LSN 1800 Test 3

Which equipment will the nurse obtain to perform a Rinne test? A. Otoscope B. Tuning fork C. Audiometer D. Ticking watch

B. Tuning fork Rationale: Rinne testing is done using a tuning fork. The other equipment is used for other types of ear examinations

A patient with a right lower leg fracture will be discharged home with an external fixation device in place. Which information will the nurse teach? A. "Check and clean the pin insertion sites daily." B. "Remove the external fixator for your shower." C. "Remain on bedrest until bone healing is complete." D. "Take prophylactic antibiotics until the fixator is removed."

A. "Check and clean the pin insertion sites daily." Rationale: Pin insertion sites should be cleaned daily to decrease risk for infection at the site. An external fixator allows the patient to be out of bed and avoid the risks of prolonged immobility. The device is surgically placed and is not removed until the bone is stable. Prophylactic antibiotics are not routinely given during external fixator use.

The nurse is assessing a 65 year old patient for presbyopia. Which instruction will the nurse give the patient before the test? A. "Hold this card and read the print out loud." B. "Cover one eye while reading the wall chart." C. "You'll feel a short burst of air directed at your eyeball." D. "A light will be used to look for a changed in your pupils."

A. "Hold this card and read the print out loud." Rationale: The Jaeger card is used to assess near vision problems and presbyopia in persons older than 40 years of age. The card should be held 14 inches away from eyes while the patient reads words in various print sizes. Using a penlight to determine pupil change is testing pupil response. A short burst of air may be used to test extraocular pressure but is not used for testing presbyopia. Covering one eye at a time while reading a wall chart at 20 feet describes the Snellen test

A 65 year old patient is being evaluated for glaucoma. Which information given by the patient has implications for the patient's treatment plan? A. "I take metoprolol (Lopressor) for angina." B. "I take aspirin when I have a sinus headache." C. "I have had frequent episodes of conjunctivitis D. "I have not had an eye examination in 10 years

A. "I take metoprolol (Lopressor) for angina." Rationale: It is important to note whether the patient takes any beta-blockers because this classification of medications is also used to treat glaucoma, and there may be an increase in adverse effects. The use of aspirin does not increase intraocular pressure and is safe for patients with glaucoma. Although older patients should have yearly eye examinations, the treatment for this patient will not be affected by the 10 year gap in eye care. Conjunctivitis does not increase the risk for glaucoma

After the nurse has taught a 28-year-old with fibromyalgia, which statement by the patient indicates a good understanding of effective self-management? A. "I will need to stop drinking so much coffee and soda." B. "I am going to join a soccer team to get more exercise." c. "I will call the doctor every time my symptoms get worse." d. "I should avoid using over-the-counter medications for pain."

A. "I will need to stop drinking so much coffee and soda." Rationale: Dietitians frequently suggest patients with fibromyalgia limit their intake of caffeine and sugar because these substances are muscle irritants. Mild exercise such as walking is recommended for patients with fibromyalgia, but vigorous exercise is likely to make symptoms worse. Because symptoms may fluctuate from day to day, the patient should be able to adapt the regimen independently rather than calling the provider whenever symptoms get worse. Over the counter medications such as ibuprofen and acetaminophen are frequently used for symptom managment

A 54-yr-old patient with acute osteomyelitis asks the nurse how this problem will be treated initially. 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 present." D. "Drainage of the foot and instillation of antibiotics into the affected area are the usual therapy."

A. "IV antibiotics are usually required for several weeks." Rationale: The standard treatment for acute osteomyelitis consists of several weeks of IV antibiotic therapy. However, as many as 3 to 6 months may be required. Bone is denser and less vascular than other tissues, and it takes time for the antibiotic therapy to eradicate all microorganisms. Surgery may be used for chronic osteomyelitis, to include debridement of the devitalized, infected tissue and irrigation of the affected bone with antibiotics.

A 24-yr-old female patient with systemic lupus erythematosus (SLE) tells the nurse she wants to have a baby and is considering getting pregnant. Which response by the nurse is most appropriate? A. "Infertility can result from some medications used to control your disease." B. "Temporary remission of your signs and symptoms is common during pregnancy." C. "Autoantibodies transferred to the baby during pregnancy will cause heart defects." D. "The baby is at high risk for neonatal lupus erythematosus being diagnosed at birth."

A. "Infertility can result from some medications used to control your disease." Rationale: Infertility may be caused by renal involvement and the previous use of high-dose corticosteroid and chemotherapy drugs. Neonatal lupus erythematosus rarely occurs in infants born to women with SLE. Exacerbation is common after pregnancy during the postpartum period. Spontaneous abortion, stillbirth, and intrauterine growth retardation are common problems with pregnancy related to deposits of immune complexes in the placenta and because of inflammatory responses in the placental blood vessels. There is not an increased risk for heart defects.

A nurse performs discharge teaching for a 58-yr-old woman after a left hip arthroplasty using the posterior approach. Which statement by the patient indicates teaching is successful? A. "Leg-raising exercises are necessary for several months." B. "I should not try to drive a motor vehicle for 2 to 3 weeks." C. "I will not have any restrictions now on hip and leg movements." D. "Blood tests will be done weekly while taking enoxaparin (Lovenox)."

A. "Leg-raising exercises are necessary for several months." Rationale: Exercises designed to restore strength and muscle tone will be done for months after surgery. The exercises include leg raises in supine and prone positions. Driving a car is not allowed for 4 to 6 weeks. In the posterior approach hip arthroplasties, extremes of internal rotation and 90-degree flexion of the hip must be avoided for 4 to 6 weeks postoperatively. The knees must be kept apart. The patient should never cross the legs or twist to reach behind. To prevent thromboembolism, enoxaparin is administered subcutaneously and can be given at home. Enoxaparin does not require monitoring of the patient's coagulation status.

The nurse working in the vision and hearing clinic receives telephone calls from several patients who want appointments in the clinic as soon as possible. Which patient should be seen first? A. 71-year-old who has noticed increasing loss of peripheral vision B. 74-year-old who has difficulty seeing well enough to drive at night C. 60-year-old who has difficulty hearing clearly in a noisy environment D. 64-year-old who has decreased hearing and ear "stuffiness" without pain

A. 71-year-old who has noticed increasing loss of peripheral vision Rationale: Increasing loss of peripheral vision is characteristic of glaucoma, and the patient should be scheduled for an examination as soon as possible. The other patients have symptoms commonly associated with aging; presbycusis, possible cerumen impaction, and impaired night vision

The nurse is providing health promotion teaching to a group of older adults. Which information will the nurse include when teaching about routine glaucoma testing? A. A Tono-Pen will be applied to the surface of the eye B. The test involves reading a Snellen chart from 20 feet. C. Medications will be used to dilate the pupils for the test. D. The examination involves checking the pupil's reaction to light.

A. A Tono-Pen will be applied to the surface of the eye Rationale: Glaucoma is caused by an increase in intraocular pressure, which would be measured using the Tono-Pen. The other techniques are used in testing for other eye disorders

Which finding related to primary open-angle glaucoma would the nurse expect to find when reviewing a patient's history and physical examination report? A. Absence of pain or pressure B. Blurred vision in the morning C. Seeing colored halos around lights D. Eye pain accompanied with nausea and vomiting

A. Absence of pain or pressure Rationale: Primary open-angle glaucoma is typically symptom free, which explains why patients can have significant vision loss before a diagnosis is made unless regular eye examinations are being performed. Primary angle-closure glaucoma manifestations include sudden, excruciating pain in or around the eye, seeing colored halos around lights, and nausea and vomiting.

Which action will the nurse include in the plan of care for a patient with newly diagnosed ankylosing spondylitis? A. Advise the patient to sleep on the back with a flat pillow B. Emphasize that application of heat may worsen symptoms C. Schedule annual laboratory assessment for the HLA-B27 antigen D. Assist patient to choose physical activities that involve spinal flexion

A. Advise the patient to sleep on the back with a flat pillow Rationale: Because ankylosing spondylitis results in flexion deformity of the spine, postures that extend the spine (e.g. sleeping on the back and with a flat pillow) are recommended. HLA-B27 antigen is assessed for initial diagnosis but is not needed annually. To counteract the development of flexion deformities, the patient should choose activities that extend the spine, such as swimming. Heat application is used to decrease localized pain

The patient reports a loss of central vision. What test should the nurse teach the patient about to identify changes in macular function? A. Amsler grid test B. B-scan ultrasonography C. Fluorescein angiography D. Intraocular pressure testing with Tono-Pen

A. Amsler grid test Rationale: The Amsler grid test is self-administered and regular testing is necessary to identify any changes in macular function. B-scan ultrasonography is used to diagnose ocular pathologic conditions (e.g., intraocular foreign bodies or tumors, vitreous opacities, retinal detachments). Fluorescein angiography is used to diagnose problems related to the flow of blood through pigment epithelial and retinal vessels. Intraocular pressure testing with a Tono-Pen is done to test for glaucoma.

The nurse developing a teaching plan for a patient with herpes simplex keratitis should include which instruction? A. Apply antibiotic drops to the eye several times daily. B. Wash hands frequently and avoid touching the eyes. C. Apply a new occlusive dressing to the affected eye at bedtime. D. Use corticosteroid ophthalmic ointment to decrease inflammation.

A. Apply antibiotic drops to the eye several times daily. Rationale: The best way to avoid the spread of infection from one eye to another is to avoid rubbing or touching the eyes and to use careful hand washing when touching the eyes is unavoidable. Occlusive dressings are not used for herpes keratitis. Herpes simplex is a virus, and antibiotic drops will not be prescribed. Topical corticosteroids are immunosuppressive and typically are not ordered because they can contribute to a longer course of infection and more complications

The patient has frostbite on the distal toes of both feet. The patient is scheduled for amputation of damaged tissue. Which assessment finding or diagnostic study is most objective in determining tissue viability? A. Arteriogram showing blood vessels B. Peripheral pulse palpation bilaterally C. Patches of black, indurated, cold tissue D. Bilateral pale, cool skin below the ankles

A. Arteriogram showing blood vessels Rationale: Arteriography determines viable tissue for salvage based on blood flow observed in real time and is considered the gold standard for evaluating arterial perfusion. Only arteriography determines where tissue perfusion stops and amputation needs to occur. Bilateral peripheral pulse assessment and areas of black, indurated, cold, and pale skin indicate ischemia.

Which action will the nurse take in order to evaluate the effectiveness of Buck's traction for a patient who has an intracapsular fracture of the right femur? A. Assess for hip pain. B. Assess for contractures C. Check for peripheral pulses D. Monitor for hip dislocation

A. Assess for hip pain. Rationale: Buck's traction keeps the leg immoibilized and reduces painful muscle spasm. Hip contractures and dislocation are unlikely to occur in this situation. The peripheral pulses will be assessed, but this does not help in evaluating the effectiveness of Buck's traction

The nurse admits a 55-yr-old woman with multiple sclerosis to a long-term care facility. Which finding represents a safety concern? A. Ataxic gait B. Radicular pain C. Severe fatigue D. Urinary retention

A. Ataxic gait Rationale: An ataxic gait is a staggering, uncoordinated gait. Fall risk is the highest in individuals with gait instability and 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.

The nurse is admitting a patient with a history of a herniated lumbar disc and low back pain. Which action would most likely aggravate 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 Rationale: Back pain related to a herniated lumbar disc is aggravated by events and activities that increase 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). Moist heat, sleeping position, and ability to sit in a fully extended recliner do not aggravate the pain of a herniated lumbar disc.

Which finding for a patient who is taking hydroxychloroquine (Plaquenil) to treat rheumatoid arthritis is likely to be an adverse effect of the medication? A. Blurred vision B. Joint tenderness C. Abdominal cramping D. Elevated blood pressure

A. Blurred vision Rationale: Plaquenil can cause retinopathy. The medication should be stopped. Other findings are not related to the medication although they will also be reported

The nurse is caring for a patient hospitalized with a herniated lumbar disc and an exacerbation of chronic bronchitis. Which breakfast choice would be most appropriate for the patient to select from the breakfast menu? A. Bran muffin B. Scrambled eggs C. Puffed rice cereal D. Buttered white toast

A. Bran muffin Rationale: Each meal should contain one or more sources of fiber to reduce the risk of constipation and straining with defecation, which increases back pain. A patient with chronic breathing difficulties also will benefit from regularity and ease of bowel evacuation. In addition, if lumbar nerve compression is present, bowel and bladder function may be impaired. Bran is a typical high-fiber food choice and is an appropriate selection from the menu. Scrambled eggs, puffed rice cereal, and buttered white toast do not have as much fiber.

A 50-yr-old patient reports shoulder discomfort after raking the yard. Which problem should the nurse suspect? A. Bursitis B. Fasciitis C. Sprained ligament D. Achilles tendonitis

A. Bursitis Rationale: Bursitis is common in adults older than age 40 years and with repetitive motion, such as raking. Plantar fasciitis 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 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 from repetitive motion.

A patient who has had open reduction and internal fixation (ORIF) of a hip fracture tells the nurse he is ready to get out of bed for the first time. Which action should the nurse take? A. Check the patient's prescribed weight bearing status B. Use a mechanical lift to transfer the patient to the chair C. Delegate the transfer to nursing assistive personnel (NAP) D. Decrease the pain medication before getting the patient up

A. Check the patient's prescribed weight bearing status Rationale: The nurse should be familiar with the weight bearing orders for the patient before attempting the transfer. Mechanical lifts are not typically needed after this surgery. Pain medications should be given because the movement is likely to be painful for the patient. The registered nurse (RN) should supervise the patient during the initial transfer to evaluate how well the patient is able to accomplish the transfer

Which finding from the analysis of fluid from a patient's right knee arthrocentesis will be of concern to the nurse? A. Cloudy fluid B. Scant thin fluid C. Pale yellow fluid D. Straw-colored fluid

A. Cloudy fluid Rationale: The presence of purulent (cloudy) fluid suggests a possible joint infection. Normal synovial fluid is scant in amount and pale yellow/straw colored

When administered long-term, which medication requires ongoing musculoskeletal assessment? A. Corticosteroids B. β-Adrenergic blockers C. Antiplatelet aggregators D. Calcium-channel blockers

A. Corticosteroids Rationale: 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.

A patient with Meniere's disease is admitted with vertigo, nausea, and vomiting. Which nursing intervention will be included in the care plan? A. Dim the lights in the patient's room B. Encourage increased oral fluid intake C. Change the patient's position every 2 hours D. Keep the head of the bed elevated 45 degrees

A. Dim the lights in the patient's room Rationale: A darkened, quiet room will decrease the symptoms of the acute attack of Meniere's disease. Because the patient will be nauseated during an acute attack, fluids are administered IV. Position changes will cause vertigo and nausea. The head of the bed can be positioned for patient comfort

The nurse is providing discharge instructions for a patient using contact lenses who is diagnosed with bacterial conjunctivitis. What is most important for the nurse to include in the instructions? A. Discard all opened or used lens care products. B. Disinfect contact lenses by soaking in a cleaning solution for 48 hours. C. Put all used cosmetics in a plastic bag for 1 week to kill any bacteria before reusing. D. Disinfect all lens care products with the prescribed antibiotic drops for 1 week after infection.

A. Discard all opened or used lens care products. Rationale: The patient who wears contact lenses and develops infections should discard all opened or used lens care products and cosmetics to decrease the risk of reinfection from contaminated products. The risk of conjunctivitis is increased with not disinfecting lenses properly, wearing contact lenses too long, or using water or homemade solutions to store and clean lenses.

A college student reports eye pain after studying for finals. What assessment should the nurse make first in determining the possible etiology of this eye pain? A. Do you wear contacts? B. Do you have any allergies? C. Do you have double vision? D. Describe the change in your vision.

A. Do you wear contacts? Rationale: College students frequently wear contact lenses and stay up late or all night studying for finals. If the student wears contacts, the wearing of them while studying, care of them, and length of wear time will be assessed before looking for a corneal abrasion from extended wear with fluorescein dye. There are no manifestations of allergies, diplopia, or visual changes mentioned.

A patient reporting frequent vertigo is scheduled for electronystagmography to test vestibular function. Which instructions should the nurse provide to the patient before the procedure? A. Eat a light meal before the procedure. B. Avoid carbonated beverages before the procedure. C. Take nothing by mouth for 3 hours before the procedure. D. No special dietary restrictions are needed until after the procedure.

A. Eat a light meal before the procedure. Rationale: Instruct patient to eat a light meal before the test to avoid nausea. Results of vestibular tests can be altered by use of caffeine, other stimulants, sedatives, and antivertigo drugs.

The nurse teaches a 64-yr-old man with gouty arthritis about food that may be consumed on a low-purine diet. The patient's choice of which food item would indicate an understanding of the instructions? A. Eggs B. Liver C. Salmon D. Chicken

A. Eggs Rationale: Gout is caused by an increase in uric acid production, underexcretion of uric acid by the kidneys, or increased intake of foods containing purines, which are metabolized to uric acid by the body. Liver is high in purine, and chicken and salmon are moderately high in purine

A 19-yr-old male patient has a plaster cast applied to the right arm for a Colles' fracture after a skateboarding accident. Which nursing action is most appropriate? A. Elevate the right arm on two pillows for 24 hours. B. Apply heating pad to reduce muscle spasms and pain. C. Limit movement of the thumb and fingers on the right hand. D. Place arm in a sling to prevent movement of the right shoulder

A. Elevate the right arm on two pillows for 24 hours. Rationale: The casted extremity should be elevated at or above heart level for 24 hours to reduce swelling or inflammation. The cast should be supported on pillows during the drying period to prevent denting and flattening of the cast. Ice (not heat) should be applied for the first 24 to 36 hours to reduce swelling or inflammation. Active movement of the thumb and fingers should be encouraged to reduce edema and increase venous return. A sling may be used to support and protect the extremity after the cast is completely dry, but the patient should perform active movements of the shoulder to prevent stiffness or contracture.

A patient is prescribed intravenous (IV) gentamicin after repair of an intestinal perforation. The nurse should assess for which adverse effect of this medication? A. Hearing loss B. Exophthalmos C. Conjunctivitis D. Recurrent fever

A. Hearing loss Rationale: Aminoglycosides such as gentamicin are drugs that are potentially ototoxic and may cause damage to the auditory nerve. When this drug is used, careful monitoring for hearing and balance problems (e.g., hearing loss, tinnitus, vertigo) is essential. Exophthalmos is related to a symptom of hyperthyroidism. Conjunctivitis is a bacterial or a viral infection of the conjunctiva. Recurrent fever can be related to many issues and is not related to the use of IV gentamicin.

Which nursing action is correct when performing the straight leg raising test for an ambulatory patient with back pain? A. Lift the patient's leg to a 60 degree angle from the bed B. Place the patient in the prone position on the exam table C. Ask the patient to dangle both legs over the edge of the exam table D. Instruct the patient to elevate the legs and tense the abdominal muscles

A. Lift the patient's leg to a 60 degree angle from the bed Rationale: When performing the straight leg raising test, the patient is in the supine position and the nurse passively lifts the patients legs to a 60 degree angle. The other actions would not be correct for this test

An older adult patient states they don't seem to hear well and have to ask people to repeat themselves. What should the nurse do first to determine the cause of the hearing loss? A. Look for cerumen in the ear. B. Assess for increased hair growth in the ear. C. Tell the patient it is probably related to aging. D. Ask the patient if he has fallen because of dizziness.

A. Look for cerumen in the ear. Rationale: Gerontologic differences in the assessment of the auditory system include increased production of and drier cerumen, which can become impacted in the ear canal and contribute to hearing loss. Conductive hearing loss with impacted cerumen may lead to speaking softly as the patient's voice conducted through bone seems loud to the patient. Although increased hair growth occurs, it will not impact the hearing. Presbycusis may be occurring, but it should not be assumed. There is no reason to ask the patient if he has fallen because dizziness and vertigo are not a normal change of aging of the ear.

A patient who has had open reduction and internal fixation (ORIF) of left lower leg fractures continues to complain of severe pain in the leg 15 minutes after receiving the prescribed IV morphine. Pulses are faintly palpable and the foot is cool to the touch. Which action should the nurse take next? A. Notify the health care provider B. Assess the incision for redness C. Reposition the left leg on pillows D. Check the patient's blood pressure

A. Notify the health care provider Rationale: The patient's clinical manifestations suggest compartment syndrome and delay in diagnosis and treatment may lead to severe functional impairment. The data do not suggest problems with blood pressure or infection. Elevation of the leg will decrease arterial flow and further reduce perfusion.

Assessment of a patient's visual acuity reveals that the left eye can see at 20 feet what a person with normal vision can see at 50 feet and the right eye can see at 20 feet what a person with normal vision can see at 40 feet. The nurse records which finding? A. OS 20/50; OD 20/40 B. OU 20/40; OS 50/20 C. OD 20/40; OS 20/50 D. OU 40/20; OD 50/30

A. OS 20/50; OD 20/40 Rationale: When documenting visual acuity, the first number indicates the standard (for normal vision) of 20 feet and the second number indicates the line that the patient is able to read when standing 20 feet from the Snellen chart. OS is the abbreviation for the left eye, and OD is the abbreviation for the right eye. The three remaining answers do not correctly describe the patient's visual acuity

The nurse is performing a musculoskeletal assessment on an 81-yr-old patient whose mobility has been progressively declining. How should the nurse safely assess 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 the patient's legs from a supine position to full flexion.

A. Observe the patient's unassisted ROM in the affected leg. Rationale: Observing the patient's active ROM is more accurate and safe than lifting weights. Passive ROM should be performed with extreme caution; it may cause harm when performed on older patients.

Which information about a patient who had a stapedotomy yesterday is most important for the nurse to communicate to the health care provider? A. Oral temperature is 100.8 B. The patient complains of ear "fullness." C. Small amount of dried drainage on dressing D. The patient reports that hearing has gotten worse

A. Oral temperature is 100.8 Rationale: An elevated temperature may indicate a postoperative infection. Although the nurse would report all the data, a temporary decrease in hearing, bloody drainage on the dressing, and a feeling of congestion (because of accumulation of blood and drainage in the ear) are common after this surgery

Four patients have been newly diagnosed with connective tissue disorders. The nurse should be aware of safety issues and interstitial lung involvement for the patient with which diagnosis? A. Polymyositis B. Reactive arthritis C. Sjögren's syndrome D. Systemic lupus erythematosus (SLE)

A. Polymyositis Rationale: Polymyositis is an inflammatory disease affecting striated muscle and resulting in muscle weakness that increases the patient's risk of falls and injury. Weakened pharyngeal muscles also increase the risk for aspiration, with interstitial lung disease in up to 65% of patients. Safety concerns and interstitial lung involvement are not associated with reactive arthritis (Reiter's syndrome) or Sjögren's syndrome. Safety may be an issue later in disease progression of SLE.

The nurse is caring for a 76-yr-old man who has undergone left total knee arthroplasty to relieve the pain of severe osteoarthritis. What care would be expected postoperatively? A. Progressive leg exercises to obtain 90-degree flexion B. Early ambulation with full weight bearing on the left leg C. Bed rest for 3 days with the left leg immobilized in extension D. Immobilization of the left knee in 30-degree flexion to prevent dislocation

A. Progressive leg exercises to obtain 90-degree flexion Rationale: The patient is encouraged to engage in progressive leg exercises until 90-degree flexion is possible; continuous passive motion also may be used based on surgeon preference. Early ambulation is implemented, sometimes the day of surgery, but orders are likely to indicate weight bearing as tolerated rather than full weight bearing. Immobilization and bed rest are not indicated. The patient's knee is unlikely to dislocate.

Which nursing action for a patient who had a right hip arthroplasty can the nurse delegate to experienced unlicensed assistive personnel (UAP)? A. Reposition the patient ever 1-2 hours B. Assess for skin irritation on the patient's back C. Teach the patient quadriceps setting exercises D. Determine the patient's pain intensity and tolerance

A. Reposition the patient ever 1-2 hours Rationale: Repositioning of orthopedic patients is within the scope of practice of UAP (after they have been trained and evaluated in this skill). The other actions should be done by licensed nursing staff members

Inflammation and infection of the eye A. are caused by irritants and microorganisms B. have a higher incidence in sexually active patients C. are chronic problems that result in a loss of vision D. are frequently treated with cold compresses and antibiotics

A. are caused by irritants and microorganisms Rationale: Inflammation or infection of the eye is caused by external irritants or microorganisms. The nurse teaches the patient appropriate interventions related to the specific disorder. Common interventions include application of warm, moist compresses and administration of antibiotics

Which action will the nurse take when when caring for a patient with osteomalacia? A. Teach about the use of Vitamin D supplements B. Educate about the need for weight bearing experience C. Discuss the use of medications such as bisphosphonates D. Emphasize the importance of sunscreen use when outside

A. Teach about the use of Vitamin D supplements Rationale: Osteomalacia is caused by inadequate intake or absorption of Vitamin D. Weight bearing exercise and bisphosphonate administration may be used for osteoporosis but will not be beneficial for osteomalacia. Because ultraviolet light is needed for the body to synthesize vitamin D, the patient might be taught that 20 minutes a day of sun exposure is beneficial

A patient who had arthroscopic surgery of the right knee 7 days ago is admitted with a red, swollen, and hot knee. Which assessment finding by the nurse should be reported to the health care provider immediately? A. The blood pressure is 86/50 mm Hg. B. The patient says the knee pain is severe. C. The white blood cell count is 11,500/µL. D. The patient is taking ibuprofen (Motrin).

A. The blood pressure is 86/50 mm Hg. Rationale: The low blood pressure suggests the patient may be developing septicemia as a complication of septic arthritis. Immediate blood cultures and initiation of antibiotic therapy are indicated. The other information is typical of septic arthritis and should also be reported to the health care provider, but it does not indicate any immediately life threatening problems

A patient has a new order for magnetic resonance imaging (MRI) to evaluate for left femur osteomyelitis after a hip replacement surgery. Which information indicates that the nurse should consult with the health care provider before scheduling the MRI? A. The patient has a pacemaker. B. The patient is claustrophobic. C. The patient wears a hearing aid. D. The patient is allergic to shellfish.

