Exam 3

Question 1

Which statements about intraocular pressure are true? Select all that apply.

Answer 1

if the IOP is too low, the eyeball can collapse. (can happen in end stage glaucoma)

If the IOP is too high, pressure is exerted on the blood vessels.

High IOP can cause glaucoma.

Question 2

Which clinical findings does the nurse assess in the affected area of a patient with osteomyelitis? Select all that apply.

Answer 2

Mnemonic: PEST

• *P**ulsating pain that worsens with movement
• *E**rythema around the affected area
• *S**welling around the affected area
• *T**emperature above 101

Rationale: In a patient with acute osteomyelitis, the nurse would assess fever with a temperature above 101° F. There is swelling, erythema, and tenderness around the affected area. The patient also experiences localized bone pain that is constant, pulsating, and worsens with movement. Ulceration resulting in sinus tract and drainage from the affected area are characteristic features of chronic osteomyelitis.

Question 3

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 the patients assessment?

Answer 3

Sitting to observe for shoulder droop

Question 4

The nurse assesses the client with a below knee amputation, BKA.Which assessment of the skin flap requires immediate action?

Answer 4

Pale and cool to the touch

Rationale: The skin flap should appear pink in a light-skinned person and not discolored in a darker-skinned person. The area should feel warm but not hot. Pale and cool skin could indicate inadequate blood flow to the area. The nurse would notify the provider.

Question 5

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 regarding the use of crutches?

Answer 5

The device allows for early ambulation

Question 6

The patient comes from the emergency department (ED) after accidentally puncturing his hand with an automatic nail gun. Which disorder is this patient primarily at risk for?

Answer 6

Osteomyelitis

Question 7

What is the rationale for elevating an extremity after a soft tissue injury, such as a sprained ankle?

Answer 7

Elevation reduces edema formation

Rationale: Elevating the extremity uses gravity to facilitate venous return to reduce edema. Elevation should have no significant effect on the pain threshold. Elevation should not affect metabolism. Venous return to the heart, not vasodilation, is facilitated by elevation.

Question 8

After an open reduction and internal fixation (ORIF) of an fractured hip. What assessments of the clients effective leg should the nurse make? Select all that apply.

Answer 8

Mnemonic: PS2

presence of pedal pulses
skin temp
sensation in the toes

Rationale: increased skin temp may indicate the presence of an infection; decreased skin temp suggests impaired circulation. sensation of the toes assesses the neural integrity distal to the surgical site. pedal pulse assesses the circulatory integrity distal to the surgical site

Question 9

Which factors affect bone healing after a fracture has occurred? Select all that apply.

Answer 9

Mnemonic: HTPP

• *H**ow the fracture is managed
• *T**ype of bone injured
• *P**atient’s age
• *P**resence of infection at the fracture site

Question 10

What priority laboratory analysis should the nurse review when caring for a patient with Crohn’s disease?

Answer 10

Hemoglobin

Rationale: Crohn’s disease presents as transmural inflammation that causes a thickened bowel wall, strictures, and deep ulcerations that result in severe diarrhea and malabsorption of vital nutrients. Anemia is common, usually from iron deficiency or malabsorption issues. C-reactive protein may be monitored as a marker of inflammation, albumin to assess nutritional status, and potassium related to losses from diarrhea.

Question 11

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?

Answer 11

Constriction of the peripheral vessels increases the force of flow.

Rationale: Constriction of the peripheral blood vessels and the resulting increase in blood pressure impairs circulation and limits the amount of oxygen being delivered to body cells, particularly in the extremities. Nicotine constricts all peripheral vessels, not just superficial ones. Its primary action is vasoconstriction; it will not dilate deep vessels. Nicotine constricts rather than dilates peripheral vessels.

Question 12

The nurse is performing a nursing history and assessment on an older adult. Which common findings in the older adult are related to the musculoskeletal system? Select all that apply.

Answer 12

Mnemonic: RADD

• *R**educed range of motion of the joints
• *A**trophy of the muscle tissue
• *D**egeneration of cartilage
• *D**ecrease in bone density

Rationale: In the older adult, common findings include a decrease in bone density, atrophy of muscle tissue, cartilage degeneration, and a decrease in range of motion. In addition, falls increase as the result of kyphotic posture, widened gait, and an alteration in the center of gravity, creating an unsteady walking pattern. Increased bony prominences are observed in the older adult because less soft tissue is present to cushion the bone, and pressure ulcers are a threat.

