Test 5 NUR 327

A group of students are studying for an examination on joints. The students demonstrate understanding of the material when they identify which of the following as an example of a synarthrodial joint? Between the vertebrae In the fingers At the hip Skull at the temporal and occipital bones

A synarthrodial joint is immovable and can be found at the suture line of the skull between the temporal and occipital bones. Amphiarthrodial joints are slightly moveable and are found between the vertebrae. The finger and hip joints are examples of diarthrodial joints that are freely moveable.

What clinical manifestation would the nurse expect to find in a client who has had osteoporosis for several years? Bone spurs Diarrhea Increased heel pain Decreased height

Decreased height

The nurse is caring for a client with symptoms of ototoxicity from aminoglycoside administration. On which structure does the medication produce the ototoxic effect? The auditory canal The eighth cranial nerve The tympanic membrane The cochlear nerve

The eighth cranial nerve Explanation: Ototoxicity describes the detrimental effect of aminoglycosides on the eighth cranial nerve. Signs and symptoms include tinnitus and sensorineural hearing. The other options are not related to the ototoxic effects.

There are thousands of components of the musculoskeletal system that facilitate mobility and independent function. The function of skeletal muscle is promoting: movement of skeletal bones. organ function. involuntary function. All options are correct.

movement of skeletal bones. Explanation: The skeletal muscles promote movement of the bones of the skeleton.

A client has been diagnosed with a muscle strain. What does the physician mean with the term "strain"? stretched or pulled beyond its capacity injury resulting from a blow or blunt trauma injuries to ligaments surrounding a joint subluxation of a joint

stretched or pulled beyond its capacity Explanation: A strain is an injury to a muscle when it is stretched or pulled beyond its capacity.

Health education for a woman over age 50 includes providing information about the importance of adequate amounts of calcium and vitamin D to prevent osteoporosis. Select the daily dosage of calcium and vitamin D that the nurse should recommend. 1,800 mg; 1,600 IU 1,600 mg; 1,400 IU 1,400 mg; 1,200 IU 1,200 mg; 1,000 IU

1,200 mg; 1,000 IU Explanation: The daily recommended dosage is 1,200 mg of calcium and 1,000 IU of vitamin D.

A client comes back to the clinic with a continued complaint of back pain. What time frame does the nurse understand constitutes "chronic pain"? 4 weeks 3 months 6 months 1 year

3 months Explanation: The typical client reports either acute back pain (lasting fewer than 3 months) or chronic back pain (3 months or longer without improvement) and fatigue.

Which symptoms may a client with Ménière disease report before an attack? Nystagmus Low blood pressure Photosensitivity A full feeling in the ear

A full feeling in the ear Explanation: Clients with Ménière disease experience symptoms of headache and a full feeling in the ear before an attack. Nystagmus is an episodic symptom that occurs during an attack, and, at times, the client is symptom free. Ménière disease does not cause low blood pressure or photosensitivity.

The nurse is providing care for an adult client who has sought care for the treatment of obesity. When performing an assessment of this client, the nurse should address what potential contributing factors? Select all that apply. Activity level Neurologic factors Family history and genetics Endocrine factors Microbiota

Activity level Family history and genetics Endocrine factors Microbiota Explanation: Obesity is a multifactorial health problem, which involves contributions related to physical activity, family history, genetics and hormonal factors. The role of the microbiota is also being investigated as an etiologic factor. Disruptions to normal neurologic function, however, have not been identified as possible causes of obesity.

A patient is diagnosed with osteogenic sarcoma. What laboratory studies should the nurse monitor for the presence of elevation? Magnesium level Potassium level Alkaline phosphatase Troponin levels

Alkaline phosphatase Explanation: Serum alkaline phosphatase levels are frequently elevated with osteogenic sarcoma or bone metastasis. Hypercalcemia is also present with bone metastases from breast, lung, or kidney cancer. Symptoms of hypercalcemia include muscle weakness, fatigue, anorexia, nausea, vomiting, polyuria, cardiac dysrhythmias, seizures, and coma. Hypercalcemia must be identified and treated promptly.

A patient has been diagnosed with osteomalacia. What common symptoms does the nurse recognize that correlate with the diagnosis? Bone fractures and kyphosis Bone pain and tenderness Muscle weakness and spasms Softened and compressed vertebrae

Bone pain and tenderness Explanation: Osteomalacia is a metabolic bone disease characterized by inadequate mineralization of bone. As a result, the skeleton softens and weakens, causing pain, tenderness to touch, bowing of the bones, and pathologic fractures. On physical examination, skeletal deformities (spinal kyphosis and bowed legs) give patients an unusual appearance and a waddling gait.

Which is an indicator of neurovascular compromise? Warm skin temperature Diminished pain Pain upon active stretch Capillary refill of more than 3 seconds

Capillary refill of more than 3 seconds Explanation: Capillary refill of more than 3 seconds is an indicator of neurovascular compromise. Other indicators include cool skin temperature, pale or cyanotic color, weakness, paralysis, paresthesia, unrelenting pain, pain upon passive stretch, and absence of feeling. Cool skin temperature is an indicator of neurovascular compromise. Unrelenting pain is an indicator of neurovascular compromise. Pain upon passive stretch is an indicator of neurovascular compromise.

Loud, persistent noise has been found to have which of the following effects on the body? Select all that apply. Constriction of peripheral blood vessels Increased blood pressure Increased heart rate Decreased gastrointestinal motility Dilation of peripheral blood vessels

Constriction of peripheral blood vessels Increased blood pressure Increased heart rate Explanation: Loud, persistent noise has been found to cause constriction of peripheral blood vessels, increased blood pressure and heart rate (because of increased secretion of adrenalin), and increased gastrointestinal activity, well as disturbed patterns of sleep.

A nurse cares for a client with sepsis who had bariatric surgery two weeks ago. What is the mostlikely source of the sepsis? Disruption at the site of anastomosis. Perforation of the gastric contents. Bacterial infiltration at the surgical site of the skin. Colonization of bacteria in the bladder.

Disruption at the site of anastomosis. Explanation: The most likely source of infection after bariatric surgery is disruption at the site of anastomosis. The other answer choices may potentially occur in the client who is postoperative from bariatric surgery; however, these are not the most likely sources of infection the client may develop.

A client is diagnosed with a fracture of a diarthrosis joint. What is an example of this type of joint? Symphysis pubis Skull Elbow Fifth thoracic vertebrae

Elbow Explanation: A diarthrosis joint, like the elbow, is freely movable. The skull is an example of an immovable joint. The vertebral joints and symphysis pubis are amphiarthrosis joints that have limited motion.

The femur fracture that commonly leads to avascular necrosis or nonunion because of an abundant supply of blood vessels in the area is a fracture of the: Condylar area. Femoral neck. Shaft of the femur. Trochanteric region.

Femoral neck. Explanation: A fracture of the neck of the femur may damage the vascular system and the bone will become ischemic. Therefore, a vascular necrosis is common.

The nurse should monitor for which manifestation in a client who has undergone LASIK? Excessive tearing Cataract formation Halos and glare Stye formation

Halos and glare Explanation: Symptoms of central islands and decentered ablations can occur after LASIK surgery; these include monocular diplopia or ghost images, halos, glare, and decreased visual acuity. These procedures do not cause excessive tearing or result in cataract or stye formation.

What pathophysiological concept is related to the increase in the hormone leptin, as it relates to satiety and hunger? Increased adipose stores Increased caloric intake Decreased carbohydrate intake Alterations in metabolism

Increased adipose stores Explanation: Increased fat stores increases the level of leptin in the bloodstream.

A client comes to the walk-in clinic complaining of a "bug in my ear." What action should be taken when there is an insect in the ear? Instillation of mineral oil Instillation of carbamide peroxide Instillation of hot water Use of a small forceps

Instillation of mineral oil Explanation: Mineral oil is instilled into the ear to smother an insect. Carbamide peroxide is used to soften dried cerumen and small forceps are used to remove solid objects. Hot liquids cause dizziness and should not be instilled in the ear.

A client who is post op from bariatric surgery reports constipation. What is the most likely cause of the client's symptoms? Insufficient water intake Diuretic medications Gastric dysfunction Impaired gastric motility

Insufficient water intake Explanation: The most likely cause of the client's complaint of constipation is insufficient water intake. Diuretic medications would not typically be prescribed for bariatric surgery and would not be the cause of the client's report of symptoms. Gastric dysfunction and impaired gastric motility are not the primary cause of constipation.

To avoid the side effects of corticosteroids, which medication classification is used as an alternative in treating inflammatory conditions of the eyes? Miotics Nonsteroidal anti-inflammatory drugs (NSAIDs) Mydriatics Cycloplegics

Nonsteroidal anti-inflammatory drugs (NSAIDs) Explanation: NSAIDs are used as an alternative in controlling inflammatory eye conditions and postoperatively to reduce inflammation. Miotics are used to cause the pupil to constrict. Mydriatics cause the pupil to dilate. Cycloplegics cause paralysis of the iris sphincter.

A patient has a long leg cast applied. Where does the nurse understand a common pressure problem may occur? Dorsalis pedis Peroneal nerve Popliteal artery Posterior tibialis

Peroneal nerve Explanation: The nurse assesses circulation by observing the color, temperature, and capillary refill of the exposed toes. Nerve function is assessed by observing the patient's ability to move the toes and by asking about the sensations in the foot. Numbness, tingling, and burning may indicate peroneal nerve injury resulting from pressure at the head of the fibula.

A nurse performs a neurovascular assessment on a client 2 weeks after a wrist cast had been removed. The nurse documents in the client's chart that there is normal sensation in the ulnar nerve. What finger assessment test will the nurse perform on this client? Prick the skin midway between the thumb and second finger. Prick the distal fat pad on the small finger. Prick the top or distal surface of the index finger. Prick the top of the middle finger.

Prick the distal fat pad on the small finger. Explanation: See Table 40-2 in the text. The ulnar nerve runs near the ulnar bone and enters the palm of the hand. It branches to the fifth finger (small finger) and the ulnar side of the fourth finger.

Positive end-expiratory pressure (PEEP) therapy has which effect on the heart? Bradycardia Tachycardia Increased blood pressure Reduced cardiac output

Reduced cardiac output Explanation: PEEP reduces cardiac output by increasing intrathoracic pressure and reducing the amount of blood delivered to the left side of the heart. It doesn't affect heart rate, but a decrease in cardiac output may reduce blood pressure, commonly causing compensatory tachycardia, not bradycardia. However, the resulting tachycardia isn't a direct effect of PEEP therapy itself.

The nurse is caring for a client who lives alone and had a total knee replacement. An appropriate nursing diagnosis for the client is: Risk for ineffective therapeutic regimen management Disturbed body image Situational low self-esteem Risk for avascular necrosis of the joint

Risk for ineffective therapeutic regimen management Explanation: The client without adequate support and resources is at risk for ineffective therapeutic regimen management. A total knee replacement may be used to treat avascular necrosis. While an orthopedic client is at risk for disturbed body image and situational low self-esteem, there is no evidence that these exist for this client.

A client sustains an injury to the ligaments surrounding a joint. What will the nurse identify this injury as? Strain Contusion Sprain Fracture

Sprain Explanation: A sprain is an injury to the ligaments surrounding a joint. A strain is an injury to a muscle when it is stretched or pulled beyond its capacity. A contusion is a soft tissue injury resulting from a blow or blunt trauma. A fracture is a break in the continuity of a bone.

A client is seen in the emergency room for a knee injury that happened during a basketball game. Diagnostic tests reveal torn cords of fibrous connective tissue that connect muscles to bones. What type of tear has this client sustained? Fascia Ligament Bursa Tendon

Tendon Explanation: Tendons are broad, flat sheets of connective tissue that attach muscles to bones, soft tissue, and other muscles. Ligaments bind bones together. A bursa is a synovial-filled sac, and fascia surround muscle cells.

A client experiences a musculoskeletal injury that involves the structure that connects a muscle to the bone. The nurse understands that this injury involves which structure? Ligament Tendon Cartilage Joint

Tendon Explanation: Tendons are cordlike structures that attach muscles to the periosteum of the bone. Ligaments consisting of fibrous tissue connect two adjacent, freely movable bones. Cartilage is a firm dense type of connective tissue that reduces friction between articular surfaces, absorbs shock, and reduces the stress on joint surfaces. A joint is the junction between 2 or more bones.

A client had a total left hip arthroplasty. What clinical manifestation would indicate to the nurse that the prosthesis is dislocated? The left leg is internally rotated. The leg length is the same as the right leg. The client has discomfort when moving in bed. There are diminished peripheral pulses on the affected extremity.

The left leg is internally rotated. Explanation: The nurse must monitor the client for signs and symptoms of dislocation of the prosthesis, which include abnormal external or internal rotation of the affected extremity. The length of the leg with a dislocated prosthesis may be shorter. The client's discomfort will not indicate a dislocation. Diminshed peripheral pulse of the affected extremity would be a indication of circulation issues.

A client has severe osteoarthritis in the left hip and is having surgery to replace both articular surfaces of the hip. What type of surgical procedure will the nurse prepare the client for? Arthrodesis Hemiarthroplasty Total arthroplasty Osteotomy

Total arthroplasty Explanation: A total arthroplasty is a replacement of both articular surfaces within one joint. An arthrodesis is a fusion of a joint for stabilization and pain relief and is usually done on a wrist or knee. A hemiarthroplastyis the replacement of one of the articular surfaces in a joint, such as the femoral head but not the acetabulum. An osteotomy is the cutting and removal of a wedge of bone to change the bone's alignment, thereby improving function and relieving pain.

A middle-aged obese female presents to the ED with severe radiating right-sided flank pain, nausea, vomiting, and fever. A likely cause of these symptoms is: acute cholecystitis hepatitis A hepatitis B pancreatitis

acute cholecystitis Explanation: Gallstones are more frequent in women, particularly women who are middle-aged and obese. With acute cholecystitis, clients usually are very sick with fever, vomiting, tenderness over the liver, and severe pain that may radiate to the back and shoulders. The patient profile and symptoms are suggestive of acute cholecystitis.

A client reports a sudden onset of tinnitus, hearing loss, and vertigo. The nurse carefully reviews the client's medication list to determine whether the client is taking a medication that might cause ototoxicity. Which medications would the nurse be most concerned with? Select all that apply. aspirin lasix cisplatin cephalexin

aspirin lasix cisplatin Explanation: Salicylates, loop diuretics, and certain chemotherapeutic agents are drugs associated with ototoxicity. Cephalosporins are not known to cause ototoxicity.

