1 1. A nurse cares for a dying client. Which manifestation of dying should the nurse treat first?a. Anorexiab. Painc. Nausea d. Hair loss ANS: B 2 2. A nurse plans care for a client who is nearing end of life. Which question should the nurse ask when developing this clients plan of care?a. Is your advance directive up to date and notarized?b. Do you want to be at home at the end of your life?c. Would you like a physical therapist to assist you with range-of-motion activities? d. Have your children discussed resuscitation with your health care provider? ANS: B 3 3. A nurse is caring for a client who has lung cancer and is dying. Which prescription should the nurse question?a. Morphine 10 mg sublingual every 6 hours PRN for pain level greater than 5b. Albuterol (Proventil) metered dose inhaler every 4 hours PRN for wheezesc. Atropine solution 1% sublingual every 4 hours PRN for excessive oral secretions d. Sodium biphosphate (Fleet) enema once a day PRN for impacted stool ANS: A 4 4. A client tells the nurse that, even though it has been 4 months since her sisters death, she frequently findsherself crying uncontrollably. How should the nurse respond?a. Most people move on within a few months. You should see a grief counselor. b. Whenever you start to cry, distract yourself from thoughts of your sister. c. You should try not to cry. Im sure your sister is in a better place now. ANS: D 5 5. After teaching a client about advance directives, a nurse assesses the clients understanding. Which statement indicates the client correctly understands the teaching?a. An advance directive will keep my children from selling my home when Im old.b. An advance directive will be completed as soon as Im incapacitated and cant think for myself.c. An advance directive will specify what I want done when I can no longer make decisions about health care. d. An advance directive will allow me to keep my money out of the reach of my family. ANS: CAn advance directive is a written document prepared by a competent individual that specifies what, if any, extraordinary actions a person would want taken when he or she can no longer make decisions about personal health care. It does not address issues such as the clients residence or financial matters. 6 6. A nurse teaches a client who is considering being admitted to hospice. Which statement should the nurse include in this clients teaching?a. Hospice admission has specific criteria. You may not be a viable candidate, so we will look at alternative plans for your discharge.b. Hospice care focuses on a holistic approach to health care. It is designed not to hasten death, but rather to relieve symptoms.c. Hospice care will not help with your symptoms of depression. I will refer you to the facilitys counseling services instead. d. You seem to be experiencing some difficulty with this stage of the grieving process. Lets talk about your feelings. ANS: B 7 7. A nurse is caring for a dying client. The clients spouse states, I think he is choking to death. How should the nurse respond?a. Do not worry. The choking sound is normal during the dying process.b. I will administer more morphine to keep your husband comfortable.c. I can ask the respiratory therapist to suction secretions out through his nose. d. I will have another nurse assist me to turn your husband on his side. ANS: DThe choking sound or death rattle is common in dying clients. The nurse should acknowledge the spouses concerns and provide interventions that will reduce the choking sounds. Repositioning the client onto one side with a towel under the mouth to collect secretions is the best intervention. The nurse should not minimize the spouses concerns. Morphine will assist with comfort but will not decrease the choking sounds. Nasotracheal suctioning is not appropriate in a dying client. 8 8. The nurse is teaching a family member about various types of complementary therapies that might be effective for relieving the dying clients anxiety and restlessness. Which statement made by the family member indicates understanding of the nurses teaching?a. Maybe we should just hire an around-the-clock sitter to stay with Grandmother.b. I have some of her favorite hymns on a CD that I could bring for music therapy.c. I dont think that shell need pain medication along with her herbal treatments. d. I will burn therapeutic incense in the room so we can stop the anxiety pills. ANS: B 9 9. A nurse is caring for a terminally ill client who has just died in a hospital setting with family members at the bedside. Which action should the nurse take first?a. Call for emergency assistance so that resuscitation procedures can begin.b. Ask family members if they would like to spend time alone with the client.c. Ensure that a death certificate has been completed by the physician. d. Request family members to prepare the clients body for the funeral home. ANS: BBefore moving the clients body to the funeral home, the nurse should ask family members if they would like to be alone with the client. Emergency assistance will not be necessary. Although it is important to ensure that adeath certificate has been completed before the client is moved to the mortuary, the nurse first should ask family members if they would like to be alone with the client. The clients family should not be expected to prepare the body for the funeral home. 10 10. A nurse assesses a client who is dying. Which manifestation of a dying client should the nurse assess to determine whether the client is near death?a. Level of consciousnessb. Respiratory ratec. Bowel sounds d. Pain level on a 0-to-10 scale ANS: B 11 11. A nurse is caring for a client who is terminally ill. The clients spouse states, I am concerned because he does not want to eat. How should the nurse respond?a. Let him know that food is available if he wants it, but do not insist that he eat.b. A feeding tube can be placed in the nose to provide important nutrients.c. Force him to eat even if he does not feel hungry, or he will die sooner. d. He is getting all the nutrients he needs through his intravenous catheter. ANS: A 12 12. A nurse discusses inpatient hospice with a client and the clients family. A family member expresses concern that her loved one will receive only custodial care. How should the nurse respond?a. The goal of palliative care is to provide the greatest degree of comfort possible and help the dying person enjoy whatever time is left.b. Palliative care will release you from the burden of having to care for someone in the home. It does not mean that curative treatment will stop.c. A palliative care facility is like a nursing home and costs less than a hospital because only pain medications are given. d. Your relative is unaware of her surroundings and will not notice the difference between her home and a palliative care facility. ANS: A 13 13. An intensive care nurse discusses withdrawal of care with a clients family. The family expresses concerns related to discontinuation of therapy. How should the nurse respond?a. I understand your concerns, but in this state, discontinuation of care is not a form of active euthanasia.b. You will need to talk to the provider because I am not legally allowed to participate in the withdrawal of life support.c. I realize this is a difficult decision. Discontinuation of therapy will allow the client to die a natural death. d. There is no need to worry. Most religious organizations support the clients decision to stop medical treatment. ANS: C 14 14. A hospice nurse is caring for a variety of clients who are dying. Which end-of-life and death ritual is paired with the correct religion?a. Roman Catholic Autopsies are not allowed except under special circumstances.b. Christian Upon death, a religious leader should perform rituals of bathing and wrapping the body in cloth.c. Judaism A person who is extremely ill and dying should not be left alone. d. Islam An ill or dying person should receive the Sacrament of the Sick. ANS: C 15 1. A hospice nurse is caring for a dying client and her family members. Which interventions should the nurseimplement? (Select all that apply.)a. Teach family members about physical signs of impending death.b. Encourage the management of adverse symptoms.c. Assist family members by offering an explanation for their loss.d. Encourage reminiscence by both client and family members. e. Avoid spirituality because the clients and the nurses beliefs may not be congruent. ANS: A, B, D 16 2. A nurse admits an older adult client to the hospital. Which criterion should the nurse use to determine if the client can make his own medical decisions? (Select all that apply.)a. Can communicate his treatment preferencesb. Is able to read and write at an eighth-grade levelc. Is oriented enough to understand information providedd. Can evaluate and deliberate information e. Has completed an advance directive ANS: A, C, D 17 3. A hospice nurse plans care for a client who is experiencing pain. Which complementary therapies should the nurse incorporate in this clients pain management plan? (Select all that apply.)a. Play music that the client enjoys.b. Massage tissue that is tender from radiation therapy.c. Rub lavender lotion on the clients feet.d. Ambulate the client in the hall twice a day. e. Administer intravenous morphine. ANS: A, C 18 1. A nurse is working with a community group promoting healthy aging. What recommendation is best to help prevent osteoarthritis (OA)?a. Avoid contact sports.b. Get plenty of calcium.c. Lose weight if needed. d. Engage in weight-bearing exercise. ANS: CObesity can lead to OA, and if the client is overweight, losing weight can help prevent OA or reduce symptoms once it occurs. Arthritis can be caused by contact sports, but this is less common than obesity. Calcium and weight-bearing exercise are both important for osteoporosis. 