Review Questions (Modules 4-7)

The nurse is performing an assessment on a patient with amyotrophic lateral sclerosis (ALS). Which of the following symptoms would the nurse expect to find? (Select all that apply) a. Urinary incontinence b. Asymmetric muscle weakness c. Nasal vocal quality d. Fatigue e. Muscle weakness beginning in lower extremities

B, C, D Function of the anal and bladder sphincters usually remains intact with patients with ALS because the disease does not affect those nerves. Muscle weakness usually begins in the distal upper extremities. Fatigue, nasal vocal quality, and assymetric muscle weakness are all signs of ALS

A 64-year-old patient who has amyotrophic lateral sclerosis (ALS) is hospitalized with pneumonia. Which nursing action will be included in the plan of care? a. Assist with active range of motion (ROM). b. Observe for agitation and paranoia. c. Give muscle relaxants as needed to reduce spasms. d. Use simple words and phrases to explain procedures.

a. Assist with active range of motion (ROM). ALS causes progressive muscle weakness but assisting the patient to perform active ROM will help maintain strength as long as possible. Psychotic manifestations such as agitation and paranoia are not associated with ALS. Cognitive function is not affected by ALS, and the patient's ability to understand procedures will not be impaired. Muscle relaxants will further increase muscle weakness and depress respirations.

A nurse is caring for four clients in the neurologic intensive care unit. After receiving the hand-off report, which client should the nurse see first? a. Client with a Glasgow Coma Scale score that was 10 and is now is 8 b. Client with a Glasgow Coma Scale score that was 9 and is now is 12 c. Client with a moderate brain injury who is amnesic for the event d. Client who is requesting pain medication for a headache

a. Client with a Glasgow Coma Scale score that was 10 and is now is 8 A 2-point decrease in the Glasgow Coma Scale score is clinically significant and the nurse needs to see this client first. An improvement in the score is a good sign. Amnesia is an expected finding with brain injuries, so this client is lower priority. The client requesting pain medication should be seen after the one with the declining Glasgow Coma Scale score.

A client is recovering from an injury to the frontal lobe of the brain. The nurse realizes that which of the following will be affected by this injury? a. Higher intellectual functioning b. Visual perception c. Coordination d. Respiratory rate

a. Higher intellectual functioning The major function of the frontal lobe of the cerebral hemisphere is high-level cognitive activity. This is what will be affected in the client with an injury to the frontal lobe. Visual perception occurs in the occipital lobe. Coordination occurs from the cerebellum. Respiratory rate is controlled by the brainstem.

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

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

The nurse has received a change-of-shift report about the following patients with COPD. Which patient should the nurse assess first? a. with a respiratory rate of 38 b. with loud expiratory wheezes c. with jugular vein distention and peripheral edema d. who has a cough productive of thick, green mucus

a. with a respiratory rate of 38 a respiratory rate of 38 indicates severe respiratory distress, and the patient needs immediate assessment and intervention to prevent possible respiratory arrest. The other patients also need assessment ASAP, but they do not need to be assessed as urgently as the tachypneic patient

A patient whose work involves lifting has a history of chronic back pain. After the nurse has taught the patient about correct body mechanics, which patient statement indicates that the teaching has been effective? a.I plan to start doing exercises to strengthen the muscles of my back. b.I will try to sleep with my hips and knees extended to prevent back strain. c.I can tell my boss that I need to change to a job where I can work at a desk. d.I will keep my back straight when I need to lift anything higher than my waist.

a.I plan to start doing exercises to strengthen the muscles of my back. Exercises can help to strengthen the muscles that support the back. Flexion of the hips and knees places less strain on the back. Modifications in the way the patient lifts boxes are needed but sitting for prolonged periods can aggravate back pain. The patient should not lift above the level of the elbows.

After the nurse has received change-of-shift report, which patient should the nurse assess first? a. A patient with pneumonia who has crackles in the right lung base b. A patient with possible lung cancer who has just returned after bronchoscopy c. A patient with hemoptysis and a 16-mm induration with tuberculin skin testing d. A patient with chronic obstructive pulmonary disease (COPD) and pulmonary function testing (PFT) that indicates low forced vital capacity

b. A patient with possible lung cancer who has just returned after bronchoscopy Because the cough and gag are decreased after bronchoscopy, this patient should be assessed for airway patency. The other patients do not have clinical manifestations or procedures that require immediate assessment by the nurse.

A client is being treated in the clinic for an exacerbation of multiple sclerosis. The nurse would anticipate administering which drug? a. Diazepam (Valium) b. Interferon b1b (Betaseron) c. Lioresal (Baclofen) d. Methylprednisolone (Solu-Cortef)

b. Interferon b1b (Betaseron) Drugs used to treat exacerbations in ambulatory clients include Interferon b1b, Interferon b1a (Avonex), and glatiramer acetate (Copaxone). Diazepam and lioresal could be used to treat spasticity, while steroids are used for acute relapses.

Which finding will the nurse expect when assessing a 60-year-old patient who has osteoarthritis (OA) of the left knee? a. Heberden's nodules b. Pain upon joint movement c. Redness and swelling of the knee joint d. Stiffness that increases with movement

b. Pain upon joint movement Initial symptoms of OA include pain with joint movement. Heberden's nodules occur on the fingers. Redness of the joint is more strongly associated with rheumatoid arthritis (RA), and stiffness in OA is worse right after the patient rests and decreases with joint movement.

Which exercise does the nurse recommend to a client at risk for osteoporosis? a. High-impact aerobics 45 minutes once weekly b. Walking 30 minutes three times weekly c. Jogging 30 minutes four times weekly d. Bowling for 1 hour twice weekly

b. Walking 30 minutes three times weekly Weight-bearing, non-jarring exercises have been proved to reduce or slow bone loss without causing vertebral compression. High-impact aerobics, jogging, and bowling are activities that could cause fracture in a client with osteoporosis. Walking would be the best choice as an exercise.

After the nurse has finished educating a patient with osteoarthritis (OA) of the left hip and knee about how to manage OA, which patient statement indicates a need for further teaching? a.I can take glucosamine to help decrease my knee pain. b.I will take 1 g of acetaminophen (Tylenol) every 4 hours. c.I will take a shower in the morning to help relieve stiffness. d.I can use a cane to decrease the pressure and pain in my hip.

b.I will take 1 g of acetaminophen (Tylenol) every 4 hours. No more than 4 g of acetaminophen should be taken daily to avoid liver damage. The other patient statements are correct and indicate good understanding of OA management.

Which assessment is most important for the nurse to make regarding a patient with myasthenia gravis? a. Pupil size b. Grip strength c. Respiratory effort d. Level of consciousness

c. Respiratory effort Because respiratory insufficiency may be life threatening, it will be most important to monitor respiratory function. The other data also will be assessed but are not as critical.

A patient is being evaluated for Alzheimer's disease (AD). The nurse explains to the patient's adult children that a. the most important risk factor for AD is a family history of the disorder. b. new drugs have been shown to reverse AD dramatically in some patients. c. a diagnosis of AD is made only after other causes of dementia are ruled out. d. the presence of brain atrophy detected by magnetic resonance imaging (MRI) will confirm the diagnosis of AD.

c. a diagnosis of AD is made only after other causes of dementia are ruled out. The diagnosis of AD is usually one of exclusion. Age is the most important risk factor for development of AD. Drugs may slow the deterioration but do not reverse the effects of AD. Brain atrophy is a common finding in AD, but it can occur in other diseases as well and does not confirm a diagnosis of AD.

a patient with COPD has rhonchi throughout the lung fields and a chronic, nonproductive cough. Which nursing action will be most effective? a. Change the oxygen flow rate to the highest prescribed ate b. reinforce the ongoing use of pursed lip breathing techniques c. educate the patient to use the Flutter airway clearance device d. teach the patient about consistent use of inhaled corticosteroids

c. educate the patient to use the Flutter airway clearance device airway clearance devices assist with moving mucus into larger airways where it can more easily be expectorated. The other actions may be appropriate for some patients with COPD, but they are not indicated for this patient's problem of thick mucus secretion

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

c. keep the head elevated slightly and flex the knees when resting in bed. Resting with the head elevated and knees flexed will reduce the strain on the back and decrease muscle spasms. Twisting from side to side will increase tension on the lumbar area. A pillow placed under the upper back will cause strain on the lumbar spine. Alternate application of cold and heat should be used to decrease pain.

