Ortho/Neuro Final Exam
A nurse is teaching a client who is starting to take alendronate effervescent tablets to treat osteoporosis. Which of the following information should the nurse include? A. "Sit upright or stand for at least 30 minutes after taking this medication" B. "Take this medication with food" C. "Take this medication with orange juice" D. "Chew or suck on the tablet"
A.
A nurse in the emergency department is caring for a client who has myathenia gravis and is in crisis. Which of the following factors should the nurse identify as possible causes of myasthenic crisis? A. Developing a respiratory infection B. Taking too much prescribed medication C. Diet high in protein D. Not exercising enough
A. -are respiratory infection, not taking, or taking too little, of the prescribed medication, surgery, and high environmental temperatures.
A nurse is caring for a client who is postoperative following a left corneal transplant. The nurse observes purulent drainage from the affected eye. Which of the following actions is the the nurse's priority? A. Notify the surgeon B. Instill an antibiotic solution in both eyes. C. Clean eye from inner to outer canthus. D. Apply a non-pressure patch to the affected eye.
A. -manifestation of infection
A nurse is performing a mental status examination (MSE) on a client who has a new diagnosis of dementia. Which of the following components should the nurse include? (Select all that apply) A. Grooming B. Long term memory C. Support systems D. Affect E. Presence of pain
A. B. D.
A nurse is preparing a presentation at a community center about osteoarthritis. The nurse should plan to include which of the following information? (Select all that apply) A. Affects weight-bearing joints B. Crepitus can occur in affected joints C. Affects bilateral, symmetrical joints D. Causes joint stiffness E. Causes joint pain
A. B. D. E.
A nurse is assessing a client who has Bell's palsy. Which of the following findings should the nurse expect? (Select all that apply) A. Muscle Distortion B. Pain behind the ear C. Hearing loss D. Facial twitching E. Impaired taste
A. B. E.
A nurse is monitoring a client who has a leaking cerebral aneurysm. Which of the following manifestiations should indicate to the nurse the client is experiencing an increase in intracranial pressure? (Select all that apply) A. Headache B. Neck pain and stiffness C. Slurred speech D. Pupillary changes E. Disorientation
A. C. D. E.
An occupational health nurse is instructing workers at an industrial facility in emergency procedures in the event of a traumatic amputation. Which of the following guidelines should the nurse include for emergency care? (Select all that apply) A. Wrap the part in dry sterile gauze B. Place the severed end of the part into crushed ice C. Put the severed part in a dry waterproof plastic bag D. Elevated the extremity E. Prevent contact of the severed part with water
A. C. D. E. -B = ice water that is 1 part ice and 3 part water
A nurse is caring for a client who has a stroke involving the right cerebral hemisphere. The nurse should monitor for which of the following findings? A. Poor impulse control B. Unable to discriminate words and letters C. Deficits in the right visual field D. Motor retardation
A.
A nurse is preparing to administer an osmotic diuretic IV to a client with increased intracranial pressure. Which of the following should the nurse identify as the purpose of the medication? A. Reduce edema of the brain B. Provide fluid hydration C. Increase cell size in the brain D. Expand extracellular fluid volume
A.
A nurse is preparing to assist with applying a cast to a preschooler's arm. Which of the following actions should the nurse take? A. Wrap the arm of the child's doll or toy prior to the procedure B. Tell the child, "This will make your arm feel better" C. Place a heated fan at the bedside to facilitate drying D. Support the casted arm with a firm grasp
A.
A nurse is providing discharge instructions for a client who is postoperative following inner maxillary fixation with wiring. Which of the following information should the nurse include? A. Cut the wiring if emesis occurs B. Consume three meals daily as part of a low-protein diet C. Swab the mouth with hydrogen peroxide if wiring produces oral irritation. D. Resume a soft diet in 3 to 5 days.
A.
A nurse is providing teaching to the family of a client who has Parkinson's disease. Which of the following information should the nurse include in the teaching? A. Provide client supervision B. Limit client physical activity C. Speak loudly to the client D. Leave the television on continuously
A.
A nurse is teaching a client about how to use her new hearing aids. Which of the following statements should the nurse identify as an indication that the client needs further instruction? A. "I will clean my hearing aids with alcohol wipes" B. "I will not use hairspray if I am wearing the hearing aids." C. "I will change the batteries once a week." D. "I will expect the hearing aids to whistle when I cup my hand over them."
A.
A nurse is teaching a client who has a new diagnosis of gout about managing the disorder. Which of the following instructions should the nurse include in the teaching? A. Eat less liver, sardines, and shrimp B. Use aspirin for management of gout pain C. Drink 1 to 1.5 L of fluid each day D. Have a glass of red wine with dinner each day
A.
A nurse is caring for a client who has a suspected diagnosis of myasthenia gravis. The provider prescribes a tensilon test. Which of the following findings indicates a positive test? A. A pill-rolling tremor appears B. Muscle contractions become progressively stronger C. Electrical charge in a muscle increases in intensity D. Muscle strength shows no change
B. - positive test is indicated by a 4-5 min period of improved muscle tone and strength
A nurse is providing discharge teaching to a client who has systemic lupus erythematosus. Which of the following instructions should the nurse include? A. Avoid using moisturizing lotions on the skin B. Wash the hair with a mild protein shampoo C. Apply powder liberally to sensitive skin areas D. Use a sun blocking agent with a sun protection factor of at least 15
B. -D = sun block should be at least 30 spf
A nurse is completing a physical assessment of a client who has early osteoarthritis. Which of the following manifestations should the nurse expect? A. Symmetric joints affected B. Pain worsens with activity C. Weight loss D. Ulnar deviation
B. -RA affects bilateral joints
A nurse is caring for an older adult client who has a femoral head fracture 24 hours ago and is in skin traction. The client reports shortness of breath and dyspnea. The nurse should suspect that the client has developed which of the following complications? A. Pneumonia B. Fat embolism C. Pneumothroax D. Airway obstruction
B. -at risk for 12 to 48 hours after fracture
A nurse is assessing a client who has a suspected diagnosis of Guillan-Barre Syndrome. Which of the following questions should the nurse ask the client? A. "Do you have a history of chronic alcohol abuse?" B. "Have you had a recent influenza infection?" C. "Have you traveled overseas recently?" D. "Are you taking a multivitamin?"
B. -cause is unknown but usually follows a viral infection
A nurse is assessing a client who has systemic lupus erythematosus and is taking hydrpxychloroquine. The nurse should report which of the following adverse effects to the provider immediately? A. Diarrhea B. Blurred Vision C. Pruritus D. Fatigue
B. -sign of toxicity and can be sign of renal damage
A nurse at an ophthalmology clinic is providing teaching to a client who has open angle glaucoma and a new prescription for timolol eye drops. Which of the following instructions should the nurse provide? A. The medication is to be applied when the client is experiencing eye pain B. The medication will be used until the client's intraocular pressure returns to normal C. The medication should be applied on a regular schedule for the rest of the client's life D. The medication is to be used for approximately 10 days, followed by a gradual tapering off
C.
