MS4

The health care provider has prescribed a diet that limits purine- rich foods. Which foods should this client avoid?

Anchovies, sardines, and kidneys. Sweetbreads, red meats, and alcohol.

A nurse is performing a neurovascular assessment. What should the nurse include in this assessment?

A correct neurovascular assessment should include capillary refill, movement, pulses, and warmth. Neurovascular assessment involves nerve and blood supply to an area.

A 30- year- old female client is suspected of having cholecystitis. What question should the nurse ask this client?

"Has anyone in your family ever been diagnosed with cholecystitis?" "What is your daily activity routine?" "Do you take birth control pills?" "Are you on hormone replacement therapy?" Risk factors for cholecystitis include a family history, a sedentary lifestyle, and the use of birth control pills. The client is 30 years old, and may have undergone gynecological surgery that would require hormone replacement therapy.

The nurse is obtaining a health history from a client who has been taking ibuprofen. What PRIORITY questions should the nurse ask this client?

"How often do you take this medication?" "Have you had any difficulty breathing?" "Have you ever had tarry, black stools?" "Have you ever vomited blood?"

A nurse is providing discharge teaching to a client following a left hip replacement. The nurse determines that discharge teaching has been effective when the client states:

"I am allowed limited weight bearing." After a hip replacement, the client will have limited weight bearing restrictions. The client will be allowed to love with restrictions for approximately two to three months.

A nurse is interviewing a client who has a pattern of non- chronic gout. Which statement, by the client, BEST describes the pattern of non- chronic gout?

"I have occasional painful attacks with pain free periods between attacks." The usual pattern of gout involves painful attacks with pain- free periods between attacks. Chronic gout may lead to frequent attacks with persistently painful joints.

A 42- year- old client recently had a total hysterectomy and bilateral oophorectomy. Which response by the client would indicate an understanding about osteoporosis?

"I need to take precautions to prevent osteoporosis because I have had surgically induced menopause." Menopause, at any age, puts a woman at risk for osteoporosis because of the associated hormonal imbalance.

Which statement indicates that a client understands the administration of a Mantoux test?

"I will come to get it read within 72 hours." Mantoux test results should be read 48 to 72 hours after placement by measuring the diameter of the induration at the site of the injection. The Mantoux test is injected intradermally on the volar surface of the forearm.

A nurse has given discharge instructions to a client with chronic cholecystitis. The nurse understands that teaching has been effective when the client states:

"I will take my anticholinergic medications as prescribed." Conservative therapy for chronic cholecystitis includes weight reduction by increasing physical activity, a low- fat diet, antacid use to treat muscles and reduce ductal tone and spasm.

A nurse has instructed a client to accurately measure the circumference of both calves each morning and to report any increase in size. The nurse determines that these instructions were understood when the client states:

"I'll use a measuring tape to check circumference"

Which statement, by a client diagnosed with gout, would indicate an understanding of the discharge instructions?

"Increasing fluid intake will cause my body to excrete more uric acid."

A client asks the nurse what caused the development of a hiatal hernia? What is the nurse's BEST response?

"It is caused by weakness of the diaphragmatic muscle" A hiatal hernia is caused by weakness of the diaphragmatic muscle, and increased abdominal pressure. This weakness allows the stomach to slide into the esophagus.

The nurse has provided teaching to a client newly diagnosed with gout. The nurse determines that teaching has been effective when the client states:

"Weight loss will decrease uric acid levels and decrease stress on joints."

The nurse informs a client diagnosed with gout that his X-rays are normal. Which statement by the nurse, the MOST appropriate when the client asks if he still has gout?

"Yes, X-rays remain normal in the early stages of gout."

Which clinical manifestation would lead the nurse to suspect a fat embolus in a client who has a left femur fracture?

Dyspnea. A fat embolism usually present as acute respiratory distress. Symptoms include chest pain, cyanosis, dyspnea, tachypnea, and apprehension.

A client with a spinal cord injury has dexamethasone 16 mg ordered IV. The drug vial contains 24 mg/ml. The nurse plans to use a tuberculin syringe to measure the dose. How much should the nurse daw up to give to this client?