A 27-year-old patient is hospitalized with new onset of Guillain-Barre syndrome. The most essential assessment for the nurse to carry out is a. determining level of consciousness. b. checking strength of the extremities. c. observing respiratory rate and effort. d. monitoring the cardiac rate and rhythm.

c. observing respiratory rate and effort. The most serious complication of Guillain-Barre syndrome is respiratory failure, and the nurse should monitor respiratory function continuously. The other assessments will also be included in nursing care, but they are not as important as respiratory assessment.

The nurse reminds a group of students about the major component of pathophysiology in multiple sclerosis (MS), which is a. damage occurs primarily to the dendrites and oligodendrocytes. b. once damaged, myelin cannot regenerate at all. c. plaques occur anywhere in the white matter of the central nervous system (CNS). d. Schwann cells are destroyed slowly but relentlessly.

c. plaques occur anywhere in the white matter of the central nervous system (CNS). Although plaques may occur anywhere in the white matter of the CNS, the areas most commonly involved are the optic nerves, cerebrum, and cervical spinal cord

A client is being worked up for a possible brain tumor. An important intervention the nurse would include in the nursing care plan specific to this client is a. documenting manifestations. b. preparing the client for tests. c. seizure precautions. d. supporting the client and family.

c. seizure precautions. Options a, b, and d are always important interventions for the client who is being worked up for a medical condition. But the specific care this client needs is seizure precautions, because seizures are a common manifestation in clients with brain tumors.

which topic will the nurse include in medication teaching for a patient with diagnosed persistent asthma? a. use of long-acting b-adrenergic medications b. side effects of sustained release theophylline c. self-administration of inhaled corticosteroids d. complications associated with oxygen therapy

c. self-administration of inhaled corticosteroids inhaled corticosteroids are more effective in improving asthma than any other drug and are indicated for all patients with persistent asthma. The other therapies would not typically be first-line treatments for newly diagnosed asthma

Prednisone (Deltasone) is prescribed for a patient with an acute exacerbation of rheumatoid arthritis. Which laboratory result will the nurse monitor to determine whether the medication has been effective? a.Blood glucose test b.Liver function tests c.C-reactive protein level d.Serum electrolyte levels

c.C-reactive protein level C-reactive protein is a marker for inflammation, and a decrease would indicate that the corticosteroid therapy was effective. Blood glucose and serum electrolyte levels also will be monitored to check for side effects of prednisone. Liver function is not routinely monitored for patients receiving steroids.

A patient with a herniated intravertebral disk undergoes a laminectomy and discectomy. Following the surgery, the nurse should position the patient on the side by a.Instructing the patient to move the legs before turning the rest of the body. b.Having the patient turn by grasping the side rails and pulling the shoulders over. c.Placing a pillow between the patient's legs and turning the entire body as a unit. d.Turning the patients head and shoulders first, followed by the hips, legs, and feet.

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

When planning care for a client affected by fibromyalgia, the nurse addresses the potential problem of activity intolerance. What will the nurse recommend to the client in order to most effectively address this problem? a. Daily meditation and guided imagery b. NSAID medications taken on a regular schedule c. Referral to physical therapy for an assistive device d. A program of regular, mild to moderate exercise

d. A program of regular, mild to moderate exercise Regular, mild to moderate exercise improves conditioning and activity tolerance. Meditation and guided imagery can reduce anxiety. NSAIDs address the problem of pain. Assistive devices do not increase conditioning or activity tolerance in the absence of injury or neurologic deficits.

The nurse has educated a client on Paget's disease. Which statement by the client indicates good understanding of causative factors? a. It is caused by lack of calcium in my diet. b. I probably had a fracture that caused it. c. This disease occurs because of lack of exercise. d. I may have a genetic predisposition.

d. I may have a genetic predisposition. Paget's disease has been noted in up to 30% of people with a positive family history. The other responses are not accurate as a cause of Paget's disease

After change-of-shift report on the Alzheimer's disease/dementia unit, which patient will the nurse assess first? a. Patient who has not had a bowel movement for 5 days b. Patient who has a stage II pressure ulcer on the coccyx c. Patient who is refusing to take the prescribed medications d. Patient who developed a new cough after eating breakfast

d. Patient who developed a new cough after eating breakfast A new cough after a meal in a patient with dementia suggests possible aspiration and the patient should be assessed immediately. The other patients also require assessment and intervention, but not as urgently as a patient with possible aspiration or pneumonia.

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

d. Start progressive knee exercises to obtain 90-degree flexion. After knee arthroplasty, active or passive flexion exercises are used to obtain a 90-degree flexion of the knee. The goal for extension of the knee will be 180 degrees. A compression bandage is used to hold the knee in an extended position after surgery. Full weight bearing is expected before discharge.

A patient with chronic obstructive pulmonary disease (COPD) has a nursing diagnosis of impaired breathing pattern related to anxiety. Which nursing action is most appropriate to include in the plan of care? a. Titrate oxygen to keep saturation at least 90% b. Discuss a high-protein, high-calorie diet with the patient c. Suggest the use of OTC sedative meds d. Teach the patient how to effectively use pursed-lip breathing

d. Teach the patient how to effectively use pursed-lip breathing Pursed lip breathing techniques assist in prolonging the expiratory phase of respiration and decrease air trapping. There is no indication that the patient requires oxygen therapy or an improved diet. Sedative medications should be avoided because they decrease respiratory drive.

Which information about a 60-year-old patient with MS indicates that the nurse should consult with the health care provider before giving the prescribed dose of dalfampridine (Ampyra)? a. The patient has relapsing-remitting MS. b. The patient walks a mile a day for exercise. c. The patient complains of pain with neck flexion. d. The patient has an increased serum creatinine level.

d. The patient has an increased serum creatinine level. Dalfampridine should not be given to patients with impaired renal function. The other information will not impact whether the dalfampridine should be administered

A 62-year-old patient who has Parkinson's disease is taking bromocriptine (Parlodel). Which information obtained by the nurse may indicate a need for a decrease in the dose? a. The patient has a chronic dry cough. b. The patient has four loose stools in a day. c. The patient develops a deep vein thrombosis. d. The patient's blood pressure is 92/52 mm Hg.

d. The patient's blood pressure is 92/52 mm Hg. Hypotension is an adverse effect of bromocriptine, and the nurse should check with the health care provider before giving the medication. Diarrhea, cough, and deep vein thrombosis are not associated with bromocriptine use.

When preparing a patient with possible asthma for pulmonary function testing, the nurse will teach the patient to a. Avoid eating or drinking for several hours before the testing b. Use rescue meds immediately before the tests are done c. Take oral corticosteroids at least 2 hours before the examination d. Withhold bronchodilators for 6-12 hours before the examination

d. Withhold bronchodilators for 6-12 hours before the examination Bronchodilators are held before pulmonary function testing so that a baseline assessment of airway function can be determined. Testing is repeated after bronchodilator use to determine whether the decrease in lung function is reversible. There is no need for the patient to be NPO. Oral corticosteroids also should be held before the examination and corticosteroids given 2 hours before the examination would be at a high level. Rescue medications (which are bronchodilators) would not be given until after the baseline pulmonary function was assessed.

a patient with COPD has a nursing diagnosis of imbalanced nutrition: less than body requirements. An appropriate intervention for the problem is to a. increase the patient's intake of fruits and fruit juices b. have the patient exercise for 10min before meals c. assist the patient in choosing foods with a lot of texture d. offer high calorie snacks between meals and at bedtime

d. offer high calorie snacks between meals and at bedtime eating small amounts more frequently (as occurs with snacking) will increase caloric intake by decreasing the fatigue and feelings of fullness associated with large meals. Patients with COPD should rest before meals. Foods that have a lot of texture may take more energy to eat and lead to decreased intake. Although fruits and juices are not contraindicated, foods high in protein are a better choice

The nurse counseling a client with osteoporosis identifies one of the medications that may have contributed to the condition as a. aspirin. b. colchicine. c. ibuprofen. d. prednisone.

d. prednisone. Osteoporosis can also result from underlying medical conditions, such as hyperparathyroidism, thyrotoxicosis, anorexia nervosa, and Cushing's syndrome, and from long-term use of medications such as thyroid hormone, anticonvulsants, furosemide, and corticosteroids (e.g., prednisone).