Question 13

The nurse is caring for several patients on an orthopedic trauma unit. Which conditions have a high risk for development of acute compartment syndrome? Select all that apply.

Answer 13

Lower legs caught between the bumpers of two cars
Massive infiltration of IV fluid into forearm
Multiple insect bites to lower legs
Severe burns to the upper extremities

Rationale: The cause of acute compartment syndrome are classified into two different categories: externa and internal pressure. External pressure includes tight, bulky dressing and casts. Internal pressure causes fluid or blood flow in the compartment and accumulates. Other common causes of acute compartment syndrome include crush injuries or overuse injuries, extensive insect bites or snakebites, or massive infiltration of IV fluids (Ignatavicius, 2018, p. 1033).

Question 14

An adult patient has been diagnosed with Meniere’s disease.Which points does the nurse include in the teaching plan for this patient? Select all that apply.

Answer 14

Mnemonic: MRS

• *M**ake slow head movements.
• *R**educe the intake of salt.
• *S**top smoking.

Question 15

A 39-year-old patient who was hospitalized for repair of a fractured tibia and fibula, reports shortness of breath. Which complication related to the injury might the patient be experiencing?

Answer 15

Fat embolism

Question 16

Prior to liver biopsy, it is most important for the nurse to be aware of which lab test result.

Answer 16

Prothrombin time

Question 17

An older patient diagnosed with bacterial gastroenteritis reports abdominal cramping, diarrhea, nausea and vomiting, and fatigue for the past 24 hours. The nurse should monitor the patient for what priority assessment?

Answer 17

Dehydration

Rationale: In older adults, dehydration occurs with viral and bacterial gastroenteritis and may require hospitalization. Electrolyte imbalances are also common, especially hypokalemia and hypernatremia. The aging skin is also at risk of compromise from frequent exposure to enzymes in the stool.

Question 18

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 the 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 0-10. What is the priority nursing action at this time?

Answer 18

Obtain a Doppler of the right foot pulse.

Question 19

A patient comes to the ED with Crush syndrome from a crush injury to the 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 the patient will focus on preventing which complications? Select all that apply.

Answer 19

Mnemonic: AC / Atlantic City

• *A**cute kidney failure/ Acute tubular necrosis
• *C**ardiac dysrhythmias

Question 20

A nurse is reviewing orders for a patient who was admitted for 24-hour observation of a leg fracture. Cast is in place: which order does the nurse question?

Answer 20

Perform neurovascular assessments (“circ checks”) every 8 hours.

Perform neurovascular (NV) assessments (also known as “circ checks” or CMS assessments) frequently before and after fracture treatment. Patients who have extremity casts, splints with elastic bandage wraps, and open reduction with internal fixation (ORIF) or external fixation are especially at risk for NV compromise. If blood flow to the distal extremity is impaired, the patient reports increased pain and decreased sensory perception and movement. At risk for acute compartment syndrome.

Question 21

Which condition can result from the bone demineralization associated with immobility?

Answer 21

Osteoporosis

Rationale: Bone demineralization leads to a negative calcium balance, osteoporosis, pathologic fractures, extraosseous bone formation, and renal calculi

Question 22

Dietary management of gout includes which measures. Select all that apply.

Answer 22

Low purine

• Rationale: Dietary treatment for gout aims to reduce sodium urate through a low-purine diet which means avoidance of bacon, turkey, veal, liver, kidney, bran, anchovies, sardines, herring, smelt, mackerel, salmon, and legumes.
• Alcohol should also be avoided because it increases uric acid production and reduces uric acid excretion.

Question 23

When assessing a female client, the nurse learns that the client has several risk factors for osteoporosis. Which risk factor will be the priority for client teaching?

Answer 23

Low calcium intake and vitamin D intake

Rationale: The client’s calcium intake is the only risk factor that the client can change. The nurse will discuss the other risk factors as contributing to osteoporosis, but the teaching will focus on ways to increase calcium intake. Postmenopausal status, positive family history, and previous use of steroids are not risk factors that the client can change. These risk factors should be discussed, but are not the priority for this client.

