exam 3

A nurse is caring for a client who has had a total hip replacement. The nurse is reviewing health education prior to discharge. Which of the client's statements would indicate to the nurse that the client requires further teaching?

"I will need my husband to assist me in getting off the low toilet seat at home."

A client with a right tibial fracture is being discharged home after having a cast applied. What instruction should the nurse provide in relationship to the client's cast care?

"Keep your right leg elevated above heart level."

A client was brought to the emergency department after a fall. The client is taken to the operating room to receive a right hip prosthesis. In the immediate postoperative period, what health education should the nurse emphasize?

"Make sure you don't bring your knees close together."

The nurse is teaching the client on bed rest to perform quadriceps setting exercises. Which instruction should the nurse give the client?

"Push the knees into the mattress."

A 30-year-old client has just returned from the operating room after having a "flap" done following a motorcycle accident. The client's spouse asks the nurse about the major complications following this type of surgery. What would be the nurse's best response?

"The major complication is when the blood supply fails and the tissue in the flap dies."

A nurse is providing self-care education to a client who has been receiving treatment for acne vulgaris. What instruction should the nurse provide to the client?

"Wash your face with water and gentle soap each morning and evening."

The surgical nurse is admitting a client from postanesthetic recovery following the client's below-the-knee amputation. The nurse recognizes the client's high risk for postoperative hemorrhage and should keep what equipment at the bedside?

A tourniquet

A nurse is caring for a client who is being assessed following reports of severe and persistent low back pain. The client is scheduled for diagnostic testing in the morning. Which of the following are appropriate diagnostic tests for assessing low back pain? Select all that apply.

A. Computed tomography (CT) Magnetic resonance imaging (MRI) Ultrasound E. X-ray

A client requires a full-thickness graft to cover a chronic wound. How is the donor site selected?

An area matching the color and texture of the skin at the surgical site is selected.

Which of the following clients should the nurse recognize as being at the highest risk for the development of osteomyelitis?

An older adult client with an infected pressure ulcer in the sacral area

A client has just undergone surgery for malignant melanoma. Which of the following nursing actions should be prioritized?

Anticipate the need for, and administer, appropriate analgesic medications.

A client has suffered a muscle strain and is reporting pain at 6 on a 10-point scale. The nurse should recommend what action?

Applying a cold pack to the injured site

A nurse in a busy emergency department provides care for many clients who present with contusions, strains, or sprains. What are treatment modalities that are common to all of these musculoskeletal injuries? Select all that apply.

Applying ice Compression dressings Resting the affected extremity Elevating the injured limb

A client has recently been admitted to the orthopedic unit following total hip arthroplasty. The nurse assesses that the indwelling urinary catheter was removed one hour ago in the post-anesthesia care unit and that the client has not yet voided. Which action should the nurse take?

Ask if the client needs to void.

A nurse is providing care for a client who has psoriasis. Following the appearance of skin lesions, the nurse should prioritize what assessment?

Assessment of the client's joints for pain and decreased range of motion

An older adult client has fallen in the home and is brought to the emergency department by ambulance with a suspected fractured hip. X-rays confirm a fracture of the left femoral neck. When planning assessments during the client's presurgical care, the nurse should be aware of the client's heightened risk of what complication?

Avascular necrosis

An older adult resident of a long-term care facility has been experiencing generalized pruritus that has become more severe in recent weeks. What intervention should the nurse add to this resident's plan of care?

Avoid using hot water during the client's baths

A nurse practitioner is seeing a 16-year-old client who has come to the dermatology clinic for treatment of acne. The nurse practitioner would know that the treatment may consist of which of the following medications?

Benzoyl peroxide and erythromycin

An older, female client with osteoporosis has been hospitalized. Prior to discharge, when teaching the client, the nurse should include information about which major complication of osteoporosis?

Bone fracture

A nurse is reviewing the pathophysiology that may underlie a client's decreased bone density. What hormone should the nurse identify as inhibiting bone resorption and promoting bone formation?

