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Evolve, back of book questions, iclicker

In a patient with a disease that affects the myelin sheath of the nerves such as multiple sclerosis, the glial cells affected are the

a.microglia
b.astrocytes
c.ependymal cells
d.oligodendrocytes

D

Drugs or diseases the impair the function of the extrapyramidal system may cause loss of

a. sensations of pain and temperature
b. regulation of the autonomic nervous system
c. integration of somatic and special sensory inputs
d. automatic movements associated with skeletal muscle activity

D

An obstruction of the anterior cerebral arteries will affect functions of

a. visual imaging
b. balance and coordination
c. judgment, insight, and reasoning
d. visual and auditory integration for language comprehension

C

Paralysis of lateral gaze indicates a lesion of cranial nerve

a. II
b. III
c. IV
d.VI

D

A result of stimulation of the parasympathetic nervous system is (select all that apply)

a. constriction of the bronchi
b. dilation of skin blood vessels
c. increased secretion of insulin
d. increased blood glucose levels
e. relation of the urinary sphincters

A,B,C,E

Assessment of muscle strength of older adults cannot be compared with that of younger adults because

a. stroke is more common in older adults
b. nutritional status is better in young adults
c. most young people exercise more than older people
d. aging leads to a decrease in muscle bulk and strength

D

Data regarding mobility, strength, coordination, and activity tolerance are important for the nurse to obtain because

a. many neurologic diseases affect one or more of these areas
b. patients are less able to identify other neurologic impairments
c. these are the first functions to be affected by neurologic disease
d. aspects of movement are the most important function of the nervous system

A

During neurologic testing, the patient is able to perceive pain elicited by pinprick. Based on this finding, the nurse may omit testing for

a. position sense
b. patellar reflexes
c. temperature perception
d. heel-to-shin movements

C

A patient's eyes jerk while the patient looks to the left. You will record this finding as

a.nystagmus
b. CN VI palsy
c. oculocephalia
d. ophthalmic dyskinesia

A

The nurse is caring for a patient with peripheral neuropathy who is going to have EMG studies tomorrow morning. The nurse should

a. ensure the patient has an empty bladder
b. instruct the patient that there is no risk of electric shock
c. ensure the patient has no metallic jewelry or metal fragments
d. instruct the patient that she or he may experience pain during the study

B

Vasogenic cerebral edema increases intracranial pressure by

a. shifting fluid in the gray matter
b. altering the endothelial lining of cerebral capillaries
c. leaking molecules from the intracellular fluid to the capillaries

B

A patient with intracranial pressure monitoring has pressure of 12 mm Hg. The nurse understands that this pressure reflects

a. a severe decrease in cerebral perfusion pressure
b. an alteration in the production of cerebrospinal fluid
c. the loss of autoregulatory control of intracranial pressure.
d. a normal balance between brain tissue, blood, and cerebrospinal fluid

D

The nurse plans care for the patient with increased intracranial pressure with the knowledge that the best way to position the patient is to

a. keep the head of the bed flat
b. elevate the head of the bed to 30 degrees
c. maintain patient of the left side with the head supported on a pillow
d. use a continuous rotation bed to continuously change patient position

B

The nurse is alerted to a possible acute subdural hematoma in the patient who

a. has a linear skull fracture crossing a major artery
b. has focal symptoms of brain damage with no recollection of a head injury
c. develops decreased level of consciousness and a headache within 48 hours of a head injury
d. has an immediate loss of consciousness with a brief lucid interval followed by decreasing level of consciousness

C

During admission of a patient with a severe head injury to the emergency department, the nurse places the highest priority on assessment for

a. patency of airway
b. presence of a neck injury
c. neurologic status with the glasgow coma scale
d. cerebrospinal fluid leakage from the ears or nose

A

A patient is suspected of havbiong a cranial tumor. The signs and symptoms include memory deficits, visual disturbances, weakness of right upper and lower extremities, and personality changes. The nurse recognizes that the tumor is most likely located in the

a. frontal lobe
b. parietal lobe
c. occipital lobe
d. temporal lobe

A

Nursing management of a patient with a brain tumor includes (select all that apply)

a. discussing with the patient methods to control inappropriate behavior
b. using diversion techniques to keep the patient stimulated and motivated
c. assisting and supporting the family in understanding any changes in behavior
d. limiting self-care activities until the patient has regained maximum physical functioning
e. plan for seizure precautions and teaching the patient and caregiver about antiseizure drugs

C,E

The nurse on the clinical unit is assigned to four patients. Which patient should she assess first?

a. patient with a skull fracture whose nose is bleeding
b. elderly patient with a stroke who is confused and whose daughter is present
c. patient with meningitis who is suddenly agitated and reporting a headache of 10 on a zero to ten scale
d. patient who had a craniotomy for a brain tumor who is now 3 days postoperative and has had continued emesis

C

A nursing measure that is indicated to reduce the potential for seizures and increased intracranial pressure in the patient with bacterial meningitis is

a. administering codeine for relief of head and neck pain
b. controlling fever with prescribed drugs and cooling techniques
c. keeping the room darkened and quite to minimize environmental stimulation
d. maintaining the patient on strict bed rest with the head of the bed slightly elevated

