3A Flashcards
1
Q
The nurse is caring for a patient receiving medication therapy to prevent recurrent stroke. Which medication is pharmacologically appropriate for this purpose?
a. Enteric-coated aspirin (Ecotrin)
b. Gabapentin (Neurontin)
c. Recombinant tissue plasminogen activator (Retavase)
d. Bevacizumab (Avastin)
A
a
2
Q
Which abnormality occurs during embryonic development?
Aneurysm
Vasospasm
Atherosclerosis
Arteriovenous malformation(AVM)
A
Arteriovenous malformation(AVM)
3
Q
What type of complication would a patient with the condition depicted in the image be at risk for developing?
(AVM)
Embolic stroke
Thrombotic stroke
Intracerebral stroke
Subarachnoid stroke (subarachnoid hemorrhage)
A
Subarachnoid stroke (subarachnoid hemorrhage)
4
Q
A client is hospitalized when they present to the Emergency Department with right-sided weakness. Within 6 hours of being admitted, the neurologic deficits had resolved and the client was back to their presymptomatic state. The nurse caring for the client knows that the probable cause of the neurologic deficit was what?
a) Cerebral aneurysm
b) Transient ischemic attack
c) Left-sided stroke
d) Right-sided stroke
A
b
5
Q
A patient in the ED has slurred speech, confusion, and visual problems, and has been having intermittent episodes of worsening symptoms. The symptoms have a gradual onset. The patient also has a history of hypertension and atherosclerosis. What does the nurse suspect that the patient is probably experiencing?
A
Thrombotic stroke
6
Q
A patient with an ischemic stroke is placed on a cardiac monitor. Which cardiac dysrhythmia places the patient at risk for emboli?
a. Sinus bradycardia
b. Atrial fibrillation
c. Sinus tachycardia
d. First-degree heart block
A
b
7
Q
A patient has a history of deep vein thrombosis(DVT) in the lower leg. The patient arrives at the emergency department due to fears of having a stroke. Given this history, what type of stroke might the nurse first suspect?
A
embolic
8
Q
Which type of stroke shows interrupted vessel integrity and bleeding that occurs into the brain tissue or into the subarachnoid space?
A
Hemorrhagic stroke
9
Q
Which of the following is the best outcome for stroke management?
A
prevention
Make sure the patient’s cholesterol, weight, BP, If they exercise, stress, obese, diet is good
Diet, exercise, high cholesterol
10
Q
Which treatment regimen is preferred to reduce blood pressure and keep the lipid profile within normal limits in a patient with atherosclerosis?
Niacin+lovastatin
Aspirin+pravastatin
Ezetimibe+simvastatin
amlodipine+atorvastatin
A
amlodipine+atorvastatin
11
Q
Which medications are commonly used for lowering low-density lipoprotein cholesterol (LDL-C) levels?(sata)
Simvastatin
Lovastatin
Amlodipine
Metoprolol
Pravastatin
Acetylsalicylic acid
A
simvastin
lovastatin
pravastatin
12
Q
A family member of a client with a hemorrhagic stroke asks about anticoagulant therapy. The nurse explains that anticoagulant therapy for the client
A
. Is contraindicated because it will increase bleeding
13
Q
What do you give to thrombotic stroke?
A
TPA
14
Q
Best thing to do is prevent, when you can’t prevent it, if the patient has a stroke, cat scanner, and it does not show me the patient still has symptoms, assessment is done, thrombotic stroke, what are we going to give?
A
TPA
15
Q
If you can’t give tPA?
A
Heparin, Lovenox
16
Q
Which of the following is the drug of choice for a client who just arrived ED and got diagnosed with an ischemic stroke?
A
Alteplase (tPA [tissue plasminogen activator])
17
Q
The nurse is caring for a patient treated with alteplase following a stroke. Which assessment finding is the highest priority for the nurse?
A. Client’s blood pressure is 144/90.
B. Client is having epistaxis.
C. Client ate only half of the last meal.
D. Client continues to be drowsy
A
B
18
Q
The nurse is caring for a patient treated with alteplase following a stroke. Which assessment finding is the highest priority for the nurse?
A. Client’s blood pressure is 144/90.
B. Client is having epistaxis.
C. Client ate only half of the last meal.
D. Client continues to be drowsy
A
b
19
Q
A patient received rtPA for the treatment of ischemic stroke and the physician ordered an IV Sodium heparin infusion. In relation to the drug therapy, what do?
a. Elevated prothrombin level
b. Bleeding gums or bruising
c. Nausea and vomiting
d. Elevated hematocrit or hemoglobin
A
b
20
Q
A 56-year-old patient arrives in the emergency department with hemiparesis and dysarthria that started 2 hours previously, and health records show a history of several transient ischemic attacks (TIAs). The nurse anticipates preparing the patient for
a. surgical endarterectomy.
b. transluminal angioplasty.
c. intravenous heparin administration.
d. tissue plasminogen activator (tPA) infusion.
A
d
21
Q
The nurse is caring for a patient with a history of transient ischemic attacks (TIAs) and moderate carotid stenosis who has undergone a carotid endarterectomy. Which of the following postoperative findings would cause the nurse the most concern?
a) Blood pressure (BP): 128/86 mm Hg
b) Neck pain: 3/10 (0 to 10 pain scale)
c) Mild neck edema
d) Difficulty swallowing
A
d
22
Q
A patient is being evaluated for thrombolytic therapy. What are absolute contraindications for this procedure?(sata)
a. Ischemic stroke within 3 months
b. pregnancy
c. Suspected aortic aneurysm
d. major trauma in the last 12 months
e.Intracranial hemorrhage
f. Malignant intracranial neoplasm
A
acef
23
Q
A patient has received thrombolytic therapy for treatment of acute MI. What are the nursing post-administration responsibilities for this treatment? (Sata)
a. Document the patient’s neurologic status
b. Observe all IV sites for bleeding and patency
c. Monitor WBC count and differential
d. Monitor clotting studies
e. Monitor hemoglobin and hematocrit
f Test stools, urine, and emesis for occult blood
A
abdef
24
Q
A client who has had a stroke with left-sided hemiparesis has been referred to a rehabilitation center. The client asks, “Why do I need rehabilitation?” How does the nurse respond?
