Exam 3 Messer Practice Questions

Question 1

Mrs. Smith is 89, post-op following a hip replacement (left hip arthroplasty, cement & posterior approach).
VS: Temp 96.1 F, BP 172/69, HR 93 bpm, RR 20 bmp, SpO2 94% on 2L NC
Awake, Oriented X 3 (slightly confused situationally).
Bandage on left hip.
Complaining of pain & says her hip hurts “really bad.”
What are your priority assessments?
Discuss “hip precautions”…

Answer 1

1. CMS
2. Pain medications –AVOID OPIOIDS (delirium)
3. Abduction pillow to prevent dislocation
   - great intervention for confused pts

Question 2

The following morning, Mrs. Smith is slightly more confused than the day before (Oriented X 2). She has been trying to get out of bed and as you walk by the room, she has her left leg dangling over the side of the bed.
Discuss assessment and actions.

Answer 2

Assessment:

1. Calm the patient
2. Assist pt back to bed
3. VS, especially Sp02
4. Neuro & Respiratory assessment
5. Assess Hip–CMS

Actions:

1. Abduction pillow
2. Fall precautions-bed alarm, call bell, etc.

Question 3

Despite your best efforts, Mrs. Smith gets out of the bed and falls to the floor. She states that her left leg is hurting worse than it has been. Her left leg is severely rotated and appears to be shorter than the right leg. What is happening? What should you do?

Answer 3

Hip Dislocation

1. Call for help
2. Stay with the patient
3. Further assess
4. Be nice :)

Question 4

Which of the following patients are candidates for joint replacement? For the patients who are not, which have absolute contraindications for joint replacement?

1. Patient with bacterial pneumonia
2. Patient with severe osteoporosis
3. Patient who needs several cavities filled
4. Patient who had a valve replacement 4 years ago
5. Patient with a urinary catheter
6. Patient with a UTI
7. Patient on chronic steroids

Answer 4

1. No; Treat PNA first
2. No; CONTRAINDICATED; risk vs benefit
3. No; Major dental work should be done first
4. Yes
5. Yes
6. No; Treat UTI first
7. Yes, but proceed with caution* (risk for infection & OP)

Question 5

What are the differences between cemented and fit-pressed joint replacements?

Differences in precautions?

Answer 5

Cemented: fixed hardware immediately

• Weight-bearing allowed immediately post-op
• Recommended for older adult patients

Fit-pressed: requires bone to fuse to hardware:
- NO weight-bearing immediately post-op

Question 6

Mr. Jones, 67, is seen in the clinic for chronic knee pain. He is diagnosed with Osteoarthritis.
Discuss educational priorities.
Mr. Jones has been a runner for years and asks if he can still run. Can he? He asks about medications he can take. Discuss standard medications used for OA.

Answer 6

Patient Education:

1. pain management
2. education on causes of OA
   - how to prevent further worsening

He can still run, BUT, as long as he understands that this may worsen his OA.
Suggest Cross-training
Cycling, walking, strength training, yoga, etc.

Medications:
Tylenol, ibuprofen, and supplements (glucosamine, chondroitin, CBD)

Question 7

Mrs. Calhoun has OA and is 40 lbs overweight. She is in the clinic and states that her pain is getting worse. What are your priorities?

Answer 7

Further assess pain

Discuss relationship b/t weight & OA

• Obesity is complex and requires addressing with compassion (and an understanding that weight loss is not a simple task [or a fix-all])
• Educate that weight loss can help to alleviate the pain associated with OA.

Question 8

What are the manifestations of OA?

Answer 8

Joint stiffness and pain that
- Diminishes after rest
- Worsens after activity
Limited ROM
Crepitus 
Enlarged hardened joints
Atrophy of muscles

Question 9

What causes OA?