19 2. A nurse in the family clinic is teaching a client newly diagnosed with osteoarthritis (OA) about drugs used to treat the disease. For which medication does the nurse plan primary teaching?a. Acetaminophen (Tylenol)b. Cyclobenzaprine hydrochloride (Flexeril)c. Hyaluronate (Hyalgan) d. Ibuprofen (Motrin) ANS: AAll of the drugs are appropriate to treat OA. However, the first-line drug is acetaminophen. Cyclobenzaprine is a muscle relaxant given to treat muscle spasms. Hyaluronate is a synthetic joint fluid implant. Ibuprofen is a nonsteroidal anti-inflammatory drug. 20 3. The clinic nurse assesses a client with diabetes during a checkup. The client also has osteoarthritis (OA). The nurse notes the clients blood glucose readings have been elevated. What question by the nurse is most appropriate?a. Are you compliant with following the diabetic diet?b. Have you been taking glucosamine supplements?c. How much exercise do you really get each week? d. Youre still taking your diabetic medication, right? ANS: B 21 4. The nurse working in the orthopedic clinic knows that a client with which factor has an absolute contraindication for having a total joint replacement?a. Needs multiple dental fillingsb. Over age 85c. Severe osteoporosis d. Urinary tract infection ANS: COsteoporosis is a contraindication to joint replacement because the bones have a high risk of shattering as the new prosthesis is implanted. The client who needs fillings should have them done prior to the surgery. Age greater than 85 is not an absolute contraindication. A urinary tract infection can be treated prior to surgery. 22 5. An older client has returned to the surgical unit after a total hip replacement. The client is confused and restless. What intervention by the nurse is most important to prevent injury?a. Administer mild sedation.b. Keep all four siderails up.c. Restrain the clients hands. d. Use an abduction pillow. ANS: D 23 6. What action by the perioperative nursing staff is most important to prevent surgical wound infection in a client having a total joint replacement?a. Administer preoperative antibiotic as ordered.b. Assess the clients white blood cell count.c. Instruct the client to shower the night before. d. Monitor the clients temperature postoperatively. ANS: ATo prevent surgical wound infection, antibiotics are given preoperatively within an hour of surgery. Simply taking a shower will not help prevent infection unless the client is told to use special antimicrobial soap. The other options are processes to monitor for infection, not prevent it. 24 7. The nurse on the postoperative inpatient unit assesses a client after a total hip replacement. The clients surgical leg is visibly shorter than the other one and the client reports extreme pain. While a co-worker calls thesurgeon, what action by the nurse is best? a. Assess neurovascular status in both legs. b. Elevate the affected leg and apply ice.c. Prepare to administer pain medication. d. Try to place the affected leg in abduction. ANS: AThis client has manifestations of hip dislocation, a critical complication of this surgery. Hip dislocation can cause neurovascular compromise. The nurse should assess neurovascular status, comparing both legs. The nurse should not try to move the extremity to elevate or abduct it. Pain medication may be administered if possible, but first the nurse should thoroughly assess the client. 25 8. A client has a continuous passive motion (CPM) device after a total knee replacement. What action does the nurse delegate to the unlicensed assistive personnel (UAP) after the affected leg is placed in the machine whilethe client is in bed?a. Assess the distal circulation in 30 minutes.b. Change the settings based on range of motion.c. Raise the lower siderail on the affected side. d. Remind the client to do quad-setting exercises. ANS: C 26 9. After a total knee replacement, a client is on the postoperative nursing unit with a continuous femoral nerve blockade. On assessment, the nurse notes the clients pulses are 2+/4+ bilaterally; the skin is pale pink, warm,and dry; and the client is unable to dorsiflex or plantarflex the affected foot. What action does the nurse perform next?a. Document the findings and monitor as prescribed.b. Increase the frequency of monitoring the client.c. Notify the surgeon or anesthesia provider immediately. d. Palpate the clients bladder or perform a bladder scan. ANS: C 27 10. A nurse is discharging a client to a short-term rehabilitation center after a joint replacement. Which action by the nurse is most important?a. Administering pain medication before transportb. Answering any last-minute questions by the client c. Ensuring the family has directions to the facility d. Providing a verbal hand-off report to the facility ANS: D 28 11. A nurse works in the rheumatology clinic and sees clients with rheumatoid arthritis (RA). Which client should the nurse see first?a. Client who reports jaw pain when eatingb. Client with a red, hot, swollen right wristc. Client who has a puffy-looking area behind the knee d. Client with a worse joint deformity since the last visit ANS: B 29 12. A client with rheumatoid arthritis (RA) is on the postoperative nursing unit after having elective surgery. The client reports that one arm feels like pins and needles and that the neck is very painful since returning fromsurgery. What action by the nurse is best?a. Assist the client to change positions.b. Document the findings in the clients chart.c. Encourage range of motion of the neck. d. Notify the provider immediately. ANS: D 30 13. The nurse working in the rheumatology clinic is seeing clients with rheumatoid arthritis (RA). What assessment would be most important for the client whose chart contains the diagnosis of Sjgrens syndrome?a. Abdominal assessmentb. Oxygen saturationc. Renal function studies d. Visual acuity ANS: D 31 14. The nurse is working with a client who has rheumatoid arthritis (RA). The nurse has identified the priority problem of poor body image for the client. What finding by the nurse indicates goals for this client problem are being met?a. Attends meetings of a book clubb. Has a positive outlook on lifec. Takes medication as directed d. Uses assistive devices to protect joints ANS: A 32 16. The nurse in the rheumatology clinic is assessing clients with rheumatoid arthritis (RA). Which client should the nurse see first?a. Client taking celecoxib (Celebrex) and ranitidine (Zantac)b. Client taking etanercept (Enbrel) with a red injection sitec. Client with a blood glucose of 190 mg/dL who is taking steroids d. Client with a fever and cough who is taking tofacitinib (Xeljanz) ANS: DTofacitinib carries a Food and Drug Administration black box warning about opportunistic infections, tuberculosis, and cancer. Fever and cough may indicate tuberculosis. Ranitidine is often taken with celecoxib, which can cause gastrointestinal distress. Redness and itchy rashes are frequently seen with etanercept injections. Steroids are known to raise blood glucose levels. 33 17. A client with rheumatoid arthritis (RA) has an acutely swollen, red, and painful joint. What nonpharmacologic treatment does the nurse apply?a. Heating pad b. Ice packs c. Splints ANS: B 34 18. The nurse on an inpatient rheumatology unit receives a hand-off report on a client with an acute exacerbation of systemic lupus erythematosus (SLE). Which reported laboratory value requires the nurse to assess the client further?a. Creatinine: 3.9 mg/dLb. Platelet count: 210,000/mm3c. Red blood cell count: 5.2/mm3 d. White blood cell count: 4400/mm3 ANS: A 35 19. A client who has had systemic lupus erythematosus (SLE) for many years is in the clinic reporting hip pain with ambulation. Which action by the nurse is best?a. Assess medication records for steroid use.b. Facilitate a consultation with physical therapy.c. Measure the range of motion in both hips. d. Notify the health care provider immediately. ANS: AChronic steroid use is seen in clients with SLE and can lead to osteonecrosis (bone necrosis). The nurse should determine if the client has been taking a steroid. Physical therapy may be beneficial, but there is not enough information about the client yet. Measuring range of motion is best done by the physical therapist. Notifying the provider immediately is not warranted. 36 20. A client with systemic lupus erythematosus (SLE) was recently discharged from the hospital after an acute exacerbation. The client is in the clinic for a follow-up visit and is distraught about the possibility of another hospitalization disrupting the family. What action by the nurse is best?a. Explain to the client that SLE is an unpredictable disease.b. Help the client create backup plans to minimize disruption.c. Offer to talk to the family and educate them about SLE. d. Tell the client to remain compliant with treatment plans. ANS: B 37 24. A client in the orthopedic clinic has a self-reported history of osteoarthritis. The client reports a low-grade fever that started when the weather changed and several joints started acting up, especially both hips and knees. What action by the nurse is best?a. Assess the client for the presence of subcutaneous nodules or Bakers cysts.b. Inspect the clients feet and hands for podagra and tophi on fingers and toes.c. Prepare to teach the client about an acetaminophen (Tylenol) regimen. d. Reassure the client that the problems will fade as the weather changes again. ANS: AOsteoarthritis is not a systemic disease, nor does it present bilaterally. These are manifestations of rheumatoid arthritis. The nurse should assess for other manifestations of this disorder, including subcutaneous nodules and Bakers cysts. Podagra and tophi are seen in gout. Acetaminophen is not used for rheumatoid arthritis. Telling the client that the symptoms will fade with weather changes is not accurate. 38 25. A nurse is caring for a client after joint replacement surgery. What action by the nurse is most important to prevent wound infection?a. Assess the clients white blood cell count.b. Culture any drainage from the wound.c. Monitor the clients temperature every 4 hours. d. Use aseptic technique for dressing changes. ANS: DPreventing surgical wound infection is a primary responsibility of the nurse, who must use aseptic technique to change dressings or empty drains. The other actions do not prevent infection but can lead to early detection of an infection that is already present. 