PrepU Exam 4 Questions

A 75-year-old client had surgery for a left hip fracture yesterday. When completing the plan of care, the nurse should include assessment for which complications? Select all that apply. a. Pneumonia b. Necrosis of the humerus c. Skin breakdown d. Sepsis e. Delirium

a. pneumonia; c. skin breakdown; d. sepsis; e. delirium explanation: Complications in clients with hip fractures are often related to the client's age. During the first 24 to 48 hours following surgery for hip fracture, atelectasis or pneumonia can develop as a result of the anesthesia. Thromboemboli are possible, as is sepsis. Elderly clients are also at risk for delirium in hospital settings because of the stress of the trauma, unfamiliar surroundings, sleep deprivation, and medications. An elderly client with decreased mobility is at risk for skin breakdown. Necrosis is a potential complication of the surgery, but the complication would be with the femur, not the humerus.

A client who has experienced an ischemic stroke has been admitted to the medical unit. The client's family is adamant that the client remain on bed rest to hasten recovery and to conserve energy. What principle of care should inform the nurse's response to the family? a. The client should mobilize as soon as physically able. b. To prevent contractures and muscle atrophy, bed rest should not exceed 4 weeks. c. The client should remain on bed rest until the client expresses a desire to mobilize. d. Lack of mobility will greatly increase the client's risk of stroke recurrence.

a. the client should mobilize as soon as physically able explanation: As soon as possible, the client is assisted out of bed and an active rehabilitation program is started. Delaying mobility causes complications, but not necessarily stroke recurrence. Mobility should not be withheld until the client initiates.

A nurse is teaching a client with osteomalacia about the role of diet. What would be the best choice for breakfast for a client with osteomalacia? a. Cereal with milk, a scrambled egg, and grapefruit b. Poached eggs with sausage and toast c. Waffles with fresh strawberries and powdered sugar d. A bagel topped with butter and jam with a side dish of grapes

a. cereal with milk, a scrambled egg, and grapefruit explanation: The best meal option is the one that contains the highest dietary sources of calcium and vitamin D. The best selection among those listed is cereal with milk, and eggs, as these foods contain calcium and vitamin D in a higher quantity over the other menu options.

A client is brought by ambulance to the ED after suffering what the family thinks is a stroke. The nurse caring for this client is aware that an absolute contraindication for thrombolytic therapy is what? a. Evidence of hemorrhagic stroke b. Blood pressure of ≥ 180/110 mm Hg c. Evidence of stroke evolution d. Previous thrombolytic therapy within the past 12 months

a. evidence of hemorrhagic stroke explanation: Thrombolytic therapy would exacerbate a hemorrhagic stroke with potentially fatal consequences. Stroke evolution, high BP, or previous thrombolytic therapy does not contraindicate its safe and effective use.

The nurse is caring for a client who had a hemorrhagic stroke. What assessment finding constitutes an early sign of deterioration? a. Generalized pain b. Alteration in level of consciousness (LOC) c. Tonic-clonic seizures d. Shortness of breath

b. alteration in level of consciousness (LOC) explanation: Alteration in LOC is the earliest sign of deterioration in a client after a hemorrhagic stroke, such as mild drowsiness, slight slurring of speech, and sluggish papillary reaction. Sudden headache may occur, but generalized pain is less common. Seizures and shortness of breath are not identified as early signs of hemorrhagic stroke.

Which assessment findings would the nurse expect to find in the client with osteomyelitis? a. Column A b. Column B c. Column C d. Column D

b. column B explanation: Osteomyelitis is characterized by elevated white blood cell count and erythrocyte sedimentation rate.

A client with a new diagnosis of ischemic stroke is deemed to be a candidate for treatment with tissue plasminogen activator (t-PA) and has been admitted to the ICU. In addition to closely monitoring the client's cardiac and neurologic status, the nurse monitors the client for signs of what complication? a. Acute pain b. Septicemia c. Bleeding d. Seizures

c. bleeding explanation: Bleeding is the most common side effect of t-PA administration, and the client is closely monitored for any bleeding. Septicemia, pain, and seizures are much less likely to result from thrombolytic therapy.

A nurse is teaching an educational class to a group of older adults at a community center. In an effort to prevent osteoporosis, the nurse should encourage participants to ensure that they consume the recommended intake of what nutrients? Select all that apply. a. Vitamin B12 b. Potassium c. Calcitonin d. Calcium e. Vitamin D

d. calcium and e. vitamin D explanation: A diet rich in calcium and vitamin D protects against skeletal demineralization. Intake of vitamin B12 and potassium does not directly influence the risk for osteoporosis. Calcitonin is not considered to be a dietary nutrient.

The nurse is assessing a client with a suspected stroke. What assessment finding is most suggestive of a stroke? a. Facial droop b. Dysrhythmias c. Periorbital edema d. Projectile vomiting

a. facial droop explanation: Facial drooping or asymmetry is a classic abnormal finding on a physical assessment that may be associated with a stroke. Periorbital edema (swelling around the eyes) is not suggestive of a stroke, and clients less commonly experience dysrhythmias or vomiting.

The nurse is reviewing the medication administration record of a client who possesses numerous risk factors for stroke. Which of the client's medications carries the greatest potential for reducing her risk of stroke? a. Naproxen 250 PO b.i.d. b. Calcium carbonate 1,000 mg PO b.i.d. c. Aspirin 81 mg PO o.d. d. Lorazepam 1 mg SL b.i.d. PRN

c. aspirin 81 mg PO o.d. explanation: Research findings suggest that low-dose aspirin may lower the risk of stroke in women who are at risk. Naproxen, lorazepam, and calcium supplements do not have this effect.

A client is reporting pain in her casted leg. The nurse has administered analgesics and elevated the limb. Thirty minutes after administering the analgesics, the client states the pain is unrelieved. The nurse should identify the warning signs of what complication? a. Subcutaneous emphysema b. Skin breakdown c. Compartment syndrome d. Disuse syndrome

c. compartment syndrome explanation: Compartment syndrome may manifest as unrelenting, uncontrollable pain. This presentation of pain is not suggestive of disuse syndrome or skin breakdown. Subcutaneous emphysema is not a complication of casting.

When communicating with a client who has sensory (receptive) aphasia, the nurse should: a. allow time for the client to respond. b. speak loudly and articulate clearly. c. give the client a writing pad. d. use short, simple sentences.

d. use short, simple sentences explanation: Although sensory aphasia allows the client to hear words, it impairs the ability to comprehend their meaning. The nurse should use short, simple sentences to promote comprehension. Allowing time for the client to respond might be helpful but is less important than simplifying the communication. Because the client's hearing isn't affected, speaking loudly isn't necessary. A writing pad is helpful for clients with expressive, not receptive, aphasia.

A client with Parkinson's disease is prescribed amantadine hydrochloride 100 mg twice a day. The pharmacy supplies amantadine syrup, because the client has a history of difficulty swallowing tablets. The label reads 50 mg/5 mL. How many milliliters would the nurse administer to the client for each dose? Enter the correct number ONLY.

10mL explanation: Because each 5 mL contains 50 mg, the client would receive 10 mL for the prescribed dose of 100 mg. To calculate the amount, set up a proportion: 5/50 = x/100; cross multiply and solve for x, which is 10.

A nurse practitioner provides health teaching to a patient who has difficulty managing hypertension. This patient is at an increased risk of which type of stroke? a. Intracerebral hemorrhage b. Subarachnoid hemorrhage c. Hemorrhage due to an aneurysm d. Arteriovenous malformation

a. intracerebral hemorrhage explanation: About 80% of hemorrhagic strokes are intracerebral, and they are caused primarily by uncontrolled hypertension.

A client has suffered a muscle strain and is reporting pain at 6 on a 10-point scale. The nurse should recommend what action? a. Taking an opioid analgesic as prescribed b. Applying a cold pack to the injured site c. Performing passive ROM exercises d. Applying a heating pad to the affected muscle

b. applying a cold pack to the injured site explanation: Most pain can be relieved by elevating the involved part, applying cold packs, and administering analgesics as prescribed. Heat may exacerbate the pain by increasing blood circulation, and ROM exercises would likely be painful. Analgesia is likely necessary, but NSAIDs would be more appropriate than opioids.

From which direction should a nurse approach a client who is blind in the right eye? a. From directly in front of the client b. From the right side of the client c. From the left side of the client d. From directly behind the client

c. from the left side of the client explanation: The nurse should approach the client from the left side so that the client can be aware of the nurse's approach. Likewise, personal items should be placed on the client's left side so that he can see them easily.

