Lewis NCLEX Ch 62 - Musculoskeletal System, Lewis NCLEX Ch 64 Musculoskeletal Problems, 556 Quizzes 1-3, Iggy Neuro Book Questions
During assessment of the patient with trigeminal neuralgia, the nurse should (select all that apply) A. inspect all aspects of the mouth and teeth. B. assess the gag reflex and respiratory rate and depth. C. lightly palpate the affected side of the face for edema. D. test for temperature and sensation perception on the face. E. ask the patient to describe factors that initiate an episode.
A. inspect all aspects of the mouth and teeth. D. test for temperature and sensation perception on the face. E. ask the patient to describe factors that initiate an episode.
The nurse assessing a patient with newly diagnosed trigeminal neuralgia will ask the patient about A. triggers leading to facial discomfort. B. weakness on the affected side of the face. C. visual problems caused by ptosis. D. poor appetite caused by loss of taste.
A. triggers leading to facial discomfort.
The nurse at the clinic is interviewing a 64-year-old woman who is 5 feet, 3 inches tall and weighs 125 pounds (57 kg). The patient has not seen a health care provider for 20 years. She walks 5 miles most days and has a glass of wine 2 or 3 times a week. Which topics will the nurse plan to include in patient teaching about cancer screening and decreasing cancer risk (select all that apply)? A. Sunscreen use B. Tobacco use C. Pap testing D. Colorectal screening E. Mammography
Answer Key: A, C, D, E Feedback: The patient's age, gender, and history indicate a need for screening and/or teaching about colorectal cancer, mammography, Pap smears, and sunscreen. The patient does not use excessive alcohol or tobacco, she is physically active, and her body weight is healthy.
While the nurse is transporting a patient on a stretcher to the radiology department, the patient begins having a tonic-clonic seizure. Which action should the nurse take? A. Insert an oral airway during the seizure to maintain a patent airway. B. Restrain the patient's arms and legs to prevent injury during the seizure. C. Consider time and observe and record the details of the seizure and postictal state. D. Avoid touching the patient to prevent further nervous system stimulation.
Answer Key: C
To prevent autonomic hyperreflexia, which nursing action will the home health nurse include in the plan of care for a patient who has paraplegia at the T4 level ? A. Support selection of a high-protein diet. B. Discuss options for sexuality and fertility. C. Assist in planning a prescribed bowel program. D. Use quad coughing to strengthen cough efforts.
Answer Key: C Feedback: Fecal impaction is a common stimulus for autonomic hyperreflexia. Dietary protein, coughing, and discussing sexuality and fertility should be included in the plan of care but will not reduce the risk for autonomic hyperreflexia.
A patient who had a total hip replacement had an intraoperative hemorrhage 14 hours ago. Which laboratory test result would the nurse expect? A. Hemoglobin of 13.8 g/dL B. Decreased white blood cell (WBC) count C. Elevated reticulocyte count D. Hematocrit of 46%
Answer Key: C Feedback: Hemorrhage causes the release of reticulocytes (immature red blood cells) from the bone marrow into circulation. The hematocrit and hemoglobin levels are normal. The WBC count is not affected by bleeding.
Which intervention should the nurse take with the client recently diagnosed with ALS? A. Discuss a percutaneous gastrostomy tube. B. Explain how a fistula is accessed. C. Provide an advance directive. D. Refer to a PT for leg braces.
Answer Key: C Feedback: It is never too early to discuss advance directives with a client diagnosed with a terminal illness
The nurse notes pallor of the skin and nail beds in a newly admitted patient. The nurse should ensure that which laboratory test has been ordered? A. White blood cell count B. Platelet count C. Hemoglobin level D. Neutrophil count
Answer Key: C Feedback: Pallor of the skin or nail beds is indicative of anemia, which would be indicated by a low Hgb level. Platelet counts indicate a person's clotting ability. A neutrophil is a type of white blood cell that helps to fight infection.
The health care provider's progress note for a patient states that the complete blood count (CBC) shows a "shift to the left." Which assessment finding will the nurse expect? A. Cool extremities B. Pallor and weakness . C. Elevated temperature D. Low oxygen saturation
Answer Key: C Feedback: The term "shift to the left" indicates that the number of immature polymorphonuclear neutrophils (bands) is elevated and that finding is a sign of infection. There is no indication that the patient is at risk for hypoxemia, pallor or weakness, or cool extremities.
A 63-yr-old patient who began experiencing right arm and leg weakness is admitted to the emergency department. In which order will the nurse implement these actions included in the stroke protocol? a. Obtain CT scan without contrast. b. Infuse tissue plasminogen activator (tPA). c. Administer oxygen to keep O2 saturation >95%. d. Use National Institute of Health Stroke Scale to assess patient. A. A, B, C, D. B. B, C, A, D. C. D, C, A, B. D. C, D, A, B.
Answer Key: D
The nurse is reinforcing teaching with a newly diagnosed patient with amyotrophic lateral sclerosis. Which statement would be appropriate to include in the teaching? A. "ALS results from an excess chemical in the brain, and the symptoms can be controlled with medication." B. "Even though the symptoms you are experiencing are severe, most people recover with treatment." C. "You need to consider advance directives now, since you will lose cognitive function as the disease progresses." D. "This is a progressing disease that eventually results in permanent paralysis, though you will not lose any cognitive function."
Answer Key: D Feedback: The disease results in destruction of the motor neurons in the brainstem and spinal cord, causing gradual paralysis. Cognitive function is maintained. Because no cure exists for amyotrophic lateral sclerosis (ALS), interprofessional care is palliative and based on symptom relief. Death often occurs within 2 to 5 years after diagnosis
The nurse reviews the laboratory test results of a patient admitted with abdominal pain. Which information will be most important for the nurse to communicate to the health care provider? A. Monocytes 4% B. Hemoglobin 13.6 g/dL C. Platelet count 168,000/µL D. White blood cell (WBC) count 15,500/µL
Answer Key: D Feedback: The elevation in WBCs indicates that the patient has an inflammatory or infectious process ongoing, which may be the cause of the patient's pain, and that further diagnostic testing is needed. The monocytes are at a normal level. The hemoglobin and platelet counts are normal.
The nurse reviews the laboratory results of a patient who is receiving chemotherapy. Which laboratory result is most important to report to the health care provider? A. Platelets of 95,000/µL B. Hemoglobin of 10 g/L C. Hematocrit of 30% D. White blood cell (WBC) count of 2700/µL
Answer Key: D Feedback: The low WBC count places the patient at risk for severe infection and is an indication that the chemotherapy dose may need to be lower or that WBC growth factors such as filgrastim (Neupogen) are needed. Although the other laboratory data indicate decreased levels, they do not indicate any immediate life-threatening adverse effects of the chemotherapy.
The nurse is caring for a patient who has been diagnosed with stage I cancer of the colon. When assessing the need for psychologic support, which question by the nurse will provide the most information? A. "How long ago were you diagnosed with this cancer?" B. "Are you familiar with the stages of emotional adjustment to a diagnosis like cancer of the colon? C. "Do you have any concerns about body image changes?" D. "Can you tell me what has been helpful to you in the past when coping with stressful events?"
Answer Key: D Feedback: The patient may be at increased risk for colon cancer, but the nurse's first action should be further assessment. The other actions may be appropriate, depending on the information that is obtained from the patient with further questioning.
Which diagnostic test is used to confirm ALS? A. Electromyelogram (EMG) B. Muscle biopsy C. Serum creatinine D. Pulmonary function test
B. Muscle biopsy
The nurse is instructing a client with Parkinson's disease about preventing falls. Which client statement reflects a need for further teaching? A. "I can sit down to put on my pants and shoes." B. "I try to exercise every day and rest when I'm tired." C. "My son removed all loose rugs from my bedroom." D. "I don't need to use my walker to get to the bathroom."
D. "I don't need to use my walker to get to the bathroom."
A 50-year-old patient is reporting a sore shoulder after raking the yard. The nurse should suspect which problem? A. Bursitis B. Fasciitis C. Sprained ligament D. Achilles tendonitis
A. Bursitis Bursitis is common in adults over age 40 and with repetitive motion, such as raking. Plantar fasciitis frequently occurs as a stabbing pain at the heel caused by straining the ligament that supports the arch. Achilles tendonitis is an inflammation of the tendon that attaches the calf muscle to the heel bone, not the shoulder, and causes pain with walking or running. A sprained ligament occurs when a ligament is stretched or torn from a direct injury or sudden twisting of the joint, not repetitive motion.
Which diagnostic test is used to confirm ALS? A. Electromyelogram (EMG) B. Muscle biopsy C. Serum creatinine D. Pulmonary function test
Answer Key: B
A 30 year old patient is admitted with a diagnosis of myasthenia gravis and worsening of symptoms. In taking a history, which of the following complaints would the nurse consider most typical? A. stooped posture, dysphagia, tremor B. numbness, dysphagia, spasticity C. fading voice, dysphagia, exercise intolerance D. Spasticity, incontinence of bladder, auditory problems
Answer Key: C
A 65-yr-old woman was just diagnosed with Parkinson's disease. The priority nursing intervention is A. searching the Internet for educational videos. B. evaluating the home for environmental safety. C. promoting physical exercise and a well-balanced diet. D. designing an exercise program to strengthen and stretch specific muscles.
Answer Key: C
Which nursing diagnosis is a priority in the care of a patient with myasthenia gravis (MG)? A. Acute confusion B. Bowel incontinence C. Activity intolerance D. Disturbed sleep pattern
Answer Key: C Feedback: The primary feature of MG is fluctuating weakness of skeletal muscle. Bowel incontinence and confusion are unlikely signs of MG. Although sleep disturbance is likely, activity intolerance is of primary concern.
Smoking may significantly increase the risk of secondary malignancies True False
Answer Key: True
The nurse is admitting a patient to the nursing unit with a history of a herniated lumbar disc and low back pain. In completing a more thorough pain assessment, the nurse should ask the patient if which action aggravates the pain? A. Bending or lifting B. Application of warm moist heat C. Sleeping in a side-lying position D. Sitting in a fully extended recliner
A. Bending or lifting Back pain that is related to a herniated lumbar disc often is aggravated by events and activities that increase the stress and strain on the spine, such as bending or lifting, coughing, sneezing, and lifting the leg with the knee straight (straight leg-raising test). Application of moist heat, sleeping position, and ability to sit in a fully extended recliner do not aggravate the pain of a herniated lumbar disc.
The nurse is caring for a client diagnosed with Guillain-Barré syndrome. Which assessment findings require nursing action? Select all that apply. A. Blood pressure of 80/42 B. Respiratory rate of 24 C. Shallow breathing pattern D. Peripheral oxygen saturation (SpO2) of 85% E. Diminished breath sounds in all lung fields
A. Blood pressure of 80/42 C. Shallow breathing pattern D. Peripheral oxygen saturation (SpO2) of 85% E. Diminished breath sounds in all lung fields
Which of the following symptoms do you as the nurse expect to see in the patient with primary progressive multiple sclerosis? (Select All that Apply): A. Blurred double vision B. Fatigue C. Diarrhea D. Intention tremors E. Paralytic ileus
A. Blurred double vision B. Fatigue D. Intention tremors
The nurse is caring for a patient hospitalized with exacerbation of chronic bronchitis and herniated lumbar disc. Which breakfast choice would be most appropriate for the nurse to encourage the patient to check on the breakfast menu? A. Bran muffin B. Scrambled eggs C. Puffed rice cereal D. Buttered white toast
A. Bran muffin Each meal should contain one or more sources of fiber, which will reduce the risk of constipation and straining with defecation, which increases back pain. Bran is typically a high-fiber food choice and is appropriate for selection from the menu. Scrambled eggs, puffed rice cereal, and buttered white toast do not have as much fiber.