A. The patient has a pacemaker. Rationale: Patients with permanent pacemakers cannot have an MRI because of the force exerted by the magnetic field on metal objects. An open MRI will not cause claustrophobia. The patient will need to be instructed to remove the hearing aid before the MRI, but this does not require consultation with the health care provider. Because contrast medium will not be used, shellfish allergy is not a contraindication to MRI

The nurse is assessing a patient who was recently treated with amoxicillin for acute otitis media of the right ear. Which finding is a priority to report to the health care provider A. The patient has a temperature of 100.6 B. The patient complains of "popping" in the ear C. Clear fluid is visible through the tympanic membrane D. The patient frequently asks the nurse to repeat information

A. The patient has a temperature of 100.6 Rationale: The fever indicates that the infection may not be resolved, and the patient might need further antibiotic therapy. A feeling of fullness, "popping" in the ear, decreased hearing, and fluid in the middle ear are indications of otitis media with effusion. These symptoms are normal for weeks to months after an episode of acute otitis media and usually resolve without treatment

A patient with dermatomyositis is receiving long-term prednisone (Deltasone) therapy. Which assessment finding by the nurse is most important to report to the health care provider? A. The patient has painful hematuria B. Acne is noted on the patient's face C. Fasting blood glucose is 112mg/dL D. The patient has an increased appetite

A. The patient has painful hematuria Rationale: Corticosteroid use is associated with and increased risk for infection, so the nurse should report the urinary tract symptoms immediately to the health care provider. The increase in blood glucose, increased appetite, and acne are also adverse effects of corticosteroid use but do not need diagnosis and treatment as rapidly as the probable urinary tract infection

A patient with left knee pain is diagnosed with bursitis. The nurse will explain that bursitis is an inflammation of A. a fluid filled sac found at some joints B. a synovial membrane that lines the joint C. the connective tissue joining bones with a joint D. the fibrocartilage that acts as a shock absorber in the knee

A. a fluid filled sac found at some joints Rationale: Bursae are fluid filled sacs that cushion joints and bony prominences. Fibrocartilage is a solid tissue that cushions some joints. Ligaments are connective tissue joining bones within a joint. The synovial membrane lines many joints but not a bursa.

An injured soldier underwent left leg amputation 2 weeks ago, but now reports shooting pain and heaviness in the left leg. What action by the nurse is supported by research findings? A. Use mirror therapy. B. Give opioid analgesics. C. Rebandage the residual limb. D. Show the patient the leg is gone

A. Use mirror therapy. Rationale: Mirror therapy has been shown to reduce phantom limb pain in some patients. Opioid analgesics, rebandaging the residual limb, and showing the patient that the leg is gone may not decrease phantom limb pain.

Always assess the patient with an ophthalmic problem for A. visual acuity. B. pupillary reactions. C. intraocular pressure. D. confrontation visual fields.

A. Visual acuity Rationale: Always assess and record the patient's visual acuity for medical and legal reasons

Presbyopia occurs in older individuals because A. the eyeball elongates. B. the lens becomes inflexible. C. the corneal curvature becomes irregular. D. light rays are focusing in front of the retina.

B. the lens becomes inflexible Rationale: Presbyopia is the loss of accommodation in association with age. As the eye ages, the lens becomes larger, firmer, and less elastic

A patient undergoes a left above-the-knee amputation with an immediate prosthetic fitting. When the patient arrives on the orthopedic unit after surgery, the nurse should A. assess the surgical site for hemorrhage B. remove the prosthesis and wrap the site C. place the patient in a side lying position D. keep the residual limb elevated on a pillow

A. assess the surgical site for hemorrhage Rationale: The nurse should monitor for postoperative hemorrhage. The prosthesis will not be removed. To avoid flexion contracture of the hip, the leg will not be elevated on a pillow. Unless contraindicated, the patient will be placed in a prone position for 30 minutes several times a day to prevent hip flexion contracture

The nurse teaching a support group of women with rheumatoid arthritis (RA) about how to manage activities of daily living suggests that they A. avoid activities that require repetitive use of the same muscles and joints. B. protect the knee joints by sleeping with a small pillow under the knees. C. stand rather than sit when performing household and yard chores. D. strengthen small hand muscles by wringing out sponges or washcloths.

A. avoid activities that require repetitive use of the same muscles and joints. Rationale: Patients are advised to avoid repetitious movements. Sitting during household chores is recommended to decrease stress on joints. Wringing water out of sponges would increase joint stress. Patients are encouraged to position joints in the extended neutral position. Sleeping with a pillow behind the knees would decrease the ability of the knee to extend and also decrease knee range of motion.

The increased risk for falls in older adults 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 Rationale: 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 a pelvic fracture should be monitored for A. changes in urine output B. petechiae on the abdomen C. a palpable lump in the buttock D. sudden increase in blood pressure

A. changes in urine output Rationale: Pelvic fractures may cause serious intraabdominal injury, such as hemorrhage, and laceration of the urethra, bladder, or colon. Patients may survive the initial pelvic injury, only to die of sepsis, FES, or VTE. Because a pelvic fracture can damage other organs, the nurse should assess bowel and urinary elimination and distal neurovascular status

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 Rationale: 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

A patient with severe kyphosis is scheduled for a dual energy x-ray absorptiometry (DXA) testing. The nurse will plan to A. explain the procedure B. start an IV line for contrast medium injection C. give an oral sedative 60 to 90 minutes before the procedure D. screen the patient for allergies to shellfish or iodine products

A. explain the procedure Rationale: DXA testing is painless and noninvasive. No IV access is necessary. Contrast medium is not used. Shellfish or iodine allergies are not a concern with DXA testing. Because the procedure is painless, no antianxiety medications are required

A patient with a humoral fracture is returning for a 4 week checkup. The nurse explains that an initial evidence of healing on x ray is indicated by A. formulation of callus B. complete bony union C. hematoma at the fracture site D. presence of granulation tissue

A. formulation of callus Rationale: Bone goes through a remarkable reparative process of self healing (i.e. union) that occurs in stages. The third stage is callus formation. As minerals (i.e. calcium, phosphorous, and magnesium) and new bone matrix are deposited in the osteoid, an unorganized network of bone is formed that is woven about the fracture parts. Callus is composed primarily of cartilage, osteoblasts, calcium, and phosphorous, It usually appears by the end of the second week after injury. Evidence of callus formation can be verified on x-rays

The patient who has conductive hearing loss A. hears better in a noisy environment B. hears sound but does not understand speech C. often speaks loudly because his or her own voice seems low D. experiences clearer sound with a hearing aid if the loss is less than 30 dB

A. hears better in a noisy environment Rationale: The patient with conductive hearing loss often speaks softly because hearing his or her own voice (which is conducted by bone) seems loud. This patient hears better in a noisy environment. The first step is to identify and treat the cause if possible. If correction of the cause is not possible, a hearing aid may help if the loss is greater than 40 to 50 dB

The nurse instructs the patient with an above the knee amputation that the residual limb should not be routinely elevated because this position promotes A. hip flexion contracture B. clot formation at the incision C. skin irritation and breakdown D. increased risk of wound dehiscence

A. hip flexion contracture Rationale: Flexion contractures may delay the rehabilitation process after amputation. The most common and debilitating contracture is hip flexion. To prevent flexion contractures, the patient should avoid sitting in a chair for more than 1 hours with hips flexed or with pillows under the surgical extremity. Unless specifically contraindicated, assist the patient to lie on the abdomen fo 30 minutes three or four times each day, and position the hip in extension while prone

A normal assessment finding of the musculoskeletal system is A. no deformity B. muscle and bone strength of 4 C. ulnar deviation and subluxation D. angulation of bone toward midline

A. no deformity Rationale: 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

The occupational health nurse will teach the patient whose job involves many hours of typing to A. obtain a keyboard pad to support the wrist B. do stretching exercises before starting work C. wrap the wrists with compression bandages every morning D. avoid using nonsteroidal antiinflammatory drugs (NSAIDs) for pain.

A. obtain a keyboard pad to support the wrist Rationale: Repetitive strain injuries caused by prolonged work at a keyboard can be prevented by using a pad to keep the wrists in a straight position. Stretching exercises during the day may be helpful, but these would not be needed before starting work. Use of a compression bandage is not needed, although a splint may be used for carpal tunnel syndrome. NSAIDs are appropriate to decrease swelling

The nurse determines that colchicine has been effective for a patient with an acute attack of gout upon finding A. reduced joint pain B. increased urine output C. elevated serum uric acid D. increase white blood cells (WBC)

A. reduced joint pain Rationale: Colchicine reduces joint pain in 24 to 48 hours by decreasing inflammation. The recommended increase in fluid intake of 2-3 L/day during gout would increase urine output but would not indicate the effectiveness of colchicine. Elevated serum uric acid would result in increased symptoms. The WBC count might decrease with decreased inflammation but would not increase

The nurse should teach the patient with ankylosing spondylitis the importance of A. regularly exercising and maintaining proper posture B. avoiding extremes in environmental temperatures C. maintaining patient's usual physical activity D. applying hot and cool compresses for relief of local symptoms

A. regularly exercising and maintaining proper posture Rationale: Patients with ankylosing spondylitis (AS) should exercise after pain and stiffness are managed. Postural control is important for minimizing spinal deformity. The exercise regimen should include back, neck, and chest stretches. Teach the patient with AS about regular exercise and attention to posture, local moist heat applications, and knowledgeable use of drugs. Discourage excessive physical exertion during periods of active flare up of the disease. Proper positioning at rest is essential. The mattress should be firm and the patient should sleep on the back with a flat pillow, avoiding positions that encourage flexion deformity. Postural training emphasizes avoiding spinal flexion (e.g. leaning over a desk), heavy lifting, and prolonged walking, standing, or sitting.

The priority nursing diagnosis for a patient experiencing an acute attack of Meniere's disease is A. risk for falls related to episodic dizziness B. impaired verbal communication related to tinnitus C. self care deficit (bathing and dressing) related to vertigo D. imbalanced nutrition: less than body requirements related to nausea

A. risk for falls related to episodic dizziness Rationale: All the nursing diagnoses are appropriate, but because sudden attacks of vertigo can lead to "drop attacks", the major focus of nursing care is to prevent injuries associated with dizziness

What would the nurse recognize as a possible difference in the assessment of a gerontologic patient A. slowed reaction time B. Quicker reflex response C. decreased joint stiffness D. increased fine motor dexterity

A. slowed reaction time Rationale: Gerontologic patients will experience a decrease in reaction times as a result of slowed conduction of nerve impulses along motor units

A 25-year-old female patient with systemic lupus erythematosus (SLE) who has a facial rash and alopecia tells the nurse, "I never leave my house because I hate the way I look." The nurse will plan interventions with the patient to address the nursing diagnosis of A. social isolation B. activity intolerance C. impaired skin integrity D. impaired social interaction

A. social isolation Rationale: The patient's statement about not going anywhere because of hating the way he or she looks expresses social isolation because of embarrassment about the effects of the SLE. Activity intolerance is a possible problem for patients with SLE, but the information about this patient does not support this. The rash with SLE is nonpruritic. There is no evidence of lack of social skills for this patient

The nurse is testing the visual acuity of a patient in the outpatient clinic. The nurse's instructions for this test include asking the patient to A. stand 20 feet away from the wall chart B. follow the examiner's finger with the eyes only C. look at an object far away and then near to the eyes D. look straight ahead while a light is shone into the eyes

A. stand 20 feet away from the wall chart Rationale: When the Snellen chart is used to check visual acuity, the patient should stand 20 feet away. Accommodation is tested by looking at an object at both near and far distances. Shining a pen light into the eyes tests for pupil response. Following the examiner's fingers with the eyes tests extraocular movements

While performing passive range of motion for a patient, the nurse puts the ankle joint through the movements of A. flexion and extension B. inversion and eversion C. pronation and supination D. flexion, extension, abduction, adduction E. pronation, supination, rotation, and circumduction

A.B. Flexion and extension; inversion and eversion Rationale: Common movements that occur at the ankle include inversion, eversion, flexion, and extension

Teach the patient with fibromyalgia the importance of limiting intake of which foods (Select all that apply) A. Sugar B, Alcohol C. Caffeine D. Red Meat E. Root vegetables

A.B.C. Sugar, Alcohol, Caffeine Rationale: Dietitians often urge patients with fibromyalgia to limit their intake of sugar, caffeine, alcohol, because these substances have been shown to be muscle irritants

Which patient behaviors would the nurse promote for healthy eyes and ears (select all that apply)? A. Wearing protective sunglasses when bicycling B. Supplemental intake of B vitamins and magnesium C. Playing amplified music at 75% of maximum volume D. Patient notifying the health care provider of tinnitus while on antibiotics E. A woman avoiding pregnancy for 4 weeks after receiving measles, mumps, rubella (MMR) immunization

A.D. Wearing protective sunglasses when bicycling; patient notifying the health care provider of tinnitus while on antibiotics Rationale: Wearing sunglasses may contribute to the prevention of cataract development and age related macular degeneration. Protective eyewear during sports activities reduces the risk of eye injuries. Antibiotics, salicylates, diuretics, antineoplastic drugs are commonly associated with ototoxicity. Women should avoid pregnancy for at least 3 months after being immunized with MMR

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 construction worker who is 6'2 and weighs 260lbs C. A 44 year old female chef with prior compression fracture of the spine D. A 30 year old nurse who works on an orthopedic unit and smokes E. A 28 year old female who is a yoga instructor who is 5'6 and weighs 130lbs

A.B.C.D. A 63 year old man who is a long distance truck driver; A 36 year old construction worker who is 6'2 and weighs 260lbs; A 44 year old female chef with prior compression fracture of the spine; A 30 year old nurse who works on an orthopedic unit and smokes Rationale: Risk factors associated with low back pain include lack of muscle tone, excess body weight, stress, poor posture, cigarette smoking, pregnancy, prior spinal compression fractures, 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 sitting are also associated with low back pain. Low back pain is most often caused by a musculoskeletal problem. Causes of low back pain of the musculoskeletal origin include (1) acute lumbosacral strain, (2) instability of the lumbosacral spine, (3) osteoarthritis of the lumbosacral vertebrae, (4) degenerative disc disease, and (5) herniated disc. Health care personnel are at high risk for low back pain. Lifting and moving patients, excessive time being stooped over or leaning forward, and frequent twisting can cause low back pain

A patient with fibromyalgia has pain at 12 of the 18 identified tender sites, including the neck, upper back, and knees. The patient also reports nonrefreshing sleep, depression, and anxiety when dealing with multiple tasks. Which treatments will be included in the plan of care (select all that apply.)? A. Massage therapy B. Low-impact aerobic exercise C. Relaxation strategy (biofeedback) D. Antiseizure drug pregabalin (Lyrica) E. Morphine sulfate extended-release tablets F. Serotonin reuptake inhibitor (e.g., sertraline [Zoloft])

A.B.C.D.F. Massage therapy; Low-impact aerobic exercise; Relaxation strategy (biofeedback); Antiseizure drug pregabalin (Lyrica); Serotonin reuptake inhibitor (e.g., sertraline [Zoloft]) Rationale: Massage will improve blood flow and relaxation. Low-impact aerobic exercise will prevent muscle atrophy without increasing pain at the knees. Relaxation using biofeedback may decrease the patient's stress and anxiety. Because the treatment of fibromyalgia is symptomatic, this patient will preferably be prescribed a nonopioid pain medication, an antiseizure medication such as pregabalin to help with widespread pain, and a serotonin reuptake inhibitor for depression. Long-acting opioids such as morphine are generally avoided unless pain cannot be relieved by other medications.

During assessment of a patient with fibromyalgia, the nurse would expect the patient to report which of the following? (select all that apply) A. sleep disturbances B. multiple tender points C. cardiac palpitations and dizziness D. multijoint inflammation and swelling E. Widespread bilateral, burning musculoskeletal pain

A.B.E. Sleep disturbances, Multiple tender points, widespread bilateral, burning musculoskeletal pain Rationale: These symptoms are commonly described in patients with fibromyalgia. Cardia involvement and joint inflammation are not typical of fibromyalgia

Age related changes in the auditory system commonly include (select all that apply) A. drier cerumen B. tinnitus in both ears C. auditory nerve degeneration D. atrophy of the tympanic membrane E. greater ability to hear high pitched sounds

A.C.D. drier cerumen; auditory nerve degeneration; atrophy of the tympanic membrane Rationale: Age related changes include increased production of drier cerumen, atrophic changes of tympanic membrane, and neuron degeneration in auditory nerve and central pathways

A 40-yr-old African American woman has longstanding Raynaud's phenomenon. Currently, she reports red spots on her hands, forearms, palms, face, and lips. Which additional findings will the nurse expect (select all that apply.)? A. Calcinosis B. Weight loss C. Sclerodactyly D. Difficulty swallowing E. Weakened leg muscles F. Skin thickening below the elbow and knee

A.C.D.F. Calcinosis; Sclerodactyly; Difficulty swallowing; Skin thickening below the elbow and knee Rationale: This patient is at risk for scleroderma. The acronym CREST represents the clinical manifestations. C: calcinosis, painful calcium deposits in the skin; R: Raynaud's phenomenon; E: esophageal dysfunction, difficulty swallowing; S: sclerodactyly, tightening of skin on fingers and toes; and T: telangiectasia. Weight loss and weakened leg muscles are associated with polymyositis and dermatomyositis, not scleroderma.

The nurse understands that patients have the most difficulties with diarthrodial joints. Which joints are included in this group (select all that apply.)? A. Hinge joint of the knee B. Ligaments joining the vertebrae C. Gliding joints of the wrist and hand D. Fibrous connective tissue of the skull E. Ball and socket joint of the shoulder or hip F.Cartilaginous connective tissue of the pubis joint

A.C.E. Hinge joint of the knee; Gliding joints of the wrist and hand; ball and socket joint of the shoulder or hip Rationale: The diarthrodial joints include the hinge joint of the knee and elbow, ball and socket joint of the shoulder and hip, pivot joint of the radioulnar joint, and 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.

What should be included in the postoperative teaching of the patient who has undergone cataract surgery? (Select all that apply) A. Eye discomfort is often relieved with mild analgesics B. A decline in visual acuity is common for the first week C. Stay on bed rest and limit activity for the first few days D. Notify surgeon if an increase in redness or drainage occurs E. Nighttime eye shielding and activity restrictions are essential tor prevent eyestrain

A.D. Eye discomfort is often relieved with mild analgesics. Notify surgeon if an increase in redness or drainage occurs Rationale: After cataract surgery, the nurse should teach the patient and caregiver about the following topics before discharge; topical antibiotics; topical corticosteroids or other anti-inflammatory agents; mild analgesia, if necessary; eye shield if used (usually worn overnight and removed during the first postoperative visit); and activity restrictions as preferred by the patient's surgeon (activities that increase the intraocular pressure, such as bending or stooping, coughing or lifting, may be restricted). Complications that should be reported include intense pain (which may indicate hemorrhage), infection, increased intraocular pressure, increased or purulent drainage, increased redness, and any decrease in visual acuity

Before injecting fluorescein for angiography, it is important for the nurse to (select all that apply) A. obtain an emesis basin. B. ask if the patient is fatigued. C. administer a topical anesthetic. D. inform patient that skin may turn yellow. E. assess for allergies to iodine-based contrast media.

A.D. obtain an emesis basin; inform patient that skin may turn yellow Rationale: Fluorescein dye sometimes causes nausea or vomiting, and the dye may cause a transient yellow-orange discoloration of urine and skin. Extravasation of the dye causes tissue toxicity. Systemic allergic reactions to the dye are rare, but the nurse should be familiar with emergency equipment and procedures

Which actions will the nurse include in the plan of care when caring for a patient with metastatic bone cancer of the left femur (select all that apply)? A. Monitor serum calcium level. B. Teach about the need for strict bed rest. C. Discontinue use of sustained-release opioids D. Support the left leg when repositioning the patient. E. Support family and patient as they discuss the prognosis

A.D.E. Monitor serum calcium level; support the left leg when repositioning the patient; support the family and patient as they discuss the prognosis Rationale: The nurse will monitor for hypercalcemia caused by bone decalcification. Support of the leg helps reduce the risk for pathologic fractures. Although the patient may be reluctant to exercise, activity is important to maintain function and avoid complications associated with immobility. Adequate pain medication, including sustained release and rapid acting opioids, is needed for the severe pain often associated with bone cancer. The prognosis for metastatic bone cancer is poor so thee patient and family need to be supported as they deal with the reality of the situation

A nurse assesses a 38-yr-old patient with joint pain and stiffness who was diagnosed with stage III rheumatoid arthritis (RA). Which additional characteristics should the nurse expect (select all that apply.)? A. Presence of nodules B. Consistent muscle strength C. Localized disease symptoms D. No destructive changes on x-ray E. Subluxation of joints without fibrous ankyloses F. Joint space narrowing and formation of osteophytes

A.E. Presence of nodules; Subluxation of joints without fibrous ankyloses Rationale: In stage III severe RA, extraarticular soft tissue lesions or nodules may be present along with subluxation without fibrous or bony ankylosis. Muscle strength is decreased because of extensive muscle atrophy. Manifestations are systemic rather than localized. There is x-ray evidence of cartilage and bone destruction in addition to osteoporosis. Joint space narrowing with osteophytes is consistent with osteoarthritis.

A 28-yr-old woman with a fracture of the proximal left tibia in a long leg cast and complains of severe pain and a prickling sensation in the left foot. The toes on the left foot are pale and cool. Which nursing action is a priority? A.Notify the health care provider immediately. B. Elevate the left leg above the level of the heart. C. Administer prescribed morphine sulfate intravenously. D. Apply ice packs to the left proximal tibia over the cast.

A.Notify the health care provider immediately. Rationale: Notify the health care provider immediately of this change in patient's condition, which suggest development of compartment syndrome. Pain unrelieved by drugs and out of proportion to the level of injury is one of the first indications of impending compartment syndrome. Changes in sensation (tingling) also suggest compartment syndrome. Because elevation of the extremity may lower venous pressure and slow arterial perfusion, the extremity should not be elevated above heart level. Similarly, the application of cold compresses may result in vasoconstriction and exacerbate compartment syndrome. Administration of morphine may be warranted, but it is not the first priority.

Which nursing activity is appropriate for the registered nurse (RN) working in the eye clinic to delegate to experienced unlicensed assistive personnel (UAP)? A. Instilling antiviral drops for a patient with a corneal ulcer B Application of a warm compress to a patient's hordeolum C. Instruction about hand washing for a patient with herpes keratitis D. Looking for eye irritation in a patient with possible conjunctivitis

B Application of a warm compress to a patient's hordeolum Rationale: Application of cold and warm packs is included in UAP education and the ability to accomplish this safely would be expected for UAP working in an eye clinic. Medication administration, patient teaching, and assessment are high level skills appropriate for the education and legal practice level of the RN

The nurse determines additional instruction is needed when a patient diagnosed with scleroderma makes which statement? A. "Paraffin baths can be used to help my hands" B. "I should lie down for an hour after each meal." C. "Lotions will help if I rub them in for a long time." D. "I should perform range of motion exercises daily."

B. "I should lie down for an hour after each meal." Rationale: Because of esophageal scarring, patients should sit up for 2 hours after eating, The other patient statements are correct and indicate teaching has been effective

Which statement by a patient with systemic lupus erythematosus (SLE) indicates that the patient has understood the nurse's teaching about the condition A. "I will exercise even if I am tired." B. " I will use sunscreen when I am outside." C. " I should avoid nonsteroidal antiinflammatory drugs." D. "I should take birth control pills to avoid getting pregnant."

B. " I will use sunscreen when I am outside." Rationale: Severe skin reactions can occur in patients with SLE who are exposed to the sun. Patient should avoid fatigue by balancing exercise with rest periods as needed. Oral contraceptives can exacerbate lupus. Aspirin and nonsteroidal antiinflammatory drugs are used to treat the musculoskeletal manifestations of SLE

The nurse provides instructions to a 30-yr-old female office worker who has low back pain. Which statement indicates additional patient teaching is required? A. "Switching between hot and cold packs may relieve pain and stiffness." B. "Acupuncture to the lower back would cause irreparable nerve damage." C. "Smoking may aggravate back pain by decreasing blood flow to the spine." D. "Sleeping on my side with knees and hips bent reduces stress on my back."

B. "Acupuncture to the lower back would cause irreparable nerve damage." Rationale: 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.

The triage nurse at an ambulatory clinic receives a call from an individual with possible metal fragments in both eyes. Which instructions would the nurse provide for emergency care of this possible eye injury? A. "Remove any visible metal fragments." B. "Apply a loose dressing over your eyes." C. "Rinse your eyes immediately with water." D. "Keep your eyes open to allow tears to form."

B. "Apply a loose dressing over your eyes." Rationale: An initial intervention for a penetrating eye injury includes covering the eye(s) with a dry, sterile patch and protective shield. The fragments should not be removed by the individual or others. Penetrating eye injuries should not be irrigated (only irrigate for chemical eye injuries).

The patient informs the nurse that he has a "sty" that has been present for some time on the upper eyelid and reports using warm moist compresses with no improvement. What is the best response by the nurse? A. "Go to the pharmacy to get some eye drops." B. "Come in so the ophthalmologist can assess the lesion." C. "The health care provider will need to inject it with an antibiotic." D. "Wash the eyelid margins with baby shampoo to remove the crusting."

B. "Come in so the ophthalmologist can assess the lesion." Rationale: A chalazion may evolve from a "sty" or hordeolum as it did for this patient. Initial treatment is with warm compresses, but when they are ineffective, the lesion may be surgically removed or injected with corticosteroids. Washing the eyelid margins with baby shampoo is done with blepharitis.

A patient complains of shoulder pain when the nurse moves the patient's arm behind the back. Which question should the nurse ask? A. "Are you able to feed yourself without difficulty?" B. "Do you have difficulty when you are putting on a shirt?" C. "Are you able to sleep through the night without waking?" D. "Do you ever have trouble lowering yourself to the toilet?"

B. "Do you have difficulty when you are putting on a shirt?" Rationale: The patient's pain will make it more difficult to accomplish tasks such as putting on a shirt or jacket. This pain should not affect the patient's ability to feed himself or use the toilet because these tasks do not involve moving the arm behind the patient. The arm will not usually be positioned behind the patient during sleeping

A 66-yr-old man with type 2 diabetes mellitus and atrial fibrillation has begun taking glucosamine and chondroitin for osteoarthritis. Which question is most important for the nurse to ask? A. "Did you have any hypoglycemic reactions?" B. "Have you noticed any bruising or bleeding?" C. "Have you had any dizzy spells when standing up?" D. "Do you have any numbness or tingling in your feet?"

