inserts an 18-gauge IV catheter in the client B. Verifies blood compatibility and expiration date of the blood with an assistive personnel C. Administers dextrose 5% in 0.9% sodium chloride IV with the transfusion D. Obtains vital signs every 15 min throughout the procedure.

D. Obtains vital signs every 15 min throughout the procedure

A nurse is assessing a client who has chronic peripheral arterial disease. Which of the following findings should the nurse expect? A. Edema around the ankles and feet B. Ulceration around the medial malleoli C. Scaling eczema of the lower legs with stasis dermatitis D. Pallor on elevation of the limbs, and rubor when the legs are dependent.

D. Pallor on elevation of the limbs, and rubor when the legs are dependent

A nurse in a clinic is assessing a client who has sinusitis. Which of the following techniques should the nurse use to identify manifestations of this disorder? A. Percussion of posterior lobes of lungs B. Auscultation of the trachea C. Inspection of the conjunctive D. Palpation of the orbital areas

D. Palpation of the orbital areas

A nurse is teaching a client who has a new diagnosis of severe peripheral arterial disease. Which of the following instructions should the nurse include? A. Wear tightly fitted insulated socks with shoes when going outside. B. Elevate both legs above the heart when resting. C. Apply a heating pad to both legs for comfort. D. Place both legs in dependent position while sleeping

D. Place both legs in dependent position while sleeping

A nurse is caring for a client who has a C4 spinal cord injury. The nurse should recognize the client is at greatest risk for which of the following complications? A. Neurogenic shock B. Paralytic ileus C. Stress ulcer D. Respiratory compromise

D. Respiratory compromise

A nurse is admitting a client who has suspected rheumatic endocarditis. The nurse should anticipate a prescription from the provider for which of the following lab tests to assist in confirmation of this diagnosis? A. Arterial blood gases B. Serum albumin C. Liver enzymes D. Throat culture

D. Throat culture

A nurse is caring for a client who has suspected Meniere's disease. Which of the following is an expected finding? A. Presence of a purulent lesion in the external ear canal B. Feeling of pressure in the ear C. Bulging, red bilateral tympanic membranes D. Unilateral hearing loss

D. Unilateral hearing loss

Sensorineural haring loss is caused by?

Damage to cranial nerve VIII

Physical findings for varicose veins

Distended, superficial veins that are visible just below the skin and are tortuous in nature Muscle cramping and aches, pain after sitting, and pruritus

Medications to treat heart failure

Diuretics Afterload-reducing agents Inotropic agents Beta-blockers Vasodilators Human B-type natriuretic peptides Anticoagulants

Expected findings of asthma

Dyspnea Chest tightness Anxiety or stress Coughing Wheezing Mucus production Prolonged exhalation Barrel chest Poor oxygen saturation

Expected findings of rheumatic endocarditis

Fever Chest pain Joint pain Tachycardia Shortness of breath Rash on trunk and extremities Friction rub Murmur and muscle spasms

Physical assessment findings of pneumonia

Fever Chills Flushed face Diaphoresis Shortness of breath Tachypnea Pleuritic chest pain (sharp) Sputum production (yellow-tinged) Crackles and wheezes Coughing Dull chest percussion

Expected findings of infective endocarditis

Fever Flu-like manifestations Murmur Petechiae Positive blood cultures Splinter hemorrhages (red streaks under the nail bed)

Risk factors of seizures

Genetic predisposition Acute febrile state Head trauma Cerebral edema Abrupt cessation of antiepileptic drugs Infection Metabolic disorder Exposure to toxins Stroke Heart disease Brain tumor Hypoxia Acute substance withdrawal Fluid and electrolyte imbalances

Medications for spinal cord injury

Glucocorticoids- decrease edema of the spinal cord Vasopressors- treat hypotension, particularly during neurogenic shock Atropine- treat bradycardia Dextran- A volume expander, used to treat hypotension secondary to spinal shock Muscle relaxants Cholinergics Analgesics Anticoagulants Stool softeners and bulk-forming laxatives Vasodilators

Atherosclerosis

Gradual thickening of the arteries

Risk factors of hyperthyroidism

Graves' disease is the most common cause Toxic nodular goiter

Arteriosclerosis

Hardening of the arteries

Risk factors of BPH

Increased age Smoking, chronic alcohol use Sedentary lifestyle, obesity Western diet (High fat, protein, cab; low fiber) Diabetes, heart disease

Triggering factors of seizures

Increased physical activity Excessive stress Hyperventilation Overwhelming fatigue Acute alcohol ingestion Excessive caffeine intake Exposure of flashing lights Substances such as cocaine, aerosols, and inhaled glue products

Infective endocarditis

Infection of the endocardium due to staphylococci, streptococci, fungi, or other infectious organisms Common in IV drug users

Pericarditis

Inflammation of the pericardium Commonly follows a respiratory infection Can be due to a MI

Client education of peripheral arterial disease

Instruct the client to avoid crossing the legs. Tell the client to refrain from wearing restrictive garments. Tell the client to elevate the legs to reduce swelling, but not to elevate them above the level of the heart.

Expected findings of hypothyroidism

Intolerance to cold Weight gain without an increase in caloric intake Pale skin Thick, brittle fingernails Thickening of the skin

Generalized seizures

Involves both cerebral hemispheres

Spinal cord injury

Loss of motor function, sensory function, reflexes, and control of elimination. Injuries in the cervical region- Quadriplegia Injuries below T1- Paraplegia

What diet should a client with gout follow?

