Exam #5 NCLEX Qs
A client with altered mobility is unable to bear weight on their wrists. Which type of assistive device should the nurse expect to be prescribed for the client? A.Platform crutches B.Cane C.Axillary crutches D.Lofstrand crutches
A
Which intervention is an appropriate nonpharm treatment for the nurse to include in the plan of care for a client with ASD? (Select all that apply.) A.Promoting enhanced communication B.Teaching the family about studies on complementary care C.Establishing support for the parents and family D.Creating an environment that is conducive to positive behavior management E.Encouraging parents not to vaccinate their children
A, B, C, D. Children with ASD will benefit from the following nonphar TX options: establishing support for parents & family; creating an environment that is conducive to positive behavior management; promoting enhanced communication; & educating the family about studies on the use of complementary care.
The nurse is caring for a client diagnosed with RA. Which client outcome leads the nurse to determine that treatment is successful? (Select all that apply.) A.The client has an active role in managing the disease. B.The client maintains joint mobility. C.The client uses stress management techniques to cope with the disease. D.The client maintains a positive body image. E.The client uses pain medication only when pain is severe.
A, B, C, D. Pt diagnosed with RA endures chronic pain. Pain meds should be taken regularly & prior to planned activities to remain pain-free.
A client with a history of joint pain and autoimmune disease presents to the clinic. Which question should the nurse include in the nursing assessment for this client? (Select all that apply.) A."Do you have any rashes?" B."Have you had any recent infections?" C."Have you had any fever or generalized weakness?" D."What kind of medications are you taking currently?" E."Do you have any numbness or tingling in your extremities?"
A, B, C, D. When interviewing a Pt with an immune system dysfunction, nurse needs to ask about current meds, whether the Pt has any rashes or fever, & hx of recent infections. All of these can trigger flare-up of autoimmune disease.
Which problem should the nurse include in the plan of care for a client with M)? (Select all that apply.) A.Risk of hopelessness B.Impaired physical mobility C.Altered urinary elimination patterns D.Risk of fatigue E.Acute pain
A, B, C, D. nurse needs to address the following problems: impaired physical mobility, risk of fatigue, altered urinary elimination patterns, & risk of hopelessness.
A client with RA complains of pain and discomfort in the hands and knees. Which intervention should the nurse implement to reduce the pain and discomfort? (Select all that apply.) A.Providing periods of exercise B.Administering prescribed NSAIDs C.Providing a balanced diet D.Providing periods of sun exposure E.Administering prescribed corticosteroids
A, B, C, E.
The nurse is addressing a group of high-risk teen mothers. Which risk factor that can lead to ADHD in teens should the nurse include in the discussion? (Select all that apply.) A.Exposure to high levels of lead in childhood B.Poor nutrition C.Drinking alcohol during pregnancy D.Affluence E.Lack of proper parenting
A, B, C, E.
Which assessment finding should the nurse expect in a child with autism spectrum disorder (ASD)? (Select all that apply.) A.Reiteration of questions as opposed to answering them B.Use of the word you to represent I C.Echolalia D.Stuttering E.Enchantment with rhythmic repetition of verse or song
A, B, C, E. Echolalia (parroting a particular word or phrase), repetition of inquiries rather than responding to them, using you to represent I, & fascination with things that are lyrical in nature such as a song or verse are typical speech patterns for children with ASD. Stuttering is not a clinical manifestation of ASD.
Which instruction should the nurse include when teaching the parents of a 3 YO with ASD? (Select all that apply.) A.Providing for play with other children of the same age B.Providing methods to decrease the incidence of head banging C.Teaching problem solving regarding client issues D.Administering stimulants to calm repetitive motions E.Establishing therapies to assist with building play skills
A, B, C, E. Pts c ASD have behaviors that interfere c functioning & can be harmful, like banging their head or hitting solid objects. Provide pts c ASD early PT & OT may be beneficial in developing some play & social skills. pts c ASD may keep themselves in isolation, assisting them to be able to be in presence of others is a focus of tx. They may not progress to living independently; so, parents need to learn problem-solving skills to assist them & the pt throughout life. Stimulants are a pharm, not nonpharm tx for asd
A parents group asks the nurse what they should look for if they suspect their school-age child has ADHD. Which observation should parents report to their child's HCP? (Select all that apply.) A.Excessive motor activity B.Limited attention span when speaking with parent C.Inability to stay on an assigned task to completion D.Deliberately destroying other people's property E.Having difficulty with learning at school
A, B, C, E. Required findings for a dx of ADHD are limited attention span, inability to stay on assigned task, & excessive motor activity with the inability to sit still for more than a few mins. Clients c ADHD are frequently labeled as poor achievers c difficulty learning.
During a home visit, nurse is concerned that a client is experiencing acute inflammation. Which finding caused the nurse to make this determination? (Select all that apply.) A.Skin area reddened B.Skin area hot to touch C.Pain level of 7 on a scale from 1 to 10 D.Pink and red wound tissue E.Skin area swollen
A, B, C, E. With acute inflammation, the typical signs of inflammation—redness, swelling, pain, heat, & impaired function—occur.
A client diagnosed with RA states that the pain is controlled with NSAIDs. Which instruction related to the disease process and supportive care should the nurse provide? (Select all that apply.) A.Applying heat or cold to relieve pain B.Being aware of the adverse effects of prescribed medications C.Exercising in the pool because it relieves pressure on the joints D.Avoiding exercise E.Taking NSAIDs at regular intervals with food or milk
A, B, C, E. priorities for PT c RA are supportive care & education. Taking NSAIDs at regular intervals provides continued control of pain & discomfort. Taking NSAIDs c food or milk decreases GI upset. Pts should consume well-balanced diet, use application of heat & cold for pain, exercise in pool because it supports pt's wt & relieves pressure on joints
After performing a physical assessment, the nurse suspects that a client is experiencing manifestations of osteoarthritis (OA). Which finding supports the nurse's suspicion? (Select all that apply.) A.Joint stiffness B.Crepitation C.Reduced joint flexibility D.Joint tenderness E.Leg tremors
A, B, C,D. OA affects cartilage. Manifestations: crackling sounds, or crepitation, with joint movement; joint stiffness (stiffness lasting LESS than 30 min. - RA is MORE than 30 min); tenderness; & reduced joint flexibility, Heberden's (distal) & Bouchard's (proximal) nodes. Rest painful joint & do low impact exercises (water aerobics, ROM, lift weights)
PT diagnosed with RA tells the nurse, "Because of my pain & fatigue, I can no longer take care of my family the way I used to. I feel like such a failure." Which intervention is appropriate for the nurse to implement for this client? (Select all that apply.) A.Help pt to ID strengths & what they are still able to do for the fam B.Encouraging pt to make decisions about treatment C.Encouraging pt to talk about changes brought about by RA D.Encouraging the client to seek physician-centered care
A, B, C. As pt becomes unable to fulfill normal familial roles, stress occurs in the family. Talking about changes, identifying strengths, helping the pt realize what they can still do for their family, & encouraging the client to continue to make medical decisions are important for maintaining a sense of self-control & self-esteem.
he nurse is teaching colleagues about nonspecific immune responses. Which response should the nurse exclude from the presentation? A.Skin B.Mucus C.Body fluids D.Antigens
A, B, C. Mucus, body fluids & skin are all part of the nonspecific immune response.
The nurse assessing a client diagnosed with rheumatoid arthritis (RA) notes the presence of joint deformities. Which additional extra-articular manifestation of RA should the nurse look for in the client? (Select all that apply.) A.Pericarditis B.Subcutaneous nodules C.Splenomegaly D.Hearing loss E.Hepatitis
A, B, C. RA has many systemic effects including subcut nodules, pericarditis, & splenomegaly. These are the result of inflammation or high levels of circulating rheumatoid factors.
The nurse is caring for a client who was recently diagnosed with RA. Which treatment goal should the nurse assign to the client? (Select all that apply.) A.Reducing pain B.Preserving function C.Curing the disease D.Reducing inflammation E.Preventing deformity
A, B, D, E.
The fam of a client with mobility difficulties asks the nurse, "What age-related changes to the musculoskeletal system should we expect our father might experience?" Which change should the nurse include? (Select all that apply.) A.Flexed position of hips B.Muscle fiber atrophy C.Increased bone density D.Ligament tears E.Decreased joint fluid
A, B, D, E. Changes in the musculoskeletal system that occur c aging include tears in ligaments, atrophy of muscle fibers, decreased joint fluid, and a flexed position of the hips. Bone density decreases with aging.
The nurse is planning care for a client with limited knee function due to arthritis. Which intervention should the nurse include in this client's plan of care? (Select all that apply.) A.Encouraging participation in physical therapy as prescribed B.Encouraging rest of the affected joint C.Providing antipyretics as prescribed D.Providing antiarthritis medications as prescribed E.Assessing pain level and providing medication as prescribed
A, B, D, E. Interventions appropriate when function is impaired because of inflammation include encouraging rest of affected joint, assessing & providing analgesics, treating underlying health problem, & participating in PT. Antipyretics would be appropriate if the inflam were systemic & not localized.
A client is admitted for uncontrolled pain caused by rheumatoid arthritis (RA). Which ongoing problem should the nurse assess in relation to the RA? (Select all that apply.) A.Ineffective role performance B.Fatigue C.Weight gain D.Chronic pain E.Poor self-esteem
A, B, D, E. Ongoing probs related to RA include chronic pain, fatigue, poor self-esteem related to body-image issues, and ineffective role performance. Weight loss is an issue for clients with RA.
The nurse is assessing a high-functioning adult client who is diagnosed with ASD. Which characteristic of ASD should the nurse anticipate this client will demonstrate during the nursing assessment? (Select all that apply.) A.Choosing inappropriate topics to discuss B.Lacking the ability to participate in small talk C.Displaying problems with sentence structure D.Having trouble with double meanings E.Not understanding body language
A, B, D, E. Socialization & communication, especially understanding nonverbal communication, are lifelong struggles for the adult c ASD. Behaviors the nurse will anticipate include choosing inappropriate topics to discuss, not engaging in small talk, not understanding body language, & having trouble with double meanings. The nurse would not expect the adult client c ASD to display problems c sentence structure.
Which goal is appropriate for the nurse to set for a client with MS? (Select all that apply.) A.The client will state methods to reduce urinary incontinence. B.The client will receive psychologic counseling as needed. C.The client will sleep 5 hours per night. D.The client will participate in an exercise program to maintain independence. E.The client will verbalize methods to prevent and treat diarrhea.
