Med Surg Final
A client diagnosed with Parkinson disease will be starting ropinirole for symptom control. Which statement by the client indicates a need for furthering teaching? A. "I know the drug will probably help me prevent constipation" B. "this drug should help decrease my tremors and help me move better" C. "I should take the drug at the same time each day for the best effect" D. "I need to change positions slowly to prevent dizziness or falls"
A. "I know the drug will probably help me prevent constipation"
A client asks the nurse what the difference is between osteoarthritis (OA) and rheumatoid arthritis (RA). Which response is correct? A. "OA is a noninflammatory joint disease. RA is characterized by inflamed, swollen joints." B. "OA and RA are very similar. OA affects the smaller joints and RA affects the larger, weight-bearing joints." C. "OA affects joints on both sides of the body. RA is usually unilateral." D. "OA is more common in women. RA is more common in men."
A. "OA is a noninflammatory joint disease. RA is characterized by inflamed, swollen joints."
The home care nurse is doing a weekly visit to a client with Alzheimer's disease. What statement by the client would be of greatest concern? A. "When I go to the grocery store to get a few things, it takes me a really long time to get home." B. "My daughter organizes my medications and I have an alarm that goes off to let me know when to take them." C. "Sometimes when the phone rings I am not sure how to answer it so I just let it ring until it stops." D. "I thought you were going to come to see me last week but you didn't come until I called you today."
A. "When I go to the grocery store to get a few things, it takes me a really long time to get home."
Which statements would the nurse include when promoting the prevention of lower back pain? (select all that apply) A. "wear flat instead of high heeled shoes to work each day" B. "avoid prolonged standing or sitting, including driving" C. "participate in an exercise program to strengthen back muscles" D. "its best if you sleep on your stomach" E."wear the neck collar as much as tolerated each day"
A. "wear flat instead of high heeled shoes to work each day" B. "avoid prolonged standing or sitting, including driving" C. "participate in an exercise program to strengthen back muscles"
A client with quadriplegia is in spinal shock. What finding should the nurse expect? A. Absence of reflexes along with flaccid extremities B. Positive Babinski's reflex along with spastic extremities C. Hyperreflexia along with spastic extremities D. Spasticity of all four extremities
A. Absence of reflexes along with flaccid extremities
A client who has been experiencing chest pain takes aspirin when he has an attack of angina. Which of the following are contraindications to aspirin use? Select all that apply. A. An allergy to NSAIDs B. A client who has mitral valve prolapse C. The presence of inflammation D. Thrombocytopenic purpura E. A child with chicken pox
A. An allergy to NSAIDs D. Thrombocytopenic purpura E. A child with chicken pox
A client with a new onset of rib and spine pain is being evaluated for multiple myeloma. For which manifestations will the nurse assess this client? Select all that apply. A. Anemia B. Lymph enlargement C. Hypercalcemia D. Renal dysfunction E. Bone destructions
A. Anemia C. Hypercalcemia D. Renal dysfunction E. Bone destructions
The nurse is caring for a client at high risk for thrombocythemia. Which treatments will the nurse anticipate being prescribed for this client? Select all that apply. A. Aspirin B. Anagrelide C. Hydroxyurea D. Diphenhydramine E. Interferon-alfa
A. Aspirin B. Anagrelide C. Hydroxyurea E. Interferon-alfa
Which nursing intervention is the priority for a client in myasthenic crisis? A. Assessing respiratory effort B. Administering intravenous immunoglobin (IVIG) per orders C. Preparing for plasmapheresis D. Ensuring adequate nutritional support
A. Assessing respiratory effort
A client who has AIDS reports having diarrhea after every meal, and wants to know what can be done to stop this symptom. What should the nurse advise? A. Avoid fibrous foods, lactose, fat, and caffeine. B. Consume large, high-fat meals. C. Reduce food intake. D. Increase intake of iron and zinc.