Question 24

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?

Answer 24

Mnemonic: VTE

Venous stasis leading to thrombi or emboli formation

Rationale: The physiologic effects of immobilization, as a result of decreased muscle contraction, include venous stasis. This can lead to pulmonary emboli or thrombi. The metabolic rate decreases with immobilization. Loss of joint mobility leads to contractures. Bone demineralization with osteoporosis and hypercalcemia occur with immobilization.

Question 25

The nurse is caring for a patient with a cast applied recently for a fractured tibia. Which assessment findings indicate possible compartment syndrome? Select all that apply.

Answer 25

Mnemonic; SIT

• *S**evere pain not relieved by analgesics
• *I**nability to move extremity
• *T**ingling of extremity

Rationale: Indications of compartment syndrome are severe pain not relieved by analgesics, tingling of extremity, and inability to move extremity. A palpable distal pulse and capillary refill to the extremity less than 3 seconds are expected findings.

Question 26

The nurse is caring for a client who is admitted with mastoiditis. Which of these assessment data obtained by the nurse requires the most immediate action?

Answer 26

The client reports a headache and a stiff neck.

Rationale: This finding may indicate meningitis and is a serious illness requiring further assessment and immediate intervention.

Question 27

A myringotomy may need to be performed for ___________________________.

Answer 27

permit drainage of infected middle ear fluid and thus improve hearing and equalize pressure

Question 28

Your client has a fracture and is being treated with skeletal traction. Which assessment causes the nurse to take immediate action?

Answer 28

The traction weights are resting on the floor.

Rationale: The immediate action of the nurse should be to reapply the weights to give traction to the fracture. The health care provider must be notified that the weights were lying on the floor, and the client should be realigned in bed. Slight oozing of clear fluid is normal as is the capillary refill time. The client’s blood pressure is slightly elevated; this could be related to pain and muscle spasms resulting from lack of pressure to reduce the fracture.

Question 29

The patient’s chart indicates a sensorineural hearing loss. Which assessment question does the nurse ask to determine the possible cause?

Answer 29

“Have you been exposed to loud noises?”

Rationale: Sensorineural hearing loss can occur from damage to the cochlea, the eighth cranial nerve, or the brain. Exposure to loud music is one etiology. The other questions relate to conductive hearing loss.

Question 30

The nurse is teaching a client and family regarding symptoms to report to the primary health care provider after cataract surgery. Which symptoms would the nurse include in the teaching? (Select all that apply.)

Answer 30

Mnemonic: BiG FEDS

• *B**lindness in the surgical eye
• *G**reen or yellow discharge from the surgical eye
• *F**lashes or floaters seen in the surgical eye
• *E**yelid swelling of the surgical eye
• *D**ecreased vision in the surgical eye
• *S**harp sudden pain in the surgical eye

Rationale: All of these symptoms are not normal and should be reported immediately to the surgeon or other appropriate primary health care provider.

Question 31

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:

Answer 31

“I don’t need medication unless I’m having a severe attack.”

Rationale: Treatment of gout includes both nutrition and medication therapy. The client should be encouraged to limit the use of alcohol and reduce the consumption of foods high in purines. Such foods include sardines, herring, mussels, liver, kidney, goose, venison, and sweetbreads. Medication therapy is a primary component of management for clients with gout, and the physician normally prescribes a medication that will promote uric acid excretion or reduce its production. Fluid intake is important in preventing the development of uric acid stones. Fad or starvation diets can precipitate an acute attack because of the rapid breakdown of cells they induce. Excessive physical and emotional stress can exacerbate the disease.

Question 32

Which is a potentially fatal complication of acute compartment syndrome? Select all that apply.

Answer 32

Myoglobinuric renal failure

Question 33

The nurse is caring for a client with a fractured femur. What factor in the client’s history may impede healing of the fracture?

Answer 33

Paget’s disease

Rationale: Paget’s disease and bone cancer can cause pathologic fractures such as a fractured femur that do not achieve total healing. The other factors do not impede healing but may cause other health risks.

Question 34

Which type of drug therapy does the nurse anticipate giving to the client with Meniere’s disease to decrease endolymph volume?