The nursing care of a client with muscular dystrophy is focused on symptomatic treatment and supportive care, with a major emphasis on problems pertinent to a. ambulation. b. elimination. c. nutrition. d. respiration.

d. respiration. Treatment of muscular dystrophy is largely symptomatic. Care focuses on increasing the clients comfort and functional ability. Breathing exercises may be initiated for respiratory decompensation. Death usually occurs from respiratory or cardiac failure.

When assessing a 64-year-old woman, the nurse notes that the patient has lost 1 inch in height since the previous visit 2 years ago. The nurse will plan to teach the patient about a.discography studies. b.myelography testing. c.magnetic resonance imaging (MRI). d.dual-energy x-ray absorptiometry (DEXA).

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

A patient is scheduled for a computed tomography (CT) of the chest with contrast media. Which assessment findings should the nurse immediately report to the health care provider (select all that apply)? a. Patient is claustrophobic. b. Patient is allergic to shellfish. c. Patient recently used a bronchodilator inhaler. d. Patient is not able to remove a wedding band. e. Blood urea nitrogen (BUN) and serum creatinine levels are elevated.

B & E

When caring for a patient who has osteoarthritis, the nurse will anticipate the need to teach the patient about which of these medications? a.Adalimumab (Humira) b.Prednisone (Deltasone) c.Capsaicin cream (Zostrix) d.Sulfasalazine (Azulfidine)

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

A client presents complaining of abnormal muscle weakness and fatigability. The physician suspects myasthenia gravis. Which drug can be used to test for this disease? a. Pyridostigmine (Mestinon) b. Neostigmine (Prostigmin) c. Ambenonium (Mytelase) d. Edrophonium (Tensilon)

d. Edrophonium (Tensilon) Tensilon, a short-acting anticholinesterase agent, is the drug of choice for diagnosing myasthenia gravis. The client's response is a rapid improvement of manifestations within 15 to 30 seconds that last 5 minutes. The other medications are used to treat clients diagnosed with myasthenia gravis.

Which nursing diagnosis is of highest priority for a patient with Parkinson's disease who is unable to move the facial muscles? a. Activity intolerance b. Self-care deficit: toileting c. Ineffective self-health management d. Imbalanced nutrition: less than body requirements

d. Imbalanced nutrition: less than body requirements The data about the patient indicate that poor nutrition will be a concern because of decreased swallowing. The other diagnoses may also be appropriate for a patient with Parkinson's disease, but the data do not indicate that they are current problems for this patient.

A client has been diagnosed with Parkinson's disease. Which of the following will the nurse most likely assess in this client? (Select all that apply.) a. Tremor b. Muscle rigidity c. Akinesia d. Mask-like face e. Dysphagia f. Reduced appetite

A, B, C, D, E Signs and symptoms of Parkinson's disease include tremor, muscle rigidity, akinesia, masklike face, and dysphagia. Reduced appetite is not a sign or symptom of Parkinson's disease.

An older client is hospitalized with Guillain-Barre syndrome. A family member tells the nurse the client is restless and seems confused. What action by the nurse is best? a. Assess the client's oxygen saturation. b. Check the medication list for interactions. c. Place the client on a bed alarm. d. Put the client on safety precautions.

a. Assess the client's oxygen saturation. In the older adult, an early sign of hypoxia is often confusion and restlessness. The nurse should first assess the clients oxygen saturation. The other actions are appropriate, but only after this assessment occurs.

a patient who is experiencing an acute asthma attack is admitted to the ED. the nurse's first action should be to: a. listen to the patient's breath sounds b. ask about inhaled corticosteriod use c. determine when the dyspnea started d. obtain the FEV flow rate

a. listen to the patient's breath sounds Assessment of the patient's breath sounds will help determine how effectively the patient is ventilating and whether rapid intubation may be necessary. The length of time the attack has persisted is not as important as determining the patient's status at present. Most patients having an acute attack will not be able to cooperate with an FEV measurement. It is important to know about the medications the patient is using but not as important as assessing the breath sounds

An assessment finding that alerts the nurse to the presence of osteoporosis in a middle-aged patient is a. measurable loss of height. b. the presence of bowed legs. c. an aversion to dairy products. d. statements about frequent falls.

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

A client diagnosed with ALS is dealing with muscle spasticity. Which of the following medications is most likely to be prescribed? a. Hydralazine b. Baclofen (Lioresal) c. Lidocaine (Xylocaine) d. Methylprednisolone (SoluMedrol)

b. Baclofen (Lioresal) Baclofen is a skeletal muscle relaxant and is the first drug of choice for muscle spasms in ALS, MS and MG.

When a 74-year-old patient is seen in the health clinic with new development of a stooped posture, shuffling gait, and pill rolling type tremor, the nurse will anticipate teaching the patient about a. oral corticosteroids. b. antiparkinsonian drugs. c. magnetic resonance imaging (MRI). d. electroencephalogram (EEG) testing.

b. antiparkinsonian drugs. The diagnosis of Parkinson's is made when two of the three characteristic manifestations of tremor, rigidity, and bradykinesia are present. The confirmation of the diagnosis is made on the basis of improvement when antiparkinsonian drugs are administered. This patient has symptoms of tremor and bradykinesia. The next anticipated step will be treatment with medications. MRI and EEG are not useful in diagnosing Parkinson's disease, and corticosteroid therapy is not used to treat it.

The nurse caring for a client who has undergone total hip replacement (THR) assesses for manifestations of the most common and serious complication after hip surgery, which is a. contractures. b. deep vein thrombosis. c. infection. d. prosthesis dislocation.

b. deep vein thrombosis. Venous thromboembolism, the most common and most serious complication after THR, can be manifested as a deep vein thrombosis. Infection is another complication but is not seen as often

Which information will the nurse include when teaching the patient with asthma about the prescribed medications? a. utilize the inhaled corticosteroid when SOB occurs b. inhale slowly and deeply when using the dry-powder inhaler (DPI) c. Hold your breath for 5s after using the bronchodilator inhaler d. tremors are an expected side effect of rapidly acting bronchodilators

d. tremors are an expected side effect of rapidly acting bronchodilators tremors are a common side effect of short-acting b2-adrenergic (SABA) medications and not a reason to avoid using the SABA inhaler. Inhaled corticosteroids do not act rapidly to reduce dyspnea. Rapid inhalation is needed when using a DPI. The patient should hold the breath for 10s after using inhalers

Which menu choice by a patient with osteoporosis indicates that the nurses teaching about appropriate diet has been effective? a.Pancakes with syrup and bacon b.Whole wheat toast and fruit jelly c.Two-egg omelet and a half grapefruit d.Oatmeal with skim milk and fruit yogurt

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

A client diagnosed with asthma is receiving instructions about the use of albuterol. The client should be aware that albuterol may cause: a. bradycardia. b. drowsiness. c. nasal congestion. d. nervousness.

d. nervousness. Albuterol causes nervousness, tachycardia, insomnia, dizziness, tremors, hypertension, headache, and irritation to the nasal and throat passages. Albuterol does not cause bradycardia, drowsiness, or nasal congestion.

Which of the following would the patient most likely report as triggers for asthma attack? Select all that apply. a. Exercise b. Warm air c. Cold air d. Inhaled corticosteroids e. Pollen

A,C,E These triggers are often also allergens. Inhaled corticosteroids are often used to treat asthma, so they would most likely not trigger an asthma attack. Warm, but not overly humid air is less likely to induce an asthma attack than cold air. Pollen and exercise might lead to an exacerbation.