A
“Rehabilitation will help you function at the highest level possible.”
25
A patient with carotid atherosclerosis asks the nurse to describe a carotid endarterectomy. Which response by the nurse is accurate?
a. "The obstructing plaque is surgically removed from an artery in the neck."
b. "The diseased portion of the artery in the brain is replaced with a synthetic graft."
c. "A wire is threaded through an artery in the leg to the clots in the carotid artery and the clots are removed."
d. "A catheter with a deflated balloon is positioned at the narrow area, and the balloon is inflated to flatten the plaque."
a
26
You give a water, if they cough that means fail-
Start NPO until they have normal speech and swallowing
27
A patient experiences imparired swallowing after a stroke and has worked with speech-language pathology on eating. What nursing assessment best indicates that a priority goal for this problem has been met?
a. Chooses preferred items from the menu
b. Eats 75% to 100% of all meals and snacks
c. Has clear lung sounds on auscultation
d. Gains 2 pounds after 1 week
c
28
Which of the following is the best outcome for stroke management?
prevention
29
After a stroke, a patient has ataxia. What intervention is most appropriate to include on the patient’s plan of care?
Ambulate only with a gait belt
30
Initially after a brain attack (stroke, cerebrovascular accident), a client’s pupils are equal and reactive to light. Four hours later the nurse identifies that one pupil reacts more slowly than the other. The client's systolic blood pressure is beginning to increase. The nurse concludes that these signs are suggestive of:
ICP
31
The nurse is caring for a client who had a stroke. Which nursing intervention does the nurse implement during the first 72 hours to prevent complications?
Monitor neurologic and vital signs closely to identify early changes in status.
32
Following the ED Provider’s assessment of an acute stroke patient, The ED nurse continues to assess the patient every 15 minutes. The patient’s son is sitting by the bedside while the nurse assesses the patient. Which assessment findings warrant immediate intervention by the nurse? (sata)
GCS changes from 12 to 9
positive Babinski's reflex bilaterally
unable to verbalize response to questions
33
What is a potential adverse outcome of autonomic dysreflexia in a patient with a spinal cord injury?
a. Heatstroke
b. Paralytic ileus
c. Hypertensive stroke
d. Aspiration pneumonia
c
34
The Emergency Department (ED) nurse completes the admission assessment. Mr. Jones is alert but struggles to answer questions. When he attempts to talk, he slurs his speech and appears very frightened. Which additional clinical manifestations should the nurse expect to find if Mr. Jones' symptoms have been caused by a stroke?
carotid bruit
elevated BP
hyporeflexic DTR
35
. In demyelinating GBS, symptoms typically begin in the legs and spread to the arms and upper body. This is referred to as
ascending paralysis.,, need mechanical ventilation
36
An autoimmune process that occurs a few days or weeks after a
viral or bacterial infection
37
The nurse would expect to see which initial symptoms in a patient who is first showing signs of GBS?(sata)
Severe achy
cramplike pain
Floppy rag-doll-like movement
weakness and tingling of the limbs
38
Which of the following peripheral nerve disorders is being investigated for an association for occurrence after a vaccination, surgical procedure, or stressful event?
a. Bell's palsy
b. Trigeminal neuralgia
c. Meniere's disease
d. Guillain-Barre syndrome
d
39
What does the nurse understand that clients with Myasthenia Gravis, Guillain-Barre syndrome, and Amyotrophic Lateral Sclerosis (ALS) share in common?
Increased risk for respiratory complications
40
The nurse recognizes which pathophysiologic feature as a hallmark of Guillain-Barre syndrome?
a. Nerve impulses are not transmitted to skeletal muscle.
b. The immune system destroys the myelin sheath.
c. The distal nerves degenerate and retract.
d. Antibodies to acetylcholine receptor sites develop.
b
41
The nurse assesses a client who has Guillain-Barre syndrome. Which clinical manifestation does the nurse expect to find in this client?
a. Ophthalmoplegia and diplopia
b. Progressive weakness without sensory involvement
c. Progressive, ascending weakness and paresthesia
d. Weakness of the face, jaw, and sternocleidomastoid muscles
c
42
The patient with GBS describes a chronological progression of motor weakness that started in the legs and then spread to the arms and the upper body. Which type of GBS do these symptoms indicate?
a. Ascending
b. Pure motor
c. Descending
d. Miller-Fisher variant
a
43
The nurse is caring for a client diagnosed with Guillain Barre syndrome. Which assessment findings require nursing action? (Select all that apply.)
a. Blood pressure of 80/42
b. A respiratory rate of 24
c. Shallow breathing pattern
d. A peripheral oxygen saturation (Spo2) of 85%
e. Diminished breath sounds in all lung fields
acde
44
A patient is undergoing a Tensilon test. If the patient has Myasthenia Gravis, the nurse expects the patient to:
Cardiac dysrhythmias and cardiac arrest
45
The Nurse is assessing a patient with Myasthenia Gravis (MG). Which manifestations can the nurse expect to observe? (sata)
a. Ptosis
b. Diplopia
c. Delayed pupillary responses to light
d. Ocular palsies
e. Decreased pupillary accommodation
f. Fatigue
abdf
46
What can happen with this medication? - when the drug is not working
Drug holiday
Should start from low dos
47
What does sinemet do
Decrease tremors or rigidity
Improvement in spontaneous movement, effective for bradykinesia, more ambulatory
48
A nurse administers carbidopa-levodopa (Sinemet) to a client with Parkinson disease. Which therapeutic effect does the nurse expect the medication to procedure?