A, B, D. Appropriate goals for client c MS include participating in exercise program to maintain independence, stating methods to reduce urinary incontinence, & receiving psychologic counseling as needed. Constipation is usually a problem for pts c MS
The nurse is assessing a client suspected of having MS. Which manifestation should the nurse expect to observe in the client? (Select all that apply.) A.Lack of coordination B.Spastic movements C.Tachycardia D.Double vision E.Decreased level of consciousness
A, B, D. Double vision is consistent c MS causes demyelination & plaque formation in the CNS, including damage to the optic nerve. Spastic movements are consistent cMS because it is an upper motor neuron disorder.. Lack of coordination is consistent with MS; coordination & balance are controlled in cerebellum, & damage to nerve transmission in the cerebellum can cause loss of coordination & poor balance
The nurse is teaching the parents of a child with autism spectrum disorder (ASD) who is being treated with a gluten-free and casein-free diet. Which food should the nurse teach the parents to eliminate in the child's diet? (Select all that apply.) A.Cheese B.Grain C.Beef D.Milk E.Corn
A, B, D. Foods that should be avoided include grains and dairy products, such as milk and cheese
The nurse is caring for a client with localized inflammation. Which finding should the nurse expect to assess in this client? (Select all that apply.) A.Tenderness with palpation or movement B.Localized edema C.Oral temperature of 101°F D.Palpable warmth of the extremity E.WBC count of 15,000
A, B, D. Localized edema, tenderness c palpation or movement, & palpable warmth of extremity are all signs of localized edema. Additional signs are redness & reduced function of extremity. Increased oral temp and elevated WBCs are indicative of systemic inflammation.
A client with inflammation caused by a severe ankle injury is being prepared for discharge. Which intervention to reduce inflammation should the nurse include when teaching the client and family? (Select all that apply.) A.Coping skills B.Application of ice packs C.Aerobic exercise D.Positioning E.Limiting fluid intake
A, B, D. nurse should teach the client coping skills to deal c the healing & recovery time, positioning to reduce discomfort & prevent further injury, & application of ice packs to reduce swelling & pain.
A client newly diagnosed with RA is prescribed therapy with a nonsteroidal anti-inflammatory agent (NSAID). Which side effect should the nurse list for the client? (Select all that apply.) A.Bleeding ulcers B.Stomach lining irritation C.Bone marrow depression D.Increased risk for infection E.Nephrotoxicity
A, B, E.
The nurse assesses a child suspected of having autism spectrum disorder (ASD). Which behavior noted in the assessment supports the diagnosis? (Select all that apply.) A.Stereotypy B.Echolalia C.Emotional calm D.Deep set eyes E.An aversion to being touched
A, B, E. Behaviors indicative of ASD include stereotypy (rigid & obsessive behavior), echolalia (the compulsive parroting of a word or phrase just stated by another), & an aversion to being touched.
Which is a common risk factor for osteoarthritis? (Select all that apply.) A.Obesity B.Activities affecting weight-bearing joints C.Ingestion of large amounts of purine D.Autoimmune disorder E.Overuse of joints from sports or strenuous activities
A, B, E. Common risk factor: obesity, overuse of joints from sports injuries or strenuous activities, & activities affecting weight-bearing joints, genetics. RA is thought to be an autoimmune disorder. Ingestion of large amounts of purines is a risk factor for gout.
Which Q should the nurse ask as part of the health hx assessment for a client with a disorder of the immune system? (Select all that apply.) A."Are you taking any antibiotics?" B."Do you have any food allergies?" C."How far can you walk without stopping?" D."Are you eating vegetables that are high in vitamin K?" E."When did you receive your pneumococcal pneumonia vaccine?"
A, B, E. It is appropriate to ask the client about vaccinations, food allergies, and medications.
The nurse is completing a health history on a client with short bowel syndrome. Which medical history should the nurse identify as being associated with this health problem? (Select all that apply.) A.Crohn disease B.Gastric bypass C.Down syndrome D.Colonoscopy E.Stomach cancer
A, B, E. PT c a hx of gastric bypass, stomach cancer, or Crohn disease is at risk for development short bowel syndrome.
The nurse is teaching the parents of a very young client newly diagnosed with ADHD regarding therapeutic interventions. Which intervention should the nurse encourage the parents to implement during study time at home? (Select all that apply.) A.Provide a clutter-free area to study. B.Reduce environmental stimuli such as music and television. C.Administer stimulant med at least 30 min prior to studying. D.Give the child a snack to eat during study time. E.Allow the child as much screen time as he desires.
A, B. During study time, client should have a quiet, clutter-free area to study & complete homework. Giving a snack would provide a distraction, so this should happen either before or after study time. Minimizing screen time is an important environmental control that should be implemented. Stimulant meds are administered 1st thing in the morning, not prior to tasks.
Which independent nursing intervention should the nurse implement to support the immune system? (Select all that apply.) A.Reducing stress B.Limiting activity C.Promoting proper rest D.Providing proper nutrition E.Promoting moderate exercise
A, C, D, E.
A client is admitted with a suspected autoimmune deficiency in which the number of leukocytes is decreased. Which intervention should the nurse include in the client's plan of care? (Select all that apply.) A.Rest periods B.Fluid support C.Moderate exercise D.Nutritional support E.Infection prevention
A, C, D, E. A PT c an immune system deficiency will require nutritional support, prevention of infection & rest periods to prevent fatigue. Also, mod exercise has a positive effect on the immune system by causing lymph fluid to be pumped more efficiently throughout the body. Fluid support is not an intervention the nurse would focus on
The nurse is assessing a 3 YO with autism spectrum disorder (ASD). In which area should the nurse expect to find impairments? (Select all that apply.) A.Social interactions B.Ability to engage in complex thought process C.Communication D.Social adaptability E.Ability to organize responses to situations
A, C, D, E. Impairments are noted in the social interactions & ability to adapt socially at the appropriate age level. Young child with ASD will have a decreased ability to communicate as well as an inability to organize situational responses. Developmentally, the 3 is not old enough for complex thought
Which independent nursing intervention should the nurse implement to treat a client diagnosed with RA? (Select all that apply.) A.Promoting a well-balanced diet B.Suggesting arthrodesis for joint fusion C.Teaching about low-impact aerobics D.Instructing the client to alternate periods of activity and rest E.Advising the client to avoid sun exposure
A, C, D. Independent interventions: monitoring and treating chronic pain, preventing fatigue, addressing ineffective role performance, promoting a healthy body image, & providing support related to impaired mobility. Interventions for RA include teaching about low-impact aerobic (walking & swimming); alternating periods of activity & rest; &promoting a well-balanced diet.
Which clinical manifestation of osteoarthritis (OA) should the nurse include when teaching about osteoarthritis? (Select all that apply.) A.Crepitus with movement of joint B.Mild fever C.Joint pain with activity D.Pain and stiffness at night E.Abrupt onset
A, C, D. Joint pain C activity, grating or crepitus noted C movement, & pain & stiffness C prolonged inactivity are general manifestations of OA. Mild fever is associated with rheumatoid arthritis, not OA. Osteoarthritis is a degenerative disease that develops over time, although symptoms may appear suddenly.
Which health promotion activity supports a healthy lifestyle for clients with osteoarthritis? (Select all that apply.) A.Using proper body mechanics B.Increasing dietary intake of calcium C.Maintaining a normal weight D.Using assistive devices as needed E.Using soft chairs and recliners for rest
A, C, D. Maintaining norm wt places less strain on joints. Assistive devices (grab bars, a shower chair, or long-handled grippers) help to maintain an independent lifestyle in safety. Using proper body mechanics during activities reduces stress on joints. Although Ca intake is essential for preventing osteoporosis increasing daily Ca intake does not have a positive effect on OA. Chairs & mattresses should provide support & help to maintain norm body alignment. Soft chairs & recliners do not provide such support.
The community health nurse is conducting a teaching session for community members on RA. Which characteristic should the nurse list as being a risk factor for the development of RA? (Select all that apply.) A.Psychological stressors B.Diet C.Genetic predisposition D.Family history E.Male sex
A, C, D. Risk factors for RA: genetic, environmental, reproductive, & hormonal factors. Autoimmune disorders such as RA are more prevalent in women. Diet is not a known risk factor in the development of RA.
nurse performs an admission assessment on a client diagnosed with MS. Which assessment should the nurse perform as a part of the physical examination? (Select all that apply.) A.The client's speech B.The client's breathing sounds C.The client's balance D.The client's ability to hear E.The client's affect
A, C, E.
The nurse is teaching a client who is lactose intolerant about pharmacologic therapies used in tx of the disorder. Which med should the nurse include in the teaching? (Select all that apply.) A.Calcium supplements B.Vitamin K C.Lactase enzymes D.Corticosteroids E.Vitamin D
A, C, E. Pharm therapy for the client with a lactase deficiency will include lactase enzyme supplementation, calcium supps, & vit D. Corticosteroids may be used in celiac disease to mediate the inflammatory response & vit K is used in celiac disease if coagulation is delayed.
The nurse is teaching a client experiencing inflammation. Which sign of inflammation should the nurse include in the teaching? (Select all that apply.) A.Pain B.Paresthesia C.Redness D.Paralysis E.Swelling
A, C, E. The typical signs of inflammation are redness, swelling, pain, heat, and impaired function. Paralysis and paresthesia are not signs of inflammation.
The nurse is conducting a health interview to determine a client's mobility status. Which lifestyle behavior is most appropriate for the nurse to assess? (Select all that apply.) A.Smoking habits B.Taking no medications C.Living alone D.Primarily working on a computer E. Long-distance running
A, D, E.
he nurse begins an early ambulation routine with a client diagnosed with altered mobility. Which benefit of early ambulation should the nurse explain to the client? (Select all that apply.) A.Improves self-esteem B.Improves skin turgor C.Promotes diarrhea D.Strengthens muscles E.Reduces risk of thrombophlebitis
A, D, E.
The nurse is developing a plan of care for a client experiencing an alteration in mobility. Which objective is most appropriate for the nurse to include? (Select all that apply.) A.Promote education B.Promote healthy relationships C.Recommend immunizations D.Promote comfort E.Prevent injury
A, D, E. Independent nursing interventions for the client C an alteration in mobility focus on promoting education, comfort & preventing injury. Although promoting healthy relationships & recommending imms may be important for all clients, these nursing interventions are not specifically important to clients with alterations in mobility.
The nurse is teaching a client who is newly diagnosed with inflammation. Which systemic manifestation of inflammation should the nurse include in the teaching? (Select all that apply.) A.Oral temp of 101°F B.WBC count of 4000/mm3 C.BP of 148/88 mmHg D.Resp rate of 22 breaths per minute E.Heart rate of 104 beats per minute
A, D, E. There is no specific parameter for BP & systemic inflammation.WBC count of 4000/mm3 is a low normal value & does not indicate presence of inflammation.
The nurse is completing a health hx & physical on a client admitted for celiac disease. Which info should the nurse make a priority during this assessment? (Select all that apply.) A.Height and weight B.Recent headaches C.Urinary frequency D.Characteristics of stool E.Current medications
A, D, E. When completing a health HX & physical exam on a client with celiac disease, the nurse should collect info on the number and characteristics of stool, current meds, & height & weight.
The parents of a young client newly diagnosed with ADHD are concerned about the school environment &the child's grades. Which suggestion should the nurse encourage the parents to discuss with the child's teacher? (Select all that apply.) A.Provide a quiet area for examinations and extra time if necessary. B.Don't allow the child to do special tasks or run errands without supervision. C.Place the child in the back of the classroom. D.Place the child in the front of the classroom close to the teacher. E.Remind the child to pay attention in front of the class.
