1430 Exam 2 exemplars

What is some nutritional therapy for someone that has had a hip operation?

Requires adequate:- Protein and calcium- Increased fluid intake- High fiber (Prevention of the strain for a BM)

Patient Education: Hip Prosthesis DO's:

-Use high-backed chair with arm rests -Use elevated toilet seats -Use chair in tub or shower -Use pillow or abductor brace between legs when lying or turning -Maintain hip in neutral position -Notify dentist before dental work -Notify MD if severe pain or loss of function

Preoperative care for a client with a hip fracture includes which nursing​ intervention? A: Discussing​ long-term options B: Correcting use of crutches C: Immobilizing the hip with traction D: Administering steroids

Answer: C

Which intervention is the​ first-line treatment of a client with a hip​ fracture? A: Anticoagulants B: Antibiotics C: Bed rest D: Surgery

Answer: D

A client reports to the nurse that her grandmother with Alzheimer's disease recently moved in with her and her two school-aged children. The client states the grandmother becomes agitated and starts yelling and crying frequently. The woman asks, "What can I do?" The nurse first responds: A. "You need to remain calm during the outbursts." B. "Start rubbing her shoulders and her back." C. "Play quiet music that your grandmother may like." D. "What precipitates the outbursts?"

Correct response: "What precipitates the outbursts?" Explanation: A client with Alzheimer's disease may respond to exciting or confusing events with a catastrophic reaction, such as screaming, crying, or becoming abusive. The nurse needs to assess the situation and what precipitates the catastrophic reactions to best address how to prevent these events. Other nursing interventions include telling the client's granddaughter to remain calm and to distract the grandmother with quiet music, stroking, or both.

What are some Hip Fracture Complications?

DVT/Pulmonary embolism -Dislocation-UTI/pneumonia -Muscle atrophy Postoperatively: -infection -mental status change -avascular necrosis -nonunion or malunion of bone (dislocation)

What are some complications of an open reduction internal fixation?

Difficult for elderly to comply - Nail penetrating femoral head - Decrease ROM - Infection

Patient education: Hip Prosthesis DO NOT's:

-No adduction -No sitting on chairs without arm rests -No low chairs -No internal rotation -No flexing hip greater than 90 degrees -No side lying on operative side - No extreme internal/external rotation -No putting on shoes and socks for 8 weeks without device -No crossing legs or feet

Which statement by the wife of a patient with Alzheimer's disease (AD) demonstrates an accurate understanding of her husband's medication regimen? A) "I'm really hoping his medications will slow down his mental losses." B) "We're both holding out hope that this medication will cure his disease." C) "I know that this won't cure him, but we learned that it might prevent a bodily decline while he declines mentally." D) "I learned that if we are vigilant about his medication schedule, he may not experience the physical effects of his disease."

A) "I'm really hoping his medications will slow down his mental losses." Rationale: There is presently no cure for Alzheimer's disease, and drug therapy aims at improving or controlling decline in cognition. Medications do not directly address the physical manifestations of AD.

A nurse is monitoring a client who is post-op and unable to respond to questions. Which nonverbal behaviors should the nurse identify as indication of pain? (select all that apply) A. Restlessness B. Grimacing C. Moaning D. Clenching E. Drowsiness

A, B, C Restlessness is correct. Clients who have uncontrolled pain often become restless and anxious in response to the discomfort. Grimacing is correct. Facial movements such as grimacing, tightly closing the eyes, and biting the lower lip are behavioral indicators of pain. Moaning is incorrect. Moaning, groaning, crying, and screaming are vocalizations, not nonverbal behaviors, that indicate pain. Clenching is correct. Clenching the teeth and biting the lower lip are common findings in clients who have pain. Drowsiness is incorrect. Agitation and aggressiveness, not drowsiness, are common indicators of pain.

The nurse is assessing a patient's ability to perform basic activities of daily living (BADLs). Which of the following activities are considered in the BADLs assessment? Select all that apply. A. Brushing teeth or dentures B. Dressing oneself in the mornings C. Washing, drying, and folding laundry D. Counting own pulse and taking heart pill E. Taking the bus to the park F. Calling family members

A,B BADLs include actions related to self care and mobility and also includes eating, personal hygiene, and grooming activities. Instrumental activities of daily living (IADLs) include shopping, meal preparation, housekeeping, doing laundry, managing finances, using the telephone, taking medications, and using transportation.

A nurse caring for a client postop following a cholecystectomy and reports pain. Which actions should the nurse take? (select all that apply) A. Offer the client a back rub. B. Remind the client to use incisional splinting. C. Identify the client's pain level. D. Assist the client to ambulate. E. Change the client's position.

A,B,C,D,E Offer the client a back rub is correct. Nonpharmacological comfort measures can improve pain management. Remind the client to use incisional splinting is correct. Holding a pillow against the incision when moving, turning, or coughing can help the client with self-management of pain. Identify the client's pain level is correct. The nurse should use a standard scale to determine and document the severity of the client's pain. Assist the client to ambulate is incorrect. If the client reports pain, the nurse should implement interventions to manage the pain, such as administering analgesia and giving it time to take effect, before assisting the client to ambulate. Change the client's position is correct. Nonpharmacological measures for managing pain include repositioning, imagery, and distraction.

Which of the following interventions are priorities in a plan of care for a patient who had a stroke 30 days ago and is now in home care rehabilitation? Select all that apply. A. Promoting rest and sleep B. Promoting a diet rich in protein C. Promoting exercise and ambulation D. Assisting the patient with ADLs E. Limiting visitors and social contacts

A,C It is important to promote independence in ADLs early in the plan of care to increase independence in general. Promoting rest and sleep will promote well-being. Ambulation and exercise promote well-being and increase healing by circulating oxygen to the brain. Protein promotes healing in postsurgical patients but is not a main focus in stroke patients. Assisting the patient does not promote independence. Limiting visitors will isolate the patient, which can lead to depression.

A nurse is educating coworkers about how to minimize back strain and avoid repeated episodes of low back pain. Which strategies should the nurse inculde? (select all that apply) A. Avoid prolonged sitting. B. Apply heat for 10 min every hour. C. Sleep in a side-lying position with flexed knees. D. Sleep on a soft mattress. E. Try padded shoe insoles.

A,C,E Avoid prolonged sitting is correct. Staying in any one position for too long, even lying down, can worsen back pain. Changing positions frequently is essential. Apply heat for 10 min every hour is incorrect. The recommendation for low back pain is applying moist heat for 20 to 30 min at least four times per day, to decrease pain and muscle spasms. Cold packs can also help with pain and swelling. Sleeping in a side-lying position with flexed knees is correct. This position prevents unnecessary pressure on the support muscles and lumbosacral joints. Sleep on a soft mattress is incorrect. The recommendation is to sleep on a firm mattress for added support. Try padded shoe insoles is correct. These can be especially helpful for people who must stand or walk for extended periods at work.

A nurse is providing info about pain control for a client who has acute pain following a subtotal gastric resection. Which client statement indicates an understanding of pain control? A. "I will call for pain medication before the previous dose wears off." B. "I will call for pain medication as my pain starts to increase again." C. "I will wait for you to evaluate my pain before asking for more medication." D. "I will ask for less medication to avoid addiction."

