AH2 Review
A nurse is providing discharge teaching to a client who has osteoarthritis. Which of the following instructions should the nurse include? A. "Rest frequently after periods of activity." B. "Perform your exercises only on days that you feel good." C. "Perform your exercises after applying cold packs to your joints." D. "Place a large pillow under your knees when lying down."
A. "Rest frequently after periods of activity."
A client with a severe electrical burn injury is treated in the burn unit. Which laboratory result would cause the nurse the most concern? A. BUN: 28 mg/dL B. Na+: 145 mEq/L C. K+: 5.0 mEq/L D. Ca: 9 mg/dL
A. BUN: 28 mg/dL - indicate possible renal failure
The nurse is assessing a client's knee. The area has a grating sensation. What would this be documented as? A. Crepitus B. Shortening C. False motion D. Dislocation
A. Crepitus
This type of T lymphocyte is responsible for altering the cell membrane and initiating cellular lysis. Choose the T lymphocyte. A. Cytotoxic T cell B. Helper T cell C. Memory T cell D. Suppressor T cell
A. Cytotoxic - also known as killer T cells, attack the antigen directly and release cytotoxic enzymes and cytokines
Which blood test confirms the presence of antibodies to HIV? A. Enzyme immunoassay (EIA) B. Reverse transcriptase C. p24 antigen D. Erythrocyte sedimentation rate (ESR)
A. Enzyme immunoassay (EIA) - EIA and Western blotting identify and confirm presence of HIV antibodies
A nurse who is contributing to the care of a patient with burns recognizes that the patient's injuries are associated with severe and debilitating pain at nearly all stages of treatment and recovery. What pharmacological intervention is most commonly used in the treatment of burn pain? A. Intravenous morphine B. Oral oxycodone C. Intravenous hydromorphone (Dilaudid) D. Oral codeine
A. IV morphine - it is titrated to obtain pain relief based on client's self-report of pain
Which of the following is the effect of protein catabolism in a client with severe burns? A. It compromises wound healing and immunocompetence. B. It compromises dexterity and mobility. C. It maximizes the risk of sodium retention and hypotension. D. It maximizes the risk of impaired ventilation.
A. It compromises wound healing and immunocompetence.
After teaching a client how to self-administer epinephrine, the nurse determines that the teaching plan has been successful when the client demonstrates which action? A. Jabs the autoinjector into the outer thigh at a 90-degree angle B. Avoids massaging the injection site after administration C. Maintains pressure on the auto-injector for about 30 seconds after insertion D. Pushes down on the grey release cap to administer the medication
A. Jabs the autoinjector into the outer thigh at a 90-degree angle
A client is undergoing photochemotherapy involving a combination of a photosensitizing chemical and ultraviolet light. What health problem does this client most likely have? A. Psoriasis B. Plantar warts C. Undesired tattoo D. Dandruff
A. Psoriasis
Following a burn injury, the nurse determines which area is the priority for nursing assessment? A. Pulmonary system B. Cardiovascular system C. Nutrition D. Pain
A. Pulmonary system
The nurse is caring for a client recovering from a major burn. Burns affect the immune system by causing a loss of large amounts of which of the following? A. Serum, which depletes the body's store of immunoglobulins B. Plasma, which depletes the body's store of calcitonin C. Plasma, which depletes the body's store of catecholamines D. Serum, which depletes the body's store of glucagon
A. Serum, which depletes the body's store of immunoglobulins
A patient has a burn injury that has damaged the epidermis. There are no blisters, and the skin is pink in color. This type of burn injury would be documented as which of the following? A. Superficial B. Deep partial-thickness C. Superficial partial-thickness D. Full-thickness
A. Superficial
The nursing student is learning about the elderly and the instructor is discussing physical changes associated with the aging process. What would the instructor tell the student about common changes in the skin associated with the aging process? A. The elderly have skin atrophy. B. The elderly have increased hair distribution. C. The elderly have decreased xerosis. D. The elderly have thickened skin.
