Med Surg Exam 5
A nurse is caring for a client who experienced a cervical spine injury 3 months ago. The nurse should plan to implement which of the following types of bladder management methods? a. Condom catheter b. Intermittent urinary catheterization c. Credé's method d. Indwelling urinary catheter
a
A nurse is providing teaching for a client who has a history of low back injury. Which of the following instructions should the nurse give the client to prevent future problems with low back pain? (select all that apply) a. Engage in regular exercise including walking b. Sit for up to 10 hr each day to rest the back c. Maintain weight within 25% of ideal body weight d. Create a smoking cessation plan e. Wear low-heeled shoes
a,d,e
During assessment of the patient with trigeminal neuralgia, the nurse should (select all that apply) a. Inspect all aspects of the mouth and teeth b. Assess the gag reflex and respiratory rate and depth c. Lightly palpate the affected side of the face for edema d. Test for temperature and sensation perception on the face e. Ask the patient to describe factors that initiate an episode
a,d,e
The bone cells that function in the formation of new bone tissue after a patient sustains a fracture are called a. osteoids b. osteocytes c. osteoclasts d. osteoblasts
d
The nurse in urgent care suspects an ankle sprain when a patient describes a. Being hit by another soccer player during a game b. Having ankle pain after sprinting around the track c. Dropping a 10-Ib weight on his lower leg at the health club d. Twisting his ankle while running bases during a baseball game
d
The nurse provides counseling to a family of a patient with Duchenne muscular dystrophy with the knowledge that a. Patients are usually female b. All daughters of a carrier will be carriers c. Genetic testing can help determine treatment d. Only males can pass the gene of their offspring
d
When caring for a patient after lumbar spinal surgery, the nurse would immediately report which finding to the HCP? a. The patient reports mild low back pain b. The patient has a single episode of emesis c. The patient is nauseated and has not voided in 4 hours d. The patient has loss of sensation to the perineum, buttocks, inner thighs, and back of the legs
d
A nurse is assessing a client who has a casted compound fracture of the femur. Which of the following findings is a manifestation of a fat embolus? a. Altered mental status b. Reduced bowel sounds c. Swelling of the toes distal to the injury d. Pain with passive movement of the foot distal to the injury
a
A nurse is completing discharge teaching to client who had a wound debridement for osteomyelitis. Which of the following information should the nurse include? a. Antibiotic therapy should continue for 3 months b. Relief of pain indicates the infection is eradicated c. Airborne precautions are used during wound care d. Expect paresthesia distal to the wound
a
A nurse is planning care for a client who has a spinal cord injury (SCI) involving a T12 fracture 1 week ago. The client has no muscle control of the lower limbs, bowel, or bladder. Which of the following should be the nurse's highest priority? a. Prevention of further damage to the spinal cord b. Prevention of contractures of the lower extremities c. Prevention of skin breakdown of areas that lack sensation d. Prevention of postural hypotension when placing the client in a wheelchair
a
A nurse is teaching a client who has a new diagnosis of rheumatoid arthritis. Which of the following statements should the nurse include in the teaching? a. "You can experience morning stiffness when you get out of bed" b. "You can experience abdominal pain" c. "You can experience weight gain" d. "Youc an experience low blood sugar"
a
A patient with a humeral fracture is returning for a 4-week checkup. The nurse explains that initial evidence of healing on x-ray is indicated by a. Formation of callus b. Complete bony union c. Hematoma at the fracture site d. Presence of granulation tissue
a
A patient with a torn ligament in the knee asks what the ligament does. The nurse would respond that ligaments a. Connect bone to bone b. Provide strength to muscle c. Lubricate joints with synovial fluid d. Relieve friction between moving parts
a
A patient with osteoporosis shows an understanding of appropriate self-care when they state a. "I should remove trip hazards such as throws rugs in my house to make it safer" b. "I am not using the cane my HCP recommended. I don't want to look that old!" c. "I can continue to go downhill skiing as long as I'm careful and don't ever fall" d. "I need to take up running to help strengthen my bones. Walking is just not enough"