A. The client should call for pain medication before the previous dose of medication wears off or before the pain becomes severe. The client should call for pain medication before the pain starts to increase. The client should not wait for the nurse to initiate an evaluation to control postoperative pain. The client should receive enough pain medication to control postoperative pain safely.

A nurse is assessing a client who reports acute pain. They should anticipate which of the following findings? A. Increased heart rate B. Decreased respiratory rate. C. Hyperactive bowel sounds D. Decreased blood pressure

A. Acute pain stimulates the sympathetic nervous system and can cause an increase in heart rate. Acute pain can cause tachypnea. Acute pain can cause pallor and diaphoresis. Acute pain can cause increased blood pressure.

Which nursing intervention is appropriate for minimizing muscle spasms in the client with a hip fracture? A. Maintain Buck's traction. B. Assist the client with use of a trapeze. C. Maintain the internal fixator. D. Apply a soft compression dressing.

A. Maintain Buck's traction.

A nurse is caring for a client who is taking aspirin for arthirits. The nurse should identify which of the following findings as an adverse effect of this medication? A. Tinnitus B. Clay colored stools C. Nystagmus D. Respiratory depression

A. The nurse should identify tinnitus, or ringing in the ears, as an adverse effect of aspirin that indicates salicylism. The nurse should identify tarry, black colored stools as an adverse effect of aspirin that indicates gastric bleeding.The nurse should identify hyperpnea as an adverse effect of aspirin that indicates that salicylism is causing respiratory alkalosis

A nurse is caring for a client who requires cold applications with an ice bag to reduce swelling and pain from ankle injury. Which action should the nurse take? A. Apply the bag for 30 min at a time. B. Reapply the bag 30 min after removing it. C. Allow room for some air inside the bag. D. Place the bag directly on the skin.

A. The nurse should leave the bag in place for 30 min, but should check the client's skin after 15 min to make sure there are no adverse effects. After removing the ice bag, the nurse should not reapply it any sooner than 1 hr later. The nurse should squeeze the sides of the bag to remove excess air before putting the cap back on the bag. Air can block the conduction of cold to the injury. The nurse should place a towel, the bag's cover material, or a pillowcase between the ice bag and the client's skin.

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

Answer: 1 Rationale: An altered mental state is an early indication of fat emboli; therefore, clear mentation is a good indicator that a fat embolus is resolving. Eupnea, not minimal dyspnea, is a normal sign. Arterial oxygen levels should be 80 to 100 mm Hg. Oxygen saturation should be higher than 95%. Test-Taking Strategy: Note the strategic word, most. Knowing that the arterial oxygen and oxygen saturation levels are below normal helps eliminate options 3 and 4. Dyspnea, even at a minimal level, is not normal, so eliminate option 2.

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

Answer: 2 Rationale: The earliest symptom of compartment syndrome is paresthesia (numbness and tingling in the fingers). Other symptoms include pain unrelieved by opioids, pain that increases with limb elevation, and pallor and coolness to the distal limb. Cyanosis is a late sign. Pain that is out of proportion to the severity of the fracture, along with other symptoms associated with the pain, is not an early manifestation. Test-Taking Strategy: Note the strategic word, early. Knowing that compartment syndrome is characterized by insufficient circulation and ischemia caused by pressure will direct you to the correct option.

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

Answer: 3 Rationale: Signs of infection under a casted area include odor or purulent drainage from the cast or the presence of "hot spots," which are areas of the cast that are warmer than others. The primary health care provider should be notified if any of these occur. Signs of impaired circulation in the distal limb include coolness and pallor of the skin, diminished distal pulse, and edema. Test-Taking Strategy: Focus on the subject, signs of infection. Think about what you would expect to note with infection—redness, swelling, heat, and purulent drainage. With this in mind, you can eliminate options 2 and 4 easily. From the remaining options, remember that "dependent edema" is not necessarily indicative of infection. Swelling would be continuous. The hot spot on the cast could signify infection underneath that area.

The nurse is evaluating a client in skeletal traction. When evaluating the pin sites, the nurse would be most concerned with which finding? 1. 1. Redness around the pin sites 2. 2. Pain on palpation at the pin sites 3. 3. Thick, yellow drainage from the pin sites 4. 4. Clear, watery drainage from the pin sites

Answer: 3 Rationale: The nurse should monitor for signs of infection such as inflammation, purulent (thick white or yellow) drainage, and pain at the pin site. However, some degree of inflammation, pain at the pin site, and serous drainage would be expected; the nurse should correlate assessment findings with other clinical findings, such as fever, elevated white blood cell count, and changes in vital signs. Additionally, the nurse should compare any findings to baseline findings to determine if there were any changes. Test-Taking Strategy: Note the strategic word, most. Determine if an abnormality exists. Recall that purulent drainage is indicative of infection, and that some degree of pain, inflammation, and serous drainage should be expected.

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

Answer: 4 Rationale: After arthroscopy, the client usually can walk carefully on the leg once sensation has returned. The client is instructed to avoid strenuous exercise for the length of time prescribed by the surgeon. The client may resume the usual diet. Signs and symptoms of infection should be reported to the primary health care provider. Test-Taking Strategy: Focus on the subject, teaching points following knee arthroscopy. Recalling the general client teaching points related to surgical procedures and that a risk for infection exists after a surgical procedure will direct you to the correct option.

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

Answer: 4 Rationale: An absent pulse to an extremity of the affected limb after a bone fracture could mean that the child is developing or experiencing compartment syndrome. This is an emergency situation, and the PHCP needs to be notified immediately. Administering analgesics would not improve circulation. The skin traction should not be released without a PHCP's prescription. Applying ice to an extremity with absent perfusion will worsen the problem. Ice may be prescribed when perfusion is adequate to decrease swelling. Test-Taking Strategy: Use the ABCs—airway, breathing, and circulation. Focusing on the data in the question indicates that circulation is impaired. This should direct you to the correct option.

A client with a hip fracture asks the nurse about Buck's (extension) traction that is being applied before surgery and what is involved. The nurse should provide which information to the client? 1. 1. Allows bony healing to begin before surgery and involves pins and screws 2. 2. Provides rigid immobilization of the fracture site and involves pulleys and wheels 3. 3. Lengthens the fractured leg to prevent severing of blood vessels and involves pins and screws 4. 4. Provides comfort by reducing muscle spasms, provides fracture immobilization, and involves pulleys and wheels

Answer: 4 Rationale: Buck's (extension) traction is a type of skin traction often applied after hip fracture before the fracture is reduced in surgery. Traction reduces muscle spasms and helps immobilize the fracture. Traction does not allow for bony healing to begin or provide rigid immobilization. Traction does not lengthen the leg for the purpose of preventing blood vessel severance. This type of traction involves pulleys and wheels, not pins and screws. Test-Taking Strategy: Focus on the subject, use of traction following a hip fracture. Read each option carefully and note that each option has more than one part. All parts of the option need to be correct in order for the answer to be correct. Noting the words provides comfort and fracture immobilization will direct you to the correct option.

