NUR2101 Test #4 QUESTIONS Neurology and Musculoskeletal

A client with rheumatoid arthritis is receiving hydroxychloroquine (Plaquenil) in the recent months. The nurse tells the client to visit which of the following while taking this treatment? 1. Dentist 2. Ophthalmologist 3. Pulmonologist 4. Endocrinologist

2. Ophthalmologist This medication can adversely affect the eyes and cause retinal damage. Clients taking this medication should have an eye exam at least once a year.

A nurse is admitting a client to an orthopedic unit following a total knee arthroplasty. Which of the following actions should the nurse take? Select all that apply 1. Check continuous passive motion device settings 2. Palpate dorsal pedal pulses 3. Place a pillow under the knees 4. Elevate heels off the bed 5. Apply heat therapy to the incision

1, 2 and 4 The nurse should place one pillow under the lower calf and foot to cause a slight extension of the knee joint and prevent flexion contractures. Then he can also rest flat on the bed. Pressure ulcers can be prevented by elevating the heel off the bed with a pillow.

A nurse is assisting with 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 1. Complete autologous blood donation 2. Sit in a low reclining chair 3. Cross legs when in bed 4. Use an abductor pillow when turning 5. Perform isometric exercises

1, 4 and 5

A nurse is collecting data from 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 1. Heberden's nodes 2. Swelling of all joints 3. Small body frame 4. Enlarged joint size 5. Limp when walking

1, 4 and 5 Heberden's nodes are enlarged nodules on the distal inter-phalangeal joints of the hands and feet of a client who has osteoarthritis. Swelling and pain of all joints is a manifestation of rheumatoid arthritis. Local inflammation is related to osteoarthritis. A small body frame is a risk factor for rheumatoid arthritis. Obesity is a risk factor for osteoarthritis. Enlarged joints can occur due to bone hypertrophy. A client can manifest a limp when walking due to pain from inflammation in the localized joint

A nurse has instructed client to accurately measure the circumference of both calves each morning and to report any increase in circumference. Which client statement indicates that the teaching has been effective? 1. "I'll use a measuring tape to check circumference" 2. "I only have to call if one leg is significantly larger than the other" 3. "I can measure my calves either near the knee or closer to the ankle" 4. "I'll use the standardize chart for limb circumference"

1. "I'll use a measuring tape to check circumference"

A client taking probenecid is complaining of gout pain. Which of the following medications should the nurse expect to be administered? 1. Acetaminophen 2. Aspirin 3. Orphenadrine (Norflex) 4. Tizanidine (Zanaflex)

1. Acetaminophen Aspirin can cause an increase in uric acid levels. The other two options are muscle relaxants

Which is the highest priority nursing diagnosis when caring for a patient with increased ICP who has an intraventricular catheter? 1. Risk for infection 2. Fluid volume deficit 3. Ineffective cerebral tissue perfusion 4. Risk for injury

3. Ineffective cerebral tissue perfusion The brain must be adequately perfused to maintain function and prevent long-term disability due to lack of oxygenation.

A nurse is collecting data from a client who has a casted compound fracture of the femur. The nurse should identify which of the following findings as a manifestation of fat emboli? 1. Altered mental status 2. Reduced bowel sounds 3. Swelling of the toes distal to the injury 4. Pain with passive movement of the foot distal to the injury

1. Altered mental status Altered mental status is an early manifestation of fat emboli. Other manifestations include dyspnea, chest pain and hypoxemia Swelling of the toes is a manifestation of reduced circulation. Pain with passive movement of the foot distal to the injury is an expected finding.

Osteoblast activity is needed for which function? 1. Bone formation 2. Estrogen production 3. Hematopoiesis 4. Muscle formation

1. Bone formation

A client reports new left calf pain 4/5 on pain scale that worsens to touch with dorsiflexion of left foot. +4 non-pitting edema left foot to the knee noted. Prominent superficial veins noted on left leg. Dr. notified. The nurse knows these findings are consistent with which condition? 1. Deep vein thrombosis DVT 2. Fat embolus 3. Infection 4. Pulmonary embolism

1. Deep vein thrombosis DVT

Which neurotransmitter is responsible for may of the functions of the frontal lobe? 1. Dopamine 2. GABA 3. Histamine 4. Norepinephrine

1. Dopamine The frontal lobe primarily functions to regulate thinking, planning, and affect. Dopamine is known to circulate widely throughout this lobe, which is why it's such an important neurotransmitter in schizophrenia.

A 51-year-old client has undergone a total hip replacement on her right side. After surgery, how often should the nurse turn the client? 1. Every 1 to 2 hours, from the unaffected side to the back 2. Every 1 to 2 hours, from the affected side to the back 3. Every 4 to 6 hours, from the unaffected side to the back 4. Every 4 to 6 hours, from the affected side to the back

1. Every 1 to 2 hours, from the unaffected side to the back

A client is taking salicylates for osteoarthritis. The presence of which of the following indicates that further assessment is needed? 1. Hearing loss 2. Increased pain in joints 3. Decreased calcium absorption 4. Increased bone demineralization

1. Hearing loss

A client complains of low back pain that radiates down the right leg, with numbness and weakness of the right leg. The nurse recognizes these complaints as related to which disorder? 1. Herniated nucleus pulposus (HNP) 2. Muscular dystrophy 3. Parkinson's disease 4. Osteoarthritis

1. Herniated nucleus pulposus (HNP)

Which discharge instruction about home activity should be given to a client with osteoarthritis? 1. Learn to pace activity 2. Remain as sedentary as possible 3. Return to a normal level of activity 4. Include vigorous exercise in your daily routine

1. Learn to pace activity

A nurse is conducting health fair on spinal cord injuries at a local high school. The nurse relays that which of the following is the most common cause of spinal cord injury? 1. MVA 2. Sports related injuries 3. Falls 4. Acts of violence

1. MVA

To reduce the roughness of a cast, which measure should be used? 1. Petal the edges 2. Elevate the limb 3. Break off the rough area 4. Distribute pressure evenly

1. Petal the edges

The physician has ordered tests for a client to diagnose a suspected case of gout. The nurse should expect to see which result? 1. Presence of urate crystals in the synovial fluid of the affected area 2. Presence of urate crystals in the bloodstream 3. Elevated blood calcium levels 4. Decreased red blood cell count

1. Presence of urate crystals in the synovial fluid of the affected area

The nurse is caring for a client who's on complete bed rest following complete hip replacement. In an effort to reduce sensory deprivation, the nursing assistant should be instructed to do which of the following? 1. Provide mouth care before meals 2. Monitor the client's urine output every two hours 3. Check bilateral hand grasps every four hours 4. Orient the client to date and time frequently

1. Provide mouth care before meals

After falling 20', a 36-year-old man sustains a C6 fracture with spinal cord transaction. Which other findings should the nurse expect? 1. Quadriplegia with gross arm movement and diaphragmatic breathing 2. Quadriplegia and loss of respiratory function 3. Paraplegia with intercostal muscle loss 4. Loss of bowel and bladder control

1. Quadriplegia with gross arm movement and diaphragmatic breathing A client with a spinal cord injury at levels C5 to C6 has quadriplegia with gross arm movement and diaphragmatic breathing. Injury levels C1 to C4 leads to quadriplegia with total loss of respiratory function. Paraplegia with intercostal muscle loss occurs with injuries at T1 to L2. Injuries below L2 cause paraplegia and loss of bowel and bladder control.

What is the most common cause of osteomyelitis? 1. Staphylococcus aureus 2. Pseudomonas 3. H. influenzae

1. Staphylococcus aureus

Which of the following respiratory patterns indicate increasing ICP in the brain stem? 1. Slow, irregular respirations 2. Rapid, shallow respirations 3. Asymmetric chest expansion 4. Nasal flaring

1. Slow, irregular respirations Neural control of respiration takes place in the brain stem. Deterioration and pressure produce irregular respiratory patterns. Rapid, shallow respirations, asymmetric chest movements, and nasal flaring are more characteristic of respiratory distress or hypoxia.

A nurse is caring for a patient immediately following a spinal cord injury. Which of the following is an acute complication of spinal cord injury? 1. Spinal shock 2. Paraplegia 3. Tetraplegia 4. Cardiogenic shock

1. Spinal shock Acute complications of Spinal cord injuries include spinal and neurogenic shock and deep vein thrombosis.

The nurse is instructing a nursing assistant on the proper care of a client in Buck's extension traction following a fracture of his left fibula. Which observation indicates that the teaching was effective? 1. The weights are allowed to hang freely over the end of the bed 2. The nursing assistant lifts the weights when assisting the client to move up in bed 3. The leg in traction is kept externally rotated 4. The nursing assistant instructs the client to perform ankle rotation exercises

1. The weights are allowed to hang freely over the end of the bed

A patient with increased ICP has a cerebral perfusion pressure of 40 mmHg. How should the nurse interpret the CPP? 1. The CPP is low 2. The CPP reading is inaccurate 3. The CPP is within normal limits 4. The CPP is high

1. The CPP is low Normal CPP is 70 to 100 mmHg

Which type of traction is used to treat lower back pain? 1. Bryant's traction 2. Buck's traction 3. Pelvic traction belt 4. Russell traction

3. Pelvic traction belt

A client is admitted to the emergency department with a foot fracture. Which reason explains why the foot is placed in a brace? 1. To act as a splint 2. To prevent infection 3. To allow for movement 4. To encourage direct contact

1. To act as a splint

A female patient with meningitis has a history of seizures. Which of the following actions by the nurse is appropriate while the patient is actively seizing? 1. Turn the patient to the side 2. Place a cooling blanket 3. Administer mannitol 4. Insert oral airway

1. Turn the patient to the side

A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor? 1. Unequal pupil size 2. Decreasing systolic blood pressure 3. Tachycardia 4. Decreasing body temperature

1. Unequal pupil size Increasing ICP causes unequal pupils as a result of pressure on the third cranial nerve. Increasing ICP causes an increase in the systolic pressure, which reflects the additional pressure needed to perfuse the brain. It increases the pressure on the vagus nerve, which produces bradycardia, and it causes an increase in body temperature from hypothalamic damage.

Which of the following are used to help reduce ICP? 1. Using a cervical collar 2. Keeping the head of bed flat 3. Rotating the neck to the far right with neck support 4. Extreme hip flexion supported by pillows

1. Using a cervical collar Use of a cervical collar promotes venous drainage and prevents jugular vein distortion which can increase ICP.

A client has been prescribed an anti-inflammatory for osteoarthritis and the nurse has instructed the client about taking the medication. Which statement by the client indicates that the nurse's teaching has been effective? 1. "If I'm not free from pain in a week, I'll come back to the clinic" 2. "It can take up to 2 to 3 weeks for me to feel the full effects from the medication" 3. "I'll increase my dose if I'm not better in a few days" 4. "If I don't experience pain relief in a few days, I need to stop taking the medication"

2. "It can take up to 2 to 3 weeks for me to feel the full effects from the medication"

A client is being discharged with an arm cast wants to shower at home. The nurse teaches her how to shower without getting the cast wet. For which reason is this important? 1. A wet cast can cause a foul odor 2. A wet cast will weaken or decompose 3. A wet cast is heavy and difficult to maneuver 4. It's all right to get the cast wet, just use a hair dryer to dry it off

2. A wet cast will weaken or decompose

A 52-year-old client complains of severe pain in his left great toe. He states that the pain last from 1 to 2 weeks and then improves. He has had the symptoms intermittently for the last several years and is pain-free between the attacks. The nurse recognizes that the symptoms described by the client are associated with which disorder? 1. Chronic gout 2. Acute gout 3. Osteoporosis 4. Rheumatoid arthritis

2. Acute gout Chronic is continuous and acute comes and goes

The nurse is caring for an 82-year-old patient diagnosed with cranial arteritis. What is the priority nursing intervention? 1. Assess for weight loss 2. Administer corticosteroids as ordered 3. Give acetaminophen per orders 4. Document signs and symptoms of inflammation

2. Administer corticosteroids as ordered Cranial arteritis is caused by inflammation. The inflammation can lead to visual impairment or rupture of the vessel.

A nurse is caring for a client who is receiving cyclobenzaprine hydrochloride (Flexeril) for the treatment of muscle spasm. Which of the following medical conditions is contraindicated with use of this medication? 1. DM 2. Angle closure glaucoma 3. Emphysema 4. Urinary tract infection

2. Angle closure glaucoma Flexeril has an anti-cholinergic affect and should be used with caution in patients with angle closure glaucoma, urinary retention and increased intraocular pressure.