A 27-year-old patient who has been treated for status epilepticus in the emergency department will be transferred to the medical nursing unit. Which equipment should the nurse have available in the patient's assigned room (select all that apply)? A. Side-rail pads B. Tongue blade C. Oxygen mask D. Suction tubing E. Urinary catheter F. Nasogastric tube
A. side-rail pads C. Oxygen mask D. Suction tubing
The nurse is caring for a client diagnosed with Guillain Barre Syndrome. Which assessment finding requires nursing action? Select all that apply A.Blood pressure of 80/42 B.A respiratory rate of 24 C.A peripheral oxygen saturation of 85% D. Diminished breath sounds in all lung fields
A.Blood pressure of 80/42 C.A peripheral oxygen saturation of 85% D. Diminished breath sounds in all lung fields
Which statement made by the client allows the nurse to recognize whether the client who is receiving brachytherapy for ovarian cancer understands the treatment plan? A. "I will have a radioactive device in my body for a short time." B. "I must be positioned in the same way during each treatment." C. "I will be placed in a semiprivate room for company." D. "I may lose my hair during this treatment."
Answer Key: A Feedback: Brachytherapy refers to short-term insertion of a radiation source.
A patient who has a positive test for human immunodeficiency virus (HIV) antibodies is admitted to the hospital with Pneumocystis jiroveci pneumonia (PCP) and a CD4+ T-cell count of less than 200 cells/microliter. Based on diagnostic criteria established by the Centers for Disease Control and Prevention (CDC), which statement by the nurse is correct? A. "The patient has developed acquired immunodeficiency syndrome (AIDS)." B. "The patient will develop symptomatic HIV infection within 1 year." C. "The patient meets the criteria for a diagnosis of acute HIV infection." D. "The patient will be diagnosed with asymptomatic chronic HIV infection."
Answer Key: A Feedback: Development of PCP meets the diagnostic criteria for AIDS. The other responses indicate earlier stages of HIV infection than is indicated by the PCP infection.
The nurse assessing a patient with newly diagnosed trigeminal neuralgia will ask the patient about A. triggers leading to facial discomfort. B. weakness on the affected side of the face. C. visual problems caused by ptosis. D. poor appetite caused by loss of taste.
Answer Key: A Feedback: The major clinical manifestation of trigeminal neuralgia is severe facial pain triggered by cutaneous stimulation of the nerve. Ptosis, loss of taste, and facial weakness are not characteristics of trigeminal neuralgia.
A patient who is scheduled for a right breast biopsy asks the nurse the difference between a benign tumor and a malignant tumor. Which answer by the nurse is correct? A. "Malignant tumors may spread to other tissues or organs." B. "Benign tumors are likely to recur in the same location." C. "Benign tumors do not cause damage to other tissues." D. "Malignant cells do not cause damage to other tissues than normal cells."
Answer Key: A Feedback: The major difference between benign and malignant tumors is that malignant tumors invade adjacent tissues and spread to distant tissues and benign tumors never metastasize. The other statements are inaccurate. Both types of tumors may cause damage to adjacent tissues. Benign tumors do not usually recur.
After a patient experienced a brief episode of tinnitus, diplopia, and dysarthria with no residual effects, the nurse anticipates teaching the patient about A. oral low-dose aspirin therapy. B. heparin intravenous infusion. C. cerebral aneurysm clipping. D. tissue plasminogen activator (tPA).
Answer Key: A Feedback: The patient's symptoms are consistent with transient ischemic attack (TIA), and drugs that inhibit platelet aggregation are prescribed after a TIA to prevent a stroke. Continuous heparin infusion is not routinely used after TIA or with acute ischemic stroke. The patient's symptoms are not consistent with a cerebral aneurysm. tPA is used only for acute ischemic stroke, not for TIA.
Your patient is scheduled for a lumbar puncture to help diagnose multiple sclerosis. The patient wants clarification about what will be found in the cerebrospinal fluid during the lumbar puncture to confirm the diagnosis of MS. You explain that ____________ may be present in the fluid if MS is present. A. increase in IgG B. high amounts of RBC C. low amounts of WBC D. oblong red blood cells and glucose
Answer Key: A Feedback: Your patient is scheduled for a lumbar puncture to help diagnose multiple sclerosis. The patient wants clarification about what will be found in the cerebrospinal fluid during the lumbar puncture to confirm the diagnosis of MS. You explain that ____________ may be present in the fluid if MS is present.
Priority nursing actions when caring for a hospitalized patient with a new onset temperature of 102.2 degrees F (39 degrees C) and severe neutropenia include (select all that apply) A. administering the prescribed antibiotic STAT. B. taking a full set of vital signs and notifying the physician immediately. C. drawing peripheral and central line blood cultures. D. administering transfusions of WBCs treated to decrease immunogenicity. E. ongoing monitoring of the patient's vital signs for septic shock.
Answer Key: A, B, C, E Feedback: See Evolve for Rationale
Which of the following symptoms do you as the nurse expect to see in the patient with primary progressive multiple sclerosis? (Select All that Apply): A. Blurred double vision B. Fatigue C. Diarrhea D. Intention tremors E. Paralytic ileus
Answer Key: A, B, D
A 27-year-old patient who has been treated for status epilepticus in the emergency department will be transferred to the medical nursing unit. Which equipment should the nurse have available in the patient's assigned room (select all that apply)? A. Side-rail pads B. Tongue blade C. Oxygen mask D. Suction tubing E. Urinary catheter F. Nasogastric tube
Answer Key: A, C, D Feedback: The patient is at risk for further seizures, and oxygen and suctioning may be needed after any seizures to clear the airway and maximize oxygenation. The bed's side rails should be padded to minimize the risk for patient injury during a seizure. Use of tongue blades during a seizure is contraindicated. Insertion of a nasogastric (NG) tube is not indicated because the airway problem is not caused by vomiting or abdominal distention. A urinary catheter is not required unless there is urinary retention.
During assessment of the patient with trigeminal neuralgia, the nurse should (select all that apply) A. inspect all aspects of the mouth and teeth. B. assess the gag reflex and respiratory rate and depth. C. lightly palpate the affected side of the face for edema. D. test for temperature and sensation perception on the face. E. ask the patient to describe factors that initiate an episode.
Answer Key: A, D, E
The nurse has received in report that the client receiving chemotherapy has severe neutropenia. Which of the following does the nurse plan to implement? Select all that apply. A. Assess for fever. B. Do not allow his 16-year-old son to visit. C. Observe for bleeding. D. Do not permit fresh flowers or plants in the room. E. Teach the client to omit raw fruits and vegetables from his diet.
Answer Key: A, D, E Feedback: Any temperature elevation in a client with neutropenia is considered a sign of infection and should be reported immediately. All fruits and vegetables should be cooked well; raw fruits and vegetables may harbor organisms, as well as Flowers and plants. Thrombocytopenia cause bleeding, not low neutrophils.The client is at risk for infection, not the visitors, if they are well. However, very small children, who may get frequent colds and viral infections, may pose a risk.
The nurse includes which of the following in teaching regarding the warning signs of cancer? Select all that apply. A. Scab present for 6 months B. Curdlike vaginal discharge C. Headache D. Axillary swelling E. Persistent constipation
Answer Key: A, D, E Rationale: axillary swelling could be due to swollen lymph, constipation could be colorectal Feedback: Change in bowel habit, A sore that does not heal, A lump or thickening in the breast or elsewhere is a warning signal of cancer.
A 38 year old woman has newly diagnosed Multiple Sclerosis (MS) and asks the nurse what is going to happen to her. The best response by the nurse is: A. " You need to plan for continuous loss of movement, sensory functions and mental capabilities" B. " Most people with MS have periods of attacks and remission, with progressively more nerve damage over time" C. " You will most likely have a steady course of chronic progressive nerve damage that will change your personality" D. " It is common for people with MS to have an acute attack of weakness and then a reversal of MS."
Answer Key: B
Myasthenia gravis occurs when antibodies attack the __________ receptors at the neuromuscular junction leading to ____________. A. metabotropic; muscle weakness B. nicotinic acetylcholine; muscle weakness C. dopaminergic adrenergic; muscle contraction D. nicotinic adrenergic; muscle contraction
Answer Key: B
The complete blood count (CBC) indicates that a patient is thrombocytopenic. Which action should the nurse include in the plan of care? A. Check temperature every 4 hours. B. Avoid intramuscular injections. C. Encourage increased oral fluids. D. Increase intake of iron-rich foods.
Answer Key: B
The nurse assesses a patient with pernicious anemia. Which assessment finding would the nurse expect? A. Yellow-tinged sclerae B. Numbness of the extremities C. Gum bleeding and tenderness D. Shiny, smooth tongue
Answer Key: B
The nurse is admitting a patient who has a neck fracture at the C6 level to the intensive care unit. Which assessment findings indicate neurogenic shock? A. Hyperactive reflexes below the injury B. Hypotension and warm extremities C. Lack of sensation or movement below the injury D. Involuntary and spastic movement
Answer Key: B Feedback: Neurogenic shock is characterized by hypotension, bradycardia, and vasodilation leading to warm skin temperature. Spasticity and hyperactive reflexes do not occur at this stage of spinal cord injury. Lack of movement and sensation indicate spinal cord injury but not neurogenic shock.
A patient with a left-brain stroke suddenly bursts into tears when family members visit. The nurse should A. explain to the family that depression is normal following a stroke. B. teach the family that emotional outbursts are common after strokes. C. use a calm voice to ask the patient to stop the crying behavior. D. have the family members leave the patient alone for a few minutes.
Answer Key: B Feedback: Patients who have left-sided brain stroke are prone to emotional outbursts that are not necessarily related to the emotional state of the patient. Depression after a stroke is common, but the suddenness of the patient's outburst suggests that depression is not the major cause of the behavior. The family should stay with the patient. The crying is not within the patient's control, and asking the patient to stop will lead to embarrassment.
The client receiving chemotherapy will experience the lowest level of bone marrow activity and neutropenia during which period? A. Peak B. Nadir C. Trough D. Adjuvant
Answer Key: B Feedback: The lowest point of bone marrow function is referred to as the nadir. The peak of bone marrow function occurs when the client's blood levels are at their highest.Trough, which means low, is typically used in reference to drug levels.
The nurse will assess a 67-year-old patient who is experiencing a cluster headache for A. nuchal rigidity. B. unilateral ptosis. C. projectile vomiting. D. throbbing, bilateral facial pain.
Answer Key: B Feedback: Unilateral eye edema, tearing, and ptosis are characteristic of cluster headaches. Nuchal rigidity suggests meningeal irritation, such as occurs with meningitis. Although nausea and vomiting may occur with migraine headaches, projectile vomiting is more consistent with increased intracranial pressure (ICP). Unilateral sharp, stabbing pain, rather than throbbing pain, is characteristic of cluster headaches.
A patient you are caring for has just been told that he has ALS. You know that he has a sedentary lifestyle, was a cigarette smoker for 10 years, and has a high stress job. He asks you what he could have done to prevent this disease. Your best response is: A. Smoking and an inactive lifestyle greatly contribute to the disease ALS. B. There is nothing that you could have done to prevent the ALS disease. C. Consistent high stress has been linked to the ALS diagnosis. D. Because your grandfather had ALS, you were likely to get it too.
Answer Key: B Feedback: the most common cause of ALS remains unknown and is currently under study. There is not currently any one known predictor or cause of disease
During your discharge teaching to a patient with multiple sclerosis, you educate the patient on how to avoid increasing symptoms and relapses. You tell the patient to avoid (select all that apply): A. Rest B. Infection C. Overexertion D. High caffeine intake
Answer Key: B, C, D
What is the treatment for Acute Myelogenous Leukemia (AML)? Select all that apply: A. Dialysis B. Chemotherapy C. Stem cell transplant D. Radiation E. Cricothyrotomy
Answer Key: B, C, D
A patient with a T4 spinal cord injury asks the nurse if he will be able to be sexually active. Which initial response by the nurse is best? Incorrect A. Reflex erections frequently occur, but orgasm may not be possible. B. Sildenafil (Viagra) is used by many patients with spinal cord injury. C. Multiple options are available to maintain sexuality after spinal cord injury. D. Penile injection, prostheses, or vacuum suction devices are possible options.