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

Answer: 4 Rationale: Risk factors for osteoporosis include female gender, being postmenopausal, advanced age, a low-calcium diet, excessive alcohol intake, being sedentary, and smoking cigarettes. Long-term use of corticosteroids, anticonvulsants, and/or furosemide also increases the risk. Test-Taking Strategy: Focus on the subject, risk factors for osteoporosis. The 25-year-old woman who runs (exercises using the long bones) has negligible risk. The 36-year-old man with asthma is eliminated next because his only risk factor might be long-term corticosteroid use (if prescribed) to treat the asthma. Of the remaining options, the 65-year-old woman has higher risk (age, gender, postmenopausal, sedentary, smoking) than the 70-year-old man (age, alcohol consumption).

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

Answer: 4 Rationale: When a child is in traction, the nurse would check the PHCP's prescription to verify the prescribed amount of traction weight. The nurse would maintain the correct amount of weight as prescribed, ensure that the weights hang freely, check the ropes for fraying and ensure that they are on the pulleys appropriately, monitor the neurovascular status of the involved extremity, and monitor for signs and symptoms of complications of immobilization. The nurse would provide therapeutic and diversional play activities for the child. Test-Taking Strategy: Focus on the subject, care of the child in traction. Eliminate option 3 first because of the word restrict. Next recall the general principles related to traction, recalling that weights should hang freely and ropes should remain in the pulleys. Level of Cognitive Ability: Creating

A client is suspected of having a hip fracture. Which diagnostic test assists in confirming this​ diagnosis?​ A: X-ray B: Ultrasound C: Doppler study D: Endoscopy

Answer: A

The nurse is preparing to send the client who is​ one-day postoperative from a hip arthroplasty for physical therapy. Which intervention should the nurse perform ​first? A. Administer analgesics B. Provide the client lunch C. Administer a diuretic D. Apply sequential compression stockings

Answer: A Rationale: The nurse should administer analgesics about​ 30-60 minutes prior to attending physical therapy. This minimizes pain during exercise and allows better movement. The nurse would not administer a diuretic prior to going to therapy because the client would have to urinate frequently. The client can eat​ lunch, but it is not a priority. Sequential stockings can only be used while the client is in bed.

The home care nurse is visiting an older adult client with a new diagnosis of macular degeneration and decreased visual acuity. Which instruction should the nurse provide the caregiver to decrease the​ client's risk of sustaining a fall and a hip​ fracture? (Select all that​ apply.) A. Remove throw rugs B. Clear pathways C. Eliminate alcohol D. Use​ night-lights E. Increase calcium

Answer: A, B, D ​Rationale: An older adult client with decreased visual acuity is at high risk for falling.​ Therefore, the nurse would instruct the family to clear the​ pathways, use​ night-lights, and remove throw rugs. Calcium should be increased for postmenopausal women. Excessive alcohol intake should be avoided.

Which recommendation should the nurse make to the client with Parkinson disease​ (PD) to improve gait and​ balance? (Select all that​ apply.) A. Looking ahead instead of down B. Not moving too quickly C. Not using an assistive device D. Standing straight E. Placing the heel on the ground before the toes

Answer: A, B, D, E Rationale: For improving gait and balance in the client with​ PD, the nurse may recommend walking technique that includes standing​ straight, not moving too​ quickly, looking ahead and not​ down, and placing the heel on the ground before the toes. The client may use assistive devices to improve balance and gait.

The nurse is assessing an older adult client. Which finding should cause the nurse to suspect the client has Parkinson disease (PD)? (Select all that​ apply.) A. The client has hand tremors at rest. B. The client does not remember what he ate for breakfast. C. The​ client's blood pressure increases when the client stands up. D. The client has a slurred speech. E. The​ client's facial expression shows no emotion.

Answer: A, B, D, E​ Rationale: PD causes slowed​ movements, including slurred speech. Tremors at rest are very common in PD and easy to identify. Tremors may occur in the​ hands, face,​ neck, lips,​ tongue, and jaw. PD causes a​ frozen, mask-like expression​ (lack of​ affect). The client will not have an expression that is consistent with the emotions the client is feeling. Memory loss occurs in Parkinson disease because of the loss of neurons and other changes in the brain. The client may develop dementia. Postural​ hypotension, not​ hypertension, is a common manifestation in clients with PD. This is caused by damage to the autonomic nervous system.

Which health promotion activity should be the focus of teaching for a client with Parkinson disease​ (PD)? (Select all that​ apply.) A. Participating in occupational therapy B. Improving balance C. Avoiding exercise D. Preventing injury from falls E. Promoting independence

Answer: A, B, D, E​Rationale: The focus of teaching for the client with PD should be on improving​ balance, preventing​ falls, promoting​ independence, and participating in​ physical, occupational, and speech therapy. Clients should be taught to participate in exercise to optimize​ mobility, not avoid it.

The nurse is teaching an older adult client about preventing hip fractures. Which information should the nurse​ include? (Select all that​ apply.) A. Obtaining a screening to test for osteoporosis B. Maintaining adequate intake of calcium and vitamin D C. Ensuring throw rugs are placed throughout the home D. Performing​ weight-bearing exercises daily E. Drinking one glass of red wine every night

Answer: A, B, D​ Rationale: Teaching the client about avoiding falls can be helpful in preventing hip fractures.​ Weight-bearing exercises increase strength and adequate intake of calcium and vitamin D helps bone health. Screening for osteoporosis can lead to early treatment to help diminish the risk of bone fractures. Throw rugs are not recommended because the client can trip or slip on them. There is no recommendation to drink red​ wine; in​ fact, alcohol should be consumed with caution as it can impair balance and increase the risk for a fall.

Which surgery is performed on a client with a hip​ fracture?​(Select all that​ apply.) A: Open internal fixation B: Arthroplasty C: Appendectomy D: Fractional ablation E: Hemiarthroplasty

Answer: A, B, E

Which risk factor is associated with hip​ fractures?​(Select all that​ apply.) A: Tobacco use B: Arthritis C: Lack of physical activity D: Osteoporosis E: Deficiency in calcium

Answer: A, C, D, E

The nurse is assessing a​ client's risk for sustaining a hip fracture. Which information should the nurse obtain when obtaining the health​ history? (Select all that​ apply.) A. History of osteoporosis B. Skin integrity C. Age D. Vital signs E. History of falls

Answer: A, C, E​ Rationale: The health history of a client with a hip fracture should include​ age, history of​ falls, and history of osteoporosis. Vital signs and skin integrity are obtained when performing a physical examination.

Which information should the nurse provide a​ 70-year-old client to prevent falls and hip​ fractures? (Select all that​ apply.) A. Having an eye exam every year B. Limiting cigarette smoking C. Taking 500 mg of calcium every day D. Participating in​ weight-bearing exercises E. Avoiding excessive alcohol use

Answer: A, D, E​ Rationale: Yearly eye​ exams, daily​ weight-bearing exercises, and avoiding excessive alcohol use are interventions to help reduce falls and prevent hip fractures. Any amount of cigarette smoking places a client at risk of hip​ fractures; the client needs to refrain from smoking altogether. A postmenopausal woman who is not on estrogen replacement should take​ 1,500 mg of calcium daily.