1. The client has cogwheel motion when swinging the arms.
2. The client does not display emotions when discussing the illness.
3. The client is able to walk upright without stumbling.
4. The client eats 30%-40% of meals within 1 hour.
3
49
Carbidopa-levodopa (Sinemet) is prescribed for a client with Parkinson’s disease. The nurse monitors the client for which side effects of the medication? (Sata)
a.vomiting
b.anorexia
c.slow heart rate
d.changes in mood
e.peripheral edema
abd
50
The nurse is assessing a patient with Parkinson’s disease. Which cardinal findings does the nurse expect to observe? (sata)
1. Tremors
2. Rigidity
3. Postural Instability
4. Slow movements
The nurse is assessing a patient with Parkinson’s disease. Which cardinal findings does the nurse expect to observe? (sata)
1. Tremors
2. Rigidity
3. Postural Instability
4. Slow movements
51
During the nurse’s assessment of a patient with Parkinson disease, the nurse notes that the patient has a mask like facies. What functional assessment is now a priority?
Ability to chew and swallow
52
Carbidopa-levodopa (Sinemet) is prescribed for a client with Parkinson’s disease. The nurse monitors the client for which side effects of the medication? (Sata)
Orthostatic hypotension, dizziness, anorexia, trouble sleeping, unusual dreams, a headache, lightheadedness , diarrhea, change in sense of taste, forgetfulness, constipation, nausea, vomiting, confusion,mydriasis, dry mouth,
53
What is a pathological (spontaneous) fracture?
Fracture that occurs to bone that is weak from a disease process, such as bone cancer or osteoporosis.
54
After a motor vehicle accident, a patient presents with a deformity to the leg with decreased pedal pulses. The fibula protrudes from the lateral aspect of the leg. How should the nurse classify the fracture?
Open & displaced
55
Which term is used to describe a type of fracture that produces a break in the skin?
Compound
Complicated
Greenstick
Spiral
a
56
The nurse is caring for a client admitted to the intensive care unit after incurring a basilar skull fracture. Which complication of this injury does the nurse monitor for?
a. is clear and tests negative for glucose
b. is grossly bloody in appearance and has a pH of 6
c. clumps together on the dressing and has a pH of 7
d. separates into concentric rings and tests positive for glucose
d
57
The nurse is caring for a client who has a vertebral fracture. Which intervention does the nurse implement to prevent deterioration of the client’s neurologic status?
Immobilize the affected portion of the spinal column.
58
A patient with a fractured pelvis is initially treated with bed rest with no turning from side to side permitted. The second day after admission, the patient develops chest pain, tachypnea, and tachycardia. The nurse determines that the patient's symptoms are most likely related to fat embolism when assessment of the patient reveals: (select all that apply)
A. hypotension
B. warm, reddened areas in her leg
C. paresthesia
D. petechiae of the neck and anterior chest wall
E. restlessness and confusion
de
59
A patient is in traction after a major leg injury. What nursing care is necessary for the patient? (sata)
Inspect the skin every 14 hours
Remove the belt used for traction once in a day
Ensure the weights are freely hanging at all times
Inspect the traction equipment every 8 to 12 hours
Monitor circulation every 4 hours after traction is applied
cd
60
A patient is in skeletal traction. Which nursing intervention ensures proper care of this patient?
Inspect the skin at least every 8 hours
61
Balanced suspension traction produced by counterforce
client in low Fowler's position
62
What statements about performing a closed reduction for a dislocated clavicle are correct? (sata)
It does not require sedation or analgesics
It is most commonly used for simple fractures
A fiberglass synthetic cast is used to immobilize the arm
The ends of the bones are manually pulled and realigned
A commercial immobilizer is used to keep the bone in place
bde
63
Which should cause a nurse to suspect that an infection has developed under a cast?
A Complaint of paresthesia
B. cold toes
C increased reparations
D Hot Spots felt on the cast surface
d
64
The nurse is caring for a patient with an external fixation of bone fracture. What are the advantages of this type of treatment (SATA)
A. It is less painful than other treatments
B. it allows for earlier ambulation
C. it decreases the risk for infection
D. It maintains bone alignment
E. It stabilizes comminuted fractures that require bone grafting.
bde
65
The nurse is educating a patient who will have external fixation for treatment of a compound tibial fracture. What information does the nurse include in the teaching session?
The device allows for early ambulation
There is some danger for blood loss, but no danger of infection
The device is substitute therapy for a cast
The advantage of the device is rapid bone healing
a
66
A client sustains a fractured femur and pelvic fractures in a motor vehicle crash. For which signs and symptoms, indicative of hypovolemic shock, does the nurse monitor the client closely? Select all that apply.
1.Tachycardia
2. Fever
3. Hypotension
4. Oliguria
5. Bradypnea
134
67
A 39-year-old patient who is hospitalized for repair of a fractured tibia and fibula reports shortness of breath. Which complication related to the injury might the patient be experiencing?
A hypovolemic shock
B Fat Embolism
C. Acute compartment Syndrome
D Pneumonia
b
68
A client has a fracture and is being treated with skeletal traction. Which assessment causes the nurse to take immediate action?