A. The elderly have skin atrophy
The nurse teaches the client who demonstrates herpes zoster (shingles) that? A. the infection results from reactivation of the chickenpox virus. B. a person who has had chickenpox can contract it again upon exposure to a person with shingles. C. once a client has had shingles, they will not have it a second time. D. no known medications affect the course of shingles.
A. The infection results from reactivation of the chickenpox virus
A client with suspected exposure to HIV has been tested with the enzyme-linked immunosorbent assay (ELISA) with positive results twice. The next step for the nurse to explain to the client for confirmation of the diagnosis is to perform a: A. Western blot test for confirmation of diagnosis. B. p24 antigen test for confirmation of diagnosis. C. T4-cell count for confirmation of diagnosis. D. polymerase chain reaction test for confirmation of diagnosis.
A. Western blot test for confirmation of diagnosis
What is the most common cause of anaphylaxis? A. Radiocontrast agent B. Opioids C. Penicillin D. NSAIDs
C Penicillin
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? A. "There may be some slight discrepancy between the measuring tools used." B. "The posture begins to stoop after middle age." C. "After menopause, the body's bone density declines, resulting in a gradual loss of height." D. "After
C. "After menopause, the body's bone density declines, resulting in a gradual loss of height." - loss of estrogen leads to a loss in bone density
A client is experiencing an acute exacerbation of rheumatoid arthritis. What should the nursing priority be? A. Supplying adaptive devices, such as a zipper-pull, easy-to-open beverage cartons, lightweight cups, and unpackaged silverware B. Performing meticulous skin care C. Administering ordered analgesics and monitoring their effects D. Providing comprehensive client teaching; including symptoms of the disorder, treatment options, and expected outcomes
C. Administering ordered analgesics and monitoring their effect - RA can by very painful, pain management is the priority
A nurse is assessing a client who has a fractured left femur and is in skeletal traction. Which of the following findings should the nurse report to the provider? A. Ecchymosis of the thigh B. Serous drainage at the pin site C. Chest petechiae D. Muscle spasms in the left leg
C. Chest petechiae - a sign of fat embolism
The nurse is working in an allergy clinic with a client with tuberculosis. What other reaction is a type IV hypersensitivity disorder? A. atopic dermatitis B. anaphylaxis C. contact dermatitis D. allergic rhinitis
C. Contact dermatitis anaphylaxis, atopic dermatitis, and allergic rhinitis are type 1 reactions
A nurse is assessing a client with Kaposi's sarcoma. What initial sign does the nurse know to look for during assessment? A. Severe joint pain B. Venous stasis and phlebitis formation C. Deep purple cutaneous lesions D. Lymphedema of the lower extremities
C. Deep purple cutaneous lesions
Which group is at the greatest risk for osteoporosis? A. African American women B. Asian American women C. European American women D. Men
C. European American women - small-framed, nonobese European American women are a greatest risk for osteoporosis
Which type of burn injury requires skin grafting? A. Deep partial-thickness B. Superficial C. Full-thickness D. Superficial partial-thickness
C. Full-thickness
The nurse is caring for a client who has sustained severe burns to 50% of the body. The nurse is aware that fluid shifts during the first week of the acute phase of a burn injury cause massive cell destruction. What should the nurse report if it occurs immediately after burn injury? A. Hypernatremia B. Hypokalemia C. Hyperkalemia D. Hypercalcemia
C. Hyperkalemia - results from massive cell destruction
When caring for a client in a prenatal clinic who has history of acne vulgaris, which client medication would the nurse advise against? A. Benzoyl peroxide B. Tazarotene C. Isotretinoin D. Tretinoin
C. Isotretinoin - contraindicated for pregnant females or those who may become pregnant due to the potential of first trimester miscarriages and congenital formations
The nurse is preparing to perform a Wood's light examination. Which of the following would be most important for the nurse to do? A. Protect the patient from the light. B. Apply a special dye to the area. C. Make sure that the room is darkened. D. Obtain samples of the lesion by scraping.