A client is scheduled for a total hip replacement due to a hip fracture. Which intervention should the nurse incorporate into the preoperative plan of​ care? A: Placing the client in Buck​'s traction B: Administering antibiotics as prescribed C: Demonstrating crutch walking with a​ three-point gait D: Applying a leg compression device

Answer: B

The nurse is caring for a client following the surgical repair of a hip fracture. Which intervention assists in reducing the risk of a deep vein thrombosis​ (DVT)? (Select all that​ apply.) A. Positioning an abduction pillow between the legs B. Administering anticoagulants as prescribed C. Using an incentive spirometer every hour D. Placing compression stockings on the client E. Turning the client every 2 hours

Answer: B, D​ Rationale: To reduce the risk of a​ DVT, administer anticoagulants as prescribed and place compression stockings on the client. Using an incentive spirometer reduces the risk of pneumonia. Turning the client every 2 hours prevents skin breakdown. Positioning an abduction pillow between the legs keeps the surgical hip in alignment.

A client diagnosed with a hip fracture is scheduled for an arthroplasty. How should the nurse describe this type of surgery to the​ client? A: Percutaneous pinning or compression hip screws that slide within the barrel of the plate B: Replacement of the ball and socket or head and acetabulum of the hip joint C: Insertion of an intramedullary nail into the marrow canal of the bone via an opening made in the greater trochanter D: Partial replacement of the ball or head of the femur

Answer: B​ Rationale: Arthroplasty is a total replacement of the ball and socket or head and acetabulum of the hip joint. Partial hip replacement of the ball or head of the femur is a hemiarthroplasty. Insertion of an intramedullary nail into the marrow canal of the bone via an opening made in the greater trochanter is hardware placed when a client has an extracapsular fracture. Percutaneous pinning or compression hip screws that slide within the barrel of the plate is hardware placed when a client has an intracapsular fracture.

A client with Parkinson disease​ (PD) complains of increased tremor while eating. Which action should the nurse​ recommend? A. Having someone feed them B. Liquefying all meals and drinking them through a straw C. Holding a piece of bread in the other hand while eating D. Using their nondominant hand to eat

Answer: B​ Rationale: Holding a piece of bread in the opposite hand or purposeful movement will decrease tremors while eating. The client should be encouraged to eat independently for as long as possible. Using the nondominant hand may lack coordination. As the client with PD is prone to​ choking, liquefying all meals would not be recommended.

The nurse assesses an older adult woman and determines the client is at high risk for osteoporosis and hip fractures. Based on these​ findings, which test should the nurse request from the healthcare​ provider? A. Computerized tomography​ (CT) scan B. Bone density testing C. Magnetic resonance imaging​ (MRI) scan D. ​X-rays

Answer: B​ Rationale: Postmenopausal women with low calcium intake are at a very high risk of osteoporosis and hip fractures.​ Therefore, the healthcare provider will prescribe bone density testing to determine further treatment.​ X-rays, CT​ scans, and MRIs are used to diagnose hip fractures.

Which is the main pathology of Parkinson disease that causes changes in muscular and sensory​ function? A. Reduction of acetylcholine in the brain B. Reduction of dopamine in the brain C. Genetic predisposition D. Presence of Lewy bodies

Answer: B​ Rationale: The changes in muscular and sensory function in Parkinson disease​ (PD) are caused by a decreased amount of dopamine in the​ brain, which in turn​ increases, not​ reduces, the amount of acetylcholine. The presence of Lewy bodies​ (abnormal aggregates of​ proteins) in the neurons is a characteristic of​ PD, but it is unclear whether they are helpful or harmful. Although there is a genetic link in approximately 15dash​25% of​ cases, it is a risk factor rather than a cause of PD manifestations.

The nurse is assigned to care for a client who experienced a recent fall. Which manifestation indicates that the​ client's hip is​ fractured? A. Complaints of stiffness when transferring to chair B. The affected leg is shorter than the other and turned outward C. Bruising noted to the injured hip and leg D. Discomfort when performing range of motion exercises

Answer: B​ Rationale: The leg of the injured hip is shorter than the uninjured leg and is sometimes turned outward in clients with hip fracture. These clients complain of severe​ pain, not​ discomfort, when flexing and rotating the hip. Bruising noted to the hip and leg may or may not be related to the fall. Complaints of stiffness may be related to the fall or from lying in bed.

The parish health nurse notices a higher incidence of hip fractures in the church community. Which intervention should the nurse implement to help decrease the​ clients' risk of a hip​ fracture? A. Obtain assistive devices B. A walking program C. Periodic home care visits D. Use of medical alert systems

Answer: B​ Rationale: Weight-bearing exercise can decrease an​ individual's risk for hip fractures.​ Therefore, establishing a walking program would benefit the parishioners. Assistive devices would help with gait​ stability, but are not required by every individual. Periodic home care visits can check medication compliance and blood​ pressures, but will not prevent hip fractures. Medical alert systems can signal for help after a fall and fracture have​ occurred, but does not prevent it.

An older adult client was diagnosed with Parkinson disease 3 months ago. Since the​ diagnosis, the client has not gone out of the house. Which statement by the nurse is most​ appropriate? A. "Tell your family to come and take you out of the​ house." B. "Can I ask why you​ aren't going out of the​ house?" C. "You need to start getting​ out." D. ​"Getting out of the house will help you to feel less​ depressed."

Answer: B​Rationale: Asking an​ open-ended question and inquiring about the reason why the client is not going out of the house will encourage the client to discuss and share information. Advising the client about going​ out, telling the client that they will feel better by going​ out, or involving the family will not encourage the client to discuss the reason behind staying at home.

An older adult client with Parkinson disease uses a​ walker, speaks in a slurred manner with poor​ articulation, but tries to speak louder to accommodate for this impairment. The client​ states, "I catch my daughter looking at me angrily​ sometimes, but she​ doesn't say​ anything." Which nursing diagnosis is the priority​? A. Communication: Verbal, Impaired B. Caregiver Role Strain C. ​Falls, Risk for D. Nutrition, Imbalanced: Less than Body Requirements

Answer: B​Rationale: The client is making accommodations for preventing falls by using a walker. Being the primary​ caregiver, the​ client's daughter assists the client in feeding so imbalanced nutrition is not a risk. The client is also practicing speech by speaking louder. It is the​ caregiver's role strain that is the major risk for this client.​

Which information should the nurse include in discharge teaching for a client who had a hip​ arthroplasty? A: "Place an abduction pillow between the legs only at night." B: "Extend the operative leg backward." C: "Use an elevated toilet seat." D: "Restrict motion for 2 weeks."

Answer: C

Which type of therapy is used to manage problems with eating and​ swallowing? A. Physical B. Occupational C. Speech D. Nutritional

Answer: C​ Rationale: Speech therapy is used to manage problems with eating and swallowing. Occupational therapy is used to maintain​ self-care activities, not specifically eating and swallowing. Physical therapy is used to improve coordination of balance and gait. There is no nutritional therapy needed for a client with Parkinson disease.

The nurse is assessing the neurovascular status of a child who is in a hip spica cast for a hip fracture. Which finding indicates the child has good circulation to the affected​ limb? A. Pallor B. Paralysis C. Pain​ 1/10 D. Paresthesia

Answer: C​ Rationale: The nurse should assess the neurovascular status of a client in a spica cast. This includes assessing​ color, temperature, and sensation. A pain level of​ 1/10 indicates good circulation.​ Pallor, paralysis, and paresthesia indicate circulatory deficits and need to be reported to the healthcare provider.