Answer 9

Wear and tear
Repetitive activity/ overuse
Injury
Obesity (contributes)
Diseases

Question 10

Who has osteoporosis & who has osteopenia based on bone density test:

1. T-score of -1.5
2. T-score of -3
3. T-score of +1
4. T-score of 0
5. T-score of -2.7
6. T-score of -2

Answer 10

1. T-score of -1.5 –> Osteopenia
2. T-score of -3 –> Osteoporosis
3. T-score of +1 –> Normal
4. T-score of 0 –> Normal
5. T-score of -2.7 –> Osteoporosis
6. T-score of -2 –> Osteopenia

Normal: b/t -1 and +1
Osteopenia = -1 and above -2.5
Osteoporosis = lower than -2.5

Question 11

You are tasked with planning an osteoporosis prevention event. Who will your focus population be? Give 2-3 examples of venues where you would provide education

Answer 11

Under 30, especially females

• College
• HS
• bar (ayyye)

Question 12

You have a patient admitted for pneumonia who has a history of severe osteoporosis.
What are your priorities regarding the OP?
Discuss specific strategies to ensure your priorities are met.

Answer 12

Priority --> Injury prevention! 
Fall precautions
-bed low and locked
-bed alarm
-call bell
-non-skid socks

Question 13

What are risk factors for osteomyelitis? (6)

Answer 13

Infections
Catheters
IV drug use
Salmonella
Poor dental care
Trauma

Question 14

What are the manifestations of osteomyelitis?

Answer 14

Bone pain (localized), worsens with movement, fever, 
Redness, swelling, tender, heat

Question 15

What are the priorities of care for osteomyelitis?

Answer 15

1. Antibiotic treatment!
2. Assessing for the ability to adhere to medications
3. Pain management
4. Wound management

Question 16

1. Manifestations of Compartment syndrome (CS)?
2. How do you prevent CS?
3. How do you prevent complications of CS?

Answer 16

1. the 6 P’s!
2. Assess fracture OFTEN (CMS) & notify provider of subtle changes EARLY!
3. Ensure wraps/casts aren’t too tight, no jewelry, and teach pt to assess for color, warmth, sensation, and movement (CMS)

Question 17

Skeletal versus Skin traction? Compare :)

what is it, purpose, impacted by movement of patient?

Answer 17

Skeletal: Traction is attached to bones
- Used to realign bones/ maintain traction

Skin: Traction is applied via splint or exterior wrap
- Can be used to align bones, but mostly for pain relief

BOTH: impact on patient movement–IT DEPENDS!
Depends on whether traction is balanced or running

Question 18

Balanced versus Running traction

What is it, purpose, impacted by movement?

Answer 18

Balanced: Fractured extremity is suspended with
two opposing forces
- Patient movement DOESN’T impact traction
- Used for alignment

Running: Force exerted in one plane only
(fractured limb is the opposing force)
- AFFECTED by patient movement
- Used for rest, pain management & sometimes alignment

Question 19

What are the manifestations of fatty emboli syndrome?

Priority actions?

Prevention?

Answer 19

Lungs: low O2, Dyspnea, tachypnea
Brain: Confusion, headache, seizure, altered LOC
Skin: Petechia on neck, chest, and arms

Priority actions –> Oxygenation assessment & treatment

• Give O2, (raise HOB.. won’t make a difference)
• Fluids (with albumin)

Prevention –> early fixation

Question 20

A patient in the ED has a new cast on the right forearm. What is your priority assessment?
Priority Education?

Answer 20

Priority Assessment –> CMS checks

Teach patient to check for:

• sensation
• movement
• warmth
• color

Question 21

A patient comes in with an open fracture of the forearm. The patient has a bracelet on the affected extremity.

What are your priority assessments and actions?

Answer 21

1. Remove jewelry
2. Perform CMS assessment
3. Immobilize
4. Elevate
5. Ice and pain management
   (further medical interventions including reduction and immobilization)

Question 22

Which discharge instruction will the emergency department nurse include for a patient with a sprained ankle?
A) Keep the ankle loosely wrapped with gauze.
B) Apply a heating pad to reduce muscle spasms.
C) Use pillows to elevate the ankle above the heart.
D) Gently move the ankle through the range of motion

Answer 22

C) Use pillows to elevate the ankle above the heart.