The nurse is caring for a client who suffered a spinal cord injury 48 hours ago. The nurse monitors for GI complications by assessing for: 1. A flattened abdomen 2. Hematest positive nasogastric tube drainage 3. Hyperactive bowel sounds 4. A history of diarrhea

2. Hematest positive nasogastric tube drainage After spinal cord injury, the client can develop paralytic ileus, which is characterized by the absence of bowel sounds and abdominal distention. Development of a stress ulcer can be detected by hematest positive NG tube aspirate or stool.

A 67-year-old male is seen in the clinic with complaints of right hip pain that worsens after activity, decreased range of motion of the right hip, and difficulty getting up after sitting for long periods. The nurse observes crepitus in the right hip upon movement. The nurse recognizes that the symptoms are associated with which condition? 1. Gout 2. Osteoarthritis 3. Rheumatoid arthritis 4. Hip fractures

2. Osteoarthritis This is the clinical definition of osteoarthritis. Rheumatoid arthritis is systemic and affects multiple joints.

A nurse is assisting in the care of a client immediately following vertebroplasty of the thoracic spine. Which of the following actions should the nurse take? 1. Apply heat to the puncture site 2. Place the client in a supine position 3. Turn the client every one hour 4. Ambulate the client within the first hour post procedure

2. Place the client in a supine position The client should have cold therapy applied to the puncture site and stay in the supine position with the bed flat for 1 to 2 hours following the procedure

Which of the following conditions indicates that spinal shock is resolving in a client with C7 quadriplegia? 1. Absence of pain sensation in chest 2. Spasticity 3. Spontaneous respirations 4. Urinary continence

2. Spasticity Spasticity, the return of reflexes, is a sign of resolving shock. Spinal shock descends from the injury, and respiratory difficulties occur at C4 and above.

Which characteristic of the fascia can cause it to develop compartment syndrome? 1. It's highly flexible 2. It's fragile and weak 3. It's unable to expand 4. It's the only tissue within the compartment

3. It's unable to expand

A 20-year-old female is complaining of severe pain in her right upper arm. Which x-ray findings would indicate the need for further investigation? 1. Longitudinal fracture 2. Oblique fracture 3. Spiral fracture 4. Transverse fracture

3. Spiral fracture

Which type of brain injury is characterized by a loss of consciousness associated with stupor and confusion? 1. Diffuse axonal injury 2. Intracranial hemorrhage 3. Concussion 4. Contusion

4. Contusion Other characteristics can include tissue alteration and neurologic deficit without hematoma formation, alteration in consciousness without localizing signs, and hemorrhage into the tissue that varies in size and is surrounded by edema. Hemorrhage and edema peak after about 18 to 36 hours.

Which of the following should be avoided in patients with increased ICP? 1. Position changes 2. Suctioning 3. Minimal environmental stimuli 4. Enemas

4. Enemas The Valsalva maneuver can cause increased ICP.

Which type of hematoma results from a skull fracture that causes a rupture or laceration of the middle meningeal artery? 1. Subdural 2. Intra-cerebral 3. Diffuse axonal injury 4. Epidural

4. Epidural

A nurse is caring for a client who has a prescription for cyclosporine to treat rheumatoid arthritis. Which of the following medications increases the risk of toxicity when taken concurrently with cyclosporine? 1. Phenytoin 2. Rifampin 3. Carbamazepine 4. Erythomycin

4. Erythomycin The other three medications can decrease cyclosporine levels.

The nurse is caring for a patient with a head injury. The patient is experiencing CSF rhinorrhea. Which of the following orders should the nurse question? 1. Out of bed to chair three times a day 2. Serum sodium level 3. Urine testing for acetone 4. Insertion of a nasogastric tube

4. Insertion of a nasogastric tube With CSF rhinorrhea, an oral feeding tube should be inserted instead of a nasal tube.

Which characteristic applies to a closed fracture? 1. Extensive tissue damage 2. Increased risk of infection 3. Same as for a compound fracture 4. Intact skin over the fracture site

4. Intact skin over the fracture site

A client is diagnosed with a fat emboli. Which signs and symptoms with the nurse expect to find when assessing this client? 1. Tachypnea, tachycardia, shortness of breath, paresthesia 2. Paresthesia, bradypnea, bradycardia, petechial rash on chest and neck 3. Bradypnea, bradycardia, shortness of breath, petechial rash on chest and neck 4. Tachypnea, tachycardia, shortness of breath, petechial rash on chest and neck

4. Tachypnea, tachycardia, shortness of breath, petechial rash on chest and neck

Gold sodium thiomalate is prescribed to a client with rheumatoid arthritis. Which of the following side effects indicates an overdose of the medication? 1. Flushing 2. Dizziness 3. Joint pain 4. Metallic taste

4. Metallic taste Toxicity signs of this drug are pruritus, diarrhea, dermatitis, stomatitis and metallic taste. Flushing and dizziness are side effects that may occur soon after the injection and increased joint pain may occur 1 to 2 days after the injection.

Which symptoms are considered signs of a fracture? 1. Tingling, coolness, loss of pulses 2. Loss of sensation, redness, warmth 3. Coolness, redness, pain at the site of injury 4. Redness, warmth, pain at the site of injury

4. Redness, warmth, pain at the site of injury

Which intervention would help prevent DVT's after hip surgery? 1. Immobility 2. Convoluted foam mattress 3. Vigorous pulmonary care 4. Subcutaneous heparin and pneumatic compression boots

4. Subcutaneous heparin and pneumatic compression boots

An osmotic diuretic, such as mannitol, is given to the patient with increased ICP for which of the following therapeutic effects? 1. To reduce cellular metabolic demands 2. To lower uncontrolled fevers 3. To increase urine output 4. To dehydrate the brain and reduce cerebral edema

4. To dehydrate the brain and reduce cerebral edema

Which instruction would be considered primary prevention of injury from osteoarthritis? 1. Stay on bed rest 2. Avoid physical activity 3. Perform only repetitive tasks 4. Warm up before exercise and avoid repetitive tasks

4. Warm up before exercise and avoid repetitive tasks

What is the common presentation of a impact hip fracture?

A shorter and externally rotated adducted leg

For proper use of crutches, what is the correct positioning?

The elbows should be at 30 degree angle when handgrips are held The pads need to be 3 finger widths below the axillae When ambulating, all the weight should be on the hands, NOT the axillae

A client has been pronounced brain dead. Which findings would the nurse assess? Check all that apply. 1. Decerebrate posturing 2. Dilated nonreactive pupils 3. Deep tendon reflexes 4. Absent corneal reflex

2, 3 and 4 A client who is brain dead typically demonstrates nonreactive dilated pupils and nonreactive or absent corneal and gag reflexes. The client may still have spinal reflexes such as deep tendon and Babinski reflexes in brain death.

Synthetic casts take approximately how long to set? 1. Immediately 2. 20 minutes 3. 45 minutes 4. Two hours

2. 20 minutes

A 45-year-old client is diagnosed with a long bone fracture. A nurse who is aware of the most serious complications of long bone fractures should monitor the client closely for which potential complication? 1. Bone emboli 2. Fat emboli 3. Platelet emboli 4. Serous emboli

2. Fat emboli

A 20-year-old male client has just had a plaster cast applied to his right forearm following reduction of a closed radius fracture due to an in-line skating accident. It's most important for the nurse to check which of the following? 1. Whether the cast is completely dry 2. Sensation and movement of the fingers 3. Whether the client is having any pain 4. Whether the cast needs petaling

2. Sensation and movement of the fingers

The nurse is discussing the purpose of an electroencephalogram (EEG) with the family of a client with massive cerebral hemorrhage and loss of consciousness. It would be most accurate for the nurse to tell family members that the test measures which of the following conditions? 1. Extent of intracranial bleeding 2. Sites of brain injury 3. Activity of the brain 4. Percent of functional brain tissue

3. Activity of the brain

Which of the following conditions occurs when bleeding occurs between the dura matter and arachnoid membrane? 1. Epidural hematoma 2. Extradural hematoma 3. Subdural hematoma 4. Intra-cerebral hemorrhage

3. Subdural hematoma

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? 1. Remove the initial pressure dressing 2. Encourage use of cold therapy 3. Question whether the pain is real 4. Administer an anti-epileptic medication

4. Administer an antiepileptic medication

Client education about gout includes which information? 1. Good foot care will reduce complications 2. Increased dietary intake of purine is needed 3. Production of uric acid in the kidney affects joints 4. Uric acid crystals cause inflammatory destruction of the joint

4. Uric acid crystals cause inflammatory destruction of the joint

A nurse is contributing to the plan of care for a client who undergo an electromyography (EMG). which of the following actions should the nurse include in the plan of care? Select all that apply 1. Check for bruising 2. Apply ice to insertion sites 3. Determine whether the client takes a muscle relaxant 4. Instruct the client to flex her muscles during needle insertion 5. Expect swelling, redness and tenderness at the insertion sites

1, 2, 3 and 4 Flexing the muscle will make insertion of the needle easier into the muscle. Swelling, redness and tenderness can indicate an infection.

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 following information should the nurse provide? Select all that apply 1. Clients who smoke should consider smoking cessation programs 2. Clients who have DM should maintain blood glucose within the expected reference range 3. Unplug electrical equipment when performing repairs 4. Clients who have vascular disease should maintain good foot care 5. Wait two hours after taking pain medication before driving

1, 2, 3 and 4 Unplugging electrical equipment before performing repairs prevents electrocution an injury to an extremity that could lead to amputation

A nurse is collecting data from a client who has increased ICP. Which of the following findings should the nurse expect? Select all that apply 1. Disoriented to time and place 2. Restlessness and irritability 3. Unequal pupils 4. ICP 15 mmHg 5. Headache

1, 2, 3 and 5

A nurse is reinforcing teaching with a client about how to manage an external fixation device upon discharge. Which of the following client statements indicate understanding? Select all that apply 1. "I will clean the pins twice a day" 2. "I will use a separate cotton swab for each pin" 3. "I will report loosening of the pins to my doctor" 4. "I will clean the pins with tapwater and antibacterial soap" 5. "I will report increased redness at the pin sites"

1, 2, 3 and 5 Chlorhexidine or sterile saline is recommended for cleansing. Tapwater is not sterile and increases the risk of infection. Reporting redness, heat or drainage is important because it could indicate an infection that can lead to osteomyelitis.

A nurse is reviewing information with a client who has osteoarthritis of the hip and knee. Which of the following instructions should the nurse reinforce? Select all that apply 1. Apply heat to joints to alleviate pain 2. Ice inflamed joints following activity 3. Install an elevated toilet seat 4. Take tub baths 5. Complete high energy activities in the morning

1, 2, 3 and 5 Taking a tub bath places the client at risk for increased strain and pain on affected joints when getting in and out of the tub and increases the risk for falls

A nurse is reinforcing discharge teaching on home safety for an older adult client who has osteoporosis. Which of the following information should the nurse include? Select all that apply 1. Remove throw rugs in walkways 2. Use prescribed assistive devices 3. Remove clutter from the environment 4. Walk with caution on icy surfaces 5. Maintain lighting of the doorway areas

1, 2, 3 and 5 The client should avoid walking on icy services during inclement weather to prevent a fall

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 1. Encourage dependent positioning of the residual limb 2. Inspect for presence and amount of drainage on the dressing 3. Implement shrinkage intervention of the residual limb 4. Wrap the residual limb in a circular manner using gauze 5. Observe for body image changes

1, 2, 3 and 5 The limb should be wrapped in a figure eight to prevent restriction of blood flow.

A nurse is collecting data from an older adult client who has arteriosclerosis and is scheduled for right lower extremity amputation. Which of the following are expected findings in the affected extremity? Select all that apply 1. Skin cool to touch from midcalf to the toes 2. Lower leg appearing dusky when client sitting 3. Palpable pounding pedal pulse 4. Lack of hair on lower leg 5. Blackened areas on several toes

1, 2, 4 and 5 Decreased hair growth occurs because of decreased vascularization.

The nurse is caring for a client with a T5 complete spinal cord injury. Upon assessment, the nurse notes flushed skin, diaphoresis above the T5, and a blood pressure of 162/96. The client reports a severe, pounding headache. Which of the following nursing interventions would be appropriate for this client? Select all that apply. 1. Elevate the HOB to 90 degrees 2. Loosen constrictive clothing 3. Use a fan to reduce diaphoresis 4. Assess for bladder distention and bowel impaction 5. Administer antihypertensive medication

1, 2, 4 and 5 The client has S/S of autonomic dysreflexia. The potentially life-threatening condition is caused by an uninhibited response from the sympathetic nervous system resulting from a lack of control over the autonomic nervous system. The nurse should immediately elevate the HOB to 90 degrees and place extremities dependently to decrease venous return to the heart and increase venous return from the brain. Because tactile stimuli can trigger autonomic dysreflexia, any constrictive clothing should be loosened. The nurse should also assess for distended bladder and bowel impaction, which may trigger autonomic dysreflexia, and correct any problems. Elevated blood pressure is the most life-threatening complication of autonomic dysreflexia because it can cause stroke, MI, or seizures. If removing the triggering event doesn't reduce the client's blood pressure, IV antihypertensives should be administered. A fan shouldn't be used because cold drafts may trigger autonomic dysreflexia.

