Adult health II Exam 1

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? A) 10 to 12 weeks B) 6 to 8 weeks C) 14 to 16 weeks D) 2 to 4 weeks

ANS: 6 to 8 weeks

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? A) Tendon B) Ligament C) Joint D) Cartilage

ANS: A

A client will be receiving a hepatitis B vaccination series prior to employment in a dialysis center. What type of immunity will this provide? A) Artificially acquired active immunity B) Naturally acquired active immunity C) Passive immunity D) Forced immunity

ANS: A

A nurse is answering a call light for a client who reports that their broken arm suddenly hurts. Upon inspecting the arm in the splint, the nurse notes a major increase in swelling. The clients capillary refill is about 5 seconds long. The nurse knows this client is experiencing compartment syndrome and prepares the client for which of the folllwing? A) Fasciotomy B) Reduction of the bones C) Application of a splint D) No treatment

ANS: A

A patient has just been admitted into the ER with a femur fracture. The nurse knows which device will most likely be used for this patient? A) Skeletal traction B) Bucks Traction C) Plaster cast D) Splint

ANS: A

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

ANS: A

hich of the following protective responses begin with the B lymphocytes? A) Humoral B) Cellular C) Recognition D) Phagocytic

ANS: A

Which findings could potentially occur with a paget disease? A) Bone fractures B) Loss of hearing C) Pain D) Increase cranial size E) Bone warmth F) All of the above

ANS: All the above

A patient sustained an open fracture of the femur 24 hours ago. While assessing the patient, the nurse observes the patient is having difficulty breathing, and oxygen saturation decreases to 88% from a previous 99%. What does the nurse understand is likely occurring with this patient? A) Fat emboli B) Delayed Union C) Avascular necrosis D) Cast syndrome

ANS: A Rational: The symptom of Fat Emboi are hypoxia or hypoxemia, Petechia rash, as well as confusion, and lethargy. B) Delayed Union is when 2 broken bones take awhile to heal. C) Avascular necrosis occurs when the bone dies. The main symptom is pain D) This is a Psychological reaction to being in a cast. The main symptoms are hypertension and an increased heart rate

pin site assessment care will be required for Which of the following? A) ORIF B)Bucks traction C) Skeletal traction D) External fixation

ANS: A AND D

A nurse is caring for a client placed in traction to treat a fractured femur. Which nursing intervention has the highest priority? A) Assessing the extremity for neurovascular integrity B) Keeping the client from sliding to the foot of the bed C) Ensuring that the weights hang free at all times D) Keeping the ropes over the center of the pulley

ANS: A) Assessing the extremity for neurovascular integrity Rational: Although all measures are correct, assessing neurovascular integrity takes priority because a decrease in neurovascular integrity could compromise the limb. The pull of the traction must be continuous to keep the client from sliding. Sufficient countertraction must be maintained at all times by keeping the ropes over the center of the pulley. The line of pull is maintained by allowing the weights to hang free.

An experiment is designed to determine specific cell types involved in cell-mediated immune response. The experimenter is interested in finding cells that attack the antigen directly by altering the cell membrane and causing cell lysis. Which cells should be isolated? A) B cells B) Helper T cells C) Cytotoxic T cells D) Macrophages

ANS: C

Which intervention is most important for a patient with osteomalacia? A) Encourage swimming 3 times a week B) Consume 1 glass of wine per day C) Increase exposor to the sun D) Administer bicarbonates

ANS: C

A nurse on an orthopedic unit is doing rounds on her patients. One of her patients who has a full body cast on is complaining of abdominal pain, and extreme gas. Upon further inspection the nurse notices that the patient has decreased bowel sounds. Which of the following complications would the nurse be most worried about regarding the symptoms this patient is reporting? A) Atelectisis B) Urinary stasis infection C) illus D) DvT

ANS: C Rational: This patient is experiencing Superior mesenteric artery syndrom and a long tern side effect of this syndrome is an illus

An important nursing assessment, post fracture, is to evaluate neurovascular status. Therefore, the nurse should check for: A) Shortening and deformity. B) Crepitus. C) Capillary refill. D) Swelling and discoloration.

ANS: C) Capillary refill.

The patient presents to the emergency room with an open fracture of the femur. Which action would the nurse implement to prevent the most serious complication of an open fracture? A) Apply a pressure bandage to decrease tissue damage. B) Immobilize the joint to prevent movement of bone fragments. C) Cover the wound with a sterile dressing to prevent infection. D) Reduce the fracture to prevent additional tissue damage.

ANS: C) Cover the wound with a sterile dressing to prevent infection.

A patient is seen at the urgent care center after falling on the right arm and shoulder. It will be most important for the nurse to determine a. whether there is bruising at the shoulder area. b. whether the right arm is shorter than the left. c. the amount of pain the patient is experiencing. d. how much range of motion (ROM) is present.

ANS: Correct Answer: B Rationale: A shorter limb after a fall indicates a possible dislocation, which is an orthopedic emergency. The nurse will expect bruising and pain at the area, even without an injury that requires surgery. The shoulder should be immobilized until it is evaluated by the health care provider.

Following the application of a hip spica cast for a patient with a fracture of the proximal third of the left femur, an appropriate nursing intervention is to a. use the cast support bar to reposition the patient every 2 to 3 hours. b. ask the patient about any abdominal discomfort or nausea. c. discuss the reasons for remaining on bed rest for several weeks. d. promote drying of the cast by placing the patient in a prone position every 4 hours.

