Practice questions for exam 3 Flashcards
The nurse is preparing a list of home care instructions for a pt who has been hospitalized for TB. Which instructions would the nurse include in the list? SATA
1. activities should be resumed gradually
2. avoid contact with other individuals except family members for 6 months
3. A sputum culture is needed every 2-4 wks once medication therapy is initiated
4. Respiratory isolation is not necessary, because family members already have been exposed
5. cover the mouth and nose when coughing or sneezing and put used tissues in a plastic bag
6. when one sputum culture is negative the client is no longer considered infectious and usually can return to former employment
1,3,4,5
NCLEX pg 696
The nurse has conducted discharge teaching with a client diagnosed with TB who has been recieving medication for 2 wks. The nurse determines that the client has understood the information if the client makes which statement
1. I need to continue medication therapyy for 1 month
2. I can’t shop at the mall for the next 6 months
3. I can return to work if a sputum culture comes back negative
4. I won’t be contagious after 2-3 wks of medication therapy
4
NCLEX pg 697
The nurse is preparing to give a bed bath to a immobilized pt with TB. The nurse would wear which items when preforming this care?
1. Surgical mask and gloves
2. Particulate respirator, gown, and gloves
3. Particulate respirator and protective eye wear
4. Surgical mask, gown, and protective eye wear
2
NCLEX PG 697
A clent has experienced pulmonary embolism. The nurse would assess for which symptom, which is MOST commonly reported>
1. Hot, flushed feeling
2. Sudden chills and fever
3. Chest pain that occurs suddenly
4. Dyspnea when deep breaths are taken
3
NCLEX pg 697
A client with HIV has a PPD test that has a 7-mm induration at the site of the skin test and interprets the result as which finding?
1. positive
2. Negative
3. Inconclusive
4. Need for repeating testing
1
NCLEX pg 697
A community health nurse is conducting an education session with community members regarding the S/S associated with TB. The nurse informs the participants that TB is considered as a dx if which S/S are present? SATA
1. Dyspnea
2. Headache
3. Night sweats
4. Bloody, productive cough
5. A cough with the expectoration of mucoid sputum
1,3,4,5
NCLEX pg 697
The nurse preforms an admission assessment on a pt with a dx of TB. The nurse would check the results of which diagnostic test that will confirm the dx?
1. CHXR
2. Bronchoscopy
3. Sputum Culture
4. Tuberculin SKin Test
3
NCLEX pg 697
A pt has been taking isoniazid for 2 months. The pt complains to the nurse about numbness, paresthesias, and tingling in the extremities. The nurse interprets that the client is experiencing which problem?
1. hypercalcemia
2. peripheral neuritis
3. small blood vessel spasm
4. Impaired peripheral circulation
2
NCLEX pg 714
A client is to begin 6-month course of therapy with isoniazid. The nurse would plan to teach the client to take which action?
1. use alcohol in small amounts only
2. report yellow eyes or skin immediately
3. increase intake of swiss or aged cheeses
4. avoid vitamin supplements during therapy
2
NCLEX pg 714
Client has been started on long term therapy with rifapin. The nurse would provide which information to the client about the medication?
1. would always be taken with food and antacids
2. would be double dosed if one dose if forgotten
3. causes orange discoloration of sweat, tears, urine and feces
4. may be discontinued independently if symptoms are gone in 3 months
3
NCLEX pg 715
The nurse has given a client taking ethambutol information about the medication. The nurse determines that the client inderstands the instructions if the client states that they will immediately report which finding?
1. Impaired sense of hearing
2. GI side effects
3. Orange-red discolorations of body secretions
4. DIfficulty in discriminating the color red from green
4
NCLEX pg 715
A client with TB is starting antituberculosis therapy with isoniazid. Before giving the client the first dose. the nurse would ensure that which baseline study has been completed?
1. electrolyte levels
2. coagulation times
3. liver enzymes
4. serum creatinine level
3
NCLEX pg 715
Rifabutin is prescribed for a client with active mycobacterium avium complex (MAC) disease and tuberculosis. The nurse would monitor for which side and adverse effects of rifabutin? SATA
1. signs of hepatitis
2. Flulike symptoms
3. Low neutrophil count
4. Vitamin B 6 deficiency
5. Ocular pain or blurred vision
6. Tingling and numbness of fingers
1,2,3,5
NCLEX pg 715
The nurse is instructing a pt with parkinsons disease about preventing falls. Which statement by the client statement reflects a need for futher teaching?
1. I can sit down to put on my pants anf shoes
2. I try to exercise every day and rest when I’m tired
3. my son removed all loose rugs from my bedroom
4. I don’t need to use my walker to get to the bathroom
4
NCLEX pg 873
Carvidopa-Levodopa is prescribed for a client with parkinsons disease, The nurse monitors the client for S/E and A/E of the medication. Which finding indicates that the pt is experiencing an adverse effect?
1. Puritis
2. Tachycardia
3. hypertension
4. Impaired voluntary movements
4
NCLEX pg 885
The nurse is conducting health screening for osteoporosis. Which client is at greatest risk of developing this problem?
1. 25 yr old client who runs
2. A 36 yr old client who has asthma
3. 70 yr old client who consumed excess alcohol
4. A sedentary 65 yr old client who smokes cigarettes
4
NCLEX pg 905
The nurse has given instructions to a client who sustained a ligament injury who is returning home after a knee arthroscopy. Which statement by the client indicates that the instructions are understood?
1. I can resume regular exercise tomorrow
2. I can’t eat food for the remainder of the day
3. I need to stay off the leg entirely for the rest of the day
4. I need to report a fever, redness around my incisions, or persistent drainage to my health care provider
4
NCLEX pg 905
The nurse witnessed a vehicle hit a pedestrian. The victim is dazed and tries to get up. A leg appears to be fractured. What interventions would the nurse take?
1. try to reduce the fracture manually
2. assist the victim to get up and walk to the side walk
3. leave the victim for a few moments to call an ambulance
4. stay with the victim and encourage the victim to remain still
4
NCLEX pg 905
Which cast care instructions would the nurse provide to a client who just had a plaster cast applied to the right forearm? SATA
1. Keep the cast clean and dry
2. Allow the cast 24-72 hrs to dry
3. Keep the cast and extremity elevated
4. Expect tingling and numbness in the extremity
5. Use a hair dryer on a warm-hot setting to dry cast
6. Use a soft, padded object that will fit under the cast to scratch the skin under the cast
1, 2, 3
NCLEX pg 905
THe nurse is evaluating a client in a skeletal traction. When evaluating the pin sites, the nurse would be most concerned with which finding?
1. redness around the pin sites
2. Pain on palpation at the pin sites
3. Thick yellow drainage from the pin sites
4. Clear watery drainage from the pin sites
3
NCLEX pg 905
The nurse is assessing the casted extremity of a client. Which sign is indicitive of infection?
1. dependent edema
2. Diminished distal pulse
3. Presence of a “hot spot” on the cast
4. Coolness and pallor of the extremity
3
NCLEX pg 905
A client has sustained a closed fx and has just had a cast applied to the affected arm. The client is complaining of intense pain. The nurse elevates the limb and applies an ice bag, and administes an analgesic with little relief. Which problem may be causing this pain?
1. Infection under the cast
2. The anxiety of the client
3. Impaired tissue perfusion
4. The recent occurrence of the fracture
3
NCLEX pg 905
The nurse is admitting a client with multiple trauma injuries to the nursing unit. The client has a leg fracture and has a plaster cast applied. Which positioning would be best for the casted leg?
1. eleated for 3 hrs, then flat for 1 hr
2. flat for 3 hrs, then elevated for 1 hr
3. flat for 12 hrs, then elevated for 12 hrs
4. Elevated on pillows continuously for 24 hrs to 48 hrs
4
NCLEX pg 905
The nurse is caring for a client being treated for a fat embolus after multiple fx. Which data would the nurse evaluate as the most favorable indication of resolution of the fat embolism?
1. Clear mentation
2. minimal dyspnea
3. Oxygen staturation of 85%
4. Arterial oxygen level of 78mm Hg
1
NCLEX pg 906
The nurse has conducted teaching with a client in an arm cast about the S/S of compartment syndrome. The nurse determines that the client understands the information if the client states that they will report which early symptoms of compartment syndrome?
1. Cold, bluish-colored fingers
2. Numbness and tingling in the fingers
3. Pain that increases when the arm is dependent
4. Pain that is out of proportion to the severity of the fracture
2
NCLEX pg 906
A pt is complaining of low back pain that radiates down the left posterior thigh. The nurse could ask the client if the pain is worsened or aggravated by what factor?
1. bed rest
2. Ibuprofen
3. bending or lifting
4. Application of heat
3
The nurse is caring for client who has had a spinal fusion, with insertion of hardware. The nurse would be most concerned with which assessment finding?
1. Temp of 101.6 F (38.7 C) orally
2. C/O discomfort during repositioning
3. Old bloody drainage outlined on the surgical dressing
4. Discomfort during coughing and deep breathing
1
NCLEX pg 906
A client with a hip fx asks the nurse what is involved with bucks traction, which is being applied before surgery. THe nurse would provide which information to the client?
1. Allows bony healing to begin before surgery and involves pins and screws
2. Provides rigid immobilization of the fx siteand involves pulleys and wheels
3. Lengthens the fx leg to prevent severing of blood vessels and involves pins and screws
4. Provides comfort by reducing muscle spasms, provides fx immobilization and involves pulleys and wheels
4
NCLEX pg 906
Alendronate is prescribed for a client with osteoporosis, and the nurse is providing instructions on administration of the medication. Which instruction would the nurse provide?