A hip spica cast: encloses the trunk and a lower extremity. encircles the trunk. is a short or long leg cast reinforced for strength. extends from the junction of the upper and middle third of the thigh to the base of the toes. The knee may be slightly flexed.

encloses the trunk and a lower extremity. Explanation: A hip spica cast encloses the trunk and a lower extremity. A double hip spica cast includes both legs. A body cast encircles the trunk. A walking cast is a short or long leg cast reinforced for strength. A long leg cast extends from the junction of the upper and middle third of the thigh to the base of the toes. The knee may be slightly flexed.

A client has noticed recently having clearer vision at a distance than up close. What is the term used to describe this client's visual condition? hyperopia emmetropia myopia astigmatism

hyperopia Explanation: Hyperopia is farsightedness. People who are hyperopic see objects that are far away better than objects that are close.

A client has an exaggerated convex curvature of the thoracic spine. What is this condition called? kyphosis lordosis scoliosis diaphysis

kyphosis Explanation: Kyphosis is an exaggerated convex curvature of the thoracic spine. Lordosis is an excessive concave curvature of the lumbar spine. Scoliosis is a lateral curvature of the spine. Diaphyses are the long shafts of bones in the arms and legs.

A variety of complications can occur after a leg amputation. Which is not a possibility in the immediate postoperative period? osteomyelitis hematoma hemorrhage infection

osteomyelitis Explanation: Chronic osteomyelitis may occur after persistent infection in the late postoperative period. Hematoma, hemorrhage, and infection are potential complications in the immediate postoperative period.

The nurse is admitting a client whose medication regimen includes regular injections of vitamin B12. The nurse should question the client about a history of: total gastrectomy. bariatric surgery. diverticulitis. gastroesophageal reflux disease (GERD).

total gastrectomy. Explanation: If a total gastrectomy is performed, injection of vitamin B12 will be required for life, because intrinsic factor, secreted by parietal cells in the stomach, binds to vitamin B12 so that it may be absorbed in the ileum. Bariatric surgery, diverticulitis and GERD do not necessitate total gastrectomy and subsequent vitamin B12 supplementation.

A client is receiving mechanical ventilation. How frequently should the nurse auscultate the client's lungs to check for secretions? Every 30 to 60 minutes Every 1 to 2 hours Every 2 to 4 hours Every 4 to 6 hours

Every 2 to 4 hours Explanation: Continuous positive-pressure ventilation increases the production of secretions regardless of the patient's underlying condition. The nurse assesses for the presence of secretions by lung auscultation at least every 2 to 4 hours.

x A client is brought to the emergency department by the paramedics. The client is a type 2 diabetic and is experiencing hyperglycemic hyperosmolar syndrome (HHS). The nurse should identify what components of HHS? Select all that apply. Leukocytosis Glycosuria Dehydration Hypernatremia Hyperglycemia

Glycosuria Dehydration Hypernatremia Hyperglycemia Explanation: In HHS, persistent hyperglycemia causes osmotic diuresis, which results in losses of water and electrolytes. To maintain osmotic equilibrium, water shifts from the intracellular fluid space to the extracellular fluid space. With glycosuria and dehydration, hypernatremia and increased osmolarity occur. Leukocytosis does not take place.

The nurse is managing a gastric (Salem) sump tube for a patient who has an intestinal obstruction and will be going to surgery. What interventions should the nurse perform to make sure the tube is functioning properly? Maintain intermittent or continuous suction at a rate greater than 120 mm Hg. Keep the vent lumen above the patient's waist to prevent gastric content reflux. Irrigate only through the vent lumen. Tape the tube to the head of the bed to avoid dislodgement.

Keep the vent lumen above the patient's waist to prevent gastric content reflux. Explanation: The blue vent lumen should be kept above the patient's waist to prevent reflux of gastric contents through it; otherwise, it acts as a siphon.

x A nurse assesses a patient diagnosed with hepatic encephalopathy. She observes a number of clinical signs, including asterixis and fetor hepaticus; the patient's electroencephalogram (EEG) is abnormal. The nurse documents that the patient is exhibiting signs of which stage of hepatic encephalopathy? Stage 1 Stage 2 Stage 3 Stage 4

Stage 2 Explanation: The signs listed in the question plus disorientation, mood swings, and increased drowsiness are all indicators of stage 2 hepatic encephalopathy. Refer to Table 25-2 in the text.

When preparing to insert a nasogastric tube, the nurse determines the length of the tube to be inserted. The nurse nurse places the distal tip of the tube at which location? Tip of patient's nose Tragus of the ear Base of the neck Tip of the xiphoid process

Tip of patient's nose Explanation: To measure the length of the nasogastric tube, the nurse first places the distal tip of the tubing at the tip of the patient's nose, extends the tube to the tragus of the ear, and then extends the tube straight down to the tip of the xiphoid process.

Which statement by the client preparing for a bone scan indicates further teaching by the nurse is needed? "I will need to limit my fluid intake so as not to interfere with the isotope." "The scan is done a couple of hours after the isotope is injected." "The radioisotope will be injected through my IV." "I will need to empty my bladder before I go for the scan."

"I will need to limit my fluid intake so as not to interfere with the isotope." Explanation: The client needs to increase fluid intake to help distribute the isotope and to promote its excretion.

The nurse is caring for a patient after arthroscopic surgery for a rotator cuff tear. The nurse informs the patient that full activity can usually resume after what period of time? 3 to 4 weeks 8 weeks 3 to 4 months 6 to 12 months

6 to 12 months Explanation: The course of rehabilitation following repair of a rotator cuff tear is lengthy (i.e., 6 to 12 months); functionality after rehabilitation depends on the patient's dedication to the rehabilitation regimen (NAON, 2007).

A group of students are reviewing information about cast composition in preparation for a discussion on the advantages and disadvantages of each. The students demonstrate understanding of the topic when they cite which of the following as an advantage of a plaster cast? Better molding to the client Quicker drying Longer-lasting More breathable

Better molding to the client Explanation: Plaster casts require a longer time for drying, but mold better to the client, and are initially used until the swelling subsides. Fiberglass casts dry more quickly, are lighter in weight, longer-lasting, and breathable.

Choose the correct statement about the endosteum, a significant component of the skeletal system: Covers the marrow cavity of long bones Supports the attachment of tendons to bones Contains blood vessels and lymphatics Facilitates bone growth

Covers the marrow cavity of long bones Explanation: The endosteum is a thin vascular membrane that covers the marrow cavity of long bones and the spaces in cancellous bone. Osteoclasts are located near the endosteum.

Which finding would indicate a decrease in pressure with mechanical ventilation? Kinked tubing Increase in compliance Decrease in lung compliance Plugged airway tube

Increase in compliance Explanation: A decrease in pressure in the mechanical ventilator may be caused by an increase in compliance. Kinked tubing, decreased lung compliance, and a plugged airway tube cause an increase in peak airway pressure.

A client comes to the eye clinic for a routine check-up. The client tells the nurse he thinks he is color blind. What screening test does the nurse know will be performed on this client to assess for color blindness? Rosenbaum Jaeger Ishihara Snellen

Ishihara Explanation: Color vision is assessed with Ishihara polychromatic plates. The client receives a series of cards on which the pattern of a number is embedded in a circle of colored dots. The numbers are in colors that color-blind persons commonly cannot see. Clients with normal vision readily identify the numbers. The Jaeger and the Rosenbaum test near vision while the Snellen tests far vision.

Which of the following deformity causes a exaggerated curvature of the lumbar spine? Lordosis Scoliosis Kyphosis Steppage gait

Lordosis Explanation: Lordosis is an exaggerated curvature of the lumbar spine. Scoliosis is a lateral curving deviation of the spine. Kyphosis is an increased forward curvature of the thoracic spine. Steppage gait is not a type of spinal deformity.

The nurse is caring for a patient who had a total hip replacement. What lethal postoperative complication should the nurse closely monitor for? Atelectasis Hypovolemia Pulmonary embolism Urinary tract infection

Pulmonary embolism Explanation: Patients having orthopedic surgery are particularly at risk for venous thromboembolism, including deep vein thrombosis and pulmonary embolism.

A client has just undergone arthrography. What is the most important instruction for the nurse to include in the teaching plan? Avoid sunlight or harsh, dry climate. Avoid intake of dairy products. Report joint crackling or clicking noises occurring after the second day. Gently massage joints with any crackling or clicking joint noises.

Report joint crackling or clicking noises occurring after the second day. Explanation: After undergoing arthrography, the client must be informed that he or she may hear crackling or clicking noises in the joints for up to 2 days, but if noises occur beyond this time, they should be reported. These noises may indicate the presence of a complication, and therefore should not be ignored or treated by the client. Massage is not indicated. The client need not be asked to avoid sunlight or dairy products.

Which hormones released throughout the gastrointestinal tract promote satiety? Select all that apply. Somatostatin Cholecystokinin Insulin Ghrelin Neuropeptide y

Somatostatin Cholecystokinin Insulin Explanation: Somatostatin, cholecystokinin, and insulin are all hormones released throughout the gastrointestinal tract that promote satiety. Ghrelin and neuropeptide y are orexigenic, and stimulate hunger.

A client with low back pain is being seen in the clinic. In planning care, which teaching point should the nurse include? Sleep on the stomach to alleviate pressure on the back. A soft mattress is most supportive by conforming to the body. Avoid twisting and flexion activities. Use the large muscles of the leg when lifting items.

Use the large muscles of the leg when lifting items. Explanation: The large muscles of the leg should be used when lifting.

x Bursitis is an inflammation of the bursa, a fluid-filled sac that cushions bone ends to enhance a gliding movement. What possible assessment findings would be present in a client with bursitis? Select all that apply. painful movement of a joint a distinct lump Bouchard's nodes hyperuricemia

painful movement of a joint a distinct lump Explanation: Painful movement of a joint and a distinct lump are two of the findings with bursitis. Bouchard's nodes are bony enlargements of the distal interphalangeal joints and are seen with osteoarthritis. Hyperuricemia is found with gout.

The nurse cares for clients with obesity and understands that causes are multifactorial. What factors contribute to the development of obesity? Select all that apply. Behavior Environment Physiology Genetics Immunology

Behavior Environment Physiology Genetics Explanation: The causes of obesity are complex and multifactorial, and include behavioral, environmental, physiologic, and genetic factors.

The health care provider is preparing to bivalve the client's cast. Which supplies should the nurse assemble? Elastic compression bandages Gauze bandages and tape Sterile saline and basin Stockinette and cotton padding

Elastic compression bandages Explanation: Bivalving of a cast involves splitting the cast longitutdinally and spreading the cast apart to relieve pressure. The fractured extremity is immobilized by securing the two parts of the cast together with an elastic compression bandage.

The nurse is educating the patient with low back pain about the proper way to lift objects. What muscle should the nurse encourage the patient to maximize? Gastrocnemius Latissimus dorsi Quadriceps Rectus abdominis

Quadriceps Explanation: The nurse instructs the patient in the safe and correct way to lift objects using the strong quadriceps muscles of the thighs, with minimal use of weak back muscles (Fig. 42-3).

A client with osteoporosis is prescribed a selective estrogen receptor modifier (SERM) as treatment. The nurse would identify which drug as belonging to this class? Alendronate (Fosamax) Calcium gluconate Tamoxifen (Nolvadex) Raloxifene (Evista)

Raloxifene (Evista) Explanation: An example of a selective estrogen receptor modifier (SERM) is raloxifene (Evista). Alendronate is a biphosphonate; calcium gluconate is an oral calcium preparation; tamoxifen is an antiestrogen agent.

Which of the following surgical procedures involves taking a piece of silicone plastic or sponge and sewing it onto the sclera at the site of a retinal tear? Scleral buckle Pars plana vitrectomy Pneumatic retinopexy Phacoemulsification

Scleral buckle Explanation: The scleral buckle is a procedure in which a piece of silicone plastic or sponge is sewn onto the sclera at the site of the retinal tear. The buckle holds the retina against the sclera until scarring seals the tear. The other surgeries do not use this type of procedure.

Which is one of the most common causes of death in clients diagnosed with fat emboli syndrome? Myocardial infarction Stroke Acute respiratory distress syndrome Pulmonary embolism

Acute respiratory distress syndrome Explanation: Acute pulmonary edema and acute respiratory distress syndrome are the most common causes of death.

The nurse is caring for an older adult who reports xerostomia. The nurse evaluates for use of which medication? Steroids Antibiotics Antiemetics Diuretics

Diuretics Explanation: Diuretics, frequently taken by older adults, can cause xerostomia (dry mouth). This is uncomfortable, impairs communication, and increases the client's risk for oral infection. Antibiotics, antiemetics, and steroids are not medications typically taken orally by adults that cause dry mouth.

Which term refers to a disease of a nerve root? Radiculopathy Involucrum Sequestrum Contracture

Radiculopathy Explanation: When the client reports radiating pain down the leg, the client is describing radiculopathy. Involucrum refers to new bone growth around the sequestrum. Sequestrum refers to dead bone in an abscess cavity. Contracture refers to abnormal shortening of muscle or fibrosis of joint structures.

A client undergoes an invasive joint examination of the knee. What will the nurse closely monitor the client for? Lack of sleep and appetite Serous drainage Signs of depression Signs of shock

Serous drainage Explanation: When the client undergoes an invasive knee joint examination, the nurse should inspect the knee area for swelling, bleeding, and serous drainage. An invasive joint examination does not cause lack of sleep or appetite, depression, or shock. The client may be in shock due to the injury itself.

A mechanically ventilated client is receiving a combination of atracurium and the opioid analgesic morphine. The nurse monitors the client for which potential complication? Venous thromboemboli Pneumothorax Pulmonary hypertension Cor pulmonale

Venous thromboemboli Explanation: Neuromuscular blockers predispose the client to venous thromboemboli (VTE), muscle atrophy, foot drop, peptic ulcer disease, and skin breakdown. Nursing assessment is essential to minimize the complications related to neuromuscular blockade. The client may have discomfort or pain but be unable to communicate these sensations.

A nurse is caring for a client with eczema. Which medication would be prescribed when an allergy is a factor causing the skin disorder? Dexamethasone Chlorpheniramine Dicloxacillin Bupivacaine

vChlorpheniramine Explanation: Antihistamines such as chlorpheniramine are frequently prescribed when an allergy is a factor in causing a skin disorder. Antihistamines relieve itching and shorten the duration of allergic reaction. Corticosteroids such as dexamethasone are used to relieve inflammatory or allergic symptoms. Antibiotics such as dicloxacillin are used to treat infectious disorders. Local anesthetics such as bupivacaine are used to relieve minor skin pain and itching.

The nurse, caring for a patient with emphysema, understands that airflow limitations are not reversible. The end result of deterioration is: Diminished alveolar surface area. Hypercapnia resulting from decreased carbon dioxide elimination. Hypoxemia secondary to impaired oxygen diffusion. Respiratory acidosis.

