CA1 EXAM 2

In teaching a patient who is using topical fluorouracil (5-FU) to treat actinic keratosis, the nurse should tell the patient which of the following? Select all that apply. 1 Systemic side effects are very rare. 2 The patient will look worse before looking better. 3 The patient needs to avoid sunlight during treatment. 4 Treatment with this medication is limited to one week. 5 Abruptly discontinuing the use of the medication may cause a reappearance of the actinic keratosis.

1, 2, 3. 5-FU is a topical treatment for actinic keratosis, a premalignant lesion, and certain skin malignancies. Systemic absorption of the drug is minimal, systemic side effects are virtually nonexistent. Because 5-FU is a photosensitizing drug, instruct the patient to avoid sunlight during treatment. Teach patients about the effect of the medication and that they will look worse before they look better. Treatments last from two to six weeks. Abruptly discontinuing 5-FU does not cause the condition to return.

A 74-year-old patient is prescribed gentamycin (Garamycin) for osteomyelitis developed in the left arm after an injury. What nursing considerations should the nurse expect with this patient? Select all that apply. 1 Monitor the patient's peak and trough levels regularly 2 Complete renal function testing on the patient regularly 3 Assess for dehydration before the beginning of therapy 4 Instruct patient to take medication 30 minutes before meals 5 Instruct patient to remain upright for 30 minutes after meals

1, 2, 3. The patient on gentamycin may need adjustments to maintain peak serum gentamycin concentrations of 4 to 10 mcg/mL, and trough concentrations of 1 to 2 mcg/mL. Too high of a peak or trough concentration is associated with toxicity. Renal function testing is completed to ensure that the gentamycin has not caused an adverse effect of nephrotoxicity. If the patient is dehydrated and begins the gentamycin therapy, it can lead to chemical irritation of the renal tubules. Gentamycin is given either intravenously (IV) or intramuscularly (IM); it is not given by mouth, so there are no gastrointestinal concerns when giving the medication.

When teaching a group of young adults, what general measures should a nurse teach to prevent injuries? Select all that apply. 1 Use seat belts regularly. 2 Avoid drunken driving. 3 Drive slower than the posted speed limit. 4 Use safety equipment at work. 5 Use protective athletic equipment. 6 While driving, talk on the phone only if the call is important.

1, 2, 4, 5. A nurse plays a pivotal role in teaching patients to take appropriate measures to prevent injuries. Some of these measures include regularly using seat belts; avoiding drunken driving, using protective athletic equipment (helmets and knee, wrist, and elbow pads), and using safety equipment at work. Obeying the speed limit is sufficient; the nurse does not need to teach that people should always drive slower than the speed limit. The teaching should encourage people not to use the phone at all while driving; if an important call must be made, the driver should find a safe place to stop before making it.

The nurse is providing education on managing type 2 diabetes with lifestyle modification to a group of patients. Which of the following topics should the nurse include in the education session? 1 Proper nutrition 2 Regular physical activity 3 Drug therapy with insulin 4 Maintenance of recommended body weight 5 Drug therapy with oral agents

1, 2, 4. In newly diagnosed type 2 diabetics, proper nutrition, regular physical activity, and maintenance of recommended body weight or promoting weight loss is the focus to try and control the disease. Medications are not considered topics for lifestyle change.

A nurse is taking the health history of a patient suffering from a backache. What are the questions that she should include in the health history related to his complaint? Select all that apply. 1 Did you lift a heavy object? 2 Describe your usual daily activities. 3 Did you have any unsafe sexual activity? 4 Do you have any vision problems? 5 Do you find it difficult to perform your daily activities?

1, 2, 5. The nurse should ask if the patient tried lifting any heavy object. The nurse should record the patient's daily activities and ask if the patient experiences any discomfort in performing them. This gives an idea of the severity of the ailment. Vision problems do not have a direct bearing on backache. Having unsafe sexual activity exposes the person to various serious, sexually transmitted infections (STIs) but does not affect the musculoskeletal system.

A patient is admitted to the hospital with Boutonnière deformity. What are the signs and symptoms that the nurse is likely to find during assessment? Select all that apply. 1 Flexion of proximal interphalangeal joint 2 Hyperextension of the distal interphalangeal joint 3 Flexion of the metacarpophalangeal joint 4 Fingers drift to ulnar side of forearm 5 Partial dislocation of finger joints

1, 2. Boutonnière deformity is the deformity of rheumatoid and psoriatic arthritis caused by the rupture of the extensor tendons over the fingers. It is characterized by the flexion of the proximal interphalangeal (PIP) joint and hyperextension of the distal interphalangeal (DIP) joints of the fingers. Flexion of the metacarpophalangeal joint occurs in swan neck deformity. Ulnar drift refers to the deformity of rheumatoid arthritis due to tendon contracture. Dislocation of the finger joints does not happen in Boutonnière deformity.

A 70-year-old male patient is admitted with slight erosion of cartilage in the knee joint. What are the symptoms that the nurse is likely to find in this patient? Select all that apply. 1 Crepitation 2 Deformity 3 Joint stiffness 4 Limited range of motion 5 Complete inability to walk

1, 3, 4. Cartilage erosion can result in direct contact between ends of two bones. This presents as possible crepitation on movement, joint stiffness, decreased mobility, and limited range of motion. There is pain with motion and/or weight bearing. Deformity and complete inability occur in severe and chronic cases, not in slight erosion of cartilage.

A patient is admitted with diabetes mellitus, malnutrition, and cellulitis. The patient's potassium level is 5.6 mEq/L. The nurse understands that what could be contributing factors for this laboratory result? Select all that apply. 1 The level may be increased as a result of dehydration that accompanies hyperglycemia. 2 The patient may be excreting extra sodium and retaining potassium because of malnutrition. 3 The level is consistent with renal insufficiency that can develop with renal nephropathy. 4 The level may be raised as a result of metabolic ketoacidosis caused by hyperglycemia.

1, 3, 4. The additional stress of cellulitis may lead to an increase in the patient's serum glucose levels. Dehydration may cause hemoconcentration, resulting in elevated serum readings. Kidneys may have difficulty excreting potassium if renal insufficiency exists. Finally, the nurse must consider the potential for metabolic ketoacidosis because potassium will leave the cell when hydrogen enters in an attempt to compensate for a low pH. Malnutrition does not cause sodium excretion accompanied by potassium retention. Thus it is not a contributing factor to this patient's potassium level. The elevated potassium level does not demonstrate adequate treatment of cellulitis or effective serum glucose control.

A nurse is caring for a patient who has undergone a knee joint replacement. What measures should a nurse take to prevent constipation of the patient in the postoperative period? Select all that apply. 1 Advise the patient to drink more than 2500mL/day of fluids. 2 Instruct the patient to drink cold fluids. 3 Advise the patient to eat more fruits and vegetables. 4 Advise the patient to maintain complete bed rest until recovery. 5 Use stool softeners and laxatives as advised.

1, 3, 5. Patients often have reduced mobility after a fracture, which may result in constipation. The nurse should implement appropriate measures, such as high fluid intake (more than 2500mL/day unless contraindicated) and a diet high in bulk and roughage (fruits and vegetables) to prevent constipation. If these measures fail to maintain normal bowel pattern, then laxatives and stool softeners can be used. Constipation can be relieved by drinking warm fluids, not cold ones. Physical activity also helps in bowel activity, so the patient should ambulate as early as the indications and provider prescriptions allow.

What questions should the nurse ask a patient with severe back pain in the lumbar region when taking the health history? Select all that apply. 1 Have you been vaccinated against hepatitis? 2 Does your work involve lifting any heavy objects? 3 Has this pain affected your social or professional life? 4 Have you taken any high-dose antibiotic recently? 5 Do you consume any dietary supplements like calcium or vitamin D? 6 Do you require frequent change of position while you are sleeping because of the pain?

2, 3, 5, 6. Lifting heavy objects can lead to back pain; therefore, it is important to know whether the patient's work involves lifting heavy objects. Knowing if the pain has affected the patient's social and professional life helps to determine the severity of the problem. Knowing if the patient is taking dietary supplements like calcium and Vitamin D helps to understand how the patient is treating self and also helps in planning future interventions for the patient. Similarly, knowing if the patient has frequent changes in position while asleep helps to understand the severity of the complaint. Vaccination against hepatitis is not connected to back pain. Similarly, antibiotic therapy is not relevant in the back pain assessment.

A patient experiences a phenylalanine deficiency. The nurse identifies that what other hormones will also be deficient in the patient? Select all that apply. 1 Cortisol 2 Dopamine 3 Adrenaline 4 Aldosterone 5 Noradrenaline

2, 3, 5. Catecholamines such as dopamine, adrenaline, and noradrenaline are synthesized from the amino acid phenylalanine. Therefore, in the absence of phenylalanine, the body will not produce dopamine, adrenaline, and noradrenaline, causing its deficiency. Hormones such as cortisol and aldosterone are not synthesized from the amino acid phenylalanine; therefore, the patient is not likely to have a deficiency of cortisol and aldosterone.

The nurse reviews a patient's medical record and notes that the morning cortisol levels are 27 mcg/dL and that the patient has experienced a steady weight gain. The nurse anticipates what other assessment findings? Select all that apply. 1 Cold sensitivity 2 Truncal obesity 3 Thin extremities 4 Decreased body hair 5 Purple abdominal striae

2, 3, 5. Normal cortisol levels are 5 to 23 mcg/dL. A cortisol level of 27 mcg/dL indicates that the patient has hypercortisolism. The patient with hypercortisolism has truncal obesity, thin extremities, and purple abdominal striae. An increase in cortisol levels does not cause hypothermia and cold sensitivity in the patient. A patient with hypercortisolism would have excess body hair.

A nurse is examining a patient who is in a body jacket brace. The patient complains that the brace is applied too tightly. What findings in the patient may indicate that the brace is too tightly applied? Select all that apply. 1 Burning sensation 2 Abdominal pain 3 Guarding and rigidity 4 Increased abdominal pressure 5 Nausea and vomiting

2, 4, 5. After application of the body jacket brace, it is important to assess the patient for the development of superior mesenteric artery syndrome (cast syndrome). This condition occurs if the brace is applied too tightly, compressing the superior mesenteric artery against the duodenum. The patient generally complains of abdominal pain, abdominal pressure, nausea, and vomiting. Burning sensations, guarding, and rigidity may not be found in cast syndrome; these symptoms are more prominent if an intraabdominal disorder is present.

The nurse is assessing an older patient. When assessing the hair and nails, the nurse will recognize that age-related changes in the hair and nails include which of these? Select all that apply. 1 Thicker hair 2 Scaly scalp 3 Thinner nails 4 Longitudinal ridging on nails 5 Prolonged blood return when nails are blanched

2, 4, 5. Decreased oil leads to dry, coarse hair and a scaly scalp. The hair becomes thinner. Decreased peripheral blood supply leads to thick, brittle nails, Longitudinal ridging in the nails also may occur with aging. There is prolonged blood return to the nails when they are blanched because of decreased circulation. Thicker hair and thinner nails are not normal age-related changes.

A patient complains of excessive itching along the abdomen near the umbilicus. What instructions should the nurse give to the patient to relieve pruritus? Select all that apply. 1 Rub the affected area gently. 2 Place moist cotton sheets on the affected area. 3 Warm the affected area with warm compresses. 4 Apply menthol or camphor locally to the affected area. 5 Use good-quality moisturizers on the affected area after drying it.

2, 4, 5. Pruritus, or severe itching, needs to be controlled because an excoriated lesion may be difficult to assess. A variety of measures can be used to control pruritus. The pruritic area should always be moist because dry skin increases the itch sensation. When applied topically, menthol and camphor numb the itch receptors and thus decrease itch sensation. Applying moisturizers and moist linen can be helpful in controlling itch. Heat and rubbing the affected area causes vasodilation, which worsens itching.

A nurse is assessing an infant who has scabies. Which of the following are expected findings? (Select all that apply.) A. Presence of nits on the hair shaft B. Pencil-like marks on hands C. Blisters on the soles of the feet D. Bluish-gray skin color E. Pimples on the trunk

B, C, E

A nurse is teaching a parent of a child who has pediculosis capitis. Which of the following should the nurse include in the teaching? A. Apply mayonnaise to the affected area at night. B. Treat all household pets. C. Use an over-the-counter medication containing 1% permethrin. D. Discard the child's stuffed animals.

C

What are the clinical manifestations of scleroderma? Select all that apply. A Uveitis B Cervicitis C Calcinosis D Dysphonia E Bull's eye rash F Raynaud's phenomenon

C, F. Scleroderma is a connective tissue disorder characterized by painful deposits of calcium in the skin or calcinosis and abnormal blood flow in response to stress identified as Raynaud's phenomenon. Ankylosing spondylitis is associated with uveitis or intraocular inflammation. Reactive arthritis is characterized by cervicitis or inflammation of the cervix. Dysphonia is a symptom of polymyositis and dermatomyositis. Bull's eye rash is a skin lesion caused by tick bite and associated with Lyme disease.

The nurse working in an endocrine clinic knows that Chvostek's sign is a diagnostic tool that is used to assess for which electrolyte disturbance? 1 Hypokalemia 2 Hypocalcemia 3 Hyperkalemia 4 Hypercalcemia

Chvostek's sign is a diagnostic tool that is used to assess for tetany, a sign of hypocalcemia. This is an important assessment when the nurse is dealing with patients in an endocrine clinic, especially those that may have hypoparathyroidism. A positive Chvostek's sign is specific to hypocalcemic tetany, and therefore would not indicate a state of hypercalcemia, hypokalemia, or hyperkalemia.

A patient is diagnosed with herpes zoster and is at risk for developing postherpetic neuralgia. What action should the nurse take to prevent postherpetic neuralgia in the patient? 1 Administer mild sedatives at night. 2 Administer acyclovir (Zovirax) as prescribed within 72 hours. 3 Apply silver sulphadiazine on the ruptured vesicles. 4 Apply wet compresses to the affected area.

Classic clinical manifestation of herpes zoster (shingles) is a linear distribution of grouped vesicles along a dermatome. Often there is a burning pain preceding an outbreak. Postherpetic neuralgia is a preventable condition if the antiviral agents are administered within 72 hours. Using a mild sedative at night, applying silver sulphadiazine on the vesicles, and applying wet compresses may decrease symptoms, but they have no effect on the prevention of postherpetic neuralgia.

A patient with a long leg cast reports pain in the toes. The nurse discovers that the toes are pale and cool to the touch with intact pulses and minimal neuropathy. The findings indicate that the patient may be experiencing: 1 A pressure ulcer 2 Osteomyelitis 3 A fat embolism 4 Compartment syndrome

Compartment syndrome is the progressive compromise of neurovascular function of tissue in a confined space such as a cast. It may also result from circumferential inflammation around an extremity. The earliest sign is paresthesias, followed by pain, pressure resulting from edema, pallor, paralysis, and absence of pulse. (Absence of the peripheral pulse is a late and ominous sign.) A pressure ulcer is caused by decreased circulation due to pressure, tissue hypoxia, and destruction. Osteomyelitis is an infectious process within the bone. A fat embolism is an acute event in which fat globules released into circulation obstruct pulmonary circulation. It is seen with fractures of long bones such as the femur.

The school nurse is conducting an assessment for pediculosis capitis (head lice) on a group of school-age children. Which describes a child with a positive head check? A. Maculopapular lesions behind the ears B. White, flaky particles throughout the entire scalp area C. Lesions in the scalp extending from the hairline to the neck D. White sacs attached to the hair shafts in the occipital area

D. Evidence of pediculosis capitis includes white sacs (nits) attached to the hair shafts and usually located in the occipital area. Lesions may be present from itching, but the positive sign is evidence of the nits. White flaky particles appear with dandruff, and lice nits must be distinguished from dandruff. Lesions may be present from itching, but the positive sign is evidence of the nits.

An 8-year-old has been diagnosed with moderate cerebral palsy (CP). The child recently began participation in a regular classroom for part of the day. The child's mother asks the school nurse about joining the after-school Scout troop. The nurse's response should be based on knowledge that A. most activities such as Scouts cannot be adapted for children with CP. B. after-school activities usually result in extreme fatigue for children with CP. C. trying to participate in activities such as Scouts leads to lowered self-esteem in children with CP. D. after-school activities often provide children with CP with opportunities for socialization and recreation.

D. Recreational outlets and after-school activities should be considered for the child who is unable to participate in athletic programs in order to promote socialization opportunities. Most activities can be adapted for children with CP. The child, family, and activity director should assess the degree of activity to ensure it matches the child's capabilities. A supportive environment associated with after-school activities will add to the child's self-esteem.

The patient has a prescription for gentamicin (Garamycin). The nurse would hold the dose and notify the health care provider if the patient developed which complaint? 1 Constipation 2 Fever 3 Tinnitus 4 Epistaxis

Gentamicin is an aminoglycoside antibiotic that can cause ototoxicity and nephrotoxicity. For this reason, the nurse would notify the health care provider of tinnitus as this may indicate that ototoxicity is developing. Fever would indicate infection, which is the reason the patient would be prescribed this medication. Constipation and epistaxis are unrelated to gentamicin use.

A patient with low levels of parathormone in the blood is experiencing frequent muscle spasms in the extremities. Which diet should the nurse suggest to this patient? 1 Calcium-rich diet 2 Folic acid-rich diet 3 Potassium-rich diet 4 Carbohydrate-rich diet

Hypoparathyroidism, or low levels of parathormone, may lead to tetany in the patient. Tetany manifests as muscle spasms in the extremities at irregular intervals. Tetany may occur due to low levels of calcium. Parathormone regulates calcium levels in the blood. Therefore, the patient with low levels of parathormone and tetany may benefit from a calcium-rich diet. A diet that is rich in folic acid may be suggested for a patient with anemia. A patient with hypokalemia may be advised to maintain a diet rich in potassium. A carbohydrate-rich diet may not help a patient with a calcium deficiency.

The nurse suspects that a patient has hypothyroidism based on which total thyroxine (T4) and free thyroxine (FT4) levels? 1 50 nmol/L; 5 pmol/L 2 60 nmol/L; 20 pmol/L 3 70 nmol/L; 30 pmol/L 4 80 nmol/L; 35 pmol/L

Hypothyroidism refers to a condition in which the patient will have low levels of total thyroxine (T4) and free thyroxine (FT4) in blood. The normal levels of total thyroxine (T4) and free thyroxine (FT4) are 59 to 142 nmol/L and 10 to 35 pmol/L respectively. Therefore, T4 and FT4levels of 50 nmol/L and 5 pmol/L indicate hypothyroidism. T4 and FT4 levels of 60 nmol/L and 20 pmol/L are normal findings. T4 and FT4 levels of 70 nmol/L and 30 pmol/L do not indicate hypothyroidism, because these values fall within the range of normal levels. T4 and FT4 levels of 80 nmol/L and 35 pmol/L do not indicate hypothyroidism, because these values are within the normal range.

The nurse is reviewing laboratory results for the patient with diabetes and coronary artery disease. Which laboratory result would help predict possible macrovascular disease as a complication of diabetes? 1 Increased low-density lipoproteins 2 Decreased blood urea nitrogen 3 Increased white blood cell count 4 Decreased C-reactive protein

Increased low-density lipoprotein levels are associated with the macrovascular changes in diabetes mellitus. For this reason, the patient should limit the amount of fat in the diet. A decreased blood urea nitrogen or C-reactive protein is not clinically significant. An increased white blood cell count would indicate infection.

A newborn baby has sustained an uncomplicated midshaft fracture of the femur. In how many weeks will the fracture heal? Record your answer as a whole number. 1 3 weeks 2 7 weeks 3 10 weeks 4 20 weeks

Many factors influence fracture healing, including displacement, the site of the fracture, the blood supply to the area, and any immobilization and internal fixation devices (e.g., screws, pins). Healing time for fractures increases with age. An uncomplicated midshaft fracture of the femur heals in 3 weeks in a newborn and in 20 weeks in an adult.

Which statement by a patient indicates an insufficient understanding of the prescribed medication metformin (Glucophage)? 1 "I should take this medication in the morning with breakfast." 2 "I will need to have my hemoglobin A1c level checked in three months." 3 "I may have diarrhea with this medication but I should not stop taking it." 4 "I will take this medication when my blood sugar is greater than 200 mg/dL."

Metformin should be taken daily for diabetes control; it is not indicated for as-needed use. It should be taken with breakfast and may initially cause diarrhea, which will resolve.

The nurse identifies that a patient may have complications during labor in terms of uterine contractions based on what laboratory result? 1 Low levels of oxytocin 2 Low levels of glucagon 3 Low levels of calcitonin 4 Low levels of somatotropin

Oxytocin helps stimulate uterine contractions during labor. Low levels of this hormone during pregnancy may lead to complications during the labor process. Lower levels of glucagon may lead to the suppression of glycogenolysis and gluconeogenesis in the body. Low levels of calcitonin may lead to an imbalance in the calcium and phosphorus levels in the patient. Low levels of somatotropin may lead to a decrease in protein anabolism, which leads to growth suppression.

The nurse is performing a musculoskeletal assessment of an 81-year-old female patient whose mobility has been decreasing progressively in recent months. How should the nurse best assess the patient's range of motion (ROM) in the affected leg? 1 Observe the patient's unassisted ROM in the affected leg 2 Perform passive ROM, asking the patient to report any pain 3 Ask the patient to lift progressive weights with the affected leg 4 Move both of the patient's legs from a supine position to full flexion

Passive ROM should be performed with extreme caution, and may be best avoided when assessing older patients. Observing the patient's active ROM is more accurate and safer than asking the patient to lift weights with her legs.

A 54-year-old patient is about to have a bone scan. What information should be included when teaching the patient about this procedure? 1 Two additional follow-up scans will be required 2 There will be only mild pain associated with the procedure 3 The procedure takes approximately 15 to 30 minutes to complete 4 The patient will be asked to drink increased fluids after the procedure

Patients are asked to drink increased fluids after a bone scan to aid in excretion of the radioisotope, if not contraindicated by another condition. No follow-up scans and no pain are associated with bone scans, which take one hour of lying supine.

What practice should the nurse teach a patient to follow when the patient is applying topical medication? 1 Avoid applying medications directly on to dressings 2 Use a tongue blade whenever the patient's skin integrity allows 3 Avoid covering skin regions that have topical medication in place 4 Apply a layer of medication that is just thick enough to ensure coverage

Patients should be directed to avoid applying topical medications too thickly. Medications may be applied directly on to dressings, and regions with medications may be covered. A tongue blade is not normally used for the application of a thin coat.

A 57-year-old patient with osteoarthritis of the knees has been taking celecoxib (Celebrex) 200 mg every 12 hours. The patient states that the drug does not seem to work as well as it used to in controlling the pain. The nurse's response to the patient is based on the knowledge that: 1 This patient may respond better to an alternate nonsteroidal antiinflammatory drug (NSAID). 2 The patient is now tolerant of the medication and will need to double the dose. 3 If NSAIDs are not effective in controlling symptoms, the next line of therapy is systemic corticosteroids. 4 It may take several months for NSAIDs to reach maximal effectiveness.

Patients vary in their responses to medications, and another type of NSAID may be tried. This NSAID is a cyclooxygenase-2 (COX-2) inhibitor, which decreases the risk of gastrointestinal (GI) bleeding. Systemic corticosteroids are not indicated for osteoarthritis related to the adverse reactions associated with them. It is not within the nurse's scope of practice to increase the patient's medication dose; maximal effectiveness occurs within several days, not months.

A patient has sensitive skin and breaks out with rashes when using ordinary soap. What advice should the nurse give the patient regarding hygienic skin measures? 1 Use mild, moisturizing soaps. 2 Use hot water to take a bath. 3 Rub the skin vigorously. 4 Avoid antibacterial soaps

People with sensitive skin should use mild, moisturizing soaps and lipid-free cleansers. The patient should avoid hot water and vigorous scrubbing, as they may cause local skin irritation and inflammation. Antibacterial soaps without sulphites should be used on the areas with skin piercings where jewelry has been inserted.

To determine the presence of petechiae in a patient with dark skin, the nurse should assess what part of the body? 1 Nail 2 Face 3 Buttocks 4 Conjunctiva

Petechiae are small pinpoint lesions. The nurse should check for these lesions in the conjunctiva of the eye or buccal mucosa in dark- skinned people. Unlike fair-skinned people, these lesions are difficult to see on the nail, face, or buttocks of dark-skinned people.

The nurse is reviewing proper body mechanics with a patient with a history of low back pain caused by a herniated lumbar disc. The nurse would determine proper understanding if the patient states: 1 "Physical therapy may help to alleviate the pain." 2 "I should limit exercise to one to two times per week to avoid excess strain." 3 "I should try to get out of bed in one smooth, quick motion." 4 "I will never bend down below waist level to avoid additional injury."

Physical therapy is recommended to improve symptom management and pain control. The patient should get out of bed by sliding to the edge of the mattress, turning onto the side, and pushing up from the bed with one or both arms. This keeps the spine in alignment and reduces strain on the lumbar spine. Exercise should not be limited, and bending down is permitted using proper body mechanics.

The nurse assessed the patient's skin lesions as circumscribed, with a superficial collection of serous fluid, and less than 0.5 cm in diameter. These lesions would be called: 1 Wheals 2 Papules 3 Pustules 4 Vesicles

Vesicles are circumscribed, with superficial collection of serous fluid, less than 0.5 cm in diameter. Examples include varicella (chickenpox), herpes zoster (shingles), and second-degree burn. Wheals are firm, edematous areas such as insect bites. Papules are solid lesions (warts). Pustules are fluid-filled lesions (acne or impetigo). Refer to Table 23-4 for descriptions of other skin lesions.

When attending a patient who has undergone hip replacement surgery, what interventions should a nurse perform to prevent thromboembolism? Select all that apply. 1 Administer a prophylactic anticoagulant drug, such as warfarin (Coumadin). 2 Administer low-molecular-weight heparin, such as enoxaparin (Lovenox). 3 Apply compression gradient stockings. 4 Avoid moving toes of the affected extremities. 5 Perform range-of-motion exercises on the affected extremity.

1, 2, 3. Because of the high risk of venous thromboembolismin the orthopedic surgical patient, prophylactic anticoagulant drugs, such as warfarin (Coumadin), or low-molecular-weight heparin, such as enoxaparin (Lovenox), may be prescribed. In addition to wearing compression gradient stockings, the patient should move (dorsiflex and plantar flex) the toes of the affected extremity against resistance and perform range-of-motion exercises on the unaffected lower extremities.

A 40-year-old man has a mandibular fracture from an accident, and there is prominent swelling around it. What are the important nutritional measures that need to be followed in the postoperative stages? Select all that apply. 1 Include liquid protein supplements. 2 Give prune juice to drink. 3 Administer bulk-forming laxatives. 4 Give a low-carbohydrate, high-bulk diet. 5 Instruct the patient to chew food properly.

1, 2, 3. Ingestion of sufficient nutrients poses a challenge because the diet must be liquid. The patient easily tires of sucking through a straw or laboriously using a spoon. Liquid protein supplements may be helpful for improving the nutritional status. The low-bulk, high-carbohydrate diet and the intake of air through the straw can create problems related to constipation and flatus. Prune juice and bulk-forming laxatives may help to ward off these problems. The constraint of the diet to only liquids usually results in a low-bulk, high-carbohydrate diet. Chewing is not applicable here, because the diet must be liquid with any form of mandibular immobilization.

Which hormones are released by the adrenal medulla? Select all that apply. 1 Dopamine 2 Epinephrine 3 Norepinephrine 4 Glucocorticoids 5 Mineralocorticoids

1, 2, 3. The adrenal medulla secretes the catecholamines epinephrine (adrenaline), norepinephrine (noradrenaline), and dopamine. Glucocorticoids and mineralocorticoids are secreted by the adrenal cortex.

A patient scheduled for an arthrocentesis is anxious about the procedure. What information should the nurse give to the patient to alleviate anxiety? Select all that apply. 1 This procedure is performed to obtain samples of synovial fluid or to remove excess fluid from the joint cavity. 2 The procedure is performed under local anesthesia. 3 This procedure can be performed at the bedside or in an examination room. 4 There are serious complications, such as respiratory distress, related to the procedure. 5 This procedure is performed to visualize and examine interior of the joint cavity.

1, 2, 3. The nurse should explain to the patient that arthrocentesis involves an incision or puncture of the joint capsule to obtain samples of synovial fluid or remove excess fluid from within the joint cavity. Local anesthesia and aseptic preparation are used before the needle is inserted into the joint and fluid is aspirated. It is useful in the diagnosis of joint inflammation, infection, meniscal tears, and subtle fractures. The procedure is usually done at the bedside or in an examination room. Respiratory distress is not a complication of this procedure, as local anesthesia is given. The interior of the joint cavity is visualized and examined during arthroscopy and not during arthrocentesis.

The nurse is preparing an educational session on Type 2 diabetes for the public. Which symptoms of type 2 diabetes would the nurse include in the presentation? Select all that apply. 1 Fatigue 2 Polyuria 3 Weight loss 4 Visual changes 5 Recurrent infections

1, 2, 4, 5. The onset of type 2 diabetes usually is delayed, resulting in chronic complications having already manifested. The patient will have slower wound healing and infection healing, fatigue, and visual changes as a result of the disease progression. Some patients with type II diabetes may have polyuria. Weight loss is typically seen with type I diabetes.

When performing a skin assessment on a patient, which principles should the nurse follow? Select all that apply. 1 Be systematic and proceed from head to toe. 2 Use the metric system when taking measurements. 3 Ensure the patient is wearing a comfortable dress. 4 Have a private examination room with a moderate temperature. 5 Perform a lesion-specific examination followed by a general inspection

1, 2, 4. Assessment should always be systematic and proceed from head to toe so that an area is not missed. Measurements should be taken using the metric system. A private examination room should be made available. The room should have a moderate temperature and exposure to sunlight. The patient should wear a dressing gown for easy access to all areas of the skin. A general inspection should be done first followed by lesion-specific examination.

A patient with a nonunion of the tibia receives repair via an external fixation. What signs in the patient may indicate infection around the fixator pins? Select all that apply. 1 Pain at the pin site 2 Exudate from the pin site 3 Pin looseness 4 Edema around the pin 5 Pale skin around the pin

1, 2, 4. External fixation is often used as an attempt to salvage extremities that otherwise might require amputation. Because the use of an external device is a long-term process, ongoing assessment for pin loosening and infection is critical. Infection is indicated by the presence of pain, exudates, and edema around the pin site. Pin looseness does not indicate infection. In the presence of infection, the skin around the pin site is red (erythematous), not pale.