When preparing to discharge a client home, the nurse has met with the family and warned them that the client may exhibit unexpected emotional responses. The nurse should teach the family that these responses are typically a result of what cause? a. Frustration around changes in function and communication b. Unmet physiologic needs c. Changes in brain activity during sleep and wakefulness d. Temporary changes in metabolism

a. frustration around changes in function and communication explanation: Emotional problems associated with stroke are often related to the new challenges around ADLs and communication. These challenges are more likely than metabolic changes, unmet physiologic needs, or changes in brain activity, each of which should be ruled out.

In planning care for a patient with an extrapyramidal disorder, the nurse recognizes that a major difference between Parkinson's disease and Huntington's disease is the development of ________ in clients with advanced Huntington's disease. a. hallucinations and delusions b. depression c. bradykinesia d. muscle fasciculations

a. hallucinations and delusions explanation: As Huntington's disease progresses, hallucinations, delusions, and impaired judgment develop due to degeneration of the cerebral cortex. Depression is a likely symptom for clients with both Parkinson's disease and Huntington's disease. Bradykinesia, slowness in performing spontaneous movement, is commonly associated with Parkinson's disease. Muscle fasciculations, or twitching, are commonly associated with ALS.

A healthcare provider orders several drugs for a client with hemorrhagic stroke. Which drug order should the nurse question? a. Heparin sodium b. Dexamethasone c. Methyldopa d. Phenytoin

a. heparin sodium explanation: Administering heparin, an anticoagulant, could increase the bleeding associated with hemorrhagic stroke. Therefore, the nurse should question this order to prevent additional hemorrhage in the brain. In a client with hemorrhagic stroke, the healthcare provider may use dexamethasone (Decadron) to decrease cerebral edema and pressure, methyldopa (Aldomet) to reduce blood pressure, and phenytoin (Dilantin) to prevent seizures.

A nurse is providing care for a client who has a recent diagnosis of Paget disease. When planning this client's nursing care, what should interventions address? Select all that apply. a. Impaired physical mobility b. Acute pain c. Disturbed auditory sensory perception d. Risk for injury e. Risk for unstable blood glucose

a. impaired physical mobility; b. acute pain; c. disturbed auditory sensory perception; d. risk for injury explanation: Clients with Paget disease are at risk for decreased mobility, pain, hearing loss, and injuries resulting from decreased bone density. Paget disease does not affect blood glucose levels.

The nursing care plan for a client in traction specifies regular assessments for venous thromboembolism (VTE). When assessing a client's lower limbs, what sign or symptom is suggestive of deep vein thrombosis (DVT)? a. Increased warmth of the calf b. Decreased circumference of the calf c. Loss of sensation to the calf d. Pale-appearing calf

a. increased warmth of the calf explanation: Signs of DVT include increased warmth, redness, swelling, and calf tenderness. These findings are promptly reported to the health care provider for definitive evaluation and therapy. Signs and symptoms of a DVT do not include a decreased circumference of the calf, a loss of sensation in the calf, or a pale-appearing calf.

A nurse is admitting a client to the unit who presented with a lower extremity fracture. What signs and symptoms would suggest to the nurse that the client may have a peroneal nerve injury? a. Numbness and burning of the foot b. Pallor to the dorsal surface of the foot c. Visible cyanosis in the toes d. Inadequate capillary refill to the toes

a. numbness and burning of the foot explanation: Peroneal nerve injury may result in numbness, tingling, and burning in the feet. Cyanosis, pallor, and decreased capillary refill are signs of inadequate circulation.

A nurse is caring for a 78-year-old client with a history of osteoarthritis (OA). When planning the client's care, what goal should the nurse prioritize? a. The client will express satisfaction with the ability to perform ADLs. b. The client will recover from OA within 6 months. c. The client will adhere to the prescribed plan of care. d. The client will deny signs or symptoms of OA.

a. the client will express satisfaction with the ability to perform ADLs explanation: Pain management and optimal functional ability are major goals of nursing interventions for OA. Cure is not a possibility and it is unrealistic to expect a complete absence of signs and symptoms. Adherence to the plan of care is highly beneficial, but this is not the priority goal of care; adherence is of little benefit if the regimen has no effect on the client's functional status.

A physician orders aspirin, 325 mg P.O. daily for a client who has experienced a transient ischemic attack (TIA). The nurse should teach the client that the physician has ordered this medication to: a. control headache pain. b. enhance the immune response. c. prevent intracranial bleeding. d. reduce the chance of blood clot formation.

d. reduce the chance of blood clot formation explanation: TIAs are considered forerunners of stroke. Because strokes may result from clots in cerebral vessels, physicians order aspirin to prevent clot formation by reducing platelet agglutination. A 325-mg dose of aspirin is inadequate to relieve headache pain in an adult. Aspirin doesn't affect the body's immune response. Intracranial bleeding isn't associated with TIAs, and aspirin probably would worsen any existing bleeding.

A nurse is caring for a client diagnosed with a hemorrhagic stroke. When creating this client's plan of care, what goal should be prioritized? a. Prevent complications of immobility. b. Maintain and improve cerebral tissue perfusion. c. Relieve anxiety and pain. d. Relieve sensory deprivation.

b. maintain and improve cerebral tissue perfusion explanation: Each of the listed goals is appropriate in the care of a client recovering from a stroke. However, promoting cerebral perfusion is a priority physiologic need, on which the client's survival depends.

The nursing instructor gives their students an assignment of making a plan of care for a client with Huntington's disease. What would be important for the students to include in the teaching portion of the care plan? a. How to exercise b. How to perform household tasks c. How to take a bath d. How to facilitate tasks such as using both hands to hold a drinking glass

d. how to facilitate tasks such as using both hands to hold a drinking glass explanation: The nurse demonstrates how to facilitate tasks such as using both hands to hold a drinking glass, using a straw to drink, and wearing slip-on shoes. The teaching portion of the care plan would not include how to exercise, perform household tasks, or take a bath.

The nurse provides teaching to a client with osteoarthritis (OA). Which statement(s) indicate that teaching about pain management and functional ability were effective? Select all that apply. a. "I will spend more time resting." b. "I will need to lose some weight." c. "I will avoid using a cane to walk." d. "I will take the pain medication after exercising." e. "I will increase the amount of walking I do every day."

a. "I will need to lose some weight."; e. "I wil increase the amount of walking I do every day." explanation: Pain management and optimal functional ability are the major goals of nursing interventions. With those goals in mind, nursing management of the client with OA includes pharmacologic and nonpharmacologic approaches as well as education. Weight loss is an important approach to lessen pain and disability caused by OA. Exercises such as walking should be begin in moderation and gradually increase. A sedentary lifestyle contributes to the development of OA so resting would not be encouraged. Canes or other assistive devices for ambulation should be considered, and any stigma about the use of these devices should be explored. Clients should plan daily exercise for a time when the pain is least severe or plan to use an analgesic agent before exercising.

An older adult has encouraged the spouse husband to visit their primary provider, stating that concern that spouse may have Parkinson disease. Which description of the spouse's health and function is most suggestive of Parkinson disease? a. "Lately he seems to move far more slowly than he ever has in the past." b. "He often complains that his joints are terribly stiff when he wakes up in the morning." c. "He's forgotten the names of some people that we've known for years." d. "He's losing weight even though he has a ravenous appetite."

a. "lately he seems to move far flower than he ever has in the past." explanation: Parkinson disease is characterized by bradykinesia. It does not manifest as memory loss, increased appetite, or joint stiffness.

A client was brought to the emergency department after a fall. The client is taken to the operating room to receive a right hip prosthesis. In the immediate postoperative period, what health education should the nurse emphasize? a. "Make sure you don't bring your knees close together." b. "Try to lie as still as possible for the first few days." c. "Try to avoid bending your knees until next week." d. "Keep your legs higher than your chest whenever you can."

a. "make sure you dont bring your knees close together" explanation: After receiving a hip prosthesis, the affected leg should be kept abducted. Mobility should be encouraged within safe limits. There is no need to avoid knee flexion and the client's legs do not need to be higher than the level of the chest.

During a client's recovery from stroke, the nurse should be aware of predictors of stroke outcome in order to help clients and families set realistic goals. What are the predictors of stroke outcome? Select all that apply. a. National Institutes of Health Stroke Scale (NIHSS) score b. Race c. LOC at time of admission d. Gender e. Age

a. National Institutes of Health Stroke Scale (NIHSS) score; c. LOC at time of admission; e. age explanation: It is helpful for clinicians to be knowledgeable about the relative importance of predictors of stroke outcome (age, NIHSS score, and LOC at time of admission) to provide stroke survivors and their families with realistic goals. Race and gender are not significant predictors of stroke outcome.