1. Take the medication at bedtime
2. Take the medication in the morning with breakfast
3. Lie back down for 30 min after takinf the medication
4. Take the medication with a full glass of water after rinsing in the morning
4
NCLEX pg 915
The nurse is analyzing laboratory studies on a client recieving dantrolene to treat muscle spasms from an injury. Which laboratory test would identify an adverse effect associated with the administration of this medication?
1. Platelet count
2. Creatinine level
3. Liver function tests
4. Blood urea nitrogen level
3
NCLEX pg 915
Cyclobensaprine is prescribed for a client for muscle spasms, and the nurse is reviewing the clients record. Which disorder, if noted in the record, would indicate a need to contact the primary health care provider about the administration of this medication?
1. Glaucoma
2. Emphysema
3. Hypothyroidism
4. Diabetes Mellitus
1
NCLEX pg 915
The home health nurse visits a client at home and determines that the client is dependent on drugs. During the assessment, which action would the nurse take to plan appropriate nursing care?
1. Ask the client why they started taking illegal drugs
2. Ask the client about the amount of drug use and its effects
3. ask the client how long they thought that they could take drugs without someone finding out
4. Not ask any questions for feat that the client is in denial and will throw the nurse out of the home
2
NCLEX pg 983
Which interventions are most appropriate for caring for a client in alcohol withdrawl? SATA
1. Monitor vital signs
2. Provide a safe environment
3. address hallucinations therapeutically
4. Provide stimulation in the environment
5. Provide reality orientation as appropriate
6. Maintain NPO status
1, 2, 3, 5
NCLEX pg 983
The nurse determines that the spouse of an alcoholic client is benefiting from attending an Al-anon group if the nurse hears the spouse, make which statement?
1. I no longer feel that I deserve the beating my partner inflicts on me
2. My attendance at the meetings has helped me to see that I provoke my partner’s violence
3. I enjoy attending the meetings because they get me out of the house and away from my partner
4. I can tolerate my partners destructive behavior
1
NCLEX pg 984
A hospitalized client with a hx of alcohol use disorder tells the nurse “I am leaving now. I must go. I do not want any more treatment. I havethings that I have to do right away.” The client has not been discharged and is scheduled for an important diagnostic test to be preformed in 1 hr. After the nurse discusses the clients concerns with the client, the nurse dresses ad begins to walk out of the hospital room. What action would the nurse take?
1. Call the nursing supervisor
2. Call security to block all exit areas
3. Restrain the client until the PCP
4. Tell the client that client cannot return to this hospital again if the client leaves now
1
NCLEX pg 984
The nurse is assessing a client who was admitted 24 hrs ago for a fx humerus. Which finding would alert the nurse to the potential for alcohol withdrawl delirium?
1. Hypotension, ataxia, hunger
2. Stupor, lethargy, muscular rigidity
3. Hypotension, coarse hand tremors, lethargy
4. Hypertension, changes in level of consciousness, hallucinations
4
NCLEX pg 984
The spouse of a client admitted to the mental health unit for alcohol withdrawl says to the nurse, “I need to ger out of this bad situation” Which would be the most helpful response by the nurse?
1. Why don’t you tell you spouse about this?
2. What do you find difficult about this situation
3. This is not the best time to make that decision
4. I agree with you. You should get out of this situation
2
NCLEX pg 984
Min, a 55-year old postmenopausal Asian female, is visiting her healthcare provider for an annual physical. She is approximately 50 pounds overweight. Min states that she is a pack-a-day smoker and takes a daily multivitamin designed for women older than 50. When questioned by the healthcare provider, the client says she has never had bone mineral density testing.
The nurse recognizes that that Min is at risk for osteoporosis because of which identified factors? Select all that apply.
- Gender
- Postmenopausal age
- Smoker
- Overweight
- Multivitamin use
1, 2, 3, 4
Davis Advantage activity
After the healthcare provider completes a fracture risk assessment screening, Min is scheduled for outpatient diagnostic testing to further evaluate her risk for osteoporosis. Which diagnostic test will be used to evaluate her bone density?
- Dual-energy x-ray absorptiometry (DEXA)
- Quantitative computerized tomography (qCT)
- Serum biochemical markers
- X-ray of the pelvis
1
Davis Advantage activity
Min is upset by the new diagnosis and fearful of complications. What can the nurse tell her to provide some comfort?
1. “Osteoporosis is genetic and you had no control over getting the disease.”
2. “Osteoporosis is curable and with proper treatment, you won’t have residual effects.”
3. “Preventive lifestyle and medications can slow the progression of the disease.”
4. “Surgery is often a great alternative to living with the debilitating disease.”
3
Davis Advantage activity
After the results of the DEXA scan, Min is started on a daily bisphosphonate. She states that she takes her daily medications at bedtime but has developed indigestion. What information should the nurse share with the client regarding this class of drug?
1. Bedtime is an acceptable time to take the medication with a glass of milk.
2. The medication should be taken at lunch with a large meal.
3. The medication should be taken on an empty stomach first thing in the morning.
4. The medication should be taken on an empty stomach 1 hour after a meal.
3
Davis advantage activity
Min states she wants to lose weight and lead a healthier lifestyle. Which statement by the client requires additional teaching?
1. “I can drink orange juice with Vitamin D added to help my body with the absorption of calcium.”
2. “My diet should focus on carbohydrates and fat with little protein.”
3. “I need to find an exercise activity to add to my life, along with a healthy diet to help manage my osteoporosis.”
4. “Along with a healthy diet, I should plan to take a multivitamin daily.”
2
Davis advantage
Min is concerned that her pain level will worsen as she becomes more active. What would be an appropriate nurse response?
1. “Your pain may increase, but you should strive for an active lifestyle.”
2. “Your pain should not increase when you add more activity in your life.”
3. “You cannot add pain medication to the medications that you take for osteoporosis.”
4. “You will find that your pain will decrease when you become more active.”
1
Davis advantage
Min is started on calcium but feels like the dose is too high. The nurse learns she is taking 1,200 mg each day in divided doses. What should the nurse suggest to Min?
1. That dose is appropriate and should be continued.
2. Decrease the dose by half.
3. Clarify the dose with your provider.
4. Increase the dose to 1,500 mg/day.
1
Davis Advantage
The nurse also suggests that Min increase the amount of vitamin D that she consumes to improve absorption. What foods should the nurse suggest? Select all that apply.
1. Fish
2. Milk
3. Cereals
4. Liver
5. Egg whites
1, 2, 3, 4
Davis advantage
Min tells the nurse she doesn’t like any of the food and asks if there is another way to get vitamin D. What should the nurse suggest?
1. Taking a multivitamin with vitamin D
2. Sitting in the sun 15 minutes each day.
3. Increasing the amount of table salt in her diet.
4. Increasing weight-bearing exercises.
2
Davis advantage
Which populations have a high risk of osteoporosis? Select all that apply.
- Women younger than 50
- Women of Asian descent
- Individuals with a family history of osteoporosis
- Individuals who are overweight
- Individuals who use tobacco
2, 3, 4, 5
Davis advantage
The nurse is speaking with a female client in her 40s who has a family history of osteoporosis and wants to know what dietary changes can decrease her risk of developing the disorder. What nutrient deficiencies have been correlated with osteoporosis? Select all that apply.
- Magnesium
- Calcium
- Vitamin E
- Vitamin D
- Potassium
2, 4,
Davis Advantage
The nurse is seeing a client with osteoporosis who started on a bisphosphonate last month to treat osteoporosis. The client states “Ever since I started taking that medicine, my stomach has really been bothering me.” What is the nurse’s best response?
- “Are you taking the medication with food? Sometimes taking the medication when you haven’t eaten can cause an upset stomach.”
- “What time of day are you taking the medicine? Most individuals have fewer side effects if the medicine is taken at bedtime.”
- “When have you been taking the medication? The best time to take this medication is first thing in the morning, on an empty stomach.”
- “Are you having any other stomach issues? Gastrointestinal issues are very common with this drug.”
3
Davis Advantage
The nurse is providing client teaching to a client suspected to have osteoporosis who is scheduled for a dual-energy x-ray absorptiometry (DEXA) scan. What would be included in the nurse’s client teaching?
- The DEXA scan requires a barium swallow.
- The client should have a family member or friend present to drive the client home at the end of the scan.
- The DEXA scan will require an overnight hospital stay the night before the procedure.
- The DEXA scan is noninvasive and requires no preparation.
4
Davis advantage
The nurse is talking with a client who is confused about modifiable and non-modifiable risk factors for osteoporosis. Which of these are examples of modifiable risk factors? Select all that apply.
- Diet
- Weight
- Gender
- Lifestyle
- Ethnicity
1, 2, 4
Davus advantage
Which are secondary risk factors for a patient with osteoporosis? Select all that apply.
1. Cigarette smoking
2. cushings disease
3. steroid use
4. gender
5. downs syndrome
2, 3, 5
Davis advantage
A patient reports fever, swelling, and warmth at the site of swelling. Which musculoskeletal disorder should the nurse be concerned about?
1. Osteoporosis
2. Osteomyelitis
3. Paget’s disease
4. Muscular dystrophy
2
The nurse is caring for a patient after a total hip replacement. The nurse observes the patient sitting at a 90 degree angle. What action should the nurse take?