Answer 34

Diuretics
Rationale: Mild diuretics are prescribed to decrease endolymph volume.

Question 35

A client has been prescribed an antibiotic for otitis media asks the nurse “why did the doctor tell me not to discontinue this medication until the pills are gone?” Which response by the nurse is appropriate?

Answer 35

“Completing the medication ensures that the infection will be resolved.”

Question 36

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’s first intervention?

Answer 36

Assess pedal pulses

Rationale: The symptoms represent early warning of acute compartment syndrome. In acute compartment syndrome, sensory deficits such as paresthesias precede changes in vascular or motor signs. If the nurse finds a decrease in pedal pulses, the health care provider should be notified as soon as possible.

Question 37

The nurse administers carbidopa, levodopa (Sinemet) client with Parkinson’s disease. Which therapeutic effect does the nurse expect the medication to produce?

The expected outcome for a patient taking levodopa as a drug therapy for Parkinson’s disease would be a what?

Answer 37

Decrease in rigidity

Question 38

What are the common symptoms of stroke? Select all that apply.

Answer 38

The symptoms selected (sudden numbness/weakness of face, arm, or leg, especially on one side of the body; difficulty speaking; sudden changes in vision; dizziness and sudden severe headache) are signs of a stroke, and should be presented to patients as situations that require emergency assistance.

Question 39

The nurse is assessing a patient with Parkinson’s disease. Which Cardinal findings does the nurse expect to observe? Select all that apply.

Answer 39

Mnemonic: TRIPS

Tremors, Rigidity, Postural Instability, Slow movements

Question 40

After a stroke, a patient has ataxia. What intervention is most appropriate to include in the patient’s plan of care?

Answer 40

Ambulate only with a gait belt

Question 41

The nurse assesses a client who has Guillain-Barre syndrome. Which clinical manifestation does the nurse expect to find in this client?

Answer 41

Progressive ascending weakness and parathesia

Question 42

Which is the most common type of facial paralysis?

Answer 42

BELLS PALSY

Question 43

Which of the following peripheral nerve disorder is being investigated for an association for occurence after a vaccination, surgical procedure, or stressful event?’

Answer 43

Guillian Barre syndrome

Question 44

The patient is being evaluated for thrombolytic therapy. What are absolute contraindications for this procedure? Select all that apply

Answer 44

Mnemonic: HAMS

Intracranial Hemorrhages

Suspected Aortic aneurysm

Malignant Intracranial Neoplasm

Ischemic Stroke within 3 month

Question 45

A client who has had a stroke with left sided hemiparesis has been referred to a rehabilitation center. The client asked “why do I need rehabilitation”? How does the nurse respond?

Answer 45

restore back to functioning

Question 46

What should a nurse who was caring for a hospitalized older client with dementia considered before planning care?

Answer 46

Routines will provide stability for clients with dementia

Question 47

The nurse is assessing a patient with Myasthenia Gravis (MG). Which manifestations can the nurse expect to observe? Select all that apply.

Answer 47

Ptosis

Diplopia

Ocular palsies

Fatigue

Question 48

A patient experiences impaired 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?

Answer 48

Has clear lung sounds on auscultation

Rationale: Impaired swallowing can lead to aspiration, so the priority goal for this problem is no aspiration. Clear lung sounds is the best indicator that aspiration has not occurred. Choosing menu items is not related to this problem. Eating meals does not indicate the client is not still aspirating. A weight gain indicates improved nutrition but still does not show a lack of aspiration.

Question 49

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? Select all that apply.

Answer 49

GCS changes from 12 to 9

positive Babinski’s reflex bilaterally

unable to verbalize response to questions

Question 50

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?

Answer 50

watch closely and monitor neurologic status

Question 51

The nurse recognizes which Pathophysiologic feature as a hallmark of Gillian Barr syndrome?

Answer 51

The immune system destroys the myelin sheath

Question 52

The Emergency Department nurse. Completes the mission assessment. Mr. Smith is alert but struggles to answer questions. When he talks, he slurs his speech and appears frightened. Which additional clinical manifestation should the nurse expect to find? If Mr. Smith’s symptoms have been caused by a stroke? Select all that apply.