An older adult client sustained a hip fracture secondary to a fall and undergoes an arthroplasty. The client refuses to get out of bed due to pain and fatigue. Which response by the nurse is​ correct? A. "It is okay to rest​ today, but you need to participate​ tomorrow." B. "You have to get out of bed today because the healthcare provider ordered​ it." C. ​"Early ambulation promotes healing and reduces​ complications." D. "We will give you pain medication after you get up and participate in​ therapy."

Answer: C​ Rationale: The nurse should inform the client that getting out of bed the first postoperative day will decrease complications and improve mobility. The nurse would not tell the client it is okay to wait one day. The nurse would not inform the client that they need to get out of bed because the healthcare provider ordered it. This is not therapeutic communication and does not provide information. Pain medication should be administered prior to​ therapy, not after.

The daughter of an older adult client with advancing Parkinson disease tells the nurse that they need to dress their mother each​ morning, because the mother is​ "not fast​ enough." Which is the most appropriate response from the​ nurse? A. "It is important for you to get to work on​ time." B. "Can you let her dress​ herself? C. "It is best for you to let your mother dress herself for as long as she​ can." D. "That is really quite​ normal.

Answer: C​ Rationale: The nurse should tell the caregiver​ that, by allowing independence in​ dressing, the client will have an improved sense of​ well-being and lessened depression. Asking​ closed-ended questions or just remarking that it is normal will not support the​ client's needs.

Which intervention should the nurse include in the plan of care to prevent infection for a client who is recovering from a hip​ replacement? A. Administer anticoagulants as prescribed. B. Remove staples​ 3-5 days after surgery. C. Keep the incision clean and dry. D. Refrain from moving the hip joint.

Answer: C​Rationale: The nurse should keep the incision clean and dry and assess for signs of infection. The client should be encouraged to move the new hip joint to increase mobility. Staples are usually removed​ 10-14 days after surgery. Anticoagulants prevent deep vein​ thromboses, not infection.

The nurse observed a client with Parkinson disease frequently wiping their mouth with a handkerchief. After the nurse requested a prescription for an anticholinergic medication from the healthcare​ provider, the client​ asked, "I feel​ better, why do I need another​ medication?" Which response by the nurse is​ correct? A. "It helps dopamine work​ better." B. ​"It will make you feel​ better." C. "The healthcare provider thinks it will help your​ symptoms." D. "It will help reduce tremors and uncontrolled​ drooling.

Answer: D ​Rationale: The client stated that they are feeling better. It is levodopa and not an anticholinergic that will make dopamine work better. Stating that the healthcare provider thinks it will help with the​ client's symptoms will be an incomplete answer. To give a complete​ response, the nurse would state that an anticholinergic reduces tremors and uncontrolled drooling.

The nurse is caring for a client with Parkinson disease​ (PD) who reports problems with stiffness and the ability to move. Which action by the nurse will address the​ client's mobility? A. Ask the client if they know about the medications to treat the stiffness B. Advise bedrest for muscle recovery C. Tell the client that this is part of the disease process that cannot be stopped D. Recommend a regular exercise routine and walking

Answer: D​ Rationale: The best way to promote mobility in the client with PD is to recommend the client ambulate daily and exercise on a regular basis. Bedrest would only make the stiffness worse. Although there are medications that can help with​ rigidity, it is outside of the​ nurse's scope of practice to recommend medication. Telling the client that this is just part of the disease process is not appropriate or therapeutic.

The nurse is caring for four clients. Which client should the nurse identify as having the highest risk for sustaining a hip fracture if they sustain a​ fall? A. 60-year-old man admitted for treatment of pneumonia B. 80-year-old man admitted for benign prostatic hypertrophy C. ​50-year-old woman with a history of osteoarthritis D. 70-year-old woman who consumes 800 mg​ calcium/day

Answer: D​ Rationale: Women who are postmenopausal and not taking estrogen should consume a minimum of 1500 mg of calcium per day to maintain bone health. The​ 70-year-old woman who only consumes 800 mg of calcium per day is at the highest risk for a hip fracture if she falls. The​ 50-year-old woman may not be postmenopausal and is at a lower​ risk, and the men are at a lower risk.

The nurse is teaching a group of older adults about risk factors related to hip fractures. Which information should the nurse include in the​ presentation? (Select all that​ apply.) A. Arthritis B. Lack of physical activity C. Osteoporosis D. Tobacco use E. Calcium deficiency

Answer: ​B, C, D, E Rationale: Risk factors for hip fractures include lack of physical​ activity; deficiency in calcium or vitamin​ D; tobacco and alcohol​ use; and osteoporosis. Arthritis is not considered a risk factor for hip fractures.

Instruments such as the Functional Activities Questionnaire (FAQ) for postoperative patients who are at home, the Minimum Data Set for Nursing Facility Resident Assessment and Care Screening (MDS) for nursing home patients, the Functional Status Scale (FSS) for children, and the Edmonton Functional Assessment Tool for cancer patients are used to assess activities of daily living (ADLs). The nurse needs to remember that a disadvantage of these instruments includes: A. the measurement of efficacy and reliability of the instruments used to assess activities of daily living (ADLs). B. the variations in assessments and responses may be subjective because of self-reporting of functional activities. C. the instruments do not show a true measure of ability because of a lack of interactivity during the assessments. D. the information contained in the instruments is insufficient to make a determination about functional status in these populations.

B A disadvantage of many of the ADLs and instrumental activities of daily living (IADLs) instruments is the self-reporting of functional activities. Efficacy and reliability are not measured when assessing ADLs and IADLs. Interaction with the patient is necessary to complete the ADL and IADL assessments. The FAQ and FSS are comprehensive tools that can help the nurse determine functional status.

A 59-year-old female patient, who has frontotemporal lobar degeneration, has difficulty with verbal expression. One day she walks out of the house and goes to the gas station to get a soda but does not understand that she needs to pay for it. What is the best thing the nurse can suggest to this patient's husband to keep the patient safe during the day while the husband is at work? A) Assisted living B) Adult day care C) Advance directives D) Monitor for behavioral changes

B) Adult day care Rationale: To keep this patient safe during the day while the husband is at work, an adult day care facility would be the best choice. This patient would not need assisted living. Advance directives are important but are not related to her safety. Monitoring for behavioral changes will not keep her safe during the day.

When providing community health care teaching regarding the early warning signs of Alzheimer's disease, which signs should the nurse advise family members to report (select all that apply)? A) Misplacing car keys B) Losing sense of time C) Difficulty performing familiar tasks D) Problems with performing basic calculations E) Becoming lost in a usually familiar environment

B) Losing sense of time C) Difficulty performing familiar tasks D) Problems with performing basic calculations E) Becoming lost in a usually familiar environment Rationale: Difficulty performing familiar tasks, problems with performing basic calculations, losing sense of time, and becoming lost in a usually familiar environment are all part of the early warning signs of Alzheimer's disease. Misplacing car keys is a normal frustrating event for many people.

The patient has been diagnosed with the mild cognitive impairment stage of Alzheimer's disease. What nursing interventions should the nurse expect to use with this patient? A) Treat disruptive behavior with antipsychotic drugs. B) Use a calendar and family pictures as memory aids. C) Use a writing board to communicate with the patient. D) Use a wander guard mechanism to keep the patient in the area.