1. None; correct positioning is occuring
2. encourage the patient to lean forward when sitting
3. Stop the patient from sitting and have them lay down
4. Have the client stand rather than sit
1
Davis advantage
A nurse is teaching a about total joint replacement (TJR). Which statement indicates a need for further teaching?
1. it is also reffered to as an arthroplasty
2. It’s a replacement like span is 5-6 yrs
3. It is most commonly associated with the joints of the hip and the knee
4. It is the surgical procedure designed to repair an articulatinf surface with a synovial joint
2.
Which type of muscular dystrophy is most common in men and children?
1. Becker muscular dystrophy
2. Myotonic muscular dystrophy
3. Duchenne muscular dystrophy
4. Limb-girdle muscular dystrophy
1
Davis advantage
A patient reports a stabbing heel pain that worsens when walking in the morning. What condition should the nurse consider?
1. Bunion
2. Pes Planus
3. Plantar fasciitis
4. Morton’s neuroma
3
Davis advantage
While assessing a patient , the nurse observes uneven waist and shoulders. Which musculoskeletal disorder could cause this?
1. scoliosis
2. Bone cancer
3. Osteomyelitis
4. Muscular Dystrophy
1
Davis Advantage
A patient has undergone joint replacement. Which complications should the nurse monitor for? Select all that apply.
1. myeloma
2. HYpotension
3. Spinal deformty
4. Hypovolemic shock
5. Deep vein thrombosis
2, 4, 5
Davis Advantage
Which patient most likely has Paget’s disease, based on the symptom provided:
1. Calf enlargement woth pain and redness, depression
2. Back pain, constipation with abdominal cramping
3. Generalized pain in lower back and bone, spine curvature
4. General malaise, lethargy, and fevers
1
Davis advantage
The nurse is teaching about home care for patients who have undergone joint replacement. Which statement indicates the need for further teaching?
1. I should encourage the patient to use slip socks
2. I should encourage the patient to use walking devices
3. I should encourage the patient to sit with legs crossed
4. I should encourge the patient to use a raised toilet seat and pull bar in the bathroom
3
Davis advantage
Sharon, a 58-year-old female client, presents to the hospital with an exacerbation of multiple sclerosis (MS) symptoms. She was diagnosed with the disease 4 years ago after noticing some unusual muscle movement and weakness. She continues to work full-time so that she can maintain her health insurance coverage for herself and her two sons in college.
In performing the health admission assessment, the nurse identifies several abnormalities. Which clinical symptoms are associated with MS? Select all that apply.
- Migraine headache
- Bladder infection
- Hypertension
- Numbness in legs
- Increased thirst
2, 4
Davis Advantage
Sharon has been taking beta interferon to manage the disease. What is the purpose of this medication?
- Modifies the course of disease progression
- Provides pain relief
- Supports immune function to help normalize bowel function
- Helps normalize glucose levels
1
Davis Advantage
Sharon is now experiencing increased muscle spasticity. Which medication can be added to the treatment plan to help alleviate this clinical symptom?
1. Corticosteroids
2. Bronchodilators
3. Muscle relaxants
4. Pain analgesics
3
Davis advantage
Sharon is prescribed a corticosteroid while in the hospital. She tells the nurse, “I hate that medication. It makes me feel like I’m crazy. Why is it needed?” What rationale should the nurse provide?
- “It suppresses your adrenal gland so it doesn’t have to work as hard.”
- “It decreases the inflammatory and immunologic factors involved in the exacerbation.”
- “It provides an increased glucose level so you won’t become hypoglycemic.”
- “We can give you something if you feel crazy.”
2
Davis advantage
Which finding leads the nurse to believe that additional education on managing the disease is required for this client?
- Use of cane assistive device to support ambulation
- Taking a hot bath at bedtime to relax
- Working out in a gym once a week with a personal trainer
- Increasing intake of fresh fruits and vegetables
2
Davis Advantage
Sharon is being discharged from the hospital and is looking forward to going home. Which health promotion method should be included in her discharge teaching?
- Return to office for follow up corticosteroid injection therapy to prevent infection.
- Avoid dairy to prevent excessive mucus formation.
- Continue walking with assistance to prevent injury.
- Use a hot tub each day to help reduce inflammation.
3
Davis Advantage
Sharon returns to the provider a month later and reports the diplopia is getting worse. What intervention can the nurse suggest?
1. Stand slowly with eyes closed.
2. Place a patch over one eye or the other each day.
3. Ask the provider for steroid eye drops.
4. Ask eye doctor for a contact lens adjustment.
2
Davis Advantage
Sharon is also concerned about the burden she is becoming on others, especially her family. What should the nurse suggest?
1. She considers going to a nursing home.
2. She pays someone to care for her.
3. She includes her family in her clinic visits so their concerns can be addressed.
4. She takes out a good nursing home insurance policy.
3
Davis Advantage
A patient is diagnosed with amyotrophic lateral sclerosis (ALS) characterized by flaccidity. Which complication is associated with this?
1. Dementia
2. Dysphagia
3. Lower Back pain
4. Slurred speech
- Lower Back pain
The nurse is teaching about caring for a patient who has undergone surgery for herniated nucleus pulposus. Which statement indicates a need for further education? Select all that apply.
- Changes in respiratory rate and effort may indicate a cerebrospinal fuid leak
- I will inspect the surgical site to detect signs of hemorrhage or cerebrospinal fluid leak
- Monitoring the neurological status of the patient helps to detect early subtle changes
- I will advise the patient to maintain the body in good alignment since it helps to prevent infection
- Encourage range of motion exercises in the patients decreases the risk of contracture development
1 4
Davis advantage
A patient reports numbness, pain, weakness in the lower extremities, and an inability to control motor movement. The primary healthcare provider prescribes gabapentin and tramadol. What should be the outcome of this intervention?
1. Decreased lower back pain
2. Supression of spinal cord tumors
3. Reduced symptoms of multipule sclerosis
4. Relief of multiple sclerosis
5. Relief from symptoms associated and amyotrophic lateral sclerosis (ALS)
1
Davis Advantage
This nurse is caring for a patient with this stabilization device. What is the nurse’s priority action to prevent complications?
- Administer pain medications
- Clean pin to prevent infection
- Confirm that weights are hanging freely
- Monitor for bleeding at pin site
2
Davis Advantage
Which patient is the most appropriate candidate for administration of riluzole?
- 42 yr old with lower back
- 32 yr old newly dx with MS
- 54 yr old with herniated nucleus pulposus after a motor vehicle accident
- 67 yr old with newly diagnosed amyotrophic lateral sclerosis (ALS)
D
Davis Advantage
The nurse is teaching about monitoring for clinical manifestations when assessing spinal shock in a patient. Which statement indicates effective teaching? Select all that apply.
1. The patient would have low urine output
2. the patient would have improper digestion
3. the patient would have low BP
4. the patient would have a decreased HR
5. The patient would not show reflexes if tapped on the knee
1 2 5
Davis Advantage
A patient involved in an auto accident has severe spinal cord injuries. If the patient is having difficulty with diaphragmatic breathing, which level of the spinal cord is injured?
- C6-C7
- T1-T5
- T6-T12
- Below L1
1
Davis Advantage
Which type of multiple sclerosis (MS) is characterized by the gradual progression of symptoms without remissions?
1. Relapsing remitting
2. Primary progressive
3. Progressive relapsing
4. Secondary Progressive
2
Davis advantage
Which spinal cord disorder is characterized by the buildup of scar tissue or plaques?
1. MS
2. Spinal cord tumors
3. Herniated nucleus pulposus
4. Amyotrophic Lateral Sclerosis (ALS)
1
Davis Advantage
The nurse is caring for a patient diagnosed with autonomic dysreflexia (AD). Which action performed by the nurse indicates a need for correction?
1. Placing an indwelling urinary ctheter in the patient
2. Applying antiembolism stockings on the patient
3. Monitoring the patients blood pressure every 5 mins
4. Checking the patients body for the presence of pressure ulcers
1
Davis advantage
Rationale: applying antiembolism stockings should help prevent pooling of blood in the patients lower extremities and reduce the blood pressure, which may be the source of an episode of AD
Which spinal cord disorder is characterized by the buildup of scar tissue or plaques?
- MS
- Spinal cord tumors
- Herniated nucleus pulposus
- Amyotrophic lateral sclerosis (ALS)
1
Davis advantage
The nurse is providing care to William Parish, who presents in the emergency department with symptoms indicative of tuberculosis (TB).
Which action should the nurse take when triaging William upon his arrival to the emergency department?
- Ask William to wear a gown while in the waiting area.
- Ask William to wear gloves until transferred to a room.
- Ask William to place a face mask over his mouth and nose.
- Ask William to use hand sanitizer after using the restroom.
3
Davis advantage
Which type of room should the William be placed in when transferred from the waiting room to an ED room?
- A client room with negative airflow capability.
- A multiple client room with curtains for privacy.
- A client room with contact precaution capability.
- A semi-private room with another client with respiratory symptoms.
1
Davis Advantage
Which type of precautions should be used when providing care for William? Select all that apply.
- Standard precautions
- Contact precautions
- Droplet precautions
- Airborne precautions
- Reverse isolation precautions
1, 4
Davis advantage
Which personal protective equipment (PPE) should the nurse don prior to entering the room to assist William after he has vomited? Select all that apply.
