NUR 211 test 3 (2)
A client recently diagnosed with systemic lupus erythematosus (SLE) is in the clinic for a follow-up visit. The nurse evaluates that the client practices good self-care when the client makes which statement? a. I always wear long sleeves, pants, and a hat when outdoors. b. I try not to use cosmetics that contain any type of sunblock. c. Since I tend to sweat a lot, I use a lot of baby powder. d. Since I can't be exposed to the sun, I have been using a tanning bed.
a
A child is upset because, when the cast is removed from her leg, the skin surface is caked with desquamated skin and sebaceous secretions. What technique should the nurse suggest to remove this material? a Soak in a bathtub. b Vigorously scrub the leg. c Carefully pick material off the leg. d Apply powder to absorb the material.
a
A client has just been diagnosed with human immune deficiency virus (HIV). The client is distraught and does not know what to do. What intervention by the nurse is best? a. Assess the client for support systems. b. Determine if a clergy member would help. c. Explain legal requirements to tell sex partners. d. Offer to tell the family for the client.
a
A client is started on etanercept (Enbrel). What teaching by the nurse is most appropriate? a. Giving subcutaneous injections b. Having a chest x-ray once a year c. Taking the medication with food d. Using heat on the injection site
a
A client who has had systemic lupus erythematosus (SLE) for many years is in the clinic reporting hip pain with ambulation. Which action by the nurse is best? a. Assess medication records for steroid use. b. Facilitate a consultation with physical therapy. c. Measure the range of motion in both hips. d. Notify the health care provider immediately.
a
A client with human immune deficiency virus infection is hospitalized for an unrelated condition, and several medications are prescribed in addition to the regimen already being used. What action by the nurse is most important? a. Consult with the pharmacy about drug interactions. b. Ensure that the client understands the new medications. c. Give the new drugs without considering the old ones. d. Schedule all medications at standard times.
a
A nurse has educated a client on an epinephrine auto-injector (EpiPen). What statement by the client indicates additional instruction is needed? a. I don't need to go to the hospital after using it. b. I must carry two EpiPens with me at all times. c. I will write the expiration date on my calendar. d. This can be injected right through my clothes.
a
A nurse is talking with a client about a negative enzyme-linked immunosorbent assay (ELISA) test for human immune deficiency virus (HIV) antibodies. The test is negative and the client states Whew! I was really worried about that result. What action by the nurse is most important? a. Assess the clients sexual activity and patterns. b. Express happiness over the test result. c. Remind the client about safer sex practices. d. Tell the client to be retested in 3 months.
a
A nurse works on a unit that has admitted its first client with acquired immune deficiency syndrome. The nurse overhears other staff members talking about the AIDS guy and wondering how the client contracted the disease. What action by the nurse is best? a. Confront the staff members about unethical behavior. b. Ignore the behaviorthey will stop on their own soon. c. Report the behavior to the units nursing management. d. Tell the client that other staff members are talking about him or her.
a
After teaching a patient who is recovering from a vertebroplasty, the nurse assesses the patient's understanding. Which statement by the patient indicates a need for additional teaching? "I can drive myself home after the procedure." "I will monitor the puncture site for signs of infection." "I can start walking tomorrow and increase my activity slowly." "I will remove the dressing the day after discharge."
a
All of the following interventions the nurse will recommend for the client who is to be discharged to home following total hip replacement surgery except: a continuous passive motion machine b elevated toilet seat c walker d TED hose
a
An HIV-negative client who has an HIV-positive partner asks the nurse about receiving Truvada (emtricitabine and tenofovir). What information is most important to teach the client about this drug? a. Truvada does not reduce the need for safe sex practices. b. This drug has been taken off the market due to increases in cancer. c. Truvada reduces the number of HIV tests you will need. d. This drug is only used for postexposure prophylaxis.
a
The client has been in a body cast for the past 2 days to treat numerous broken vertebrae from a fall. The client is reporting dyspnea, vomiting, epigastric pain, and abdominal distention. Which action demonstrates the nurse's best clinical judgment? a Immediately notify the health care provider 🡪 showing signs of cast syndrome b Initiate oxygen at 2 liters per nasal cannula c Place ice packs around the outside of the cast d Administer ondansetron prescribed q6hrs prn
a
The nurse is assisting in planning care for a client with a diagnosis of immunodeficiency and should incorporate which action as a priority in the plan? a protecting the client from infection b proving emotional support to decrease fear c encouraging discussion about lifestyle changes d Identifying factors that decreased the immune function
a
The nurse is caring for a client 3 days after a below-knee amputation. Which is a priority intervention? range-of-motion exercises use of a very soft bed mattress placement of a pillow between the client's knees placing the client in a high Fowler's position
a
The nurse is presenting information to a community group on safer sex practices. The nurse should teach that which sexual practice is the riskiest? a. Anal intercourse b. Masturbation c. Oral sex d. Vaginal intercourse
a
The nurse on an inpatient rheumatology unit receives a hand-off report on a client with an acute exacerbation of systemic lupus erythematosus (SLE). Which reported laboratory value requires the nurse to assess the client further? a. Creatinine: 3.9 mg/dL b. Platelet count: 210,000/mm3 c. Red blood cell count: 5.2/mm3 d. White blood cell count: 4400/mm3
a
The nurse provides home care instructions to a client with SLE and tells the client about methods to manage fatigue. Which statement by the client indicates a need for further teaching? "I should take hot baths because they are relaxing." "I should sit whenever possible to conserve my energy." "I should avoid long periods of rest because it causes joint stiffness." "I should do some exercises, such as walking, when I am not fatigued."