A The client blood pressure is 136/72
B. Capillary refill time of the extremity is less than 3 seconds
C. Slight clear drainage is noted at the pin site
D. The traction weights are resting on the floor.
d
69
A patient with a fractured pelvis is initially treated with bed rest with no turning from side to side permitted. The second day after admission, the patient develops chest pain, tachypnea, and tachycardia. The nurse determines that the patient's symptoms are most likely related to fat embolism when assessment of the patient reveals: (select all that apply)
A. hypotension
B. warm, reddened areas in her leg
C. paresthesia
D. petechiae of the neck and anterior chest wall
E. restlessness and confusion
de
70
A patient sustained a head injury and multiple other injuries in an automobile accident. The health care team has addressed the ABCs. Which priority assessment should be addressed next?
Rule out cervical spine fracture
71
A patient in a body case reports nausea, vomiting and epigastric pain. The nurse notifies the physician for orders. Which interventions is the most conservative. and therefore the first thing to try to address the patients symptoms?
A insert a nasogastric tube and attach to low wall suction
B Cut a window over the abdominal area of the cast
C Obtain an order for an x-ray to diagnose a paralytic ileus
D Administer PRN Antiemetic and PRN pain medication
b
72
Can you put ice over a cast?
yes
73
Which factors affect bone healing after a fracture has occurred? (SATA)
A. patient’s age
B. Patient occupation
C. Type of bone injured
D. How the fracture was managed
E. Presence of infection at the fracture site
acde
74
Which clinical findings does the nurse assess in the affected area of a patient with osteomyelitis (SATA)
A Erythema
B. Tenderness
C. Numbness and tingling
D. Swelling
E. Constant bone pain
abde
75
Which condition can result from the bone demineralization associated with immobility?
A. Osteoporosis
B. Urinary Retention
C. Pooling of blood
D. Susceptibility to infection
a
76
can result from the bone demineralization
osteoporosis
77
Which information from the client's history would the nurse identify as a risk factor for developing osteoporosis?
Receives long-term steroid therapy
78
____is a side effect of taking calcium and cause serious damage to the urinary system
hypercalcemia
79
Bleeding from the bone, soft tissue damage, possibly internal bleeding, hypovolemic shock-
Treat? Give fluid initially, but if it's from blood, administer blood, after patient is symptomatic-
How do you know the pt is hypovolemic shock? BP drop, fatigue, tachycardia(increased HR), weak pulses(decreased pulse pressure), decreased in MAP
80
A closed fracture of which bone poses the greatest risk of hypovolemic shock?
pelvis
81
A patient comes to the ED with crush syndrome from a crush injury to his right upper extremity and right lower extremity when heavy equipment fell on him at a construction site. The patient has signs and symptoms of hypovolemia, hyperkalemia, and compartment syndrome. Management of care for this patient will focus on preventing which complications? (Select all)
a) Sepsis
b) Cardiac dysrhythmias
c) Respiratory failure
d) Acute kidney failure
e) Fluid overload
bd
82
The nurse knows that a patient with crush injuries to the lower extremities is at high risk for what complication?
A Bradycardia
B Hypotension
C Acute kidney injury
D spinal nerve injury
c
83
A client who has sustained a crush injury to the right lower leg reports numbness and tingling of the affected extremity. The skin of the right leg appears pale. Which is the nurse first intervention?
A Assess pedal pulses
B. Apply oxygen via nasal cannula
C. increase the IV flow rate
a
84
A 25-year-old patient sustained a crush injury to his right upper extremity and right lower extremity when heavy equipment fell on him. Signs and symptoms of hypovolemia and compartment syndrome are present. Management of care for this patient will focus on preventing which complication?
Myoglobinuric renal failure
85
On the first postoperative day, a patient with a below-the-knee amputation complains of pain in the amputated limb. An appropriate action by the nurse is to
a. administer prescribed opioids to relieve the pain.
b. explain the reasons for phantom limb pain.
c. loosen the compression bandage to decrease incisional pressure.
d. remind the patient that this phantom pain will diminish over time.
a
86
The nurses assess a client with a below- Knee amputation. Which of the skin flaps requires immediate action?
A pink and warm to touch
B Pale and cool to the touch
C Dark, pink, and dry to the touch
D Pink and slightly moist to the touch
b
87
The nurse is caring for a patient with an above-the-knee amputation. To prevent hip flexion contractures, how does the nurse position the patient?
Prone position every 3-4 hours for 20-30 mins periods
88
What statements about amputation are correct? (sata)
a Traumatic amputations are caused by peripheral vascular disease
b Lisfranc and chopart amputations are types of midfoot amputations
c in a syme amputation, most of the foot is removed but the ankle remains
d Lower extremity amputations are less common in black and hispanic populations
e Lower extremity amputations are more common than upper extremity amputations
bce
89
Osteopenia - mild case of osteoporosis
90
A client with a fractured head of the right femur and osteoporosis is placed in Buck’s extension before surgical repair. What should the nurse do when caring for this client until surgery is performed?
1 Remove the weights from the traction every 2 hours to promote comfort.
2 Turn the client from side to side every 2 hours to prevent pressure on the coccyx.
3 Raise the knee gatch on the bed every 2 hours to limit the shearing force of traction.
4 Assess the circulation of the affected leg every 2 hours to ensure adequate tissue perfusion.
4
91
Which patient is most likely to be at risk for osteoporosis related to cultural differences and nutritional intake?
Older aftrican-american male who is a vegetarian
Young chinese american female who has anorexia nervosa
middle -aged native american female who has type 2 diabetes
Young white irish american male who is overweight
b
92
Which patient has the most risk factors associated with osteoporosis?
Female, white, menopausal, thin, lean, immobilized
93
When assessing a female client the nurse learns that the client has several risk for osteoporosis. Which factor will the priority for the client teaching?
A Low calcium intake
B. Postmenopausal status
C. Positive family history
D. Previous use of steroids
a
94
The patient is diagnosed with osteoporosis. Which intervention by the nurse would be appropriate?