A client has undergone a leg amputation. What teachings should the nurse offer such a client to prevent abduction deformity? Select all that apply. a. Advise the client to use a trochanter roll. b. Advise the client to adduct the stump so it presses against the other leg when the client is lying on the stomach. c. Advise the client to use antiembolism stockings on both legs. d. Advise the client to place pillows between the legs.

a. advise the client to use trochanter roll; b. advise the client to adduct the stump so it presses against the other leg when the client is lying on the stomach explanation: Use a trochanter roll to prevent external rotation of the hip and knee. Avoid placing pillows between the legs. If the client is lying on the stomach, the nurse should advise the client to adduct the stump so it presses against the other leg. Adduction stretches flexor muscles and prevents abduction deformity. The client should only use an antiembolism stocking on the unaffected leg.

The nurse is taking care of a client with a history of headaches. The nurse takes measures to reduce headaches and administer medications. Which appropriate nursing interventions may be provided by the nurse to such a client? a. Apply warm or cool cloths to the forehead or back of the neck b. Maintain hydration by drinking eight glasses of fluid a day c. Perform the Heimlich maneuver d. Use pressure-relieving pads or a similar type of mattress

a. apply warm or cool cloths to the forehead or back of the neck explanation: Applying warm or cool cloths to the forehead or back of the neck and massaging the back relaxes muscles and provides warmth to promote vasodilation. These measures are aimed at reducing the occurrence of headaches in the client. A client with transient ischemic attacks is advised to maintain hydration and drink eight glasses of fluid a day. A Heimlich maneuver is performed to clear the airway if the client cannot speak or breathe after swallowing food. The nurse uses pressure-relieving pads or a similar type of mattress to maintain peripheral circulation in the client's body.

A client with an arm cast reports pain. What nursing interventions should the nurse provide in order to reduce the incidence of complications? Select all that apply. a. Assess the fingers for color and temperature. b. Administer a prescribed analgesic to promote comfort and allay anxiety. c. Assess for a pressure sore d. Determine the exact site of the pain. e. Cut the cast with a cast saw

a. assess the fingers for color and temperature; c. assess for pressure sore; d. determine the exact site of pain explanation: Neurovascular assessment includes the assessment of peripheral circulation, motion, and sensation of the affected extremity, assessing the fingers or toes of the affected extremity, and comparing them with those of the opposite extremity. When assessing peripheral circulation, the nurse must check peripheral pulses as well as capillary refill response (within 3 seconds), edema, and the color and temperature of the skin. The nurse must carefully evaluate pain associated with the musculoskeletal condition, asking the client to indicate the exact site and to describe the character and intensity of the pain using a pain rating scale. Severe burning pain over bony prominences, especially the heels, anterior ankles, and elbows, warns of an impending pressure ulcer.

The nurse is caring for a client with osteoporosis. Which information will the nurse include when teaching actions to manage the condition? Select all that apply. a. Avoid excessive alcohol intake b. Plan for smoking cessation c. Consider estrogen replacement therapy d. Engage in regular weight-bearing exercise e. Swim for 30 minutes four to five times a week

a. avoid excessive alcohol intake; b. plan for smoking cessation; d. engage in regular weight- bearing exercise explanation: Care of the client with osteoporosis focuses on actions to improve bone density. These actions include avoiding the excessive intake of alcohol. Clients who use tobacco products should be advised to quit. Regular weight-bearing exercise promotes bone formation. Recommendations include 20 to 30 minutes of aerobic, bone-stressing exercise daily. Current guidelines recommend that hormone therapy with estrogen not be used for primary prevention of bone loss in female clients who are postmenopausal. Swimming is not a weight-bearing exercise.

The nurse is caring for a patient with a pelvic fracture. What nursing assessment for a pelvic fracture should be included? (Select all that apply.) a. Checking the urine for hematuria b. Palpating peripheral pulses in both lower extremities c. Testing the stool for occult blood d. Assessing level of consciousness e. Assessing pupillary response

a. checking the urine for hematuria; b. palpating peripheral pulses in both lower extremities; c. testing the stool for occult blood explanation: In pelvic fracture, the nurse should palpate the peripheral pulses, especially the dorsalis pedis pulses of both lower extremities; absence of a pulse may indicate a tear in the iliac artery or one of its branches. To assess for urinary tract injury, the patient's urine is analyzed for blood.

Which of the following outcomes would be most appropriate to include in the plan of care for a client diagnosed with a muscular dystrophy? a. Client participates in activities of daily living using adaptive devices. b. Client demonstrates understanding of the need to adhere to medication therapy. c. Client verbalizes understanding of the chronic nature of the disorder. d. Client describes the importance of diagnostic follow-up to evaluate the disorder.

a. client participates in activities of daily living using adaptive devices explanation: The muscular dystrophies are a group of incurable muscle disorders characterized by progressive weakening and wasting of the skeletal or voluntary muscles. Nursing care focuses on maintaining the client at his or her optimal level of functioning and enhancing the quality of life. Therefore, the outcome of participating in activities of daily living with adaptive devices would be most appropriate. Medications are not used to treat these disorders; however, they may be necessary if the client develops a complication such as respiratory dysfunction. The disorder is incurable and progressive, not chronic. Diagnostic follow-up would provide little if any information about the course of the disorder.

The nurse is planning care in the home for a client with rheumatoid arthritis. What instruction(s) should the nurse include in the plan of care? Select all that apply. a. Collaborate with occupational therapists for specialized equipment. b. Identify the exercise regimen planned by physical therapist. c. Provide nursing assistance for ADLs. d. Teach the nursing assistant to allow extra time in the evening for hygiene or other procedures. e. Ensure the home environment is safe.

a. collaborate with occupational therapists for specialized equipment; b. identify the exercise regimen planned by physical therapist; c. provide nursing assistance for ADLs; d. ensure the home environment is safe explanation: The nurse should collaborate with occupational therapists for specialized equipment, identify the exercise regimen planned by physical therapist, provide nursing assistance for ADLs, and ensure the home environment is safe. The nurse should teach the nursing assistant to allow extra time in the morning, not the evening, for hygiene or other procedures.

The nurse caring for a client in a persistent vegetative state is regularly assessing for potential complications. The nurse should assess for which complications? Select all that apply. a. Contractures b. Hemorrhage c. Pressure ulcers d. Venous thromboembolism e. Pneumonia

a. contractures; c. pressure ulcers; d. venous thromboembolism; e. pneumonia explanation: Based on the assessment data, potential complications (partially based on immobility) may include respiratory distress or failure, pneumonia, aspiration, pressure ulcer, deep vein thrombosis (DVT), and contractures. A persistent vegetative state does not directly create a heightened risk for hemorrhage.. A persistent vegetative state condition is when the client is wakeful but devoid of conscious content, without cognitive or affective mental function.

A nurse is caring for a client who is 12 hours postoperative following foot surgery. The nurse assesses the presence of edema in the foot. What nursing measure should the nurse implement to control the edema? a. Elevate the foot on several pillows. b. Apply warm compresses intermittently to the surgical area. c. Administer a loop diuretic as prescribed. d. Increase circulation through frequent ambulation.

a. elevate the foot on several pillows explanation: To control the edema in the foot of a client who experienced foot surgery, the nurse will elevate the foot on several pillows when the client is sitting or lying. Diuretic therapy is not an appropriate intervention for edema related to inflammation. Intermittent ice packs should be applied to the surgical area during the first 24 to 48 hours after surgery to control edema and provide some pain relief. Ambulation will gradually be resumed based on the guidelines provided by the surgeon.

A client is recovering from a below-the-knee traumatic amputation and is 72 hours post surgery. Which actions will the nurse take to promote healing of the wound? Select all that apply. a. Measure the residual limb every 8 to 12 hours. b. Elevate the residual limb on a pillow when seated. c. Assess neurovascular function of the residual limb. d. Apply an elastic compression bandage over the wound site. e. Remind to place the residual limb in a dependent position when sitting.

a. measure the residual limb every 8 to 12 hours; c. assess neurovascular function of the residual limb; d. apply an elastic compression bandage over the wound site explanation: Amputation is the removal of a body part by a surgical procedure or trauma. Trauma is the second most common indication for an amputation. To promote wound healing, the residual limb should be measured every 8 to 12 hours. Neurovascular status of the residual limb should also be assessed every 8 to 12 hours. If the rigid or soft dressing inadvertently comes off, the residual limb should be wrapped with an elastic compression bandage. Application of consistent pressure to the residual limb reduces edema formation and helps to shape the residual limb so that it may fit a prosthetic. The limb should only be elevated for 24 hours after the amputation. After this period, elevation, abduction, external rotation, and flexion of the lower limb are to be avoided. The client is encouraged not to sit for long periods of time to prevent flexion contracture or with the affected extremity dangling or in a dependent position to prevent edema.