Answer Key: C
The RN is caring for a PT with increased ICP. Which nursing action should be avoided? A. Reposition the patient every two hours. B. Position the patient with the head elevated 30 degrees. C. Suction the airway every two hours per standing orders. D. Provide continuous oxygen as ordered.
Answer Key: C
The client with experiencing status epilepticus is admitted to the intensive care unit Which collaborative intervention should the nurse anticipate? A. Assess the client's neurological status every hour. B. Monitor the client's heart rhythm via telemetry. C. Administer an anticonvulsant medication by IV. D. Prepare to administer a glucocorticosteroid orally.
Answer Key: C
The nurse determines that teaching about management of migraine headaches has been effective when the patient says which of the following? A. "I can take the (Topamax) as soon as a headache starts." B. A glass of wine might help me relax and prevent a headache." C. "I will lie down someplace dark and quiet when the headaches begin." D. "I should avoid taking aspirin and sumatriptan (Imitrex) at the same time."
Answer Key: C
The nurse is caring for a client with Parkinson's disease. Which finding about gait should the nurse expect to note in the client? A. Walking on the toes B. Unsteady and staggering C. Shuffling and propulsive D. Broad-based and waddling
Answer Key: C
What components of the lab results suggest acute leukemia? A. A positive troponin lab B. increased AST, LDL levels C. Multiple myeloblasts specific to AML, WBC count, platelet count, low hematocrit, low hemoglobin D. Elevated BNP, CKMB
Answer Key: C
What is a hallmark feature of Hodgkin's lymphoma A. Downey cells B. Increased number of B cells C. Reed-Sternbery cells from lymph node biopsy D. Chronic cough
Answer Key: C
A male client with a nagging cough makes an appointment to see the physician after reading that this symptom is one of the seven warning signs of cancer. What is another warning sign of cancer? A. Rash B. Chronic ache or pain C. Indigestion D. Persistent nausea
Answer Key: C Feedback: Indigestion, or difficulty swallowing, is one of the seven warning signs of cancer. The other six are a change in bowel or bladder habits, a sore that does not heal, unusual bleeding or discharge, a thickening or lump in the breast or elsewhere, an obvious change in a wart or mole, and a nagging cough or hoarseness. Persistent nausea may signal stomach cancer but isn't one of the seven major warning signs. Rash and chronic ache or pain seldom indicate cancer.
Previous administrations of chemotherapy agents to a cancer patient have resulted in diarrhea. Which of the following dietary modifications should the nurse recommend? A. A diet emphasizing whole and organic foods B. A high-protein, high-calorie diet C. A bland, low-fiber diet D. A diet high in fresh fruits and vegetables
Answer Key: C Feedback: Patients experiencing diarrhea secondary to chemotherapy and/or radiation therapy often benefit from a diet low in seasonings and roughage. Fresh fruits and vegetables are high in fiber and should be minimized during treatment. Whole and organic foods do not prevent diarrhea.
The nurse is caring for a group of patients on a medical unit. After receiving report, which patient should the nurse see first? A. A 42-yr-old patient with multiple sclerosis who was admitted with sepsis. B. A 72-yr-old patient with Parkinson's disease who has aspiration pneumonia C. A 38-yr-old patient with myasthenia gravis who declined prescribed medications D. A 45-yr-old patient with amyotrophic lateral sclerosis who refuses enteral feedings
Answer Key: C Feedback: Patients with myasthenia gravis who discontinue pyridostigmine (Mestinon) will experience myasthenic crisis. Myasthenia crisis results in severe muscle weakness and can lead to a respiratory arrest.
Which finding about a patient with polycythemia vera is most important for the nurse to report to the health care provider? A. Hematocrit 55% B. Presence of plethora C. Calf swelling and pain D. Platelet count 450,000/mL
Answer Key: C Feedback: The calf swelling and pain suggest that the patient may have developed a deep vein thrombosis, which will require diagnosis and treatment to avoid complications such as pulmonary embolus. The other findings will also be reported to the health care provider but are expected in a patient with this diagnosis.
Which of these does the nurse recognize as the goal of palliative surgery for the client with cancer? A. Cure of the cancer B. Prolonging the client's survival time C. Relief of symptoms or improved quality of life D. Allowing other therapies to be more effective
Answer Key: C Feedback: The focus of palliative surgery is to improve quality of life during the survival time.
A chemotherapy drug that causes alopecia is prescribed for a patient. Which action should the nurse take to maintain the patient's self-esteem? A. Tell the patient to limit social contacts until regrowth of the hair occurs. B. Teach the patient to gently wash hair with a mild shampoo to minimize hair loss. C. Encourage the patient to purchase a wig or hat and wear it once hair loss begins. D. Inform the patient that hair usually grows back once the chemotherapy is complete.
Answer Key: C Feedback: The patient is taught to anticipate hair loss and to be prepared with wigs, scarves, or hats. Limiting social contacts is not appropriate at a time when the patient is likely to need a good social support system. The damage occurs at the hair follicle and will occur regardless of gentle washing or use of a mild shampoo. The information that the hair will grow back is not immediately helpful in maintaining the patient's self-esteem
A 35 years old client has been receiving chemotherapy to treat cancer. Which assessment finding suggests that the client has developed stomatitis (inflammation of the mouth)? A. Rust-colored sputum B. White, cottage cheese-like patches on the tongue C. Red, open sores on the oral mucosa D. Yellow tooth discoloration
Answer Key: C Feedback: The tissue-destructive effects of cancer chemotherapy typically cause stomatitis, resulting in ulcers on the oral mucosa that appear as red, open sores. White, cottage cheese-like patches on the tongue suggest a candidal infection, another common adverse effect of chemotherapy. Yellow tooth discoloration may result from antibiotic therapy, not cancer chemotherapy. Rust-colored sputum suggests a respiratory disorder, such as pneumonia.
A patient with left-sided weakness that started 60 minutes earlier is admitted to the emergency department and diagnostic tests are ordered. Which test should be done first? A. 12-Lead electrocardiogram (ECG) B. Chest radiograph (chest x-ray) C. Complete blood count (CBC) D. Computed tomography (CT) scan
Answer Key: D
The nurse is instructing a client with Parkinson's disease about preventing falls. Which client statement reflects a need for further teaching? A. "I can sit down to put on my pants and shoes." B. "I try to exercise every day and rest when I'm tired." C. "My son removed all loose rugs from my bedroom." D. "I don't need to use my walker to get to the bathroom."
Answer Key: D
The nurse will explain to the patient who has a T2 spinal cord transection injury that A. tachycardia is common with this type of injury. B. use of the shoulders will be limited. C. total loss of respiratory function may occur. D. function of both arms should be retained.
Answer Key: D
Which assessment data should the nurse assess in the client diagnosed with Guillain-Barré syndrome? A. An exaggerated startle reflex and memory changes. B. Cogwheel rigidity and inability to initiate voluntary movement. C. Sudden severe unilateral facial pain and inability to chew. D. Progressive ascending paralysis of the lower extremities and numbness.
Answer Key: D
A 72-year-old client recovering from lung cancer surgery asks the nurse to explain how she developed cancer when she has never smoked. Which factor may explain the possible cause? A. A diagnosis of diabetes treated with insulin and diet B. An exercise regimen of jogging 3 miles 4x/wk C. A history of cardiac disease D. Advancing age
Answer Key: D Feedback: Advancing age is the single most important risk factor for cancer. As a person ages, immune protection decreases.
When the nurse is counseling a 60-year-old African-American male client with all of these risk factors for lung cancer, teaching should focus most on which risk factor? A. Gender B. Increased age C. Ethnicity D. Tobacco use
Answer Key: D Feedback: Although all of these are risk factors for lung cancer, the client's tobacco use is the only factor that he can change.
Which nursing action has the highest priority for a patient who was admitted 16 hours earlier with a C5 spinal cord injury? A. Application of pneumatic compression devices to legs B. Cardiac monitoring for bradycardia C. Administration of low-molecular-weight heparin D. Assessment of respiratory rate and effort
Answer Key: D Feedback: Edema around the area of injury may lead to damage above the C4 level, so the highest priority is assessment of the patient's respiratory function. The other actions also are appropriate for preventing deterioration or complications but are not as important as assessment of respiratory effort.
Which stroke risk factor for a 48-yr-old male patient in the clinic is most important for the nurse to address? A. The patient works at a desk and relaxes by watching television. B. The patient is 25 lb above the ideal weight. C. The patient drinks a glass of red wine with dinner daily. D. The patient's usual blood pressure (BP) is 170/94 mm Hg.
Answer Key: D Feedback: Hypertension is the single most important modifiable risk factor. People who drink more than 1 (for women) or 2 (for men) alcoholic beverages a day may increase their risk for hypertension. Physical inactivity and obesity contribute to stroke risk but not as much as hypertension.
A patient who is diagnosed with acquired immunodeficiency syndrome (AIDS) tells the nurse, "I feel obsessed with morbid thoughts about dying." Which response by the nurse is appropriate? A. "Do you think that taking an antidepressant might be helpful?" B. "It is important to focus on the good things about your life now." C. "Thinking about dying will not improve the course of AIDS." D. "Can you tell me more about the thoughts that you are having?"
Answer Key: D Feedback: More assessment of the patient's psychosocial status is needed before taking any other action. The statements, "Thinking about dying will not improve the course of AIDS" and "It is important to focus on the good things in life" or suggesting an antidepressant discourage the patient from sharing any further information with the nurse and decrease the nurse's ability to develop a trusting relationship with the patient.
The RN working on an oncology unit has just received report on these clients. Which client should be assessed first? A. A client with xerostomia associated with laryngeal cancer who needs oral care before breakfast B. A client with lymphoma who will need administration of an antiemetic before receiving chemotherapy C. A client with metastatic breast cancer who is scheduled for external beam radiation in 1 hour D. A client with chemotherapy-induced neutropenia who has just been admitted with an elevated temperature
Answer Key: D Feedback: Neutropenia poses high risk for life-threatening sepsis and septic shock, which develop and progress rapidly in immune suppressed people; the nurse should see this client first.
The nurse administers an IV vesicant chemotherapeutic agent to a patient. Which action is most important for the nurse to take? A. Infuse the medication over a short period of time. B. Hold the medication unless a central venous line is available. C. Administer the chemotherapy through a small-bore catheter. D. Stop the infusion if swelling is observed at the site.
Answer Key: D Feedback: Swelling at the site may indicate extravasation, and the IV should be stopped immediately. The medication generally should be given slowly to avoid irritation of the vein. The size of the catheter is not as important as administration of vesicants into a running IV line to allow dilution of the chemotherapeutic drug. These medications can be given through peripheral lines, although central vascular access devices (CVADs) are preferred.
A patient arrives in the emergency department with hemiparesis and dysarthria that started 2 hours previously, and health records show a history of several transient ischemic attacks (TIAs). The nurse anticipates preparing the patient for A. transluminal angioplasty. B. intravenous heparin drip administration. C. surgical endarterectomy. D. tissue plasminogen activator (tPA) infusion.
Answer Key: D Feedback: The patient's history and clinical manifestations suggest an acute ischemic stroke, and a patient who is seen within 4.5 hours of stroke onset is likely to receive tPA (after screening with a CT scan). Heparin administration in the emergency phase is not indicated. Emergent carotid transluminal angioplasty or endarterectomy is not indicated for the patient who is having an acute ischemic stroke.
A 42-year-old man who is scheduled for an arthrocentesis arrives at the outpatient surgery unit and states, "I do not want this procedure done today." Which response by the nurse is most appropriate? A. "When would you like to reschedule the procedure?" B. "Tell me what your concerns are about this procedure." C. "The procedure is safe, so why should you be worried?" D. "The procedure is not painful because an anesthetic is used."