Respiratory acidosis. Explanation: Decreased carbon dioxide elimination results in increased carbon dioxide tension (hypercapnia), which leads to respiratory acidosis and chronic respiratory failure.

A nurse works in a bariatric clinic and cares for client with obesity who will or have undergone bariatric surgery. What is the nurse's understanding of how the procedure works? Restricts the client's ability to eat. Impairs caloric absorption. Restricts the client's ability to digest fat. Impairs gastric motility.

Restricts the client's ability to eat. Explanation: Bariatric surgical procedures work by restricting a patient's ability to eat (restrictive procedure), interfering with ingested nutrient absorption (malabsorptive procedures), or both. Bariatric procedures do not impair caloric absorption; rather, nutrients are impaired by malabsorption.

The client is postoperative for a right total-knee arthroplasty, and medications include lidocaine 5% (Lidoderm). Past history includes a left mastectomy and herpes zoster following treatment with chemotherapy. The best nursing action is to: Question the use of lidocaine 5%. Apply the patch to the right thigh. Remove the patch after 12 hours. Withhold opioids during lidocaine use.

Remove the patch after 12 hours. Explanation: The lidocaine 5% patch is applied for 12 hours daily and is approved for use with postherpetic neuralgia. The patch may be applied in various areas on the body.

Which nursing action is most important in caring for the client following an arthrogram? Apply ice to the joint. Keep the joint below the level of the heart. Administer morphine sulfate. Assist the client with passive range of motion.

Apply ice to the joint. Explanation: Ice is applied to minimize edema and provide analgesia to the joint. The joint is elevated to minimize edema. Mild analgesics are sufficient to control pain. The joint is usually rested for 12 hours post-procedure.

A client is newly diagnosed with benign paroxysmal positional vertigo. Which is the prioritynursing intervention? Attempt the Epley/canalith repositioning procedure. Administer meclizine for 1 to 2 weeks. Teach balance exercises. Encourage bed rest.

Encourage bed rest. Explanation: Bed rest is recommended for clients with acute symptoms. Best rest can ease the symptoms while keeping the client safe. Epley/canalith repositioning procedures may be used to resolve attacks of vertigo. The client will usually vomit and may need to be medicated with an antiemetic before the procedure can be tried. Clients with acute vertigo may be medicated with meclizine for 1 to 2 weeks, but because safety is a concern, encouraging bed rest would be the highest priority. Balance exercises would not be taught until the acute symptoms have eased. These exercises will help the brain compensate for the vestibular disorder.

A nurse cares for a client who is postoperative bariatric surgery and has experienced frequent episodes of dumping syndrome. The client now reports anorexia. What is the primary reason for the client's report of anorexia? Fear of eating Taste of food Size of the stomach Absorption of food

Fear of eating Explanation: Dumping syndrome is an unpleasant set of GI and vasomotor symptoms that commonly occur in clients who have had bariatric surgery. The symptoms are so unpleasant that the client may develop a fear of eating, leading to anorexia.

The nurse is working on a general medical unit. A client is scheduled for an upper gastrointestinal series. Upon return to the nursing unit, what does the nurse identify as the client goal? Recover from the general anesthesia Decrease nausea and vomiting Increase the amount of fluids Ambulate independently

Increase the amount of fluids Explanation: The client, returning from an upper gastrointestinal series, needs to increase fluids in an effort to eliminate the barium from the body through a bowel movement. General anesthesia is not used. The client typically does not have nausea and vomiting following the procedure. If the client is able to ambulate independently prior to the procedure, the client will be able to ambulate independently following.

Postoperative nursing assessment for a patient who has had a mastoidectomy should include observing for facial paralysis, which might indicate damage to which cranial nerve? First Fourth Seventh Tenth

Seventh Explanation: Injury to the seventh cranial nerve, also known as the facial nerve, is a complication of a mastoidectomy, although rare. Hearing loss of less than 30 dB is a more common complication.

The nurse is preparing the client with a right neck mass for magnetic resonance imaging (MRI). Which question should the nurse ask? Select all that apply. "When is the last time you had food or drink?" "Are you wearing any jewelry?" "Have you removed your hearing aid?" "Do you have a pacemaker?" "Did you take your medications this morning?"

"Are you wearing any jewelry?" "Have you removed your hearing aid?" "Do you have a pacemaker?" Explanation: Magnetic resonance imaging (MRI) is a noninvasive imaging technique that uses magnetic fields, radiowaves, and computers to demonstrate abnormalities of soft tissue. Individuals with any metal implants, clips, or pacemakers are not candidates for MRI. Individuals do not need to be NPO and can take usual medications.

To prepare a client who has a fractured femur for ambulation, the nurse teaches the client how to do quadriceps setting exercises. Which instruction is the most accurate? "Contract and relax your buttocks." "Try to lift your legs up when I press against your feet." "Press the back of your knee against the bed." "Flex and extend your toes."

"Press the back of your knee against the bed." Explanation: Quadriceps setting exercises help the immobilized client keep the quadriceps muscles strong and ready for resuming ambulation. Pressing the back of the knee against the bed promotes tightening of the quadriceps muscle.

A nurse is planning discharge instructions for the client with osteomyelitis. What instructions should the nurse include in the discharge teaching? "Use your continuous passive motion machine for 2 hours each day." "You need to perform weight-bearing exercises twice a week." "You need to limit the amount of protein and calcium in your diet." "You will receive IV antibiotics for 3 to 6 weeks."

"You will receive IV antibiotics for 3 to 6 weeks." Explanation: Treatment of osteomyelitis requires IV antibiotics for 3 to 6 weeks. Continuous passive range of motion is used for clients with osteoarthritis. Weight-bearing exercises are used with clients who have osteoporosis. Limiting protein and calcium is not part of the plan of care for clients with osteomyelitis.

A 16-year-old client newly diagnosed with type 1 diabetes has a very low body weight despite eating regular meals. The client is upset because friends frequently state, "You look anorexic." Which statement by the nurse would be the best response to help this client understand the cause of weight loss due to this condition? "I will refer you to a dietician who can help you with your weight." "You may be having undiagnosed infections, causing you to lose extra weight." "Your body is using protein and fat for energy instead of glucose." "Don't worry about what your friends think; the carbohydrates you eat are being quickly digested, increasing your metabolism."

"Your body is using protein and fat for energy instead of glucose." Explanation: Persons with type 1 diabetes, particularly those in poor control of the condition, tend to be thin because when the body cannot effectively utilize glucose for energy (no insulin supply), it begins to break down protein and fat as an alternate energy source. Patients may be underweight at the onset of type 1 diabetes because of rapid weight loss from severe hyperglycemia. The goal initially may be to provide a higher-calorie diet to regain lost weight and blood glucose control.

A client is to undergo surgery to repair a ruptured Achilles tendon and application of a brace. The client demonstrates understanding of activity limitations when stating that a brace must be worn for which length of time? 2 to 4 weeks 6 to 8 weeks 10 to 12 weeks 14 to 16 weeks

6 to 8 weeks Explanation: Following surgical repair for a ruptured Achilles tendon, the client wears a brace or cast for 6 to 8 weeks.

At its most fundamental level, what does obesity result from? A metabolic imbalance A hormone imbalance A genetic alteration A lifestyle imbalance

A metabolic imbalance

The nurse is caring for a client with a hip fracture. The physician orders the client to start taking a bisphosphonate. Which medication would the nurse document as given? Alendronate Raloxifene Teriparatide Denosumab

Alendronate Explanation: Alendronate is a bisphosphonate medication. Raloxifene is a selective estrogen receptor modulator. Terparatide is an anabolic agent, and denosumab is a monoclonal antibody agent.

The primary functions of cartilage are to reduce friction between articular surfaces, absorb shocks, and reduce stress on joint surfaces. Where in the human body is cartilage found? All options are correct. between the ribs covering elbow joints between the vertebrae

All options are correct.

A client's health history is suggestive of inflammatory bowel disease. Which of the following would suggest Crohn's disease, rather than ulcerative colitis, as the cause of the client's signs and symptoms? A pattern of distinct exacerbations and remissions Severe diarrhea An absence of blood in stool Involvement of the rectal mucosa

An absence of blood in stool Explanation: Bloody stool is far more common in cases of UC than in Crohn's. Rectal involvement is nearly 100% in cases of UC (versus 20% in Crohn's) and clients with UC typically experience severe diarrhea. UC is also characterized by a pattern of remissions and exacerbations, while Crohn's often has a more prolonged and variable course.

What is the most commonly prescribed treatment for the common cold? Antihistamines Decongestants Antitussives Expectorants

Antihistamines Explanation: Antihistamines are the first group of medications recommended for treating sneezing, pruritus, rhinorrhea, and nasal congestion associated with the common cold.

The nurse is performing a neurological assessment. What will this assessment include? Ask the client to plantar flex the toes. Observe for capillary refill of the great toe. Palpate the dorsalis pedis pulse. Inspect the foot for edema.

Ask the client to plantar flex the toes. Explanation: A neurological assessment evaluates sensation and motion. Assessing plantar flexion of the toes would be included in a neurological assessment. Capillary refill, palpation of pulses, and inspecting for edema would be included in a vascular assessment.

A client in the emergency department reports that a piece of meat became stuck in the throat while eating. The nurse notes the client is anxious with respirations at 30 breaths/min, frequent swallowing, and little saliva in the mouth. An esophagogastroscopy with removal of foreign body is scheduled for today. What would be the first activity performed by the nurse? Assess lung sounds bilaterally. Administer prescribed morphine intravenously. Obtain consent for the esophagogastroscopy. Suction the oral cavity of the client.

Assess lung sounds bilaterally. Explanation: All these activities are things the nurse may do for a client with a foreign body in the esophagus. This client is at risk for esophageal perforation, and thus pneumothorax. By auscultating lung sounds the nurse will be able to assess if a pneumothorax is present. The client has little saliva in the oral cavity and does not need to be suctioned. A client may also report pain with a foreign body. However, ABCs (airway, breathing, circulation) take priority. The consent for the esophagogastroscopy may be obtained after the nurse has completed the client assessment.

A nurse is caring for a client who has sustained ligament and a meniscal injury to the knee. Which action would be most appropriate to allow the client to progress without causing further injury? Administer nonsteroidal anti-inflammatory drugs (NSAIDs) regularly. Apply heat to the affected area every night. Apply a cold pack to the affected area every night. Assist with a gradual introduction of activity.

Assist with a gradual introduction of activity. Explanation: A gradual introduction of activity assists the client with a knee injury to ambulate without causing any further injury. Using NSAIDs or applying ice during the first 48 hours helps ease the pain and the inflammation. The application of heat at a later stage improves the blood circulation. However, the regular use of NSAIDs, cold packs, or heat does not help the client progress without causing any further injury.

A patient is to have an angiography done using fluorescein as a contrast agent to determine if the patient has macular edema. What laboratory work should the nurse monitor prior to the angiography? BUN and creatinine AST and ALT Hemoglobin and hematocrit Platelet count

BUN and creatinine Explanation: Angiography is done using fluorescein or indocyanine green as contrast agents. Fluorescein angiography is used to evaluate clinically significant macular edema, document macular capillary nonperfusion, and identify retinal and choroidal neovascularization (growth of abnormal new blood vessels) in age-related macular degeneration. It is an invasive procedure in which fluorescein dye is injected, usually into an antecubital vein. Prior to the angiography, the patient's blood urea nitrogen (BUN) and creatinine should be checked to ensure that the kidneys will excrete the contrast agent (Fischbach & Dunning, 2011).

A home care nurse assesses for disease complications in a client with bone cancer. Which laboratory value may indicate the presence of a disease complication? Potassium level of 6.3 mEq/L Calcium level of 11.6 mg/dl Sodium level of 110 mEq/L Magnesium level of 0.9 mg/dl

Calcium level of 11.6 mg/dl Explanation: In clients with bone cancer, tumor destruction of bone commonly causes excessive calcium release. When the calcium-excreting capacity of the kidneys and GI tract is exceeded, the serum calcium level rises above normal, leading to hypercalcemia (a serum calcium level greater than 10.2 mg/dl). Hyperkalemia (a potassium level greater than 5 mEq/L) isn't caused by bone cancer and is seldom associated with chemotherapy. Hyponatremia (a sodium level less than 135 mEq/L) and hypomagnesemia (a magnesium level less than 1.3 mg/dl) are potential adverse effects of chemotherapy; these electrolyte disturbances don't result directly from bone cancer.

A thoracentesis is performed to obtain a sample of pleural fluid or a biopsy specimen from the pleural wall for diagnostic purposes. What does serous fluid indicate? Trauma Infection Cancer Emphysema

Cancer Explanation: A thoracentesis may be performed to obtain a sample of pleural fluid or to biopsy a specimen from the pleural wall for diagnostic purposes. Serous fluid may be associated with cancer, inflammatory conditions, or heart failure. Blood fluid typically suggests trauma. Purulent fluid is diagnostic for infection. Complications that may follow a thoracentesis include pneumothorax and subcutaneous emphysema.

Which of the following medication classifications increases aqueous fluid outflow in the patient with glaucoma? Cholinergics Beta blockers Alpha-adrenergic agonists Carbonic anhydrase inhibitors

Cholinergics Explanation: Cholinergics increase aqueous fluid outflow by contracting the ciliary muscle, causing miosis and opening the trabecular meshwork. Beta blockers decrease aqueous humor production. Alpha-adrenergic agonists decrease aqueous humor production. Carbonic anhydrase inhibitors decrease aqueous humor production.

A client who has been fitted with a hearing aid comes for a follow-up evaluation. During the visit, the client states, "I've noticed that I still don't seem to hear well enough. The hearing aid doesn't seem to make the sounds louder." Which of the following might the nurse determine as the possible cause? Ear mold is loose. Client has cerumen in the ear. The mold is not properly fitted. The client has an ear infection.

Client has cerumen in the ear. Explanation: The client reports that the hearing aid is not helping, such that the sounds are not loud enough. This statement is consistent with inadequate amplification. Cerumen in the ears is a possible cause. A loose ear mold would cause a whistling noise. An improperly fitted mold or middle ear infection would lead to pain from the mold.

A client comes to the emergency department complaining of localized pain and swelling of his lower leg. Ecchymotic areas are noted. History reveals that the client got hit in the leg with a baseball bat. Which of the following would the nurse suspect as most likely? Fracture Contusion Sprain Strain

Contusion Explanation: The client's description of blunt trauma by a baseball bat and localized pain in conjunction with swelling and ecchymosis would most likely suggest a contusion. A fracture would be manifested by pain, loss of function, deformity, swelling, and spasm. A sprain would be manifested by pain and swelling; ecchymosis may appear later. A strain is characterized by inflammation, local tenderness, and muscle spasms.