A. Teach her to cut down on her cigarette smoking.
B. Recommend walking for 30 minutes 3 to 5 times a week. Physical activity is important
C. Suggest a diet that is high in protein and calcium but low in vitamin D (want to increase vitamin D). chest largest area to absorb sunlight for vit d
D. Tell her to include high-impact activities, such as running, in her exercise regimen
b
95
Which information from the client's history would the nurse identify as a risk factor for developing osteoporosis?
Receives long-term steroid therapy
96
During the intake assessment and interview, what information indicates that a patient has an increased risk for osteoporosis? (Select all that apply).
- Body mass index of 19
- Excessive alcohol use.
97
Before performing a physical examination. What assessments related to the patient's hearing can be done while observing the patient? SATA
a. observe if the patient is anxious or overly talkative
b. notice if the patient asks for questions to be repeated
c. notice the patient's response when not looking in the direction of sound
d. notice whether the patient tilts the head toward the examiner
e. observe the patient’s body posture and position
f. observe the patient’s clothes and hygiene
bcde
98
What is the rationale for elevating an extremity after a soft tissue injury such as a sprained ankle?
A. elevation increases the pain threshold
B. elevation increase metabolism in the tissues
C. elevation produces deep vasodilation
D. elevation reduces edema formation
d
99
The nurse performing a nursing history and assessment on an older patient. Which common findings in the older patient are related to the musculoskeletal system? SATA
A atrophy of muscle tissue
B degeneration of cartilage
C decrease in bone density
D decrease in falls due to lack of activity
E decrease in bone prominence
ac
100
The nurse is assessing a patient with an injury to the shoulder and upper arm after being thrown from their bicycle. What is the best position for this patient assessment?
A Supine so the extremity can be elevated
B. Low fowlers on an exam table for patient comfort
C. Slow ambulation to observe for natural arm movement
D Sitting to observe for shoulder droop
d
101
The nurse is caring for a patient with a cast applied recently for a fractured tibia. Which assessment findings indicate possible compartment syndrome (SATA).
A Capillary refill to extremity <3 seconds
B Palpable distal pulse
c. Severe pain not relieved by analgesics
D. Tingling of extremity
E inability to move extremity
cd
102
A 54 year old man presents to the ED with a deformed right ankle. He states that he was jogging close to the edge of a hillside and that he tripped and fell down the hill. There are No openings in the skin. A pulse cannot be obtained by touch to the right foot, Which is pale and cool to palpation. The patient rates his pain as an “8” on a scale of zero to 10. What is the priority nursing action at this time?
A. Administer pain medication.
B. Prepare for reduction.
C. Obtain a Doppler of the right foot pulse.
D. Notify the physician of the lack of a pulse in the right foot
c
103
A patient who recently suffered a broken tibia presents with edema, a great deal of pain, pale skin, and a weakened pulse. Upon palpation, the area is noted to be tense. What is most likely the concern?
Acute compartment syndrome
104
The nurse is caring for several patients on an orthopedic trauma unit. Which conditions pose a high risk for development of acute compartment syndrome? Select all that apply.
a.Lower legs caught between the bumpers of two cars
b.Massive infiltration of IV fluid into forearm
c.Bivalve cast on the lower leg
d.Multiple insect bites to lower legs
e.Daily use of oral contraceptives
f.Severe burns to the upper extremity
abdf
105
Which is a potentially fatal complication of acute compartment syndrome(SATA)
A Myoglobinuric renal failure
B Ischemic heart failure
C Sepsis from Gangrene
D Hypovolemic shock
ac
106
A patient is informed by the health care provider that a fiberglass cast must be applied to the lower extremity. What does the nurse teach the patient about the procedure before the cast is applied?
a. "The stockinette should be changed once a week."
b. "The cast material will dry and become rigid in a few minutes."
c. "The cast will increase your risk for skin breakdown"
d. "The fiberglass is not waterproof, so avoiding getting it wet."
b
107
After an open reduction and internal fixation of a fractured hip. What assessments of the client’s affected leg should the nurse make? ( SATA)
A skin temperature
B. Mobility of the hip
C. Sensation in the toes
D. Condition of the pins
E. Presence of pedal pulse
ace
108
The nurse case manager is making a home visit to assist an older patient with a hip fracture. During the home visit, the nurse reviews home environment safety. Which observation indicates a need for additional teaching?
a. Patient's bed has been moved to the ground floor level.
b. There are handle bars around the toilet and tub.
c. Floors are clean and shiny and covered with throw rugs.
d. Patient's walker is close to the patient's bedside.
c
109
The nurse is caring for a patient immobilized by a fractured hip. Which complication should the nurse monitor related to the patient’s immobilization status?
A. Metabolic rate increases
B. Increased joint mobility leading to contractures
C. Bone calcium increases releasing excess calcium into the body
D. Venous stasis leading to thrombi or Emboli formation
d
110
An older adult patient has skin traction in place for a hip fracture. Which outcome statement reflects that the goal of the therapy is successful?
Patient reports a decrease in pain for muscle spasms
111
A nurse provides instructions to a client about measures to prevent an acute attack of gout. The nurse determines that the client needs additional instructions if the client states:
A. it's important for me to drink a lot of fluids
B. a fad diet or starvation diet can cause an acute attack
C. I don’t need medication unless I’m having a severe attack
D. Physical and emotional stress can cause an attack
c
112
Dietary management of Gout includes which measures (SATA)
A Weight Reduction
B Salt Restriction
C High caloric intake
D Avoiding foods high in purine
E High carbohydrate diet
ad
113
During a home health visit you are helping a patient with gout identify foods in their pantry they should avoid eating. Select all the foods below the patient should avoid:
A. Sardines
B. Whole wheat bread
C. Sweetbreads
D. Crackers
E. Craft beer
F. Bananas
ace
114
A 75 year old male is admitted for chronic renal failure. You note that the patient has white/yellowish nodules on the helix of the ear and fingers. The patient reports they are not painful. As you document your nursing assessment findings, you will document this finding as?