B

Of the following patients, the nurse recognizes that the one with the highest risk for a stroke is

a. an obese 45 year old native american
b. a 35 year old asian american woman who smokes
c. a 32 year old white woman taking oral contraceptives
d. a 65 years old African American man with hypertension

D

The factor related to cerebral blood flow that most often determines the extent of cerebral damage from a stroke is the
a. amount of cardiac output
b. oxygen content of the blood
c. degree of collateral circulation
d. level of carbon dioxide in the blood

C

Information provided by the patient that would help differentiate a hemorrhagic stroke from a thrombotic stroke includes

a. sensory disturbance
b. a history of hypertension
c. presence of motor weakness
d. sudden onset of severe headache

D

A patient with right sided hemiplegia and asphasia resulting from a stroke most likely has involvement of the

a. brainstem
b. vertebral artery
c. left middle cerebral artery
d. right middle cerebral artery

C

The nurse explains to the patient with a stroke who is scheduled for aniography that this test is used to determine

a. presence of increased ICP
b. site and size of the infarction
c. patency of the cerebral blood vessels
d. presence of blood in the cerebrospinal fluid

C

A patient experiencing TIAs is scheduled for a carotid endarterectomy. The nurse explains that this procedure is done to

a. decreased cerebral edema
b. reduce the brain damage that occurs during a stroke in evolution
c. prevent a stroke by removing atherosclerotic plaques blocking cerebral blood flow
d. provide a circulatory bypass around thrombotic plaques obstructing cranial circulation

C

For a patient who is suspected of having a stroke, one of the most important pieces of information that the nurse can obtain is

a. time of the patient's last meal
b. time at which stroke symptoms first appeared
c. patient's hypertension history and management
d. family history of stroke and other cardiovascular diseases

B

Bladder training in a male patient who has urinary incontinence after a stroke includes

a. limiting fluid intake
b. keeping a urinal in place at all times
c. assisting the patient to stand to void
d. catherizing the patient every four hours

C

Common psychosocial reactions of the stroke patient to the stroke include (select all that apply)

a. depression
b. disassociation
c. intellectualization
d. sleep disturbances
e. denial of the severity of the stroke

A,D,E

A 50 year old man complains of recurring headaches. He describes these as sharp, stabbing, and located around his left eye. He also reports that his eye seems to swell and get teary when these headaches occur. Based on this history you suspect that he has

a. cluster headaches
b. tension headaches
c. migraine headaches
d. medication overuse headaches

A

A 65 year old woman was just diagnosed with parkinson's disease. The priority nursing intervention is

a. searching the internet for educational videos
b. evaluating the home for environmental safety
c. promoting physical exercise and a well balanced diet
d. designing an exercise program to strengthen and stretch specific muscles

C

The nurse assesses that a n 87 year old woman with alzheimers disease is continually rubbing, flexing, and kicking out her legs throughout the day. The night shift reports that this same behavior escalates at night, preventing her from obtaining her required sleep. The next step the nurse should take is to

a. ask the physician for a daytime sedative for the patient
b. request soft restraints to prevent her from falling out of her bed
c. ask the physician for a nighttime sleep medication for the patient
d. assess the patient more closely, suspecting a disorder such as restless leg syndrome

D

Social effects of a chronic neurologic disease include (select all that apply)

a. divorce
b. job loss
c. depression
d. role changes
e. loss of self esteem

A,B,C,D,E

One major goal of treatment for a patient with huntingtons disease is

a. disease cure
b. symptomatic relief
c. maintaining employment
d. improving muscle strength

B

During assessment of the patient with trigeminal neuralgia, the nurse should (select all that apply)

a. inspect all aspects of the mouth and teeth
b. assess the gag reflex and respiratory rate and depth
c. lightly palpate the affected side of the face for edema
d. test for temperature and sensation perception n the face
e. ask the patient to describe factors that initiate an episode

A,D,E

During routine assessment of a patient with guillain-barre syndrome, the nurse finds the patient to be short of breath. The patient's respiratory distress is caused by

a. elevated protein levels in the CSF
b. immobility resulting from ascending paralysis
c. degeneration of motor neurons in the brainstem and spinal cord
d. paralysis ascending to the nerves that stimulate the thoracic area

D

A patient is admitted to the ICU with a C7 spinal cord injury and diagnosed with brown-sequard syndrome. On physical examination, the nurse would most likely find

a. upper extremity weakness only
b. complete motor and sensory loss below C7
c. loss of position sense and vibration in both lower extremities
d.ipsilateral motor loss and contralateral sensory loss below C7

D

A patient is admitted to the hospital with a C4 spinal cord injury after a motorcycle collision. The patient's BP is 83/49 mm Hg, and his pulse is 39 beats/min, and he remains orally intubated. The nurse identifies this pathophysiologic response as caused by

a. increased vasomotor tone after injury
b. a temporary loss of sensation and flaccid paralysis below the level of injury
c.loss of parasympathetic nervous system innervation resulting in vasoconstriction
d. loss of sympathetic nervous system innervation resulting in peripheral vasodilation

D

Goals of rehabilitation for the patient with an injury at the C6 level include (select all that apply)

a. stand erect with leg brace
b. feed self with hand devices
c. drive an electric wheelchair
d. assist with transfer activities
e. drive adapted van from wheelchair