B. "Have you noticed any bruising or bleeding?" Rationale: Glucosamine and chondroitin are dietary supplements commonly used to treat osteoarthritis. Both may increase the risk of bleeding. Patients with atrial fibrillation routinely take an anticoagulant to reduce the risk of venous thromboembolism and stroke. Use of glucosamine and chondroitin along with an anticoagulant may precipitate excessive bleeding. Glucosamine may decrease the effectiveness of insulin or other drugs used to control blood glucose, and hyperglycemia may occur.

Which statement by a patient who has had an above the knee amputation indicates the nurse's discharge teaching has been effective? A. "I should elevate my residual limb on a pillow 2 or 3 times daily." B. "I should lie flat on my abdomen for 30 minutes 3 or 4 times daily." C. "I should changed the limb sock when it becomes soiled or each week." D. "I should use lotion on the stump to prevent skin drying and cracking."

B. "I should lie flat on my abdomen for 30 minutes 3 or 4 times daily." Rationale: The patient lies in the prone position several times daily to prevent flexion contractures of of the hip. The limb sock should be changed daily. Lotion should not be used on the stump. The residual limb should not be elevated because this would encourage hip flexion contracture

A patient whose employment requires frequent lifting has a history of chronic back pain. After the nurse has taught the patient about correct body mechanics, which patient statement indicates the teaching has been effective? A. "I will keep my back straight when I lift above than my waist." B. "I will begin doing exercises to strengthen and support my back." C. "I will tell my boss I need a job where I can stay seated at a desk." D. "I can sleep with my hips and knees extended to prevent back strain."

B. "I will begin doing exercises to strengthen and support my back." Rationale: Exercises can help strengthen the muscles that support the back. Flexion of the hips and knees places less strain on the back than keeping these joints extended. Sitting for prolonged periods can aggravate back pain. Modifications in the way the patient lifts boxes are needed, but the patient should not lift above the level of the elbows

Which statement by a patient with bacterial conjunctivitis indicates a need for further teaching? A. "I will wash my hands often during the day." B. "I will remove my contact lenses at bedtime." C. "I will not share towels with my friends or family." D. "I will monitor my family for eye redness or drainage."

B. "I will remove my contact lenses at bedtime." Rationale: Contact lenses should not be usedwhen patients have conjunctivitis because they can further irritate the conjunctiva. Hand washing is the major means to prevent the spread of conjunctivitis. Infection may be spread by sharing towels or other contact. It is common for bacterial conjunctivitis to spread through a family or other group in close contact

After the nurse has finished teaching a patient with osteoarthritis (OA) of the right hip about how to manage the OA. which patient statement indicates the need for more teaching? A. "I can exercise every day to help maintain joint motion." B. "I will take 1g of acetaminophen (Tylenol) every 4 hours." C. "I will take a shower in the morning to help relieve stiffness." D. "I can use a cane to decrease the pressure and pain in my hip."

B. "I will take 1g of acetaminophen (Tylenol) every 4 hours." Rationale: No more than 4g of acetaminophen (1g every 6 hours) should be taken daily to decrease the risk for liver damage. Regular exercise, moist heat, and supportive equipment are recommended for OA management.

A 54-yr-old patient admitted with cellulitis and probable osteomyelitis received an injection of radioisotope at 9:00 AM for a bone scan. Which statement by the nurse is correct? A. "Decreased isotope uptake is seen with osteomyelitis." B. "Isotopes injected for the scan are not harmful to you." C. "The scan will be performed in one hour at 10:00 AM." D. "The procedure takes approximately 10 minutes to complete."

B. "Isotopes injected for the scan are not harmful to you." Rationale: The isotope does not harm the patient. A technician 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. Increased isotope uptake indicates osteomyelitis. Bone scans are completed in about 1 hour.

The nurse is providing care for a patient with loss of hearing acuity over the past several years. Which statement by the nurse is most accurate? A. "This is often due to an infection that will resolve on its own." B. "Many people experience an age-related decline in their hearing." C. "This is likely an effect of your medications. Try stopping them for a few days." D. "You can likely accommodate for your hearing loss with a few small changes in your routine."

B. "Many people experience an age-related decline in their hearing." Rationale: Presbycusis is a loss of hearing that is both common and age-related. Infections are most often accompanied by different symptoms. It would be inappropriate to counsel the patient to stop his medications. It would be simplistic to advise the patient to accommodate the hearing loss rather than seek intervention.

A patient with two school-age children has recently been diagnosed with rheumatoid arthritis (RA) and tells the nurse that home life is very stressful. Which initial response by the nurse is most appropriate? A. "You need to see a family therapist for some help with stress." B. "Tell me more about the situations that are causing you stress." C. "Your family should understand the impact of your rheumatoid arthritis." D. "Perhaps it would be helpful for your family to be involved in a support group."

B. "Tell me more about the situations that are causing you stress." Rationale: The initial action by the nurse should be further assessment. The other three responses might be appropriate based on the information the nurse obtains with further assessment

A 42-yr-old man who is scheduled for 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." Rationale: 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 conclude the patient is concerned about pain or assume the patient is asking to reschedule the procedure.

A patient with glaucoma who has been using timolol (Timoptic) drops for several days tells the nurse that the eye drops cause eye burning and visual blurriness for a short time after administration. The best response to the patient's statement is A. "Those symptoms may indicate a need for an increased dosage of the eye drops." B. "The drops are uncomfortable, but it is important to use them to retain your vision." C. "These are normal side effects of the drug, which should be less noticeable with time." D. "Notify your health care provider so that different eye drops can be prescribed for you."

B. "The drops are uncomfortable, but it is important to use them to retain your vision." Rationale: Patients should be instructed that eye discomfort and visual blurring are expected side effects of the ophthalmic drops but that the drops must be used to prevent further visual field loss. The temporary burning and visual blurriness might not lessen with ongoing use and do not indicate a need for a dosage or medication change

When teaching a patient about the pathophysiology related to open-angle glaucoma, which statement is most appropriate? A. "The retinal nerve is damaged by an abnormal increase in the production of aqueous humor." B. "There is decreased draining of aqueous humor in the eye, causing pressure damage to the optic nerve." C. "The lens enlarges with normal aging, pushing the iris forward, which then covers the outflow channels of the eye." D. "There is a decreased flow of aqueous humor into the anterior chamber by the lens of the eye blocking the papillary opening."

B. "There is decreased draining of aqueous humor in the eye, causing pressure damage to the optic nerve." Rationale: With primary open-angle glaucoma, there is increased intraocular pressure because the aqueous humor cannot drain from the eye. This leads to damage to the optic nerve over time. Primary angle-closure glaucoma is caused by the lens bulging forward and blocking the flow of aqueous humor into the anterior chamber.

A 57-yr-old postmenopausal woman is scheduled for dual-energy x-ray absorptiometry (DXA). Which statement by the patient 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." Rationale: DXA is painless and measures the bone mass of spine, femur, forearm, and total body with minimal radiation exposure. A quantitative ultrasound evaluates bone density using ultrasound of the calcaneus (heel). MRI would require removal of objects such as hearing aids that have metal parts.

A patient complains of intermittent eye dryness. Which question should the nurse ask the patient to determine the etiology of this symptom? A. "Do you take ginkgo to treat asthma or tinnitus?" B. "What do you take if you have allergy symptoms?" C. "Are you taking propranolol for an anxiety disorder?" D. "How long have you been taking prednisone (Deltasone)?"

B. "What do you take if you have allergy symptoms?" Rationale: Antihistamines or decongestants taken for allergies or colds can cause ocular dryness. Ginkgo biloba is an herbal product and has been used to treat asthma and tinnitus. Side effects of ginkgo may include headache, nausea, gastrointestinal upset, diarrhea, dizziness, allergic skin reactions, and increased bleeding. β-Adrenergic blockers can potentiate drugs used to treat glaucoma. Long-term use of prednisone (corticosteroids) may contribute to the development of glaucoma or cataracts.

A tennis player has an arthroscopic repair of a rotator cuff injury performed in same-day surgery. When the nurse plans postoperative teaching for the patient, which information will be included? A. "You will not be able to serve a tennis ball again." B. "You will begin work with a physical therapist tomorrow." C. "Keep the shoulder immobilizer on for the first 4 days to minimize pain." D. "The surgeon will use the drop-arm test to determine the success of surgery."

B. "You will begin work with a physical therapist tomorrow." Rationale: Physical therapy after a rotator cuff repair begins on the first postoperative day to prevent "frozen shoulder". A should immobilizer is used immediately after the surgery, but leaving the arm immobilized for several days would lead to loss of range of motion. The drop-arm test is used to test for rotator cuff injury but not after surgery. The patient may be able to return to tennis after rehabilitation

Which information will the nurse provide to the patient scheduled for refractometry? A. "You should not take any of your eye medicines before the examination." B. "You will need to wear sunglasses for a few hours after the examination." C. "The doctor will shine a bright light into your eye during the examination." D. " The surface of your eye will be numb while the doctor does the examination."

B. "You will need to wear sunglasses for a few hours after the examination." Rationale: The pupils are dilated using cycloplegic medications during refractometry. This effect will last several hours and cause photophobia. The other teaching would not be appropriate for a patient who was having refractometry

Which information will the nurse include when teaching a patient with newly diagnosed systemic exertion intolerance disease (SEID) about self management? A. Symptoms usually progress as patients become older B. A gradual increase in daily exercise may help decrease fatigue C. Avoid use of over the counter antihistamines or decongestants D. A low residue, low fiber diet will reduce any abdominal distention

B. A gradual increase in daily exercise may help decrease fatigue Rationale: A graduated exercise program is recommended to avoid fatigue while encouraging ongoing activity. Because many patients with SEID syndrome have allergies, antihistamines and decongestants are used to treat allergy symptoms. A high fiber diet is recommended. SEID usually does not progress

A patient with a complex pelvic fracture from a motor vehicle crash is on bed rest. Which nursing assessment finding indicates a potential complication of the fracture? A. The patient states the pelvis feels unstable B. Abdomen is distended and bowel sounds are absent C. The patient complains of pelvic pain with palpation D. Ecchymoses are visible across the abdomen and hips

B. Abdomen is distended and bowel sounds are absent Rationale: The abdominal distention and absent bowel sounds may be due to complications of pelvic fractures such as paralytic ileus or hemorrhage or trauma to the bladder, urethra, or colon. Pelvic instability, abdominal pain with palpation , and abdominal bruising would be expected with this type of injury.

When using the otoscope, the nurse is unable to see the landmarks or light reflex of the tympanic membrane. The tympanic membrane is bulging and red. What does the nurse determine is most likely occurring in the patient's ear? A. Swimmer's ear B. Acute otitis media C. Impacted cerumen D. Chronic otitis media

B. Acute otitis media Rationale: The manifestations of inability to see the landmarks or light reflex of the tympanic membrane and the bulging and redness of the tympanic membrane are those of acute otitis media. With swimmer's ear and chronic otitis media, there is frequently drainage in the external auditory canal. Impacted cerumen would block the visualization of the tympanic membrane.

The day after having a right below-the-knee amputation, a patient complains of pain in the right foot. Which action is best for the nurse to take? A. Explain the reasons for the pain. B. Administer prescribed analgesics. C. Reposition the patient to assure good alignment D. Inform the patient that this pain will diminish over time.

B. Administer prescribed analgesics. Rationale: Acute phantom limb sensation is treated as any other type of postoperative pain would be treated. Explanations of the reason for the pain may be given, but the nurse should still medicate the patient. Alignment is important but is unlikely to relieve the pain. Although the pain may decrease over time, it currently requires treatment

Before assisting a patient with ambulation 2 days after a total hip replacement, which action is most important for the nurse to take? A. Observe output from the surgical drain. B. Administer prescribed pain medication. C. Instruct the patient about benefits of early ambulation. D. Change the dressing and document the wound appearance.

B. Administer prescribed pain medication. Rationale: The patient should be adequately medicated for pain before any attempt to ambulate. Instructions about the benefits of ambulation may increase the patient's willingness to ambulate, but decreasing pain with ambulation is more important. The presence of an incisional drain or timing of dressing change will not affect ambulation

After being hospitalized for 3 days with a right femur fracture, a patient suddenly develops shortness of breath and tachypnea. The patient tells the nurse, "I feel like I am going to die!" Which action should the nurse take first? A. Stay with the patient and offer reassurance. B. Administer the prescribed PRN oxygen at 4 L/min. C. Check the patient's legs for swelling or tenderness. D. Notify the health care provider about the symptoms.

B. Administer the prescribed PRN oxygen at 4 L/min. Rationale: The patient's clinical manifestations and history are consistent with a pulmonary embolism, and the nurse's first action should be to ensure adequate oxygenation. The nurse should offer reassurance to the patient, but meeting the physiologic need for O2 is a higher priority. The health care provider should be notified after the O2 is started and pulse oximetry obtained concerning suspected fat embolism or venous thromboembolism

The health care provider has prescribed the following interventions for a patient who is taking azathioprine (Imuran) for systemic lupus erythematosus. Which order will the nurse question? A. Draw anti-DNA blood titer B. Administer varicella vaccine C. Naproxen (Aleve) 200mg BID D. Famotidine (Pepcid) 20mg daily

B. Administer varicella vaccine Rationale: Live virus vaccines, such as varicella, are contraindicated in a patient taking immunosuppressive drugs. The other orders are appropriate for the patient

Which topic will the nurse teach after a patient has had outpatient cataract surgery and lens implantation? A. Use of oral opioids for pain control B. Administration of corticosteroid eye drops C. Importance of coughing and deep breathing exercises D. Need for bed rest for the first 1 to 2 days after the surgery

B. Administration of corticosteroid eye drops Rationale: Antibiotic and corticosteroid eye drops are commonly prescribed after cataract surgery. The patient should be able to administer them using safe technique. Pain is not expected after cataract surgery, and opioids will bot be needed. Coughing and deep breathing exercises are not needed because a general anesthetic agent is not used. There is not bed rest restriction after cataract surgery

A female patient with a history of rheumatoid arthritis complains of stiffness in her right knee and complete fixation of the joint. What problem does the nurse anticipate will be identified in the patient's history and physical examination? A. Atrophy B. Ankylosis C. Crepitation D. Contracture

B. Ankylosis Rationale: Ankylosis is stiffness or fixation of a joint, and contracture is reduced movement as a consequence of fibrosis of soft tissue (muscles, ligaments, or tendons). Atrophy is a wasting of muscle leading to decreased function and tone. Crepitation is a grating or crackling sound that accompanies joint movement. Problem identification leads to determination of an appropriate treatment.

Which action will the urgent care nurse take for a patient with a possible knee meniscus injury? A. Encourage bed rest for 24 to 48 hours B. Apply an immobilizer to the affected leg C. Avoid palpation or movement of the knee D. Administer intravenous opioids for pain management

B. Apply an immobilizer to the affected leg Rationale: A knee immobilizer may be used for several days after a meniscus injury to stabilize the knee and minimize the pain. Patients are encouraged to ambulate with crutches. The knee is assessed by flexing, internally rotating, and extending the knee (McMurray's test). The pain associated with a meniscus injury will not typically require IV opioid administration. Nonsteroidal antiinflammatory drugs (NSAIDs) are usually recommended for pain management

Which information will the nurse include when preparing teaching materials for a patient with an exacerbation of rheumatoid arthritis? A. Affected joints should not be exercised when pain is present B. Applying cold packs before exercise may decrease joint pain C. Exercises should be performed passively by someone other than the patient D. Walking may substitute for range of motion (ROM) exercises on some days

B. Applying cold packs before exercise may decrease joint pain Rationale: Cold application is helpful in reducing pain during periods of exacerbation of RA. Because the joint pain is chronic, patients are instructed to exercise even when joints are painful. ROM exercises are intended to strengthen joints and improve flexibility, so passive ROM alone is not sufficient. Recreational exercise is encouraged but is not a replacement for ROM exercises

Which action will the nurse take first when a patient is seen in the outpatient clinic with neck pain? A. Provide information about therapeutic neck exercises B. Ask about numbness or tingling of the hands and arms C. Suggest the patient alternate the use of heat and cold to the neck D. Teach about the use of nonsteroidal antiinflammatory drugs (NSAIDs)

B. Ask about numbness or tingling of the hands and arms Rationale: The nurse's initial action should be further assessment of related symptoms because cervical nerve root compression will require different treatment than musculoskeletal neck pain. The other actions may also be appropriate, depending on the assessment findings

Which nursing intervention will be included in the plan of care after a patient with a right femur fracture has a hip spica cast applied? A. Avoid placing the patient in a prone position B. Ask the patient about abdominal discomfort C. Discuss remaining on bed rest for several weeks D. Use the cast support bar to reposition the patient

B. Ask the patient about abdominal discomfort Rationale: Assessment of bowel sounds, abdominal pain, and nausea and vomiting will detect the development of abdominal cast syndrome. To avoid breakage, the cast support bar should not be used for repositioning. After the cast dries, the patient can begin ambulating with the assistance of physical therapy personnel and may be turned to the prone position

A 75 year old patient who lives alone at home tells the nurse, "I am afraid of losing my independence because my eyes don't work as well as they used to ." Which action should the nurse take first? A. Discuss the increased risk for falls that is associated with impaired vision B. Ask the patient about what type of vision problems are being experienced C. Explain that there are many ways to compensate for decreases in visual acuity D. Suggest ways of improving the patient's safety, such as using brighter lighting

B. Ask the patient about what type of vision problems are being experienced Rationale: The nurse's initial action should be further assessment of the patient's concerns and visual problems. The other actions may be appropriate, depending on what the nurse finds with further assessment

A patient with muscular dystrophy is hospitalized with pneumonia. Which nursing action will be included in the plan of care? A. Logroll the patient every 2 hours B. Assist the patient with ambulation C. Discuss the need for genetic testing with the patient D. Teach the patient about the muscle biopsy procedure

B. Assist the patient with ambulation Rationale: Because the goal for the patient with muscular dystrophy is to keep the patient active for as long as possible, assisting the patient to ambulate will be part of the care plan. The patient will not require logrolling. Muscle biopsies are necessary to confirm the diagnosis but are not necessary for a patient who already has a diagnosis. There is no need for genetic testing because the patient already knows the diagnosis

A patient with Ménière's disease had decompression of the endolymphatic sac to reduce the frequent and incapacitating attacks being experienced. What should the nurse include in the discharge teaching for this patient? A. Airplane travel will be more comfortable now. B. Avoid sudden head movements or position changes. C. Cough or blow the nose to keep the Eustachian tubes clear. D. Take antihistamines, antiemetics, and sedatives for recovery.

B. Avoid sudden head movements or position changes. Rationale: After ear surgery, the patient should avoid sudden head movements or position changes. The patient should not cough or blow the nose because this increases pressure in the Eustachian tube and middle ear cavity and may disrupt healing. Airplane travel should be avoided at first as increased pressure and ear popping is normally experienced, which will disrupt healing. Antihistamines, antiemetics, and sedatives are used to decrease the symptoms of acute attacks of Ménière's disease.

Which laboratory result will the nurse monitor to determine if prednisone has been effective for a patient with an acute exacerbation of rheumatoid arthritis? A. blood glucose B. C reactive protein C. serum electrolytes D. Liver function tests

B. C reactive protein Rationale: C-reactive protein is a serum marker for inflammation, and a decrease would indicate the corticosteroid therapy was effective. Blood glucose and serum electrolytes will also be monitored to assess for side effects of prednisone. Liver function is not routinely monitored in patients receiving corticosteroids

Which action could the registered nurse (RN) who is working in the eye and ear clinic delegate to a licensed practical/vocational nurse (LPN/LVN)? A. Evaluate a patient's ability to administer eye drops B. Check a patient's visual acuity using a Snellen chart C. Inspect a patient's external ear for signs or irritation caused by a hearing aid D. Teach a patient with otosclerosis about use of sodium fluoride and Vitamin D

B. Check a patient's visual acuity using a Snellen chart Rationale: Using standardized screening tests such as a Snellen chart to test visual acuity is included in LPN education and scope of practice. Evaluation, assessment, and patient teaching are higher level skills that require RN education and scope of practice

The public health nurse is providing community education to increase the number of people who seek care after a tick bite. What priority information should the nurse provide to people at risk for tick bites? A. The best therapy for the acute illness is an IV antibiotic. B. Check for an enlarging reddened area with a clear center. C. Surveillance is necessary during the summer months only. D. Antibiotics will prevent Lyme disease if taken for 10 days.

B. Check for an enlarging reddened area with a clear center. Rationale: After a tick bite, the expanding "bull's eye rash" is the most characteristic symptom that usually occurs in 3 to 30 days. Flu-like symptoms and migrating joint and muscle pain also may be present. Active lesions are treated with oral antibiotics for 2 to 3 weeks; doxycycline is effective in preventing Lyme disease when given within 3 days after the bite of a deer tick. IV therapy is used with neurologic or cardiac complications. Although ticks are most prevalent during summer months, residents of high-risk areas should check for ticks whenever they are outdoors. No vaccine is available.

A patient with psoriatic arthritis and back pain is receiving etanercept (Enbrel). Which finding is most important for the nurse to report to the health care provider? A. Red, scaly patches are noted on the arms B. Crackles are auscultated in the lung bases C. Hemoglobin is 11.1g/dL and hematocrit is 35% D. Patient has continued pain after first week of etanercept therapy

B. Crackles are auscultated in the lung bases Rationale: Because heart failure is a possible adverse effect of etanercept, the medication may need to be discontinued. The other information will also be reported to the health care provider but does not indicate a need for change in treatment. Red, scaly patches of skin and mild anemia are commonly seen with psoriatic arthritis. Treatment with biologic therapies requires time to improve systems

The nurse notes crackling sounds and a grating sensation with palpation of an older patient's elbow. How will this finding be documented? A. Torticollis B. Crepitation C. Subluxation D. Epicondylitis

B. Crepitation Rationale: Crackling sounds and a grating sensation that accompany movement are described as crepitus or crepitation. Torticollis is a twisting of the neck to one side, subluxation is a partial dislocation of the joint, and epicondylitis is an inflammation of the elbow causing a dull ache that increases with movement

The nurse completes an admission history for a 73-yr-old man with osteoarthritis scheduled for total knee arthroplasty. Which response is expected when asking the patient the reason for admission? A. Recent knee trauma B. Debilitating joint pain C. Repeated knee infections D. Onset of frozen knee joint

B. Debilitating joint pain Rationale: The most common reason for knee arthroplasty is debilitating joint pain despite exercise, weight management, and drug therapy. Recent knee trauma, repeated knee infections, and onset of frozen knee joint are not primary indicators for a knee arthroplasty.

A nurse is working with a 73-yr-old patient with osteoarthritis. Which description of the disorder should be included in the teaching plan? A. Joint destruction caused by an autoimmune process B. Degeneration of articular cartilage in synovial joints C. Overproduction of synovial fluid resulting in joint destruction D. Breakdown of tissue in non-weight-bearing joints by enzymes

B. Degeneration of articular cartilage in synovial joints Rationale:

A nurse is working with a 73-yr-old patient with osteoarthritis. Which description of the disorder should be included in the teaching plan? A. Joint destruction caused by an autoimmune process B. Degeneration of articular cartilage in synovial joints C. Overproduction of synovial fluid resulting in joint destruction D. Breakdown of tissue in non-weight-bearing joints by enzymes

B. Degeneration of articular cartilage in synovial joints Rationale: OA is a degeneration of the articular cartilage in diarthrodial (synovial) joints from damage to the cartilage. The condition has also been referred to as degenerative joint disease. OA is not an autoimmune disease. There is no overproduction of synovial fluid causing destruction or breakdown of tissue by enzymes.

A nurse should include which instructions when teaching a patient with repeated hordeolum how to prevent further infection A. apply cold compresses B. Discard used eye cosmetics C. Wash the scalp and eyebrows with an antiseborrheic shampoo D. Be examined for recurrent sexually transmitted infections (STIs)

B. Discard used eye cosmetics Rationale: Hordeolum (styes) are commonly caused by staphylococcus aureus, which may be present in cosmetics that the patient is using. Warm compresses are recommended to treat hordeolum. Antiseborrheic shampoos are recommended for seborrheic blepharitis. Patients with adult inclusion conjunctivitis, which is caused by chlamydia trachomatis, should be referred for STI testing

Which finding will the nurse expect when assessing a patient who has osteoarthritis (OA) of the knee? A. Presence of Heberden's nodules B. Discomfort with joint movement C. Redness and swelling of the knee joint D. Stiffness that increases with movement

B. Discomfort with joint movement Rationale: Initial symptoms of OA include pain with joint movement. Herberden's nodules occur on the fingers. Redness of the joint is associated with inflammatory arthritis such as rheumatoid arthritis. Stiffness in OA is worse right after the patient rests and decreases with joint movement.

The nurse is developing a plan of care for a patient diagnosed with adult inclusion conjunctivitis (AIC) caused by Chlamydia trachomatis. Which action should be included in the plan of care? A. Applying topical corticosteroids to decrease inflammation B. Discussing the need for sexually transmitted infection testing C. Educating about the use of antiviral eyedrops to treat the infection D. Assisting with applying for community visual rehabilitation services

B. Discussing the need for sexually transmitted infection testing Rationale: Patients with AIC have a high risk for concurrent genital Chlamydia infection and should be referred for sexually transmitted infection testing. AIC is treated with antibiotics. Antiviral and corticosteroid medications are not appropriate therapies. Although some types of Chlamydia infection do cause blindness, AIC does not lead to blindness, so referral for visual rehabilitation is not appropriate

Which information will the nurse include when teaching a patient with newly diagnosed ankylosing spondylitis (AS) about management of the condition? A. Exercise by taking long walks B. Do daily deep breathing exercises C. Sleep on the side with hips flexed D. Take frequent naps during the day

B. Do daily deep breathing exercises Rationale: Deep breathing exercises are used to decrease the risk for pulmonary complications that may result from reduced chest expansion that can occur with AS. Patients should sleep on the back and avoid flexed positions. Prolonged standing and walking should be avoided. There is no need for frequent naps

Which nursing action can the registered nurse (RN) delegate to unlicensed assistive personnel (UAP) who are assisting with the care of patient with scleroderma? A. Monitor for difficulty in breathing B. Document the patient's oral intake C. Check finger strength and movement D. Apply capsaicin (Zostrix) cream to hands

B. Document the patient's oral intake Rationale: Monitoring and documenting patient's oral intake is included in UAP education and scope of practice. Assessments for changes in physical status and administration of medications require more education and scope of practice, and should be done by RNs

A patient has ptosis resulting from myasthenia gravis. Which assessment finding would the nurse expect to see in this patient? A. Redness and swelling of the conjunctiva B. Drooping of the upper lid margin in one or both eyes C. Redness, swelling, and crusting along the eyelid margins D. Small, superficial white nodules along the eyelid margin

B. Drooping of the upper lid margin in one or both eyes Rationale: Ptosis is the term used to describe drooping of the upper eyelid margin, which may be either unilateral or bilateral. Ptosis can be a result of mechanical causes, such as an eyelid tumor or excess skin, or from myogenic causes such as myasthenia gravis. Redness, swelling of the conjunctive, or crusting along the eyelid margins may indicate an infection such as viral or bacterial conjunctivitis. Small superficial white nodules along the eyelid margin may indicate hordeolum (sty).