A. Nodosa
B. Keloid
C. Dermoid
D. Tophi
d
115
The nurse is caring for a patient with GERD who presents with retrosternal burning. What term does the nurse use to document this symptom?
pyrosis
116
Which symptoms should be assessed for in a patient suspected of having GERD?(SATA)
Nausea
Vomiting
Eructation
Flatulence
Weight loss
cd
117
What symptom should be assessed for in a patient suspected of having GERD?
Eructation
118
A patient with GERD reports onset of midsternal chest pain radiating to the left arm. What is the correct priority action by the nurse?
Report the symptom to the provider so the cause can be determined
119
Which are the two most common manifestations of GERD? (SATA)
Dyspepsia(indigestion)
Eructation
Water brash
Regurgitation
Odynophagia (painful swallowing)
Flatulence
ad
120
A patient with acute gastritis is receiving treatment to block and buffer gastric acid secretion to relieve pain. Which drug does the nurse identify as an antisecretory agent (Proton Pump Inhibitor)?
Omeprazole
121
A patient with a hiatal hernia is prescribed famotidine. What is the action of this drug in the treatment of hiatal hernia?
Decreases gastric acid secretions
122
Esomeprazole is prescribed to a patient with GERD. What adverse effect might this medication cause?
GI infection
123
A patient is prescribed liquid Maalox for the treatment of GERD. What statement by the patient indicates a need for further teaching?
This should help with pain as well
I will take the medication with food
This antacid is a combination of two different types of antacids
I should have fewer side effects with this than the antacid I was chewing
b
124
A Patient newly diagnosed with gastroesophageal reflux disease asks the nurse what the prescribed medications are intended to do. What does the nurse tell the patient?
One goal of drug therapy is to prevent severe complications
125
A patient who will begin taking ranitidine to treat GERD asks the nurse if the medication will cure the disease. Which answer by the nurse is correct?
Ranitidine does not prevent actual reflux
126
The nurse is teaching a patient about taking an antacid containing magnesium salts to treat heartburn associated with GERD. What does the nurse include in the teaching?
If you develop diarrhea, you may need to try an aluminum salt antacid
127
A patient with GERD on a medication that raises the pH of gastric contents. Which drug does the nurse expect to administer?
Mylanta
128
By which actions do drugs used to treat GERD help to decrease the pain and discomfort the patient experiences? (sata)
Inhibition of gastric acid production
Blocking of pain sensation in the CNS
Accelerating gastric emptying
Decreasing lower esophageal sphincter pressure
Protecting the gastric mucosa
Destroying H. pylori bacteria
ace
129
An older adult with gastroesophageal reflux disease (GERD) is prescribed omeprazole. What priority teaching point must the nurse instruct the patient about while taking this drug?
a.Older adults taking this drug may be at increased risk for hip fracture because it interferes with calcium absorption.
b.Because of this drug’s effect of decreasing potassium, the patient may be prescribed a potassium supplement.
c.This drug causes sodium retention so the patient may be prescribed a sodium restriction.
d.A heart monitor may be needed because of changes in magnesium that can lead to life-threatening dysrhythmias.
a
130
Which symptoms alert the nurse that a patient may have a paraesophageal hiatal hernia?
Dysphagia
Eructation
Regurgitation
Breathlessness
Breathlessness
131
A patient in the outpatient clinic tells the nurse about experiencing heartburn and nighttime coughing episodes. Which action does the nurse take first?
Asks the patient about medications and dietary intake
132
A patient who had open Nissen fundoplication 2 days ago has been instructed to begin oral fluids but reports dysphagia associated with fluid intake. Which action by the nurse is correct?
Reassure the patient that this is a temporary problem after this type of surgery
133
The nurse is taking a GI health history from a newly admitted patient. Which questions would the nurse include in the interview? Select all that apply.
a.“Have you lost or gained weight recently?”
b.“Have you had any recent cardiac or respiratory surgeries?”
c.“Do you wear dentures, and if so, how do they fit you?”
d.“Do you have difficulty chewing or swallowing?”
e.“Have you traveled in the USA recently, and where?”
f.“What is your usual bowel elimination pattern?”
acdf
134
During abdominal assessment, the nurse detects a loud bruit near midline. What must the nurse do?
a.Measure the circumference of the patient’s abdomen just under the diaphragm.
b.Check the patient’s record for a history of stomach ulcers.
c.Avoid palpation or percussion of the abdomen.
D. Ask the patient about nausea and gastric reflux.
c
135
A client is admitted to the hospital with GI bleeding and a NG tube is inserted. The hcp prescribes the NG tube to be irrigated with NS whenever necessary to maintain patency. What should the nurse do first when it is determined that the nG tube is not patent?
Check the tube for placement
136
Which substances predispose a patient to peptic ulcer disease and gastrointestinal (GI) bleeding? Select all that apply.
a.Nonsteroidal anti-inflammatory drugs
b.Anticoagulants
c.Aspirin
d.Lasix
e.Digitalis
f.Caffeine
abcf
137
A patient being seen the emergency depart- ment (ED) has been vomiting blood for the past 12 hours. What test will likely be ordered for the patient?
a.Endoscopic retrograde cholangiopancrea- tography (ERCP)
b.Upper GI radiographic series
c.Esophagogastroduodenoscopy (EGD)
d.Barium enema
c
138
The nurse is providing care for a patient after an esophagogastroduodenoscopy (EGD). What is the first priority action after this diagnostic study?
a.Monitor vital signs.
b.Auscultate breath sounds.
c.Keep patient NPO until gag reflex returns.
d.Keep accurate intake and output.
c
139
The laboratory report of a patient with acute gastritis states there are traces of blood in the stool. What term does the nurse use to document this finding?
melena
140
The nurse is caring for a patient who has granular dark vomitus that resembles coffee grounds. Which type of ulcer does the nurse suspect in this patient?