A nurse in the emergency department is caring for a client who sustained a head injury. The nurse notes the client's IV fluids are infusing at 125 ml/hr. Which of the following is an appropriate action by the nurse? A. Slow the rate to 20ml/hr B. Continue the rate at 125ml/hr C. Slow the rate to 50 ml/hr D. Increased the rate to 250 ml/hr
C.
A nurse is assessing a client who has Parkinson's Disease. Which of the following manifestation should the nurse expect? A. Prurius B. Hypertension C. Bradykinesia D. Xerostomia
C.
A nurse is assessing a client who has a puncture wound on his foot. Which of the following findings is a manifestation of acute osteomyelitis? A. Numbness of toes on the affected foot B. Hypothermia C. Localized erythermia D. Bradycardia
C.
A nurse is assessing an older adult client who has osteoporosis. Which of the following spinal deformities should the nurse expect to find in this client? A. Lordosis B. Ankylosis C. Kyphosis D. Scoliosis
C.
A nurse is caring for a client who has right sided paralysis from a stroke. Which of the following interventions should the nurse implement to prevent footdrop? A. Place sandbags to maintain right plantar flexion B. Position soft pillows against the bottom of the feet C. Apply a protective boot to the right ankle D. Splint the right lower extremity maintain proper alignment
C.
A nurse is teaching a group of newly licensed nurses about the progressive nature of Alzheimer's disease. Which of the following should the nurse include in the teaching as manifestations seen in the moderate stage of Alzheimer's Disease? (Select all that apply) A. Inability to find commonly used items B. Inability to perform common tasks C. Difficulty with talking or reading D. Difficulty remembering how to swallow E. Inability to recognize family members
B. C. - A= mild stage, D and E are late stage
A nurse in the emergency department is preparing to discharge a client following a Grade II (moderate) ankle sprain. Which of the following instructions should the nurse plan to give to the client? A. Perform passive range-of-motion exercises of the ankle hourly. B. Keep the affected extremity in a dependent position. C. Wrap a loose dressing around the affected ankle. D. Apply cold compresses to the extremity intermittently.
D.
A nurse is assessing a client who has a new diagnosis of systemic lupus erythematosus. The nurse should identify which of the following as a cutaneous manifestation of SLE? A. Facial pallor B. Muscle atrophy C. Foot ulcers D. Butterfly rash on face
D.
A nurse is caring for a client who has a spinal cord injury and suspects the client is developing autonomic dyreflexia. Which of the following actions should the nurse take first? A. Check the client for a fecal impaction. B. Examine the client for areas of skin breakdown. C. Check the client's bladder for distention. D. Place the client in a sitting position.
D.
A nurse is caring for a client who is scheduled for an arthroplasty. The nurse asks client to state if he understands the procedure that is being preformed. Which of the following statements by the client indicates an understanding of the procedure? A. "This procedure determines the extent of joint damage" B. "This procedure will fuse my point to reduce my pain" C. "This procedure will prevent further joint damage" D. "This procedure will replace my joint to improve function"
D.
A nurse is caring for an older adult client who has rheumatoid arthritis and is taking aspirin 650 mg every 4 hours. Which of the following diagnosis tests should the nurse monitor to evaluate the effectiveness of this medication? A. White blood cell count B. Rheumatoid factor C. Antinuclear antibody D. Erythrocyte sedimentation rate
D.
A nurse is on a long term care unit is creating a plan of care for a client who has Alzheimer's disease. Which of the following interventions should the nurse include in the plan? A. Rotate assignment of daily caregivers B. Provide an activity schedule that changes from day to day C. Limit time for the client to perform activities D. Talk the client through tasks one step at a time
D.
A nurse is performing discharge teaching for a client who has seizures and a new prescription for phenytoin. Which of the following statements by the client indicates a need for further teaching? A. "I will notify my doctor before taking any other medications" B. "I have made an appointment to see my dentist next week" C. "I know that cannot switch brands of this medication" D. "I'll be glad when I can stop taking this medicine"
D.
A nurse is providing discharge instructions to a parent and his school age child who has juvenile idiopathic arthritis. Which of the following instructions should the nurse include? A. Encourage the child to take a 45 min nap daily B. Allow the child to stay home on days when her joints are painful C. Apply cool compresses for 20 minutes every hour D. Administer prednisone on an alternate day schedule
D.
A nurse suspects that a client admitted for treatment of bacterial meningitis is experiencing increased intracranial pressure. Which of the following assessment findings by the nurse supports this suspicion? A. Photophobia B. Nuchal rigidity C. Positive Kernig's sign D. Restlessness
D.
A nurse is caring for a child who is experiencing a seizure. Which of the following actions should the nurse take? A. Attempt to stop the seizure B. Restrain the child's arms C. Use a padded tongue blade D. Position the child laterally
D
A nurse is caring for a client who has an intracranial pressure reading of 40 mmHg. Which assessment should the nurse recognize as a late sign of ICP? (Select all that apply) A. Confusion B. Tachycardia C. Hypotension D. Nonreactive dilated pupils E. Slurred speech
A, D, E -B = bradycardia is part of cushings triad which is a late sign. C = severe hypertension is part of cushings triad
A client is starting celecoxib to treat osteoarthritis. The nurse should instruct the client to watch for and report which of the following adverse effects? A. Black, tarry stools B. Bone pain C. Dry mouth D. Polyuria
A.
A nurse is preparing to administer valproic acid 400 mg PO bid for migraine headaches. Available is valproic acid 250mg/5 mL. How many mL should the nurse administer per dose?
8 mg
A nurse is preparing a response protocol for botulism as a bioterrorism agent. The nurse should prepare the protocol based on which of the following information? (Select all that apply) A. Botulism can produce paralysis within 12 to 72 hr following exposure. B. Notify the Centers for Disease Control and Prevention (CDC) when more than three cases are confirmed. C. Botulism is acquired through direct contact with an infected person. D. Vomiting and diarrhea are expected findings following exposure. E. Botulism is a toxin found in castor beans.
A. D. -CDC notified if one case occurs, Ricin is found in castor beans
A nurse is the ED is implementing a plan of care for a conscious client who has a suspected cervical cord injury. Which of the following immediate interventions should the nurse implement? (Select all that apply) A. Hypotension B. Polyuria C. Hyperthermia D. Absence of bowel sounds E. Weakened gag reflex