0.67 ml

The health care provider orders 2g of ampicillin in 50 ml of D5W, to infuse IV piggyback over 30 minutes, for a client who had a right total knee replacement secondary to osteoarthritis. At what rate would the nurse set the IV infusion pump in ml/hr?

100 ml/hr

A client is admitted with the diagnosis of gallstones. Which assessment finding does the nurse expect with this client?

A positive Murphy's sign. Murphy's sign is elicited when the client reacts to pain, and stops inhaling when the examiner's fingers are on the location of the gallbladder. It's a common finding in clients with cholecystitis. The nurse should teach the client about possible interventions for gallstones. In addition, the nurse should evaluate the client's risk factors for gallstones to determine the cause and prevent future occurrences.

Which intervention is MOST appropriate to reduce the exacerbation of pain for a client with pancreatitis?

Abstaining from alcohol. Abstaining from alcohol is imperative to reducing pancreatic injury, and may completely control pain.

The nurse is planning interventions for a client who is having an acute gout attack. What is the PRIORITY nursing intervention for this client?

Administer prescribed analgesics.

A client has undergone hip surgery. Which intervention, by the nurse, would help prevent postoperative deep vein thrombosis?

Administer the ordered subcutaneous enoxaparin and pneumatic compression boots. Enoxaparin is a low molecular weight heparin injection that inhibits clot formation. Pneumatic boots will prevent stasis of fluid in the lower extremities that could precipitate clot formation.

What is the MOST important information for the nurse to teach the client about the development of pancreatitis?

Alcohol abuse. Alcohol abuse is the major cause of acute pancreatitis in males, although gallbladder disease is more commonly implicated in women.

Which laboratory test would the nurse anticipate to help diagnose pancreatitis?

Amylase level. Amylase is an enzyme secreted by the pancreas. When elevated, it's useful in diagnosing pancreatitis.

What is the PRIORITY nursing intervention for a client with acute appendicitis?

Assess for symptoms of peritonitis. The focus of care is to assess for peritonitis, or inflammation of the peritoneal cavity. Peritonitis is most commonly caused by appendix rupture and invasion of bacteria, which would be lethal.

A client with a left arm cast reports a foul odor emanating from the cast. What is the appropriate action by the nurse?

Assess further because this may be a sign of an infection. A foul odor emanating from a cast may be a sign of an infection. The nurse should assess for fever, malaise, and, possibly, an elevation in white blood cells.

The nurse is caring for a client with acute cholecystitis. What is a PRIORITY intervention for this client?

Assessment of vital signs. Assessment of vital signs would be a priority to determine ay hemodynamic changes such as bleeding or perforation.

A nurse is performing an assessment on a client diagnosed with osteoarthritis. Which clinical manifestations would the nurse anticipate in this client?

Asymmetrical joint involvement. Asymmetrical joint involvement is present in osteoarthritis.

A nurse is teaching about primary prevention of injury to a client diagnosed with osteoarthritis. Examples of primary prevention include:

Avoiding repetitive tasks. Warming up before exercising. Examples of primary prevention of injury from osteoarthritis include warming up before exercise, and avoiding repetitive tasks.

The nurse will be assisting with the diagnostic tests for a client who may have a hiatal hernia. For which test should the nurse prepare to assist?

Barium swallow with fluoroscopy.

A client with pancreatitis may exhibit Cullen's sign on physical examination. Which assessment finding best describes Cullen's sign?

Bluish discoloration of the periumbilical area. Cullen's sign is bluish discoloration of the periumbilical area from subcutaneous intraperitoneal hemorrhagic pancreatitis.

A client has had a knee- high cast removed six weeks after suffering an ankle fracture. Palpation reveals a hard, non- tender lump at the fracture site. How should the nurse interpret this finding?

Callus formation normally occurs at this stage and may feel like a lump on the bone. Callus formation is a normal stage of bone repair. It is characterized by an overgrowth of bone that is reabsorbed gradually during the remodeling stage. This deformity is painless, whereas misalignment and malunion typically cause pain.

A client with lactose intolerance requires dietary teaching. Which foods should the nurse advise the client to eat to ensure adequate calcium intake?

Collard greens and spinach. Dark green, leafy vegetables are the best non- dairy sources of calcium.