B. "Tell me what your concerns are about this procedure." The nurse should use therapeutic communication to determine the patient's concern about the procedure. The nurse should not provide false reassurance. It is not appropriate for the nurse to assume the patient is concerned about pain or to assume the patient is asking to reschedule the procedure.
A 57-year-old postmenopausal woman is scheduled for dual-energy x-ray absorptiometry (DXA). Which statement, if made by the patient to the nurse, indicates understanding of the procedure? A. "The bone density in my heel will be measured." B. "This procedure will not cause any pain or discomfort." C. "I will not be exposed to any radiation during the procedure." D. "I will need to remove my hearing aids before the procedure."
B. "This procedure will not cause any pain or discomfort." Dual-energy x-ray absorptiometry (DXA) is painless and measures the bone mass of spine, femur, forearm, and total body with minimal radiation exposure. A quantitative ultrasound (QUS) evaluates density, elasticity, and strength of bone using ultrasound of the calcaneus (heel). Magnetic resonance imaging would require removal of objects such as hearing aids that have metal parts.
During a health screening event which assessment finding would alert the nurse to the possible presence of osteoporosis in a white 61-year-old female? A. The presence of bowed legs B. A measurable loss of height C. Poor appetite and aversion to dairy products D. Development of unstable, wide-gait ambulation
B. A measurable loss of height A gradual but measurable loss of height and the development of kyphosis or "dowager's hump" are indicative of the presence of osteoporosis in which the rate of bone resorption is greater than bone deposition. Bowed legs may be caused by abnormal bone development or rickets but is not indicative of osteoporosis. Lack of calcium and Vitamin D intake may cause osteoporosis but are not indicative it is present. A wide gait is used to support balance and does not indicate osteoporosis.
A female patient with a long-standing history of rheumatoid arthritis has sought care because of increasing stiffness in her right knee that has culminated in complete fixation of the joint. The nurse would document the presence of which problem? A. Atrophy B. Ankylosis C. Crepitation D. Contracture
B. Ankylosis Ankylosis is stiffness or fixation of a joint, whereas contracture is reduced movement as a consequence of fibrosis of soft tissue (muscles, ligaments, or tendons). Atrophy is a flabby appearance of muscle leading to decreased function and tone. Crepitation is a grating or crackling sound that accompanies movement.
The nurse identifies a nursing diagnosis of pain related to muscle spasms for a 45-year-old patient who has low back pain from a herniated lumbar disc. What would be an appropriate nursing intervention to treat this problem? A. Provide gentle ROM to the lower extremities. B. Elevate the head of the bed 20 degrees and flex the knees. C. Place the bed in reverse Trendelenburg with the feet firmly against the footboard. D. Place a small pillow under the patient's upper back to gently flex the lumbar spine.
B. Elevate the head of the bed 20 degrees and flex the knees. The nurse should elevate the head of the bed 20 degrees and flex the knees to avoid extension of the spine and increasing the pain. The slight flexion provided by this position often is comfortable for a patient with a herniated lumbar disc. ROM to the lower extremities will be limited to prevent extremes of spinal movement. Reverse Trendelenburg and a pillow under the patient's upper back will more likely increase pain.
During a client's neurologic assessment, the nurse finds that the client continues to be drowsy but is easily awakened. How does the nurse document this client's level of consciousness? A. Stuporous B. Lethargic C. Comatose D. Alert
B. Lethargic
The nurse is caring for a patient admitted to the nursing unit with osteomyelitis of the tibia. Which symptom will the nurse most likely find on physical examination of the patient? A. Nausea and vomiting B. Localized pain and warmth C. Paresthesia in the affected extremity D. Generalized bone pain throughout the leg
B. Localized pain and warmth Osteomyelitis is an infection of bone and bone marrow that can occur with trauma, surgery, or spread from another part of the body. Because it is an infection, the patient will exhibit typical signs of inflammation and infection, including localized pain and warmth. Nausea and vomiting and paresthesia of the extremity are not expected to occur. Pain occurs, but it is localized, not generalized throughout the leg.
The home care nurse visits an 84-year-old woman with pneumonia after her discharge from the hospital. Which assessment finding would the nurse expect because of age-related changes in the musculoskeletal system? A. Positive straight-leg-raising test B. Muscle strength is scale grade 3/5 C. Lateral S-shaped curvature of the spine D. Fingers drift to the ulnar side of the forearm
B. Muscle strength is scale grade 3/5 Decreased muscle strength is an age-related change of the musculoskeletal system caused by decreased number and size of the muscle cells. The other assessment findings indicate musculoskeletal abnormalities. A positive straight-leg-raising test indicates nerve root irritation from intervertebral disk prolapse and herniation. An ulnar deviation or drift indicates rheumatoid arthritis due to tendon contracture. Scoliosis is a lateral curvature of the spine.
The nurse will assess a 67-year-old patient who is experiencing a cluster headache for A. nuchal rigidity. B. unilateral ptosis. C. projectile vomiting. D. throbbing, bilateral facial pain.
B. unilateral ptosis.
The nurse determines that teaching about management of migraine headaches has been effective when the patient says which of the following? A. "I can take the (Topamax) as soon as a headache starts." B. A glass of wine might help me relax and prevent a headache." C. "I will lie down someplace dark and quiet when the headaches begin." D. "I should avoid taking aspirin and sumatriptan (Imitrex) at the same time."
C. "I will lie down someplace dark and quiet when the headaches begin."
The nurse receives report from the licensed practical nurse about care provided to patients on the orthopedic surgical unit. It is most important for the nurse to follow up on which statement? A. "The patient who had a spinal fusion 12 hours ago has hypoactive bowel sounds and is not passing flatus." B. "The patient who had cervical spine surgery 2 days ago wants to wear her soft cervical collar when out of bed." C. "The patient who had spinal surgery 3 hours ago is complaining of a headache and has clear drainage on the dressing." D. "The patient who had a laminectomy 24 hours ago is using patient-controlled analgesia with morphine for pain management."
C. "The patient who had spinal surgery 3 hours ago is complaining of a headache and has clear drainage on the dressing." After spinal surgery there is potential for cerebrospinal fluid (CSF) leakage. Severe headache or leakage of CSF (clear or slightly yellow) on the dressing should be reported immediately. The drainage is CSF if a dipstick test is positive for glucose. Patients after spinal surgery may experience paralytic ileus and interference with bowel function for several days. Postoperatively most patients require opioids such as morphine IV for 24 to 48 hours. Patient-controlled analgesia is the preferred method for pain management during this time. After cervical spine surgery patients often wear a soft or hard cervical collar to immobilize the neck.
A 54-year-old patient admitted with cellulitis and probable osteomyelitis received an injection of radioisotope at 9:00 AM before a bone scan. The nurse should plan to send the patient for the bone scan at what time? A. 9:30 PM B. 10:00 AM C. 11:00 AM D. 1:00 PM
C. 11:00 AM A technician usually administers a calculated dose of a radioisotope 2 hours before a bone scan. If the patient was injected at 9:00 AM, the procedure should be done at 11:00 AM. 10:00 AM would be too early; 1:00 PM and 9:30 PM would be too late.
The nurse is caring for a group of patients on a medical unit. After receiving report, which patient should the nurse see first? A. A 42-yr-old patient with multiple sclerosis who was admitted with sepsis. B. A 72-yr-old patient with Parkinson's disease who has aspiration pneumonia C. A 38-yr-old patient with myasthenia gravis who declined prescribed medications D. A 45-yr-old patient with amyotrophic lateral sclerosis who refuses enteral feedings
C. A 38-yr-old patient with myasthenia gravis who declined prescribed medications
The nurse determines that dietary teaching for a 75-year-old patient with osteoporosis has been successful when the patient selects which highest-calcium meal? A. Chicken stir-fry with 1 cup each onions and green peas, and 1 cup of steamed rice B. Ham and Swiss cheese sandwich on whole wheat bread, steamed broccoli, and an apple C. A sardine (3 oz) sandwich on whole wheat bread, 1 cup of fruit yogurt, and 1 cup of skim milk D. A two-egg omelet with 2 oz of American cheese, one slice of whole wheat toast, and a half grapefruit
C. A sardine (3 oz) sandwich on whole wheat bread, 1 cup of fruit yogurt, and 1 cup of skim milk The highest calcium content is present in the lunch containing milk and milk products (yogurt) and small fish with bones (sardines). Chicken, onions, green peas, rice, ham, whole wheat bread, broccoli, apple, eggs, and grapefruit each have less than 75 mg of calcium per 100 g of food. Swiss cheese and American cheese have more calcium, but not as much as the sardines, yogurt, and milk.
The nurse is caring for a client with chronic confusion who often yells and screams when touched. Which nursing intervention is most appropriate when caring for this client? A. Provide a large clock and calendar for the patient to read. B. Use removable restraints such as a roll-waist belt to prevent wandering. C. Approach the patient so the nurse can be seen clearly. D. Place the patient in a room close to the nurses' station for frequent observation.
C. Approach the patient so the nurse can be seen clearly.
To prevent autonomic hyperreflexia, which nursing action will the home health nurse include in the plan of care for a patient who has paraplegia at the T4 level ? A. Support selection of a high-protein diet. B. Discuss options for sexuality and fertility. C. Assist in planning a prescribed bowel program. D. Use quad coughing to strengthen cough efforts.
C. Assist in planning a prescribed bowel program.
A 63-year-old woman has been taking prednisone (Deltasone) daily for several years after a kidney transplant to prevent organ rejection. What is most important for the nurse to assess? A. Staggering gait B. Ruptured tendon C. Back or neck pain D. Tardive dyskinesia
C. Back or neck pain Osteoporosis with resultant fractures is a frequent and serious complication of systemic corticosteroid therapy. The ribs and vertebrae are affected the most, and patients should be observed for signs of compression fractures (back and neck pain). Phenytoin (Dilantin) is an antiseizure medication. An adverse effect of phenytoin is an ataxic (or staggering) gait. A rare adverse effect of ciprofloxacin (Cipro) and other fluoroquinolones is tendon rupture, usually of the Achilles tendon. The highest risk is in people age 60 and older and in people taking corticosteroids. Antipsychotics and antidepressants may cause tardive dyskinesia, which is characterized by involuntary movements of the tongue and face.
While the nurse is transporting a patient on a stretcher to the radiology department, the patient begins having a tonic-clonic seizure. Which action should the nurse take? A. Insert an oral airway during the seizure to maintain a patent airway. B. Restrain the patient's arms and legs to prevent injury during the seizure. C. Consider time and observe and record the details of the seizure and postictal state. D. Avoid touching the patient to prevent further nervous system stimulation.
C. Consider time and observe and record the details of the seizure and postictal state.
The nurse is preparing a teaching plan for a client with migraine headaches. Which of these foods or food additives that may trigger a migraine will the nurse include in the teaching? Select all that apply. A. Sugar B. Salt C. Monosodium glutamate (MSG) D. Caffeine E. Wine F. Tyramine
C. Monosodium glutamate (MSG) D. Caffeine E. Wine F. Tyramine
The nurse is caring for a client with Parkinson's disease. Which finding about gait should the nurse expect to note in the client? A. Walking on the toes B. Unsteady and staggering C. Shuffling and propulsive D. Broad-based and waddling
C. Shuffling and propulsive
The RN is caring for a PT with increased ICP. Which nursing action should be avoided? A. Reposition the patient every two hours. B. Position the patient with the head elevated 30 degrees. C. Suction the airway every two hours per standing orders. D. Provide continuous oxygen as ordered.
C. Suction the airway every two hours per standing orders.
When analyzing the cerebrospinal fluid of a pt diagnosed with MS, which of the following results would the healthcare provider anticipate? A. Cloudy with increased turbidity B. Clear with decreased white blood cells C. clear with increased proteins D. pinkish with increased red blood cells.