A. D. E. -A = systolic BP should be above 90.
A nurse is assessing a client who is 24 hr postoperative following an above the elbow amputation. Which of the following findings should the nurse identify as the priority? A. Report of muscle spasms B. Inability to get dressed without assistance C. Report feelings of anger D. Refusal to look at the affected limb
A. Report of muscle spams
A nurse is assessing a client who is 48 hours postoperative following an open reduction and internal fixation of a fractured tibia. Which of the following findings should the nurse report to the provider? A. Toes cold to the touch B. Serous drainage from the pin sites C. Blanching of the toenail beds with pressure D. Pink tissue around the fixator insertion sites
A. Toes cold to the touch
A nurse is teaching a client who is taking benztropine to treat Parkinson's Disease. The nurse should instruct the client to report which of the following adverse effects? A. Excess salivation B. Difficulty voiding C. Diarrhea D. Slow pulse
B. -anticholingeric medication (used to decrease rigidity and tremors)
A nurse is caring for an unconscious client who has a loss of the corneal reflex. Which of the following actions should the nurse take? A. Keep the room darkened B. Apply lubricating eye drops C. Alternate warm saline compresses to the eyes D. Clean the eyes with mild soap
B. -client will be unable to blink
A nurse is planning care for a 6 year old child who has bacterial meningitis. Which of the following nursing interventions is unnecessary in the client's plan of care? A. Place the client in a semi-Folwer's position B. Admit the client to a private room C. Measure head circumference every shift D. Implement seizure precautions
C. -fontanels and sutures will not change because child is over 18 months old
A nurse is caring for a client who has had a spinal cord injury at the level of the T2-T3 vertebrae. When planning care, the nurse should anticipate which of the following types of disability? A. Paresthesia B. Hemiplegia C. Quadriplegia D. Paraplegia
D. -seen in spinal cord injurys below T1
A nurse is caring for a client who has a T-4 spinal cord injury. Which of the following client findings should the nurse identify as an indication the client is at risk for experiencing autonomic dysreflexia? A. The client states having a severe headache. B. The client's bladder becomes distended. C. The client's blood pressure becomes elevated. D. The client states having nasal congestion.
B.
A nurse is caring for a client who has a herniated lumbar disc and reports pain. The nurse should assist the client into which of the following positions to help reduce the pain? A. Prone with arms raised about the head B. Semi fowlers with a pillow under the knees C. Supine with her arms elevated on pillows D. Supine with the head of the bed elevated to 15 degrees
B.
A nurse is caring for a client who has a history of dementia. The client is alert and orientated to person, place, and time, and has advanced directives. The client is scheduled for a procedure that requires informed consent. Which of the following persons should sign the informed consent? A. The client's partner B. The client C. The client's daughter, who is the primary caregiver D. The client's son, who has a durable power of attorney
B.
A nurse is caring for a client who has an intracranial aneurysm and requires precautions. Which of the following interventions should the nurse take? A. Place the client in protective isolation B. Minimize environmental stimuli C. Elevate the head of client's bed 45 degrees D. Limit the client's ambulation to once a day
B.
A nurse is caring for a client who has fractures of the symphysis pubis and pelvis. The nurse should monitor the client for which of the following findings of a common complication of pelvic fractures? A. Diarrhea B. Hematuria C. Increased thirst D. Impaired taste
B.
A nurse is caring for a client who has had a hemorrhagic stroke following a ruptured cerebral aneurysm. Which of the following manifestations should the nurse expect? A. Gradual onset of several hours B. Manifestations preceded by a severe headache C. Maintains consciousness D. History of neurologic deficits last less than 1 hour
B.
A nurse is caring for a client who is 1 day postoperative following total hip arthroplasty. It is 0830 and the client is schedule for physical therapy at 0900. Which of the following interventions should the nurse take? A. Encourage the client to use full weight bearing B. Identify the client's pain level and medicate if needed C. Teach the client which positions to avoid during PT D. Perform the client's morning care
B.
A nurse is caring for a client who is in skeletal traction following a femur fracture. The nurse finds the client has slid down toward the foot of the bed and the traction weight is resting on the floor. Which of the following actions should the nurse take? A. Remove the weight temporarily to reposition the client to the correct alignment in bed. B. Have the client use a trapeze to pull himself up while ensuring the weight hangs freely. C. Lift the rope off the pulley while the client rocks back and forth to reposition. D. Lift the weight manually while another staff member moves the client up in bed.
B.
A nurse is caring for a female client who has rheumatoid arthritis and a new prescription for methotrexate. The client tells the nurse she is planning pregnancy. Which of the following instructions should the nurse give the client? A. Dietary modifications occur during pregnancy when taking this medication B. The medication should be discontinued 3 months prior to a planned pregnancy C. Dosage of the medication will be reduced during pregnancy D. The client can breast feed when taking this medication
B.
A nurse is planning care for a client who is postoperative following a total hip arthroplasty. Which of the following interventions should the nurse include in the plan of care? A. Instruct the client to avoid movement of the affected leg B. Prevent hip flexion of the affected extremity C. Position the lower extremities so that they are touching D. Ensure that the client's heels are touching the bed
B.
A nurse is providing teaching to a parent of a child who has a fracture of an epiphyseal plate. Which of the following statements should the nurse make? A. "The blood supply to the bone is disrupted" B. "Normal bone growth can be affected" C. "Bone marrow can be lost through the fracture" D. "The younger the child the longer the healing process will take"
B.
A nurse is providing teaching to a parent of a child who has a fracture of an epiphyseal plate. Which of the following statements should the nurse make? A. "The blood supply to the bone is disrupted" B. "Normal bone growth can be affected" C. "Bone marrow can be lost through the fracture" D. "The younger the child the longer the healing process will take."
B.
A nurse is proving discharge teaching for a client who is postoperative following an inner maxillary fixation for facial fractures. Which of the following instructions should the nurse include in the teaching? A. Swallow using the supraglottic method B. Keep wire cutters with you C. Floss teeth daily D. Eat a mechanical soft diet
B.
A nurse is assessing a client who has a fracture of the femur. The nurse obtains vital signs on admission and again 2 hours. Which of the following changes in assessment should indicate to the nurse that the client could be developing a serious complication? A. Increased respiratory rate from 18 to 44/min B. Increased oral temperature from 36.6 C to 37 C C. Increased blood pressure from 112/68 to 120/72 mmHg D. Increased heart rate from 68 to 72/ min
A.
A nurse is assessing a client who has an acoustic neuroma. Which of the following clinical manifestations should the nurse expect? A. Vertigo B. Dysphagia C. Diplopia D. Apraxia
A.
A nurse is assessing a client who has meningitis. Which of the following findings should the nurse expect? A. Severe headache B. Bradycardia C. Blurred vision D. Oriented to person, place, and year
A.
A nurse is assessing a client who sustained a basal skull fracture and notes a thin stream of clear drainage coming from the client's right nostril. Which f the following actions should the nurse take first? A. Test the drainage for glucose B. Suction the nostril C. Notify the physician D. Ask the client to blow his nose
A.
A nurse is assessing a toddler at a well-child visit. At what point in the physical examination should the nurse examine the child's tympanic membrane? A. At the end B. At the beginning C. Before examining the head and neck D. Before auscultating the chest and abdomen
A.
A nurse is caring for a child who has Legg-Calve-Perthe disease and is in Buck extension traction. Which of the following actions should the nurse take? A. Reposition the child every 2 hours B. Remove the traction boot during baths C. Apply antibiotic ointment to pin sites daily D. Reduce fluid intake
A.
A nurse is caring for a child who has otitis media. Which of the following assessment findings should the nurse expect? A. Tugging on the affected ear lobe B. Clear drainage from affected ear C. Pain when manipulating the affected ear lobe D. Erythema and edema of the affected ear
A.
A nurse is caring for a child who has suspected diagnosis of bacterial meningitis. Which of the following actions is the nurse's priority? A. Administer antibiotics when available B. Reduce environmental stimuli C. Document intake and output D. Maintain seizure precautions
A.