Question 23

Which statement by the patient indicates a good understanding of the nurse’s teaching about a new short-arm synthetic/ fiberglass cast?
A) “I can get the cast wet as long as I dry it right away with a hairdryer.”
B) “I should avoid moving my fingers and elbow until the cast is removed.”
C) “I will apply an ice pack to the cast over the fracture site off and on for 24 hours.”
D) “I can use a cotton-tipped applicator to rub lotion on any dry areas under the cast.”

Answer 23

C) “I will apply an ice pack to the cast over the fracture site off and on for 24 hours.”

Question 24

A patient who has had open reduction and internal fixation (ORIF) of left lower leg fractures continues to complain of severe pain in the leg 15 minutes after receiving the prescribed IV morphine. Pulses are faintly palpable and the foot is cool to the touch. Which action should the nurse takenext?
A) Notify the health care provider.
B) Assess the incision for redness.
C) Reposition the left leg on pillows.
D) Check the patient’s blood pressure.

Answer 24

A) Notify the health care provider.

Question 25

Which action will the nurse take in order to evaluate the effectiveness of Buck’s traction for a patient who has an intracapsular fracture of the right femur?
A) Assess for hip pain.
B) Assess for contractures.
C) Check peripheral pulses.
D) Monitor for hip dislocation.

Answer 25

A) Assess for hip pain.

Question 26

A patient with a right lower leg fracture will be discharged home with an external fixation device in place. Which information will the nurse teach?
A) “Check and clean the pin insertion sites daily.”
B) “Remove the external fixator for your shower.”
C) “Remain on bed rest until bone healing is complete.”
D) “Take prophylactic antibiotics until the fixator is removed.”

Answer 26

A) “Check and clean the pin insertion sites daily.”

Question 27

A patient who has had open reduction and internal fixation (ORIF) of a hip fracture tells the nurse he is ready to get out of bed for the first time. Which action should the nurse take?
A) Check the patient’s prescribed weight-bearing status.
B) Use a mechanical lift to transfer the patient to the chair.
C) Delegate the transfer to nursing assistive personnel (NAP).
D) Decrease the pain medication before getting the patient up.

Answer 27

A) Check the patient’s prescribed weight-bearing status.

Question 28

The nurse is caring for a patient who is to be discharged from the hospital 4 days after insertion of a femoral head prosthesis using a posterior approach. Which statement by the patient indicates a need for additional instruction?
A)“I should not cross my legs while sitting.”
B) “I will use a toilet lift on the toilet seat.”
C) “I will have someone else put on my shoes and socks.”
D) “I can sleep in any position that is comfortable for me.”

Answer 28

D) “I can sleep in any position that is comfortable for me.”

actually, you can’t hoe

Question 29

When giving home care instructions to a patient who has comminuted left forearm fractures and a long-arm cast, which information should the nurse include?
A) Make sure that only clean objects be used to scratch the skin underneath the cast.
B) Avoid nonsteroidal anti-inflammatory drugs (NSAIDs).
C) Call the health care provider for loss of sensation of the hand.
D) Keep the hand immobile to prevent soft tissue swelling.

Answer 29

C) Call the health care provider for loss of sensation of the hand.

Question 30

A patient is being discharged 4 days after hip arthroplasty using the posterior approach. Which patient action requires intervention by the nurse?
A) The patient uses crutches with a swing-to gait.
B) The patient leans over to pull on shoes and socks.
C) The patient sits straight up on the edge of the bed.
D) The patient bends over the sink while brushing teeth.

Answer 30

B) The patient leans over to pull on shoes and socks.

No bending and snapping fo’ YOU

Question 31

After being hospitalized for 3 days with a right femur fracture, a patient suddenly develops shortness of breath and tachypnea. The patient tells the nurse, “I feel like I am going to die!” Which action should the nurse takefirst?
A) Stay with the patient and offer reassurance.
B) Administer prescribed PRN O2at 4 L/min.
C) Check the patient’s legs for swelling or tenderness.
D) Notify the health care provider about the symptoms.

Answer 31

B) Administer prescribed PRN O2at 4 L/min.

chill out bro

Question 32

A patient arrived at the emergency department after tripping over a rug and falling at home. Which finding ismostimportant for the nurse to communicate to the health care provider?
A) There is bruising at the shoulder area.
B) The patient reports arm and shoulder pain.
C) The right arm appears shorter than the left.
D) There is decreased shoulder range of motion.

