Adult Health Chapters 51, 62, 63, 67, and 68 NCLEX questions and clinical judgement Flashcards
p. 1061, Physiological Integrity
A client has a new synthetic leg cast for a tibial fracture. What health care teaching does the nurse include for the client’s self-management at home? Select all that apply.
A. “Keep your leg elevated, preferably above your heart, as much as possible.”
B. “Apply ice on the cast for the first 24 hours to increase blood flow for healing.”
C. “Report severe numbness or inability to move your toes to your health care provider.”
D. “Take your pain medication as needed according to the prescription directions.”
E. “Don’t cover the cast with anything because it will stay wet for 24 hours.”
Answer: A, C, D
Rationale: The leg should remain elevated as much as possible to reduce swelling. Ice can be applied for the first 24 to 36 hours to reduce swelling and inflammation; this would not increase blood flow. Numbness or the inability to move toes should be immediately reported because this can indicate that a cast is too tight. Pain medication should be taken as directed. A fiberglass cast will become rigid within minutes.
p. 1066, Physiological Integrity
A client returns to the same-day surgical unit after having an ankle open reduction internal fixation (ORIF). What is the nurse’s priority action when caring for this client?
A. Monitor the client’s vital signs frequently.
B. Assess the client’s abdomen for bowel sounds.
C. Keep the client’s affected leg on a pillow.
D. Encourage the client to drink fluids.
Answer: A
Rationale: The postoperative care for a patient undergoing ORIF or external fixation is similar to that provided for any patient undergoing surgery. Because bone is a vascular, dynamic body tissue, the patient is at risk for complications specific to fractures and musculoskeletal surgery. As the priority, monitor vital signs frequently to assess for signs of bleeding, shock, or infection.
p. 1073, Psychosocial Integrity
A client who had an elective above-the-knee amputation (AKA) reports pain in the foot that was amputated. What is the nurse’s best response to the client’s pain?
A. “The pain will go away in a few days or so.”
B. “That’s phantom limb pain and every amputee has that.”
C. “On a scale of 0 to 10, how would you rate your pain?”
D. “The pain is not real, so we don’t treat it.”
Answer: C
Rationale: The client is experiencing phantom limb pain, which should be treated the same as any other type of pain. The best response is for the nurse to have the patient rate the pain and proceed to treat it appropriately. The nurse can then explain the concept and mechanism of phantom limb pain, as well as its expected duration.
p. 1075, Physiological Integrity The nurse is concerned that a client who had an ankle open reduction and internal fixation is at risk for complex regional pain syndrome. What assessment findings at the affected area are common when a client has this complication? Select all that apply. A. Burning pain B. Increase in sweating C. Muscle weakness D. Absent pedal pulse E. Edema
Answer: A, B, E
Rationale: A triad of clinical manifestations is present in complex regional pain syndrome (CRPS), including abnormalities of the autonomic nervous system (changes in color, temperature, and sensitivity of skin over the affected area; excessive sweating; edema), motor symptoms (paresis, muscle spasms, loss of function), and sensory perception symptoms (intense burning pain that becomes intractable [unrelenting]).
p. 1056, Patient-Centered Care; Evidence-Based Practice
A 63-year-old woman fell while standing on a step ladder to reach an item on the top shelf of her closet. After calling 911, she sat in a recliner chair while protecting her swollen right arm. When the paramedics arrived, the woman was drowsy but could be awakened. She had no other apparent injury or problem. Upon arrival at the emergency department (ED), you greet the patient and help her transfer into a room. The patient continues to become very drowsy at times but stated that she did not “hit her head” when she fell.
1. What are your priority evidence-based assessments for the patient when coming into the ED?
2. What history questions will you ask the patient once her pain is controlled?
3. The patient has a fractured right distal radius and reports that she is still in pain even though the emergency medical technician (EMT) gave her IV fentanyl. How will you respond to this patient, and what action will you take?
4. The patient’s husband comes to the ED and asks you if his wife’s history of bone loss may have caused the fracture. How will you answer him?
Suggested responses:
- What are your priority evidence-based assessments for the patient when coming into the ED?
Assess the patient’s neurological, cardiovascular, and musculoskeletal statuses as the priority while continuing to conduct a full head-to-toe assessment. - What history questions will you ask the patient once her pain is controlled?
Obtain a full medical, social and family history. Collect information about the context of today’s accident. Ask about alcohol, tobacco, and recreational and prescribed drug use. - The patient has a fractured right distal radius and reports that she is still in pain even though the emergency medical technician gave her intravenous fentanyl. How will you respond to this patient, and what action will you take?