A nurse is caring for a client who had a below the knee amputation for gangrene of the right foot. The client reports sensations of burning and crushing pain in the toes of the right foot. Which of the following statements should the nurse make? A. "This type of pain usually decreases over time as the limb becomes less sensitive." B. "Try to look at the surgical wound as a reminder the limb is gone." C. "Use a cold compress intermittently to decrease these pain sensations." D. "Grief over the lost limb can sometimes cause denial that the limb is really gone."
A.
A nurse is caring for a client who had a fiberglass cast placed on her left arm several hours ago and now reports itching under the cast. Which of the following actions should the nurse plan to take? A. Use a hair drier on a cool setting to blow air into the cast B. Ask the provider to bivalve the cast C. Provide the client with a sterile cotton swab to rub the affect skin D. Wrap the extremity with a dry heating pad
A.
A nurse is caring for a client who had a stroke involving the left cerebral hemisphere. The nurse should monitor for which of the following findings? A. Impaired sense of humor B. Loss of depth perception C. Poor judgement D. Intellectual impairment
A.
A nurse is caring for a client who has a cast in place for a fractured tibia. Which of the following nursing actions is the priority immediately after the provider has applied the cast? A. Checking capillary refill distal to the cast B. Teaching the client about case care C. Managing pain D. Performing range of motion
A.
A nurse is caring for a client who has a mild traumatic brain injury. Which of the following manifestations should the nurse immediately report to the provider? A. A change in a the Glasglow Coma Scale score from 13 to 11 B. Diplopia C. A drop in heart rate from 76 to 70/min D. Ataxia
A.
A nurse is caring for a client who has acute osteomyelitis. Which of the following interventions is the nurse's priority? A. Provide the client with antipyretic therapy B. Administer antibiotics to the client C. Increase the client's protein intake D. Teach relaxation breathing to reduce the client's pain
A.
A nurse is talking with a client who is scheduled for surgery to repair retinal detachment. Which of the following preoperative instructions should the nurse include? A. Keep both eyes patched B. Restricted head movement C. Eye drops to constrict the pupils will be prescribed D. Apply cool compresses
B. -prevents further detachment
A nurse enter a client's room and finds him on the floor in the clonic phase of a tonic-clonic seizure. Which of the following actions should the nurse take? A. Insert a padded tongue blade into the client's mouth. B. Place a pillow under the client's head. C. Gently restrain the client's extremities. D. Apply a face mask for oxygen administration.
B. -protect head, and turn head to prevent aspiration
A nurse in an acute care facility is assessing a client who had hip surgery and has Alzheimer's disease. The nurse asks the client how therapy went that morning. Which of the following statements by the client should the nurse document as confabulation? A. "This morning, this morning, this morning..." B. "It was good, The Queen of England visited me there." C. "I just don't remember what I did this morning" D. "Snip, snap. Take a nap"
B. -unconsciously makes up or fills in made up information when they have memory loss
A nurse is administering vaccines at a county health immunization clinic. Which of the following clients shoudl the nurse plan to administer the meningococcal conjugate vaccine? A. A 4 year old B. An 11 year old (school aged) C. A 4 month old infant D. A 2 year old toddler
B. - single dose should be given
A nurse is caring for a client who has had a stroke involving the right hemisphere. Which of the following alterations in function should the nurse expect? A. Difficulty reading B. Inability to recognize his family members C. Right hemiparesis D. Aphasia
B. -A, C, D are all left hemisphere
A clinic nurse is performing a physical assessment on a client who has systemic lupus erythematosus. Which of the following findings should the nurse expect? A. A grey colored non purpuric papular rash B. A dry red rash across the bridge of the nose and on the cheeks C. Pitting edema of the hands and fingers D. Subcutaneous nodules on the ulnar side of the arm
B. -C is a sign of scleroderma. D is a sign of RA
A nurse is caring for a child who is having a tonic -clonic seizure and vomiting. Which of the following actions is the nurse's priority? A. Place a pillow under the child's head B. Position the child side-lying C. Loosen restrictive clothing D. Clear the area of hazards
B. -prevent aspiration
A nurse is caring for a client who is taking naproxen following an exacerbation of rheumatoid arthritis. Which of the following statements by the client requires further discussion by the nurse? A. "I signed up for a swimming class" B. "I've been taking an antacid to help with indigestion" C. "I've lost 2 pounds since my appointment 2 weeks agp" D. "The naproxen is easier to take when I crush it and put it in applesauce"
B. -report all gastrointestinal problems
A nurse is caring for a client who has aphasia following a stroke. A family member asks the nurse how she should communicate with the client. Which of the following responses by the nurse is appropriate? A. "Incorporate nonverbal cues in the conversation" B. "Ask multiple choice questions as part of the conversation" C. "Use a higher-pitched tone of voice when speaking" D. "Use simple, child-like statements when speaking"
A.
A nurse is giving change-of-shift report using SBAR to the oncoming nurse on a client who has a traumatic brain injury. Which of the following information should the nurse include in the background segment of SBAR? A. Glasglow results B. Intracranial pressure readings C. Code status D. Plan of care changes for upcoming shift
C.
A nurse at a rehabilitation center is planning care for a client who had a left hemispheric cerebrovascular accident 3 weeks ago. Which of the following goals should the nurse include in the client's rehab program? A. Establish the ability to communicate effectively B. Compensate for loss of depth perception C. Learn to control impulsive behavior D. Improve left side motor function
A.
A nurse in a long term care facility is caring for an older adult client who has a stoke 4 weeks ago and who is unable to move independently. The nurse should monitor for which of the following complications of immobility? A. A reddened area over the sacrum B. Stiffness in the lower extremities C. Difficulty moving the upper extremities D. Difficulty hearing some types of sounds
A.
A nurse is administering ear drops to a toddler and pulls the auricle down and back. The mother asks, "Why are you pulling the ear that way?" Which of the following explanations should the nurse provide? A. "This technique opens the ear canal, allowing medication to reach the inner ear region" B. "When this technique is used, the toddler experiences less pain" C. "This is the safest and easiest way to administer this medication" D. "When this technique is used, the medication will not run out of the ear"
A.
A nurse is caring for a client who has late-stage Alzheimer's disease and is hospitalized for the treatment of pneumonia. During the night shift, the client is found climbing into the bed of another client who becomes upset and frightened. Which of the following actions should the nurse take? A. Assist the client to the correct room. B. Place the client in restraints. C. Reorient the client to time and place. D. Move the client to a room at the end of the hall.
A.
A nurse is caring for a client who has sustained a traumatic brain injury. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure? A. Decreased level of consciousness B. Tachypnea C. Bilateral weakness of extremities D. Hypotension
A.
A nurse is caring for a client who is postoperative following a total hip arthroplasty. The nurse assists the client into a supine position. Which of the following action is appropriate to prevent dislocation of the hip? A. Place a wedge pillow between the legs B. Elevate the head of bed to a Fowler's position C. Position the legs in alignment with the spine D. Place a footboard on the bed
A.
A nurse is caring for a client who is postoperative following an open reduction internal fixation of a femur fracture. Which of the following parameters should the nurse include in the evaluation of the neurovascular status of the client's affect extremity? (Select all that apply) A. Color B. Temperature C. Ecchymosis D. Skin integrity E. Sensation
A.