A, D.
parents of a child newly diagnosed with juvenile OA are concerned about their child's future ability to be disability free and remain independent. Which info should the nurse give the parents? (Select all that apply.) A."Children may outgrow OA as they age." B."OA in children is generalized, thus impacting all joints and increasing possible impairment." C."OA in children is usually idiopathic, making it difficult to determine how it will affect them as adults." D."Children with OA are less likely to become disabled." E."The amount of disability will depend on how well the OA is managed as a child."
A, D. Children c OA are less likely to become disabled as adults and may outgrow the OA as they age. It is not likely that children with OA will be disabled as adults.
A client c PD is prescribed an anticholinergic agent to treat tremors & rigidity. The nurse should teach the client about which adverse effect they may experience from this med? (Select all that apply.) A.Loss of perspiration B.Drooling C.Rigidity D.Tremors E.Dry mouth
A, E. Anticholinergic meds can cause a decrease in salivation, causing dry mouth. This med decreases tremors & reduces rigidity by blocking acetylcholine. The client taking this med will have problems c temp control because they will not be able to perspire
An adolescent client presents for a well-child visit. Which vaccine should the nurse anticipate administering if the adolescent has not yet received it? (Select all that apply.) A.HPV B.DTaP C.MMR D.Herpes zoster E.Meningococcal
A, E. HPV & meningococcal vaccines are immunizations that are initiated in adolescence. MMR & DTaP are vaccine schedules that are started in childhood, with periodic boosters needed throughout adolescence & adulthood. The herpes zoster vaccine is given to older adults, not adolescents.
A nurse is explaining to a client some abnormal ways that fluid is lost in the body. Which statement should be included in this lesson? (Select all that apply.) A."Fluid is lost when you perspire." B."Fluid is lost when you vomit." C."Fluid is lost when you urinate." D."Fluid is lost when you bleed." E."Fluid is lost when you have a fever."
A, E. Some abnormal fluid losses occur through fever, draining wounds, or excessive perspiration.
The nurse is caring for a client who is deficient in T cells. The nurse should anticipate that the cause of T-cell deficiency is related to which manifestation? (Select all that apply.) A.Decrease in leukocytes B.Decrease in monocytes C.Decrease in granulocytes D.Hypersensitivity reaction E.Impaired cellular immunity
A, E. T cells are subtypes of leukocytes & they are a key factor in cellular immunity - therefore the PT may have impaired cellular immunity & a decrease in leukocytes.
The nurse prepares teaching for a client recently diagnosed with celiac disease. Which client statement demonstrates teaching has been effective? (Select all that apply.) A."I should weigh myself daily." B."I should not consume any soy products." C."I can eat a high-carbohydrate diet." D."I should not drink more than 24 ounces daily." E."If I gain more than 5 pounds, then I should contact the healthcare provider."
A, E. instruct the PT to frequently monitor wt. Wt gain of 5 lbs or more in less than a wk usually reflects fluid gain, a possible adverse effect of corticosteroids & requires immediate clinical attention.
Which assistive device should the nurse recommend to a client with osteoarthritis (OA) of the hands? (Select all that apply.) A.Zipper hook B.Handrails C.Large-handled toothbrush D.Electric can opener E.Reacher device
A,C,D. Zipper hooks, electric can openers, & large-handled toothbrushes can be helpful for clients c OA of the hands. Handrails can be useful for clients with OA of the hips. Reacher devices can be helpful for clients with OA of the shoulders.
The nurse is counseling a newly pregnant client with osteoarthritis (OA). Which information should the nurse include? A."Your pain from the OA may increase due to the weight gain of pregnancy." B."You need to restrict your participation in low-impact aerobic exercises." C."You may continue to take your prescription nonsteroidal anti-inflammatory drug without any risk of harm to the fetus." D."Pregnancy has no impact on OA if you keep your weight gain within the recommended limits."
A.
The nurse is developing a plan of care for a client diagnosed with ASD. Which nursing diagnosis is most appropriate? A.Communication: Verbal, Impaired B.Infection, Risk for C.Airway Clearance, Ineffective D.Macrocephaly, Risk for
A.
The nurse is planning care for a client with OA. Which nursing diagnosis is a priority for the nurse to address? A.Pain, Chronic B.Skin Integrity, Impaired C.Lifestyle, Sedentary D.Family Processes, Interrupted
A.
The school nurse is helping to create an individualized education plan (IEP) for a young client with ADHD. Which behavioral goal should the nurse include in the plan of care? A.The client will respect the boundaries of others. B.The client will achieve school performance to minimum competency. C.The client will demonstrate a decrease in attentiveness. D.The client will accurately manage medication administration.
A.
The nurse is caring for a child who is suspected of having an inflammatory disorder involving internal organs. Which diagnostic test should the nurse expect will be ordered for the child? A.Exhaled breath condensates B.Bronchoalveolar lavage C.Bronchoscopy D.Blood tests
A. : The best procedure to assess for inflammation in internal organs of children is to analyze exhaled breath condensates. This test is noninvasive and appropriate for children
While assessing a pediatric client's lab results, the nurse notes a high eosinophil count. Which diagnosis should the nurse anticipate based on this laboratory result? A.Allergies B.Salmonella C.Lyme disease D.Rubella
A. A high eosinophil count is an indication that the client has allergies.
A client is being treated for an inflammatory response. Which strategy should the nurse emphasize to prevent episodes of inflammation in the future? A.Avoiding a trigger B.Eating a well-balanced diet C.Taking aspirin prophylactically D.Engaging in frequent hand washing
A. A major strategy to prevent the onset of an inflammatory response is to avoid a known trigger for the response
A client asks how to prevent developing inflammation when aging. Which response should the nurse make to this client? A."The best way is to avoid known triggers, if you have them." B."Smoking has been shown to decrease inflammation." C."Avoid over-the-counter medications and supplements." D."The best way is to eat a diet high in refined sugars and low in fiber."
A. A trigger is a substance that causes an inflam response. Triggers can be food or beverages or substances like pollen, dust, animal dander, or smoke. Avoiding triggers will prevent an excessive inflam response. A diet low in refined sugars & high in fiber will decrease the risk for inflam. Some OTC meds (aspirin & ibuprofen) & supps (omega-3 fish oil) are helpful in treating inflam.
Which symptom for a client with Parkinson disease (PD) is due to the lack of automatic muscle movement? A.Alterations in sleep pattern B.Reduced ability to swallow C.Diminished physical mobility D.Diminished voice volume
A. Alterations in sleep pattern may occur due to lack of automatic muscle movement in a client with PD. Reduced ability to swallow, diminished voice volume, & diminished physical mobility are all related to dysfunction of voluntary muscle movement.
The home care nurse is visiting a child diagnosed with ASD. Which intervention is appropriate for the nurse to include in the TX plan for this family? A.Providing appropriate education regarding what to expect for the child B.Recommending that the home be a therapy-free zone C.Encouraging the family to get over negative feelings regarding the diagnosis D.Focusing on the child's limitations
A. An appropriate intervention for the family of a child diagnosed c ASD is for the nurse to provide education about what to expect. encourage the family to grieve the loss of the "perfect child" & encourage them to focus on the child's strengths & talents. In order for therapy to be effective, the nurse would recommend that treatments be continued at home.
During a well-child visit, a female high school student complains about their inability to do as much physically as their twin brother. Which response by the nurse is accurate? A."Boys have more muscle mass than girls." B."Girls have less muscle after the age of 16." C."Muscle growth in girls peaks at age 13." D."Girls need to eat more to have more muscle."
A. Boys have more muscle mass than girls. Muscle growth in girls peaks between the ages of 16 and 20.
Which teaching point is important for the nurse to include in the plan of care for a client who is diagnosed with ASD? A.Establishing a routine B.Focusing on limitations in order to see progress in care C.Maintaining the home as a treatment-free zone D.Keeping the same pediatric healthcare provider for all children in the family
A. Clients who are diagnosed with ASD thrive when routines are established and followed
Which intervention is most appropriate for the nurse to include in the plan of care for a child with autism spectrum disorder (ASD)? A.Encouraging the pt's family to bring in familiar objects from home B.Putting the television on loud to provide stimulation for the client C.Rearranging hospital room until a comfortable arrangement found D.Scheduling procedures for different times each day
A. Clients with ASD need structure & predictable course of action. Bringing in familiar objects from home provides comfort for the client. It is important for the nurse to be oriented to the room and care should be taken not to relocate objects in the environment.
A client diagnosed with MS is being treated with disease-modifying therapy. Which form of MS should the nurse suspect the client has? A.Relapsing-remitting MS B.Secondary-progressive MS C.Primary-progressive MS D.Progressive-relapsing MS
A. Disease-modifying therapies are only used for the relapsing-remitting form. Clients c progressive forms are treated c meds that are specific for their symptoms.
Which assistive device should the nurse expect to be ordered for an older client who is unsteady when ambulating? A.Walker B.Lofstrand crutches C.Cane D.Axillary crutches
A. For older, unsteady adults, the best assistive device for ambulation is a walker. A walker provides maximum stability for the client.
Which characteristic is typically seen less in girls, when compared with boys, having ADHD? A.Impulsiveness B.Cognitive problems C.Anxiety D.Mood swings
A. Girls with ADHD typically show less aggression and impulsiveness than boys. Girls tend to show more anxiety, mood swings, social withdrawal, rejection, and cognitive and language problems.
A client with possible OA is scheduled for a synovial fluid analysis. The nurse should explain to the client that this diagnostic test is being completed for which reason? A.To rule out inflammatory arthritis and gout B.To identify irregular joint space narrowing C.To evaluate for increased density of subchondral bone D.To determine the extent of joint damage
A. Joint fluid analysis is used to detect inflammation, bacteria, & uric acid crystals to rule out inflammatory arthritis & gout
A client is prescribed a NSAID for arthritis. Which info should the nurse teach the client about this medication? A.Report any gastrointestinal distress to the healthcare provider. B.Avoid driving or using machinery while taking this medication. C.This medication may cause confusion and hallucinations. D.Take this medication with calcium supplements.
A. NSAIDs can cause GI distress, which should be reported to the healthcare provider.
The nurse educator provides a teaching session on malabsorption with a group of new staff nurses. Which process should the nurse ask the staff to ID that causes nutrients to be absorbed into the small intestines? A.Simple diffusion B.Evaporation C.Transference D.Osmosis
A. Nutrients are absorbed by the processes of simple diffusion (water and small lipids), facilitated diffusion (water-soluble vitamins), and active transport (glucose and amino acids).
The nurse is planning care for a client with celiac disease. Which prob should the nurse identify as the priority of care for this client? A.Nutritional imbalance B.Constipation C.Activity intolerance D.Fatigue
A. Nutritional imbalance is the priority problem for the nurse to address because celiac disease is a disease of malabsorption.
A parent tells the nurse that they are thinking of not giving their child any vaccinations. How should the nurse respond? A.Provide the risks and benefits of vaccinating their child. B.Inform the parent that they don't have the right to make this decision. C.Suggest they provide all except the measles, mumps, and rubella vaccine. D.Let them know that "herd immunity" will protect their child.
A. Parental education should include discussion of the vaccine's risks & benefits. The nurse has the responsibility to provide the parent with the most current Vaccine Information Statements (VISs) prior to any vaccination of a minor.