Which of the following nursing interventions would be appropriate for a client diagnosed with Alzheimer's disease? (Select all that apply.) a. Make changes to the room often to stimulate memory function. b. Assign simple tasks to be completed by the client. c. Assist the client with any needs associated with activities of daily living (ADLs). d. Have personal/familiar items around the client. e. Do complex games and puzzles to improve memory.

B, C, D Alzheimer's disease progressively alters the client's ability to function in the normal ways of living. Personal and familiar items help to keep the client oriented, and simple tasks keep the client functioning at the highest levels as long as possible.

After change-of-shift report, which patient should the nurse assess first? a. Patient with myasthenia gravis who is reporting increased muscle weakness b. Patient with a bilateral headache described as like a band around my head c. Patient with seizures who is scheduled to receive a dose of phenytoin (Dilantin) d. Patient with Parkinson's disease who has developed cogwheel rigidity of the arms

a. Patient with myasthenia gravis who is reporting increased muscle weakness Because increased muscle weakness may indicate the onset of a myasthenic crisis, the nurse should assess this patient first. The other patients should also be assessed, but do not appear to need immediate nursing assessments or actions to prevent life-threatening complications.

The nurse cautions clients with ALS and their families to be aware that (Select all that apply) a. activities should be spaced throughout the day. b. clients experience incontinence, an early cause of falling. c. cognition will usually decline late in the disease. d. muscle weakness may cause a risk for injury.

A, D Safety is a prime concern with ALS (and with any degenerative neurologic disorder). Muscle weakness is progressive, leading to increased risk of falls. Some interventions to prevent this include spacing activities throughout the day, conserving energy, avoiding extremes of hot and cold, and using assistive devices such as canes or wheelchairs. Clients with ALS usually do not experience incontinence and cognition remains intact for the duration of the disorder.

Which nursing actions could the nurse delegate to a licensed practical/vocational nurse (LPN/LVN) who is part of the team caring for a patient with Alzheimer's disease (select all that apply)? a. Develop a plan to minimize difficult behavior. b. Administer the prescribed memantine (Namenda). c. Remove potential safety hazards from the patient's environment. d. Refer the patient and caregivers to appropriate community resources. e. Help the patient and caregivers choose memory enhancement methods. f. Evaluate the effectiveness of the prescribed enteral feedings on patient nutrition.

B, C LPN/LVN education and scope of practice includes medication administration and monitoring for environmental safety in stable patients. Planning of interventions such as ways to manage behavior or improve memory, referrals, and evaluation of the effectiveness of interventions require registered nurse (RN)level education and scope of practice.

A nurse assesses a client with early-onset multiple sclerosis (MS). Which clinical manifestation should the nurse expect to find? a. Hyperresponsive reflexes b. Excessive somnolence c. Nystagmus d. Heat intolerance

c. Nystagmus Early signs and symptoms of MS include changes in motor skills, vision, and sensation. Hyperresponsive reflexes, excessive somnolence, and heat intolerance are later manifestations of MS.

The nurse instructs a client who has myasthenia gravis to take prescribed medications on time and to eat meals 45 to 60 minutes after taking anticholinesterase drugs. The client asks why the timing of meals is so important. Which is the nurse's best response? a. "This timing allows the drug to have maximum effect, so it is easier for you to chew, swallow, and not choke." b. "This timing prevents your blood sugar level from dropping too low and causing you to be at risk for falling." c. "These drugs are very irritating to your stomach and could cause ulcers if taken too long before meals." d. "These drugs cause nausea and vomiting. By waiting a while after you take the medication, you are less likely to vomit."

a. "This timing allows the drug to have maximum effect, so it is easier for you to chew, swallow, and not choke." Skeletal muscle weakness extends to the ability to chew and swallow. Clients who have myasthenia gravis are at risk for aspiration during meals. Timing the medication so that most of the meal is eaten when the drugs have produced their peak effect enables the client to chew and swallow more easily. The medication has no effect on blood glucose levels, ulcers, or nausea.

The nurse in the emergency department receives arterial blood gas results for four recently admitted patients with obstructive pulmonary disease. Which patient will require the most rapid action by the nurse? a. 22-year-old with ABG results: pH 7.28, PaCO2 60 mm Hg, and PaO2 58 mm Hg b. 34-year-old with ABG results: pH 7.48, PaCO2 30 mm Hg, and PaO2 65 mm Hg c. 45-year-old with ABG results: pH 7.34, PaCO2 33 mm Hg, and PaO2 80 mm Hg d. 65-year-old with ABG results: pH 7.31, PaCO2 58 mm Hg, and PaO2 64 mm Hg

a. 22-year-old with ABG results: pH 7.28, PaCO2 60 mm Hg, and PaO2 58 mm Hg The pH, PaCO2, and PaO2 indicate that the patient has severe uncompensated respiratory acidosis and hypoxemia. Rapid action will be required to prevent increasing hypoxemia and correct the acidosis. The other patients also should be assessed as quickly as possible but do not require interventions as quickly as the 22-yearold.

A patient with chronic hypoxemia (SaO2 levels of 89% to 90%) caused by chronic obstructive pulmonary disease (COPD) has been hospitalized with increasing shortness of breath. In planning for discharge, which of these actions by the nurse will be most effective in improving compliance with discharge teaching? a. Arrange for the patient's spouse to be present during the teaching b. Start giving the patient discharge teaching on the day of admission c. Accomplish the patient teaching just before the scheduled discharge d. Have the patient repeat the instructions immediately after the teaching

a. Arrange for the patient's spouse to be present during the teaching Hypoxemia interferes with the patient's ability to learn and retain information, so having the patients spouse present will increase the likelihood that discharge instructions will be followed. Having the patient repeat the instructions will indicate that the information is understood at the time, but it does not guarantee retention of the information. Because the patient is likely to be distracted just before discharge, giving discharge instructions just before discharge is not ideal. The patient is likely to be anxious and even more hypoxemic than usual on the day of admission, so teaching about discharge should be postponed.

The nurse recognizes which pathophysiologic feature as a hallmark of Guillain-Barré syndrome? a. Nerve impulses are not transmitted to skeletal muscle. b. The immune system destroys the myelin sheath. c. The distal nerves degenerate and retract. d. Antibodies to acetylcholine receptor sites develop.

b. The immune system destroys the myelin sheath. In Guillain-Barré syndrome, the immune system destroys the myelin sheath, causing segmental demyelination. Nerve impulses are transmitted more slowly but remain in place. Antibodies are not developed. The nerves do not degenerate and retract

Which of the following is used to diagnose ALS? a. CT scan b. PET scan c. Physical Exam d. hCGprotein

c. Physical Exam The diagnosis of ALS is found based on clinical symptoms. An MRI and EMG may show some signs of the disease, they are not used to diagnose.

A patient who has numbness and weakness of both feet is hospitalized with Guillain-Barre syndrome. The nurse will anticipate the need to teach the patient about a. intubation and mechanical ventilation. b. administration of IV corticosteroid drugs. c. insertion of a nasogastric (NG) feeding tube. d. IV infusion of immunoglobulin (Sandoglobulin).

d. IV infusion of immunoglobulin (Sandoglobulin). Because the Guillain-Barre syndrome is in the earliest stages (as evidenced by the symptoms), use of high-dose immunoglobulin is appropriate to reduce the extent and length of symptoms. Mechanical ventilation and tube feedings may be used later in the progression of the syndrome but are not needed now. Corticosteroid use is not helpful in reducing the duration or symptoms of the syndrome.

The nurse develops a teaching plan to help increase activity tolerance at home for an older adult with severe chronic obstructive pulmonary disease (COPD). Which instructions would be most appropriate for the nurse to include in the plan of care? a. Stop exercising when short of breath b. Walk until pulse rate exceeds 130 bpm c. Limit exercise to activities of daily living (ADLs) d. Walk 15-20 minutes daily at least 3x/week

d. Walk 15-20 minutes daily at least 3x/week Encourage the patient to walk 15 to 20 minutes a day at least three times a week with gradual increases. Shortness of breath is normal with exercise and not an indication that the patient should stop. Limiting exercise to ADLs will not improve the patients exercise tolerance. A 70-year-old patient should have a pulse rate of 120 or less with exercise (80% of the maximal heart rate of 150).