A. Avoid fibrous foods, lactose, fat, and caffeine.
At which of the following spinal cord injury levels does the patient have full head and neck control? A. C5 B. C4 C. C3 D. C2
A. C5
Which is usually the most important consideration in the decision to initiate antiretroviral therapy? A. CD4+ counts B. HIV RNA C. Western blotting assay D. ELISA
A. CD4+ counts
Which of the following is the earliest and most significant sign of increasing intracranial pressure (ICP)? A. Change in level of consciousness (LOC) B. Seizures C. Restlessness D. Pupil changes
A. Change in level of consciousness (LOC)
The nurse is caring for a client with a stiff and painful neck and sensitivity to light. Which diagnostic test will the nurse expect to be prescribed for this client? Select all that apply. A. Computed tomography scan B. Neck x-rays C. Urine culture D. Blood cultures E. Ophthalmologic exam
A. Computed tomography scan D. Blood cultures
The client with a brain tumor may be at increased risk for aspiration. What does the nurse determine is the most important nursing intervention? A. Evaluation of gag reflex and ability to swallow B. Assistance with self care C. Frequent reorientation D. Monitoring vital signs
A. Evaluation of gag reflex and ability to swallow
A client who has suffered a myocardial infarction requires percutaneous transluminal coronary angioplasty. The nurse is preparing the client for the procedure. Which information should be given as part of pre-operative teaching for the client? A. Explain that the client will have a sand bag or closure device placed on the site to provide pressure after the procedure B. Describe the procedure, its risks and benefits, and potential alternative treatments C. Discuss that the client will have some body hair shaved and he will feel a cold, tingling sensation during the procedure D. Tell the client that he will not be awake during the procedure and he won't feel a thing
A. Explain that the client will have a sand bag or closure device placed on the site to provide pressure after the procedure
Which of the following interventions will you implement for a patient with angina? Select all that apply. A. Give oxygen per nasal cannula B. Administer nitroglycerin sublingually C. Raise the head of bed to 30° D. Administer IV morphine E. Administer NSAID crushed
A. Give oxygen per nasal cannula B. Administer nitroglycerin sublingually D. Administer IV morphine
When assessing a female client with a disorder of the hematopoietic or the lymphatic system, which assessment is most essential? A. Health history, such as bleeding, fatigue, or fainting B. Menstrual history C. Age and gender D. Lifestyle assessments, such as exercise routines
A. Health history, such as bleeding, fatigue, or fainting
hich of the following symptoms are indicative of a rapidly expanding acute subdural hematoma? Select all that apply. A. Hemiparesis B. Tachypnea C. Decreased reactivity of the pupils D. Bradycardia E. Hypotension F. Coma
A. Hemiparesis C. Decreased reactivity of the pupils D. Bradycardia F. Coma
Which assessment findings would alert the nurse to a complication specific to an open traditional anterior cervical fusion? (select all that apply) A. Hoarse voice B. Hypertension C. Bradycardia D. Constipation E. Difficulty swallowing
A. Hoarse voice E. Difficulty swallowing
A patient is hospitalized with a severe case of gout. The patient has gross swelling of the large toe and rates pain a 10 out of 10. With a diagnosis of gout, what should the laboratory results reveal? A. Hyperuricemia B. Glucosuria C. Ketonuria D. Hyperproteinuria
A. Hyperuricemia
The nurse instructs a client receiving chemotherapy on actions to prevent the development of stomatitis. Which client statement indicates to the nurse that teaching has been effective? A. I will brush my teeth after every meal B. I will eat spicy foods with a cool beverage C. I will reduce smoking to after meals only D. I will limit alcoholic beverages to one a day
A. I will brush my teeth after every meal
A nurse assesses a client who is recovering from an open traditional lumbar laminectomy with fusion. Which complications would the nurse report to the primary health care provider? (select all that apply) A. Incisional bulging B. surgical discomfort C. Sudden and severe headache D. Clear drainage on the dressing E. Redness and itching at the incision site
A. Incisional bulging C. Sudden and severe headache D. Clear drainage on the dressing
A nurse is completeing an assessment of a client who has increased intracranial pressure (ICP). Which of the following are expected findings? (select all that apply) A. Increasing disorientation to time and place B. Restlessness and irritability C. Equal pupils D. Headache
A. Increasing disorientation to time and place B. Restlessness and irritability D. Headache
The home care nurse is doing an initial assessment for a client with a diagnosis of Alzheimer's disease and congestive heart failure. What assessment findings indicate a potential risk to the client's safety? Select all that apply. A. Lives with daughter who works outside the home all day. B. Struggles with telling time on the large wall clock. C. Able to ambulate without assistive devices. D. Often disoriented to place and time. E. Has meals delivered when daughter is at work.
A. Lives with daughter who works outside the home all day. B. Struggles with telling time on the large wall clock. D. Often disoriented to place and time.