Calcitonin

A nurse is teaching an educational class to a group of older adults at a community center. In an effort to prevent osteoporosis, the nurse should encourage participants to ensure that they consume the recommended intake of what nutrients? Select all that apply.

Calcium Vitamin D

A client tells the nurse that they haves pain and numbness in the thumb, first finger, and second finger of the right hand. The nurse discovers that the client is employed as an auto mechanic, and that the pain is increased while working. This may indicate that the client has what health problem?

Carpel tunnel syndrome

A client has just been diagnosed with psoriasis and frequently has lesions around his right eye. What should the nurse teach the client about topical corticosteroid use on these lesions?

Cataract development is possible.

A 65-year-old man presents at the clinic reporting nodules on both legs. The man tells the nurse that his son, who is in medical school, encouraged him to seek prompt care and told him that the nodules are related to the fact that he is Jewish. What health problem should the nurse suspect?

Classic Kaposi sarcoma

A nurse is caring for an older adult client who is preparing for discharge following recovery from a total hip replacement. What outcome must be met prior to discharge?

Client is able to perform transfers safely.

A nurse is providing discharge teaching for a client who underwent foot surgery. The nurse is collaborating with the occupational therapist and discussing the use of assistive devices. On what variables does the choice of assistive devices primarily depend?

Client's general condition, balance, and weight-bearing prescription

A nurse is caring for a client who has a diagnosis of bullous pemphigoid and who is being treated on the medical unit. The nurse knows that systemic treatment will most likely include which element?

Corticosteroid therapy

A nurse is reviewing the care of a client who has a long history of lower back pain that has not responded to conservative treatment measures. The nurse should anticipate the administration of what drug?

Cyclobenzaprine

A nurse is planning the care of a client with herpes zoster. What medication, if given within the first 24 hours of the initial eruption, can arrest herpes zoster?

D. Acyclovir

A client is admitted to the orthopedic unit with a fractured femur after a motorcycle accident. The client has been placed in traction until the femur can be rodded in surgery. For what early complication(s) should the nurse monitor this client? Select all that apply.

Deep vein thrombosis Compartment syndrome Fat embolism

A client has returned to the unit after undergoing limb-sparing surgery to remove a metastatic bone tumor. The nurse providing postoperative care in the days following surgery assesses for what complication from surgery?

Delayed wound healing

A client's electronic health record notes that the client has hallux valgus. What signs and symptoms should the nurse expect this client to manifest?

Deviation of a great toe laterally

23. A nurse is assessing a teenage client with acne vulgaris. The client's mother states, "I keep telling him that this is what happens when you eat as many french fries as he does." What aspect of the pathophysiology of acne should inform the nurse's response?

Diet is thought to play a minimal role in the development of acne.

A client has a diagnosis of seborrhea and has been referred to the dermatology clinic, where the nurse contributes to care. When planning this client's care, the nurse should include what nursing diagnosis?

Disturbed body image related to excess sebum production

A public health nurse is participating in a health promotion campaign that has the goal of improving outcomes related to skin cancer in the community. What action has the greatest potential to achieve this goal?

Educating participants about the early signs and symptoms of skin cancer

16. A nurse is caring for a client who is 12 hours' postoperative following foot surgery. The nurse assesses the presence of edema in the foot. What nursing measure should the nurse implement to control the edema?

Elevate the foot on several pillows.

A client with a total hip replacement has developed decreased breath sounds What is the nurse's best action?

Encourage use of the incentive spirometer.

A nurse is caring for a client who had a right below-the-knee amputation (BKA). The nurse recognizes the importance of implementing measures that focus on preventing flexion contracture of the hip and maintaining proper positioning. What nursing action will best achieve these goals?

Encouraging the client to turn from side to side and to assume a prone position

A nurse is providing care for a client who has developed Kaposi sarcoma secondary to HIV infection. The nurse should be aware that this form of malignancy originates in what part of the body?