A nurse caring for a patient with osteoarthritis instructs the patient about the various nonpharmaceutical interventions for the management of pain. Which information should the nurse include in these instructions? Select all that apply. 1 Regulation of a normal body mass index (BMI) 2 Use of paraffin baths or hot packs 3 Immobilization of the affected joint 4 Use of crutches or walker if required 5 Strenuous exercise to keep the joints functional

1, 2, 4. Osteoarthritis is usually caused by a known event or condition that directly damages cartilage or causes joint instability. Pain management in osteoarthritis involves regulation of a normal body mass index, as increase in weight may pose stress on the joints. Paraffin baths or hot packs may be used to relieve the associated pain by reducing inflammation. The use of assistive devices like a walker or crutches can ease mobility while avoiding undue excessive pressure on the affected joint. The affected joint should not be immobilized; however, strenuous activities of the joint should be avoided. Strenuous exercise can worsen the situation, and so rest should be taken during periods of acute inflammation.

A pregnant patient is diagnosed with systemic lupus erythematosus (SLE). Which information about associated complications should be given to the patient? Select all that apply. 1 Stillbirth and spontaneous abortion 2 Intrauterine growth retardation 3 Aggravation of disease due to pregnancy 4 High maternal and fetal risk due to organ involvement 5 Therapeutic termination recommended in majority of cases

1, 2, 4. SLE is characterized by the production of a large variety of autoantibodies against nucleic acids and various self-proteins and internal organ involvement posing a threat to the fetus and the mother. The SLE patient should understand that spontaneous abortion, stillbirth, and intrauterine growth retardation may occur because of deposits of immune complexes in the placenta and because of inflammatory responses in the placental blood vessels. There is a high maternal and fetal risk due to organ involvement of renal, cardiovascular, pulmonary, and central nervous systems. Exacerbation of the disease is common during postpartum period. If proper therapeutic management and monitoring is done, therapeutic termination may not be required, and the patient can give birth to a healthy baby.

The nurse is providing discharge instructions to a patient who has a neurogenic bladder. Which self-care activities would the patient identify to facilitate bladder emptying to help prevent urinary stasis and infection? Select all that apply. 1 Sitting to void 2 Using the Credé maneuver when voiding 3 Emptying the bladder at least three times a day 4 Tightening the abdominal muscles when voiding 5 Maintaining a fluid restriction of 1200 mL per day

1, 2, 4. Sitting to void, the Credé maneuver, and tightening the abdominal muscles when voiding all aid in fully emptying the bladder, which will help to prevent urinary stasis and infection. The patient should also empty the bladder every three hours. Fluid restriction will not aid in emptying the bladder.

A nurse is taking a patient's health history related to musculoskeletal system. What are the common symptoms of musculoskeletal impairments? Select all that apply. 1 Stiffness 2 Weakness 3 Changes in pigmentation 4 Joint crepitation 5 Redness and blisters

1, 2, 4. Stiffness and loss of range of motion are very commonly seen symptoms in musculoskeletal impairments. Weakness is also a common symptom. Joint crepitation is also seen in such disorders. Redness and blisters are not common symptoms seen in musculoskeletal impairments. Redness and blisters are associated with burns and infections. Similarly, a change in pigmentation is not a common symptom. It is usually a result of hormonal changes, aging, or other dermatologic conditions.

A patient is admitted to the hospital with severe burn injury. An eschar is formed on the wounds. What are the various ways in which the eschar can be removed safely to accelerate the healing process in this patient? Select all that apply. 1 Surgical escharotomy 2 Enzymatic debridement 3 Freeze debridement 4 Thermal debridement 5 Mechanical debridement

1, 2, 5. Eschar is removed by surgicalescharotomy, enzymatic debridement, and/or mechanical debridement. Surgical escharotomy involves removal of eschar by making a full-length incision on the eschar. In enzymatic debridement, the removal of necrotic tissues is done using an enzymatic preparation. Mechanical debridement involves removal of damaged dead tissues and cellular debris physically. Eschars are not removed by application of heat or by freezing and cryotherapy. STUDY TIP: In the first pass through the exam, answer what you know and skip what you do not know. Answering the questions you are sure of increases your confidence and saves time. This is buying you time to devote to the questions with which you have more difficulty.

When teaching sun safety guidelines, what instructions should the nurse include when teaching about sunscreen lotion and creams? Select all that apply. 1 Sunscreens should have a minimum sun protection factor (SPF) of 15. 2 Sunscreens should be applied 20 to 30 minutes before going outdoors. 3 Sunscreens are not required in cloudy weather. 4 Sunscreens should be reapplied after 6 hours. 5 Sunscreens should be reapplied immediately after swimming.

1, 2, 5. Sunscreens are creams and lotions that filter both ultraviolet A and ultraviolet B rays and can prevent dermatologic problems. When choosing a sunscreen, the patient should consider one with SPF 15. A patient with a family or personal history of melanoma should be advised to use a sunscreen with SPF 30. Sunscreen should be applied on the skin 20 to 30 minutes before going outdoors. Though many sunscreens are waterproof, they should be reapplied immediately after swimming in case the sunscreen is diluted in the water or rubbed off. Sunscreen should be applied even in cloudy weather, as the ultraviolet rays can penetrate clouds. As the effect of a sunscreen decreases with time, it should be reapplied every 2 hours.

A nurse is instructing a group of caregivers about the home care of a patient with rheumatoid arthritis. What are the instructions that the nurse should include in the teaching? Select all that apply. 1 Perform aquatic exercise in warm water. 2 Never place pillows below the knees. 3 Ensure complete bed rest for patients. 4 Apply heat for at least 30-60 minutes. 5 Use lifts and elevators instead of the stairs.

1, 2, 5. The goals of rheumatoid arthritis therapy include satisfactory pain management and minimal loss of functional ability of the affected joints. Aquatic exercise in warm water helps in pain management. It helps relieve joint stiffness and allows the patient to perform daily activities more comfortably. Good body alignment while resting can be maintained, and to decrease the risk of joint contracture, pillows should never be placed under the knees. A small, flat pillow may be used under the head and shoulders. Lifts and elevators should be used rather than stairs to help protect the affected joint. Patients with RA should alternate between rest and activity regimens. Heat application should not exceed 20 minutes at a time, as it may aggravate the condition.

Which hormones act on a patient's mammary glands? Select all that apply. 1 Oxytocin 2 Prolactin 3 Growth hormone 4 Antidiuretic hormone 5 Thyroid stimulating hormone

1, 2. Oxytocin and prolactin act on the mammary glands. Oxytocin stimulates milk ejection from the breasts of lactating women and stimulates the rhythmic contraction of smooth muscles in the uterus. Prolactin is a lactogenic hormone that is responsible for the secretion of milk in lactating women. Growth hormone promotes bodily growth indirectly by stimulating the liver and other tissues. Antidiuretic hormone (ADH) acts on kidney tubules and promotes water retention by the kidney tubules. Thyroid stimulating hormone (TSH) stimulates the development and secretion of the thyroid gland.

To demonstrate an understanding of Somogyi effect, the nurse correctly identifies which defining characteristics? Select all that apply. 1 Documented morning hyperglycemia 2 Caused by not rotating insulin injection sites 3 May be avoided by consuming a bedtime snack 4 Treatment is a lower dose of insulin in the evening 5 Documented hypoglycemia between 2:00 AM and 4:00 AM 6 Requires an adjustment of administration time of evening insulin

1, 3, 4, 5. Hyperglycemia in the morning can be caused by the Somogyi effect, which can be stimulated by too much insulin in the evening. During the night, typically between 2:00 AM and 4:00 AM, hypoglycemia occurs, which stimulates a release in counterregulatory hormones in an attempt to raise the blood sugar. What results is rebound hyperglycemia resulting in higher blood sugar readings upon awakening. Somogyi effect must be differentiated from dawn phenomenon. which also results in higher morning blood sugar readings. The treatment for Somogyi effect includes consuming a bedtime snack or reducing the evening insulin dose, while the treatment for dawn phenomenon is an increase in the evening insulin dose or an adjustment in the timing of the evening insulin dose. Not rotating insulin injection sites does not result in either Somogyi effect or dawn phenomenon. In fact, current recommendations are to use the same anatomical injection site (ex. abdomen) for one week before moving to another anatomical injection site.

A patient who has been on a high dose of corticosteroids for one week for the treatment of polymyositis is complaining of weakness. What measures should be taken to ensure that the patient adheres to the therapy? Select all that apply. 1 Inform that benefit of therapy is often delayed. 2 Administer NSAIDs and immunomodulators. 3 Pay special attention to patient safety. 4 Use assistive devices as a fall prevention strategy. 5 Inform that medication will be replaced as soon as possible.

1, 3, 4. Corticosteroid therapy is often associated with weakness initially, and the positive effects are often delayed. The patient should be taught about the disease, prescribed therapies, diagnostic tests, and the importance of regular medical care. It is important for the patient to understand that the benefits of therapy are often delayed. Special attention should be paid to patient safety. The use of assistive devices as a fall prevention strategy should be encouraged. Replacement with other medications can be done if the patient is irresponsive to corticosteroid therapy for more than 4 weeks. Immunomodulators can be administered for conditions refractory to the therapy.

A patient has been prescribed isotretinoin (Accutane) for severe acne. What assessment should the nurse perform before administering the drug? Select all that apply. 1 Assess liver function test. 2 Perform pulmonary function tests. 3 Ask the patient whether she is pregnant. 4 Ask the patient whether she is planning to conceive. 5 Assess the patient's fluid intake.

1, 3, 4. The drug isotretinoin is known to interfere with liver functions and may also have teratogenic effects. Therefore, liver function tests should be conducted to test for abnormalities. The nurse should assess whether the patient is pregnant or planning to become pregnant before administering the drug. There is no need for pulmonary function tests. The amount of fluid intake by the patient does not contribute to the patient's condition as a result of taking this medication.

A patient is admitted to the orthopedic surgical unit for a fracture of the left tibia. What instructions should a nurse give concerning the prevention of venous thromboembolism? Select all that apply. 1 Wear compression gradient stockings. 2 Perform range-of-motion exercises on the left lower limb. 3 Perform range-of-motion exercises on the right lower limb. 4 Exercise toes of the left lower limb against resistance. 5 Exercise toes of the right lower limb against resistance.

1, 3, 4. There is a high risk of venous thromboembolism in the orthopedic surgical patient. Therefore measures should be taken by the attending nurse to prevent it. These measures include instructing the patient to wear compression gradient stockings (antiembolism hose) and to use sequential compression devices. The patient should also be encouraged to move (dorsiflex and plantar flex) the fingers or toes of the affected extremity against resistance and perform range-of-motion exercises on the unaffected lower extremities.

A patient is scheduled for a technetium [Tc]-99m bone scan. What nursing interventions are appropriate for the patient? Select all that apply. 1 Ensure that patient's bladder is emptied before scan. 2 Explain to the patient that blood sample will be obtained in the test. 3 Explain to the patient that radioisotope is given 2 hours before the procedure. 4 Explain to the patient that it will be painless, as general anesthesia will be administered. 5 Increase fluid intake after the examination.

1, 3, 5. A bone scan involves injecting a radioisotope (usually technetium [Tc]-99m) that is absorbed by the bone. A uniform uptake of the isotope is normal. The patient should empty the bladder before the procedure. The nurse should explain to the patient that radioisotope is given 2 hours before procedure. The patient should be informed that the procedure requires 1 hour while the patient lies supine and that no pain or harm will result from isotopes. Fluid intake should be increased after the examination to help elimination of the radioisotope through urine. No blood sample is needed, and anesthesia is not administered during this test.

The nurse is instructed to apply a swathe to a patient. What is true about a swathe? Select all that apply. 1 It is used for shoulder dislocations. 2 It is used for hip dislocations. 3 It encircles the trunk and humerus. 4 It encircles the trunk and femur. 5 It may be used after surgical repairs.

1, 3, 5. A swathe is a type of immobilizer used to prevent glenohumeral movement. It encircles the trunk and humerus as an additional binder and is often used after surgical repairs or shoulder dislocations. It is not used for hip dislocations and is not used to encircle the trunk and femur.

A patient suffering from major trauma has recovered. The patient received information that food items containing vitamin C would be beneficial for wound healing. The nurse should recommend which foods that contain the recommended vitamin? Select all that apply. 1 Yellow bell peppers 2 Seafood 3 Broccoli 4 Soy nuts 5 Citrus fruits

1, 3, 5. High vitamin C foods include yellow bell peppers, broccoli, and citrus fruits. Seafood is high in zinc, not vitamin C. Soy nuts are a good source of protein, not vitamin C. Vitamin C is an essential nutrient required by the body for the development and maintenance of scar tissue, blood vessels, and cartilage.

A nurse is assessing a patient with a bee sting. To relieve pain, what will most likely be included in the patient's treatment plan? Select all that apply. 1 Cold compresses 2 Chlorocyclohexane 3 Antipruritic lotion 4 gamma-Benzene hexachloride 5 Antihistamines

1, 3, 5. The symptoms of a bee sting are burning pain, swelling, and itching in the affected area. Cool compresses are used to reduce the burning sensation. Antipruritic lotion is used to reduce itching. Antihistamines are used for allergies. Chlorocyclohexane is used to control bedbugs. Gamma-benzene hexachloride is used to treat pediculosis.

The nurse is teaching a patient about the skin's ability to synthesize vitamin D when exposed to sunlight. Which instructions should the nurse include? Select all that apply. 1 Vitamin D is synthesized by the action of ultraviolet (UV) light. 2 The papillary layer helps in activating the precursors to vitamin D. 3 Ultraviolet rays act on vitamin D precursors present in the epidermis. 4 The reticular layer of the dermis plays an important role in vitamin D synthesis. 5 Endogenous synthesis of vitamin D is critical for calcium and phosphorus balance.

1, 3, 5. Vitamin D can be synthesized endogenously by the skin on exposure to sunlight. Endogenous synthesis of vitamin D, which is critical to calcium and phosphorus balance, occurs in the epidermis. Vitamin D is synthesized by the action of UV light on vitamin D precursors in epidermal cells. The papillary and reticular layers of dermis have no contribution to the endogenous synthesis of vitamin D.

When treating a patient with compartment syndrome, what measures should the nurse consider to be contraindicated? Select all that apply. 1 Elevation of the limb above heart level. 2 Bivalving of the bandage. 3 Application of cold compresses. 4 Reduction in traction weight. 5 Bandage removal.

1, 3. Elevation of the extremity may lower venous pressure and slow arterial perfusion. Therefore the extremity should not be elevated above heart level in case of compartment syndrome. Similarly, the application of cold compresses may result in vasoconstriction and exacerbate compartment syndrome. It may also be necessary to remove or loosen the bandage and split the cast in half (bivalving). A reduction in traction weight may also decrease external circumferential pressures.

Which hormones produced in a patient's body have an antagonistic effect on each other? Select all that apply. 1 Insulin 2 Prolactin 3 Growth hormone 4 Thyroid-stimulating hormone 5 Adrenocorticotropic hormone

1, 3. Insulin and growth hormone (GH) function as antagonists in the human body. Insulin is produced from the pancreas and has a hypoglycemic effect, because it promotes the entry of glucose into the cells. Growth hormone (GH) indirectly inhibits glucose metabolism and increases the blood glucose levels. Increased levels of GH cause an increase in glucose levels, which suppress insulin production. Prolactin is a lactogenic hormone that stimulates and promotes the secretion of milk in nursing mothers. Thyroid-stimulating hormone (TSH) promotes and maintains the development of the thyroid gland. Adrenocorticotropic hormone (ACTH) promotes and maintains the development of the cortex of the adrenal gland. Prolactin, TSH, and ACTH do not have antagonistic effects.

When performing the physical examination of a patient, how should the nurse assess the function of the peroneal nerve? Select all that apply. 1 Assess dorsiflexion of the foot. 2 Assess plantar flexion of the foot. 3 Assess sensation in the sole of the foot between the first and second toes. 4 Assess sensation in the sole of the foot between the third and fourth toes. 5 Assess sensation in the dorsal part of the foot between the first and second toes.

1, 3. The peroneal nerve has motor and sensory functions. The motor function is assessed by looking for dorsiflexion of the foot, whereas the sensory function is assessed by looking for sensation on the dorsal aspect of the foot between the first and second toes. Plantar flexion of the foot and sensory supplies to the sole of the foot are the functions of the tibial nerve. The function of the peroneal nerve is not assessed by sensation in the sole of the foot between the third and fourth toes or by sensation in the dorsal part of the foot between the first and second toes, because the peroneal nerve does not supply these areas.

A nurse is performing a musculoskeletal assessment on a patient. What are the findings that denote a normal musculoskeletal system? Select all that apply. 1 Muscle strength of 5 2 No eruptions on the joints 3 No pigmentation on the joints 4 No joint swelling, deformity, or crepitation 5 Full range of motion of all joints without pain or laxity 6 No tenderness on palpation of spine, joints, or muscles

1, 4, 5, 6. The components of a normal musculoskeletal system include muscle strength of 5, no joint swelling, deformity, or crepitation, a full range of motion of all joints without pain or laxity, and no tenderness on palpation of spine, joints, or muscles. Eruptions and pigmentations are characteristics of a skin assessment and are not included in musculoskeletal assessment.

A patient has been prescribed diclofenac sodium (Voltaren Gel). What precautions should be taken with its use? Select all that apply. 1 Avoid exposure to sunlight. 2 Antacids should be used concomitantly. 3 Sunscreen should be used concomitantly. 4 Avoid external heat or occlusive dressings. 5 Do not coadminister with oral aspirin (Ecotrin).

1, 4, 5. Diclofenac sodium is a nonsteroidal antiinflammatory drug. Its gel form is used topically to the affected joints. When using the drug, exposure to sunlight should be avoided to prevent ultraviolet ray-induced skin tumors (reported in animals). Also the use of external heat or occlusive dressing can lead to burns. Coadministration of oral aspirin should not be done due to the potential for increased side effects. Concomitant use of sunscreen lotion should be avoided, as it may result in skin reactions or change the absorption of the drug. Antacids are generally used for oral NSAIDs and not as topical formulations.

A patient will undergo a computed tomography (CT) scan of the knee joint. What nursing interventions should the nurse perform to prepare the patient for the procedure? Select all that apply. 1 Inform the patient that procedure is painless. 2 Ensure that the patient is shaved completely. 3 Administer local anesthesia and obtain a blood sample. 4 Inform the patient of the importance of remaining still during the procedure. 5 If a contrast medium is being used, verify that patient does not have shellfish allergy.

1, 4, 5. While preparing a patient for a CT scan, the nurse should inform the patient that the procedure is painless, and it is important to remain still during the procedure. If a contrast medium is being used, verify that the patient does not have a shellfish allergy. There is no need to shave the patient, as it does not involve any invasive techniques. For a CT scan, local anesthesia and blood samples are not needed because it is a noninvasive procedure.

When working with patients, the nurse knows that patients have the most difficulties with diarthrodial joints. Which joints are included in the group of diarthrodial joints? Select all that apply. 1 Hinge joint of the knee 2 Ligaments joining the vertebrae 3 Fibrous connective tissue of the skull 4 Ball and socket joint of the shoulder or hip 5 Cartilaginous connective tissue of the pubis joint

1, 4. The diarthrodial joints include the hinge joint of the knee and elbow, the ball and socket joint of the shoulder and hip, the pivot joint of the radioulnar joint, and the candyloid, saddle and gliding joints of the wrist and hand. The ligaments and cartilaginous connective tissue joining the vertebrae and pubis joint and the fibrous connective tissue of the skull are synarthrotic joints.

A nurse is conducting a class on the physiology of the integumentary system for a group of nursing students. To test the students' knowledge, the nurse asks them the reason for the greying of hair. What are appropriate responses? Select all that apply. 1 Decrease in the production of melanin 2 Increase in the production of melanin 3 Increase in the number of melanocytes 4 Decrease in the number of melanocytes 5 Decreased exposure to sun in old age

1, 4. With aging, the number of melanocytes decreases, causing a decrease in melanin production. An increase in the number of melanocytes causes an increase in the production of melanin, which is characterized by tanning of skin and darkening of hair. Exposure to sun is not related to the greying of hair.

The patient had a lumbar spine arthrodesis. What should the nurse include in discharge teaching? Select all that apply. 1 Do not smoke cigarettes. 2 You should not walk for three weeks. 3 You must wear your brace at all times. 4 You may drive as soon as you feel like it. 5 Do not bend your spine until your follow-up appointment.

1, 5. After a spinal fusion, the patient should not smoke cigarettes as nonunion tends to occur more often with smokers. Preventing pressure by not bending or twisting the spine or lifting more than 10 pounds will facilitate healing over time. The amount of time that is needed will be determined by the health care provider at follow-up appointments, but healing usually takes 6 to 9 months. An important aspect of healing is progressively increasing walking, which increases circulation of nutrients and oxygen for healing. If a brace is prescribed to protect the surgical area, the health care provider will prescribe how often the patient should wear it. Driving is not done until the health care provider allows it and the patient is no longer taking opioids for pain.

A nurse advises a patient with skin that is extremely sensitive to the sun to select a sunscreen which blocks both UVA and UVB rays. Which statements by the patient indicate that the teaching is effective? Select all that apply. 1 "The sunscreen should have an SPF of at least 15." 2 "The sunscreen should be waterproof." 3 "The sunscreen should be labeled as broad spectrum." 4 "The sunscreen should have benzophenone as the major constituent." 5 "The sunscreen should have Para-aminobenzoic Acid (PABA) as the major constituent."

2, 3, 4.

What measures should a nurse take to prevent muscle spasms in cases of musculoskeletal injuries? Select all that apply. 1 Massage the muscle spasms. 2 Align the affected extremity appropriately. 3 Use thermotherapy on the affected extremity. 4 Place the affected extremity in a comfortable position. 5 Provide isometric muscle strengthening exercises.

2, 3, 4. Muscle spasms are caused by involuntary muscle contraction after fracture, strain, or nerve injury. These may displace a nondisplaced fracture or prevent it from healing spontaneously. Therefore it is important to take measures to prevent muscles spasms. The affected extremity should be aligned appropriately. Thermotherapy may reduce muscle spasm. The extremity should be placed in a comfortable position. Massaging a muscle spasm may stimulate muscle tissue contraction, further increasing pain and spasm. Therefore it is not advisable to massage spasms. An isometric muscle strengthening exercise regimen will not prevent muscle spasms in this injured patient.

A nurse is caring for a patient with reported fracture of the tibia. A plaster cast has been applied to the patient. What interventions are important for the care of the cast during the drying period and immediately thereafter? Select all that apply. 1 Cover the cast with a cloth. 2 Avoid direct pressure on the cast. 3 Handle the cast gently with an open palm. 4 Avoid petaling the cast. 5 Place several strips of tape over the rough edges.

2, 3, 5. Avoid direct pressure on the cast during the drying period. Handle the cast gently with an open palm to avoid denting the cast. The health care provider should place several strips (petals) of tape over the rough areas to ensure a smooth cast edge. A fresh plaster cast should never be covered, because covering it prevents air from circulating; this lack of air circulation allows heat to build up in the cast (which may cause a burn) and may also result in a delay in drying. After drying, the edges may need to be petaled to avoid skin irritation from rough edges and to prevent plaster of Paris debris from falling into the cast and causing irritation or pressure necrosis.

A nurse is assessing a patient who has numerous nevi on the face. The nurse determines that the nevi are not cancerous. Which observations led the nurse to conclude that the nevi are normal? Select all that apply. 1 The nevi are larger than 5 mm in size. 2 The nevi are well circumscribed. 3 The nevi are dark in color. 4 The skin over the nevi is eroded. 5 There is discharge from the nevi

2, 3. Normal nevi are well circumscribed and dark in color. Atypical or dysplastic nevi are larger than 5mm in size. Eroded skin around the nevi and discharge of pus from the nevi are not associated with normal nevi. They are associated with skin cancer.

A patient with acute osteomyelitis has been prescribed gentamicin (Garamycin) therapy. Before initiating the therapy, what actions should the nurse take? Select all that apply. 1 Monitor blood glucose levels. 2 Monitor serum creatinine levels. 3 Check for symptoms of dehydration. 4 Determine number of red blood cells. 5 Assess for symptoms of pulmonary edema.

2, 3. The nurse should determine if the patient has symptoms of dehydration to prevent hypovolemia. Gentamicin (Garamycin) is an aminoglycoside antibiotic that causes fluid loss and impairs renal functioning. The nurse should evaluate the patient's renal function by monitoring serum creatinine levels. This intervention helps reduce the risk of renal disorders in the patient. Gentamicin (Garamycin) does not impair pancreatic functioning and does not increase blood glucose levels. Corticosteroids increase blood glucose levels. Gentamicin (Garamycin) will not alter the red blood cell count; chemotherapeutic medications do. Gentamycin does not cause pulmonary edema in the patient; excess fluid volume causes pulmonary edema.

A nurse is caring for a patient with quadriplegia who is confined to bed. The patient shows signs of skin irritation. Which measures are appropriate for preventing further skin damage when bathing the patient? Select all that apply. 1 Use hot water for baths. 2 Scrub the skin very lightly. 3 Use lipid-free cleansers. 4 Use soaps having a high acid content. 5 Apply a moisturizer after wiping the skin dry with a towel.

2, 3. The patient shows signs of skin irritation, so the skin should be scrubbed lightly. Vigorous scrubbing may increase skin irritation. Use of mild, lipid-free cleansers can also reduce skin irritation. Hot water can increase the dryness of the skin, making it more prone to irritation. Soaps having high acid content can also cause skin irritation and are therefore not recommended for this patient. Moisturizers should always be applied on damp skin so that the moisture is sealed.

A patient sustained a fall 1 week ago, but did not have a fracture. The patient reports pain in the right hip, which increases in intensity with activity. The patient has a fever and the site of injury is swollen and tender to the touch. Which diagnostic tests would help determine the cause of the patient's condition? Select all that apply. 1 X-ray of the hip 2 Bone tissue biopsy 3 White blood cell count 4 Radionuclide bone scans 5 Magnetic resonance imaging

2, 4, 5. Osteomyelitis and its causative organisms are best determined through a bone tissue biopsy, which involves the excision of a small amount of tissue from the affected area. Radionuclide bone scans may be helpful in indicating the area of infection. Magnetic resonance imaging may help to identify the extent of infection in the hip bone. X-ray of the hip may not show the osteomyelitic changes immediately; it could be only evident after 10 days or few weeks. The white blood cell count may be elevated due to infection, but the test is very non-specific.

An occupational health nurse is conducting an awareness program to prevent limb amputations. When explaining the risk of amputation, which population group would the nurse indicate as at high risk for amputation? Select all that apply. 1 Patients with ulcerative colitis 2 Patients with diabetes mellitus 3 Patients with myasthenia gravis 4 Patients with chronic osteomyelitis 5 Patients with peripheral vascular disease

2, 4, 5. Patients with diabetes mellitus, chronic osteomyelitis, or peripheral vascular disease are predisposed to increased risk of amputation. Controlling these diseases can eliminate or delay the need for amputation. Ulcerative colitis and myasthenia gravis do not lead to gangrene in the limbs or to amputation

A patient has been advised treatment with gold sodium thiomalate (Myochrysine) therapy for rheumatoid arthritis. What precautions should be taken to ensure patient safety? Select all that apply. 1 Monitor pulmonary output. 2 Monitor hepatic and renal function. 3 Administer monthly electrocardiogram (ECG). 4 Advise patient to immediately report body rash. 5 Rule out pregnancy before initiation of therapy.

2, 4, 5. The treatment with parenteral gold compounds is often associated with undue side effects. Monitoring the hepatic and renal function is necessary to eliminate the advent of hepatotoxicity and renal toxicity. Many patients on this therapy are more sensitive to sun rays and often develop rashes. Gold compounds are toxic to the fetus and induce abnormalities; therefore, pregnancy should be ruled out before use. However, pulmonary output and ECG are not desirable, as the gold compounds do not have adverse effects on these systems.

Which discharge instructions would a nurse give to a patient with a cast? Select all that apply. 1 Use talcum powder under the cast as needed. 2 Keep the extremity elevated as much as possible. 3 Take pain medications only when the pain is unbearable. 4 Report a fever or a foul odor coming from beneath the cast. 5 Report itching under the cast that could indicate an infection. 6 Keep the extremity in a dependent position as much as possible.

2, 4. A fever or a foul odor coming from beneath the cast may indicate an infection and requires immediate attention. No product such as talcum powder, cornstarch, or lotion should be put down a cast to relieve itching, because this may increase the risk of infection. If pain is present, the patient should take pain medication before reaching an unbearable level. Itching under the cast is normal and does not need to be reported to the primary healthcare provider, but the patient must be advised to avoid scratching, because breaks in the skin under the cast can easily become infected. The extremity should be elevated as much as possible to prevent edema. Keeping the extremity elevated, not dependent, decreases edema.

A patient has been admitted to the hospital for a scheduled knee arthroplasty. What should a nurse do in the preoperative management of this patient? Select all that apply. 1 Assess muscle strength in the lower limbs. 2 Assess muscle strength in the upper limbs. 3 Assess joint function of the lower limbs. 4 Assess joint function of the upper limbs. 5 Assess pain sensation in the lower limbs. 6 Assess pain sensation in the upper limbs.

2, 4. If lower extremity surgery is planned, the nurse should assess upper extremity muscle strength and joint function to determine the type of assistive devices needed postoperatively for ambulation and activities of daily living. Therefore, in this case, the assessment of muscle strength and joint function of the upper limbs is required. Assessment of pain sensation is not important.

A 35-year-old man fell from a 20-foot height onto his right elbow. The radiograph revealed a fracture in the middle third of the right humerus, with sharp edges. What are the structures that may be at risk of damage due to the sharp edges of broken bone in this patient? Select all that apply. 1 Axillary nerve 2 Radial nerve 3 Brachial plexus 4 Brachial artery 5 Ulnar nerve

2, 4. The radial nerve is present in the axillary groove of the humerus, and the brachial artery is located on the anterior aspect of the humerus. Therefore the radial nerve and brachial artery are likely to be damaged by the sharp edges of fractured bone margins of the humerus. The axillary nerve and brachial plexus are present in the axilla. Therefore they are unlikely to be damaged. The ulnar nerve is usually unaffected by bone fractures, owing to the presence of muscles and soft tissues.