C. Make sure that the room is darkened - to allow visualization of the fluorescent light to differentiate epidermal from dermal lesions
A patient is visiting the physician to determine what type of allergy is causing a rash. What type of testing does the nurse anticipate the physician will schedule? A. Skin scrapings B. Skin biopsy C. Patch test D. Tzanck smear
C. Patch test - involves applying the suspected allergens, such a nickel or fragrances, to normal skin under occlusive patches
A nurse is planning care for a client following a total hip arthroplasty. Which of the following interventions should the nurse include in the plan? A. Position the client with her legs adducted B. Internally rotate the client's affected hip C. Place a pillow between the client's legs D. Instruct the client to avoid flexing her hip more than 95º
C. Place a pillow between the client's legs - to reduce the risk of hip dislocation
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 affected leg in a position of adduction. B. Keep the hip flexed by placing pillows under the client's knee. C. Prevent internal rotation of the affected leg. D. Use measures other than turning to prevent pressure ulcers.
C. Prevent internal rotation of the affected leg.
A patient visits a clinic for assessment of an inflammatory skin disorder. The nurse diagnoses the condition as psoriasis based on the appearance of the skin. Which of the following describes the dermatoses? A. Clear vesicles with a dusky base B. Flat, elongated scales, dark in color C. Red, raised patches of skin covered with silvery scales D. Clusters of pustules with irregular borders
C. Red, raised patches of skin covered with silvery scales
Which statement describes the clinical manifestations of a delayed hypersensitivity (type IV) allergic reaction to latex? A. They may worsen when hand lotion is applied before donning latex gloves. B. They occur within minutes after exposure to latex. C. They are localized to the area of exposure, usually the back of the hands. D. They can be eliminated by changing glove brands or using powder-free gloves.
C. They are localized to the area of exposure, usually the back of the hands. - delayed hypersensitivity reaction are localized to the area of exposure
The nurse is documenting an hourly assessment of a patient who is being treated for full-thickness burns to his lower extremities. Assessment has revealed that the patient's abdominal girth is steadily increasing. This is most likely attributable to what pathophysiological process? A. Bladder distention due to urinary retention B. Presence of free air under the patient's diaphragm C. Third spacing D. Paralytic ileus
C. Third spacing - fluid shifts into the abdominal cavity
Which type of hypersensitivity reaction involves immune complexes forming when antigens bind to antibodies? A. Type I B. Type II C. Type III D. Type IV
C. Type III
The nurse teaches the client with a high risk for osteoporosis about risk-lowering strategies, including which action? A. Increase fiber in the diet B. Decrease the intake of vitamin A and D C. Walk or perform weight-bearing exercises outdoors D. Reduce stress
C. Walk or perform weight-bearing exercises outdoors
A nurse is preparing a community education program about reducing the risk of osteoporosis. Which of the following pieces of information should the nurse include? A. Avoid sun exposure. B. Take a calcium supplement once each day if at risk for osteoporosis. C. Walking is the preferred mode of exercise to maintain strong bones. D. Caffeine intake minimizes the risk of developing osteoporosis.
C. Walking is the preferred mode of exercise to maintain strong bones
A nurse is caring for a client who is scheduled to undergo surgery to repair an open hip fracture. In which of the following positions should the nurse plan to place the client postoperatively? A. With the leg on the affected side adducted B. With the hip externally rotated on the affected side C. With the leg on the affected side abducted D. With the hip flexed to 90° on the affected side
C. With the leg on the affected side abducted
The nurse teaches the client that osteoarthritis A. affects young males. B. Affects the cartilaginous joints of the spine and surrounding tissues. C. is the most common and frequently disabling of joint disorders. D. requires early treatment because most of the damage appears to occur early in the course of the disease.