Answer 32

C) The right arm appears shorter than the left.

Question 33

A young adult arrives in the emergency department with ankle swelling and severe pain after twisting an ankle playing basketball. Which of these prescribed interprofessional interventions will the nurse implementfirst?
A) Send the patient for ankle x-rays.
B) Immobilize the ankle and apply an ice pack.
C) Administer naproxen (Naprosyn) 500 mg PO.
D) Give acetaminophen with codeine

Answer 33

B) Immobilize the ankle and apply an ice pack.

SIT DOWN MEOW

Question 34

Which nursing action for a patient who has had right hip arthroplasty can the nurse delegate to experienced unlicensed assistive personnel (UAP)?
A) Reposition the patient every 1 to 2 hours.
B) Assess for skin irritation on the patient’s back.
C) Teach the patient quadriceps-setting exercises.
D) Determine the patient’s pain intensity and tolerance.

Answer 34

A) Reposition the patient every 1 to 2 hours.

No Assessin’ or Teachin’ Tamera

Question 35

The second day after admission with a fractured pelvis, a patient suddenly develops confusion and is disoriented X 3 (Oriented only to person). Which action should the nurse takefirst?
A) Take the blood pressure.
B) Assess patient orientation.
C) Check the O2saturation.
D) Observe for facial asymmetry.

Answer 35

C) Check the O2saturation.

Question 36

After a motorcycle accident, a patient arrives in the emergency department with severe swelling of the left lower leg. Which action will the nurse takefirst?
A) Elevate the leg on 2 pillows.
B) Apply a compression bandage.
C) Assess leg pulses and sensation.
D) Place ice packs on the lower leg.

Answer 36

C) Assess leg pulses and sensation.

Question 37

Which finding in a patient with a Colles’ fracture of the left wrist ismostimportant to communicate immediately to the health care provider?
A) Swelling is noted around the wrist.
B) The patient is reporting severe pain.
C) The wrist has a deformed appearance.
D) Capillary refill to the fingers is prolonged.

Answer 37

D) Capillary refill to the fingers is prolonged.

Question 38

Discuss the pathophysiology of rheumatoid arthritis (RA). Compare this patho with that of osteoarthritis (OA) Differences? Similarities?

Answer 38

OA: wear and tear disease
RA: autoimmune disease

Question 39

Discuss the manifestations of RA and compare and contrast with OA.

Answer 39

Joint Characteristics:
OA: hard and bony
RA: soft, warm, tender

Primary Joints Affected:
OA: distal phalangeal joints; base of thumb
RA: proximal phalangeal joints, knuckles,

Pain/Stiffness + Activity:
OA: more pain/stiff after activity
RA more pain/stiff after rest

ESR/CRP:
OA: normal
RA: elevated

Question 40

Discuss the nursing interventions for RA and compare with OA.
Treatment
Hot vs Cold therapy
Management (exercise, rest, positioning, ADLs, psychosocial)

Answer 40

Treatment:
OA: drug therapy-Analgesics (nonopioid), supplements (glucosamine, Chondroitin), & Surgery
RA: immunosuppressants, steroids

Hold vs Cold therapy:
OA: focus on heat
RA: cold or heat (paraffin, hot showers)

Management:
OA: Exercise (swim, walk, cycle) and Rest balance, home adjustments, weight control, positioning, supportive shoes

RA: Rest (balance and set priorities), positioning, OT, assistive devices, coping, body image

Question 41

Differentiate early and late manifestations of RA.

How does this affect the difference in nursing interventions for someone with early versus late RA?

Answer 41

Early = vague Sxs
fatigue, malaise, low-grade fever, joint pain
- drug therapy, set priorities, rest/balance, hot/cold therapy, hot showers

Late= Joint deformity with more joint involvement
- Need for more assistive devices/PT/OT/Home changes

Question 42

When a patient has one hot, swollen, painful joint and a diagnosis of RA, should you be concerned about this finding? Provide a rationale for your answer.

Answer 42

Oh yes, Much concern
Infection needs to be R/O and treated before making
assumptions that it is something else

Question 43

If your patient with RA complains of cervical pain, what should you assess and prioritize?