The nurse is evaluating the effectiveness of colchicine, prescribed for a client recently diagnosed with gout. What outcomes would indicate that this medication has been effective?

Decreased inflammation. Fewer gout attacks. Effective pain management. The client is able to perform daily living activities. The action of colchicine is to decrease inflammation by reducing the migration of leukocytes to synovial fluid, which will decrease pain and the frequency of gout attacks.

The nurse is assessing a client in traction. Which condition places the client at risk for traction- related complications?

Diabetes mellitus. Because people with diabetes commonly have microvascular compromise and delayed would healing, they require careful monitoring for early signs of skin breakdown.

What is the BEST information for the nurse to share with a client who has tinea capitis?

Do not share combs or brushes. Tinea capitis is a fungal infection of the scalp. Dermatophyte infections can differ in lesion appearance, body location, and species of the infecting organism Infections are spread by direct contact. The client should not share combs or brushes.

A nurse is caring for a client, diagnosed with osteoarthritis, who refuses to perform independent care. What is the MOST important nursing intervention for this client?

Encourage and support the client to perform as much self- care as possible.

The nurse has just admitted a client to "rule out" peptic ulcer. Which diagnostic study would the nurse anticipate?

Esophagogastroduodenoscopy (EGD)

If a client's gastric ulcer perforates, which action should the nurse include in the management of care?

Fluid and electrolyte replacement. The client should be treated with antibiotics as well as fluid, electrolyte, and blood replacement per provider's order.

The nurse asks a client, in the late stages of osteoarthritis, to describe the pain. The nurse anticipates that this client will describe the pain how?

Grating. In the late stages of osteoarthritis, the client often describes the joint pain as gratin. As the disease progresses, the cartilage covering the ends of bones is destroyed and bones rub against each other.

The client tells the nurse that she experiences pain and numbness in her fingers when typing on a computer keyboard. Which action will help the nurse assess for Phalen's sign?

Having the client hold both wrists in acute flexion with the dorsal surfaces touching for 60 seconds. Acute wrist flexion places pressure on the inflamed median nerve, causing the pain and numbness of Phalen's sign.

A client is admitted with a hiatal hernia. Which symptoms would the nurse expect to find on assessment?

Heartburn Dysphagia Esophageal reflux

The trauma nurse is caring for a client who was involved in an automobile accident. The client was wearing a seatbelt at the time of the accident. Which area would the trauma nurse assess for fracture?

Humerus and clavicle

What should the nurse assess for while admitting a client to the hospital with suspected acute pancreatitis?

Hypocalcemia. The client with acute pancreatitis may exhibit hypocalcemia due to the deposit of calcium in areas of fat necrosis.

A nurse has witnessed an automobile accident. Which nursing interventions are BEST for a client with a suspected fracture at the scene of this accident?

Immobilize the extremity. Move the client to safety immediately. At the scene of an accident, a client with a suspected fracture should have the extremity immobilized and then moved to safety. If the client is in a safe place, do not try to move him.

The nurse is caring for a client who has been diagnosed with psoriasis. Which intervention will hasten this client's recovery?

Increase exposure to sunlight. Psoriasis is a chronic skin condition that often occurs without family history. Exposure to warmer climates and sunlight will decrease the severity and likelihood of a psoriasis breakout.

A client with cirrhosis reports that his skin always feels itchy. Which abnormality, associated with cirrhosis, results in itching?

Increased bilirubin level. High bilirubin levels irritate peripheral nerves, causing an intense itching sensation.

A nurse is caring for a client who has been admitted to the hospital with a musculoskeletal injury. Why has cold therapy been ordered for this client?

It causes local vasoconstriction and prevents edema or muscle spasm. Cold causes the blood vessels to constrict which reduces the leakage of fluid into the tissue and prevents swelling and muscle spasms. Cold therapy may reduce pain by numbing the nerves and tissues. Heat therapy promotes circulation, enhancing flexibility, reduces muscle spasms, and also provides analgesia

The client asks the nurse for information about osteoarthritis. What is the MOST appropriate information for the nurse to include about the disease?.

It is a non- inflammatory joint disease, with degeneration and loss of articular cartilage in synovial joints.

The nurse is performing an admission assessment on a client with osteoarthritis. Which clinical manifestations would the nurse anticipate in this client?