Which is a circulatory indicator of peripheral neurovascular dysfunction? Weakness Paresthesia Cool skin Paralysis

Cool skin Explanation: Indicators of peripheral neurovascular dysfunction related to circulation include pale, cyanotic, or mottled skin with a cool temperature. The capillary refill is more than 3 seconds. Weakness and paralysis are related to motion. Paresthesia is related to sensation.

A client arrives in the emergency department reporting shortness of breath. She has 3+ pitting edema below the knees, a respiratory rate of 36 breaths per minute, and heaving respirations. The nurse auscultates the client's lungs to reveal coarse, moist, high-pitched, and non-continuous sounds that do not clear with coughing. The nurse will document these sounds as which type? Wheezes Rhonchi Crackles Pleural rub

Crackles Explanation: Crackles are adventitious breath sounds that are high-pitched, discontinuous, and popping; they may or may not clear with coughing and are moist. Often crackles are associated with heart failure.

x A client with a diagnosis of cirrhosis has developed variceal bleeding and will imminently undergo variceal banding. What psychosocial nursing diagnosis should the nurse most likely prioritize during this phase of the client's treatment? Decisional Conflict Deficient Knowledge Death Anxiety Disturbed Thought Processes

Death Anxiety Explanation: The sudden hemorrhage that accompanies variceal bleeding is intensely anxiety-provoking. The nurse must address the client's likely fear of death, which is a realistic possibility. For most clients, anxiety is likely to be a more acute concern than lack of knowledge or decisional conflict. The client may or may not experience disturbances in thought processes.

A nurse is caring for a client with a cast on the left arm after sustaining a fracture. Which assessment finding is most significant for this client? Fingers on the left hand are swollen and cool Presence of a normal popliteal pulse Cast edges are rough, with skin irritation present Minimal pain in the left arm

Fingers on the left hand are swollen and cool Explanation: Swollen and cool fingers on the left hand are the most significant assessment findings. They represent altered circulation to the hand caused by the cast. A normal radial, not popliteal, pulse should be present in the left arm; the popliteal pulse is found on the leg. Skin irritation is an abnormal assessment finding but it isn't as significant as altered circulation. Minimal pain in the left arm is expected.

Which factor increases blood urea nitrogen (BUN)? Gastrointestinal bleeding Overhydration Decreased protein intake Hypothermia

Gastrointestinal bleeding Explanation: Factors that increase BUN include gastrointestinal bleeding, decreased renal function, dehydration, increased protein intake, fever, and sepsis.

A patient in pelvic traction needs circulatory status assessed. How should the nurse assess for a positive Homans' sign? Have the patient extend both hands while the nurse compares the volume of both radial pulses. Have the patient extend each leg and dorsiflex each foot to determine if pain or tenderness is present in the lower leg. Have the patient plantar flex both feet while the nurse performs the blanch test on all of the patient's toes. Have the patient squeeze the nurse's hands with his or her hands to evaluate any difference in strength.

Have the patient extend each leg and dorsiflex each foot to determine if pain or tenderness is present in the lower leg. Explanation: The nurse should assess for pain on passive flexion of each foot, which could indicate deep vein thrombosis.

A client has undergone a myringotomy. The nurse interprets this as which of the following? Incision of the eardrum Placement of ventilation tubes Surgical reconstruction of the eardrum Reconstruction of the middle ear bones

Incision of the eardrum Explanation: A myringotomy refers to an incision of the tympanic membrane. Ventilation tubes may be inserted after a myringotomy. Tympanoplasty refers to the surgical reconstruction of the eardrum. Ossiculoplasty refers to the surgical reconstruction of the middle ear bones.

Which area of the spinal column is subject to the greatest mechanical stress and degenerative changes? Lower lumbar Upper lumbar Thoracic Cervical

Lower lumbar Explanation: The lower lumbar disks, L4 to L5 and L5 to S1, are subject to the greatest mechanical stress and greatest degenerative changes.

A client has undergone an external fixation. Which actions would be the priority for this client? Maintaining pin care. Planning the client's diet. Monitoring the client's urine output. Monitoring the client's blood pressure.

Maintaining pin care. Explanation: Pin care is a priority for a client with external fixation, because pin sites are entry points for infection. The nurse should also monitor redness, drainage, and tenderness at the site. Planning the client's diet and monitoring the client's urine output and blood pressure, although necessary, are not as important as maintaining pin care.

During surgery a patient develops hypothermia. The circulating nurse would monitor the patient closely for which of the following? Rebound hyperthermia Metabolic acidosis Anaphylaxis Hypoxia

Metabolic acidosis Explanation: When a patient's temperature falls, glucose metabolism is reduced. As a result, metabolic acidosis may develop. Rebound hyperthermia, anaphylaxis, and hypoxia are not associated with hypothermia during surgery.

The nurse is working on an orthopedic floor caring for a client injured in a football game. The nurse is reviewing the client's chart noting that the client has previously had an injured tendon. The nurse anticipates an injury between the periosteum of the bone and which of the following? Joint Muscle Ligament Cartilage

Muscle Explanation: Tendons attach muscles to the periosteum of bone. Joints are a junction between two or more bones. Ligaments connect two freely movable bones. Cartilage is a dense connective tissue used to reduce friction between two structures.

A client is having traction applied to a fractured left lower extremity prior to surgery. What outcomes does the nurse expect from the application of the traction for the client? Select all that apply. Surgery will not be required. Muscle spasms will be relieved. The bones of the left leg will be aligned. Immobilization of the left leg will be maintained. Less pain medication will be required.

Muscle spasms will be relieved. The bones of the left leg will be aligned. Immobilization of the left leg will be maintained. Explanation: Traction is used to relieve muscle spasm, align bones, and maintain immobilization when used properly. It will not replace surgery to correct the fracture. The client will still require pain medication prior to surgical correction.

A client is informed that he has a benign bone tumor but that this type of tumor that may become malignant. The nurse knows that this is characteristic of which type of tumor? Osteochondroma Enchondroma Osteoclastoma Osteoid osteoma

Osteoclastoma Explanation: An osteoclastoma is a giant cell tumor that may invade local tissue; usually soft and hemorrhagic and may become malignant. An osteochondroma occurs as a large projection of bone at the ends of long bones, developing during growth periods and then becoming static bone mass. An enchondroma is a hyaline cartilage tumor that develops in the hand, ribs, femur, tibia, humerus, or pelvis. An osteoid osteoma is a painful tumor surrounded by reactive bone tissue.

The nurse is reviewing the blood gas results for a patient with pneumonia. What arterial blood gas measurement best reflects the adequacy of alveolar ventilation? PaO2 PaCO2 pH SaO2

PaCO2 Explanation: When the minute ventilation falls, alveolar ventilation in the lungs also decreases, and the PaCO2 increases.

A nurse would implement droplet precautions for a client with which condition? Select all that apply. Ebola virus Pertussis Mumps Scabies Parvovirus B 19

Pertussis Mumps Parvovirus B 19 Explanation: Disorders requiring droplet precautions include pertussis, mumps, and parvovirus B 19. Scabies and viral hemorrhagic infections such as Ebola would require contact precautions.

A client with a short arm cast is suspected to have compartment syndrome. What actions should the nurse include in the plan of care? Select all that apply. Elevate the arm above the heart. Prepare to remove the cast. Provide support to the injured extremity. Assess neurovascular status every 8 hours. Apply ice to extremity.

Prepare to remove the cast. Provide support to the injured extremity. Explanation: The nurse should anticipate immediate removal of the cast and provide support to the injured extremity. Neurovascular status should be assessed more frequently than every 8 hours. If the client's neurovascular status is not improving, then a fasciotomy may be needed. Waiting 8 hours to assess neurovascular status may cause permanent damage to the extremity. To promote arterial blood flow, the arm should be elevated to the heart level, not above. Ice should not be used, as it could further decrease blood flow to the extremity.

A nurse is preparing to discharge a client newly diagnosed with peptic ulcer disease. The client's diagnostic test results were positive for H. pylori bacteria. The health care provider has ordered the "triple therapy" regimen. Which medications will the nurse educate the client on? H2-receptor antagonist and two antibiotics H2-receptor antagonist, proton-pump inhibitor, and an antibiotic Proton-pump inhibitor, an antibiotic, and bismuth salts Proton-pump inhibitor and two antibiotics

Proton-pump inhibitor and two antibiotics Explanation: Currently, the most commonly used therapy for peptic ulcers is a combination of antibiotics, proton-pump inhibitors, and bismuth salts that suppress or eradicate H. pylori bacteria. Recommended therapy for 10 to 14 days includes triple therapy with two antibiotics (e.g., metronidazole [Flagyl] or amoxicillin [Amoxil] and clarithromycin [Biaxin]) plus a proton-pump inhibitor (e.g., lansoprazole [Prevacid], omeprazole [Prilosec], or rabeprazole [Aciphex]), or quadruple therapy with two antibiotics (metronidazole and tetracycline) plus a proton-pump inhibitor and bismuth salts (Pepto-Bismol). Research is being conducted to develop a vaccine against H. pylori.

A client is brought to the emergency department by a softball team member who states the client and another player ran into each other, and the client is having severe pain in the right shoulder. What symptoms of a fractured clavicle does the nurse recognize? Client complains of tingling and numbness in the right shoulder. Right shoulder is elevated above the left. Client complains of pain in the unaffected shoulder. Right shoulder slopes downward and droops inward.

Right shoulder slopes downward and droops inward. Explanation: The client with a fractured clavicle has restricted motion, and the affected shoulder appears to slope downward and droop inward. The client will have pain, not typically tingling and numbness in the right shoulder. Pain is not felt in the unaffected shoulder.

A client has a fracture that is being treated with open rigid compression plate fixation devices. What teaching will the nurse reinforce to the client about how the progress of bone healing will be monitored? The plate will be removed to determine if the bone is growing back. Serial x-rays will be taken. An arthroscopy will be performed. The bone will heal on its own without intervention.

Serial x-rays will be taken. Explanation: Serial x-rays are used to monitor the progress of bone healing. The plate need not be disturbed. An arthroscopy is used to visualize joints. While the bone will heal without interference, monitoring of bone healing is needed to ensure further adjustments are not necessary.

The nurse is asking the client with acute pancreatitis to describe the pain. What pain symptoms does the client describe related to acute pancreatitis? Dull pain, points to epigastric area Sharp, stabbing pain in the left lower quadrant of the abdomen Severe mid-abdominal to upper abdominal pain radiating to both sides and to the back Severe abdominal pain that radiates to the right shoulder

Severe mid-abdominal to upper abdominal pain radiating to both sides and to the back Explanation: The most common complaint of clients with pancreatitis is severe mid-abdominal to upper abdominal pain, radiating to both sides and straight to the back. The other answers are not pain that is usually associated with acute pancreatitis.

pain radiating down the dorsal surface of the forearm weak grasp Explanation: Tennis elbow is characterized by pain radiating down the dorsal surface of the forearm and weak grasp. Carpal tunnel syndrome is characterized by pain or burning in one or both hands and pain more prominent at night.

Shortened, adducted, and externally rotated Explanation: With fractures of the femoral neck, the leg is shortened, adducted, and externally rotated.

Which of the following occurs when there is deviation from perfect ocular alignment? Strabismus Ptosis Chemosis Nystagmus

Strabismus Explanation: Strabismus is a condition in which there is deviation from perfect ocular alignment. Ptosis is a drooping eyelids. Chemosis is edema of the conjunctiva. Nystagmus is an involuntary oscillation of the eyeball.

In chronic osteomyelitis, antibiotics are adjunctive therapy in which situation? Wound packing Wound irrigation Vitamin supplements Surgical debridement

Surgical debridement Explanation: In chronic osteomyelitis, antibiotics are adjunctive therapy to surgical debridement.

Morton neuroma is exhibited by which clinical manifestation? Swelling of the third (lateral) branch of the median plantar nerve High arm and a fixed equinus deformity Diminishment of the longitudinal arch of the foot Inflammation of the foot-supporting fascia

Swelling of the third (lateral) branch of the median plantar nerve Explanation: Morton neuroma is swelling of the third branch of the median plantar nerve. Pes cavus refers to a foot with an abnormally high arch and a fixed equinus deformity of the forefoot. Flatfoot is a common disorder in which the longitudinal arch of the foot is diminished. Plantar fasciitis is an inflammation of the foot-supporting fascia.

x A client with peptic ulcer disease has been prescribed sucralfate. What health education should the nurse provide to this client? Take the medication 2 hours before or after other medications Blood levels will be evaluated after 1 week Take the medication at bedtime to accommodate sedative effects Ensure adequate potassium intake during therapy

Take the medication 2 hours before or after other medications Explanation: Sucralfate should be taken at least 2 hours before or after other medications. It does not decrease potassium levels and laboratory follow up is unnecessary. Sucralfate does not cause sedation.

A provider prescribes a subcutaneous anabolic agent for an older adult client to prevent fractures associated with osteoporosis. What is the most likely prescribed drug? Alendronic acid Calcitonin Raloxifene Teriparatide

Teriparatide Explanation: Teriparatide (Forteo) is a subcutaneously administered anabolic agent that is taken once daily. The other drug choices are oral preparations.

Why would a client with COPD report feeling fatigued? Select all that apply. The client is using all expendable energy just to breathe. Muscle function gradually decreases over time in clients with COPD. The client is using all expendable energy for activities of daily living (ADLs). Lung function gradually decreases over time in clients with COPD.

The client is using all expendable energy just to breathe. Lung function gradually decreases over time in clients with COPD. Explanation: The client is using all expendable energy just to breathe. Lung function, not muscle function, gradually decreases over time in clients with COPD. In a client with COPD, fatigue and a feeling of exhaustion stem directly from the disease, not from activity level.

Which is not a guideline for avoiding hip dislocation after replacement surgery. The hip may be flexed to put on clothing such as pants, stockings, socks, or shoes. Keep the knees apart at all times. Put a pillow between the legs when sleeping. Never cross the legs when seated.

The hip may be flexed to put on clothing such as pants, stockings, socks, or shoes. Explanation: Guidelines for avoiding hip dislocation after replacement surgery specify that the hip should not be flexed to put on clothing such as pants, stockings, socks, or shoes. Clients should keep the knees apart at all times, put a pillow between the legs when sleeping, and never cross the legs when seated.

The nurse is working in the emergency department when a physician asks for help as the client is performing a Romberg test. In which position would the nurse stand to be most helpful? The nurse would stand directly in front of the client. The nurse would stand between the client and physician. The nurse would stand across the room but in direct alignment from the client. The nurse would stand laterally to the client, opposite side to where the physician is standing.