Answer 43

Breathing!!

RA causing inflammation to the cervical spine can potentially be life-threatening

Question 44

Discuss the pathophysiology of systemic lupus erythematosus (SLE) and compare it to systemic sclerosis (SS).

Answer 44

SLE: Autoimmune disorder leading to formation of immune complexes which invade healthy tissue and can cause impairment of blood flow to tissue. These complexes really like the kidneys

SS: Complex autoimmune disorder that leads to fibrosis of tissue (and hence organs)

Question 45

Discuss the manifestations of SLE and compare and contrast with SS.

Answer 45

SLE: “Butterfly” rash, low-grade fever
Fatigue, Weakness, Weight loss, Anorexia
Polyarthritis, Osteonecrosis, Muscle atrophy, Myalgia
+ Kidney failure, lung effusions, PNA, pericarditis Reynaud’s, Neuro issues, lymph enlargement

SS: CREST for limited-SS, Pitting edema of hands/fingers/forearms that may progress, Shiny taut skin w/ no wrinkles, Joint pain/stiffness
\+ Digestive issues (includes swallowing problems), 
CV issues (Raynaud’s), Lung problems, Kidney failure

Question 46

Discuss the nursing interventions for SLE and compare with SS.
Drug therapy, interventions, etc.

Answer 46

Drug therapy:
SLE: immunosuppressants
SS: immunosuppressants
-educate on increased infection risk

SLE: skin integrity, knowledge deficits, psychosocial
SS: Skin integrity, comfort care, swallow study

Question 47

Discuss two important educational points you should provide your patient with SLE that are different from RA.

Answer 47

Fever – sign of exacerbation
Need to protect skin
Monitoring kidneys

Question 48

What is the most common cause of death for someone with SLE? Why?

Answer 48

Kidney failure- immune complexes are nephrophilic and can collect there causing damage to the glomerulus

Question 49

What is the difference between limited and diffuse cutaneous SS? What is Crest Syndrome?

Answer 49

Limited SS: CREST Syndrome; distal extremities + head

Diffuse SS: affects entire body

Question 50

What causes gout?

What is the difference in primary and secondary gout?

Answer 50

Increased levels of uric acid

Primary = genetic-several inborn errors of purine metabolism
Onset: age 50-60

Secondary = Hyperuricemia secondary to another disease or problem
Onset: any age

Question 51

What is the first typical finding from gout?

Answer 51

Acute gouty arthritis –“Attack” (Stage II)
Excruciating pain and inflammation
Metatarsophalangeal joint of BIG toe (Podagra)

Question 52

Your patient has newly diagnosed gout and is starting medication. Provide appropriate education.
How is it managed?
Dietary changes?
What to avoid?

Answer 52

1. Easily managed with pharmaceuticals
   
   • Colchicine, Allopurinol
2. Take maintenance medication after meals
3. Encourage fluids
4. Low Purine diet
   
   • No organ meat, shellfish, oily fish with bones
5. Avoid aspirin, diuretics, and Avoid stress
6. Stress management

Question 53

The nurse teaches a 64-yr-old man with gouty arthritis about food that may be consumed on a low-purine diet. The patient’s choice of which food item would indicate an understanding of the instructions?
A) Eggs
B) Liver
C) Salmon
D) Turkey

Answer 53

A) Eggs

Question 54

Which nursing intervention would bemostappropriate for a patient with Sjögren’s syndrome?
A) Ambulate with assistive devices
B) Use lubricating eye drops frequently
C) Administer acetaminophen as needed
D) Apply ice or heat compresses to affected areas

Answer 54

B) Use lubricating eye drops frequently

Question 55

A female patient’s complex symptomatology over the past year has led to a diagnosis of systemic lupus erythematosus (SLE). Which statement demonstrates the patient’s need for further teaching about the disease?
A) “I’ll try my best to stay out of the sun this summer.”
B) “I know that SLE is associated with exacerbations”
C)“I’m hoping surgery will be an option for me in the future.”
D)“I understand I’m going to be vulnerable to getting infections.”