Provide therapeutic communication; assure the patient that pain control is a priority. Explain that another method of pain control may be ordered, since fentanyl requires ongoing cardiac monitoring for patients who are older than 50. Conduct a thorough pain assessment, and collaborate with the ED health care provider to obtain orders for medication to control pain that will be administered in a timely fashion in addition to continued assessment and treatment. - The patient’s husband comes to the ED and asks you if his wife’s history of bone loss may have caused the fracture. How will you answer him?
Provide therapeutic communication and active listening. Explain that bone loss can contribute to the risk for fracture. Osteoporosis is often considered to be a “silent disease” because people do not know they have it until they have encountered a fracture.
p. 1074, Patient-Centered Care; Teamwork and Collaboration; Informatics
A 45-year-old man attempted to remove excess grass from his electric lawn mower blades while the mower continued to run. As a result, he severed part of his right hand. The amputated hand parts are mangled and cannot be salvaged. His wife called 911, and he was admitted to the emergency department (ED). He rates his pain as a 9 on a 0-to-10 pain intensity scale on admission.
1. As his nurse, what is your priority action when assessing this patient?
2. What other assessments will you perform and document in the electronic medical record (EMR)?
3. A hand surgeon evaluates the patient and finds that he will require surgery to débride and close the wound. What preoperative teaching will the patient require?
4. His wife is very concerned that he will lose his job if he cannot return to work soon. What is your best response at this time?
5. With what members of the health care team will you consult and collaborate?
Suggested responses:
- As his nurse, what is your priority action when assessing this patient?
Preventing and monitoring for sufficient perfusion, hemorrhage (and thus, shock) and infection. - What other assessments will you perform and document in the electronic medical record (EMR)?
Perform and document a full head-to-toe assessment, with priority attention given to cardiovascular, respiratory, and musculoskeletal status. You will also conduct and document a pain assessment, interventions to decrease pain, and the patient’s response to these interventions. It is important to continue to assess, be attentive to, and document the patient’s psychological reaction to the trauma as well. - A hand surgeon evaluates the patient and finds that he will require surgery to debride and close the wound. What preoperative teaching will the patient require?
Teach the patient that surgery is needed to maintain as much function as possible and to prevent hemorrhage. Assure the patient that pain will continue to be managed. - His wife is very concerned that he will lose his job if he cannot return to work soon. What is your best response at this time?
Provide therapeutic communication and active listening within a safe environment. Answer the wife’s questions and concerns honestly and openly. Do not provide false reassurance; rather, provide assurance that the patient’s status will be clearly disclosed to him and his wife as soon as the surgery is completed. The patient and family may need further referral to the surgeon to clarify understanding of the long-term prognosis, to a spiritual leader of their choice, and to other providers of care who can provide psychosocial support during this difficult time. - With what members of the health care team will you consult and collaborate?
Collaborate with all members of the health care team to decrease the chance for infection postoperatively. Collaborate with the patient’s surgeon and health care providers to continue to deliver appropriate mechanisms of pain control. Collaborate with the case manager (later in care) to make appropriate arrangements for continuity of care at the time of discharge or facility transfer. Consider referral to a social worker to talk with the patient and his wife based on the wife’s concern about the patient’s ability to return to work. At the patient’s request, collaborate with a spiritual leader of choice. The patient may also benefit from referral to community resources at the time of discharge or facility transfer.
p. 1268, Safe and Effective Care Environment
For which client does the nurse question the prescription of androgen replacement therapy?
A. 35-year-old man who has had a vasectomy
B. 48-year old man who takes prednisone for severe asthma
C. 62-year-old man who has a history of prostate cancer
D. 70-year-old man who has hypertension and type 2 diabetes
Answer: C
Rationale: Prostate cancer tends to increase its growth rate in the presence of any type of androgen. Thus, the man who has a history of prostate cancer should avoid exogenous androgen because it could enhance the growth if the previously treated cancer returns. None of the other conditions are contraindicated for androgen replacement therapy.
p. 1273, Physiological Integrity
Which urine properties indicate to the nurse that the client with syndrome of inappropriate (SIADH) antidiuretic hormone is responding to interventions?
A. Urine output volume increased; urine specific gravity increased
B. Urine output volume increased; urine specific gravity decreased
C. Urine output volume decreased; urine specific gravity increased
D. Urine output volume decreased; urine specific gravity decreased
Answer: B
Rationale: SIADH involves excessive secretion of vasopressin (ADH) when it is not needed. Water is reabsorbed, causing an increase in blood volume and a decrease in urine volume. Blood concentration is diluted, and urine concentration, as measured by specific gravity, is highly increased. When interventions to counter act SIADH are effective, the person slows water reabsorption so that urine output volume increases at the same time that urine concentration decreases, seen as a decreased urine specific gravity.
p. 1280, Health Promotion and Maintenance
The client who is about to have a unilateral adrenalectomy for an adenoma that is causing hypercortisolism asks the nurse if she will have to continue the severe sodium restriction after surgery. What is the nurse’s best response?