1. Surgical mask
2. N95 respirator
3. Head covering
4. Shoe protectors
5. Gloves
2, 5
Davis advantage
William’s family arrives for a visit. Which personal protective equipment (PPE) should the nurse educate the family to wear?
- Gown
- Gloves
- Surgical mask
- Shoe protection
3
Davis advantage
William is admitted to the medical-surgical unit. Which action is appropriate when transporting him from the ED to the unit?
1. Wearing an N95 respirator during the transport
2. Placing a surgical mask on the client for transport
3. Asking the client to use the steps during transport
4. Clearing all people from the route used for transport
2
Davis Advantage
The nurse is preparing to conduct the admission assessment now that William is settled into the room after transport. Which findings should the nurse anticipate when conducting the client’s respiratory assessment? Select all that apply.
1. Clear breath sounds
2. Audible wheezing
3. Eupnea (normal respiration)
4. Rales (disconti. nuous crackle and pop sounds)
5Rhonchi (rattling sounds)
2, 4, 5
Davis Advantage
What should the nurse recommend for the client’s family members based on the current information?
1. Annual chest x-rays
2. Isolation precautions
3. Tuberculosis skin tests
4. Prophylactic antibiotics
3
Davis Advantage
The current plan of care includes discharge of William to home once the criteria to decrease the risk of disease transmission have been obtained. Which should the nurse assess to determine if he is likely to have successful adherence to treatment after discharge?
1. Occupation
2. Support system
3. Financial resources
4. Type of health insurance
2
Davis Advantage
Which discharge teaching should the nurse include in the teaching plan for a client who was treated for tuberculosis? Select all that apply.
- “Family members should have chest x-rays done.”
- “Stop medication when coughing subsides.”
- “Persons living with you should have skin testing.”
- “Use your best judgment in terms of your daily medications.”
- “Maintain adequate nutrition.”
3, 5
Davis Advantage
Which nursing actions are appropriate when caring for a client diagnosed with tuberculosis? Select all that apply.
- Place on droplet precautions.
- Humidify oxygen when administered.
- Request dietary consult.
- Offer family members N95 masks.
- Medication teaching.
2, 3, 5
Davis Advantage
The nurse should include which priority preventive measure when teaching a group of adults about preventing the spread of tuberculosis?
- Handwashing
- Annual vaccination
- Isolation
- Covering mouth when coughing
3
Davis Advantage
The nurse is caring for a client with a diagnosis of active tuberculosis. Which symptoms does the nurse expect this client to exhibit? Select all that apply.
- Fever
- Abdominal rigidity
- Abnormal breathing sounds
- Hypothermia
- Decreased oxygen saturation
1, 3, 5
Davis Advantage
Which instruction should the nurse provide to a client who has just received a PPD (purified protein derivative)?
- Return to the clinic in 48–72 hours to have the test read.
- Take antiviral medication as prescribed.
- Massage the subcutaneous injection site.
- There may be a very small amount of bleeding on the forearm.
1
Davis advantage
The nurse is assessing a patient who has developed orthopnea and rales. On further investigation, the nurse finds that the patient often coughs up rust-colored sputum. The patient also has night sweats and weight loss. Which kind of tuberculosis (TB) does the nurse expect the patient to be diagnosed with in this situation?
- Latent TB Infection (LTBI)
- Multidrug-resistant TB (MDR TB)
- Primary Progressive TB Infection (PPTBI)
- Primary TB Infection (PTBI)
3
The nurse is teaching about the epidemiology of tuberculosis (TB). Which statements indicated the need for further teaching? Select all that apply.
- TB is present in foreign-born individuals
- Low socioeconomics groups are the most affected
- The most affected age groups vary from 40 to 60 yrs old
- About half of the HIV-infected population in the united states is affected by Mycobcterium TB
- Individuals with AIDS are the most prone TB
3, 4
Davis Advantage
Which is true regarding primary progressive TB infection (PPTBI)?
1. It may develop in individuals who are exposed to bacterium 2. It may mean that the first-line medications used for treatment of TB will be ineffective
3. It is often asymptomatic and is only confirmed by positive sputum cultures and a positive skin test
4. It is only when the immune sustem becomes compromised that the disease can become reactivated
1
Davis Advantage
The nurse is teaching about the pathophysiology of tuberculosis (TB). Which statement made is correct?
- Destruction of the lung tissue occurs in the patient during granuloma formation
- Pleuritic chest pain is the result of sputum present
- The unexplained weight loss is due to the destruction of lung tissue
- Micro bleeds are the result of the collection of WBC in an attempt to wal off the infection
1
Davis Advantage
Which nursing intervention should be considered a priority when caring for a patient with tuberculosis (TB) infection?
1. conducting a mantoux tuberculin skin test as prescribed
2. isolating the patient in a private room with negative air flow
3. conducting CHXR per order of the provider
4. Administering first-line antituberculer medications as prescribed
2
Davis Advantage
Which is the main cause of blood tinged, rust-colored sputum in a patient suffering from tuberculosis (TB)?
- The destruction of lung parenchyma tissue
- The inflammatory process of the lungs
- Decreased pH and increased CO2
- Tachypmea and Tachycardia
1
Davis Advantage
Which safety measures followed by the nurse when caring for a patient with suspected tuberculosis (TB) infection can cause the spread of pathogens to other individuals?
1. Keeping the patient isolated in a private room with negative airflow
2. Donning an N95 mask respirator when entering the patients private room
3. Instructing the visitors to wear a snug fitting surgical mask when entering the patients private room
4. Ensuring the patient leaves the negative pressure room connected to a SPO2 probe
4
Davis Advantage
Which classification of tuberculosis (TB) infection can be caused by primary or secondary spread?
- Multidrug-resistant TB or MDR TB
- Latent TB Infection of LTBI
- Primary TB Infection or PTBI
- Primary Progressive (symptomatic) TB Infection or PPTBI
1
Davis Advantage
The nurse is assessing a patient with tuberculosis (TB). Which best describes the gas exchange in the patient?
- Alteration in gas exchange r/t necrosis of lung tissue
- Alteration in comfort: pain r/t pleurisy
- Risk for fluid volume deficit r/t insensuble losses from fever and tachypnea
- Alteration in gas exchange: decreased r/t impaired alveolar capillary interface
1
Davis Advantage
Mr. Harold Markham is admitted to the medical unit with the diagnosis of TB. He remains in a private negative airflowroom on strict isolation and airborne precautions. He started on the four-drug recommended therapy for treatment of TB. He will stay on the drug therapy for 9-12 months. It is suspected that he was exposed to TB at the HIV clinic where he volunteers. Centers for Disease Control and Prevention personnel are alerted and sent to screen patients and staff at the clinic
Which statement is correct related to isolation and airborne precautions for Mr. Markham?
A. Mr. Markham should wear a mask at all times
B. Staff entering the room should wear a surgical mask
C. visitors entering the room should wear an N95 respirator
D. Staff entering the room should wear an N95 mask respirator
D
Davis Med-surg case study pg 474
Mr. Harold Markham is admitted to the medical unit with the diagnosis of TB. He remains in a private negative airflowroom on strict isolation and airborne precautions. He started on the four-drug recommended therapy for treatment of TB. He will stay on the drug therapy for 9-12 months. It is suspected that he was exposed to TB at the HIV clinic where he volunteers. Centers for Disease Control and Prevention personnel are alerted and sent to screen patients and staff at the clinic
The nurse should question which order concerning Mr. Markham’s care?
A.Humidified oxygen via nasal cannula
B.NPO
C.Vital signs with oxygen saturation every 4 hours
D.Activity as tolerated
B
Davis Med-surg Case study pg 474
Mr. Harold Markham is admitted to the medical unit with the diagnosis of TB. He remains in a private negative airflowroom on strict isolation and airborne precautions. He started on the four-drug recommended therapy for treatment of TB. He will stay on the drug therapy for 9-12 months. It is suspected that he was exposed to TB at the HIV clinic where he volunteers. Centers for Disease Control and Prevention personnel are alerted and sent to screen patients and staff at the clinic
Mr. Markham’s TB can be characterized as which type of infection?
A.An LTBI
B.A PTBI
C.A symptomatic, noncontagious TB infection
D.A symptomatic TB infection
D
Davis Med-Surg Case study wrap up pg 474
Mr. Harold Markham is admitted to the medical unit with the diagnosis of TB. He remains in a pricate negative airflowroom on strict isolation and airborne precautions. He started on the four-drug recommended therapy for treatment of TB. He will stay on the drug therapy for 9-12 months. It is suspected that he was exposed to TB at the HIV clinic where he volunteers. Centers for Disease Control and Prevention personnel are alerted and sent to screen patients and staff at the clinic
Which statement demonstrates adequate teaching has been done?
A.“Wow! I’m going to be on these drugs for a long time!”
B.“I can stop taking the drugs when I feel better.”
C.“My family doesn’t need to wear a mask when they come to visit.”
D.“I’m looking forward to going down to the cafeteria to get something to eat.”
A
Davis Med-Surg Case study wrap up pg. 474
Mr. Harold Markham is admitted to the medical unit with the diagnosis of TB. He remains in a pricate negative airflowroom on strict isolation and airborne precautions. He started on the four-drug recommended therapy for treatment of TB. He will stay on the drug therapy for 9-12 months. It is suspected that he was exposed to TB at the HIV clinic where he volunteers. Centers for Disease Control and Prevention personnel are alerted and sent to screen patients and staff at the clinic
What symptoms indicate a resolving TB infection? (Select all that apply.)