Answer 52

Mnemonic; What the HEC?1

hyporeflexic DTR

elevated BP

carotid bruit

Question 53

A client who first experienced symptoms related to a confirmed thrombolytic stroke two hours ago is brought to the intensive care unit. Which prescribed medication. Does the nurse prepare to administer?

Answer 53

TPA Tissue Plasminogen Activator

Rationale: The client who has had a thrombotic stroke has a 3-hour time frame from the onset of symptoms to receive recombinant tissue plasminogen activator (rt-PA) to dissolve the cerebral artery occlusion and re-establish blood flow. Clients must meet eligibility criteria for administration of this therapy. The other medications do not assist in the re-establishment of blood flow for a client with a confirmed thrombotic stroke.

Question 54

A patient is undergoing a Tensilon test. If the patient has Myasthenia gravis, the nurse expects the patient to:

Answer 54

Have facial weakness and ptosis which will be relieved for approximately 5 minutes, 30 seconds after administration

Question 55

What does the nurse understand that clients with Myasthenia Gravis, Guillain-Barre syndrome, and Amyotrophic Lateral Sclerosis (ALS) share in common?

Answer 55

Increased risk for respiratory complications

Question 56

A family member of a client with hemorrhagic stroke asks about anticoagulant therapy. The nurse explains that anticoagulant therapy for the client:

Answer 56

Is contraindicated because it will increase bleeding

Rationale: Administration of an anticoagulant to a client who is bleeding will interfere with clotting and increase bleeding. Anticoagulants are not used in the is situation because they will increase bleeding, they may be used for a client with a cerebral thrombosis

Question 57

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. On which condition should the nurse be prepared to focus care?

Answer 57

ICP

Rationale: Increased intracranial pressure is manifested by a sluggish pupillary reaction and elevation of the systolic blood pressure.

Question 58

The nurse is caring for a patient with an external fixation of a bone fracture. What are the advantages of this type of treatment? Select all that apply.

Answer 58

Mnemonic: BLES

It maintains bone alignment.

It is less painful than other treatments.
It allows for earlier ambulation.
It stabilizes commuted fractures that require bone grafting.

Question 59

Before performing a physical exam, what assessments related to the patient’s hearing can be done while observing the patient? (Select all that apply.)

Answer 59

Mnemonic: PAT

Observe body posture and position
See if the patient asks for questions to be repeated
Note whether the patient tilts the head toward the examiner

Question 60

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)

Answer 60

Mnemonic; HOT

• *H**ypotension
• *O**liguria
• *T**achycardia

Rationale: Clients who sustain fractures of the femur, pelvis, thorax, and spine are at risk for hypovolemic shock. Bone fragments can damage blood vessels, leading to hemorrhage into the abdominal cavity and the thigh. This can occur with closed as well as open fractures. Signs of hypovolemic shock include tachycardia, hypotension, and diminished urine output. Fever and bradypnea are not associated with hypovolemic shock.

Question 61

Which desired effect of medical therapy should the nurse explain to the client who has primary angle-closure glaucoma?

Answer 61

Controlling intraocular pressure

Rationale: Glaucoma is a disease in which there is increased intraocular pressure resulting from narrowing of the aqueous outflow channel (canal of Schlemm). This can lead to blindness, caused by compression of the nutritive blood vessels supplying the rods and cones. Pupil dilation increases intraocular pressure because it narrows the canal of Schlemm. Intraocular pressure is not affected by activity of the eye. Although secondary infections are not desirable, the priority is to maintain vision by controlling the pressure.

Question 62

The pancreas performs which functions? select all that apply

Answer 62

Mnemonic; P Squared

• *S**ecretes enzymes for digestion from the exocrine part of the organ
• *P**roduces glucagon from the endocrine part of the organ
• *P**roduces enzymes that digest carbohydrates, fats, and proteins

Question 63

A nurse’s 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?

Answer 63

Client who is a tree-trimmer and uses a chainsaw 6 to 7 hours a day

Rationale: A chainsaw becomes dangerous to hearing after 2 hours of exposure without hearing protection. This client needs to be referred as the priority. Normal car traffic is safe for more than 8 hours. Motorcycle noise is safe for about 8 hours. The safe exposure time for a front-row rock concert seat is 3 minutes, but this client was in the back, and so had less exposure. In addition, a one-time exposure is less damaging than chronic exposure.