A nurse is presenting information to the public about preventive measures to reduce the risk for contracting West Nile virus. Which of the following instructions should the nurse include? A. Encourage the use of mosquito repellant B. Wait until dusk to go for a walk C. Increase standing pools of water around the home D. Check pets for ticks before bringing them into the home
A.
A nurse is providing education for a client who has glaucoma. Which of the following statements should the nurse include in the teaching? A. "Without treatment, glaucoma can cause blindness" B. "Double vision is a common symptom of glaucoma" C. "Glaucoma is caused by inadequate production of fluid within the eye" D. "Use of eye drops will improve vision over time"
A.
A nurse is teaching a client who has multiple sclerosis and a new prescription for dantrolene. Which of the following statements by the client indicates an understanding of the teaching? A. "I need to apply sunscreen when I go outside" B. "I can take an over the counter antihistamine for allergies when I'm taking this drug" C. "I should take this medication when my spasms are bad" D. "My muscle strength should improve a lot in 2 to 3 days"
A.
A nurse is teaching a client who is schdeuled for dual-energy xray absorptiometry (DXA) to screen for osteoporosis. Which of the following instructions should the nurse include in the teaching? A. "You will need to remove all jewelry before the test" B. "You will need to lie flat for 4 hours following the test" C. "You will need to empty your bladder before the test" D. "You will need to fast for 12 hours before the test"
A.
A nurse is teaching the family of a client who has Alzheimer's disease about donepezil. Which of the following information should the nurse include in the teaching? A. "Syncope episodes may occur when taking this medication" B. "This medication may cause tachycardia" C. "You should administer the medication each morning" D. "You will need to monitor for constipation"
A.
A nurse is working on a medical unit is caring for a client who is prescribed seizure precautions. Which of the following interventions should the nurse include in the client's plan of care? A. Obtain IV access B. Keep the lights on when the client is sleeping C. Place the client's bed in the high position D. Keep a padded tongue blade available at the client's bedside
A.
A nurse is teaching a client who has multiple sclerosis about a new prescription for baclofen. Which of the following instructions should the nurse include in the teaching? A. "Do not take antihistamines with this medication." B. "Take the medication on an empty stomach." C. "Stop taking the medication immediately for a headache." D. "Expect to develop diarrhea initially."
A. -Antihistamines will intensify the depressant effects of baclofen.
A nurse is assessing a client who has a spinal cord injury. Which of the following actions should the nurse take to monitor C4 function? A. Apply downward pressure while the client shrugs his shoulders upward. B. Apply resistance while the client lifts his legs from the bed. C. Ask the client to grasp an object and form a fist. D. Apply resistance while the client flexes his arms.
A. -assesses C4 and C5
A nurse is caring for a client following surgical treatment for a supratentorial brain tumor. Which of the following interventions should the nurse take? A. Elevate head of bed to 30 degrees B. Notify the provider for drainage greater than 80 mL/8 hr C. Place the client in a flat, lateral position D. Provide passive range of motion exercises to the neck
A. -prevents increased ICP
A nurse is caring for a client with a new diagnosis of Paget's disease. The nurse anticipates the provider will prescribe which of the following medications for the client? A. Alendronate B. Colchicine C. Prednisone D. Allopurinol
A. -A is a biophosphonate = decreases bone resorption and minimizes loos of bone density. B and D= treat gout. C = treats gout and RA
A nurse is teaching a client who has chronic tophaceous gout about his new prescription for allopurinol. The nurse should explain that the purpose of this medication is to reduce blood levels of which of the following substances? A. Uric acid B. Chloride C. Interleukin 1 D. Potassium
A. -Allopurinol reduces synthesis of uric acid
A nurse is planning care for a client who has a detached retina and is preoperative for a surgical repair. The nurse should prepare to administer which of the following medications? A. Phenylephrine B. Latanoprost C. Pilocarpine D. Timolol
A. -Mydriatic medication -dilates pupils (preoperatively)
A nurse is caring for a client who has a right-sided acoustic neuroma resulting in impairment of cranial nerves IX and X. Which of the following actions should the nurse take? A. Place suction equipment at the client's bedside B. Apply an eye patch to the client's right eye. C. Avoid the use of warm water to wash the client's face. D. Provide range-of-motion exercises to the client's neck and shoulders.
A. -Risk for aspiration due to glossopharyngeal and vagus impairment
A nurse is providing education for a client who has glaucoma. Which of the following statements should the nurse include in the teaching? A. "Without treatment, glaucoma can cause blindness" B. "Double vision is a common symptom of glaucoma." C. "Glaucoma is caused by inadequate production of fluid within the eye." D. "Use of eye drops will improve vision over time."
A. -irreversible damage to the retina and optic nerve
A nurse is caring for an adolescent who has spina bifida and is paralyzed from the waist down. Which of the following statements by the client should indicate to the nurse a need for further teaching? A. "I only need to catheterize myself twice every day." B. "I carry a water bottle with me because I drink a lot of water." C. "I use a suppository every night to have a bowel movement." D. "I do wheelchair exercises while watching TV."
A. -needs to be performed every 4 hours
A nurse is assessing a client who has a suspected diagnosis of Gullain Barre syndrome. Which of the following questions should the nurse ask the client? A. "Do you have a history of chronic alcohol abuse" B. "Have you had a recent influenza infection" C. "Have you traveled overseas recently" D. "Are you taking a multivitamin"
B.
A nurse is creating a plan of care for a client who has a history of tonic-clonic seizure disorder. Which of the following interventions should the nurse include? (Select all that apply) A. Provide a suction setup at the bedisde B. Elevate the side rails near the head when the client is in bed C. Place the bed in lowest position D. Keep an oxygen set up at beside E. Furnish restraints at the bedside
A. B. C. D.
A home health nurse is reinforcing coping strategies with the family caregiver of a client who has Alzheimer's Disease. Which of the following information should the nurse include in the teaching? (Select all that apply) A. Actions to reduce stress B. Identification of a social support system C. Referral to available community resources D. Instruction on client medication administration E. Expected physiological changes of the disease
A. B. C. E. - D = does not involve coping
A nurse in a provider's office is providing teaching to a client about modifiable risk factors for osteoporosis. Which of the following factors should the nurse include? (Select all that apply) A. Sedentary lifestyle B. Obesity C. Carbonated beverages D. Caffeine intake E. Smoking tobacco products
A. C. D. E. -B= risk factor for osteoarthritis
A nurse is assessing a client who has a herniated cervical intervertebral disc. Which of the following findings should the nurse expect? (Select all that apply) A. Tingling in the arms B. Low back pain C. Shoulder pain D. Muscle spasms E. Stiff neck
A. C. E. -B and D are common with herniated lumbar intervertebral disc
A nurse is educating coworkers about how to minimize back strain and avoid repeated episodes of low back pain. Which of the following strategies should the nurse include? (Select all that apply) A. Avoid prolonged sitting B. Apply heat for 10 min every hour C. Sleep in a side-lying position with flexed knees D. Sleep on a soft mattress E. Try padded shoe insoles
A. C. E. -B= recommended 20-30 mins 4 times a day. D= sleep on firm mattress
A nurse is assessing a client who has multiple fractures in his left leg notes increasing edema. The nurse should recognize this finding as an early manifestation of which of the following complication? A. Fat embolism syndrome B. Acute compartment syndrome C. Pulmonary embolism D. Osteomyelitis
B.