A.Decreased sputum production
B.Productive cough
C.Stable body weight
D.Fevers only at night
E.Cessation of night sweats
A, C, E
Davis Med-Surg Case study wrap up
The nurse monitors for which clinical manifestations in the patient diagnosed with osteoarthritis? (Select all that apply.)
A.Pain that improves with activity
B.Joint pain
C.Joint swelling
D.Unsteady gait
E.Increased temperature
B, C, D
Davis Med-Surg connection check 20.2 pg 382
The nurse recognizes which patient to be at greatest risk for developing osteoarthritis?
A.A 70-year-old African American male
B.A 45-year-old Caucasian female
C.A 65-year-old obese African American female
D.A 30-year-old Caucasian male
C
Davis Med-Surg Connection check 20.1 pg 381
Which statement by the patient with fibromyalgia indicates that teaching has been effective?
A.“Because of my fibromyalgia, I may get inflammatory arthritis, which may lead to joint damage.”
B.“I won’t know for sure about my diagnosis until I have diagnostic tests such as x-rays and blood tests done.”
C.“My only option to treat my pain is narcotic analgesics.”
D.“It’s frustrating, but I understand that fibromyalgia typically presents with a normal physical examination with no evidence of joint or muscle inflammation.”
D
Davis Med-surg Connection check 20.10 pg 405
The nurse recognizes that the patient with Parkinson’s disease is at risk for which complication?
A.Excessive dry mouth due to autonomic dysfunction
B.Facial twitching secondary to seizure activity
C.Orthostatic hypotension due to involvement of the sympathetic nervous system
D.Flaccid extremities related to the increased levels of dopamine
C
Davis Med-surg connection check 36.9 pg 804
Which clinical manifestations are included in a diagnosis of Parkinson’s disease? (Select all that apply.)
A.Flaccidity
B.Total resistance to movement
C.Bradykinesia
D.Tremors
E.Photophobia
C, D
Davs Med-Surg connection check 36.10 pg 805
What interprofessional team members are involved in the management of the patient with Parkinson’s disease? (Select all that apply.)
A.Oncologist
B.Speech therapist
C.Occupational therapist
D.Interventional radiologist
E.Physical therapist
B, C, E
Davis Med-Surg Connection check 36.11 pg 806
The nurse recognizes which factor as placing a patient at the greatest risk for new onset of low-back problems?
A.Sedentary lifestyle
B.Recent long-distance car trip
C.Prolonged standing
D.Cigarette smoking
D
Davis Med-Surg Connection check 37.1 pg 815
In completing the history and physical assessment of a patient with back pain, which finding is most suggestive of a herniated nucleus pulposus?
A.Constipation
B.Numbness in left lower extremity
C.Hyperactive reflexes
D.Hematuria
B
Davis Med-Surg connection check 37.2
A
Davis Med-Surg Connection Check 37.3 pg 824
Medical management for Paget’s disease is based on which of the following characteristics? (Select all that apply.)
A.Presence of symptoms of active disease
B.Distribution of the pagetic bone
C.Metabolic activity of a pagetic lesion
D.Absence of symptoms of active disease
E.Decreased calcium and phosphorous levels
A, B, C, D
Davis Med-Surg Connection Check 53.4 pg 1211
John, a 28-year-old man, has been recently diagnosed with osteomyelitis following an open reduction internal fixation to his tibia fracture. What is the most appropriate nursing diagnosis for John?
A.Hypotension associated with tibia fracture
B.Infection associated with tibia fracture
C.Fear associated with tibia fracture
D.Pain associated with tibia fracture
B
Davis Med-Surg Connection Check 53.5 pg 1215
What is considered a nursing priority for a patient with scoliosis?
A.Maintain bedrest
B.Encourage exercise
C.Restrict fluids
D.Restrict pain medication
B
Davis Med-surg Connection check 53.6 pg 1218
Which symptom is an appropriate indication for TJR?
A.An inability to perform activities of daily living without pain
B.A desire to participate in contact sports without pain
C.A knee injury that may restrict aggressive skiing
D.A hip injury that restricts a prior running routine
A
Davis Med-Surg connection check 53.7 pg 1221
Ms. Eileen Doherty demonstrates classic signs of osteoporosis (vertebral changes noted as kyphosis, or “dowager’s hump”). She states she has noticed that her pants seem longer. She complains of back pain and increased difficulty with simple activities of daily living such as short walks. Initial diagnostic results for Ms. Doherty reveal an elevated ESR, decreased serum calcium level, and a –2.5 T score for BMD study. These results are consistent with primary osteoporosis. The healthcare provider orders Ms. Doherty to begin bisphosphonate therapy with ibandronate (Boniva) by mouth.
Ms. Doherty demonstrates the need for more teaching by which of the following statements?
A.“I don’t need to take calcium or vitamin D anymore.”
B.“I know I need to develop an exercise plan.”
C.“I may need to remove a lot of the small throw rugs around the house.”
D.“I know I will need to follow up on a regular basis.”
A
Davis Med-surg case study wrap up pg 1226
Ms. Eileen Doherty demonstrates classic signs of osteoporosis (vertebral changes noted as kyphosis, or “dowager’s hump”). She states she has noticed that her pants seem longer. She complains of back pain and increased difficulty with simple activities of daily living such as short walks. Initial diagnostic results for Ms. Doherty reveal an elevated ESR, decreased serum calcium level, and a –2.5 T score for BMD study. These results are consistent with primary osteoporosis. The healthcare provider orders Ms. Doherty to begin bisphosphonate therapy with ibandronate (Boniva) by mouth.
The nurse understands which screening tool will help evaluate home safety?
A.FRAX
B.Medication
C.Dietary
D.Activity
A
Davis Med-surg case study wrap up pg 1226
Ms. Eileen Doherty demonstrates classic signs of osteoporosis (vertebral changes noted as kyphosis, or “dowager’s hump”). She states she has noticed that her pants seem longer. She complains of back pain and increased difficulty with simple activities of daily living such as short walks. Initial diagnostic results for Ms. Doherty reveal an elevated ESR, decreased serum calcium level, and a –2.5 T score for BMD study. These results are consistent with primary osteoporosis. The healthcare provider orders Ms. Doherty to begin bisphosphonate therapy with ibandronate (Boniva) by mouth.
Ms. Doherty’s greatest risk factor for the development of osteoporosis is which of the following?
A.A low BMD
B.A high BMD
C.A low FRAX
D.A high QCT
A
Davis Med-surg case study wrap up pg 1226
Ms. Eileen Doherty demonstrates classic signs of osteoporosis (vertebral changes noted as kyphosis, or “dowager’s hump”). She states she has noticed that her pants seem longer. She complains of back pain and increased difficulty with simple activities of daily living such as short walks. Initial diagnostic results for Ms. Doherty reveal an elevated ESR, decreased serum calcium level, and a –2.5 T score for BMD study. These results are consistent with primary osteoporosis. The healthcare provider orders Ms. Doherty to begin bisphosphonate therapy with ibandronate (Boniva) by mouth.
The nurse understands which of the following is an important teaching point for Ms. Doherty?
A.Boniva must be taken on an empty stomach.
B.Boniva is taken once a week.
C.Boniva may cause joint pain.
D.Boniva is taken instead of calcium.
A
Davis Med-surg case study wrap up pg 1226
Ms. Eileen Doherty demonstrates classic signs of osteoporosis (vertebral changes noted as kyphosis, or “dowager’s hump”). She states she has noticed that her pants seem longer. She complains of back pain and increased difficulty with simple activities of daily living such as short walks. Initial diagnostic results for Ms. Doherty reveal an elevated ESR, decreased serum calcium level, and a –2.5 T score for BMD study. These results are consistent with primary osteoporosis. The healthcare provider orders Ms. Doherty to begin bisphosphonate therapy with ibandronate (Boniva) by mouth.
The nurse understands which of the following is implicated in the development of osteoporosis?
A.An increase in calcitonin level
B.A decrease in estrogen level
C.A decrease in the parathyroid hormone
D.A decrease in phosphorus level
B
Davis Med-surg case study wrap up pg 1226
The nurse correlates which diagnostic result for an older adult with a suspected pathologic fracture?
A.Decreased bone density
B.Increased osteocytes
C.Hypertension
D.Coagulopathy
A
Davis Med-Surg Connection check 54.3 pg 1235
A patient has returned from the postanesthesia care unit after having surgery to have an external fixator placed for an open tibia fracture with extensive soft tissue damage. What should the nurse do immediately?
A.Conduct a neurovascular assessment
B.Elevate the extremity
C.Perform pin site care
D.Remove the dressing and assess the wound
A
Davis Med-Surg Connection check 54.4 pg 1240
The nurse prioritizes which nursing diagnosis in the patient immediately after arthroscopic surgical repair of the medial meniscus injury?
A.High risk for ineffective airway clearance associated with general anesthesia
B.High risk for ineffective breathing associated with intubation
C.Self-care deficit associated with pain, edema, and immobility
D.Pain associated with inflammation
A
Davis Med-Surg Connection check 54.7
The nursing diagnosis “ineffective peripheral tissue perfusion associated with deficient knowledge of aggravating factors” applies to which fracture patient with the highest risk of developing VTE?