The nurse identifies a nursing diagnosis of pain related to muscle spasms for a 45-yr-old patient who has low back pain from a herniated lumbar disc. Which nursing intervention would be most appropriate? A. Provide gentle ROM to the lower extremities. B. Elevate the head of the bed 20 degrees and flex the knees. C. Place a small pillow under the patient's upper back to gently flex the lumbar spine. D. Place the bed in reverse Trendelenburg with the patient's feet firmly against the footboard.

B. Elevate the head of the bed 20 degrees and flex the knees. Rationale: To reduce pain, the nurse should elevate the head of the bed 20 degrees and have the patient flex the knees to avoid extension of the spine. 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.

Which result for a patient with systemic lupus erythematosus (SLE) is most important for the nurse to communicate to the health care provider? A. Decreased C-reactive protein (CRP) B. Elevated blood urea nitrogen (BUN) C. Positive antinuclear antibodies (ANA) D. Positive lupus erythematosus cell prep

B. Elevated blood urea nitrogen (BUN) Rationale: Elevated BUN and serum creatinine indicate possible lupus nephritis and a need for a change in therapy to avoid further renal damage. The positive lupus erythematosus cell prep and ANA would be expected in a patient with SLE. A drop in CRP shows decreased inflammation

Which action will the nurse include in the plan of care of a patient with a new diagnosis of rheumatoid arthritis (RA)? A. Instruct the patient to purchase a soft mattress B. Encourage the patient to take a nap in the afternoon C. Teach the patient to use lukewarm water when bathing D. Suggest exercise with light weights several times daily

B. Encourage the patient to take a nap in the afternoon Rationale: Adequate rest helps decrease the fatigue and pain associated with RA. Patients are taught to avoid stressing joints, use warm baths to relieve stiffness, and use a firm mattress. When the disease is stabilized, a therapeutic exercise program is usually developed by a physical therapist to include exercises that improve flexibility and strength of affected joints, as well as the patient's general endurance

When caring for a patient who is using Buck's traction after a hip fracture, which action can the nurse delegate to unlicensed assistive personnel (UAP)? A. Remove and reapply traction periodically B. Ensure the weight of the traction is hanging freely C. Monitor the skin under the traction boot for redness D. Check the intact sensation and movement in the affected leg

B. Ensure the weight of the traction is hanging freely Rationale: UAP can be responsible for maintaining the integrity of the traction after it has been established. The RN should assess the extremity and assure manual traction is maintained if the traction device has to be removed and reapplied. Assessment of skin integrity and circulation should be done by the registered nurse

The patient with presbycusis is fitted with binaural hearing aids. Which information will the nurse include when teaching the patient how to use the hearing aids? A. Keep the volume low on the hearing aids for the first week B. Experiment with volume and hearing in a quiet environment C. Add the second hearing aid after making adjustments to the first hearing aid D. Begin by wearing the hearing aids for an hour a day, gradually increasing the use

B. Experiment with volume and hearing in a quiet environment Rationale: Initially the patient should use the hearing aids in a quiet environment such as at home, experimenting with increasing and decreasing the volume as needed. There is no need to gradually increase the time of wear. The patient should experiment with the level of volume to find what works well in various situations. Both hearing aids should be used

When administering medications to the patient with chronic gout, the nurse would recognize which of the following as a treatment for chronic disease? a. Colchicine b. Febuxostat c. Sulfasalazine d. Cyclosporine

B. Febuxostat Rationale: Febuxostat (Uloric), a selective inhibitor of xanthine oxidase, is given for long term management of hyperuricemia in persons with chronic gout. An acute episode of gout is treated with colchicine and nonsteroidal antiinflammatory drugs (NSAIDs)

Which action will the nurse take when performing ear irrigation for a patient with cerumen impaction? A. Assist the patient to a supine position for the irrigation B. Fill the irrigation syringe with body temperature solution C. Use a sterile applicator to clean the ear canal before irrigating D. Occlude the ear canal completely with the syringe while irrigating

B. Fill the irrigation syringe with body temperature solution Rationale: Solution at body temperature is used for ear irrigation. The patient should be sitting for the procedure. Use of cotton tipped applicators to clear the ear may result in forcing the cerumen deeper into the ear canal. The ear should not be completely occluded with the syringe

The occupational health nurse is caring for an employee who is complaining of bilateral eye pain after a cleaning solution splashed into the employee's eyes. Which action will the nurse take? A. Apply cool compresses B. Flush the eyes with saline C. Apply anesthetic ophthalmic ointment to the eyes D. Cover the eyes with dry sterile patches and shields

B. Flush the eyes with saline Rationale: In the case of chemical exposure, the nurse should begin treatment by flushing the eyes until the patient has been assessed by a health care provider and orders are available

A patient is being discharged after 1 week of IV antibiotic therapy for acute osteomyelitis in the right leg. Which information will be included in the discharge teaching? A. How to apply warm packs to the leg to reduce pain B. How to monitor and care for a long term IV catheter C. The need for daily aerobic exercise to help maintain muscle strength D. The reason for taking oral antibiotics for 7 to 10 days after discharge

B. How to monitor and care for a long term IV catheter Rationale: The patient will be taking IV antibiotics for several months. The patient will need to recognize signs of infection at the IV site and know how to care for the catheter during daily activities such as bathing. IV antibiotics rather than oral antibiotics are used for acute osteomyelitis. Patients are instructed to avoid exercise and heat application because these will increase swelling and the risk for spreading infection

The nurse is assessing a patient's medical history. What aspects of the patient's medical history are most likely to have potential consequences for the patient's visual system? A. Hypothyroidism and polycythemia B. Hypertension and diabetes mellitus C. Atrial fibrillation and atherosclerosis D. Vascular dementia and chronic fatigue

B. Hypertension and diabetes mellitus Rationale: Hypertension and diabetes frequently contribute to visual pathologies. The other health problems are less likely to have a direct, deleterious effect on a patient's vision.

A patient with acute osteomyelitis of the left femur is hospitalized fro regional antibiotic irrigation. Which intervention will the nurse include in the initial plan of care? A. Quadriceps-setting exercises B. Immobilization of the left leg C. Positioning with the left leg in flexion D. Assisted weight bearing ambulation

B. Immobilization of the left leg Rationale: Immobilization of the affected leg helps to decrease pain and reduce the risk for pathologic fracture. Weight bearing exercise increases the risk for pathologic fractures. Flexion of the affected limb is avoided to prevent contractures

A patient has scleroderma manifested by CREST (calcinosis, Raynaud's phenomenon, esophageal dysfunction, sclerodactyly, and telangiectasia) syndrome. Which action will the nurse include in the plan of care? A. Avoid use of capsaicin cream on hands. B. Keep the environment warm and draft free. C. Obtain capillary blood glucose before meals. D. Assist to bathroom every 2 hours while awake.

B. Keep the environment warm and draft free. Rationale: Keeping the room warm will decrease the incidence fo Raynaud's phenomenon, one aspect of the CREST syndrome. Capsaicin cream may be used to improve circulation and decrease pain. There is no need to obtain blood glucose or to assist the patient to the bathroom every 2 hours

The home care nurse visits a 74-yr-old man diagnosed with Parkinson's disease who fell while walking this morning. What observation is of most concern to the nurse? A. 2 × 6 cm right calf abrasion with sanguineous drainage B. Left leg externally rotated and shorter than the right leg C. Stooped posture with a shuffling gait and slow movements D. Mild pain and minimal swelling of the right ankle and foot

B. Left leg externally rotated and shorter than the right leg Rationale: Clinical manifestations of hip fracture include external rotation, muscle spasm, shortening of the affected extremity, and severe pain and tenderness in the region of the fracture site. Expected clinical manifestations of Parkinson's disease include a stooped posture, shuffling gait, and slow movements. An abrasion is a soft tissue injury. Mild pain and minimal swelling may occur with a sprain or strain.

The nurse is caring for a patient admitted to the nursing unit with osteomyelitis of the tibia. When completing a focused assessment, which symptom will the nurse expect? 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 Rationale: 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 rather than generalized throughout the leg.

Which prescribed medication should the nurse give first to a patient who has just been admitted to a hospital with acute angle-closure glaucoma? A. Morphine sulfate 4mg IV B. Mannitol (Osmitrol) 100mg IV C. Betaxolol (Betoptic) 1 drop in each eye D. Acetazolamide (Diamox) 250mg orally

B. Mannitol (Osmitrol) 100mg IV Rationale: The most immediate concern for the patient is to lower iintraocular pressure, which will occur most rapidly with IV administration of a hyperosmolar diuretic such as mannitol. The other medications are also appropriate for a patient with glaucoma but would not be the first medication administered

During a health screening event, which assessment finding in a white, 61-yr-old woman would alert the nurse to the possible presence of osteoporosis? A. Presence of bowed legs B. Measurable loss of height C. Poor appetite and aversion to dairy products D. Development of unstable, wide-gait ambulation

B. Measurable loss of height Rationale: A gradual but measurable loss of height and the development of kyphosis ("dowager's hump") are indicative of the presence of osteoporosis. Bowed legs may be caused by abnormal bone development or rickets but are not indicative of osteoporosis. Lack of calcium and Vitamin D intake may cause osteoporosis but are not indicative of its presence. A wide gait is used to support balance and does not indicate osteoporosis.

The home care nurse visits an 84-yr-old woman with pneumonia after her discharge from the hospital. Which age-related change in the musculoskeletal system is expected? 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 Rationale: 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.

Which action can the nurse delegate to unlicensed assistive personnel (UAP) who are working in the orthopedic clinic? A. Grade leg muscle strength for a patient with back pain. B. Obtain blood sample for uric acid from a patient with gout. C. Perform straight-leg-raise testing for a patient with sciatica. D. Check for knee joint crepitation before arthroscopic surgery.

B. Obtain blood sample for uric acid from a patient with gout. Rationale: In clinic setting, drawing blood specimens is a common skill performed by UAP who are trained. The other actions are assessments and require registered nurse (RN) level judgement and critical thinking

What should the nurse explain to the student regarding normal bone remodeling? A. Osteoclasts add canaliculi. B. Osteoblasts deposit new bone. C. Osteocytes are immature bone cells. D. Osteons synthesize organic bone matrix.

B. Osteoblasts deposit new bone. Rationale: 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; however, they are not involved with bone remodeling.

The nurse is admitting a patient who is scheduled for knee arthroscopy related to osteoarthritis. Which finding should the nurse expect when examining the patient's knees? A. Ulnar drift B. Pain with joint movement C. Reddened, swollen affected joints D. Stiffness that increases with movement

B. Pain with joint movement Rationale: Osteoarthritis is characterized predominantly by joint pain upon movement and is a classic feature of the disease. Ulnar drift occurs with rheumatoid arthritis, not osteoarthritis. Local inflammation (red, swollen joints) is unlikely with osteoarthritis. Stiffness decreases with movement.

Which information obtained by the nurse about a patient with a lumbar vertebral compression fracture requires immediate report to the health care provider? A. Patient refuses to be turned due to back pain B. Patient has been incontinent of urine and stool C.Patient reports lumbar area tenderness to palpation D. Patient frequently uses oral corticosteroids to treat asthma

B. Patient has been incontinent of urine and stool Rationale: Changes in bowel or bladder function indicate possible spinal cord compression and should be reported immediately because surgical intervention may be needed. The other findings are also pertinent but are consistent with the patient's diagnosis and do not require immediate intervention

A nurse who works on the orthopedic unit has just received the change-of-shift report. Which patient should the nurse assess first? A. Patient who reports foot pain after hammertoe surgery B. Patient who has not voided 10 hours after having a laminectomy C. Patient with low back pain and a positive straight leg raise test D. Patient with osteomyelitis who has a temperature of 100.5° F (38.1°

B. Patient who has not voided 10 hours after having a laminectomy Rationale: Difficulty in voiding may indicate damage to the spinal nerves and should be assessed and reported to the surgeon immediately. The information about the other patients is consistent with their diagnoses. The nurse will need to assess them as quickly as possible, but the information about them does not indicate a need for immediate intervention

Which patient arriving at the urgent care center will the nurse assess first? A. Patient with purulent left eye discharge, pruritus, and conjunctival inflammation B. Patient with acute right eye pain that began while using home power tools C. Patient who is complaining of intense discomfort after an insect crawled into the right ear D. Patient who has Meniere's disease and is complaining of nausea, vomiting, and dizziness

B. Patient with acute right eye pain that began while using home power tools Rationale: The history and symptoms suggest eye trauma with a possible penetrating injury. Blindness may occur unless the patient is assessed and treated rapidly. The other patients should be treated as soon as possible, but do not have clinical manifestations that indicate any acute risk for vision or hearing loss

Which action can the nurse working in the emergency department delegate to experienced unlicensed assistive personnel (UAP)? A. Ask a patient with decreased visual acuity about medications taken at home. B. Perform Snellen testing of visual acuity for a patient with a history of cataracts C. Obtain information from a patient about any history of childhood ear infections D. Inspect a patient's external ear for redness, swelling, or presence of skin lesions

B. Perform Snellen testing of visual acuity for a patient with a history of cataracts Rationale: The Snellen test does not require nursing judgement and is appropriate to delegate to UAP who have been trained to perform it. History taking about infection or medications and assessment are actions that require critical thinking and should be done by the RN

A patient is diagnosed with severe myopia. Which type of correction is the patient planning to have if they state, "I can't wait to be able to see after they implant a contact lens over my lens"? A. Photorefractive keratectomy (PRK) B. Phakic intraocular lenses (phakic IOLs) C. Refractive intraocular lens (refractive IOL) D. Laser-assisted in situ keratomileusis (LASIK)

B. Phakic intraocular lenses (phakic IOLs) Rationale: Phakic intraocular lenses (phakic IOLs) is the implantation of a contact lens in front of the natural lens. PRK is used with low to moderate amounts of myopia, and the epithelium is removed and the laser sculpts the cornea to correct the refractive error. Refractive IOL is also for patients with a high degree of myopia or hyperopia and involves removing the natural lens and implanting an intraocular lens. LASIK surgery is similar to PRK except that the epithelium is replaced after surgery.

When the patient turns his head quickly during the admission assessment, the nurse observes nystagmus. What is the indicated nursing action? A. Assess the patient with a Rinne test. B. Place a fall-risk bracelet on the patient. C. Ask the patient to watch the mouths of staff when they are speaking. D. Remind unlicensed assistive personnel to speak loudly to the patient.

B. Place a fall-risk bracelet on the patient. Rationale: Problems with balance related to vestibular function may present as nystagmus or vertigo and indicate an increased risk for falls. The Rinne test is used to check hearing. Reading lips and louder speech are compensatory behaviors for decreased hearing

Which nursing intervention is most appropriate when turning a patient after spinal surgery? A. Having the patient turn to the side by grasping the side rails to help turn B. Placing a pillow between the patient's legs and turning the body as a unit 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

B. Placing a pillow between the patient's legs and turning the body as a unit Rationale: 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 after spinal surgery. The other interventions will not maintain proper spine alignment and may cause spinal damage.

A patient who underwent eye surgery is required to wear an eye patch until the scheduled postoperative clinic visit. Which nursing diagnosis will the nurse include in the plan of care? A. Disturbed body image related to eye trauma and eye patch B. Risk for falls related to temporary decrease in stereoscopic vision C. Ineffective health maintenance related to inability to see surroundings D. Ineffective coping related to inability to admit the impact of the eye injury

B. Risk for falls related to temporary decrease in stereoscopic vision Rationale: The loss of stereoscopic vision created by the eye patch impairs the patient's ability to see in three dimensions and to judge distances. It also increases the risk for falls. There is no evidence in the assessment data for ineffective health maintenance, disturbed body image, or ineffective denial

When examining the patient's ear with an otoscope, the nurse observes discharge in the canal and the patient reports pain with the examination. What should the nurse next assess the patient for? A. Sebaceous cyst B. Swimmer's ear C. Metabolic disorder D. Serous otitis media

B. Swimmer's ear Rationale: Swimmer's ear or an infection of the external ear is probably the cause of the discharge and pain. Asking the patient about swimming, ear protection, and exposure to types of water can identify contact with contaminated water. After clearing the discharge, the tympanic membrane can be assessed for otitis media. A sebaceous cyst and metabolic disorders would not cause drainage or discomfort in the external ear canal.

A patient diagnosed with osteosarcoma of the humerus demonstrates understanding of his treatment options when he states A. I accept that I have to lose my arm with surgery B. The chemotherapy before the surgery will shrink the tumor C. This tumor is related to the melanoma I had three years ago D. I'm glad they can take out the cancer with such a small scar

B. The chemotherapy before the surgery will shrink the tumor Rationale: A patient with osteosarcoma usually has preoperative chemotherapy to decrease tumor size. Limb salvage procedures, including wide surgical resection of the tumor, thus can be used more often. Osteosarcoma is an extremely aggressive primary bone tumor that rapidly metastasizes to distant sites

The charge nurse observes a newly hired nurse performing all the following interventions for a patient who has just undergone right cataract removal and an intraocular lens implant. Which one requires that the charge nurse intervene? A. The nurse leaves the eye shield in place B. The nurse encourages the patient to cough C. The nurse elevates the patient's head to 45 degrees D. The nurse applies corticosteroid drops to the right eye

B. The nurse encourages the patient to cough Rationale: Because coughing will increase intraocular pressure, patients are generally taught to avoid coughing during the acute postoperative time. The other actions are appropriate for a patient after having this surgery

A patient who is to have not weight bearing on the left leg is learning to walk using crutches. Which observation by the nurse indicates the patient can safely ambulate independently? A. The patient moves the right crutch with the right leg and then the left crutch with the left leg B. The patient advances the left leg and both crutches together and then advances the right leg C. The patient uses the bedside chair to assist in balance as needed when ambulating the room D. The patient keeps the padded area of the crutch firmly in the axillary area when ambulating

B. The patient advances the left leg and both crutches together and then advances the right leg Rationale: Patients are usually taught to move the crutches and the injured leg forward at the same time and then to move the unaffected leg. Patients are discouraged from using furniture to assist with ambulation. The patient is taught to place weight on the hands, not in the axilla, to avoid brachial plexus damage. If the 2 or 4 point gaits are to be used, the crutch and leg on opposite sides move forward, not the crutch and same side leg

Which assessment finding for a patient using naproxen (Naprosyn) to treat osteoarthritis is likely to require a change in medication? A. The patient has gained 3lb. B. The patient has dark colored stools C. The patient's pain affects multiple joints D. The patient uses capsaicin cream (Zostrix)

B. The patient has dark colored stools Rationale: Dark colored stools may indicate the patient is experiencing gastrointestinal bleeding caused by the naproxen. The patient's ongoing pain and weight gain will also be reported an may indicate a need for a different treatment and/or counseling about avoiding weight gain, but these are not as large a concern as the possibility of gastrointestinal bleeding. Use of capsaicin cream with oral medication is appropriate

A 29-year-old woman is taking methotrexate to treat rheumatoid arthritis. Which information from the patient's health history is important for the nurse to report to the health care provider related to the methotrexate? A. The patient had a history of infectious mononucleosis as a teenager B. The patient is trying to get pregnant before her disease becomes more severe C. The patient has a family history of age related macular degeneration to the retina D. Th patient has been using large doses of vitamins and health foods to treat the RA

B. The patient is trying to get pregnant before her disease becomes more severe Rationale: Methotrexate is teratogenic, and the patient should be taking contraceptives during methotrexate therapy. The other information will not impact the choice of methotrexate as therapy

In caring for a patient after a spinal fusion, the nurse would immediately report which of the following to the surgeon? 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 Rationale: After spinal fusion surgery, the nurse should frequently monitor peripheral neurovascular condition. Movement of the arms and legs and assessment of sensation should be no worse in comparison with the preoperative status. These assessments are repeated at least every 2 to 4 hours during the first 48 hours after surgery, and findings are compared with the preoperative assessment. Paresthesia, such as numbness and tingling, may not be relieved immediately after surgery. The nurse should immediately report any new muscle weakness or paresthesia to the surgeon and document this in the patient's medical record

A patient is being discharged 4 days after hip arthroplasty using the posterior approach. Which patient action requires intervention by the nurse? A. The patient uses crutches with a swing to gait B. The patient leans over to pull on shoes and socks C. The patient sits straight up on the edge of the bed D. The patient bends over the sink while brushing teeth

B. The patient leans over to pull on shoes and socks Rationale: Leaning over would flex the hip at greater than 90 degrees and predispose the patient to hip dislocation. The other patient actions are appropriate and do not require any immediate action by the nurse to protect the patient

The nurse is performing an eye examination on a 76 year old patient. The nurse should refer the patient for a more extensive assessment based on which finding? A. The patient's sclerae are light yellow B. The patient reports persistent photophobia C. The pupil recovers slowly after responding to a bright light D. There is a whitish gray ring encircling the periphery of the iris

B. The patient reports persistent photophobia Rationale: Photophobia is not a normally occurring change with aging and would require further assessment. The other assessment data are common gerontologic differences in assessment and would not be unusual in a 76 year old patient

A patient with an acute attack of gout in the right great toe has a new prescription for probenecid. Which information about the patient's home routine indicates a need for teaching regarding gout management? A. The patient sleeps 8-10 hours each night B. The patient usually eats beef once a week C. The patient takes one aspirin a day to prevent angina D. The patient usually drinks about 3 quarts water each day

B. The patient usually eats beef once a week Rationale: Aspirin interferes with the effectiveness of probenecid and should not be taken when the patient is taking probenecid. The patient's sleep pattern will not affect gout management. Drinking 3 quarts of water and eating beef only once or twice a week are appropriate for the patient with gout

Which assessment information obtained by the nurse indicates a patient with an exacerbation of rheumatoid arthritis (RA) is experiencing a side effect of prednisone? A. The patient has joint pain and stiffness B. The patient's blood glucose is 165 mg/dL C. The patient has experienced a recent 5 pound weight loss D. The patient's erythrocyte sedimentation rate (ESR) has increased

B. The patient's blood glucose is 165 mg/dL Rationale: Corticosteroids have the potential to cause diabetes mellitus. The finding of elevated blood glucose reflects this side effect of prednisone. Corticosteroids increase appetite and lead to weight gain. An elevated ESR with no improvement in symptoms would indicate the prednisone was not effective but would not be side effects of the medication

Which information in a 67 year old woman's health history will alert the nurse to the need for a more focused assessment of the musculoskeletal system? A. The patient sprained her ankle at age 13 B. The patient's mother became shorter with aging C. The patient takes ibuprofen for occasional headaches D. The patient's father died of complications of miliary tuberculosis

B. The patient's mother became shorter with aging Rationale: A family history of height loss with aging may indicate osteoporosis, and the nurse should perform a more thorough assessment of the patient's current height and other risk factors for osteoporosis. A sprained ankle during adolescence does not place the patient at increased risk for musculoskeletal problems. A family history of tuberculosis is not a risk factor. Occasional nonsteroidal antiinflammatory drug (NSAID) use does not indicate any increased musculoskeletal risk

The nurse is examining a patient's ear in the clinic to determine if recent treatment for acute otitis media has been effective. Which assessment finding indicates resolution of the middle ear infection? A. Fenestrations are visible in the tympanic membrane. B. Tympanic membrane is gray, shiny, and translucent. C. Cone of light is not visible on the tympanic membrane. D. Tympanic membrane is blue and bulging with no landmarks.

B. Tympanic membrane is gray, shiny, and translucent. Rationale: The tympanic membrane (TM) is normally pearly gray, white or pink, shiny, and translucent. Perforation of the TM that has not healed will appear as open areas of the tympanic membrane. The absence of the cone of light indicates a retracted TM. A bulging red or blue eardrum and lack of landmarks indicates a fluid-filled middle ear. The fluid may be pus or blood.

The nurse should report which assessment finding immediately to the health care provider? A. Cone of light is visible B. Tympanum is blue tinged C. Skin in the ear canal is dry and scaly D. Cerumen is present in the auditory canal

B. Tympanum is blue tinged Rationale: A bluish tinged tympanum can occur with acute otitis media, which requires immediate care to prevent perforation of the tympanum. Cerumen in the ear canal may need to be removed before proceeding with the examination but is not unusual or pathologic. The presence of a cone of light on the eardrum is normal. Dry and scaly skin in the ear canal may need further assessment but does not require urgent care

Unlicensed assistive personnel (UAP) perform all the following actions when caring for a patient with Meniere's disease who is experiencing an acute attack. Which action by UAP indicates that the nurse should intervene? A. UAP raise the side rails on the bed B. UAP turn on the patient's television C. UAP place an emesis basin at the bedside D. UAP helps the patient turn to the right side

B. UAP turn on the patient's television Rationale: Watching television may exacerbate the symptoms of an acute attack of Meniere's disease. The other actions are appropriate because the patient will be at high fall risk and may suffer from nausea during the acute attack

Which nursing intervention would be most appropriate for a patient with Sjögren's syndrome? A. Ambulate with assistive devices B. Use lubricating eye drops frequently C. Administer acetaminophen as needed D. Apply ice or heat compresses to affected areas

B. Use lubricating eye drops frequently Rationale: Sjögren's syndrome is an autoimmune disorder in which lymphocytes attack moisture-producing glands. Treatment is symptomatic, including adding moisture to eyes and increasing intake of fluids, especially with meals.