A client broke his arm in a sports accident and required the application of a cast. Shortly following application, the client reported an inability to straighten his fingers and was subsequently diagnosed with Volkmann contracture. What pathophysiologic process caused this complication? a. Obstructed arterial blood flow to the forearm and hand b. Simultaneous pressure on the ulnar and radial nerves c. Irritation of Merkel cells in the client's skin surfaces d. Uncontrolled muscle spasms in the client's forearm

a. obstructed arterial blood flow to the forearm and hand explanation: Volkmann contracture occurs when arterial blood flow is restricted to the forearm and hand and results in contractures of the fingers and wrist. It does not result from nerve pressure, skin irritation, or spasms.

An 80-year-old man in a long-term care facility has a chronic leg ulcer and states that the area has become increasingly painful in recent days. The nurse notes that the site is now swollen and warm to the touch. The client should undergo diagnostic testing for what health problem? a. Osteomyelitis b. Osteoporosis c. Osteomalacia d. Septic arthritis

a. osteomyelitis explanation: When osteomyelitis develops from the spread of an adjacent infection, no signs of septicemia are present, but the area becomes swollen, warm, painful, and tender to touch. Osteoporosis is noninfectious. Osteomalacia is a metabolic bone disease characterized by inadequate mineralization of bone. Septic arthritis occurs when joints become infected through spread of infection from other parts of the body (hematogenous spread) or directly through trauma or surgical instrumentation.

A client with a new diagnosis of amyotrophic lateral sclerosis (ALS) is overwhelmed by the diagnosis and the known complications of the disease. How can the client best make known their wishes for care as the disease progresses? a. Prepare an advance directive. b. Designate a most responsible health care provider (MRP) early in the course of the disease. c. Collaborate with representatives from the Amyotrophic Lateral Sclerosis Association. d. Ensure that witnesses are present when he provides instruction.

a. prepare an advanced directive explanation: Clients with ALS are encouraged to complete an advanced directive or "living will" to preserve their autonomy in decision making. None of the other listed actions constitutes a legally binding statement of end-of-life care.

A nurse is caring for an older woman with a hip fracture. What are appropriate risk factors for the nurse to consider related to the client's hip fracture? Select all that apply. a. Presence of anemia b. Muscular agility c. Female gender d. Osteoporosis e. History of diverticulitis

a. presence of anemia; c. female gender; d. osteoporosis explanation: Anemia, female gender, and osteoporosis are risk factors for hip fractures. Muscular agility decreases the risk for hip fracture. A history of diverticulitis is not related to hip fractures.

The client has been diagnosed with aphasia after suffering a stroke. What can the nurse do to best make the client's atmosphere more conducive to communication? a. Provide a board of commonly used needs and phrases. b. Have the client speak to loved ones on the phone daily. c. Help the client complete his or her sentences as needed. d. Speak in a loud and deliberate voice to the client.

a. provide a board of commonly used needs and phrases explanation: The inability to talk on the telephone or answer a question or exclusion from conversation causes anger, frustration, fear of the future, and hopelessness. A common pitfall is for the nurse or other health care team member to complete the thoughts or sentences of the client. This should be avoided because it may cause the client to feel more frustrated at not being allowed to speak and may deter efforts to practice putting thoughts together and completing a sentence. The client may also benefit from a communication board, which has pictures of commonly requested needs and phrases. The board may be translated into several languages.

A nurse is caring for a client with a cerebral aneurysm. Which nursing interventions would be most useful to the nurse to avoid bleeding in the brain? Select all that apply. a. Report changes in neurologic status as soon as a worsening trend is identified. b. Use a well-lighted room for assessments every 2 hours. c. Follow the healthcare provider's orders to increase fluid volume. d. Maintain the head of the bed at 30 degrees. e. Avoid any activities that cause a Valsalva maneuver.

a. report changes in neurologic status as soon as worsening trend is identified; d. maintain the head of the bed at 30 degrees; e. avoid any activities that cause a valsalva maneuver explanation: Cerebral aneurysm precautions are implemented for the patient with a diagnosis of aneurysm to provide a nonstimulating environment, prevent increases in intracranial pressure, and prevent further bleeding. The patient is placed on bed rest in a quiet, nonstressful environment, because activity, pain, and anxiety are thought to elevate the blood pressure, which may increase the risk for bleeding. The head of the bed is elevated 30 degrees to promote venous drainage and decrease intracranial pressure. Any activity that suddenly increases the blood pressure or obstructs venous return is avoided. This includes the Valsalva maneuver, straining, forceful sneezing, pushing oneself up in bed and acute flexion or rotation of the head and neck (which compromises the jugular veins). Stool softeners and mild laxatives are prescribed to prevent constipation, which can cause an increase in intracranial pressure. Dim lighting is helpful for photophobia. Increasing fluid volume does not affect brain bleeding.

A client who suffered an ischemic stroke now has disturbed sensory perception. What principle should guide the nurse's care of this client? a. The client should be approached on the side where visual perception is intact. b. Attention to the affected side should be minimized in order to decrease anxiety. c. The client should avoid turning in the direction of the defective visual field to minimize shoulder subluxation. d. The client should be approached on the opposite side of where the visual perception is intact to promote recovery.

a. the client should be approached on the side where visual perception is intact explanation: Clients with decreased field of vision should first be approached on the side where visual perception is intact. All visual stimuli should be placed on this side. The client can and should be taught to turn the head in the direction of the defective visual field to compensate for this loss. The nurse should constantly remind the client of the other side of the body and should later stand at a position that encourages the client to move or turn to visualize who and what is in the room.

The nurse is caring for the client with chronic osteomyelitis of the jaw with a draining wound. Which client goal is a priority for the client? Select all that apply. a. The client will experience a tolerable level of pain. b. The client will demonstrate wound care. c. The client will maintain adequate nutritional intake. d. The client will remain free from injury. e. The client will maintain effective airway clearance.

a. the client will experience a tolerable level of pain; b. the client will demonstrate wound care; c. the client will maintain adequate nutritional intake explanation: Pain is a priority problem for the client with osteomyelitis, and it can interfere with mobility of joint. In this situation, the client's jaw is the site of infection. Pain in this location can interfere with nutritional intake of the individual. Chronic osteomyelitis presents with a nonhealing ulcer over the infected bone with a connecting sinus that will intermittently and spontaneously drain pus. The client will need to be able to provide wound care in the home setting. Remaining free from injury and maintaining an effective airway clearance are not priority goals for the client.

A continuous passive motion (CPM) machine is used to promote healing and flexibility in the knee and hip joint and increase circulation to the operative area. What is true about the use of CPM? Select all that apply. a. The physician orders the amount of extension and flexion produced by the machine. b. The physician orders the frequency of use of the machine. c. The amount of flexion for clients with hip replacements should never exceed 30 degrees in the CPM machine. d. The amount of flexion for clients with hip replacements should never exceed 60 degrees in the CPM machine.

a. the physician orders the amount of extension and flexion produced by the machine; b. the physician orders the frequency of use of the machine; c. the amount of flexion for the clients with hip replacements should never exceed 30 degrees in the CPM machine explanation: The physician orders the amount of extension and flexion produced by the machine. The physician orders the frequency of use of the machine. The amount of flexion for clients with hip replacements should never exceed 30 degrees in the CPM machine.

Identify descriptors of the pathophysiologic process seen in osteomalacia. Select all that apply. a. There is a deficiency of activated vitamin D (calcitriol). b. Calcium and phosphate are not moved to the bones. c. The bone mass is structurally weaker, and bone deformities occur. d. Excessive osteoclastic activity causes the bones to become soft and bowed initially; later, the bones thicken but are not well formed, making the bones weak and prone to fracture.

a. there is a deficiency of activated vitamin D (calcitriol); b. calcium and phosphate are not moved to the bones; c. the bone mass is structurally weaker, and bone deformities occur explanation: In the pathophysiologic process seen in osteomalacia, there is a deficiency of activated vitamin D (calcitriol), calcium and phosphate are not moved to the bones, the bone mass is structurally weaker, and bone deformities occur.

A client exhibiting an altered level of consciousness (LOC) due to blunt force trauma to the head is admitted to the emergency department (ED). The nurse should first gauge the client's LOC on the results of what diagnostic tool? a. Monro-Kellie hypothesis b. Glasgow Coma scale c. Cranial nerve function d. Mental status examination

b. Glasgow Coma Scale explanation: LOC, a sensitive indicator of neurologic function, is assessed based on the criteria in the Glasgow Coma scale: eye opening, verbal response, and motor response. The Monro-Kellie hypothesis states that because of the limited space for expansion within the skull, an increase in any one of the components (blood, brain tissue, cerebrospinal fluid) causes a change in the volume of the others. Cranial nerve function and the mental status examination would be part of the neurologic examination for this client, but would not be the priority in evaluating LOC. Glasgow coma scale can be done quickly and establishes a baseline of neurologic function.