39 26. A nurse is discharging a client after a total hip replacement. What statement by the client indicates good potential for self-management?a. I can bend down to pick something up.b. I no longer need to do my exercises.c. I will not sit with my legs crossed. d. I wont wash my incision to keep it dry. ANS: C 40 27. The nurse is caring for a client using a continuous passive motion (CPM) machine and has delegated some tasks to the unlicensed assistive personnel (UAP). What action by the UAP warrants intervention by the nurse?a. Checking to see if the machine is workingb. Keeping controls in a secure place on the bedc. Placing padding in the machine per request d. Storing the CPM machine under the bed after removal ANS: D 41 28. A client recently diagnosed with systemic lupus erythematosus (SLE) is in the clinic for a follow-up visit. The nurse evaluates that the client practices good self-care when the client makes which statement?a. I always wear long sleeves, pants, and a hat when outdoors.b. I try not to use cosmetics that contain any type of sunblock.c. Since I tend to sweat a lot, I use a lot of baby powder. d. Since I cant be exposed to the sun, I have been using a tanning bed. ANS: A 42 29. A client is scheduled to have a hip replacement. Preoperatively, the client is found to be mildly anemic and the surgeon states the client may need a blood transfusion during or after the surgery. What action by the preoperative nurse is most important?a. Administer preoperative medications as prescribed.b. Ensure that a consent for transfusion is on the chart.c. Explain to the client how anemia affects healing. d. Teach the client about foods high in protein and iron. ANS: B 43 30. An older client is scheduled to have hip replacement in 2 months and has the following laboratory values: white blood cell count: 8900/mm3, red blood cell count: 3.2/mm3, hemoglobin: 9 g/dL, hematocrit: 32%. What intervention by the nurse is most appropriate?a. Instruct the client to avoid large crowds.b. Prepare to administer epoetin alfa (Epogen).c. Teach the client about foods high in iron. d. Tell the client that all laboratory results are normal. ANS: BThis client is anemic, which needs correction prior to surgery. While eating iron-rich foods is helpful, to increase the clients red blood cells, hemoglobin, and hematocrit within 2 months, epoetin alfa is needed. This colony-stimulating factor will encourage the production of red cells. The clients white blood cell count is normal, so avoiding infection is not the priority. 44 31. A client is getting out of bed into the chair for the first time after an uncemented hip replacement. What action by the nurse is most important?a. Have adequate help to transfer the client.b. Provide socks so the client can slide easier.c. Tell the client full weight bearing is allowed. d. Use a footstool to elevate the clients leg. ANS: AThe client with an uncemented hip will be on toe-touch only right after surgery. The nurse should ensure there is adequate help to transfer the client while preventing falls. Slippery socks will encourage a fall. Elevating the leg greater than 90 degrees is not allowed. 45 32. A client has fibromyalgia and is prescribed duloxetine hydrochloride (Cymbalta). The client calls the clinic and asks the nurse why an antidepressant drug has been prescribed. What response by the nurse is best?a. A little sedation will help you get some rest.b. Depression often accompanies fibromyalgia.c. This drug works in the brain to decrease pain. d. You will have more energy after taking this drug. ANS: C 46 33. A client has been diagnosed with rheumatoid arthritis. The client has experienced increased fatigue and worsening physical status and is finding it difficult to maintain the role of elder in his cultural community. The elder is expected to attend social events and make community decisions. Stress seems to exacerbate the condition. What action by the nurse is best?a. Assess the clients culture more thoroughly.b. Discuss options for performing duties.c. See if the client will call a community meeting. d. Suggest the client give up the role of elder. ANS: A 47 34. A client has rheumatoid arthritis that especially affects the hands. The client wants to finish quilting a baby blanket before the birth of her grandchild. What response by the nurse is best?a. Lets ask the provider about increasing your pain pills.b. Hold ice bags against your hands before quilting.c. Try a paraffin wax dip 20 minutes before you quilt. d. You need to stop quilting before it destroys your fingers. ANS: C 48 35. A client has newly diagnosed systemic lupus erythematosus (SLE). What instruction by the nurse is most important?a. Be sure you get enough sleep at night.b. Eat plenty of high-protein, high-iron foods.c. Notify your provider at once if you get a fever. d. Weigh yourself every day on the same scale. ANS: CFever is the classic sign of a lupus flare and should be reported immediately. Rest and nutrition are important but do not take priority over teaching the client what to do if he or she develops an elevated temperature. Daily weights may or may not be important depending on renal involvement. 49 37. A client takes celecoxib (Celebrex) for chronic osteoarthritis in multiple joints. After a knee replacement, the health care provider has prescribed morphine sulfate for postoperative pain relief. The client also requests the celecoxib in addition to the morphine. What action by the nurse is best?a. Consult with the health care provider about administering both drugs to the client.b. Inform the client that the celecoxib will be started when he or she goes home.c. Teach the client that, since morphine is stronger, celecoxib is not needed. d. Tell the client he or she should not take both drugs at the same time. ANS: ADespite getting an opioid analgesic for postoperative pain, the nurse should be aware that the client may be on other medications for arthritis in other joints. The nonsteroidal anti-inflammatory drug celecoxib will also helpwith the postoperative pain. The nurse should consult the provider about continuing the celecoxib while the client is in the hospital. The other responses are not warranted, as the client should be restarted on this medication postoperatively. 50 1. The nursing student studying rheumatoid arthritis (RA) learns which facts about the disease? (Select all thatapply.)a. It affects single joints only.b. Antibodies lead to inflammation.c. It consists of an autoimmune process.d. Morning stiffness is rare. e. Permanent damage is inevitable. ANS: B, CRA is a chronic autoimmune systemic inflammatory disorder leading to arthritis-type symptoms in the joints and other symptoms that can be seen outside the joints. Antibodies are created that lead to inflammation. Clients often report morning stiffness. Permanent damage can be avoided with aggressive, early treatment. 51 2. A nurse is teaching a female client with rheumatoid arthritis (RA) about taking methotrexate (MTX) (Rheumatrex) for disease control. What information does the nurse include? (Select all that apply.)a. Avoid acetaminophen in over-the-counter medications.b. It may take several weeks to become effective on pain.c. Pregnancy and breast-feeding are not affected by MTX.d. Stay away from large crowds and people who are ill. e. You may find that folic acid, a B vitamin, reduces side effects. ANS: A, B, D, E 52 3. A client has been diagnosed with fibromyalgia syndrome but does not want to take the prescribed medications. What nonpharmacologic measures can the nurse suggest to help manage this condition? (Select all that apply.)a. Acupunctureb. Stretching c. Supplements d. Tai chi NS: A, B, D 53 4. The nurse working in the rheumatology clinic assesses clients with rheumatoid arthritis (RA) for late manifestations. Which signs/symptoms are considered late manifestations of RA? (Select all that apply.)a. Anorexiab. Feltys syndromec. Joint deformityd. Low-grade fever e. Weight loss ANS: B, C, E 54 5. An older client returning to the postoperative nursing unit after a hip replacement is disoriented and restless. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)a. Apply an abduction pillow to the clients legs.b. Assess the skin under the abduction pillow straps.c. Place pillows under the heels to keep them off the bed.d. Monitor cognition to determine when the client can get up. e. Take and record vital signs per unit/facility policy. ANS: A, C, E 55 9. A client has rheumatoid arthritis (RA) and the visiting nurse is conducting a home assessment. What options can the nurse suggest for the client to maintain independence in activities of daily living (ADLs)? (Select allthat apply.)a. Grab bars to reach high itemsb. Long-handled bath scrub brushc. Soft rocker-recliner chaird. Toothbrush with built-up handle e. Wheelchair cushion for comfort ANS: A, B, D Grab bars, long-handled bath brushes, and toothbrushes with built-up handles all provide modifications for daily activities, making it easier for the client with RA to complete ADLs independently. The rocker-recliner 56 10. A home health care nurse is visiting a client discharged home after a hip replacement. The client is still on partial weight bearing and using a walker. What safety precautions can the nurse recommend to the client?(Select all that apply.)a. Buy and install an elevated toilet seat.b. Install grab bars in the shower and by the toilet.c. Step into the bathtub with the affected leg first.d. Remove all throw rugs throughout the house. e. Use a shower chair while taking a shower. ANS: A, B, D, E 57 11. A client with fibromyalgia is in the hospital for an unrelated issue. The client reports that sleep, which is always difficult, is even harder now. What actions by the nurse are most appropriate? (Select all that apply.)a. Allow the client uninterrupted rest time.b. Assess the clients usual bedtime routine.c. Limit environmental noise as much as possible.d. Offer a massage or warm shower at night. e. Request an order for a strong sleeping pill. ANS: A, B, C, D 58 1. The nurse is caring for a client diagnosed with human immune deficiency virus. The clients CD4+ cell count is 399/mm3. What action by the nurse is best?a. Counsel the client on safer sex practices/abstinence.b. Encourage the client to abstain from alcohol.c. Facilitate genetic testing for CD4+ CCR5/CXCR4 co-receptors. d. Help the client plan high-protein/iron meals. ANS: AThis client is in the Centers for Disease Control and Prevention stage 2 case definition group. He or she remains highly infectious and should be counseled on either safer sex practices or abstinence. Abstaining from alcohol is healthy but not required. Genetic testing is not commonly done, but an alteration on the CCR5/CXCR4 co-receptors is seen in long-term nonprogressors. High-protein/iron meals are important for people who are immunosuppressed, but helping to plan them does not take priority over stopping the spread of the disease. 