Clients with multiple myeloma have abnormal plasma cells that proliferate in the bone marrow where they release osteoclast-activating factor, resulting in the formation of osteoclasts. What is the most common complication of the pathology resulting from this process? A. Pathologic fractures B. Osteoporosis C. Calcified bones D. Increased mobility
A. Pathologic fractures
A nurse is receiving a client with a radioactive implant for the treatment of cervical cancer. What is the nurse's best action? A. Place the client in a private room. B. Place a chair next to the bed to allow the spouse to sit. C. Have visitors wear dosimeters for safety. D. Allow visitors to telephone only.
A. Place the client in a private room.
During an initial assessment of a client with coronary artery disease, the nurse wants to assess the client's dietary intake to determine if diet is contributing to his health condition. Which question would most likely give the nurse an idea of the client's everyday diet? A. Please tell me what food and drinks you have had in the past 24 hours B. How much milk do you drink? C. I will say the name of a food, and you tell me if you like it or not D. Are you allergic to any medications?
A. Please tell me what food and drinks you have had in the past 24 hours
During which step of cellular carcinogenesis do cellular changes exhibit increased malignant behavior? A. Progression B. Initiation C. Promotion D. Prolongation
A. Progression
A nurse is caring for a client complaining of chest pain. A 12-lead EKG (ECG) shows normal sinus rhythm. After 30 minutes, the client's lab work results and shows elevated troponin. What are the priority interventions at this time? Select all that apply. A. Repeat the EKG (ECG) B. Administer the ordered morphine C. Re-evaluate the chest pain D. Re-draw the troponin E. Notify the provider
A. Repeat the EKG (ECG) C. Re-evaluate the chest pain E. Notify the provider
What actions would the nurse take after discovering cerebrospinal fluid leaking onto a client's surgical dressing? (select all that apply) A. Report the leak to the surgeon immediately B. Place the client in a flat position C. Monitor vital signs for hypotension D. Assess for abdominal distension E. Monitor client for chest pain
A. Report the leak to the surgeon immediately B. Place the client in a flat position
The nurse is developing a bowel training program for a patient. What education can the nurse provide for the patient that will increase the chance of success of the bowel program? (Select all that apply.) A. Set a daily defecation time that is within 15 minutes of the same time every day. B. Have an adequate intake of fiber containing foods. C. Have a fluid intake between 2 and 4 L/day. D. Take a retention enema daily. E. Take a laxative daily.
A. Set a daily defecation time that is within 15 minutes of the same time every day. B. Have an adequate intake of fiber containing foods. C. Have a fluid intake between 2 and 4 L/day.
The nurse assesses a client who has Parkinson's disease. Which signs and symptoms would the nurse recognize as a key feature of this disease? A. Stooped posture B. Uncontrolled drooling C. Tachycardia D. Slow movements E. long, extended streps
A. Stooped posture B. Uncontrolled drooling D. Slow movements
A client who has recovered from cardiac surgery is getting ready to go home from the hospital. The nurse is providing discharge care instructions to the client before he leaves. What information would the nurse include as part of discharge instructions? Select all that apply. A. Tests or blood work that need to be done B. A list of medications and when to take them C. Activities that are allowed and what to avoid D. Information about how to manage cardiac complications at home E. What signs or symptoms that require a call to the provider
A. Tests or blood work that need to be done B. A list of medications and when to take them C. Activities that are allowed and what to avoid E. What signs or symptoms that require a call to the provider
A 77-year-old client is seen in the ED for chest pain. The provider orders lab work to determine if damage has been done to the heart muscle. Which lab tests are cardiac enzymes (biomarkers) that would be ordered to check for heart damage? Select all that apply A. Troponin B. Creatinine C. BNP D. CK-MB E. Myoglobin
A. Troponin D. CK-MB E. Myoglobin
A nurse is caring for a client receiving chemotherapy. Which nursing action is most appropriate for handling chemotherapeutic agents? A. Wear disposable gloves and protective clothing. B. Break needles after the infusion is discontinued. C. Disconnect I.V. tubing with gloved hands. D. Throw I.V. tubing in the trash after the infusion is stopped.
A. Wear disposable gloves and protective clothing.
The presence of crystals in synovial fluid obtained from arthrocentesis is indicative of A. gout. B. infection. C. inflammation. D. degeneration.
A. gout.
According to the TNM classification system, T0 means there is A. no evidence of primary tumor. B. no regional lymph node metastasis. C. no distant metastasis. D. distant metastasis.
A. no evidence of primary tumor.
A client who has been severely beaten is admitted to the emergency department. The nurse suspects a basilar skull fracture after assessing: A. raccoon's eyes and Battle sign. B. nuchal rigidity and Kernig's sign. C. motor loss in the legs that exceeds that in the arms. D. pupillary changes.