a
The nurse knows that which patient are at risk of developing secondary osteoporosis? (Select all that apply.) a Type 2 Diabetes b Has a thyroid disorder c Diagnosed with Cushing's disease d Takes inhalers for asthma e Being treated for rheumatoid arthritis
a, b, c, e
A nurse assesses a client who has Parkinson disease. Which manifestations would the nurse recognize as a key feature of this disease? (Select all that apply.) a Flexed trunk b Long, extended steps c Slow movements d Uncontrolled drooling e Tachycardia
a, c, e
A nurse assesses cerebrospinal fluid leaking onto a patient's surgical dressing. What actions would the nurse take? (Select all that apply.) a Place the patient in a flat position. b Monitor vital signs for hypotension c Utilize a bedside commode. d Assess for abdominal distension. e Report the leak to the surgeon
a, e
A client having severe allergy symptoms has received several doses of IV antihistamines. What action by the nurse is most important? a. Assess the clients bedside glucose reading. b. Instruct the client not to get up without help. c. Monitor the client frequently for tachycardia. d. Record the clients intake, output, and weight.
b
A nurse assesses the health history of a patient who is prescribed ziconotide (Prialt) for chronic back pain. Which assessment question would the nurse ask? "Are you taking a nonsteroidal anti-inflammatory drug?" "Do you have a mental health disorder?" 🡪 will not take this med if have mental health disorder "Are you able to swallow medications?" "Do you smoke cigarettes or any illegal drugs?"
b
A nurse works in the rheumatology clinic and sees clients with rheumatoid arthritis (RA). Which client should the nurse see first? a. Client who reports jaw pain when eating b. Client with a red, hot, swollen right wrist c. Client who has a puffy-looking area behind the knee d. Client with a worse joint deformity since the last visit
b
After a client with multiple fractures of the left femur is admitted to the hospital for surgery, the client demonstrates cyanosis, tachycardia, dyspnea, restlessness, and petechiae on the chest. What should the nurse do first? (THIS IS SIGNS OF FAT EMBOLUS!!!) Obtain vital signs Administer oxygen Call the healthcare provider Place the client in the high-Fowler position
b
The nurse is caring for clients on the medical-surgical unit. What action by the nurse will help prevent a client from having a type II hypersensitivity reaction? a. Administering steroids for severe serum sickness b. Correctly identifying the client prior to a blood transfusion c. Keeping the client free of the offending agent d. Providing a latex-free environment for the client
b
The nurse prepares to give a bath and change the bed linens of a client with cutaneous Kaposi's sarcoma lesions. The lesions are open and draining a scant amount of serous fluid. Which would the nurse incorporate into the plan during the bathing of this client? a Wear gloves b wear gown and gloves c wear a gown, gloves, and a mask d wear a gown and gloves to change the bed linens, and gloves only for the bath
b
The type of multiple sclerosis (MS) that has the characteristics of a steady and gradual neurologic deterioration without remission of symptoms is: a Progressive-relapsing MS (PRMS) b Primary progressive MS (PPMS) c Relapsing-remitting MS (RRMS) d Secondary progressive MS (SPMS)
b
What finding is characteristic of fractures in children? a Fractures rarely occur at the growth plate site because it absorbs shock well. b Rapidity of healing is inversely related to the child's age. c Pliable bones of growing children are less porous than those of adults. d The periosteum of a child's bone is thinner, is weaker, and has less osteogenic potential compared to that of an adult
b
What is an appropriate nursing intervention when caring for a child in traction? a Removing adhesive traction straps daily to prevent skin breakdown b Assessing for tightness, weakness, or contractures in uninvolved joints and muscles c Providing active range of motion exercises to affected extremity three times a day d Keeping child prone to maintain good alignment
b
An emergency nurse assesses a patient who is admitted with a pelvic fracture. Which assessments would the nurse monitor to prevent a complication of this injury? (Select all that apply.) a Temperature b Urinary output c Blood pressure d Pupil reaction e Skin color
b, c, e
A 14-year-old adolescent is severely injured in a motor vehicle collision. There are multiple fractures, contusions, and muscle spasms, causing the teenager to refuse to move. How can the nurse best support the adolescent and encourage movement? Allowing friends to visit daily Explaining that some pain is inevitable Encouraging decision-making regarding care Setting specific limits regarding this behavior
c
A client has newly diagnosed systemic lupus erythematosus (SLE). What instruction by the nurse is most important? a. Be sure you get enough sleep at night. b. Eat plenty of high-protein, high-iron foods. c. Notify your provider at once if you get a fever. d. Weigh yourself every day on the same scale.