The nurse is caring for a patient who is being assessed for brain death. Which of the following are cardinal signs of brain death? Select all that apply 1. Coma 2. No brain waves 3. Apnea 4. Absence of brainstem reflexes

1, 3 and 4

Which of the following are risk factors for a spinal cord injury? Select all that apply 1. Alcohol use 2. Caucasian ethnicity 3. Young age 4. Drug abuse 5. Female gender

1, 3 and 4

A nurse is reviewing a prescription for dexamethasone with a client who has an expanding brain tumor. Which of the following are appropriate statements by the nurse? Select all that apply 1. "It is given to reduce swelling of the brain." 2. "You will need to monitor for low blood sugar." 3. "You may notice weight gain." 4. "Tumor growth will be delayed." 5. "It can cause you to retain fluids."

1, 3 and 5

The nurse is assigned to care for patients with spinal cord injuries on rehabilitation unit. Which of the following does the nurse recognize are clinical manifestations of autonomic dysreflexia? Select all that apply 1. Nasal congestion 2. Fever 3. Diaphoresis 4. Tachycardia 5. Hypertension

1, 3 and 5 Bradycardia, not tachycardia occurs with autonomic dysreflexia.

A nurse is assisting with planning discharge teaching for a client who had a total hip arthroplasty. Which of the following instructions should the nurse include? Select all that apply 1. Clean the incision daily with soap and water 2. Turn the toes inward when sitting or lying 3. Sit in a straight backed armchair 4. Bend at the waist when putting on socks 5. Use a raised toilet seat

1, 3 and 5 Toes should be externally rotated to prevent dislocation of the prosthesis. Bending at the waist greater than 90° can dislocate the prosthesis.

A nurse is contributing to the plan of 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 1. Inspect color and temperature of the extremity 2. Apply warm compresses to incision sites 3. Place pillows under the extremity 4. Administer analgesic medication 5. Check pulse and sensation in the foot

1, 3, 4 and 5

A nurse is collecting data from a client who had an external fixation device applied two hours ago for a fracture of the left tibia and fibula. The nurse should identify which of the following findings as manifestations of compartment syndrome? Select all that apply 1. Intense pain when the left foot is passively moved 2. Capillary refill of three seconds on the left toes 3. Hard, swollen muscle in the left leg 4. Burning and tingling of the left foot 5. Client report of minimal pain relief following a second dose of opioid medication

1, 3, 4 and 5 Capillary refill of three seconds is within the expected reference range. Prolonged refill greater than three seconds is an indication of decreased arterial perfusion

A nurse is assisting with health screenings at a health fair. The nurse should identify that which of the following clients are at risk for osteoporosis? Select all that apply 1. 40-year-old client who takes prednisone for asthma 2. 30-year-old client who jogs 3 miles daily 3. 45-year-old client who takes phenytoin for seizures 4. 65-year-old client who has a sedentary lifestyle 5. 70-year-old client who has smoked for 50 years

1, 3, 4 and 5 Prednisone affects the absorption of metabolism of calcium and places the client at risk for osteoporosis. Seizure medications can reduce calcium absorption.

A nurse is reinforcing teaching with a client who has a history of low back injury. Which of the following instructions should the nurse reinforce with the client to prevent low back pain? Select all that apply 1. Engage in regular exercise including walking 2. Sit up for 10 hours each day to rest the back 3. Maintain weight within 25% of ideal body weight 4. Create a smoking cessation plan 5. Wear low heeled shoes

1, 4 and 5 Long periods of sitting or standing can cause low back pain. Advise the client to use foot stools or ergonomic chairs when sitting as necessary. The client should maintain weight within 10% of ideal body weight. Obesity can cause low back pain.

Which of the following is a late sign of increased ICP? 1. Altered respiratory patterns 2. Irritability 3. Headache 4. Slowing of speech

1. Altered respiratory patterns The other three options are early signs of increased ICP.

A nurse is reinforcing discharge teaching with a client who had a wound debridement for osteomyelitis. Which of the following information should the nurse include? 1. Antibiotic therapy should continue for three months 2. Relief of pain indicates the infection is eradicated 3. Airborne precautions are used during wound care 4. Expect paresthesia distal to the wound

1. Antibiotic therapy should continue for three months Contact precautions are indicated. The patient should monitor and report neurovascular compromise.

When evaluating an ABG from a client with a subdural hematoma, the nurse notes the PaCO2 is 30 mm Hg. Which of the following responses best describes this result? 1. Appropriate; lowering carbon dioxide (CO2) reduces intracranial pressure (ICP) 2. Emergent; the client is poorly oxygenated. 3. Normal 4. Significant; the client has alveolar hypoventilation.

1. Appropriate; lowering carbon dioxide (CO2) reduces intracranial pressure (ICP) A normal PaCO2 value is 35 to 45 mm Hg. CO2 has vasodilating properties; therefore, lowering PaCO2 through hyperventilation will lower ICP caused by dilated cerebral vessels.

The client is about to start a treatment for juvenile rheumatoid arthritis. Before the administration of etanercept (Enbrel), it is important for the nurse to? 1. Ask for an allergy to latex 2. Ask the client to postpone vacation trip abroad 3. Tell the client to not miss their vaccination while on treatment 4. Avoid people with a recent injection of etanercept

1. Ask for an allergy to latex The prefilled syringe or auto injectors for this medication contain a natural dry rubber.

A client describes a foul odor from his cast. Which response or intervention would be most appropriate? 1. Assessing further because this may be a sign of infection 2. Teaching him proper cast care, including hygiene measures 3. Doing nothing. This is normal, especially when a cast is in place for a few weeks. 4. Assessing further because this may be a sign of neurovascular compromise

1. Assessing further because this may be a sign of infection

Which nursing intervention is appropriate for a client in traction? 1. Assessing the pin sites every shift and as needed 2. Adding and removing weights as the client desires 3. Making sure the knots in the rope catch on the pulley 4. Giving range of motion to all joints, including those immediately proximal and distal to the fracture every shift

1. Assessing the pin sites every shift and as needed

A 20-year-old client developed osteomyelitis two weeks after a fishhook was removed from his foot. Which rationale best explains the expected long-term antibiotic therapy? 1. Bone has poor circulation 2. Tissue trauma requires antibiotics 3. Feet are normally difficult to treat 4. Fishook injuries are highly contaminated

1. Bone has poor circulation

The client with a head injury has been urinating copious amounts of dilute urine through the Foley catheter. The client's urine output for the previous shift was 3000 ml. The nurse implements a new physician order to administer: 1. Desmopressin (DDAVP, stimate) 2. Dexamethasone (Decadron) 3. Ethacrynic acid (Edecrin) 4. Mannitol (Osmitrol)

1. Desmopressin A complication of a head injury is diabetes insipidus, which can occur with insult to the hypothalamus, the antidiuretic storage vesicles, or the posterior pituitary gland. Urine output that exceeds 9 L per day generally requires treatment with desmopressin.

A client with head trauma develops a urine output of 300 ml/hr, dry skin, and dry mucous membranes. Which of the following nursing interventions is the most appropriate to perform initially? 1. Evaluate urine specific gravity 2. Anticipate treatment for renal failure 3. Provide emollients to the skin to prevent breakdown 4. Slow down the IV fluids and notify the physician

1. Evaluate urine specific gravity Urine output of 300 ml/hr may indicate diabetes insipidus, which is a failure of the pituitary to produce anti-diuretic hormone. This may occur with increased intracranial pressure and head trauma; the nurse evaluates for low urine specific gravity, increased serum osmolarity, and dehydration. Slowing the rate of IV fluid would contribute to dehydration when polyuria is present.

Clients in the late stages of osteoarthritis commonly use which term to describe joint pain? 1. Grating 2. Dull ache 3. Deep aching pain 4. Deep aching, relieved with rest

1. Grating Cartilage is destroyed and bones rub against each other

The nurse is collecting a health history from a 63-year-old man who may have gout. What joint is most commonly affected in the client with gout? 1. Great toe 2. Wrist 3. Ankle 4. Knee

1. Great toe

A client is admitted to the ER for head trauma is diagnosed with an epidural hematoma. The underlying cause of epidural hematoma is usually related to which of the following conditions? 1. Laceration of the middle meningeal artery 2. Rupture of the carotid artery 3. Thromboembolism from a carotid artery 4. Venous bleeding from the arachnoid space

1. Laceration of the middle meningeal artery Epidural hematoma or extradural hematoma is usually caused by laceration of the middle meningeal artery. An embolic stroke is a thromboembolism from a carotid artery that ruptures. Venous bleeding from the arachnoid space is usually observed with subdural hematoma.

Adalimumab (Humira) is given to a client for the treatment of rheumatoid arthritis. Which of the following side effects is associated with this medication? 1. Numbness 2. Diarrhea 3. Urinary retention 4. Weight gain

1. Numbness This medication has been associated with neurological side effects such as numbness, tingling, dizziness, visual disturbances and weakness in the legs.

An 18-year-old client is admitted with a closed head injury sustained in a MVA. His intracranial pressure (ICP) shows an upward trend. Which intervention should the nurse perform first? 1. Reposition the client to avoid neck flexion 2. Administer 1 g Mannitol IV as ordered 3. Increase the ventilator's respiratory rate to 20 breaths/minute 4. Administer 100 mg of pentobarbital IV as ordered.

1. Reposition the client to avoid neck flexion The nurse should first attempt nursing interventions, such as repositioning the client to avoid neck flexion, which increases venous return and lowers ICP. If nursing measures prove ineffective, notify the physician, who may prescribe mannitol, pentobarbital, or hyperventilation therapy.

A nurse is caring for a client who is at risk for increased ICP. Which of the following actions should the nurse take to decrease the potential for raising the client's ICP? Select all that apply 1. Suction the client frequently 2. Decrease the noise level in the client's room 3. Elevate the client's head on two pillows 4. Administer a stool softener 5. Keep the client well hydrated

2 and 4 Suctioning should be PRN Avoid hyper flexion of the neck Avoid over hydrating because it can increase ICP

The following statements match nursing interventions with nursing diagnosis. Which statements are true for a patient who has suffered a head injury? Select all that apply 1. Ineffective cerebral tissue perfusion: maintaining cerebral perfusion pressure less than or equal to 50 mmHg 2. Disturbed sleep pattern: provide the patient with back rubs 3. Interrupted family process: encourage family to join a support group 4. Ineffective airway clearance: suction patient as indicated 5. Deficient fluid volume: administer 1 L of normal saline daily

2, 3 and 4

Which interventions are appropriate for a patient with increased ICP? Select all that apply 1. Elevating the head of the bed at 90° 2. Maintaining aseptic technique with the intraventricular catheter 3. Frequent oral care 4. Administering prescribed antipyretics 5. Encouraging deep breathing and coughing every two hours

2, 3 and 4

A patient has been diagnosed with a concussion. The patient is preparing to be discharge from the emergency department. The nurse teaches the family members who will be caring for the patient to contact the physician or return to the ED if the patient demonstrates or complains of which of the following? Select all that apply 1. Sleeps for short periods of time 2. Slurred speech 3. Vomiting 4. Weakness on one side of the body 5. Headache

2, 3 and 4 A decrease in LOC, worsening headache, dizziness, seizures, abnormal people response, vomiting, irritability, slurred speech, numbness or weakness in the arms or legs should be reported immediately. Also, difficulty in waking the patient.

A client is diagnosed with gout. Which foods should the nurse instruct the client to avoid? Select all that apply 1. Green leafy vegetables 2. Liver 3. Cod 4. Chocolate 5. Sardines 6. Eggs 7. Whole milk

2, 3 and 5

A nurse is reinforcing preoperative teaching with 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 1. "Avoid damage or moisture to the cast on your arm" 2. "Inspect your incision daily for indications of infection" 3. "Apply ice packs to the area for the first 24 hours" 4. "Keep your arm in a dependent position" 5. "Perform isometric exercises"

2, 3 and 5

A nurse is instructing a client with a recent leg fracture and cast. Which statements by the client indicates that further teaching is needed? Select all that apply 1. " I need to report any numbness or tingling in my leg at once" 2. "It's normal to have some numbness or tingling following a fracture" 3. "It's normal to have severe pain even after the cast is on" 4. "I need to keep my leg elevated as much as possible" 5. "The color and temperature of my toes will be checked frequently" 6. "It's normal to have swelling and for the cast of feel really tight"

2, 3 and 6

Which of the following activities would a patient with a T4 spinal cord injury be able to perform independently? Select all that apply 1. Ambulating 2. Writing 3. Breathing 4. Eating 5. Transferring to a wheelchair

2, 3, 4 and 5

A nurse is collecting data on a client who is scheduled to undergo a right knee arthroplasty. The nurse should expect which of the following findings? Select all that apply 1. Skin reddened over the joint 2. Pain when bearing weight 3. Joint crepitus 4. Swelling of the affected joint 5. Limited joint motion

2, 3, 4 and 5 Degeneration of the joint tissue can cause crepitus.