A. raccoon's eyes and Battle sign.
A client suspected of having systemic lupus erythematosus (SLE) is being scheduled for testing. The client asks which of the tests ordered will determine positivity for the disorder. Which statement by the nurse is most accurate? A. "You should discuss that matter with your health care provider." B. "The diagnosis won't be based on the findings of a single test but by combining all data found." C. "SLE is a very serious systemic disorder." D. "Tell me more about your concerns about this potenti
B. "The diagnosis won't be based on the findings of a single test but by combining all data found."
A client taking antiretroviral therapy (ART) for stage 1 of HIV wants new medications because the CD4+ level is not much higher one year after initiation of therapy. The nurse knows that which response will be correct when educating the client about their disease? A. "You are entering another stage of the illness." B. "The viral load results can show improvement." C. "This means that medication doses have been skipped." D. "It's possible that other medication would be more effec
B. "The viral load results can show improvement."
A nurse teaches assistive personnel (AP) about how to care for a client with Parkinson's disease. Which statement would the nurse include as part of this teaching? A. "assist the client with frequent and meticulous oral care" B. "allow the client to be as independent as possible with activities" C. "assess the client's ability to eat and swallow before each meal" D. "schedule appointments early in the morning to ensure rest in the afternoon"
B. "allow the client to be as independent as possible with activities"
The nurse just received reports on the following 4 clients. Which client should the nurse see first? A. 91-year-old female with abdominal pain rating pain at 8/10 B. 40-year-old male with chest pain C. 29-year-old male with an anxiety attack D. 10-year-old female with eye pain
B. 40-year-old male with chest pain
A nurse is caring for a client who is 4 hours postop following CABG surgery. The client is able to inspire 200 mL with the incentive spirometer, then declines to try to cough because of fatigue and pain. Which of the following actions should the nurse take? A. Allow the client to rest, and return in 1 hour B. Administer IV bolus of analgesic, and return in 15 minutes C. Document the 200 mL as an appropriate inspired volume D. Tell the client coughing after incentive spirometry is required
B. Administer IV bolus of analgesic, and return in 15 minutes
A client is experiencing an acute exacerbation of rheumatoid arthritis. What should the nursing priority be? A. Providing comprehensive client teaching; including symptoms of the disorder, treatment options, and expected outcomes B. Administering ordered analgesics and monitoring their effects C. Performing meticulous skin care D. Supplying adaptive devices, such as a zipper-pull, easy-to-open beverage cartons, lightweight cups, and unpackaged silverware
B. Administering ordered analgesics and monitoring their effects
A patient with acute myeloid leukemia (AML) is having hematopoietic stem cell transplantation (HSCT) with radiation therapy. In which complication do the donor's lymphocytes recognize the patient's body as foreign and set up reactions to attack the foreign host? A. Acute respiratory distress syndrome B. Graft-versus-host disease C. Remission D. Bone marrow depression
B. Graft-versus-host disease
Which is the most common cause of acute encephalitis in the United States? A. Western equine bacteria B. Herpes simplex virus (HSV) C. Lyme Disease D. Human immunodeficiency virus (HIV)
B. Herpes simplex virus (HSV)
The RN provides teaching to a client who is prescribed prednisone 10mg orally daily. Which statements by the client indicate that teaching was effective? Select all that apply A. I can take aspirin if I need it for pain B. I need to take the medication at the same time daily C. I need to check for bruising on my skin D. If I gain more than 5 lbs a week, I will call my provider
B. I need to take the medication at the same time daily C. I need to check for bruising on my skin D. If I gain more than 5 lbs a week, I will call my provider
A client is admitted with a cervical spine injury sustained during a diving accident. When planning this client's care, the nurse should assign highest priority to which nursing diagnosis? A. Impaired physical mobility B. Ineffective breathing pattern C. Disturbed sensory perception (tactile) D. Dressing or grooming self-care deficit
B. Ineffective breathing pattern
The nurse working on a neurological unit is mentoring a nursing student. The student asks about a client who has sustained a primary and secondary brain injury. The nurse correctly tells the student which of the following, related to the primary injury? A. It results from inadequate delivery of nutrients and oxygen to the cells. B. It results from initial damage to the brain from the traumatic event. C. It refers to the permanent deficits seen after the rehabilitation process. D. It refers to t
B. It results from initial damage to the brain from the traumatic event.
The RN suspects a postoperative client who had a thyroidectomy may have had an inadvertent removal of the parathyroid when the client began to experience which symptoms Select all that apply. A. Hematoma formation B. Laryngeal stridor C. Tingling of lips, hands, and toes D. Positive Chvostek's sign E. Sensation of fullness at the incision site
B. Laryngeal stridor C. Tingling of lips, hands, and toes D. Positive Chvostek's sign
A nurse is caring for a client after a bone marrow transplant. What is the nurse's priority in caring for the client? A. Monitor the client's toilet patterns. B. Monitor the client to prevent sepsis. C. Monitor the client's physical condition. D. Monitor the client's heart rate.