B) Use a calendar and family pictures as memory aids. Rationale: The patient with mild cognitive impairment will have problems with memory, language, or another essential cognitive function that is severe enough to be noticeable to others but does not interfere with activities of daily living. A calendar and family pictures for memory aids will help this patient. This patient should not yet have disruptive behavior or get lost easily. Using a writing board will not help this patient with communication.

The nurse is assessing a patient's ability to perform instrumental activities of daily living (IADLs). Which of the following activities are considered in the IADLs assessment? Select all that apply. A. Feeding oneself B. Preparing a meal C. Balancing a checkbook D. Walking E. Toileting F. Grocery shopping

B,C,F IADLs include shopping, meal preparation, housekeeping, doing laundry, managing finances, taking medications, and using transportation. The other activities listed are activities of daily living (ADLs) related to self-care. IADLs are more complex skills that are essential to living in a community.

A nurse is caring for a client who is postoperative. The nurse should base her pain management interventions primarily on which of the following methods of determining the intensity of the clients pain? A. Vital signs B. Client's self-report of pain severity C. Visual observation for nonverbal signs of pain D. Nature and invasiveness of the surgical procedure

B. Because nurses cannot measure pain objectively, it is standard practice to accept that pain is what the client says it is and to intervene accordingly. Pain can affect vital signs, for example, causing tachycardia, but this is not a reliable indicator of pain for all clients at all times. Nonverbal signs, such as grimacing, can indicate pain, but this is not a reliable indicator of pain for all clients at all times. The nature and invasiveness of a surgical procedure is useful for predicting that the client will experience pain, but it does not indicate how severe a client's pain is at any particular time.

A nurse is caring for a client who is receiving heat applications using a aquathermia pad. Which action should the nurse take when applying the pad? A. Set the pad's temperature to 42.2° C (108° F). B. Stop the treatment if the client's skin becomes red. C. Leave the pad in place for at least 40 min. D. Use safety pins to keep the pad in place.

B. Reactions such as unusual pain or redness are indications for removing the pad and notifying the provider. The temperature setting for most aquathermia pads is 40° C (104° F). The heat application should last no longer than 30 min. Safety pins can puncture the pad and cause leakage. The nurse should use gauze or tape to keep the pad in place.

A nurse is caring for a client receiving hydromorphone HCL via PCA oump and reports continuous pain of 6 on a scale of 0 to 10. Which actions should the nurse take first? A. Administer a bolus of medication. B. Check the display on the PCA pump. C. Obtain an order for another pain medication for breakthrough pain. D. Encourage the client to administer a demand dose.

B. The first action the nurse should take using the nursing process is to assess the client; therefore, the nurse should assess the display on the PCA pump to determine the amount of medication administered. Some clients are fearful of developing an addiction to narcotics and may be reluctant to use the PCA. The nurse should administer a bolus of medication to achieve a more rapid desired outcome for pain control; however, there is another action the nurse should take first. The nurse should obtain an order for another pain medication for breakthrough pain if needed; however, there is another action the nurse should take first.. The nurse should encourage the client to administer a demand dose of medication to increase the blood level of medication for pain control; however, there is another action the nurse should take first.

The nurse expects a neurovascular problem based on assessment of A. Exaggerated strength with movement B. Increased edema of limb C. Decreased sensation distal to fracture site D. Purulent draining at site of open fracture

C. Decreased sensation Rationale: Musculoskeletal injuries can cause changes in the neurovascular condition of an injured extremity. The neurovascular assessment consists of peripheral vascular evaluation (e.g., color, temperature, capillary refill, peripheral pulses, and edema) and peripheral neurologic evaluation (e.g., sensation and motor function). Paresthesia and partial or full loss of sensation (paresis or paralysis) may be a sign of neurovascular damage. Pallor, a cool-to-cold extremity, or a delay in capillary refill time below the injury occur with arterial insufficiency. A decreased or absent pulse distal to the injury can indicate vascular dysfunction and insufficiency.

A nurse is applying a cold compress for a client who has pain and minor swelling in a sutured laceration on the forearm. Which of the following assessments should the nurse use to determine whether the treatment is effective? A. Inspect site for reduced swelling B. Monitor client's pulse rate C. Ask client to rate pain D. Have client perform range of motion of affected arm

C. Pain is a subjective experience. The nurse should encourage the client to quantify the pain on a pain scale before, during, and after cold application to determine its effectiveness

A nurse is caring for a client who reports low back pain and asks the nurse for specific exercise recommendations. Which should the nurse suggest? A. Tennis B. Canoeing C. Swimming D. Rowing

C. Some exercises, such as swimming and walking, can help clients who have low back pain because they strengthen back muscles.

A nurse is caring for a client who is postoperative following abdominal surgery and reports incisional pain. The surgeon has prescribed morophine 4 mg IV bolus 6 hr prn. Before administrating the medication, the nurse should complete which priority assessment? A. Blood pressure B. Apical Heart Rate C. Respiratory Rate D. Temperature

C. The priority action the nurse should take when using the airway, breathing, and circulation (ABC) approach to client care is to evaluate the client's respirations. The respiratory rate is especially important because opioid analgesics like morphine can cause respiratory depression.

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

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

A patient with osteoarthritis is scheduled for a total hip arthroplasty. The purpose of this procedure is (select all that apply) A. Fuse the joint B. Replace the joint C. Prevent further damage D. Improve or maintain ROM E. Decrease the amount of destruction in the joint

Correct answers: b, d Rationale: Arthroplasty is the reconstruction or replacement of a joint. This surgical procedure is done to relieve pain, improve or maintain range of motion, and correct deformity. Total hip arthroplasty (THA) provides significant pain relief and improved function for a patient with osteoarthritis (OA).

A family of a patient with Alzheimer's disease asks the nurse what causes this condition? Which response by the nurse would be most appropriate? A. "The numerous drugs that he was taking contributed to his current confusion." B."A specific gene is involved in the development of this disorder." C. "Evidence shows that there are changes in nerve cells and brain chemicals." D. "This condition is most likely due to a stroke that the patient didn't realize he had.

Correct response: "Evidence shows that there are changes in nerve cells and brain chemicals." Explanation: Specific neuropathologic and biochemical changes are found in patients with Alzheimer's disease. These include neurofibrillary tanges and neuritic plaques as well as altered neurotransmitter function, specifically acetylcholine. Vascular dementia is associated with a subclinical stroke. Although genetics is being studied as an underlying mechanism for Alzheimer's disease, no specific gene or gentic marker has been identified. Delirium is often the result of the interaction or use of multiple drugs.

A patient with Alzheimer's disease is prescribed donepezil (Aricept). When teaching the patient and family about this drug, which of the following would the nurse include?" A. This drug will help to stop the disease from getting worse." B. "The drug helps to control the symptoms of the disease." C. "He'll need to take this drug for the rest of his life." D. "Once it becomes effective, you can stop the drug."

Correct response: "The drug helps to control the symptoms of the disease." Explanation: Donepezil is a cholinesterase inhibitor used to control symptoms of Alzheimer's disease. It does not cure or slow progression. Typically cognitive ability improves within 6 to 12 months of therapy, but if stopped, cognitive progression occurs. It is recommended that treatment continue at least through the moderate stage of the illness. However, it usually is not prescribed as life-long therapy.