C. clear with increased proteins.
All of the following are risk factors for Huntington's Disease EXCEPT: A)Dominant inheritance B)Having a parent with HD C)Being 30-50 years of age D)Being of Caucasian descent
D)Being of Caucasian descent
An 82-year-old patient is frustrated by her flabby belly and rigid hips. What should the nurse tell the patient about these frustrations? A. "You should go on a diet and exercise more to feel better about yourself." B. "Something must be wrong with you because you should not have these problems." C. "You have arthritis and need to go on nonsteroidal antiinflammatory drugs (NSAIDs)." D. "Decreased muscle mass and strength and increased hip rigidity are normal changes of aging."
D. "Decreased muscle mass and strength and increased hip rigidity are normal changes of aging." The musculoskeletal system's normal changes of aging include decreased muscle mass and strength; increased rigidity in the hips, neck, shoulders, back, and knees; decreased fine motor dexterity; and slowed reaction times. Going on a diet and exercising will help but not stop these changes. Telling the patient "Something must be wrong with you..." will not be helpful to the patient's frustrations.
Which stroke risk factor for a 48-yr-old male patient in the clinic is most important for the nurse to address? A. The patient works at a desk and relaxes by watching television. B. The patient is 25 lb above the ideal weight. C. The patient drinks a glass of red wine with dinner daily. D. The patient's usual blood pressure (BP) is 170/94 mm Hg.
D. The patient's usual blood pressure (BP) is 170/94 mm Hg.
Which patient has the highest priority? a.A 50-year old man recently diagnosed with ALS who presents crackles upon auscultation. b.A 40-year old woman with ALS who has been on Riluzole (Rilutek) and is experiencing yellowing of the skin. c.A 29 year old admitted a day ago for a 30 feet fall while intoxicated, landing on his buttocks, with a comminuted 3 column burst fracture of the L4 vertebral body. He is scheduled for a Helial CT scan through the upper sacrum w/out contrast. d.A 70 year old patient who has sacral pressure ulcer type II.
a) A 50-year old man recently diagnosed with ALS who presents crackles upon auscultation
A patient with osteomyelitis is treated with surgical debridement with implantation of antibiotic beads. When the patient asks why the beads are used, the nurse answers (select all that apply) a."The beads are used to directly deliver antibiotics to the site of the infection." b."There are no effective oral or IV antibiotics to treat most cases of bone infection." c."This is the safest method of delivering long-term antibiotic therapy for a bone infection." d."The beads are an adjunct to debridement and oral and IV antibiotics for deep infections." e."The ischemia and bone death that occur with osteomyelitis are impenetrable to IV antibiotics."
a."The beads are used to directly deliver antibiotics to the site of the infection." d."The beads are an adjunct to debridement and oral and IV antibiotics for deep infections." Treatment of chronic osteomyelitis includes surgical removal of the poorly vascularized tissue and dead bone and the extended use of IV and oral antibiotics. Antibiotic-impregnated polymethylmethacrylate bead chains may be implanted during surgery to aid in combating the infection.
The increased risk for falls in the older adult is most likely due to a.changes in balance. b.decrease in bone mass. c.loss of ligament elasticity. d.erosion of articular cartilage.
a.changes in balance Aging can cause changes in a person's sense of balance, making the person unsteady, and proprioception may be altered. The risk for falls also increases in older adults partly because of a loss of strength.
A patient with tendonitis asks what the tendon does. The nurse's response is based on the knowledge that tendons a.connect bone to muscle. b.provide strength to muscle. c.lubricate joints with synovial fluid. d.relieve friction between moving parts.
a.connect bone to muscle Tendons are composed of dense, fibrous connective tissue that contains bundles of closely packed collagen fibers arranged in the same plane for additional strength. They connect the muscle sheath to adjacent bone.
While performing passive range of motion for a patient, the nurse puts the ankle joint through the movements of (select all that apply) a.flexion and extension. b.inversion and eversion. c.pronation and supination d.flexion, extension, abduction, and adduction. e.pronation, supination, rotation, and circumduction.
a.flexion and extension. b.inversion and eversion. Common movements that occur at the ankle include inversion, eversion, flexion, and extension.
A normal assessment finding of the musculoskeletal system is a.no deformity or crepitation. b.muscle and bone strength of 4. c.ulnar deviation and subluxation. d.angulation of bone toward midline.
a.no deformity or crepitation Normal physical assessment findings of the musculoskeletal system include normal spinal curvatures; no muscle atrophy or asymmetry; no joint swelling, deformity, or crepitation; no tenderness on palpation of muscles and joints; full range of motion of all joints without pain or laxity; and muscle strength score of 5.
Before discharge from the same-day surgery unit, instruct the patient who has had a surgical correction of bilateral hallux valgus to a.rest frequently with the feet elevated. b.soak the feet in warm water several times a day. c.expect the feet to be numb for the next few days. d.expect continued pain in the feet, since this is not uncommon.
a.rest frequently with the feet elevated. After surgical correction of bilateral hallux valgus, the feet should be elevated with the heel off the bed to help reduce discomfort and prevent edema.
The nurse is reinforcing patient teaching with a newly diagnosed patient with Huntington's Disease. Which statement would be appropriate to include in the teaching? a)"This is a reversible disease, so staying compliant with your drug therapy will help you not lose any cognitive function" b)"Even though the symptoms you are experiencing are severe, there is no cure but drug therapy can help manage symptoms." c) HD etiology is unknown but it could originate from exposure to toxins and viruses"
b)"Even though the symptoms you are experiencing are severe, there is no cure but drug therapy can help manage symptoms."
3. The nurse is assessing a 65-year-old female patient with newly diagnosed trigeminal neuralgia will ask the patient about a. Visual problems caused by ptosis. b. Triggers leading to facial discomfort. c. Poor appetite caused by loss of taste. d. Weakness on the affected side of the face.
b. Triggers leading to facial discomfort.
The nurse is providing nutrition teaching to a patient with Parkinson's. Which statement made by the patient would indicate the need for further instruction by the nurse? a."I should increase my fiber intake" b."I'm going to make sure I get enough fish and beef to ensure I get adequate amounts of Vitamin B6." c."I may need to work with a speech therapist as my disease progresses." d."I will eat 6 small meals a day."
b."I'm going to make sure I get enough fish and beef to ensure I get adequate amounts of Vitamin B6."
A patient has been diagnosed with osteosarcoma of the humerus. He shows an understanding of his treatment options when he states a."I accept that I have to lose my arm with surgery." b."The chemotherapy before surgery will shrink the tumor." c."This tumor is related to the melanoma I had 3 years ago." d."I'm glad they can take out the cancer with such a small scar."
b."The chemotherapy before surgery will shrink the tumor." A patient with osteosarcoma usually has preoperative chemotherapy to decrease tumor size before surgery. As a result, limb-salvage procedures, including a wide surgical resection of the tumor, are being used more often. Osteosarcoma is a primary bone tumor that is extremely aggressive and rapidly metastasizes to distant sites.
You are teaching a patient with osteopenia. What is important to include in the teaching plan? a.Lose weight. b.Stop smoking. c.Eat a high-protein diet. d.Start swimming for exercise
b.Stop smoking. Patients with osteopenia should be instructed to quit smoking in order to decrease loss of bone mass.
In caring for a patient after a spinal fusion, the nurse would immediately report to the physician which patient symptom? a.The patient experiences a single episode of emesis. b.The patient is unable to move the lower extremities. c. The patient is nauseated and has not voided in 4 hours. d. The patient complains of pain at the bone graft donor site.
b.The patient is unable to move the lower extremities. After spinal fusion surgery, the nurse should frequently monitor peripheral neurologic signs. Movement of the arms and legs and assessment of sensation should be unchanged in comparison with the preoperative status. These assessments are usually repeated every 2 to 4 hours during the first 48 hours after surgery, and findings are compared with those of the preoperative assessment. Paresthesias, such as numbness and tingling sensation, may not be relieved immediately after surgery. The nurse should document any new muscle weakness or paresthesias and report this to the surgeon immediately.
A patient is scheduled for an electromyogram (EMG). The nurse explains that this diagnostic test involves a.incision or puncture of the joint capsule. b.insertion of small needles into certain muscles. c.administration of a radioisotope before the procedure. d.placement of skin electrodes to record muscle activity.
b.insertion of small needles into certain muscles Electromyography (EMG) is an evaluation of electrical potential associated with skeletal muscle contraction. Small-gauge needles are inserted into certain muscles and attached to leads that record electrical activity of muscle. Results provide information related to lower motor neuron dysfunction and primary muscle disease
The nurse receives report about a patient diagnosed with Parkinson's Disease. The nurse remembers that the disease is caused by... a.Accumulation of amyloid plaques in brain b.Autoimmune destruction of myelin sheaths in the CNS c.Loss of dopaminergic neurons in the CNS d.Antibody attachment acetylcholine receptors at neuromuscular junction of skeletal muscles
c.Loss of dopaminergic neurons in the CNS
42 year old female presents to the ER with worsening bilateral facial droop,muscle weakness and fatigue. You believe the patient has MG. What complication is MOST important to monitor for? a. Hypotension b. Bradycardia c.Respiratory depression d.Vasoconstriction
c.Respiratory depression
While obtaining subjective assessment data related to the musculoskeletal system, it is particularly important to ask a patient about other medical problems such as a.hypertension. b.thyroid problems. c.diabetes mellitus. d.chronic bronchitis.
c.diabetes mellitus The nurse should question the patient about past medical problems because certain illnesses are known to affect the musculoskeletal system directly or indirectly. These diseases include tuberculosis, poliomyelitis, diabetes mellitus, parathyroid problems, hemophilia, rickets, soft tissue infection, and neuromuscular disabilities.
The bone cells that function in the resorption of bone tissue are called a.osteoids b.osteocytes c.osteoclasts d.osteoblasts
c.osteoclasts Osteoclasts participate in bone remodeling by assisting in the breakdown of bone tissue.
When grading muscle strength, the nurse records a score of 3, which indicates a.no detection of muscular contraction. b.a barely detectable flicker of contraction. c.active movement against full resistance without fatigue. d.active movement against gravity but not against resistance.
d. active movement against gravity but not against resistance Muscle strength score of 3 indicates active movement only against gravity and not against resistance
The nurse is reinforcing teaching with a newly diagnosed patient with amyotrophic lateral sclerosis. Which statement would be appropriate to include in the teaching? a."ALS results from an excess chemical in the brain, and the symptoms can be controlled with medication." b."Even though the symptoms you are experiencing are severe, most people recover with treatment." c."You need to consider advance directives now, since you will lose cognitive function as the disease progresses." d."This is a progressing disease that eventually results in permanent paralysis, though you will not lose any cognitive function."
d."This is a progressing disease that eventually results in permanent paralysis, though you will not lose any cognitive function."
A patient is receiving the anti-parkinson medication Levadopa in the hospital. The nursing instructor would have to intervene if the student nurse caring for the patient did which of the following? a.Takes the patient's blood pressure before administering medication b.Assists the patient from lying down to sitting before standing c.Monitors the patient for any hallucinations d.Gives medication with meals to increase absorption across the blood brain barrier.
d.Gives medication with meals to increase absorption across the blood brain barrier.
To prevent muscle atrophy, the nurse teaches the patient with a leg immobilized in traction to perform (select all that apply) a.flexion contractions. b.tetanic contractions. c.isotonic contractions. d.isometric contractions. e.extension contractions.
d.isometric contractions Isometric contractions increase the tension within a muscle but do not produce movement. Repeated isometric contractions make muscles grow larger and stronger. Muscular atrophy (i.e., decrease in size) occurs with the absence of contraction that results from immobility.
4. The nurse's responsibility for a patient with a suspected disc herniation who is experiencing acute pain and muscle spasms is a.encouraging total bed rest for several days. b.teaching the principles of back strengthening exercises. c.stressing the importance of straight-leg raises to decrease pain. d.promoting the use of cold and hot compresses and pain medication.
d.promoting the use of cold and hot compresses and pain medication. If the acute muscle spasms and accompanying pain are not severe and debilitating, the patient may be treated on an outpatient basis with nonsteroidal antiinflammatory drugs (NSAIDs; e.g., acetaminophen) and muscle relaxants (e.g., cyclobenzaprine [Flexeril]). Massage and back manipulation, acupuncture, and the application of cold and hot compresses may help some patients. Severe pain may necessitate a brief course of opioid analgesics. A brief period (1 to 2 days) of rest at home may be necessary for some people; most patients do better with a continuation of their regular activities. Prolonged bed rest should be avoided. All patients during this time should refrain from activities that aggravate the pain, including lifting, bending, twisting, and prolonged sitting.