C. is the most common and frequently disabling of joint disorders
A client asks the nurse how to identify rheumatoid nodules with rheumatoid arthritis. What characteristic will the nurse include? A. reddened B. nonmovable C. located over bony prominence D. tender to the touch
C. located over bony prominence
The older client asks the nurse how best to maintain strong bones. What is the nurse's best response? A. "Weight-bearing exercises can strengthen bones." B. "Range-of-motion exercises build bone mass." C. "Cardio training is the best way to build bones." D. "Weight-resistance exercises can strengthen bones."
A. "Weight-bearing exercises can strengthen bones." -Weight-bearing exercises maintain bone mass. Weight-resistance exercises maintain and strengthen muscles. Cardio training is important for heart health and weight maintenance/reduction. Range-of-motion exercises are essential for joint mobility.
A nurse is caring for a client with a hip fracture who has Buck's extension traction in place. Which of the following pieces of information should the nurse give the client about this type of traction? (Select all that apply.) A. "You'll have considerably less pain with the traction in place." B. "You'll have the traction in place for a week or so." C. "The traction will help decrease muscle spasms." D. "The weights act as a pulling force to keep your leg and hip still." E. "We have to make sure
A. "You'll have considerably less pain with the traction in place." C. "The traction will help decrease muscle spasms." D. "The weights act as a pulling force to keep your leg and hip still."
The palm represents which percentage of a person's TBSA? A. 1% B. 5% C. 15% D. 10%
A. 1%
When assisting the patient to interpret a negative HIV test result, the nurse informs the patient that the results mean which of the following? A. Antibodies to HIV are not present in his blood. B. He has not been infected with HIV. C. He is immune to HIV. D. Antibodies to HIV are present in his blood.
A. Antibodies to HIV are not present in his blood
Which is usually the most important consideration in the decision to initiate antiretroviral therapy? A. CD4+ counts B. Western blotting assay C. ELISA D. HIV RNA
A. CD4+ counts
A nurse is required to monitor the effectiveness of fluid resuscitation in a client who is being treated for burns. Which of the following assessments would indicate the success of the fluid resuscitation? A. The client's heart rate is rapid and regular. B. The client's breathing is unlabored, and skin is clammy. C. The client's urinary output is 0.5 to 1 mL/kg/hour. D. The client is alert and conscious.
C. The client's urinary output is 0.5 to 1 mL/kg/hour.
A nurse is discussing the difference between rheumatoid arthritis (RA) and osteoarthritis with a newly licensed nurse. Which of the following pieces of information should the nurse include about osteoarthritis? A. "Osteoarthritis is caused by autoimmune processes." B. "Osteoarthritis leads to a decreased erythrocyte sedimentation rate." C. "Osteoarthritis affects other organ systems." D. "Osteoarthritis can impair a joint on a single side of the body."
D. "Osteoarthritis can impair a joint on a single side of the body." - OA: unilateral joint involvement - RA: symmetrical joint impairment
A dark-skinned firefighter is admitted to the emergency room with smoke inhalation. An assessment result indicates possible carbon monoxide poisoning. What is the indicator noted on the assessment? A. Dull or yellow-brown shade to his chest B. Ashen gray and dull color to his face C. Purplish tinge to the hands D. Cherry red color to the nail beds, lips, and oral mucosa
D. Cherry red color to the nail beds, lips, and oral mucosa
A patient has a burn injury that has destroyed all of the dermis and extends into the subcutaneous tissue, involving the muscle. This type of burn injury would be documented as which of the following? A. Superficial B. Deep partial-thickness C. Superficial partial-thickness D. Full-thickness
D. Full-thickness
A nurse is assessing a client who is bedridden and was admitted from home. The nurse notes a shallow crater in the epidermis of the client's sacral area. The nurse should document that the client has a pressure ulcer at which of the following stages? A. IV B. I C. III D. II
D. II
After several weeks of antibiotic therapy for the treatment of osteomyelitis, a patient is preparing for discharge. When providing health education related to self-care, the nurse should emphasize which of the following topics? A. The need to avoid ASA and anticoagulants B. The importance of maintaining a healthy diet C. The need to resume normal physical activity as soon as possible D. The importance of adhering to further antibiotic treatment
D. The importance of adhering to further antibiotic treatment
When providing a bath for a patient with a skin disorder, the nurse should do which of the following? A. Use only water to wash and rinse the patient's skin surfaces B. Use a deodorant soap C. Avoid using a towel to dry the patient's skin D. Use a mild soap or a soap substitute
D. Use a mild soap or a soap substitute
A nurse is preparing a discharge teaching plan for a client with atopic dermatitis. Which instruction should the nurse include in the teaching plan? A. Keep the thermostat above 75° F (23.9° C). B. Wear only synthetic fabrics. C. Bathe only three times per week. D. Use a topical skin moisturizer daily.