Joint pain following exercise that is relieved by rest. The most common symptom of osteoarthritis is joint pain following exercise or weight bearing, that is usually relieved by rest.

The nurse is teaching a 57- year- old female client about post- menopausal bone loss. Which factors are MOST likely to cause bone loss in this client?

Lack of sunlight exposure. Decreased estrogen level. Lack of sunlight exposure decreases absorption of vitamin D, which must be present for calcium to be absorbed from the small intestine.

What should the nurse instruct a client to do to reduce occurrences of dumping syndrome?

Lie down after meals for 30 minutes. To reduce occurrences of dumping syndrome, clients should lie down for 30 minutes after eating. They should eat small, frequent low- carbohydrate, high- protein, moderate- fat meals, and avoid sweets. Eating in a semi recumbent position is also helpful.

The nurse is providing discharge teaching for a client who was hospitalized with gout. The nurse determines that teaching was effective when the client states the need to reduce intake of which food?

Liver. A client with gout should reduce their intake of purine- rich food, such as liver.

The nurse is teaching a class on primary prevention of osteoporosis. What is the MOST important information for the nurse to provide?

Maintain optimal calcium intake. Primary prevention of osteoporosis includes maintaining optimal calcium, intake.

Which sign would a nurse's assessment most likely reveal in a client diagnosed with a duodenal ulcer?

Melena. The client with a duodenal ulcer may have bleeding that the ulcer site, which shows up as melena.

A nurse is caring for a client with a history of spinal cord injury. Which nursing actions can reduce the risk for autonomic dysreflexia?

Monitor the patency of the indwelling urinary catheter. Promote a high fiber diet, and the use of a stool softener. Bowel and bladder distention are common causes of autonomic dysreflexia (AD).

A client has been diagnosed with secondary syphilis. What does the nurse expect to find on assessment

Nodular, pustular, annular lesions. Nodular, pustular, annular lesions and generalized lymphadenopathy occur in secondary syphilis.

The nurse is caring for a client who is two days postoperative from an open reduction and internal fixation of a fractured left tibia/ fibula. The client reports severe pain in the left leg. The nurse administers the prescribed morphine sulfate, 2 mg IV. The client continues to report severe pain. The client's right leg appears normal. The nurse assesses the left leg and finds that it's cool, pale, and has absent pulses and a capillary refill greater than three seconds. What is the nurse's PRIORITY action?

Notify the health care provider. Skin that is cool to touch, has no pulse, and with capillary refill greater than three seconds would indicate that the client has impaired circulation. Several complications such as compartment syndrome or deep vein thrombosis, can impede circulation and would require immediate action to prevent damage to the nerves and tissues and necrosis.

A client asks the nurse, "What is the difference between rheumatoid arthritis (RA) and osteoarthritis (OA)?" What is the nurse's MOST appropriate response?

OA is a localized disease; RA is systemic. OA is a degenerative disease caused primarily from wear and tear on the joints, whereas RA is an autoimmune disease. Both types of arthritis are more common in women than men. OA and RA are more prevalent in older adults, but RA can develop at any age. Clients have dislocations and subluxations in both disorders.

A client with type 2 diabetes mellitus has been placed in skeletal traction following a motor vehicle collision. The provider is concerned because the client demonstrates symptoms of developing osteomyelitis. The provider orders IV antibiotics, blood culture, reaction therapy, and pin site care. What is the PRIORITY nursing intervention for this client?

Obtain a blood specimen for culture.

A client has just returned from the postanesthesia care unit following internal fixation of a left femoral neck fracture. In which way should the nurse position this client?

On his back with two pillows between his legs. The operative leg must be kept abducted to prevent dislocation of the hip.

A client asks the nurse for information about osteoarthritis. What is the MOST appropriate information for the nurse to include?

Osteoarthritis is the most common form of arthritis.

An elderly client with RA, is being treated with prednisone. What complications can occur with long- term steroid therapy?

Osteoporosis and diabetes mellitus. Long- term prednisone therapy can increase the loss of calcium from bones, slow down the formation of new bone tissues, resulting in osteoporosis, and alter glucose metabolism.

The nurse performs an assessment and determines that a client has head lice. Which finding is conclusive of head lice?