The nurse would stand laterally to the client, opposite side to where the physician is standing. Explanation: The Romberg test is used to evaluate a person's ability to sustain balance. The client stands with the feet together and arms extended. In the event that the client begins to sway (an abnormal result), the nurse is most helpful to stand on the lateral side of the client, opposite side to where the physician is standing to ensure that the client does not fall.

The nurse assesses soft subcutaneous nodules along the line of the tendons in a patient's hand and wrist. What does this finding indicate to the nurse? The patient has osteoarthritis. The patient has lupus erythematosus. The patient has rheumatoid arthritis. The patient has neurofibromatosis.

The patient has rheumatoid arthritis. Explanation: The subcutaneous nodules of rheumatoid arthritis are soft and occur within and along tendons that provide extensor function to the joints. Osteoarthritic nodules are hard and painless and represent bony overgrowth that has resulted from destruction of the cartilaginous surface of bone within the joint capsule. Lupus and neurofibromatosis are not associated with the production of nodules.

x Which of the following are indicators that a client is ready to be weaned from a ventilator? Select all that apply. Vital capacity of 13 mL/kg Tidal volume of 8.5 mL/kg Rapid/shallow breathing index of 112 breaths/min PaO2 of 64 mm Hg FiO2 45%

Vital capacity of 13 mL/kg Tidal volume of 8.5 mL/kg PaO2 of 64 mm Hg Explanation: Weaning criteria for clients are as follows: Vital capacity 10 to 15 mL/kg; Maximum inspiratory pressure at least -20 cm H2; Tidal volume: 7 to 9 mL/kg; Minute ventilation: 6 L/min; Rapid/shallow breathing index below 100 breaths/min; PaO2 > 60 mm Hg; FiO2 < 40%

Which instructions regarding swimming should the nurse give to a client who is recovering from otitis externa? Wear soft plastic earplugs. Wear a scarf. Avoid cold water. Insert a loose cotton earplug in the external ear.

Wear soft plastic earplugs. Explanation: The nurse should advise the client to wear soft plastic earplugs to prevent trapping water in the ear while swimming. Wear soft plastic earplugs to prevent trapping water in the ear while swimming. Cotton can be used, but if so it needs to be covered in petroleum jelly to prevent water from entering the external canal. Wearing a scarf does not help prevent or treat otits externa. Swimming in cold water is not related to otitis externa.

The nurse is caring for a client with a decrease in airway diameter causing airway resistance. The client experiences coughing and mucus production. Upon lung assessment, which adventitious breath sounds are anticipated? Crackles Rhonchi Rubs Wheezes

Wheezes Explanation: A decrease in airway diameter, such as in asthma, produces breath sounds of wheezes. Wheezes are a whistling type of sound relating to the narrowing on the airway. A wheeze can have a high-pitched or low-pitched quality. Crackles, also noted as rales, are crackling or rattling sounds signifying fluid or exudate in the lung fields. Rhonchi are a course rattling sound similar to snoring usually caused by secretion in the bronchial tree. Rubs are secretions that can be heard in the large airway.

A nurse provides nutritional health teaching to an adult client who had two fractures in 1 year. Besides recommending supplemental calcium, the nurse suggests a high-calcium diet. What would the nurse recommend that the client increase intake of? Canned mixed fruit. Salmon and sardines. Yogurt and cheese. Almonds and peanuts.

Yogurt and cheese. Explanation: Yogurt and cheese are excellent sources of calcium. The other choices are low-calcium foods.

During assessment for cranial nerve functions, the client closes the eyes and begins to fall to one side. Which cranial nerve alteration causes this response? cranial nerve VIII optic nerve cranial nerve VII facial nerve

cranial nerve VIII Explanation: Nerve receptors for balance are found both in the vestibule and semicircular canals. They transmit information about motion through the vestibular nerve, which joins with the cochlear nerve to form the eighth cranial nerve (formally called the auditory or acoustic nerve).

The nurse is teaching a client about osteoporosis. What diagnostic test will the nurse include with the client teaching? dual-energy x-ray absorptiometry bone biopsy arthrocentesis arthroscopy

dual-energy x-ray absorptiometry Explanation: Osteoporosis is characterized by decreased bone density. Dual-energy x-ray absorptiometry can determine the extent of bone loss. A bone biopsy is used to detect abnormal cells such as a malignancy. An arthrocentesis is used for joint swelling or arthritis. An arthroscopy is used to detect joint problems.

A client has symptoms suggestive of peritonitis. Nursing management would not include: limiting analgesics to avoid the formation of paralytic ileus. accurate recording of input and output. inserting a nasogastric tube. inserting a urinary retention catheter.

limiting analgesics to avoid the formation of paralytic ileus. Explanation: Analgesics such as meperidine or IV morphine sulfate are ordered to relieve pain and promote rest. Because hypovolemia can occur from fluids leaking into the peritoneal cavity, input and output are monitored closely to assist in determining fluid replacement. A nasogastric tube is used to relieve abdominal distention by suctioning the accumulated gas and stagnant upper GI fluids. If hypovolemia is present, renal perfusion can become decreased, requiring close monitoring.

The nurse identifies the nursing diagnosis of deficient knowledge related to a new hearing aid for a client. After teaching a client about caring for his new hearing aid, the nurse determines that the outcome has been achieved when the client states which of the following? "I need to wipe the ear mold daily with a moist washcloth." "I need to keep my ear canal clean and dry." "I should wash the receiver with soap and water once a week." "I should insert the ear mold when it is wet."

"I need to keep my ear canal clean and dry." Explanation: The client demonstrates understanding of the care of a hearing aid when stating the need to keep the ear canal clean and dry. The ear mold is the only part of the hearing aid that can be washed frequently, that is daily with soap and water. It should be allowed to dry completely before it is snapped into the receiver or inserted into the ear.

The nurse just completed educating a client on hearing aid care. Which statement by the client indicates that the teaching was effective? "I will wash the entire hearing aid daily with soap and water." "I will notify the hearing aid dealer if the hearing aid whistles." "I will use a small pipe cleaner to clean the cannula on the hearing aid." "I will dry my ears with a cotton-tipped applicator before inserting the hearing aid."

"I will use a small pipe cleaner to clean the cannula on the hearing aid." Explanation: The cannula on the hearing aid should be cleaned with a small pipe cleaner or pipe cleaner-like object. Only the ear mold should be cleaned daily using soap and water; no other part of the hearing aid should be cleaned with soap and water. The client should be taught to troubleshoot if the hearing aid whistles. Many times the client can fix the issue when this happens. The ears should not be dried using a cotton-tipped applicator because it can cause trauma and lead to otitis externa.

Which evaluation finding requires follow up by the nurse caring for a client with a total knee replacement? Select all that apply. Client reports pain rating of 2. Pedal pulses strong and equal bilaterally 650 ml bloody drainage in drain wound Knee flexion at 30 degrees Client ambulates 10 feet by postoperative day 2

650 ml bloody drainage in drain wound Knee flexion at 30 degrees Explanation: A suction drain removes fluid accumulating in the wound. Typical drainage ranges from 200 to 400 ml the first 24 hours after surgery and declines to fewer then 25 ml by 48 hours. Knee mobility is increased with a continuous passive motion (CPM) device. Initial settings of the CPM are usually 10 degrees of extension and 50 degrees of flexion with an ultimate goal of full extension (0 degrees) and 90 degrees of flexion by discharge. A pain rating of 2 is an indicator of effective pain management. Strong and equal pedal pulses are an expected finding. Progressive ambulation begins on the day after surgery; ambulating 10 feet on postoperative day would be expected.

A client with suspected osteomalacia has a fractured tibia and fibula. What test would give a definitive diagnosis of osteomalacia? A bone biopsy Demineralization of the bone Increased and decreased areas of bone metabolism Elevated levels of alkaline phosphatase

A bone biopsy Explanation: A definitive diagnosis is obtained by bone biopsy. Radiographic studies demonstrate demineralization of the bone. A bone scan detects increased and decreased areas of bone metabolism. Alkaline phosphatase levels are detected from a blood sample.

x The nurse is providing care for a client who has recently been diagnosed with chronic gastritis. What health practice should the nurse address when teaching the client to limit exacerbations of the disease? Performing 15 minutes of physical activity at least three times per week Avoid taking aspirin to treat pain or fever Taking multivitamins as prescribed and eating organic foods whenever possible

Avoid taking aspirin to treat pain or fever Explanation: Aspirin and other NSAIDs are implicated in chronic gastritis because of their irritating effect on the gastric mucosa. Organic foods and vitamins confer no protection. Exercise and a healthy body weight are beneficial to overall health but do not prevent gastritis.

A group of students is reviewing information about cast composition in preparation for a discussion on the advantages and disadvantages of each. The students demonstrate understanding of the topic when they cite which of the following as an advantage of a plaster cast? Better molding to the client Quicker drying Longer lasting More breathable

Better molding to the client Explanation: Plaster casts require a longer time for drying but mold better to the client and are initially used until the swelling subsides. Fiberglass casts dry more quickly, are lighter in weight, longerlasting, and breathable.

An elderly client with macular degeneration has received injections of angiogenesis inhibitors. Which assessment finding would indicate the condition is worsening? Blurred vision Burning sensation of the eyes Loss of peripheral field vision Central vision impairment

Central vision impairment Explanation: When the macula becomes irreparably damaged, central vision is lost and the client can only see images via peripheral field. Blurred vision is the initial symptom of the disease and does not signify worsening. Burning sensation is a common adverse reaction to the treatment inject

The nurse is caring for a client who sustained rib fractures in an automobile accident. What symptoms does the nurse recognize as a complication of rib fractures and should immediately be reported to the physician? Blood pressure of 140/90 mm Hg Crackles in the lung bases Client complains of pain in the affected rib area when taking a deep breath Heart rate of 94 beats/minute

Crackles in the lung bases Explanation: Crackles in the lung bases can be an indicator that the client has developed pneumonia from shallow respirations. The blood pressure is high but may be due to pain. It is expected that the client will have pain in the rib area when taking deep breaths. A heart rate of 94 beats/minuteis within normal range. Reference:

Which is an inappropriate use of traction? Immobilize a fracture Decrease space between opposing structures Reduce deformity Minimize muscle spasms

Decrease space between opposing structures Explanation: Traction is done to increase the space between opposing surfaces. Traction is used to minimize muscle spasms, to reduce, align, and immobilize fractures, and to reduce deformity.

Which surgical procedure involves flattening the anterior curvature of the cornea by removing a stromal lamella layer? Photorefractive keratectomy (PRK) Laser-assisted stromal in situ keratomileusis (LASIK) Keratoconus Keratoplasty

Laser-assisted stromal in situ keratomileusis (LASIK) Explanation: LASIK involves flattening the anterior curvature of the cornea by removing a stromal lamella or layer. PRK is used to treat myopia and hyperopia with or without astigmatism. Keratoconus is a cone-shaped deformity of the cornea. Keratoplasty involves replacing abnormal host tissue with healthy donor (cadaver) corneal tissue.

Which terms refers to the progressive hearing loss associated with aging? Presbycusis Exostoses Otalgia Sensorineural hearing loss

Presbycusis Explanation: Age-related changes of both the middle and inner ear result in hearing loss. Exostoses refer to small, hard, bony protrusions in the lower posterior bony portion of the ear canal. Otalgia refers to a sensation of fullness or pain in the ear. Sensorineural hearing loss is loss of hearing related to damage of the end organ for hearing and/or cranial nerve VIII.

Morton neuroma is exhibited by which clinical manifestation? Swelling of the third (lateral) branch of the median plantar nerve High arm and a fixed equinus deformity Longitudinal arch of the foot is diminished Inflammation of the foot-supporting fascia

Swelling of the third (lateral) branch of the median plantar nerve Explanation: Morton neuroma is swelling of the third branch of the median plantar nerve. Pes cavus refers to a foot with an abnormally high arch and a fixed equinus deformity of the forefoot. Flatfoot is a common disorder in which the longitudinal arch of the foot is diminished. Plantar fasciitis is an inflammation of the foot-supporting fascia.

The nurse is assessing a client for objective symptoms of hearing difficulties. Which symptom leads the nurse to take alternate measures to ensure client understanding of teaching? The client interrupts by asking the nurse to repeat instruction. The client is quiet and responds appropriately. The client leans forward and turns the head. The client quietly reads the instructional literature.

The client leans forward and turns the head. Explanation: The nurse assesses objective symptoms of leaning forward and turning the head as symptoms of having difficulty hearing. The nurse would use alternate formats of teaching to reinforce key points. Asking to repeat information is a subjective indication of hearing difficulty. Responding appropriately and reading instructional literature does not indicate a hearing difficulty.

Which intervention should the nurse implement during the intraoperative period to protect the client from injury? Select all that apply. Verify scheduled procedure with client. Administer anti-anxiety medication. Cover the client with warm blankets. Assess the client for allergies. Confirm the consent form is signed.

Verify scheduled procedure with client. Assess the client for allergies. Confirm the consent form is signed. Explanation: To protect the client from injury, the nurse needs to verify the procedure scheduled, assess for allergies, and confirm the consent form has been signed. Anti-anxiety medications reduce anxiety but do not protect the client from injury. Covering the client with warm blankets promotes comfort and prevents hypothermia, a potential complication of anesthesia.

It is important for the nurse to provide required information and appropriate explanations of diagnostic procedures to clients with respiratory disorders in order to ensure adequate rest periods. manage respiratory distress. aid the client's caregivers. manage decreased energy levels.

manage decreased energy levels. Explanation: In addition to the nursing management of individual tests, clients with respiratory disorders require informative and appropriate explanations of any diagnostic procedures they will experience. Nurses must remember that for many of these clients, breathing may in some way be compromised and energy levels may be decreased. For that reason, explanations should be brief, yet complete, and may need to be repeated later after a rest period. The nurse must also ensure adequate rest periods before and after the procedures. After invasive procedures, the nurse must carefully assess for signs of respiratory distress.

A client who plays tennis is experiencing elbow discomfort. Following assessment, the client receives a diagnosis of tendinitis, epicondylitis, or tennis elbow. What symptoms and signs did the client have? Select all that apply. pain radiating down the dorsal surface of the forearm weak grasp pain or burning in one or both hands pain more prominent at night

pain radiating down the dorsal surface of the forearm weak grasp Explanation: Tennis elbow is characterized by pain radiating down the dorsal surface of the forearm and weak grasp. Carpal tunnel syndrome is characterized by pain or burning in one or both hands and pain more prominent at night.