D. Use a topical skin moisturizer daily
A client is recovering from an attack of gout. What will the nurse include in the client teaching? A. Weight loss will increase uric acid levels and reduce stress on joints. B. Weight loss will reduce purine levels. C. Weight loss will reduce inflammation. D. Weight loss will reduce uric acid levels and reduce stress on joints.
D. Weight loss will reduce uric acid levels and reduce stress on joints.
The occupational health nurse is called to the floor of the factory where a patient has sustained a flash burn to the right arm. The nurse arrives and the flames have been extinguished. The next step is to "cool the burn." How should the nurse cool the burn? A. Apply ice to the site of the burn for 5 to 10 minutes. B. Wrap the patients affected extremity in ice until help arrives. C. Apply an oil-based substance or butter to the burned area until help arrives. D. Wrap cool towels around the
D. Wrap cool towels around the affected extremity intermittently.
A nurse is assessing a client with possible osteoarthritis. What is the most significant risk factor for primary osteoarthritis? A. congenital deformity B. obesity C. trauma D. age
D. age
A client on antiretroviral drug therapy informs the nurse about sometimes forgetting to take the medication for a few days. What should the nurse inform the client can occur when the medications are not taken as prescribed? A. The funding for the medications will cease if the client is not taking the meds correctly. B. The client is risking the development of drug resistance and drug failure. C. The client will have to take the drugs intravenously to ensure compliance. D. The client will have to
B. The client is risking the development of drug resistance and drug failure.
A female patient is sufficiently stable to be transferred from the PACU to the postsurgical unit following her total hip replacement surgery early this morning. When preparing to admit this patient, the nurse on the postsurgical unit should anticipate that the patient will require what positioning? A. Supine with her knees slightly elevated B. With her legs slightly abducted C. In a high Fowler's position with knees elevated D. With a low head-of-bed and with her knees touching each other
B. With her legs slightly abducted
Kaposi sarcoma (KS) is diagnosed through A. skin scraping. B. biopsy. C. computed tomography. D. visual assessment.
B. biopsy
A new patient has come to the dermatology clinic to be assessed for a reddened rash on his abdomen. What diagnostics would be completed to identify the causative allergen? A. Skin biopsy B. Skin scrapings C. Tzanck smear D. Patch testing
D. Patch testing
A nurse is aware that after a burn injury and respiratory difficulties have been managed, the next most urgent need is to: A. Monitor cardiac status. B. Prevent renal shutdown. C. Measure hourly urinary output. D. Replace lost fluids and electrolytes.