Question 64

A patient in a cast reports a painful “hot spot” underneath the cast and the nurse notices an unpleasant odor. Which intervention is the nurse most likely to perform first?

Answer 64

Take the patient’s temperature and other vital signs

Question 65

Healthcare provider is educating a 65 year old patient on a new diagnosis of primary open-angle glaucoma (POAG). Which assessment by the patient shows an understanding of the discussion?

Answer 65

“I will need to follow my treatment plan to prevent damage to the optic nerve.”

Rationale: Once diagnosed, the priority for glaucoma is to keep the intraoptic pressure (IOP) low in order to prevent optic nerve damage.

Question 66

The student nurse is caring for a patient with an acute attack of Meniere’s disease. Which finding indicates a need for further teaching of the student nurse?

Answer 66

The patient is placed in the dayroom to watch a favorite action movie.

Rationale: When caring for a patient with an acute attack of Ménière’s disease, the nurse should plan interventions that minimize vertigo and provide for patient safety. Avoiding fluorescent or flickering lights or a television will minimize the attack and/or symptoms.

Question 67

The patient is diagnosed with osteoporosis. Which intervention by the nurse would be appropriate?

Answer 67

Recommend walking for 30 minutes three to five times a week.

Rationale: The single most effective exercise for osteoporosis is walking 30 minutes three to five times a week. Patients should include increased vitamin D along with calcium in the diet. Smoking should be avoided, as should high-impact exercises, which may cause vertebral compression fractures.

Question 68

On the first post-operative day, a patient with a below-the-knee amputation (BKA) complains of pain in his toes of the limb that was amputated. an appropriate action by the nurse is to:

Answer 68

Administer prescribed opioids to relieve the pain.

Rationale: Phantom limb pain is treated like any other type of postoperative pain would be treated. Explanations of the reason for the pain may be given, but the nurse should still medicate the patient. The compression bandage is left in place except during physical therapy or bathing. Although the pain may decrease over time, it still requires treatment now.

Question 69

Which statement about retinal detachment is true (accurate)?

Answer 69

Mnemonic: R Squared

Retinal detachments are classified by the cause.

Restricting head movement can prevent further detachment.

Spontaneous reattachment of a totally detached retina is rare.

Rationale: A retinal detachment is the separation of the retina from the epithelium and is classified by the cause of the detachment. The onset of retinal detachment is painless as there are no pain fibers located in the retina. Spontaneous reattachment of a totally detached retina is rare. Surgery to reattach the retina is called scleral buckling. It is performed under general anesthesia. Preoperatively, the patient should be instructed to restrict activity and head movement to prevent further detachment

Question 70

Please place the steps in correct order for emergency care of patient with fracture using number 1 through 6;

____ a. Cover the affected area with a dressing (preferably sterile)

____ b. Check the neurovascular status of the area distal to the extremity; temperature, color, sensation, movement, and capillary refill. Compare affected and unaffected limbs.

____ c. Remove the patient’s clothing (cut if necessary) to inspect the affected area above and below the injury. Do not remove shoes because this can cause increased trauma.

____ d. Apply direct pressure on the area if there is bleeding and pressure over the proximal artery nearest the fracture.

____ e. Immobilize extremity by splinting; include joint above and below the fracture site. Recheck circulation after splinting.

____ f. Put the patient in a Supine position; keep patient warm.

Answer 70

Answer: a. 6, b. 4, c. 1, d. 2, e. 5, f. 3

1. c. Remove the patient’s clothing (cut if necessary) to inspect the affected area above and below the injury. Do not remove shoes because this can cause increased trauma.
2. d. Apply direct pressure on the area if there is bleeding and pressure over the proximal artery nearest the fracture.
3. f. Put the patient in a Supine position; keep patient warm.
4. b. Check the neurovascular status of the area distal to the extremity; temperature, color, sensation, movement, and capillary refill. Compare affected and unaffected limbs.
5. e. Immobilize extremity by splinting; include joint above and below the fracture site. Recheck circulation after splinting.
6. a. Cover the affected area with a dressing (preferably sterile)

Question 71

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?