A. “No, once the tumor has been removed and your cortisol levels have normalized, you will not retain excess sodium anymore.”
B. “No, after surgery you will have to take oral cortisol, which can easily be controlled so that your sodium levels do not rise.”
C. Yes, the fact that you are retaining sodium and have high blood pressure is related to your age and lifestyle, not the tumor.”
D. “Yes, sodium is very bad for people and everyone needs to eliminate sodium completely from their diets for the rest of their lives.”
Answer: A
Rationale: A tumor secreting excessive amounts of cortisol is this patient’s reason for needing to severely restrict her sodium. After the tumor is removed, she will not have hypercortisolism but may have to take oral cortisol until the remaining adrenal gland begins to secrete sufficient cortisol. She will no longer experience severe sodium retention. Although people in North America tend to have high-sodium diets and many could stand to reduce their sodium intake, sodium is an essential element and cannot be eliminated from the diet.
Answer Key—Clinical Judgment Challenges
p. 1276, Patient-Centered Care; Quality Improvement; Safety
The patient is a 32-year-old woman admitted to your unit after surgery for fractures of the left arm and leg resulting from a car crash. She is awake and able to verify her medical history of rheumatoid arthritis and her usual daily medications. These are 10 mg of prednisone, naproxen 800 mg twice daily, oral contraceptives, calcium 600 mg, and one multiple vitamin tablet. All of these are prescribed for her to receive during her hospitalization. She is concerned about pain management and how long the recovery will be for the fractures. She is friendly, somewhat anxious, asks many questions, and wants to do “her part” to ensure good recovery. Over the next 4 days, she has become quieter, mumbles that her head and stomach hurt, and now does not recognize the assistant who has been providing her daily care. When she receives her medications, she has difficulty picking them up. The nursing assistant remarks that taking her pulse is difficult because it is so slow and irregular. When you assess her, she is so weak that she is unable to lift her arm for a blood pressure check. Her blood pressure is 92/50, which is down from the 128/84 reading on admission. You also verify that her heart beat is slow and irregular.
1. What other assessment data should you obtain immediately and why?
2. What is the most likely cause of the changes in this patient’s physical and mental status?
3. How could this problem been avoided?
4. What specifically would be the nurse’s role in preventing this problem?
5. What could be done to prevent this problem from happening again?
Suggested responses:
- What other assessment data should you obtain immediately and why?
Listen to her apical pulse to assess the true heart rate. With some dysrhythmias, especially if she is having premature contraction, the radial pulse can be very different from the apical pulse. Assess her oxygen saturation to determine whether cardiac function is adequate for the moment or whether the rapid response team is needed now. (Cardiac arrest is possible because of hyperkalemia.) Perform a finger stick blood glucose analysis immediately to determine whether she is hypoglycemic. - What is the most likely cause of the changes in this patient’s physical and mental status?
The most likely cause is acute adrenal insufficiency as a result of increased cortisol needs related to the stress of surgery and injury. Because she has been on prednisone long term, she has some degree of adrenal suppression and cannot increase the extra cortisol needed during the additional stress. Although she is receiving 10 mg of prednisone daily, it is not enough for her current needs. - How could this problem been avoided?
Daily assessment of her salivary or serum cortisol levels could have indicated a need for a higher dose. Also, because she was receiving prednisone, daily blood glucose levels should have been performed. Examining these parameters would provide data to determine the adequacy of her therapy, as well as its potential side effects. - What specifically would be the nurse’s role in preventing this problem?
This type of adrenal insufficiency develops over a period of days. Monitoring trends for level of consciousness, blood pressure, and heart rate and rhythm should be something all nurses do on every patient. It is very likely that changes were present earlier and not recognized. - What could be done to prevent this problem from happening again?
Any patient who routinely takes a corticosteroid should be automatically evaluated on a daily basis for manifestations of adrenal insufficiency. Ideally, the person would receive additional corticosteroid therapy in advance of changes to prevent adrenal insufficiency. At the very least, assessing for early manifestations could have identified this problem earlier and prevented a near tragedy.
p. 1288, Physiological Integrity Which manifestations are most often seen in general hyperthyroidism? Select all that apply. A. Increased appetite B. Cold intolerance C. Constipation D. Increased sweating E. Insomnia F. Palpitations G. Tremors H. Weight gain
Answer: A, D, E, F, G
Rationale: The person with any type of hyperthyroidism has increased metabolism, which causes an increased appetite, increased sweating, increased nervous system stimulation (tremors and insomnia), and increased cardiovascular responses (palpitations). In most people with hyperthyroidism, all other systems are also stimulated, causing increased bowel movements (not constipation) and an elevated body temperature (not cold intolerance). Even though appetite is increased, most people lose weight.
p. 1291, Safe and Effective Care Environment
For which assessment finding in a client who has severe hyperthyroidism does the nurse notify the Rapid Response Team?