When assessing the skin of an older adult, which findings would the nurse consider normal? Select all that apply. 1 Excoriation 2 Fissure 3 Dry skin 4 Wrinkling 5 Decreased turgor

3, 4, 5. Older adults do not have the same skin as younger adults, and there are many skin changes associated with aging that are normal. These include dry skin, wrinkling, and a decrease in turgor. Older adults may have decreased extracellular water, surface lipids, and sebaceous gland activity, leading to dry skin. Decreased subcutaneous fat, muscle laxity, degeneration of elastic fibers, and collagen stiffening may lead to wrinkling and decreased turgor. Excoriation and fissures are abnormal findings on the skin and need further evaluation.

A patient will undergo debridement of the shoulder joint. After the nurse explains the procedure, the patient asks the nurse what will be removed from the joint. How should the nurse answer? Select all that apply. 1 Synovial membrane 2 A wedge of bone 3 Joint debris 4 Degenerated menisci 5 Osteophytes

3, 4, 5. The procedure of debridement involves removing from a joint any devitalized tissue, such as loose bodies, joint debris, degenerated menisci, and osteophytes. This procedure is usually performed on the knee or the shoulder using a fiber optic arthroscope. Removal of synovial membrane is called synovectomy. The removal of a wedge of bone is called osteotomy.

The nurse is performing a physical examination on a patient with sciatica. Which statements are correct for the straight-leg-raising test? Select all that apply. 1 The patient should lie prone for the test. 2 The patient is instructed to actively raise his or her legs to 60 degrees. 3 The test is positive if the patient complains of pain along the distribution of the sciatic nerve. 4 A positive test indicates nerve root irritation from intervertebral disc prolapse and herniation. 5 The nerve root at the level of L4-5 or L5-S1 may be involved.

3, 4, 5. The straight-leg-raising test is performed on a patient with sciatica or leg pain. The test is positive if the patient complains of pain along the distribution of the sciatic nerve when the leg is raised to 60 degrees or less. A positive test indicates nerve root irritation from intervertebral disc prolapse and herniation; usually, the nerve root at the level of L4-5 or L5-S1 is involved. The test is conducted with the patient in supine position. The nurse passively raises the patient's legs 60 degrees or less.

A patient with scleroderma is troubled by hyperacidity. What instructions should the nurse give to the patient to help alleviate this condition? Select all that apply. 1 Use dairy products. 2 Increase coffee intake. 3 Elevate head position while sleeping. 4 Use antacids 45 to 60 minutes after meal. 5 Do not sleep immediately after eating food.

3, 4, 5. Using antacids neutralizes the gastric acids released after ingestion of food. Using additional pillows or raising the head of the bed on blocks may help reduce nocturnal gastroesophageal reflux. The patient should not sleep immediately after a meal. The patient should be instructed to sit upright for at least 2 hours after eating to prevent gastric reflux. Increasing coffee intake or dairy products can cause acid reflux.

A patient is one day postoperative after having a hernia repair. During the morning assessment, the nurse notes that the patient has incisional pain, a 99.2° F temperature, slight redness at the incision margins, and 20 mL of serosanguineous drainage in the Jackson-Pratt drain. Based on these assessment data, what conclusion would the nurse make? 1 The abdominal incision is showing signs of an infection. 2 The patient's abdominal hernia repair was not successful. 3 The patient is experiencing a normal inflammatory response. 4 The abdominal incision is showing signs of impending dehiscence.

3. The local response to inflammation includes the manifestations of redness, heat, pain, swelling, and loss of function. Typical drainage from a surgical tube is serosanguionous; purulent drainage would indicate an infection. The response is normal, not a sign of infection or of impending dehiscence. The symptoms do not necessarily indicate the hernia repair was not successful.

A patient asks the nurse what the surgeon meant by "the wound will be allowed to heal by secondary intention." How should the nurse explain this to the patient? 1 The wound will be stapled together until it heals. 2 The healing will contract the area to close the wound. 3 The wound will be left open and heal from the edges inward. 4 The wound will be sutured after the current infection is controlled

3. With secondary healing, the wound is left open and heals from the edges inward and from the bottom up. With primary intention, the wound edges are stapled or sutured, and healing occurs until the contraction of the healing area closes the defect and brings the skin edges closer together to form a mature scar. With tertiary healing, the contaminated wound is left open and closed after the infection is controlled. TEST-TAKING TIP: Monitor questions that you answer with an educated guess or changed your answer from the first option you selected. This will help you to analyze your ability to think critically. Usually your first answer is correct and should not be changed without reason.

A patient with scleroderma has been recommended to exercise daily. Which exercises should the nurse suggest to the patient? Select all that apply. 1 Jogging 2 Dancing 3 Swimming 4 Mouth excursion 5 Isometric exercises

4, 5. Mouth excursion (yawning with an open mouth) is a good exercise to help with temporomandibular joint function. Isometric exercises prevent skin retraction and promotes vascularization. Isometric exercises are most appropriate if the patient has arthropathy, as these do not involve joint movements. Jogging, dancing, and swimming may be exhausting. The patient should adopt activities that preserve strength and reduce disability.

A nurse is assessing a client who has a casted compound fracture of the right forearm. Which of the following findings is an early indication of neurovascular compromise? A. Paresthesia B. Pulselessness C. Paralysis D. Pallor

A

A nurse is caring for a child who has cellulitis on the hand. Which of the following is an appropriate action for the nurse to take? A. Apply hot compresses. B. Cleanse area using Burow's solution. C. Prepare for cryotherapy. D. Administer antifungal medication.

A

A nurse is caring for a client who has a major burn and is experiencing severe pain. Which of the following is an appropriate nursing intervention to manage this client's pain? A. Administer morphine sulfate IV via continuous infusion. B. Administer meperidine (Demerol) IM as needed. C. Administer acetaminophen (Tylenol) PO every 4 hr. D. Administer hydrocodone (Vicodin) PO every 6 hr.

A

The patient has had rashes and alopecia. What vitamin in which foods should be encouraged as a nutritional aid to these problems? 1 Vitamin A in sweet potatoes, carrots, and dark leafy greens 2 Vitamin B7 (biotin) in liver, cauliflower, salmon, and carrots 3 Vitamin C in peppers, dark leafy greens, broccoli, and kiwi 4 Vitamin D in canned salmon, sardines, fortified dairy, and eggs

A deficiency of Vitamin B7 (biotin) may result in rashes and alopecia. Eating foods with biotin will help decrease these problems. Vitamins A and C are needed for wound healing . Vitamin D is needed for bone and body health.

Which laboratory test is the best indicator of glucose control and long-term diabetes management in the patient with type 2 diabetes mellitus? 1 Urine microalbumin 2 Oral glucose tolerance test 3 A glycoslated hemoglobin level 4 Fasting blood sugar

A glycosylated hemoglobin level detects the amount of glucose that is bound to red blood cells. When circulating glucose levels are high, glucose attaches to the red blood cells and remains there for the life of the blood cell, which is approximately 120 days. Thus, the test can give an indication of glycemic control over approximately two months. Urine microalbumin is used to monitor microvascular kidney damage secondary to poor blood glucose control. Fasting blood sugar and oral glucose tolerance testing indicates current, not long-term, blood sugar levels.

During a health screening event, which assessment finding would alert the nurse to the possible presence of osteoporosis in a white 61-year-old female? 1 The presence of bowed legs 2 A measurable loss of height 3 Poor appetite and aversion to dairy products 4 Development of unstable, wide-gait ambulation

A gradual but measurable loss of height and the development of kyphosis or "dowager's hump" are indicative of the presence of osteoporosis, in which the rate of bone resorption is greater than bone deposition. Bowed legs may be caused by abnormal bone development or rickets but is not indicative of osteoporosis. Lack of calcium and Vitamin D intake may cause osteoporosis, but are not indicative of osteoporosis. A wide gait is used to support balance and does not indicate osteoporosis.

Which assessment parameter is of highest priority when caring for a patient undergoing a water deprivation test? 1 Serum glucose 2 Patient weight 3 Arterial blood gases 4 Patient temperature

A patient is at risk for severe dehydration during a water deprivation test. The test should be discontinued and the patient rehydrated if the patient's weight drops more than 2 kg at any time. Serum glucose, arterial blood gases, and the patient's temperature do not assess fluid balance.

A patient is receiving alendronate (Fosamax) for treatment of osteoporosis. The nurse would become concerned after noting which action by the patient? The patient: 1 Takes the medication with 8 ounces of water 2 Increases intake of calcium and vitamin D 3 Takes the medication immediately before bed 4 Continues to perform weight-bearing exercises

A patient taking alendronate should remain in an upright position, not lie down and go to bed. Alendronate is indicated for the treatment of osteoporosis and should be taken with a full glass of water. The patient should then remain in an upright position for at least 30 minutes to reduce epigastric discomfort. Taking the medication with 8 ounces of water, increased intake of calcium and vitamin D, and weight-bearing exercises are all correct actions.

Which forefoot disorder is associated with swelling of the bursa and formation of a callus over a bony enlargement? 1 Hallux valgus 2 Morton's neuroma 3 Hammertoe 4 Hallux rigidus

A patient with Hallux valgus disorder, or a bunion, has a painful deformity of the great toe towards the second toe. Swelling of the bursa and formation of a callus over a bony enlargement are the common symptoms of a bunion. A Morton's neuroma is characterized by a neuroma developing in the web space between the third and fourth metatarsal heads. The neuroma causes sharp and sudden attacks of pain and a burning sensation in the patient. With hammertoe, the patient has difficulty walking or wearing shoes and pain and a burning sensation on the bottom of the foot. Hallux rigidus is associated with painful stiffness at the metatarsophalangeal joint.

A patient with diabetes mellitus who has multiple infections every year needs a mitral valve replacement. What is the most important preoperative teaching the nurse should provide to prevent a cardiac infection postoperatively? 1 Avoid sick people and wash hands 2 Obtain comprehensive dental care 3 Maintain hemoglobin A1C below 7% 4 Coughing and deep breathing with splinting

A person with diabetes is at high risk for postoperative infections. The most important preoperative teaching to prevent a postoperative infection in the heart is to have the patient obtain comprehensive dental care because the risk of septicemia and infective endocarditis increases with poor dental health. Avoiding sick people, hand washing, maintaining hemoglobin A1c below 7%, and coughing and deep breathing with splinting would be important for any type of surgery, but not the priority with mitral valve replacement for this patient.

The nurse is assessing the recent health history of a 43-year-old patient with osteoarthritis. The nurse determines that the patient was managing the condition well when the patient states that his or her activity pattern has consisted of which of the following? 1 Minimal exercise with frequent rest periods 2 Bed rest and walking to the restroom 3 Walking and swimming regularly 4 Running three miles most days of the week

A regular low-impact exercise such as walking is important in helping to maintain joint mobility in the patient with osteoarthritis. Exercise should continue to improve symptom management and decrease pain. Bed rest is not warranted and high impact exercise, such as running, may worsen pain.

A nurse is assessing the recent health history of a 63-year-old patient with osteoarthritis (OA). The nurse determines that the patient is trying to manage the condition appropriately when the patient describes which activity pattern? 1 Bed rest with bathroom privileges 2 Daily high-impact aerobic exercise 3 Regular exercise program that involves walking 4 Frequent rest periods with minimal exercise

A regular low-impact exercise, such as walking, is important in helping to maintain joint mobility in the patient with osteoarthritis. A balance of rest and activity is needed. High-impact aerobic exercises would cause stress to affected joints and further damage.

A 54-year-old patient admitted with cellulitis and probable osteomyelitis received an injection of radioisotope at 9:00 am before a bone scan. At what time should the nurse plan to send the patient for the bone scan? 1 9:30 pm 2 10:00 am 3 11:00 am 4 1:00 pm

A technician usually administers a calculated dose of a radioisotope two hours before a bone scan. If the patient was injected at 9:00 am, the procedure should be done at 11:00 am. 10:00 am would be too early; 1:00 pm and 9:30 pm would be too late.

A patient's recent medical history is indicative of diabetes insipidus. The nurse would perform patient teaching related to which diagnostic test? 1 Thyroid scan 2 Fasting glucose test 3 Oral glucose tolerance 4 Water deprivation test

A water deprivation test is used to diagnose the polyuria that accompanies diabetes insipidus. Glucose tests and thyroid tests are not related directly to the diagnosis of diabetes insipidus.

A nurse is planning care for a child who has tinea capitis. Which of the following should the nurse include in the plan of care? (Select all that apply.) A. Treat infected house pets. B. Use selenium sulfide shampoo. C. Cleanse area with Burow's solution. D. Administer antiviral medication. E. Use moist, warm compresses.

A, B

A nurse is caring for a child who has a fracture. Which of the following are clinical manifestations of a fracture? (Select all that apply.) A. Crepitus B. Edema C. Pain D. Fever E. Ecchymosis

A, B, C, E

A 15 year-old is admitted to the intensive care unit (ICU) with a spinal cord injury. The most appropriate nursing interventions for this adolescent are (select all that apply) A. monitoring neurologic status. B. administering corticosteroids. C. monitoring for respiratory complications. D. discussing long-term care issues with the family. E. monitoring and maintaining hemodynamic status.

A, B, C, E. <div>Close monitoring of sensory and motor function is important to prevent further deterioration of neurologic status as a result of spinal cord edema.<br> Corticosteroids are administered to minimize the inflammation associated with the injury.<br> Close monitoring of respiratory status for possible need of ventilator support. Remember A-B-Cs, airway, breathing, circulation.<br> Monitoring and maintaining hemodynamic status may require immediate attention related to increased intracranial pressure resulting in hypotension and bradycardia.<br> The discussion of long-term care issues with the family is not appropriate in the acute phase of spinal cord injury.</div>

A nurse is assessing an infant who has eczema. Which of the following are clinical manifestations of eczema in an infant? (Select all that apply.) A. Generalized distribution B. Papules C. Clusters D. Crusting lesions E. Lichenification

A, B, D

A nurse is caring for a client who has major burns and suspected septic shock. Which of the following findings are consistent with septic shock? (Select all that apply.) A. Increased body temperature B. Altered sensorium C. Decreased capillary refill D. Decreased urine output E. Increased bowel sounds

A, B, D

A nurse is instructing a client on home care after a culture for a bacterial infection and cellulitis. Which of the following information should the nurse include in the teaching? (Select all that apply.) A. Bathe with antibacterial soap. B. Apply antibacterial topical medication to the crusted exudate. C. Apply warm compresses to the affected area. D. Cover affected area with snug fitting clothing. E. Allow lesions to dry before applying topical medication.

A, C, E

Based on the nurse's knowledge of wounds and wound healing, what are factors that can delay or cause dysfunctional wound healing? (Select all that apply) A. Overweight B. Hypoxemia C. Hypervolemia D. Prolonged infection E. Corticosteroid therapy

A, C, E. Poor nutrition without proper protein and calorie intake affects healing more than being overweight itself. Hypovolemia, not hypervolemia, inhibits wound healing due to low circulating blood volume and oxygenation of tissues. Corticosteroid therapy or other immunocompromising therapy prevents macrophages from migrating to the site of injury, thus suppressing epithelialization. Hypoxemia makes tissues more susceptible to infection due to insufficient oxygenation. Prolonged infection affects the healing process and causes increased scarring.

A nurse is assessing a client who has osteoarthritis of the knees and fingers. Which of the following clinical manifestations should the nurse expect to find? (Select all that apply.) A. Heberden's nodes B. Swelling of all joints C. Small body frame D. Enlarged joint size E. Limp when walking

A, D, E

The nurse is teaching an adolescent, newly diagnosed with type I diabetes, ways to minimize discomfort with insulin injections. Which interventions are helpful in minimizing injection discomfort? (Select all that apply.) A. Do not reuse needles B. Inject insulin when it is cold C. Flex or tense the muscle during injection D. Remove all bubbles from the syringe prior to injection E. Do not move the direction of the needle-syringe during insertion or withdrawal

A, D, E. <div>The reuse of needles leads to more discomfort on injection from decreased sharpness of the needle and being an infection control problem.<br>Removing bubbles from the syringe will minimize discomfort.<br>Keeping the direction of the syringe constant during the insertion and withdrawal minimizes discomfort.<br>Insulin should be injected at room temperature to minimize discomfort.<br>Flexing or tensing muscles during injections causes more discomfort.</div>

The nurse is caring for a 12-year-old who sustained major burns when putting charcoal lighter on a campfire. The nurse observes that the child is "very brave" and appears to accept pain with little or no response. What is the most appropriate nursing action related to this? A. Request a psychological consultation. B. Ask the child why the child does not have pain. C. Praise the child for the ability to withstand pain. D. Encourage continued bravery as a coping strategy.

A. A psychological consultation will assist the child in verbalizing fears. This age group is very concerned with physical appearance. The psychologist can help integrate the issues the child is facing. It is likely that the child is having pain but not acknowledging the pain. Speaking with a psychologist might assist the child in relaying his or her fears and pain. If the child is feeling pain, the nurse should not praise the child for hiding the pain. The nurse should encourage the child to speak up during painful episodes so that the pain can be managed appropriately. Bravery may not be an effective coping strategy if the child is in severe pain.

A breastfed newborn has just been diagnosed with galactosemia. The therapeutic management for this newborn is to A. stop breastfeeding. B. add amino acids to the breast milk. C. substitute a lactose-containing formula for breast milk. D. give the appropriate enzyme along with breast milk.

A. All milk- and lactose-containing formulas, including breast milk, must be stopped during infancy. Soy protein is the formula of choice for newborns and infants with galactosemia. Breast milk should not be used in newborns and infants with galactosemia. The formula used for a newborn and infant with galactosemia cannot contain lactose. Breast milk should not be used in newborns and infants with galactosemia.

Which statement is the most descriptive of rhabdomyosarcoma? A. The most common sites are the head and neck. B. It is a common hereditary neoplasm of childhood. C. It is the most common bone tumor of childhood. D. It is a benign tumor and unusual in children.

A. Although striated muscle fibers from which this tumor arises can be found anywhere in the body, the most common sites are the head and neck. Rhabdomyosarcoma is not known to be hereditary. Rhabdomyosarcoma arises from skeletal muscle tissue, not bone. Rhabdomyosarcoma is highly malignant.

A 6-year-old child born with a myelomeningocele has a neurogenic bladder. The parents have been performing clean intermittent catheterization. What should the nurse recommend? A. Teach the child to do self-catheterization. B. Teach the child appropriate bladder control. C. Continue having the parents do the catheterization. D. Encourage the family to consider urinary diversion.

A. At 6 years of age, this child should have the dexterity to perform the intermittent catheterization. This will give the child more control and mastery over the disability. Bladder control cannot be taught in a child with a neurogenic bladder. School-age children, even as young as 6 years, should be able to begin self-catheterization. A urinary diversion is not necessary for a neurogenic bladder.

The nurse is planning care for a child recently diagnosed with diabetes insipidus. Which nursing intervention should be planned? A. Encourage the child to wear medical identification. B. Discuss with the child and family ways to limit fluid intake. C. Teach the child and family how to do required urine testing. D. Reassure the child and family that diabetes insipidus is usually not a chronic or life-threatening illness.

A. Because of the unstable nature of the child's fluid and electrolyte balance, wearing a medical alert bracelet or carrying a medical identification card is an extremely important intervention. With diabetes insipidus, the child should have unrestricted access to fluids because the child will characteristically have polyuria due to a hyposecretion of antidiuretic hormone. No urine testing is required with diabetes insipidus. This disorder should not be confused with diabetes mellitus. Diabetes insipidus is both lifelong and life-threatening. Medication must be taken and the effects monitored closely.

Which statement best describes Cushing syndrome? A. It is caused by excessive production of cortisol. B. The major clinical features are exophthalmia and pigmentary changes. C. Treatment involves replacement of cortisol. D. Diagnosis is suspected with findings of hypotension, hyperkalemia, and polyuria.

A. Cushing syndrome is a description of the clinical manifestations caused by too much circulating cortisol. Exophthalmia and pigmentary changes are manifestations of hyperthyroidism, not Cushing syndrome. The treatment for Cushing syndrome involves the reduction of circulating cortisol. If the cause is a pituitary tumor, surgery is indicated. Hypertension and hypokalemia—not hypotension, hyperkalemia, or polyuria—are expected findings with Cushing syndrome.

The nurse is caring for a child hospitalized with acute adrenocortical insufficiency. The acute phase seems to be over when ascending flaccid paralysis occurs. What is the most appropriate nursing action? A. Reassure the family that this condition is temporary. B. Reassure the family that flaccid paralysis is not problematic. C. Prepare the family for impending death. D. Prepare the family for the long-term consequences of paralysis.

A. During the recovery phase, paralysis may develop. It is a temporary, quickly reversible clinical manifestation. Flaccid paralysis is problematic if not reversible. Flaccidity can indicate impending death in a child with neurologic deficits but is not associated with adrenocortical insufficiency. Ascending flaccid paralysis is a reversible condition when associated with adrenocortical insufficiency. Paralysis is a temporary, quickly reversible clinical manifestation.

What is the most important nursing consideration related to congenital hypothyroidism? A. Early identification of the disorder B. Facilitation of parent-infant attachment C. Initiation of referrals for mental retardation D. Help for parents in dealing with the child's future prospects

A. Early diagnosis of congenital hypothyroidism is imperative. Because brain growth is complete by 2 to 3 years of age, the thyroid hormone deficiency must be detected and replacement therapy begun as soon as possible to prevent long-term or life-threatening complications. The promotion of parent-infant attachment is important with all infants. With appropriate intervention, the child may not have any developmental deficit. With appropriate intervention, the child may not have any developmental deficit.

An infant is born with ambiguous genitalia. Tests are being done to assist in gender assignment. The parents tell the nurse that family and friends are asking what caused the baby to be this way. What should the nurse's explanation include? A. Explain the disorder so that the parents can explain it to others. B. Help the parents understand that no one knows how this occurs. C. Suggest that the parents avoid family and friends until the gender is assigned. D. Encourage the parents not to worry while the tests are being done.

A. Explaining the disorder to the parents so that they can explain it to others is the most therapeutic approach while the parents await the gender assignment of their child. Ambiguous genitalia are caused by decreased enzyme activity required for adrenocortical production of cortisol. Avoidance of family and friends is impractical and would isolate the family from their support system while awaiting test results. The parents will be concerned. Telling the parents not to worry without giving them specific alternative actions will not be effective.

During the summer, many children are more physically active. What changes in the management of the child with type 1 diabetes mellitus should be expected as a result of more exercise? A. Increased food intake B. Decreased food intake C. Increased risk of hyperglycemia D. Decreased risk of insulin shock

A. Food intake should be increased in the summer when the child is more active. During races and other competitions, more food may be required than at other practice times to maintain a balance between glucose and exogenously administered insulin. The child will require increased food on days of increased activity. The increased activity lowers blood glucose levels. Blood sugars must be monitored closely to avoid administering too much insulin during a time of reduced need.

Which measure is important in managing hypercalcemia in a child who is immobilized? A. Promote adequate hydration B. Change position frequently C. Encourage a diet high in calcium D. Provide a diet high in protein and calories

A. Hydration is extremely important to help remove the excess calcium from the body. This can help prevent hypercalcemia. Changing the child's position frequently will help with managing skin integrity but will not affect calcium levels. The calcium will not be incorporated into bone because of the lack of weight bearing. The child is at risk of developing hypercalcemia. The child's metabolism is slower because of the immobilization. A diet with sufficient calories and nutrients for healing is important.

Which statement is most accurate in describing tetanus? A. Acute infectious disease caused by an exotoxin produced by an anaerobic, gram-positive bacillus B. Inflammatory disease that causes extreme, localized muscle spasm C. Acute infection that causes meningeal inflammation, resulting in symptoms of generalized muscle spasm D. Disease affecting the salivary gland with resultant stiffness of the jaw

A. Tetanus is an acute, preventable disease caused by an exotoxin produced by an anaerobic spore-forming, gram-positive bacillus, Clostridium tetani. Tetanus is caused by the effect of the exotoxins becoming fixed on nerve cells and is not an inflammatory disorder that causes muscle spasms. Tetanus is not an acute infection that leads to generalized muscle spasms. Tetanus is not a disease that affects the salivary glands, with resultant stiffness of the jaw.

Which physiologic alteration is characterized by destruction of pancreatic beta cells that produce insulin? A. Type 1 diabetes B. Type 2 diabetes C. Impaired glucose tolerance D. Gestational diabetes

A. Type 1 diabetes is characterized by destruction of the insulin-producing pancreatic beta cells. Type 2 diabetes is a result of insulin resistance. The insulin-producing pancreatic beta cells are destroyed in type 1 diabetes and are not associated with impaired glucose tolerance. Gestational diabetes occurs during pregnancy and is not associated with the destruction of pancreatic beta cells that produce insulin.

A patient is admitted with dehydration and polyuria. The nurse knows that the patient might be experiencing an alteration in which hormone? 1 Antidiuretic hormone (ADH) 2 Follicle-stimulating hormone (FSH) 3 Thyroid-stimulating hormone (TSH) 4 Adrenocorticotropic hormone (ACTH)

ADH decreases urine production by causing the renal tubules to reabsorb water from the urine and return it to the circulating blood. This patient is demonstrating excessive urination, which might indicate an alteration in this hormone. FSH functions in ovum and sperm formation. TSH stimulates thyroid function. ACTH stimulates adrenal function.

Which patient statement most clearly suggests a need to assess the patient for ankylosing spondylitis (AS)? 1 "My right elbow has become red and swollen over the last few days." 2 "I wake up stiff every morning and my knees just don't want to bend." 3 "My spouse tells me that my posture has become so stooped this winter." 4 "My lower back pain seems to be getting worse all the time and nothing seems to help."

AS primarily affects the axial skeleton. Based on this, symptoms of inflammatory spine pain are often the first clues to a diagnosis of AS. Knee or elbow involvement is not consistent with the typical course of AS. Back pain is likely to precede the development of kyphosis.

The nurse is caring for a patient with pain in the posterior leg, initially when walking and later at rest. What does the nurse suspect based on these symptoms? 1 Atrophy 2 Ankylosis 3 Antalgic gait 4 Achilles tendonitis

Achilles tendonitis occurs due to cumulative stress on the Achilles tendon resulting in inflammation. Initially the patient experiences pain in the posterior leg while running or walking and later it is felt even at rest. Atrophy occurs due to muscle denervation, contracture, and prolonged disuse. It results in a flabby appearance of the muscle with decreased function and tone. Ankylosis occurs due to chronic joint inflammation and destruction. It results in stiffness and fixation of a joint. Antalgic gait occurs due to trauma or other disorders. There is pain in the lower extremity on bearing weight. It results in shortened strides with little weight-bearing on the affected side.

A patient asks the nurse why an arthrogram has been scheduled. The nurse should reply that this test is designed to identify: 1 Fractures of the bone 2 The risk for osteoporosis 3 Disorders of the cartilage 4 Peripheral vasculature patency

An arthrogram involves the injection of a radiopaque solution into a joint to outline the joint for visualization of cartilage and joint structures. It is useful in diagnosing an arthropathy. An arthrogram may show fractures, but this is not its primary purpose. An arthrogram will not show bone abnormalities such as osteoporosis. The test does not show vasculature structures or abnormalities.

The nurse interacts with a patient who has arrived at the hospital for a scheduled electromyogram. The nurse concludes that that the test will need to be rescheduled based on what patient statement? 1 "I drank apple juice last night." 2 "I have been taking antibiotics for one week." 3 "I have had knee pain since early this morning." 4 "I drank 2 cups of coffee this morning."

An electromyogram helps to record electrical activity of the muscles. The nurse should advise the patient to refrain from taking stimulants, such as caffeine, for 24 hours before the test. If a patient drinks 2 cups of coffee on the day of the scheduled test, it may alter the test results. The nurse should alert the primary care provider of the finding so the test can be rescheduled for more accurate results. Drinking apple juice does not impair the electrical activity of the muscles. Antibiotics do not alter the test results. An electromyogram helps to assess muscle activity but not knee pain; therefore, knee pain will not affect the test results.

A patient with a fracture of the femur has the extremity in skeletal traction and is encouraged to use an overhead trapeze apparatus. The nurse explains that the primary purpose of the overhead trapeze is: 1 To assist with leg exercises 2 To enhance breathing and lung expansion 3 To promote circulation throughout the body 4 To facilitate independent movement while the patient is in bed

An overhead trapeze will facilitate independent movement in bed. It also maintains range of motion of the upper extremities and strengthens the biceps. Assisting with stump exercises, enhancing breathing and lung expansion, and promoting circulation throughout the body are secondary benefits to using an overhead trapeze but are not the primary purpose.

A female patient with a long-standing history of rheumatoid arthritis has sought care because of increasing stiffness in her right knee that has culminated in complete fixation of the joint. The nurse would document the presence of which problem? 1 Atrophy 2 Ankylosis 3 Crepitation 4 Contracture

Ankylosis is stiffness or fixation of a joint, whereas contracture is reduced movement as a consequence of fibrosis of soft tissue (muscles, ligaments, or tendons). Atrophy is a flabby appearance of muscle leading to decreased function and tone. Crepitation is a grating or crackling sound that accompanies movement.

Which nursing intervention would be most effective in improving the comfort of a patient with herpes zoster? 1 Direct sunlight 2 Dry heating pad 3 Cool, wet dressing 4 Warm, moist compress

Application of a cool, wet dressing followed by an analgesic is usually effective in relieving discomforts related to herpes zoster (shingles). The application of any form of warmth may increase the sensitivity of nerve endings and worsen the pain.

What action should a nurse should implement to prevent foot drop in a patient who has a full-leg cast? 1 Encourage bed rest 2 Maintain the foot in a boot with 45 degrees of flexion 3 Support the foot with 90 degrees of flexion 4 Place an antiembolic garment on the affected leg and foot.

As a means of preventing foot drop in a leg with a cast, the foot should be supported with 90 degrees of flexion. Encouraging bed rest for his patient is not required. Supporting the foot with 45 degrees of flexion will not prevent foot drop. Antiembolic garments will protect against thromboembolic events but not foot drop.

A patient has a visible mass in the throat. What intervention is performed when assessing the patient? 1 Auscultate the lateral lobes with a stethoscope. 2 Palpate using the anterior approach. 3 Palpate using the posterior approach. 4 Feel the neck when patient sips water.