A.A 30-year-old female on oral contraceptives who smokes one pack of cigarettes per day
B.A 40-year-old male who ambulates four times a day with a walker
C.A 70-year-old diabetic female who attends rehabilitation once a day
D.A 20-year-old male who smokes 10 cigarettes per day and ambulates with crutches
A
Davis Med-Surg Connection check 54.8 pg 1246
Zachary is admitted to the ward from the operating room at 0600 in the morning. Frequent nursing assessments noting the six Ps are performed to assess neurovascular function. Laboratory testing to include serum myoglobin and CPK are ordered. His urine remains clear yellow, ruling out the presence of rhabdomyolysis. His pain is controlled with PO oxycodone. His provider’s orders include the provision of adequate hydration and nutrition and an order for physical therapy to evaluate his readiness for exercise and ambulation using assistive devices. If he continues to improve, he will be discharged to home soon.
Zachary has undergone placement of an external fixator for an open displaced femur fracture. Immediately following surgery, he begins to exhibit dyspnea, pleuritic chest pain, anxiety, and tachycardia. The nurse suspects which complication?
A.Pneumothorax
B.Deep vein thrombosis
C.Fat embolism
D.Myocardial infarction
A
Davis Med-Surg Case study wrap up pg 1248
~~~
*
```Zachary is admitted to the ward from the operating room at 0600 in the morning. Frequent nursing assessments noting the six Ps are performed to assess neurovascular function. Laboratory testing to include serum myoglobin and CPK are ordered. His urine remains clear yellow, ruling out the presence of rhabdomyolysis. His pain is controlled with PO oxycodone. His provider’s orders include the provision of adequate hydration and nutrition and an order for physical therapy to evaluate his readiness for exercise and ambulation using assistive devices. If he continues to improve, he will be discharged to home soon.*
Following the surgical procedure for an open displaced femur fracture, what action does the nurse frequently perform?
A.ROM exercises
B.Neurovascular assessments
C.Dressing changes
D.Pain assessments
B
Davis Med-Surg Case study wrap up pg 1248
Zachary is admitted to the ward from the operating room at 0600 in the morning. Frequent nursing assessments noting the six Ps are performed to assess neurovascular function. Laboratory testing to include serum myoglobin and CPK are ordered. His urine remains clear yellow, ruling out the presence of rhabdomyolysis. His pain is controlled with PO oxycodone. His provider’s orders include the provision of adequate hydration and nutrition and an order for physical therapy to evaluate his readiness for exercise and ambulation using assistive devices. If he continues to improve, he will be discharged to home soon.
The nurse monitors for which common symptom of compartment syndrome?
A.Passive pain at rest
B.Pain with movement
C.Pallor
D.Paresthesia
A
Davis Med-Surg Case study wrap up pg 1248
Zachary is admitted to the ward from the operating room at 0600 in the morning. Frequent nursing assessments noting the six Ps are performed to assess neurovascular function. Laboratory testing to include serum myoglobin and CPK are ordered. His urine remains clear yellow, ruling out the presence of rhabdomyolysis. His pain is controlled with PO oxycodone. His provider’s orders include the provision of adequate hydration and nutrition and an order for physical therapy to evaluate his readiness for exercise and ambulation using assistive devices. If he continues to improve, he will be discharged to home soon.
Because Zachary has lost a significant amount of blood, what complication should the nurse monitor for?
A.Bradycardia
B.Hypotension
C.Metabolic alkalosis
D.Hyperkalemia
B
Davis Med-Surg Case study wrap up pg 1248
Zachary is admitted to the ward from the operating room at 0600 in the morning. Frequent nursing assessments noting the six Ps are performed to assess neurovascular function. Laboratory testing to include serum myoglobin and CPK are ordered. His urine remains clear yellow, ruling out the presence of rhabdomyolysis. His pain is controlled with PO oxycodone. His provider’s orders include the provision of adequate hydration and nutrition and an order for physical therapy to evaluate his readiness for exercise and ambulation using assistive devices. If he continues to improve, he will be discharged to home soon.
The nurse monitors Zachary for which signs of rhabdomyolysis?
A.Bloody urine and abdominal pain
B.Anuria, nausea, and severe flank pain
C.Low serum myoglobin, fever, and severe headaches
D.Elevated serum myoglobin, tea-colored urine, and severe flank pain
D
Davis Med-Surg Case study wrap up pg 1248
Mr. White is admitted to the hospital after an extended period of binge alcohol drinking. His wife reports that he has been a heavy drinker for a number of years. Laboratory reports reveal that he has a blood alcohol level of 250 mg/dL. He is placed on the chemical addiction unit for detoxification. When would the first signs of alcohol withdrawal symptoms be expected to occur?
a. Several hours after the last drink
b. 2 to 3 days after the last drink
c. 4 to 5 days after the last drink
d. 6 to 7 days after the last drink
A
Davis Mental Health Review questions pg 333
Symptoms of alcohol withdrawal include which of the following?
a. Euphoria, hyperactivity, and insomnia
b. Depression, suicidal ideation, and hypersomnia
c. Diaphoresis, nausea and vomiting, and tremors
d. Unsteady gait, nystagmus, and profound disorientation
C
Davis Mental Health Review questions pg 333
Which of the following medications is the physician most likely to order for a patient experiencing alcohol withdrawal syndrome?
a. Haloperidol (Haldol)
b. Chlordiazepoxide (Librium)
c. Methadone (Dolophine)
d. Cannabidiol (Epidiolex)
B
Davis Mental Health Review questions pg 333
Dan, who has been admitted to the alcohol rehabilitation unit after being fired for drinking on the job, states to the nurse, “I don’t have a problem with alcohol. I can handle my booze better than anyone I know. My boss is a jerk! I haven’t missed any more days than my coworkers.” What is the nurse’s best response?
a. “Maybe your boss is mistaken, Dan.”
b. “You are here because your drinking was interfering with your work, Dan.”
c. “Get real, Dan! You’re a boozer and you know it!”
d. “Why do you think your boss is a jerk, Dan?”
B
Davis Mental Health Review questions pg 333
Dan, who has been admitted to the alcohol rehabilitation unit after being fired for drinking on the job, states to the nurse, “I don’t have a problem with alcohol. I can handle my booze better than anyone I know. My boss is a jerk! I haven’t missed any more days than my coworkers.” What defense mechanism is Dan using?
a. Denial
b. Projection
c. Displacement
d. Rationalization
A
Davis Mental Health Review questions pg 333
Dan has been admitted to the alcohol rehabilitation unit after being fired for drinking on the job. Dan’s drinking buddies come for a visit, and when they leave, the nurse smells alcohol on Dan’s breath. Which of the following would be the best intervention with Dan at this time?
a. Search his room for evidence.
b. Ask, “Have you been drinking alcohol, Dan?”
c. Send a urine specimen from Dan to the laboratory for drug screening.
d. Tell Dan, “These guys cannot come to the unit to visit you again.”
C
Davis Mental Health Review questions pg 333
Dan begins to attend AA meetings. Which of the statements by Dan reflects the purpose of this organization?
a. “They claim they will help me stay sober.”
b. “I’ll dry out in AA, then I can have a social drink now and then.”
c. “AA is only for people who have reached the bottom.”
d. “If I lose my job, AA will help me find another.”
A
Davis Mental Health Review questions pg 333
From which of the following symptoms might the nurse identify a chronic cocaine user?
a. Clear, constricted pupils
b. Red, irritated nostrils
c. Muscle aches
d. Conjunctival redness
B
Davis Mental Health Review questions pg 333
An individual who is addicted to heroin is likely to experience which of the following symptoms of withdrawal?
a. Increased heart rate and blood pressure
b. Tremors, insomnia, and seizures
c. Incoordination and unsteady gait
d. Nausea and vomiting, diarrhea, and diaphoresis
D
Davis Mental Health Review questions pg 333
A polysubstance abuser makes the statement, “The green and whites do me good after speed.” How might the nurse interpret the statement?
a. The client abuses amphetamines and anxiolytics.
b. The client abuses alcohol and cocaine.
c. The client is psychotic.
d. The client abuses narcotics and marijuana.
A
Davis Mental Health Review questions pg 333
A client admitted to the emergency department smells strongly of alcohol, and his wife reports that he has been a heavy drinker for the last 25 years. Which of the following assessment findings are consistent with long-term chronic alcohol abuse? (Select all that apply.)
a. The client reports weak leg muscles, and his gait is unsteady.
b. The client’s abdomen is distended.
c. The client reports that he was coughing up some blood.
d. The client reports that he has double vision.
e. Blood tests reveal a low white blood cell count.
A, B, C, D, E
Davis Mental Health Review questions pg 333
Sharon, a woman with multiple cuts and abrasions, arrives at the emergency department with her three small children. She tells the nurse that her husband inflicted these wounds on her. She says, “I didn’t want to come. I’m really okay. He only does this when he has too much to drink. I just shouldn’t have yelled at him.” Which of the following is the best response by the nurse?
a. “How often does he drink too much?”
b. “It is not your fault. You did the right thing by coming here.”
c. “How many times has he done this to you?”
d. “He is not a good husband. You have to leave him before he kills you.”