A health care team is involved in caring for a client with advanced Alzheimer's disease. During a team conference, a newly hired nurse indicates that she has never cared for a client with advanced Alzheimer's disease. Which key point about the disease should the charge nurse include when teaching this nurse? A. The nursing staff should rely on the family to assist with care because family members know the client best. B. As long as the client receives the ordered medication, special care measures aren't necessary. C. Alzheimer's disease affects memory so the client doesn't need an explanation before procedures are performed. D. Clients with Alzheimer's disease are at high risk for injury because of their impaired memory and poor judgment.

Correct response: Clients with Alzheimer's disease are at high risk for injury because of their impaired memory and poor judgment. Explanation: The charge nurse should inform the new nurse that clients with Alzheimer's disease are at high risk for injury because they have impaired memory and poor judgment. Maintaining a safe environment takes top priority. Families are an important part of the client care team; however, they shouldn't be relied upon to deliver care. Family members may take turns sitting with the hospitalized client to help maintain client safety. All procedures should be explained in simple terms that the client can understand. Medications should be administered as ordered; however, they don't typically improve symptoms. Instead, they slow disease progression.

A client with Alzheimer disease becomes agitated while the nurse is attempting to take vital signs. What action by the nurse is most appropriate? A. Document the inability to assess vital signs due to client's agitation. B. Continue taking the vital signs. C. Place the client in a secluded room until calm. D. Distract the client with a familiar object or music.

Correct response: Distract the client with a familiar object or music. Explanation: The nurse should try to calm the patient by using distraction with a familiar object or music. Continuing to take the vital signs will cause further agitation and possible harm to the client or nurse. Placing the client in a secluded room may increase agitation and should not be used in this situation. The nurse should document the inability to assess vital signs and the reason why this should be done after the client's basic needs have been met.

A client has recently brought her elderly mother home to live with her family. The client states that her mother has moderate Alzheimer's disease and asks about appropriate activities for her mother. The nurse tells the client to A. Turn off lights at night so that the mother differentiates night and day. B. Encourage the mother to take responsibility for cooking and cleaning the house. C. Ensure that the mother does not have access to car keys or drive an automobile. D. Allow the mother to smoke cigarettes outside on the porch without supervision.

Correct response: Ensure that the mother does not have access to car keys or drive an automobile. Explanation: A person with Alzheimer's disease needs to be provided with a safe environment. Driving is prohibited. Cooking and cleaning may be too much stimulation and place the client in danger. Daily activities must be simplified, short, and achievable. Smoking is allowed only with supervision. The person needs adequate lighting, and nightlights are helpful, particularly if the person has increased confusion at night.

The plan of care for a patient with advanced Alzheimer's disease includes the nursing diagnosis of risk for injury. The nurse has identified this nursing diagnosis most likely as related to which of the following? A. Personality changes Communication difficulties C. Separation from others D. Impaired memory

Correct response: Impaired memory Explanation: Patients with Alzheimer's disease are at high risk for injury because they have impaired memory and poor judgment. They also exhibit impulsivity, which increases their risk. Maintaining a safe environment takes top priority. Communication difficulties could be the basis for several nursing diagnoses such as impaired verbal communication, powerlessness, and impaired social interaction. Separation from others could lead to social isolation, impaired social interaction, and social isolation. Personality changes may lead to a risk for self- or other directed violence, chronic low self-esteem, and risk for suicide.

A client with moderate Alzheimer's disease has been eating poorly, losing weight, and playing with food at meals. The nurse best intervenes by A. Cutting the client's food into small pieces B. Converting liquid foods to a gelatin texture C. Serving hot foods at a warm temperature D. Placing one food at a time in front of the client during meals

Correct response: Placing one food at a time in front of the client during meals Explanation: Tasks should be simplified for the client with Alzheimer's disease. All options are steps the nurse can take to promote eating for the client with Alzheimer's disease. Offering one food at a time, however, helps to prevent the client from playing with food.

What is a nurse's role in providing home care for a client with Alzheimer disease? A. Provide assistance with administering IV fluids B. Support client with household errands C. Provide emotional and physical support D. Contact the Motor Vehicle Department to have driver's license revoked.

Correct response: Provide emotional and physical support. Explanation: Home health care nurses provide emotional support and intervene if family caregivers become overburdened. The nurse also instructs the family about physical care, the disease process, and treatment. Administering IV fluids or supporting clients with household errands is not a relevant role for a home nurse. The nurse should provide education about safety, saying that the client with Alzheimer disease should not drive, but contacting the licensing department is not the nurse's responsibility.

The nurse is attempting to take vital signs of an older adult hospitalized following knee surgery. The client continuously yells, "It's 1999 and you are going to hurt me!" What action should the nurse do first? A. Reorient the patient B. Take the vital signs C. Notify the physician D. Assess for infection.

Correct response: Reorient the patient. Explanation: The first action that should be taken by the nurse is to reorient the patient. Hospitalized older adults are at risk for disorientation and confusion. Although the nurse will still need to take the vital signs and assess for infection, reorienting the client remains the first action. If the client can be reoriented, then the nurse may be able to complete the other actions without difficulty or potentially harming the client. The nurse may need to notify the physician if the client is unable to be oriented or if the assessment is abnormal.

A client with Alzheimer's disease is admitted for hip surgery after falling and fracturing the right hip. The client's spouse tells the nurse about feeling guilty for letting the accident happen and reports not sleeping well lately because the spouse has been getting up at night and doing odd things. Which nursing diagnosis is most appropriate for the client's spouse? A. Defensive coping related to diagnosis of Alzheimer's disease B. Risk for caregiver role strain related to increased client care needs C. Decisional conflict related to lack of relevant treatment information D. Relocation stress syndrome related to hospitalization

Correct response: Risk for caregiver role strain related to increased client care needs Explanation: The client's spouse is at risk for caregiver role strain because the client has started to exhibit care needs beyond the spouse's capacity to provide. A diagnosis of Relocation stress syndrome may be appropriate for a client with inadequate preparation for hospital admission, transfer, or discharge; however, this client is confused and may be unable to grasp the meaning of such preparation. The spouse, on the other hand, is more likely to be relieved, at least physically, and able to rest because of the client's admission. Defensive coping and Decisional conflict aren't pertinent nursing diagnoses in this situation because the client's spouse is aware of and has accepted the client's disease.

The nurse is caring for a client with late-stage Alzheimer disease. The client's wife states that the client has now become completely dependent and that she feels guilty if she takes any time for herself. What outcomes would be appropriate for the nurse to develop in order to assist the client's wife? A. The caregiver distinguishes essential obligations from those that can be controlled or limited. B. The caregiver prioritizes her own health over that of the client. C. The caregiver leaves the client at home alone for short periods of time to encourage independence. D. The caregiver learns to explain to the client why she needs time for herself.

Correct response: The caregiver distinguishes essential obligations from those that can be controlled or limited. Explanation: For prolonged periods, it is not uncommon for caregivers to neglect their own emotional and health needs. The caregiver must learn to distinguish obligations that she must fulfill and limit those that are not completely necessary. The caregiver can tell the client when she leaves, but she should not expect that the client will remember or will not become angry with her for leaving. The caregiver should not leave the client home alone for any length of time because it may compromise the client's safety. Being thoughtful and selective with her time and energy is not synonymous with prioritizing her own health over than of the client; it is more indicative of balance and sustainability.