Which of the following clients should the nurse recognize as being at the highest risk for the development of osteomyelitis? a. A middle-aged adult who takes ibuprofen daily for rheumatoid arthritis b. An older adult client with an infected pressure ulcer in the sacral area c. A 17-year-old football player who had orthopedic surgery 6 weeks prior d. An infant diagnosed with jaundice

b. an older adult client with an infected pressure ulcer in the sacral area explanation: Clients who are at high risk of osteomyelitis include those who are poorly nourished, older adults, and clients who are obese. The older adult client with an infected sacral pressure ulcer is at the greatest risk for the development of osteomyelitis, as this client has two risk factors: age and the presence of a soft-tissue infection that has the potential to extend into the bone. The client with rheumatoid arthritis has one risk factor and the infant with jaundice has no identifiable risk factors. The client 6 weeks' postsurgery is beyond the usual window of time for the development of a postoperative surgical wound infection.

A nurse is taking care of a client with swallowing difficulties after a stroke. What are some interventions the nurse can accomplish to prevent the client from aspirating while eating? Select all that apply. a. Encourage the client to increase his/her intake of water and juice. b. Assist the client out of bed and into the chair for meals. c. Instruct the client to tuck his/her chin towards their chest when swallowing. d. Request a swallowing assessment by a speech therapist before the client's discharge. e. Recommend the insertion of a percutaneous endoscopic gastrostomy (PEG) tube.

b. assist the client out of bed and into the chair for meals; c. instruct the client to tuck his/ her chin towards their chest when swallowing explanation: If swallowing function is partially impaired, it may return over time, or the client may be educated in alternative swallowing techniques, advised to take smaller boluses of food, and educated about types of foods that are easier to swallow. The client may be started on a thick liquid or pureed diet, because these foods are easier to swallow than thin liquids. Having the client sit upright, preferably out of bed in a chair, and instructing them to tuck the chin toward the chest as they swallow will help prevent aspiration. Recommending the insertion of a percutaneous endoscopic gastrostomy (PEG) tube would not prevent the client from aspirating while eating. A PEG tube could be placed if the client was unable to tolerate or resume an oral intake. A swallowing assessment should be done before allowing any oral intake and preferably within 4 to 24 hours after a stroke. A nurse can also accomplish a swallowing study using a validated and reliable assessment tool.

The nurse is caring for a client who is known to be at risk for cardiogenic embolic strokes. What arrhythmia does this client most likely have? a. Ventricular tachycardia b. Atrial fibrillation c. Supraventricular tachycardia d. Bundle branch block

b. atrial fibrillation explanation: Cardiogenic embolic strokes are associated with cardiac arrhythmias, which is usually atrial fibrillation. Absence of a regular contraction of the fibrillating atria leads to an increase of atrial pressure and dilation, which together with hemoconcentration, endothelial dysfunction, and a prothrombotic state are prerequisites for thrombus formation. In other words, the irregularity of the heartbeat caused by atrial fibrillation makes the heart more likely to form clots. Studies have shown that strokes that are caused by atrial fibrillation have an increased poor outcome in terms of severity and resulting disability. The other listed arrhythmias are less commonly associated with this type of stroke.

The orthopedic surgeon has prescribed balanced skeletal traction for a client. What advantage is conferred by balanced traction? a. Balanced traction can be applied at night and removed during the day. b. Balanced traction allows for greater client movement and independence than other forms of traction. c. Balanced traction is portable and may accompany the client's movements. d. Balanced traction facilitates bone remodeling in as little as 6 days.

b. balanced traction allows for greater client movement and independence than other forms of traction explanation: Often, skeletal traction is balanced traction, which supports the affected extremity, allows for some client movement, and facilitates client independence and nursing care while maintaining effective traction. It is not portable, however, and it cannot be removed. Bone remodeling takes longer than 6 days.

A client is sitting in a chair and begins having a tonic-clonic seizure. The most appropriate nursing response is to: a. hold the client's arm still to keep him from hitting anything. b. carefully move the client to a flat surface and turn him on his side. c. allow the client to remain in the chair but move all objects out of his way. d. place an oral airway in the client's mouth to maintain an open airway.

b. carefully move the client to a flat surface and turn him on his side explanation: When caring for a client experiencing a tonic-clonic seizure, the nurse should help the client to a flat non-elevated surface and then position him on his side to ensure that he doesn't aspirate and to protect him from injury. These steps help reduce the risk of injury from falling or hitting surrounding objects and help establish an open airway. The client shouldn't be restrained during the seizure. Also, nothing should be placed in his mouth; anything in the mouth could impair ventilation and damage the inside of the mouth.

A client with a fractured fibula has an external fixator device applied. Which interventions to care for this device will the nurse add to the client's plan of care? Select all that apply. a. Examine pin insertion sites daily b. Cover sharp fixator pins with caps c. Elevate the extremity to heart level d. Tighten loose pins on the device during pin care e. Monitor neurovascular status every 2 to 4 hours

b. cover sharp fixator pins with caps; c. elevate the extremity to heart level; e monitor neurovascular status every 2 to 4 hours explanation: External fixation is a technique that involves the surgical insertion of pins through the skin and soft tissues into and through the bone. A metal external frame is attached to these pins and is designed to hold the fracture in proper alignment to enable healing to occur. After the external fixator device is applied, any sharp areas on the pins can be covered with caps. The extremity should be elevated to the level of the heart to reduce swelling. Neurovascular status of the extremity with the device is to be assessed every 2 to 4 hours. Pin sites are to be assessed every 8 to 12 hours. The pins should not be adjusted on the device during pin care. The healthcare provider should be notified if pins need to be tightened.

Which intervention would the nurse implement with the client in skeletal traction? Select all that apply. a. Apply 8-pound weight to the rope. b. Ensure the pins or wires are covered with caps. c. Remove foam boot and inspect skin daily. d. Position trapeze within the client's reach. e. Instruct the client on isometric exercises for immobilized extremity.

b. ensure the pins or wires are covered with caps; d. position trapeze within client's reach; e. instruct the client on isometric exercises for immobilized extremity explanation: Nursing care of the client in skeletal traction includes ensuring the trapeze is within the client's reach and the pins or wires are covered with caps. The nurse instructs the client on isometric exercises for the immobilized extremity. A foam boot is used with Buck's traction (skin traction) not skeletal traction. An 8-pound weight is used with Buck's traction, whereas a 15- to 25-pound weight is applied in skeletal traction.

A client has recently begun mobilizing during the recovery from an ischemic stroke. To protect the client's safety during mobilization, the nurse should perform what action? a. Support the client's full body weight with a waist belt during ambulation. b. Have a colleague follow the client closely with a wheelchair. c. Avoid mobilizing the client in the early morning or late evening. d. Ensure that the client's family members do not participate in mobilization.

b. have a colleague follow the client closely with a wheelchair explanation: During mobilization, a chair or wheelchair should be readily available in case the client suddenly becomes fatigued or feels dizzy. The family should be encouraged to participate, as appropriate, and the nurse should not have to support the client's full body weight. Morning and evening activities are not necessarily problematic.

The nurse is providing care for a client who is unconscious. What nursing intervention takes highest priority? a. Maintaining accurate records of intake and output b. Maintaining a patent airway c. Inserting a nasogastric (NG) tube as prescribed d. Providing appropriate pain control

b. maintaining a patent airway explanation: Maintaining a patent airway always takes top priority, even though each of the other listed actions is necessary and appropriate.

A client with muscle weakness and an abnormal gait is being evaluated for muscular dystrophy. What is the supportive goal for the client diagnosed with muscular dystrophy? a. Client will be free of respiratory complications. b. Minimized functional deterioration in the client. c. Genetic testing will identify specific gene mutations. d. Client will complete end-of-life decisions.

b. minimized functional deterioration in the client explanation: The goal of supportive management is to keep the client active and functioning as normally as possible and to minimize functional deterioration. Client will have respiratory complications at times, but this is not the target of the supportive goal. Gene mutations are useful, but not a generalized goal for clients. Clients with muscular dystrophy should make end-of-life decisions, but this is not the client's supportive goal.