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

d. calcium loss from bones can be slowed by increasing calcium intake and weight-bearing exercise Progression of osteoporosis can be slowed by increasing calcium intake and weight-bearing exercise. Estrogen replacement therapy does help prevent osteoporosis, but it is not the only treatment and is not appropriate for some patients. Corticosteroid therapy increases the risk for osteoporosis.

In reviewing a 55-year-old patients medical record, the nurse notes that the last eye examination revealed an intraocular pressure of 28 mm Hg. The nurse will plan to assess a. visual acuity. b. pupil reaction. c. color perception. d. peripheral vision.

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

Which assessment information will the nurse obtain to evaluate the effectiveness of the prescribed calcitonin (Cibacalcin) and ibandronate (Boniva) for a patient with Paget's disease? a. Pain level b. Oral intake c. Daily weight d. Grip strength

a. Pain level Bone pain is one of the common early manifestations of Paget's disease, and the nurse should assess the pain level to determine whether the treatment is effective. The other information will also be collected by the nurse but will not be used in evaluating the effectiveness of the therapy.

When the nurse is assessing a patient with myasthenia gravis, which action will be most important to take? a. Check pupillary size. b. Monitor grip strength. c. Observe respiratory effort. d. Assess level of consciousness.

c. Observe respiratory effort. Because respiratory insufficiency may be life threatening, it will be most important to monitor respiratory function. The other data also will be assessed but are not as critical.

A patient who has rheumatoid arthritis is seen in the outpatient clinic and the nurse notes that rheumatoid nodules are present on the patients elbows. Which action will the nurse take? a. Draw blood for rheumatoid factor analysis. b. Teach the patient about injection of the nodule. c. Assess the nodules for skin breakdown or infection. d. Discuss the need for surgical removal of the nodule.

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

which action should the nurse anticipate taking first when a patient who is experiencing an asthma attack develops bradycardia and a decrease in wheezing? a. assist with endotracheal intubation b. document changes in respiratory status c. encourage the patient to cough and deep breathe d. administer IV methylprednisolone (SoluMedrol)

a. assist with endotracheal intubation the patient's assessment indicates impending respiratory failure, and the nurse should prepare to assist with intubation and mechanical ventilation. IV corticosteroids require several hours before having an effect on respiratory status. The patient will not be able to ocugh or deep breathe effectively. Documentation is not a priority at this time.

Nursing activities for a client with ALS and family include helping them a. decide on an acceptable level of care early in the course of the disease. b. determine if they want to share the diagnosis to allow genetic testing. c. incorporate nonpharmacologic pain control techniques in the plan of care. d. plan for extensive rehabilitation after exacerbations.

a. decide on an acceptable level of care early in the course of the disease. Disease management in ALS includes topics such as tube feedings and mechanical ventilation. Planning for an acceptable level of care should begin early in the disease, before a crisis occurs. Of course, decisions should be re-evaluated occasionally as the clients wishes may changes with their experiences with the disease. ALS is not a genetically-acquired disorder. Pain control is usually not an issue in the disease, and as the disease is relentlessly progressive (rather than characterized by remissions and exacerbations), extensive rehabilitation is not utilized.

A patient with chronic broncitis who has a new prescription for Advair Diskus (combined fluticasone and salmeterol) asks the nurse the purpose of using two drugs. The nurse explains that: a. one drug decreases inflammation, and the other acts as a bonchodilator b. Advair is a combination of long-acting and slow-acting bronchodilators c. The combination of two drugs works more quickly in an acute asthma attack d. the two drugs work together to block the effects of histamine on the bronchioles

a. one drug decreases inflammation, and the other acts as a bonchodilator Salmeterol is a long-acting bronchodilator, and fluticasone is a corticosteroid. They work together to prevent asthma attacks. Neither medication is an antihistamine. Advair is not use during an acute attack because the medication does not work rapidly

The nurse is assessing a client diagnosed with asthma. The client's breath sounds initially had wheezing but are diminishing until no audible sounds are heard. This has occurred because: a. swelling has increased, and it has blocked airways. b. the attack has passed. c. the client used an inhaler. d. no mucus is present.

a. swelling has increased, and it has blocked airways. This client needs to be evaluated immediately and receive prompt treatment to reduce the airway obstruction and reverse inflammation. Lack of audible breath sounds does not mean that the attack has passed, the client has used an inhaler, or there is no mucus present.

Which topic will the nurse include in patient teaching after a patient has had outpatient cataract surgery and lens implantation? a. Use of oral opioids for pain control b. Administration of antibiotic eyedrops c. Importance of coughing and deep breathing exercises d. Need for bed rest for the first 24 hours after the surgery

b. Administration of antibiotic eyedrops Antibiotic and corticosteroid eyedrops are commonly prescribed after cataract surgery, and the patient should be able to administer them using safe technique. Pain is not expected after cataract surgery and opioids will not be needed. Coughing and deep breathing exercises are not needed since a general anesthetic agent is not used. There is no bed rest restriction after cataract surgery.

When the nurse is evaluating the effectiveness of therapy for a patient who has received treatment during an asthma attack, which finding is the best indicator that the therapy has been effective? a. No wheezes are audible b. SpO2 is >90% c. Accessory muscle use has decreased d. Respiratory rate is 16 bpm

b. SpO2 is >90% The goal for treatment of an asthma attack is to keep the oxygen saturation >90%. The other patient data may occur when the patient is too fatigued to continue with the increased work of breathing required in an asthma attack

An 82-year-old patient who is being admitted to the hospital repeatedly asks the nurse to speak up so that I can hear you. Which action should the nurse take? a. Overenunciate while speaking. b. Speak normally but more slowly. c. Increase the volume when speaking. d. Use more facial expressions when talking.

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

A 73-year-old patient with Parkinson's disease has a nursing diagnosis of impaired physical mobility related to bradykinesia. Which action will the nurse include in the plan of care? a. Instruct the patient in activities that can be done while lying or sitting. b. Suggest that the patient rock from side to side to initiate leg movement. c. Have the patient take small steps in a straight line directly in front of the feet. d. Teach the patient to keep the feet in contact with the floor and slide them forward

b. Suggest that the patient rock from side to side to initiate leg movement. Rocking the body from side to side stimulates balance and improves mobility. The patient will be encouraged to continue exercising because this will maintain functional abilities. Maintaining a wide base of support will help with balance. The patient should lift the feet and avoid a shuffling gait.

The nurse is trying to communicate with a hearing-impaired client. The best way to do this is to: a. write down all of the message. b. shout in the impaired ear. c. speak slowly and clearly while facing the client. d. talk in a regular voice in the good ear.

c. speak slowly and clearly while facing the client. When trying to communicate with the hearing-impaired client, the nurse should speak slowly and clearly while facing the client to give her the opportunity to see and hear the words being spoken. The nurse should not write down all of the messages. Shouting in the impaired ear will not improve the clients hearing. Talking in a regular voice into the good ear will not improve hearing.

A nurse assesses a client with a neurologic disorder. Which assessment finding should the nurse identify as a late manifestation of amyotrophic lateral sclerosis (ALS)? a. Dysarthria b. Dysphagia c. Muscle weakness d. Impairment of respiratory muscles

d. Impairment of respiratory muscles In ALS, progressive muscle atrophy occurs until a flaccid quadriplegia develops. Eventually, the respiratory muscles are involved, which leads to respiratory compromise. Dysarthria, dysphagia, and muscle weakness are early clinical manifestations of ALS.

To determine whether a new patient's confusion is caused by dementia or delirium, which action should the nurse take? a. Assess the patient using the Mini-Mental Status Exam. b. Obtain a list of the medications that the patient usually takes. c. Determine whether there is positive family history of dementia. d. Use the Confusion Assessment Method tool to assess the patient.

d. Use the Confusion Assessment Method tool to assess the patient. The Confusion Assessment Method tool has been extensively tested in assessing delirium. The other actions will be helpful in determining cognitive function or risk factors for dementia or delirium, but they will not be useful in differentiating between dementia and delirium.