Endothelial cells lining small blood vessels

A client with a simple arm fracture is receiving discharge education from the nurse. What would the nurse instruct the client to do?

Engage in exercises that strengthen the unaffected muscles.÷

The nurse is providing care for a client who has had a below-the-knee amputation. The nurse enters the client's room and finds the client resting in bed with the residual limb supported on a pillow. What is the nurse's most appropriate action?

Explain the risks of flexion contracture to the client.

A client has just begun been receiving skeletal traction and the nurse is aware that muscles in the client's affected limb are spastic. How does this change in muscle tone affect the client's traction prescription?

Extra weight is needed initially to keep the limb in proper alignment.

A client presents at a clinic reports heel pain that impairs walking ability. The client is subsequently diagnosed with plantar fasciitis. This client's plan of care should include what intervention?

Gently stretching the foot and the Achilles tendon

A client comes to the clinic reporting a red rash of small, fluid-filled blisters and is suspected of having herpes zoster. What presentation is most consistent with this diagnosis?

Grouped vesicles in linear patches along a dermatome

A client has received a diagnosis of irritant contact dermatitis. What action should the nurse prioritize in the client's subsequent care?

Helping the client identify and avoid the offending agent

A 35-year-old kidney transplant client comes to the clinic exhibiting new skin lesions. The diagnosis is Kaposi sarcoma. The nurse caring for this client recognizes that this is what type of Kaposi sarcoma?

Iatrogenic

An older adult woman's current medication regimen includes alendronate. What outcome would indicate successful therapy?

Increased bone mass

The nursing care plan for a client in traction specifies regular assessments for venous thromboembolism (VTE). When assessing a client's lower limbs, what sign or symptom is suggestive of deep vein thrombosis (DVT)?

Increased warmth of the calf

A nurse is caring for a client who is being treated in the hospital for a spontaneous vertebral fracture related to osteoporosis. The nurse should address the nursing diagnosis of Acute Pain Related to Fracture by implementing what intervention?

Intermittent application of heat to the client's back

A nurse is discussing conservative management of tendonitis with a client. What is the nurse's best recommendation?

Intermittent application of ice and heat

An older adult client sought care for the treatment of a swollen, painful knee joint. Diagnostic imaging and culturing of synovial fluid resulted in a diagnosis of septic arthritis. The nurse should prioritize what aspect of care?

Intravenous administration of antibiotics

The nurse educator on an orthopedic trauma unit is reviewing the safe and effective use of traction with some recent nursing graduates. What principle should the educator promote?

Knots in the rope should not be resting against pulleys.

A client comes to the dermatology clinic requesting the removal of epidermal nevi on the client's right cheek. The nurse knows that the procedure especially useful in treating such lesions is what?

Laser treatment

A nurse is caring for a client who has been diagnosed with psoriasis. The nurse is creating an education plan for the client. What information should be included in this plan?

Lifelong management is likely needed.

6. While performing an initial assessment of a client admitted with appendicitis, the nurse observes an elevated blue-black lesion on the client's ear. The nurse knows that this lesion is consistent with what type of skin cancer?

Malignant melanoma

A client with diabetes is attending a class on the prevention of associated diseases. What action should the nurse teach the client to reduce the risk of osteomyelitis?

Monitor and control blood glucose levels.

A school nurse has sent home four children who show evidence of pediculosis capitis. What is an important instruction the nurse should include in the note being sent home to parents?

Nits may have to be manually removed from the child's hair shafts.

A client who had a total hip replacement two days ago reports new onset calf tenderness to the nurse. Which action should the nurse take?

Notify the health care provider.

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

Osteomyelitis

A client with diabetes has been diagnosed with osteomyelitis. The nurse observes that the client's right foot is pale and mottled, cool to touch, with a capillary refill of greater than 3 seconds. The nurse should suspect what type of osteomyelitis?