B,C,D,E

A patient with a C7 spinal cord injury undergoing rehabilitation tells the nurse he must have the flu because he as had a bad headache and nausea. The initial action of the nurse is to

a. call the physician
b. check the patient's temperature
c. take the patient's blood pressure
d. elevate the head of the bed to 90 degrees

C

For a 65 year old woman who has lived with a T1 spinal cord injury for 20 years, which of the following health teaching instructions should the nurse emphasize?

a. a mammogram needed every year
b. bladder function tends to improve with age
c. heart disease is not common in persons with spinal cord injury
d. as a person ages the need to change body position is less important

A

The most common early symptom of a spinal cord tumor is

a. urinary incontinence
b. back pain that worsens with activity
c. paralysis below the level of involvement
d. impaired sensation of pain, temperature, and light touch

B

The bone cells that function in the resorption and formation of bone tissue are called (select all that apply)

a. osteoids
b. osteocytes
c. osteoblasts
d. osteoclasts

C,D

While performing passive pange of motion for a patient, the nurse puts a synovial joint through the movements of

a. inversion and eversion
b. pronation and supination
c. flexion, extension, abduction, and adduction
d, flexion, extension, rotation, and circumduction

C

To prevent muscle atrophy, the nurse teaches the patient with a leg immobilized in traction to perform

a. flexion contractions
b. tetanic contractions
c. isotonic contractions
d. isometric contractions

D

A patient with bursitis of the should asks what the bursa does. The nurse's response is based on the knowledge that bursae.

a. connect bone to muscle
b. provide strength to muscle
c. lubricate joints with synovial fluid
d. relieve friction between moving parts

D

The increased risk for falls in the older adult is most likely due to

a. changes in balance
b. decreased in bone mass
c. loss of ligament elasticity
d. erosion of articular cartilage

A

While obtaining subjective assessment data related to the musculoskeletal system, it is particularly important to ask a patient about other medical problems such as

a. hemophilia
b. hypertension
c. thyroid problems
d. pulmonary disease

A

When grading muscle strength, the nurse records a score of 1, which indicates

a. no detection of muscular contraction
b. a barely detectable flicker of contraction
c. active movement against gravity with some resistance
d. active movement against full resistance without fatigue

B

A normal assessment finding of the musculoskeletal system is

a. muscle and bone strength of 4
b. ulnar deviation and subluxation
c. angulation of bone toward midline
d. no tenderness with spine palpation

D

A patient is scheduled for an arthrocentesis. The nurse explains that this diagnostic test involves

a. incision or puncture of the joint capsule
b. measurement of heat from muscle contractions
c. administration of a radioisotope before the procedure
d. placement of skin electrodes to record muscle activity

A

The nurse suspects an ankle sprain when a patient at the urgent care center relates

a. being hit by another soccer player during a game
b. having ankle pain after sprinting around the track
c. dropping a 10 pound weight on his lower leg at the health center
d. twisting his ankle while running bases during a baseball game

D

The nurse explains to a patient with a distal tibial fracture who is returning for a three week checkup that healing is indicated by
a. formation of callus
b. complete bony union
c. hematoma at fracture site
d. presence of granulation tissue

A

A patient with a comminuted fracture of the femur is to have an open reduction with internal fixation (ORIF) of the fracture. The nurse explains that ORIF is indicated when
a. the patient is unable to tolerate prolonged immobilization
b. the patient cannot tolerate the surgery of a closed reduction
c. a temporary cast would be too unstable to provide normal motility
d. adequate alignment cannot be obtained by other nonsurgical methods

D

An indication of a neurovascular problem noted during assessment of the patient with a fracture is
a. exaggeration of strength with movement
b. increased redness and heat below the injury
c.decreased sensation distal to the fracture site
d. purulent drainage at the site of an open fracture

C

A patient with a stable, closed fracture of the humerus caused by trauma to the arm has a temporary splint with bulky padding applied with an elastic bandage. The nurse suspects compartment syndrome and notifies the physician when the patient experiences
a. increasing edema of the limb
b. muscle spasms of the lower arm
c. rebounding pulse at the fracture site
d. pain when passively extending the fingers

D

A patient with a fracture of the pelvis should be monitored for
a. changes in urinary output
b. petechiae on the abdomen
c. a palpable lump in the buttock
d. sudden decrease in blood pressure

A

During the postoperative period, the nurse instructs the patient with an above the knee amputation that the residual limb should not be routinely elevated because this position promotes
a. hip flexion contractures
b. skin irritation and breakdown
c. clot formation at the incision site
d. increased risk of wound dehiscence

A

A patient with rheumatoid arthritis is scheduled for a total hip arthroplasty. The nurse explains that the purpose of this procedure is to (select all that apply)
a. fuse the joint
b. replace the joint
c. prevent further damage
d. improve or maintain ROM
e. decrease the amount of destruction in the joint

B,D

In teaching a patient scheduled for a total ankle replacement it is important that the nurse tell the patient that after surgery he should avoid
a. lifting heavy objects
b. sleeping on the back
c. abduction exercises of the affected ankle
d. bearing weight on the affected leg for 6 weeks