The day shift nurse at the long-term care facility learns that a patient with dementia experienced sundowning late in the afternoon on the previous two days. Which action should the nurse take? a. Keep blinds open during the daytime hours. b. Provide hourly orientation to time and place. c. Have the patient take a brief mid-morning nap. d. Move the patient to a quieter room late in the afternoon.

a. Keep blinds open during the daytime hours. A likely cause of sundowning is a disruption in circadian rhythms and keeping the patient active and in daylight will help reestablish a more normal circadian pattern. Moving the patient to a different room might increase confusion. Taking a nap will interfere with nighttime sleep. Hourly orientation will not be helpful in a patient with dementia.

A 31-year-old woman who has multiple sclerosis (MS) asks the nurse about risks associated with pregnancy. Which response by the nurse is accurate? a. MS symptoms may be worse after the pregnancy. b. Women with MS frequently have premature labor. c. MS is associated with an increased risk for congenital defects. d. Symptoms of MS are likely to become worse during pregnancy.

a. MS symptoms may be worse after the pregnancy. During the postpartum period, women with MS are at greater risk for exacerbation of symptoms. There is no increased risk for congenital defects in infants born of mothers with MS. Symptoms of MS may improve during pregnancy. Onset of labor is not affected by MS.

Which nursing action for a patient with chronic obstructive pulmonary disease (COPD) could the nurse delegate to experienced unlicensed assistive personnel (UAP)? a. Obtain oxygen saturation using pulse oximetry. b. Monitor for increased oxygen need with exercise. c. Teach the patient about safe use of oxygen at home. d. Adjust oxygen to keep saturation in prescribed parameters.

a. Obtain oxygen saturation using pulse oximetry. UAP can obtain oxygen saturation (after being trained and evaluated in the skill). The other actions require more education and a scope of practice that licensed practical/vocational nurses (LPN/LVNs) or registered nurses (RNs) would have.

The patient is scheduled for endoscopic carpal tunnel release surgery in the morning. What key point will you be sure to teach the patient? a. Pain and numbness may be experienced for several days to weeks. b. Immediately after surgery, the patient will no longer need assistance. c. After surgery, the dressing will be large with dots of drainage d. After surgery, the pain and paresthesia will no longer be present.

a. Pain and numbness may be experienced for several days to weeks. Post-operative pain and numbness can occur for a longer period with endoscopic carpal tunnel release than with the open procedure. Patients often need assistance post-operatively, even after they are discharged. The dressing from the endoscopic procedure is usually very small and there should not be a lot of drainage.

The nurse advises a patient with myasthenia gravis (MG) to a. Perform physically demanding activities early in the day b. anticipate the need for weekly plasmapheresis treatments. c. do frequent weight-bearing exercise to prevent muscle atrophy. d. protect the extremities from injury due to poor sensory perception.

a. Perform physically demanding activities early in the day Muscles are generally strongest in the morning, and activities involving muscle activity should be scheduled then. Plasmapheresis is not routinely scheduled but is used for myasthenia crisis or for situations in which corticosteroid therapy must be avoided. There is no decrease in sensation with MG, and muscle atrophy does not occur because although there is muscle weakness, they are still used.

The nurse obtains this information when assessing a patient with chronic obstructive pulmonary disease (COPD) who has been admitted with increasing dyspnea over the last 3 days. Which finding is most important to report to the health care provider? a. Respirations are 36 bpm b. Anterior-posterior chest ratio is 1:1 c. Lung expansion is decreased bilaterally d. Hyperresonance to percussion is present

a. Respirations are 36 bpm The increase in respiratory rate indicates respiratory distress and a need for rapid interventions such as administration of oxygen or medications. The other findings are common chronic changes occurring in patients with COPD

A client who has myasthenia gravis is receiving atropine for a cholinergic crisis. Which intervention does the nurse implement for this client? a. Suction the client to remove secretions. b. Turn and reposition the client every 2 hours. c. Measure urinary output every 30 minutes. d. Administer prescribed anticholinergic drugs as needed.

a. Suction the client to remove secretions. Atropine can cause thickening of secretions and formation of mucous plugs. The client is maintained on a ventilator during the crisis. Measures to remove secretions to prevent the buildup of secretions and the possibility of pneumonia are most important. The other interventions do not relate to the administration of atropine.

Question 1When caring for a patient who has Guillain-Barre syndrome, which assessment data obtained by the nurse will require the most immediate action? a. The patient has continuous drooling of saliva. b. The patient's blood pressure (BP) is 106/50 mm Hg. c. The patient's quadriceps and triceps reflexes are absent. d. The patient complains of severe tingling pain in the feet.

a. The patient has continuous drooling of saliva. Drooling indicates decreased ability to swallow, which places the patient at risk for aspiration and requires rapid nursing and collaborative actions such as suctioning and possible endotracheal intubation. The foot pain should be treated with appropriate analgesics, and the BP requires ongoing monitoring, but these actions are not as urgently needed as maintenance of respiratory function. Absence of the reflexes should be documented, but this is a common finding in Guillain-Barr syndrome.

When caring for a patient who has Guillain-Barre syndrome, which assessment data obtained by the nurse will require the most immediate action? a. The patient has continuous drooling of saliva. b. The patients blood pressure (BP) is 106/50 mm Hg. c. The patient's quadriceps and triceps reflexes are absent. d. The patient complains of severe tingling pain in the feet.

a. The patient has continuous drooling of saliva. Drooling indicates decreased ability to swallow, which places the patient at risk for aspiration and requires rapid nursing and collaborative actions such as suctioning and possible endotracheal intubation. The foot pain should be treated with appropriate analgesics, and the BP requires ongoing monitoring, but these actions are not as urgently needed as maintenance of respiratory function. Absence of the reflexes should be documented, but this is a common finding in Guillain-Barre syndrome.

Question 5 A 68-year-old patient who is hospitalized with pneumonia is disoriented and confused 3 days after admission. Which information indicates that the patient is experiencing delirium rather than dementia? a. The patient was oriented and alert when admitted. b. The patient's speech is fragmented and incoherent. c. The patient is oriented to person but disoriented to place and time. d. The patient has a history of increasing confusion over several years.

a. The patient was oriented and alert when admitted. The onset of delirium occurs acutely. The degree of disorientation does not differentiate between delirium and dementia. Increasing confusion for several years is consistent with dementia. Fragmented and incoherent speech may occur with either delirium or dementia.

A client diagnosed with chronic obstructive pulmonary disease is experiencing pneumonia. The nurse applies oxygen at 2 L/min via nasal cannula. When the nurse leaves the room, a family member increases the oxygen to 5 L. Which complication may occur? a. Angina b. Apnea c. Metabolic acidosis d. Respiratory alkalosis

b. Apnea The COPD clients drive to breathe is hypoxia. Increasing the oxygen removes this drive and leads to apnea. Angina occurs because of decreased oxygen to the myocardial tissues. Neither respiratory alkalosis nor metabolic acidosis would occur with the increased oxygen level.

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

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

A 23-year-old patient with a history of muscular dystrophy is hospitalized with pneumonia. Which nursing action will be included in the plan of care? a. Logroll the patient every 2 hours. b. Assist the patient with ambulation. c. Discuss the need for genetic testing with the patient. d. Teach the patient about the muscle biopsy procedure.

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

For a client diagnosed with Parkinson's disease, which of the following might be contraindicated? a. Performing range-of-motion exercises b. Drinking bottled water c. Instituting fall precautions d. Taking naps

b. Drinking bottled water Some clients diagnosed with Parkinson's disease develop swallowing difficulties. Powders to thicken liquids and using an upright position will help with these difficulties. Clients diagnosed with Parkinson's disease will benefit from range-of-motion exercises and resting. The client diagnosed with Parkinson's disease should be placed on fall precautions.