Auscultate the lateral lobes of an enlarged thyroid gland with the stethoscope bell to identify a bruit, a soft swishing sound that may indicate a goiter or hyperthyroidism. If there is no noticeable enlargement of the thyroid gland, the nurse can perform palpation using either a posterior or anterior approach. The nurse could also feel the neck when the patient is sipping water. Palpation may trigger the release of thyroid hormones, especially when examining patients with a diagnosis of goiter or hyperthyroidism; hence it is performed only by experienced clinicians.

A nurse in a clinic is preparing to obtain a skin specimen from a client who has a suspected herpes infection. Which of the following actions should the nurse take? (Select all that apply.) A. Scrape the site with a wooden tongue depressor. B. Puncture the crusted area with a sterile needle. C. Swab the crusted area with a sterile cotton-tipped applicator. D. Place cotton-tipped applicator in culturette tube. E. Place culturette tube in ice.

B, D, E

A 3-year-old has cerebral palsy (CP) and is hospitalized for orthopedic surgery. The child's mother states the child has difficulty swallowing and cannot hold a utensil to self-feed. The child is slightly underweight for height. What is the most appropriate nursing action related to feeding? A. Bottle-feed or tube-feed the child with a specialized formula until sufficient weight is gained. B. Stabilize the child's jaw with one hand (either from a front or side position) to facilitate swallowing. C. Place the child in a well-supported, semireclining position to make use of gravity flow. D. Place the child in a sitting position with the neck hyperextended to make use of gravity flow.

B. Because the jaw is compromised, more normal control can be achieved if the feeder provides stability. Manual jaw controls assist with head control, correction of neck and trunk hyperextension, and jaw stabilization. The child is too old to be bottle-fed. The neuromuscular compromise of the jaw interferes with the child's ability to eat. The child should be sitting up for meals to prevent aspiration. For swallowing, the neck should not be hyperextended.

What is the most common cause of secondary hyperparathyroidism? A. Diabetes mellitus B. Chronic renal disease C. Congenital heart disease D. Growth hormone deficiency

B. Chronic renal disease is the most common cause of secondary hyperparathyroidism. The parathyroid gland plays an integral role in the maintenance of calcium in the body, as do the kidneys. Diabetes mellitus does not contribute to secondary hypoparathyroidism. Congenital heart disease does not contribute to secondary hypoparathyroidism. Growth hormone deficiency does not contribute to secondary hypoparathyroidism.

When teaching the adolescent about the management of acne, the nurse should include what instructions? A. Clean the face with an antibacterial soap twice each day. B. Clean the face gently with a mild soap once or twice each day. C. Avoid foods with a high-fat content such as French fries and chocolate. D. Express comedones by gentle squeezing; then cleanse with alcohol.

B. Cleansing the face with mild soap and water will remove surface dirt and oil, which is essential in the management of acne. Antibacterial soaps may be too drying when used in combination with topical medications and may exacerbate acne. No relationship has been established between food intake and acne. Squeezing the acne can break down the ductal walls of the lesions and cause the acne to worsen.

The nurse should recognize that when a child develops diabetic ketoacidosis (DKA), treatment will be instituted as described in which of the following statements? A. No treatment is required, because DKA is an expected outcome of type 1 diabetes mellitus B. Immediate treatment is required because DKA is a life-threatening situation C. DKA is best treated at home D. DKA is best treated at a practitioner's office or clinic

B. DKA is the complete state of insulin deficiency. It is a medical emergency that must be diagnosed and treated immediately. The child is usually admitted to an intensive care unit for assessment, intravenous insulin administration, and fluid and electrolyte replacement. DKA is a medical emergency needing prompt assessment and intervention, usually in an intensive care environment. It is not an expected outcome of type 1 diabetes mellitus. DKA is a medical emergency that requires hospitalization, usually in an intensive care unit. DKA is a medical emergency that requires hospitalization, usually in an intensive care unit.

What is characteristic of fractures in children? A. Fractures rarely occur at the growth plate site because it absorbs shock well. B. Rapidity of healing is inversely related to the child's age. C. Pliable bones of growing children are less porous than those of adults. D. The periosteum of a child's bone is thinner, is weaker, and has less osteogenic potential compared with that of the adult.

B. Fractures heal in less time in children than in adults. As the child ages, the healing time increases. The cartilage epiphyseal plate is the weakest point of the long bone. Therefore, it is a frequent site of damage and fractures. The periosteum is thickened, and there is a great production of osteoclasts when a bone injury occurs. Bone healing in children is rapid due to the thickened periosteum and generous blood supply.

An 8-year-old child is hospitalized with infectious polyneuritis (Guillain-Barré syndrome). When explaining this disease process to the parents, what should the nurse consider? A. Paralysis is progressive, with little hope for recovery. B. Muscle function will gradually return, and recovery is possible in most children. C. Guillain-Barré syndrome results from an apparently toxic reaction to certain medications. D. Guillain-Barré syndrome is inherited as an autosomal recessive, sex-linked gene.

B. Most patients regain full muscle strength following recovery from Guillain-Barré syndrome. The return of function is in reverse order of onset. Onset occurs as ascending paralysis; recovery occurs as descending return of function. The paralysis is progressive in Guillain-Barré syndrome, but most children have full recovery. Supportive nursing care is essential. Guillain-Barré syndrome is an immune-mediated disease most often associated with viral infections. During the history, the parents should be asked about the child's having a cold or viral infection within the past 2 weeks. Guillain-Barré syndrome is an immune-mediated disease most often associated with viral infections.

A toddler has a deep laceration contaminated with dirt and sand. Before suturing, the nurse should irrigate the wound with A. alcohol. B. normal saline. C. hydrogen peroxide. D. povidone-iodine.

B. Normal saline is the only acceptable fluid for irrigation from the choices given above. The nurse should cleanse the wound with a forced stream of normal saline or water. Alcohol should not be used as an irrigation solution, because it is toxic to the wound. Hydrogen peroxide should not be used as an irrigation solution, because it is toxic to the wound. Povidone-iodine should not be used as an irrigation solution, because it is toxic to the wound.

Which statement is true concerning osteogenesis imperfecta (OI)? A. OI is easily treated. B. OI is an inherited disorder. C. With a later onset, the disease usually runs a more difficult course. D. Braces and exercises are of no therapeutic value.

B. OI is an autosomal dominant inherited disorder. OI is a lifelong problem caused by defective bone mineralization, abnormal bone architecture, and increased susceptibility to fracture. OI has a predictable course that is determined by the pathophysiologic processes, not the time of onset. Lightweight braces and splints can help support limbs and fractures.

What is the most important nursing consideration in the management of cellulitis? A. Application of Burow solution compresses B. Administration of oral or parenteral antibiotics C. Topical application of an antibiotic D. Incision and drainage of severe lesions

B. Oral or parenteral antibiotics are indicated depending on the extent of the cellulitis. Warm water compresses may be indicated for limited cellulitis. Antibiotics need to be administered systemically (orally or parenterally), not topically. If incision and drainage are implemented, there is a risk of spreading infection or making the lesion worse.

When giving instructions to a parent whose child has scabies, the school nurse should tell the parent to A. treat all family members if symptoms develop. B. be prepared for symptoms to last 2 to 3 weeks. C. notify the practitioner so an antibiotic can be prescribed. D. carefully treat only those areas where there is a rash.

B. The mite responsible for scabies will most likely be killed with the administration of medications. It will take 2 to 3 weeks for the stratum corneum to heal. That is when the symptoms will abate. Only the affected child needs to be treated for scabies. A scabicide is used. Permethrin and lindane are currently used for topical administration. Permethrin is applied to all skin surfaces in the treatment of scabies.

An infant is born with one lower limb deficiency. When is the optimum time for the child to be fitted with a prosthetic device? A. As soon as possible after birth B. When the infant is developmentally ready to stand up C. At about age 12 to 15 months, when most children are walking D. At about 4 years, when the healthy limb is not growing so rapidly

B. The optimum time for the child to be fitted with a prosthetic device is when he or she is developmentally ready to stand up. The prosthetic device will be integrated into the child's capabilities. Fitting the infant for a prosthesis as soon as possible after birth will not be useful, because the child is not ready to use the leg. Waiting until age 12 to 15 months to fit the child for a prosthesis may be too late. The fitting should be provided when the child is showing readiness to stand. Waiting until age 4 years to fit the child for a prosthesis may be too late. The fitting should be provided when the child is showing readiness to stand.

During the rehabilitative phase of care, pressure dressings are primarily applied to burned areas to A. relieve pain. B. decrease blood supply to scar. C. limit motion during the healing process. D. encourage healing through scar formation.

B. Uniform pressure to the scar decreases the blood supply. The use of pressure garments serves to decrease the blood supply to the hypertrophic tissue. This is done to prevent scarring and contractures. The goal of the pressure dressing is to improve the appearance of scars by decreasing the blood supply to the area. Motion is encouraged because it prevents contractures. Movement should take place to the point of pain, but no further. The goal of the pressure dressing is to minimize the development of scar tissue.

What is associated with infant botulism? A. Contaminated soil B. Honey and corn syrup C. Commercial infant cereals D. Improperly sterilized bottles

B. Unlike adult botulism, infant botulism is caused by ingesting spores of Clostridium botulinum, with the subsequent release of the toxin. The bacterium has been found in honey and corn syrup that were fed to affected infants. Contaminated soil is not associated with infants who develop infant botulism. Commercial infant cereals are not associated with the development of infant botulism. Improperly sterilized bottles are not associated with the development of infant botulism.

In teaching a patient with basal cell carcinoma (BCC) about this disorder, the nurse considers that which statement about this skin cancer is true? 1 BCC is the most deadly type of skin cancer. 2 BCC is the most common type of skin cancer. 3 Prognosis depends upon the thickness of the lesion. 4 The cancerous cells of BCC usually spread beyond the skin

BCC is a locally invasive malignancy arising from epidermal basal cells. It is the most common type of skin cancer and also the least deadly. The cancerous cells of BCC almost never spread beyond the skin. BCC is the least deadly type of skin cancer. Prognosis depends on other factors too, not just the thickness of the lesion. BCC does not generally spread beyond the skin.

A 45-year-old patient is admitted to the nursing unit with a history of a herniated lumbar disc and lower-back pain. The nurse would suspect which causative factor of increasing pain? 1 Bending forward 2 Sleeping on a firm mattress 3 Frequent position changes 4 Humid weather

Back pain that is related to a herniated lumbar disc often is aggravated by events and activities that increase stress and strain on the spine, such as bending or lifting, coughing, sneezing, or lifting the leg with the knee straight (straight-leg-raise test). Sleeping on a firm mattress and frequent position changes are recommended to reduce pain, and warm weather will not increase pain.

What would the nurse plan as an appropriate short-term goal for a patient with degenerative joint disease (DJD)? 1 The patient will limit physical activity in the morning. 2 The patient will participate in physical therapy activities. 3 The patient will eliminate the use of narcotic analgesics if diarrhea develops. 4 The patient will limit pain medications to nonnarcotic drugs to prevent addiction.

Because pain and discomfort are major clinical manifestations of degenerative joint disease (DJD), or osteoarthritis, relief measures are the first priority. Relief can be achieved with physical therapy and other pain-management measures. Limitation of physical therapy, elimination of pain medication, and limitation of pain medication to nonnarcotic drugs are all incorrect goals for a patient with DJD. The patient needs to stay physically active and use narcotic or nonnarcotic analgesics, depending on the level of pain.

A patient presents with intense pain and pruritus from a recent bee sting. What is the most appropriate nursing action? 1 Apply warm compresses. 2 Apply a local antipruritic lotion. 3 Administer antibiotics as prescribed. 4 Apply moisturizers.

Bee stings may cause intense pain and pruritus. These symptoms are usually relieved by a local application of antipruritic lotions. Cold compresses can be given to soothe the burning sensation. Antihistamines can be administered. Antibiotics are not indicated, as there is no evidence of infection. Moisturizers are not helpful in relieving the symptoms.

A patient with osteoporosis is treated with analgesics and biphosphonates. The nurse teaches the patient about safe administration of the drug. Which patient action may interfere with the therapeutic action of the drug? 1 Taking the biphosphonates with a full glass of water 2 Taking the biphosphonates 30 minutes before a meal 3 Taking the analgesics and biphosphonates at the same time 4 Remaining upright for 30 minutes after taking bisphosphonates

Biphosphonates should not be taken at the same time as other medications, such as analgesics, as its absorption can be hampered. The patient should take the analgesic 30 minutes after taking biphosphonates. Taking the biphosphonates with a full glass of water helps prevent gastric irritation. Taking the biphosphonates 30 minutes before a meal facilitates the drug's absorption. Remaining upright for 30 minutes after taking biphosphonates prevents gastric irritation.

In reviewing bone remodeling, what should the nurse know about the involvement of bone cells? 1 Osteoclasts add canaliculi 2 Osteoblasts deposit new bone 3 Osteocytes are mature bone cells 4 Osteons create a dense bone structure

Bone remodeling is achieved when osteoclasts remove old bone and osteoblasts deposit new bone. Osteocytes are mature bone cells and osteons or Haversian systems create a dense bone structure, but these are not involved with bone remodeling.

A patient's blood test reveals elevated levels of growth hormone (GH) and adrenocorticotropic hormone (ACTH). In discussing these results with the patient, the nurse explains that both of these hormones have which feature? 1 Stimulate the release of cortisol 2 Are secreted by the anterior pituitary 3 Stimulate the release of aldosterone 4 Are secreted by the posterior pituitary

Both GH and ACTH are secreted by the anterior pituitary, not the posterior pituitary. ACTH does stimulate the release of cortisol from the adrenal cortex, but GH does not. Release of aldosterone is stimulated by renin from the kidney.

A nurse is caring for a child who has muscular dystrophy. For which of the following findings should the nurse assess? (Select all that apply.) A. Purposeless, involuntary, abnormal movements B. Spinal defect and saclike protrusion C. Muscular weakness in lower extremities D. Unsteady, wide-based or waddling gait E. Upward slant to the eyes

C, D

A nurse is caring for a child who has type 1 diabetes. Which of the following is a clinical manifestation of diabetic ketoacidosis? (Select all that apply.) A. Blood glucose 58 mg/dL B. Weight gain C. Dehydration D. Mental confusion E. Fruity breath

C, D, E

A nurse is caring for an infant with developmental dysplasia of the hip (DDH). Based on the nurses knowledge of DDH, which clinical manifestation should the nurse expect to observe? (Select all that apply.) A. Lordosis B. Negative Babinski sign C. Asymmetric thigh and gluteal folds D. Positive Ortolani and Barlow tests E. Shortening of limb on affected side

C, D, E. <div>Asymmetric thigh and gluteal folds are clinical manifestation of DDH and seen from birth to two months.<br>Positive Ortolani and Barlow tests are clinical manifestations of DDH. Ortolani test is the abducting of the thighs to test for hip subluxation or dislocation. Barlow test is the adducting to feel if the femoral head slips out of the socket postolaterally.<br>Shortening of limb on affected side is another clinical manifestation of DDH.<br>Lordosis is the inward curve of the lumbar spine just above the buttocks and is not a clinical manifestation of DDH.<br>A negative Babinski sign is not a clinical manifestation of DDH. It is a neurological reflex.</div>

The nurse is caring for a patient with mucocutaneous lesions, urethritis, and conjunctivitis. Which drug therapy does the nurse expect the primary health care provider to prescribe for the patient? Select all that apply. A Pregabalin (Lyrica) B Infliximab (Remicade) C Nifedipine (Afeditab CR) D Methotrexate (Otrexup) E Sulfasalazine (Azulfidine) F Ibuprofen (Advil)

C, D, E. Mucocutaneous lesions, urethritis, and conjunctivitis are the clinical signs of reactive arthritis. Methotrexate is used in the treatment of mucocutaneous lesions. Sulfasalazine is used to treat chronic inflammation. Nonsteroidal antiinflammatory drugs such as ibuprofen (Advil) are given in the initial stages of reactive arthritis. Pregabalin (Lyrica) is used to treat anxiety or peripheral neuropathic pain. This medication is not indicated for a patient with mucocutaneous lesions, urethritis, and conjunctivitis. Nifedipine (Afeditab CR) is a vasodilator that helps decrease arterial blood pressure. Infliximab (Remicade) is a tissue necrotic factor (TNF) inhibitor used in the treatment of patients with ankylosing spondylitis (AS).

What statement should the nurse include when discussing a child's precocious puberty with the parents? A. The child is not yet fertile. B. Sexual interest is usually advanced. C. Dress and activities should be appropriate to the chronologic age. D. The appearance of secondary sex characteristics does not proceed in the usual order.

C. Development of the secondary sex characteristics proceeds in the usual order. Functioning sperm or ova may be produced, making the child fertile. Heterosexual interest is usually appropriate to the chronologic age. Because of the child's early sexual maturation, both the family and child require extensive teaching. Included in this teaching is the information that the child should be engaged in activities according to his or her chronologic age.

Enteral feedings are ordered for a young child with burns covering 40% of the total body surface area. The nurse should know that A. oral feedings are contraindicated. B. enteral feedings must be stopped during painful procedures. C. paralytic ileus precludes use of enteral feedings. D. the feedings will be high in carbohydrate and low in protein.

C. Enteral feedings can begin when the paralytic ileus resolves. Oral feedings are not contraindicated. Oral feedings are encouraged. Most children with burns are unable to consume sufficient calories by mouth, but every possible effort is made to encourage oral feeding. Enteral feedings can continue during procedures. A high-protein, high-calorie diet is recommended to compensate for the increased basal metabolic rate that occurs after a burn injury.

A school-age child recently diagnosed with type 1 diabetes mellitus asks the nurse if playing soccer, playing baseball, and swimming are still possible. The nurse's response should be based on knowledge that A. Exercise is contraindicated in the type 1 diabetic child B. Soccer and baseball are too strenuous, but swimming is acceptable C. Exercise is not restricted unless indicated by other health conditions D. The level of activity depends on the type of insulin required

C. Exercise is encouraged for children with type 1 diabetes because it lowers blood glucose levels. Insulin and meal requirements require careful monitoring to ensure the child has sufficient energy for exercise. Exercise is highly encouraged. The decrease in blood glucose can be accommodated by having snacks available. Sports are encouraged, with insulin and food adjusted for the exercise. The child needs to be cautioned to monitor responses to the exercise. The level of activity does not depend on the type of insulin used. Long-acting and short-acting insulin may both be used to provide coverage for the training and sporting events.

The mother of a child with type 1 diabetes mellitus asks why her child cannot avoid all those "shots" and take pills as an uncle does. The most appropriate response by the nurse is A. "The pills work with an adult pancreas only." B. "The drugs affect fat and protein metabolism, not sugar." C. "Your child needs to have insulin replaced, and the oral hypoglycemics only add to an existing supply of insulin." D. "Perhaps when your child is older, the pancreas will produce its own insulin, and then your child can take oral hypoglycemics."

C. In type 1 diabetes, the beta cells have been destroyed. It is necessary to supply the insulin no longer produced by the beta cells. The oral medications have different modes of action that supplement insulin production by the pancreas, decreasing insulin resistance or affecting liver production of glucose. They are not insulin substitutes and are primarily used in type 2 diabetes mellitus. Oral hypoglycemics can supplement insulin production by the pancreas, decrease insulin resistance, or affect the liver production of glucose. In type 1 diabetes, the beta cells have been destroyed. Without a pancreatic beta cell transplant, it is unlikely that insulin would be produced.

An occlusive dressing, is applied to a large abrasion. This is advantageous because the dressing will A. provide an antiseptic for the wound. B. deliver vitamin C to wound. C. maintain a moist environment for healing. D. promote mechanical friction for healing.

C. Occlusive dressings such as Acuderm do not adhere to the wound site. They provide a moist wound surface and insulate the wound. Acuderm does not have antiseptic capabilities. Acuderm does not contain vitamin C. Acuderm protects against friction.

A 3-year-old has just returned from surgery in a hip spica cast. The priority nursing intervention is to A. elevate the head of the bed. B. offer sips of water. C. check circulation, sensation, and motion of toes. D. turn the child to the right side, then the left side every 4 hours.

C. The chief concern is that the extremity may continue to swell. The circulation, sensation, and motion of the toes must be assessed to ensure that the cast does not become a tourniquet and cause complications. Elevating the head of the bed might help with comfort, but it is not a priority. The nurse must be observant to the risk of increased swelling in the extremities. Offering sips of water is acceptable once assessment of the extremities has been completed. The child's position should be changed every 2 hours. Positioning a child with a spica cast is important to prevent injury.

What are considered major goals of the therapeutic management of juvenile rheumatoid arthritis (JRA)? A. Prevent joint discomfort; regain proper alignment. B. Prevent loss of joint function; achieve cure. C. Prevent physical deformity; preserve joint function. D. Prevent skin breakdown; relieve symptoms.

C. The goals of treatment for JRA include the prevention of physical deformity, the preservation of joint function, and the control of pain. Once the joint is damaged from the physiologic processes of JRA, it may not be possible to regain proper alignment. Children with JRA may be cured of the disease. Skin breakdown is usually not an issue in JRA.

A neonate with a goiter has just been admitted to the newborn nursery. A priority nursing intervention is to A. position the neonate on the left side. B. explain to the parents how to place the dressing on the goiter. C. have a tracheostomy set at bedside. D. suction at least every 5 to 10 minutes.

C. The goiter puts the infant at risk for respiratory failure. Preparations are made for emergency ventilation, including having a tracheostomy set at the bedside. Placing the neonate in a side-lying position is not indicated. Hyperextension of the child's neck may facilitate breathing. No dressing is indicated in a neonate who has a goiter. There is no indication for suctioning in a neonate with goiter.

A 17-year-old with type 1 diabetes mellitus tells the school nurse about recently starting to drink alcohol with friends on weekends. The most appropriate intervention by the nurse is to A. tell the adolescent not to drink alcohol. B. ask the adolescent about the reasons for drinking alcohol. C. teach the adolescent about the effects of alcohol on type 1 diabetes mellitus and how to prevent problems associated with alcohol intake. D. recommend counseling so that the adolescent understands the serious consequences of alcohol consumption.

C. The nurse is taking a proactive approach. The adolescent is provided with information to facilitate the management of the illness. Telling someone not to drink will not help should the person choose to continue drinking. Asking the adolescent why the drinking is occurring will provide information to the nurse but will not address the information that the adolescent needs to have about managing the disease. Counseling can be included in the teaching plan.

Which statement best describes pseudohypertrophic (Duchenne) muscular dystrophy (DMD)? A. DMD is inherited as an autosomal dominant disorder. B. DMD is characterized by weakness of the proximal muscles of both the pelvic and shoulder girdles. C. DMD is characterized by muscle weakness, usually beginning at about age 3 years. D. The onset of DMD occurs in later childhood and adolescence.

C. Usually, children with DMD reach the early developmental milestones, but the muscular weakness is usually observed in the third year of life. DMD is inherited as an X-linked recessive disorder. Weakness in a child with DMD is usually first noted in walking. Progressive muscle weakness in other muscle groups then follows. DMD usually develops in the third year of life.

The school nurse is seeing a child who brought poison ivy to school in a leaf collection. The child says that only hands touched it. The most appropriate nursing action is to A. apply Burow solution compresses immediately. B. soak hands in warm water. C. rinse hands in cold, running water. D. scrub hands thoroughly with antibacterial soap.

C. Washing the child's hands in cold running water is the recommended first action. Once contact has been made, it is desirable to flush the skin with cold running water within 15 minutes of exposure. This will neutralize the urushiol not yet bonded to the skin. Applying Burrow solution is effective for soothing the skin lesions once the dermatitis has begun. Cold running water, not warm water, is effective in removing the oil. The antibacterial soap removes protective skin oils and dilutes the urushiol, allowing it to spread.

What most accurately describes bowel function in children born with a myelomeningocele? A. Incontinence cannot be prevented. B. Enemas and laxatives are contraindicated. C. Some degree of fecal continence can usually be achieved. D. A colostomy is usually required by the time the child reaches adolescence.

C. With diet modification and regular toilet habits (bowel training) to prevent constipation and impaction, some degree of fecal continence can be achieved. Although a lengthy process, continence can be achieved with modification of diet, use of stool softeners, and/or enemas. Enemas and stool softeners are part of the strategy to achieve continence. Laxatives should be used only as a last resort, although they may be used in some instances. A colostomy is not indicated for the child with myelomeningocele.

The nurse is caring for a patient who has yellow discoloration of the skin. The nurse also observes that the patient's sclerae are not yellow in color. What is the best nursing action in this situation? 1 Advise the patient to undergo a diagnostic test for jaundice. 2 Advise the patient to decrease the intake of food rich in Vitamin B12. 3 Advise the patient to undergo an immunofluorescent microscopic test. 4 Advise the patient to decrease consumption of vegetables rich in carotene.

Carotenemia is a condition that occurs due to excessive consumption of vegetables rich in carotene. It is characterized by yellow discoloration of the skin, mostly noticeable on the palms and soles, but not in the sclerae. Jaundice also causes yellow discoloration of skin but is best observed in the sclerae. There is no need for the patient to undergo a diagnostic test for jaundice, because the patient shows no yellow discoloration of the sclerae. Vitamin B12 is a water-soluble vitamin responsible for the functioning of the brain and nervous system. Decreasing intake of vitamin B12 will not reduce the symptoms of carotenemia. An immunofluorescent test is used to identify the specific, abnormal antibody proteins that cause certain skin diseases. Carotenemia is caused due to an increase in carotene levels, not due to the production of abnormal antibodies. Therefore, an immunofluorescent test is not required for this patient.

The patient has been snacking on carrots each day and has developed carotenemia. The nurse knows that improvement in this condition will be most evident on which part of the patient's body? 1 Face 2 Chest 3 Sclera 4 Palms of hands

Carotenemia or carotenosis is yellow discoloration of the skin without yellowing sclera. It is most noticeable on the palms of the hands and the soles of the feet. It is not noticeable on the face, chest, or sclera.

During the assessment of a patient, the nurse notes an area of irregularly round verrucous papules with well-defined shapes. The patient states that they have become darker over the past few months and are often itchy and irritating. The nurse recognizes this finding as 1 Lentigo 2 Psoriasis 3 Acne vulgaris 4 Seborrheic keratosis

Clinical manifestations of seborrheic keratosis include irregularly round or oval, often verrucous papules or plaques with well-defined shape and the appearance of being stuck on. The lesions increase in pigmentation with time and are usually multiple and possibly itchy Clinical manifestations of lentigo include hyperpigmented, brown to black macule or patch (flat lesion) over sun-exposed areas. Clinical manifestations of psoriasis include sharply demarcated silvery scaling plaques on reddish colored skin commonly on the scalp, elbows, knees, palms, soles, and fingernails. Acne vulgaris is manifested by noninflammatory lesions, including open comedones (blackheads) and closed comedones (whiteheads), and inflammatory lesions, including papules and pustules.

The nurse finds that a patient has frequent, audible crackling sounds and grating upon joint movement. Which condition does the nurse suspect based on these findings? 1 Scoliosis 2 Crepitation 3 Contracture 4 Festinating gait

Crepitation is associated with fracture, dislocation, temporomandibular joint dysfunction, and osteoarthritis. It manifests as frequent, audible crackling sounds with palpable grating during movement. Scoliosis is the asymmetric elevation of shoulders, scapulae, and iliac crests with lateral spine curvature. It is often a congenital condition or occurs due to fracture or dislocation. Contracture is the resistance to movement of a muscle or a joint as a result of fibrosis of the supporting soft tissues. Festinating gait is a condition where the neck, trunk, and knees flex but the body is rigid while walking.

A nurse is assessing a fracture of a patient's hand. Which phenomenon would the nurse note as the bone fragments rub against each other? 1 Crepitation 2 Reabsorption 3 Proliferation 4 Subluxation

Crepitation is the grating sensation and sound produced when broken bone fragments rub against one another. Reabsorption is the loss of bone mass due to a loss of calcium resulting in porous, weak bones. Proliferation is reproduction or multiplication of similar forms, usually referring to increases of cells. Subluxation is a partial or incomplete dislocation or displacement of a bone from its normal position.

A nurse scrapes off the superficial layer of the skin lesion of the patient. This specimen is sent to the laboratory for culture. What is the purpose of this culture? 1 To identify an allergen 2 To identify a fungal infection 3 To identify a viral infection 4 To identify a bacterial infection

Culture of the skin lesion specimen is used to identify the fungal, bacterial, or viral infection. Scraping or swab of the skin is performed to obtain the specimen for identification of fungal infection. For bacteria, the sample for culture is obtained from intact pustules, bullae, or abscesses. For a virus, the vesicle or bulla and exudates are taken from the base of the lesion. Culture cannot be used to determine the agent causing skin allergies. The patch test is used to determine the allergen causing the skin lesions.

The nurse is evaluating the patient who has developed diabetes as a result of another medical condition. The nurse knows that which condition can be linked to diabetes? 1 Cushing's syndrome 2 Syndrome of inappropriate antidiuretic hormone secretion (SIADH) 3 Hypothyroidism 4 Celiac disease

Cushing's syndrome is treated with corticosteroids, which will then cause diabetes. SIADH and hypothyroidism will not. Celiac disease is another autoimmune disease that a patient with diabetes is at a greater risk of developing.

A nurse is caring for a child. Which of the following diagnostic procedure should the nurse prepare the child for to determine if the child has Legg-Calve-Perthes disease? A. Bone biopsy B. Genetic testing C. MRI D. Radiographs

D

A nurse is caring for a toddler who is diagnosed with hip dysplasia and has been placed in a hip spica cast. The child's mother asks the nurse why a Pavlik harness is not being used. Which of the following responses by the nurse appropriately addresses the mother's question? A. "The Pavlik harness is used for children with scoliosis, not hip dysplasia." B. "The Pavlik harness is used for school-age children." C. "The Pavlik harness cannot be used for your child because her condition is too severe." D. "The Pavlik harness is used for infants less than 6 months of age."

D

Which measures reduce the risk of osteoarthritis in a patient? Select all that apply. A Avoiding intake of fish B Exercising on a hard surface C Increasing the intake of vitamin K D Avoiding bending the knee past 90 degrees E Avoiding forceful, repetitive movements

D, E. Bending the knees past 90 degrees increases the risk of knee injury. Hence, maintaining an appropriate angle during exercise will prevent osteoarthritis. Forceful and repetitive movements on a hard surface may tear the ligaments and cause permanent damage. There is no reason for patients with osteoarthritis to avoid eating fish. Exercising on a soft surface will prevent injuries to the smaller joints. Vitamin K supplements reduce the risk of bleeding disorders but not the risk of osteoarthritis.