Musculoskeletal assessment is an important component of care for patients on what type of long-term therapy? A. Corticosteroids B. β-Adrenergic blockers C. Antiplatelet aggregators D. Calcium-channel blockers
A. Corticosteroids Corticosteroids are associated with avascular necrosis and decreased bone and muscle mass. β-blockers, calcium-channel blockers, and antiplatelet aggregators are not commonly associated with damage to the musculoskeletal system.
The nurse cares for the client being evaluated for Guillain-Barre Syndrome. Which sign is most suggestive of Guillain-Barre Syndrome? A. Ascending paralysis B. Numbness and tingling of the fingers C. Hyperactive reflexes D. Tinnitus
Answer Key: A
Which assessment finding should the nurse caring for a patient with thrombocytopenia communicate immediately to the health care provider? A. The patient is difficult to arouse. B. There are large bruises on the patient's back. C. There are purpura on the oral mucosa. D. The platelet count is 52,000/µL.
Answer Key: A
Which medication does the nurse plan to administer to a client before chemotherapy to decrease the incidence of nausea? A. Ondansetron (Zofran) B. Diazepam (Valium) C. Morphine D. Naloxone (Narcan)
Answer Key: A Feedback: Ondansetron is a 5-HT3 receptor blocker that blocks serotonin to prevent nausea and vomiting. Diazepam is a benzodiazepine, which is an antianxiety medication only. Lorazepam, a benzodiazepine, may be used for nausea. What is Narcan used for?
The nurse is teaching a group of clients about cancers related to tobacco or tobacco smoke. Identify the common cancers related to tobacco use. Select all that apply. A. Cardiac cancer B. Lung cancer C. Cancer of the tongue D. Skin cancer E. Cancer of the larynx
Answer Key: B
Which signs or symptoms should the nurse report immediately because they indicate thrombocytopenia secondary to cancer chemotherapy? Select all that apply. A. Fever B. Bruises C. Petechiae D. Pallor E. Epistaxis
Answer Key: B Feedback: Fever is a sign of infection secondary to neutropenia.Pallor is a sign of anemia.
When caring for a client diagnosed with Guillain-Barre syndrome, which does the nurse identify as the MOST serious complication of this syndrome? A. Urinary retention B. Immobility C. Respiratory failure D. Loss of communication
Answer Key: C
The nurse cares for the client being evaluated for Guillain-Barre Syndrome. Which sign is most suggestive of Guillain-Barre Syndrome? A. Ascending paralysis B. Numbness and tingling of the fingers C. Hyperactive reflexes D. Tinnitus
A. Ascending paralysis
During your discharge teaching to a patient with multiple sclerosis, you educate the patient on how to avoid increasing symptoms and relapses. You tell the patient to avoid (select all that apply): A. Rest B. Infection C. Overexertion D. High caffeine intake
B. Infection C. Overexertion D. High caffeine intake
A 65-yr-old woman was just diagnosed with Parkinson's disease. The priority nursing intervention is A. searching the Internet for educational videos. B. evaluating the home for environmental safety. C. promoting physical exercise and a well-balanced diet. D. designing an exercise program to strengthen and stretch specific muscles.
C. promoting physical exercise and a well-balanced diet.
Which of these assessment findings should the healthcare provider expect to identify as an early clinical characteristic of multiple sclerosis (MS)? A.Muscle atrophy B.Dementia C.Changes in Vision D.Clonus
C.Changes in Vision
When the nurse is planning care for a hospitalized patient who is experiencing an acute episode of trigeminal neuralgia, an appropriate action to include is a. Teach facial and jaw relaxation techniques b. Assess intake and output and dietary intake c. Apply ice packs for no more than 20 minutes d.Spend time at the bedside talking with the patient
B) Assess intake and output and dietary intake
A 30 year old patient is admitted with a diagnosis of myasthenia gravis and worsening of symptoms. In taking a history, which of the following complaints would the nurse consider most typical? A. stooped posture, dysphagia, tremor B. numbness, dysphagia, spasticity C. fading voice, dysphagia, exercise intolerance D. Spasticity, incontinence of bladder, auditory problems
C. fading voice, dysphagia, exercise intolerance
Which priority client problem is the highest priority for the client diagnosed with Guillain Barre Syndrome? 1. High risk for injury. 2. Fear and anxiety. 3. Altered nutrition. 4. Ineffective breathing pattern.
4. Ineffective breathing pattern.
Which individuals would be at high risk for low back pain (select all that apply)? a.A 63-year-old man who is a long-distance truck driver b.A 36-year-old 6 ft, 2 in construction worker who weighs 260 lb c.A 28-year-old female yoga instructor who is 5 ft, 6 in and weighs 130 lb d.A 30-year-old male nurse who works on an orthopedic unit and smokes e.A 44-year-old female chef with prior compression fracture of the spine
A, B, D, E Risk factors associated with low back pain include a lack of muscle tone and excess body weight, stress, poor posture, cigarette smoking, pregnancy, prior compression fractures of the spine, spinal problems since birth, and a family history of back pain. Jobs that require repetitive heavy lifting, vibration (such as a jackhammer operator), and prolonged periods of sitting are also associated with low back pain. Low back pain is most often caused by a musculoskeletal problem. The causes of low back pain of musculoskeletal origin include (1) acute lumbosacral strain, (2) instability of the lumbosacral bony mechanism, (3) osteoarthritis of the lumbosacral vertebrae, (4) degenerative disc disease, and (5) herniation of an intervertebral disc. Health care personnel are at high risk for the development of low back pain. Lifting and moving patients, excessive time being stooped over or leaning forward, and frequent twisting can result in low back pain.
The nurse provides instructions to a 30-year-old female office worker who has low back pain. Which statement by the patient requires an intervention by the nurse? A. "Acupuncture to the lower back would cause irreparable nerve damage." B. "Smoking may aggravate back pain by decreasing blood flow to the spine." C. "Sleeping on my side with knees and hips bent reduces stress on my back." D. "Switching between hot and cold packs provides relief of pain and stiffness."
A. "Acupuncture to the lower back would cause irreparable nerve damage." Acupuncture is a safe therapy when the practitioner has been appropriately trained. Very fine needles are inserted into the skin to stimulate specific anatomic points in the body for therapeutic purposes.
he nurse is teaching a client about taking a new prescription for pyridostigmine. Which statements by the nurse indicate correct information about this drug? Select all that apply. A. "Avoid opioids and other sedating drugs when taking this medication." B. "Report increased mucous secretions and sweating immediately to the primary health care provider." C. "Take the prescribed medication after meals to increase intestinal absorption." D. "Avoid taking antibiotics, especially neomycin, while on this medication." E. "Maintain the exact same dose of this medication every day."
A. "Avoid opioids and other sedating drugs when taking this medication." B. "Report increased mucous secretions and sweating immediately to the primary health care provider." D. "Avoid taking antibiotics, especially neomycin, while on this medication."
The nurse is teaching a client about what to expect during a cerebral angiographic examination. Which statement by the client indicates a need for further teaching? A. "I can't have this test because I am allergic to shellfish." B. "My head will be strapped in place so I don't move." C. "I'll have to keep my leg very still after the procedure." D. "I'll have a temporary dressing on my groin."
A. "I can't have this test because I am allergic to shellfish."
The nurse provides health teaching for a client beginning glatiramer acetate therapy. Which statement by the client indicates a need for additional teaching? A. "I'll take this drug with food every morning." B. "I'll look for signs of skin reaction at the injection site." C. "I'll stay away from kids who have colds." D. "I'll avoid large crowds so I don't get sick."
A. "I'll take this drug with food every morning."
A 54-year-old patient with acute osteomyelitis asks the nurse how this problem will be treated. Which response by the nurse is most appropriate? A. "IV antibiotics are usually required for several weeks." B. "Oral antibiotics are often required for several months." C. "Surgery is almost always necessary to remove the dead tissue that is likely to be present." D. "Drainage of the foot and instillation of antibiotics into the affected area is the usual therapy."
A. "IV antibiotics are usually required for several weeks." The standard treatment for acute osteomyelitis consists of several weeks of IV antibiotic therapy. This is because bone is denser and less vascular than other tissues, and it takes time for the antibiotic therapy to eradicate all of the microorganisms. Surgery may be used for chronic osteomyelitis, which may include debridement of the devitalized and infected tissue and irrigation of the affected bone with antibiotics.
The nurse is teaching a client about self-management measures to help prevent low back pain. Which teaching should be included? Select all that apply. A. "Losing weight can decrease strain on your back." B. "Avoid twisting at your waist." C. "Exercise on a regular basis, including walking." D. "Don't bend at your waist when lifting a heavy object." E. "Eat foods high in calcium and vitamin D to prevent bone loss."
A. "Losing weight can decrease strain on your back." B. "Avoid twisting at your waist." C. "Exercise on a regular basis, including walking." D. "Don't bend at your waist when lifting a heavy object." E. "Eat foods high in calcium and vitamin D to prevent bone loss."
The nurse admits a 55-year-old female with multiple sclerosis to a long-term care facility. Which finding is of most immediate concern to the nurse? A. Ataxic gait B. Radicular pain C. Severe fatigue D. Urinary retention
A. Ataxis gait An ataxic gait is a staggering, uncoordinated gait. Fall risk is the highest in individuals with gait instability or visual or cognitive impairments. The other signs and symptoms (e.g., fatigue, urinary retention, radicular pain) may also occur in the patient with multiple sclerosis and need to be managed, but are not the priority.
Which of the following interventions will the healthcare provider put in place when caring for a patient who has been diagnosed with Huntington's Disease (HD)? Select all that apply. A. Auscultate the patient's lung sounds B. Advise the patient to make position changes slowly C. Advocate for a diet that consists of broths and liquids that help prevent aspiration D. Educate the patient that Isocarboxazid (Marplan) and tetrabenazine (Xenazine) should be taken together 2 hours before bedtime to help alleviate insomnia
A. Auscultate the patient's lung sounds B. Advise the patient to make position changes slowly
When working with patients, the nurse knows that patients have the most difficulties with diarthrodial joints. Which joints are included in this group of joints? (Select all that apply.) A. Hinge joint of the knee B. Ligaments joining the vertebrae C. Fibrous connective tissue of the skull D. Ball and socket joint of the shoulder or hip E. Cartilaginous connective tissue of the pubis joint
A. Hinge joint of the knee D. Ball and socket joint of the shoulder or hip The diarthrodial joints include the hinge joint of the knee and elbow, the ball and socket joint of the shoulder and hip, the pivot joint of the radioulnar joint, and the condyloid, saddle, and gliding joints of the wrist and hand. The ligaments and cartilaginous connective tissue joining the vertebrae and pubis joint and the fibrous connective tissue of the skull are synarthrotic joints.
The nurse is performing a musculoskeletal assessment of an 81-year-old female patient whose mobility has been progressively decreasing in recent months. How should the nurse best assess the patient's range of motion (ROM) in the affected leg? A. Observe the patient's unassisted ROM in the affected leg. B. Perform passive ROM, asking the patient to report any pain. C. Ask the patient to lift progressive weights with the affected leg. D. Move both of the patient's legs from a supine position to full flexion.
A. Observe the patient's unassisted ROM in the affected leg. Passive ROM should be performed with extreme caution and may be best avoided when assessing older patients. Observing the patient's active ROM is more accurate and safe than asking the patient to lift weights with her legs.