A client recovering from bowel resection 2 wks ago is experiencing explosive diarrhea and has lost 15 lbs. Which should the nurse expect the healthcare provider to prescribe for this client? A.TPN B.IV antibiotic C.Lactated ringers D.Electrolytes
A. Pts c severe manifestations of short bowel syndrome may require TPN. This prevents development of malnutrition & enhances intestinal adaptation.
The nurse is evaluating a client who has OA of hips & knees. Which statement by the indicates progress toward meeting identified activity goals? A."I've been able to manage my pain so that I can independently complete my daily activities." B."I've increased my running time to 30 min 3x a week" C."I limit the use of acetaminophen unless I absolutely need it to decrease my risk of liver toxicity." D."I have been completing ROM for all joints every other day."
A. ROM should be done every day for all joints. Acetaminophen should be used regularly to help avoid severe pain from occurring. Running is high-impact activity that can increase stress on joints. Low-activity aerobic exercise, not high-impact exercise, should be included in activity goals
A client with altered mobility reports gastric upset. Which medication should the nurse suspect is causing the client's symptoms? A.Nonsteroidal anti-inflammatory drug (NSAID) B.Direct-acting antispasmodic C.Bone growth stimulator D.Skeletal muscle relaxant
A. Side effects of nonsteroidal anti-inflammatory drugs (NSAIDs) include gastric upset and bleeding.
The nurse conducts screening for inflammatory diseases with clients of a community health clinic. Which test should the nurse perform? A.Skin test B.MRI C.X-ray D.Urine test
A. Skin testing identifies allergens that trigger an inflammatory response.
A client diagnosed with RA reports having trouble doing the prescribed physical therapy exercises because of stiffness. Which intervention should the nurse suggest to help the client follow the prescribed physical therapy program? A."Try doing water aerobics at the gym." B."Stop exercising for a few weeks." C."Wear lightweight clothing when you exercise." D."Try exercising for several hours each day at the gym."
A. Swimming or water aerobics is a good option for individuals with rheumatoid arthritis because the water supports the body, decreasing the amount of stress on the joints
An adult client recently diagnosed with ADHD asks about treatment options. Which treatment option should the nurse recommend? A.Requesting a nonstimulant medication from the healthcare provider B.Minimizing all changes in the home and work environment C.Having a loose, flexible schedule so that activities can be adjusted quickly D.Requesting a stimulant medication from the healthcare provider
A. The nonstimulant med atomoxetine (Strattera) is approved for use in adults. Stimulant meds such as dexmethylphenidate (Focalin) are not approved for use in adults.
A client diagnosed with localized idiopathic osteoarthritis (OA) asks the nurse what this means. Which response by the nurse provides the most accurate information? A."Idiopathic OA has no identifiable cause; when it is localized, it only affects one or two joints." B."Idiopathic OA, as compared with secondary OA, is caused by some kind of underlying condition." C."Idiopathic describes OA overall while localized indicates that it affects one body joint only." D."Idiopathic refers to the fact that the OA has already progressed significantly in one or two joints."
A. There are 2 types of OA, idiopathic & secondary. Idiopathic OA: no identifiable cause & can be further subdivided as localized or generalized, C localized indicating that OA only affects 1 or 2 joints. Idiopathic OA is not due to an underlying condition. Idiopathic refers to cause, not progression of disease.
The nurse is teaching a client with celiac disease about the disease process. Which reason should the nurse provide as the cause for the reaction occurring in the small bowel with this disorder? A.Inflammatory B.Cellular C.Nervous system D.Allergic stress
A. the immune response prompts an inflam response in the small bowel, resulting in loss of villi & microvilli.
A client considering pregnancy has a family history of primary immune deficiencies and wants to know the risk for their child. Which statement by the nurse is appropriate? A."You should consider long-term contraceptive use to prevent severe immunodeficiency in your offspring." B."You may want to seek genetic counseling to determine the specific risk." C."A weight-loss program prior to pregnancy will decrease your infant's risk of getting one of these diseases." D."Tell me more about your concerns regarding pregnancy."
B
The nurse is teaching a class about the joints commonly affected by osteoarthritis (OA). Which joints should the nurse include? A.Neck, shoulders, and ankles B.Hands, knees, and hips C.Ankles, feet, and spine D.Knees, feet, and spine
B
A pregnant client presents with back pain. Which condition is most likely the cause of this pain? (Select all that apply.) A.Improper lifting B.Stretched abdominal muscles C.Instability of the pelvis D.Strain from the growing uterus and fetus E.Bulging discs
B, C, D
Which recommendation should the nurse make to the client with PD to improve gait and balance? (Select all that apply.) A.Not using an assisstive device B.Placing the heel on the ground before the toes C.Not moving too quickly D.Looking ahead instead of down E.Standing straight
B, C, D, E.
The nurse is teaching the parents of a child recently diagnosed with autism spectrum disorder (ASD). Which etiologies should the nurse include? (Select all that apply.) A.Mercury-containing vaccinations B.Neurotransmitters C.Genetics D.Environmental factors E.Immunologic factors
B, C, D, E. Etiology of ASD is uncertain,is believed to be result of an intricate co-action between genetic, immunologic, & environmental circumstances. There is research being conducted on the role of neurotransmitters, such as dopamine & serotonin.
In reviewing a client's health history, which factor should the nurse consider to be a risk for developing a disorder of the immune system? (Select all that apply.) A.Male sex B.Physical stressors C.African American race D.Genetic predisposition E.Psychological stressors
B, C, D, E. Risk factors for disorders of the immune system include genetics and physical or psychological stressors. Immune system disorders are also more prevalent in African Americans. Autoimmune disorders are more prevalent in women.
Which health promotion activity should be the focus of teaching for a client with PD? (Select all that apply.) A.Avoiding exercise B.Improving balance C.Promoting independence D.Participating in occupational therapy E.Preventing injury from falls
B, C, D, E. The focus of teaching for the client with PD should be on improving balance, preventing falls, promoting independence, and participating in PT, OT, and speech therapy. Clients should be taught to participate in exercise to optimize mobility,
The nurse is planning care for a client diagnosed with MS. Which collaborative service should be consulted to help maintain or improve functional status of this client? (Select all that apply.) A.Pastoral care B.Cognitive therapy C.Vocational rehabilitation D.Physical therapy E.Occupational therapy
B, C, D, E. Vocational rehab should be consulted because this trains client to use assistive devices. PT helps to maintain mobility & optimal functioning. OT enhances independence, productivity, safety & retention of skills. Cognitive therapy helps to improve ability to think, reason, concentrate & remember.
Which item should the nurse include in a focused immune system assessment? (Select all that apply.) A.Assess the genitourinary system. B.Inspect the mucous membranes. C.Observe for fatigue and weakness. D.Assess the musculoskeletal system. E.Observe skin color, moisture, and temperature.
B, C, D, E. When conducting a focused assessment for the immune system, the nurse would include observations for fatigue & weakness, a musculoskeletal system assessment, a skin assessment, and inspection of the mucous membranes. The nurse would not include the genitourinary system
The nurse is assessing an older adult client. Which finding should cause the nurse to suspect the client has Parkinson disease (PD)? (Select all that apply.) A.The client's BP increases when the client stands up. B.The client has hand tremors at rest. C.The client has slurred speech. D.The client's facial expression shows no emotion. E.The client does not remember what he ate for breakfast.
B, C, D, E. causes slowed movements, including slurred speech. Tremors at rest very common & easy to ID. Tremors occur in hands, face, neck, lips, tongue & jaw. PD causes frozen, mask-like expression (lack of affect). Memory loss occurs because of loss of neurons & other changes in the brain. Client may develop dementia. Postural hypotension is common manifestation in clients c PD. This is caused by damage to ANS
The nurse conducts discharge planning for a client diagnosed with MS. Which intervention should the nurse include? (Select all that apply). A.Arrangement for pastoral care consultation B.Teaching of a bladder training program C.Teaching of good body mechanics D.Assessment of home safety E.Instruction for a low fat, low salt diet
B, C, D.
Which intervention should the nurse include in the plan of care for a young client with ADHD? (Select all that apply.) A.Increasing environmental stimulation B.Promoting self-esteem C.Encouraging therapeutic play D.Using time-outs E.Varying consequences for negative behaviors
B, C, D.
A client states, "My HCP says my problem with mobility is with my connective tissues. What are connective tissues?" Which structure should the nurse include in the response? (Select all that apply.) A.Muscle B.Tendons C.Ligaments D. Cartilage E.Bones
B, C, D. Cartilage is flexible connective tissue & is less flexible than muscle but not as stiff as bone. Ligaments connect bones to other bones to form a joint and serve to strengthen and stabilize the joint.
The nurse prepares an educational program on malabsorption disorders for a group of community members. Which ex of this disorder should the nurse include? (Select all that apply.) A.Cirrhosis B.Celiac disease C.Short bowel syndrome D.Lactase deficiency E.Biliary obstruction
B, C, D. Celiac disease is a malabsorption disorder of small intestine in which absorption of nutrients is impaired. lactase deficiency, a malabsorption disorder, body is unable to digest & metabolize lactose. Short bowel syndrome is a malabsorption disorder that results from reduction in length of GI system, which in return reduces amount of time & contact that digesting food has c the absorbing bowel
A pt with inflammation is prescribed naproxen. Which info should the nurse include when teaching about this med? (Select all that apply.) A."This medication increases the risk for infection." B."Take this medication with food or milk." C."This medication might interact with diuretics." D."Watch for bleeding or bruising while on this medication." E."Do not abruptly discontinue this medication."
B, C, D. Naproxen is an NSAID. NSAIDs can cause gastric upset, so they should always be taken c food or milk. They also increase clotting time, so pts should watch out for bleeding or bruising. NSAIDs may interact c diuretics, causing a decrease in the effectiveness of the NSAID. Glucocorticoids increase risk for infection & should not be stopped abruptly.
The nurse is teaching older adults with OA actions to effectively manage chronic pain. Which recommendation should the nurse include? (Select all that apply.) A.Limiting isometric exercises to reduce strain on the joints B.Teaching proper posture & good body mechanics for activities of mobility C.Encouraging resting painful joints D.Applying cool compresses to painful joints to reduce inflammation E.Using firm support in chairs & mattresses to properly align the body
B, C, E. Chronic pain associated c OA. When joints painful, they should be rested, balanced c periods of activity to reduce stiffness. Using proper posture & good body mechanics places body in proper alignment & offers joints neutral platform to perform ROM. Firm chairs & mattresses assist body in proper alignment. Heat should be applied to joints, which will increase joint mobility. Cool compresses may increase joint pain & limit joint mobility. Isometric exercises strengthen muscles, Strong muscles will reduce strain on joints.
Which instruction should the nurse include when teaching parents strategies to enhance communication with a child diagnosed with ASD? (Select all that apply.) A.Using complex words to stimulate the child's vocabulary B.Using pictures, computers, or other visual aids C.Considering using sign language D.Speaking loudly E.Using short, direct sentences
B, C, E. Clients with ASD have impaired communication skills. Strategies to improve communication include using short, direct sentences that are easy to understand, supplementing verbal communication with the use of pictures, computers, or other visual aids, and using sign language.