The major goal of therapy for children with cerebral palsy (CP) is A. reversing degenerative processes that have occurred. B. curing the underlying defect causing the disorder. C. preventing spread to individuals in close contact with the children. D. recognizing the disorder early and promoting optimal development.

D. Because CP is currently a permanent disorder, the goal of therapy is to promote optimal development. This is done through early recognition and beginning of therapy. It is difficult to reverse the degenerative processes associated with CP. The underlying defect(s) associated with the development of CP cannot be cured. CP is not contagious.

Therapeutic management of the patient with systemic lupus erythematosus (SLE) includes A. application of cold salts to suppress the inflammatory process. B. a high-protein, low-salt diet. C. a rigorous exercise regimen to build up muscle strength and endurance. D. administration of corticosteroids to control inflammation.

D. Corticosteroid administration is the primary mode of therapy currently for SLE. The application of cold salts will not affect the inflammatory process associated with SLE. A balanced diet without exceeding caloric expenditures is recommended. Exercise should be done in moderation.

What is the rationale for elevating an extremity after a soft tissue injury such as a sprained ankle? A. Elevation increases the pain threshold. B. Elevation increases metabolism in the tissues. C. Elevation produces deep tissue vasodilation. D. Elevation reduces edema formation.

D. Elevating the extremity uses gravity to facilitate venous return to reduce edema. Elevation should have no significant effect on the pain threshold. Elevation should not affect metabolism. Venous return to the heart, not vasodilation, is facilitated by elevation.

A woman who is 6 weeks pregnant tells the nurse that she is worried her baby might have spina bifida because of a family history. What should the nurse's response be based on? A. There is no genetic basis for the defect. B. Prenatal detection is not possible yet. C. Chromosomal studies done on amniotic fluid can diagnose the defect prenatally. D. The concentration of α-fetoprotein in amniotic fluid can potentially indicate the presence of the defect prenatally.

D. Fetal ultrasound and elevated concentrations of α-fetoprotein in amniotic fluid many indicate the presence of anencephaly, myelomeningocele, or other neural tube defects. The origin of neural tube defects is unknown but appears to have a multifactorial inheritance pattern. Prenatal detection is possible through amniotic fluid or chorionic villi sampling. There are no chromosomal studies currently that can diagnose spina bifida prenatally.

The nurse is caring for an immobilized preschool child. What is helpful during this period of immobilization? A. Encourage the child to wear pajamas. B. Let the child have few behavioral limitations. C. Keep the child away from other immobilized children if possible. D. Take the child for a "walk" by wagon outside the room.

D. It is important for children to have activities outside of the room if possible. This can give them opportunities to meet their normal growth and developmental needs. The child should be encouraged to wear street clothes during the day. Limit setting is necessary with all children. There is no reason to segregate children who are immobilized unless there are other medical issues that need to be addressed.

What is a secondary effect when a child experiences decreased muscle strength, tone, and endurance from immobilization? A. Increased metabolism B. Increased venous return C. Increased cardiac output D. Decreased exercise tolerance

D. Muscle disuse leads to tissue breakdown and loss of muscle mass or muscle atrophy. It may take weeks or months to recover. Metabolism decreases during periods of immobility. There is decreased venous return due to decreased muscle activity secondary to immobility. There is decreased cardiac output secondary to immobility.

The callus that develops at a fracture site is important because it provides A. use of the injured part. B. sufficient support for weight bearing. C. means for adequate blood supply. D. means for holding bone fragments together.

D. New bone cells are formed in large numbers and stimulated to maximum activity. They are found at the site of the injury. In time, calcium salts are absorbed to form the callus. Functional use cannot occur until the fracture site is stable. Sufficient support for weight bearing cannot occur until the fracture site is stable. The callus does not provide an adequate blood supply.

What is important when caring for a child with myelomeningocele in the preoperative stage? A. Place the child on one side to decrease pressure on the spinal cord. B. Apply a heat lamp to facilitate drying and toughening of the sac. C. Keep the skin clean and dry to prevent irritation from diarrheal stools. D. Measure the head circumference and examine the fontanels for signs that might indicate developing hydrocephalus.

D. Obstructive hydrocephalus is frequently associated with myelomeningocele. Assessment of the fontanels and daily measurements of the head circumference will aid in early detection of associated increased intracranial pressure. Preoperatively, the child is kept in a prone position to decrease tension on the sac and reduce the risk of trauma or sac tearing. The sac must be kept moist. Sterile, moist, nonadherent dressings are placed over the sac as prescribed by the physician. Most infants do not have diarrheal stools. The sac area, though, should be kept clean and dry and out of contact with urine and stools.

What is an appropriate nursing intervention when caring for the child with chronic osteomyelitis? A. Provide active range-of-motion exercises of the affected extremity. B. Administer pain medication with meals. C. Encourage frequent ambulation. D. Move and turn the child carefully and gently to minimize pain.

D. Osteomyelitis is extremely painful. Movement is carried out only as needed and then carefully and gently. Active range-of-motion exercises are contraindicated until pain has subsided. Pain medication should be administered as needed. Ambulation is contraindicated until pain has subsided.

The newborn diagnosed with phenylketonuria (PKU) will require long-term follow-up to assess for the development of A. obesity. B. diabetes insipidus. C. respiratory distress. D. mental retardation.

D. PKU, an inborn error of metabolism, may lead to mental retardation if early intervention is not performed. Obesity is not associated with PKU. Diabetes insipidus is not associated with PKU. Respiratory distress is not associated with PKU.

An adolescent has had a lower leg amputation secondary to a motorcycle accident and is complaining of pain in the missing extremity. The nurse should recognize that this is A. indicative of narcotic addiction B. indicative of the need for psychological counseling C. abnormal and suggests nerve damage D. normal and called phantom limb sensation

D. Phantom limb sensation is an expected experience because the nerve-brain connections are still present. They gradually fade. This should be discussed preoperatively with the child. There is no indication of narcotic addiction by the adolescent complaining of pain in the amputated extremity. Phantom limb pain is expected after an amputation; psychological counseling is not required for the adolescent experiencing it. Phantom limb pain is expected after an amputation and is not suggestive of nerve damage.

A nurse should explain that ringworm is A. a noncontagious disorder. B. a sign of uncleanliness. C. expected to resolve spontaneously. D. spread by direct and indirect contact.

D. Ringworm is spread by both direct and indirect contact. Children should wear protective caps at night to avoid transfer of ringworm to bedding. Ringworm is an infectious disorder. Because ringworm is easily transmitted, it is not a sign of uncleanliness. It can be acquired from theater seats or gym mats and by animal-to-human transmission. The drug griseofulvin (Fulvicin) is indicated for a prolonged course, possibly several months.

A neural tube defect that is not visible externally in the lumbosacral area would be called A. meningocele. B. myelomeningocele. C. spina bifida cystica. D. spina bifida occulta.

D. Spina bifida occulta is completely enclosed. Often, this disorder will not be noticed. A clue to the presence of this internal disorder will be a dimple or tuft of hair on the lumbosacral area. A meningocele contains meninges and spinal fluid but no neural tissue and is evident at birth as a sac in the lumbosacral area. Transillumination of light will be present. A myelomeningocele is a neural tube defect that contains meninges, spinal fluid, and nerves and is evident at birth as a sac in the lumbosacral area. Transillumination of light will not be present. Spina bifida cystica is a cystic formation with an external saclike protrusion.

A child is being seen in the emergency department with multiple facial abrasions and lacerations. A combination agent containing lidocaine, adrenaline, and tetracaine (LAT gel) is applied topically to the wounds. The purpose of this combination therapy is to A. cleanse the wound. B. promote scab formation. C. prevent infection of the wound. D. provide anesthesia to the wound.

D. The combination of lidocaine, adrenaline, and tetracaine provides anesthesia within 10 to 15 minutes of application. LAT does not have a cleansing effect. LAT has no effect on scab formation. LAT has no antibacterial effect.

When applying wet compresses or dressings to the skin, what should the nurse do? A. Apply the dressing so that the area is totally immobilized. B. Apply the dressing when it is saturated and dripping. C. Pour or syringe a new solution over a dressing that has become dry. D. Apply the desired solution on cotton gauze or soft cotton cloths, such as clean cloths.

D. The desired solution should be applied to Kerlix gauze; soft cotton cloths; or strips from cloth diapers, sheets, or pillowcase material. The moist dressing should be laid flat on the area with an attempt to not restrict movement. After immersion in the solution, the dressings are wrung out to avoid dripping. The material should be moistened and then reapplied. When the solution dries, concentrated residue is left in the dressing. The addition of fluid may result in a more concentrated soak being placed on the sensitive tissue.

What is most descriptive of atopic dermatitis (eczema) in the infant? A. Eczema is worse in summer months. B. Eczema is worse in humid climates. C. Eczema is associated with upper respiratory tract infections. D. Eczema is associated with hereditary allergies.

D. The majority of children with atopic dermatitis have a family history of eczema, asthma, food allergies, or allergic rhinitis. This suggests a genetic predisposition. Atopic dermatitis worsens in fall and winter months. Eczema improves in humid climates. Eczema is associated with allergies.

Cerebral palsy (CP) may result from a variety of causes. It is now known that the most common cause of CP is A. birth asphyxia B. neonatal diseases C. cerebral trauma D. prenatal brain abnormalities

D. The most common currently identifiable cause of CP is existing brain abnormalities during the prenatal period. Birth asphyxia had previously been thought of as a factor in the development of CP. Neonatal diseases have previously been thought of as factors in the development of CP. Cerebral trauma has previously been thought of as a factor in the development of CP.

Which factor promotes wound healing? A. Antiseptics B. Eschar formation C. Dry wound environment D. Moist, crust-free wound environment

D. This environment enhances the migration of epithelial cells across the wound and facilitates healing. Antiseptics, such as hydrogen peroxide and povidone-iodine, have a cytotoxic effect on healthy cells and little effect on controlling infections. Eschar formation does not promote wound healing. Eschar is burn crust or dead tissue that inhibits wound healing. A dry wound environment does not facilitate wound healing.

A patient with type 2 diabetes who takes metformin daily to manage blood sugar is scheduled for an intravenous pyelogram (IVP). Which question by the nurse is most important to ask the patient when preparing for the procedure? 1 "Have you ever skipped a dose of metformin?" 2 "When was the last time you took your metformin?" 3 "How many times a day do you take your metformin?" 4 "How long have you been taking metformin for diabetes?

During an IVP, contrast dye is injected so that the urinary system can be visualized. To reduce risk of kidney injury, metformin should be discontinued a day or two before the procedure and for 48 hours following the procedure. Medication administration adherence, dosage, and history are important to assess, but will not affect the interaction.

A 49-year-old male is hospitalized with diabetes mellitus and a herniated lumbar disc. Which breakfast choice is most appropriate for this patient? 1 White toast and orange juice 2 Bran cereal and milk 3 Egg-white omelet 4 Protein shake

Each meal should contain at least one source of fiber, which will reduce the risk of constipation and straining at stool, which increases back pain. Bran, a high-fiber food, is appropriate for selection from the menu. White toast, egg whites, and a protein shake are not high in fiber; the white toast and orange juice also may elevate the patient's blood sugar.

The nurse is caring for a patient who was hospitalized with exacerbation of chronic bronchitis and herniated lumbar disc. Which breakfast choice would be most appropriate for the nurse to encourage the patient to check on the breakfast menu to prevent constipation? 1 Bran muffin 2 Scrambled eggs 3 Puffed rice cereal 4 Buttered white toast

Each meal should contain one or more sources of fiber, which will reduce the risk of constipation and straining with defecation, which increases back pain. Bran is typically a high-fiber food choice and is appropriate for selection from the menu. Scrambled eggs, puffed rice cereal, and buttered white toast do not have as much fiber and will not prevent constipation as well as the bran will

A patient will undergo electromyography. What information should the nurse give to the patient? Select all that apply. 1 Small-gauge needles are inserted into certain muscles. 2 This test can be carried out at the bedside. 3 There may be some discomfort because of the needles. 4 It is useful in identifying any lower motor neuron dysfunction or primary muscle diseases. 5 There may be severe bleeding and pain, and local anesthesia may be given.

Electromyography helps to evaluate electrical potential associated with skeletal muscle contraction. Small-gauge needles are inserted into certain muscles. Needle probes are attached to leads that feed information to an electromyogram (EMG) machine. Recordings of electrical activity of the muscle are traced on audio transmitter and on oscilloscope and recording paper. There may be some discomfort because of the needles. It is useful in identifying any lower motor neuron dysfunction or primary muscle diseases. The procedure is usually done in an EMG laboratory while the patient lies supine on a special table. It is not performed at the bedside. There is no major bleeding, and it is not performed under anesthesia.

A nurse is assessing a patient who has yellow skin and nails. Which chemical or pigment abnormality does the nurse expect the patient to have? 1 Excess melanin 2 Excess carotenes 3 Excess oxyhemoglobin 4 Excess deoxyhemoglobin

Excess carotene in the body gives a yellow color to the skin. Excess melanin in the body gives a brown color to the skin. Excess oxyhemoglobin gives a red color to the skin. Excess deoxyhemoglobin gives a blue color to the skin.

A patient reports excessive itchiness all over the body which has caused an inability to sleep for three days. What nursing assessment finding indicates a lack of proper sleep? 1 Dry, scaly skin 2 Reddening of the skin 3 Supple, moist skin 4 Dark circles under the eyes

Excessive tiredness or sleeplessness causes dark circles under the eyes because of dullness and dehydration. Dry and scaly skin causes itching but is not directly associated with sleeplessness. Reddening of the skin and the presence of supple, moist skin are not indicative of disturbed sleep. Reddening of skin is a manifestation of dilated blood vessels. Suppleness and good hydration are indicators of healthy skin.

A patient presents with diabetic ketoacidosis (DKA). The nurse initiates the collaborative plan of care with the understanding that the initial goal of the treatment plan is: 1 Treatment for hypokalemia 2 Rapid reduction of elevated blood glucose 3 Rehydration through intravenous fluid replacement 4 Reduction of ketosis by encouraging oral nourishment

Fluid imbalance is potentially life threatening for patients with DKA. The initial goal of therapy is to establish intravenous (IV) access and begin fluid replacement. Once urine output is established, electrolyte replacement will be addressed. Potassium levels will need to be monitored as insulin therapy, which is needed to correct the hyperglycemia, may further reduce the potassium level. Insulin therapy will be used to lower the blood glucose gradually to prevent rapid drops in serum glucose, leading to fluid shifts and the potential for cerebral edema. Ketosis results from the use of fat stores for energy because excess glucose is not being transported to the cells and used as source of energy. Patients with DKA often present with nausea and vomiting; oral nourishment may be limited until symptoms lessen.

A patient has been administered a patch test to determine the patient's allergy to rubber. What is an important nursing intervention for this patient? 1 Instruct the patient to return in 48 to 72 hours for removal of allergens. 2 Keep the patient in the health care facility for close observation. 3 Instruct the patient to come back after a week for a preliminary evaluation. 4 Teach the patient how to administer an epinephrine injection, if required.

Following a patch test, the nurse should instruct the patient to return after 48 to 72 hours for the removal of the allergen, and again after 96 hours for a preliminary evaluation of the test. The patient should be monitored for some time, and can be sent home if comfortable. It is not necessary to teach the patient about an epinephrine injection.

The nurse is caring for a patient who underwent spinal surgery a day ago. A change in which clinical factor needs to be immediately reported to the primary health care provider? 1 Pain intensity 2 Urinary voiding 3 Bowel movements 4 Movement of the leg

Following a spinal surgery, the movement of the leg should be assessed. Ideally, it should be unchanged; any change in the leg movement indicates a complication and should be reported immediately. The pain intensity may increase due to surgery and muscle spasms. Urinary voiding and bowel movements may be changed, due to paralytic ileus and immobility.

Because the incidence of Lyme disease is very high in Wisconsin, the public health nurse is planning to provide community education to increase the number of people who seek health care promptly after a tick bite. What information should the nurse provide when teaching people who are at risk for a tick bite? 1 The best therapy for the acute illness is an intravenous (IV) antibiotic. 2 Check for an enlarging reddened area with a clear center. 3 Surveillance is necessary during the summer months only. 4 Antibiotics will prevent Lyme disease if taken for 10 days.

Following a tick bite, the expanding "bull's eye rash" is the most characteristic symptom, which usually occurs in 3 to 30 days. There also may be flu-like symptoms and migrating joint and muscle pain. Active lesions are treated with oral antibiotics for two to three weeks and doxycycline is effective in preventing Lyme disease when given within three days after the bite of a deer tick. IV therapy is used with neurologic or cardiac complications. Although ticks are most prevalent during summer months, residents of high-risk areas should check for ticks whenever they are outdoors.

A nurse is caring for a patient diagnosed with shingles. The primary health care provider prescribes acyclovir (Zorivax) to be administered as soon as possible. The most likely reason for the medication is to prevent what? 1 To prevent pain 2 To prevent postherpetic neuralgia 3 To prevent worsening of symptoms 4 To prevent the patient from getting restless

Following the onset of symptoms of shingles (herpes zoster), antiviral agents such as acyclovir should be administered within 72 hours to prevent postherpetic neuralgia. Analgesics are given to relieve pain and mild sedatives to prevent restlessness. Symptomatic treatment is given to prevent worsening of symptoms.

A patient has been admitted with edema in the right knee and is unable to bear weight on the right leg. The complaint started with a fall. The health care provider diagnoses this as hemarthrosis and decides to aspirate the fluid. Which bore needle will be used for aspiration in this patient? 1 24-gauge 2 22-gauge 3 20-gauge 4 18-gauge

For aspirating fluid from the knee cavity, a large bore needle is required. In this scenario, 18-gauge or wider bore needle should be used. 24-, 22-, and 20-gauge needles have small bores not appropriate for aspirating fluids and, therefore, should not be used.

he nurse is assigned to care for a 76-year-old patient with type 2 diabetes. To encourage the patient to become an active participant in his or her care, the nurse must first: 1 Assess the patient's understanding of the disease 2 Make a list of food restrictions for proper diabetes management 3 Refer the patient to a nutritionist 4 Set long-term goals to decrease the risk of complications

For teaching to be effective, the first step is assessing the patient. Teaching can be individualized once the nurse is aware of what a diagnosis of diabetes means to the patient. Food restrictions, nutritionist referral, and setting long-term goals can occur once the nurse is confident the patient understands what it means to have diabetes.

Which laboratory findings can be observed in a patient with hair loss and decreased skin pigmentation? 1 Cortisol levels of 2 mcg/dL 2 Somatomedin C level of 250 ng/mL 3 Thyroid stimulating (TSH) levels of 7 μU/mL 4 Parathyroid hormone (PTH) levels of 60 pg/mL

Hair loss and decreased skin pigmentation are clinical manifestations of hypothyroidism. The normal levels of thyroid stimulating hormone (TSH) in the body are 0.4 to 4.2 μU/mL. The THS levels are governed by a negative feedback mechanism. Therefore, an increase in TSH levels to compensate for low T3 and T4 indicates hypothyroidism in the patient. The normal level of cortisol in the morning is 5 to 23 mcg/dL and in the evening it is 3 to 16 mcg/dL. Therefore, a cortisol level of 2 mcg/dL indicates hypocortisolism in the patient. Hypocortisolism results in increased skin pigmentation, not decreased skin pigmentation. Hypopituitarism results in hair loss and decreased skin pigmentation in the patient. Somatomedin C is an insulin-like growth facto that is released by the pituitary gland. Somatomedin C levels of 250 ng/mL indicate normal levels in the body, but not hypopituitarism. Parathyroid levels are considered normal in range of 50 to 330 pg/mL. Therefore, the patient has normal parathyroid levels.

The nurse reviews lab values for a male patient with herpes zoster. With which result should the nurse be most concerned? 1 Calcium: 9.0 mg/dL 2 Hemoglobin: 14 g/dL 3 Platelets: 150,000/ mm3 4 White blood cell count: 1000/mm3

Herpes zoster may occur as reactivation of the varicella virus, which is dormant in the ganglion after a primary case of chickenpox. Reactivation is seen in immunocompromised patients. The nurse would be concerned about the patient's immune status, and therefore a check of the white blood cell count would be warranted. A normal white blood cell count is 4000 to 10,000 mm3. The other answer options all contain lab values within normal limits: platelets 150,000 to 350,000/mm3 , hemoglobin 13 to 18 g/dL in males and 12 to 16 g/dL in females, and calcium 8.5 to 10.5 mg/dL.

A patient diagnosed with diabetes type 1 has had elevated blood sugar readings each morning for the past four days. Which intervention by the nurse should be performed initially? 1 Check the patient's blood sugar at 3 AM. 2 Provide the patient with an evening snack. 3 Rotate insulin injection sites between the abdomen, thigh, and arm. 4 Contact the health care provider to increase the evening insulin dose.

Hyperglycemia in the morning may be caused by the Somogyi effect. If a patient is experiencing morning hyperglycemia, checking blood glucose levels between 2:00 and 4:00 AM for hypoglycemia will help determine if the cause is the Somogyi effect. Diabetics should be given evening snacks to prevent hypoglycemia during the night, but glucose assessment is a priority to rule out Somogyi effect. Injection sites are rotated to prevent lypodystrophy. An increased dose of evening insulin may cause further decrease in early morning glucose and increased rebound hyperglycemia.

A patient reports weight loss, increased appetite, chest pain, and hair loss. Assessment findings include large and protruding eyes, skin that is warm, smooth, and moist, an elevated blood pressure, and an increased heart rate. The nurse suspects that the patient has which condition? 1 Goiter 2 Hyperthyroidism 3 Addison's disease 4 Hypoparathyroidism

Hyperthyroidism occurs due to the hypersecretion of thyroid hormone, resulting in an increased basal metabolic rate. Signs and symptoms that include weight loss, large and protruding eyes, warm, smooth, moist skin, hair loss, chest pain indicates hyperthyroidism. Increased heart rate indicates tachycardia. Elevated blood pressure and tachycardia also occur due to hyperthyroidism. Increased metabolism, as a result of hyperthyroidism, may lead to weight loss. A goiter is characterized by the enlargement of the thyroid gland, and may occur due to iodine deficiency and an imbalance of thyroid hormones. Addison disease is characterized by darkening of the skin in skinfolds, weakness, irritability, and decreased cold tolerance. Hypoparathyroidism is characterized by tetany, tachycardia, hyperreflexia, and increased phosphate levels.

A nurse is assessing a patient who has thick, dry skin, weight gain, and cold insensitivity. What possible cause does the nurse suspect? 1 Hypothyroidism 2 Hyperthyroidism 3 Addison's disease 4 Cushing syndrome

Hypothyroidism is a condition in which the body lacks sufficient thyroid hormone. Low thyroid hormone levels cause low metabolism and result in weight gain. Hyperthyroidism is associated with an increase in thyroid hormone levels. A patient with hyperthyroidsm has increased metabolism and weight loss. Addison's disease is caused by low cortisol levels. The physical symptoms of Addison's disease include hyperpigmentation of the skin. Cushing syndrome is a hormonal disorder associated with high levels of cortisol. The main symptom of Cushing syndrome is the presence of striae on the skin surface.

The nurse recognizes that early treatment of Lyme disease is important in preventing which complication that occurs late in the disease? 1 Arthritis 2 Sterility 3 Renal failure 4 Lung abscess

If Lyme disease goes untreated, arthritis pain and swelling in large joints; neurological problems such as headaches, temporary facial paralysis, and poor motor coordination; and cardiac abnormalities may arise late in the disease's course. Sterility, renal failure, and lung abscesses are not complications of Lyme disease.

While performing a capillary refill test, the nurse observes that a patient's nail beds become blanched and remain discolored even when the pressure on the nail beds is released. What can the nurse interpret from this finding? 1 The findings are normal. 2 Jaundice may be present. 3 The patient may have a thyroid disorder. 4 The patient may have subcutaneous bleeding.

If blanching of the nail persists in spite of removing pressure from the nail bed, it may indicate subcutaneous bleeding. It is not a normal finding because the nail bed should turn back to pink once the pressure is removed. In jaundice, the nail bed is yellow in color. In thyroid disorders, the nail becomes uneven and thick.

A patient, who is admitted with diabetes mellitus, has a glucose level of 380 mg/dL and a moderate level of ketones in the urine. As the nurse assesses for signs of ketoacidosis, which respiratory pattern would the nurse expect to find? 1 Central apnea 2 Hypoventilation 3 Kussmaul respirations 4 Cheyne-Stokes respirations

In diabetic ketoacidosis , the lungs try to compensate for the acidosis by blowing off volatile acids and carbon dioxide. This leads to a pattern of Kussmaul respirations, which are deep and nonlabored. Central apnea occurs because the brain temporarily stops sending signals to the muscles that control breathing, which is unrelated to ketoacidosis. Hypoventilation and Cheyne-Stokes respirations do not occur with ketoacidosis.

A patient is admitted with diabetic ketoacidosis. Which signs/symptoms would the nurse expect to find upon physical examination? 1 Blood sugar 200 mg/dL and bradypnea 2 Hypotension and blood sugar 68 mg/dL 3 Diaphoresis and extreme hunger 4 Dry skin and ketonurea

In diabetic ketoacidosis, the lungs try to compensate for the acidosis by blowing off volatile acids and carbon dioxide. This leads to a pattern of Kussmaul respirations, which are deep and nonlabored. The patient also will present with dry, loose skin. Blood pressure will not be low and respiratory rate will be increased, not decreased.

A nurse is dressing the wound of a patient whose fingers were injured in an accident. One of the fingernails is missing. The patient asks the nurse about when the fingernail will grow back. What is the most appropriate answer? 1 Within 3 months 2 Within 6 months 3 Within 12 months 4 Within 15 months

In healthy individuals, a lost fingernail usually regenerates in 3 to 6 months. Therefore the most appropriate answer given by the nurse would be within 6 months.

A nurse is assessing a patient with psoriasis. The nurse explains the pathology of psoriasis, stating that it occurs due to abnormal changes in the cell cycle of the skin layers. Which change in the cell cycle is the nurse referring to? 1 The outer dead layer of skin cells is not shed. 2 The inner layer of skin stops producing new skin cells. 3 The rate of removal of outer dead skin is much more than the rate of production of new skin cells. 4 The rate of new skin cell production is much more than the rate of removal of outer dead skin cells.

In psoriasis, new skin cells are formed faster than old cells are shed. This causes the skin in psoriasis patients to become scaly and thickened. In psoriasis, the outer layer of the dead skin is shed at a normal rate. The inner layer of the skin does not stop producing new skin cells but produces new skin cells at a much faster rate. If the rate of removal of outer dead skin is much more than the rate of production of new skin cells, the skin becomes too thin.

A patient who had been diagnosed with pre-diabetes six months ago is following up in the outpatient diabetes clinic. The nurse is reviewing the assessment data and understands the best reflection of good management of this condition is: 1 A 20-pound weight loss 2 Hemoglobin A1C of 5.5% 3 Reduction of total cholesterol to 200 mg/dL 4 Decrease in polyuria, polydipsia, and polyphagia

Individuals with pre-diabetes are at increased risk for development of type-2 diabetes mellitus. Prediabetes is an intermediate stage between normal glucose homeostasis and elevated blood glucose levels (diabetes). The best indicator of control of this condition is a hemoglobin A1C within normal limits for the non-diabetic patient. Hemoglobin A1C measures the amount of glucose that binds with the component of hemoglobin (A1C), which gives an indication of average glucose levels in the blood over a 90-day period. Although a reduction of risk factors through weight reduction, dietary management, and exercise is important, weight loss and cholesterol within normal limits does not reflect prevention of diabetes. Because the patient does not have true diabetes, the patient would not be experiencing the classic symptomology of the disease: polyuria, polydipsia, and polyphagia.

The charge nurse is making assignments for the day shift. An appropriate assignment to the Licensed Practical Nurse (LPN) would be: 1 A 45-year-old type 1 diabetic who is nothing by mouth (NPO) for an endoscopy at noon. 2 A 28-year-old who is a type 1 diabetic being admitted with diabetic ketoacidosis (DKA) 3 An 8-year-old newly diagnosed type 1 diabetic who is being discharged 4 A 62-year-old type 1 diabetic with a bedside glucose meter reading of 285 who is due for sliding scale coverage

Insulin can be administered by the licensed practical nurse (LPN). The most appropriate assignment would be the patient who has a scheduled sliding scale dose due. A diabetic patient who is NPO for surgery must be monitored closely, which is within the scope of practice for an LPN; however, the patient is not going to surgery until noon and therefore a plan must be in place to avoid hypoglycemia. Developing a plan to avoid hypoglycemia is not within the scope of practice of the LPN. A newly admitted patient with DKA requires close observation and frequent interventions by the RN to prevent acute complications. A newly diagnosed diabetic patient will have complex discharge instructions, including an evaluation of understanding of the teaching plan on management of disease, which is beyond the scope of practice of the LPN.

A postoperative knee replacement patient with a history of osteoarthritis (OA) is admitted to the orthopedic unit. The nurse knows that: 1 Inflammation is not characteristic with OA. 2 Referred pain to the buttocks, groin, or thigh rarely occurs. 3 Patients with OA also have complaints of fever, fatigue, and organ involvement. 4 With OA, the body generally is able to keep up with necessary cartilage repair.

Joint inflammation occurs in patients with rheumatoid arthritis (RA) and not in OA. With OA, pain frequently is referred to the buttocks, groin, or thigh. Systemic complaints related to fever, fatigue, and organ involvement occur in patients with RA and not OA. The body generally is unable to keep up with necessary cartilage repair, and destruction then occurs.

The nurse should recognize which patient as likely to have the poorest prognosis? 1 A 60-year-old diagnosed with nodular ulcerative basal cell carcinoma 2 A 59-year-old man who is being treated for stage IV malignant melanoma 3 A 70-year-old woman who has been diagnosed with late squamous cell carcinoma (SCC) 4 A 51-year-old woman whose biopsy has revealed superficial squamous cell carcinoma

Late detection of malignant melanoma is associated with a poor outcome. Basal cell carcinomas often have very effective treatment success rates. Although late SCC has worse outcomes than superficial SCC, these are both exceeded in mortality by late-stage malignant melanoma.

The nurse is admitting a patient who complains of a new onset of lower back pain. To differentiate between the pain of a lumbar herniated disc and lower back pain from other causes, what would be the best question for the nurse to ask the patient? 1 "Is the pain worse in the morning or in the evening?" 2 "Is the pain sharp or stabbing, or burning or aching?" 3 "Does the pain radiate down the buttock or into the leg?" 4 "Is the pain totally relieved by analgesics, such as acetaminophen (Tylenol)?"