A client with a history of seizures is placed on seizure precautions. Which emergency equipment will the nurse provide at the bedside? Select all that apply. A. Oropharyngeal airway B. Oxygen C. Nasogastric tube D. Suction setup E. Padded tongue blade
A. Oropharyngeal airway B. Oxygen D. Suction setup
Which nursing intervention is most appropriate when turning a patient following spinal surgery? A. Placing a pillow between the patient's legs and turning the body as a unit B. Having the patient turn to the side by grasping the side rails to help turn over C. Elevating the head of bed 30 degrees and having the patient extend the legs while turning D. Turning the patient's head and shoulders and then the hips, keeping the patient's body centered in the bed
A. Placing a pillow between the patient's legs and turning the body as a unit Placing a pillow between the legs and turning the patient as a unit (logrolling) helps to keep the spine in good alignment and reduces pain and discomfort following spinal surgery. Having the patient turn by grasping the side rail to help, elevating the head of the bed, and turning with extended legs or turning the patient's head and shoulders and then the hips will not maintain proper spine alignment and may cause damage.
Your patient is scheduled for a lumbar puncture to help diagnose multiple sclerosis. The patient wants clarification about what will be found in the cerebrospinal fluid during the lumbar puncture to confirm the diagnosis of MS. You explain that ____________ may be present in the fluid if MS is present. A. increase in IgG B. high amounts of RBC C. low amounts of WBC D. oblong red blood cells and glucose
A. increase in IgG
After a patient experienced a brief episode of tinnitus, diplopia, and dysarthria with no residual effects, the nurse anticipates teaching the patient about A. oral low-dose aspirin therapy. B. heparin intravenous infusion. C. cerebral aneurysm clipping. D. tissue plasminogen activator (tPA).
A. oral low-dose aspirin therapy.
Which are the following are example of possible skin reactions that occur after Chemotherapy? A. Dry Desquamation B. Wet Desquamation C. Acne Vulgaris D. Contact Dermatitis
Answer Key: A, B
A patient with a stroke experiences facial drooping on the right side and right-sided arm and leg paralysis. When admitting the patient, which clinical manifestation will the nurse expect to find? A. Hyperactive left-sided tendon reflexes B. Right-sided neglect C. Impulsive behavior D. Difficulty comprehending instructions
Answer Key: D
The nurse is preparing to administer Sinemet to a client whose highest blood pressure is 88/50 while lying in bed. What is the nurse's priority action at this time? A. Instruct the client to get out of bed slowly. B. Withhold the drug until contacting the primary health care provider. C. Ask the client about the presence of hallucinations. D. Take the client's apical pulse and temperature.
B. Withhold the drug until contacting the primary health care provider.
A 38 year old woman has newly diagnosed Multiple Sclerosis (MS) and asks the nurse what is going to happen to her. The best response by the nurse is: A. " You need to plan for continuous loss of movement, sensory functions and mental capabilities" B. " Most people with MS have periods of attacks and remission, with progressively more nerve damage over time" C. " You will most likely have a steady course of chronic progressive nerve damage that will change your personality" D. " It is common for people with MS to have an acute attack of weakness and then a reversal of MS."
B. " Most people with MS have periods of attacks and remission, with progressively more nerve damage over time"
A client with early dementia asks the nurse to find her mother, who is deceased. What is the nurse's most appropriate response? A. "We can call her in a little while if you want." B. " Your mother died over 20 years ago." C. "What did your mother look like?" D. "I'll ask your father to find her when he visits."
B. " Your mother died over 20 years ago."
Which statements about stroke prevention indicate a client's understanding of health teaching by the nurse? Select all that apply. A. "I will take aspirin every day." B. "I have decided to stop smoking." C. "I will try to walk at least 30 minutes most days of the week." D. "I need to cut down a lot on my drinking." E. "I'm going to decrease salt in my diet."
B. "I have decided to stop smoking." C. "I will try to walk at least 30 minutes most days of the week." D. "I need to cut down a lot on my drinking." E. "I'm going to decrease salt in my diet."
The nurse is assessing a client who opens both eyes when spoken to, obeys commands, and seems confused during conversation. Which Glasgow Coma Score (GCS) will the nurse document? A. 15 B. 14 C. 11 D. 9
B. 14
The 24-year-old male patient who was successfully treated for Paget's disease has come to the clinic with a gradual onset of pain and swelling around the left knee. The patient is diagnosed with osteosarcoma without metastasis. The patient wants to know why he will be given chemotherapy before the surgery. What is the best rationale the nurse should tell the patient? A. The chemotherapy is being used to save your left leg. B. Chemotherapy is being used to decrease the tumor size. C. The chemotherapy will increase your 5-year survival rate. D. Chemotherapy will help decrease the pain before and after surgery.
B. Chemotherapy is being used to decrease the tumor size. Preoperative chemotherapy is used to decrease tumor size before surgery. The chemotherapy will not save his leg if the lesion is too big or there is neurovascular or muscle involvement. Adjunct chemotherapy after amputation or limb salvage has increased 5-year survival rate in people without metastasis. Chemotherapy is not used to decrease pain before or after surgery.
The nurse is caring for a patient treated with alteplase following a stroke. Which assessment finding is the highest priority for the nurse? A. Client's blood pressure is 144/90. B. Client is having epistaxis. C. Client ate only half of the last meal. D. Client continues to be drowsy.
B. Client is having epistaxis.
A patient shows signs of fatigue, muscle weakness, dysphagia, as well as stiff and clumsy gait. Which diagnostic test(s) will be used to confirm the diagnosis of ALS? Select all that apply. a. EED b. Serum Creatine Kinase c.MRI d. Pulmonary function test e. Electromyography(EMG)
C) MRI E) EMG
The nurse assesses an older adult with a diagnosis of severe, late-stage Alzheimer's disease. Which assessment findings would the nurse expect for this client? Select all that apply. A. Acute confusion B. Hallucinations C. Wandering D. Urinary incontinence E. Difficulty eating
B. Hallucinations D. Urinary incontinence E. Difficulty eating
The nurse performs an initial assessment on an older client. Which assessment findings would the nurse expect to be the result of normal physiologic aging? Select all that apply. A. Confusion B. Hearing loss C. Decerebrate positioning D. Slurred speech E. Constipation F. Urinary incontinence
B. Hearing loss E. Constipation
The nurse is admitting a patient who has a neck fracture at the C6 level to the intensive care unit. Which assessment findings indicate neurogenic shock? A. Hyperactive reflexes below the injury B. Hypotension and warm extremities C. Lack of sensation or movement below the injury D. Involuntary and spastic movement
B. Hypotension and warm extremities
The client diagnosed with Guillain Barre Syndrome is on a ventilator. Which intervention will assist the client to communicate with the nursing staff? A. Provide an erase slate board for the client to write on B. Instruct the client to blink once for "no" and twice for "yes." C. Refer to a speech therapist to help with communication. D. Leave the call light within easy reach of the client.
B. Instruct the client to blink once for "no" and twice for "yes.
A client returns from the postanesthesia care unit (PACU) after a surgical removal of a brainstem tumor. In what position will the nurse place the client at this time? A. Turn the patient from side to side to prevent aspiration. B. Keep the client flat in bed or up 10 degrees and reposition from side to side. C. Elevate the head of the bed to at least 30 degrees at all times. D. Keep the client in a sitting position in bed at all times.
B. Keep the client flat in bed or up 10 degrees and reposition from side to side.
In reviewing bone remodeling, what should the nurse know about the involvement of bone cells? A. Osteoclasts add canaliculi. B. Osteoblasts deposit new bone. C. Osteocytes are mature bone cells. D. Osteons create a dense bone structure.
B. Osteoblasts deposit new bone. Bone remodeling is achieved when osteoclasts remove old bone and osteoblasts deposit new bone. Osteocytes are mature bone cells, and osteons or Haversian systems create a dense bone structure, but these are not involved with bone remodeling.
A nurse is caring for a client who has a hard cervical collar for a complete cervical spinal cord injury. Which assessment finding will the nurse report to the primary health care provider? A. Purulent drainage from the pin sites on the client's forehead B. Painful pressure injury under the collar C. Inability to move legs or feet D. Oxygen saturation of 95% on room air
B. Painful pressure injury under the collar
A patient you are caring for has just been told that he has ALS. You know that he has a sedentary lifestyle, was a cigarette smoker for 10 years, and has a high stress job. He asks you what he could have done to prevent this disease. Your best response is: A. Smoking and an inactive lifestyle greatly contribute to the disease ALS. B. There is nothing that you could have done to prevent the ALS disease. C. Consistent high stress has been linked to the ALS diagnosis. D. Because your grandfather had ALS, you were likely to get it too.
B. There is nothing that you could have done to prevent the ALS disease.
The nurse is planning health promotion teaching for a 45-year-old patient with asthma, low back pain from herniated lumbar disc, and schizophrenia. What does the nurse determine would be the best exercise to include in an individualized exercise plan for the patient? A. Yoga B. Walking C. Calisthenics D. Weight lifting
B. Walking The patient would benefit from an aerobic exercise that takes into account the patient's health status and fits the patient's lifestyle. The best exercise is walking, which builds strength in the back and leg muscles without putting undue pressure or strain on the spine. Yoga, calisthenics, and weight lifting would all put pressure on or strain the spine.
Myasthenia gravis occurs when antibodies attack the __________ receptors at the neuromuscular junction leading to ____________. A. metabotropic; muscle weakness B. nicotinic acetylcholine; muscle weakness C. dopaminergic adrenergic; muscle contraction D. nicotinic adrenergic; muscle contraction
B. nicotinic acetylcholine; muscle weakness
A patient with a left-brain stroke suddenly bursts into tears when family members visit. The nurse should A. explain to the family that depression is normal following a stroke. B. teach the family that emotional outbursts are common after strokes. C. use a calm voice to ask the patient to stop the crying behavior. D. have the family members leave the patient alone for a few minutes.
B. teach the family that emotional outbursts are common after strokes.
The nurse is admitting a patient who complains of a new onset of lower back pain. To differentiate between the pain of a lumbar herniated disc and lower back pain from other causes, what would be 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 or stabbing or burning or aching?" C. "Does the pain radiate down the buttock or into the leg?" D. "Is the pain totally relieved by analgesics, such as acetaminophen (Tylenol)?"
C. "Does the pain radiate down the buttock or into the leg?" Lower back pain associated with a herniated lumbar disc is accompanied by radiation along the sciatic nerve and can be commonly 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 family member asks the nurse about whether there would be any long-term psychological effects from a client's mild traumatic brain injury. What is the nurse's best response? A. "You need to talk with the client's primary health care provider." B. "Usually any effects last for only a few weeks or months." C. "Each person's reaction to brain injury is different." D. "You should expect a change in the client's personality.
C. "Each person's reaction to brain injury is different."
The nurse has reviewed proper body mechanics with a patient with a history of low back pain caused by a herniated lumbar disc. Which statement made by the patient indicates a need for further teaching? A. "I should sleep on my side or back with my hips and knees bent." B. "I should exercise at least 15 minutes every morning and evening." C. "I should pick up items by leaning forward without bending my knees." D. "I should try to keep one foot on a stool whenever I have to stand for a period of time."
C. "I should pick up items by leaning forward without bending my knees." The patient should avoid leaning forward without bending the knees. Bending the knees helps to prevent lower back strain and is part of proper body mechanics when lifting. Sleeping on the side or back with hips and knees bent and standing with a foot on a stool will decrease lower back strain. Back strengthening exercises are done twice a day once symptoms subside.
The nurse is caring for patients in a primary care clinic. Which individual is most at risk to develop osteomyelitis caused by Staphylococcus aureus? A. 22-year-old female with gonorrhea who is an IV drug user B. 48-year-old male with muscular dystrophy and acute bronchitis C. 32-year-old male with type 1 diabetes mellitus and a stage IV pressure ulcer D. 68-year-old female with hypertension who had a knee arthroplasty 3 years ago
C. 32-year-old male with type 1 diabetes mellitus and a stage IV pressure ulcer Osteomyelitis caused by Staphylococcus aureus is usually associated with a pressure ulcer or vascular insufficiency related to diabetes mellitus. Osteomyelitis caused by Staphylococcus epidermidis is usually associated with indwelling prosthetic devices such as joint replacements. Osteomyelitis caused by Neisseria gonorrhoeae is usually associated with gonorrhea. Osteomyelitis caused by Pseudomonas is usually associated with IV drug use. Muscular dystrophy is not associated with osteomyelitis.