D

A patient with osteomyelitis is treated with surgical debridement with implantation of antibiotic beads. In responding to the patient who asks why the beads are used, the nurse answers (select all that apply)

a. the beads are used to directly deliver antibiotics to the site of infection
b. there are no effective oral or IV antibiotics to treat most cases of bone infection
c. the beads are adjunct to debridement and oral and IV antibiotics for deep infections
d. The ischemia and bone death that occurs with osteomyelitis are impenetrable to IV antibiotics

A,C

A patient has been diagnosed with osteosarcoma of the femur. He shows an understanding of his treatment options when he states
a. I accept that I have to lose my leg with surgery
b. the chemotherapy before surgery will shrink the tumor
c. this tumor is related to the colon cancer I had 3 years ago
d. I'm glad they can take out the cancer with such a small scar

B

In assessing the joints of a patient with rheumatoid arthritis, the nurse understands that the joints are damaged by (select all that apply)
a. bony ankylosis following inflammation of the joints
b. the deterioration of cartilage by proteolytic enzymes
c. the development of heberdens nodes in the joint capsule
d. increased cartilage and bony growth at the joint margins
e. invasion of pannus into the joint causing a loss of cartilage

A,E

Assessment data in the patient with osteoarthritis commonly include
a. gradual weight loss
b. elevated WBC count
c. joint pain that worsens with use
d. straw colored synovial fluid

C

Teach the patient with ankylosing spondylitis the importance of
a. regular exercise and maintaining proper posture
b. continuing with physical activity during flare ups
c. avoiding extremes in environmental temperatures
d. applying cool compresses for relief of local symptoms

A

When administering medications to the patient with gout, the nurse would recognize which of the following as a treatment for chronic disease?
a. colchicine
b. febuxostat
c. sulfasalazine
d. cyclosporine

B

In teaching a patient with SLE about the disorder, the nurse knows that the pathophysiology of SLE includes
a. circulating immune complexes formed from IgG autoantibodies reacting with IgG
b. an autoimmune T cell reaction that results in destruction of the deep dermal skin layer
c. immunologic dysfunction leading to chronic inflammation in the cartilage and muscles
d. the production of a variety of autoantibodies directed against component of the cell nucleus

D

When caring for a patient with systemic sclerosis, the nurse knows it is important to instruct the patient related to (select all that apply)
a. avoiding consumption of high purine foods
b. strategies for good dental hygiene and mouth care
c. protecting the extremities from hot and cold temperatures
d. maintaining joint function and preserving muscle strength
e. performing mouth excursion (yawning) exercises on a daily basis

B,C,D,E

In teaching a patient with chronic fatigue syndrome (CFS) about this disorder, the nurse understands that
a. palpating tender points is an indicator of CFS severity
b. many symptoms are similar to fibromyalgia syndrome
c. definitive treatment includes low dose hydrocortisone
d. CFS is characterized by progressive memory impairment

D

Management of the patient with bacterial meningitis includes:

1.Administering antibiotics immediately after collection of specimens for culture.
2.Waiting for results of a CSF culture to identify an organism before initiating treatment.
3.Providing symptomatic and supportive treatment because drug therapy is not effective in treatment.
4.Obtaining skull x-rays and CT scans to determine the extent of the disease before treatment is started.

Answer: 1

Rationale: Bacterial meningitis is a medical emergency. Rapid diagnosis based on history and physical examination is crucial because the patient is usually in a critical state when health care is sought. When meningitis is suspected, antibiotic therapy is instituted after collection of specimens for cultures, even before the diagnosis is confirmed.

A patient with right-sided paresthesias and hemiparesis is hospitalized and diagnosed with a thrombotic stroke. Over the next 72 hours, the nurse plans care with the knowledge that the patient:

1.Is ready for aggressive rehabilitation.
2.Will show gradual improvement of the initial neurologic deficits.
3.May show signs of deteriorating neurologic function as cerebral edema increases.
4.Should not be turned or exercised to prevent extension of the thrombus and increased neurologic deficits.

Answer: 3

Rationale: Ischemic stroke symptoms may progress in the first 72 hours as infarction and cerebral edema increase

While performing health screening at a health fair, the nurse identifies which of the following individuals at greatest risk for experiencing a stroke?

1.A 46-year-old white female with hypertension and oral contraceptive use for 10 years.
2.A 58-year-old white male salesman who has a total cholesterol level of 285 mg/dL.
3.A 42-year-old African American female with diabetes mellitus who has smoked for 30 years.
4.A 62-year-old African American male with hypertension who is 35 pounds overweight.

Answer: 4

Rationale: Option 4: This individual has five risk factors: age, African American, male, hypertension, and overweight.

A patient with a stroke has dysphagia. Before allowing the patient to eat, which of the following actions should the nurse take first?

1. Check the patient's gag reflex.
2. Request a soft diet with no liquids.
3. Place the patient in high-Fowler's position.
4. Test the patient's ability to swallow with a small amount of water.

Answer: 1

Rationale: Before initiation of feeding, assess the gag reflex by gently stimulating the back of the throat with a tongue blade. If a gag reflex is present, the patient will gag spontaneously. If it is absent, defer the feeding, and begin exercises to stimulate swallowing. To assess swallowing ability, elevate the head of the bed to an upright position (unless contraindicated), and give the patient a small amount of crushed ice or ice water to swallow.