Gastric
Pyloric
Duodenal
esophageal
gastric
141
The nurse inserts a nasogastric (NG) tube for gastric lavage in a patient who is vomiting blood. What is the appropriate practice for gastric lavage?
A large-bore NG tube is required for gastric lavage
Cold water is instilled in volumes of 200 to 300 mL
Sterile saline is used rather than tap water for gastric lavage
A sample of gastric contents is aspirated using a 10mL syringe
a
142
A patient with peptic ulcer disease has developed a pyloric obstruction, and the provider orders placement of a nasogastric (NG) tube. The NG tube is used for which purpose in this patient?
Prevention of peritonitis
Decompression of the stomach
Irrigation to remove blood clots
Provision of fluids and nutrients
decompress
143
A patient with a NG tube in place to help treat a gatric ulcer develops severe epigastric pain, and the nurse notes a rigid, board-like abdomen. The nurse notifies the provider of this condition. Which action does the nurse take first?
Maintain nasogastric suction
144
When the nurse assesses a patient after abdominal surgery, assessment reveals diminished, hypoactive bowel sounds. What is the nurse’s best action?
a. Notify the surgeon immediately.
b. Document the finding and continue to monitor.
c. Place an NG (nasogastric) tube.
d. Obtain a stat abdominal x-ray.
b
145
The nurse is caring for a client who is admitted with mastoiditis. Which assessment data obtained by the nurse requires the most immediate action?
a. The eardrum is red, thick-appearing, and immobile.
b. The lymph nodes are swollen and painful to touch.
c. The client reports a headache and a stiff neck.
d. The client's oral temperature is 100.1° F (37.8° C).
c
146
An adult patient with a history of otitis media states that his left ear pain is better. Now, the patient has noticed some pus with blood in the affected ear. What does the nurse suspect has happened?
a.Antibiotics are resolving the infection.
b.The eardrum has perforated.
c.The infection has worsened.
d.The ear is permanently damaged.
b
147
An older adult patient reports ear pain. To differentiate the cause, which clinical manifestation is more indicative of otitis media?
Vertigo
Dry, flaky cerumen
Ringing in the ears
Pain on movement of the tragus
vertigo
148
An adult patient with a history of otitis media states that his left ear pain is better. Now, the patient has noticed some pus with blood in the affected ear. What does the nurse suspect has happened?
a.Antibiotics are resolving the infection.
b.The eardrum has perforated.
c.The infection has worsened.
d.The ear is permanently damaged.
b
149
An older adult patient reports ear pain. To differentiate the cause, which clinical manifestation is more indicative of otitis media?
Vertigo
Dry, flaky cerumen
Ringing in the ears
Pain on movement of the tragus
vertigo
150
What comfort measures may the patient with external otitis find helpful?
Minimizing had movements
151
A myringotomy may need to be performed for______.
relieve pressure or promote drainage
otitis media
Procedure that makes an incision into the tympanic membrane usually done to relieve inflammation in the middle ear
152
Increased IOP- Glaucoma- irreversible blindness
153
Which statements about intraocular pressure are true ? (SATA) (don't know the final answer)
a. If the IOP is too low, the eyeball can collapse
b. The IOP is normally low in the eyeball
c. If the IOP is too high, pressure is exerted on the blood vessels
d. High IOP can cause glaucoma
e. High IOP maintains an adequate blood flow to the retina
acd
154
Which desired effect of therapy should the nurse explain to the client who has primary angle-closure glaucoma?(fill in or multiple choice)
1. Dilating the pupil
2. Resting the eye muscles
3. Preventing secondary infection
4. Controlling intraocular pressure
4
155
The health care provider is educating a 65-year-old patient on a new diagnosis of primary open-angle glaucoma (POAG). Which statement by the patient shows an understanding of the discussion?
"I will need to follow my treatment plan to prevent damage to the optic nerve."
156
The nurse is caring for four clients. Which has the highest risk for development of age-related macular degeneration (AMD)?
A. 25-year-old, 70 inches tall, with fracture of the right femur
B. 38-year-old, 71 inches tall, who has just given birth to a healthy baby
C. 45-year-old, 67 inches tall, who is a vegetarian
D. 57-year-old, 60 inches tall, with hypertension
d
157
What is an early sign/symptom of macular degeneration?
a.Mild blurring
b.Decreased tear production
c.Loss of central vision
d.Difficulty with activities of daily living
a.Mild blurring
158
In caring for a patient who was recently diagnosed with dry age-related macular degeneration, which teaching point would the nurse emphasize?
a.Importance of adhering to the exact schedule for eye drops
b.Dietary modifications to slow progression of vision loss
c.Avoiding activities that cause rapid or jerking head movements
d.Good handwashing and keeping the tip of the eyedropper clean
b
159
The nurse is caring for a client with a fractured femur. Which factor in the client's history may impede healing of the fracture?
a. A sedentary lifestyle
b. A history of smoking
c. Oral contraceptive use
d. Paget's disease
d
160
The client's chart indicates a sensorineural hearing loss. What assessment question does the nurse ask to determine the possible cause?
a. "Do you feel like something is in your ear?"
b. "Do you have frequent ear infections?"
c. "Have you been exposed to loud noises?"
d. "Have you been told your ear bones don't move?"
c
161
A nurse is teaching a community group about noise-induced hearing loss. Which client who does not use ear protection should the nurse refer to an audiologist as the priority?
a. Client with an hour car commute on the freeway each day
b. Client who rides a motorcycle to work 20 minutes each way
c. Client who sat in the back row at a rock concert recently
d. Client who is a tree-trimmer and uses a chainsaw 6 to 7 hours a day
d
162
Tinnitus may be caused by which factors? (Select all that apply.)
b. Otosclerosis
c. Continuous exposure to loud noise
d. Medications
e. Ménière's disease
163
An older adult in the family practice clinic reports a decrease in hearing over a week. What action by the nurse is most appropriate?
a. Assess for cerumen buildup.
b. Facilitate audiological testing.
c. Perform tuning fork tests.
d. Review the medication list.
a
164
Which statements about retinal detachment are accurate? Select all that apply.