B
Davis Mental Health review questions pg 695
Sharon, a woman with multiple cuts and abrasions, arrives at the emergency department with her three small children. She tells the nurse that her husband inflicted these wounds on her. In the interview, Sharon tells the nurse, “He’s been getting more and more violent lately. He’s been under a lot of stress at work the last few weeks, so he drinks a lot when he gets home. He always gets mean when he drinks. I was getting scared. So I just finally told him I was going to take the kids and leave. He got furious when I said that and began beating me with his fists.” With knowledge about the cycle of battering, what does this situation represent?
a. Phase I. Sharon was desperately trying to stay out of his way and keep everything calm.
b. Phase I. A minor battering incident for which Sharon assumes all the blame.
c. Phase II. The acute battering incident that was provoked by her threat to leave.
d. Phase III. The honeymoon phase when the husband believes that he has “taught her a lesson and she won’t act up again.”
C
Davis Mental Health Review questions pg 695
A battered woman presents to the emergency department with multiple cuts and abrasions. Her right eye is swollen shut. She says that her husband did this to her. Which of the following is the priority nursing intervention?
a. Tending to the immediate care of her wounds
b. Providing her with information about a safe place to stay
c. Administering the prn tranquilizer ordered by the physician
d. Explaining how she may go about bringing charges against her husband
A
Davis Mental Health review questions pg 695
A woman who has a long history of being battered by her husband is staying at the woman’s shelter. She has received emotional support from staff and peers and has been made aware of the alternatives open to her. Nevertheless, she decides to return to her home and marriage. Which of the following is the best response by the nurse to the woman’s decision?
a. “I just can’t believe you have decided to go back to that horrible man.”
b. “I’m just afraid he will kill you or the children when you go back.”
c. “What makes you think things have changed with him?”
d. “I hope you have made the right decision. Call this number if you need help.”
D
Davis Mental Health Review questions pg 695
Jana, age 5, is sent to the school nurse’s office with an upset stomach. She has vomited and soiled her blouse. When the nurse removes her blouse, she notices that Jana has numerous bruises on her arms and torso in various stages of healing. She also notices some small scars. Jana’s abdomen protrudes on her small, thin frame. From the objective physical assessment, the nurse suspects that:
a. Jana is experiencing physical and sexual abuse.
b. Jana is experiencing physical abuse and neglect.
c. Jana is experiencing emotional neglect.
d. Jana is experiencing sexual and emotional abuse.
B
Davis Mental Health review questions pg 695
A school nurse notices bruises and scars on a child’s body, but the child refuses to say how she received them. What is another way in which the nurse can get information from the child?
a. Have her evaluated by the school psychologist.
b. Tell her she may select a “treat” from the treat box (e.g., sucker, balloon, junk jewelry) if she answers the nurse’s questions.
c. Explain to her that if she answers the questions, she may stay in the nurse’s office and not have to go back to class.
d. Use a “family” of dolls to role-play the child’s family with her.
D
Davis Mental Health review questions pg 696
A school nurse notices bruises and scars on Jana’s body. The nurse suspects that the child is being physically abused. How should the nurse proceed with this information?
a. As a healthcare worker, report the suspicion to child protective services.
b. Check Jana again in a week and see if there are any new bruises.
c. Meet with Jana’s parents and ask them how Jana got the bruises.
d. Initiate paperwork to have Jana placed in foster care.
A
Davis Mental Health review questions pg 696
Kate is an 18-year-old freshman at the state university. She was extremely flattered when Don, a senior star football player, invited her to a party. On the way home, he parked the car in a secluded area by the lake. He became angry when she refused his sexual advances. He began to beat her and finally raped her. She tried to fight him, but his physical strength overpowered her. He dumped her in the dorm parking lot and left. The dorm supervisor rushed Kate to the emergency department. Kate says to the nurse, “It’s all my fault. I shouldn’t have allowed him to stop at the lake.” Which of the following is the nurse’s best response?
a. “Yes, you’re right. You put yourself in a very vulnerable position when you allowed him to stop at the lake.”
b. “You are not to blame for his behavior. You obviously made some right decisions, because you survived the attack.”
c. “There’s no sense looking back now. Just look forward, and make sure you don’t put yourself in the same situation again.”
d. “You’ll just have to see that he is arrested so he won’t do this to anyone else.”
B
Davis Mental Health review questions pg 696
A young woman who was a recent victim of a sexual assault is brought into the emergency department by a friend. Which of the following is the priority nursing intervention?
a. Help her to bathe and clean herself up.
b. Provide physical and emotional support during evidence collection.
c. Provide her with a written list of community resources for survivors of rape.
d. Discuss the importance of a follow-up visit to evaluate for sexually transmitted diseases.
B
Davis Mental Health review questions pg 697
A woman who was sexually assaulted 6 months ago by a man with whom she was acquainted has since been attending a support group for survivors of rape. From this group, she has learned that the most likely reason the man raped her was:
a. Because he had been drinking, he was not in control of his actions.
b. He had not had sexual relations with a girl in many months.
c. He was predisposed to become a rapist by virtue of the poverty conditions under which he was reared.
d. He was expressing power and dominance by means of sexual aggression and violence.
D
Davis Mental Health review questions pg 697
A nurse is caring for a client who displays manifestations of stave III Parkinson’s disease. Which of the following actions should the nurse include?
1. recommend a community support group
2. Integrate a daily exercise routine
3. Provide a walker for ambulation
4. Preform ADL’s for the client
3
ATI med surg ch 7
A nurse is developing a plan of care for the nutritional needs of a client who has stage IV Parkinson’s disease. Which of the following actions should the nurse include? SATA
- Provide three large balanced meals daily
- Record diet and fluid intake daily
- Document weigh every other week
- Offer cold fluids such as milkshakes
- Offer nutritional supplements between meals
2, 4, 5
ATI med-surg ch 7
A nurse is reinforcing teaching with a client who has parkinson’s disease and has a new prescription for bromocriptine. Which of the followinf instructions should the nurse include?
1. Rise slowly when standing
2. Expect urine to become dark-colored
3. Avoid foods containing tyramine
4. Report any skin discoloration
1
ATI Med-Surg ch 7
A Nurse is assessing a client for manifestations of parkinsons disease. Which of the followinf are expected findings? SATA
1. Decreased vision
2. Pill-rolling tremor of the fingers
3. Shuffling gait
4. Drooling
5. Bilateral ankle edema
6. Lack of facial expression
2, 3, 4, 6
ATI Med-Surg ch 7
A nurse is caring for a client who has parkinsons disease and is starting to display bradykinesia. Which of the following is an appropriate action by the nurse?
1. Teach the client to walk more quickly when ambulating
2. complete passive ROM exercise daily
3. Place the client on a low-protein, low-calorie diet
4. Give the client extra time to preform activities
D
ATI Med-Surg ch 7
A nurse is carinf for a client who has MS. Which of the following findings should the nurse expect
1. fluctations in blood pressure
2. loss of cognative function
3. ineffective cough
4. Drooping eye lids
2
ATI Med-Surg ch 10
A nurse is beginning a physical assessment of a client who has a new dx of MS. Which of the following findings should the nurse expect? SATA
1. Areas of paresthesia
2. Involuntary eye movements
3. Alopecia
4. Increased salivation
5. Ataxia
1, 2, 5
ATI Med-Surg ch10
A nurse is teaching a client who has MS and a new prescription for baclofen. Which of the followinf statements should the nurse include in the teaching?
1. This medication will help you with your tremors
2. This medication will help you with your bladder function
3. This medication can cause your skin to bruise easily
4. This medication can cause you to experience dizziness
4
ATI Med-Surg ch 10
A home health nurse is teaching a client who has active TB and is followinf a medication regimen that includes a combination of isoniazid, rifampin, pyrazinamide, and ethambutol. Which of the following client statements indicate understanding? SATA
1. I can substitute one medication for another if I run out becuase they all fight infection
2. I will wash my hands each time I cough
3. I will wear a mask when I am in a public area
4. I am glad I don’t have to have any more sputum specimens
5. I don’t need to worry where I go once I start taking my medications
2, 3
ATI Med-Surg ch 23
A nurse is teaching a client who has TB. Which of the following statements should the nurse include?
1. You will need to continue to take the multimedication regimen for 4 months
2. you will need to provide sputum samples every 4 wks to monitor the effectiveness
3. you will need to remin hospitalized for treatment
4. you will need to wear a mask at all times
2
ATI Med-Surg ch 23
A nurse is caring for a client who has a new dx of TB and has been placed on a multimedication regimen. Which of the following instructions should the nurse give the client related to ethambutol?
1. your urine can turn a dark orange
2. watch for a change in the sclera of your eyes
3. watch for any changes in vision
4. take vitamin B6 daily
3
ATI Med-Surg ch 23
A nurse is preparing to administer a new prescription for isoniazid (INH) to a light-skinned client who has TB. The nurse should instruct the client to report which of the followinf findings as an adverse efect of the medication?