Which intervention will the nurse include in the plan of care for a patient who has latestage Alzheimer's disease (AD)? a. Encourage the patient to discuss events from the past. b. Maintain a consistent daily routine for the patients care. c. Reorient the patient to the date and time every 2 to 3 hours. d. Provide the patient with current newspapers and magazines.

b. Maintain a consistent daily routine for the patients care. Providing a consistent routine will decrease anxiety and confusion for the patient. In latestage AD, the patient will not remember events from the past. Reorientation to time and place will not be helpful to the patient with late-stage AD, and the patient will not be able to read.

Following a thymectomy, a 62-year-old male patient with myasthenia gravis receives the usual dose of pyridostigmine (Mestinon). An hour later, the patient complains of nausea and severe abdominal cramps. Which action should the nurse take first? a. Auscultate the patient's bowel sounds. b. Notify the patients health care provider. c. Administer the prescribed PRN antiemetic drug. d. Give the scheduled dose of prednisone (Deltasone).

b. Notify the patients health care provider. The patient's history and symptoms indicate a possible cholinergic crisis. The health care provider should be notified immediately, and it is likely that atropine will be prescribed. The other actions will be appropriate if the patient is not experiencing a cholinergic crisis.

The intensive care nurse is caring for a client who has Guillain-Barré syndrome. The nurse notes that the client's vital capacity has declined to 12 mL/kg, and the client is having difficulty clearing secretions. Which is the nurse's priority action? a. Place the client in a high Fowler's position. b. Prepare the client for elective intubation. c. Administer oxygen via a nasal cannula. d. Auscultate for breath sounds.

b. Prepare the client for elective intubation. Deterioration in vital capacity to less than 15 mL/kg and an inability to clear secretions are indications for elective intubation. The other interventions may assist with breathing and oxygenation but would not reverse the deterioration in vital capacity or help clear secretions.

Which action will the nurse plan to take for a 40-year-old patient with multiple sclerosis (MS) who has urinary retention caused by a flaccid bladder? a. Decrease the patients evening fluid intake. b. Teach the patient how to use the Cred method. c. Suggest the use of adult incontinence briefs for nighttime only. d. Assist the patient to the commode every 2 hours during the day.

b. Teach the patient how to use the Cred method. The Cred method can be used to improve bladder emptying. Decreasing fluid intake will not improve bladder emptying and may increase risk for urinary tract infection (UTI) and dehydration. The use of incontinence briefs and frequent toileting will not improve bladder emptying.

Which assessment finding about a patient who has been using naproxen (Naprosyn), an NSAID, for 6 weeks to treat osteoarthritis is most important for the nurse to report to the health care provider? a. The patient has gained 3 pounds. b. The patient has dark-colored stools. c. The patient's pain has become more severe. d. The patient is using capsaicin cream (Zostrix).

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

When obtaining a health history and physical assessment for a patient with possible multiple sclerosis (MS), the nurse should a. assess for the presence of chest pain. b. inquire about any urinary tract problems. c. inspect the skin for rashes or discoloration. d. question the patient about any increase in libido.

b. inquire about any urinary tract problems. Urinary tract problems with incontinence or retention are common symptoms of MS. Chest pain and skin rashes are not symptoms of MS. A decrease in libido is common with MS.

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

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

A client with advanced ALS is admitted to the hospital. Because of manifestations that are common in clients with ALS, the nurse should a. attempt to institute bowel-training activities. b. provide the client with small, frequent feedings. c. obtain an order for intermittent catheterization. d. orient the client to his or her surroundings frequently.

b. provide the client with small, frequent feedings. The course of the disease is relentlessly progressive. Cognition, as well as bowel and bladder sphincters, remains intact. The client may be malnourished because of dysphagia. Encourage small, frequent, high-nutrient feedings. The nurse should assess for aspiration and choking. A feeding tube may be considered during the course of the illness.

A 35-year-old patient with three school-age children who has recently been diagnosed with rheumatoid arthritis (RA) tells the nurse that the inability to be involved in many family activities is causing stress at home. Which response by the nurse is most appropriate? a.You may need to see a family therapist for some help. b.Tell me more about the situations that are causing stress. c.Perhaps it would be helpful for you and your family to get involved in a support group. d.Your family may need some help to understand the impact of your rheumatoid arthritis.

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

A clinician is providing teaching for inhaled corticosteroid technique. Which information should be included in teaching? a. "You should inhale as quickly and as deeply as possible when you take a puff." b. "Spacers are not necessary. They are mostly for looks" c. "Press the cannister down, breathe in slowly and deeply, hold your breath for a few seconds and then slowly exhale." d. "It is not necessary to rinse your mouth after using your inhaler."

c. "Press the cannister down, breathe in slowly and deeply, hold your breath for a few seconds and then slowly exhale." Think about what would allow the medication to have full effect. Spacers are typically suggested as they prevent the medication from collecting on the tongue and the back of the throat. Inhalers can cause Candida infections. The patient should always rinse his or her mouth after use. Breathing in slowly and deeply and then holding one's breath allows for the medication to move further down the airway.

The nurse is planning discharge teaching for a client who has peripheral neuropathy of the lower extremities. Which instruction does the nurse include in the teaching plan? a. "Cut all calluses and corns from your feet as soon as you notice them." b. "Your balance will be steadier if you go barefoot while at home." c. "Use a thermometer to check the temperature of bath water." d. "Avoid using lotion on the feet and legs."

c. "Use a thermometer to check the temperature of bath water." The client with neuropathy has loss of sensation in the lower extremities, which can predispose the client to thermal injury. The client should be instructed to use a thermometer to check the temperature of the bath water to avoid a burn. Checking the water with the hands is not recommended because neuropathy may have a stocking and glove distribution that could also affect the hands. The client should be taught to wear shoes at all times, to assess feet and legs daily, to keep skin moist and clean, and not to cut calluses or corns from the feet.

A patient with chronic obstructive pulmonary disease (COPD) has poor gas exchange. Which action by the nurse would be most appropriate? a. Have the patient rest in bed with the head elevated to 15-20 degrees b. Ask the patient to rest in bed in a high-Fowlers position with the knees flexed c. Encourage the patient to sit up at bedside in a chair and lean slightly forward d. Place the patient in the Trendelenburg position with several pillows behind the head

c. Encourage the patient to sit up at bedside in a chair and lean slightly forward Patients with COPD improve the mechanics of breathing by sitting up in the tripod position. Resting in bed with the head elevated in a semi-Fowlers position would be an alternative position if the patient was confined to bed but sitting in a chair allows better ventilation. The Trendelenburg position or sitting upright in bed with the knees flexed would decrease the patient's ability to ventilate well.

A nurse cares for several clients on a neurologic unit. Which prescription for a client should direct the nurse to ensure that an informed consent has been obtained before the test or procedure? a. Sensation measurement via the pinprick method b. Computed tomography of the cranial vault c. Lumbar puncture for cerebrospinal fluid sampling d. Venipuncture for autoantibody analysis

c. Lumbar puncture for cerebrospinal fluid sampling A lumbar puncture is an invasive procedure with many potentially serious complications. The other assessments or tests are considered noninvasive and do not require an informed consent.