B. Monitor the client to prevent sepsis.
A nurse is caring for a client who has just undergone a craniotomy for a brain tumor and has a respiratory rate of 12 breaths per minute. Which of the following postoperative prescriptions should the nurse clarify with the provider? A. Dexamethason 30 mg IV push B. Morphine 2 mg IV push q2 hours PRN pain C. Ondanestron 4 mg IV push q4 hours PRN nausea D. Phenytoin 100 mg IV push TID
B. Morphine 2 mg IV push q2 hours PRN pain
The nurse cares for an older adult client with unprovoked back pain and increased serum protein. Which hematologic neoplasm does the nurse suspect the client has? A. Chronic myeloid leukemia B. Multiple myeloma C. Hodgkin lymphoma D. Non-Hodgkin lymphoma
B. Multiple myeloma
The nurse cares for a client with Huntington's disease. What intervention is a priority for safe care? A. Administering anticonvulsants B. Protecting the client from falls C. Administering chemotherapy D. Ensuring the client always uses their wheelchair
B. Protecting the client from falls
A client with Alzheimer's disease has had difficulties eating and is not getting enough nutrients in his diet. The client's daughter asks the nurse if there is anything that can be done to improve his nutrition intake. Which recommendation should the nurse give? A. Limit calories to have better control of behavior B. Provide stand-by assistance when the client eats to offer support C. Help the client choose his own eating utensils D. Use more salt when cooking and serving food
B. Provide stand-by assistance when the client eats to offer support
A nurse is caring for a client receiving chemotherapy. Which assessment finding places the client at the greatest risk for an infection? A. White blood cell (WBC) count of 9,000 cells/mm3 B. Stage 3 pressure ulcer on the left heel C. Ate 75% of all meals during the day D. Temperature of 98.3° F (36.8° C)
B. Stage 3 pressure ulcer on the left heel
A client on antiretroviral drug therapy informs the nurse about sometimes forgetting to take the medication for a few days. What should the nurse inform the client can occur when the medications are not taken as prescribed? A. The funding for the medications will cease if the client is not taking the meds correctly. B. The client is risking the development of drug resistance and drug failure. C. The client will have to take the drugs intravenously to ensure compliance. D. The client will have t
B. The client is risking the development of drug resistance and drug failure.
A nurse is managing the care of a client with osteoarthritis. What is the appropriate treatment strategy the nurse will teach the about for osteoarthritis? A. administration of opioids for pain control. B. administration of nonsteroidal anti-inflammatory drugs (NSAIDs) C. administration of monthly intra-articular injections of corticosteroids. D. vigorous physical therapy for the joints.
B. administration of nonsteroidal anti-inflammatory drugs (NSAIDs)
The nurse is admitting a client who states, "When I was pregnant I would get heartburn so bad, I was eating antacids like crazy. I now feel the same way, except I am not pregnant. The antacids aren't helping me and now I have this pain between my shoulder blades." Which part of this statement is most concerning and must be investigated further? A. "When I was pregnant I would get heartburn so bad" B. "I was eating antacids like crazy" C. "I have this pain between my shoulder blades" D. "The antacids aren't helping me"
C. "I have this pain between my shoulder blades"
The parents of a client intubated due to the progression of Guillain-Barré syndrome ask whether their child will die. What is the best response by the nurse? A. "Don't worry; your child will be fine." B. "Once Guillain-Barré syndrome progresses to the diaphragm, survival decreases significantly." C. "There are no guarantees, but a large portion of people with Guillain-Barré syndrome survive." D. "It's too early to give a prognosis."