The nurse is providing teaching about home care for a client with OA of the knees. Which info should be included? (Select all that apply.) A.Continuing activity with repetitive movement B.Using assistive devices to minimize stress placed on affected joint C.Installing handrails in the bathroom D.Encouraging heavy lifting to maintain muscle strength E.Taking pain medications as ordered
B, C, E. Taking pain meds as ordered will assist c pain management & allow pt to participate in daily activities. Installing handrails is info that should be included when educating to keep client safer during adls at home. educate client on the importance of using assistive devices to minimize joint stress. instruct client to avoid repetitive movement & to avoid heavy lifting, because these actions will increase pain & joint degeneration
The nurse admitting a child who is suspected of having ASD knows that it is necessary to rule out medical causes for their behavior before diagnosing ASD. Which diagnostic test should the nurse anticipate will be ordered? (Select all that apply.) A.ABG B.DNA analysis C.CT scan D.KUB x-ray E.Electroencephalography
B, C, E. To rule out medical causes for behavior in a suspected ASD pt, HCP should order a CT scan, MRI, DNA analysis, lead screening & electroencephalography. KUB x-ray is a radiograph of the kidneys, ureters, and bladder.
The nurse is reviewing the care needs for a client with a malabsorption disorder. Which should the nurse closely monitor? (Select all that apply.) A.Frequency of getting out of bed B.Dietary records C.Laboratory results D.Speech ability E.Mental status
B, C. Accurate dietary records are needed to eval adherence to prescribed diet & adequacy of nutrient intake. Lab results are monitored to confirm nutritional status & guard against development of secondary conditions like anemia. Mental status changes are part of the nursing assessment but not specifically related to malabsorption issues. Speech & mobility issues are not directly related to nutrition.
The nurse taught a client about ways to prevent alterations in mobility. Which client behavior indicates that the teaching has been effective? (Select all that apply.) A.Client applies ice to inflamed joints twice a day B.Client walks every day for 30 minutes C.Client consumes fresh fruits and vegetables every day D.Client smokes a half pack of cigarettes per day E.Client drinks milk with every meal
B, C. E. best way to avoid an alteration in mobility is to prevent the development of musculoskeletal disorders. Prevention strategies include good nutrition, adequate calcium intake, and regular exercise.
The nurse admits a client suspected of having MS. Which diagnostic test should the nurse expect to be ordered? (Select all that apply.) A.Cystoscopy B.Lumbar puncture C.Magnetic resonance imaging (MRI) D.Electrocardiography E.Colonoscopy
B, C. MRI & lumbar puncture are diagnostic tests that are useful in diagnosing MS. MRI is used to detect presence of lesions in CNS that indicate demyelination
The nurse evaluates the care of a client diagnosed with MS. Which assessment should the nurse perform? (Select all that apply.) A.Bowel sounds B.Emotional stability of the client C.The progression from relapsing-remitting MS to primary-progressive MS D.Need for assisstive devices E.Presence of complications
B, D, E.
The parents state that the behavior of a child with ADHD is creating stress for the environment in their home. Which suggestion should the nurse encourage the parents to consider to minimize this stress? (Select all that apply.) A.Allow the child to listen to music during study time. B.Make a schedule for bedtime, meals, and recreational activities. C.Allow the child as many choices as possible to decrease conflict in the home. D.Provide appropriate rewards when the child meets expected behavior. E.Set boundaries and consequences.
B, D, E. Boundaries & consequences should be set. When the child meets expected behaviors, appropriate rewards such as playing outside or riding a bike for 30 min should be allowed to continue to reinforce positive behaviors. providing a schedule of activities, meals, & bedtime will provide structure
The nurse is teaching the family of a client diagnosed with ASD about a gluten-free and casein-free diet. Which food should the nurse include? (Select all that apply.) A.Cheese B.Grilled salmon C.Yogurt D.Cornmeal E.Soy milk
B, D, E. Gluten-free & casein-free diet eliminates wheat & dairy. Foods that support a gluten-free & casein-free diet include cornmeal, grilled salmon & soy milk.
The nurse is teaching a group of parents about ADHD. Which psychosocial history consideration should the nurse include when addressing this group? (Select all that apply.) A.High self-esteem B.Ostracized by peer group C.Viewed as overachiever D.Excessive talking E.Interrupts others
B, D, E. Hyperactivity, impulsivity, & inattentiveness in the client c ADHD often manifest as excessive talking & interruption of others. Because of these disruptive behaviors, clients c ADHD are also often ostracized by their peer group & have low self-esteem. ADHD can cause difficulty at school & work, so clients are often viewed as underachievers
The nurse is teaching a client diagnosed with MS about the factors that may precipitate a relapse. Which factor should the nurse include? (Select all that apply.) A.Constipation B.Fatigue C.Acetaminophen use D.Stress E.Increases in body temperature
B, D, E. While there are no common triggers for relapses in MS, several factors such as stress, fatigue, and increases in body temp may influence a relapse.
Which med should the nurse expect to find on the med administration record (MAR) for a child with autism spectrum disorder (ASD)? (Select all that apply.) A.Beta blocker B.Mood stabilizer C.Angiotensin-converting enzyme (ACE) inhibitor D.Stimulant E.Selective serotonin reuptake inhibitor (SSRI)
B, D, E. While there is no medication to cure ASD, meds are prescribed to manage behaviors and symptoms. These meds include stimulants, SSRIs & mood stabilizers.
A client with inflam asks about foods or supps that can reduce inflammation. Which nutrient should the nurse list as being beneficial to the client? (Select all that apply.) A.Saturated fats B.Probiotics C.Foods rich in cholesterol D.Omega-3 fatty acids E.Antioxidant vitamins
B, D, E. anti-inflammatory diet consists of foods high in omega-3 fatty acids, antioxidant vits, & probiotics. Pro-inflammatory foods contain saturated fats, cholesterol, & a high glycemic index.
A client is diagnosed with several fractures of the axial skeleton. Which bone fracture should the nurse anticipate providing care for in this client? (Select all that apply.) A.Arm B.Vertebra C.Femur D.Ribs E.Lower leg
B, D. axial skeleton is made up of the ribs, sternum, vertebral column, and skull. The appendicular skeleton is made up of the pectoral girdles, upper limbs, pelvic girdle, and lower limbs.
Which recommendation should the nurse make to a client with PD who reports constipation? (Select all that apply.) A.Decreasing fluid intake B.Increasing fiber intake C.Limiting exercise D.Decreasing fiber intake E.Increasing fluid intake
B, E.
A client with celiac disease is prescribed a corticosteroid. Which info should the nurse provide when teaching about this medication? A.Take the medication first thing in the morning. B.Do not stop taking the medication abruptly. C.Take the medication with milk. D.Discontinue the medication if any side effects occur. E.Take the medication with food.
B, E. If corticosteroids have been prescribed, stress the importance of taking the med as prescribed. Oral cortisone can cause stomach ulcers & should not be taken on an empty stomach. Emphasize importance of not stopping the med abruptly.
The nurse is preparing to teach about the manifestations of MS to a client newly diagnosed with the disease. Which manifestation should the nurse include in this teaching? A.Frequent dry cough B.Difficulty chewing C.Fever D.Hypertension
B.
The nurse administers an IV antibiotic to a client experiencing a complicated infection. 5 min later the client reports chest pain, coughing, and itching. Which action should the nurse implement first A.Slow down the infusion rate. B.Discontinue the infusion. C.Administer an antihistamine. D.Notify the healthcare provider.
B. 1st step would be to discontinue the infusion, but leave the IV in place. Once the infusion has been d/c, the nurse should notify the HCP & be prepared to administer an antihistamine, such as diphenhydramine (Benadryl) or adrenergic agonist, such as epinephrine.
A client diagnosed with RA is scheduled for surgery to stabilize the client's cervical spine. For which type of surgery should the nurse expect to receive preoperative orders? A.Hysterectomy B.Arthrodesis C.Synovectomy D.Arthroplasty
B. An arthrodesis is a joint fusion surgery. It is performed to stabilize joints such as the cervical vertebrae, wrists, or ankles.
Which nursing diagnosis is appropriate for the nurse to assign to a client diagnosed with RA A.Gastrointestinal Motility, Dysfunctional B.Body Image, Disturbed C.Gas Exchange, Impaired D.Pain, Acute
B. Because of the joint deformities, clients diagnosed with RA often have a disturbed body image. RA produces chronic pain, not acute pain.
A client diagnosed with MS tells the nurse about exploring complementary health practices to help deal c the MS. Which health practice should concern the nurse most? A.Therapeutic horseback riding B.Bee venom therapy C.Low-dose naltrexone D.Acupuncture
B. Bee venom therapy carries more risk (due to anaphylactic shock). Therapeutic horseback riding & acupuncture have low risk & may be beneficial for some clients & for some symptoms. Low-dose naltrexone has been shown to improve quality of life, but has no impact on physical symptoms.
A nurse is preparing a presentation on PD for a health fair at a local community center. Which info should the nurse include A.Parkinson disease is the result of an infection. B.Parkinson disease usually affects people older than the age of 60 years. C.Parkinson disease is inherited in over 50% of those affected. D.Parkinson disease affects both men and women at the same rate.
B. Cause of PD is not known. There is no evidence of an infection that causes PD. It is inherited in only 15-25%of cases. PD affects men more than it does women. PD is more common in people over 60. It can also occur in younger people, but is less common.
The nurse observed a client with PD frequently wiping their mouth c a handkerchief. After the nurse requested a prescription for an anticholinergic med from the HCP, the client asked, "I feel better, why do I need another med?" Which response by the nurse is correct? A."It helps dopamine work better." B."It will help reduce tremors and uncontrolled drooling." C."The healthcare provider thinks it will help your symptoms." D."It will make you feel better."
B. Client stated that they are feeling better. It is levodopa, not an anticholinergic that will make dopamine work better. Stating the HCP thinks it will help c the client's symptoms is a incomplete answer. To give a complete response, state that an anticholinergic reduces tremors & uncontrolled drooling.
The nurse is teaching the parents of a client with ADHD about the prescribed medication methylphenidate (Ritalin). Which statement from the parents reflects an understanding of the med regimen? A."We should observe for excessive sleepiness during the day." B."We can stop giving the medication during the summer." C."The medication can be given any time of the day." D."We should restrict calories due to possible weight gain."
B. Clients on stimulant meds go on a drug holiday during the summer breaks. Clients who are on stimulant meds can experience insomnia and anorexia; thus, calories would not be restricted.
client diagnosed c MS asks whether woodworking & carving objects can still be done as a hobby. Which response by the nurse is correct A.Having client remember and describe how all previous projects were assembled B.Assisting client in identifying modifications that may be needed C.Advising client to increase intricate patterns of work D.Tell pt to continue to use all the woodworking tools as before
B. Continuing a long-standing hobby is possible. The client will need help to assist with some planned modifications. visual blurring of MS combined with spasticity would make working on intricate patterns difficult.