The nurse is planning health promotion teaching for a 45-yr-old patient with asthma who is experiencing low back pain from herniated lumbar disc. What activity will the nurse include in an individualized exercise plan for the patient? A. Yoga B. Walking C. Calisthenics D. Weight lifting

B. Walking Rationale: The patient would benefit from an aerobic exercise that considers 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. If the patient has exercise-induced asthma, the nurse would recommend use of a rescue inhaler prior to exercise. Yoga, calisthenics, and weight lifting would all put pressure on or strain the spine.

A young adult arrives in the emergency department with ankle swelling and severe pain after twisting an ankle playing basketball. Which of these prescribed interprofessional interventions will the nurse implement first? A. Send the patient for ankle x-rays B. Wrap the ankle and apply an ice pack C. Administer Naproxen (Naprosyn) 500mg PO D. Give acetaminophen with Codeine (Tylenol #3)

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

An assessment finding for a 55-year-old patient that alerts the nurse to the presence of osteoporosis is A. bowed legs B. a loss of height C. the report of frequent falls D. an aversion to dairy products

B. a loss of height Rationale: Osteoporosis occurring in the vertebrae produces a gradual loss of height. Bowed legs are associated with osteomalacia. Low intake of dairy products is a risk factor for osteoporosis, but it does not indicate osteoporosis is present. Frequent falls increase the risk for fractures but are not an indicator of osteoporosis

The nurse suggests that a patient recently diagnosed with rheumatoid arthritis (RA) plan to start each day with A. b. a short routine of isometric exercises. B. a warm bath followed by a short rest. C. active range-of-motion (ROM) exercises. D. stretching exercises to relieve joint stiffness.

B. a warm bath followed by a short rest. Rationale: Taking a warm shower or bath is recommended to relieve joint stiffness, which is worse in the morning. Isometric exercises would place stress on joints and would not be recommended. Stretching and ROM should be done later in the day, when joint stiffness is decreased

When administering alendronate (Fosamax) to a patient with osteoporosis, the nurse will A. ask about any leg cramps or hot flashes B. assist the patient to sit up at the bedside C. be sure that the patient has recently eaten D. administer the ordered calcium carbonate

B. assist the patient to sit up at the bedside Rationale: To avoid esophageal erosions, the patient taking bisphosphonates should be upright for at least 30 minutes after taking the medication. Fosamax should be taken on an empty stomach, not after taking other medications or eating. Leg cramps and hot flashes are not side effects of bisphosphonates

A patient has a long-arm plaster cast applied for immobilization of a fractured left radius. Until the cast has completely dried, the nurse should A. keep the left arm in dependent position. B. avoid handling the cast using fingertips. C. place gauze around the cast edge to pad any roughness. D. cover the cast with a small blanket to absorb the dampness.

B. avoid handling the cast using fingertips Rationale: Until a plaster cast has dried, using the palms rather than the fingertips to handle the cast helps prevent creating protrusions inside the cast that could place pressure on the skin. The left arm should be elevated to prevent swelling. The edges of the cast may be petaled once the cast is dry, but padding the edges before that may cause the cast to misshapen. The cast should not be covered until it is dry because heat builds up during drying

In patient who has a hemorrhage in the posterior cavity of the eye, the nurse know that blood is accumulating A. in the aqueous humor B. between the lens and retina C. between the cornea and lens D. in the space between the iris and lens

B. between the lens and retina Rationale: The posterior chamber lies between the anterior surface of the lens and the posterior surface of the iris. The posterior cavity lies in the large space behind the lens and in from of the retina

A patient with gout has a new prescription for losartan (Cozaar) to control the condition. The nurse will plan to monitor A. blood glucose. B. blood pressure. C. erythrocyte count. D. lymphocyte count.

B. blood pressure. Rationale: Losartan, an angiotensin II receptor agonist, will lower blood . pressure. It does not affect blood glucose, red blood cells, or lymphocytes

The nurse evaluates that wearing bifocals has improved the patient's myopia and presbyopia by A. strength of the eye muscles B. both near and distant vision C. cloudiness in the eye lenses D. intraocular pressure changes

B. both near and distant vision Rationale: The lenses are prescribed to correct the patient's near and distant vision. The nurse may also assess for cloudiness of the lenses, increased ocular pressure, and eye movement, but these data do no evaluate whether the patient's bifocals are effective

After laminectomy with a spinal fusion to treat a herniated disc, a patient reports numbness and tingling of the right lower leg. The first action the nurse should take is to A. report the patient's complaint to the surgeon. B. check the chart for preoperative assessment data. C. check the vital signs for indications of hemorrhage. D. turn the patient to the left to relieve pressure on the right leg.

B. check the chart for preoperative assessment data. Rationale: The postoperative movement and sensation of the extremities should be unchanged (or improved) from the preoperative assessment. If the numbness and tingling are new, this information should be immediately reported to the surgeon. Numbness and tingling are not symptoms associated with hemorrhage at the site. Turning the patient will not relieve the numbness

The nurse will instruct the patient with a fractured left radius that the cast will need to remain in place A. for several months. B. for at least 3 weeks. C. until swelling of the wrist has resolved. D. until x-rays show complete bony union.

B. for at least 3 weeks Rationale: Bone healing starts immediately after the injury, but because ossification does not begin until 3 weeks after injury, the cast will need to be worn for at least 3 weeks. Complete union may take up to 1 year. Resolution of swelling does not indicate bone healing.

The nurse's discharge teaching for a patient who has had a repair of a fractured mandible will include information about A. administration of nasogastric tube feedings. B. how and when to cut the immobilizing wires. C. the importance of high-fiber foods in the diet. D. the use of sterile technique for dressing changes.

B. how and when to cut the immobilizing wires. Rationale: The jaw will be wired for stabilization, and the patient should know what emergency situations require the wires to be cut to protect the airway. There are no dressing changes for this procedure. The diet is liquid, and patients are not able to chew high fiber foods. Initially, the patient may receive nasogastric tube feedings, but by discharge, the patient will swallow liquid through a straw

In assessing the joints of a patient with osteoarthritis, the nurse understands that Bouchard's nodes A. are often red, swollen, and tender B. indicate osteophyte formation at the PIP joints C. are the result of pannus formation at the DIP joints D. occur from deterioration of cartilage by proteolytic enzymes

B. indicate osteophyte formation at the PIP joints Rationale: Bouchard's nodes are bony deformities of the proximal interphalangeal joints that indicate osteophyte formation and loss of joint space in osteoarthritis

A patient is scheduled for and electromyogram (EMG). The nurse explains that this diagnostic test involves A. incision and 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 Rationale: 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

To determine whether treatment is effective for a patient with primary open-angle glaucoma (POAG), the nurse can evaluate the patient for improvement by A. questioning the patient about blurred vision B. noting any changes in the patient's visual field C. asking the patient to rate the pain using a 0 to 10 scale D. assessing the patient's depth perception when climbing stairs

B. noting any changes in the patient's visual field Rationale: POAG develops slowly and without any symptoms except for a gradual loss of visual fields. Acute closed-angle glaucoma may present with excruciating pain, colored halos, and blurred vision. Problems with depth perception are not associated with POAG

The nurse is observing a student who is preparing to perform an ear examination for a 30 year old patient. The nurse will need to intervene if the student A. pulls the auricle of the ear up and posterior B. chooses a speculum larger than the ear canal C. stabilizes the hand holding the otoscope on the patient's head D. stops inserting the otoscope after observing impacted cerumen

B. places a speculum larger than the ear canal Rationale: The speculum should be smaller than the ear canal so it can be inserted without damage to thee external ear canal. The other actions are appropriate when performing and ear examination

When teaching a patient about the treatment of acoustic neuroma, the nurse will include information about A. applying sunscreen B. preventing fall injuries C. decreasing dietary sodium D. chemotherapy side effects

B. preventing fall injuries Rationale: Intermittent vertigo occurs with acoustic neuroma, so the nurse should include information about how to prevent falls. Diet is not a risk factor for acoustic neuroma and no dietary changes are needed. Sunscreen would be used to prevent skin cancers on the external ear. Acoustic neuromas are benign and do not require chemotherapy

A patient arrives in the emergency department complaining of eye itching and pain after sleeping with contact lenses in place. To facilitate further examination of the eye, fluorescein angiography is ordered. The nurse will teach the patient to A. hold a card and fixate on the center dot B. report any burning or pain at the IV site C. remain still while the cornea is anesthetized D. let the examiner know when images shown appear clear

B. report any burning or pain at the IV site Rationale: Fluorescein angiography involves injecting IV dye. If extravasation occurs, fluorescein is toxic to the tissues. The patient should be instructed to report any signs of extravasation such as pain or burning. The nurse should closely monitor the IV site as well. The cornea is anesthetized during ultrasonography. Refractometry involves measuring visual acuity and asking the patient to choose lenses that are the sharpest; it is a painless test. The Amsler grid test involves using a hand held card with grid lines. The patient fixates on the center dot and records any abnormalities of the grid lines

A patient who has had surgical correction of bilateral hallux valgus is being discharged from the same day surgery unit. The nurse will instruct the patient to A. expect continued pain in the feet B. rest frequently with the feet elevated C. soak the feet in warm water several times a day D. expect the feet to be numb for the next few days

B. rest frequently with the feet elevated Rationale: After surgical correction of bilateral hallux valgus, the feet should be elevated with the heel off the bed to reduce discomfort and decrease edema

A patient hospitalized with polymyositis has joint pain; erythematous facial rash; eyelid edema; and a weak, hoarse voice. The safety priority for the patient is addressing the A. acute pain B. risk for aspiration C. disturbed visual perception D. risk for impaired skin integrity

B. risk for aspiration Rationale: The patient's vocal weakness and hoarseness indicate weakness of pharyngeal muscles and a high risk for aspiration. The other concerns are also appropriate but are not as high a priority as the maintenance of the patient's airway

A patient complains of dizziness when bending over and of nausea and dizziness associated with physical activities. The nurse will plan to teach the patient about A. tympanometry B. rotary chair testing C. pure tone audiometry D. bone conduction testing

B. rotary chair testing Rationale: The patient's clinical manifestations of dizziness and nausea suggest a disorder of the labyrinth, which controls balance and contains three semicircular canals and the vestibule. Rotary chair testing is used to test vestibular function. The other tests are used to test for problems with hearing

What is most important to include in the teaching plan for a patient with osteopenia? A. lose weight B. stop smoking C. eat a high protein diet D. start swimming for exercise

B. stop smoking Rationale: Patients with osteopenia should be instructed to quit smoking in order to decrease bone loss

A patient with osteomyelitis undergoes surgical debridement with implantation of antibiotic beads. When the patient asks why the beads are used, the nurse answers (select all that apply) A. Oral or IV antibiotics are not effective in most cases of bone infection B. The beads are an adjunct to debridement and antibiotics for deep infection C. The beads are used to deliver antibiotics directly to the site of the infection D. This is the safest method to deliver long term antibiotic therapy for bone infection E. Ischemia and bone death related to osteomyelitis are impenetrable to IV antibiotics

B.C. The beads are an adjunct to debridement and antibiotics for deep infection; the beads are used to deliver antibiotics directly to the site of infection Rationale: Treatment of chronic osteomyelitis includes surgical removal of the poorly perfused tissue and dead bone in addition to the extended use of IV and oral antibiotics. Antibiotic acrylic bead chains may be placed during surgery to help fight the infection

An acoustic neuroma is removed from a patient. The nurse instructs the patient about tumor recurrence. What should the nurse instruct the patient to monitor (select all that apply.)? A. Lack of coordination B. Episodes of dizziness C. Worsening of hearing D. Inability to close the eye E. Clear drainage from the nose

B.C.D. Episodes of dizziness; worsening of hearing; inability to close the eye Rationale: An acoustic neuroma is a unilateral benign tumor that occurs where the vestibulocochlear nerve (cranial nerve [CN] VIII) enters the internal auditory canal. Clinical manifestations of tumor recurrence including facial nerve (CN VII) paralysis can be manifested by intermittent vertigo, hearing loss, and inability to close the eye. Lack of coordination and clear nasal drainage do not manifest with acoustic neuroma.

A patient with osteoarthritis is scheduled for a total hip arthroplasty. The nurse explains the purpose of this procedure is to (select all that apply) A. fuse the joint B. replace the joint C. prevent further damage D. improve or maintain ROM E. decrease the amount of destruction in the joint

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

Instruct the patient who is newly fitted with bilateral hearing aids to (select all that apply) A. replace the batteries monthly. B. clean the ear molds weekly or as needed. C. clean ears with cotton-tipped applicators daily. D. disconnect or remove the batteries when not in use. E. initially restrict usage to quiet listening in the home.

B.D.E. Clean the ear molds weekly or as needed. Disconnect or remove the batteries when not in use. Initially restrict usage to quiet listening in the home Rationale: Initially, use of the hearing aid should be restricted to quiet situations in the home. As adjustment to the increase in sounds and background noise occurs, the patient can progress to using the hearing aid in situations in which several people are talking simultaneously. Next, use can be expanded to outdoors and then shopping malls or grocery stores. When the hearing aid is not being worn, the battery should be disconnected or removed when not in use. Battery life averages 1 week. Ear molds should be cleaned weekly or as needed

Which strategies would best assist the nurse in communicating with at patient who has a hearing loss (select all that apply) A. Over-enunciate speech B. Speak normally and slowly C. Exaggerate facial expressions D. Raise the voice to a higher pitch. E. Write out names or difficult words

B.E. Speak normally and slowly. Write out names or difficult words Rationale: Speak normally and slowly directly into the patient's better ear. Do not exaggerate facial expressions. Do not over-enunciate. Use simple sentences; rephrase sentences; use different words. Write out names or difficult words. Avoid shouting

A patient with rheumatoid arthritis is experiencing articular involvement. The nurse recognizes these characteristics changes include (Select all that apply) A. bamboo shaped fingers B. metatarsal head dislocation in feet C. noninflammatory pain in large joints D. asymmetric involvement of small joints E. morning stiffness lasting 60 minutes or more

B.E. metatarsal head dislocation in feet; morning stiffness last 60minutes or more Rationale: Morning stiffness may last from 60 minutes to several hours or more, depending on disease activity. Metatarsal head dislocation and subluxation in the feet may cause pain and walking disability. Joint symptoms occur symmetrically and frequently affect the small joints of the hands (proximal interphalangeal [PIP] and metacarpophalangeal [MCP] joints) and feet (metatarsophalangeal [MTP] joints). Larger peripheral joints such as the wrists, elbows, shoulders, knees, hips, ankles, and jaw may also be involved. Rheumatoid arthritis (RA) is an inflammatory disorder. In early disease, the fingers may become spindle shaped from synovial hypertrophy and thickening of the joint capsule

A 24-yr-old male patient has come to the clinic with a gradual onset of pain and swelling in the left knee. The patient is diagnosed with osteosarcoma without metastasis. Chemotherapy is ordered before surgery. How will the nurse explain the reason for preoperative chemotherapy? A. "The chemotherapy is being used to save your left leg." B. "Chemotherapy will increase your 5-year survival rate." C. "Chemotherapy is being used to decrease the tumor size." D. "Chemotherapy will help decrease the pain before and after surgery."

C. "Chemotherapy is being used to decrease the tumor size." Rationale: Preoperative chemotherapy is used to decrease the 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 rates in people without metastasis. Chemotherapy is not used to decrease pain before or after surgery.

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

C. "Does the pain radiate down the buttock or into the leg?" Rationale: Lower back pain associated with a herniated lumbar disc is accompanied by radiation along the sciatic nerve 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.

When the nurse is taking a health history of a new patient at the ear clinic, the patient states, "I have to sleep with the television on." Which follow up question is appropriate to obtain more information about possible hearing problems? A. "Do you grind your teeth at night?" B. "What time do you usually fall asleep?" C. "Have you noticed ringing in your ears?" D. "Are you ever dizzy when you are lying down?"

C. "Have you noticed ringing in your ears?" Rationale: Patients with tinnitus may use masking techniques, such as playing a radio, to block out the ringing in the ears. The responses "Do you grind your teeth at night?" and "Are you ever dizzy when you are lying down?" would be used to obtain information about other ear problems, such as vestibular disorders and referred temporomandibular joint pain. The response "What time do you usually fall asleep?" would not be helpful in assessing problems with the patien't ears

A 21-yr-old soccer player has injured the anterior crucial ligament (ACL) and is having reconstructive surgery. Which patient statement indicates more teaching is required? A. "I probably won't be able to play soccer for 6 to 8 months." B. "They will have me do range of motion with my knee soon after surgery." C. "I can't wait to get this done now so I can play soccer for the next tournament." D. "I will need to wear an immobilizer and progressively bear weight on my knee."

C. "I can't wait to get this done now so I can play soccer for the next tournament." Rationale: The patient does not understand the severity of ACL reconstructive surgery if planning to resume playing soccer soon; safe return will not occur for 6 to 8 months. Initial range of motion, immobilization, and progressive weight bearing will be overseen by a physical therapist.

The nurse is preparing to administer timolol eye drops for treatment of glaucoma. What statement made by the patient would cause the nurse to hold the medication and report to the health care provider? A. "I have sinusitis." B. "I have migraine headaches a lot." C. "I have chronic obstructive pulmonary disease." D. "I have a history of chronic urinary tract infections."

C. "I have chronic obstructive pulmonary disease." Rationale: Timolol is a nonselective β-adrenergic blocker that could lead to bronchoconstriction and bronchospasm. For this reason, it should not be used in patients with COPD. Timolol may be used to treat migraine headaches, and it does not affect sinusitis or chronic urinary tract infections.

The nurse is providing discharge teaching to a patient with type 2 diabetes after a scleral buckling procedure. Which statement, if made by the patient, indicates that the discharge teaching is effective? A. "I doubt my other eye will ever be affected." B. "I can expect severe pain after this procedure." C. "I should avoid lifting heavy objects and straining." D. "The procedure will correct my vision immediately."

C. "I should avoid lifting heavy objects and straining." Rationale: Patients should avoid heavy lifting (more than 20 lb) and straining. A patient with a detached retina is at risk for detachment of the other retina. Patients usually have little to no discomfort after scleral buckling. Severe, persistent pain should be reported immediately to the health care provider. Vision is restored in about 90% of retinal detachments. Vision will not be restored immediately and takes days to weeks to improve.

The nurse has reviewed proper body mechanics with a patient who has a history of low back pain caused by a herniated lumbar disc. Which patient statement 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." Rationale: 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 for 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.

When reinforcing health teaching on management of osteoarthritis (OA), which patient statement indicates additional instruction is needed? A. "I can use a cane to relieve the pressure on my back and hip." B. "I should take the Naprosyn as prescribed to help control the pain." C. "I should try to stay standing all day to keep my joints from becoming stiff." D. "A warm shower in the morning will help relieve the stiffness I have when I get up."

C. "I should try to stay standing all day to keep my joints from becoming stiff." Rationale: Maintaining a balance between rest and activity is important to prevent overstressing joints affected by OA. Naproxen may be used for moderate to severe OA pain. Using a cane and warm shower to help relieve pain and morning stiffness are helpful.

Which statement by the patient indicates a good understanding of the nurse's teaching about a new short-arm synthetic cast? A. "I can get the cast wet as long as I dry it right away with a hair dryer." B. "I should avoid moving my fingers and elbow until the cast is removed." C. "I will apply an ice pack to the cast over the fracture site off and on for 24 hours." D. "I can use a cotton tipped applicator to rub lotion on any dry areas under the cast."

C. "I will apply an ice pack to the cast over the fracture site off and on for 24 hours." Rationale: Ice application for the first 24 hours after a fracture will help reduce swelling and can be placed over the cast. Plaster casts should not get wet. Patients should not insert objects inside the cast

A high school teacher with ulnar drift caused by rheumatoid arthritis (RA) is scheduled for a left hand arthroplasty. Which patient statement to the nurse indicates a realistic expectation for the surgery? A. "This procedure will correct the deformities in my fingers." B. "I will not have to do as many hand exercises after the surgery." C. "I will be able to use my fingers with more flexibility to grasp things." D. "My fingers will appear more normal in size and shape after this surgery."

C. "I will be able to use my fingers with more flexibility to grasp things." Rationale: The goal of hand surgery in RA is to restore function, not to correct for cosmetic deformity or treat the underlying process. Hand exercises will be prescribed after the surgery

A patient diagnosed with external otitis is being discharged from the emergency department with an ear wick in place. Which statement by the patient indicates a need for further teaching? A. "I will apply the eardrops to the cotton wick in the ear canal." B. "I can use aspirin or acetaminophen (Tylenol) for pain relief." C. "I will clean the ear canal daily with a cotton tipped applicator." D. "I can use warm compresses to the outside of the ear for comfort."

C. "I will clean the ear canal daily with a cotton tipped applicator." Rationale: Insertion of instruments such as cotton tipped applicators into the ear should be avoided. The other patient statements that the teaching has been successful

Which statement by the patient to the home health nurse indicates a need for more teaching about self administering eardrops? A. "I will leave the ear wick in place while administering the drops." B. "I will hold the tip of the dropper above the ear to administer the drops." C. "I will refrigerate the medication until I am ready to administer the drops." D."I should lie down before and for 5 minutes after administering the drops."

C. "I will refrigerate the medication until I am ready to administer the drops." Rationale: Administration of cold eardrops can cause dizziness because of simulation of the semicircular canals. The other patient actions are appropriate.

A female patient's complex symptomatology over the past year has led to a diagnosis of systemic lupus erythematosus (SLE). Which statement demonstrates the patient's need for further teaching about the disease? A. "I'll try my best to stay out of the sun this summer." B. "I know that I have a high chance of getting arthritis." C. "I'm hoping surgery will be an option for me in the future." D. "I understand I'm going to be vulnerable to getting infections."

C. "I'm hoping surgery will be an option for me in the future." Rationale: Surgery is not a key treatment modality for SLE, so this indicates a need for further teaching. SLE carries an increased risk of infection, sun damage, and arthritis.

When the nurse brings medications to a patient with rheumatoid arthritis, the patient refuses the prescribed methotrexate (Rheumatrex). The patient tells the nurse, "My arthritis isn't that bad yet. The side effects of methotrexate are worse than the arthritis." The most appropriate response by the nurse is A. "You have the right to refuse to take the methotrexate." B. "Methotrexate is less expensive than some of the newer drugs." C. "It is important to start methotrexate early to decrease the extent of joint damage." D. "Methotrexate is effective and has fewer side effects than some of the other drugs."

C. "It is important to start methotrexate early to decrease the extent of joint damage." Rationale: Disease-modifying antirheumatic drugs (DMARDs) are prescribed early to prevent the joint degeneration that occurs as soon as the first year with RA. The other statements are accurate, but the most important point for the patient to understand is that it is important to start DMARDs as quickly as possible

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." Rationale: 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 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.

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-yr-old female patient with gonorrhea who is an IV drug user B. 48-yr-old male patient with muscular dystrophy and acute bronchitis C. 32-yr-old male patient with type 1 diabetes mellitus and stage IV pressure ulcer D. 68-yr-old female patient with hypertension who had a knee arthroplasty 3 years ago

C. 32-yr-old male patient with type 1 diabetes mellitus and stage IV pressure ulcer Rationale: 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 from joint arthroplasty. 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.

Which patient seen by the nurse in the outpatient clinic is most likely to require teaching about ways to reduce risk for osteoarthritis (OA)? A. A 56-year-old man who is a member of a construction crew B. A 38-year-old man who plays on a summer softball team C. A 56-year-old woman who works on an automotive assembly line D. A 38-year-old woman who is newly diagnosed with diabetes mellitus

C. A 56-year-old woman who works on an automotive assembly line Rationale: OA is more likely to occur in women as a result of estrogen reduction at menopause and in individuals whose work involves repetitive movements and lifting. Moderate exercise, such as softball, reduces the risk for OA. Diabetes is not a risk factor for OA. Sedentary work is not a risk factor for OA

The patient developed gout while hospitalized for a heart attack. Because the patient takes aspirin for its antiplatelet effect, what should the nurse recommend in preventing future attacks of gout? A. Limited fluid intake. B. Administration of probenecid C. Administration of allopurinol D. Administration of nonsteroidal antiinflammatory drugs (NSAIDs)

C. Administration of allopurinol Rationale: To prevent future attacks of gout, the urate-lowering drug allopurinol may be administered. Increased fluid will be encouraged to prevent precipitation of uric acid in the renal tubules. This patient will not be able to take the uricosuric drug probenecid because the patient's aspirin will inactivate its effect, resulting in urate retention. NSAIDs for pain management will not be used, related to the aspirin, because of the potential for increased side effects.