Low-purine diet No shellfish No organ meats

Risk factors for spinal cord injury

Males age 16-30 High-risk activities Participation in impact sports Acts of violence Alcohol or drug use Disease Falls

iron deficiency anemia

Most common cause of anemia in children, adolescents, and pregnant women

Expected findings of hyperthyroidism

Muscle weakness Heat intolerance Weight change and increased appetite Insomnia and interrupted sleep Bruit over the thyroid gland Bulging eyes Goiter (enlarged thyroid)

Complications of spinal cord injury

Orthostatic hypotension Spinal shock Neurogenic shock Autonomic dysreflexia

Conductive hearing loss is caused by?

Otitis media Otosclerosis Impacted cerumen

Expected findings of anemia

Pallor Fatigue Irritability Numbness and tingling of extremities Dyspnea on exertion Sensitivity to cold Pain and hypoxia with sickle-cell crisis

Vitamin B12 deficiency anemia

Pernicious anemia due to deficiency of intrinsic factors produced by gastric mucosa, which is necessary for absorption of vitamin B12

Nursing care for pneumonia

Position patient in high-Fowler's Encourage coughing or suction Administer breathing treatments and medications Administer oxygen therapy Encourage use of incentive spirometer

Peripheral venous disease

Problems with the veins that interfere with adequate return of blood flow from the extremities

Benign prostatic hyperplasia

Prostate gland becomes enlarged and causes urinary dysfunction Very common condition in older adult males

Allergic blood transfusion reaction

Results from a sensitivity reaction to a component of the transfused blood products. Findings include itching, urticaria, and flushing

Bacterial blood transfusion reaction

Results from a transfusion of contaminated blood products. Findings include wheezing, dyspnea, chest tightness, cyanosis, hypotension, and shock

Circulatory overload blood transfusion reaction

Results from a transfusion rate that is too rapid for the client. Findings include crackles, dyspnea, cough, anxiety, jugular vein distention, and tachycardia

Peripheral arterial disease

Results from atherosclerosis that usually occurs in the arteries of the lower extremities and is characterized by inadequate flow of blood

Febrile blood transfusion reaction

Results from the development of anti-WBC antibodies. Findings include chills, increase of 1 degree F, flushing, hypotension, and tachycardia

Left-sided heart failure

Results in inadequate left ventricle output and consequently in inadequate tissue perfusion

Right-sided heart failure

Results in inadequate right ventricle output and systemic venous congestion

Physical findings of venous insufficiency

Stasis dermatitis- brown discoloration along the ankles that extends up the calf relative to the level of insufficiency Edema Stasis ulcers (typically around ankles)

Client education for pneumonia treatment

Take antibiotics and anti-inflammatories with food Increase fluid intake Suck on hard candies to moisten dry mouth while taking ipratropium Avoid crowded areas

Medications to treat hyperthyroidism

Thionamides Beta-adrenergic blockers Iodine solutions

Diagnostic test for varicose veins

Trendelenburg test- patient is in a supine position with legs elevated, when patient sits up, the veins will fill from the proximal end if varicose veins are present (veins normally fill from the distal end)

Immediate Hypersensitivity (Anaphylactic Reaction) is what type of hypersensitivity reaction?

Type I Ex. Anaphylaxis

Cytotoxic reaction (Antibody-dependent) is what type of hypersensitivity reaction?

Type II Ex. Blood transfusion reaction

Immune Complex Reaction is what type of hypersensitivity reaction?

Type III Ex. SLE

Cell-Mediated (Delayed hypersensitivity) is what type of hypersensitivity reaction?

Type IV Ex. Antibiotic reactions, poison ivy resulting in contact dermatitis

Expected findings of BPH

Urinary frequency, urgency, hesitancy, or incontinence; incomplete emptying of the bladder; dribbling post-voiding; nocturia; diminished force of urinary stream; straining with urination; and hematuria

Types of peripheral venous disease

Venous thromboembolism (VTE) Venous insufficiency Varicose veins

Risk factors of hypothyroidism

Women 30-60 years old Use of certain medications (lithium, amiodarone) Inadequate intake of iodine Radiation therapy to the head and neck

Expected findings of left-sided heart failure

*Dyspnea, orthopnea, nocturnal dyspnea *Fatigue *Hypertrophy *S3 heart sound *Pulmonary congestion *Frothy sputum *Altered mental status *Manifestations of organ failure

Nursing care for venous insufficiency

*Elevate legs for at least 20 min, four to five times a day. *Elevate the legs above the heart when in bed. *Instruct clients to avoid crossing legs and wearing constrictive clothing or stockings *Instruct clients to wear elastic compression stockings and apply them after the legs have been elevated and when swelling is at a minimum

Nursing care for DVT

*Facilitate bed rest and elevation of the extremity above the level of the heart as prescribed. *Administer intermittent or continuous warm moist compresses as prescribed. * Do not massage the affected limb *Provide thigh-high compression or antiembolism stockings

Risk factors of left-sided heart failure

*Hypertension *Coronary artery disease, angina, MI *Valvular disease

Expected findings for right-sided heart faliure

*Jugular vein distention *Ascending dependent edema *Abdominal distention, ascites *Fatigue, weakness *Nausea, and anorexia *Polyuria at rest *Liver enlargement and tenderness *Weight gain

Risk factors of right-sided heart failure

*Left-sided heart failure *Right ventricular MI *Pulmonary problems