Answer 55

C)“I’m hoping surgery will be an option for me in the future.”

Question 56

A patient is admitted for pneumonia and experiences a gout attack of the large left toe.  What interventions should the nurse include in the care plan? (SATA)
A) Bed Cradle
B) Massage of large toe
C) Allopurinol
D) Colchicine
E) Aspirin
F) Diet high in purine

Answer 56

A) Bed Cradle
C) Allopurinol
D) Colchicine

Question 57

Which of the following is the most important assessment finding for a patient with Systemic Sclerosis?
A) Fingertips are blue and cyanotic
C) Patient is having difficulty swallowing
D) Patient has a skin breakdown on top of toe
E) Patient has a new pleural rub

Answer 57

C) Patient is having difficulty swallowing

Question 58

Which of the following is a priority assessment finding for a patient with SLE?
A) A fever
B) Fatigue
C) Constipation
D) Hoity doity attitude

Answer 58

A) A fever

Question 59

A patient with HIV is only infectious when he or she is first infected with the virus and the viral load is abnormally high. TRUE or FALSE

Answer 59

False

Once infected with HIV, patients remain infectious

Question 60

A person who is HIV seropositive, has a CD4 count of 250, and a history of pneumocystis jeroveci pneumonia has AIDS. TRUE or False.

Answer 60

True; AIDS is defined as a:
1. CD4 count < 200
or
2. CD4 >200 + AIDS-defining illness (such as PCP)

Question 61

A normal CD4 count is __________mm3

Answer 61

500-1500 mm3

Question 62

Why is it such a big deal that CD4 (T helper cells) are attacked by the HIV virus?

Answer 62

CD4 cells are responsible for signaling other immune cells to defend the body from infectious agents. Destruction of the T-helper cells causes the body to
be vulnerable to infections

Question 63

What does acute HIV infection look like?

Answer 63

Flu-like Sxs developing 2-4 weeks after initial exposure

- fever, malaise, etc.

Question 64

How long does it take for someone to go from being HIV positive to having AIDS (without antiretroviral therapy)

Answer 64

About ten years

Question 65

Can I get HIV from:

1. Tattoo
2. Ear piercing
3. Emptying a urine bag   
4. Wiping someone’s tears  
5. Mosquito bites
6. Toilet seats

Answer 65

1. No (but yes in theory); no known cases
2. No
3. No
4. No
5. No
6. No

Question 66

What is the benefit of the 4th generation HIV testing?

Answer 66

Detects earlier and more accurately–21 days

- detects both Ag’s (14 days) & Aby’s (21 days)

Question 67

What are the three ways HIV is spread? Provide examples of each.

Answer 67

1. Parenteral route –> needles, transfusions
2. Sexual Contact –> oral, vaginal, anal
3. Perinatal route –> placenta, vaginal birth, breastfeeding

Question 68

What are the safety precautions for healthcare workers when caring for patients who are HIV+?

Answer 68

1. STANDARD PRECAUTIONS!

Question 69

A patient is admitted to the hospital with disseminated MAC. Which of the following would the nurse expect to find (Select all that apply)
A) Patient’s CD4+ count is 100 cells/mm^3
B) The patient is not on antiretroviral therapy
C) The patient is on antiretroviral therapy
D) Patient’s CD4+ count is 34 cells/mm^3
E) Patient has a high viral load

Answer 69

B) The patient is not on antiretroviral therapy

D) Patient’s CD4+ count is 34 cells/mm3 (<50 Cells/mm3)

Question 70

A patient with AIDS is hospitalized with pneumocystis pneumonia. The patient’s CD4+ count is critically low. Discuss priorities for infection prevention for this patient.

Answer 70

1. Optimize Supportive therapies: O2/antimicrobials
2. Infection prevention: Reverse isolation
   - No fresh flowers, no sick visitors
   - Strict handwashing before entering the room
3. Antiretroviral therapy

Question 71

Who should be tested for HIV? For those who should be tested, indicate frequency-annually or More frequently?
Part I:
1. 20 y.o female who had multiple sexual partners in the last year.
2. female in her 30s with one female sexual partner in her lifetime.
3. male in his 20s in a monogamous relationship with a male.
4. male in his 20s who had sex with multiple men in the last year.
5. female who uses IV drugs nearly every day.