A gerontologic nurse planning the neurologic assessment of an older adult is considering normal, age-related changes that may influence the assessment results. Of what phenomenon should the nurse be aware? a. Hyperactive deep tendon reflexes b. Reduction in cerebral blood flow c. Increased cerebral metabolism d. Hypersensitivity to painful stimuli

b. reduction in cerebral blood flow explanation: Reduction in cerebral blood flow (CBF) is a change that occurs in the normal aging process. Deep tendon reflexes can be decreased or, in some cases, absent. Cerebral metabolism decreases as the client advances in age. Reaction to painful stimuli may be decreased with age. Because pain is an important warning signal, caution must be used when hot or cold packs are used.

A client scheduled for magnetic resonance imaging (MRI) has arrived at the radiology department. The nurse who prepares the client for the MRI should prioritize what action? a. Withholding stimulants 24 to 48 hours prior to exam b. Removing all metal-containing objects c. Instructing the client to void prior to the MRI d. Initiating an IV line for administration of contrast

b. removing all metal containing objects explanation: Client preparation for an MRI consists of removing all metal-containing objects prior to the examination. Withholding stimulants would not affect an MRI; this relates to an electroencephalography (EEG). Instructing the client to void is client preparation for a lumbar puncture. Initiating an IV line for administration of contrast would be done if the client was having a CT scan with contrast.

A family member brings the client to the clinic for a follow-up visit after a stroke. The family member asks the nurse what he can do to decrease his chance of having another stroke. What would be the nurse's best answer? a. "Have your heart checked regularly." b. "Stop smoking as soon as possible." c. "Take your prescribed medication to bring down your sodium levels." d. "Eat a nutritious diet."

b. stop smoking as soon as possible explanation: Smoking is a modifiable and highly significant risk factor for stroke. The significance of smoking, and the potential benefits of quitting, exceed the roles of sodium, diet, and regular medical assessments.

A nurse is assessing a client for risk factors known to contribute to osteoarthritis. What assessment finding should the nurse interpret as a risk factor? a. the client has a 30 pack- year smoking history b. The client's body mass index is 34 (obese). c. The client has primary hypertension. d. The client is 58 years old.

b. the client's body mass index is 34 (obese) explanation: Risk factors for osteoarthritis include obesity and previous joint damage. Risk factors of OA do not include smoking or hypertension. Incidence increases with age, but a client who is 58 years old would not yet face a significantly heightened risk.

A nurse is preparing a client for a computed tomography (CT) scan that requires infusion of radiopaque dye. Which question is the most important for the nurse to ask? a. "When did you last have something to eat or drink?" b. "When did you last take any medication?" c. "Are you allergic to seafood or iodine?" d. "How much do you weigh?"

c. "are you allergic to seafood or iodine?" explanation: Seafood and the radiopaque dye used in CT contain iodine. To prevent an allergic reaction to the radiopaque dye, the nurse should ask the client about allergies to seafood or iodine before the CT scan. Because fasting is unnecessary before a CT scan, the nurse doesn't need to obtain information about the client's last food and fluid intake. The client's last dose of medication and current weight also are irrelevant.

A nurse is assisting a client who had a recent stroke with getting dressed for physical therapy. The client looks at each piece of clothing before putting it on the body. The client states, "This is how I know what item I am holding." What impairment is this client likely experiencing? a. Homonymous hemianopsia b. Receptive aphasia c. Agnosia d. Hemiplegia

c. agnosia explanation: Agnosia is the loss of the ability to recognize objects through a particular sensory system; it may be visual, auditory, or tactile. The client was able to see what was being held but was not recognizing specific garments by just touching them. Because the client was able to see homonymous hemianopsia, which is blindness in half of the visual field in one or both eyes, is unlikely. Receptive aphasia is an inability to understand language. Hemiplegia is a motor/ambulatory dysfunction. The presented scenario did not support these findings.

A nurse is caring for a client with Paget disease and is reviewing the client's most recent laboratory values. Which of the following values are most characteristic of Paget disease? a. An elevated level of parathyroid hormone and low calcitonin levels b. A low serum alkaline phosphatase level and a low serum calcium level c. An elevated serum alkaline phosphatase level and a normal serum calcium level d. An elevated calcitonin level and low levels of parathyroid hormone

c. an elevated serum alkaline phosphatase level and a normal serum calcium level explanation: Clients with Paget disease have normal blood calcium levels. Elevated serum alkaline phosphatase concentration and urinary hydroxyproline excretion reflect the increased osteoblastic activity associated with this condition. Alterations in PTH and calcitonin levels are atypical.

A white female client is admitted to an acute care facility with a diagnosis of stroke. Her history reveals bronchial asthma, exogenous obesity, and iron-deficiency anemia. Which history finding is a risk factor for stroke? a. Being white b. Being female c. Being obese d. Having bronchial asthma

c. being obese explanation: Obesity is a risk factor for stroke. Other risk factors include a history of ischemic episodes, cardiovascular disease, diabetes mellitus, atherosclerosis of the cranial vessels, hypertension, polycythemia, smoking, hypercholesterolemia, hormonal contraceptive use, emotional stress, family history of stroke, and advancing age. The client's race, gender, and bronchial asthma aren't risk factors for stroke.

A nurse is reviewing the pathophysiology that may underlie a client's decreased bone density. What hormone should the nurse identify as inhibiting bone resorption and promoting bone formation? a. Estrogen b. Parathyroid hormone (PTH) c. Calcitonin d. Progesterone

c. calcitonin explanation: Calcitonin inhibits bone resorption and promotes bone formation, estrogen inhibits bone breakdown, and parathyroid increases bone resorption. Estrogen, which inhibits bone breakdown, decreases with aging. Parathyroid hormone (PTH) increases with aging, increasing bone turnover and resorption. Progesterone is the major naturally occurring human progestogen and plays a role in the female menstrual cycle.

The nurse is discharging home a client who had a stroke. The client has a flaccid right arm and leg and is experiencing urinary incontinence. The nurse makes a referral to a home health nurse because of an awareness of what common client response to a change in body image? a. Confusion b. Uncertainty c. Depression d. Disassociation

c. depression explanation: Depression is a common and serious problem in the client who has had a stroke. It can result from a profound disruption in his or her life and changes in total function, leaving the client with a loss of independence. The nurse needs to encourage the client to verbalize feelings to assess the effect of the stroke on self-esteem. Confusion, uncertainty, and disassociation are not the most common client response to a change in body image, although each can occur in some clients.

A client, brought to the clinic by the client's spouse and son, is diagnosed with Huntington disease. When providing anticipatory guidance, the nurse should address the future possibility of what effect of Huntington disease? a. Metastasis b. Risk for stroke c. Emotional and personality changes d. Pathologic bone fractures

c. emotional and personality changes explanation: Huntington disease causes profound changes to personality and behavior. It is a nonmalignant disease and stroke is not a central risk. The disease is not associated with pathologic bone fractures.

A client experiences loss of consciousness, tongue biting, and incontinence, along with tonic and clonic phases of seizure activity. The nurse should document this episode as which type of seizure? a. Jacksonian b. Absence c. Generalized d. Sensory

c. generalized explanation: A generalized seizure causes generalized electrical abnormality in the brain. The client typically falls to the ground, losing consciousness. The body stiffens (tonic phase) and then alternates between episodes of muscle spasm and relaxation (clonic phase). Tongue biting, incontinence, labored breathing, apnea, and cyanosis may also occur. A Jacksonian seizure begins as a localized motor seizure. The client experiences a stiffening or jerking in one extremity, accompanied by a tingling sensation in the same area. Absence seizures occur most commonly in children. They usually begin with a brief change in the level of consciousness, signaled by blinking or rolling of the eyes, a blank stare, and slight mouth movements. Symptoms of a sensory seizure include hallucinations, flashing lights, tingling sensations, vertigo, déjà vu, and smelling a foul odor.

The nurse is caring for a client who underwent a total hip replacement yesterday. What should the nurse do to prevent dislocation of the new prosthesis? a. Keep the affected leg in a position of adduction. b. Have the client reposition himself independently. c. Protect the affected leg from internal rotation. d. Keep the hip flexed by placing pillows under the client's knee.

c. protect the affected leg from internal rotation explanation: Abduction of the hip helps to prevent dislocation of a new hip joint. Rotation and adduction should be avoided. While the hip may be flexed slightly, it shouldn't exceed 90 degrees and maintenance of flexion isn't necessary. The client may not be capable of safe independent repositioning at this early stage of recovery.

A nurse is caring for a client who has a leg cast. The nurse observes the client using a pencil to scratch the skin under the edge of the cast. How should the nurse respond to this observation? a. Allow the client to gently scratch inside the cast with a pencil. b. Give the client a sterile tongue depressor to use for scratching instead of the pencil. c. Provide a fan to blow cool air into the cast to relieve itching. d. Obtain a prescription for a sedative, such as lorazepam, to prevent the client from scratching.

c. provide a fan to blow cool air into the cast to relieve itching explanation: The client may receive relief from itching by using a fan or hair dryer to blow cool air into the cast. Scratching should be discouraged using a pencil or a sterile tongue depressor because of the risk for skin breakdown or damage to the cast. Benzodiazepines would not be given for this purpose.