A nurse is assisting in the admission of an older adult client who has suspected osteoporosis. Which of the following findings should the nurse expect? Select all that apply 1. History of consuming one glass of wine daily 2. Loss in height of 5.1 cm or 2 inches 3. Body mass index of 21 4. Kyphotic curve at upper thoracic spine 5. History of lactose intolerance

2, 3, 4 and 5 Low bodyweight and then body build decreases bone mass. Lactose intolerance suggests a possible lack of calcium intake. Three glasses of wine a day or more is a risk factor for osteoporosis.

A nurse is reinforcing teaching with clients at a health fair about DEXA scans (dual energy x-ray absorptiometry) which of the following information should the nurse include in the teaching? Select all that apply 1. "The test requires use of contrast material" 2. "The hip and spine are the usual areas the device scans" 3. "The scan detects osteoarthritis" 4. "Bone pain can indicate a need for a scan" 5. "At age 40, you should have a baseline skin"

2, 4 and 5 A DEXA scan detects osteoporosis not osteoarthritis. Bone pain, loss of height and fractures can indicate the need for a DEXA scan

Which statement by a client who recently had a cast applied indicates that the nurse's teaching has been effective? 1. "The cast will need to be removed if I feel any heat" 2. "Heat is a normal sensation as a cast dries" 3. "The heat I feel is most likely caused by infection" 4. "I'll call my physician if I feel any heat"

2. "Heat is a normal sensation as a cast dries"

The nurse knows that a client with osteoarthritis of the knee understands the discharge instructions when the client makes which statement? 1. "I'll take my ibuprofen on an empty stomach" 2. "I'll try taking a warm shower in the morning" 3. "I wear my knee splint every night" 4. "I'll jog at least a mile every evening"

2. "I'll try taking a warm shower in the morning"

A client has been prescribed a skeletal muscle relaxant to treat a herniated nucleus pulposus. After the nurse has instructed the client about taking the medication, which client statement indicates that further teaching is needed? 1. "I'll stand up slowly to avoid dizziness" 2. "If I miss a dose of the medicine, I'll take an extra pill at the next dose" 3. "I'll call my doctor before taking over the counter medications" 4. "I'll avoid activities that require alertness while taking the medication"

2. "If I miss a dose of the medicine, I'll take an extra pill at the next dose"

A client asked the nurse, "What's the difference between rheumatoid arthritis and osteoarthritis?" Which statement is the correct response? 1. "Osteoarthritis is gender specific; rheumatoid arthritis isn't." 2. "Osteoarthritis is a localized disease; rheumatoid arthritis is systemic." 3. "Osteoarthritis is a systemic disease; rheumatoid arthritis is localized" 4. "Osteoarthritis has dislocations and subluxations; rheumatoid arthritis doesn't"

2. "Osteoarthritis is a localized disease; rheumatoid arthritis is systemic."

The physician has just removed the cast from a 20-year-old male client's lower leg. During the removal, a small superficial abrasion occurred over the ankle. Which statement by the client indicates the need for additional client teaching? 1. "I must use a moisturizing lotion on the dry areas" 2. "The dry, peeling skin will go away by itself" 3. "I can wash the abrasion on my ankle with soap and water" 4. "I'll wait until the abrasion is healed before I go swimming"

2. "The dry, peeling skin will go away by itself"

In compartment syndrome, how long would it take for tissue death to occur? 1. 2 to 4 hours 2. 6 to 8 hours 3. 24 hours 4. 72 hours

2. 6 to 8 hours

A 23-year-old patient with a recent history of encephalitis is admitted to the medical unit with new onset generalized tonic-clonic seizures. Which nursing activities included in the patient's care will be best to delegate to an LPN/LVN whom you are supervising? 1. Document the onset time, nature of seizure activity, and postictal behaviors for all seizures. 2. Administer phenytoin (Dilantin) 200 mg PO daily. 3. Teach patient about the need for good oral hygiene. 4. Develop a discharge plan, including physician visits and referral to the Epilepsy Foundation.

2. Administer phenytoin (Dilantin) 200 mg PO daily. Administration of medications is included in LPN education and scope of practice. Collection of data about the seizure activity may be accomplished by an LPN/LVN who observes initial seizure activity. An LPN/LVN would know to call the supervising RN immediately if a patient started to seize. Documentation of the seizure, patient teaching, and planning of care are complex activities that require RN level education and scope of practice.

Which of the following medication classifications is utilized to preoperatively to decrease the risk of postoperative seizures? 1. Diuretics 2. Anticonvulsants 3. Corticosteroids 4. Anti-anxiety

2. Anticonvulsants

Colchicine is prescribed for a client with gout. The nurse reviews the clients record knowing that this medication would be used with caution in which of the following medical conditions? 1. Behcet disease 2. Aplastic anemia 3. Amyloidosis 4. Familial Mediterranean fever

2. Aplastic anemia Colchicine is contraindicated for patients with serious G.I., renal, hepatic, cardiac or blood dyscrasias like aplastic anemia.

A client with a spinal cord injury suddenly experiences an episode of autonomic dysreflexia. After checking the client's vital signs, list in order of priority, the nurse's actions (Number 1 being the first priority and number 5 being the last priority). A. Check for bladder distention B. Raise the head of the bed C. Contact the physician D. Loosen tight clothing on the client E. Administer an antihypertensive medication B, D, A, C, E. 1. A, B, C, D, E 2. B, D, A, C, E. 3. C, A, D, E, B 4. C, D, A, B, E

2. B, D, A, C, E.

A patient in the ER has bruising over the mastoid bone and rhinorrhea. The triage nurse suspects the patient has what type of skull fracture? 1. Comminuted 2. Basilar 3. Simple 4. Linear

2. Basilar Basilar skull fractures are also suspected when CSF escapes from the ears and the nose.

A nurse is caring for a client who has a right hip fracture. Which of the following immobilization devices should the nurse anticipate? 1. Skeletal traction 2. Buck's traction 3. Halo traction 4. Bryant's traction

2. Buck's traction This is a temporary immobilization device applied to a client who has a femur or hip fracture to diminish muscle spasms and immobilize the affected extremity until surgery is performed Skeletal traction is for immobilization of a long bone or cervical spine. Halo traction immobilizes the cervical spine. Bryant's traction is for congenital hip dislocation in children

A client receiving vent-assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate? 1. Count the rate to be sure the ventilations are deep enough to be sufficient 2. Call the physician while another nurse checks the vital signs and ascertains the patient's Glasgow Coma score. 3. Call the physician to adjust the ventilator settings. 4. Check deep tendon reflexes to determine the best motor response

2. Call the physician while another nurse checks the vital signs and ascertains the patient's Glasgow Coma score. Cluster breathing consists of clusters of irregular breaths followed by periods of apnea on an irregular basis. A lesion in the upper medulla or lower pons is usually the cause of cluster breathing. Because the client had a bleed in the occipital lobe, which is superior and posterior to the pons and medulla, clinical manifestations that indicate a new lesion are monitored very closely in case another bleed ensues. The physician is notified immediately so that treatment can begin before respirations cease. Another nurse needs to assess vital signs and score the client according to the GCS, but time is also of the essence. Checking deep tendon reflexes is one part of the GCS analysis.

Which areas would be included in a neurovascular assessment? 1. Orientation, movement, pulses, warmth 2. Capillary refill, movement, pulses, warmth 3. Orientation, pupillary response, temperature, pulses 4. Respiratory pattern, orientation, pulses, temperature

2. Capillary refill, movement, pulses, warmth

Which of the following is the earliest sign of increasing ICP? 1. Headache 2. Change in LOC 3. Vomiting 4. Posturing

2. Change in LOC

A 23-year-old client has been hit on the head with a baseball bat. The nurse notes clear fluid draining from his ears and nose. Which of the following nursing interventions should be done first? 1. Position the client flat in bed 2. Check the fluid for dextrose with a dipstick 3. Suction the nose to maintain airway patency 4. Insert nasal and ear packing with sterile gauze

2. Check the fluid for dextrose with a dipstick Clear fluid from the nose or ear can be determined to be cerebral spinal fluid or mucous by the presence of dextrose. Placing the client flat in bed may increase ICP and promote pulmonary aspiration. The nose wouldn't be suctioned because of the risk for suctioning brain tissue through the sinuses. Nothing is inserted into the ears or nose of a client with a skull fracture because of the risk of infection.

The nurse has documented a patient diagnosed with a head injury as having a GCS score of seven. The score is generally interpreted as which of the following? 1. Minimally responsive 2. Coma 3. Least responsive 4. Most responsive

2. Coma

Gold salt toxicity can be reversed using which medication? 1. Acetaminophen 2. Dimercaprol 3. Calcium salts 4. Hydroxycobalamin

2. Dimercaprol Dimercaprol treats arsenic, gold or mercury poisoning. Calcium salts is the antidote for fluoride ingestion Hydroxycobalamin is the antidote for cyanide poisoning

In planning the care for a client who has had a posterior fossa (infratentorial) craniotomy, which of the following is contraindicated when positioning the client? 1. Keeping the client flat on one side or the other 2. Elevating the head of the bed to 30 degrees 3. Log rolling or turning as a unit when turning 4. Keeping the head in neutral position

2. Elevating the head of the bed to 30 degrees Elevating the HOB to 30 degrees is contraindicated for infratentorial craniotomies because it could cause herniation of the brain down onto the brainstem and spinal cord, resulting in sudden death. Elevation of the head of the bed to 30 degrees with the head turned to the side opposite of the incision, if not contraindicated by the ICP; is used for supratentorial craniotomies.

The nurse is reviewing the clients history who is about to take methotrexate. Which of the following drugs can be safely administered together with methotrexate? 1. Tetracycline 2. Folic acid 3. Sulfamethoxazole 4. Phenytoin (Dilantin)

2. Folic acid Folic acid supplementation lowers the risk of G.I. problems and mouth sores brought about by the use of methotrexate

A 70 year old female client complains of pain in her lower back. She has a markedly aged appearance and says she doesn't eat well. She is diagnosed with osteoporosis. The nurse teaches the client about injury prevention because she's concerned about preventing which condition that's the primary complication of osteoporosis? 1. Pain 2. Fractures 3. Hardening of the bones 4. Increased bone matrix and remineralization

2. Fractures

A client who had a transsphenoidal hypophysectomy should be watched carefully for hemorrhage, which may be shown by which of the following signs? 1. Bloody drainage from the ears 2. Frequent swallowing 3. Guaiac-positive stools 4. Hematuria

2. Frequent swallowing Frequent swallowing after brain surgery may indicate fluid or blood leaking from the sinuses into the oropharynx. Blood or fluid draining from the ear may indicate a basilar skull fracture.

Which condition is the cause of primary osteoporosis? 1. Alcoholism 2. Hormonal imbalance 3. Malnutrition 4. Osteogenesis imperfecta

2. Hormonal imbalance

A client with C7 quadriplegia is flushed and anxious and complains of a pounding headache. Which of the following symptoms would also be anticipated? 1. Decreased urine output or oliguria 2. Hypertension and bradycardia 3. Respiratory depression 4. Symptoms of shock

2. Hypertension and bradycardia Hypertension, bradycardia, anxiety, blurred vision, and flushing above the lesion occur with autonomic dysreflexia due to uninhibited sympathetic nervous system discharge.