Osteomyelitis with vascular insufficiency

A client diagnosed with a stasis ulcer has been hospitalized. There is an order to change the dressing and provide wound care. Which activity should the nurse first perform when providing wound care?

Perform hand hygiene.

What nursing intervention should the nurse prioritize to facilitate healing in a client who has suffered a hip fracture?

Place a pillow between the client's legs when turning.

A nurse is caring for a client who is postoperative day 1 following a total arthroplasty of the right hip. How should the nurse position the client?

Place a pillow between the legs.

A client was fitted with an arm cast after fracturing the humerus. Twelve hours after the application of the cast, the client tells the nurse that the injured arm hurts. Analgesics do not relieve the pain. What would be the most appropriate nursing action?

Prepare the client for opening or bivalving of the cast.

A client who has had an amputation is being cared for by a multidisciplinary rehabilitation team. What is the primary goal of this multidisciplinary team?

Promote the client's highest possible level of function.

A nurse is assessing the neurovascular status of a client who has had a leg cast recently applied. The nurse is unable to palpate the client's dorsalis pedis or posterior tibial pulse and the client's foot is pale. What is the nurse's most appropriate action?

Promptly inform the primary care provider.

A nurse is caring for a client who has a leg cast. The nurse observes the client using a pencil to scratch the skin under the edge of the cast. How should the nurse respond to this observation?

Provide a fan to blow cool air into the cast to relieve itching,

A client's blistering disorder has resulted in the formation of multiple lesions in the client's mouth. What intervention should be included in the client's plan of care?

Provide chlorhexidine solution for rinsing the client's mouth.

A client is admitted to the intensive care unit with what is thought to be toxic epidermal necrolysis (TEN). When assessing the health history of the client, the nurse would be alert to what precipitating factor?

Recent administration of new medications

A nurse is writing a care plan for a client admitted to the emergency department (ED) with an open fracture. The nurse will assign priority to what nursing diagnosis for a client with an open fracture of the radius?

Risk for infection

9. A client presents at a clinic reporting back pain that goes all the way down the back of the leg to the foot. The nurse should document the presence of what type of pain?

Sciatica

A nurse is caring for a client whose chemical injury has necessitated a skin graft to the client's left hand. Which statement is true regarding skin graft use?

Skin is transferred from a distant site to the graft site.

A nursing educator is reviewing the risk factors for osteoporosis with a group of recent graduates. What of the following risk factors should the educator describe?

Small frame and female sex

A client presents to a clinic reporting a leg ulcer that isn't healing; subsequent diagnostic testing suggests osteomyelitis. The nurse is aware that the most common pathogen to cause osteomyelitisis

Staphylococcus aureus.

A nurse is collaborating with the physical therapist to plan the care of a client with osteomyelitis. What principle should guide the management of activity and mobility in this client?

Stress on the weakened bone must be avoided.

22. A 32-year-old client comes to the clinic reporting shoulder tenderness, pain, and limited movement. Upon assessment the nurse finds edema. An MRI shows hemorrhage of the rotator cuff tendons and the client is diagnosed with impingement syndrome. What action should the nurse recommend in order to promote healing?

Support the affected arm on pillows at night.

A nurse is caring for a client with a bone tumor. The nurse is providing education to help the client reduce the risk for pathologic fractures. What should the nurse teach the client?

Support the affected extremity with external supports such as splints.

A client with squamous cell carcinoma has been scheduled for treatment of this malignancy. The nurse should anticipate that treatment for this type of cancer will primarily consist of what intervention?

Surgical excision

A nurse is caring for a client whose skin cancer will soon be removed by excision. Which of the following actions should the nurse perform?

Teach the client about self-care after treatment.

A nurse is caring for a client receiving skeletal traction. Due to the client's severe limits on mobility, the nurse has identified a risk for atelectasis or pneumonia. What intervention should the nurse provide in order to prevent these complications?

Teach the client to perform deep breathing and coughing exercises.

A nurse is working with a family whose 5-year-old child has been diagnosed with impetigo. What educational intervention should the nurse include in this family's care?