D. Replace lost fluids and electrolytes - to prevent irreversible shock by replacing fluids & electrolytes
Which term refers to an injury to ligaments and other soft tissues surrounding a joint? A. Dislocation B. Strain C. Subluxation D. Sprain
D. Sprain
The school nurse is assisting the teacher of a science class and a girl asks where the thickest part of the dermis is. What should the nurse answer? A. The knees B. The elbows C. The scalp D. The palms of the hands
D. The palms of the hands - the dermis is thickest over the palm of the hands and soles of the feet
A client has burns to his anterior trunk and left arm. Using the Rule of the Nines, what is the TBSA burned? A. 18% B. 27% C. 45% D. 36%
B. 27% - anterior trunk = 19% - left arm = 9%
A nurse in a provider's office is caring for a client who has a new diagnosis of herpes zoster. The nurse should anticipate a prescription for which of the following medications? A. Zoster vaccine B. Acyclovir C. Amoxicillin D. Infliximab
B. Acyclovir
What quick assessment technique should the nurse use to assess the percentage of burn injury? A. Check the client's vital signs B. Compare the client's palm with the size of the burn wound C. Observe the color of the client's wound D. Observe the client's level of consciousness
B. Compare the client's palm with the size of the burn wound
A nurse practitioner administers first aid to a patient with a deep partial-thickness burn on his left foot. The nurse describes the skin involvement as the: A. Entire dermis and subcutaneous tissue. B. Epidermis and a portion of deeper dermis. C. Dermis and connective tissue. D. Epidermal layer only.
B. Epidermis and a portion of deeper dermis
A 66-year-old man who originally sought care because of increasing pain in his great toe has subsequently been diagnosed with gout. In addition to pharmacological interventions, what dietary regimen should the nurse recommend to this patient? A. High calcium intake and low fat intake B. High fluid intake and low protein intake C. High simple carbohydrate intake and avoidance of dairy products D. Low complex carbohydrate intake and high potassium intake
B. High fluid intake and low protein intake
The nurse is caring for a patient who sustained a full-thickness burn to his arm when he was scalded with boiling water. How did the nurse determine that the patient's burns are full-thickness burns? A. Not associated with edema formation B. Identification by the destruction of the dermis and epidermis C. Usually very painful because of exposed nerve endings D. Classification by the appearance of blisters
B. Identification by the destruction of the dermis and epidermis
What type of immunoglobulin does the nurse recognize that promotes the release of vasoactive chemicals such as histamine when a client is having an allergic reaction? A. IgA B. IgE C. IgM D. IgG
B. IgE
The nurse assesses the client and observes reddish-purple to dark blue macules, plaques, and nodules. The nurse recognizes that these manifestations are associated with which condition? A. Syphilis B. Kaposi sarcoma C. Allergic reactions D. Platelet disorders
B. Kaposi sarcoma
Which factor inhibits fracture healing? A. Exercise B. Local malignancy C. Vitamin D D. Maximum bone fragment contact
B. Local malignancy - other factors: bone loss, and extensive local trauma
A client with rheumatoid arthritis reports joint pain. What intervention is a priority to assist the client? A. Surgery B. Nonsteroidal anti-inflammatory drugs C. Ice packs D. Opioid therapy
B. NSAIDs - NSAIDs are the mainstay of treatment of RA pain.
A 49-year-old man with a history of poorly controlled type 1 diabetes has developed osteomyelitis adjacent to a chronic diabetic ulcer on his great toe. The patient has been informed that medical treatment for osteomyelitis requires a longer course of antibiotics than most other infections because: A. Osteomyelitis is usually caused by simultaneous infection with several microorganisms, which must be treated sequentially. B. Osteomyelitis involves the active infection of bone tissue, which is la
B. Osteomyelitis involves the active infection of bone tissue, which is largely avascular.
Which is a strategy for lowering risk for osteoporosis? A. Increased age B. Smoking cessation C. Low initial bone mass D. Diet low in calcium and vitamin D
B. Smoking cessation
A nurse is evaluating the laboratory values of a client who is in the resuscitation phase following a major burn. Which of the following laboratory findings should the nurse expect? A. Hemoglobin 10 g/dL B. Sodium 132 mEq/L C. Albumin 3.6 g/dL D. Potassium 4.0 mEq/dL
B. Sodium 132 mEq/L - low sodium level due to because sodium is trapped in interstitial space