The nurse is caring for a client with severe systemic inflammation. Which medication should the nurse expect to find listed on the client's medication administration record (MAR)? A.Regular insulin B.Dexamethasone C.Sumatriptan D.Esomeprazole
B. Dexamethasone is a glucocorticoid, a steroid used in the treatment of severe inflammation
A client newly diagnosed with Parkinson disease asks the nurse, "What does dopamine do in the brain?" Which is the most appropriate response? A."Dopamine stimulates the neurons to transmit sensory and motor impulses." B."Dopamine helps maintain coordinated motor movement." C."Dopamine enhances the action of acetylcholine." D."Dopamine causes spinal cord neurons to transmit impulses."
B. Dopamine is responsible for coordination. It balances the neurotransmitter acetylcholine, which stimulates the neurons. Dopamine prevents this stimulation from becoming excessive. Dopamine provides regulation rather than stimulation - regulation of motor neuron impulses & balances acetylcholine
The nurse caring for a client diagnosed with MS identifies a goal of promoting self-care. Which intervention should the nurse include? A.Teach the client to limit fluid intake. B.Encourage the client to wear arm or wrist braces. C.Encourage the client to take responsibility for all food preparation duties. D.Teach the client to perform self-care activities at the end of the day.
B. Encouraging the client to wear or use assistive devices as necessary promotes independence. Wearing arm or wrist braces provides stability during self-care activities
HCP of an older adult client with advancing Parkinson disease suggested that the client start an exercise regime. Which exercise should the nurse recommend? A.Football B.T'ai chi C.Running D.Weight lifting
B. For a client with PD, an exercise regime that promotes balance and walking is the best. So, the nurse may recommend t'ai chi.
The nurse prepares to administer dexamethasone to a client with DM experiencing inflammation. For which side effect should the nurse monitor in the client? A.Hypotension B.Hyperglycemia C.Hyperkalemia D.Increased temperature
B. Glucocorticoids can elevate blood sugar. When giving the med to clients c diabetes, the nurse should monitor for hyperglycemia. Other potential side effects include hypokalemia, HTN & signs of heart failure
A client presents with double vision & increasing weakness in the lower extremities. Which additional info should lead the nurse to expect that diagnostic testing for MS will be ordered? A.The client reports pain in the lower back for the past few days. B.The client reports previous episodes, each lasting 1-day, and then no problems for at least 1 month. C.The client reports increasing manifestations over the past week. D.The client reports episodes of rapid heart rate during periods of weakness in the lower extremities.
B. MS can cause episodes lasting for more than 24 hours, and the episodes occur more than 1 month apart.
A pregnant client is diagnosed with an inflammatory disorder. Which disorder should the nurse monitor for in the client? A.Placenta previa B.Preeclampsia C.Preterm birth D.Low-birth-weight infant birth
B. Preeclampsia. Preeclampsia is an inflammatory-mediated hypertensive disorder of pregnancy.
The nurse administers a vaccine to a child. The nurse should instruct the parent to observe for which sign that may indicate a systemic reaction? A.Pain at the injection site B.Irritability C.Redness or swelling D.Induration
B. Signs of a systemic reaction can include fever, fussiness or irritability, malaise, or loss of appetite. Some vaccines may cause a rash or arthralgia. A local reaction can cause pain, redness, swelling, or induration at injection site.
The nurse formulates the plan of care for a client diagnosed with MS. The client stays up late at night, takes long hot showers, sleeps in a cool bedroom, loves fresh air all year round, and naps after lunch. Which lifestyle changes should the nurse suggest for the client? A.Keeping night hours B.Turning down the shower's temperature C.Eliminating the post-lunch nap D.Turning the bedroom heat off and opening the windows
B. Temp extremes should be avoided by the client with MS, so the client should have a warm, not hot, shower. A heated bedroom with closed windows might help with MS symptoms
The nurse is caring for a client with PD who reports problems with stiffness & ability to move. Which action by the nurse will address the client's mobility? A.Advise bedrest for muscle recovery B.Recommend a regular exercise routine and walking C.Ask the client if they know about the meds to treat the stiffness
B. The best way to promote mobility in the client with PD is to recommend the client ambulate daily and exercise on a regular basis. Bedrest would only make the stiffness worse.
The nurse is caring for an adolescent client newly diagnosed with ADHD. Which nursing dx should the nurse prioritize for this client? A.Mobility: Physical, Impaired B.Injury, Risk for C.Pain, Chronic D.Development: Delayed, Risk for
B. The client with ADHD is at increased risk for injury because the impulsivity and inattentiveness seen with this disorder are risk factors for antisocial behavior, substance abuse, and serious accidents.
The daughter of an older adult client with advancing PD tells the nurse that they need to dress their mother each morning, because the mother is "not fast enough." Which is the most appropriate response from the nurse? A."Can you let her dress herself? B."It is best for you to let your mother dress herself for as long as she can." C."That is really quite normal." D."It is important for you to get to work on time."
B. The nurse should tell the caregiver that, by allowing independence in dressing, the client will have an improved sense of well-being and lessened depression.
The nurse is caring for a client with asthma who is recovering from an acute exacerbation. Which complementary and alternative therapy should the nurse teach this client to begin after hospitalization? A.Daily use of a maintenance inhaler B.Daily vitamin C C.Weekly use of a steroid inhaler D.Weekly gene transfer therapy
B. Vit A, C, D, and E regimens and plant-based therapies have all been studied for their efficacy as immune stimulants and have shown varying degrees of effectiveness in the tx of asthma & inflammatory diseases.
The family of an older adult client tells the nurse that they want their mother to remain as active as possible for as long as possible. Which instruction should the nurse provide? (Select all that apply.) A.Adequate rest and sleep B.Daily stretching C.Adequate calcium intake D.Good nutritional intake E.Regular exercise
C, D, E. best way to avoid an alteration in mobility is to prevent the development of musculoskeletal disorders. Prevention strategies include good nutrition, adequate calcium intake, and regular exercise
A client has been diagnosed with relapsing-remitting MS. Which statement by the nurse most accurately explains to the client the onset of symptoms with this type of MS? A."Symptoms will not develop for at least several years after DX." B."Symptoms will flare up at times, with periods of partial or complete remission." C."Symptoms will become progressively worse c periods of flare-ups." D."Symptoms will develop slowly, but continuously with no periods of remission."
B. c relapsing-remitting MS will experience periods of flare-ups followed by periods of partial or complete remission. pts experience slow but continuous worsening of disease c no remissions c primary-progressive MS. pts experience progressive worsening of disease c periods of flare-ups c progressive-relapsing MS. Symptoms of MS typically develop immediately, not several yrs after dx.
The nurse is caring for a client who can bear weight but has a weak limb. Which assistive device is the most appropriate for this client? A.Wheelchair B.Crutches C.Cane D.Walker
C
Which type of therapy is used to manage problems with eating & swallowing? A.Physical B.Occupational C.Speech D.Nutritional
C
Which modifiable risk factor can affect the development of autoimmune diseases and requires specific teaching? (Select all that apply.) A.Race B.Gender C.Chronic stress D.Alcohol, drug, and cigarette use E.Early introduction of solid foods
C, D, E.
The nurse is performing a health history of a client diagnosed with MS. Which data should the nurse gather? (Select all that apply.) A.Reflex assessment B.Cranial nerve assessment C.Exposure to environmental hazards D.Factors that affect symptoms E.Onset of symptoms
C, D, E. : When performing a health HX on a client with MS, the nurse needs to obtain info about factors that affect symptoms, onset of symptoms, & exposure to environmental hazards. Cranial nerve and reflex assessment are part of the physical exam.
Which is characteristic of ADHD? (Select all that apply.) A.Acetylcholine deficit in some children B.Impulsivity persists in adults C.Linked to heredity D.Often persists into adulthood E.Linked to exposure to excess lead
C, D, E. ADHD characterized by inattention, hyperactivity & impulsivity. Exposure to excess lead can contribute to development. There is a strong link between heredity & development of ADHD. 30-70% of ADHD cases persist into adulthood. Hyperactivity and impulsivity often improve as client gets older, C inattentiveness becoming most persistent characteristic in adults
Which surgical tx should the nurse anticipate may be offered to clients with osteoarthritis who cannot be managed with traditional tx? (Select all that apply.) A.Cortisone therapy B.Serum hyaluronic acid C.Joint fusion D.Osteotomy E.Arthroplasty
C, D, E. Arthroplasty, osteotomy, & joint fusion are all surgical interventions for a client with osteoarthritis. Serum hyaluronic acid is a diagnostic blood test for knee osteoarthritis and is not a surgical TX. Cortisone therapy is not a surgical TX; it is injected into the joint.
Which intervention should the nurse teach the parents of a school-age client with ADHD? (Select all that apply.) A.Asking the healthcare provider to provide drug holidays every other week B.Giving time-outs only for the worst negative behaviors C.Maintaining a consistent bedtime routine and time D.Turning off the television when the client is doing homework E.Praising all positive behaviors
C, D, E. Children with ADHD do best with structured & consistent routines, which include maintaining a consistent time & routine for bedtime and praising all positive behaviors. Reducing environmental stimuli by turning off the TV will also help. To reduce stimulant abuse, drug holidays during weekends & school breaks,
The nurse is assessing a client with PD. Which factor should the nurse include in the assessment? (Select all that apply.) A.Dizziness when sitting B.Difficulty waking C.Cognitive deficits D.Bowel changes E.Response to medication
C, D, E. Postural hypotension is common in Parkinson disease, resulting in BP that drops when the client stands up, not while sitting.
The nurse admits a client to the hospital who is suspected of having RA. Which diagnostic test should the nurse expect to be ordered for the client? (Select all that apply.) A.Renal function test B.Antinuclear antibody (ANA) test C.C-reactive protein (CRP) levels D.Erythrocyte sedimentation rate (ESR) E.Kidney biopsy
C, D. Lab tests used to DX RA include C-reactive protein (CRP) levels and erythrocyte sedimentation rate (ESR), which are nonspecific inflammatory markers
A parent is not convinced that a gluten-free diet is required for a child with celiac disease. Which risk factor should the nurse review with the parent? (Select all that apply.) A.Hydrocephalus B.Mood disorders C.Risk for GI cancers D.Growth retardation E.Kidney failure
C, D. Reinforce that discontinuing the diet in kids increases risk for growth retardation & GI cancers in adults. The intestine cells become damaged & this causes poor absorption of nutrients which leads to issues of growth. Cont. ingestion of gluten in celiac pt leads to development of a mass of tissue that alters make up of the organ that it emerges from - causing an opportunity for intestinal cancer
The nurse prepares teaching for a client with lactose intolerance. Which food should the nurse instruct this client to avoid? (Select all that apply.) A.Spinach B.Beans C.Cream soups D.Eggs E.Cottage cheese
C, E.
The mother of a 10 YO is pleased to hear that the child's blood work for inflammation was negative but asks why the child continues to have symptoms. Which response is the most appropriate? A."The level of inflammation has subsided." B."Blood tests are not useful to diagnose the presence of inflammation." C."Normal results are common in children with inflammation." D."The child is experiencing a mild case of inflammation."