An elderly client's hip joint is immobilized prior to surgery to correct a femoral head fracture. What is the nurse's priority assessment? a. The presence of leg shortening b. The client's complaints of pain c. Signs of neurovascular compromise d. The presence of internal or external rotation

c. signs of neurovascular compromise explanation: Because impaired circulation can cause permanent damage, neurovascular assessment of the affected leg is always a priority assessment. Leg shortening and internal or external rotation are common findings with a fractured hip. Pain, especially on movement, is also common after a hip fracture.

The nurse is preparing health education for a client who is being discharged after hospitalization for a hemorrhagic stroke. What content should the nurse include in this education? a. Mild, intermittent seizures can be expected. b. Take ibuprofen for a serious headache. c. Take antihypertensive medication as prescribed. d. Drowsiness is normal for the first week after discharge.

c. take antihypertensive medication as prescribed explanation: The client and family are provided with information that will enable them to cooperate with the care and restrictions required during the acute phase of hemorrhagic stroke and to prepare the client to return home. Client and family teaching includes information about the causes of hemorrhagic stroke and its possible consequences. Symptoms of hydrocephalus include gradual onset of drowsiness and behavioral changes. Hypertension is the most serious risk factor, suggesting that appropriate antihypertensive treatment is essential for a client being discharged. Seizure activity is not normal; reports of a serious headache should be reported to the health care provider before any medication is taken. Drowsiness is not normal or expected.

The nurse is caring for a client diagnosed with an ischemic stroke and knows that effective positioning of the client is important. Which of the following should be integrated into the client's plan of care? a. The client's hip joint should be maintained in a flexed position. b. The client should be in a supine position unless ambulating. c. The client should be placed in a prone position for 15 to 30 minutes several times a day. d. The client should be placed in a Trendelenburg position two to three times daily to promote cerebral perfusion.

c. the client should be placed in a prone position for 15 to 30 minutes several times a day explanation: If possible, the clients placed in a prone position for 15 to 30 minutes several times a day. A small pillow or a support is placed under the pelvis, extending from the level of the umbilicus to the upper third of the thigh. This helps to promote hyperextension of the hip joints, which is essential for normal gait, and helps prevent knee and hip flexion contractures. The hip joints should not be maintained in flexion and the Trendelenburg position is not indicated.

A nurse is caring for a client who has had a total hip replacement. The nurse is reviewing health education prior to discharge. Which of the client's statements would indicate to the nurse that the client requires further teaching? a. "I'll need to keep several pillows between my legs at night." b. "I need to remember not to cross my legs. It's such a habit." c. "The occupational therapist is showing me how to use a 'sock puller' to help me get dressed." d. "I will need my husband to assist me in getting off the low toilet seat at home."

d. "i will need my husband to assist me in getting off the low toilet seat at home" explanation: To prevent hip dislocation after a total hip replacement, the client must avoid bending the hips beyond 90 degrees. Assistive devices, such as a raised toilet seat, should be used to prevent severe hip flexion. Using an abduction pillow or placing several pillows between the legs reduces the risk of hip dislocation by preventing adduction and internal rotation of the legs. Likewise, teaching the client to avoid crossing the legs also reduces the risk of hip dislocation. A sock puller helps a client get dressed without flexing the hips beyond 90 degrees.

A nurse is caring for a client who is in skeletal traction. To prevent the complication of skin breakdown in a client with skeletal traction, what action should be included in the plan of care? a. Apply occlusive dressings to the pin sites. b. Encourage the client to push up with the elbows when repositioning. c. Encourage the client to perform isometric exercises once a shift. d. Assess the pin insertion site every 8 hours.

d. assess the pin insertion site every 8 hours explanation: The pin insertion site should be assessed every 8 hours for inflammation and infection. Loose cover dressings should be applied to pin sites. The client should be encouraged to use the overhead trapeze to shift weight for repositioning. Isometric exercises should be done 10 times an hour while awake.

A client is admitted to an acute care facility after an episode of status epilepticus. After the client is stabilized, which factor is most beneficial in determining the potential cause of the episode? a. The type of anticonvulsant prescribed to manage the epileptic condition b. Recent stress level c. Recent weight gain and loss d. Compliance with the prescribed medication regimen

d. compliance with the prescribed medication regimen explanation: The most common cause of status epilepticus is sudden withdraw of anticonvulsant therapy. The type of medication prescribed, the client's stress level, and weight change don't contribute to this condition.

A nursing student is writing a care plan for a newly admitted client who has been diagnosed with a stroke. What major nursing diagnosis should most likely be included in the client's plan of care? a. Adult failure to thrive b. Post-trauma syndrome c. Hyperthermia d. Disturbed sensory perception

d. disturbed sensory perception explanation: The client who has experienced a stroke is at a high risk for disturbed sensory perception. Stroke is associated with multiple other nursing diagnoses, but hyperthermia, adult failure to thrive, and post-trauma syndrome are not among these.

What should be included in the client's care plan when establishing an exercise program for a client affected by a stroke? a. Schedule passive range of motion every other day. b. Keep activity limited, as the client may be overstimulated. c. Have the client perform active range-of-motion (ROM) exercises once a day. d. Exercise the affected extremities passively four or five times a day.

d. exercise the affected extremities passively four or five times a day explanation: The affected extremities are exercised passively and put through a full ROM four or five times a day to maintain joint mobility, regain motor control, prevent development of a contracture in the paralyzed extremity, prevent further deterioration of the neuromuscular system, and enhance circulation. Active ROM exercises should ideally be performed more than once per day.

Lifestyle risk factors for osteoporosis include: a. lack of aerobic exercise. b. a low-protein, high-fat diet. c. an estrogen deficiency or menopause. d. lack of exposure to sunshine.

d. lack of exposure to sunshine explanation: Lifestyle risk factors for osteoporosis include lack of exposure to sunshine, a diet low in calcium and vitamin D, cigarette smoking, consumption of alcohol and/or caffeine, and lack of weight-bearing exercise. Lack of weight-bearing exercise, not aerobic exercise, is a lifestyle risk factor for osteoporosis. A diet low in calcium and vitamin D, not a low-protein, high-fat diet, is a lifestyle risk factor for osteoporosis. An estrogen deficiency or menopause is an individual risk factor for osteoporosis. Other individual risk factors include female gender, non-Hispanic white or Asian race, increased age, low weight and body mass index, family history of osteoporosis, low initial bone mass, and contributing coexisting medical conditions and medications.

A client with a fractured femur is in balanced suspension traction. The client needs to be repositioned toward the head of the bed. During repositioning, what should the nurse do? a. Place slight additional tension on the traction cords. b. Release the weights and replace them immediately after positioning. c. Reposition the bed instead of repositioning the client. d. Maintain consistent traction tension while repositioning.

d. maintain consistent traction tension while repositioning explanation: Traction is used to reduce the fracture and must be maintained at all times, including during repositioning. It would be inappropriate to add tension or release the weights. Moving the bed instead of the client is not feasible.

A client with epilepsy is having a seizure. During the active seizure phase, the nurse should: a. place the client on his back, remove dangerous objects, and insert a bite block. b. place the client on his side, remove dangerous objects, and insert a bite block. c. place the client on his back, remove dangerous objects, and hold down his arms. d. place the client on his side, remove dangerous objects, and protect his head.

d. place the client on his side, remove dangerous objects, and protect his head explanation: During the active seizure phase, the nurse should initiate precautions by placing the client on his side, removing dangerous objects, and protecting his head from injury. A bite block should never be inserted during the active seizure phase. Insertion can break the teeth and lead to aspiration. Placing the client on his back and holding down the arms could cause injury to the client and the nurse.

A client is diagnosed with a right-sided stroke. The client is now experiencing hemianopsia. How might the nurse help the client manage the potential sensory and perceptional difficulties? a. Keep the lighting in the client's room low. b. Place the client's clock on the affected side. c. Approach the client on the side where vision is impaired. d. Place the client's extremities where the client can see them.

d. place the client's extremities where the client can see them explanation: The client with homonymous hemianopsia (loss of half of the visual field) turns away from the affected side of the body and tends to neglect that side and the space on that side; this is called amorphosynthesis. In such instances, the client cannot see food on half of the tray, and only half of the room is visible. It is important for the nurse to remind the client constantly of the other side of the body, to maintain alignment of the extremities, and if possible, to place the extremities where the client can see them. Clients with a decreased field of vision should be approached on the side where visual perception is intact. All visual stimuli (clock, calendar, and television) should be placed on this side. The client can be taught to turn the head in the direction of the defective visual field to compensate for this loss. Increasing the natural or artificial lighting in the room and providing eyeglasses are important in increasing vision. There is no reason to keep the lights dim.