A new clinic patient with joint swelling and pain is being tested for systemic lupus erythematosus. Which test will provide the most specific findings for the nurse to review? A. Rheumatoid factor (RF) B. Antinuclear antibody (ANA) C. Anti smith antibody (Anti-Sm) D. Lupus erythemtosus (LE) cell prep

C. Anti smith antibody (Anti-Sm) Rationale: The anti-Sm is antibody found almost exclusively in SLE. The other blood tests are also used in screening but are not specific to SLE

Question patients using eye drops to treat their glaucoma about A. use of corrective lenses B. their usual sleep pattern C. a history of heart or lung disease D. a sensitivity to opioids or depressants

C. a history of heart or lung disease Rationale: Assess whether the patient is taking B-adrenergic blockers, because these drugs can be potentiated by the B-adrenergic blockers used to treat glaucoma. Many preparations for colds contain a form of epinephrine (i.e. pseudoephedrine) that can cause the pupils dilate, and antihistamines or decongestants can cause ocular dryness

A patient who has bacterial endophthalmitis in the left eye is restless, frequently asking whether the eye is healing and whether removal of the eye will be necessary. Based on the assessment data, which nursing diagnosis is appropriate at this time? A. Grieving related to current loss of functional vision B. Ineffective health management related to inability to see C. Anxiety related to the possibility of permanent vision loss D. Situational low self esteem related to loss of visual function

C. Anxiety related to the possibility of permanent vision loss Rationale: The patient's restlessness and questioning of the nurse indicate anxiety about the future possible loss of vision. Because the patient can see with the right eye, functional vision is relatively intact. There is no indication of impaired self esteem at this time

Which action should the nurse take when providing patient teaching to a 76 year old patient with mild presbycusis? A. Use patient education handouts rather than discussion B. Use a higher-pitched tone of voice to provide instructions C. Ask for permission to turn off the television before teaching D. Wait until family members have left before initiating teaching

C. Ask for permission to turn off the television before teaching Rationale: Normal changes with aging make it more difficult for older patients to filter out unwanted sounds, so a quiet environment should be used for teaching. Loss of sensitivity for high pitched tones is lost lost with presbycusis. Because the patient has mild presbycusis, the nurse should use both discussion and handouts. There is no need to wait until all family members have left to provide patient teaching

The nurse notices a circular lesion with a red border and clear center on the arm of a summer camp counselor who is in the clinic complaining of chills and muscle aches. Which action should the nurse take to follow up on that finding? A. Palpate the abdomen B. Auscultate the heart sounds C. Ask the patient about recent outdoor activities D. Question the patient about immunization history

C. Ask the patient about recent outdoor activities Rationale: The patient's clinical manifestations suggest possible Lyme disease. A history of recent outdoor activities such as hikes will help confirm the diagnosis. The patient's symptoms do not suggest cardiac or abdominal problems or lack of immunization

After a motorcycle accident, a patient arrives in the emergency department with severe swelling of the left lower leg. Which action will the nurse take first? A. Elevate the leg of 2 pillows B. Apply a compression bandage C. Assess leg pulses and sensation D. Place ice packs on the lower leg

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

A patient who slipped and fell in the shower at home has a proximal humerus fracture immobilized with a left-sided long-arm cast and a sling. Which nursing intervention will be included in the plan of care? A. Use surgical net dressing to hang the arm from an IV pole. B. Immobilize the fingers of the left hand with gauze dressings. C. Assess the left axilla and change absorbent dressings as needed. D. Assist the patient in passive range of motion (ROM) for the right arm.

C. Assess the left axilla and change absorbent dressings as needed. Rationale: The axilla can become excoriated when a sling is used to support the arm, and the nurse should check the axilla and apply absorbent dressings to prevent this. A patient with a sling would not have traction applied by hanging. The patient will be encouraged to move the fingers on the injured arm to maintain function and to help decrease swelling. The patient will do active ROM on the uninjured side.

A patient being seen in the clinic has rheumatoid nodules on the elbows. Which action will the nurse take? A. Draw blood for rheumatoid factor analysis. B. Teach the patient about injections for the nodules. C. Assess the nodules for skin breakdown or infection. D. Discuss the need for surgical removal of the nodules.

C. Assess the nodules for skin breakdown or infection. Rationale: Rheumatoid nodules can break down or become infected. They are not associated with changes in rheumatoid factor, and injection is not needed. Rheumatoid nodules are usually not removed surgically because of a high probability or recurrence

A pedestrian who was hit by a car is admitted to the emergency department with possible right lower leg fractures. The initial action by the nurse should be to A. elevate the right leg B. splint the lower leg C. assess the pedal pulses D. verify tetanus immunization

C. Assess the pedal pulses Rationale: The initial nursing action should be assessment of the neurovascular condition of the injured leg. After assessment, the nurse may need to splint and elevate the leg based on the assessment data. Information about tetanus should be obtained if there is an open wound

A 63-yr-old woman with a kidney transplant has been taking prednisone (Deltasone) daily for several years to prevent organ rejection. What is the most important assessment for the nurse to perform? A. Staggering gait B. Ruptured tendon C. Back or neck pain D. Tardive dyskinesia

C. Back or neck pain Rationale: Osteoporosis with fractures is a serious complication of corticosteroid therapy. The ribs and vertebrae fractures cause back and neck pain. Ataxic (staggering) gait is an adverse effect of phenytoin, an antiseizure medication. A rare adverse effect of ciprofloxacin and other fluoroquinolones is tendon rupture, usually the Achilles tendon. Antipsychotics and antidepressants may cause tardive dyskinesia, characterized by involuntary movements of the tongue and face.

The nurse will instruct a patient who has undergone a left tympanoplasty to A. remain on bed rest B. keep the head elevated C. avoid blowing the nose D. irrigate the left ear canal

C. avoid blowing the nose Rationale: Coughing or blowing the nose increases pressure in the eustachian tube and middle ear cavity and disrupts postoperative healing. There is no postoperative need for prolonged bed rest, eleation of the head, or continuous antibiotic irrigation

What should be included in the nursing plan for a patient who needs to administer antibiotic eardrops? A. Cool the drops so that they decrease swelling in the canal B. Avoid placing a cotton wick to assist in administering the drops C. Be careful to avoid touching the tip of the dropper bottle to the ear D. Keep the head tilted 5 to 7 minutes after administration of the drops

C. Be careful to avoid touching the tip of the dropper bottle to the ear Rationale: Hands should be washed before or after administration of otic drops (eardrops). The drops should be administered at room temperature, because cold drops can cause vertigo and heated drops can burn the tympanum. To prevent contamination of the entire bottle of drops, the tip of the dropper should not touch the ear during administration. The ear is positioned so that drops can rum into the canal. This position should be maintained for 2 minutes after each eardrop administration to allow the drops to become instilled. Drops can be placed onto a wick of cotton that is placed in the ear canal. Instruct the patient not to push the cotton farther into the ear. Material saturated with drainage should be carefully handled and discarded

Which assessment finding alerts the nurse to provide patient teaching about cataract development? A. History of hyperthyroidism B. Unequal pupil size and shape C. Blurred vision and light sensitivity D. Loss of peripheral vision in both eyes

C. Blurred vision an light sensitivity Rationale: Classic signs of cataracts include blurred vision and light sensitivity. Thyroid problems are a major cause of exophthalmos. Unequal pupil is not indicative of cataracts. Loss of peripheral vision is a sign of glaucoma

Which information will the nurse teach seniors at a community recreation center about ways to prevent fractures? A. Tack down scatter rugs in the home B. Expect most falls to happen outside the home C. Buy shoes that provide good support and are comfortable to wear D. Get instruction in range of motion exercises from a physical therapist

C. Buy shoes that provide good support and are comfortable to wear Rationale: Comfortable shoes with good support will help decrease the risk for falls. Scatter rugs should be eliminated, not just tacked down. Activities of daily living provide range of motion exercise; these do not need to be taught by a physical therapist. Falls inside the home are responsible for many injuries

When giving home care instructions to a patient who has comminuted left forearm fractures and a long-arm cast, which information should the nurse include? A. Keep the left shoulder elevated on a pillow or cushion B. Avoid nonsteroidal antiinflammatory drugs (NSAIDs) C. Call the health care provider for numbness of the hand D. Keep the hand immobile to prevent soft tissue swelling

C. Call the health care provider for numbness of the hand Rationale: Increased swelling or numbness may indicate increased pressure at the injury, and the health care provider should be notified immediately to avoid damage to nerves and other tissues. The patient should be encouraged to move the joints above and below the cast to avoid stiffness. There is no need to elevate the shoulder, although the forearm should be elevated to reduce swelling. NSAIDs are appropriate to treat mild to moderate pain after a fracture

The nurse will anticipate the need to teach a patient who has osteoarthritis (OA) about which medication? A. Prednisone B. Adalimumab (Humira) C. Capsaicin cream (Zostrix) D. Sulfasalazine (Azulfidine)

C. Capsaicin cream (Zostrix) Rationale: Capsaicin cream blocks the transmission of pain impulses and is helpful for some patients in treating OA. The other medications would be used for patients with rheumatoid arthritis

The second day after admission with a fractured pelvis, a patient suddenly develops confusion. Which action should the nurse take first? A. Take the blood pressure B. Assess patient orientation C. Check the O2 saturation D. Observe for facial symmetry

C. Check the O2 saturation Rationale: The patient's history and clinical manifestations suggest a fat embolism. The most important assessment is oxygenation. The other actions are also appropriate but will be done after the nurse assesses the O2 saturation.

Based on the information in the accompanying figure obtained for a patient in the emergency room, which action will the nurse take first? History: Age 23 years; Right lower leg injury Physical assessment: Reports severe right lower leg pain; reports feeling short of breath; bone protruding from right lower leg Diagnostic exams: CBC- WBC 9400; HgB 11.6; Right leg x-ray-right tibial fracture A. Administer the prescribed morphine 4mg IV B. Contact the operating room to schedule surgery C. Check the patient's O2 saturation using pulse oximetry D. Ask the patient about the date of the last tetanus immunization

C. Check the patient's O2 saturation using pulse oximetry Rationale: Because fat embolism can occur with a tibial fracture, the nurse's first action should be to check the patient's O2 saturation. The other actions are also appropriate but not as important at this time as obtaining the patient's O2 saturation

A patient with a head injury after a motorcycle crash arrives in the emergency department (ED) complaining of shortness of breath and severe eye pain. Which action will the nurse take first? A. Assess cranial nerve function B. Administer the prescribed analgesic C. Check the patient's oxygen saturation D. Examine the eye for evidence of trauma

C. Check the patient's oxygen saturation Rationale: The priority action for a patient after a head injury is to assess and maintain airway and breathing. Because the patient is complaining of shortness of breath, it is essential that the nurse assess the oxygen saturation. The other actions are also appropriate but are not the first action the nurse will take

In teaching a patient with Sjogren's syndrome about drug therapy for this disorder, the nurse includes instruction on use of which drug? A. Pregabalin (Lyrica) B. Etanercept (Enbrel) C. Cyclosporine (Restasis) D. Cyclobenzaprine (Flexeril)

C. Cyclosporine (Restasis) Rationale: Cyclosporine (Restasis) ophthalmic drops can be used to treat the chronic dry eye associated with Sjogren's syndrome

While obtaining subjective assessment data related to the musculoskeletal system, the nurse must ask a patient about other medical problems such as A. hypertension B. thyroid problems C. diabetes mellitus D. chronic bronchitis

C. Diabetes mellitus Rationale: The nurse should question the patient about past medical problems because certain illnesses are known to affect the musculoskeletal system directly or indirectly. These disease include tuberculosis, poliomyelitis, diabetes mellitus, parathyroid problems, hemophilia, rickets, soft tissue infection, and neuromuscular disabilities

A patient working in a noisy factory reports being off balance when standing or walking but not while lying down. What term will the nurse use to document this patient's symptoms? A. Vertigo B. Syncope C. Dizziness D. Nystagmus

C. Dizziness Rationale: Dizziness is a sensation of being off balance that occurs when standing or walking; it does not occur when lying down. Nystagmus is an abnormal eye movement that may be observed as a twitching of the eyeball or described by the patient as a blurring of vision with head or eye movement. Vertigo is a sense that the person or objects around the person are moving or spinning and is usually stimulated by movement of the head. Syncope is a brief lapse in consciousness accompanied by a loss in postural tone (fainting).

The nurse is caring for a patient with bilateral knee osteoarthritis. Which measure will the nurse recommend to slow progression of the disease? A. Use a wheelchair to avoid walking as much as possible. B. Sit in chairs that cause the hips to be lower than the knees. C. Eat a well-balanced diet to maintain a healthy body weight. D. Use a walker for ambulation to relieve the pressure on the hips.

C. Eat a well-balanced diet to maintain a healthy body weight. Rationale: Because maintaining an appropriate load on the joints is essential to the preservation of articular cartilage integrity, the patient should maintain an optimal overall body weight or lose weight if overweight. Walking is encouraged. The best chairs for this patient have a higher seat and armrests to facilitate sitting and rising from the chair. Relieving pressure on the hips is not important for knee disease.

When planning care for a patient with disturbed sensory perception related to increased intraocular pressure caused by primary open-angle glaucoma, what nursing action would be a priority? A.Recognizing that eye damage caused by glaucoma can be reversed in the early stages B. Giving anticipatory guidance about the eventual loss of central vision that will occur C. Encouraging compliance with drug therapy for the glaucoma to prevent loss of vision D. Managing the pain experienced by patients with glaucoma that persists until the optic nerve atrophies

C. Encouraging compliance with drug therapy for the glaucoma to prevent loss of vision Rationale: Drug therapy is necessary to prevent the eventual vision loss that may occur as a consequence of glaucoma. For this reason, encourage the patient to remain compliant with drug therapy.

When assessing an adult patient's external ear canal and tympanum, what assessment techniques should the nurse use? A. Ask the patient to tip his or her head toward the nurse. B. Identify a pearl gray tympanic membrane as a sign of infection. C. Gently pull the auricle up and backward to straighten the canal. D. Identify a normal light reflex by the appearance of irregular edges.

C. Gently pull the auricle up and backward to straighten the canal. Rationale: When examining a patient's external ear canal and tympanum, ask the patient to tilt the head toward the opposite shoulder. Grasp and gently pull the auricle up and backward to straighten the canal. A healthy, normal tympanic membrane will appear pearl gray, white, or pink and have a cone-shaped light reflex.

A patient who takes multiple medications develops acute gouty arthritis. The nurse will consult the health care provider before giving the prescribed dose of A. sertraline (Zoloft) B. famotidine (Pepcid) C. hydrochlorithazide D. Oxycodone (Roxicodone)

C. HCTZ Rationale: Diuretic use increases uric acid levels can can precipitate gout attacks. The other medications are safe to administer

When administering eye drops to a patient with glaucoma, which nursing measure is most appropriate to minimize systemic effects of the medication? A. Apply pressure to each eyeball for a few seconds after administration. B. Have the patient close the eyes and move them back and forth several times. C. Have the patient put pressure on the inner canthus of the eye after administration. D. Have the patient try to blink out excess medication immediately after administration.

C. Have the patient put pressure on the inner canthus of the eye after administration. Rationale: Systemic absorption can be minimized by applying pressure to the inner canthus of the eye. The other options will not minimize systemic effects of the medication.

The nurse instructs a patient who has osteosarcoma of the tibia about a scheduled above the knee amputation. Which statement by the patient indicates additional patient teaching is needed? A. I will need to participate in physical therapy after this surgery B. I wish I did not need to have chemotherapy after this surgery C. I did not have this bone cancer until my leg broke a week ago D. I can use the patient controlled analgesia (PCA) to manage postoperative pain

C. I did not have this bone cancer until my leg broke a week ago Rationale Osteogenic sarcoma may be diagnosed following a fracture, but it is not caused by the injury. The other statements indicate patient teaching has been effective

The nurse recording health histories in the outpatient clinic would plan a focused hearing assessment for adult patients taking which medication? A. Atenolol (Tenormin) taken to prevent angina B. Acetaminophen (Tylenol) taken frequently for headaches C. Ibuprofen (Advil) taken for 20 years to treat osteoarthritis D. Albuterol (Proventil) taken since childhood to treat asthma

C. Ibuprofen (Advil) taken for 20 years to treat osteoarthritis Rationale: Non-steroidal anti-inflammatory drugs are potentially ototoxic. Acetaminophen, atenolol, and albuterol are not associated with hearing loss

A patient newly diagnosed with glaucoma asks the nurse what has made the pressure in the eyes so high. Which is the nurse's most accurate response? A. Back pressure from cardiac congestion causes corneal edema. B. Cerebral venous dilation prevents normal interstitial fluid resorption. C. Increased production of aqueous humor or blocked drainage increases pressure. D. Congenital anomalies of the lacrimal gland or duct obstruct the passage of tears.

C. Increased production of aqueous humor or blocked drainage increases pressure. Rationale: Intraocular pressure is increased in glaucoma as a result of excess aqueous humor production or decreased outflow. Cardiac or cerebral circulation changes do not cause glaucoma. Lacrimal anomalies do not affect aqueous humor production.

The nurse is caring for a patient with osteoarthritis scheduled for total left knee arthroplasty. Preoperatively, the nurse assesses for which contraindication to surgery? A. Pain B. Left knee stiffness C. Left knee infection D. Left knee instability

C. Left knee infection Rationale: The patient must be free of infection before total knee arthroplasty. An infection in the joint could lead to even greater pain and joint instability, requiring more extensive surgery. The nurse must assess the patient for signs of infection, such as redness, swelling, fever, and elevated white blood cell count. Pain, knee stiffness, or instability are typical of osteoarthritis.

A 42-yr-old man underwent amputation below the knee on the left leg after a recent heavy farm machinery accident. Which intervention should the nurse include in the plan of care? A. Sit in a chair for 1 to 2 hours three times each day. B. Dangle the residual limb for 20 to 30 minutes every 6 hours. C. Lie prone with hip extended for 30 minutes four times per day. D. Elevate the residual limb on a pillow for 4 to 5 days after surgery.

C. Lie prone with hip extended for 30 minutes four times per day. Rationale: To prevent hip flexion contractures, the patient should lie on the abdomen for 30 minutes three or four times each day and position the hip in extension while prone. The patient should avoid sitting in a chair for more than 1 hour with hips flexed or having pillows under the surgical extremity. The patient should avoid dangling the residual limb over the bedside to minimize edema.

Which nursing action included in the care of a patient after laminectomy can the nurse delegate to experienced unlicensed assistive personnel (UAP)? A. Check ability to plantar and dorsiflex the foot B. Determine the patient's readiness to ambulate C. Log toll the patient from side to side every 2 hours D. Ask about pain management with the patient controlled analgesia (PCA)

C. Log toll the patient from side to side every 2 hours Rationale: Repositioning a patient is included in the education and scope of practice of UAP, and experienced UAP will be familiar with how to maintain alignment in the postoperative patient. Evaluation of the effectiveness of pain medications, assessment of neurologic, and evaluation of a patient's readiness to ambulate after surgery require higher level nursing education and scope of practice

An older adult is diagnosed with Paget's disease. Which finding would indicate improvement in the condition? A. Waddling gait B. Curvature in affected bones C. Lower serum alkaline phosphatase D. Uptake of radiolabeled bisphosphonate in affected bones

C. Lower serum alkaline phosphatase Rationale: Paget's disease is characterized by excessive bone resorption and replacement of normal marrow with vascular, fibrous connective tissue. A normalizing alkaline phosphatase indicates bone resorption has slowed or stopped. Additional characteristics of the disease include bone pain, a waddling gait, loss of stature, and curved bones. Uptake of radiolabeled bisphosphonate indicates a bone is affected. Treatment of the disease includes administration of calcium, vitamin D, calcitonin, and bisphosphonates. Additional recommendations would include creating a safe environment, using firm mattress, wearing a corset, and using appropriate body mechanics and assistive devices.

The nurse is completing discharge teaching with an 80-yr-old male patient who is recovering from a right total hip arthroplasty by posterior approach. Which patient action indicates further instruction is needed? A. Uses an elevated toilet seat B. Sits with feet flat on the floor C. Maintains hip in adduction and internal rotation D. Verifies need to notify future caregivers about the prosthesis

C. Maintains hip in adduction and internal rotation Rationale: The patient should not force hip into adduction or internal rotation because these movements could dislocate the hip prosthesis. Sitting with feet flat on the floor (avoiding crossing the legs), using an elevated toilet seat, and notifying future caregivers about the prosthesis indicate understanding of discharge teaching.

Otoscopic examination of the patient's left ear indicates the presence of an exostosis. What does the nurse prepare to teach the patient about regarding the growth? A. Surgery B. Electrocochleography C. Monitoring of the growth D. Irrigation of the ear canal

C. Monitoring of the growth Rationale: An exostosis is a bony growth into the ear canal that normally does not require intervention or correction.

The bone cells that function in the reabsorption of bone tissue are A. osteoids B. Osteocytes C. Osteoclasts D. Osteoblasts

C. Osteoclasts Rationale: Osteoclasts participate in bone remodeling by assisting in the breakdown of bone tissue

During a health history, a 43-yr-old teacher complains of increasing difficulty reading printed materials for the past year. What change related to aging does the nurse suspect? A. Myopia B. Hyperopia C. Presbyopia D. Astigmatism

C. Presbyopia Rationale: Presbyopia is a loss of accommodation causing an inability to focus on near objects. This occurs as a normal part of aging process starting around age 40 years. Myopia is nearsightedness (near objects are clear and far objects are blurred). Astigmatism results in visual distortion related to unevenness in the cornea. Hyperopia is farsightedness (near objects are blurred and far objects are clearly seen).

A nurse is assessing the recent health history of a 63-yr-old patient with osteoarthritis. Which activity pattern will the nurse recommend? A. Bed rest with bathroom privileges B. Daily high-impact aerobic exercise C. Regular exercise program of walking D. Frequent rest periods with minimal exercise

C. Regular exercise program of walking Rationale: A regular low-impact exercise, such as walking, is important in helping to maintain joint mobility in patients with osteoarthritis. A balance of rest and activity is needed. High-impact aerobic exercises would cause stress to affected joints and further damage.

A patient who received a corneal transplant 2 weeks ago calls the ophthalmology clinic to report that his vision has not improved with the transplant. Which action should the nurse take? A. Suggest the patient arrange a ride to the clinic immediately B. Ask about the presence of floaters in the patient's visual field C. Remind the patient it may take months to restore vision after transplant D. Teach the patient to continue using prescribed pupil dilating medications

C. Remind the patient it may take months to restore vision after transplant Rationale: Vision may not be restored for up to 1 year after corneal transplant. Because the patient is not experiencing complications of the surgery, an emergency clinic visit is not needed. Because floaters are not associated with complications of corneal transplant, the nurse will not need to ask the patient about their presence. Corticosteroid drops, not mydriatic drops, are used after corneal transplant

Which action should the nurse take before administering gentamicin (Garamycin) to a patient with acute osteomyelitis? A. Ask the patient about any nausea B. Obtain the patient's oral temperature C. Review the patient's serum creatinine D. Change the prescribed wet to dry dressing

C. Review the patient's serum creatinine Rationale Gentamicin is nephrotoxic and can cause renal failure as reflected in the patient's serum creatinine. Monitoring the patient's temperature before gentamicin administration is not necessary. Nausea is not a common side effect of IV gentamicin. There is no need to change the dressing before gentamicin admnistration

The nurse determines dietary teaching for a 75-yr-old patient with osteoporosis has been successful when the patient selects which meal as highest in calcium? 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. 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. Sardine (3 oz) sandwich on whole wheat bread, 1 cup of fruit yogurt, and 1 cup of skim milk Rationale: 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.

When assessing a patient's consensual pupil response, the nurse should A. have the patient cover one eye while facing the nurse B. observe for a light reflection in the center of both pupils C. shine a light into one eye and observe responses of both pupils D. instruct the patient to follow a moving object using only the eyes

C. Shine a light into one eye and observe the responses of both pupils Rationale: The consensual pupil response is tested by a shining light into one pupil and observing for both pupils to constrict. Observe the corneal light reflex to evaluate for weakness or imbalance of the extraocular muscles. In a darkened room, ask the patient to look straight ahead while a penlight is shone directly on the cornea. The light reflection should be located in the center of both corneas as the patient faces the light source. To perform confrontation visual field testing, the patient faces the examiner and covers one eye and then counts the number of fingers that the examiner brings into the visual field. Instructing the patient to follow a moving object only with the eyes is testing for visual fields and extraocular movements

A patient is admitted to the emergency department with a left femur fracture. Which information obtained by the nurse is most important to report to the health care provider? A. Ecchymosis of the left thigh B. Complaints of severe thigh pain C. Slow capillary refill of the left foot D. Outward pointing toes on the left foot

C. Slow capillary refill of the left foot Rationale: Prolonged capillary refill may indicate complications such as compartment syndrome. The other findings are typical with a left femur fracture

An older patient who is being admitted to the hospital repeatedly asks the nurse to "speak up so that I can hear you." Which action should the nurse take? A. Increase the speaking volume B. Over enunciate while speaking C. Speak normally but more slowly D. Use more facial expressions while talking

C. Speak normally but slowly Rationale: Patient understanding of nurse's speech will be enhanced by speaking at a normal tone, but more slowly. Increasing the volume, overenunciating, and exaggerating facial expressions will not improve the patient's ability to comprehend

A patient with rheumatoid arthritis (RA) complains to the clinic nurse about having chronically dry eyes. Which action by the nurse is most appropriate? A. Ask the health care provider about discontinuing methotrexate B. Remind the patient that RA is a chronic health condition C. Suggest that the patient use over-the-counter (OTC) artificial tears. D. Teach the patient about adverse effects of the RA medications.

C. Suggest that the patient use over-the-counter (OTC) artificial tears. Rationale: The patient's dry eyes are consistent with Sjogren's syndrome, a common extraarticular manifestation of RA. Symptomatic therapy such as OTC eye drops is recommended. Dry eyes are not a side effect of methotrexate. A focus on the prognosis for RA is not helpful. The dry eyes are not caused by RA treatment but by the disease itself

Which action will the nurse include in the plan of care for a patient with benign paroxysmal positional vertigo? A. Teach the patient about the use of medications to reduce symptoms B. Place the patient in a dark, quiet room to avoid stimulating BPPV attacks C. Teach the patient that canalith repositioning may be used to reduce dizziness D. Speak with a low pitched voice so that the patient is able to hear instructions

C. Teach the patient that canalith repositioning may be used to reduce dizziness Rationale: The Epley maneuver is used to reposition "ear rocks" in BPPV. Medications and placement in a dark room may be used to treat Meniere's disease, but are not necessary for BPPV. There is no hearing loss with BPPV

Which medication information will the nurse identify as a concern for a patient's musculoskeletal status? A. The patient takes a daily multivitamin and calcium supplement. B. The patient takes hormone therapy (HT) to prevent "hot flashes." C. The patient has severe asthma and requires frequent therapy with oral corticosteroids. D. The patient has migraine headaches treated with nonsteroidal antiinflammatory drugs (NSAIDs).

C. The patient has severe asthma and requires frequent therapy with oral corticosteroids. Rationale: Frequent or chronic corticosteroid use may lead to skeletal problems such as avascular necrosis and osteoporosis. The use of HRT and calcium supplements will help prevent osteoporosis. NSAID use does not increase the risk for musculoskeletal problems

Which information obtained during the nurse's assessment of a patient's nutritional-metabolic pattern may indicate increased risk for musculoskeletal problems? A. The patient takes a multivitamin daily B. The patient dislikes fruits and vegetables C. The patient is 5'2 and weighs 180lb D. The patient prefers whole milk to nonfat milk

C. The patient is 5'2 and weighs 180lb Rationale: The patient's height and weight indicate obesity, which places stress on weight bearing joints and predisposes the patient to osteoarthritis. The use of whole milk, avoidance of fruits and vegetables, and use of a daily multivitamin are not risk factors for musculoskeletal problems

The nurse at the outpatient surgery unit obtains the following information about a patient who is scheduled for cataract extraction and implantation of an intraocular lens. Which information is most important to report to the health care provider at this time? A. The patient has had blurred vision for 3 years. B. The patient has not eaten anything for 8 hours. C. The patient takes 2 antihypertensive medications. D. The patient gets nauseated with general anesthesia.