a
During rehabilitation, a patient with spinal cord injury begins to ambulate with long leg braces. Which level of injury does the nurse associate with this degree of recovery? a. L1-2 b. T6-7 c. T1-2 d. C7-8
a
The nurse obtained a health history of a patient with a fracture. Which problem, if reported by the patient, would most concern the nurse? a. Diabetes b. Hypertension c. Chronic bronchitis d. Nephrotic syndrome
a
The nurse teaches the patient with an above-the-knee amputation that the residual limb should not be routinely elevated because this position promotes a. Hip flexion contracture b. Clot formation at the incision c. Skin irritation and breakdown d. Increased risk for wound dehiscence
a
The nurse would monitor a patient with a pelvic fracture for a. Changes in urine output b. Petechiae on the abdomen c. A palpable lump in the buttock d. Sudden increase in blood pressure
a
Which drug would the nurse prepare to administer to the patient with acute gout? a. Colchicine b. Allopurinol c. Sulfalazine d. Cyclosporine
a
A nurse is presenting information to a group of clients at a health fair about measures to reduce the risk of amputation. Which of the follow information should the nurse provide? (select all that apply) a. Encourage clients who smoke to consider smoking cessation programs b. Encourage clients who have diabetes mellitus to maintain blood glucose within the expected reference range c. Instruct clients to unplug electrical equipment when performing repairs d. Encourage clients who have vascular disease to maintain good foot care e. Advise clients to wait 2 hr after taking pain medication before driving
a,b,c,d
Which persons are at high risk for chronic low back pain? (select all that apply) a. A 63-year-old man who is a long-distance truck driver b. A 30-year-old nurse who works on an orthopedic unit and smokes c. A 55-year-old construction worker who is 6 ft, 2 in and weighs 250 Ib d. A 44-year-old female yoga instructor who is 5 ft, 6 in, and weighs 130 Ib
a,b,c,d
A nurse is caring for a client following a below-the-elbow amputation. Which of the following actions should the nurse take? (select all that apply) a. Encourage dependent positioning of the residual limb b. Inspect for presence and amount of drainage c. Implement shrinkage intervention of the residual limb d. Wrap the residual limb in a circular manner using gauze e. Assess for feelings of body image changes
a,b,c,e
A nurse is planning discharge teaching on home safety for an adult client who has osteoporosis. Which of the following information should the nurse include in the teaching? (select all that apply) a. Remove throw rugs in walkways b. Use prescribed assistive devices c. Remove clutter from the environment d. Wear soft-bottomed shoes e. Maintain lighting of doorway areas
a,b,c,e
A nurse is teaching a client how to manage an external fixation device upon discharge. Which of the following statements by the client indicates understanding? (select all that apply) a. "I will clean the pins more often if drainage from the pins increases" b. "I will use a seperate cotton swab for each pin" c. "I will report loosening of the pins to my doctor" d. "I will move my leg by lifting the device in the middle" e. "I will report increased redness at the pin sites"
a,b,c,e
The increased risk for falls in the older adult is likely due to (increased all that apply) a. Changes in balance b. Decrease in bone mass c. Loss of ligament elasticity d. Erosion of articular cartilage e. Decrease in muscle mass and strength
a,b,c,e
A nurse is admitting a client to the orthopedic unit following a total knee arthroplasty. Which of the following actions by the nurse are appropriate? (Select all that apply) a. Check continuous passive motion device setting b. Palpate dorsal pedal pulses c. Place a pillow behind the knee d. Elevate heels off bed e. Apply heat therapy to incision
a,b,d
A patient with acute osteomyelitis is being discharged on antibiotic therapy. What would the nurse include in the teaching plan? (select all that apply) a. It is important to finish all the antibiotics even if you feel better b. You will need to schedule periodic through bone scans and ESR testing c. If the infection comes back, you must contact the HCP to schedule surgery d. Signs such as fever and night sweats may be present but are usually not severe e. Contact the HCP if signs of infection such as pain and swelling at the site occur
a,b,d,e