A home health nurse is assessing an older adult client in the home who has decreased vision due to a history of glaucoma. Which of the following findings should the nurse identify as a safety risk? A. Electrical cords are placed along the walls B. Scatter rugs are present in the kitchen C. Hand rials are present in the bathroom D. Uses a microwave for cooking
B.
A home health nurse is caring for a client who is quadriplegic following a spinal cord injury and who is adjusting to the home environment. Which of the following client statements indicate the client is adapting? A. "My wife tries to get me to go to the grocery store, but I don't like to go out much." B. "I am using the modified feeding utensils at every meal. I still spill, but I'm getting better." C. "My greatest pleasure each day is having a few beers every day." D. "I have all the equipment to take a shower, but I prefer a bed bath, because it is easier."
B.
A nurse is assessing a client following a head injury and a brief loss of consciousness. Which of the following findings should the nurse report to the provider? A. Edematous bruise on forehead B. Small drops of clear fluid in left ear C. Pupils are 4 mm and reactive to light D. Glasglow Coma Scale score of 12
B.
A nurse in the emergency department is assessing a client who was in a motor-vehicle crash 2 days ago and sustained fractures to his tibia, ulna, and several ribs. The client is now disoriented to time and place, SaO2 of 87%, and the nurse notes generalized petechiae on the client's skin. Which of the following complications should the nurse expect? A. Hypovolemic shock B. Fat embolism syndrome C. Thrombophlebitis D. Avascular bone necrosis
B. -triad of neurologic changes, petechial rash, and hypoxemia = fat embolism syndrome
A nurse is caring for a client immediately following application of a plaster cast. The nurse should monitor for and report which of the following findings as an indication of compartment syndrome? A. Sensation of heat on the surface of the cast B. Paresthesias of the extremity C. Pruitus of of the extremity D. Musty odor noted from cast materials
B. Paresthesias of the extremity -other symptoms include: numbness, tingling, weakness, and pain (that does not respond to medication)
A nurse is caring for a client who has a pelvic fracture. The client reports sudden shortness of breath, stabbing chest pain, and feelings of doom. The nurse should identify that the client is experiencing which of the following complications? A. Pneumonia B. Pulmonary embolus C. Tension pneumothroax D. Tuberculosis
B. Pulmonary embolus
A nurse is caring for a client who is 3 days postoperative following a right total hip arthroplasty. While transferring to a chair, the client cries out in pain. The nurse should assess the client for which of the following manifestations for dislocation of the hip prothesis? A. Bulging in the area over the surgical incision B. Shortening of the right leg C. Sensation of warmth over the surgical incision D. Pallor following elevation of the right leg
B. Shortening of the right leg
A nurse is caring for a child who has influenza. The nurse should identify that which of the following statements by the parents indicated the child has increased risk for Reye's syndrome? A. "I give my child ibuprofen when his muscles are aching" B. "I am encouraging my child to drink grapefruit juice" C. "I give my child aspirin to reduce fever" D. "I am leaving a humidifier on in my child's room when he naps"
C,
A nurse is assessing a client who has meningitis and notes when passively flexing the client's neck there is an involuntary flexion of both legs. Which of the following conditions is the client displaying? A. Kernig's sign B. Nuchal Rigidity C. Brudzinski's sign D. Bradykinesia
C.
A nurse is caring for a client who had a right sided stroke and is exhibiting homonyous hemianopsia when eating. Which of the following actions should the nurse take? A. Provide a nonskid mat to alleviate plate movement B. Encourage the client to use his right hand when feeding himself C. Remind the client to look for food on the left side of the tray D. Encourage the use of the wide grip utensils
C.
A nurse is caring for a client who has a fractured tibia as a result of a fall. The client x-ray shows that the bone is splintered into several pieces around the shaft. The nurse should identify that the client has which of the following types of fractures? A. Impacted B. Transverse C. Commiunted D. Oblique
C.
A nurse is caring for a client who has osteoporosis and takes a daily calcium supplement. Which of the following adverse effects of calcium should the nurse suspect when the client reports having flank pain? A. Hepatitis B. Hip fracture C. Renal stones D. Pancreatitis
C.
A nurse is caring for a client who is postoperative following a total knee arthroplasty and is prescribed a continous passive motion machine and a PCA. The client tells the nurse, "I am in so much pain." Which of the following actions should the nurse take first? A. Remind the client to push the button for the PCA device. B. Discuss activities the client may use to distract from the pain. C. Ask the client to describe the characteristics of the pain. D. Pause the CPM machine briefly to apply a cold pack to the client's knee.
C.
A nurse is caring for a client who is postoperative following hip arthroplasty. The nurse should anticipate which of the following prescriptions for this client? A. Aspirin B. Clopidogrel C. Enoxaparin D. Alteplase
C.
A nurse is caring for a client who is postoperative following shoulder surgery. The client has a prescription to keep the affected arm adducted. Which of the following instructions should the nurse provide the client? A. "Keep your arm bent at the elbow." B. "Use a pillow to prop your shoulder up close to your ear." C. "Hold your arm against the side of your body." D. "Position your arm with the shoulder at a 90-degree angle."
C.
A nurse is caring for a client who received a diagnosis of systemic scleroderma 5 years ago. The nurse plans to assess the client to document the disease's progression. In addition to skin changes, which of the following findings should the nurse expect? A. Periorbital edema B. Excessive salivation C. Finger contractures D. Thinning of skin
C.
A nurse is caring for a client who received a diagnosis of systemic scleroderma 5 years ago. The nurse plans to assess the client to document the disease's progression. In addition to skin changes, which of the following findings should the nurse expect? A. Periorbital edema B. Excessive salivation C. Finger contractures D. Thinning of the skin
C.
A nurse is instructing a client's family members about feeding safety for a client who has dysphagia following a stroke. Which of the following instructions should the nurse include? A. Encourage brief exercise before meals to promote appetite B. Place food in the affected side of the mouth C. Encourage the client to take small bites D. Place the client with the head reclined back to facilitate swallowing
C.
A nurse is monitoring a client who had a cerebral aneurysm rupture. Which of the following findings should the nurse identify as a manifestation of increased intracranial pressure? A. Hypotension B. Tachycardia C. Irritability D. Tinnitus
C.
A nurse is planning care for an infant who has spina bifida and is to undergo surgical closure of the myelomeningocele sac Which of the following interventions should the nurse include in the plan of care? A. Maintain the infant in the supine position B. Initiate contact precautions C. Provide a latex-free environment D. Limit visitors to immediate family members
C.
A nurse is planning care for an infant who has spina bifida and is to undergo surgical closure of the myelomeningocele sac? Which of the following interventions should the nurse include in the plan of care? A. Maintain the infant in the supine position B. Initiate contact precautions C. Provide a latex free environment D. Limit visitors to immediate family members
C.