The nurse is caring for a patient with a ventriculostomy. Which assessment finding documented demonstrates effectiveness of the ventriculostomy? 1. The pupils are dilated and fixed. 2. ICP is 12 mmHg 3. The mean arterial pressure is equal to the intracranial pressure 4. Cerebral perfusion pressure is 21 mmHg

2. ICP is 12 mmHg Normal ICP is 0 to 50 mmHg 12 mmHg would demonstrate the effectiveness of the ventriculostomy.

A client with osteoporosis is asking the nurse regarding the use of salmon calcitonin (Miacalcin) nasal spray. The nurse tells the client to do all of the following except? 1. Delivery system contains enough medication for at least 30 doses. Discard any unused solution after 30 doses. 2. If you don't feel the spray while using it, repeat the dose on the other nostril 3. Miacalcin is usually given as one spray per day into only one nostril 4. Take extra vitamin D while you are using Miacalcin

2. If you don't feel the spray while using it, repeat the dose on the other nostril

The nurse is instructing a nursing assistant on how to properly position a 45-year-old male client who underwent total hip replacement. The nurse explains that the client's hip needs to be in which position? 1. Straight with the knee flexed 2. In an abducted position 3. In an adducted position 4. Externally rotated

2. In an abducted position

A nurse is reviewing information about capsaicin cream with a client who reports continuous knee pain from osteoarthritis. Which of the following information should the nurse reinforce? 1. Continuous pain relief is provided 2. Inspect for skin irritation and cuts prior to application 3. Cover the area with tight bandages after application 4. Apply the medication every two hours during the day

2. Inspect for skin irritation and cuts prior to application

Allopurinol (Zyloprim) is prescribed for a client for the treatment of gout. The nurse is providing medication instructions. What should the nurse tell the client to do? 1. Take the medication on an empty stomach 2. Limit the use of vitamin C 3. A rash is a normal side effect of the medication 4. The effect of the medication will happen immediately

2. Limit the use of vitamin C Large doses of vitamin C while taking allopurinol can cause kidney stones to occur. It should be taken with milk or a meal and the full therapeutic effect usually takes a week or longer

A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse would avoid which of the following measures to minimize the risk of recurrence? 1. Strict adherence to a bowel retraining program 2. Limiting bladder catheterization to once every 12 hours 3. Keeping the linen wrinkle-free under the client 4. Preventing unnecessary pressure on the lower limbs

2. Limiting bladder catheterization to once every 12 hours The most frequent cause of autonomic dysreflexia is a distended bladder. Straight catherization should be done every 4 to 6 hours, and Foley catheters should be checked frequently to prevent kinks in the tubing.

A client has just returned from the post anesthesia care unit after undergoing internal fixation of a left femoral neck fracture. The nurse should place the client in which position? 1. On his left side with his right knee bent 2. On his back with two pillows between his legs 3. On his right side with his left knee bent 4. Sitting at a 90° angle

2. On his back with two pillows between his legs The operative leg must be kept abducted to prevent dislocation of the hip

The nurse is caring for a patient immediately following supratentorial intra-cranial surgery. What action by the nurse is appropriate? 1. Place patient in prone position with head turned to unaffected side 2. Place patient in supine position with head slightly elevated 3. Placed patient in the dorsal recumbent position 4. Placed patient in the Trendelenberg position

2. Placed patient in supine position with head slightly elevated. Alternatively, the patient could be put in a side lying position on the unaffected side. All other positions would increase intercranial pressure.

A nurse is assisting with preparing a plan of care to prevent a client from developing flexion contractures following a below the knee amputation 24 hours ago. Which of the following actions should the nurse include in the plan of care? 1. Limit any type of exercise to the residual limb for the first 48 hours after surgery 2. Position the client prone several times each day 3. Wrap the stump in a figure eight pattern 4. Encourage sitting in a chair during the day

2. Position the client prone several times each day Positioning prone several times a day for 20-30 minutes will prevent hip flexion contractures. Figure eight is correct, but won't prevent contractures. If the stump hangs in a bent position for an extended period of time, contractures can occur.

A client with a subarachnoid hemorrhage is prescribed a 1,000-mg loading dose of Dilantin IV. Which consideration is most important when administering this dose? 1. Therapeutic drug levels should be maintained between 20 to 30 mg/ml. 2. Rapid dilantin administration can cause cardiac arrhythmias. 3. Dilantin should be mixed in dextrose in water before administration. 4. Dilantin should be administered through an IV catheter in the client's hand.

2. Rapid dilantin administration can cause cardiac arrhythmias. Dilantin IV shouldn't be given at a rate exceeding 50 mg/minute. Rapid administration can depress the myocardium, causing arrhythmias. Therapeutic drug levels range from 10 to 20 mg/ml. Dilantin shouldn't be mixed in solution for administration. When given through an IV catheter hand, dilantin may cause purple glove syndrome.

Which of the following interventions describes an appropriate bladder program for a client in rehabilitation for spinal cord injury? 1. Insert an indwelling urinary catheter to straight drainage 2. Schedule intermittent catheterization every 2 to 4 hours 3. Perform a straight catheterization every 8 hours while awake 4. Perform Crede's maneuver to the lower abdomen before the client voids.

2. Schedule intermittent catheterization every 2 to 4 hours Intermittent catherization should begin every 2 to 4 hours early in the treatment. When residual volume is less than 400 ml, the schedule may advance to every 4 to 6 hours. Indwelling catheters may predispose the client to infection and are removed as soon as possible.

A nurse is caring for a client who injured her lower back during a fall and describes sharp pain in her back and down her left leg. In which of the following positions should the nurse plan to place the client to attempt to decrease her pain? 1. Prone without use of pillows 2. Semi Fowler's with a pillow under the knees 3. High Fowler's with the knees flat on the bed 4. Supine with the head flat

2. Semi Fowler's with a pillow under the knees This position has been found to relieve low back pain caused by bulging discs and nerve root involvement.

A female patient is receiving hypothermic treatment for uncontrolled fever is related to increased intracranial pressure ICP. Which of the following assessment findings requires immediate intervention? 1. Urine output of 100 mL per hour 2. Shivering 3. Cool, dry skin 4. Capillary refill of two seconds

2. Shivering Shivering can increase intracranial pressure by increasing vasoconstriction and circulating catecholamines. Shivering also increases oxygen consumption.

A client with gout is receiving indomethacin (Indocin) for pain. Which instruction should the nurse give to the client taking nonsteroid anti-inflammatory drugs NSAID's? 1. Bleeding is not a problem with NSAID's 2. Take NSAID's with food to avoid an upset stomach 3. Take NSAID's on an empty stomach to increase absorption 4. Don't take NSAID's at bedtime because they may cause excitement

2. Take NSAID's with food to avoid an upset stomach

The Monro-Kellie hypothesis refers to which of the following statements? 1. The brain's unresponsiveness to the environment 2. The dynamic equilibrium of cranial contents 3. The patient being wakeful but devoid of conscious content, without cognitive or affective mental function 4. The brains attempt to restore blood flow by increasing arterial pressure to overcome the increased intracranial pressure

2. The dynamic equilibrium of cranial contents. The theory states that because of the limited space for expansion with in the school, and increase in any one of the cranial contents causes a change in the volume of the others.

A nurse is caring for a client who has a new prescription for has a new prescription for adalimumab for rheumatoid arthritis. Based on the route of administration of adalimumab, which of the following should the nurse plan to monitor? 1. The vein for thrombophlebitis during IV administration 2. The subcutaneous site for redness following injection 3. The oral mucosa for ulceration after oral administration 4. The skin for irritation following removal of transdermal patch

2. The subcutaneous site for redness following injection adalimumab is administered SQ

A client with a cervical spine injury has Gardner-Wells tongs inserted for which of the following reasons? 1. To hasten wound healing 2. To immobilize the cervical spine 3. To prevent autonomic dysreflexia 4. To hold bony fragments of the skull together

2. To immobilize the cervical spine Gardner-Wells, Vinke, and Crutchfield tongs immobilize the spine until surgical stabilization is accomplished.

A nurse is reinforcing dietary teaching about calcium rich foods to a client who has osteoporosis. Which of the following foods should the nurse include in the instructions? 1. White bread 2. White beans 3. White meat of chicken 4. White rice

2. White beans

A client is prescribed colchicine. After taking three doses, the client complains of nausea, vomiting and loose bowels. Which of the following should the client do? 1. Skip the next dose and take another dose 2. Withhold the medication and notify the physician 3. Continue taking the medication as the symptoms will go away 4. Cut the next dosage in half

2. Withhold the medication and notify the physician G.I. symptoms are a sign of overdosage that can be fatal

A client who is regaining consciousness after a craniotomy becomes restless and attempts to pull out her IV line. Which nursing intervention protects the client without increasing her ICP? 1. Place her in a jacket restraint 2. Wrap her hands in soft "mitten" restraints 3. Tuck her arms and hands under the draw sheet 4. Apply a wrist restraint to each arm

2. Wrap her hands in soft "mitten" restraints It is best for the client to wear mitts which help prevent the client from pulling on the IV without causing additional agitation. Using a jacket or wrist restraint or tucking the client's arms and hands under the draw sheet restrict movement and add to feelings of being confined, all of which would increase her agitation and increase ICP.

A client is about to undergo total hip replacement surgery. Before the surgery, the nurse conducts a preoperative teaching session with him. The nurse can tell that her teaching has been effective when the client verbalizes the importance of avoiding which actions? Select all that apply 1. Keeping the legs apart while lying in bed 2. Periodically tightening the leg muscles 3. Internally rotating the feet 4. Bending to pick up items from the floor 5. Sleeping in a side lying position

3 and 4

The nurse is assessing the LOC of a patient who has suffered a head injury. The clients GCS score is 15. Which of the following did the nurse observed to arrive at a score of 15? Select all that apply 1. Bradycardia and hypotension 2. Incomprehensible sounds 3. Obeying motor commands 4. Oriented to person place and time 5. Spontaneous eye-opening 6. Unequal pupils size

3, 4 and 5

A nurse is reinforcing teaching with a client who has gout and a new prescription for allopurinol. For which of the following adverse effects should the client monitor? Select all that apply 1. Stomatitis 2. Insomnia 3. Nausea 4. Rash 5. Increased gout pain

3, 4 and 5 An increase in gout attacks can occur during the first few months of allopurinol

A client is admitted for closed spine surgery to repair a herniated disk. The nurse is discussing the surgery with the client. Which statement should she include in the discussion? 1. "It's riskier than open spine surgery" 2. "Intense physical therapy is needed" 3. "An endoscope is used to perform the surgery" 4. "Recovery time is no longer than with open spine surgery"

3. "An endoscope is used to perform the surgery"

Which response by the client indicates that the nurse's teaching regarding back safety has been effective? 1. "I'll start carrying objects at arm's length from my body" 2. "I'll sleep on my back at night" 3. "I'll carry objects close to my body" 4. "I'll lift items by bending over at my waist"

3. "I'll carry objects close to my body"

The nurse is caring for a patient following and SCI who has a halo device in place. The patient is preparing for discharge. Which of the following statements made by the patient indicates the need for further instruction? 1. "I will change the vessel liner often." 2. "I can apply powder under the liner to help with sweating." 3. "If a pin becomes detached, I'll notify the surgeon." 4. "I'll check under the liner for blisters and redness."

3. "I'll check under the liner for blisters and redness."

A nurse is reinforcing teaching with a client who has rheumatoid arthritis and a new prescription for methotrexate. Which of the following client statements indicates understanding? 1. "I'll be sure to return to the clinic yearly to have my blood drawn while I'm taking methotrexate" 2. "I will take this medication on an empty stomach" 3. "I'll let the doctor know if I develop sores in my mouth while taking this medication" 4. "I should stop taking oral contraceptives while I'm taking methotrexate"

3. "I'll let the doctor know if I develop sores in my mouth while taking this medication" Ulcerations of the oral mucosa are usually the first findings of methotrexate toxicity. It should be taken with food to decrease GI upset. It is contraindicated for pregnancy r/t fetal damage. CBC are monitored frequently.

Which statement by client diagnosed with gout indicates that he understands his discharge instructions? 1. "I'll increase my fluids so that the inflammation will be reduced" 2. "Increasing fluid intake will increase the calcium my body absorbs." 3. "Increasing fluid intake will cause my body to excrete more uric acid" 4. "Increasing fluids will help provide a cushion for my bones"

3. "Increasing fluid intake will cause my body to excrete more uric acid"

A nurse is caring for a client who has a benign brain tumor. The client asks the nurse if he can expect the same type of tumor to occur in other areas of his body. Which of the following is an appropriate response by the nurse? 1. "It can spread to breasts and kidneys." 2. "It can develop in your gastrointestinal tract." 3. "It is limited to brain tissue." 4. "It probably started in another area of your body and spread to your brain."

3. "It is limited to brain tissue."

A client asks for information about osteoarthritis. Which statement should you include in teaching the client about this condition? 1. "Osteoarthritis is rarely debilitating" 2. "Osteoarthritis is a rare form of arthritis" 3. "Osteoarthritis is the most common form of arthritis." 4. "Osteoarthritis afflicts people older than age 60."

3. "Osteoarthritis is the most common form of arthritis"

An 18-year-old client was hit in the head with a baseball during practice. When discharging him to the care of his mother, the nurse gives which of the following instructions? 1. "Watch him for keyhole pupil the next 24 hours." 2. "Expect profuse vomiting for 24 hours after the injury." 3. "Wake him every hour and assess his orientation to person, time, and place." 4. "Notify the physician immediately if he has a headache."

3. "Wake him every hour and assess his orientation to person, time, and place." Changes in LOC may indicate expanding lesions such as subdural hematoma; orientation and LOC are assessed frequently for 24 hours. Severe or worsening headaches should be reported.