C. "There are no guarantees, but a large portion of people with Guillain-Barré syndrome survive."
The nurse visits an older adult home care client who is bedridden and being cared for by her family. The nurse is discussing with the client and family about the importance of changing position in bed. The nurse's teaching is direct toward preventing complications in which area when a client is immobile? A. Nausea B. Jaundice C. Atelectasis D. Mental confusion
C. Atelectasis
A nurse is caring for a client following an angioplasty that was inserted through the femoral artery. While turning the client, the nurse discovers blood underneath the client's lower back. Which of the following findings should the nurse suspect? A. Retroperitoneal bleeding B. Cardiac tamponade C. Bleeding from the incisional site D. Heart failure
C. Bleeding from the incisional site
An adult client presents to the emergency department with a chief complaint of heartburn. What is the nurse's immediate priority? A. Find out the last time the client had oral intake B. Start an IV C. Call for an EKG D. Inspect the client's mouth
C. Call for an EKG
A 44-year-old client is recovering in the hospital following a myocardial infarction. The client asks the nurse about participation in cardiac rehabilitation. Which of the following is an accurate explanation of cardiac rehabilitation? A. Cardiac rehabilitation is designed to teach a person what to do if they have a heart attack again B. Cardiac rehabilitation is designed for people over the age of 60 for additional physical therapy after a heart attack C. Cardiac rehabilitation can help you to improve activity levels and exercise tolerance after a heart attack D. Cardiac rehabilitation is designed only for people who were born with congenital heart disease and have experienced a heart attack
C. Cardiac rehabilitation can help you to improve activity levels and exercise tolerance after a heart attack
A nurse is assessing a client with Kaposi's sarcoma. What initial sign does the nurse know to look for during assessment? A. Severe joint pain B. Lymphedema of the lower extremities C. Deep purple cutaneous lesions D. Venous stasis and phlebitis formation
C. Deep purple cutaneous lesions
What foods should the nurse suggest that the patient consume less of in order to reduce nitrate intake because of the possibility of carcinogenic action? A. Eggs and milk B. Fish and poultry C. Ham and bacon D. Green, leafy vegetables
C. Ham and bacon
Which disease is a chronic, progressive, hereditary disease of the nervous system that results in progressive, involuntary dancelike movements and dementia? A. Parkinson's disease B. Multiple sclerosis C. Hunting's disease D. Amyotrophic lateral sclerosis
C. Hunting's disease
A client diagnosed with a brain tumor is receiving phenytoin. The client's partner questions the use of the drug, since there is no history of a seizure disorder. What response will the nurse provide to best address the partners concern? A. Preventing febrile seizures with a tumor is important B. This drug is used to sedate with a brain tumor C. Increased pressure from the tumor can cause seizures D. Seizures always occur in clients with brain tumors
C. Increased pressure from the tumor can cause seizures
Which medication is the most effective agent in the treatment of Parkinson's disease? A. Amantadine B. Benzotropine C. Levodopa D. Bromocriptine mesylate
C. Levodopa
A client with a concussion is discharged after the assessment. Which instruction should the nurse give the client's family? A. Have the client avoid physical exertion B. Emphasize complete bed rest C. Look for signs of increased intracranial pressure D. Look for a halo sign
C. Look for signs of increased intracranial pressure
Which adaptation of the environment is most important for the RN to include in the plan of care for a client diagnosed with myxedema? A. Reduce environmental stimuli B. Prevent direct sunlight from entering the room C. Maintain a warm room temperature D. Minimize exposure to visitors
C. Maintain a warm room temperature
Which is the primary vector of arthropod-borne viral encephalitis in North America? A. Birds B. Spiders C. Mosquitoes D. Ticks
C. Mosquitoes
A client presents to the emergency department stating numbness and tingling occurring down the left leg into the left foot. When documenting the experience, which medical terminology would the nurse be most correct to report? A. Sciatic nerve pain B. Herniation C. Paresthesia D. Paralysis
C. Paresthesia
The nurse is assisting the client with multiple myeloma to ambulate. What is the most important nursing intervention to help prevent fractures in the client? A. Increase mobility. B. Provide adequate hydration. C. Promote safety. D. Encourage adequate nutrition.