Answer 71

Patient reports a decrease in painful muscle spasms

Question 72

An older adult in a Family Practice Clinic reports a decrease in hearing over a week. Which action by the nurse is most appropriate?

Answer 72

Assess for cerumen buildup.

Rationale: All options are possible actions for the client with hearing loss. The first action the nurse should take is to look for cerumen buildup, which can decrease hearing in the older adult. If this is normal, medications should be assessed for ototoxicity. Further auditory testing may be needed for this client.

Question 73

The client is being assessed for rotator cuff injury. What physical assessment is consistent with this type of injury?

Answer 73

The client is unable to initiate or maintain abduction of the affected arm at the shoulder.

Question 74

After a motor vehicle accident, a patient presents with a deformity to the leg with decrease pedal pulses. The fibula protrudes from the lateral aspect of the leg. How should the nurse classify the fracture? (select all that apply)

Answer 74

Open

The patient has an open fracture because the fibula protrudes through the skin

Displaced

The patient has a displaced fracture because one portion of the fibula protrudes through the skin and the ends of the bone are separated and out of their normal position.

Question 75

Which information from the client’s history does the nurse identify as a risk factor for developing osteoporosis?’

Answer 75

Receives long-term steroid therapy

Rationale: Increased levels of steroids will accelerate bone demineralization. Hyperparathyroidism, not hypoparathyroidism, accelerates bone demineralization. Weight-bearing that occurs with strenuous activity promotes bone integrity by preventing bone demineralization. Estrogen promotes deposition of calcium into bone which may prevent, not cause, osteoporosis.

Question 76

A patient is informed by the healthcare 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?

Answer 76

The cast material will dry and become rigged in a few minutes.

Question 77

____________ is a side effect of taking calcium and can cause serious damage to the urinary system.

Answer 77

Renal Calculi

Kidney stones

Hypercalcemia

Question 78

Tinnitus may be caused by which factors (select all that apply)

Answer 78

Mnemonic COMM

Continuous exposure to loud noise

Otosclerosis

Medications

Ménière’s disease

Question 79

A patient follows up with her primary care provider to ensure that she has adequate healing of a recent fracture. At her appointment the nurse interviews the patient. During the intake assessment and interview, what information indicates that the patient has an increase risk for osteoporosis? (select all that apply)

Answer 79

Body mass index of 19

Excessive alcohol use.

Being Female

Caucasian or Asia Ethnicity

A thin body build, evidenced by a body was index of 19, is a risk factor for osteoporosis. Additional risk factors include being female and of Caucasian or Asian ethnicity. Consuming greater than 2 alcoholic beverages daily is a risk factor for osteoporosis

Question 80

Which precautions does the nurse instruct a patient to take after having ear surgery? (select all that apply)

Answer 80

Instruct the client to protect the ear from water for several weeks.

Assisting the client with ambulation as needed to avoid falling

Don’t blow your nose for 2 to 3 weeks.”

Rationale: To prevent infection, the client is instructed to prevent water from entering the external auditory canal for 6 weeks. Ototoxic medications and temperature extremes do not present a risk for infection. Removal of cerumen during the healing process should be avoided due to the possibility of trauma.

The client is instructed to avoid heavy lifting, straining, exertion, and nose blowing for 2 to 3 weeks after surgery to prevent dislodging the tympanic membrane graft or ossicular prosthesis. Side-lying is not contraindicated; sneezing could cause trauma.

Question 81

The nurse is admitting a patient with a history of a herniated lumbar disc and low back pain. Which action would most likely aggravate the pain?

Answer 81

Bending or lifting

Rationale: Back pain related to a herniated lumbar disc is aggravated by events and activities that increase stress and strain on the spine, such as bending or lifting, coughing, sneezing, and lifting the leg with the knee straight (straight leg-raising test). Moist heat, sleeping position, and ability to sit in a fully extended recliner do not aggravate the pain of a herniated lumbar disc.

Question 82

Sequentially order the events that allow for hearing. Use 1 for the first step and 6 for the final step.

Sound waves are transferred to the malleus.

Sound waves are transferred to the Incas and the stapes.

Vibrations are transmitted to the cochlea.

Neural impulses are conducted to the auditory nerve.

Sound waves strike the mastoid and the movable tympanic membrane.