A nurse is providing preoperative teaching for a client who is scheduled for a total knee arthroplasty. Which of the following statements by the client should the nurse identify as understanding of the teaching? A. "I will wear a continuous movement machine on my knee for 24 hours a day" B. "I should avoid taking NSAID medications for pain after surgery" C. "I should wear elastic stockings on both of my legs" D. "I will begin exercising my legs the after surgery"
C.
A nurse is providing teaching to a client who has a new diagnosis of parkinson's disease. On which of the following medication should the nurse prepare to instruct the client? A. Piperacillin/Tazobactam B. Levothyroxine C. Levodopa/Carbidopa D. Carbamazepine
C.
A nurse is teaching a client who has osteoarthritis. Which of the following instructions should the nurse include in the teaching? A. "Apply a heat pack at a temperature below your body temperature" B. "Elevate the affected joint on large pillows" C. "Take acetaminophen as the primary medication to treat the pain" D. "Decrease foods high in purines"
C.
A nurse is teaching a female client who has a new prescription for transdermal sumatriptan to treat migraine headaches. Which of the following instructions should the nurse include? A. "take this medication daily to prevent headache" B. "Activate the patch 30 minutes after application" C. "Use contraception while taking this medication" D. "You can bathe with the patch in place"
C.
A nurse is teaching the family of an older adult client who has a new diagnosis of dementia. Which of the following statements should the nurse include in the teaching? A. "Dementia is characterized by a sudden onset of confusion." B. "An altered level of consciousness is associated with dementia." C. "The signs of dementia are progressive and irreversible." D. "Dementia can be triggered by a high fever or dehydration."
C.
An acute care nurse receives shift report for a client who has increased intracranial pressure. The nurse is told that the client demonstrates decorticate posturing. Which of the following findings should the nurse expect to observe when assessing the client? A. Extension of the arms B. Pronation of the hands C. Plantar flexion of the legs D. External rotation of the lower extremities
C.
The family of an older adult client brings him to the ED after finding him wandering outside. During the initial assessment, the nurse notes that the client flinches when she palpates his abdomen yet responds to questions only by nodding and smiling. Which of the following factors should the nurse identify as a likely explanation for the client's behavior? A. He is hard of hearing B. Pain C. Confusion D. Language barrier
C.
A nurse is administering timolol eye drops to a client who has glaucoma. Which of the following actions should the nurse take? A. Apply pressure to the bridge of the nose after administration. B. Wipe the eye from the outer canthus to the inner canthus before instillation. C. Drop prescribed amount of medication into the conjunctival sac D. Protect the distal portion of the eyedropper using clean technique.
C. -After instilling the drops, ask the client to close his eye gently. If the client is to receive more than one eye medication to the same eye, wait at least 5 min before administering the next medication
A nurse is assessing a client who has systemic lupus eryhthematosus. Which of the following findings is the highest priority for the nurse to report to the provider? A. Client report of feelings of depression B. Dry, raised rash on the face C. Presence of peripheral edema D. Joint pain in hands and knees
C. -edema is a sign of peripheral edema
A nurse is instructing a woman who is contemplating pregnancy about nutritional needs. To reduce the risk of giving birth to a newborn who has a neural tube defect, which of the following information should the nurse include in the teaching? A. Limit alcohol consumption. B. Increase intake of iron-rich foods. C. Consume foods fortified with folic acid. D. Avoid foods containing aspartame.
C. -folic acid consumption should be increased 3 months before pregnancy
A nurse is caring for a client who is postoperative following an open reduction and internal fixation of a fractured femur. Which of the following actions is the most important for the nurse to complete in the postoperative period? A. Medicate the client for pain B. Instruct the client on use of crutches C. Perform neurovascular checks of the extremities D. Direct the client to perform exercises of the ankles and toes
C. -should be monitored every hour for the first 24 hours
A nurse on an oncology unit is assessing a child who has a brain tumor. Which of the following findings should the nurse expect? A. Negative Babinski reflex B. Increased appetite C. Hyporeflexia D. Tachycardia
C. -A = child would have a positive babinski reflex. B= child would have decreased appetite. D= child would have decreased pulse rate
A nurse is caring for a child who has otitis media with effusion. The nurse should identify that which of the following manifestations indicates a tympanic membrane rupture? A. Green-blue discharge in the ear canal B. Increased temperature C. Sudden pain relief D. Popping sensation when swallowing
C. -caused by pressure behind the tympanic membrane
A nurse is caring for a client who is postpartum. The client tells the nurse that the newborn's maternal grandmother was born deaf and asks how to tell if her newborn hears well. Which of the following statements should the nurse make? A. "There is no need to worry about that. Most forms of hearing loss are not inherited." B. "Look at how she looks as you when you speak. That's a good sign." C. "We do routine hearing screenings on newborns. You'll know the results before you leave the hospital" D. "The best way to determine if your baby can hear is to clap your hands loudly and see if she startles."
C. -does not diagnose hearing loss, just shows if there is need for further evaluation
A nurse is caring for client who has dementia due to Alzheimer's Disease and was admitted into a long term care facility following the death of her partner of 40 years. The client states "I want to go home, my husband is waiting for me to cook dinner" Which of the following response by the nurse is appropriate? A. "This is where you live now." B. "This is a safer place for you to live." C. "Tell me what you like to cook for dinner." D. "Your family said there is no one to care for you at home."
C. -form of validation therapy
A nurse is caring for a client who has a fractured ulna and a new prescriptio for cyclobenzaprine. Before administering, which of the following explanations should the nurse provide to explain the purpose of the medication? A. The medication will kill microorganisms that can cause infection at the fracture site B. Cyclobenzaprine will reduce itching that might occur as the fracture begins to heal C. The medication will relieve muscle spasms that might occur with a fracture D. Cyclobenzaprine will relieve any nausea associated with a fracture
C. -pruritus (itching) and nausea are adverse effects of this medication
A nurse is reinforcing teaching with a client who has a new prescription for colchicine orally to treat gout. The nurse should inform the client that which of the following findings is an adverse effect of colchicine? A. Increased appetite B. Urinary retention C. Diarrhea D. Sore throat
C. -sign of toxicity
A nurse is reviewing the medical record of a client who has a prescription for probenecid to treat gout. The nurse should identify that which of the following medications can interact with probenecid? A. Colchine B. Naproxen C. Aspirin D. Prednisone
C. Aspirin
A nurse is performing medication reconcilliation for a newly admitted client who has rheumatoid arthritis (RA). Which of the following medications should the nurse identify as the treatment for this condition? A. Misoprostol B. Dantrolene C. Celecoxib D. Colchicine
C. Celecoxib -type of NSAID, called cyclooxygenase-2 (COX-2) inhibitors - the medication is also prescribed for osteoarthritis, spondylitis, and painful menstruation.
A nurse is teaching a client about risk factors for osteoarthritis. Which of the following factors should the nurse include in the teaching? (Select all that apply) A. Bacteria B. Diuretics C. Aging D. Obesity E. Smoking
C. D. E. -B is a risk factor for gout
A nurse is developing a plan of care to prevent skin breakdown for a client with a spinal cord injury and paralysis. Which of the following nursing actions are appropriate? (Select all that apply) A. Massage over erythematous bony prominences. B. Implement turning schedule every 4 hr. C. Use pillows to keep heels off the bed surface. D. Keep the client's skin dry with powder. E. Minimize skin exposure to moisture.