C. Promote safety.
A client with HIV will be started on a medication regimen of three medications. What class of drugs will the nurse instruct the client about? A. Anticholinergics B. Disinhibitors C. Reverse transcriptase inhibitors D. Hydroxyurea
C. Reverse transcriptase inhibitors
A client with systemic lupus erythematosus (SLE) is prescribed hydroxychloroquine. Which teaching will the nurse include for this client? A. Exercise B. High-protein diet C. Smoking cessation D. Vitamin D supplements
C. Smoking cessation
The nurse is caring for a client immediately following a spinal cord injury (SCI). Which is an acute complication of SCI? A. Cardiogenic shock B. Tetraplegia C. Spinal shock D. Paraplegia
C. Spinal shock
A client with AIDS is admitted to the hospital with severe diarrhea and dehydration. The physician suspects an infection with Cryptosporidium. What type of specimen should be collected to confirm this diagnosis? A. Urine specimen for culture and sensitivity B. Blood specimen for electrolyte studies C. Stool specimen for ova and parasites D. Sputum specimen for acid fast bacillus
C. Stool specimen for ova and parasites
What is a positive Kernig sign? A. Extreme sensitivity to light B. Any attempts at flexion of the head are difficult because of spasms in the muscles of the neck C. When the patient is lying with the thigh flexed on the abdomen, the leg cannot be completely extended D. When the patient's neck is flexed, flexion of the knees and hips is produced; when the lower extremity of one side is passively flexed, a similar movement is seen in the opposite extremity
C. When the patient is lying with the thigh flexed on the abdomen, the leg cannot be completely extended
For a client with Hodgkin lymphoma, who is at a risk for ineffective airway clearance and impaired gas exchange, the nurse places the client in a high Fowler's position to A. reduce deficits in the blood oxygen concentration. B. detect compromised ventilation. C. increase lung expansion. D. anticipate the need for airway management.
C. increase lung expansion.
The nurse instructs a client with polymyositis rheumatica (PMR) about prescribed corticosteroids. Which statement regarding corticosteroid is correct? A. "I will cut the dose in half if I begin gaining weight." B. "I will take the medication until my symptoms disappear." C. "I will skip a dose of the medication if I experience gastric upset." D. "I will take the medication until my health care provider tells me to stop."
D. "I will take the medication until my health care provider tells me to stop."
Which statement by a client undergoing external radiation therapy indicates the need for further teaching? A. "I'll wash my skin with mild soap and water only." B. "I'll not use my heating pad during my treatment." C. "I'll wear protective clothing when outside." D. "I'm worried I'll expose my family members to radiation."
D. "I'm worried I'll expose my family members to radiation."
A client with gout has been advised to lose weight. The client informs the nurse of plans to go on a "guaranteed rapid weight loss" plan that involves fasting and heavy exercise. Which response would be most appropriate? A. "The fasting is okay, but make sure you drink fluids when exercising." B. "Make sure to eat some fat occasionally with all that exercise." C. "Try combining the fasting with moderate exercise." D. "There might be some difficulties with your plan and fasting
D. "There might be some difficulties with your plan and fasting."
You are a neurotrauma nurse working in a neuro ICU. What would you know is an acute emergency and is seen in clients with a cervical or high thoracic spinal cord injury after the spinal shock subsides? A. Areflexia B. Paraplegia C. Tetraplegia D. Autonomic dysreflexia
D. Autonomic dysreflexia
A client is taking a corticosteroid for the treatment of systemic lupus erythematosus. When the nurse is providing instructions about the medication to the client, what priority information should be included? A. If the client experiences nausea, omit the dose. B. The client should be alert for joint aches. C. This medication is commonly used for many inflammatory reactions and is relatively safe. D. Be alert for signs and symptoms of infection and report them immediately to the physician.