Sound is processed and interpreted to the brain.

Answer 82

Answer:

1. Sound waves strike the mastoid and the movable tympanic membrane.
2. Sound waves are transferred to the malleus.
3. Sound waves are transferred to the malleus.
4. Vibrations are transmitted to the cochlea
5. Neural impulses are conducted by the auditory nerve.
6. Sound is processed and interpreted by the brain.

Question 83

A teenager is brought to the emergency department by a group of excited friends. he is dazed and unable to answer questions. The nurse observes deformity to the right forearm and ecchymosis over the right lateral chest and abdomen. what is the most important reason to ask the friends about mechanism of injury?

Answer 83

To aid in making the diagnosis of other types of injuries.

Question 84

Sequentially order the events that allow for hearing. Use 1 for the first step and 6 for the final step.

Sound waves are transferred to the malleus.

Sound waves are transferred to the Incas and the stapes.

Vibrations are transmitted to the cochlea.

Neural impulses are conducted to the auditory nerve.

Sound waves strike the mastoid and the movable tympanic membrane.

Sound is processed and interpreted to the brain.

Answer 84

Answer:

1. Sound waves strike the mastoid and the movable tympanic membrane.
2. Sound waves are transferred to the malleus.
3. Sound waves are transferred to the malleus.
4. Vibrations are transmitted to the cochlea
5. Neural impulses are conducted by the auditory nerve.
6. Sound is processed and interpreted by the brain.

Question 85

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:

Answer 85

petechiae of the neck and anterior chest wall

restlessness and confusion

Question 86

The nurse gently taps over the patient’s mastoid process and the patient reports tenderness. This finding may indicate which condition?

Answer 86

Inflammatory Process

Question 87

A nurse is caring for a patient who reports a loss of peripheral vision that developed over time. _________ would be the diagnostic tests ordered by the physician to reach a diagnosis.

Answer 87

Tonometry. The patient presents with a sign of glaucoma, which results from increased intraocular pressure. Tonometry, or measurement of intraocular pressure, is important to diagnosing glaucoma.

Gonioscopy. The patient presents with a sign of glaucoma, which results from increased intraocular pressure due to decreased drainage. Gonioscopy allows the examiner to view the irideocorneal angle to evaluate whether drainage can occur.

Question 88

The nurse is teaching a client about preventing intraocular pressure increase after cataract surgery. Which health teaching would the nurse include? (Select all that apply.)

Answer 88

“Avoid blowing your nose or sneezing.”

“Don’t bend down from the waist.”

“Don’t strain to have a bowel movement.”

“Avoid having sexual intercourse.”

“Don’t wear tight shirt or blouse collars.”

Question 89

The ED nurse teaches patients with sports injuries to remember the acronym RICE. This acronym stands for which of the following combinations of treatment?

Answer 89

Rest, ice, compression, elevation

Explanation:
RICE is used for the treatment of contusions, sprains, and strains. While circulation problems must be examined, the RICE treatment does not refer to circulation and examination.

Question 90

The nurse is assessing a client admitted to the emergency department with possible retinal detachment. What assessment findings would the nurse expect? (Select all that apply.)

Answer 90

Presence of bright light flashes

Decreased visual field in affected eye

Feeling like a curtain is over one eye

Rationale:

Changes that occur in clients experiencing retinal detachment are usually sudden and painless. Typical changes that occur include bright light flashes, sudden decrease in visual filed, and a feeling like a curtain is over all or part of the affected eye.

Question 91

The nurse is teaching a client about care after surgery to repair a retinal detachment. What health teaching would the nurse include? (Select all that apply.)

Answer 91

“Report sudden pain in the surgical eye.”

“Report if the surgical eye remains dilated.”

“Avoid close vision activities in the first week.”

“Avoid activities that increase intraocular pressure.”

“Report sudden reduced visual acuity.”

Question 92

A nurse is caring for a patient with a new diagnosis of primary open-angle glaucoma (POAG). When reviewing the health care provider’s orders, which prescription should the nurse question?

Answer 92

Ibuprofen

Nonsteroidal antiinflammatory drugs, such as ibuprofen, may be used preoperatively for patients undergoing cataract surgery, but they are not indicated for a patient with POAG