59 2. The nurse is presenting information to a community group on safer sex practices. The nurse should teach that which sexual practice is the riskiest?a. Anal intercourseb. Masturbationc. Oral sex d. Vaginal intercourse ANS: A 60 3. The nurse providing direct client care uses specific practices to reduce the chance of acquiring infection with human immune deficiency virus (HIV) from clients. Which practice is most effective?a. Consistent use of Standard Precautionsb. Double-gloving before body fluid exposurec. Labeling charts and armbands HIV+ d. Wearing a mask within 3 feet of the client ANS: AAccording to The Joint Commission, the most effective preventative measure to avoid HIV exposure is consistent use of Standard Precautions. Double-gloving is not necessary. Labeling charts and armbands in this fashion is a violation of the Health Information Portability and Accountability Act (HIPAA). Wearing a mask within 3 feet of the client is part of Airborne Precautions and is not necessary with every client contact. 61 4. A client with human immune deficiency virus is admitted to the hospital with fever, night sweats, and severe cough. Laboratory results include a CD4+ cell count of 180/mm3 and a negative tuberculosis (TB) skin test 4 days ago. What action should the nurse take first?a. Initiate Droplet Precautions for the client.b. Notify the provider about the CD4+ results.c. Place the client under Airborne Precautions. d. Use Standard Precautions to provide care. ANS: C 62 5. A nurse is talking with a client about a negative enzyme-linked immunosorbent assay (ELISA) test for human immune deficiency virus (HIV) antibodies. The test is negative and the client states Whew! I was reallyworried about that result. What action by the nurse is most important?a. Assess the clients sexual activity and patterns.b. Express happiness over the test result.c. Remind the client about safer sex practices. d. Tell the client to be retested in 3 months. ANS: A 63 6. A client with human immune deficiency virus (HIV) has had a sudden decline in status with a large increase in viral load. What action should the nurse take first?a. Ask the client about travel to any foreign countries.b. Assess the client for adherence to the drug regimen.c. Determine if the client has any new sexual partners. d. Request information about new living quarters or pets. ANS: BAdherence to the complex drug regimen needed for HIV treatment can be daunting. Clients must take their medications on time and correctly at a minimum of 90% of the time. Since this clients viral load has increased dramatically, the nurse should first assess this factor. After this, the other assessments may or may not be needed. 64 7. A client is hospitalized with Pneumocystis jiroveci pneumonia. The client reports shortness of breath with activity and extreme fatigue. What intervention is best to promote comfort? b. Perform most activities for the client.c. Increase the clients oxygen during activity. d. Pace activities, allowing for adequate rest. ANS: D 65 8. A client with HIV wasting syndrome has inadequate nutrition. What assessment finding by the nurse best ndicates that goals have been met for this client problem?a. Chooses high-protein foodb. Has decreased oral discomfortc. Eats 90% of meals and snacks d. Has a weight gain of 2 pounds/1 month ANS: D 66 9. A client with acquired immune deficiency syndrome is hospitalized and has weeping Kaposis sarcoma lesions. The nurse dresses them with sterile gauze. When changing these dressings, which action is most important?a. Adhering to Standard Precautionsb. Assessing tolerance to dressing changesc. Performing hand hygiene before and after care d. Disposing of soiled dressings properly ANS: D 67 10. A client has a primary selective immunoglobulin A deficiency. The nurse should prepare the client for self management by teaching what principle of medical management?a. Infusions will be scheduled every 3 to 4 weeks.b. Treatment is aimed at treating specific infections.c. Unfortunately, there is no effective treatment. d. You will need many immunoglobulin A infusions. ANS: B 68 11. An HIV-positive client is admitted to the hospital with Toxoplasma gondii infection. Which action by the nurse is most appropriate?a. Initiate Contact Precautions.b. Place the client on Airborne Precautions.c. Place the client on Droplet Precautions. d. Use Standard Precautions consistently. ANS: D 69 12. A client has just been diagnosed with human immune deficiency virus (HIV). The client is distraught and does not know what to do. What intervention by the nurse is best?a. Assess the client for support systems.b. Determine if a clergy member would help.c. Explain legal requirements to tell sex partners. d. Offer to tell the family for the client. ANS: A 70 13. A nurse works on a unit that has admitted its first client with acquired immune deficiency syndrome. The nurse overhears other staff members talking about the AIDS guy and wondering how the client contracted the disease. What action by the nurse is best?a. Confront the staff members about unethical behavior.b. Ignore the behavior; they will stop on their own soon.c. Report the behavior to the units nursing management. d. Tell the client that other staff members are talking about him or her. ANS: A 71 14. A client has been hospitalized with an opportunistic infection secondary to acquired immune deficiency syndrome. The clients partner is listed as the emergency contact, but the clients mother insists that she should be listed instead. What action by the nurse is best?a. Contact the social worker to assist the client with advance directives.b. Ignore the mother; the client does not want her to be involved.c. Let the client know, gently, that nurses cannot be involved in these disputes. d. Tell the client that, legally, the mother is the emergency contact. ANS: A 72 15. A client with human immune deficiency virus infection is hospitalized for an unrelated condition, and several medications are prescribed in addition to the regimen already being used. What action by the nurse is most important?a. Consult with the pharmacy about drug interactions.b. Ensure that the client understands the new medications.c. Give the new drugs without considering the old ones. d. Schedule all medications at standard times. ANS: A 73 16. A client with acquired immune deficiency syndrome has been hospitalized with suspected cryptosporidiosis. What physical assessment would be most consistent with this condition?a. Auscultating the lungsb. Assessing mucous membranesc. Listening to bowel sounds d. Performing a neurologic examination ANS: BCryptosporidiosis can cause extreme loss of fluids and electrolytes, up to 20 L/day. The nurse should assess signs of hydration/dehydration as the priority, including checking the clients mucous membranes for dryness. The nurse will perform the other assessments as part of a comprehensive assessment. 74 17. A client with HIV/AIDS asks the nurse why gabapentin (Neurontin) is part of the drug regimen when the client does not have a history of seizures. What response by the nurse is best?a. Gabapentin can be used as an antidepressant too. b. I have no idea why you should be taking this drug. c. This drug helps treat the pain from nerve irritation. ANS: C 75 18. A nurse is caring for four clients who have immune disorders. After receiving the hand-off report, which client should the nurse assess first?a. Client with acquired immune deficiency syndrome with a CD4+ cell count of 210/mm3 and a temp of 102.4 F (39.1 C)b. Client with Brutons agammaglobulinemia who is waiting for discharge teachingc. Client with hypogammaglobulinemia who is 1 hour post immune serum globulin infusion d. Client with selective immunoglobulin A deficiency who is on IV antibiotics for pneumonia ANS: A 76 19. An HIV-negative client who has an HIV-positive partner asks the nurse about receiving Truvada (emtricitabine and tenofovir). What information is most important to teach the client about this drug?a. Truvada does not reduce the need for safe sex practices.b. This drug has been taken off the market due to increases in cancer.c. Truvada reduces the number of HIV tests you will need. d. This drug is only used for postexposure prophylaxis. ANS: ATruvada is a new drug used for pre-exposure prophylaxis and appears to reduce transmission of human immune deficiency virus (HIV) from known HIV-positive people to HIV-negative people. The drug does notreduce the need for practicing safe sex. Since the drug can lead to drug resistance if used, clients will still need HIV testing every 3 months. This drug has not been taken off the market and is not used for postexposure prophylaxis. 77 1. A student nurse is learning about human immune deficiency virus (HIV) infection. Which statements about HIV infection are correct? (Select all that apply.)a. CD4+ cells begin to create new HIV virus particles.b. Antibodies produced are incomplete and do not function well. c. Macrophages stop functioning properly. d. Opportunistic infections and cancer are leading causes of death. ANS: A, B, C, D 78 2. Which findings are AIDS-defining characteristics? (Select all that apply.)a. CD4+ cell count less than 200/mm3 or less than 14%b. Infection with Pneumocystis jirovecic. Positive enzyme-linked immunosorbent assay (ELISA) test for human immune deficiency virus (HIV)d. Presence of HIV wasting syndrome e. Taking antiretroviral medications ANS: A, B, DA diagnosis of AIDS requires that the person be HIV positive and have either a CD4+ T-cell count of less than 200 cells/mm3 or less than 14% (even if the total CD4+ count is above 200 cells/mm3) or an opportunistic infection such as Pneumocystis jiroveci and HIV wasting syndrome. Having a positive ELISA test and taking antiretroviral medications are not AIDS-defining characteristics. 79 3. A nurse is traveling to a third-world country with a medical volunteer group to work with people who are infected with human immune deficiency virus (HIV). The nurse should recognize that which of the followingmight be a barrier to the prevention of perinatal HIV transmission? (Select all that apply.)a. Clean drinking waterb. Cultural beliefs about illnessc. Lack of antiviral medicationd. Social stigma e. Unknown transmission routes ANS: A, B, C, D 80 4. A client with acquired immune deficiency syndrome (AIDS) is hospitalized with Pneumocystis jiroveci pneumonia and is started on the drug of choice for this infection. What laboratory values should the nurse report to the provider as a priority? (Select all that apply.)a. Aspartate transaminase, alanine transaminase: elevatedb. CD4+ cell count: 180/mm3c. Creatinine: 1.0 mg/dL d. Platelet count: 80,000/mm3 e. Serum sodium: 120 mEq/L ANS: A, D, EThe drug of choice to treat Pneumocystis jiroveci pneumonia is trimethoprim with sulfamethoxazole (Septra). Side effects of this drug include hepatitis, hyponatremia, and thrombocytopenia. The elevated liver enzymes, low platelet count, and low sodium should all be reported. The CD4+ cell count is within the expected range for a client with an AIDS-defining infection. The creatinine level is normal. 