Of the following patients, the nurse recognizes that the one with the highest risk for a stroke is

1.An obese 45-year-old Native American
2.A 35-year-old Asian American woman who smokes
3.A 32-year-old white woman taking oral contraceptives
4.A 65-year-old African American man with HTN

Answer: 4

Rationale: Stroke risk increases with age, doubling each decade after 55-years-old. 2/3 of all strokes occur in ages greater than 65. African American men are 4 times more likely....

A patient experiencing TIAs is scheduled for a carotid endarterectomy. The nurse explains that this procedure is done to
1.Decrease cerebral edema
2.Reduce the brain damage that occurs during a stroke in evolution
3.Prevent a stroke by removing atherosclerotic plaques blocking cerebral blood flow
4.Provide a circulatory bypass around thrombotic plaques obstructing cranial circulation

Answer: 3

Rationale: This is completed to prevent impending cerebral infarction. Atherosclerotic plaques are removed.

The nurse is called to the patient's room by the patient's spouse when the patient experiences a seizure. Upon finding the patient in a clonic reaction, the nurse should:

1.Turn the patient to the side.
2.Start oxygen by mask at 6 L/min.
3.Restrain the patient's arms and legs to prevent injury.
4.Record the time sequence of the patient's movements and responses as they occur

Answer: 1

Rationale: During the seizure, the nurse should maintain a patent airway, protect the patient's head, turn the patient to the side, loosen constrictive clothing, and ease the patient to the floor, if seated. The patient should not be restrained, and no objects should be placed in the mouth. After the seizure, the patient may require repositioning to open and maintain the airway, suctioning, and oxygen. When a seizure occurs, the nurse should carefully observe and record details of the event because diagnosis and subsequent treatment often rest solely on the seizure description.

Interferon β-1b (Betaseron) has been prescribed for a young woman who has been diagnosed with relapsing-remitting multiple sclerosis. The nurse determines that additional teaching about the drug is needed when the patient says,

1."I will need to rotate injection sites with each dose I inject."
2."I should report any depression or suicidal thoughts that develop."
3."I should avoid direct sunlight and use sunscreen and protective clothing when out of doors."
4."Because this drug is a corticosteroid, I should reduce my sodium intake to prevent edema."

Answer: 4

Rationale: Interferon β-1b (Betaseron) is an immunomodulator drug (and not a corticosteroid). The drug is given subcutaneously every other day. Patient teaching should include the following: rotate injection sites with each dose; assess for depression and suicidal ideation; wear sunscreen and protective clothing while exposed to the sun; and know that flu-like symptoms are common following initiation of therapy.

An appropriate nursing diagnosis for a patient with advanced Parkinson's disease is

1.Risk for injury related to limited vision.
2.Risk for aspiration related to impaired swallowing.
3.Urge incontinence related to effects of drug therapy.
4.Ineffective breathing pattern related to diaphragm fatigue.

Answer: 2

Rationale: As swallowing becomes more difficult (dysphagia), malnutrition or aspiration may result

A 69-year-old patient is admitted to the hospital with a urinary infection and possible bacterial sepsis. The patient is disoriented and has a disturbed sleep-wake cycle. The nurse administers the Confusion Assessment Method (CAM) tool to differentiate among various cognitive disorders, primarily because:

1.Delirium can be reversed by treating the underlying causes.
2.Depression is a common cause of dementia in older adults.
3.Nursing care should be based on the cause of the cognitive impairment.
4.Drug therapy with antipsychotic agents is indicated in the treatment of dementia.

Answer: 1

Rationale: Delirium, a state of temporary but acute mental confusion, is a common, life-threatening, and possibly preventable syndrome in older adults. Clinically, delirium is rarely caused by a single factor. It is often the result of the interaction of the patient's underlying condition with a precipitating event.

The daughter of a patient with early familial Alzheimer's disease (AD) asks how AD can be detected. The nurse describes early warning signs of AD, including:

1.Forgetting a colleague's name at a party.
2.Repeatedly misplacing car keys or a wallet.
3.Leaving a pot on the stove that boils dry and burns.
4.Having no memory of preparing a meal and forgetting to serve or eat it.

Answer: 4

A patient with Alzheimer's disease has a nursing diagnosis of impaired memory related to effects of dementia. An appropriate nursing intervention for the patient is to:

1.Let the patient know what behavior is socially appropriate.
2.Assist the patient with all self-care to maintain self-esteem.
3.Maintain familiar routines of sleep, meals, drug administration, and activities.
4.At every encounter with the patient, ask the day, time, and place to promote orientation.

Answer: 3

Rationale: The nurse should maintain familiar routines by identifying usual patterns of behavior for activities such as sleep, medication use, elimination, food intake, and self-care.

Which of the following clients is most at risk for deep vein thrombosis?

1.50-year-old female with a fractured ankle who takes aspirin for rheumatoid arthritis
2.25-year-old male athlete with a fractured clavicle
3.40-year-old female diabetic with fractured ribs
4.60-year-old male smoker with a fractured pelvis

Answer is #4
• Deep vein thrombosis as a complication with bone fractures occurs more often when the fractures are sustained in the lower extremities and the client has additional risk factors for thrombus formation. Other risk factors include obesity, smoking, oral contraceptives, previous thrombus events, advanced age, venous stasis, and heart disease.

Which of the following clients is most at risk of infection after a fracture?