Teaching about the importance of maintaining high standards of hygiene

A nurse is leading a health promotion workshop that is focusing on cancer prevention. What action is most likely to reduce participants' risks of basal cell carcinoma (BCC)?

Teaching participants to limit their sun exposure

A client who has sustained third-degree facial burns and a facial fracture is undergoing reconstructive surgery and implantation of a prosthesis. The nurse has identified a nursing diagnosis of Low Self Esteem related to use of facial prosthetic secondary to reconstructive surgery. Which nursing intervention would be appropriate for this diagnosis?

Teaching the client how to use and care for the prosthesis

A nurse is caring for a client who has had a plaster arm cast applied. Immediately after application, the nurse should provide what teaching to the client?

The cast will only have full strength when dry.

A nurse is caring for a 78-year-old client with a history of osteoarthritis (OA). When planning the client's care, what goal should the nurse prioritize?

The client will express satisfaction with the ability to perform ADLs.

A nurse is assessing a client for risk factors known to contribute to osteoarthritis. What assessment finding should the nurse interpret as a risk factor?

The client's body mass index is 34 (obese).

A nurse is assessing a client who is receiving traction. The nurse's assessment confirms that the client is able to perform plantar flexion. What conclusion can the nurse draw from this finding?

The client's tibial nerve is functional.

An orthopedic nurse is caring for a client who is postoperative day 1 following foot surgery. What nursing intervention should be included in the client's subsequent care?

The foot should be elevated in order to prevent edema.

A nurse is providing a class on osteoporosis at the local center for older adults. Which statement related to osteoporosis is most accurate?

The use of corticosteroids increases the risk of osteoporosis.

A client is admitted to the orthopedic unit in skeletal traction for a fractured proximal femur. Which explanation should the nurse give the client about skeletal traction?

Traction involves passing a pin through the bone."

A client is brought to the emergency department by ambulance after stepping in a hole and falling. While assessing the client the nurse notes that the client's right leg is shorter than the left leg; the right hip is noticeably deformed and the client is in acute pain. Imaging does not reveal a fracture. What is the most plausible explanation for this client's signs and symptoms?

Traumatic hip dislocation

A client has just been told that he has deep malignant melanoma. The nurse caring for this client should anticipate that the client will undergo what treatment?

Wide excision

A 55-year-old woman is scheduled to have a chemical face peel. The nurse is aware that the client is likely seeking treatment for which of the following?

Wrinkles near the lips and eyes

A client has been admitted to the hospital with a spontaneous vertebral fracture related to osteoporosis. Which of the following nursing diagnoses must be addressed in the plan of care?

constipation related to vertebral fracture

A school nurse is assessing a student who was kicked in the shin during a soccer game. The area of the injury has become swollen and discolored. The triage nurse should organize care for a:

contusion.

A client has come to the clinic for a routine annual physical. The nurse practitioner notes a palpable, painless projection of bone at the client's shoulder. The projection appears to be at the distal end of the humerus. The nurse should suspect the presence of:

osteochondroma.

A nurse is caring for an adult client diagnosed with a back strain. What health education should the nurse provide to this client?

Avoid lifting more than one-third of body weight without assistance.

A nurse is preparing to assist a surgeon in a skin grafting procedure. What can a skin graft can be used for?

Denuded skin after burns.

A client presents at the free clinic with a black, wart-like lesion on his face, stating, "I've done some research, and I'm pretty sure I have malignant melanoma." Subsequent diagnostic testing results in a diagnosis of seborrheic keratosis. The nurse should recognize what significance of this diagnosis?

The client requires no treatment unless he finds the lesion to be cosmetically unacceptable.

The nurse is caring for a client who developed a pressure injury as a result of decreased mobility. The nurse on the previous shift has provided client teaching about pressure injuries and healing promotion. The nurse determines that the client has understood the teaching by observing the client:

avoid placing body weight on the healing site.