81 5. A client with acquired immune deficiency syndrome has oral thrush and difficulty eating. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)a. Apply oral anesthetic gels before meals.b. Assist the client with oral care every 2 hours.c. Offer the client frequent sips of cool drinks.d. Provide the client with alcohol-based mouthwash. e. Remind the client to use only a soft toothbrush. ANS: B, C, EThe UAP can help the client with oral care, offer fluids, and remind the client of things the nurse (or other professional) has already taught. Applying medications is performed by the nurse. Alcohol-based mouthwashes are harsh and drying and should not be used. 82 6. A client with acquired immune deficiency syndrome is in the hospital with severe diarrhea. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)a. Assessing the clients fluid and electrolyte statusb. Assisting the client to get out of bed to prevent fallsc. Obtaining a bedside commode if the client is weakd. Providing gentle perianal cleansing after stools e. Reporting any perianal abnormalities ANS: B, C, D, E 83 7. A client with acquired immune deficiency syndrome and esophagitis due to Candida fungus is scheduled for an endoscopy. What actions by the nurse are most appropriate? (Select all that apply.)a. Assess the clients mouth and throat.b. Determine if the client has a stiff neck.c. Ensure that the consent form is on the chart.d. Maintain NPO status as prescribed. e. Percuss the clients abdomen. ANS: A, C, DOral Candida fungal infections can lead to esophagitis. This is diagnosed with an endoscopy and biopsy. The nurse assesses the clients mouth and throat beforehand, ensures valid consent is on the chart, and maintains the client in NPO status as prescribed. A stiff neck and abdominal percussion are not related to this diagnostic procedure. 84 10. After teaching the wife of a client who has Parkinson disease, the nurse assesses the wifes understanding. Which statement by the clients wife indicates she correctly understands changes associated with this disease?a. His masklike face makes it difficult to communicate, so I will use a white board.b. He should not socialize outside of the house due to uncontrollable drooling.c. This disease is associated with anxiety causing increased perspiration. d. He may have trouble chewing, so I will offer bite-sized portions. ANS: DBecause chewing and swallowing can be problematic, small frequent meals and a supplement are better for meeting the clients nutritional needs. A masklike face and drooling are common in clients with Parkinsondisease. The client should be encouraged to continue to socialize and communicate as normally as possible. The wife should understand that the clients masklike face can be misinterpreted and additional time may be needed for the client to communicate with her or others. Excessive perspiration is also common in clients with Parkinson disease and is associated with the autonomic nervous systems response. 85 11. A nurse plans care for a client with Parkinson disease. Which intervention should the nurse include in this clients plan of care?a. Ambulate the client in the hallway twice a day.b. Ensure a fluid intake of at least 3 liters per day.c. Teach the client pursed-lip breathing techniques. d. Keep the head of the bed at 30 degrees or greater. ANS: DElevation of the head of the bed will help prevent aspiration. The other options will not prevent aspiration, which is the greatest respiratory complication of Parkinson disease, nor do these interventions address any of the complications of Parkinson disease. Ambulation in the hallway is usually implemented to prevent venous thrombosis. Increased fluid intake flushes out toxins from the clients blood. Pursed-lip breathing increases exhalation of carbon dioxide. 86 21. A nurse delegates care for a client with Parkinson disease to an unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating this clients care?a. Allow the client to be as independent as possible with activities.b. Assist the client with frequent and meticulous oral care.c. Assess the clients ability to eat and swallow before each meal. d. Schedule appointments early in the morning to ensure rest in the afternoon. ANS: A 87 1. A nurse promotes the prevention of lower back pain by teaching clients at a community center. Which instruction should the nurse include in this education?a. Participate in an exercise program to strengthen muscles.b. Purchase a mattress that allows you to adjust the firmness.c. Wear flat instead of high-heeled shoes to work each day. d. Keep your weight within 20% of your ideal body weight. ANS: A 88 2. A nurse plans care for a client with lower back pain from a work-related injury. Which intervention should the nurse include in this clients plan of care?a. Encourage the client to stretch the back by reaching toward the toes.b. Massage the affected area with ice twice a day.c. Apply a heating pad for 20 minutes at least four times daily. d. Advise the client to avoid warm baths or showers. ANS: C 89 3. A nurse assesses a client who is recovering from a diskectomy 6 hours ago. Which assessment finding should the nurse address first?a. Sleepy but arouses to voiceb. Dry and cracked oral mucosac. Pain present in lower back d. Bladder palpated above pubis ANS: D 90 4. A nurse assesses clients at a community center. Which client is at greatest risk for lower back pain?a. A 24-year-old female who is 25 weeks pregnantb. A 36-year-old male who uses ergonomic techniquesc. A 45-year-old male with osteoarthritis d. A 53-year-old female who uses a walker ANS: C 91 6. A nurse assesses a client who is recovering from anterior cervical diskectomy and fusion. Which complication should alert the nurse to urgently communicate with the health care provider?a. Auscultated stridorb. Weak pedal pulsesc. Difficulty swallowing d. Inability to shrug shoulders ANS: APostoperative swelling can narrow the trachea, cause a partial airway obstruction, and manifest as stridor. The client may also have trouble swallowing, but maintaining an airway takes priority. Weak pedal pulses and an inability to shrug the shoulders are not complications of this surgery. 92 7. A nurse assesses a client with a spinal cord injury at level T5. The clients blood pressure is 184/95 mm Hg, and the client presents with a flushed face and blurred vision. Which action should the nurse take first?a. Initiate oxygen via a nasal cannula.b. Place the client in a supine position.c. Palpate the bladder for distention. d. Administer a prescribed beta blocker. ANS: CThe client is manifesting symptoms of autonomic dysreflexia. Common causes include bladder distention, tight clothing, increased room temperature, and fecal impaction. If persistent, the client could experience neurologic injury. Precipitating conditions should be eliminated and the physician notified. The other actions would not be appropriate. 93 8. An emergency room nurse initiates care for a client with a cervical spinal cord injury who arrives via emergency medical services. Which action should the nurse take first?a. Assess level of consciousness.b. Obtain vital signs.c. Administer oxygen therapy. d. Evaluate respiratory status. ANS: D 94 9. An emergency department nurse cares for a client who experienced a spinal cord injury 1 hour ago. Which prescribed medication should the nurse prepare to administer?a. Intrathecal baclofen (Lioresal)b. Methylprednisolone (Medrol)c. Atropine sulfate d. Epinephrine (Adrenalin) ANS: BMethylprednisolone (Medrol) should be given within 8 hours of the injury. Clients who receive this therapy usually show improvement in motor and sensory function. The other medications are inappropriate for this client. 95 11. A nurse is caring for a client with paraplegia who is scheduled to participate in a rehabilitation program. The client states, I do not understand the need for rehabilitation; the paralysis will not go away and it will notget better. How should the nurse respond?a. If you dont want to participate in the rehabilitation program, Ill let the provider know.b. Rehabilitation programs have helped many clients with your injury. You should give it a chance. c. The rehabilitation program will teach you how to maintain the functional ability you have and prevent further disability. d. When new discoveries are made regarding paraplegia, people in rehabilitation programs will benefit first. ANS: C 96 12. After teaching a client with a spinal cord injury, the nurse assesses the clients understanding. Which client statement indicates a correct understanding of how to prevent respiratory problems at home?a. Ill use my incentive spirometer every 2 hours while Im awake.b. Ill drink thinned fluids to prevent choking.c. Ill take cough medicine to prevent excessive coughing. d. Ill position myself on my right side so I dont aspirate. ANS: A 97 13. A nurse assesses a client with early-onset multiple sclerosis (MS). Which clinical manifestation should the nurse expect to find?a. Hyperresponsive reflexesb. Excessive somnolencec. Nystagmus d. Heat intolerance ANS: C 98 14. A nurse cares for a client who presents with an acute exacerbation of multiple sclerosis (MS). Which prescribed medication should the nurse prepare to administer?a. Baclofen (Lioresal)b. Interferon beta-1b (Betaseron)c. Dantrolene sodium (Dantrium) d. Methylprednisolone (Medrol) ANS: D 99 15. A nurse assesses a client with multiple sclerosis after administering prescribed fingolimod (Gilenya). For which adverse effect should the nurse monitor?a. Peripheral edemab. Black tarry stoolsc. Bradycardia d. Nausea and vomiting ANS: C 100 16. A nurse is teaching a client with multiple sclerosis who is prescribed cyclophosphamide (Cytoxan) and methylprednisolone (Medrol). Which statement should the nurse include in this clients discharge teaching?a. Take warm baths to promote muscle relaxation.b. Avoid crowds and people with colds.c. Relying on a walker will weaken your gait. d. Take prescribed medications when symptoms occur. ANS: B 101 19. A nurse prepares a client for prescribed magnetic resonance imaging (MRI). Which action should the nurse implement prior to the test?a. Implement nothing by mouth (NPO) status for 8 hours.b. Withhold all daily medications until after the examination.c. Administer morphine sulfate to prevent claustrophobia during the test. d. Place the client in a gown that has cloth ties instead of metal snaps. ANS: DMetal objects are a hazard because of the magnetic field used in the MRI procedure. Morphine sulfate is not administered to prevent claustrophobia; lorazepam (Ativan) or diazepam (Valium) may be used instead. The client does not need to be NPO, and daily medications do not need to be withheld prior to MRI. 102 20. A nurse cares for a client with a spinal cord injury. With which interdisciplinary team member should the nurse consult to assist the client with activities of daily living?a. Social workerb. Physical therapistc. Occupational therapist d. Case manager ANS: CThe occupational therapist instructs the client in the correct use of all adaptive equipment. In collaboration with the therapist, the nurse instructs family members or the caregiver about transfer skills, feeding, bathing, dressing, positioning, and skin care. The other team members are consulted to assist the client with unrelated issues. 