Cerebral edema peaks at which time frame after intra-cranial surgery? 1. 48 hours 2. 72 hours 3. 24 hours 4. 12 hours

3. 24 hours Cerebral edema tends to peak 24 to 36 hours after surgery

Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia? 1. A client with a brain injury 2. A client with a herniated nucleus pulposus 3. A client with a high cervical spine injury 4. A client with a stroke

3. A client with a high cervical spine injury Autonomic dysreflexia refers to uninhibited sympathetic outflow in clients with spinal cord injuries about the level of T10. The other clients aren't prone to dysreflexia.

The nurse is caring for a patient involved in a motorcycle accident seven days ago. Since admission the patient has been on responsive to painful stimuli. The patient had a ventriculostomy placed upon admission to the ICU. The current assessment findings include ICP a 14 with good waveforms, pulse 92, respirations per vent to later, temperature of 102.7°F rectal, urine output 320 mL in four hours, pupils pin point and briskly reactive, and hot dry skin. Which of the following is the priority nursing action? 1. Inspect the ICP monitor to ensure it is working properly 2. Assess for signs and symptoms of infection 3. Administer Tylenol per orders 4. Provide ventriculostomy care

3. Administer Tylenol per orders Tylenol will help control the fever. An increase in the patient's temperature can lead to increased cerebral metabolic demands and poor outcomes if not properly treated.

The ED nurse is receiving a patient handoff report at the beginning of the nursing shift. The departing nurse noted patient with a head injury has Battle's sign. The nurse will expect which of the following clinical manifestations? 1. Escape of CSF from the patient's nose 2. Escape of CSF from the patient's ear 3. An area of bruising over the mastoid bone 4. A bloodstain surrounded by a yellowish stain on the head dressing

3. An area of bruising over the mastoid bone Fractures of the base of the skull tend to traverse the paranasal sinus of the frontal bone or the middle ear located in the temporal bone. Therefore, they frequently produce hemorrhage from the nose, fair next, ears and blood may appear under the conjunctiva. An area of ecchymosis may be seen over the mastoid.

When discharging a client from the ER after a head trauma, the nurse teaches the guardian to observe for a lucid interval. Which of the following statements best described a lucid interval? 1. An interval when the client's speech is garbled. 2. An interval when the client is alert but can't recall recent events. 3. An interval when the client is oriented but then becomes somnolent. 4. An interval when the client has a "warning" symptom, such as an odor or visual disturbance.

3. An interval when the client is oriented but then becomes somnolent. A lucid interval is described as a brief period of unconsciousness followed by alertness; after several hours, the client again loses consciousness.

The nurse is caring for a male patient who has emerged from a coma following a head injury. The patient is agitated. Which of the following interventions will the nurse implement to prevent patient injury? 1. Turning and repositioning the patient every two hours 2. Administering opioids to control restlessness 3. Applying an external urinary sheath catheter 4. Providing a dimly lit room to prevent visual hallucinations

3. Applying an external urinary sheath catheter

An unresponsive patient is brought to the emergency department by a family member. The family states, "we don't know what happened". Which of the following is the priority nursing intervention? 1. Assess pupils 2. Assess Glasgow coma scale 3. Assess for a patent airway 4. Assess vital signs

3. Assess for a patent airway

Conservative treatment of a HNP would include which measure? 1. Surgery 2. Bone fusion 3. Bed rest, pain medication and physiotherapy 4. Strenuous exercise, pain medication and physiotherapy

3. Bed rest, pain medication and physiotherapy

A 20-year-old client who fell approximately 30' is unresponsive and breathless. A cervical spine injury is suspected. How should the first-responder open the client's airway for rescue breathing? 1. By inserting a nasopharyngeal airway 2. By inserting a oropharyngeal airway 3. By performing a jaw-thrust maneuver 4. By performing the head-tilt, chin-lift maneuver

3. By performing a jaw-thrust maneuver If the client has a suspected cervical spine injury, a jaw-thrust maneuver should be used to open the airway. If the tongue or relaxed throat muscles are obstructing the airway, a nasopharyngeal or oropharyngeal airway can be inserted; however, the client must have spontaneous respirations when the airway is open. The head-tilt, chin-lift maneuver requires neck hyperextension, which can worsen the cervical spine injury.

Which medication directly inhibits osteoclasts thereby reducing bone loss and increasing bone mass density? 1. Teriparatide (Forteo) 2. Vitamin D 3. Calcitonin (Miacalcin) 4. Raloxifene (Evista)

3. Calcitonin

Which information is critical to include in the discharge plan for a client leaving the hospital in a leg cast? 1. Cast care procedures and devices to relieve itching 2. Skin care, mouth care and cast removal procedures 3. Cast care, neurovascular checks and hygiene measures 4. Cast removal procedures, neurovascular checks and devices to relieve itching

3. Cast care, neurovascular checks and hygiene measures

Which of the following types of posturing is exhibited by abnormal flexion of the upper extremities and plantar flexion of the feet? 1. Normal 2. Decerebrate 3. Decorticate 4. Flaccid

3. Decorticate

A client who has been recently diagnosed with gout asked the nurse to explain why he needs to take colchicine. The nurse plans her response based on the understanding that colchicine: 1. Increases estrogen levels in the blood stream 2. Decreases the risk of infection 3. Decreases inflammation 4. Decreases bone demineralization

3. Decreases inflammation

A client with osteoarthritis is refusing to perform her own daily care. Which approach would be most appropriate to use with this client? 1. Perform the care for the client 2. Explain that she needs to maintain complete independence 3. Encourage her to perform as much care as her pain will allow 4. Tell her that after she has completed her care, she'll receive her pain medication

3. Encourage her to perform as much care as her pain will allow

Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg? 1. Give the client a warming blanket 2. Administer low-dose barbiturate 3. Encourage the client to hyperventilate 4. Restrict fluids

3. Encourage the client to hyperventilate Normal ICP is 15 mm Hg or less. Hyperventilation causes vasoconstriction, which reduces CSF and blood volume, two important factors for reducing a sustained ICP of 20 mm Hg. A cooling blanket is used to control the elevation of temperature because a fever increases the metabolic rate, which in turn increases ICP. High doses of barbiturates may be used to reduce the increased cellular metabolic demands. Fluid volume and inotropic drugs are used to maintain cerebral perfusion by supporting the cardiac output and keeping the cerebral perfusion pressure greater than 80 mm Hg.

A client arrives at the ER after slipping on a patch of ice and hitting her head. A CT scan of the head shows a collection of blood between the skull and dura mater. Which type of head injury does this finding suggest? 1. Subdural hematoma 2. Subarachnoid hemorrhage 3. Epidural hematoma 4. Contusion

3. Epidural hematoma In a subdural hematoma, venous blood collects between the dura mater and the arachnoid mater. In a subarachnoid hemorrhage, blood collects between the pia mater and arachnoid membrane. A contusion is a bruise on the brain's surface.

Treatment of compartment syndrome includes which measure? 1. Amputation 2. Casting 3. Fasciotomy 4. Observation, no treatment is necessary

3. Fasciotomy

A client receiving azathioprine (Imuran) complains of hair loss. The nurse tells the client that? 1. Hair loss is irreversible 2. Hair loss is uncommon 3. Hair loss is temporary 4. Hair loss is a sign of toxicity

3. Hair loss is temporary Azathioprine is an immunosuppressant drug used to prevent organ rejection after a transplant or to treat rheumatoid arthritis.

Which term refers to the shifting of brain tissue from an area of high pressure to an area of low pressure? 1. Auto regulation 2. Cushing's response 3. Herniation 4. Monro-Kellie hypotheses

3. Herniation

A client is involved in an automobile accident and is being sent to a trauma center. Which classic fractures that typically occur from trauma should the staff be prepared to assess for? 1. Brachial and clavicle 2. Brachial and humerus 3. Humerus and clavicle 4. Occipital and humerus

3. Humerus and clavicle

A patient arrives at the emergency department via ambulance following a motorcycle accident. The paramedics state that the patient was found unconscious at the scene of the accident, but briefly regained consciousness during transport to the hospital. Upon initial assessment, the patient's GCS is seven. The nurse anticipates which of the following? 1. An order for a head CT scan 2. Intubation and mechanical ventilation 3. Immediate craniotomy 4. Administration of propofol Diprivan by IV

3. Immediate craniotomy The patient is experiencing an epidural hematoma - it is an extreme emergency. Treatment consists of making burr holes to decrease ICP, remove the clot and control the bleeding. They are often characterized by a brief loss of consciousness followed by a lucid interval in which the patient is awake and conversant. During the lucid interval, compensation for the expanding hematoma takes place by rapid absorption of CSF and decreased intravascular volume. When they can no longer compensate, even a small increase in the volume of blood produces a marked elevation an ICP. The patient then becomes increasingly restless, agitated and confused as the progressive condition becomes a coma.

A client who was casted for recent fracture of the right ulna complains of severe pain, numbness and tingling of the right arm. What would be the nurse's most appropriate response? 1. Administer Tylenol as prescribed 2. Lower the arm below the level of the heart 3. Immediately report the client's symptoms 4. Apply heating pad to the area

3. Immediately report the client's symptoms

A client comes into the ER after hitting his head in an MVA. He's alert and oriented. Which of the following nursing interventions should be done first? 1. Assess full ROM to determine extent of injuries 2. Call for an immediate chest x-ray 3. Immobilize the client's head and neck 4. Open the airway with the head-tilt chin-lift maneuver

3. Immobilize the client's head and neck All clients with a head injury are treated as if a cervical spine injury is present until x-rays confirm their absence.

The community health nurse found an elderly female client lying in the snow, unable to move her right leg because of a fracture. What's the nurse's first priority? 1. Realign the fracture ends 2. Reduce the fracture 3. Immobilize the fracture in its present position 4. Elevate the leg on whatever is available

3. Immobilize the fracture in its present position

The nurse is evaluating neurological signs of the male client in spinal shock following spinal cord injury. Which of the following observations by the nurse indicates that spinal shock persists? 1. Positive reflexes 2. Hyperreflexia 3. Inability to elicit a Babinski's reflex 4. Reflex emptying of the bladder

3. Inability to elicit a Babinski's reflex Resolution of spinal shock is occurring when there is a return of reflexes (especially flexors to noxious cutaneous stimuli), a state of hyperreflexia rather than flaccidity, reflex emptying of the bladder, and a positive Babinski's reflex.

A client with a recent fracture is suspected of having compartment syndrome. Data findings may include which symptoms? 1. Body wide decrease in bone mass 2. A growth in and around the bone tissue 3. Inability to perform active movement, pain with passive movement 4. Inability to perform passive movement, pain with active movement

3. Inability to perform active movement, pain with passive movement

The nurse is caring for a client with a cast on his left arm. Which assessment finding is most significant for this client? 1. Normal capillary refill in the great toe 2. Presence of a normal popliteal pulse 3. Intact skin around the cast edges 4. Ability to move all toes

3. Intact skin around the cast edges

Which areas of vertebral herniation are the most common? 1. L1-L2, L4-L5 2. L1-L2, L5-S1 3. L4-L5, L5-S1 4. L5-S1, S2-S3

3. L4-L5, L5-S1

A nurse is analyzing the laboratory studies on a client receiving Dantrium (dantrolene sodium). Which of the following laboratory test would identify an adverse effect associated with use of this medication? 1. BUN 2. Creatinine 3. Liver function test 4. Triglyceride

3. Liver function test Dantrium is a muscle relaxant like cyclobenzaprine (Flexeril) and Baclofen

Which description best identifies the position of an intervertebral disk? 1. Encloses the annulus fibrosus 2. Surrounds the nucleus pulposus 3. Located between the vertebrae and the spinal column 4. Located between spinal nerves in the vertebral column

3. Located between the vertebrae and the spinal column

The nurse is caring for a patient in the neurologic ICU who sustained a severe brain injury. Which of the following nursing measures will the nurse implement to aid in controlling ICP? 1. Administering enemas, as needed 2. Positioning the patient in the supine position 3. Maintaining cerebral perfusion pressure from 50 to 70 mmHg 4. Restraining the patient, as indicated

3. Maintaining cerebral perfusion pressure from 50 to 70 mmHg Other measures include elevating the head of the bed as prescribed, maintaining the patient's head and neck a neutral alignment, initiating measures to present a Valsalva maneuver, stool softeners, maintaining body temperature within normal limits, administering oxygen to maintain PaO2 greater than 90 mmHg, maintaining fluid balance with normal saline, avoiding noxious stimuli, administering sedation to reduce agitation.