Which homeostatic mechanism would the body of a critically ill client use to maintain normal pH? The lungs eliminate carbonic acid by blowing off more CO2. The lungs increase respiratory volume. The lungs retain more CO2 to lower the pH. The kidneys retain more HCO3 to raise the pH.

the lungs eliminate carbonic acid by blowing off more CO2. Explanation: To maintain normal pH in critically ill clients, the lungs eliminate carbonic acid by blowing off more CO2. To maintain normal pH in critically ill clients, the lungs conserve CO2 by slowing respiratory volume. The lungs would retain more CO2 during an acid-base imbalance in cases of metabolic alkalosis. The kidneys would retain more HCO3 to compensate during an acid-base imbalance in cases of metabolic acidosis.

An client is described as having pectus carinatum. What would be the physical manifestation of this condition? The sternum protrudes and the ribs are sloped backward. The sternum is depressed from the second intercostal space. The thoracic and lumbar spine have a lateral S-shaped curvature. The chest is rounded, ribs are horizontal, and sternum is pulled forward.

the sternum protrudes and the ribs are sloped backward. Explanation: Also known as pigeon chest, in this congenital anomaly, the sternum abnormally protrudes and the ribs are sloped backward. A depressed sternum would be considered funnel chest, or pectus excavatum. S-shaped spinal curvature would be considered scoliosis. A rounded chest would be considered barrel chest in which the anteroposterior diameter increases to equal the transverse diameter.

The nurse is educating a client on home care following removal of a ganglion cyst from the right wrist. Which statement by the client demonstrates that the nurse's teaching has been effective? "I will leave the dressing on until I follow up with my doctor as scheduled." "If my hand becomes numb and cool I will elevate it above my heart." "I will notify my doctor if I develop redness and purulent drainage for 2 days." "If my pain is not relieved I will use a heat pack and take some more medication."

"I will leave the dressing on until I follow up with my doctor as scheduled." Explanation: The first dressing is changed by the surgeon at a scheduled follow-up appointment. If the hand becomes cool and numb, the client needs to call the surgeon as soon as possible. The surgeon should be notified immediately if redness and purulent drainage develop. Medication should only be used as prescribed. The use of heat may increase swelling, which may increase pain.

When the nurse is assessing the older adult patient, what gerontologic changes in the respiratory system should the nurse be aware of? (Select all that apply.) Decreased alveolar duct diameter Increased presence of mucus Decreased gag reflex Increased presence of collagen in alveolar walls Decreased presence of mucus

Decreased gag reflex Increased presence of collagen in alveolar walls Decreased presence of mucus Explanation: Age-related changes in the respiratory system include a decrease in mucus, decrease in gag reflex, increase in collagen in the alveolar walls of the lungs, and increase in alveolar duct diameter.

The nurse suspects "compartment syndrome" for a casted extremity. What characteristic symptoms would the nurse assess that would confirm these suspicions? (Select all that apply.) Decreased sensory function Excruciating pain Loss of motion Capillary refill less than 3 seconds 2+ peripheral pulses in the affected distal pulse

Decreased sensory function Excruciating pain Loss of motion Explanation: Clinical manifestations include dusky, pale appearance of the exposed extremity; cool skin temperature; delayed capillary refill; paresthesia; and unrelenting pain not relieved by position changes, ice, or analgesia. A hallmark sign is pain that occurs or intensifies with passive range of motion (Johnston-Walker & Hardcastle, 2011). The patient may complain that the cast, brace, or splint is too tight. The primary provider must be notified immediately.

The nurse is providing care to a client who has been admitted to the hospital for treatment of an infection. The client is visually impaired. Which of the following would be most appropriate for the nurse to do when interacting with the client? Talk to the client in a loud tone of voice. Avoid using the terms "see" or "look." Face the client when speaking directly to him. Touch the client before identifying himself or herself.

Face the client when speaking directly to him. Explanation: When interacting with a client with a visual impairment, the nurse should face the client and speak directly to the client using a normal tone of voice. It is not necessary to raise the voice unless the client asks the nurse to do so and it is not necessary to avoid the terms, "see" or "look" when interacting with the client. The nurse should identify himself or herself when approaching the client and before making any physical contact.

An elderly client is admitted with the diagnosis of retinal detachment and is scheduled for laser surgery and scleral buckling procedure. The nurse anticipates which of the following symptoms to be exhibited in this client? Select all that apply. Flashing lights Cobwebs in vision field Complete loss of vision in both eyes Loss of central vision Eye pain Arcus senilis

Flashing lights Cobwebs in vision field Explanation: Many clients with detached retina experience a sensation of a curtain or veil lowering over vision field, flashing of lights, floaters, cobwebs, or spots. Complete vision loss can occur in the affected eye. Loss of central vision, eye pain, and arcus senilis is not indicated in this disorder.

What is the term for a lateral curving of the spine? Lordosis Scoliosis Diaphysis Epiphysis

Scoliosis Scoliosis is a lateral curving of the spine. Lordosis is an increase in the lumbar curvature of the spine. Diaphysis is the shaft of a long bone. Epiphysis is the end of a long bone.

A nurse is caring for a client who has been admitted for the treatment of advanced cirrhosis. What assessment should the nurse prioritize in this client's plan of care? Measurement of abdominal girth and body weight Assessment for variceal bleeding Assessment for signs and symptoms of jaundice Monitoring of results of liver function testing

Assessment for variceal bleeding Explanation: Esophageal varices are a major cause of mortality in clients with uncompensated cirrhosis. Consequently, this should be a focus of the nurse's assessments and should be prioritized over the other listed assessments, even though each should be performed.

Which of the following would lead a nurse to suspect that a client has a rotator cuff tear? Increased ability to stretch arm over the head Difficulty lying on affected side Pain worse in the morning Minimal pain with movement

Difficulty lying on affected side Explanation: Clients with a rotator cuff tear experience pain with movement and limited mobility of the shoulder and arm. They especially have difficulty with activities that involve stretching their arm above their head. Many clients find that the pain is worse at night and that they are unable to sleep on the affected side.

After surgery for removal of cataract, a client is being discharged, and the nurse has completed discharge instruction. Which client statement indicates that the outcome of the teaching plan has been met? "I need to wear sunglasses for the first 3 to 4 days even when I'm inside." "Dots or flashing lights in my vision are to be expected for the first few days." "I should avoid pulling or pushing any object that weighs more than 15 lbs." "I need to keep the eye patch on for about a week after surgery."

"I should avoid pulling or pushing any object that weighs more than 15 lbs." Explanation: After cataract surgery, the client needs to avoid lifting, pulling, or pushing any object that weighs more than 15 pounds to prevent putting excessive pressure on the surgical site. Sunglasses should be worn when outdoors during the day because the eye is sensitive to light. Dots, flashing lights, a decrease in vision, pain, and increased redness need to be reported to the physician immediately. The eye patch is worn for 24 hours after surgery, followed by eyeglasses worn during the day and a metal shield worn at night for 1 to 4 weeks.

A patient tells the nurse, "I was working out and lifting weights and now that I have stopped, I am flabby and my muscles have gone!" What is the best response by the nurse? "While you are lifting weights, endorphins are released, creating increase in muscle mass, but if the muscles are not used they will atrophy." "The muscle mass has decreased from the lack of calcium in the cells." "Your muscles were in a state of hypertrophy from the weight lifting but it will persist only if the exercise is continued." "Once you stop exercising, the contraction of the muscle does not regain its strength."

"Your muscles were in a state of hypertrophy from the weight lifting but it will persist only if the exercise is continued." Explanation: Muscles need to exercise to maintain function and strength. When a muscle repeatedly develops maximum or close to maximum tension over a long time, as in regular exercise with weights, the cross-sectional area of the muscle increases. This enlargement, known as hypertrophy, results from an increase in the size of individual muscle fibers without an increase in their number. Hypertrophy persists only if the exercise is continued.

A client presents to the ED after being in a boating accident about 3 hours ago. Now the client reports headache, fatigue, and the feeling that he "just can't breathe enough." The nurse notes that the client is restless and tachycardic with an elevated blood pressure. This client may be in the early stages of what respiratory problem? Pneumoconiosis Pleural effusion Acute respiratory failure Pneumonia

Acute respiratory failure Explanation: Early signs of acute respiratory failure are those associated with impaired oxygenation and may include restlessness, fatigue, headache, dyspnea, air hunger, tachycardia, and increased blood pressure. As the hypoxemia progresses, more obvious signs may be present, including confusion, lethargy, tachycardia, tachypnea, central cyanosis, diaphoresis, and, finally, respiratory arrest. Pneumonia is infectious and would not result from trauma. Pneumoconiosis results from exposure to occupational toxins. A pleural effusion does not cause this constellation of symptoms.

The nurse is caring for a client who has recurrent sinusitis. Which consideration could the nurse suggest to best decrease the frequency of infections? Administer an over-the-counter decongestant. Use an anti-allergy medication to decrease rhinitis. Place a warm cloth over the sinus area of the forehead. Gently blow the nose to eliminate nasal secretions.

Administer an over-the-counter decongestant. Explanation: The principle causes of sinusitis are the spread of infection from the nasal passages to the sinus and the blockage of normal sinus drainage. Interference with sinus drainage predisposes a client to sinusitis. Administering a decongestant opens the nasal passages for drainage. The other options can be helpful for a sinus infection, but opening the passages is best.

A nurse is caring for a client following removal of a Morton's neuroma. Which nursing intervention would be most appropriate? Assist the client with incentive spirometry. Assess the surgical dressing. Assist with passive range of motion exercises Perform neurovascular assessment of the hand.

Assess the surgical dressing. Explanation: Morton's neuroma is a foot problem characterized by swelling of the median plantar nerve. The nurse will need to assess the surgical dressing. Assisting with incentive spriometry is not the most important intervention. Range of motion exercises shuld be active, not passive. A hand assessment is not needed with neuroma removal from the foot.

A client you are caring for has a hearing loss. The client tells you he is self-conscious about his hearing loss. What advice should the nurse give a self-conscious client with hearing loss to protect his self-esteem? Pretend to follow conversations by nodding the head. Be forthright and inform others about the hearing deficit. Follow lip movements closely. Avoid excess socializing.

Be forthright and inform others about the hearing deficit. Explanation: The nurse should encourage clients with a hearing loss to be forthright and inform others about their hearing deficit. Clients should be advised not to hide the fact that they do not understand what has been said and should be encouraged to maintain friendships because a physical impairment is unlikely to affect genuine friendships.

Assessment of visual acuity reveals that the client has blurred vision when looking at distant objects but no difficulty seeing near objects. The nurse documents this as which of the following? Myopia Astigmatism Hyperopia Emmetropia

Myopia Explanation: Myopia, or nearsightedness, refers to the condition in which the client can see near objects but has blurred distant vision. Astigmatism is an irregularity in the curve of the cornea, which can affect both near and distant vision. Hyperopia, or farsightedness, refers to the client's ability to see distant objects clearly, but sees near objects as blurry. Emmetropia refers to normal eyesight in which the image focuses precisely on the retina.

An aging client is brought to the eye clinic by the son. The son states he has seen his parent holding reading materials at an increasing distance to focus properly. What age-related changes does this indicate? Cataract Presbyopia Myopia Macular degeneration

Presbyopia Explanation: Refractive changes, such as presbyopia, occur in older adults where the lens cannot readily accommodate aging. In such cases, the client is observed holding reading materials at an increasing distance to focus properly. In case of a cataract, the client should report increased glare, decreased vision, and changes in color perception. Macular degeneration affects the central vision. Myopia is the inability to see things at a distance clearly.

Which of the following is the only selective estrogen receptor modulator approved for osteoporosis in post menopausal women? Raloxifene Fosamax Forteo Denosumab

Raloxifene Explanation: Raloxifene is the only selective estrogen receptor modulator (SERM) approved for osteoporosis in post menopausal women as it does not increase the risk of breast or uterine cancer, but it does come with an increased risk of thromboembolism. Fosamax is a bisphosphonate. Forteo is a subcutaneously administered medication that is given one daily for the treatment of osteoporosis. Denosumab has recently been approved for treatment of postmenopausal women with osteoporosis who are at risk for fractures.

A nurse is preparing to perform the whisper test to assess a client's gross auditory acuity. Which of the following would be most appropriate for the nurse to do? Stand at a position diagonal to the client. Have the client use a finger to occlude the ear to be tested. Stand about 1 to 2 feet away from the ear to be tested. Speak a phrase in a low normal tone of voice.`

Stand about 1 to 2 feet away from the ear to be tested. Explanation: When performing the whisper test, the nurse covers the untested ear wtih the palm of the hand and then whispers softly form a distance of 1 to 2 feet from the unoccluded ear and out of the client's sight. The client with normal hearing can correctly repeat what was whispered.

Following an ophthalmologic exam, an anxious client asks the nurse, "How serious is a refraction error?" Which of the following is the best response from the nurse? "It is nothing serious." "It means corrective lenses are required." "Simple surgery can fix this problem." "This is normal for anyone your age."

"It means corrective lenses are required." Explanation: Refractive errors can be corrected with glasses or contact lenses. Telling a client that "nothing is serious" does not provide the necessary information to help alleviate fears. The word surgery can increase fears. If the refractive error is associated with aging, this is a normal finding but does not provide information to the condition.

The nurse is providing instructions to the client who is being prepared for skeletal traction. Which statement by the client indicates teaching was effective? "Metal pins will go through my skin to the bone." "I will wear a boot with weights attached." "A belt will go around my pelvis and weights will be attached." "The traction can be removed once a day so I can shower."

"Metal pins will go through my skin to the bone." Explanation: In skeletal traction, metal rods or pins are used to apply continuous traction directly to the bone. Weights are used to apply the traction. Casts, external fixators, or splints are used when the traction is discontinued.

The nurse is providing instructions to the client following application of a fiberglass cast. Which statement by the client indicates further education is needed? "Under no circumstances should I get my cast wet." "The cast should not come in contact with other plastics." "I should avoid touching the cast while it is wet." "The cast will be hot while it is drying."

"Under no circumstances should I get my cast wet." Explanation: Some fiberglass casts are waterproof, allowing the client to shower or swim. A wet fiberglass cast is susceptible to denting while it is wet. Fiberglass casting involves an exothermic reaction as the cast hardens. The cast should not come in contact with other plastics as the reaction occurs.

When developing a teaching plan for a patient scheduled for ambulatory surgery with epidural anesthesia, which of the following would the nurse include? "You shouldn't experience a headache after this type of anesthesia." "Normally, the blood pressure drops fairly low initially." "The anesthetic is introduced directly into the spinal cord." "You won't be able to move, but you'll be able to feel sensations."

"You shouldn't experience a headache after this type of anesthesia." Explanation: With epidural anesthesia, a headache usually does not occur. If the dura mater is punctured during epidural anesthesia and the anesthetic travels toward the head, high spinal anesthesia can occur, producing severe hypotension and respiratory depression and arrest. This is a complication and not a typical reaction. The anesthetic is introduced into the epidural space surrounding the dura mater of the spinal cord. It blocks sensory, motor, and autonomic functions.