A nurse is discussing gout with a client who is concerned about developing the disorder. Which of the following findings should the nurse identify as risk factors for this disease? (select all that apply) a. Diuretic use b. Obesity c. Deep sleep deprivation d. Depression e. Cardiovascular disease
a,b,e
A nurse working in an outpatient clinic is assessing a client who has rheumatoid arthritis (RA). The client reports increased joint tenderness and swelling. Which of the following findings should the nurse expect? (select all that apply) a. Recent influenza b. Decreased range of motion c. Hypersalication d. Increased blood pressure e. Pain at rest
a,b,e
When performing passive range of motion for a patient, the nurse puts the elbow joint through the movements of (select all that apply) a. Flexion and extension b. Inversion and eversion c. Pronation and supination d. Flexion, extension, abduction, and adduction e. Pronation, supination, rotation, and circumduction
a,c
A nurse is planning care for a client who will undergo an electromyography (EMG). Which of the following actions should the nurse include? (Select all that apply) a. Assess for bruising b. Administer aspirin prior to the procedure c. Determine whether the client takes a muscle relaxant d. Instruct the client to flex muscles during needle insertion e. Expect swelling, redness, and tenderness at the insertion sites
a,c,d
Teach the patient with fibromyalgia the importance of limiting intake of which foods? (select all that apply) a. Sugar b. Gluten c. Alcohol d. Caffeine e. Red meat
a,c,d
A nurse is assessing a client who had an external fixation device applied 2 hr ago for a fracture of the left tibia and fibula. Which of the following findings is a manifestation of compartment syndrome? (select all that apply) a. Intense pain when the client's left foot is passively moved b. Capillary refill of 3 sec on the client's left toes c. Hard, swollen muscle in the client's left leg d. Burning and tingling of the client's left foot e. Client report of minimal pain relief following a second dose of opioid medication
a,c,d,e
A nurse is performing health screenings at a health fair. Which of the following clients have a risk factor for osteoporosis? (select all that apply) a. A 40-year old client who has been taking prednisone for 4 months b. A 30-year-old client who jogs 3 miles daily c. A 45-year-old client who takes phenytoin for seizures d. A 65-year-old client who has a sedentary lifestyle e. A 70-year-old client who has smoked for 50 years
a,c,d,e
A nurse is planning care for a client who is postoperative following an arthroscopy of the knee. Which of the following actions should the nurse take? (Select all that apply) a. Assess color and temperature of the extremity b. Apply warm compresses to incision sites c. Place pillows under the extremity d. Administer analgesic medication e. Assess pulse and sensation in the foot
a,c,d,e
A nurse is planning discharge teaching for a client who had a total hip arthroplasty. Which of the following should the nurse include in the teaching? (select all that apply) a. Clean the incision daily with soap and water b. Turn the toes inward when sitting or lying c. Sit in a straight-backed armchair d. Bend at the waist when putting on socks e. Use a raised toilet seat
a,c,e
A nurse is providing information to a client who has osteoarthritis of the hip and knee. Which of the following information should the nurse include in the information? (select all that apply) a. Apply heat to joints to alleviate pain b. Ice inflamed joints for 30 min following activity c. Reduce the amount of exercise done on days with increased pain d. Prop the knees with a pillow while in bed e. Active range of motion is more effective than passive
a,c,e
A nurse is reviewing the plan of care for a client who has systemic lupus erythematosus (SLE). The client reports fatigue, joint tenderness, swelling, and difficulty urinating. Which of the following laboratory findings should the nurse anticipate? (select all that apply) a. Positive ANA titer b. Increased hemoglobin c. 2+ urine protein d. Increased serum C3 and C4 e. Elevated BUN
a,c,e
A nurse is assessing a client who has arteriosclerosis and is scheduled for a possible right lower extremity amputation. Which of the following are expected findings in the affected extremity? (select all that apply) a. Skin cool to touch from mid-calf to the toes b. Increased sensitivity to fine touch c. Palpable pounding pedal pulse d. Lack of hair on lower leg e. Blackened areas on several toes
a,d,e