ANS: Correct Answer: B Rationale: Assessment of bowel tones, abdominal pain, and nausea and vomiting will detect the development of cast syndrome. To avoid breakage, the support bar should not be used for repositioning. After the cast dries, the patient can begin ambulating with the assistance of physical therapy personnel. The patient should not be placed in the prone position until the cast has dried to avoid breaking the cast.

A patient arrives in the emergency department with ankle swelling and severe pain after twisting the ankle playing soccer. All of the following orders are written by the health care provider. Which one will the nurse act on first? a. Administer naproxen (Naprosyn) 500 mg PO. b. Wrap the ankle and apply an ice pack. c. Give acetaminophen with codeine (Tylenol #3). d. Take the patient to the radiology department for x-rays.

ANS: Correct Answer: B Rationale: Immediate care after a sprain or strain injury includes the application of cold and compression to the injury to minimize swelling. The other actions should be taken after the ankle is wrapped with a compression bandage and ice is applied.

A patient with lower-leg fractures has an external fixation device in place and is scheduled for discharge. Which information will the nurse include in the discharge teaching? a. "You will need to remain on bed rest until bone healing is complete." b. "The external fixator can be removed during the bath or shower." c. "Prophylactic antibiotics are needed until the external fixator is removed." d. "You will need to assess and clean the pin insertion sites daily."

ANS: Correct Answer: D Rationale: Pin insertion sites should be cleaned daily to decrease the risk for infection at the site. An external fixator allows the patient to be out of bed and avoid the risks of prolonged immobility. The device is surgically placed and is not removed until the bone is stable. Prophylactic antibiotics are not routinely given when an external fixator is used.

Following a motor-vehicle accident, a patient arrives in the emergency department with massive right lower-leg swelling. Which action will the nurse take first? a. Elevate the leg on pillows. b. Apply a compression bandage. c. Place ice packs on the lower leg. d. Check leg pulses and sensation.

ANS: Correct Answer: D Rationale: The initial action by the nurse will be to assess the circulation to the leg and to observe for any evidence of injury such as fractures or dislocations. After the initial assessment, the other actions may be appropriate based on what is observed during the assessment.

A patient with a fractured pelvis is initially treated with bed rest with no turning from side to side permitted. The second day after admission, the patient develops chest pain, tachypnea, and tachycardia. The nurse determines that the patient's symptoms are most likely related to fat embolism when assessment of the patient reveals a. a blood pressure of 100/65 mm Hg. b. anxiety, restlessness, and confusion. c. warm, reddened areas in the calf. d. pinpoint red areas on the upper chest.

ANS: Correct Answer: D Rationale: The presence of petechiae helps distinguish fat embolism from other problems. The other symptoms might occur with fat embolism but could also occur with other postoperative complications such as bleeding, myocardial infarction, venous thrombosis, or hypoxemia.

A nurse is educating a client on prevention of compartment syndrome. What does the nurse need to include? A) Elevation of extremity B) Applying ice C) Avoid heat D) Avoid Compression wrapping

ANS: D

An adult client has had mumps when the client was a child. The client had a titer prior to entering nursing school and shows immunity. What type of immunity does this reflect? A) Artificially acquired active immunity B) Natural passive immunity C) Passive immunity D) Naturally acquired active immunity

ANS: D

Which medication directly inhibits osteoclasts, thereby reducing bone loss and increasing BMD? A) Teriparatide (Forteo) B) Raloxifene (Evista) C) Vitamin D D) Calcitonin (Miacalcin)

ANS: D

A client has a left ulnar fracture. Which of the following findings would concern the nurse? A) Pulses are +1 bilaterally B) No open break in the skin B) Swelling at the break site D) Capillary refill of about 5 seconds.

ANS: D) Capillary refill of about 5 seconds.

A nurse is caring for a client who underwent a total hip replacement. What should the nurse and other caregivers do to prevent dislocation of the new prosthesis? A) Keep the hip flexed by placing pillows under the client's knee. B) Use measures other than turning to prevent pressure ulcers. C) Keep the affected leg in a position of adduction. D)Prevent internal rotation of the affected leg.

ANS: D)Prevent internal rotation of the affected leg.

A client with a right below-the-knee amputation is being transferred from the postanesthesia care unit to a medical-surgical unit. What is the highest priority nursing intervention by the receiving nurse? A) Review the physician's orders for type and frequency of pain medication. B) Delegate the gathering of enough pillows for proper positioning and comfort. C) Document the receiving report from the transferring nurse. D) Ensure that a large tourniquet is in the room.

ANS: Ensure that a large tourniquet is in the room.

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

ANS: Pulmonary embolism

Which of the following foods would you encourage a patients with osteoporosis? A) White bread B) White beans C) White meat of chicken D) White rice

ANS:B

A nurse is caring for a patient who has been put in a full body cast after a car accident. When coming to assess the patients vital signs the patient has a blood pressure of 165/94 and a respiratory rate of 35 breaths a minute and a heart rate of 120 beats per minute. The patient further expresses extreme discomfort. The nurse can assume that the patient is experiencing which of the following complications of being in a full body cast? A) Superior mesenteric artery syndrome B) Compartment Syndrome C) Cast syndrome D) Disuse Syndrome

ANS:C Rational: A) This occurs when the gut slows down because of the cast being in place. Symptoms include: abdominal pain, gas, and decreased bowel moments. B) this occurs when the cast is not allowing the muscle to expand as much as it needs to. The symptoms include extreme pain, palor, parenthesis, paralysis, pulslessness, and Poikilothermic. D) This occurs when there is atrophy from not using the muscle