A patient with a T4 spinal cord injury asks the nurse if he will be able to be sexually active. Which initial response by the nurse is best? A. Reflex erections frequently occur, but orgasm may not be possible. B. Sildenafil (Viagra) is used by many patients with spinal cord injury. C. Multiple options are available to maintain sexuality after spinal cord injury. D. Penile injection, prostheses, or vacuum suction devices are possible options.
C. Multiple options are available to maintain sexuality after spinal cord injury.
Which nursing diagnosis is a priority in the care of a patient with myasthenia gravis (MG)? A. Acute confusion B. Bowel incontinence C. Activity intolerance D. Disturbed sleep pattern
C. Activity intolerance
The client with experiencing status epilepticus is admitted to the intensive care unitWhich collaborative intervention should the nurse anticipate? A. Assess the client's neurological status every hour. B. Monitor the client's heart rhythm via telemetry. C. Administer an anticonvulsant medication by IV. D. Prepare to administer a glucocorticosteroid orally.
C. Administer an anticonvulsant medication by IV.
When assessing a patient diagnosed with multiple sclerosis (MS), which of the following would require immediate action by the healthcare provider? A. Paresthesia and tremor B.Nystagmus and diplopia C. Dysphagia and congested cough D. Fatigue and depression
C. Dysphagia and congested cough
Which intervention should the nurse take with the client recently diagnosed with ALS? A. Discuss a percutaneous gastrostomy tube. B. Explain how a fistula is accessed. C. Provide an advance directive. D. Refer to a PT for leg braces.
C. Provide an advance directive.
The nurse is caring for a client with expressive (Broca's) aphasia. Which nursing intervention is appropriate for communicating with the client? A. Refer the client to the speech-language pathologist. B. Speak loudly to help the client interpret what is being said. C. Provide pictures to help the client communicate. D. Ask the client to read messages on a white board.
C. Provide pictures to help the client communicate.
When caring for a client diagnosed with Guillain-Barre syndrome, which does the nurse identify as the MOST serious complication of this syndrome?A. Urinary retention B. Immobility C. Respiratory failure D. Loss of communication
C. Respiratory failure
The nurse prepares to administer IV ibandronate (Boniva) to a 67-year-old woman with osteoporosis. What is a priority laboratory assessment to make before the administration of ibandronate? A. Serum calcium B. Serum creatinine C. Serum phosphate D. Serum alkaline phosphatase
C. Serum phosphate Ibandronate is a bisphosphonate that is administered IV every 3 months and is administered slowly over 15 to 30 seconds to prevent renal damage. Ibandronate should not be used by patients taking other nephrotoxic drugs or by those with severe renal impairment (defined as serum creatinine above 2.3 mg/dL or creatinine clearance less than 30 mL/min).
2. Bell's palsy is associated with infection by which of the following pathogens? A)Herpes simplex 1 B) Herpes zoster C) Epstein Barr virus D) All of these are correct
D) All of these are correct
A 63-yr-old patient who began experiencing right arm and leg weakness is admitted to the emergency department. In which order will the nurse implement these actions included in the stroke protocol? a. Obtain CT scan without contrast. b. Infuse tissue plasminogen activator (tPA). c. Administer oxygen to keep O2 saturation >95%. d. Use National Institute of Health Stroke Scale to assess patient. A. A, B, C, D. B. B, C, A, D. C. D, C, A, B. D. C, D, A, B.
D) C, D, A, B.
The nurse is reinforcing teaching with a newly diagnosed patient with amyotrophic lateralsclerosis. Which statement would be appropriate to include in the teaching? A. "ALS results from an excess chemical in the brain, and the symptoms can be controlled with medication." B. "Even though the symptoms you are experiencing are severe, most people recover with treatment." C. "You need to consider advance directives now, since you will lose cognitive function as the disease progresses." D. "This is a progressing disease that eventually results in permanent paralysis, though you will not lose any cognitive function."
D. "This is a progressing disease that eventually results in permanent paralysis, though you will not lose any cognitive function."
Which nursing action has the highest priority for a patient who was admitted 16 hours earlier with a C5 spinal cord injury? A. Application of pneumatic compression devices to legs B. Cardiac monitoring for bradycardia C. Administration of low-molecular-weight heparin D. Assessment of respiratory rate and effort
D. Assessment of respiratory rate and effort
A patient with left-sided weakness that started 60 minutes earlier is admitted to the emergency department and diagnostic tests are ordered. Which test should be done first?A. 12-Lead electrocardiogram (ECG) B. Chest radiograph (chest x-ray) C. Complete blood count (CBC) D. Computed tomography (CT) scan
D. Computed tomography (CT) scan
A patient with a stroke experiences facial drooping on the right side and right-sided arm and leg paralysis. When admitting the patient, which clinical manifestation will the nurse expect to find? A. Hyperactive left-sided tendon reflexes B. Right-sided neglect C. Impulsive behavior D. Difficulty comprehending instructions
D. Difficulty comprehending instructions
The nurse is reinforcing health teaching about osteoporosis with a 72-year-old patient admitted to the hospital. In reviewing this disorder, what should the nurse explain to the patient? A. With a family history of osteoporosis, there is no way to prevent or slow bone resorption. B. Continuous, low-dose corticosteroid treatment is effective in stopping the course of osteoporosis. C. Estrogen therapy must be maintained to prevent rapid progression of the osteoporosis. D. Even with a family history of osteoporosis, the calcium loss from bones can be slowed by increased calcium intake and exercise.
D. Even with a family history of osteoporosis, the calcium loss from bones can be slowed by increased calcium intake and exercise. The rate of progression of osteoporosis can be slowed if the patient takes calcium supplements and/or foods high in calcium and engages in regular weight-bearing exercise. Corticosteroids interfere with bone metabolism. Estrogen therapy is no longer used to prevent osteoporosis because of the associated increased risk of heart disease and breast and uterine cancer.
The nurse cares for a 58-year-old woman with breast cancer who is admitted for severe back pain related to a compression fracture. The patient's laboratory values include serum potassium of 4.5 mEq/L, serum sodium of 144 mEq/L, and serum calcium of 14.3 mg/dL. Which signs and symptoms will the nurse expect the patient to exhibit? A. Anxiety, irregular pulse, and weakness B. Muscle stiffness, dysphagia, and dyspnea C. Hyperactive reflexes, tremors, and seizures D. Nausea, vomiting, and altered mental status
D. Nausea, vomiting, and altered mental status Breast cancer can metastasize to the bone. Vertebrae are a common site. Pathologic fractures at the site of metastasis are common because of a weakening of the involved bone. High serum calcium levels result as calcium is released from damaged bones. Normal serum calcium is between 8.6 to 10.2 mg/dL. Clinical manifestations of hypercalcemia include nausea, vomiting, and altered mental status (e.g., lethargy, decreased memory, confusion, personality changes, psychosis, stupor, coma). Other manifestations include weakness, depressed reflexes, anorexia, bone pain, fractures, polyuria, dehydration, and nephrolithiasis. Manifestations of hypomagnesemia include hyperactive reflexes, tremors, and seizures. Symptoms of hyperkalemia include anxiety, irregular pulse, and weakness. Symptoms of hypocalcemia include muscle stiffness, dysphagia, and dyspnea.
A 67-year-old patient hospitalized with osteomyelitis has an order for bed rest with bathroom privileges with the affected foot elevated on two pillows. The nurse would place highest priority on which intervention? A. Ambulate the patient to the bathroom every 2 hours. B. Ask the patient about preferred activities to relieve boredom. C. Allow the patient to dangle legs at the bedside every 2 to 4 hours. D. Perform frequent position changes and range-of-motion exercises.
D. Perform frequent position changes and range-of-motion exercises. The patient is at risk for atelectasis of the lungs and for contractures because of prescribed bed rest. For this reason, the nurse should place the priority on changing the patient's position frequently to promote lung expansion and performing range-of-motion (ROM) exercises to prevent contractures. Assisting the patient to the bathroom will keep the patient safe as the patient is in pain, but it may not be needed every 2 hours. Providing activities to relieve boredom will assist the patient to cope with the bed rest, and dangling the legs every 2 to 4 hours may be too painful. The priority is position changes and ROM exercises.
A client who sustained a recent cervical spinal cord injury reports feeling flushed. The client's blood pressure is 180/100. What is the nurse's best action at this time? A. Perform a bladder assessment. B. Insert an indwelling urinary catheter. C. Turn on a fan to cool the patient. D. Place the patient in a sitting position.
D. Place the patient in a sitting position.
Which assessment data should the nurse assess in the client diagnosed with Guillain-Barré syndrome? A. An exaggerated startle reflex and memory changes. B. Cogwheel rigidity and inability to initiate voluntary movement. C. Sudden severe unilateral facial pain and inability to chew. D. Progressive ascending paralysis of the lower extremities and numbness.
D. Progressive ascending paralysis of the lower extremities and numbness.
When the patient is diagnosed with muscular dystrophy, what information should the nurse include in the teaching about this disorder? A. Prolonged bed rest will be used to decrease fatigue. B. An orthotic jacket will limit mobility and may contribute to deformity. C. Continuous positive airway pressure will be used to facilitate sleeping. D. Remain active to prevent skin breakdown and respiratory complications.
D. Remain active to prevent skin breakdown and respiratory complications. With muscular dystrophy, it is important for the patient to remain active for as long as possible. Prolonged bed rest should be avoided because immobility leads to further muscle wasting. An orthotic jacket may be used to provide stability and prevent further deformity. Continuous positive airway pressure (CPAP) is used as respiratory function decreases, before mechanical ventilation is needed to sustain respiratory function.
The nurse is caring for a client with trigeminal neuralgia. Which patient problem is the priority for the nurse? A. Facial twitching B. Problems with communication C. Ptosis and diplopia D. Severe facial pain
D. Severe facial pain
A 54-year-old patient is about to have a bone scan. In teaching the patient about this procedure, the nurse should include what information? A. Two additional follow-up scans will be required. B. There will be only mild pain associated with the procedure. C. The procedure takes approximately 15 to 30 minutes to complete. D. The patient will be asked to drink increased fluids after the procedure.
D. The patient will be asked to drink increased fluids after the procedure. Patients are asked to drink increased fluids after a bone scan to aid in excretion of the radioisotope, if not contraindicated by another condition. No follow-up scans and no pain are associated with bone scans that take 1 hour of lying supine.
The nurse will explain to the patient who has a T2 spinal cord transection injury that A. tachycardia is common with this type of injury. B. use of the shoulders will be limited. C. total loss of respiratory function may occur. D. function of both arms should be retained.
D. function of both arms should be retained.
A patient arrives in the emergency department with hemiparesis and dysarthria that started 2 hours previously, and health records show a history of several transient ischemic attacks (TIAs). The nurse anticipates preparing the patient for A. transluminal angioplasty. B. intravenous heparin drip administration. C. surgical endarterectomy. D. tissue plasminogen activator (tPA) infusion.
D. tissue plasminogen activator (tPA) infusion.
The nurse advises a patient with myasthenia gravis to: a. Protect the extremities from injury due to poor sensory perception b. Perform physically demanding activities early in the day c. Do frequent weight-bearing exercise to prevent muscle atrophy d. Anticipate the need for weekly plasmapheresis treatments
b. Perform physically demanding activities early in the day
One of your patients with a diagnosis of MG has a scheduled dose of Pyridostigmine (Mestion) at 0900. It is now 0800 and breakfast is served at 0930. When should you administer the Mestion to your patient? a.Now b.0830 c.1030 d.0930
b. 0830