Retinal detachments are classified by the cause.
Restricting head movement can prevent further detachment.
Spontaneous reattachment of a totally detached retina is rare.
165
After surgery to repair a retinal detachment, an older adult client is transferred to the postanesthesia care unit with the affected eye patched. During the first four hours after surgery, the nurse should plan to notify the health care provider if the client:
Reports of sharp pain in the eye indicate that hemorrhage may be occurring in the eye.
166
_____ drug therapy is administered to a patient with meniere's disease to decrease endolymph volume
Diuretic
167
The student nurse is caring for a patient with an acute attack of Ménière's disease. Which finding indicates a need for further teaching of the student nurse?
1) The patient's urine output is measured.
2) An emesis basin is kept on the bedside table.
3) The patient is placed in the dayroom to watch a favorite action movie.
4) Three side rails on the patient's bed are placed in the upright position.
3
168
An adult patient has been diagnosed with Ménière's disease. Which points does the nurse include in the teaching plan for this patient? (Select all that apply.)
a. Make slow head movements.
b. Reduce the intake of salt.
c. Stop smoking.
d. take vitamin supplements
e.avoid red meat
f. irrigate the ears frequently to decrease cerumen
abc
169
Which statement about the Meniett device used in the treatment of Meniere’s disease is accurate?
The device improves hearing loss
Long-term success in control of vertigo is 50%
Low pressure is applied to the inner ear 5 times a day
A tympanostomy tube must first be placed in the affected ear
d
170
Which signs and symptoms should a patient who has had cataract surgery report to the health care provider? (Select all that apply.)
a. Sharp, sudden pain in the eye
b. Decreased vision
d. Green or yellow thick discharge
e. Flashes of light
f. lid swelling
g. mild eye itching
abdef
171
After cataract surgery, a client reports feeling nauseated. How can the nurse help to relieve the nausea?
1. Administer the prescribed antiemetic drug.
2.Provide some dry crackers for the client to eat.
3.Explain that this is expected following surgery.
4.Teach how to breathe deeply until the nausea subsides
1
172
The nurse is providing preoperative teaching for a client who is to have cataract surgery. Which is appropriate for the nurse to include concerning what the client should do after surgery? (Sata)
1. Do not blow your nose.
2. Remain flat for three hours.
3. Eat a soft diet for two days.
4. Breathe and cough deeply.
5. Avoid bending from the waist.
15
173
Which clinical findings does the nurse assess in the affected area of a patient with osteomyelitis (SATA)
A Erythema
B. Tenderness
C. Numbness and tingling
D Swelling
E Constant bone pain
abde
174
The nurse is caring for a patient with an open wound from chronic osteomyelitis. How does the nurse ensure that this patient receives increased tissue perfusion?
Exposing the affected area to a high concentration of oxygen
175
A patient has had a sequestrectomy of the right fibula for osteomyelitis 1 day ago. Which assessment finding requires the nurse to contact the surgeon immediately?
Paresis of right lower extremity
176
What interventions may be utilized to manage a patient with chronic osteomyelitis?(sata)
a.Irrigating wounds through the window of a cast
b.Administering systemic antibiotic therapy for 2 weeks
c.Applying strict aseptic technique for dressing changes
d.Exposing the affected area to hyperbaric oxygen therapy
e.Packing the wound with bone cement bead impregnated with antibiotic
ade
177
The nurse is assessing a patient diagnosed with acute osteomyelitis. What features of this disorder does the nurse expect to find? (sata)
a.Temperature above 101F
b.Drainage from the affected area
c.Swelling around the affected area
d.Erythema around the affected area
e.Pulsating pain that worsens with movement
f.Ulceration of the skin resulting in a sinus tract
acde
178
A patient has recently undergone surgery to treat osteomyelitis. What are the signs of neurovascular compromise after the surgery? (sata)
a.Paresthesia
b.Pulselessness
c.Purulent discharge
d.Uncontrollable pain
e.Paresis or paralysis
f.Presence of erythema
abde
179
What complication of osteomyelitis is the most likely to occur?
Formation of bone abscesses
180
A 40-year old patient is admitted for acute osteomyelitis of the left lower leg. What does the nurse expect to find documented in the patient’s admitting assessment?
Temperature greater than 101F, swelling, tenderness, erythema, and warmth of area
181
The nurse is teaching a patient about antibiotic therapy for osteomyelitis. What information does the nurse give to the patient?
The infected wound may be irrigated with one or more types of antibiotic solutions
182
Which precautions does the nurse instruct a patient to follow after having ear surgery? (Select all that apply.)
b. "Stay away from people with colds."
c. "Do not drink through a straw for 2 to 3 weeks."
d. "Keep your ear dry for 6 weeks."
e. "Avoid straining when having a bowel movement."
183
A nurse is teaching a group of clients with peripheral vascular disease about a smoking cessation program. Which physiologic effect of nicotine should the nurse explain to the group?
Constriction of the peripheral vessels increases the force of flow.
184
___ hormone responds to a low serum calcium blood level by increasing bone resorption?
PTH?