1. you might notice yellowing of your skin
2. you might experience pain in your joints
3. you migh tnotice tingling of your hands
4. you might experience a loss of appetite
3
ATI Med-Surg ch 23
A nurse is providing information about TB to a group of clients at a local community center. Which of the followinf manifestations should the nurse include? SATA
1. persistent cough
2. weight gain
3. fatigue
4. night sweats
5. purulent sputum
1, 3, 4, 5
ATI Med-Surg ch 23
A nurse is assessing a client who has a pulmonary embolism. Which of the following manifestations should the nurse expect? SATA
1. Bradypnea
2. Pleural friction rub
3. HTN
4. Petechiae
5. Tachycardia
2, 4, 5
ATI Med-Surg ch24
A nurse is completing a preoperative teaching plan for a client who is scheduled to have a total hip arthroplasty. Which of the followinf should the nurse include in the teaching plan? SATA
1. Encourge complete autologous blood donation
2. Sit in low reclining chair
3. Instruct the client to roll onto the operative hip
4. use abductor pillow when turning the client
5. predorm isometric exercises
1, 4, 5
ATI Med-Surg ch 68
A nurse is assessing a client who is schedules to undergo a right knee arthroplasty. The nurse should expect which of the following findings? SATA
1. reddened over the joint
2. pain when bearing weight
3. joint crepitus
4. swelling of the affected joint
5. limited joint motion
2, 3, 4, 5
ATI Med-Surg ch 68
A nurse is planning discharge teaching for a client who had a total hip arthroplasty. Which of the followinf should the nurse include in the teaching? SATA
1. clean incision with soap and water
2. turn the toes inward when sitting or lying
3. sit in a straight backed arm chair
4. bend at the waist when putting on socks
5. use a raised toilet seat
1, 3, 5
ATI Med-Surg ch 68
A nurse is admitting a client to the orthopedic unit following a total knee arthroplasty. Which of the following actions by the nurse are appropriate? SATA
1. check continuous passave motion device settings
2. palpate dorsal pedal pulses
3. place a pillow behind the knee
4. elevate heels off bed
5. Apply heat therapy to incision
1, 2, 4
ATI Med-Surg ch 68
A nurse is aditting an adult client who has suspected osteoporosis. Which of the following findings are risk factors for osteoporosis? SATA
1. hx of consuming one glass of wine daily
2. loss in heigh of 2 in (5.1cm)
3. BMI of 18
4. kyphotic curve at upper thoracit spine
5. hx of lactose intolerance
2, 3, 4, 5
ATI Med-surg ch 70
A nurse is providing care for a client who had a verteroplasty of the thoracic spine. Which of the following actions should the nurse take?
1. apply heat to the puncture site
2. place the client in a supine position
3. turn the client every 1 hr
4. ambulate the client within the first hour post procedure
2
ATI Med-surg ch 70
A nurse is preforming health screenings at a health fair. Which of the followinf clients have a risk factor for osteoporosis? SATA
1. A 40 yr old client who has been taking prednisone for 4 months
2. A 30 yr old client who jogs 3 miles daily
3. a 45 yr old client who takes phenytoin for seizures
4. a 65 yr old client who has a sedentary lifestyle
5. a 70 yr old client who has smoked for 50 yrs
3, 4, 5
ATI Med-Surg ch 70
A nurse is planning discharge teaching on home safety for an adult client who has osteoporosis. Which of the followinf information should the nurse include in the teaching? SATA
1. remove throw rugs in walkways
2. used prescribed assistive devices
3. remove clutter from the environment
4. wear soft-bottomed shoes
5. Maintain lighting of doorway areas
1, 2, 3, 5
ATI Med-surg ch 70
A nurse is providing dietary teaching about calcium rich foods to a client who has osteoporosis. WHich of the following foods should the nurse include in the instrutions?
1. white bread
2. kale
3. apples
4. brown rice
2
ATI Med-surg ch 70
A nurse is teaching a client how to manage an external fixation device upon discharge. WHich of the followinf statements by the client indicates understanding? SATA
1. I will clean the pins more often if the drainage from the pins increases
2. I will use separate cotton swabs for each pin
3. I will report loosening of the pins to my MD
4. I will move my leg by liftinf the device in the middle
5. I will report increased redness at the pin sites
1, 2, 3, 5
ATI Med-Surg ch 71
A nurse is assessing a client who has a casted compound fx of the femur. Which of the following findings is a manifestation of a fat embolus?
1. AMS
2. reduced bowel sounds
3. swelling of the toes distal to the injury
4. Pain with passive movement of the foot distal to the injury
1
ATI Med-Surg ch 71
A nurse is assessing a client who had an external fixation applied 2 hr ago for a fx of left tibia and fibula. Which of the followinf findings is a manifestation of compartment syndrome? SATA
1. intense pain when the client’s left foot is passively moved
2. capillary refill of 3 sec on the client’s left toes
3. hard swollen muscle in the client’s left leg
4. burning and tingling of the clients left foot
5. client report of minimal pain relief followinf a second dose of opioid medication
1, 3, 4, 5
ATI Med-surg ch 71
A nurse is completing d/c teaching to a client who had a wound debridement for osteomyelitis. Which of the followinf information should the nurse include?
1. antibiotic therapy should continue for 3 months
2. relief of pain indicates the infection is eradicated
3. airborne precautions are used during wound care
4. expected paresthesia distal to the wound
1
ATI Med-surg ch 71
A nurse in the emergency department is planning care for a client who has a right hip fracture. Which of the following immobilization devices should the nurse anticipate in the plan of care?
1. skeletal traction
2. bucks traction
3. halo traction
4. bryant’s traction
2
ATI Med-Surg ch 71
1, 4, 5
ATI Med-surg ch 72
A nurse is providing information to a client who has osteoarthritis of the hip and knee. Which of the following information should the nurse include in the information? SATA
1. apply heat to joints to alleviate pain
2. ice inflamed joints for 30 mins following activity
3. reduce amount of exercise done on days with increased pain
4. prop the knees with a pillow while in bed
5. active ROM is more effective than passive
1, 3, 5
ATI Med-surg ch 72
A nurse is providing information about capsaicin cream to a client who reports continuous knee pain from osteoarthritis. Which of the followinf information should the nurse include in the discussion?
1. continuous pain relief is provided
2. put gloves on before applying the cream to other parts of the body
3. leave cream on hands for 10 min following application
4. appy the medication ebery 2 hr during the day
2
ATI Med-surg ch 72
A nurse is caring for a client who recieved a lower back injury during a fall and describes sharp pain in the back and down the left leg. In which of the followin positions should the nurse plan to place the client to attempt to decrease the pain?
1. Prone without use of pillows
2. Semi-fowlers with a pillow under the knees
3. high fowlers with the knees flat on the bed
4. supine with the head flat
2
ATI Med-surg ch 72
A Nurse is providing teaching for a client who has a hx of low back injury. Which of the following instructions should the nurse give the client to prevent future problems with low back pain? SATA
1. engage in regular exercise including walking
2. sit up for 10 hr each day to rest the back
3. maintain weight within 25% of ideal body weight
4. create a smoking cessation plan
5. wear low-heeled shoes
1, 4, 5
ATI Med-surg ch 72
A nurse is planning a staff education program on substance use in older adults. Which of the following information should the nurse to include in the presentation?
1. older adults require higher doses of a substance to acheive a desired effect
2. older adults commonly use rationalization to cope with a substance use disorder
3. older adults are at an increased risk for substance use following retirement
4. older adults develop substance use to mask manifestations of dementia
3
ATI Mental health ch 18
A nurse is assessing a client who has alcohol use disorder and is experiencing withdrawl. Which of the following findings should the nurse expect? SATA
1. Bradycardia
2. fine tremors of both hands
3. hypotension
4. vomiting
5. restlessness
2, 4, 5
ATI Mental health ch 18
A nurse is planning care for a client who is experiencing benxodiazepine withdrawl. Which of the followinf interventions should the nurse identify as the priority?
1. orient the client frequently to time, place, and person
2. offer fluids and nourishing diet as tolerated
3. implement seizure precautions
4. encourage participation in group therapy sessions
3
ATI Med-surg ch 18
A nurse is caring for a client who has alcohol use disorder. The client is no longer experiencing withdrawl manifestations. Which of the followinf medications should the nurse anticipate administering to assist the client with maintaining abstinence from alcohol?
1. chloradiazepoxide
2. bupropion
3. disulfiram
4. carbamazepine
3
ATI Mental health ch 18
A nurse is providing teaching to the family of a client who has substance use disorder. Which of the followinf statements by a family member indicates an understanding of the teaching? SATA
1. we need to understand that our sibling is responsible for their disorder
2. eliminating codependent behavior will promote recovery
3. our sibling should partici[ate in an al-anon group to assist with recovery
4. the primary goal of treatment is abstinence from substance use
5. our sibling needs to discuss personal feelings about substance use to help with recovery
2, 4, 5
ATI Mental health ch 18
A charge nurse is leading a peer group discussion about family and community violence. Which of the following statements by a member of the group indicates an understanding of teaching?
1. children older than 5 are at greater risk for abuse
2. substance use disorder does not increase the risk for violence
3. entering an intimate relationship increases the risk for violence
4. pregnancy increases the risk for violence from a spouse or partner
4
ATI Mental health ch 32
A nurse is caring for an adult who has injuries resulting from spousal violence. The client does not wish to report the violence to law enforcement authorities. Which of the followinf nursing actions is the highest priority?
1. Advise the client about the location of safe houses and shelters
2. encourage the client to participate in support group for survivors of abuse
3. implement case management to coordinate community an dsocial services
4. educate the client about the use of stress management techniques
1
ATI Mental health ch 32
A nurse working in an emergency department is assessing a preschool-age child who reports abd pain. Which of the following findings should alert the nurse to possible abuse? SATA
1. Abrasions on knees
2. round burn marks on forearms
3. mismatched clothing
4. abdominal rebound tenderness
5. areas of ecchymosis on torso
2, 5
ATI Metal health ch 32