D. Be alert for signs and symptoms of infection and report them immediately to the physician.
A rapid, jerky, involuntary, and purposeless movement of the extremities or facial muscles is: A. paresthesia B. Dyskinesia C. Akathisia D. Chorea
D. Chorea
Which client would the RN assess first? A. Client with hyperthyroidism who is exhibiting exophthalmos B. Client with type 1 diabetes who has an inflamed foot ulcer C. Client with Cushing's disease exhibiting moon face D. Client with Addison's disease showing tremors and diaphoresis
D. Client with Addison's disease showing tremors and diaphoresis
A nurse in the emergency room has clients that are all complaining of pain. The nurse knows that the client having pain in which of the following areas is the priority? A. Bilateral flank B. Lower back C. Lower abdomen D. Jaw and neck
D. Jaw and neck
A client was admitted to the hospital with a pathologic pelvic fracture. The client informs the nurse that he has been having a strange pain in the pelvic area for a couple of weeks that was getting worse with activity prior to the fracture. What does the nurse suspect may be occurring based on these symptoms? A. Hemolytic anemia B. Polycythemia vera C. Leukemia D. Multiple myeloma
D. Multiple myeloma
Which is a chronic, degenerative, progressive disease of the central nervous system characterized by the occurrence of demyelination in the brain and spinal cord? A. Parkinson disease B. Huntington disease C. Creutzfeldt-Jakob disease D. Multiple sclerosis
D. Multiple sclerosis
Four clients in the emergency room have complaints of chest pain. The nurse should assess which client first? A. Constant chest pain 2/10; HR 110 B. Chest pain 0/10 after sublingual nitroglycerin C. Chest pain 6/10 after motor vehicle accident D. New chest pain 8/10; diaphoretic
D. New chest pain 8/10; diaphoretic
The nurse is assessing a client who is coughing so hard that his chest hurts. The client is holding his chest and asking for pain medications. What is the priority for this client? A. Get the client cough syrup B. Give the client water C. Give the client pain medications D. Obtain orders for an EKG (ECG)
D. Obtain orders for an EKG (ECG)
When describing the role of the various members of the rehabilitation team, which member would the nurse identify as the one who determines the final outcome of the process? A. Nurse B. Physician C. Physical therapist D. Patient
D. Patient
The nurse recognizes the clinical assessment of a patient with acute myeloid leukemia (AML) includes observing for signs of infection early. What nursing action will most likely help prevent infection? A. Monitor the client's temperature every shift. B. Maintain contact precautions. C. Encourage increased fluid consumption. D. Practice vigilant hand washing
D. Practice vigilant hand washing
The nurse teaches the client that corticosteroids will be used to treat his brain tumor to: A. Prevent extension of the tumor B. Identify the precise location of the tumor C. Facilitate regeneration of neurons D. Reduce cerebral edema
D. Reduce cerebral edema
The nurse is invited to present a teaching program to parents of school-age children. Which topic would be of greatest value for decreasing cancer risks? A. Pool and water safety B. Breast and testicular self-exams C. Hand washing and infection prevention D. Sun safety and use of sunscreen
D. Sun safety and use of sunscreen
When debriefing the nursing staff after a confused client has fallen, the nurse stresses the need for client safety. The nurse knows the staff understands safety when they make which statement? A. The client should eat a balanced diet. B. The client should not receive pain medicine. C. The client should have all four side rails up at all times. D. The client should wear non-skid footwear when ambulating.
D. The client should wear non-skid footwear when ambulating.
The home health nurse is assessing a client who is immunosuppressed. What is the most essential teaching for this client and the family? A. How to promote immune function through nutrition B. The importance of maintaining the client's vaccination status C. How to choose antibiotics based on the client's symptoms D. The need to report any slight changes in the client's health status
D. The need to report any slight changes in the client's health status
A nurse is teaching a client with a long leg cast how to use crutches properly while descending a staircase. The nurse should tell the client to transfer body weight to the unaffected leg, and then: A. advance both legs. B. advance the unaffected leg. C. advance the affected leg. D. advance both crutches.
D. advance both crutches.
Nursing care for the client with fibromyalgia should be guided by the assumption that patients with fibromyalgia A. all have the same type of symptoms. B. rarely respond to treatment. C. will eventually lose their ability to walk. D. may feel as if their symptoms are not taken seriously.
D. may feel as if their symptoms are not taken seriously.
The nurse is providing care for a client who has limited mobility after a stroke. In order to assess the client for contractures, the nurse should assess the client's: A. deep tendon reflexes (DTRs). B. muscle size. C. level of joint pain. D. range of motion.
D. range of motion.
True or False: contusion is a temporary loss of neurologic function with no apparent structural damage to the brain
False Concussion contusion is a temporary loss of neurologic function with no apparent structural damage to the brain. Contusion is a bruising of the brain surface
True or false: multiple sclerosis is an immune-mediated, progressive demyelinating disease of the peripheral nervous system
False Multiple sclerosis is an immune-mediated, progressive demyelinating disease of the central nervous system (not the peripheral)
True or false: myasthenia gravis is an autoimmune attack on the peripheral nerve myelin
False Myasthenia gravis is an autoimmune disorder affecting myoneural junction and is characterized by varying degrees of weakness of the voluntary muscle Guillain-Barre syndrome is an autoimmune attack on the peripheral nerve myelin
True or False: meningitis is an inflammation of the pia mater, the arachnoid, and the cerebrospinal fluid filled subarachnoid space
True
True or False: clear rhinorrhea from the nose is a sign of basilar fracture
True Signs of basilar fracture include CSF drainage and/or blood from ears & nose, battle sign, and halo sign
True or False: never massage the calves or thighs of a patient who is immobile
True The calves or thighs of a patient who is immobile should never be massaged because of the danger of dislodging an undetected thromboembolus