C. E.
A nurse is presenting discharge instructions to a client who has multiple sclerosis (MS). The client reports symptoms of diplopia, dysmetria, and sensory change. Which of the following nursing statements are appropriate? A. "Wear an eye patch on the right eye at all times" B. "Plan to relax in a hot tub spa each day" C. "Engage in a vigorous exercise program" D. "Implement a schedule to include periods of rest"
D
A nurse is caring for a child who has a suspected diagnosis of bacterial meningitis. Which of the following actions is the nurse's priority? A. Prepare the child for a lumbar puncture B. Administer an intravenous antibiotic C. Obtain blood cultures D. Place the child in isolation
D.
A nurse is caring for a client who has a traumatic head injury and is exhibiting signs of increasing intracranial pressure. Which of the following medications should the nurse plan to administer? A. Albumin 25% B. Dextran 70 C. Hydroxyethyl glucose D. Mannitol 25%
D.
A nurse is caring for a client who has increased intracranial pressure following a close head injury. Which of the following actions should the nurse take? A. Instruct the client to cough and deep breathe B. Place the client in a supine position C. Place a warming blanket on the client D. Use log rolling to reposition the client
D.
A nurse is caring for a client who is postoperative following knee arthroplasty and has a continuous passive motion machine. Which of the following actions should the nurse take? A. Store the CPM machine on the floor when not in use B. Use a special pillow to rotate the affected knee internally C. Set the CPM to fully flex knee joint D. Apply ice to the operative knee
D.
A nurse is teaching a client who has a new prescription for alendronate for treatment of osteoporosis. Which of the following statements by the clients indicates understanding of the teaching? A. "I will take the medication in the evening" B. "I will drink a full glass of milk with the medication" C. "I will take the medication at mealtime" D. "I will sit upright after taking the medication"
D.
A nurse is teaching about risk factors of developing a stroke with a group of older adult clients. Which of the following non-modifiable risk factors should the nurse include in the teaching? A. History of smoking B. Obesity C. History of hypertension D. Race
D.
A rehabilitation nurse is caring for a client who has had a spinal cord injury that resulted in paraplegia. After a week on the unit, the nurse notes that the client is withdrawn and increasingly resistant to rehabilitative efforts by the staff. Which of the following actions should the nurse take? A. Inform the client that privileges are related to participation in therapy. B. Limit visiting hours until the client begins to participate in therapy. C. Allow the client to control the timing and frequency of the therapy. D. Establish a plan of care with the client that sets attainable goals.
D.
A nurse is planning care for a 5 month old infant who is scheduled for a lumbar puncture to rule out meningitis. Which of the following actions should the nurse include in the plan of care? A. Keep the infant NPO for 6 hours prior the procedure B. Apply a eutectic mixture of lidocaine and prilocaine cream topically 15 mins prior to the procedure C. Place the infant in an infant seat for 2 hours following the procedure D. Hold the infant's chin to his chest and knees to his abdomen during the procedure
D. -A = fasting is not required. B= cream should be applied 60 minutes prior to procedure. C = infant should be flat after procedure
A nurse is an ophthamlmology clinic is interviewing a client who was referred by his primary care provider for suspicion of cataracts. The nurse should expect the client to report? A. Loss of central vision B. Having a loss of peripheral vision C. Seeing a bright flash of light and floaters D. Having a decreased ability to perceive colors
D. -A= macular degeneration. B= open angle glaucoma. C=rentinal detachment
A nurse is admitting a client who has partial hearing loss. Which of the following is a priority action by the nurse? A. Speak using his usual tone of voice. B. Stand directly in front of the client. C. Rephrase statements the client does not hear. D. Determine if the client is using hearing aids
D. -Assessment is first
A nurse in the ER is assessing a client who has brought in following a seizure. The nurse suspects the client may have meningococal meningitis when assessment findings include nuchal rigidity and petechial rash. After implementing droplet precautions, which of the following actions should the nurse initiate next? A. Complete a vascular assessment B. Administer an antipyretic C. Decrease environmental stimuli D. Assess the cranial nerves
D. -assessment comes first
A nurse is planning care for a client 1 day postoperative following a detached retina repair. Which of the following instructions should the nurse include in the plan? A. Encourage coughing, and deep-breathing. B. Allow the client to ambulate. C. Remove the eye patch during the day. D. Avoid reading and writing
D. -avoid for 1 week
A nurse is admitting a young adult client who has suspected baterial meningitis. The nurse should closely monitor the client for increased intracranial pressure as indicated by which of the following findings? A. Nuchal rigidity B. Pupils reactive to light C. Head turns to follow light D. Elevated temperature
D. -fever indicated bacterial infection
A nurse is caring for a child who is postoperative following ventriculoperitoneal shunt placement. In which of the following positions should the nurse place the client? A. Trendelenburg B. Semi-Fowlers C. Prone D. On the unoperated side
D. -laying flat prevents rapid reduction of intracranial fluid
A nurse is teaching a female client who has a new diagnosis of systemic lupus erythematosus. The nurse should recognize the need for further teaching when the client identifies which of the following as a factor that can exacerbate SLE? A. Sunlight B. Pregnancy C. Infection D. Exercise
D. -nurse should encourage the client to engage in condition exercises with rest periods
A nurse is developing a plan of care for a client who has a spinal fracture and complete spinal cord transection at the level of C5. Which of the following rehabilitation goals should the nurse add to the client's plan of care? A. Ability to achieve independent transfer from bed to wheelchair B. Independent control of bladder and bowel function C. Use of a wheelchair with a chin or mouth stick D. Ability to self-fee with the use of adaptive equipment
D. -should have full neck, partial shoulder, back, biceps, and gross elbow movements
A nurse is discussing the difference rheumatoid arthritis (RA) and osteoarthritis with a newly licensed nurse. Which of the following information should the nurse include about osteoarthritis? A. "Osteoarthritis is caused by an autoimmune process" B. "Osteoarthritis leads to a decreased erythrocyte sedimentation rate." C."Osteoarthritis affects other organ systems." D. "Osteoarthritis can impair a joint on a single side of the body."
D. -unilateral joint involvement = osteoarthritis -bilateral joint involvement = Rheumatoid arthritis
A nurse is reviewing the medical record of a female client. Which of the following findings should the nurse identify as a risk factor for osteoporosis? A. Decrease intake of phosphate-containing foods B. Spending several hours in the sun daily C. Increased estrogen levels D. History of anorexia nervosa
D. History of anorexia nervosa -inadequate protein intake
A nurse is dicussing the plan of care for a client who has osteomyelitis of an open wound on his heel. Which of the following information should the nurse include? A. "You will need to apply a cold pack to the site three times a day" B. "Your provider might ask you to walk frequently to increase circulation to the area." C. "You will need to limit consumption of high protein foods" D. "Your provider might prescribe a central catheter line for long term antibiotic therapy"
D. Will require weeks to months of IV therapy