Lower back pain associated with a herniated lumbar disc is accompanied by radiation along the sciatic nerve and commonly can be described as traveling through the buttock, to the posterior thigh, or down the leg. This is because the herniated disc causes compression on spinal nerves as they exit the spinal column. Time of occurrence, type of pain, and pain relief questions are important, but they do not elicit differentiating data.

Laboratory results have been obtained for a 50-year-old patient with a 15-year history of type 2 diabetes. Which result reflects the expected pattern accompanying macrovascular disease as a complication of diabetes? 1 Increased triglyceride levels 2 Increased high-density lipoproteins (HDL) 3 Decreased low-density lipoproteins (LDL) 4 Decreased very-low-density lipoproteins (VLDL)

Macrovascular complications of diabetes include changes to large- and medium-sized blood vessels. They include cerebrovascular, cardiovascular, and peripheral vascular disease. Increased triglyceride levels are associated with these macrovascular changes. Increased HDL, decreased LDL, and decreased VLDL are positive in relation to atherosclerosis development.

A nurse is teaching a group of patients with arthritis about the ways to protect the small joints from injury. What are the instructions that the nurse should include? Select all that apply. 1 Maintain the joint in a neutral position. 2 Perform activities like wringing water from a sponge. 3 Use strongest joints available for any task. 4 Slide objects instead of lifting them. 5 Stand in a comfortable position while cooking rather than sitting.

Maintaining joints in neutral position helps in preventing joint injury. Using the strongest joint involves better holding of the object and reduces pressure on affected joint. Sliding of objects, especially heavy objects, helps in reducing injury to the joint. Wringing water from a sponge twists the fingers and wrists. This can cause pain and stiffness in the joints. Therefore, pressing water from a sponge instead of wringing is best. Standing for a long time while cooking puts more pressure on the legs, knees, feet, and ankles. This can lead to pain and inflammation and should be avoided. Sit on a stool instead of standing during meal preparation.

A patient observes discoloration of urine during the course of the treatment for arthritis. How does the nurse explain this type of observation? Select all that apply. 1 It may be due to an infection. 2 Excess medication is excreted in the urine. 3 This is a side effect of the treatment. 4 This is a result of the interaction between the medications with the urine. 5 It will stop once the therapy is discontinued.

Many drugs often cause discoloration of the urine because of the conversion into colored metabolites (metabolism by mostly liver enzymes and not interaction with urine) in the body, which are then excreted in the urine. The discoloration of urine by the drug is due to the excess medicine being excreted in the urine, and the resultant interaction between the drug metabolite and the urine. This side effect vanishes with the discontinuation of the therapy. Infections generally do not cause discoloration. Discoloration of urine is not a side effect of the drug.

After administering glucagon to an unconscious patient, the nurse should place the patient in which position? 1 Supine 2 Side-lying 3 High-Fowler 4 Semi-Fowler

Nausea is a common reaction after glucagon injection. The patient should be placed in the side-lying position to prevent aspiration should the patient vomit. Supine, high-Fowler, and semi-Fowler positions are not advisable because of the risk of aspiration of vomitus.

The nurse is working in a trauma rehabilitation center. A patient has a trauma wound being treated by negative-pressure therapy. Arrange the procedure of negative-pressure wound therapy in correct sequence. 1. A large occlusive dressing is applied. 2. The wound is cleaned. 3. A gauze dressing is cut to the dimension of the wound. 4. A small hole is made over the gauze where the tubing is attached. 5. The tubing is attached to a pump, which creates negative pressure in the wound.

Negative-pressure wound therapy uses suction to debride the wound and promote healing. The wound is cleaned and a gauze dressing is cut to the dimension of the wound. Thereafter, a large occlusive dressing is applied. A small hole is made over the gauze where the tubing is attached. The tubing is attached to a pump, which creates negative pressure in the wound.

A 62-year-old patient is admitted with diabetes mellitus, malnutrition, and cellulitis. The patient's potassium level is 5.8 mEq/L. The nurse understands that a possible cause of hyperkalemia would be: 1 Retention of potassium related to inadequate nutrition. 2 The body's attempt to fight off the infection caused by cellulitis. 3 Excess insulin administration causing potassium to leak out of the cells. 4 Decreased secretion of potassium through the kidneys secondary to nephropathy.

Nephropathy, a complication of diabetes, results in elevated potassium levels. Malnutrition does not cause sodium excretion accompanied by potassium retention; therefore, it is not a contributing factor in this patient's potassium level. Potassium is not affected by the body's immune system. Insulin causes a decrease in potassium by pushing it into the cells.

A patient with a cast for a fractured radius reports, "My fingers feel numb." Which action is highest priority for the nurse? 1 Elevating the arm on two pillows 2 Notifying the primary health care provider 3 Performing a thorough neurovascular assessment 4 Reassuring the patient that this is a normal response

Numbness distal to a casted extremity is an indication of decreased circulation, nerve compression, and possibly compartment syndrome. The nurse should perform a full neurovascular assessment to determine the extent of the problem. After the nurse has performed the assessment, the arm may be elevated on two pillows while the primary health care provider is notified. Numbness in the fingers of the casted arm is not a normal response.

The nurse is admitting a patient who is scheduled for knee arthroscopy related to osteoarthritis (OA). Which finding should the nurse expect to be present on examination of the patient's knees? 1 Ulnar drift 2 Pain with joint movement 3 Reddened, swollen affected joints 4 Stiffness that increases with movement

OA is characterized predominantly by joint pain upon movement and is a classic feature of the disease. Ulnar drift occurs with rheumatoid arthritis (RA), not osteoarthritis. Not all joints are reddened or swollen. Stiffness decreases with movement.

After assessing the muscle strength of a patient, the nurse scores it as 1 on the Muscle Strength Scale. What does the score mean? 1 No detection of muscular contraction 2 A barely detectable flicker or trace of contraction with observation or palpation 3 Active movement of the body part with elimination of gravity 4 Active movement against gravity only and not against resistance

On the Muscle Strength Scale, grade 1 means that there is a barely detectable flicker or trace of contraction with observation or palpation in the patient. A grade 0 means no detection of muscular contraction. A grade 2 indicates active movement of body part with elimination of gravity. A grade 3 means active movement against gravity only and not against resistance.

An 86-year-old patient has osteoarthritis of the knees. Which finding would the nurse expect upon examination of the patient's knees? 1 Stiffness that is worse in the morning 2 Positive anterior drawer test 3 Positive Phalen and Tinels signs 4 Pain with joint movement

Osteoarthritis is characterized predominantly by joint pain on movement. Stiffness in the morning is associated with rheumatoid arthritis. Phalen and Tinels signs are indicative of carpal tunnel, and an anterior drawer test is not associated with osteoarthritis.

A patient has just been given a diagnosis of osteoarthritis. The nurse explains that the associated changes in the joint are the result of what type of process? 1 Malignant 2 Degenerative 3 Inflammatory 4 Immunological

Osteoarthritis occurs commonly after years of stress, or "wear and tear," on weight-bearing joints. This degenerative process causes hypertrophic changes in the joints. Malignant refers to a growth process that is resistant to treatment, such as that seen in cancer. Inflammatory is the term given to a nonspecific immune response that occurs in reaction to any type of bodily injury. Immunological refers to the immune system, which protects us from or resists disease or infection as a result of the development of antibodies or cell-mediated immunity.

A 68-year-old female patient with hypertension is admitted to the nursing unit with osteomyelitis. Which symptom will the nurse most likely find on physical examination? 1 Abdominal pain 2 Hypotension 3 Limited range of motion of the extremity 4 Nausea and vomiting

Osteomyelitis is an infection of bone and bone marrow that can occur with trauma, surgery, or extension of nearby infection. Because it is an infection, the patient will exhibit typical signs of inflammation and infection, including localized pain and redness and limited movement of the affected extremity. Nausea, vomiting, and abdominal pain are not associated with osteomyelitis. If the infection led to bacteremia, the patient may become hypotensive, indicating septic shock.

A patient who has been found to have osteomyelitis asks the nurse about the most effective treatment for this problem. The nurse should explain that osteomyelitis is best managed with: 1 Traction 2 IV antibiotics 3 Oral antibiotics 4 Pain medications

Osteomyelitis is an infection of the bone that is very difficult to heal. An extended course of IV antibiotics is usually prescribed in the aggressive treatment of this condition. Traction is not indicated in this situation. Oral antibiotics may not be strong enough to eradicate the infection. Pain medications may be used in conjunction with antibiotics if necessary.

Which hormone stimulates milk secretion in a postpartum patient? 1 Insulin 2 Oxytocin 3 Epinephrine 4 Parathormone

Oxytocin targets the mammary glands in postpartum patients and stimulates milk secretion. Insulin is the hormone that helps with glucose regulation in the body. Epinephrine is the hormone that helps augment and prolong the sympathetic nervous system effects. Parathormone helps maintain calcium and phosphorus levels in the body.

The nurse would assess a patient admitted with cellulitis for what localized manifestation? 1 Pain 2 Fever 3 Chills 4 Malaise

Pain, redness, heat, and swelling are all localized manifestation of cellulitis. Fever, chills, and malaise are generalized, systemic manifestations of inflammation and infection.

A patient's laboratory reports indicate an abnormal decrease in blood Ca+ levels, most likely due to impaired absorption of calcium from the intestine. Which hormone imbalance would cause this decrease? 1 Thyroxine (T4) 2 Calcitonin (CT) 3 Parathormone (PTH) 4 Triiodothyronine (T3)

Parathormone (PTH) is the principle hormone produced by the parathyroid glands. PTH regulates calcium by enhancing the release of calcium from bone stores, stimulating reabsorption of calcium by the kidneys and enhancing absorption of calcium in the intestine by increasing the production of activated vitamin D. Imbalance of PTH may cause impaired absorption and a decrease in blood Ca++ levels. Thyroxine, also known as tetraiodothyronine (T4), is a hormone produced by the thyroid gland. Calcitonin is a hormone produced by the parafollicular cells of the thyroid gland that increases calcium storage in bone and decreases serum Ca++ levels. Triiodothyronine (T3) is a hormone produced by the thyroid gland that increases the rate of metabolism.

A patient is examined by the nurse and found to have pink-purple, nonblanching macular pinpoint lesions. Which term best describes these findings? 1 Purpura 2 Petechiae 3 Hematoma 4 Ecchymosis

Petechiae are small pink-to-purplish macular lesions 1 to 3 mm in diameter, usually caused by minor hemorrhage of capillary blood vessels. Purpura are red or purple discolorations of the skin that do not blanch when pressure is applied. Purpura are associated with bleeding under the skin and are seen in various bleeding disorders. A hematoma is a localized collection of blood outside blood vessels that is generally the result of hemorrhage. Ecchymosis is a collection of blood under the skin, larger than a petechia, with diffuse borders.

The nurse is caring for four newly diagnosed patients with various connective tissue disorders. The nurse should be most aware of safety issues and interstitial lung involvement in the patient with which diagnosis? 1 Polymyositis 2 Reactive arthritis 3 Sjögren's syndrome 4 Systemic lupus erythematosus (SLE)

Polymyositis is an inflammatory disease affecting striated muscle and resulting in muscle weakness that increases the patient's risk of falls and injury. Weakened pharyngeal muscles increase the risk for aspiration with interstitial lung disease in up to 65% of patients. The treatment of polymyositis starts with high-dose corticosteroids that cause immunosuppression. If this does not work, other immunosuppressive drugs may be used. Reactive arthritis (Reiter's syndrome) occurs with urethritis, conjunctivitis, and mucocutaneous lesions, with the asymmetric arthritis involving large joints of the lower extremities and toes. This patient is not at increased risk for safety problems. Sjögren's syndrome decreases moisture produced by exocrine glands, especially in the mouth and eyes, and is without increased risk of injury or interstitial lung involvement. SLE is a multisystem inflammatory autoimmune disorder treated with NSAIDs and antimalarial agents. Safety would not be an important issue early in the disease.

The 24-year-old male patient who was treated successfully for Paget's disease has come to the clinic with a gradual onset of pain and swelling around the left knee. The patient is diagnosed with osteosarcoma without metastasis. The patient wants to know why he will be given chemotherapy before the surgery. What is the best rationale the nurse should tell the patient? 1 The chemotherapy is being used to save your left leg. 2 Chemotherapy is being used to decrease the tumor size. 3 The chemotherapy will increase your 5-year survival rate. 4 Chemotherapy will help decrease the pain before and after surgery.

Preoperative chemotherapy is used to decrease tumor size before surgery. The chemotherapy will not save his leg if the lesion is too big or there is neurovascular or muscle involvement. Adjunct chemotherapy after amputation or limb salvage has increased the 5-year survival rate in people without metastasis. Chemotherapy is not used to decrease pain before or after surgery.

During an assessment, the nurse observes a lateral S-shaped curvature of the patient's thoracic and lumbar spine. The nurse anticipates which other clinical manifestation? 1 Asymmetric shoulders 2 Cross knee movement 3 Fingers drifted to ulnar side of forearm 4 Abnormal flatness of the sole of the foot

Presence of a lateral S-shaped curvature of the thoracic and lumbar spine indicates that the patient has scoliosis. Due to lateral spine curvature, the patient's shoulders rise asymmetrically; therefore, the nurse would find asymmetric shoulders in the patient. A patient with cerebral palsy, hemiplegia would have cross knee movement due to spastic gait. A patient with tendon contracture would have fingers drifted to the ulnar side of the forearm. A patient with muscle paralysis, mild cerebral palsy, or early muscular dystrophy would have abnormal flatness of the sole of the foot.

A patient presents with tiny skin lesions on the chest and back that have a diameter less than 0.5 cm. Which procedure should be used to obtain a sample of these lesions? 1 Curettage 2 Skin scraping 3 Punch biopsy 4 Electrodessication

Punch biopsy is a common dermatologic procedure used to obtain a tissue sample for histologic study. It is generally reserved for lesions smaller than 0.5 cm. Curettage is useful for removing soft skin tumors and superficial lesions, such as warts and actinic keratoses. Skin scraping is done to obtain a sample of surface cells for microscopic inspection and diagnosis. Electrodessication is useful in coagulation of bleeding vessels to obtain hemostasis and destruction of small telangiectasias.

Which laboratory test would be most important to check in the patient presenting with purpura? 1 Urinalysis 2 Serum electrolytes 3 Coagulation studies 4 White blood cell count

Purpura are areas of ecchymoses that may signify a bleeding disorder. Therefore, it is most important for the nurse to assess the patient's coagulation studies. Electrolytes, urinalysis, and white blood cells would not reveal a reason for why purpura are present.

The nurse is evaluating the outcome of patient teaching regarding aspart (NovoLog) insulin. The patient demonstrates an appropriate understanding when stating: 1 "This insulin is used to treat the elevated sugar that occurs after meal intake." 2 "I cannot mix this insulin in the same syringe with any other type of insulin." 3 "I need to plan my meals well so I can inject my insulin 30 minutes before I begin to eat." 4 "The best thing about this type of insulin is I take it at bedtime and it works for 24 hours."

Rapid-acting insulins, such as aspart, are used to control postprandial blood glucose levels. The timing of insulin injection with meals is crucial. Rapid-acting insulin has a quick onset of approximately 15 minutes and should be injected within 15 minutes of mealtime. Short-acting insulin, such as Humulin-R, because of longer onset of action, can safely be administered 30 to 60 minutes before a meal. Rapid-acting insulin such as aspart can be mixed safely with intermediate-acting insulin in the same syringe. Long-acting insulin such as glargine (Lantus) and detemir (Levemir) should not be mixed with any other insulins. Because rapid acting insulins have a shorter duration of action, they are typically injected before meals.

The patient received regular insulin eight units subcutaneously (subQ) at 0900. The nurse plans to monitor this patient for signs of hypoglycemia during which time? 1 1000 and 1100 2 1100 and 1200 3 1200 and 1300 4 1300 and 1500

Regular insulin exerts peak action in two to three hours, placing the patient at greatest risk for hypoglycemia between 1100 and 1200. At this time, the nurse should offer the patient a snack. 1000 and 1100, 1200 and 1300, and 1300 and 1500 are not consistent with peak action of insulin administered at 0900.

A mother and her child have been diagnosed with scabies after attending a camp together. An appropriate measure in treating this condition is 1 Topical application of griseofulvin 2 Applying 5% peremethrin to the body 3 Moist compresses applied frequently 4 Administration of systemic antibiotics

Scabies is treated with 5% permethrin topical lotion, one overnight application with a second application 1 week later. Scabies is not treated with griseofulvin. The patient should be taught to keep the area dry. Systemic antibiotics should only be used if secondary infections are present.

The nurse should teach a patient who is taking which drug to avoid prolonged sun exposure? 1 Tetracycline 2 Ipratropium 3 Morphine sulfate 4 Oral contraceptives

Several antibiotics, including tetracycline, may cause photosensitivity . This is not the case with ipratropium, morphine, or oral contraceptives.

A patient had an infection underneath the thumbnail, and the entire nail was removed. The patient asks the nurse how long it will take the fingernail to grow back to its normal size. What should be the nurse's answer? 1 1-2 months 2 3-6 months 3 6-12 months 4 12-24 months

Sometimes fingernails may be removed due to ingrowth and infection. Fingernails grow at a rate of 0.7 to 0.84 mm per week. The nail growth may vary depending upon the person's age and health. A fingernail would usually fully regenerate in 3 to 6 months. Toenails may take longer to grow, approximately 12 months or more.

A patient is found to have a partially dislocated shoulder. How should the nurse document this finding? 1 Fracture 2 Rupture 3 Subluxation 4 Misalignment

Subluxation, also known as dislocation, may be assessed by means of palpation of the space between the head of the bone and the cavity where it is normally located. Subluxation results in partial loss of function and intense pain. A subluxation is not a fracture—there is no break in bone integrity—but a subluxation is treated similarly to a fracture. With subluxation, there is no rupture in the integrity of the bone. Subluxation may be described as a misalignment, but this is not an accurate term.

A nurse observes that a group of patients has a darker skin tone after being outside for a period of time. The nurse recalls that the reason for this finding is what? 1 The UVA rays of the sun cause tanning. 2 The UVB rays of the sun cause sunburn. 3 The UVC rays of the sun cause collagen damage. 4 The UVC rays of the sun cause increased melanin production.

Sunlight is composed of ultraviolet rays and visible light rays. Extended exposure to the sun causes the skin to tan. The sun's UVA rays increase the production of melanin in the skin, leading to a tan. UVB rays cause sunburn. UVC rays do not reach the earth as they are blocked by the atmosphere. Both UVA and UVB rays can cause collagen damage and accelerate skin aging. Melanin production increases in response to sunlight exposure. UVC rays alone do not increase melanin production.

A nurse educator explains to a group of nursing students why skin becomes darker in color when exposed to sunlight. Which statement by a student indicates the teaching has been understood? 1 "The rays from the sun burn the outer layer of the skin, making the skin dark and painful." 2 "The rays from the sun stimulate the production of melanin, giving a tan to the skin." 3 "The rays from the sun inhibit the production of melanin, causing the skin to darken." 4 "The rays from the sun cause increased blood flow to the skin, giving a dark red color to the skin."

Sunlight stimulates an organelle known as melanosome, which is present in the melanocytes (the cells responsible for production of melanin.) Stimulation of melanosome causes increased production of melanin, which gives the dark color (tan) to the skin. Extreme sun exposure can burn the skin, and the skin may become dark and painful due to sunburns. Heat in summer causes vasodilatation, which causes temporary reddening of the skin.

A patient with intervertebral disc damage caused by lumbar spinal stenosis is undergoing treatment, and reports bladder incontinence and constant back pain. The nurse prepares the patient for what outpatient procedure? 1 A laminectomy 2 An intradiscal electrothermoplasty (IDET) 3 A radiofrequency discal nucleoplasty 4 An interspinous process decompression system

Surgery is indicated because of the bladder incontinence, and an interspinous process decompression system (X-stop) is an outpatient technique used in patients with constant pain caused by lumbar spinal stenosis. Laminectomy requires a minimal hospital stay after completion. An IDET is not specifically for patients with lumbar spinal stenosis or constant pain. Radiofrequency discal nucleoplasty (coblation nucleoplasty) is not specifically for patients with lumbar spinal stenosis, and pain relief varies.

A nurse is caring for a patient who has taken a potassium hydroxide (KOH) skin test. The results of the test are positive. What would be the interpretation of this test? 1 The patient has a skin allergy. 2 The patient has a malignant skin condition. 3 The patient has a fungal infection of the skin. 4 The patient has systemic lupus erythematosus (SLE).

The KOH test indicates the presence of a fungal infection. The KOH test cannot be used to establish the presence of skin allergy, malignant skin condition, or SLE. A skin allergy is best tested with the patch test. The diagnosis of a malignant skin condition is done by a skin biopsy. Direct immunofluorescence is a special diagnostic technique used on a biopsy specimen to confirm SLE.

The hypothalamus secretes releasing hormones and inhibiting hormones. What is the target tissue of these releasing hormones and inhibiting hormones? 1 Pineal 2 Adrenal cortex 3 Posterior pituitary 4 Anterior pituitary

The anterior pituitary is the target tissue of the releasing hormones (corticotropin releasing hormone, thyrotropin releasing hormone, growth hormone releasing factor, gonadotropin releasing hormone, and prolactin releasing factor) and the inhibiting hormones (somatostatin, prolactin inhibiting factor). These hormones release or inhibit other hormones that affect the thyroid, adrenal cortex, pancreas, reproductive organs, and all body cells. The pineal gland is not affected directly by the releasing and inhibiting hormones from the hypothalamus. The posterior pituitary releases antidiuretic hormone (ADH) in response to plasma osmolality changes that is not affected directly by the hypothalamus hormones.

Which intervention would be most helpful in managing cellulitis in an 83-year-old patient with heart failure? 1 Apply warm, moist heat 2 Maintain strict bed rest 3 Perform passive range of motion exercises 4 Soak the extremity in cool, sterile saline

The application of warm, moist heat speeds the resolution of inflammation and infection when accompanied by appropriate antibiotic therapy. It does this by increasing local circulation to the affected area to bring macrophages to the area and carry off cellular debris. Strict bed rest is not advised as this will place the patient at an increased risk for blood clot formation. Passive range of motion may be performed; however, this will not alter the course of the cellulitis. The extremity should not be soaked in cool saline because of vasoconstriction and possible delayed wound healing.

A patient with psoriasis tells the nurse that the patient has quit his or her job as a restaurant hostess because the patient believes the lesions on his or her hands and arms are unattractive to customers. The nursing diagnosis that best describes this patient response is 1 Social isolation related to fear of rejection 2 Ineffective coping related to lack of social support 3 Impaired skin integrity related to presence of lesions 4 Ineffective health maintenance because of presence of lesions

The chronicity of psoriasis can be severe and disabling as people withdraw from social contacts because of visible lesions. Quality of life is also affected negatively. The information presented does not indicate the patient does not have support. Impaired skin integrity is not a priority diagnosis. There is no information to indicate the patient has ineffective health maintenance.

The nurse is evaluating a 45-year-old patient diagnosed with type 2 diabetes mellitus. Which symptom reported by the patient is considered one of the classic clinical manifestations of diabetes? 1 Excessive thirst 2 Gradual weight gain 3 Overwhelming fatigue 4 Recurrent blurred vision

The classic symptoms of diabetes are polydipsia (excessive thirst), polyuria, (excessive urine output), and polyphagia (increased hunger). Weight gain, fatigue, and blurred vision may all occur with type 2 diabetes , but are not classic manifestations.

A patient with a fracture of the right tibia has been advised to use a cane. What instructions should the nurse give to this patient? Select all that apply. 1 Hold the cane in the right hand. 2 Hold the cane in the left hand. 3 Advance the right leg first. 4 Advance the left leg first. 5 Advance the right leg last. 6 Advance the left leg last.

The decision to use assistive devices is made by the health care provider depending on the needs and lifestyle of patient. Use of these devices varies. When a cane is used, the affected limb is advanced along with or after the cane, and the unaffected limb is advanced last. The cane is held in the hand opposite the affected limb. In this case, the right leg is affected, and therefore the cane should be held in the left hand, the right leg should be advanced first, and the left leg should be advanced last.

A patient with type 1 (insulin-dependent) diabetes mellitus reports feeling shaky and lightheaded. The patient's skin is pale and sweaty. The nurse should take what immediate action? 1 Administering glucagon subcutaneously 2 Providing the patient with a glucose tablet 3 Administering supplemental regular insulin 4 Offering the patient a complex carbohydrate snack.

The described symptoms represent mild-to-moderate hypoglycemia. Rapid treatment involves providing the alert and awake patient with a rapid-dissolving buccal glucose tablet or, if unavailable, a glass of glucose-containing liquid such as orange juice. The patient is experiencing hypoglycemia when the blood sugar is already low. Therefore insulin should not be given. Administering glucagon is not necessary; the patient is awake and able to take food and fluids orally. After consuming a simple sugar, the patient requires a complex carbohydrate snack and protein to sustain the blood glucose and prevent rebound hypoglycemia.

When the nurse assesses the patient who has pancreatitis, what function may be altered related to the endocrine function of the pancreas? 1 Blood glucose regulation 2 Increased response to stress 3 Fluid and electrolyte regulation 4 Regulation of metabolic rate of cells

The endocrine functions of the pancreas are regulated by α cells that produce and secrete glucagon, β cells that produce and secrete insulin and amylin, delta cells that produce and secrete somatostatin, and F cells that secrete pancreatic polypeptide. Glucagon, insulin, amylin, and somatostatin all affect blood glucose. Pancreatic polypeptide regulates appetite. Increased response to stress occurs from epinephrine secreted by the adrenal medulla. Fluid and electrolyte regulation occurs in response to several hormones (mineralocorticoids, antidiuretic hormone, parathyroid hormone, and calcitonin) from several organs (adrenal cortex, posterior pituitary, parathyroid, and thyroid). The metabolic rate of cells is regulated by triiodothyronine (T3) from the thyroid.

The nurse determines that dietary teaching for a 75-year-old patient with osteoporosis has been successful when the patient selects which highest calcium meal? 1 Chicken stir-fry with 1 cup each onions and green peas, and 1 cup of steamed rice 2 Ham and Swiss cheese sandwich on whole wheat bread, steamed broccoli, and an apple 3 A sardine (3 oz) sandwich on whole wheat bread, 1 cup of fruit yogurt, and 1 cup of skim milk 4 A two-egg omelet with 2 oz of American cheese, one slice of whole wheat toast, and a half grapefruit

The highest calcium content is present in the lunch containing milk and milk products (yogurt) and small fish with bones (sardines). Chicken, onions, green peas, rice, ham, whole wheat bread, broccoli, apple, eggs, and grapefruit each have less than 75 mg of calcium per 100 g of food. Swiss cheese and American cheese have more calcium, but not as much as the sardines, yogurt, and milk.

Which is an example of a gliding joint? 1 Wrist 2 Shoulder 3 Between carpal bones 4 Carpometacarpal of thumb

The joint between carpal bones is a gliding joint because the bones move over the surface of each other. The wrist joint is a condyloid joint capable of flexion, extension, abduction, adduction, and circumduction. The shoulder joint is a ball-and-socket joint also capable of flexion, extension, adduction, abduction, and circumduction. The carpometacarpal joint of the thumb is a saddle joint which allows thumb-finger opposition along with flexion, extension, adduction, abduction, and circumduction.

A patient receiving long-term nonsteroidal antiinflammatory drug (NSAID) therapy for osteoarthritis develops gastrointestinal bleeding and erosion. What should be the first intervention? 1 Dietary modifications 2 Administration of antacids 3 Switch to low-dose therapy 4 Proton pump inhibitor therapy

The major side effects of nonsteroidal antiinflammatory agents area gastrointestinal bleeding and ulceration, which are to be monitored during the course of the treatment. The coadministration of a proton pump inhibitor helps to treat this condition. Low-dose therapy will still be irritating to the gastric mucosa. Antacids only decrease the irritation by increasing the pH of the stomach and do not treat the bleeding. Dietary modifications are necessary to help heal the eroded surface but are not the first intervention.

The patient has been feeling tired lately and has gained weight, reports thickened, dry skin, and increased cold sensitivity even though it is now summer. Which endocrine diagnostic test should be done first? 1 Free thyroxine (FT4) 2 Serum growth hormone (GH) 3 Follicle stimulating hormone (FSH) 4 Magnetic resonance imaging (MRI) of the head

The manifestations the patient is experiencing could be related to hypothyroidism. Free thyroxine (FT4) is considered a better indicator of thyroid function than total T4 and could be done to evaluate the patient for hypothyroidism. Growth hormone excess could cause thick, leathery, oily skin, but does not demonstrate the other manifestations. FSH is manifest with menstrual irregularity and would be useful in distinguishing primary gonadal problems from pituitary insufficiency. MRI is the examination of choice for radiologic evaluation of the pituitary gland and the hypothalamus, but would not be the first diagnostic study to further explore the basis of these manifestations.

The nurse recalls that primary intention healing takes place in various phases. Which phase best describes the migration of fibroblasts? 1 Initial phase 2 Granulation phase 3 Maturation phase 4 Regeneration phase

The migration of fibroblasts occurs in the granulation phase which lasts from 5 days to 4 weeks. In this phase collagen is secreted and there is an abundance of capillary buds in the wound making it fragile. The initial phase lasts from 3 to 5 days. In this phase, the migration of epithelial cells takes place. The clot serves as a meshwork for starting capillary growth. The maturation phase lasts from 7 days to several months. In this phase, remodeling of collagen and strengthening of the scar occurs. Regeneration is not the phase of primary intention healing.

An 82-year-old patient is frustrated by her flabby belly and rigid hips. What should the nurse tell the patient about these frustrations? 1 "You should go on a diet and exercise more to feel better about yourself." 2 "Something must be wrong with you because you should not have these problems." 3 "You have arthritis and need to go on nonsteroidal antiinflammatory drugs (NSAIDs)." 4 "Decreased muscle mass and strength and increased hip rigidity are normal changes of aging."

The musculoskeletal system's normal changes of aging include decreased muscle mass and strength, increased rigidity in the hips, neck, shoulders, back, and knees, decreased fine motor dexterity, and slowed reaction times. Going on a diet and exercising will help, but not stop these changes. Telling the patient "Something must be wrong with you" will not be helpful to the patient's frustrations. The patient does not have arthritis or need NSAIDs.