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

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

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

c. The patient takes 2 antihypertensive medications. Mydriatic medications used for pupil dilation are sympathetic nervous system stimulants and may increase heart rate and blood pressure. Using punctalocclusion when administering the mydriatic and monitoring of blood pressure are indicated for this patient. Blurred vision is an expected finding with cataracts. Patients are expected to be NPO for 6 to 8 hours before the surgical procedure. Cataract extraction and intraocular lens implantation are done using local anesthesia

The nurse assesses a client who has Guillain-Barre syndrome. Which clinical manifestation does the nurse expect to find in this client? a. Ophthalmoplegia and diplopia b. Progressive weakness without sensory involvement c. Progressive, ascending weakness and paresthesia d. Weakness of the face, jaw, and sternocleidomastoid muscles

c. Progressive, ascending weakness and paresthesia The most common clinical pattern of Guillain-Barre syndrome is the ascending variety. Weakness and paresthesia begin in the lower extremities and progress upward. The other manifestations are not associated with Guillain-Barr syndrome

When prioritizing care, which of the following patients should the nurse see first? a. The 52-year-old patient who is admitted for a relapse of MS day three whose being treated effectively with Solu-Medrol b. The patient who has been put on seizure precautions 24 hours ago c. The 32-year-old female with a recent diagnosis of Guillain-Barre syndrome d. The 65-year-old man who has just been diagnosed with early stage Parkinson's disease

c. The 32-year-old female with a recent diagnosis of Guillain-Barre syndrome Guillain Barre syndrome is a medical emergency due to its high potential for respiratory failure and autonomic dysfunction. Although B has been recently put on seizure precautions, there is no evidence that he is currently having a seizure. All other patients are in more stable conditions

The nurse is admitting a patient who has a diagnosis of an acute asthma attack. Which information obtained by the nurse indicates that the patient may need teaching regarding medication use? a. The patient says there have been no acute asthma attacks during the last year b. The patient became very short of breath an hour before coming to the hospital c. The patient has been using the albuterol (Proventil) inhaler more frequently over the last 4 days. d. The patient has been taking acetaminophen (Tylenol) 650 mg every 6 hours for chest wall pain

c. The patient has been using the albuterol (Proventil) inhaler more frequently over the last 4 days. The increased need for a rapid acting bronchodilator should alert the patient that an acute attack may be imminent and that a change in therapy may be needed. The patient should be taught to contact a health care provider if this occurs. The other data do not indicate any need for additional teaching.

The nurse's initial action for a patient with moderate dementia who develops increased restlessness and agitation should be to a. reorient the patient to time, place, and person. b. administer a PRN dose of lorazepam (Ativan). c. assess for factors that might be causing discomfort. d. assign unlicensed assistive personnel (UAP) to stay in the patient's room.

c. assess for factors that might be causing discomfort. Increased motor activity in a patient with dementia is frequently the patients only way of responding to factors like pain, so the nurses initial action should be to assess the patient for any precipitating factors. Administration of sedative drugs may be indicated, but this should not be done until assessment for precipitating factors has been completed and any of these factors have been addressed. Reorientation is unlikely to be helpful for the patient with moderate dementia. Assigning UAP to stay with the patient may also be necessary, but any physical changes that may be causing the agitation should be addressed first.

The nurse is admitting a patient who has a diagnosis of an acute asthma attack. Which information obtained by the nurse indicates that the patient may need teaching regarding medication use? a. The patient says there have been no acute asthma attacks during the last year b. the patient became very SOB an hour before coming to the hospital c. the patient has been using the albuterol (Proventil) inhaler more frequently over the last 4 days d. the patient has been taking acetaminophen (Tylenol) 650 mg every 6h for chest-wall pain

c. the patient has been using the albuterol (Proventil) inhaler more frequently over the last 4 days The increased need for a rapid acting bronchodilator should alert the patient that an acute attack may be imminent and that a change in therapy may be needed. The patient should be taught to contact a HCP if this occurs. The other data do not indicate any need for additional teaching

a home health patient with rheumatoid arthritis (RA) complains to the nurse about having chronically dry eyes. Which action by the nurse is most appropriate? a.Reassure the patient that dry eyes are a common problem with RA. b.Teach the patient more about adverse effects of the RA medications. c.Suggest that the patient start using over-the-counter (OTC) artificial tears. d.Ask the health care provider about lowering the methotrexate (Rheumatrex) dose

c.Suggest that the patient start using over-the-counter (OTC) artificial tears. The patient's dry eyes are consistent with Sjogren's syndrome, a common extraarticular manifestation of RA. Symptomatic therapy such as OTC eye drops is recommended. Dry eyes are not a side effect of methotrexate. Although dry eyes are common in RA, it is more helpful to offer a suggestion to relieve these symptoms than to offer reassurance. The dry eyes are not caused by RA treatment, but by the disease itself

The nurse is caring for a patient who is to be discharged from the hospital 5 days after insertion of a femoral head prosthesis using a posterior approach. Which statement by the patient indicates a need for additional instruction? a. I should not cross my legs while sitting. b. I will use a toilet elevator on the toilet seat. c. I will have someone else put on my shoes and socks. d. I can sleep in any position that is comfortable for me.

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

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

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

A patient with chronic obstructive pulmonary disease is prescribed methylprednisolone (Solu-Medrol). For what reason should the nurse realize that corticosteroids are used in the treatment of this health problem? a. Dry secretions b. Treat infection c. Improve the oxygen-carrying capacity of hemoglobin d. Reduce airway inflammation

d. Reduce airway inflammation Corticosteroids are potent anti-inflammatory agents. They do not dry secretions, and they may cause infection to worsen. They do not directly affect oxygenation.

You are the nurse taking care of a 40-year old African-American female who complains of fatigue and shortness of breath. Her physical exam is remarkable for erythema nodosum on the bilateral lower extremities. A chest x-ray is performed that demonstrates bilateral hilar infiltrates. She lives and works in a suburb, has not traveled outside of the United States recently, and does not work in a healthcare setting. Which of the following is the most likely diagnosis? a. Lung cancer b. Meningitis c. Pharyngitis d. Sarcoidosis e. Tuberculosis

d. Sarcoidosis this inflammatory condition is frequently found in African-American women in their 40's who present with fatigue and shortness of breath among other symptoms, who also have erythema nodosum on the lower extremities, and have bilateral hilar infiltrates on chest x-ray. This constellation of findings is highly suggestive of sarcoidosis. Sarcoidosis results in the formation of numerous non-necrotizing granulomas, most commonly found in the lungs, that can play a role in the symptoms experienced by these patients. Other findings suggestive of sarcoidosis include elevated serum calcium levels with normal serum PTH levels. Tuberculosis can present in a similar manner to sarcoidosis, however given the patient's suburban living environment, lack of a travel history, and lack of healthcare exposure, the likelihood of being exposed to tuberculosis is very low, making sarcoidosis a more likely etiology. While lung cancer can present as shortness of breath with hilar infiltration in chest x-ray, in a relatively young otherwise healthy patient who also has erythema nodosum and in whom the hilar infiltrates are bilateral, sarcoidosis would be a more likely etiology. The patient does not have any findings consistent with meningitis (leg rash in meningitis is petechial, not erythema nodosum) or pharyngitis.

A nurse is giving discharge instructions to a client with pulmonary sarcoidosis. The nurse concludes that the client understands the information if the client reports which of the following early signs of exacerbation? a. Fever b. Fatigue c. Weight loss d. Shortness of breath

d. Shortness of breath Dry cough and dyspnea are typical signs and symptoms of pulmonary sarcoidosis. Others include night sweats, fever, weight loss, and skin nodules.

A 76-year-old patient is being treated with carbidopa/levodopa (Sinemet) for Parkinson's disease. Which information is most important for the nurse to report to the health care provider? a. Shuffling gait b. Tremor at rest c. Cogwheel rigidity of limbs d. Uncontrolled head movement

d. Uncontrolled head movement Dyskinesia is an adverse effect of the Sinemet, indicating a need for a change in medication or decrease in dose. The other findings are typical with Parkinson's disease.

Which action will the nurse plan to take for a patient who is scheduled for pulmonary function testing (PFT)? a. explain reasons for NPO status b. Administer sedative drug before PFT c. assess pulse and BP after the procedure d. teach deep inhalation and forceful exhalation

d. teach deep inhalation and forceful exhalation For PFT, the patient should inhale deeply and exhale as long, hard, and fast as possible. The other actions are not needed with PFT

Which of these nursing actions included in the care of a patient after laminectomy can the nurse delegate to experienced nursing assistive personnel (NAP)? a.Ask about pain control with the patient-controlled analgesia (PCA). b.Determine the patient's readiness to ambulate. c.Check ability to plantar and dorsiflex the foot. d.Turn the patient from side to side every 2 hours.

d.Turn the patient from side to side every 2 hours. Repositioning a patient is included in the education and scope of practice of NAP, and experienced NAP will be familiar with how to maintain alignment in the postoperative patient. Evaluation of the effectiveness of pain medications, assessment of neurologic function, and evaluation of a patient readiness to ambulate after surgery require higher level nursing education and scope of practice.