c
A nurse assesses a patient with early-onset multiple sclerosis (MS). Which clinical manifestation would the nurse expect to find? a Hyperresponsive reflexes b Excessive somnolence c Nystagmus d Heat intolerance
c
A nurse cares for a patient recovering from an above-the-knee amputation of the right leg. The patient reports pain in the right foot. Which prescribed medication would the nurse administer first? a Intravenous morphine b oral acetaminophen c Intravenous calcitonin d c oral ibuprofen
c
A nurse plans care for a patient with lower back pain from a work-related injury. Which intervention would the nurse include in this patient's plan of care? a Encourage the patient to stretch the back by reaching toward the toes. b Massage the affected area with ice twice a day. c Apply a heating pad for 20 minutes at least four times daily. d Advise the patient to avoid warm baths or showers.
c
Spinal precautions are ordered for the client, who sustained a neck injury during a motor vehicle accident. The client has yet to be cleared that there is no cervical fracture. Which action is the nurse's priority when receiving the client in the emergency department? a Assessing the client using the Glasgow Coma Scale (GCS) b Assessing the level of sensation in the client's extremities c Checking that the cervical collar was correctly placed by EMS d Applying antiembolism hose to the client's lower extremities
c
***What cerebellar findings are consistent with a diagnosis of multiple sclerosis? (Select all that apply.)*** a Vertigo b Tinnitus c Dysmetria d Dysdiadochokinesia e Intention tremor
c, d, e
A client with HIV wasting syndrome has inadequate nutrition. What assessment finding by the nurse best indicates that goals have been met for this client problem? a. Chooses high-protein food b. Has decreased oral discomfort c. Eats 90% of meals and snacks d. Has a weight gain of 2 pounds/1 month
d
A client with acquired immune deficiency syndrome is hospitalized and has weeping Kaposi's sarcoma lesions. The nurse dresses them with sterile gauze. When changing these dressings, which action is most important? a. Adhering to Standard Precautions b. Assessing tolerance to dressing changes c. Performing hand hygiene before and after care d. Disposing of soiled dressings properly
d
A nurse cares for a patient in skeletal traction. The nurse notes that the skin around the patient's pin sites is swollen, red, and crusty with dried drainage. Which action would the nurse take next? a Request a prescription to decrease the traction weight. b Apply an antibiotic ointment and a clean dressing. c Cleanse the area, scrubbing off the crusty areas. d Obtain a prescription to culture the drainage.
d
A nurse cares for a patient who presents with an acute exacerbation of multiple sclerosis (MS). Which prescribed medication would the nurse prepare to administer? a Baclofen (Lioresal) b Interferon beta-1b (Betaseron) c Dantrolene sodium (Dantrium) d Methylprednisolone (Medrol)
d
A nurse plans care for a patient who is prescribed skeletal traction. Which intervention would the nurse include in this plan of care to decrease the patient's risk for infection? a Wash the traction lines and sockets once a day. b Release traction tension for 30 minutes twice a day. c Do not place the traction weights on the floor. d Schedule for pin care to be provided every shift.
d
A trauma nurse cares for several patients with fractures. Which patient would the nurse identify as at highest risk for developing deep vein thrombosis? An 18-year-old male athlete with a fractured clavicle A 36-year-old female with type 2 diabetes and fractured ribs A 55-year-old woman prescribed aspirin for rheumatoid arthritis A 74-year-old man who smokes and has a fractured pelvis
d
After teaching a client with a fractured humerus, the nurse assesses the client's understanding. Which dietary choice demonstrates that the client correctly understands the nutrition needed to assist in healing the fracture? Baked fish with orange juice and a vitamin D supplement Bacon, lettuce, and tomato sandwich with a vitamin B supplement Vegetable lasagna with a green salad and a vitamin A supplement Roast beef with low-fat milk and a vitamin C supplement
d
The nurse in the rheumatology clinic is assessing clients with rheumatoid arthritis (RA). Which client should the nurse see first? a. Client taking celecoxib (Celebrex) and ranitidine (Zantac) b. Client taking etanercept (Enbrel) with a red injection site c. Client with a blood glucose of 190 mg/dL who is taking steroids d. Client with a fever and cough who is taking tofacitinib (Xeljanz)
d
The nurse is performing an assessment on a client who has been diagnosed with an allergy to latex. In determining the client's risk factors, the nurse should questions the client about an allergy to which food item? Eggs Milk Yogurt Banana
d
The nurse working in the rheumatology clinic is seeing clients with rheumatoid arthritis (RA). What assessment would be most important for the client whose chart contains the diagnosis of Sjogren's syndrome? a. Abdominal assessment b. Oxygen saturation c. Renal function studies d. Visual acuity
d