A nurse is caring for an elderly adult client admitted to the hospital from a nursing home because of a change in behavior. The client has a diagnosis of Alzheimer's disease and has started to experience episodes of incontinence. The hospital staff is having difficulty with toileting because the client wanders around the unit all day. To assist with elimination, a nurse should: A. ask the physician to order sedation to allow the client to rest. B. Ask the physician to order restraints to prevent wandering C. incorporate the client's toileting schedule into the pattern of his wandering D. have the client wear two briefs at a time to ensure absorption of incontinent urine.

Correct response: incorporate the client's toileting schedule into the pattern of his wandering. Explanation: Incorporating the client's toileting schedule into his wandering assists with elimination and increases the chance of continent episodes. Sedation and restraints will decrease the client's mobility but won't decrease the number of incontinent episodes. Wearing two briefs at a time won't ensure urine absorption and won't address the incontinence issue.

To encourage adequate nutritional intake for a client with Alzheimer's disease, a nurse should: A. give the client privacy during meals B. help the client fill out his menu C. fill out the menu for the client D. stay with the client and encourage him to eat

Correct response: stay with the client and encourage him to eat. Explanation: Staying with the client and encouraging him to feed himself will ensure adequate food intake. A client with Alzheimer's disease can forget how to eat. Allowing privacy during meals, filling out the menu, or helping the client to complete the menu doesn't ensure adequate nutritional intake.

The home care nurse is visiting patients in the community. Which patient is exhibiting an early warning sign of Alzheimer's disease? A) A 65-year-old male does not recognize his family members and close friends. B) A 59-year-old female misplaces her purse and jokes about having memory loss. C) A 79-year-old male is incontinent and not able to perform hygiene independently. D) A 72-year-old female is unable to locate the address where she has lived for 10 years.

D) A 72-year-old female is unable to locate the address where she has lived for 10 years. Rationale: An early warning sign of Alzheimer's disease is disorientation to time and place such as geographic disorientation. Occasionally misplacing items and joking about memory loss are examples of normal forgetfulness. Impaired ability to recognize family and close friends is a clinical manifestation of middle or moderate dementia (or Alzheimer's disease). Incontinence and inability to perform self-care activities are clinical manifestations of severe or late dementia (or Alzheimer's disease).

A nurse is assessing a client prior to the administration of morphine. The nurse should recognize that which of the following assessments is priority? A. Pupil reaction B. Urine output C. Bowel sounds D. Respiratory rate

D. When using the airway, breathing, circulation approach to client care, the nurse should determine the priority assessment is respiratory rate. Morphine can cause respiratory depression. The nurse should withhold the medication and notify the prescriber if the client has a respiratory rate less than 12/min. The nurse should assess the client's pupils because morphine can cause miosis; however, another assessment is the priority. The nurse should assess the client's urine output because morphine can cause urinary retention; however, another assessment is the priority. The nurse should assess the client's bowel sounds because morphine can cause constipation; however, another assessment is the priority.

What is a fracture reduction surgery?

Open reduction internal fixation (ORIF)- "Open reduction" means surgery is needed to realign the bone fracture into the normal position. "Internal fixation" refers to the steel rods, screws, or plates used to keep the bone fracture stable in order to heal the right way and to help prevent infection.

What are some discharge instructions after a hip surgery?

- Ambulatory aids - Raised toilet seat - ADL's - Antibiotic prophylaxis for dental exams - Activation of metal detectors

What are some positive outcomes of an open reduction internal fixation?

- Shorter surgery- Safer - Economical - Early mobility and weight bearing - Weight bearing restriction 6-8 week postop

What are the goals of a joint replacement surgery?

- To relieve pain - Prevent complications - Improve stability - Improve function

Preoperative Nursing Interventions for Hip Fracture?

-Address chronic health issues -Manage muscle spasm and pain-analgesics/muscle relaxants -RICE-Xray, MRI, CT-CBC, PT/INR

The nurse is caring for an 85-year-old woman 6 weeks following a hysterectomy secondary to ovarian cancer. The patient will need chemotherapy and irradiation on an outpatient basis. The nurse should identify and address which barriers to healing? Select all that apply. A. Can feed herself and prepare meals but cannot drive to the store B. Lives on a fixed income and can balance her checkbook C. Experiences stress incontinence D. Cannot participate in activities at the senior center E. Lives alone and has no nearby relatives F. Has no transportation to the oncology clinic

C,E,F The patient will not be able to get treatment if she has no transportation or no relatives that live nearby who can help her with recovery. Stress incontinence increases the risk of falls because of urgency and rushing to get to the bathroom. Income and social abilities are lower priorities during this phase of recovery.

A client at an extended-care facility who has Alzheimer's disease is awake throughout the night. The nurse intervenes with activities that will promote sleep at night, which include: A. Walking the client in the facility yard during the day B. Providing a glass of warm milk for breakfast C. Having the client sit at the nurse's station during night-time hours D. Allowing the client to take a 2-hour nap in the afternoon

Correct response: Walking the client in the facility yard during the day Explanation: Regular exercise during the day will enhance sleep at night for clients with Alzheimer's disease. Another activity that helps for interrupted sleep, inability to fall asleep, or both is drinking warm milk at night. The nurse should discourage excessive sleep during the day. Sitting at the nurse's station may be too stimulating at night-time hours.

A major goal of treatment for the patient with AD is to a. maintain patient safety. b. maintain or increase body weight. c. return to a higher level of self-care. d. enhance functional ability over time.

a. maintain patient safety. Rationale: The overall management goals are that the patient with AD will (1) maintain functional ability for as long as possible, (2) be maintained in a safe environment with a minimum of injuries, (3) have personal care needs met, and (4) have dignity maintained. The nurse should place emphasis on patient safety while planning and providing nursing care.

Which is an outcome for a patient diagnosed with osteoporosis? a) Maintain serum level of calcium. b) Maintain independence with activities of daily living (ADLs). c) Reduce supplemental sources of vitamin D. d) Reverse bone loss through dietary manipulation.

b) Maintain independence with activities of daily living (ADLs). The main goal is to maintain independence in ADLs once osteoporosis is diagnosed. It is best to identify individuals at risk and work toward preventing the disease

Which statement(s) accurately describe(s) mild cognitive impairment (select all that apply)? a. Always progresses to AD b. Caused by variety of factors and may progress to AD c. Should be aggressively treated with acetylcholinesterase drugs d. Caused by vascular infarcts that, if treated, will delay progression to AD e. Patient is usually not aware that there is a problem with his or her memory

b. Caused by variety of factors and may progress to AD Rationale: Although some individuals with mild cognitive impairment (MCI) revert to normal cognitive function or do not go on to develop Alzheimer's disease (AD), those with MCI are at high risk for AD. No drugs have been approved for the treatment of MCI. A person with MCI is often aware of a significant change in memory.

Which region of the hip does an intracapsular hip fracture​ involve? A: The lesser trochanter B: The pelvic bones C: The trochanter region D: The head or neck of the femur within the capsule of the hip joint

nswer: D

A client with a hip fracture has undergone surgery for insertion of a hip prosthesis. Which activity should the nurse instruct the client to​ avoid? A: Using an abductor pillow while lying on the side B: Crossing the legs while sitting C: Sitting on a raised commode D: Sitting on a high chair

Answer: B