1.A client with a fractured clavicle
2.A client with an open fracture of the tibia
3.A client with a simple fracture of the wrist
4.A client with a compression fracture of a vertebra

Answer is #2
• Bone infection or osteomyelitis is most common in clients with an open fracture, because skin integrity is lost and organisms gain access easily.

A home care nurse is visiting a diabetic client with a new cast on the arm. On assessment, the nurse finds the client's fingers to be pale, cool, and slightly swollen. What is the nurse's best first action?

1.Elevate the arm above the level of the heart.
2.Withhold the next dose of insulin.
3.Apply heat to the affected hand.
4.Bivalve the cast.

Answer is #1
• Arm casts can impinge circulation when in the dependent position. The nurse should elevate the arm above the level of the heart, ensuring that the hand is above the elbow, and reassess the extremity in 15 minutes. If the

The nurse notes that the skin around the client's skeletal traction pin site is swollen, red, and crusty, with dried drainage. What is the nurse's priority action?

1.Decrease the traction weight.
2.Apply a new dressing.
3.Document the finding as the only action.
4.Notify the physician.

Answer is #4
• These clinical manifestations indicate inflammation and possible infection. Infected pin sites can lead to osteomyelitis and should be treated immediately.

A client with a ORIF of the right femur 4 days ago. The client complains of intense pain, swelling, tenderness, and warmth at the side, chills, malaise, and has a temperature of 102.2F. The data indicates which of the following?

1.Fat embolism
2.Compartment syndrome
3.Osteomyelitis
4.Malunion of bone

Answer is #3
• These are all signs and symptoms of an infection...

A patient is being treated in the ER for a possible sprained ankle after a fall. The Xray ruled out a fracture. Before sending the patient home, the nurse plans to teach the client to avoid which of the following in the next 24 hours?

1.Resting the foot
2.Applying a heat pad
3.Applying an elastic compression bandage
4.Elevating the ankle on a pillow while sitting or lying down

2

A nurse is conducting health screening for osteoporosis. Which of the following patients is at greatest risk of developing osteoporosis?

1.A 25-year-old woman who jogs
2.A 36-year-old man with asthma
3.A 70-year-old man who consumes excess alcohol
4.A sedentary 65-year-old woman who smokes

4

A patient with a hip fracture asks the nurse why the Buck's traction is being applied before surgery. The nurse explains that Buck's traction primarily:

1.Allows bony healing to begin before surgery
2.Provides rigid immobilization of the fracture site
3.Lengthens the fractured leg to prevent severing blood vessels
4.Provides comfort by reducing muscle spasms and provides fracture immobilization.

4

A nurse caring for a patient diagnosed with osteoarthritis. The nurse performs an assessment, knowing that which of the following is a clinical manifestation associated with the disorder?

1.Morning stiffness
2.A decreased sedimentation rate
3.Joint pain that diminishes after rest
4.Elevated antinuclear antibody levels

3

A plaster splint is applied with an elastic bandage to the leg of a patient hospitalized with a fractured tibia in preparation for open reduction and internal fixation of the fracture. The patient complains of increasing pain in the affected leg and foot that is not relieved by loosening of the elastic bandage. The most appropriate action by the nurse is to

1.Elevate the leg on two pillows.
2.Perform neurovascular assessment of the foot.
3.Notify the health care provider.
4.Apply ice over the fracture site.

2

When assessing a patient with a traumatic brain injury, the nurse notes uncoordinated movement of the extremities. The nurse would document this as
A) a. Ataxia.
B) b. Apraxia.
C) c. Anisocoria.
D) d. Anosognosia.

A

When assessing the accessory nerve, the nurse would
A) a. Assess the gag reflex by stroking the posterior pharynx.
B) b. Ask the patient to shrug the shoulders against resistance.
C) c. Ask the patient to push the tongue to either side against resistance.
D) d. Have the patient say "ah" while visualizing elevation of soft palate.

B

When assessing motor function of a patient admitted with a stroke, the nurse notes mild weakness of the arm demonstrated by downward drifting of the arm. The nurse would most accurately document this finding as
A) a. Athetosis.
B) b. Hypotonia.
C) c. Hemiparesis.
D) d. Pronator drift.

D

Downward drifting of the arm or pronation of the palm is identified as a pronator drift. Hemiparesis is weakness of one side of the body; hypotonia defines a flaccid muscle tone; and athetosis is a slow, writhing, involuntary movement of the extremities.

A patient's sudden onset of hemiplegia has necessitated a computed tomography (CT) of her head. Which of the following assessments should the nurse complete prior to this diagnostic study?
A) a. Assess the patient's immunization history.
B) b. Screen the patient for any metal parts or a pacemaker.
C) c. Assess the patient for allergies to shellfish, iodine, or dyes.
D) d. Assess the patient's need for tranquilizers or antiseizure medications.

C

A patient who has a neurologic disease that affects the pyramidal tract is likely to manifest which of the following signs?
A) a. Impaired muscle movement
B) b. Decreased deep tendon reflexes
C) c. Decreased level of consciousness
D) d. Impaired sensation of touch, pain, and temperature

A

Among the most important descending tracts are the corticobulbar and corticospinal tracts, collectively termed the pyramidal tract. These tracts carry volitional (voluntary) impulses from the cortex to the cranial and peripheral nerves. Dysfunction of the pyramidal tract is likely to manifest as impaired movement. Diseases affecting the pyramidal tract do not result in changes in LOC, impaired reflexes, or decreased sensation.