C. "Normal results are common in children with inflammation." Caution must be taken when interpreting results of blood tests for these clients since normal blood test results are common for children c inflam disorders. A normal blood test in a child c inflammation does not mean that the level of inflam has subsided, or that the child is experiencing a mild case of inflam
Which clinical manifestation would be required to confirm the diagnosis of Parkinson disease? A.Tremor at rest and flaccidity B.Rigidity only C.Tremors at rest and bradykinesia D.Bradykinesia only
C. A diagnosis of PD requires presence of 2 of the 3 cardinal manifestations: tremor, rigidity, & bradykinesia. Tremors at rest and bradykinesia are two of the cardinal signs. Bradykinesia alone would not be diagnostic.
The parents of a school-age child newly diagnosed with ADHD ask why the child needs a physical in addition to exams made at home and at school. Which response should the nurse make? A."The healthcare provider will be able to give you better strategies for helping your child focus at home and at school." B."We need to see whether your child has physical characteristics that go along c the behaviors of ADHD to correctly diagnose ADHD." C."We need to rule out neurologic diseases and other health problems in your child that may affect treatment of ADHD."
C. A physical exam will rule out neurologic diseases and other health problems that may mimic ADHD or affect its treatment. There are no physical characteristics of ADHD that can be found with a physical exam
The nurse is discussing the client's symptoms of decreased bowel motility and a newly prescribed med with the client. Which classification of meds should the nurse review with the client? A.Antibiotics B.Antiemetics C.Antidiarrheals D.Anticholinergics
C. Antidiarrheal meds can reduce bowel motility, allowing more time for nutrient absorption.
An older adult client was diagnosed with PD 3 months ago. Since the DX, the client has not gone out of the house. Which statement by the nurse is most appropriate? A."You need to start getting out." B."Getting out of the house will help you to feel less depressed." C."Can I ask why you aren't going out of the house?" D."Tell your family to come and take you out of the house."
C. Asking an open-ended question & inquiring about the reason why the client is not going out of the house will encourage client to discuss & share info. Advising the client about going out, telling the client that they will feel better by going out, or involving the family will not encourage the client to discuss the reason behind staying at home.
The nurse working at a flu clinic should not administer the flu vaccine to which client? A.A client with an immune deficiency B.A pregnant woman C.A client with an egg allergy D.A 10-year-old boy
C. Clients who are allergic to any component of the inactivated flu vaccine, including egg protein, should not receive the flu vaccine.
Which resource should the nurse expect the healthcare provider to use to confirm the diagnosis of autism spectrum disorder (ASD)? A.The Mental Health Rights Manual B.Teaching Social Communication to Families with Autism C.Diagnostic and Statistical Manual of Mental Disorders D.The Autism Handbook
C. Criteria for DX can be found in the American Psychiatric Association's Diagnostic & Statistical Manual of Mental Disorders, 5th edition (DSM-5), which includes screening tests to ID tendencies consistent with ASD.
The nurse is performing a physical exam on an older adult pt to screen for immune system abnormalities. Which factor should the nurse keep in mind while performing the assessment? A.It may be necessary to palpate c a great deal of pressure because of the loss of sensation experienced by the elderly B.Cartilage loss is an abnormal finding and can indicate an aggressive cancer. C.Older adult clients may be fatigued easily and should rest frequently during the assessment. D.Older adults naturally have less flexibility and ROM in the joints.
C. Fatigue is common in the older adult client, but severe fatigue may indicate the presence of an acute or chronic illness or immunodeficiency
The nurse is reviewing the history and previous charting on a client admitted for a bowel resection. When should the nurse be most concerned about fluid loss in this client? A.Forty-eight hours postoperation B.Prior to surgery C.The first 24-hour period postoperation D.During the procedure
C. Fluid losses are generally greatest in the initial periods after surgery, so the closest attention is warranted at that time.
A client newly diagnosed with RA tells the nurse, "I understand that RA affects my joints. Does it have any other effects on my body that I should know about?" In response, which additional effect of RA should the nurse include? A.Liver failure B.Headaches C.Stomach ulcers D. Anemia
D. RA often causes anemia that is resistant to iron therapy
The mother of a teen female recently diagnosed with ADHD tells the nurs, "Our daughter has a male cousin who has ADHD, but he doesn't act anything like her." Which response should the nurse make to explain the difference? A."Girls c ADHD show fewer language problems than boys c ADHD." B."Girls cADHD tend to show more aggression than boys c ADHD." C."Girls c ADHD tend to show less impulsiveness than boys c ADHD." D."Girls with ADHD tend to be diagnosed earlier than boys."
C. Girls with ADHD tend to show less aggression and impulsiveness than boys with ADHD. However, girls show more anxiety, mood swings, social withdrawal, rejection, and cognitive and language problems. Girls are usually older, than boys at the time of DX.
The nurse is caring for an older client whose C-reactive protein test is elevated. Which interpretation should the nurse derive from this result? A.The result is an indication that the client has asthma. B.The client is suffering from gallbladder disease. C.The increased result may be an indicator of overall poor health. D.The client probably has suffered a stroke.
C. In older adults, C-reactive protein (an inflammatory marker) may be an indicator of overall poor health, which makes them more susceptible to chronic illnesses and cognitive decline
A client with RA states, "My disease is normally well controlled with a regimen of meds and TXs. However, I'm experiencing a flare-up of the disease in the right knee." Which collaborative intervention should the nurse expect to implement? A.Hydroxychloroquine administration B.Oral gold salts administration C.Intra-articular corticosteroid injection D.Sulfasalazine administration
C. Intra-articular corticosteroid injections are effective in treating local disease flare-ups without having to change overall drug regimen. Sulfasalazine is used when the Pt is not responsive to other meds & is associated with toxic reactions. Hydroxychloroquine requires 3-6 months of therapy to see results; therefore, it is not useful in treating local flare-ups of the disease
A client with multiple sclerosis reports difficulty walking. Which collaborative therapy should the nurse request? A.Cognitive therapy B.Speech therapy C.Physical therapy D.Occupational therapy
C. PT helps clients with walking, strength, & balance issues. OT enhances independence and activities dealing with ADLs. Speech therapy is used for speech or swallowing problems.
The nurse is teaching an older adult recently diagnosed with osteoarthritis (OA) about interventions to help maintain mobility of the joints. Which should the nurse include? A.Glucosamine and chondroitin supplements B.Jogging three times a week C.Physical therapy D.Routine nonsteroidal anti-inflammatory drug (NSAID) use
C. PT is particularly important for older adults c OA to help maintain or improve joint mobility. NSAIDs should generally not be used by older adults due to risks associated c their use. Older adults should use acetaminophen as 1st-line drug & narcotics as 2nd
A young woman with MS is planning to get pregnant. She asks the nurse, "What are the risks?" Which response is correct? A."Pregnancy may cause your disease to progress faster." B."You should plan to have difficulty getting pregnant." C."The drug treatment you are on may be harmful to the fetus." D."You may have exacerbations during your last trimester."
C. Pharm TX of MS involves drugs that may be harmful to a fetus. Evidence suggests that pregnancy does not influence overall course of disease, & MS does not affect a woman's ability to become pregnant. Pregnant women are usually protected from exacerbations during 2nd & 3rd trimester,
The nurse instructs a client diagnosed with RA about the use of splints to reduce strain on joints. Which instruction is most important for the nurse to include in the teaching? A."The best way to splint your hip is to lie supine on a bed." B."Splints should be put on only during the day." C."Splints should be made of lightweight materials." D."Be sure to remove the splints twice a week."
C. Splints should be made of lightweight materials that are easy to remove. Splints should be removed once or twice a day to perform ROM exercises. Night splints are often used on the hands & wrists. The best way to splint a hip is to lie prone for several hrs on a firm bed.
An adult client with ADHD is being prescribed medication. About which med should the nurse prepare teaching for this client? A.Methylphenidate (Ritalin) B.Guanfacine (Intuniv) C.Atomoxetine (Strattera) D.Dextroamphetamine (Adderall)
C. The nonstimulant med atomoxetine (Strattera) is used for children over age 6, adolescents & adults to control symptoms of ADHD. Stimulants like dextroamphetamine & methylphenidate are approved for use in adults; however, there is a higher risk of adverse effects on the cardiovascular system.
The nurse is caring for a client who reports difficulty breathing and severe itching after receiving a flu vaccination. Which med should the nurse anticipate administering to this client? A.Antipyretic B.Anti-inflammatory C.Sympathomimetic D.Antibiotic
C. This is a severe allergic reaction, and the nurse will prepare a sympathomimetic agent for administration.
The nurse is assessing an older adult who has OA. Which finding indicates the impact of OA? A.Sitting in a soft chair and not getting up to greet the nurse B.Asking the nurse to retrieve items from across the room C.Leaning on furniture while walking D.Requesting a dose of acetaminophen to address joint pain
C. When assessing the client c OA, the nurse should observe how the client moves & ambulates. Noting that the client leans on furniture while walking indicates possible issues related to the OA
32 YO who has limited hip joint damage from OA asks the nurse why an osteotomy is being performed rather than other procedures. Which response provides the most accurate info? A."This procedure is usually tried first; arthroplasty will be done later if this does not work." B."An osteotomy is much less invasive than all of the other procedures." C."This procedure can be done since you are young and healthy and your hip damage is limited." D."This procedure prepares you for joint resurfacing and a total hip replacement later in life."
C. osteotomy is performed to realign joint or to shift joint load toward areas of less cartilage damage. It is used instead of joint replacement surgery if client is young, healthy, & damage is limited to only one side of joint.
The nurse is teaching the parents of a very young client newly diagnosed c ADHD about newly prescribed med methylphenidate (Ritalin). Which instruction should the nurse include? A.Give the medication prior to going to bed at night. B.Restrict the amount of calories that the client eats each day. C.Give the medication first thing in the morning. D.Observe the child for excessive sleepiness.
C. parents should give the med 1st thing in the morning to ensure attentiveness & alertness during the day at school. This med should not be given at bedtime because it can cause insomnia. client should be observed for insomnia, rather than excessive sleepiness. client should be encouraged to consume an adequate amount of calories because it can cause anorexia.
Which type of exercise should the nurse implement to maintain the strength of a limb with an immobilized joint? A.Resistive exercise B.Passive exercise C.Range-of-motion exercise D.Isometric exercise
D
The nurse admits a client suspected of having nerve probs. Which diagnostic test should the nurse expect the hcp to order? (Select all that apply.) A.Dual-photon absorptiometry B.Peripheral bone density C.Dual-energy x-ray absorptiometry D.Electromyography E.Nerve conduction studies
D, E.
Nurse is performing passive ROM exercises for a client c PD. Which nursing goal does this intervention address? (Select all that apply.) A.The client will demonstrate normal bowel elimination patterns. B.The client will participate in occupational therapy to integrate assistive devices for self-care. C.The client will participate in speech therapy for swallowing and verbal communication. D.The client will remain free from injury. E.The client will participate in physical therapy to improve walking and balance.
D, E. Physical therapy, including passive range of motion (ROM) exercises, will improve the client's walking and balance. This in turn helps prevent injury from falls
The nurse is planning care for a client who is diagnosed with ASD. Which goal is appropriate for the nurse to include? A.The client will demonstrate negative communication skills. B.The client will remain free from infection. C.The client will engage in private activities to stimulate learning. D.The client will display developmental progress.