Answer 71

1. Yes
2. Yes
3. Yes; annually
4. Yes; more frequently
5. Yes; more frequently

Question 72

Who should be tested for HIV? For those who should be tested, indicate frequency-annually or More frequently?
Part II:
6. 16 y.o. who has never had sex.  
7. 17 y.o. who is pregnant.
8. Sex worker who uses condoms. 
9. Male who had syphilis last year.
10. Male who has sex with sex workers.

Answer 72

6. FURTHER ASSESS; define sex (oral, anal, etc.)
7. Yes; recommended screening test
8. Yes; more frequently
9. Yes
10. Yes; more frequently

Question 73

A nurse at the clinic is seeing a patient with AIDS who has had significant weight loss and chronic diarrhea. Discuss educational priorities.

Answer 73

1) Determine cause and whether it can be treated
2) Managing symptoms
3) Address nutrition/food choices/fluid intake
4) Monitor I&O
5) Skin integrity

Question 74

A nurse is caring for a patient newly diagnosed with HIV. What lab value does the nurse explain to the patient the criteria for AIDS diagnosis is based on?
A) Presence of HIV antibodies
B) CD4+ T cell count below 200/μL 
C) Presence of oral hairy leukoplakia
D) White blood cell count below 5000/μL

Answer 74

B) CD4+ T cell count below 200/μL

Question 75

When teaching a patient infected with HIV about the transmission of the virus to others, which statement made by the patient would indicate a need for further teaching?
A) “I will need to isolate any tissues I use so as not to infect my family.”
B) “I will notify all of my sexual partners so they can get tested for HIV.”
C) “Unprotected sexual contact is the most common mode of transmission.”
D) “I do not need to worry about spreading this virus to others by sweating at the gym.”

Answer 75

A) “I will need to isolate any tissues I use so as not to infect my family.”
- Not spread thru oral/nasal secretions

Question 76

The nurse is providing postoperative care for a patient with HIV infection after an appendectomy. What type of precautions should the nurse observe to prevent the transmission of this disease?
A) Droplet precautions
B) Contact precautions
C) Airborne precautions
D) Standard precautions

Answer 76

D) Standard precautions

Question 77

The nurse is monitoring the effectiveness of antiretroviral therapy (ART) for a patient with AIDS. Which of the following laboratory results is evidence the medications are effective?
A) Increased viral load
B)  Decreased neutrophil count
C) Increased CD4+ T cell count 
D) Decreased white blood cell count

Answer 77

C) Increased CD4+ T cell count

Question 78

1) An older client has decided to give up driving due to cataracts. What assessment information is most important to collect?
a. Family history of visual problems
b. Feelings related to loss of driving
c. Knowledge about surgical options
d. Presence of family support

Answer 78

b. Feelings related to loss of driving

Loss of driving is often associated with loss of independence, as is decreasing vision. The nurse should assess how the client feels about this decision and what its impact will be.
Family history and knowledge about surgical options are not related as the client has made a decision to decline surgery.
Family support is also useful information, but it is most important to get the client’s perspective on this change.

Question 79

2) A client does not understand why vision loss due to glaucoma is irreversible. What explanation by the nurse is best?
a. “Because eye pressure was too high, the tissue died.”
b. “Glaucoma always leads to permanent blindness.”
c. “The traumatic damage to your eye was too great.”
d. “The infection occurs so quickly it can’t be treated.”

Answer 79

a. “Because eye pressure was too high, the tissue died.”
Glaucoma is caused when the IOP becomes too high and stays high long enough to cause tissue ischemia & death.
At that point, vision loss is permanent.

Glaucoma does not have to cause blindness.
Trauma can cause glaucoma but isn’t the most common.
Glaucoma is not an infection.

Question 80

3) A client’s intraocular pressure (IOP) is 28 mm Hg. What action by the nurse is best?
a. Educate the client on corneal transplantation.
b. Facilitate scheduling the eye surgery.
c. Plan to teach about drugs for glaucoma.
d. Refer the client to local Braille classes.