A nurse is assessing the neurovascular status of a client who has had a leg cast recently applied. The nurse is unable to palpate the client's dorsalis pedis or posterior tibial pulse and the client's foot is pale. What is the nurse's most appropriate action? a. Warm the client's foot and determine whether circulation improves. b. Reposition the client with the affected foot dependent. c. Reassess the client's neurovascular status in 15 minutes. d. Promptly inform the primary care provider.

d. promptly inform the primary care provider explanation: Signs of neurovascular dysfunction warrant immediate medical follow-up. It would be unsafe to delay. Warming the foot or repositioning the client may be of some benefit, but the care provider should be informed first.

A nurse is providing discharge education to a client who is going home with a cast on his leg. What topic should the nurse emphasize in the teaching session? a. Using crutches efficiently b. Exercising joints above and below the cast, as prescribed c. Removing the cast correctly at the end of the treatment period d. Reporting signs of impaired circulation

d. reporting signs of impaired circulation explanation: Reporting signs of impaired circulation is critical; signs of impaired circulation must be reported to the physician immediately to prevent permanent damage. For this reason, this education is a priority over exercise and crutch use. The client does not independently remove the cast.

A client is having a tonic-clonic seizure. What should the nurse do first? a. Elevate the head of the bed. b. Restrain the client's arms and legs. c. Place a tongue blade in the client's mouth. d. Take measures to prevent injury.

d. take measures to prevent injury explanation: Protecting the client from injury is the immediate priority during a seizure. Elevating the head of the bed would have no effect on the client's condition or safety. Restraining the client's arms and legs could cause injury. Placing a tongue blade or other object in the client's mouth could damage the teeth.

A nurse is providing a class on osteoporosis at the local center for older adults. Which statement related to osteoporosis is most accurate? a. High levels of vitamin D can cause osteoporosis. b. A nonmodifiable risk factor for osteoporosis is a person's level of activity. c. Secondary osteoporosis occurs in women after menopause. d. The use of corticosteroids increases the risk of osteoporosis.

d. the use of corticosteroids increases the risk of osteoporosis explanation: Corticosteroid therapy is a secondary cause of osteoporosis when taken for long-term use. Adequate levels of vitamin D are needed for absorption of calcium. A person's level of physical activity is a modifiable factor that influences peak bone mass. Lack of activity increases the risk for the development of osteoporosis. Primary osteoporosis occurs in women after menopause.

The nurse is educating a group of students about complications of an aneurysm. Which is a complication of aneurysm? a. Seizure b. Hypernatremia c. Airway collapse d. Pneumothorax

a. seizure explanation: Due to increased intracranial pressure, there is a risk for the client developing seizures. Hyponatremia, not hypernatremia, can occur. Airway collapse and pneumothorax do not occur as a complication of an aneurysm.

When developing a care plan for a client who has recently suffered a stroke, a nurse includes the nursing diagnosis Risk for imbalanced body temperature. What is the rationale for this diagnosis? a. The stroke may have impacted the body's thermoregulation centers. b. A decreased body temperature will signal the need to cover the client. c. An elevated temperature indicates cerebellum malfunction. d. An elevated body temperature indicates infection.

a. the stroke may have impacted the body's thermoregulation centers explanation: The body's thermoregulation centers are located in the hypothalamus. A stroke may impair their functioning. A decreased body temperature isn't necessarily an indication to cover the client. Although an elevated temperature may indicate cerebellum malfunction or infection, these factors aren't the focus of the risk described in the nursing diagnosis.

The nurse plays a critical role in the initial work-up of a patient with acute stroke symptoms. An immediate decision is to determine if the stroke is ischemic or hemorrhagic. Although there is overlap in some motor, sensory, and cognitive changes, hemorrhagic strokes can be identified by some specific signs. Which of the following signs are consistent with a hemorrhagic stroke? Select all that apply. a. Vomiting b. Numbness or weakness of an extremity c. Sudden, severe headache d. Loss of balance e. Seizures

a. vomiting; c. sudden, severe headache; e. seizures explanation: These three signs are usually diagnostic of a hemorrhagic stroke. The other signs can occur with both hemorrhagic and ischemic stroke.

A rehabilitation nurse caring for a client who has had a stroke is approached by the client's family and asked why the client has to do so much for self-care while obviously struggling to do so. What would be the nurse's best answer? a. "We are trying to help the client be as useful as possible." b. "The focus on care in a rehabilitation facility is to help the client to resume as much self-care as possible." c. "We aren't here to care for the client the way the hospital staff did; we are here to help the client get better and return home." d. "Rehabilitation means helping clients do exactly what they did before their stroke."

b. "the focus on care in a rehabilitation facility is to help the client to resume as much self- care as possible." explanation: In both acute care and rehabilitation facilities, the focus is on teaching the client to resume as much self-care as possible. The goal of rehabilitation is not to be "useful," nor is it to return clients to their pre-stroke level of functioning, which may be unrealistic.

While assessing a client who has had knee replacement surgery, the nurse notes that the client has developed a hematoma at the surgical site. The affected leg has a decreased pedal pulse. What would be the priority nursing diagnosis for this client? a. Risk for Infection b. Risk for Ineffective Peripheral Tissue Perfusion c. Unilateral Neglect Related to Hematoma d. Disturbed Kinesthetic Sensory Perception

b. risk for ineffective peripheral tissue perfusion explanation: The hematoma may cause an interruption of tissue perfusion. There is also an associated risk for infection because of the hematoma, but impaired perfusion is a more acute threat. Unilateral neglect and impaired sensation are lower priorities than tissue perfusion.

A client with amyotrophic lateral sclerosis (ALS) is being visited by the home health nurse who is creating a care plan. Which of the following nursing diagnoses is most likely for a client with this condition? a. Chronic confusion b. Impaired urinary elimination c. Impaired verbal communication d. Bowel incontinence

c. impaired verbal communication explanation: Impaired communication is an appropriate nursing diagnosis; the voice in clients with ALS assumes a nasal sound and articulation becomes so disrupted that speech is unintelligible. Intellectual function is marginally impaired in clients with late ALS. Usually, the anal and bladder sphincters are intact because the spinal nerves that control muscles of the rectum and urinary bladder are not affected.

A client with a left hemispheric stroke is having difficulty with their normal speech patterns. The nurse is not sure whether the client has expressive aphasia or apraxia. Which statement would most likely be reflective of apraxia? a. The nurse gives direction to get out of bed but the client does not understand. b. The client points and gestures to an object needed on the overhead table. c. The client starts by saying "good morning" but finishes with saying "good day" to the nurse. d. The client sits up and turns to one side to see the object and states what is needed.

c. the client starts by saying "good morning" but finishes with saying "good day" to the nurse explanation: Apraxia is an inability to perform a previously learned action as may be seen when a client makes verbal substitutions for desired syllables or words. The client changed "good morning" to "good day," which is suggestive of this condition. Aphasia which can be expressive aphasia (inability to express oneself) or receptive aphasia (inability to understand language) is more likely represented with the client being unable to understand directions to get out of bed and by pointing and gesturing to an object needed rather than speaking. The client turning to one side so he/she can see the object may be more indicative of blindness to one side (homonymous hemianopsia).

A client diagnosed with transient ischemic attacks (TIAs) is scheduled for a carotid endarterectomy. The nurse explains that this procedure will be done for which purpose? a. To decrease cerebral edema b. To prevent seizure activity that is common following a TIA c. To remove atherosclerotic plaques blocking cerebral flow d. To determine the cause of the TIA

c. to remove the atherosclerotic plaques blocking cerebral blood flow explanation: The main surgical procedure for select clients with TIAs is carotid endarterectomy, the removal of an atherosclerotic plaque or thrombus from the carotid artery to prevent stroke in clients with occlusive disease of the extracranial arteries. An endarterectomy does not decrease cerebral edema, prevent seizure activity, or determine the cause of a TIA.

A client diagnosed with a cerebral aneurysm reports a severe headache to the nurse. What action is a priority for the nurse? a. Sit with the client for a few minutes. b. Administer an analgesic. c. Inform the nurse manager. d. Call the health care provider immediately.

d. call the healthcare provider immediately explanation: A headache may be an indication that the aneurysm is leaking. The nurse should notify the health care provider immediately. The health care provider will decide whether administration of an analgesic is indicated. Informing the nurse manager is not necessary. Sitting with the client is appropriate, once the health care provider has been notified of the change in the client's condition.