D. A appropriate goal when providing care to a client diagnosed with ASD is for the client to display developmental progress. Other appropriate goals: remaining free of injury, demonstrating positive communication skills, participating in activities with family members or small groups of peers.
A client who is HIV-positive presents with a low T-cell count and requires a blood transfusion. Which type of blood should the nurse anticipate administering? A.A client with HIV should receive blood products with added immunoglobulin. B.A client with HIV should receive standard blood products. C.A client with HIV should not receive a blood transfusion. D.A client with HIV should receive cytomegalovirus-negative, irradiated blood products.
D. A client with a T-cell deficiency should receive blood products that are CMV negative & irradiated due to the risk of infection a & graft-versus-host disease. An individual with a T-cell deficiency can receive a blood transfusion, just not with standard blood products.
The nurse is assessing a toddler client for an upper resp infection. The nurse suspects the child may have autism spectrum disorder (ASD). Which behavior caused the nurse's suspicion? A.Speaking to the nurse in sentences B.Crying after the administration of immunizations C.Playing with the other children and toys while awaiting the nurse D.Having a tantrum when touched by the nurse
D. An assessment finding that supports the DX of ASD is having a tantrum when touched by the HCP. It is not uncommon for the child with ASD to display an inability to attend and systematize situational reactions.
The nurse is teaching a client who has recently been diagnosed with lactose intolerance. Which dietary supp should the nurse reinforce that the client should take, as prescribed? A.Folic acid B.Vitamin B12 C.Vitamin C D.Calcium
D. Because of the inability to properly absorb dairy products, this client should be encouraged to take calcium supps as prescribed.
The nurse prepares teaching on the lactose tolerance test for a client with suspected lactose intolerance. Which substance should the nurse explain is measured with this test? A.Gastric lactose levels B.Oral lactase levels C.Exhaled hydrogen levels D.Blood glucose levels
D. Blood glucose is measured as part of the lactose tolerance test. Lactose solution is orally ingest - if lactase is NOT present - ingested lactose will NOT be digested into glucose.
A client who is recovering from a spontaneous arm FX is prescribed a calcium supp. Which info is most appropriate for the nurse to explain about the relationship between calcium and bone strength? A."Calcium helps breakdown of bone tissue." B."The thyroid gland works to make calcium." C."Calcium fills in the spaces caused by the fracture." D."The body will break down bone if calcium levels are low."
D. Bone resorption is process where bone is broken down & minerals are released into bloodstream. Resorption occurs when minerals are needed for other body functions. When Ca levels are low, parathyroid hormone is released to cause osteoclast action or activity that breaks down bone tissue. The breakdown increases blood Ca levels.
Older adult client with PD uses a walker, speaks in a slurred manner c poor articulation, but tries to speak louder to accommodate for this impairment. Client states, "I catch my daughter looking at me angrily sometimes, but she doesn't say anything." Which nursing dx is priority A.Communication: Verbal, Impaired B.Falls, Risk for C.Nutrition, Imbalanced: Less than Body Requirements D.Caregiver Role Strain
D. Cient is making accommodations for preventing falls by using a walker. It is the caregiver's role strain that is the major risk for this client.
A 16 YO client presents with clinical manifestations of juvenile idiopathic arthritis (JIA). Which diagnostic test should the nurse anticipate being ordered? A.Coagulation tests B.Urine cultures C.Electrolyte panel D.Erythrocyte sedimentation rate (ESR)
D. DX of JIA is identified based on a combination of diagnostic tests. Erythrocyte sedimentation rate (ESR) is a lab test that is used as an inflammatory marker for the diagnosis of arthritis
The nurse cares for a client newly diagnosed with inflammation. Which lab test should the nurse expect to be prescribed? A.Hemoglobin and hematocrit (H/H) B.Prothrombin time (PT) C.Serum chemistries D.Erythrocyte sedimentation rate (ESR)
D. ESR is the primary lab test to detect the presence of inflammation. It measures how far the erythrocyte settles in a tube over a period of time. Higher readings indicate inflammation.
The nurse is evaluating teaching provided to a client with chronic inflammation. Which client statement indicates to the nurse that teaching has been successful? A."I ignore the pain until I can't stand it anymore." B."I think it would be best if I just died right now." C."I lie in bed most days." D."I limit doing things that aggravate the pain."
D. For chronic inflam, the client should be instructed to use coping techniques to minimize effects of physical limitations & emotional distress & disease-appropriate methods to reduce impact of the disease on their life
The nurse is performing a focused health HX for a client diagnosed with a herniated disc. Which info is most appropriate for the nurse to include in this history? A.Ethnicity B.Drug use C.Diet recall D.Work and recreational activities
D. Frequent twisting and lifting are significant risk factors for herniated disc, so work and recreational activities should be assessed.
The nurse is caring for a client with celiac disease & explains to the client that gliadin, a fraction of gluten, acts in which way to reduce absorption surface & production of carb-digesting enzymes? A."The affected area of the small intestines becomes edematous." B."An immune-mediated disorder is activated, resulting in increased antibody level and fistula formation." C."The villi of the small intestines become brittle and fragile." D."The activated immune response causes inflammation, resulting in a reduction of functional villi."
D. Gliadin initiates a T-cell-mediated immune response that causes inflammation & loss of villi function in the small bowel, reducing the absorption surface & the secretion of carb digesting enzymes.
A client with eroding cartilage of the left knee asks the nurse why bruising is absent because bruising was present when they injured their knee a few months ago. Which response is accurate? A."This injury damaged the blood vessels." B."Cartilage is eroded because blood vessels are harmed." C."The cartilage has eroded all blood vessels." D."Cartilage does not contain blood vessels."
D. Ligaments & tendons contain blood vessels, but cartilage does not. Because of this, bruising will be absent c cartilage erosion. Previous injury caused a bruise because either ligaments or tendons were injured.
The nurse is providing discharge teaching for a client diagnosed with RA. Which client statement indicates to the nurse that further teaching is required? A."I understand that the medications I am taking work to reduce inflammation." B."I am looking forward to going to physical therapy so that I can improve my mobility." C."I will make sure to perform range-of-motion exercises daily." D."I am so glad that this medication will cure my RA in a few weeks."
D. RA is a chronic disease that has no cure. Treatment is aimed at relieving pain, reducing inflammation, slowing joint damage, and improving the client's well-being
Nurse is observing a teen client c ADHD at home. Which observation should indicate to the nurse that client outcomes have been met? A.The client receives poor grades on homework for not completing assignments as requested. B.The client folds half a basket of laundry and leaves the rest to read a magazine. C.The client talks incessantly, jumping from one topic to another. D.The client receives several text messages from friends and does not respond until after asking permission to do so.
D. Texting is an age-appropriate social interaction for the client. While they can be distracting and can cause the client to lose focus, the client did ask permission before responding, which indicates that the client is controlling impulsivity and inattentiveness.
A 35 YO American Indian female with lactose intolerance asks what foods should be eaten or avoided. Which diet should the nurse recommend to this client? A.High dairy B.High fat C.Low protein D.High calorie
D. The PT has a absorption disorder. nurse should recommend a high-calorie, low-dairy, low-fat, and high-protein diet.
Which is the main pathology of Parkinson disease that causes changes in muscular and sensory function? A.Presence of Lewy bodies B.Reduction of acetylcholine in the brain C.Genetic predisposition D.Reduction of dopamine in the brain
D. The changes in muscular and sensory function in PD are caused by a decreased amount of dopamine in the brain, which in turn increases the amount of acetylcholine.
The nurse is reviewing the medical record of a 6 YO diagnosed with ASD. Which item in the health history should the nurse consider may have been a factor in the client developing ASD? A.Appropriate adaptation to new environments B.Postterm birth C.Childhood vaccinations D.Fetal alcohol syndrome
D. The ingestion of alcohol, tobacco, and toxic substances has been known to cause birth defects. Therefore, fetal alcohol syndrome could possibly be a factor in the development of ASD.
pt c ADHD taking atomoxetine (Strattera) asks about eliminating sugar & taking ginkgo biloba to control it. Which response should be made about complementary & alternative therapies for ADHD? A."You can replace your medication with these alternative txs if you like, but be sure to tell your hcp about them." B."Taking medication isn't really that bad, especially since it is the only effective way to control your symptoms & let you live a normal life." C."Why don't we ask your HCP to prescribe a different med instead of the one you're taking, if you're worried about it?" D."These are popular alternative TXs, but scientific evidence does not consistently support their effectiveness."
D. To date, there is no consistent evidence that elimination diets, dietary supplements, or herbs are effective in treating ADHD
A client with OA asks the nurse how to decrease wrist swelling. Which intervention should the nurse suggest? A.Increasing range of motion exercises for that joint to 3 times a day B.Applying a warm towel to the wrist joint 3x a day for 20 mins C.Encouraging use of assistive devices during daily activities to decrease stress on the joint D.Using compression cold packs to provide a deeper cold to the wrist joint
D. use of deep cold can best help to address swelling. Increasing ROM exercises to 3x a day is not the best approach to decrease swelling; ROM helps maintain flexibility of the joint. Heat decreases pain & increases flexibility; it does not address swelling.
A client with PD complains of increased tremor while eating. Which action should the nurse recommend? A.Liquefying all meals and drinking them through a straw B.Holding a piece of bread in the other hand while eating C.Using their nondominant hand to eat D.Having someone feed them
Holding a piece of bread in the opposite hand or purposeful movement will decrease tremors while eating. The client should be encouraged to eat independently for as long as possible.
The nurse is preparing teaching materials for the parents of a 7 YO who is newly diagnosed with a severe allergy to dust. Which instruction should the nurse include in this teaching? A."Avoid exposure to all animals and pets." B."Remove stuffed toys from the home." C."Place plants on high shelves in the home." D."Ensure that all rooms in the home are carpeted."
b. major strategy to prevent onset of an inflam response is to avoid a known trigger for the response. Clients with a history of hypersensitivity to substances such as dust should avoid them. Stuffed toys accumulate dust and should be removed from the home.
The nurse is caring for a client recently diagnosed with rheumatoid arthritis (RA). Which clinical manifestation found during the nurse's assessment supports the diagnosis of RA? A.Weight gain over the last several months B.Increased energy C.Low-grade fever D.Morning stiffness that lasts for 30 min
c. Clients diagnosed with RA often have a low-grade fever. This finding supports the DX of RA. Wt loss, morning stiffness that lasts more than 1 hr, and fatigue are other symptoms that support this DX
A client diagnosed with osteoarthritis asks the nurse, "If I am losing the cartilage in my knees, why do my knees look larger?" Which response should the nurse give? A."muscle mass is increasing as a result of exercises you must do." B."Although the cartilage is destroyed, you may be building up more bone in the knee." C."Sometimes inflammation increases the size of your knees or fluid buildup occurs." D."Your knees have developed contractures, increasing the size of the knees."
c. inflammation causes swelling of the knee joint, which makes the joint appear larger. Joint effusion or fluid buildup may also occur