103 22. A nurse assesses the health history of a client who is prescribed ziconotide (Prialt) for chronic back pain. Which assessment question should the nurse ask?a. Are you taking a nonsteroidal anti-inflammatory drug?b. Do you have a mental health disorder?c. Are you able to swallow medications? d. Do you smoke cigarettes or any illegal drugs? ANS: B 104 1. A nurse assesses a client who recently experienced a traumatic spinal cord injury. Which assessment data should the nurse obtain to assess the clients coping strategies? (Select all that apply.)a. Spiritual beliefsb. Level of painc. Family supportd. Level of independencee. Annual income f. Previous coping strategies ANS: A, C, D, FInformation about the clients preinjury psychosocial status, usual methods of coping with illness, difficult situations, and disappointments should be obtained. Determine the clients level of independence or dependenceand his or her comfort level in discussing feelings and emotions with family members or close friends. Clients who are emotionally secure and have a positive self-image, a supportive family, and financial and job security often adapt to their injury. Information about the clients spiritual and religious beliefs or cultural background also assists the nurse in developing the plan of care. The other options do not supply as much information about coping. 105 2. After teaching a client with a spinal cord tumor, the nurse assesses the clients understanding. Which statements by the client indicate a correct understanding of the teaching? (Select all that apply.)a. Even though turning hurts, I will remind you to turn me every 2 hours.b. Radiation therapy can shrink the tumor but also can cause more problems.c. Surgery will be scheduled to remove the tumor and reverse my symptoms.d. I put my affairs in order because this type of cancer is almost always fatal. e. My family is moving my bedroom downstairs for when I am discharged home. ANS: A, B, E 106 3. After teaching a male client with a spinal cord injury at the T4 level, the nurse assesses the clients understanding. Which client statements indicate a correct understanding of the teaching related to sexual effects of this injury? (Select all that apply.)a. I will explore other ways besides intercourse to please my partner.b. I will not be able to have an erection because of my injury.c. Ejaculation may not be as predictable as before.d. I may urinate with ejaculation but this will not cause infection. e. I should be able to have an erection with stimulation. ANS: C, D, E 107 6. A nurse assesses a client with paraplegia from a spinal cord injury and notes reddened areas over the clients hips and sacrum. Which actions should the nurse take? (Select all that apply.)a. Apply a barrier cream to protect the skin from excoriation.b. Perform range-of-motion (ROM) exercises for the hip joint.c. Re-position the client off of the reddened areas.d. Get the client out of bed and into a chair once a day. e. Obtain a low-air-loss mattress to minimize pressure. ANS: C, EAppropriate interventions to relieve pressure on these areas include frequent re-positioning and a low-air-loss mattress. Reddened areas should not be rubbed because this action could cause more extensive damage to thealready fragile capillary system. Barrier cream will not protect the skin from pressure wounds. ROM exercises are used to prevent contractures. Sitting the client in a chair once a day will decrease the clients risk of respiratory complications but will not decrease pressure on the clients hips and sacrum. 108 7. A nurse assesses a client who experienced a spinal cord injury at the T5 level 12 hours ago. Which manifestations should the nurse correlate with neurogenic shock? (Select all that apply.)a. Heart rate of 34 beats/minb. Blood pressure of 185/65 mm Hgc. Urine output less than 30 mL/hrd. Decreased level of consciousness e. Increased oxygen saturation ANS: A, C, D 109 8. A nurse plans care for a client with a halo fixator. Which interventions should the nurse include in this clients plan of care? (Select all that apply.)a. Tape a halo wrench to the clients vest.b. Assess the pin sites for signs of infection.c. Loosen the pins when sleeping.d. Decrease the clients oral fluid intake. e. Assess the chest and back for skin breakdown. ANS: A, B, E 110 5. A client is taking long-term corticosteroids for myasthenia gravis. What teaching is most important?a. Avoid large crowds and people who are ill.b. Check blood sugars four times a day.c. Use two forms of contraception. d. Wear properly fitting socks and shoes. ANS: ACorticosteroids reduce immune function, so clients taking these medications must avoid being exposed to illness. Long-term use can lead to secondary diabetes, but the client would not need to start checking blood glucose unless diabetes had been detected. Corticosteroids do not affect the effectiveness of contraception. Wearing well-fitting shoes would be important to avoid injury, but not just because the client takes corticosteroids. 111 6. A client with myasthenia gravis has the priority client problem of inadequate nutrition. What assessment finding indicates that the priority goal for this client problem has been met?a. Ability to chew and swallow without aspirationb. Eating 75% of meals and between-meal snacksc. Intake greater than output 3 days in a row d. Weight gain of 3 pounds in 1 month ANS: D 112 7. A client had a nerve laceration repair to the forearm and is being discharged in a cast. What statement by the client indicates a poor understanding of discharge instructions relating to cast care?a. I can scratch with a coat hanger.b. I should feel my fingers for warmth.c. I will keep the cast clean and dry. d. I will return to have the cast removed. ANS: A 113 10. A client has trigeminal neuralgia and has begun skipping meals and not brushing his teeth, and his family believes he has become depressed. What action by the nurse is best?a. Ask the client to explain his feelings related to this disorder.b. Explain how dental hygiene is related to overall health.c. Refer the client to a medical social worker for assessment. d. Tell the client that he will become malnourished in time. ANS: A 114 11. A client is receiving plasmapheresis. What action by the nurse best prevents infection in this client? b. Monitoring the clients vital signsc. Performing appropriate hand hygiene d. Placing the client in protective isolation ANS: CPlasmapheresis is an invasive procedure, and the nurse uses good hand hygiene before and after client contact to prevent infection. Antibiotics are not necessary. Monitoring vital signs does not prevent infection but could alert the nurse to its possibility. The client does not need isolation. 115 13. A client with myasthenia gravis (MG) asks the nurse to explain the disease. What response by the nurse is best?a. MG is an autoimmune problem in which nerves do not cause muscles to contract.b. MG is an inherited destruction of peripheral nerve endings and junctions.c. MG consists of trauma-induced paralysis of specific cranial nerves. d. MG is a viral infection of the dorsal root of sensory nerve fibers. ANS: A 116 1. A client with myasthenia gravis is prescribed pyridostigmine (Mestinon). What teaching should the nurse plan regarding this medication? (Select all that apply.)a. Do not eat a full meal for 45 minutes after taking the drug.b. Seek immediate care if you develop trouble swallowing.c. Take this drug on an empty stomach for best absorption.d. The dose may change frequently depending on symptoms. e. Your urine may turn a reddish-orange color while on this drug. ANS: A, B, D 117 3. A client with myasthenia gravis is malnourished. What actions to improve nutrition may the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)a. Assessing the clients gag reflexb. Cutting foods up into small bitesc. Monitoring prealbumin levelsd. Thickening liquids prior to drinking e. Weighing the client daily ANS: B, DCutting food up into smaller bites makes it easier for the client to chew and swallow. Thickened liquids help prevent aspiration. The UAP can weigh the client, but this does not help improve nutrition. The nurse assesses the gag reflex and monitors laboratory values. 