C. The patient takes 2 antihypertensive medications. Rationale: Mydriatic medications used for pupil dilation are sympathetic nervous system stimulants and may increase heart rate and blood pressure. Using punctual occlusion when administering the mydriatic and monitoring of blood pressure are indicated for this patient. Blurred vision is an expected finding with cataracts. Patients are expected to be NPO before the surgical procedure. Cataract extraction and intraocular lens implantation are done using local anesthesia

A patient with a right retinal detachment had a pneumatic retinopexy procedure. Which information will be included in the discharge teaching plan? A. The use of eye patches to reduce movement of the operative eye B. The need to wear dark glasses to protect the eyes from bright light C. The purpose of maintaining the head resting in a prescribed position D. The procedure for dressing changes when the eye dressing is saturated

C. The purpose of maintaining the head resting in a prescribed position Rationale: Following pneumatic retinopexy, the patient will need to position the head so the air bubble remains in contact with the retinal tear. Dark lenses and bilateral eye patches are not required after this procedure. Saturation of any eye dressings would not be expected following this procedure

A patient arrived at the emergency department after tripping over a rug and falling at home. Which finding is most important for the nurse to communicate to the health care provider? A. There is bruising at the shoulder area B. The patient reports arm and shoulder pain C. The right arm appears shorter than the left D. There is decreased shoulder range of motion

C. The right arm appears shorter than the left Rationale: A shorter limb after a fall indicates a possible dislocation, which is an orthopedic emergency. Bruising, pain, and decreased range of motion should also be reported, but these do not indicate emergent treatment is needed to preserve function

Which laboratory result is important to communicate to the health care provider for a patient who is taking methotrexate to treat rheumatoid arthritis (RA)? A. Rheumatoid factor is positive B. Fasting blood glucose is 90mg/dL C. The white blood cell (WBC) count is 1500/uL D. The erythrocyte sedimentation rate is elevated

C. The white blood cell (WBC) count is 1500/uL Rationale: Bone marrow suppression is a possible side effect of methotrexate, and the patient's low WBC count places the patient at high risk for infection. The elevated erythrocyte sedimentation rate and positive rheumatoid factor are expected in RA. The blood glucose is normal

When a patient arrives in the emergency department with a facial fracture, which action will the nurse take first? A Assess for nasal bleeding and pain. B. Apply ice to the face to reduce swelling. C. Use a cervical collar to stabilize the spine. D. Check the patient's alertness and orientation.

C. Use a cervical collar to stabilize the spine. Rationale: Patients who have facial fractures are at risk for cervical spine injury, and should be treated as if they have a cervical spine injury until this is ruled out. The other actions are also necessary, but the most important action is to prevent cervical spine injury

The nurse is planning care for a patient with hypertension and gout who has a red, painful right great toe. Which nursing action will be included in the plan of care? A. Gently palpate the toe to assess swelling B. Use pillows to keep the right foot elevated C. Use a footboard to hold bedding away from the toe D. Teach the patient to avoid use of acetaminophen (Tylenol)

C. Use a footboard to hold bedding away from the toe Rationale: Because any touch on the area of inflammation may increase pain, bedding should be held away from the toe, and touching the toe should be avoided. Elevation of the foot will not reduce the pain, which is caused by urate crystals. Acetaminophen can be used for pain management

Which discharge instruction will the emergency department nurse include for a patient with a sprained ankle? A. Keep the ankle loosely wrapped with gauze. B. Apply a heating pad to reduce muscle spasms. C. Use pillows to elevate the ankle above the heart. D. Gently move the ankle through the range of motion.

C. Use pillows to elevate the ankle above the heart Rationale: Elevation of the leg will reduce swelling and pain. Compression bandages are used to decrease swelling. For the first 24 to 48 hours, cold packs are used to reduce swelling. The ankle should be rested and kept immobile to prevent further swelling or injury

A patient is recovering from a motor vehicle crash that resulted in blindness. The patient is withdrawn and refuses to get out of bed. What is the nurse's priority goal for this patient? A. Use suitable coping strategies to reduce stress. B. Identify patient's strengths and support system. C. Verbalize feelings related to visual impairment D. Transition successfully to the sudden vision loss.

C. Verbalize feelings related to visual impairment. Rationale: The nurse's priority is to help the patient express his feelings about the vision loss resulting from the lack of coping effectively with the situation. Until the patient expresses how they feel, they will be unable to progress in the rehabilitation process.

The nurse suspects a neurovascular problem based on assessment of A. exaggerated strength with movement B. increased redness and heat below the injury C. decreased sensation distal to the fracture sight D. purulent drainage at the site of an open fracture

C. decreased sensation distal to the fracture sight Rationale: Musculoskeletal injuries have the potential for causing changes in the neurovascular condition of an injured extremity. Application of a cast or constrictive dressing, poor positioning, and physiologic responses to the injury can cause nerve or vascular damage, usually distal to the injury. The neurovascular assessment consists of peripheral vascular evaluation (i.e. color, temperature, capillary refill, peripheral pulses, and edema) and peripheral neurologic evaluation (i.e. sensation and motor function)

A patient with a fracture of the left femoral neck has Buck's traction in place while waiting for surgery. To assess for pressure areas on the patient's back and sacral area and to provide skin care, the nurse should A. loosen the traction and help the patient turn onto the unaffected side B. place a pillow between the patient's legs and turn gently to each side C. have the patient lift the buttocks slightly by using a trapeze over the bed D. turn the patient partially to each side with the assistance of another nurse

C. have the patient lift the buttocks slightly by using a trapeze over the bed Rationale: The patient can lift the buttocks slightly off the bed by using a trapeze. This will not affect the fracture fragments on the right leg. Turning the patient will tend to move the fracture fragments, causing pain and possible, nerve impingement. Disconnecting the traction will interrupt the weight needed to decrease muscle spasms.

A patient hospitalized with a fever and red, hot, painful knees is suspected of having septic arthritis. Information obtained during the nursing history that indicates a risk factor for septic arthritis is that the patient A. had several knee injuries as a teenager B. recently returned from South America C. is sexually active with multiple partners D. has a parent who has rheumatoid arthritis

C. is sexually active with multiple partners Rationale: Neisseria gonorrohoeae is the most common cause for septic arthritis in sexually active young adults. The other information does not pose a risk for septic arthritis

A patient is receiving IV antibiotics at home to treat chronic osteomyelitis of the left femur. The nurse identifies a need for additional teaching related to health maintenance when the nurse finds that the patient A.is frustrated with the length of treatment required B. takes and records the oral temperature twice a day C. is unable to plantar flex the foot on the affected side D. uses crutches to avoid weight bearing on the affected leg

C. is unable to plantar flex the foot on the affected side Rationale Foot drop is an indication that the foot is not being supported in a neutral position by a splint. Using crutches and monitoring the oral temperature are appropriate self care activities. Frustration with the length of treatment is not an indicator of ineffective health maintenance of the osteomyelitis

An appropriate nursing intervention for a patient who has acute low back pain and muscle spasms to teach the patient to A. keep both feet flat on the floor when prolonged standing is required B. twist gently from side to side to maintain range of motion in the spine C. keep the head elevated slightly and flex the knees when resting in bed D. avoid the use of cold packs because they will exacerbate the muscle spasms

C. keep the head elevated slightly and flex the knees when resting in bed Rational: Resting with the head elevated and the knees flexed will reduce strain on the back and decrease muscle spasms. Twisting from side to side will increase tension on the lumbar area. Prolonged standing will cause strain on the lumbar spine, even with both feet flat on the floor. Alternate application of cold and heat should be used to decrease pain

The nurse learns that a newly admitted patient has functional blindness and that the spouse has cared for the patient for many years. During the initial assessment of the patient, it is most important for the nurse to A. obtain more information about the cause of the patient's vision loss. B. obtain information from the spouse about the patient's special needs. C. make eye contact with the patient and ask about any need for assistance. D. perform an evaluation of the patient's visual acuity using a Snellen chart.

C. make eye contact with the patient and ask about any need for assistance. Rationale: Making eye contact with a partially sighted patient allows the patient to hear the nurse more easily and allows the nurse to assess the patient's facial expressions. The patient (rather than the spouse) should be asked about any need for assistance. The information about the cause of the vision loss and assessment of the patient's visual acuity are not priorities during the initial assessment

During an assessment of hearing, the nurse would expect that a normal finding would be A. absent cone of light B. bluish purple tympanic membrane C. midline tone heard equally in both ears D. fluid level at hairline in the tympanum

C. midline tone heard equally in both ears Rationale: Normal findings of physical assessment on the auditory system include symmetry of the ears in location and shape; nontenderness and no lesions of auricles and tragus; clearness of the canal; pearl gray color of tympanic membrane with landmarks and light reflex intact; ability of the patient to hear low whisper at a distance of 30cm; better Rinne test results for air conduction than for bone conduction (AC>BC); and no lateralization according to the Weber tests results

A patient who arrives at the emergency department experiencing severe left knee pain is diagnosed with a patellar dislocation. The initial patient teaching by the nurse will focus on the need for A. a knee immobilizer. B. gentle knee flexion C. monitored anesthesia care. D. physical activity restrictions.

C. monitored anesthesia care. Rationale: The first goal of interprofessional management is realignment of the knee to its original anatomic position, which will require anesthesia or monitored anesthesia care, formerly called conscious sedation. Immobilization, gentle range of motion exercise, and discussion about activity restrictions will be implemented after the patella is realigned

After completing the health history, the nurse assessing the musculoskeletal system will begin by A. having the patient move the extremities against resistance. B. feeling for the presence of crepitus during joint movement. C. observing the patient's body build and muscle configuration. D. checking active and passive range of motion for the extremities.

C. observing the patient's body build and muscle configuration. Rationale: The usual technique in the physical assessment is to begin with inspection. Abnormalities in muscle mass or configuration will allow the nurse to perform a more focused assessment of affected areas. The other assessments are also included but are usually done after inspection

The nurse should reposition the patient who has just had a laminectomy and diskectomy by A. instructing the patient to move the legs before turning the rest of the body B. having the patient turn by grasping the side rails and pulling the shoulders over C. placing a pillow between the patient's legs and turning the entire body as a unit D. turning the patient's head and shoulders first, followed by the hips, legs and feet

C. placing a pillow between the patient's legs and turning the entire body as a unit Rationale: The spine should be kept in correct alignment after laminectomy. The other positions will create misalignment of the spine

Anakinra (Kineret) is prescribed for a patient who has rheumatoid arthritis (RA). When teaching the patient about this drug, the nurse will include information about A. Avoiding concurrent aspirin use B. symptoms of gastrointestinal (GI) bleeding C. self-administration of subcutaneous injections D. taking the medication with at least 8oz of fluid

C. self-administration of subcutaneous injections Rationale: Anakinra is administered by subcutaneous injection. GI bleeding is not a side effect of this medication. Because the medication is injected, instructions to take it with 8oz of fluid would not be appropriate. The patient is likely to be concurrently taking aspirin or nonsteroidal antiinflammatory drugs (NSAIDs), and these should not be discontinued

A nurse should instruct a patient with recurrent staphylococcal and seborrheic blepharitis to A. irrigate the eyes with saline solution B. schedule an appointment for eye surgery C. use a gentle baby shampoo to clean the eyelids D. apply a cool compresses to the eyes three times daily

C. use a gentle baby shampoo to clean the eyelids Rationale: Baby shampoo is used to soften and remove crusts associated with blepharitis. The other interventions are not used in treating this disorder

In which order will the nurse take these actions when caring for a patient in the emergency department with a right leg fracture after a motor vehicle crash A. Obtain X-rays B. Check pedal pulses C. Assess lung sounds D. Take blood pressure E. Apply splint to the leg F. Administer tetanus prophylaxis

C.D.B.E.A.D.F The initial actions should be to ensure adequate airway, breathing, and circulation. This should be followed by checking the neurovascular condition of the leg (before and after splint application). Application of a splint to immobilize the leg should be done before sending the patient for x-ray examination. The tetanus prophylaxis is the least urgent of the actions

When entering the grocery store, a patient trips on the curb and sprains the right ankle. Which initial care is appropriate (select all that apply.)? A. Apply ice directly to the skin. B. Apply heat to the ankle every 2 hours. C. Administer antiinflammatory medication. D. Compress ankle using an elastic bandage. E. Rest and elevate the ankle above the heart. F. Perform passive and active range of motion.

C.D.E. Administer antiinflammatory medication; Compress ankle using an elastic bandage; Rest and elevate the ankle above the heart Rationale: Appropriate care for a sprain is represented with the acronym RICE (rest, ice, compression, and elevation). Antiinflammatory medication should be used to decrease swelling if not contraindicated for the patient. After the injury, the ankle should be immobilized and rested. Prolonged immobilization is not required unless there is significant injury. Ice is indicated, but will cause tissue damage if applied directly to the skin. Apply ice to sprains as soon as possible and leave in place for 20 to 30 minutes at a time. Moist heat may be applied 24 to 48 hours after the injury.

Which information will the nurse include when teaching a patient with acute low back pain? (select all that apply) A. Sleep in a prone position with the legs extended B. Keep the knees straight when leaning forward to pick something up. C. Expect symptoms of acute low back pain to improve in a few weeks D. Avoid activities that require twisting of the back of prolonged sitting E. Use Ibuprofen (Motrin, Advil) or acetaminophen (Tylenol) to relieve pain

C.D.E. Expect symptoms of acute low back pain to improve in a few weeks; Avoid activities that require twisting of the back of prolonged sitting; Use Ibuprofen (Motrin, Advil) or acetaminophen (Tylenol) to relieve pain Rationale: Acute back pain usually starts to improve within 2 weeks. In the meantime, the patient should use medications such as nonsteroidal antiinflammatory drugs (NSAIDs) or acetaminophen to manage pain and avoid activities that stress the back. Sleeping in a prone position and keeping the knees straight when leaning forward will place stress on the back and should be avoided

A factory line worker has repetitive strain syndrome in the left elbow. The nurse will plan to teach the patient about A. surgical options. B. elbow injections. C. wearing a left wrist splint. D. modifying arm movements.

D modifying arm movements Rationale: Treatment for repetitive strain syndrome includes changing the ergonomics of the activity. Elbow injections and surgery are not initial options for this type of injury. A wrist splint might be used for hand or wrist pain.

An 82-yr-old patient is frustrated by loose abdominal tissue and rigid hips. How should the nurse respond? 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 take nonsteroidal antiinflammatory drugs (NSAIDs)." D. "Decreased muscle mass and strength and increased hip rigidity are expected with aging."

D. "Decreased muscle mass and strength and increased hip rigidity are expected with aging." Rationale: 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..." is untrue and will not be helpful to the patient's frustrations.

This morning a 21-yr-old male patient had a long leg cast applied, and he asks to crutch walk before dinner. Which statement explains why the nurse will decline the patient's request? A. "No one is available to assist and accompany the patient." B. "The cast is not dry yet, and it may be damaged while using crutches." C. "Rest, ice, compression, and elevation are in process to decrease pain." D. "Excess edema and complications are prevented when the leg is elevated for 24 hours."

D. "Excess edema and complications are prevented when the leg is elevated for 24 hours." Rationale: For the first 24 hours after a lower extremity cast is applied, the leg should be elevated on pillows above heart level to avoid excessive edema and compartment syndrome. A plaster cast will also be drying during this 24-hour period. RICE is used for soft tissue injuries, not with long leg casts.

The nurse is assessing an older adult patient who has just been transferred to the long-term care facility. Which assessment question will best allow the nurse to assess for the presence of presbycusis? A. "Do you ever experience any ringing in your ears?" B. "Have you ever fallen down because you became dizzy?" C. "Do you ever have pain in your ears when you're chewing or swallowing?" D. "Have you noticed any change in your hearing in recent months and years?"

D. "Have you noticed any change in your hearing in recent months and years?" Rationale: Presbycusis is an age-related change in auditory acuity. Whereas ringing in the ears is termed tinnitus, dizziness and falls are related to balance and the function of the vestibular system. Presbycusis is not associated with pain during chewing and swallowing.

The nurse is caring for a patient who is to be discharged home from the hospital 4 days after insertion of a femoral head prosthesis using a posterior approach. Which statement by the nurse indicates a need for additional instruction? A. "I should not cross my legs while sitting." B. "I will use a toilet elevator on the toilet seat." C. "I will have someone else put on my shoes and socks." D. "I can sleep in any position that is comfortable for me."

D. "I can sleep in any position that is comfortable for me." Rationale: The patient needs to sleep in a position that prevents excessive internal rotation or flexion of the hip. The other patient statements indicate the patient has understood the teaching

When obtaining a health history from a 49 year old patient, which patient statement is most important to communicate to the primary health care provider? A. "My eyes are dry now" B. "It is hard for me to see at night." C. "My vision is blurry when I read." D. "I can't see as far over to the side"

D. "I can't see as far over to the side." Rationale: The decrease in peripheral vision may indicate glaucoma, which is not a normal visual changed associated with aging and requires rapid treatment. The other patient statements indicate visual problems (presbyopia, dryness, and lens opacity) that are considered a part of aging

The nurse is teaching a patient about timolol eye drops for the treatment of glaucoma. What statement made by the patient demonstrates that teaching was effective? A. "I may feel some palpitations after instilling these eye drops." B. "I should withhold this medication if my blood pressure becomes elevated." C. "I should keep my eyes closed for 15 minutes after instilling these eye drops." D. "I may have some temporary blurring of vision after instilling these eye drops."

D. "I may have some temporary blurring of vision after instilling these eye drops." Rationale: It is common for patients to have a temporary blurring of vision for a few minutes after instilling eye drops. This should not cause concern to the patient. Because timolol is a β-blocker, heart rate may slow, and blood pressure is more likely to decrease if absorbed systemically.

The nurse obtains a history from a 46-yr-old woman with rheumatoid arthritis. The nurse should follow up on which patient statement? A. "I perform range of motion exercises at least twice a day." B. "I use a heating pad for 20 minutes to reduce morning stiffness." C. "I take a 20-minute nap in the afternoon even if I sleep 9 hours at night." D. "I restrict fluids to prevent edema when taking methotrexate (Rheumatrex)."

D. "I restrict fluids to prevent edema when taking methotrexate (Rheumatrex)." Rationale: Methotrexate can affect renal function. Patients should be well hydrated to prevent nephropathy. Heat application, range of motion, and rest are appropriate interventions to manage rheumatoid arthritis.

The nurse instructs a patient prescribed dipivefrin eye drops to manage chronic open-angle glaucoma. Which statement, if made by the patient to the nurse, indicates that further teaching is needed? A. "The eye drops could cause a fast heart rate and high blood pressure." B. "I will need to take the eye drops twice a day for at least 2 to 3 months." C. "I may experience eye discomfort and redness from the use of these eye drops." D. "I will apply gentle pressure on the inside corner of my eye after each eye drop."

D. "I will apply gentle pressure on the inside corner of my eye after each eye drop." Rationale: To avoid systemic reactions such as tachycardia and hypertension, the patient should apply punctual occlusion after instillation of the eye drops. Dipivefrin will control chronic open-angle glaucoma but will not cure the disease. Side effects associated with dipivefrin include ocular discomfort and redness, tachycardia, and hypertension.

A 72 year old patient with age related macular degeneration (AMD) has just had photodynamic therapy. Which statement by the patient indicates that the discharge teaching has been effective? A. "I will use drops to keep my pupils dilated until my appointment." B. "I will need to use brighter lights to read for at least the next week." C. "I will not use facial lotions near my eyes during the recovery period." D. "I will cover up with long sleeved shirts and pants for the next 5 days."

D. "I will cover up with long sleeved shirts and pants for the next 5 days." Rationale: The photosensitizing drug used for photodynamic therapy is activated by exposure to bright light and can cause burns in areas exposed to light for 5 days after the treatment. There are no restrictions of the use of facial lotions, medications to keep the pupils dilated would not be appropriate, and bright lights would increase the risk for damage caused by the treatment

The nurse is teaching a patient with glaucoma about administration of pilocarpine. What statement is important for the nurse to include during the instructions? A. "Prolonged eye irritation is an expected adverse effect of this medication." B. "This medication will help to raise intraocular pressure to a near normal level." C. "This medication needs to be continued for at least 5 years after your initial diagnosis." D. "It is important not to do activities requiring visual acuity immediately after administration."

D. "It is important not to do activities requiring visual acuity immediately after administration." Rationale: Pilocarpine causes blurred vision and difficulty in focusing, so it is important not to engage in any activities requiring visual acuity until the vision clears. It should not cause prolonged eye irritation, and this should be immediately reported to the prescribing care provider. This medication will decrease intraocular pressure.

Which patient statement suggests a need to assess the patient for ankylosing spondylitis (AS)? A. "My right elbow has become red and swollen over the last few days." B. "I wake up stiff every morning, and my knees just don't want to bend." C. "My husband tells me that my posture has become so stooped this winter." D. "My lower back pain seems to be getting worse and nothing seems to help."

D. "My lower back pain seems to be getting worse and nothing seems to help." Rationale: AS primarily affects the axial skeleton. Based on this, symptoms of inflammatory spine pain are often the first clues to a diagnosis of AS. Knee or elbow involvement is not consistent with the typical course of AS. Back pain is likely to precede the development of kyphosis.

A 54-yr-old patient is about to have a bone scan. In teaching the patient about this procedure, the nurse should include what information? A. "Only mild pain is associated with the procedure." B. "Two additional follow-up scans will be required." C. "The procedure takes approximately 15 to 30 minutes." D. "You will need to drink increased fluids after the procedure."

D. "You will need to drink increased fluids after the procedure." Rationale: 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 are required. Only mild pain may be associated with bone scans related to 1 hour of lying supine.

The nurse finds that a patient can flex the arms when no resistance is applied but is unable to flex when the nurse applies light resistance. The nurse should document the patient's muscle strength as level A. 0. B. 1. C. 2. D. 3.

D. 3 Rationale: Muscle strength of 3 indicates the patient is unable to move against resistance but can move against gravity. Level 1 indicates minimal muscle contraction, level 2 indicates the arm can move when gravity is eliminated, level 4 indicates active movement with some resistance

A patient with poor visual acuity is diagnosed with age-related macular degeneration (AMD). Which nursing action should be the nurse's priority? A. Teach about visual enhancement techniques. B. Teach nutritional strategies to improve vision. C. Assess coping strategies and support systems. D. Assess impact of vision on normal functioning.

D. Assess impact of vision on normal functioning. Rationale: The most important nursing intervention is to assess the patient's ability to function with the visual impairment. The nurse will use this information to plan nursing care, including assessment of the patient's coping strategies and teaching about vision enhancement techniques and nutrition.

Which finding in a patient with a Colles' fracture of the left wrist is most important to communicate immediately to the health care provider? A. Swelling is noted around the wrist. B. The patient is reporting severe pain. C. The wrist has a deformed appearance. D. Capillary refill to the fingers is prolonged.

D. Capillary refill to the fingers is prolonged. Rationale: Swelling, pain, and deformity are common findings with a Colles' fracture. Prolonged capillary refill indicates decreased circulation and risk for ischemia. This is not an expected finding and should be reported immediately

During the course of an interview to assess vision, a patient complains of dry eyes. What should the nurse implement next? A. Assess for contact lenses. B. Suggest saline eye drops. C. Ask about eyeglass usage. D. Check the medication list.

D. Check the medication list. Rationale: The nurse should evaluate the patient's medication list to identify agents that can contribute to dry eyes so follow-up nursing care can be planned. Dry eyes aggravate wearing contact lenses, but contact lenses do not normally cause dry eyes. The nurse should not suggest saline eye drops until the etiology of the dry eyes is determined. Eyeglasses do not cause dry eyes.

Which information will the nurse include for a patient contemplating a cochlear implant? A. Cochlear implants are not useful for patients with congenital deafness B. Cochlear implants are most helpful as an early intervention for presbycusis C. Cochlear implants improve hearing in patients with conductive hearing loss D. Cochlear implants require extensive training in order to reach the full benefit

D. Cochlear implants require extensive training in order to reach the full benefit Rationale: Extensive rehabilitation is required after cochlear implants for patients to receive the maximum benefit. Hearing aids, rather than cochlear implants, are used initially for presbycusis. Cochlear implants are used for sensorineural hearing loss and would not be helpful for conductive loss. They are appropriate for some patients with congenital deafness

Which information will the nurse include when teaching a patient with herpes simplex type I keratitis? A. Use of Natamycin (Natacyn) antifungal eyedrops B. Application of corticosteroid ophthalmic ointment C. Avoidance of nonsteroidal antiinflammatory drugs (NSAIDs) D. Completion of the prescribed series of oral acyclovir

D. Completion of the prescribed series of oral acyclovir Rationale: Oral acyclovir may be ordered for herpes simplex infections. Corticosteroid ointments are usually contraindicated because they prolong the course of the infection. Herpes simplex type I is viral, not parasitic or fungal. Natamycin may be used for Acanthamoeba keratitis caused by a parasite. NSAIDs can be used to treat the pain associated with keratitis

A patient with septic shock is receiving multiple medications. Which intravenous (IV) medication is most likely to cause a hearing loss? A. Dopamine B. Ampicillin C. Aspirin D. Vancomycin

D. Vancomycin Rationale: The IV medication in use that is most likely to cause a hearing loss is vancomycin (Vancocin) because it is an ototoxic medication. For that reason, serum drug levels are monitored to maintain therapeutic levels and reduce the risk of ototoxicity. Aspirin can also cause hearing loss, but it is not administered IV. Neither dopamine nor ampicillin is likely to cause hearing loss.