A client is having repeated tears of the joint capsule in the shoulder, and the health care provider orders an arthrogram. What intervention should the nurse provide after the procedure is completed? Select all that apply. Apply a compression bandage to the area. Apply heat to the area for 48 hours. Administer a mild analgesic. Inform the client that a clicking or crackling noise in the joint may persist for a couple of days. Actively exercise the area immediately after the procedure.

Apply a compression bandage to the area. Administer a mild analgesic. Inform the client that a clicking or crackling noise in the joint may persist for a couple of days. Explanation: The client having an arthrogram may feel some discomfort or tingling during the procedure. After the arthrogram, a compression elastic bandage may be applied if prescribed, and the joint is usually rested for 12 hours. Strenuous activity should be avoided until approved by the primary provider. The nurse provides additional comfort measures (e.g., mild analgesia, ice) as appropriate and explains to the client that it is normal to experience clicking or crackling in the joint for 24 to 48 hours after the procedure until the contrast agent or air is absorbed.

Which ventilator mode provides full ventilatory support by delivering a present tidal volume and respiratory rate? IMV SIMV Assist control Pressure support

Assist control Explanation: Assist-control ventilation provides full ventilator support by delivering a preset tidal volume and respiratory rate. IMV provides a combination of mechanically assisted breaths and spontaneous breaths. SIMV delivers a preset tidal volume and number of breaths per minute. Between ventilator-delivered breaths, the patient can breathe spontaneously with no assistance from the ventilator for those extra breaths. Pressure support ventilation assists SIMV by applying a pressure plateau to the airway throughout the client-triggered inspiration to decrease resistance within the tracheal tube and ventilator tubing.

A nurse is working with a client in an optometrist office. What is the role of the nurse with a client who is undergoing an eye examination and tests? Select all that apply. Assuring that the client receives eye care to preserve eye function and prevent further visual loss Assessing and obtaining an accurate baseline of the function and structure of the eyes Teaching the client about the diet and the exercise regimen to be followed after an eye examination Explaining the temporary inability to maintain visual focus after mydriatric eye medications Determining whether further action is warranted

Assuring that the client receives eye care to preserve eye function and prevent further visual loss Assessing and obtaining an accurate baseline of the function and structure of the eyes Explaining the temporary inability to maintain visual focus after mydriatric eye medications Explanation: Clients often ask a nurse how often an eye exam should be done. The nurse should provide current recommendations. The nurse, through careful questioning, elicits the necessary information that can assist in diagnosis of an ophthalmic condition. A careful assessment of the function and the structure of the eyes is also important because it provides the nurse with a baseline. The nurse would review recommendations with the client. The client is educated about the temporary effects of mydriasis on vision, such as glare and the inability to focus properly. The client may have difficulty reading. The effects of the various mydriatics and cycloplegics can last 3 hours to several days. The client is advised to wear sunglasses (most eye clinics provide protective sunglasses). The ability to drive depends on the person's age, vision, and comfort level. Some clients can drive safely with the use of sunglasses, whereas others may need to be driven home. Determining further action would be a function of an eye specialist. The client does not need to follow any special diet or exercise plan after an eye examination.

While assessing an acutely ill client's respiratory rate, the nurse assesses four normal breaths followed by an episode of apnea lasting 20 seconds. How should the nurse document this finding? Eupnea Apnea Biot's respiration Cheyne-Stokes

Biot's respiration Explanation: The nurse will document that the client is demonstrating a Biot's respiration pattern. Biot's respiration is characterized by periods of normal breathing (three to four breaths) followed by varying periods of apnea (usually 10 seconds to 1 minute). Cheyne-Stokes is a similar respiratory pattern, but it involves a regular cycle where the rate and depth of breathing increase and then decrease until apnea occurs. Biot's respiration is not characterized by the increase and decrease in the rate and depth, as characterized by Cheyne-Stokes. Eupnea is a normal breathing pattern of 12 to 18 breaths per minute. Bradypnea is a slower-than-normal rate (<10 breaths per minute), with normal depth and regular rhythm, and no apnea.

The nurse is caring for a young adult client with a diagnosis of cerebral palsy who has been admitted for the relief of painful contractures in his lower extremities. When creating a nursing care plan for this client, what variables should the nurse consider? Select all that apply. Client's gender Client's comorbid conditions Type of procedure be performed Changes in neurologic function due to the procedure Prior effectiveness in relieving the pain

Client's comorbid conditions Type of procedure be performed Changes in neurologic function due to the procedure Prior effectiveness in relieving the pain Explanation: The nursing care of clients who undergo procedures for the relief of chronic pain depends on the type of procedure performed, its effectiveness in relieving the pain, and the changes in neurologic function that accompany the procedure. The client's comorbid conditions will also affect care, but his gender is not a key consideration.

A client has suspected fluid accumulation in the pleural space of the lungs and is scheduled for a thoracentesis. The nurse will implement which of the following for this procedure? Select all that apply. Place the client in the prone position. Educate the client about the need to cleanse the thoracic area. Apply pressure to the puncture site after the procedure. Prepare the client for magnetic resonance imaging after the procedure to verify tube placement. Complete a respiratory assessment after the procedure.

Educate the client about the need to cleanse the thoracic area. Apply pressure to the puncture site after the procedure. Complete a respiratory assessment after the procedure. Explanation: A thoracentesis is performed to aspirate fluid or air from the pleural space. The nurse assists the client to a sitting or side-lying position, which provides support and exposes the base of the thorax. Encouraging a position of comfort helps the client to relax for the procedure. The nurse prepares the client by explaining the steps of the procedure and begins by cleansing the thoracic area using aseptic technique. After the procedure, the nurse applies pressure to the site to help stop bleeding; then, he or she applies an air-tight, sterile dressing. A chest x-ray verifies that there is no pneumonthorax. The nurse will monitor at intervals the client's respiratory function.

What is the best action by the nurse to achieve optimal outcomes when caring for a client with a musculoskeletal disorder who is using a cast? Educate the client on cast care and complications Prepare the client for cast application Assess for neurovascular compromise Provide effective pain control

Educate the client on cast care and complications Explanation: Educating the client is essential to achieve optimal outcomes. Although the nurse should prepare the client for cast applications, assess for neurovascular compromise, and provide effective pain control, these interventions are centered on care provided by the nurse. The client is more likely to be in the home setting while a cast is in place, requiring the client to have the education to properly care for the cast and have knowledge of the complications so that early interventions can happen.

Which intervention would the nurse implement with the client in a plaster cast? Select all that apply. Protect wet cast by covering with sheet. Handle wet cast with palms of hands. Notify health care provider, if client reports warmth of the cast. Position casted extremity firmly on a hard surface while drying. Trim, reshape, and smooth edges of cast.

Handle wet cast with palms of hands. Trim, reshape, and smooth edges of cast. Explanation: An exothermic reaction occurs during the application of the cast, whereby the client will experience a sensation of increasing warmth that may be uncomfortable. The cast should not be covered to allow air to circulate to promote drying of the cast. A plaster cast requires 24 to 72 hours to dry completely. Plaster casts are susceptible to dents as they are drying. The nurse should handle the cast with the palms of the hands and avoid resting the drying cast on a hard surface. The nurse may need to trim, reshape, and smooth the edges of the cast to minimize skin irritation.

A client who is post op from bariatric surgery experiences dumping syndrome. What is the nurse's understanding of the cause of this condition? Hypertonic food draws extracellular fluid from the blood into the small intestines. Hypertonic food releases metabolic peptides. Hypotonic food pulls fluid from the blood and small intestines. Hypotonic food releases toxic substances.

Hypertonic food releases metabolic peptides. Explanation: The previous theory behind dumping syndrome was that the hypertonic food bolus drew extracellular fluid from the blood into the small intestines, causing symptoms. This theory has since been challenged and the newest theory suggests the rapid release of metabolic peptides that release from the hypertonic food bolus causes dumping syndrome symptoms.

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

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

A nurse caring for clients with obesity understands these clients are at increased risk for developing pressure ulcers. What does the nurse recognize increases the client's risk for developing pressure ulcers? Select all that apply. Increased adipose tissue decreases the supply of blood, oxygen, and nutrients to peripheral tissue. Skin folds are associated with more moisture and friction. Normal healing mechanisms are impaired. Increased adipose tissue causes thinning of the skin and risk for decreased integrity. Inflammation is worse and leads to risk of infection.

Increased adipose tissue decreases the supply of blood, oxygen, and nutrients to peripheral tissue. Skin folds are associated with more moisture and friction. Explanation: Increased adipose tissue decreases the supply of blood, oxygen, and nutrients to peripheral tissue. Additionally, skin folds are associated with more moisture and friction. These concepts increases the risk of developing pressure ulcers in the client with obesity. Obesity alone does not impair normal healing or worsen inflammation leading to infection of the skin. Increased adipose tissue does not cause the thinning of the skin.

A client is exhibiting diminished range of motion, loss of flexibility, stiffness, and loss of height. The history and physical findings are associated with age-related changes of which area? Joints Bones Muscles Ligaments

Joints Explanation: History and physical findings associated with age-related changes of the joints include diminished range of motion, loss of flexibility, stiffness, and loss of height. History and physical findings associated with age-related changes of bones include loss of height, posture changes, kyphosis, flexion of hips and knees, back pain, osteoporosis, and fracture. History and physical findings associated with age-related changes of muscles include loss of strength, diminished agility, decreased endurance, prolonged response time (diminished reaction time), diminished tone, a broad base of support, and a history of falls. History and physical findings associated with age-related changes of ligaments include joint pain on motion that resolves with rest, crepitus, joint swelling/enlargement, and degenerative joint disease (osteoarthritis).

A group of students are reviewing information about bones in preparation for a quiz. Which of the following indicates that the students have understood the material? The yellow marrow is responsible for manufacturing red blood cells. Long bones typically contain more red bone marrow than yellow. Osteoclasts are involved in the destruction and remodeling of bone. Osteocytes are transformed into osteoblasts or mature bone cells.

Osteoclasts are involved in the destruction and remodeling of bone. Explanation: Osteoclasts are the cells involved in the destruction, resorption, and remodeling of bone. Red bone marrow is responsible for manufacturing red blood cells. Long bones contain yellow bone marrow; the sternum, ileum, vertebrae, and ribs contain red bone marrow. Osteoblasts are transformed into osteocytes, mature bone cells.

A patient is diagnosed with osteomyelitis of the right leg. What signs and symptoms does the nurse recognize that are associated with this diagnosis? (Select all that apply.) Pain Erythema Fever Leukopenia Purulent drainage

Pain Erythema Fever Explanation: When the infection is bloodborne, the onset is usually sudden, occurring often with the clinical and laboratory manifestations of sepsis (e.g., chills, high fever, rapid pulse, general malaise). The systemic symptoms at first may overshadow the local signs. As the infection extends through the cortex of the bone, it involves the periosteum and the soft tissues. The infected area becomes painful, swollen, and extremely tender. The patient may describe a constant, pulsating pain that intensifies with movement as a result of the pressure of the collecting purulent material (i.e., pus). When osteomyelitis occurs from spread of adjacent infection or from direct contamination, there are no manifestations of sepsis. The area is swollen, warm, painful, and tender to touch.

The nurse is reviewing the medical record of a client with glaucoma. Which of the following would alert the nurse to suspect that the client was at increased risk for this disorder? Age younger than 40 years Hyperopia since age 20 years History of respiratory disease Prolonged use of corticosteroids

Prolonged use of corticosteroids Explanation: Risk factors associated with glaucoma include prolonged use of topical or systemic corticosteroids, older age, myopia, and a history of cardiovascular disease.

A client who is postoperative from bariatric surgery reports foul-smelling, fatty stools. What is the nurse's understanding of the primary reason for this finding? Rapid gastric dumping Excessive fat intake Decreased motility Decreased gastric size

Rapid gastric dumping Explanation: Rapid gastric dumping may lead to steatorrhea, excessive fat in the feces. The primary cause of this finding is rapid gastric dumping. Excessive fat intake can make the problem worse; however, this is not the primary cause of the symptoms. Steatorrhea results from increased motility, not decreased and the size of the stomach does not contribute to this finding.

Which action by the nurse is most appropriate when the client demonstrates subcutaneous emphysema along the suture line or chest dressing 2 hours after chest surgery? Apply a compression dressing to the area Measure the patient's pulse oximetry Report the finding to the physician immediately Record the observation

Record the observation Explanation: The nurse should record the observation. Subcutaneous emphysema is a typical finding in clients after chest surgery. Subcutaneous emphysema occurs after chest surgery as the air that is located within the pleural cavity is expelled through the tissue opening created by the surgical procedure. Subcutaneous emphysema is absorbed by the body spontaneously after the underlying leak is treated or halted. Subcutaneous emphysema results from air entering the tissue planes. It is unnecessary to report the finding to the physician or apply a compression dressing because subcutaneous emphysema is an expected finding at this stage of recovery. Subcutaneous emphysema is not an explicit risk factor for hypoxemia, so no extraordinary monitoring of pulse oximetry is necessary.

Which statement is accurate regarding refractive surgery? Refractive surgery will alter the normal aging of the eye. Refractive surgery may be performed on all clients, even if they have underlying health conditions. Refractive surgery may be performed on clients with an abnormal corneal structure as long as they have a stable refractive error. Refractive surgery is an elective, cosmetic surgery performed to reshape the cornea.

Refractive surgery is an elective, cosmetic surgery performed to reshape the cornea. Explanation: Refractive surgery is an elective procedure and is considered a cosmetic procedure (to achieve clear vision without the aid of prosthetic devices). It is performed to reshape the cornea for the purpose of correcting all refractive errors. Refractive surgery will not alter the normal aging process of the eye. Clients with conditions that are likely to adversely affect corneal wound healing (corticosteroid use, immunosuppression, elevated intraocular pressure) are not good candidates for the procedure. The corneal structure must be normal and refractive error stable.

x A nursing instructor is preparing a class about gastrointestinal intubation. Which of the following would the instructor include as reason for this procedure? Select all that apply. Remove gas and fluids from the stomach Diagnose gastrointestinal motility disorders Flush ingested toxins from the stomach Evaluate for masses in the large colon Administer nutritional substances

Remove gas and fluids from the stomach Diagnose gastrointestinal motility disorders Flush ingested toxins from the stomach Administer nutritional substances Explanation: Gastrointestinal intubation is used to decompress the stomach and remove gas and fluids, lavage the stomach and remove ingested toxins or other harmful materials, diagnose disorders of GI motility, administer medications and feedings, compress a bleeding site, and aspirate gastric contents for analysis. Because gastrointestinal intubation involves the insertion of a tube into the stomach, beyond the pylorus into the duodenum or jejunum, it could not be used to evaluate for masses in the large colon.