Oval, white dots stuck to the hair shafts.

Which intervention is a PRIORITY within the first 24 hours following bariatric surgery?

Pain control.

Which factor should be the INITIAL focus of nursing management in a client with acute pancreatitis?

Pain control. The priority is to provide adequate pain control. This is essential to minimize discomfort and restlessness, which may stimulate pancreatic secretion further.

Which clinical manifestations would lead the nurse to suspect that the client has a dislocation of the left hip?

Pain in the inguinal area, and an abnormal gait.

The nurse assesses a client diagnosed with a duodenal ulcer. Which finding would the nurse anticipate?

Pain when the stomach is empty. Pain of a duodenal ulcer occurs on an empty stomach, and is relieved by eating food or antacids.

The nurse is collaborating with the orthopedic technician regarding interventions to reduce the roughness of a cast. What is the nurse's BEST intervention?

Petal the edges. Petaling the edges will reduce the roughness of the cast.

A client diagnosed with appendicitis states that his pain is an 8 on a scale of 1 to 10. What is the nurse's BEST intervention to assist this client?

Position the client on his back with legs drawn up towards the abdomen. Lying still with the legs drawn up toward the chest helps relieve tension on the abdominal muscles, which helps to reduce the pain.

A client with a torn meniscus, caused by a football injury, arrives at the outpatient surgery clinic for an arthroscopic meniscectomy. What is the MOST important information for the nurse to give the client?

Postoperative exercises, such as straight- leg raising and quadriceps sitting. The best time to teach about postoperative care is preoperatively. Straight- leg raising and quadriceps sitting exercises help maintain the strength of the affected extremity.

A client visits the clinic with intensely itchy, dark red lesions on his hands, wrists, and waistline. Some of the lesions have been scratched open and are bleeding. What is the FIRST intervention the nurse should teach this client to decrease his itching?

Press on the lesions. Pressing the skin stimulates nerve endings, and can reduce the sensation of itching.

A client is diagnosed with a tumor in the liver, and radiation therapy is started. What information should the nurse include in the teaching plan?

Radiation may cause skin irritation. Radiation therapy usually causes skin irritation which can range from redness to blistering.

What discharge information should the nurse provide to a client with a cast?

Report fever and foul odors around the cast. Fever, foul odor, and warmth over a specific area of the cast after it is dry may be signs of infection. Itchy skin results from dry skin, and powder should NOT be used. The extremity should be elevated for 24 to 48 hours.

What symptoms would the nurse expect to find for a client with appendicitis?

Right lower quadrant pain. Anorexia. Nausea. The client experiencing appendicitis would most likely present with right lower quadrant pain, anorexia, and nausea. A low grade fever is often present.

A client is admitted with a suspected superficial fungal infection of the skin. How should the nurse collect the laboratory specimen?

Scrape scales into a clean container. Cultures for fungal infections are obtained by using a tongue blade. The skin should be scraped into a clean container and sent to the laboratory.

The nurse is assessing a client's response to skeletal traction that has been applied to a lower extremity. Which finding would be considered to be normal?

Serous drainage and crust formation at the pin insertion site.

Which statement BEST explains an open reduction of a fractured femur?

Some form of screw, plate, nail, or wire is usually used to maintain alignment. Open reduction means that the tissue must be surgically opened and the fractured bones realigned. To maintain proper alignment, a screw, plate, nail, or wire is inserted into the bone to prevent the bones from separating.

The emergency room nurse is caring for a 20- year- old female client who reports severe pain in her upper right arm. The nurse suspects domestic abuse. Which X-ray finding would indicate the need for additional investigation?

Spiral fracture. A spiral fracture seen in the upper extremities are commonly related to physical abuse.

The health care provider has prescribed indomethacin for a client with gout. What is the MOST important information for the nurse to give the client about this medication?

Take NSAIDs with food to avoid an upset stomach. Indomethacin, like other NSAIDs, should be taken with food because it can be irritating to the GI mucosa and lead to GI bleeding.

A client is ready to be discharged following arthroscopic knee surgery. Which instruction would the nurse anticipate from the health care provider?

Take acetaminophen with codeine every four hours as necessary for pain relief Mild to moderate pain is normal after this type of surgery and can be relieved by oral narcotic analgesics.