A nurse is assessing a client who has osteoarthritis of the knees and fingers. Which of the following manifestations should the nurse expect to find? (select all that apply) a. Heberden's nodes b. Swelling of all joints c. Small body frame d. Enlarged joint size e. Limp when walking
a,d,e
A nurse is completing a preoperative teaching plan for a client who is scheduled to have a total hip arthroplasty. Which of the following should the nurse include in the teaching plan? (select all that apply) a. Encourage complete autologous blood donation b. Sit in a low reclining chair c. Instruct the client to roll onto the operative hip d. Use an abductor pillow when turning the client e. Perform isometric exercises
a,d,e
A nurse in the emergency department is planning care for a client who has a right hip fracture. Which of the following immobilization devices should the nurse anticipate in the plan of care? a Skeletal traction b. Buck's traction c. Halo traction d. Bryant's traction
b
A nurse is caring for a client who has SLE and is experiencing an episode of Raynaud's phenomenon. Which of the following findings should the nurse anticipate? a. Swelling of joints of the fingers b. Pallow of toes with cold exposure c. Feet that become reddened with ambulation d. Client report of intense feeling of heat in the fingers
b
A nurse is caring for a client who has a spinal cord injury who reports a severe headache and is sweating profusely. Vital signs include blood pressure 220/110 mm Hg and apical heart rate 54/min. Which of the following actions should the nurse take first? a. Examine skin for irritation or pressure b. Sit the client upright in bed c. Check the urinary catheter for blockage d. Administer antihypertensive mediation
b
A nurse is caring for a client who received a lower back injury during a fall and describes sharp pain in the back and down the left leg. In which of the following positions should the nurse plan to place the licent to attempt to decrease the pain? a. Prone without use of pillows b. Semi-Fowler's with a pillow under the knees c. High-Fowler's with the knees flat on the bed d. Supine with the head flat
b
A nurse is preparing a plan of care to prevent a client from developing flexion contractions following a below-the-knee amputation 24 hr ago. Which of the following actions should the nurse include? a. Limit any type of exercise to the residual limb for the first 48 hr after surgery b. Position the client prone several times each day c. Wrap the residual limb in a figure-eight pattern d. Encourage sitting in a chair during the day
b
A nurse is providing care for a client who had a vertebroplasty of the thoracic spine. Which of the following actions should the nurse take? a. Apply heat to the puncture site b. Place the client in a spurine position c. Turn the client every 1 hr d. Ambulate the client within the first hour postprocedure
b
A nurse is providing dietary teaching about calcium-rich foods to a client who has osteoporosis. Which of the following foods should the nurse include in the instructions? a. White bread b. Kale c. Apples d. Brown rice
b
A nurse is providing information about capsaicin cream to a client who reports continuous knee pain from osteoarthritis. Which of the following information should the nurse include in the discussion? a. Continuous pain relief is provided b. Put on gloves before applying the cream to other parts of the body c. Leave cream on the hands for 10 min following application d. Apply the medication every 2 hr during the day
b
A patient with T4 spinal cord injury has neurogenic shock due to sympathetic nervous system dysfunction. What would the nurse recognize as characteristics of this condition? a. Tachycardia b. Hypotension c. Increased cardiac output d. Peripheral vasoconstriciton
b
A patient with history of colon cancer is diagnosed with rib fractures, and the HCP orders a bone scan. The nurse determines the patient understands teaching about the purpose of the procedure when they state a. "The bone scan will cure my rib fractures" b. "The bone scan will see if my colon cancer may have spread" c. "My colon cancer was cured so I really don't think this is necessary" d. "The results of the bone scan will only just confirm that I have a rib fracture"
b
An abnormal assessment finding of the musculoskeletal system is a. Equal leg length bilaterally b. Ulnar deviation and subluxation c. Full range of motion in all joint d. Muscle strength of 5/5 in all muscles
b
In assessing the joints of a patient with osteoarthritis, the nurse understands that Heberden nodes a. Are often red, swollen, and tender b. Indicate osteophyte formation at the DIP joints c. Are the result of pannus formation at the PIP joints d. Occur from deterioration of cartilage caused by proteolytic enzymes