How should the nurse most accurately assess the position sense of a patient with a recent traumatic brain injury?
A) a. Ask the patient to close his or her eyes and slowly bring the tips of the index fingers together.
B) b. Ask the patient to maintain balance while standing with his or her feet together and eyes closed.
C) c. Ask the patient to close his or her eyes and identify the presence of a common object on the forearm.
D) d. Place the two points of a calibrated compass on the tips of the fingers and toes and ask the patient to discriminate the points.

B

The nurse is caring for a patient admitted for evaluation and surgical removal of a brain tumor. The nurse will plan interventions for this patient based on knowledge that brain tumors can lead to which of the following complications (select all that apply)?
A) a. Vision loss
B) b. Cerebral edema
C) c. Pituitary dysfunction
D) d. Parathyroid dysfunction
E) e. Focal neurologic deficits

A,B,C,E

A patient with a suspected closed head injury has bloody nasal drainage. The nurse suspects that this patient has a cerebrospinal fluid (CSF) leak when observing which of the following?
A) a. A halo sign on the nasal drip pad
B) b. Decreased blood pressure and urinary output
C) c. A positive reading for glucose on a Test-tape strip
D) d. Clear nasal drainage along with the bloody discharge

A

When drainage containing both CSF and blood is allowed to drip onto a white pad, within a few minutes the blood will coalesce into the center, and a yellowish ring of CSF will encircle the blood, giving a halo effect. The presence of glucose would be unreliable for determining the presence of CSF because blood also contains glucose

The nurse assesses a patient for signs of meningeal irritation and observes her for nuchal rigidity. Which of the following indicates the presence of this sign of meningeal irritation?
A) a. Tonic spasms of the legs
B) b. Curling in a fetal position
C) c. Arching of the neck and back
D) d. Resistance to flexion of the neck

D

The nurse is caring for a patient admitted with a subdural hematoma following a motor vehicle accident. Which of the following changes in vital signs would the nurse interpret as a manifestation of increased intracranial pressure?
A) a. Tachypnea
B) b. Bradycardia
C) c. Hypotension
D) d. Narrowing pulse pressure

B

Changes in vital signs indicative of increased intracranial pressure are known as Cushing's triad, which consists of increasing systolic pressure with a widening pulse pressure, bradycardia with a full and bounding pulse, and irregular respirations.

The nurse is providing care for a patient who has been admitted to the hospital with a head injury and who requires regular neurologic vital signs. Which of the following assessments will be components of the patient's score on the Glasgow Coma Scale (GCS) (select all that apply)?
A) a. Judgment
B) b. Eye opening
C) c. Abstract reasoning
D) d. Best verbal response
E) e. Best motor response
F) f. Cranial nerve function

B,D,E

Which of the following nursing actions should be implemented in the care of a patient who is experiencing increased intracranial pressure (ICP)?
A) a. Monitor fluid and electrolyte status astutely.
B) b. Position the patient in a high Fowler's position.
C) c. Administer vasoconstrictors to maintain cerebral perfusion.
D) d. Maintain physical restraints to prevent episodes of agitation.

A

Magnetic resonance imaging (MRI) has revealed the presence of a brain tumor in a patient. The nurse would recognize the patient's likely need for which of the following treatment modalities?
A) a. Surgery
B) b. Chemotherapy
C) c. Radiation therapy
D) d. Pharmacologic treatment

A

Which of the following modifiable risk factors for stroke would be most important for the nurse to include when planning a community education program?
A) a. Hypertension
B) b. Hyperlipidemia
C) c. Alcohol consumption
D) d. Oral contraceptive use

A

The nurse would expect to find which of the following clinical manifestations in a patient admitted with a left-brain stroke?
A) a. Impulsivity
B) b. Impaired speech
C) c. Left-side neglect
D) d. Short attention span

B

Clinical manifestations of left-sided brain damage include right hemiplegia, impaired speech/language aphasias, impaired right/left discrimination, and slow and cautious performance. The other options are all manifestations of right-sided brain damage.

The nurse is discharging a patient admitted with a transient ischemic attack (TIA). For which of the following medications might the nurse expect to provide discharge instructions (select all that apply)?
A) a. Clopidogrel (Plavix)
B) b. Enoxaparin (Lovenox)
C) c. Dipyridamole (Persantine)
D) d. Enteric-coated aspirin (Ecotrin)
E) e. Tissue plasminogen activator (tPA)

A,C,D

Which of the following nursing interventions is most appropriate when communicating with a patient suffering from aphasia poststroke?
A) a. Present several thoughts at once so that the patient can connect the ideas.
B) b. Ask open-ended questions to provide the patient the opportunity to speak.
C) c. Use simple, short sentences accompanied by visual cues to enhance comprehension.
D) d. Finish the patient's sentences so as to minimize frustration associated with slow speech.