A client with a skin infection is prescribed linezolid 400 mg/po/q8h. What is a PRIORITY nursing intervention?

Teach the client to report diarrhea. This medication is an antibiotic, and may cause diarrhea.

A client is admitted to the medical- surgical unit for osteoarthritis and weakness in the left lower extremity. The client uses a walker at home. The health care provider orders a cane and physical therapy for the client. The client asks the nurse about the difference between the cane and walker. What is the nurse's BEST response?

The cane should be used on the unaffected side.

The nurse is preparing to administer ranitidine to a client diagnosed with peptic ulcer disease. What assessment finding indicates the client has had a therapeutic response to the medication?

The client has less gastric pain. Ranitidine is an H2- receptor antagonist that reduces acid secretion by inhibiting gastrin secretion. It will decrease gastric pain and irritation.

A nurse is caring for a client admitted to the hospital with a diagnosis of Paget's disease and HTN. Which assessment data are MOST important in planning care for this client?

The client reports having stiff legs and pain when walking . Paget's disease presents with mobility issues caused by loss of bone structure.

What information is important for the nurse to consider when planning care for a client diagnosed with squamous cell carcinoma of the face?

The client will need to be taught about surgery. Squamous cell carcinomas of the face are cancers of the epidermis. They are firm nodule lesions with a crust or central ulcers on areas of the face, neck, head and lower ip that have been exposed to sunlight. Rapid metastasis into the lymph system occurs in ten percent of cases. Clients should be informed that the lesions are potentially metastatic, and that surgical intervention may be necessary.

Which client is at highest risk of developing a hiatal hernia?

The client with a BMI of 35. Obesity may cause increased abdominal pressure that pushes the lower portion of the stomach into the thorax. Clients with a BMI of 30 are considered obese.

How would the nurse expect a client with appendicitis to describe the pain?

The pain is steady and is a 7 on a scale of 1 to 10. The pain begins in the epigastrium or periumbilical region and then shifts to the lower right quadrant then becomes steady. The pain may be moderate to severe.

The nurse is caring for a client who has been placed in traction prior to surgery. The client asks the nurse why he has been placed in traction. What is the nurse's BEST response?

Traction helps to prevent trauma and overcome muscle spasms. The purpose of traction is to guide the body part back into place and hold it steady. Traction may be used to stabilize and realign bone fractures to decrease trauma to an area, treat bone deformities caused by certain conditions, correct stiff and constricted muscles, joints, tendons, or skin and prevent painful muscle spasms.

A 75- year- old client with Paget's disease is undergoing diagnostic exams for a suspected fracture. What type of fracture would the nurse anticipate for this client?

Transverse. A transverse fracture commonly occurs with such bone diseases as osteomalacia and Paget's disease.

A client presents to the emergency department with abdominal pain, weight loss, steatorrhea, and a random glucose of 417 mg/dl. Which diagnostic test should the nurse anticipate?

Ultrasound of the abdomen. The symptoms correlate with chronic pancreatitis. An abdominal ultrasound could reveal pancreatic changes.

Which risk factors would place a client at risk for the development of cholelithiasis?

Use of oral contraceptives History of diabetes mellitus Obesity Stone formation is frequent in people who use oral contraceptives, estrogen or clofibrate. The incidence of stone formation increases with age, and is greater in those who have diabetes.

The MOST appropriate clothing for a client with osteoarthritis would include:

Velcroed clothing, slip- on shoes, and rubber grippers.

A nurse is performing a neurovascular assessment on a client admitted with a fractured right femur. The nurse notices that the pulses are not palpable. What is the nurse's MOST important action?

Verify the clinical findings with Doppler ultrasonography. If pulses are not palpable, they should be reassessed using Doppler ultrasonography, immediately notify the provider.

The nurse is providing discharge teaching to a client with osteoarthritis. What is the MOST important information for the nurse to include?

Walk and increase distance gradually. A client with osteoarthritis should pace their activities and avoid over exertion.

A client has attended a sports medicine clinic to learn how to reduce the risk of experiencing a sports- related injury. Which activity would indicate that this client understands how to prevent a sports- related injury?

Warming up. The best way to prevent a sports- related injury is to warm up.