Primary prevention of osteoporosis includes which measure? 1. Placing items within reach of the client 2. Installing bars in the bathroom to prevent falls 3. Maintaining optimal calcium and vitamin D intake and *walking* 4. Using a professional alert system in the home in case they fall occurs when the client is alone

3. Maintaining optimal calcium and vitamin D intake and *walking*

A client is admitted with a spinal cord injury at the level of T12. He has limited movement of his upper extremities. Which of the following medications would be used to control edema of the spinal cord? 1. Acetazolamide (Diamox) 2. Furosemide (Lasix) 3. Methylprednisolone (Solu-Medrol) 4. Sodium bicarbonate

3. Methylprednisolone (Solu-Medrol) High doses of Solu-Medrol are used within 24 hours of spinal injury to reduce cord swelling and limit neurological deficit.

A female client who fell while washing her outside windows has a fractured right ankle and is being fitted with a cast. After assisting with the cast application, what instructions should the nurse give the client? 1. Go home and stay in bed for about five days 2. Keep the cast covered with plastic until it feels dry 3. Move the right toes for several minutes every hour 4. Expect some swelling and blueness of the toes

3. Move the right toes for several minutes every hour

The nurse is planning care for the client in spinal shock. Which of the following actions would be least helpful in minimizing the effects of vasodilation below the level of the injury? 1. Monitoring vital signs before and during position changes 2. Using vasopressor medications as prescribed 3. Moving the client quickly as one unit 4. Applying Teds or compression stockings.

3. Moving the client quickly as one unit Reflex vasodilation below the level of the spinal cord injury places the client at risk for orthostatic hypotension, which may be profound. Measures to minimize this include measuring vital signs before and during position changes, use of a tilt-table with early mobilization, and changing the client's position slowly.

A client with a T1 spinal cord injury arrives at the emergency department with a BP of 82/40, pulse 34, dry skin, and flaccid paralysis of the lower extremities. Which of the following conditions would most likely be suspected? 1. Autonomic dysreflexia 2. Hypervolemia 3. Neurogenic shock 4. Sepsis

3. Neurogenic shock Loss of sympathetic control and unopposed vagal stimulation below the level of injury typically cause hypotension, bradycardia, pallor, flaccid paralysis, and warm, dry skin in the client in neurogenic shock.

While in the ER, a client with C8 tetraplegia develops a blood pressure of 80/40, pulse 48, and RR of 18. The nurse suspects which of the following conditions? 1. Autonomic dysreflexia 2. Hemorrhagic shock 3. Neurogenic shock 4. Pulmonary embolism

3. Neurogenic shock Symptoms of neurogenic shock include hypotension, bradycardia, and warm, dry skin due to the loss of adrenergic stimulation below the level of the lesion. Hypertension, bradycardia, flushing, and sweating of the skin are seen with *autonomic dysreflexia*. *Hemorrhagic shock* presents with anxiety, tachycardia, and hypotension; this wouldn't be suspected without an injury. *Pulmonary embolism* presents with chest pain, hypotension, hypoxemia, tachycardia, and hemoptysis; this may be a later complication of spinal cord injury due to immobility.

A client complains of joint pain in his great toe. He states that the joint becomes inflamed and painful but then subsides and recurs at irregular intervals. Which mechanism is believed to cause this? 1. Overproduction of calcium 2. Under production of calcium 3. Overproduction of uric acid 4. Under production of uric acid

3. Overproduction of uric acid

A nurse is assisting with the care of a client following surgical evacuation of a sub dural hematoma. Which of the following data is the priority to monitor? 1. Glasgow coma scale 2. Cranial nerve function 3. Oxygen saturation 4. Pupillary response

3. Oxygen saturation

A high-protein diet is ordered for a client recovering from a fracture. High protein is ordered for which reason? 1. Protein promotes glucogenesis 2. Protein has anti-inflammatory properties 3. Protein promotes cell growth and bone union 4. Protein decreases pain medication requirements

3. Protein promotes cell growth and bone union

A 30-year-old was admitted to the progressive care unit with a C5 fracture from a motorcycle accident. Which of the following assessments would take priority? 1. Bladder distension 2. Neurological deficit 3. Pulse ox readings 4. The client's feelings about the injury

3. Pulse ox readings After a spinal cord injury, ascending cord edema may cause a higher level of injury. The diaphragm is innervated at the level of C4, so assessment of adequate oxygenation and ventilation is necessary. Although the other options would be necessary at a later time, observation for respiratory failure is the priority.

A patient experiences a seizure while hospitalized for appendicitis. During the postictal phase, the patient is yelling and swings with a closed fist at the nurse. Which of the following is the appropriate action for the nurse to take? 1. Place the patient in wrist restraints 2. Apply oxygen via nasal cannula 3. Re-orient the patient while gently holding the arms 4. Administer lorazepam per orders

3. Re-orient the patient while gently holding the arms. It was not an intentional reaction and most patients do not remember becoming agitated.

A nurse is providing instructions to a client receiving Baclofen (lioresal). Which of the following would be included in the teaching plan? 1. Limit fluid intake 2. Hold the medication if diarrhea occurs 3. Restrict alcohol intake 4. Notify the physician if weakness occurs

3. Restrict alcohol intake Baclofen Is a muscle relaxant. The client should be cautioned against the use of alcohol and CNS depressants because it could potentiate the depressant activity. This drug can cause urinary retention, diarrhea and weakness that will diminish with continued medication use.

A client who had a recent total hip replacement is being seen by the home care nurse. When the nurse arrives, she notices a large number of small carpet scattered throughout the client's home. Which action should the nurse take as a result of this finding? 1. Ask the client why there are so many scattered carpets throughout the home 2. Collect the small carpets and place them together near the main door of the home 3. Review with the client the hazard small carpet play, especially for a person with musculoskeletal impairments 4. Nothing, there's nothing wrong with having small carpets scattered throughout the home

3. Review with the client the hazard small carpet play, especially for a person with musculoskeletal impairments

A client has been prescribed methotrexate (Trexall) for the treatment of rheumatoid arthritis that did not respond to any other treatments. An important reminder for this client is to? 1. Clay colored stools is a normal response of the treatment 2. Pregnancy is not contraindicated with use of this medication 3. Strict handwashing 4. Get a daily source of sunlight during the day

3. Strict handwashing Methotrexate puts the client at risk for infection. Clay colored stools are a sign of liver toxicity. Pregnancy is not allowed during the treatment. Photosensitivity may occur and the client should wear sunscreen and avoid sunlight.

A nurse is providing care for a client with a leg cast. To help prevent foot drop, which action by the nurse is the most appropriate? 1. Encouraging bed rest 2. Supporting the foot with 45° of flexion 3. Supporting the foot with 90° of flexion 4. Placing a stocking on the foot to provide warmth

3. Supporting the foot with 90° of flexion

Alendronate (Fosamax) is given to a client with osteoporosis. The nurse advises the client to? 1. Take the medication in the morning with meals 2. Take the medication two hours before bedtime 3. Take the medication with a glass of water after rising in the morning 4. Take the medication during lunch

3. Take the medication with a glass of water after rising in the morning

A client uses a cane for assistance in walking. Which statement is true about a cane or other assistive device? 1. A walker is a better choice than a cane 2. The cane should be used on the affected side 3. The cane should be used on the unaffected side 4. A client with osteoarthritis should be encouraged to ambulate without the cane

3. The cane should be used on the unaffected side

The nurse is teaching a client with metastatic bone disease about measures to prevent hypercalcemia. It would be important for the nurse to emphasize? 1. Early recognition of tetany 2. The need to have at least 5 servings of dairy daily 3. The importance of walking 4. The need to restrict fluid intake to less than 1 Liter/day

3. The importance of walking Mobility must be emphasized to prevent demineralization and breakdown of bones

A client is receiving methocarbamol (Robaxin) as an adjunct to physical therapy for the relief of painful muscle discomfort. Which of the following is not true regarding the use of the medication? 1. The parenteral form causes hypotension and bradycardia when given rapidly 2. The medicine can cause the urine to turn brown, black or green 3. The use of a cold or allergy medicine will lessen the side effects of the medication 4. The parenteral form is contraindicated in clients with liver damage

3. The use of a cold or allergy medicine will lessen the side effects of the medication Methocarbamol is a muscle relaxer. Cold and allergy medicines, sedatives, narcotics and medicines for seizures depression or anxiety add to sleepiness with this medication.

A 61-year-old male client has had gout for a long time and has developed nodules. While teaching the client, the nurse explains that these nodules are referred to by which term? 1. Cysts 2. Stones 3. Tophi 4. Calculi

3. Tophi

Use of which types of clothing would help a client with osteoarthritis perform activities of daily living at home? 1. Zippered clothing 2. Tied shoes 3. Velcro clothing, slip on shoes and rubber grippers 4. Buttoned clothing, slip on shoes and rubber grippers

3. Velcro clothing, slip on shoes and rubber grippers

If pulses aren't palpable, which intervention should be performed first? 1. Check again in an hour 2. Alert the nurse in charge immediately 3. Verify the findings with a hand-held Doppler 4. Alert the physician immediately

3. Verify the findings with a hand-held Doppler

A 40-year-old paraplegic must perform intermittent catheterization of the bladder. Which of the following instructions should be given? 1. "Clean the meatus from back to front." 2. "Measure the quantity of urine." 3. "Gently rotate the catheter during removal." 4. "Clean the meatus with soap and water."

4. "Clean the meatus with soap and water." Intermittent catheterization may be performed chronically with clean technique, using soap and water to clean the urinary meatus.

A 60-year-old female client has received teaching by her nurse about the causes of osteoarthritis. Which statement by the client indicates that further teaching is needed? 1. "My weight has played a role in my developing osteoarthritis" 2. "The broken bones I've had over the years have resulted in osteoarthritis" 3. "I'm getting older, which is associated with osteoarthritis" 4. "I have osteoarthritis because I haven't had enough calcium in my diet."

4. "I have osteoarthritis because I haven't had enough calcium in my diet." Osteoarthritis can be a result of trauma, age and obesity

A 42 year old client recently had a total hysterectomy. Which response by the client indicates that the teaching was effective? 1. "My risk for osteoporosis is low because I still have my thyroid gland." 2. "Osteoporosis affects only women over 65." 3. "I'm still producing hormones, so I don't have to worry about osteoporosis." 4. "I need to take precautions to protect myself from osteoporosis because I've had surgically induced menopause."

4. "I need to take precautions to protect myself from osteoporosis because I've had surgically induced menopause."

A client asks the nurse why she has applied a cold pack to a sprained ankle. Which response by the nurse would be most appropriate? 1. "It decreases pain and increases circulation" 2. "It numbs the nerves and dilates the blood vessels" 3. "It promotes circulation and reduces muscle spasm" 4. "It constricts local blood vessels and decreases swelling"

4. "It constricts local blood vessels and decreases swelling"

Which statement by the client indicates that client teaching regarding osteoarthritis has been effective? 1. "It's a systemic inflammatory disease of the joints" 2. "It involves fusing of the joints in the hand" 3. "It's an inflammatory joint disease that causes loss of articular cartilage in the synovial joint" 4. "It's a non-inflammatory joint disease that causes degeneration of the joints"

4. "It's a non-inflammatory joint disease that causes degeneration of the joints"

A nurse is reinforcing teaching with a client who is to have a bone scan. Which of the following statements should the nurse include? 1. "You will receive an injection of a radioactive isotope when the scanning procedure begins" 2. "You will be inside a tubelike structure during the procedure" 3. "You will need to take radioactive precautions with your urine for 24 hours after the procedure" 4. "You will have to urinate just before the procedure"

4. "You will have to urinate just before the procedure" An empty bladder promotes visualization of the pelvic bones

The nurse is caring for a patient following a head injury. The nurse understands that the patient is at risk for post traumatic seizures. A seizure that is classified as early occurs within which time frame? 1. Less than seven days following surgery 2. Four hours of injury 3. 24 hours of injury 4. 1 to 7 days of injury

4. 1 to 7 days of injury Post traumatic seizures are immediate, within 24 hours of injury, early, within 1 to 7 days after injury, or late, more than seven days after injury.

A client has been prescribed a diet that limits purine rich foods. Which food would the nurse teach her to avoid eating? 1. Bananas and dried fruits 2. Milk, ice cream, and yogurt 3. Wine, cheese, preserved fruits, meats, and vegetables 4. Anchovies, sardines, kidneys, sweet breads, and lentils

4. Anchovies, sardines, kidneys, sweet breads, and lentils

The nurse is caring for a patient with a spinal cord lesion above T6. Which of the following stimuli is known to trigger an episode of autonomic dysreflexia? 1. Diarrhea 2. Voiding 3. Placing the patient in a sitting position 4. Applying a blanket over the patient

4. Applying a blanket over the patient And object on the skin or skin pressure may precipitate an autonomic dysreflexia episode. Distended bladder, distention or contraction of the visceral organs, bowel constipation, stimulation of the skin are all noxious stimuli. Once the trigger is removed, and the patient is placed in a sitting position, the blood pressure should immediately lower.