To decrease the risk for future hearing loss, which action should the nurse implement with college students at the on campus health clinic? A. Perform tympanometry B. Schedule otoscopic examinations C. Administer influenza immunizations D. Discuss exposure to amplified music

D. Discuss exposure to amplified music Rationale: The nurse should discuss the impact of amplified music on hearing with young adults and discourage listening to very amplified music, especially for prolonged periods. Tympanometry measures the ability of the eardrum to vibrate and would not help prevent future hearing loss. Although student are at risk for the influenza virus, being vaccinated does not help prevent future hearing loss. Otoscopic examinations are not necessary for all patients

The nurse formulates a nursing diagnosis of Impaired physical mobility related to decreased muscle strength for an older adult patient recovering from left total knee arthroplasty. What nursing intervention is appropriate? A. Promote vitamin C and calcium intake in the diet. B. Provide passive range of motion to all of the joints q4hr. C. Keep the left leg in extension and abduction to prevent contractures. D. Encourage isometric quadriceps-setting exercises at least four times a day.

D. Encourage isometric quadriceps-setting exercises at least four times a day. Rationale: Emphasis is placed on postoperative exercise of the affected leg, with isometric quadriceps setting beginning on the first day after surgery. Vitamin C and calcium do not improve muscle strength, but they will facilitate healing. The patient should be able to perform active range of motion to all joints. Keeping the leg in one position (extension and abduction) may contribute to contractures.

The nurse is reinforcing health teaching about osteoporosis with a 72-yr-old patient admitted to the hospital. What should the nurse explain to the patient? A. With a family history of osteoporosis, you cannot prevent or slow bone resorption. B. Estrogen therapy must be maintained to prevent rapid progression of the osteoporosis. C. Continuous, low-dose corticosteroid treatment is effective in stopping the course of 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. Rationale: The rate of progression of osteoporosis can be slowed if the patient takes calcium supplements 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.

Which finding for a 77 year old patient seen in the outpatient clinic requires further nursing assessment and intervention? A. Symmetric joint swelling of fingers B. Decreased right knee range of motion C. Report of left hip aching when jogging D. History of recent loss of balance and fall

D. History of recent loss of balance Rationale: A history of falls requires further assessment and development of fall prevention strategies. The other changes are more typical of bone and joint changes associated with normal aging

The patient is brought to the emergency department after a car accident and is diagnosed with a femur fracture. What nursing intervention should the nurse implement at this time to decrease risk of a fat embolus? A. Administer enoxaparin (Lovenox). B. Provide range-of-motion exercises. C. Apply sequential compression boots. D. Immobilize the fracture preoperatively.

D. Immobilize the fracture preoperatively. Rationale: The nurse immobilizes the long bone to reduce movement of the fractured bone ends and decrease the risk of a fat embolus development before surgical reduction. Enoxaparin is used to prevent blood clots not fat emboli. Range of motion and compression boots will not prevent a fat embolus in this patient.

What is important for the nurse to include in the postoperative care of the patient following tympanoplasty? A. check the gag reflex B. encourage independence C. avoid changing the cotton padding D. instruct patient to refrain from forceful nose blowing

D. Instruct the patient to refrain from forceful nose blowing Rationale: Sudden pressure changes in the ear and postoperative infections can disrupt the surgical repair during the healing phase or cause facial nerve paralysis

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 Rationale: 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

The nurse assess a 78-year-old who uses naproxen (Aleve) daily for hand and knee osteoarthritis management. Which information requires a discussion with a health care provider about an urgent change in the treatment plan? A. Knee crepitation is noted with normal knee range of motion B. Patients report embarrassment about having Heberden's nodes C. Patient's knee pain while golfing has increased over the last year D. Laboratory results indicate blood urea nitrogen (BUN) is elevated

D. Laboratory results indicate blood urea nitrogen (BUN) is elevated Rationale: Older patients are at an increased risk for renal toxicity caused by nonsteroidal antiinflammatory drugs (NSAIDS) such as naproxen. The other information will also be reported to the health care provider but is consistent with the patient's diagnosis of osteoarthritis and will not require an immediate change in the patient's treatment plan

When administering a scheduled dose of pilocarpine, in which area should the nurse place the drops? A. Inner canthus B. Outer canthus C. Center of the eyeball D. Lower conjunctival sac

D. Lower conjunctival sac Rational: Ocular medications such as pilocarpine should be instilled into the lower conjunctival sac. Never apply eye drops directly to the cornea. Applying the drops to the inner canthus will cause them to be distributed systemically.

The nurse is caring for a patient placed in Buck's traction before open reduction and internal fixation of a left hip fracture. Which care can be delegated to the LPN/LVN? A. Assess skin integrity around the traction boot. B. Determine correct body alignment to enhance traction. C. Remove weights from traction when turning the patient. D. Monitor pain intensity and administer prescribed analgesics.

D. Monitor pain intensity and administer prescribed analgesics. Rationale: The LPN/LVN can monitor pain intensity and administer analgesics. Assessment of skin integrity and determining correct alignment to enhance traction are within the RN scope of practice. Removing weights from the traction should not be delegated or done. Removal of weights can cause muscle spasms and bone misalignment, and should not be delegated or done.

A 58-yr-old woman with breast cancer is admitted for severe back pain related to a vertebral 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 Rationale: Breast cancer can metastasize to the bone, with vertebrae as a common site. Pathologic fractures at the site of metastasis are common because of a weakening of the involved bone. High serum calcium results as calcium is released from damaged bones. Normal serum calcium is 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.

Which menu choice by a patient with osteoporosis indicates the nurse's teaching about appropriate diet has been effective? A. Pancakes with syrup and bacon B. Whole wheat toast and fresh fruit C. Egg-white omelet and a half grapefruit D. Oatmeal with skim milk and fruit yogurt

D. Oatmeal with skim milk and fruit yogurt Rationale: Skim milk and yogurt are high in calcium. The other choices do not contain any high-calcium foods

After change-of-shift report, which patient should the nurse assess first? A. Patient with a repaired mandibular fracture who is complaining of facial pain B. Patient with an unrepaired intracapsular left hip fracture whose leg is externally rotated C. Patient with an unrepaired Colles' fracture who has right wrist swelling and deformity D. Patient with repaired right femoral shaft fracture who is complaining of tightness in the calf

D. Patient with repaired right femoral shaft fracture who is complaining of tightness in the calf Rationale: Calf swelling after a femoral shaft fracture suggest hemorrhage and risk for compartment syndrome. The nurse should assess the patient rapidly and then notify the health care provider. The other patients have symptoms that are typical for their injuries but do not require immediate intervention

A 67-yr-old patient hospitalized with osteomyelitis has an order for bed rest with bathroom privileges and elevation of the affected foot on two pillows. The nurse would place the 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. Rationale: The patient is at risk for atelectasis of the lungs and 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 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. Dangling the legs every 2 to 4 hours may be too painful.

When the patient is diagnosed with muscular dystrophy, what information should the nurse include in the teaching plan? A. Use prolonged bed rest to decrease fatigue. B. Continuous positive airway pressure will facilitate sleeping. C. An orthotic jacket will limit mobility and may contribute to deformity. D. Remain active to prevent skin breakdown and respiratory complications.

D. Remain active to prevent skin breakdown and respiratory complications. Rationale: With muscular dystrophy, the patient must 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) may be used as respiratory function decreases before mechanical ventilation is needed to sustain respiratory function.

The nurse is working in an urgent care clinic that has standardized treatment protocols for implementation by the nursing staff. After reviewing the history, physical assessment, and vital signs for a 60 year old patient as shown in the accompanying figure, which action should the nurse take first? History: Type 2 diabetes x 5 years; mild hearing loss; Sudden loss of left eye peripheral vision today Physical Assessment: PERRLA; EOMS intact; Cerumen obstructs view of tympanic membranes Vital signs: Pulse 102; BP 146/90 (right arm); respirations 24; temperature 97.9F (36.6C) A. Check the patient's blood glucose level B. Take the blood pressure on the left arm C. Use an irrigating syringe to clean the ear canals D. Report a vision change to the health care provider

D. Report a vision change to the health care provider Rationale: The sudden change in peripheral vision may indicate an acute problem, such as retinal detachment, that should be treated quickly to preserve vision. The other data about the patient are not indicative of any acute problem. The other actions are also appropriate, but the highest priority for this patient is prevention of blindness

The nurse is completing the admission database for a patient admitted with abdominal pain and notes a history of hypertension and glaucoma. Which prescribed medication should the nurse question? A. Morphine sulfate 4mg IV B. Diazepam (Valium) 5mg IV C. Betaxolol (Betopic) 0.25% eyedrops D. Scopolamine patch (Transderm Scop) 1.5mg

D. Scopolamine patch (Transderm Scop) 1.5mg Rationale: Scopolamine is a parasympathetic blocker and will relax the iris, causing blockage of aqueous humor outflow and an increase in intraocular pressure. The other medications are appropriate for this patient

Which action will the nurse include in the plan of care for a patient who had a cemented right total knee arthroplasty? A. Avoid extension of the right knee beyond 120 degrees B. Use a compression bandage to keep the right knee flexed C. Teach about the need to avoid weight bearing for 4 weeks D. Start progressive knee exercises to obtain 90 degree flexion

D. Start progressive knee exercises to obtain 90 degree flexion Rationale: After knee arthroplasty, active or passive flexion exercises are used to obtain a 90 degree flexion of the knee. The goal for extension of the knee will be 180 degrees. A compression bandage is used to hold the knee in an extended position after surgery. Surgeon orders allow weight bearing as tolerated after this procedure; protected weight bearing is not needed

Which assessment finding for a patient who has had surgical reduction of an open fracture of the right radius requires notification of the health care provider? A. serous wound drainage B. right arm muscle spasms C. Right arm pain with movement D. Temperature 101.4F (38.6C)

D. Temperature 101.4F (38.6C) Rationale An elevated temperature suggests possible osteomyelitis. The other clinical manifestations are typical after a repair of an open fracture

Which finding in an emergency department patient who reports being struck in the right eye with a fist is a priority for the nurse to communicate to the health care provider? A. The patient complains of a right-sided headache. B. The sclera on the right eye has broken blood vessels. C. The area around the right eye is bruised and tender to the touch. D. The patient complains of "a curtain" over part of the visual field.

D. The patient complains of "a curtain" over part of the visual field. Rationale: The patient's sensation that a curtain is coming across the field of vision suggests retinal detachment and the need for rapid action to prevent blindness. The other findings would be expected with the patient's history of being hit in the eye

Which teaching point should the nurse plan to include when caring for a patient whose vision is corrected to 20/200? A. How to access audiobooks B. How to use a white cane safely C. Where Braille instruction is available D. Where to obtain hand held magnifiers

D. Where to obtain hand held magnifiers Rationale: Various types of magnifiers can enhance the remaining vision enough to allow the performance of many tasks and activities of daily living. Audio books, Braille instruction, and canes usually are reserved for patients with no functional vision

The nurse at the eye clinic made a follow-up telephone call to a patient who underwent cataract extraction and intraocular lens implantation the previous day. Which information is the priority to communicate to the health care provider? A. The patient requests a prescription refill for next week B. The patient feels uncomfortable wearing an eye patch. C. The patient complains that the vision has not improved D. The patient reports eye pain rated 5 (on a 0-10 scale)

D. The patient reports eye pain rated 5 (on a 0-10 scale) Rationale: Postoperative cataract surgery patients usually experience little or no pain, so pain at a level 5 on a 10 point pain scale may indicate complications such as hemorrhage, infection, or increased intraocular pressure. The other information given by the patient indicates a need for patient teaching or follow up does not indicate that complications of the surgery may be occurring

The home health nurse is making a follow up visit to a patient with recently diagnosed rheumatoid arthritis (RA). Which assessment made by the nurse indicates more patient teaching is needed? A. The patient takes a 2 hours nap each day B. The patient has been taking 16 aspirins each day C. The patient sits on a stool while preparing meals D. The patient sleeps with two pillows under the head

D. The patient sleeps with two pillows under the head Rationale: The joints should be maintained in an extended position to avoid contractures, so patients should use a small, flat pillow for sleeping. Rest, aspirin, and energy management are appropriate for a patient with RA and indicate teaching has been effective

A patient is scheduled for a corneal transplant and is concerned regarding the difficulty with vision that may last for up to 12 months after the transplant. What is the best response by the nurse? A. If the transplant is done soon after the donor dies, there will not be as much trouble recovering vision. B. The astigmatism the patient is experiencing may be corrected with glasses or rigid contact lenses. C. Increasing the amount of light and using a magnifier to read will be helpful if a transplant is not wanted. D. There are newer procedures in which only the damaged cornea epithelial layer is replaced, and they have a faster recovery.

D. There are newer procedures in which only the damaged cornea epithelial layer is replaced, and they have a faster recovery Rationale: The new procedures are called Descemet's stripping endothelial keratoplasty (DSEK) and Descemet's membrane endothelial keratoplasty (DMEK). Corneal transplants should be done as soon as possible, but this does not affect the rate of visual recovery. Astigmatism is not experienced with corneal scars and opacities requiring a corneal transplant. Increasing light and magnification helps a person with cataracts to read.

The nurse in the eye clinic is examining a 67 year old patient who says, "I see small spots that move around in from of my eyes." Which action will the nurse take first? A. Immediately have the ophthalmologist evaluate the patient B. Explain that spots and floaters are a normal part of aging C. Warn the patient that these spots may indicate retinal damage D. Use an ophthalmoscope to examine the posterior eye chambers

D. Use an ophthalmoscope to examine the posterior eye chambers Rationale: Although floaters are usually caused by vitreous liquefaction and are common in aging patients, they can be caused by hemorrhage into the vitreous humor or by retinal tears, so the nurse's action will be to examine the retina and posterior chamber. Although the ophthalmologist will examine the patient, the presence of spots or floaters in a 65 year old patient is not an emergency. The spots may indicate retinal damage, but the nurse should assess the eye further before discussing this with the patient

When grading muscle strength, the nurse records a score of 3/5, 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

A patient with a comminuted fracture of the tibia is to have an open reduction with internal fixation (ORIF) to the fracture. The nurse explains that ORIF is indicated when A. the patient is unable to tolerate prolonged immobilization B. the patient cannot tolerate the surgery for a closed reduction C. a temporary cast would be too unstable to provide normal mobility D. adequate alignment cannot be obtained by other nonsurgical methods

D. adequate alignment cannot be obtained by other nonsurgical methods Rationale: A comminuted fracture has more than 2 bone fragments. Open reduction with internal fixation (ORIF) is indicated for a comminuted fracture and is used to realign and maintain bony fragments. Other nonsurgical methods can result in a failure to obtain satisfactory reduction. Internal fixation reduces the hospital stay and complications associated with prolonged bed rest

A patient is scheduled for total ankle replacement. The nurse should tell the patient that after surgery he should avoid A. lifting heavy objects B. sleeping on the back C. abduction exercises of the affected ankle D. bearing weight on the affected leg for 6 weeks

D. bearing weight on the affected leg for 6 weeks Rationale: After total ankle arthroplasty (TAA), the patient may not bear weight for 6 weeks and must elevate the extremity to reduce edema. The patient must follow strategies to prevent postoperative infection and maintain immobilization as directed by the surgeon

A 54-year-old woman who recently reached menopause and has a family history of osteoporosis is diagnosed with osteopenia following densitometry testing. In teaching the woman, the nurse explains that A. with a family history of osteoporosis, there is no way to prevent or slow bone resorption B. estrogen replacement therapy must be started to prevent rapid progression to osteoporosis C. continuous, low dose corticosteroid treatment is effective in stopping the course of osteoporosis D. calcium loss from bones can be slowed by increasing calcium intake and weight bearing exercises

D. calcium loss from bones can be slowed by increasing calcium intake and weight bearing exercises Rationale: Progression of osteoporosis can be slowed by increasing calcium intake and weight bearing exercise. Estrogen replacement therapy is no longer routinely given to prevent osteoporosis because of increased risk of heart disease as well as breast and uterine cancer. Corticosteroid therapy increases the risk for osteoporosis

A patient reporting painful urination and knee pain is diagnosed with reactive arthritis. The nurse will plan to teach the patient about the need for several months of therapy with A. methotrexate B. anakinra (Kineret) C. etanercept (Enbrel) D. doxycycline (Vibramycin)

D. doxycycline (Vibramycin) Rationale: Reactive arthritis associated with urethritis is usually caused by infection with Chlamydia trachomatis and requires 3 months of treatment with doxycycline. The other medications are used for chronic inflammatory problems such as rheumatoid arthritis

The nurse who notes that a 59-year-old female patient has lost 1 inch in height over the past 2 years will plan to teach the patient about A. discography studies. B. myelographic testing. C. magnetic resonance imaging (MRI). D. dual-energy x-ray absorptiometry (DXA).

D. dual-energy x-ray absorptiometry (DXA). Rationale: The decreased height and the patient's age suggest that the patient may have osteoporosis, and bone density testing is needed. Discography, MRI, and myleography are typically done for patients with current symptoms caused by musculoskeletal dysfunction and are not the initial diagnostic tests for osteoperosis

The charge nurse must intervene immediately if observing a nurse who is caring for a patient with vestibular disease A. facing the patient directly when speaking B. speaking slowly and distinctly to the patient C. administering both the Rinne and Weber tests D. encouraging the patient to ambulate independently

D. encouraging the patient to ambulate independently Rationale: Vestibular disease affects balance, so the nurse should monitor the patient during activities that require balance. The other actions might be used for patients with hearing disorders

Increased intraocular pressure may occur as a result of A. edema of the corneal stroma B. dilation of the retinal arterioles C. blockage of the lacrimal canals and ducts D. increased production of aqueous humor by the ciliary process

D. increased production of aqueous humor by the ciliary process Rationale: Excess aqueous humor production or decreased outflow can elevate intraocular pressure above the normal 10 to 21mm Hg; this condition is called glaucoma

Patients with permanent visual impairment A. feel most comfortable with other visually impaired people B. may feel threatened when others make eye contact during a conversation C. usually need others to speak louder so that they can communicate appropriately D. may experience the same grieving process that is associated with other losses

D. may experience the same grieving process that is associated with other losses Rationale: When the patient has lost visual function or even the entire eye, he or she will grieve the loss. The nurse should help the patient through the grieving process

The nurse will determine more teaching is needed if a patient with discomfort from a bunion says, "I will A. give away my high-heeled shoes." B. take ibuprofen (Motrin) if I need it." C. use the bunion pad to cushion the area." D. only wear sandals, no closed-toe shoes."

D. only wear sandals, no closed-toe shoes." Rationale: The patient can wear shoes that have a wide forefoot (toe box). The other patient statements indicate the teaching has been effective

The nurse evaluating effectiveness of prescribed calcitonin (Cibacalcin) and ibandronate (Boniva) for a patient with Paget's disease will consider the patient's A. oral intake B. daily weight C. grip strength D. pain intensity

D. pain intensity Rationale: Bone pain is a common early manifestation of Paget's disease, and the nurse should assess the pain intensity to determine if treatment is effective. The other information will also be collected by the nurse but will not be used in evaluating the effectiveness of therapy

A patient with a stable, closed humoral fracture has a temporary splint with bulky padding applied with an elastic bandage. The nurse notifies the surgeon of possible early compartment syndrome when the patient experiences A. increasing edema of the limb B. muscle spasms of the lower arm C. bounding pulse at the fracture site D. pain when passively extending the fingers

D. pain when passively extending the fingers Rationale: One or more of the following are characteristic of early compartment syndrome: paresthesia (i.e. numbness and tingling sensation); pain distal to the injury that is not relieved by opioid analgesics and is increased on passive stretch of muscle; increased pressure in the compartment; pallor, coolness, and loss of normal color of the extremity. Paralysis (or loss of function) and pulselessness (or diminished or absent peripheral pulses) are late signs of compartment syndrome. The examination also includes assessment of peripheral edema, especially pitting edema, which may occur with severe injury

In reviewing a patient's medical record, the nurse notes that the last eye examination revealed an intraocular pressure of 28 mm Hg. The nurse will plan to assess A. visual acuity B. pupil reaction C. color perception D. peripheral vision

D. peripheral vision Rationale: The patient's increased intraocular pressure indicates glaucoma, which decreases peripheral vision. Because central visual acuity is unchanged by glaucoma, assessment of visual acuity could be normal even if the patient has worsening glaucoma. Color perception and pupil reaction to light are not affected by glaucoma

A patient with suspected disc herniation is experiencing acute pain and muscle spasms. The nurse's responsibility is to A. encourage total bed rest for several days B. teach principles of back strengthening exercises C. stress the importance of straight leg raises to decrease pain D. promote use of cold and hot compresses and pain medication

D. promote use of cold and hot compresses and pain medication Rationale: if acute pain and muscle spasms re not severe, the patient may be treated as an outpatient with NSAIDs and muscle relaxants (e.g. cyclobenzaprine [Flexeril]). Massage and back manipulation, acupuncture, and application of cold and hot compresses may help some patients. Severe pain may require a brief course of opioid analgesics. A brief period (1 to 2 days) of rest at home may be needed for some people; most patients do better if they continue their regular activities. Prolonged bed rest should be avoided. All patients should refrain from activities that aggravate the pain, including lifting, bending, twisting, and prolonged sitting

The day after a 60-year-old patient has an open reduction and internal fixation (ORIF) for an open, displaced tibial fracture, the priority nursing diagnosis is A. activity intolerance related to deconditioning. B. risk for constipation related to prolonged bed rest. C. risk for impaired skin integrity related to immobility. D. risk for infection related to disruption of skin integrity.

D. risk for infection related to disruption of skin integrity. Rationale: A patient having ORIF is at risk for problems such as wound infection and osteomyelitis. After ORIF, patients typically are mobilized starting the first preoperative day, so the other problems caused by immobility are not as likely

The most important intervention for the patient with epidemic keratoconjunctivitis is A. cleansing the affected area with baby shampoo B. monitoring spread of infection to the opposing eye C. regular instillation of artificial tears to the affected eye D. teaching the patient and family members good hygiene techniques

D. teaching the patient and family members good hygiene techniques Rationale: Epidemic keratoconjunctivitis (EKC) is the most serious ocular adenoviral disease. EKC is spread by direct contact, including sexual activity. The nurse should teach the patient and caregiver the importance of good hygiene practices to avoid spreading the disease

In teaching a patient with SLE about the disorder, the nurse knows that the pathophysiology of SLE includes a. circulating immune complexes formed from IgG autoantibodies reacting with IgG b. an autoimmune T-cell reaction that results in destruction of the deep dermal skin layer c. immunologic dysfunction leading to chronic inflammation in the cartilage and muscles d. the production of a variety of autoantibodies directed against components of the cell nucleus

D. the production of a variety of autoantibodies directed against components of the cell nucleus. Rationale: Systemic lupus erythematosus (SLE) is marked by production of many autoantibodies against nucleic acids (e.g. single and double stranded DNA), erythrocytes, coagulation proteins, lymphocytes, platelets, and other self-proteins. Autoimmune reactions (antinuclear antibodies [ANA]) are typically directed against constituents of the cell nucleus, especially DNA

The nurse performing an eye examination will document normal findings for accommodation when A. shining a light into the patient's eye causes pupil constriction in the opposite eye. B. a blink reaction follows touching the patient's pupil with a piece of sterile cotton. C. covering one eye for 1 minute and noting pupil constriction as the cover is removed. D. the pupils constrict while fixating on an object being moved closer to the patient's eyes.

D. the pupils constrict while fixating on an object being moved closer to the patient's eyes. Rationale: Accommodation is defined as the ability of the lens to adjust to various distances. The pupils constrict while fixating on an object that is being moved from far away to near the eyes. The other responses may also be elicited as part of the eye examination, but they do not indicate accommodation

When assessing for Tinel's sign in a patient with possible right carpal tunnel syndrome, the nurse will ask the patient about A. weakness in the right little finger B. burning in the right elbow and forearm C. tremor when gripping with the right hand D. tingling in the right thumb and index finger

D. tingling in the right thumb and index finger Rationale: Testing for Tinel's sign will cause a tingling in the thumb and first three fingers of the affected hand in patients who have carpal tunnel syndrome. The median nerve does not innervate the right little finger or elbow and forearm. Tremor is not associated with carpal tunnel syndrome.

The nurse suspects an ankle sprain when a patient at the urgent care center describes A. being hit by another soccer player during a game B. having ankle pain after sprinting around the track C. dropping a 10-lb weight on his lower leg at the health club D. twisting his ankle while running bases during a baseball game

D. twisting his ankle while running bases during a baseball game Rationale: A sprain is an injury to the ligaments surrounding a joint and is usually caused by a wrenching or twisting motion. Most sprains occur in the ankle and knee joints

The safest technique for the nurse to use when assisting a blind patient in ambulating to the bathroom is to A. have the patient place a hand on the nurse's shoulder and guide the patient. B. lead the patient slowly to the bathroom, holding on to the patient by the arm. C. stay beside the patient and describe any obstacles on the path to the bathroom. D. walk slightly ahead of the patient, allowing the patient to hold the nurse's elbow.

D. walk slightly ahead of the patient, allowing the patient to hold the nurse's elbow. Rationale: When using the sighted-guide technique, the nurse walks slightly in front and to the side of the patient and has the patient hold the nurse's elbow. The other techniques are not as safe in assisting a blind patient

During the preoperative assessment of the patient scheduled for a right cataract extraction and intraocular lens implantation, it is most important for the nurse to assess a. the visual acuity of the patient's left eye. b. how long the patient has had the cataract. c. for presence of a white pupil in the right eye. d. for a history of reactions to general anesthetics.

a. the visual acuity of the patient's left eye. Rationale: Because it can take several weeks before the maximum improvement in vision occurs in the right eye, patient safety and independence are determined by the vision in the left eye. A white pupil in the operative eye would not be unusual for a patient scheduled for cataract removal and lens implantation. The length of time that the patient has had the cataract will not affect and perioperative care. Cataract surgery is done using local anesthetics rather than general anesthetics

After the health care provider recommends amputation for a patient who has nonhealing ischemic foot ulcers, the patient tells the nurse that he would rather die than have an amputation. Which response by the nurse is best? a. "You are upset, but you may lose the foot anyway." b. "Many people are able to function with a foot prosthesis." c. "Tell me what you know about your options for treatment." d. "If you do not want an amputation, you do not have to have it."

c. "Tell me what you know about your options for treatment." Rationale: The initial nursing action should be to assess the patient's knowledge and feelings about the available options. Discussion about the patient's option to refuse the procedure, seriousness of the condition, or rehabilitation after the procedure may be appropriate after the nurse knows more about the patient's current knowledge and emotional state.