118 1. A nurse assesses a client with a fracture who is being treated with skeletal traction. Which assessment should alert the nurse to urgently contact the health provider?a. Blood pressure increases to 130/86 mm Hgb. Traction weights are resting on the floorc. Oozing of clear fluid is noted at the pin site d. Capillary refill is less than 3 seconds ANS: BThe immediate action of the nurse should be to reapply the weights to give traction to the fracture. The health care provider must be notified that the weights were lying on the floor, and the client should be realigned in bed. The clients blood pressure is slightly elevated; this could be related to pain and muscle spasms resulting from lack of pressure to reduce the fracture. Oozing of clear fluid is normal, as is the capillary refill time. 119 2. A nurse coordinates care for a client with a wet plaster cast. Which statement should the nurse include when delegating care for this client to an unlicensed assistive personnel (UAP)?a. Assess distal pulses for potential compartment syndrome.b. Turn the client every 3 to 4 hours to promote cast drying.c. Use a cloth-covered pillow to elevate the clients leg. d. Handle the cast with your fingertips to prevent indentations. ANS: CWhen delegating care to a UAP for a client with a wet plaster cast, the UAP should be directed to ensure that the extremity is elevated on a cloth pillow instead of a plastic pillow to promote drying. The client should beassessed for impaired arterial circulation, a complication of compartment syndrome; however, the nurse should not delegate assessments to a UAP. The client should be turned every 1 to 2 hours to allow air to circulate and dry all parts of the cast. Providers should handle the cast with the palms of the hands to prevent indentations. 120 3. A nurse obtains the health history of a client with a fractured femur. Which factor identified in the clients history should the nurse recognize as an aspect that may impede healing of the fracture?a. Sedentary lifestyleb. A 30pack-year smoking historyc. Prescribed oral contraceptives d. Pagets disease ANS: D 121 4. An emergency department nurse cares for a client who sustained a crush injury to the right lower leg. The client reports numbness and tingling in the affected leg. Which action should the nurse take first? b. Apply oxygen by nasal cannula.c. Increase the IV flow rate. d. Loosen the traction. ANS: A 122 5. A nurse assesses an older adult client who was admitted 2 days ago with a fractured hip. The nurse notes that the client is confused and restless. The clients vital signs are heart rate 98 beats/min, respiratory rate 32breaths/min, blood pressure 132/78 mm Hg, and SpO2 88%. Which action should the nurse take first?a. Administer oxygen via nasal cannula.b. Re-position to a high-Fowlers position.c. Increase the intravenous flow rate. d. Assess response to pain medications. ANS: AThe client is at high risk for a fat embolism and has some of the clinical manifestations of altered mental status and dyspnea. Although this is a life-threatening emergency, the nurse should take the time to administeroxygen first and then notify the health care provider. Oxygen administration can reduce the risk for cerebral damage from hypoxia. The nurse would not restrain a client who is confused without further assessment and orders. Sitting the client in a high-Fowlers position will not decrease hypoxia related to a fat embolism. The IV rate is not related. Pain medication most likely would not cause the client to be restless. 123 6. A trauma nurse cares for several clients with fractures. Which client should the nurse identify as at highest risk for developing deep vein thrombosis?a. An 18-year-old male athlete with a fractured clavicleb. A 36-year old female with type 2 diabetes and fractured ribsc. A 55-year-old woman prescribed aspirin for rheumatoid arthritis d. A 74-year-old man who smokes and has a fractured pelvis ANS: D 124 7. A nurse delegates care of a client in traction to an unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating hygiene care for this client?a. Remove the traction when re-positioning the client. b. Inspect the clients skin when performing a bed bath. c. Provide pin care by using alcohol wipes to clean the sites. ANS: DTraction weights should be freely hanging at all times. They should not be lifted manually or allowed to rest on the floor. The client should remain in traction during hygiene activities. The nurse should assess the clients skin and provide pin and wound care for a client who is in traction; this should not be delegated to the UAP. 125 8. A nurse notes crepitation when performing range-of-motion exercises on a client with a fractured left humerus. Which action should the nurse take next?a. Immobilize the left arm.b. Assess the clients distal pulse.c. Monitor for signs of infection. d. Administer prescribed steroids. ANS: A 126 9. A nurse reviews prescriptions for an 82-year-old client with a fractured left hip. Which prescription should alert the nurse to contact the provider and express concerns for client safety?a. Meperidine (Demerol) 50 mg IV every 4 hoursb. Patient-controlled analgesia (PCA) with morphine sulfatec. Percocet 2 tablets orally every 6 hours PRN for pain d. Ibuprofen elixir every 8 hours for first 2 days ANS: AMeperidine (Demerol) should not be used for older adults because it has toxic metabolites that can cause seizures. The nurse should question this prescription. The other prescriptions are appropriate for this clients pain management. 127 10. A nurse is caring for a client who is recovering from an above-the-knee amputation. The client reports pain in the limb that was removed. How should the nurse respond?a. The pain you are feeling does not actually exist.b. This type of pain is common and will eventually go away.c. Would you like to learn how to use imagery to minimize your pain? d. How would you describe the pain that you are feeling? ANS: DThe nurse should ask the client to rate the pain on a scale of 0 to 10 and describe how the pain feels. Although phantom limb pain is common, the nurse should not minimize the pain that the client is experiencing by stating that it does not exist or will eventually go away. Antiepileptic drugs and antispasmodics are used to treat neurologic pain and muscle spasms after amputation. Although imagery may assist the client, the nurse must assess the clients pain before determining the best action. 128 13. A nurse assesses a client with a pelvic fracture. Which assessment finding should the nurse identify as a complication of this injury?a. Hypertensionb. Constipationc. Infection d. Hematuria ANS: DThe pelvis is very vascular and close to major organs. Injury to the pelvis can cause integral damage that may manifest as blood in the urine (hematuria) or stool. The nurse should also assess for signs of hemorrhage and hypovolemic shock, which include hypotension and tachycardia. Constipation and infection are not complications of a pelvic fracture. 129 14. A nurse cares for a client placed in skeletal traction. The client asks, What is the primary purpose of this type of traction? How should the nurse respond?a. Skeletal traction will assist in realigning your fractured bone.b. This treatment will prevent future complications and back pain.c. Traction decreases muscle spasms that occur with a fracture. d. This type of traction minimizes damage as a result of fracture treatment. ANS: A 130 15. A nurse cares for a client in skeletal traction. The nurse notes that the skin around the clients pin sites is swollen, red, and crusty with dried drainage. Which action should the nurse take next?a. Request a prescription to decrease the traction weight.b. Apply an antibiotic ointment and a clean dressing.c. Cleanse the area, scrubbing off the crusty areas. d. Obtain a prescription to culture the drainage. ANS: D 131 16. A nurse cares for a client recovering from an above-the-knee amputation of the right leg. The client reports pain in the right foot. Which prescribed medication should the nurse administer first?a. Intravenous morphineb. Oral acetaminophenc. Intravenous calcitonin d. Oral ibuprofen ANS: CThe client is experiencing phantom limb pain, which usually manifests as intense burning, crushing, or cramping. IV infusions of calcitonin during the week after amputation can reduce phantom limb pain. Opioid analgesics such as morphine are not as effective for phantom limb pain as they are for residual limb pain. Oral acetaminophen and ibuprofen are not used in treating phantom limb pain. 132 17. A nurse plans care for a client who is recovering from a below-the-knee amputation of the left leg. Which intervention should the nurse include in this clients plan of care? b. Encourage range-of-motion exercises.c. Administer prophylactic antibiotics. d. Implement strict bedrest in a supine position. ANS: B 133 18. An emergency department nurse triages a client with diabetes mellitus who has fractured her arm. Which action should the nurse take first?a. Remove the medical alert bracelet from the fractured arm.b. Immobilize the arm by splinting the fractured site.c. Place the client in a supine position with a warm blanket. d. Cover any open areas with a sterile dressing. ANS: A 134 20. A nurse cares for a client with a fractured fibula. Which assessment should alert the nurse to take immediate action?a. Pain of 4 on a scale of 0 to 10b. Numbness in the extremityc. Swollen extremity at the injury site d. Feeling cold while lying in bed ANS: B 135 21. After teaching a client with a fractured humerus, the nurse assesses the clients understanding. Which dietary choice demonstrates that the client correctly understands the nutrition needed to assist in healing thefracture?a. Baked fish with orange juice and a vitamin D supplementb. Bacon, lettuce, and tomato sandwich with a vitamin B supplementc. Vegetable lasagna with a green salad and a vitamin A supplement d. Roast beef with low-fat milk and a vitamin C supplement ANS: D 136 22. A nurse cares for an older adult client with multiple fractures. Which action should the nurse take to manage this clients pain?a. Meperidine (Demerol) injections every 4 hours around the clockb. Patient-controlled analgesia (PCA) pump with morphinec. Ibuprofen (Motrin) 600 mg orally every 4 hours PRN for pain d. Morphine 4 mg intravenous push every 2 hours PRN for pain ANS: BThe older adult client should never be treated with meperidine because toxic metabolites can cause seizures. The client should be managed with a PCA pump to control pain best. Motrin most likely would not provide complete pain relief with multiple fractures. IV morphine PRN would not control pain as well as a pump that the client can control. 137 25. A nurse cares for an older adult client who is recovering from a leg amputation surgery. The client states, I dont want to live with only one leg. I should have died during the surgery. How should the nurse respond?a. Your vital signs are good, and you are doing just fine right now.b. Your children are waiting outside. Do you want them to grow up without a father?c. This is a big change for you. What support system do you have to help you cope? d. You will be able to do some of the same things as before you became disabled. ANS: CThe client feels like less of a person following the amputation. The nurse should help the client to identify coping mechanisms that have worked in the past and current support systems to assist the client with coping.The nurse should not ignore the clients feelings by focusing on vital signs. The nurse should not try to make the client feel guilty by alluding to family members. The nurse should not refer to the client as being disabled as this labels the client and may fuel the clients poor body image. 