Which of the following describes decerebrate posturing? 1. Internal rotation and adduction of arms with flexion of elbows, wrists, and fingers 2. Back hunched over, rigid flexion of all four extremities with supination of arms and plantar flexion of the feet 3. Supination of arms, dorsiflexion of feet 4. Back arched; rigid extension of all four extremities.

4. Back arched; rigid extension of all four extremities. Decerebrate posturing occurs in patients with damage to the upper brain stem, midbrain, or pons and is demonstrated clinically by arching of the back, rigid extension of the extremities, pronation of the arms, and plantar flexion of the feet. Internal rotation and adduction of arms with flexion of the elbows, wrists, and fingers described decorticate posturing, which indicates damage to corticospinal tracts and cerebral hemispheres.

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? 1. Age 78 years 2. History of cancer 3. Previous joint replacement 4. Bronchitis two weeks ago

4. Bronchitis two weeks ago

The nurse is caring for a patient with a skeletal muscle disorder. The nurse reviews the patient's lab results and expects which creatine phosphokinase isoenzyme to be elevated? 1. BB 2. MB 3. MK 4. MM

4. CK-MM is expressed during skeletal muscle disease. MB reflects cardiac muscle damage BB is expressed in the brain MK doesn't exist

If antibiotics don't eliminate osteomyelitis, which treatment is most commonly used next? 1. Bone grafts 2. Hyperbaric oxygen therapy 3. Amputation of the extremity 4. Debridement of necrotic tissue

4. Debridement of necrotic tissue

When the nurse observes that the patient has extension and X ternal rotation of the arms and wrists and extension plantar flexion and internal rotation of the feet she records the patient's posturing as which of the following? 1. Decorticate 2. Flaccid 3. Normal 4. Decerebrate

4. Decerebrate

A client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition? 1. Widening pulse pressure 2. Decrease in the pulse rate 3. Dilated, fixed pupil 4. Decrease in LOC

4. Decrease in LOC A decrease in the client's LOC is an early indicator of deterioration of the client's neurological status. Changes in LOC, such as restlessness and irritability, may be subtle. Widening of the pulse pressure, decrease in the pulse rate, and dilated, fixed pupils occur later if the increased ICP is not treated.

A nurse is caring for a client who has a new diagnosis of fibromyalgia. Which of the following medications should the nurse anticipate being prescribed for this client? 1. Colchicine 2. Hydroxychloroquine 3. Auranofin 4. Duloxetine

4. Duloxetine (Cymbalta) This medication is a seretonin morepinephrine reuptake inhibitor and is also used to treat depression and diabetic peripheral neuropathy Auranofin is a gold salt used to treat rheumatoid arthritis. Hydroxychloroquine is an anti-malarial used with methotrexate to treat rheumatoid arthritis. Cochicine is an anti inflammatory used to treat gout

The nurse is caring for the client in the ER following a head injury. The client momentarily lost consciousness at the time of the injury and then regained it. The client now has lost consciousness again. The nurse takes quick action, knowing this is compatible with: 1. Skull fracture 2. Concussion 3. Subdural hematoma 4. Epidural hematoma

4. Epidural hematoma The changes in neurological signs from an epidural hematoma begin with a loss of consciousness as arterial blood collects in the epidural space and exerts pressure. The client regains consciousness as the cerebral spinal fluid is reabsorbed rapidly to compensate for the rising intracranial pressure. As the compensatory mechanisms fail, even small amounts of additional blood can cause the intracranial pressure to rise rapidly, and the client's neurological status deteriorates quickly.

Which mechanism or condition causes healing of a fracture? 1. Scar tissue 2. Displacement 3. Necrotic tissue formation 4. Formation of new bone tissue

4. Formation of new bone tissue

Which of the following best describes how compartment syndrome can occur? 1. From internal pressure 2. From external pressure 3. From increased blood pressure 4. From internal and external pressure

4. From internal and external pressure

A nurse is reviewing the health record of a client who has a malignant brain tumor and notes the client has a positive Romberg sign. Which of the following actions should the nurse take to check for this manifestation? 1. Stroke the lateral aspect of the sole of the foot 2. Ask the client to blink his eyes 3. Observe for facial drooping 4. Have the client stand erect with eyes closed.

4. Have the client stand erect with eyes closed.

Compartment syndrome occurs under which condition? 1. Increase in scar tissue 2. Increase in bone mass 3. Decrease in bone mass 4. Hemorrhage into the muscle

4. Hemorrhage into the muscle

A 50 year old client is admitted to the emergency department with severe lower back pain, weakness and atrophy of the leg muscles. Suspecting a herniated disk, which diagnostic test would the nurse expect a physician to order? 1. Chest X-Ray, MRI, CT 2. Lumbar puncture, Chest X-Ray, MRI, CT 3. Lumbar puncture, Chest X-Ray, myelography 4. Myelography, MRI, CT scan

4. Myelography, MRI, CT scan

A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia? 1. Headache 2. Lumbar spinal cord injury 3. Neurogenic shock 4. Noxious stimuli

4. Noxious stimuli Noxious stimuli, such as a full bladder, fecal impaction, or a decub ulcer, may cause autonomic dysreflexia. A headache is a symptom of autonomic dysreflexia, not a cause. Autonomic dysreflexia is most commonly seen with injuries at T10 or above. Neurogenic shock isn't a cause of dysreflexia.

After treatment of compartment syndrome, a client reports experiencing paresthesia, which symptoms would be seen with paresthesia? 1. Fever and chills 2. Change in range of motion 3. Pain and blanching 4. Numbness and tingling

4. Numbness and tingling

Elevating a limb with a cast will prevent swelling. Which action best describes how this is done? 1. Place the limb with the cast close to the body 2. Place the limb with the cast at the level of the heart 3. Place the limb with the cast below the level of the heart 4. Place the limb with the cast above the level of the heart

4. Place the limb with the cast above the level of the heart

The nurse is caring for a client admitted with spinal cord injury. The nurse minimizes the risk of compounding the injury most effectively by: 1. Keeping the client on a stretcher 2. Logrolling the client on a firm mattress 3. Logrolling the client on a soft mattress 4. Placing the client on a Stryker frame

4. Placing the client on a Stryker frame Whenever possible, the client is placed on a Stryker frame, which allows the nurse to turn the client to prevent complications of immobility, while maintaining alignment of the spine. If a Stryker frame is not available, a firm mattress with a bed board should be used.

During an episode of autonomic dysreflexia in which the client becomes hypertensive, the nurse should perform which of the following interventions? 1. Elevate the client's legs 2. Put the client flat in bed 3. Put the client in the Trendelenburg's position 4. Put the client in the high-Fowler's position

4. Put the client in the high-Fowler's position Putting the client in the high-Fowler's position will decrease cerebral blood flow, decreasing hypertension. All of the other options will increase hypertension.

A 22-year-old client with quadriplegia is apprehensive and flushed, with a blood pressure of 210/100 and a heart rate of 50 bpm. Which of the following nursing interventions should be done first? 1. Place the client flat in bed 2. Assess patency of the indwelling urinary catheter 3. Give one SL nitroglycerin tablet 4. Raise the head of the bed immediately to 90 degrees

4. Raise the head of the bed immediately to 90 degrees Anxiety, flushing above the level of the lesion, piloerection, hypertension, and bradycardia are symptoms of autonomic dysreflexia, typically caused by such noxious stimuli such as a full bladder, fecal impaction, or decubitus ulcer. Putting the client flat will cause the blood pressure to increase even more. The indwelling urinary catheter should be assessed immediately after the HOB is raised.

A patient with neurologic infection develops cerebral edema from syndrome of inappropriate antidiuretic hormone SIADH. Which of the following is an important nursing action for this patient? 1. Maintaining adequate hydration 2. Administering prescribed antipyretics 3. Hyper oxygenation before and after tracheal suctioning 4. Restricting fluid intake and hydration

4. Restricting fluid intake and hydration

A male client with a fractured femur is in Russell's traction. He asks the nurse to help him with back care. Which nursing action is most appropriate? 1. Telling the client that he can't have back care while he's in traction 2. Removing the weight to give the client more slack to move 3. Supporting the weight to give the client more slack to move 4. Telling the client to use the trapeze to lift his back off the bed

4. Telling the client to use the trapeze to lift his back off the bed

The nurse is caring for a patient with a Trumatic brain injury. The nurse notes the following clinical findings during the reassessment of the patient. Which of the following will cause the nurse the most concern? 1. Urinary output increases from 40 mL an hour to 55 mL an hour 2. Heart rate decreases from 100 bpm to 90 bpm 3. Pulse oximetry decreases from 99% room air to 97% room air 4. Temperature increases from 98°F to 99.6°F

4. Temperature increases from 98°F to 99.6°F Fever in a patient with a TBI can be a result of damage to the hypothalamus, cerebral irritation from him Ridge or infection. The nurse should monitor the patient's temperature every 2 to 4 hours

A client who is taking methotrexate (Trexall) asks the nurse what is an appropriate activity while taking the medication. The nurse advises the client to play which activity? 1. Basketball 2. Ice hockey 3. Football 4. Tennis

4. Tennis The client should avoid contact sports or situations where bruising or injury could occur because the medication can lower the number of platelets necessary for proper blood clotting.

A client with a C6 spinal injury would most likely have which of the following symptoms? 1. Aphasia 2. Hemiparesis 3. Paraplegia 4. Tetraplegia

4. Tetraplegia

A client has a cervical spine injury at the level of C5. Which of the following conditions would the nurse anticipate during the acute phase? 1. Absent corneal reflex 2. Decerebrate posturing 3. Movement of only the right or left half of the body 4. The need for mechanical ventilation

4. The need for mechanical ventilation The diaphragm is stimulated by nerves at the level of C4. Initially, this client may need mechanical ventilation due to cord edema. This may resolve in time. The other options occur with brain injuries, not spinal cord injuries.

A client is diagnosed with a herniated nucleus pulposus (HNP) or herniated disc. Given her knowledge of HNP, how would the nurse most accurately explain the cause of pain in this condition? 1. The disk slips out of alignment 2. The disk shatters, and fragments place pressure on nerve roots 3. The nucleus tissue itself remains centralized, and the surrounding tissue is displaced 4. The nucleus of the disk puts pressure on the annulus, causing pressure on the nerve root

4. The nucleus of the disk puts pressure on the annulus, causing pressure on the nerve root

After a hypophysectomy, vasopressin is given IM for which of the following reasons? 1. To treat growth failure 2. To prevent syndrome of inappropriate antidiuretic hormone (SIADH) 3. To reduce cerebral edema and lower intracranial pressure 4. To replace antidiuretic hormone (ADH) normally secreted by the pituitary.

4. To replace antidiuretic hormone (ADH) normally secreted by the pituitary. After hypophysectomy, or removal of the pituitary gland, the body can't synthesize ADH. Somatropin or growth hormone, not vasopressin is used to treat growth failure. SIADH results from excessive ADH secretion. Mannitol or corticosteroids are used to decrease cerebral edema.

A client asks why he's been placed in traction prior to surgery. Which response by the nurse is most appropriate? 1. Traction will help prevent skin breakdown 2. Traction helps with re-positioning while in bed 3. Traction allows for more activity 4. Traction helps to prevent trauma and overcome muscle spasms

4. Traction helps to prevent trauma and overcome muscle spasms

A 75-year-old client with Paget's disease is undergoing tests for a suspected fracture. The nurse should expect to see which type of fracture? 1. Linear 2. Longitudinal 3. Oblique 4. Transverse

4. Transverse

A fracture line that is straight across the bone represents what type of fracture? 1. Linear 2. Longitudinal 3. Oblique 4. Transverse

4. Transverse

Clients with osteoarthritis may be on bed rest for prolonged periods. Which nursing intervention would be appropriate for these clients? 1. Encouraging coughing and deep breathing, and limiting fluid intake 2. Providing only passive range of motion and decreasing stimulation 3. Having the client lie as still as possible and giving adequate pain medicine 4. Turning the client every two hours and encouraging coughing and deep breathing

4. Turning the client every two hours and encouraging coughing and deep breathing

Which of the following findings in the patient who has sustained a head injury indicates increasing ICP? 1. Decreased respirations 2. Decreased body temperature 3. Increased pulse 4. Widened pulse pressure

4. Widened pulse pressure The Cushing triad is bradycardia, increasing systolic blood pressure and widening pulse pressure.

A nurse is caring for a patient diagnosed with an acute subdural hematoma following a craniotomy. The nurse is preparing to administer an IV dose of dexamethasone Decadron. The medication is available in a 20 mL IV bag and ordered to be infused over 15 minutes. At what rate will the nurse at the infusion pump?

80 mL/hr