When assessing a 73-year-old female patient, the nurse found wrinkles, sagging breasts, and tenting of the skin, gray hair, and thick brittle toenails. The nurse knows that what normal changes of aging occur that can cause these changes in the integumentary system? 1 Decreased activity of apocrine and sebaceous glands, decreased density of hair, and increased keratin in nails 2 Decreased extracellular water, surface lipids, and sebaceous gland activity, decreased scalp oil, and decreased circulation 3 Muscle laxity, degeneration of elastic fibers, collagen stiffening, decreased melanin, and decreased peripheral blood supply 4 Increased capillary fragility and permeability, cumulative androgen effect and decreasing estrogen levels, and decreased circulation

The normal changes of aging include muscle laxity, degeneration of elastic fibers, and collagen stiffening that contribute to the wrinkles, sagging breasts, and tenting of the skin. Decreased melanin and melanocytes in the hair lead to gray hair, and decreased peripheral blood supply leads to thick brittle nails with diminished growth. Decreased apocrine and sebaceous glands would lead to dry skin with minimal to no perspiration and uneven skin color. Decreased density of hair leads to thinning and loss of hair. Increased keratin in nails leads to longitudinal ridging of the nails. The decreased extracellular water, surface lipids, and sebaceous gland activity lead to dry flaking skin. Decreased scalp oil leads to dry coarse hair and a scaly scalp, and decreased circulation leads to prolonged return of blood to nails on blanching. Increased capillary fragility and permeability in aging leads to bruising. A cumulative androgen effect and decreased estrogen levels lead to facial hirsutism in women and baldness in men. Decreased circulation leads to prolonged return of blood to nails on blanching.

The nurse reviews the laboratory results of a patient and recalls that the normal range of thyroglobulin in females is what? 1 0.5-53 ng/mL 2 0.5-43 ng/mL 3 0.62-2.79 nmol/L 4 1.08-3.14 nmol/L

The normal range of thyroglobulin levels in females is 0.5 to 43 ng/mL. For males, the normal range of thyroglobulin levels is 0.5 to 53 ng/mL. The normal range of triiodothyronine (T3) in patients older than 50 years of age is 0.62 to 2.79 nmol/L. The normal range of triiodothyronine (T3) in patients between 20 and 50 years of age is 1.08 to 3.14 nmol/L.

Which white blood cell count is the best indicator that a 54-year-old patient with cellulitis has recovered from the infection? 1 2000/mm3 2 5000/mm3 3 13,000/mm3 4 16,500/mm3

The normal white blood cell count is 4000 to 11,000 cells/mm3, according to most laboratory reference books. For this reason, the patient's level would have been deemed normal if it was 5000/mm3. A white blood cell count of 2000/mm3 is categorized as leukopenia and is abnormal. White blood cell counts of 13,000 or 16,500 mm/3 would indicate continued infection.

After conducting muscle-strength tests on a patient, the nurse assigns a score of 2 on the muscle strength scale. What did the nurse observe to make this clinical determination? 1 A barely detectable flicker with palpation 2 Active movement against gravity and some resistance 3 Active movement against gravity but not against resistance 4 Active movement of the body part with elimination of gravity

The nurse assigns a score of 2 if the patient has active movement of the body part against gravity. If the patient has a barely detectable flicker or trace of muscle contraction upon palpation, the nurse assigns a score of 1. The nurse assigns a score of 4 if the patient shows active movement of the body part against gravity and some resistance. If the patient shows active movement of the body part against gravity but not against external resistance, the nurse assigns a score of 3.

The nurse is educating a patient about an ultrasound of the thyroid gland to observe for any nodules. What should the nurse teach the patient? 1 Instruct the patient to fast. 2 Inform the patient that sedation may be required. 3 Inform the patient that the test will last approximately 30 minutes. 4 Inform the patient that a gel and transducer will be used over the neck.

The nurse preparing the patient for an ultrasound to evaluate thyroid nodules should inform the patient that a gel and transducer will be used over the neck. The patient is not required to fast, and sedation is not required. The test will last 15 minutes.

The nurse is teaching a patient in the menopausal stage to include calcium-rich food in her diet to delay the onset of osteoporosis. What should the nurse recommend to the patient as a rich source of calcium? 1 Consume an apple or a banana daily. 2 Include an egg in daily diet. 3 Consume a raw fresh carrot daily. 4 Take a cup of skimmed milk daily.

The nurse should ask the patient to have a cup of skimmed milk daily, as it is a rich source of calcium. A cup of skimmed milk contains 302 mg of calcium. Eggs, apples, and bananas are poor sources of calcium. An egg contains only 28 mg of calcium. An apple or a banana contain only 10 mg of calcium, whereas a medium-sized carrot contains about 14 mg of calcium.

A patient is prescribed intranasal salmon calcitonin (Calcimar) for osteoporosis. What should the nurse teach this patient? 1 Spray both nostrils daily.The spray may cause nasal dryness. 2 Spraying at night decreases nasal irritation. 3 A common side effect of the medication is nausea.

The nurse should inform the patient that nasal dryness and irritation are frequent side effects of the nasal spray. The patient should not spray both nostrils daily; instead, spray alternate nostrils daily. The nasal spray does not cause nausea. Administering the dosage at night has not been shown to decrease nasal irritation.

The nurse is caring for a diabetic patient with neurogenic bladder. What should the nurse tell the patient about emptying the bladder? 1 Empty the bladder every 5 hours. 2 Relax abdominal muscles during voiding. 3 Massage the lower abdomen horizontally. 4 Use the Credé maneuver to completely empty the bladder.

The nurse should instruct the patient with neurogenic bladder to use the Credé maneuver to completely empty the bladder; the Credé maneuver involves mild downward massage over the lower abdomen and bladder. The nurse should also instruct the patient to empty the bladder every 3 hours in a sitting position to prevent stasis and subsequent infection. The patient should tighten the abdominal muscles and massage the lower abdomen downward to empty the bladder completely.

The nurse is educating a diabetic patient about the use of premixed insulin neutral protamine hagedorn (NPH)/regular 70/30. What should the nurse inform the patient about using this insulin? 1 Shake the bottle thoroughly to mix the insulin. 2 Rotate the injection within one anatomic site for a week. 3 Inject insulin at a 15 to 30 degree angle. 4 Inform that the fastest subcutaneous absorption is from the thigh.

The nurse should teach the patient to rotate the injection within one anatomic site, such as the abdomen, for at least 1 week before using a different site to allow for better absorption of insulin. It is important to gently roll the insulin bottle between the palms 10 to 20 times to warm the insulin and resuspend the particles. Injections must be administered at a 45- to 90-degree angle, depending on the thickness of the patient's fat pad. The fastest subcutaneous absorption is from the abdomen, followed by the arm, thigh, and buttock.

The nurse is assessing a patient with a painful deformity of the great toe with swelling of the bursa and formation of callus over the bony enlargement. The nurse suspects that the patient may have which medical diagnosis? 1 Hallux valgus 2 Hallux rigidus 3 Hammer toe 4 Morton's neuroma

The nurse would expect the medical diagnosis to be hallux valgus. Hallux rigidus is painful stiffness of the metatarsophalangeal joint caused by osteoarthritis or trauma. Hammer toe is a deformity of the 2nd to 5th toes. Morton's neuroma involves neuroma in the web space between third and fourth metatarsal heads, causing sharp, sudden attacks of pain and burning sensations.

On the assessment of a new admission, the nurse finds the toes and fingers to be a bluish hue accompanied with tingling and numbness. What should the nurse record the condition as? 1 Psoriatic arthritis 2 Reactive arthritis 3 Raynaud's phenomenon 4 Subacute cutaneous lupus

The observation is Raynaud's phenomenon, in which patients have diminished blood flow to the fingers and toes on exposure to cold due to paroxysmal vasospasm of the digits. The color changes are often accompanied by numbness and tingling. Reactive arthritis (Reiter's syndrome) is associated with a symptom complex that includes urethritis, conjunctivitis, and mucocutaneous lesions. Psoriasis is characterized by red, irritated, and scaly patches. Subacute cutaneous lupus is a dermatologic manifestation of systemic lupus erythematosus (SLE) with lesions, photosensitivity, and mild systemic disease.

Which of the following prescriptions should the nurse question? 1 Give 70 units of Lantus insulin subcutaneously at bedtime. 2 Give four units of Humalog insulin intravenous (IV) push for blood sugar greater than 200. 3 Have the patient program the insulin pump to deliver basal rate of 0.5 units per hour. 4 Administer 25 units of Humulin-N and 10 units of Humulin-R insulin subcutaneously before breakfast and supper.

The only insulin that can be administered safely intravenously is regular insulin (Humulin-R). Humalog is a rapid acting insulin and if given IV will cause a very rapid reduction in blood glucose and shifting of potassium at the cellular level. Lantus typically is given at bedtime and may require larger doses. Patients with insulin pumps, if able, can assist with glucose managing by programming pump. Insulin pumps deliver a continuous basal rate of insulin and bolus doses of insulin in response to nutritional intake. Humulin-N and Humulin-R insulin often are given together. The fast-acting regular insulin handles the meal-time glucose rise, while the intermediate acting insulin controls blood sugars between meals and throughout the night.

A 67-year-old patient hospitalized with osteomyelitis has a prescription for bed rest with bathroom privileges, with the affected foot elevated on two pillows. The nurse would place highest priority on which intervention? 1 Ambulate the patient to the bathroom every two hours. 2 Ask the patient about preferred activities to relieve boredom. 3 Allow the patient to dangle legs at the bedside every two to four hours. 4 Perform frequent position changes and range-of-motion exercises.

The patient is at risk for atelectasis of the lungs and for contractures because of prescribed bed rest. For this reason, the nurse should place the priority on changing the patient's position frequently to promote lung expansion and performing range-of-motion (ROM) exercises to prevent contractures. Assisting the patient to the bathroom will keep the patient safe as the patient is in pain, but it may not be needed every two hours. Providing activities to relieve boredom will assist the patient to cope with the bed rest, and dangling the legs every two to four hours may be too painful. The priority is position changes and ROM exercises.

The nurse has reviewed proper body mechanics with a patient with a history of low back pain caused by a herniated lumbar disc. Which statement made by the patient indicates a need for further teaching? 1 "I should sleep on my side or back with my hips and knees bent." 2 "I should exercise at least 15 minutes every morning and evening." 3 "I should pick up items by leaning forward without bending my knees." 4 "I should try to keep one foot on a stool whenever I have to stand for a period of time."

The patient should avoid leaning forward without bending the knees. Bending the knees helps to prevent lower back strain and is part of proper body mechanics when lifting. Sleeping on the side or back with hips and knees bent and standing with a foot on a stool will decrease lower back strain. Exercising 15 minutes twice daily will be done once symptoms subside, and will be aimed at back-strengthening.

A patient describes having small, firm reddened raised lesions with flat, rough patches causing intense pruritis to the nurse. What would be the nurse's next assessment? 1 History of seasonal allergies 2 Initiation of new medication 3 Previous pruritic skin lesions 4 Activities in past two to seven days

The patient's lesions are papules and plaques characteristic of contact dermatitis. The nurse should ask the patient about activities over the past two to seven days to identify potential allergens because contact dermatitis has a delayed onset. Even if an offending agent is not identified, the nurse can provide patient teaching about managing the pruritus and preventing infection by decreasing scratching. Seasonal allergies and new medications are more likely to cause urticaria than papules and plaque. The nurse should also ask about pruritic rashes in the past to determine potential illnesses that can cause dermatologic manifestations.

A patient who underwent spinal surgery reports a severe headache afterward. When changing the dressing to the incisional area, the nurse finds the drainage to be slightly yellow, and positive on a dipstick test. What is the best nursing intervention in this situation? 1 Send the drainage sample for culture. 2 Inform the primary health care provider. 3 Administer an analgesic for the headache. 4 Apply a new dressing on the incisional area.

The presence of yellowish drainage on the dressing after spinal surgery, along with patient reports of a headache, may indicate leakage of cerebrospinal fluid. Therefore, the nurse should inform the primary health care provider to determine the supportive interventions. The drainage sample does not necessarily need to be sent for culture as there are no other signs of infection such as a fever. Analgesics are administered to treat the headache; however, it may not help to resolve the cause of the headache. A new dressing should be applied to the incisional area, if the dressing is soiled. However, this intervention may not help in preventing cerebrospinal fluid leakage.

Which statement correctly illustrates the concept of the negative feedback system for control of serum cortisol? 1 A decreased serum cortisol when adrenocorticotropic hormone (ACTH) secretion is increased. 2 An increased serum cortisol when ACTH secretion is decreased. 3 A decreased secretion of ACTH when serum cortisol is increased. 4 An increased secretion of ACTH when serum cortisol is increased.

The relationship between cortisol and ACTH relies on negative feedback. Low blood levels of cortisol stimulate the pituitary gland to release ACTH, which acts on the adrenals to secrete cortisol and thereby increase blood cortisol levels. The increased blood cortisol level suppresses ACTH release. An increase in ACTH when serum cortisol is increased is an example of how a positive feedback system would work. An increased serum cortisol when ACTH is decreased indicates an abnormality, such as a cortisol-secreting adrenal tumor. A decreased serum cortisol when ACTH is increased also indicates an abnormality, such as a pituitary tumor.

On assessment, a linear crack from the epidermis to the dermis is noted at the corner of the patient's mouth. How should the nurse document this finding? 1 Scar 2 Fissure 3 Atrophy 4 Excoriation

The secondary skin lesion, called a fissure, is a linear crack or break from the epidermis to the dermis and can be dry as in athlete's foot or moist as in cracks at the corner of the mouth. A scar is an abnormal formation of connective tissue that replaces normal skin when a wound heals. Atrophy is a depression in skin resulting from thinning of the epidermis or dermis. Excoriation is an area in which the epidermis is missing, which exposes dermis (e.g., abrasion or scratch).

Which stage of rheumatoid arthritis is characterized by extensive muscle atrophy and joint deformities such as subluxation? 1 Early stage 2 Severe stage 3 Terminal stage 4 Moderate stage

The severe stage of rheumatoid arthritis is characterized by extensive muscle atrophy, and joint deformities such as subluxation, ulnar deviation, and osteoporosis. The early stage of rheumatoid arthritis is characterized by possible X-ray evidence of osteoporosis, but no destructive changes on X-ray. The terminal stage of rheumatoid arthritis is characterized by fibrous or bony ankylosis and adjacent muscle atrophy. A patient with moderate rheumatoid arthritis will experience adjacent muscle atrophy, possible presence of extraarticular lesions, and osteoporosis with or without bone destruction.

A patient with osteomyelitis asks the nurse how this problem will be treated first. What is the best response by the nurse? 1 "Surgery to remove the damaged tissue is the best way to treat this condition." 2 "It is likely that a portion of your bone will be removed to treat the infection." 3 "You will need oral antibiotics and antifungals for two to three months." 4 "Intravenous antibiotics are the first treatment choice for this condition."

The standard treatment for osteomyelitis consists of several weeks of intravenous antibiotic therapy. This is because bone is denser and less vascular than other tissues, and it takes time for the antibiotic therapy to eradicate all of the microorganisms. Oral antibiotics are not as effective as intravenous antibiotics for this severe infection. If the antibiotics fail to resolve the infection, surgery may be indicated; however, this is not the first line of treatment.

The nurse is providing postoperative care to a patient who underwent surgical repair of a fractured hip 2 days ago. Which assessment finding indicates the need for immediate nursing action and intervention? 1 Pain at the surgical site 2 Sudden shortness of breath 3 Serosanguineous wound drainage 4 Limited range of motion of the affected leg

The sudden onset of shortness of breath could be an indication of fat embolism syndrome, a potentially fatal complication of long bone fractures. Pain at the surgical site, serosanguineous wound drainage, and limited range of motion of the affected leg are all expected findings in a patient who has just undergone repair of a fractured hip.

A patient receiving intravenous (IV) vancomycin needs to have a trough drug level drawn. The medication will infuse over 60 minutes and the next dose is due to be given at 1300. The nurse should obtain a blood sample at which time? 1 1200 2 1230 3 1330 4 1400

The trough level indicates the lowest concentration of medication in the bloodstream between doses and therefore should be measured just before infusion of the next dose to be sure the patient is metabolizing and excreting the medication effectively. In this case, if the medication infuses at 1300, the sample should be drawn at 1230. 1200, 1330, and 1400 do not coincide with the proper time to evaluate the serum trough level.

A nurse is performing skin assessment on a patient. The patient is obese and a security guard by profession. The patient's skin on the sole of the feet is extremely hard and thick. What is the most likely cause for this finding? 1 Injury to the sole 2 Diminished blood supply to the feet 3 Excessive pressure due to weight bearing 4 Infection of the feet causing lesions in the soles

Thickened calluses over the heels are normal and occur due to pressure of weight bearing. The patient is obese and a watchman by profession; therefore the patient may spend more time standing. Thus the most likely cause of thickened skin of the sole is excessive pressure due to weight bearing. Injury, diminished blood supply, and foot infections are less likely causes of thickening and hardening of the skin of the sole.

Which fungal infection manifests on the surface of a patient's skin with an erythematous and typical annular scaly appearance and well-defined margins? 1 Tinea pedis 2 Tinea cruris 3 Tinea corporis 4 Tinea unguium

Tinea corporis is commonly referred to as ringworm. Tinea corporis infection has an erythematous, annular (ringlike) scaly appearance with well-defined margins. A tinea pedis fungal infection is characterized by scaly plantar surfaces that are pruritic and blistering in nature. Tinea cruris infection does not affect mucous membranes, and it is associated with well-defined scaly plaque on the patient's groin area. A patient with tinea unguium infection has brittle, thickened, and broken nails with yellowish discoloration.

During a physical assessment, the nurse asks the patient to perform inversion movement of the foot. What instruction should the nurse give to the patient? 1 Flex your ankle and toes toward the shin. 2 Turn the sole inward toward the midline of the body. 3 Turn the sole outward away from the midline of the body. 4 Flex your ankle and toes toward the plantar surface of the foot.

To perform inversion movements of the foot, the nurse should instruct the patient to turn the sole inward toward the midline of the body. Flexion of the ankle and toes toward the shin is called dorsiflexion. Turning the sole outward away from the midline of the body is called eversion, and flexion of ankle and toes toward the plantar surface of the foot is called plantar flexion.

The patient developed gout while hospitalized for a heart attack. When doing discharge teaching for this patient who takes aspirin for its antiplatelet effect, what should the nurse include about preventing future attacks of gout? 1 Limit fluid intake 2 Administration of probenecid (Benemid) 3 Administration of allopurinol (Zyloprim) 4 Administration of nonsteroidal antiinflammatory drugs (NSAIDs)

To prevent future attacks of gout, the urate-lowering drug, allopurinol, may be administered. Increased fluid will be encouraged to prevent precipitation of uric acid in the renal tubules. This patient will not be able to take the uricosuric drug probenecid because the aspirin that the patient must take will inactivate its effect, resulting in urate retention. NSAIDs for pain management will not be used, related to the aspirin, because of the potential for increased side effects.

The nurse understands that which prescribed medication is being used to treat osteomyelitis in a 60-year-old patient with diabetes mellitus? 1 Tobramycin (Nebcin) 2 Exenatide (Byetta ) 3 Hydromorphone (Dilaudid) 4 Metformin (Glucophage)

Tobramycin is an aminoglycoside-type antibiotic that often is used to treat osteomyelitis. The medication is given by the intravenous route for several weeks, and blood levels are checked periodically to ensure that they are therapeutic. Exenatide and metformin are used to treat diabetes, and hydromorphone is used to manage pain.

The nurse is reviewing prescribed treatments for a patient with a debrided stage III sacral pressure ulcer. Which one of the prescriptions should a nurse question as part of the plan of care for a patient with this ulcer? 1 Negative pressure wound therapy. 2 Turn and position the patient every two hours. 3 Assess for pain and medicate before dressing change. 4 Clean the ulcer every shift with povodone-iodine (Betadine) solution.

Topical antimicrobials and antibactericidals (e.g., povidone-iodine, Dakin's solution [sodium hypochlorite], hydrogen peroxide [H2O2], chlorhexidine [Hibiclens]) should be used with caution in wound care, because they can damage the new epithelium of healing tissue and delay healing. These topicals should never be used in a clean, granulating wound. It is appropriate to assess for pain and medicate before changing the dressing, turning the patient every two hours, and implementing negative pressure wound therapy.

A nurse is assessing a patient diagnosed with malignant melanoma. The nurse understands that the prognosis of the cancer can be assessed by using the Breslow measurement. How is the prognosis related to Breslow measurement? 1 The larger the tumor, the worse the prognosis 2 The deeper the tumor, the worse the prognosis 3 The darker the tumor, the worse the prognosis 4 The greater number of tumors, the worse the prognosis

Tumor thickness is an important prognostic factor for melanoma. The Breslow measurement is used to assess the depth of the tumor in millimeters. The deeper the tumor, the worse will be the prognosis of melanoma. Size of the tumor, color of the tumor, and an increase in the number of tumors are not determined using the Breslow measurement.

To assess the skin turgor, the most appropriate technique for the nurse to use is which of the following? 1 Palpation 2 Inspection 3 Percussion 4 Auscultation

Turgor refers to the elasticity of the skin. Assess turgor by gently pinching an area of skin under the clavicle or on the back of the hand. Skin with good turgor should move easily when lifted and should immediately return to its original position when released. Inspection, percussion, and auscultation are not useful for assessing skin turgor.

A nurse is performing a skin assessment on a patient. How should the nurse assess the turgor of the skin? 1 By pinching the patient's skin below the clavicle 2 By observing the patient's skin for any scaling or flaking 3 By palpating the skin of the patient 4 By placing the back of the hand over the patient's forehead

Turgor refers to the elasticity of the skin. It is assessed by pinching the area under the clavicle. Scaling or flaking of the skin indicates skin dryness. The nurse can assess the texture of the skin by palpating the skin of the patient. The nurse can assess the body temperature of the patient by touching the patient's forehead using the back of the hand.

A patient with diabetes mellitus is scheduled for a fasting blood glucose level at 8 AM. The nurse instructs the patient to fast for what period of time? 1 At least eight hours 2 4 AM on the day of the test 3 After dinner the evening before the test 4 7 AM on the day of the test

Typically a patient is prescribed to be nothing by mouth (NPO) for eight hours before determination of the fasting blood glucose level. For this reason, the patient who has a laboratory draw at 8 AM should not have any food or beverages containing any calories after midnight. It is not necessary to fast longer than eight hours; 4 AM and 7 AM would not allow for sufficient time to fast for morning laboratory testing.

A nurse is assessing a patient with chalky white patches on the face. The nurse learns that the patient's parent and grandparent have had similar signs. On the basis of this information, what is the most likely patient diagnosis? 1 Keloid 2 Vitiligo 3 Intertrigo 4 Hypopigmentation

Vitiligo is a skin condition characterized by complete loss of melanin in the affected area, which results in chalky white patches. This condition is usually inherited. Keloid is an overgrowth of scar tissue at the site of skin injury. Intertrigo is characterized by presence of rashes in intertriginous areas, such as the axillae and the area under the breast. It is usually due to inflammation of the overlying surface of skin. Hypopigmentation also occurs due to loss of pigmentation but is not an inherited disorder. Hypopigmentation is usually due to chemical agents, nutritional factors, burns, inflammation, or infection.

When assessing the cognitive-perceptual pattern in relation to the skin, the nurse questions the patient regarding which of these? 1 Joint pain 2 Changes in sleep habits 3 Recent changes in wound healing 4 Self-care habits related to daily hygiene

When assessing the patient's cognitive-perceptual pattern in relation to the skin, assess the mobility of the joints, because the patient's skin condition may cause alterations in mobility. Changes in sleep habits, recent changes in wound healing, and daily hygiene are not related to the cognitive-perceptual pattern in relation to the skin.

A 21-year-old female soccer player has injured her anterior crucial ligament (ACL) and is having reconstructive surgery. The nurse knows that the patient will need more teaching when the patient makes which statement? 1 "I probably won't be able to play soccer for 6 to 8 months." 2 "They will have me do range of motion with my knee soon after surgery." 3 "I can't wait to get this done now so I can play soccer for the next tournament." 4 "I will need to wear an immobilizer and progressively bear weight on my knee."

When the athlete has ACL reconstructive surgery, the patient does not understand the severity when she mentions planning to be back to playing soccer soon. The patient likely will not be able to play soccer for 6 to 8 months. The patient will be able to do range of motion soon after surgery. Immobilization and progressive weight bearing with physical therapy will occur during rehabilitation.

When the patient is diagnosed with muscular dystrophy, what information should the nurse include in the teaching about this disorder? 1 Prolonged bed rest will be used to decrease fatigue 2 An orthotic jacket will limit mobility and may contribute to deformity 3 Continuous positive airway pressure (CPAP) will be used to facilitate sleeping 4 Remaining active will prevent skin breakdown and respiratory complications or distress

With muscular dystrophy, it is important for the patient to remain active for as long as possible. Prolonged bed rest should be avoided because immobility leads to further muscle wasting. An orthotic jacket may be used to provide stability and prevent further deformity. CPAP is used as respiratory function decreases, before mechanical ventilation is needed to sustain respiratory function and maintain activity.

A nurse is caring for a client who has a suspected viral skin lesion. Which of the following laboratory findings should the nurse anticipate reviewing to confirm this diagnosis? A. Potassium hydroxide (KOH) B. Culture and sensitivity C. Tzanck smear report D. Biopsy

C

A nurse is completing preoperative teaching with an adolescent client who is going to receive spinal instrumentation for scoliosis. Which of the following information should the nurse include in the teaching? A. "You will go home the same day of surgery." B. "You will have minimal pain." C. "You will need to receive blood." D. "You will not be able to eat until the day after surgery."

C

A nurse is preparing to administer IV fluids to a client who has diabetic ketoacidosis. Which of the following is an appropriate nursing action? A. Administer an IV infusion of regular insulin at 0.3 unit/kg/hr. B. Administer an IV infusion of 0.45% sodium chloride. C. Rapidly administer an IV infusion of 0.9% sodium chloride. D. Add glucose to the IV infusion when serum glucose is 350 mg/dL.

C

A nurse is preparing to administer the morning doses of glargine (Lantus) insulin and regular (Humulin R) insulin to a client who has a blood glucose of 278 mg/dL. Which of the following is an appropriate nursing action? A. Draw up the regular insulin and then the glargine insulin in the same syringe. B. Draw up the glargine insulin then the regular insulin in the same syringe. C. Draw up and administer regular and glargine insulin in separate syringes. D. Administer the regular insulin, wait 1 hr, and then administer the glargine insulin.

C

A nurse is providing teaching to a client about a new prescription for clotrimazole (Lotrimin). Which of the following should the nurse include in the teaching? A. "It reduces the discomfort of a herpetic infection." B. "This is a cream to treat a bacterial infection." C. "Apply the topical medication for up to 2 weeks." D. "Allow the area to remain moist before applying."

C

A nurse is teaching a child who has type 1 diabetes mellitus about self care. Which of the following statements by the child indicates understanding of the teaching? A. "I should skip breakfast when I am not hungry." B. "I should increase my insulin with exercise." C. "I should drink a glass of milk when I am feeling irritable." D. "I should draw up the NPH insulin into the syringe before the regular insulin."

C

A nurse is teaching an adolescent who has diabetes about foot care. Which of the following should the nurse include in the teaching? A. "You should inspect your feet once a week." B. "You should cut your toe nails in a rounded fashion." C. "You can use cornstarch on your feet." D. "You can use over-the-counter callus removers."

C

A nurse is caring for an infant who has a myelomeningocele. Which of the following should she include in the plan of care? A. Assist the mother with breastfeeding. B. Assess the infant's temperature rectally. C. Place the infant in a supine position. D. Apply a moist dressing on the sac.

D

A nurse is caring for a patient who has developed gangrenous ulcers on the foot, which have made walking difficult. There is purulent drainage from the ulcer and black adherent necrotic tissue can be seen. What should be included in the plan of care for the patient? Select all that apply. 1 Hydrotherapy 2 Topical debridement 3 Transparent film dressing 4 Gentle atraumatic cleansing 5 Absorptive dressing covered with gauze

1, 2, 5. Hydrotherapy will help to keep the wound moist and an absorptive dressing will help absorb the purulent discharge. As black adherent necrotic tissue can be seen, topical debridement needs to be done to remove the necrotic tissue and expose healing tissue. An absorptive dressing covered with gauze is also required to absorb the exudate. Transparent film dressings are used in dry and uninfected wounds or wounds with less drainage. As this wound is infected and has purulent discharge, transparent film dressing cannot be used. Gentle atraumatic cleansing is required in freshly inflicted red wounds. Gentle cleansing will not remove the necrotic tissue present in this case.

A patient is on bed rest for two weeks. What are the precautions that a nurse should take to prevent pressure ulcers in this patient? Select all that apply. 1 Reposition the patient frequently. 2 Keep the skin clean, dry, and hygienic. 3 Have the patient walk daily for at least 15 minutes. 4 Apply antiseptic cream to pressure point areas. 5 Avoid any friction; avoid pulling the patient while trying to get him up.

1, 2, 5. Repositioning the patient frequently is extremely important in preventing pressure ulcers. Repositioning helps to maintain the circulation at the pressure points. Keeping the skin hygienic also helps in avoiding pressure ulcers. If the skin is not taken care of, skin breakdown and maceration may occur, increasing the risk of pressure ulcers. Avoiding friction helps to avoid occurrence of pressure ulcers. The patient is on bed rest and he cannot be moved, but he can be repositioned to relieve pressure from the bony prominences. Application of antiseptic creams does not help prevent ulcers.

The nurse is dressing a laceration on the palmar aspect of the hand on the patient. Which tissues have labile cells that regenerate rapidly? Select all that apply. 1 Skin 2 Bone marrow 3 Pancreas 4 Cardiac muscle cells 5 Kidney 6 Mucous membranes

1, 2, 6. Skin, bone marrow, and mucous membranes have labile cells that divide constantly. Injury to these organs is followed by rapid regeneration. Pancreas and kidney have stable cells that retain their ability to regenerate only if the organ is injured; the regeneration is slow. Cardiac muscle cells are permanent cells that do not divide; healing occurs by repair with scar tissue.