Answer 80

c. Plan to teach about drugs for glaucoma.
This increased IOP indicates glaucoma. The nurse’s main responsibility is teaching about drug therapy.

Corneal transplantation is not used in glaucoma.
Eye surgery is not indicated at this time.
Braille classes are also not indicated at this time.

Question 81

4) A client had a retinal detachment and has undergone surgical correction. What discharge instruction is most important?
a. “Avoid reading, writing, or close work such as sewing.”
b. “Dim the lights in your house for at least a week.”
c. “Keep the follow-up appointment with the ophthalmologist.”
d. “Remove your eye patch every hour for eyedrops.”

Answer 81

a. “Avoid reading, writing, or close work such as sewing.”
After surgery for retinal detachment, the client is advised to avoid reading, writing, and close work because they cause rapid eye movements.

Dim lights are not indicated.
Keeping a postoperative appointment is important for any surgical client.
The eye patch is not removed for eyedrops.

Question 82

5) A client who is near blind is admitted to the hospital. What action by the nurse is most important?
a. Allow the client to feel his or her way around.
b. Let the client arrange objects on the bedside table.
c. Orient the client to the room using a focal point.
d. Speak loudly and slowly when talking to the client.

Answer 82

c. Orient the client to the room using a focal point.
Using a focal point, orient the client to the room by giving descriptions of items as they relate to the focal point.

Letting the client arrange the bedside table is a good idea, but not as important as orienting the client to the room for safety. Allowing the client to just feel around may cause injury.
Unless the client is also hearing impaired, use a normal tone of voice.

Question 83

6) A nurse is seeing clients in the ophthalmology clinic. Which client should the nurse see first?
a. Client with an IOP reading of 24 mm Hg.
b. Client who had cataract surgery & has worsening vision.
c. Client whose red reflex is absent on ophthalmologic examination.
d. Client with a tearing, reddened eye with exudate.

Answer 83

b. Client who had cataract surgery & has worsening vision.
After cataract surgery, worsening vision indicates an infection or other complication. The nurse should see this client first.
An IOP of 24 mm Hg is slightly elevated.
An absent red reflex may indicate cataracts.
Tearing/redness/exudate may indicate an infection.

Question 84

7) A nurse is teaching a client about ear hygiene and health. What client statement indicates a need for further teaching?
a. “A soft cotton swab is alright to clean my ears with.”
b. “I make sure my ears are dry after I go swimming.”
c. “I use good earplugs when I practice with the band.”
d. “Keeping my diabetes under control helps my ears.”

Answer 84

a. “A soft cotton swab is alright to clean my ears with.”
Clients should be taught not to put anything larger than a fingertip into their ears. Using a cotton swab, although soft, can cause damage to the ears and cerumen buildup.

The other statements are accurate.

Question 85

8) 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?”

Answer 85

c. “Have you been exposed to loud noises?”

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 86

9) The nurse works with clients who have hearing problems. Which action by a client best indicates goals for an important diagnosis have been met?
a. Babysitting the grandchildren several times a week
b. Having an adaptive hearing device for the television
c. Being active in community events and volunteer work
d. Responding agreeably to suggestions for adaptive devices

Answer 86

c. Being active in community events and volunteer work
Clients with hearing problems can become frustrated and withdrawn. The client who is actively engaged in the community shows the best evidence of psychosocial adjustment to hearing loss.

Babysitting the grandchildren is a positive sign but does not indicate involvement outside the home.
Having an adaptive device is not the same as using it, and watching TV without evidence of other activities can also indicate social isolation.
Responding agreeably does not indicate the client will actually follow through.

Question 87

10) A nurse is teaching a community group about noise-induced hearing loss. Which client, who doesn’t use ear protection, should the nurse refer to an audiologist as the priority?
a. Client w/ an hour car commute via freeway each day.
b. Client rides a motorcycle to work 20 min. each way.
c. Client who sat in back row at a rock concert recently.
d. Client whose a tree-trimmer & uses a chainsaw for 6-7 hrs/day.

Answer 87

d. Client whose a tree-trimmer & uses a chainsaw for 6-7 hrs/day.
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.