A nurse is working as part of the surgical team in the semi-restricted area. Which of the following would be appropriate to wear? Select all that apply. Street clothes Scrub clothes Caps Shoe covers Masks

Scrub clothes Caps Explanation: Scrub clothes and caps are worn in the semi-restricted area. Street clothes are worn in the unrestricted area. Scrub clothes, caps, shoe covers, and masks are worn in the restricted area.

During a routine physical examination on an older female client, a nurse notes that the client is 5 feet, 3/8 inches (1.6 m) tall. The client states, "How is that possible? I was always 5 feet and 1/2? (1.7 m) tall." Which statement is the best response by the nurse? "After age 40, height may show a gradual decrease as a result of spinal compression" "After menopause, the body's bone density declines, resulting in a gradual loss of height." "There may be some slight discrepancy between the measuring tools used." "The posture begins to stoop after middle age."

"After menopause, the body's bone density declines, resulting in a gradual loss of height." Explanation: The nurse should tell the client that after menopause, the loss of estrogen leads to a loss in bone density, resulting in a loss of height. This client's history doesn't indicate spinal compression. Telling the client that measuring tools used to obtain the client's height may have a discrepancy or that the posture begins to stoop after middle age doesn't address the client's question.

Which client statement would lead the nurse to suspect that the client is experiencing bacterial conjunctivitis? "My eyes feel like they are on fire." "My eyelids were stuck together this morning." "It feels like there is something stuck in my eye." "My eyes hurt when I'm in the bright sunlight."

"My eyelids were stuck together this morning." Explanation: Burning, a sensation of a foreign body, and pain in bright light (photophobia) are signs and symptoms associated with any type of conjunctivitis. The drainage related to bacterial conjunctivitis is usually present in the morning, and the eyes may be difficult to open becacuse of adhesions caused by the exudate.

A 14-year-old client is treated in the emergency room for an acute knee sprain sustained during a soccer game. The nurse reviews discharge instructions with the client's parent. The nurse instructs the parent that the acute inflammatory stage will last how long? 24 to 48 hours 3 to 4 days 4 to 5 days At least 7 days

24 to 48 hours Explanation: Rest and ice applications during the first 24 to 48 hours produce vasoconstriction while decreasing bleeding and edema. After this time, the acute inflammatory stage decreases.

A client is evaluated for a diagnosis of Paget's disease. Which laboratory value would the nurse find to confirm the diagnosis? Calcium of 9.2 mg/dL (2.3 mmol/L) Urinary creatinine of 0.95 mg/dL (83.98 mmol/L) Alkaline phosphate of 165 IU/L (2750 mmol/L) Magnesium level of 2 mg/dL (0.82 mmol/L)

Alkaline phosphate of 165 IU/L (2750 mmol/L) Explanation: The normal range for alkaline phosphate level is 20 to 140 IU/L. An elevated serum concentration of alkaline phosphate reflects increased osteoblastic activity and is seen in clients with Paget's disease. A calcium level of 9.2 (2.3 mmol/L) is normal. A urinary creatinine level of 0.95 mg/dL (83.98 mmol/L) is normal. A magnesium level of 2 mg/dL (0.82 mmol/L) is normal.

A patient has a cast removed after bone healing takes place. What should the nurse instruct the patient to do after removal? (Select all that apply.) Apply an emollient lotion to soften the skin. Control swelling with elastic bandages, as directed. Gradually resume activities and exercise. Use friction to remove dead surface skin by rubbing the area with a towel. Use a razor to shave the dead skin off.

Apply an emollient lotion to soften the skin. Control swelling with elastic bandages, as directed. Gradually resume activities and exercise. Explanation: The skin needs to be washed gently and lubricated with an emollient lotion. The patient should be instructed to avoid rubbing and scratching the skin, because doing so can cause damage to newly exposed skin. The nurse and physical therapist educate the patient to resume activities gradually within the prescribed therapeutic regimen. Exercises prescribed to help the patient regain joint motion are explained and demonstrated. Because the muscles are weak from disuse, the body part that has been immobilized cannot withstand normal stresses immediately. In addition, the patient should be instructed to control swelling by elevating the formerly immobilized body part, no higher than the heart, until normal muscle tone and use are reestablished.

A client with an arm cast reports pain. What nursing interventions should the nurse provide in order to reduce the incidence of complications? Select all that apply. Assess the fingers for color and temperature. Administer a prescribed analgesic to promote comfort and allay anxiety. Assess for a pressure sore Determine the exact site of the pain. Cut the cast with a cast saw

Assess the fingers for color and temperature. Assess for a pressure sore Determine the exact site of the pain. Explanation: Neurovascular assessment includes the assessment of peripheral circulation, motion, and sensation of the affected extremity, assessing the fingers or toes of the affected extremity, and comparing them with those of the opposite extremity. When assessing peripheral circulation, the nurse must check peripheral pulses as well as capillary refill response (within 3 seconds), edema, and the color and temperature of the skin. The nurse must carefully evaluate pain associated with the musculoskeletal condition, asking the client to indicate the exact site and to describe the character and intensity of the pain using a pain rating scale. Severe burning pain over bony prominences, especially the heels, anterior ankles, and elbows, warns of an impending pressure ulcer.

The nurses instructs the client not to cross their legs and to have someone assist with tying their shoes. Which additional instruction should the nurse provide to client? Do not flex the hip more than 30 degrees. Do not flex the hip more than 60 degrees. Do not flex the hip more than 90 degrees. Do not flex the hip more than 120 degrees.

Do not flex the hip more than 90 degrees. Explanation: Proper alignment and supported abduction are encouraged for hip repairs. Flexion of the hip more than 90 degrees can cause damage to the a repaired hip fracture. By telling the patient to not to cross their legs, the leg stays in a the abducted position allowing for the hip to heal in the proper position. Having someone assist with the shoes does not allow for the hip to flex more than 90 degrees.

A nurse is caring for a patient who has had an amputation. What interventions can the nurse provide to foster a positive self-image? (Select all that apply.) Encouraging the patient to care for the residual limb Allowing the expression of grief Encourage the patient to have family and friends view the residual limb to decrease self-consciousness. Encouraging family and friends to refrain from visiting temporarily because this may increase the patient's embarrassment. Introducing the patient to local amputee support groups.

Encouraging the patient to care for the residual limb Allowing the expression of grief Introducing the patient to local amputee support groups. Explanation: The nurse creates an accepting and supportive atmosphere in which the patient and family are encouraged to express and share their feelings and work through the grief process. The support from family and friends promotes the patient's acceptance of the loss. The nurse helps the patient deal with immediate needs and become oriented to realistic rehabilitation goals and future independent functioning. Mental health and support group referrals may be appropriate (McFarland et al., 2010). Amputation affects the patient's ability to provide adequate self-care. The patient is encouraged to be an active participant in self-care.

The nurse is working in the triage section of a walk-in clinic. Which triad of common symptoms, when placed together, indicate Ménière's disease? Blurred vision, vertigo, nausea Syncope, vertigo, ear pain Disorientation, vertigo, nausea Hearing loss, vertigo, tinnitus

Hearing loss, vertigo, tinnitus Explanation: Hearing loss, vertigo, and tinnitus are common symptoms of many disease processes but, when placed together, indicate Ménière's disease. The other options do not include the accurate triad of symptoms.

Which intervention should the nurse implement with the client who has undergone a hip replacement? Instruct the client to avoid internal rotation of the leg. Place the client in high Fowler's position for meals. Have the client bend forward to rise from the chair. Adduct the legs by placing a pillow between the legs.

Instruct the client to avoid internal rotation of the leg. Explanation: The client should avoid all activities that can result in dislocation of the hip. The affected leg should not cross midline or be turned inward. A pillow is used to keep the legs in abduction. The hip should not bend more than 90 degrees when seated. The head of bed should be kept at 60 degrees or less.

A client undergoes open reduction with internal fixation to treat an intertrochanteric fracture of the right hip. The nurse should include which intervention in the postoperative care plan? Performing passive range-of-motion (ROM) exercises on the client's legs once each shift Keeping a pillow between the client's legs at all times Turning the client from side to side every 2 hours Maintaining the client in semi-Fowler's position

Keeping a pillow between the client's legs at all times Explanation: After open reduction with internal fixation, the client must keep the affected leg abducted at all times; placing a pillow between the legs reminds the client not to cross the legs and to keep the leg abducted. Passive or active ROM exercises shouldn't be performed on the affected leg during the postoperative period, because this could damage the operative site and cause hip dislocation. Most clients should be turned to the unaffected side, not from side to side. After open reduction with internal fixation, the client must avoid acute flexion of the affected hip to prevent possible hip dislocation; therefore, semi-Fowler's position should be avoided.

A client who was in a motor vehicle crash is diagnosed with a stable T7 spinal fracture with no neurologic deficits. Which nursing intervention should the nurse implement? Maintain bed rest with the head of the bed at 20 degrees. Withhold opioid pain medication to prevent ileus. Maintain NPO (nothing by mouth) status for surgical repair. Sit the client upright in a padded chair for meals.

Maintain bed rest with the head of the bed at 20 degrees. Explanation: The client should maintain limited bed rest with the head of the bed lower than 30 degrees. If the client's pain is not controlled with a lower form of pain medication, then an opioid may be used to treat the pain. The nurse should monitor for an ileus. Stable spinal fractures are treated conservatively and not with surgical repair. The client should avoid sitting until the pain eases.

The nurse is assessing the client who states a decline in muscle strength. Which is the primary source essential to allow muscle contraction? Myofibrils Sarcomeres Acetylcholine Actin and myosin

Myofibrils Explanation: Skeletal muscles are made up of muscle cells or fibers called myofibrils. Without muscle fibers, there can be no muscle contraction. Sliding filaments called sarcomeres make up the myofibrils. Acetylcholine stimulates the motor neuron, which innervated the muscle. Actin and myosin in the sarcomere slide together, resulting in muscle contraction.

The nurse assesses a clientafter total right hip arthroplasty and observes a shortening of the extremity. The client reports severe pain in the right side of the groin. What is the priority action of the nurse? Apply Buck's traction. Notify the health care provider. Externally rotate the extremity. Bend the knee and rotate the knee internally.

Notify the health care provider. Explanation: If any clinical manifestations of dislocation of the prosthesis occur, including acute groin pain in the affected hip or shortening of the affected extremity, the nurse (or the client, if at home) must immediately notify the surgeon, because the hip must be reduced and stabilized promptly so that the leg does not sustain circulatory and nerve damage. After closed reduction, the hip may be stabilized with Buck's traction or a brace to prevent recurrent dislocation. As the muscles and joint capsule heal, the chance of dislocation diminishes. Stresses to the new hip joint should be avoided for the first 8 to 12 weeks, when the risk of dislocation is greatest.

An unresponsive client had a plaster cast applied to the right lower leg 8 hours ago. When moving the client, the nurse notices an indentation on the posterior lower portion of the cast. What is the best action by the nurse? Document the findings. Notify the physician. Remove the cast immediately. Assess for pedal pulse and mobility of toes.

Notify the physician. Explanation: Indentations in the cast can cause skin irritation and breakdown. The physician needs to be notified to assess the need for a new cast or manipulation of the current cast to prevent the skin breakdown. The nurse will need to document the findings and actions taken to resolve the issue but cannot document actions without completing an action, such as notifying the physician. The cast does not need to be removed immediately. Pedal pulse will indicate whether a circulatory issue is present, but with the client being unresponsive, mobility of the toes cannot be assessed.

A patient has a fracture of the right femur sustained in an automobile accident. What process of fracture healing does the nurse understand will occur with this patient? Reactive phase, reparative phase, remodeling phase Primary phase, secondary phase, third phase First intention, secondary intention, third intention Active phase, dormant phase, restructure phase

Reactive phase, reparative phase, remodeling phase Explanation: The process of fracture healing occurs over three phases. These include the following: Phase I: Reactive phase; Phase II: Reparative phase; and Phase III: Remodeling phase.

A patient arrives in the emergency department with a suspected bone fracture of the right arm. How does the nurse expect the patient to describe the pain? A dull, deep, boring ache Sharp and piercing Similar to "muscle cramps" Sore and aching

Sharp and piercing Explanation: The nurse must carefully evaluate pain associated with the musculoskeletal condition, asking the patient to indicate the exact site and to describe the character and intensity of the pain using a pain rating scale. Most pain can be relieved by elevating the involved part, applying ice or cold packs, and administering analgesic agents as prescribed. Pain associated with the underlying condition (e.g., fracture, which is sharp and piercing) is frequently controlled by immobilization. Pain due to edema that is associated with trauma, surgery, or bleeding into the tissues can frequently be controlled by elevation and, if prescribed, intermittent application of ice or cold packs. Ice bags (one third to one half full) or cold application devices are placed on each side of the cast, if prescribed, making sure not to indent or wet the cast. Unrelieved or disproportionate pain may indicate complications. Pain associated with compartment syndrome is relentless and is not controlled by modalities such as elevation, application of ice or cold, and usual dosages of analgesic agents. Severe burning pain over bony prominences, especially the heels, anterior ankles, and elbows, warns of an impending pressure ulcer. This may also occur from too-tight elastic wraps used to hold splints in place.

A client reports pain in the right knee, stating, "My knee got twisted when I was going down the stairs." The client was diagnosed with an injury to the ligaments and tendons of the right knee. Which terminology, documented by the nurse, best reflects the injury? Sprain Dislocation Subluxation Strain

Sprain Explanation: A sprain is an injury to the ligaments and tendons surrounding a joint, usually caused by a wrenching or twisting motion. Dislocation refers to the separation of joint surfaces. Subluxation refers to partial separation or dislocation of joint surfaces. Strain refers to a muscle pull or tear.

Which statement is accurate regarding care of a plaster cast? The cast must be covered with a blanket to keep it moist during the first 24 hours. The cast will dry in about 12 hours. The cast can be dented while it is damp. A dry plaster cast is dull and gray.

The cast can be dented while it is damp. Explanation: The cast can be dented while it is damp. A dry plaster case is white and shiny. The cast will dry in 24 to 72 hours. A freshly applied cast should be exposed to circulating air to dry and should not be covered with clothing or bed linens or placed on plastic-coated mats or bedding.

A client is brought to the emergency department after being struck with a baseball bat on the upper arm while diving for a pitched ball. Diagnostic tests reveal that the humerus is not broken but that the client has suffered another type of injury. What type of injury would the physician likely diagnose? contusion sprain strain subluxation

contusion Explanation: A contusion is a soft tissue injury resulting from a blow or blunt trauma. Sprains are injuries to the ligaments surrounding a joint. A strain is an injury to a muscle when it is stretched or pulled beyond its capacity. A subluxation is a partial dislocation.