A bedridden patient has pressure ulcers. What are the best measures that a nurse should take while cleaning these ulcers? Select all that apply. 1 Use noncytotoxic solution to clean the wound. 2 Use hydrogen peroxide to clean the wound. 3 After cleaning the wound, cover it with gauze dressing. 4 Irrigate the wound using a 30-mL syringe and 19-gauge needles. 5 Irrigate the wound by pouring the solution over the wound and dabbing it.

1, 3, 4. When cleaning pressure ulcers, use noncytotoxic solutions that do not kill or damage cells, especially fibroblasts. After cleaning, the wound should be covered with gauze dressing to protect it from infection. It is also important to use enough irrigation pressure to adequately clean the pressure ulcer without causing trauma or damage to the wound. To obtain this pressure, use a 30-ml syringe and a 19-gauge needle. Hydrogen peroxide is cytotoxic and therefore should not be used to clean pressure ulcers. The wound cannot be adequately cleansed if the solution is just poured and dabbed.

A patient is bedridden for six weeks. Which are the areas of his body that are at the highest risk of developing pressure ulcers? Select all that apply. 1 Heel 2 Neck 3 Elbow 4 Sacrum 5 Scapular region

1, 4, 5. A pressure ulcer is a localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of pressure or pressure in combination with shear and/or friction. The heel and sacrum are the most common sites of pressure ulcers. Pressure ulcers also develop on the skin over the scapula bones. The neck and elbows are not at risk for pressure ulcers.

A patient with a major wound is admitted to the hospital.What patient conditions can result in delayed wound healing? Select all that apply. 1 The patient is obese. 2 The patient has hypertension. 3 The patient suffers from hyperlipidemia. 4 The patient suffers from diabetes mellitus. 5 The patient was on corticosteroid medications for a long time.

1, 4, 5. Obesity decreases blood supply to the wound, causing delayed wound healing. Diabetes mellitus decreases collagen synthesis, retards early capillary growth, impairs phagocytosis, and reduces the supply of oxygen and nutrients secondary to vascular disease. Corticosteroid drugs impair phagocytosis by white blood cells, inhibit fibroblast proliferation and function, depress formation of granulation tissue, and inhibit wound contraction. Hypertension and hyperlipidemia do not have direct effects on wound healing.

The nurse is assisting the radiologist while doing magnetic resonance imaging (MRI) for a patient. Which action of the nurse would be helpful to the patient during the test? 1 The nurse allows the patient to drink coffee. 2 The nurse allows the patient to listen to music. 3 The nurse allows the patient to wear a hearing aid. 4 The nurse allows the patient to keep credit cards in the pocket.

2

A patient has been advised to receive hyperbaric oxygen therapy for wound healing. How does this therapy promote wound healing? Select all that apply. 1 It prevents formation of new blood vessels. 2 It kills anaerobic bacteria. 3 It increases the killing power of white blood cells (WBCs). 4 It slows down formation of granulation tissue. 5 It increases the effectiveness of certain antibiotics.

2, 3, 5. Hyperbaric oxygen therapy involves delivering oxygen at increased atmospheric pressure. The therapy kills anaerobic bacteria in the wound, preventing further infection. It increases the killing power of WBCs and certain antibiotics. The therapy also promotes angiogenesis (growth of new blood vessels) to facilitate wound healing. Hyperbaric oxygen therapy accelerates formation of granulation tissue, which in turn accelerates the wound healing process.

A registered nurse (RN) collaborates with a licensed practical nurse (LPN) to create a plan of care for the patient with a wound on the bottom of the heel. It is appropriate for the RN to assign which functions to the LPN? Select all that apply. 1 Create a diet plan to support wound healing. 2 Perform sterile dressing changes on the wound. 3 Collect and record data about the wound's appearance. 4 Develop a plan of care to accelerate wound healing. 5 Teach the patient about care of the wound at home.

2, 3. The role of the licensed practical nurse is to perform sterile dressing changes and collect and record data about the appearance of the wound. Making a diet plan, developing a plan of care, and teaching the patient require advanced nursing judgment, and should be performed by the RN.

A nurse is caring for an adolescent who has acne and is prescribed isotretinoin 13-cis-retinoic acid (Amnesteem). Which of the following laboratory findings should be monitored? A. Cholesterol and triglycerides B. BUN and creatinine C. Serum potassium D. Serum sodium

A

A nurse is completing discharge teaching to a client who had a wound debridement for osteomyelitis. Which of the following information should the nurse include in the teaching? A. Antibiotic therapy should continue for 3 months. B. Relief of pain indicates the infection is eradicated. C. Contact precautions are used during wound care. D. Dressing changes are performed using aseptic technique.

A

A nurse is providing discharge instructions to a client who had a skin biopsy with sutures. Which of the following client statements indicates a need for further teaching? A. "I can expect redness around the site for 3 days." B. "I will call my doctor if I have a fever." C. "I should apply an antibiotic ointment to the area." D. "I will make a return appointment in 7 days for removal of my sutures."

A

A nurse is caring for a child who has cerebral palsy. Which of the following medications should the nurse expect to administer to treat painful muscle spasms? (Select all that apply.) A. Baclofen (Lioresal) B. Diazepam (Valium) C. Oxybutynin chloride (Ditropan) D. Methotrexate (Rheumatrex) E. Prednisone (Deltasone)

A, B

A nurse is teaching a client how to manage an external fixation device upon discharge. Which of the following statements by the client indicates an understanding of safe management? (Select all that apply.) A. "I will clean the pins twice a day." B. "I will use a separate cotton swab for each pin." C. "I will report loosening of the pins to my doctor." D. "I will move my leg by lifting the device in the middle." E. "I will remove any crusting that forms at the pin site."

A, B, C

A nurse is reviewing the health record of a client who has hyperglycemic-hyperosmolar state (HHS). Which of the following data confirms this diagnosis? (Select all that apply.) A. Evidence of recent myocardial infraction B. BUN 35 mg/dL C. Takes a calcium channel blocker D. Age 77 years E. No insulin production

A, B, C, D

A nurse is presenting information to a group of clients about nutrition habits that prevent type 2 diabetes mellitus. Which of the following should the nurse include in the information? (Select all that apply.) A. Eat less meat and processed foods. B. Decrease intake of saturated fats. C. Increase daily fiber intake. D. Limit saturated fat intake to 15% of daily caloric intake. E. Include omega-3 fatty acids in the diet.

A, B, C, E

A nurse is providing discharge teaching to a client who experienced diabetic ketoacidosis. Which of the following should the nurse include in the teaching? (Select all that apply.) A. Drink 3 L of fluids daily. B. Monitor blood glucose every 4 hr when ill. C. Administer insulin as prescribed when ill. D. Notify the provider when blood glucose is 200 mg/dL. E. Report ketones in the urine after 24 hr of illness.

A, B, C, E

A nurse is providing information to a client who has osteoarthritis of the hip and knee. Which of the following information should the nurse include in the information? (Select all that apply.) A. Apply heat to joints to alleviate pain. B. Ice inflamed joints following activity. C. Install an elevated toilet seat. D. Take tub baths. E. Complete high-energy activities in the morning.

A, B, C, E

A nurse is caring for a client who has a skin graft. Which of the following clinical manifestations indicate infection? (Select all that apply.) A. Green color to subcutaneous fat B. Unstable body temperature C. Generation of granulation tissue D. Subeschar hemorrhage E. Change in skin color around the affected area

A, B, D, E

A nurse is assessing a client who has seborrheic keratosis on the forehead and nose. Which of the following manifestations should the nurse expect to find? (Select all that apply.) A. Waxy appearance of the lesions B. Black, rough lesions C. Pruritus of the lesions D. Purplish skin stain around the lesion E. Wartlike surface of the lesions

A, B, E

A nurse is providing information about a new prescription for corticosteroid cream to a client who has mild psoriasis. Which of the following should the nurse include in the information? (Select all that apply.) A. Apply an occlusive dressing after application. B. Apply three to four times per day. C. Wear gloves after application to lesions on the hands. D. Avoid applying in skin folds. E. Use medication continuously over a period of several months.

A, C, D

A nurse is completing an assessment of a client who had an external fixation device applied 2 hr ago for a fracture of the left tibia and fibula. Which of the following findings indicate compartment syndrome? (Select all that apply.) A. Intense pain when the left foot is passively moved B. Edematous left toes compared to the right C. Hard, swollen muscle in the left leg D. Burning and tingling of the distal left foot E. Minimal pain relief following a second dose of opioid medication

A, C, D, E

A nurse is performing health screenings of clients at a health fair. Which of the following clients are at risk for osteoporosis? (Select all that apply.) A. A 40-year-old client who takes prednisone (Deltasone) for asthma B. A 30-year-old client who jogs 3 miles daily C. A 45-year-old client who takes phenytoin (Dilantin) for seizures D. A 65-year-old client who has a sedentary lifestyle E. A 70-year-old client who has smoked for 50 years

A, C, D, E

A nurse is caring for a child who has contact dermatitis due to poison ivy. Which of the following should be included in the plan of care? (Select all that apply.) A. Remove the clothing over the rash. B. Initiate contact isolation precautions. C. Expose the rash to a heat lamp for 15 min. D. Cleanse the affected skin with hydrogen peroxide solution. E. Apply calamine lotion to the skin.

A, E

Which type of wound dressing is easy to use over irregular-shaped wounds and forms a nonsticky gel on contact with a draining wound? 1 Foam 2 Alginate 3 Hydrogel 4 Semipermeable transparent film

Alginates form a nonsticky gel on contact with a draining wound. They are easy to use over irregular-shaped wounds and generally require a secondary dressing. Foams are sheets that hold large amounts of exudates and mostly require gauze wrapping. Hydrogels donate moisture to a dry wound and maintain a moist environment that rehydrates wound tissue. Semipermeable transparent films allow visualization of the wound and are minimally absorbent. Test-Taking Tip: Avoid looking for an answer pattern or code. There may be times when four or five consecutive questions have the same letter or number for the correct answer.

A nurse is designing a plan of care for a patient with a soft tissue injury and related inflammation as a result of a motor vehicle accident. Which nursing intervention should be included in the plan? 1 Avoid compression bandages, as they may compromise circulation. 2 Keep the injured extremity moving for proper blood circulation. 3 Elevate the injured extremity above the level of the heart to reduce pain. 4 Use hot fomentation to increase the circulation at the inflamed site during initial trauma care.

An injured extremity may become engorged with blood. Elevation of the injured extremity above the level of the heart helps to reduce pain associated with swelling by increasing the venous and lymphatic return. Compression helps to reduce vasodilation and edema. However, distal pulses should be assessed before and after a compression bandage is applied, to evaluate whether the extremity has compromised circulation. If the circulation is not compromised, a compression bandage can be used. The injured extremity should be immobilized and allowed to rest, as immobilization promotes healing by decreasing the metabolic needs of the patient. At the time of initial trauma, cold fomentation should be used to promote vasoconstriction and decrease pain, swelling, and congestion. Heat may be used 24 to 48 hours after injury to promote healing by increasing circulation at the inflamed site.

A nurse in the emergency department is planning care for a client who has a right hip fracture. Which of the following immobilization devices should the nurse anticipate in the plan of care? A. Skeletal traction B. Buck's traction C. Halo traction D. Gardner-Wells traction

B

A nurse is caring for a client who has a superficial partial thickness burn. Which of the following is an appropriate action for the nurse to take? A. Administer an IV infusion of 0.9% sodium chloride. B. Apply cool, wet compresses to affected area. C. Clean the affected area using a soft-bristle brush. D. Administer morphine sulfate.

B

A nurse is caring for a preschool-age child. Which of the following assessments should the nurse use to assess for developmental dysplasia of the hip? A. Barlow test B. Trendelenburg sign C. Manipulation of foot and ankle D. Ortolani test

B

A nurse is preparing to administer a morning dose of aspart insulin (NovoLog) to a client who has type 1 diabetes mellitus. Which of the following is an appropriate action by the nurse? A. Check the client's blood glucose immediately after breakfast. B. Administer the insulin when breakfast arrives. C. Hold breakfast for 1 hr after insulin administration. D. Clarify the prescription because insulin should not be administered at this time.

B

A nurse is providing care for a client who had a vertebroplasty of the thoracic spine. Which of the following is an appropriate action by the nurse? A. Apply heat to the client's puncture site. B. Place the client in a supine position. C. Turn the client every 4 hr. D. Ambulate the client within the first hour post-procedure.

B

A nurse is providing dietary teaching about calcium-rich foods to a client who has osteoporosis. Which of the following foods should the nurse include in the instructions? A. White bread B. White beans C. White meat of chicken D. White rice

B

A nurse is providing educational information on glucosamine to a group of clients at a health fair. Which of the following should the nurse include in the teaching? A. It decreases the amount of synovial fluid produced in the joints. B. The medication aids in the rebuilding of cartilage. C. A prescription is required for this medication. D. This medication is injected into the joint to decrease joint pain.

B

A nurse is providing information about capsaicin (Capsin) cream to a client who reports continuous knee pain from osteoarthritis. Which of the following information should the nurse include in the discussion? A. Continuous pain relief is provided. B. Inspect for skin irritation and cuts prior to application. C. Cover the area with tight bandages after application. D. Apply the medication every 2 hr during the day.

B

A nurse is teaching a client who has a history of psoriasis about photochemotherapy and ultraviolet light (PUVA) treatments. Which of the following should the nurse include in the teaching? A. Apply coal tar before each treatment. B. Administer a psoralen medication before the treatment. C. Use this treatment every evening. D. Remove the scales gently following each treatment.

B

A nurse is admitting an older adult client who has suspected osteoporosis. Which of following is an expected clinical finding? (Select all that apply.) A. History of consuming one glass of wine daily B. Loss in height of 2 in (5.1 cm) C. Body mass index (BMI) of 21 D. Kyphotic curve at upper thoracic spine E. History of lactose intolerance

B, C, D, E

A nurse is educating a female client on the use of calcipotriene (Dovonex) topical medication for the treatment of psoriasis. Which of the following information should the nurse include? (Select all that apply.) A. Recommended for facial lesions. B. Expect a stinging sensation upon application. C. Apply to the scalp. D. Obtain a pregnancy test. E. Limit application to skin folds.

B, C, D, E

A nurse is caring for a child who sustained a fracture. Which of the following are appropriate actions for the nurse to take? (Select all that apply.) A. Place a heat pack on the site of injury. B. Elevate the affected limb. C. Assess neurovascular status frequently. D. Encourage ROM of the affected limb. E. Stabilize the injury.

B, C, E

A nurse is caring for a child who is in Russell traction. Which of the following are appropriate actions for the nurse to take? (Select all that apply.) A. Remove the boots once a day for a bath. B. Assess the child's position frequently. C. Assess pin sites every 4 hr. D. Ensure the weights are hanging freely. E. Ensure the buttocks is raised off of the bed.

B, D

A nurse is assessing a child. Which of the following are clinical manifestations of Legg-Calve-Perthes disease? (Select all that apply.) A. Longer affected leg B. Hip stiffness C. Intense pain D. Limited ROM E. Limp with walking

B, D, E

A nurse is teaching a group of parents about preventing insect bites. Which of the following should the nurse include in the teaching? (Select all that apply.) A. Wear perfumes when outside. B. Avoid areas of tall grass. C. Wear bright-colored clothing. D. Wear insect repellent. E. Check house pets frequently.

B, D, E

A nurse is teaching an adolescent who has diabetes about clinical manifestations of hypoglycemia. Which of the following should be included in the teaching? (Select all that apply.) A. Increased urination B. Hunger C. Signs of dehydration D. Irritability E. Sweating and pallor F. Kussmaul respirations

B, D, E

A nurse is caring for an infant who has diaper dermatitis. Which of the following should be included in the plan of care? (Select all that apply.) A. Apply talcum powder with every diaper change. B. Allow the buttocks to air dry. C. Use commercial baby wipes to cleanse the area. D. Use cloth diapers until the rash is gone. E. Apply zinc oxide ointment to the affected area.

B, E

A nurse is assessing a client who has diabetic ketoacidosis and ketones in the urine. Which of the following are expected findings? (Select all that apply.) A. Weight gain B. Fruity odor of breath C. Abdominal pain D. Kussmaul respirations E. Metabolic acidosis

B. C, D, E

A nurse is caring for a client who has a moderate burn. Which of the following is an appropriate action for the nurse to take? A. Maintain immobilization of the affected area. B. Expose affected area to the air. C. Initiate a high-protein, high-calorie diet. D. Implement contact isolation.

C

A nurse is caring for a client who has blood glucose of 52 mg/dL. The client is lethargic but arousable. Which of the following actions should the nurse perform first? A. Recheck blood glucose in 15 min. B. Provide a carbohydrate and protein food. C. Provide 4 oz grape juice. D. Report findings to the provider

C

A nurse is teaching a group of parents about possible manifestations of Down syndrome. Which of the following should she include in the teaching? (Select all that apply.) A. A large head with bulging fontanelles B. Larger ears that are set back C. Protruding abdomen D. Broad, short feet and hands E. Hypotonia

C, D, E

A nurse is teaching foot care to a client who has diabetes mellitus. Which of the following information should the nurse include in the teaching? (Select all that apply.) A. Remove calluses using over-the-counter remedies. B. Apply lotion between toes. C. Perform nail care after bathing. D. Trim toenails straight across. E. Wear closed-toe shoes.

C, D, E

The nurse is caring for a patient who has a pressure ulcer. The patient has a 20-year history of smoking. What effect does smoking have on wound healing? 1 It decreases the blood supply in fatty tissue. 2 It impedes blood flow to healing areas. 3 It slows collagen synthesis by fibroblasts. 4 It decreases the supply of nutrients to the injured area.

Cigarettes contain nicotine. They are a potent vasoconstrictor, and thus impede blood flow to healing areas and delay wound healing. A decreased blood supply in fatty tissue is a consequence of obesity. Advanced age may result in slow collagen synthesis by fibroblasts. A decreased supply of nutrients to the injured area occurs due to inadequate blood supply.

A nurse is caring for a child who is in a plaster spica cast. Which of the following is an appropriate action for the nurse to take? A. Use a heat lamp to facilitate drying. B. Avoid turning the child until the cast is dry. C. Assist the client with crutch walking after the cast is dry. D. Apply moleskin to the edges of the cast.

D

A nurse is preparing a client who is to receive hyaluronic acid (Synvisc) injection for osteoarthritis. Which of the following statements by the nurse is appropriate? A. "Hyaluronic acid is currently approved for shoulder joint inflammation." B. "Report an allergy to shellfish before receiving hyaluronic acid." C. "Hyaluronic acid is a natural joint replacement fluid." D. "Hyaluronic acid is made from the combs of chickens."

D

A patient is admitted to the hospital 2 hours following an ankle injury. A soft tissue injury is suspected. There is no external bleeding. What measures can the nurse take for this patient to help relieve the inflammation? Select all that apply. 1 Immobilize the affected part and encourage rest. 2 Provide cold application to the affected part. 3 Make the patient lie down and keep the ankle below the level of heart. 4 Make the patient walk a little distance to increase circulation in the affected area. 5 Apply a compression bandage to the ankle and check the distal pulse.

1, 2, 3, 5. In cases of soft tissue injuries, RICE treatment (rest, ice, compression, and elevation) is given. The affected part is immobilized and given rest. Ice or cold is applied to reduce pain and inflammation. Hot applications can be given after 24-48 hours. The affected part is compressed with bandages to provide support and prevent edema. The affected part should be elevated above the heart level to prevent edema and pain. Making the patient walk would increase pain and discomfort, so it is not advisable.

A group of nurses is working on a research project that compares the healing effects of two different types of ointments on wound healing. The students need to record images of the wound at different stages using digital photography to monitor progress. What precautions should the nurse take when obtaining images of the wound? 1 Use a flash for a clearer image. 2 Position the patient the same way for each image. 3 Use shiny underpads as a background for the wound to enhance the effect. 4 Take the image from a different angle each time to cover all the sides of the wound.

If the patient is positioned in the same way for each image, the angle in which the photo is taken will not change; this will help record the wound progression correctly. It is important to avoid flash whenever possible, because a flash may reflect off the wound and affect clarity. The wound should be shown on a solid background, not on shiny underpads, for clearer images. Taking the image from different angles each time would make it more difficult to accurately monitor wound progression.

The nurse is caring for a patient who sustained full-thickness burns 2 weeks ago. The nurse weighs the patient and documents the weight. The nurse finds that the patient is losing weight. What adjustments should be made in the diet to ensure the metabolic requirements of the patient are being met? Select all that apply. 1 Low-sodium diet 2 High-protein intake 3 Low-potassium diet 4 High-carbohydrate intake 5 Adequate intake of water

The diet should be high in proteins to promote wound healing. High carbohydrate intake should be encouraged to help meet the high metabolic rate associated with burns. Fluid intake should be increased to compensate for the fluid loss. Sodium and potassium are restricted during the acute phase of a burn injury, not 2 weeks after the injury. 2, 4, 5

After the unlicensed assistive personnel (UAP) bathed the patient, the UAP then told the registered nurse (RN) about a reddened area on the patient's coccyx. After assessing the area, what should the nurse have the UAP do for the patient? 1 Reposition every two hours 2 Measure the size of the reddened area 3 Massage the area to increase blood flow 4 Evaluate the area later to see if it is better

The most important thing to do for this patient is to prevent deterioration of the ulcer and eliminate factors that led to pressure ulcers. This would include eliminating pressure on the reddened area with repositioning every two hours in bed and every hour while up in the chair. The nurse must complete the assessment of the new reddened area as well as evaluation of the area. Massage is not used when there is the possibility of damaged blood vessels or fragile skin, so the RN cannot advise the UAP to do this until the RN has assessed the patient and the area.

A patient in an ambulatory care setting has been prescribed a semirigid brace to support a wrist injury. What should the nurse do to ensure that the patient is comfortable? 1 Provide cold application to the area. 2 Assess distal pulses and capillary refill. 3 Immobilize the wrist with a splint. 4 Elevate the wrist above heart level

The nurse should assess distal pulses and capillary refill before and after application of a semirigid brace or compression device to evaluate whether compression has compromised the patient's circulation. Cold application is appropriate at the time of initial trauma to promote vasoconstriction, and decrease edema, pain, and congestion from increased metabolism in the area of inflammation. Immobilization of the inflamed or injured area promotes healing by decreasing the tissues' metabolic needs. Elevating the injured extremity above the level of the heart reduces the edema at the inflammatory site by increasing venous and lymphatic return. TEST-TAKING TIP: Answer every question because, on the NCLEX exam, you must answer a question before you can move on to the next question.

A 65-year-old diabetic patient is treated for a fractured fibula and is discharged from the health care facility. Which instructions should the nurse give the patient's caregiver to prevent occurrence of pressure ulcers in the patient? Select all that apply. 1 Reposition the patient in wheelchair every two hours. 2 Reposition the patient in bed every six hours. 3 Provide the patient with adequate nutrition. 4 Provide the patient absorbent pads or briefs. 5 Assist the patient to lift self and reposition on bed.

The nurse should teach the patient's caregiver to provide the patient with adequate nutrition to speed up the healing process. Exposure to excessive moisture from incontinence can cause pressure ulcers. The caregiver should cleanse skin after soiling and use absorbent pads or briefs to help keep the patient dry. The patient should be assisted in lifting himself or herself when repositioning in bed because sliding can cause friction and sheer. A wheelchair-bound patient should be repositioned every hour, whereas a patient confined to bed should be repositioned every two hours.

Which type of inflammatory exudate results from the rupture or necrosis of blood vessel walls? 1 Serous 2 Purulent 3 Fibrinous 4 Hemorrhagic

The products of inflammation are known as inflammatory exudates. Exudates may ooze from the cuts or areas of inflammation. Hemorrhagic exudates result from rupture or necrosis of blood vessel walls during events such as hematoma, bleeding after surgery, or tissue trauma. Serous exudates result from an outpouring of fluid, seen in early stages of inflammation. Purulent exudates are associated with a preponderance of escaped leukocytes. Fibrinous exudates are formed by the action of fibrin ferment acting upon fibrinogen or fibrin-forming substances in the presence of calcium salts. Test-Taking Tip: Avoid looking for an answer pattern or code. There may be times when four or five consecutive questions have the same letter or number for the correct answer.

The unlicensed assistive personnel (UAP) is assisting the patient with Crohn's disease with perineal care. The UAP tells the nurse that the patient had feces coming from the vagina. What should the nurse do about this situation? 1 Notify the health care provider 2 Document the fistula formation 3 Assess the patient and vaginal drainage 4 Have the UAP apply a dressing to the vagina

With Crohn's disease, a fistula may have formed between the bowel and the vagina. The nurse first should assess the patient and the drainage from the vagina. Then the nurse should notify the health care provider, document the occurrence and care prescribed, provide care prescribed, and document the care and patient response. TEST-TAKING TIP: The following are crucial requisites for doing well on the NCLEX exam: (1) A sound understanding of the subject; (2) The ability to follow explicitly the directions given at the beginning of the test; (3) The ability to comprehend what is read; (4) The patience to read each question and set of options carefully before deciding how to answer the question; (5) The ability to use the computer correctly to record answers; (6) The determination to do well; (7) A degree of confidence.

An older patient is transferred from the nursing home with a black wound on the heel. What should the nurse expect to be the first treatment of this wound? 1 Dress it with an absorbent dressing for exudate 2 Handle the wound gently and let it dry out to heal 3 Debridement of the nonviable, eschar tissue to allow healing 4 Use negative-pressure wound (vacuum) therapy to facilitate healing

With a black wound the immediate therapy should be debridement (surgical, mechanical, autolytic, or enzymatic) to prepare the wound bed for healing. Black wounds may have purulent drainage, but debridement is done first. The red wound is handled gently because it is granulating and reepithelizing, but it must be kept slightly moist to heal. The negative-pressure wound (vacuum) therapy is used to remove drainage and is more likely to be used after debridement. TEST-TAKING TIP: Try putting questions and answers in your own words to test your understanding.

A nurse is providing care to a client who is scheduled for mechanical debridement. What are methods of mechanical debridement? Select all that apply. 1 Autolytic 2 Enzymatic 3 Whirlpool 4 Wound irrigation 5 Wet-to-dry dressings

3, 4, 5. There are four types of debridement: surgical, mechanical, autolytic, and enzymatic. Mechanical debridement has thee methods: wet-to-dry dressings, wound irrigation, and whirlpool. Whirlpool is used when minimal debris is present. Wound irrigation involves debriding the wound with high irrigation pressure. Wet-to-dry dressings involve application of open-mesh gauze moistened with normal saline. It is packed on or into a wound surface and allowed to dry. Autolytic and enzymatic are different types of debridement and are not methods of mechanical debridement.

A nurse is teaching a patient how to promote healing following abdominal surgery. What should be included in the teaching? Select all that apply. 1 Take the antibiotic until the wound feels better. 2 Take the analgesic every day to promote adequate rest for healing. 3 Wound healing may not be complete for 1 to 2 weeks. 4 Take in more fluid, protein, and vitamins C, B, and A to facilitate healing. 5 Notify the health care provider of redness, swelling, and increased drainage.

4, 5. Fluid is needed to replace fluid from insensible loss and from exudates as well as the increased metabolic rate. Protein corrects the negative nitrogen balance that results from the increased metabolic rate and that is needed for synthesis of immune factors and healing. Vitamin C helps synthesize capillaries and collagen. Vitamin B-complex facilitates metabolism. Vitamin A aids in epithelialization. The health care provider should be notified if there are signs of infection. If prophylactic antibiotics are prescribed, they must be taken until they are completely gone. Initially analgesics are taken throughout the day (e.g., every three to four hours) as needed. Wound healing may not be complete for 4 to 6 weeks or longer, not 1 to 2 weeks.

The patient previously had a breast reduction. She has come to the surgeon's office complaining about excess soft pink tissue where a scar should be forming. What complication of wound healing does the nurse recognize this to be? 1 Adhesion 2 Contractions 3 Keloid formation 4 Excess granulation tissue

4. Excess granulation tissue, the excess soft pink tissue on the wound, is what this complication of wound healing is called. Adhesions are bands of scar tissue that form between or around organs. Wound contraction, which is a normal part of healing, is a complication when it results in deformity by shortening the tissue and impairing function. Keloid formation is a great protrusion of scar tissue that extends beyond the wound edges and may be uncomfortable

A nurse is planning discharge teaching on home safety for an older adult client who has osteoporosis. Which of the following information should the nurse include in the teaching? (Select all that apply.) A. Remove throw rugs in walkways. B. Use prescribed assistive devices. C. Remove clutter from the environment. D. Walk with caution on icy surfaces. E. Maintain lighting of doorway areas.

A, B, C, E

A nurse is caring for a school-age child who has juvenile idiopathic arthritis. Which of the following are appropriate home care instructions? (Select all that apply.) A. Sleep on a firm mattress. B. Use cold compresses for joint pain. C. Take ibuprofen (Motrin) on an empty stomach. D. Take frequent rest periods throughout the day. E. Perform range-of-motion exercises.

A, D, E

A nurse is reviewing sick day management with a parent of a child who has type 1 diabetes mellitus. Which of the following should the nurse include in the teaching? (Select all that apply.) A. Monitor blood glucose levels every 3 hr. B. Discontinue taking insulin until feeling better. C. Drink 8 oz of fruit juice every hour. D. Test urine for ketones. E. Call the health care provider if blood glucose is greater than 240 mg/dL.

A, D, E

A nurse is providing teaching to a client who has a prescription for methotrexate (Trexall) for severe psoriasis. Which of the following information should the nurse include? A. Drink a glass of wine daily. B. Monitor for evidence of infection. C. Monitor kidney function tests regularly. D. Expect increased bruising.

B

A nurse is reviewing laboratory reports of a client who has hyperglycemic-hyperosmolar state (HHS). Which of the following is an expected finding? A. Serum pH 7.2 B. Serum osmolarity 350 mOsm/L C. Serum potassium 3.8 mg/dL D. Serum creatinine 0.8 mg/dL

B

A nurse is teaching a group of parent about fractures. Which of the following should be included in the teaching? A. "Children need a longer time to heal from a fracture than an adult." B. "Epiphyseal plate injuries may result in altered bone growth." C. "A greenstick fracture is a complete break in the bone." D. "Bones are unable to bend, so they break."

B

A nurse is teaching the parent of an infant who has seborrheic dermatitis. Which of the following should be included in the teaching? A. "The patches are from not washing the infant's head regularly." B. "The cause is unknown and not contagious." C. "The patches are due to an infection the infant has." D. "The cause is due to the infant acquiring it from another child at day care."

B