b
The most common early symptom of a spinal cord tumor is a. Urinary incontinence b. Back pain that worsens with activity c. Paralysis below the level of involvement d. Impaired sensation of pain, temperature, and light touch
b
The nurse should teach the patient with ankylosing spondylitis the importance of a. Avoiding extremes in environmental temperatures b. Regularly exercising and maintaining proper posture c. Maintaining the patient's usual physical activity during flares d. Applying hot and cool compresses for relief of local symptoms
b
A nurse is admitting an adult client who has suspected osteoporosis. Which of the following findings are risk factors for osteoporosis? (select all that apply) a. History of consuming one glass of wine daily b. Loss in height of 2 in (5.1 cm) c. Body mass index (BMI) of 18 d. Kyphotic curve at upper thoracic spine e. History of lactose intolerance
b,c,d,e
A nurse is assessing a client who is scheduled to undergo a right knee arthroplasty. The nurse should expect which of the following findings? (select all that apply) a. Skin reddened over the joint b. Pain when bearing weight c. Joint crepitus d. Swelling of the affected joint e. Limited joint motion
b,c,d,e
A nurse is completing preoperative teaching for a client who is to undergo an arthroscopy to repair a shoulder injury. Which of the following statements should the nurse include? (select all that apply) a. "Avoid damage or moisture to the cast on your arm" b. "Inspect your incision daily for indications of infection" c. "Apply ice packs to the area for the first 24 hours" d. "Keep you arm in a dependent position" e. "Perform isometric exercises"
b,c,e
A patient who ran his first marathon has heel pain that would not resolve and was diagnosed with calcaneus stress fracture. The nurse will teach the patient to (select all that apply) a. Resume running in 1 weel b. Rest and refrain from running c. Wear a shoe heel pad when ambulating d. Walk barefoot to decrease pressure on the heel e. Apply ice to the heel and take NSAIDs as directed by HCP
b,c,e
A patient with osteoarthritis is scheduled for total hip arthroplasty. The nurse explains the purpose of this procedure is to (select all that apply) a. Fuse the joint b. Replace the joint c. Prevent further damage d. Improve or maintain ROM e. Decrease the amount of destruction in the joint
b,d
A nurse is caring for a client who has rheumatoid arthritis. Which of the following laboratory tests are used to diagnose this disease? (select all that apply) a. Urinalysis b. Erythrocyte sedimentation rate (ESR) c. BUN d. Antinuclear antibody (ANA) titer e. WBC count
b,d,e
A nurse is educating clients at a health fair about dual-energy x-ray absorptiometry (DXA) scans. Which of the following information should the nurse include? (Select all that apply) a. The test requires the use of contrast material b. The hip and spine are the usual areas the device scans c. The scan detects osteoarthritis d. Bone pain can indicate a need for a scan e. Females should have a baseline scan during their 40s
b,d,e
Assessment findings that the nurse would expect in a patient with rheumatoid arthritis who has articular involvement include (select all that apply) a. Bamboo-shaped fingers b. Metatarsal head dislocation in feet c. Noninflammatory pain in large joints d. Asymmetric involvement of small joints e. Morning stiffness lasting 60 minutes or more
b,e
A nurse is teaching a client who has SLE about self-care. Which of the following statements by the clients indicates an understanding of the teaching? a. "I should limit my time to 10 minutes in the tanning bed" b. "I will apply powder to any skin rash" c. "I should use a mild hair shampoo" d. "I will inspect my skin once a month for rashes"
c
A patient is scheduled for a bone scan. The nurse explains that this diagnostic test involves a. Incision or puncture of the joint capsule b. Insertion of small needles into certain muscles c. Administration of a radioisotope before the procedure d. Placement of skin electrodes to record muscle activity
c
A patient undergoing rehabilitation for a C7 spinal cord injury tells the nurse he must have the flu because he has a bad headache and nausea. The nurse's first priority is to a. Call the health care provider b. Check with the patient's temperature c. Measure the patient's blood pressure d. Elevate the head of the bed to 90 degrees
c