138 27. A nurse plans care for a client who is prescribed skeletal traction. Which intervention should the nurse include in this plan of care to decrease the clients risk for infection?a. Wash the traction lines and sockets once a day.b. Release traction tension for 30 minutes twice a day.c. Do not place the traction weights on the floor. d. Schedule for pin care to be provided every shift. ANS: D 139 1. A nurse teaches a client with a fractured tibia about external fixation. Which advantages of external fixation for the immobilization of fractures should the nurse share with the client? (Select all that apply.)a. It leads to minimal blood loss.b. It allows for early ambulation.c. It decreases the risk of infection.d. It increases blood supply to tissues. e. It promotes healing. ANS: A, B, E 140 2. An emergency nurse assesses a client who is admitted with a pelvic fracture. Which assessments should the nurse monitor to prevent a complication of this injury? (Select all that apply.)a. Temperatureb. Urinary outputc. Blood pressured. Pupil reaction e. Skin color ANS: B, C, E 141 3. A nurse cares for a client with a fracture injury. Twenty minutes after an opioid pain medication is administered, the client reports pain in the site of the fracture. Which actions should the nurse take? (Select all that apply.)a. Administer additional opioids as prescribed.b. Elevate the extremity on pillows.c. Apply ice to the fracture site.d. Place a heating pad at the site of the injury. e. Keep the extremity in a dependent position. ANS: A, B, CThe client with a new fracture likely has edema; elevating the extremity and applying ice probably will help in decreasing pain. Administration of an additional opioid within the dosage guidelines may be ordered. Heat will increase edema and may increase pain. Dependent positioning will also increase edema. 142 4. A nurse plans care for a client who is recovering from open reduction and internal fixation (ORIF) surgery for a right hip fracture. Which interventions should the nurse include in this clients plan of care? (Select all that apply.)a. Elevate heels off the bed with a pillow.b. Ambulate the client on the first postoperative day.c. Push the clients patient-controlled analgesia button.d. Re-position the client every 2 hours. e. Use pillows to encourage subluxation of the hip. ANS: A, B, D 143 5. A nurse assesses a client with a cast for potential compartment syndrome. Which clinical manifestations are correctly paired with the physiologic changes of compartment syndrome? (Select all that apply.)a. Edema Increased capillary permeabilityb. Pallor Increased blood blow to the areac. Unequal pulses Increased production of lactic acidd. Cyanosis Anaerobic metabolism e. Tingling A release of histamine ANS: A, C, DClinical manifestations of compartment syndrome are caused by several physiologic changes. Edema is caused by increased capillary permeability, release of histamine, decreased tissue perfusion, and vasodilation. Unequal pulses are caused by an increased production of lactic acid. Cyanosis is caused by anaerobic metabolism. Pallor is caused by decreased oxygen to tissues, and tingling is caused by increased tissue pressure. 144 7. A nurse teaches a client about prosthesis care after amputation. Which statements should the nurse include in this clients teaching? (Select all that apply.)a. The device has been custom made specifically for you.b. Your prosthetic is good for work but not for exercising.c. A prosthetist will clean your inserts for you each month.d. Make sure that you wear the correct liners with your prosthetic. e. I have scheduled a follow-up appointment for you. ANS: A, D, EA client with a new prosthetic should be taught that the prosthetic device is custom made for the client, taking into account the clients level of amputation, lifestyle (including exercise preferences), and occupation. Incollaboration with a prosthetist, the client should be taught proper techniques for cleansing the sockets and inserts, wearing the correct liners, and assessing shoe wear. Follow-up care and appointments are important for ongoing assessment. 145 1. A client has a bone density score of 2.8. What action by the nurse is best?a. Asking the client to complete a food diaryb. Planning to teach about bisphosphonatesc. Scheduling another scan in 2 years d. Scheduling another scan in 6 months ANS: B 146 2. A nurse is assessing an older client and discovers back pain with tenderness along T2 and T3. What action by the nurse is best?a. Consult with the provider about an x-ray.b. Encourage the client to use ibuprofen (Motrin).c. Have the client perform hip range of motion. d. Place the client in a rigid cervical collar. ANS: A 147 3. A client has been advised to perform weight-bearing exercises to help minimize osteoporosis. The client admits to not doing the prescribed exercises. What action by the nurse is best?a. Ask the client about fear of falling.b. Instruct the client to increase calcium.c. Suggest other exercises the client can do. d. Tell the client to try weight lifting. ANS: A 148 4. The nurse sees several clients with osteoporosis. For which client would bisphosphonates not be a good option? a. Client with diabetes who has a serum creatinine of 0.8 mg/dLb. Client who recently fell and has vertebral compression fracturesc. Hypertensive client who takes calcium channel blockers d. Client with a spinal cord injury who cannot tolerate sitting up ANS: DClients on bisphosphonates must be able to sit upright for 30 to 60 minutes after taking them. The client who cannot tolerate sitting up is not a good candidate for this class of drug. Poor renal function also makes clientsbad candidates for this drug, but the client with a creatinine of 0.8 mg/dL is within normal range. Diabetes and hypertension are not related unless the client also has renal disease. The client who recently fell and sustained fractures is a good candidate for this drug if the fractures are related to osteoporosis. 149 9. A nurse is caring for four clients. After the hand-off report, which client does the nurse see first?a. Client with osteoporosis and a white blood cell count of 27,000/mm3b. Client with osteoporosis and a bone fracture who requests pain medicationc. Post-microvascular bone transfer client whose distal leg is cool and pale d. Client with suspected bone tumor who just returned from having a spinal CT ANS: C 150 15. A nurse sees clients in an osteoporosis clinic. Which client should the nurse see first?a. Client taking calcium with vitamin D (Os-Cal) who reports flank pain 2 weeks agob. Client taking ibandronate (Boniva) who cannot remember when the last dose wasc. Client taking raloxifene (Evista) who reports unilateral calf swelling d. Client taking risedronate (Actonel) who reports occasional dyspepsia ANS: CThe client on raloxifene needs to be seen first because of the manifestations of deep vein thrombosis, which is an adverse effect of raloxifene. The client with flank pain may have had a kidney stone but is not acutely ill now. The client who cannot remember taking the last dose of ibandronate can be seen last. The client on risedronate may need to change medications. 151 16. What information does the nurse teach a womens group about osteoporosis?a. For 5 years after menopause you lose 2% of bone mass yearly.b. Men actually have higher rates of the disease but are underdiagnosed.c. There is no way to prevent or slow osteoporosis after menopause. d. Women and men have an equal chance of getting osteoporosis. ANS: AFor the first 5 years after menopause, women lose about 2% of their bone mass each year. Men have a slower loss of bone after the age of 75. Many treatments are now available for women to slow osteoporosis after menopause. 152 17. A client with osteoporosis is going home, where the client lives alone. What action by the nurse is best?a. Arrange a home safety evaluation.b. Ensure the client has a walker at home.c. Help the client look into assisted living. d. Refer the client to Meals on Wheels. ANS: A 153 1. A nurse is assessing a community group for dietary factors that contribute to osteoporosis. In addition to inquiring about calcium, the nurse also assesses for which other dietary components? (Select all that apply.)a. Alcoholb. Caffeinec. Fatd. Carbonated beverages e. Vitamin D ANS: A, B, D, E 154 2. A nurse is providing education to a community womens group about lifestyle changes helpful in preventing osteoporosis. What topics does the nurse cover? (Select all that apply.)a. Cut down on tobacco product use.b. Limit alcohol to two drinks a day.c. Strengthening exercises are important.d. Take recommended calcium and vitamin D. e. Walk 30 minutes at least 3 times a week. ANS: C, D, ELifestyle changes can be made to decrease the occurrence of osteoporosis and include strengthening and weight-bearing exercises and getting the recommended amounts of both calcium and vitamin D. Tobacco should be totally avoided. Women should not have more than one drink per day. 155 4. A client with chronic osteomyelitis is being discharged from the hospital. What information is important for the nurse to teach this client and family? (Select all that apply.)a. Adherence to the antibiotic regimenb. Correct intramuscular injection techniquec. Eating high-protein and high-carbohydrate foodsd. Keeping daily follow-up appointments e. Proper use of the intravenous equipment ANS: A, C, EThe client going home with chronic osteomyelitis will need long-term antibiotic therapyfirst intravenous, then oral. The client needs education on how to properly administer IV antibiotics, care for the IV line, adhere to the regimen, and eat a healthy diet to encourage wound healing. The antibiotics are not given by IM injection. The client does not need daily follow-up. 156 7. The nurse studying osteoporosis learns that which drugs can cause this disorder? (Select all that apply.)a. Antianxiety agentsb. Antibioticsc. Barbituratesd. Corticosteroids e. Loop diuretics ANS: C, D, E |