A. An increase in premature ventricular heart contractions from 4 per minute to 5 per minute
B. An increase in or widening of pulse pressure from 40 mm Hg to 46 mm Hg
C. An increase in temperature from 99.5° F (37.5° C) to 101.3° F (38.5° C)
D. An increase of 20 mL of urine output per hour
Answer: C
Rationale: Although all changes listed are concerning, the one most associated with impending thyroid storm (thyroid crisis) is the increase in body temperature. This client requires immediate attention.
p. 1298, Safe and Effective Care Environment
When taking the blood pressure of a client receiving treatment for hyperparathyroidism, the nurse observes the client’s hand to undergo flexion contractions. What is the nurse’s interpretation of this observation?
A. Hyperphosphatemia
B. Hypophosphatemia
C. Hypercalcemia
D. Hypocalcemia
Answer: D
Rationale: Hypocalcemia destabilizes excitable membranes and can lead to muscle twitches, spasms, and tetany. This effect of hypocalcemia is enhanced in the presence of tissue hypoxia. The flexion contractions occurring during blood pressure measurement are indicative of hypocalcemia and referred to as a positive Trousseau’s sign.
Answer Key—Clinical Judgment Challenges
p. 1295, Patient-Centered Care; Safety
The patient, a 45-year-old former school teacher, is residing in a skilled nursing facility to recover from a tibia-fibula fracture that is being managed with an external fixation system. On admission 2 weeks ago, she told you that she felt she was “getting old too fast.” She explained that she had gained 54 pounds in the previous 6 months, had no energy, was often constipated, and was always cold. She teared up and said that her ability to concentrate was so bad that not only could she no longer help her high school children with their homework, but that she didn’t recognize the step hazard that caused her to fall and break her ankle. Today the nursing assistant assigned to her care reports that the patient’s pulse is only 42 beats per minute and that her temperature was 96° F even with two blankets. When you enter her room, she is sleeping with an untouched breakfast tray on her table.
1. What are the priority assessment data you should obtain? Provide a rationale for your choices.
2. Should oxygen be applied? Why or why not?
3. What indications do you have that the changes in her health status are not related to complications of her fractured ankle?
4. What manifestations of hypothyroidism are in her history and present during this assessment?
Suggested responses:
- What are the priority assessment data you should obtain? Provide a rationale for your choices.
Check her respiratory rate and effectiveness (use pulse oximetry). Then recheck her heart rate (apically) and blood pressure. She has indications of severe hypothyroidism. Respiratory arrest is a potential cause of death for patients with this problem. Assess her level of consciousness. Coma is possible, especially if she received any opioid drugs for pain control. - Should oxygen be applied? Why or why not?
Yes, oxygen should be applied. Her heart rate is so low that she is not able to maintain good oxygenation of vital organs. Applying additional oxygen can help oxygenate those tissues. Death from hypoxia is a strong possibility. - What indications do you have that the changes in her health status are not related to complications of her fractured ankle?
Some of her health status changes could be related to her fracture, specifically sepsis and pulmonary embolism. However, because she has had some of these changes gradually over several weeks, they are more likely to be related to reduced thyroid function. By assessing her cardiac and respiratory status, you are also assessing for manifestations of sepsis. Usually, respirations are elevated for either pulmonary embolism or for sepsis. Heart rate is usually fast and thready with these two problems. - What manifestations of hypothyroidism are in her history and present during this assessment?
Many of the problems that she has listed over the past 6 months are manifestations of hypothyroidism that is slowly getting worse. These include her weight gain, having no energy, being constipated frequently, always feeling cold, and having difficulty with concentration. It is also possible that her ankle fractured more easily because of hypothyroidism-induced bone thinning.
p. 1397, Health Promotion and Maintenance
Which statement made by the client newly diagnosed with polycystic kidney disease (PKD) indicates to the nurse that additional teaching for self-management is needed?
A. “I will need to increase my daily water intake.”
B. “I will restrict my sodium to less than 2 mg daily.”
C. “Now I will need to take a blood pressure drug daily.”
D. “If I become sexually active or plan to have a family, I will seek genetic counseling.”
Answer: B
Rationale: Patients with PKD waste sodium rather than retaining it. They need an increased sodium and water intake. Aggressive control of hypertension is needed to preserve kidney function. Genetic counseling is advised before having children because PKD is inherited.