A patient with a comminuted fracture of the tibia is to have an open reduction with internal fixation (ORIF) of the fracture. The nurse explains that ORIF is indicated when a. The patient cannot tolerate the surgery for a closed reduction b. The patient cannot tolerate the surgery for a closed reduction c. Other nonsurgical methods cannot achieve adequate alignment d. A temporary cast would be too unstable to provide normal mobility
c
A patient with spinal cord injury has severe neurologic deficits. What is the most likely mechanism of injury for this patient? a. Compression b. Hyperextension c. Flexion-rotation d. Extension-rotation
c
The nurse suspects a neurovascular problem based on assessment of a. Exaggerated strength with movement b. Increased redness and heat below the injury c. Decreased sensation distal to the fracture site d. Purulent drainage at the site of an open fracture
c
Which drug would the nurse plan to administer to the patient with Sjögren syndrome with the goal of improving symptoms of dry eyes? a. Etanercept (Enbrel) b. Pilocarpine (Salagen) c. Cyclosporine (Restasis) d. Cyclobenzaprine (Flexeril)
c
A nurse is assessing a client who has a new diagnosis of SLE. Which of the following findings should the nurse expect? a. Weight gain b. Petechiae on thighs c. Systolic murmur d. Alopecia
d
A nurse is caring for a client who experienced a cervical spine injury 24 hr ago. Which of the following prescriptions should the nurse clarify with the provider? a. Anticoagulant b. Plasma expanders c. H2 antagonists d. Muscle relaxants
d
A nurse is caring for a client who had an above-the-knee amputation. The client reports a sharp, stabbing type of phantom pain. Which of the following actions should the nurse take? a. Remove the initial pressure dressing b. Encourage use of cold therapy c. Question whether the pain is real d. Administer an antiepileptic medication
d
A nurse is caring for a client who has a C4 spinal cord injury. The nurse should recognize the client is at greatest risk for which of the following complications? a. Neurogenic shock b. Paralytic ileus c. Stress ulcer d. Respiratory compromise
d
A nurse is reviewing the health record of a client who is to undergo total joint arthroplasty. The nurse should recognize which of the following findings as a contraindication to this procedure? a. Age 78 years b. History of cancer c. Previous joint replacement d. Bronchitis 2 weeks ago
d
A nurse is teaching a client who is going to have a bone scan. Which of the following statements should the nurse include? a. "You will receive an injection of a radioactive isotope when the scanning procedure begins" b. "You will be inside a tube-like structure during the procedure" c. "You will need to take radioactive precautions with your urine for 24 hours after the procedure" d. "You will have to urinate just before the procedure"
d
A patient is scheduled for total ankle replacement. The nurse should tell the patient that after surgery he should avoid a. Lifting heavy objects b. Sleeping on the back c. Abduction exercises of the affected ankle d. Bearing weight on the affected leg for 6 weeks
d
A patient with a stable, closed humeral fracture has a temporary splint with bulky padding applied with an elastic bandage. The nurse suspects early compartment syndrome when the patient has a. Increasing edema of the limb b. Muscle spasms of the lower arm c. Bounding pulse at the fracture site d. Pain when passively extending the fingers
d
During routine assessment of a patient with Guillain-Barré syndrome, the nurse finds the patient is short of breath. The patient's respiratory distress is caused by a. Elevated protein levels in the CSF b. Immobility resulting from ascending paralysis c. Degeneration of motor neurons in the brainstem and spinal cord d. Paralysis ascending to the nerves that stimulate the thoracic area
d
In teaching a patient with systemic lupus erythematosus about the disorder, the nurse knows the pathophysiology includes a. Circulating immune complexes formed from IgG autoantibodies reacting with IgG b. An autoimmune T-cell reaction that results in destruction of the deep dermal skin layer c. Immunologic dysfunction leading to chronic inflammation in the cartilage and muscles d. The production of a variety of autoantibodies directed against components of the cell nucleus
d
When grading muscle strength, the nurse records a score of 3/5, which indicates a. No detection of muscular contraction b. A barely detectable flicker of contraction c. Active movement against full resistance without fatigue d. Active movement against gravity but not against resistance
d