C

Computed tomography of a 68-year-old male patient's head reveals that he has experienced a hemorrhagic stroke. Which of the following is a nursing priority intervention in the emergency department?
A) a. Maintenance of the patient's airway
B) b. Positioning to promote cerebral perfusion
C) c. Control of fluid and electrolyte imbalances
D) d. Administration of tissue plasminogen activator (tPA)

A

A female patient has left-sided hemiplegia following an ischemic stroke that she experienced 2 weeks earlier. How should the nurse best promote the health of the patient's integumentary system?
A) a. Position the patient on her weak side the majority of the time.
B) b. Alternate the patient's positioning between supine and side-lying.
C) c. Avoid the use of pillows in order to promote independence in positioning.
D) d. Establish a schedule for the massage of areas where skin breakdown emerges.

B

Which of the following sensory-perceptual deficits is associated with left-brain stroke (right hemiplegia)?
A) a. Overestimation of physical abilities
B) b. Difficulty judging position and distance
C) c. Slow and possibly fearful performance of tasks
D) d. Impulsivity and impatience at performing tasks

C

Patients with a left-brain stroke (right hemiplegia) commonly are slower in organization and performance of tasks and may have a fearful, anxious response to a stroke.

The patient has been receiving scheduled doses of phenytoin (Dilantin) and begins to experience diplopia. The nurse immediately assesses the patient for which of the following?
A) a. An aura
B) b. Nystagmus or confusion
C) c. Abdominal pain or cramping
D) d. Irregular pulse or palpitations

B

The patient has an order for phenytoin (Dilantin) 100 mg q8hr IV. Available is a phenytoin injection containing 50 mg/ml. How many milliliters of solution should the nurse draw up for the dose?
A) a. 0.5
B) b. 2
C) c. 5
D) d. 20

B

Which of the following characteristics of a patient's recent seizure is congruent with a partial seizure?
A) a. The patient lost consciousness during the seizure.
B) b. The seizure involved lip smacking and repetitive movements.
C) c. The patient fell to the ground and became stiff for 20 seconds.
D) d. The etiology of the seizure involved both sides of the patient's brain.

B

Which of the following measures should the nurse prioritize when providing care for a patient with a diagnosis of multiple sclerosis (MS)?
A) a. Vigilant infection control and adherence to standard precautions
B) b. Careful monitoring of neurologic vital signs and frequent reorientation
C) c. Maintenance of a calorie count and hourly assessment of intake and output
D) d. Assessment of blood pressure and monitoring for signs of orthostatic hypotension

A

Infection control is a priority in the care of patients with MS, since infection is the most common precipitator of an exacerbation of the disease. Decreases in cognitive function are less likely, and MS does not typically result in hypotension or fluid volume excess or deficit.

A male patient with a diagnosis of Parkinson's disease (PD) has been admitted recently to a long-term care facility. Which of the following actions should the health care team take in order to promote adequate nutrition for this patient?
A) a. Provide multivitamins with each meal.
B) b. Provide a diet that is low in complex carbohydrates and high in protein.
C) c. Provide small, frequent meals throughout the day that are easy to chew and swallow.
D) d. Provide the patient with a minced or pureed diet that is high in potassium and low in sodium.

C

Which of the following nursing diagnoses is likely to be a priority in the care of a patient with myasthenia gravis (MG)?
A) a. Acute confusion
B) b. Bowel incontinence
C) c. Activity intolerance
D) d. Disturbed sleep pattern

C

The primary feature of MG is fluctuating weakness of skeletal muscle. Bowel incontinence and confusion are unlikely signs of MG, and although sleep disturbance is likely, activity intolerance is usually of primary concern.

The nurse is caring for a patient admitted with a spinal cord injury following a motor vehicle accident. The patient exhibits a complete loss of motor, sensory, and reflex activity below the injury level. The nurse recognizes this condition as which of the following?
A) a. Central cord syndrome
B) b. Spinal shock syndrome
C) c. Anterior cord syndrome
D) d. Brown-Séquard syndrome

B

Which of the following clinical manifestations would the nurse interpret as representing neurogenic shock in a patient with acute spinal cord injury?
A) a. Bradycardia
B) b. Hypertension
C) c. Neurogenic spasticity
D) d. Bounding pedal pulses

A

Neurogenic shock is due to the loss of vasomotor tone caused by injury and is characterized by hypotension and bradycardia. Loss of sympathetic innervation causes peripheral vasodilation, venous pooling, and a decreased cardiac output.

The nurse is caring for a patient admitted 1 week ago with an acute spinal cord injury. Which of the following assessment findings would alert the nurse to the presence of autonomic dysreflexia?
A) a. Tachycardia
B) b. Hypotension
C) c. Hot, dry skin
D) d. Throbbing headache

D

Autonomic dysreflexia is related to reflex stimulation of the sympathetic nervous system reflected by hypertension, bradycardia, throbbing headache, and diaphoresis.

When planning care for a patient with a C5 spinal cord injury, which nursing diagnosis is the highest priority?
A) a. Risk for impairment of tissue integrity caused by paralysis
B) b. Altered patterns of urinary elimination caused by quadriplegia
C) c. Altered family and individual coping caused by the extent of trauma
D) d. Ineffective airway clearance caused by high cervical spinal cord injury

D

The nurse is providing care for a patient who has been diagnosed with Guillain-Barré syndrome. Which of the following assessments should the nurse prioritize?
A) a. Pain assessment
B) b. Glasgow Coma Scale
C) c. Respiratory assessment
D) d. Musculoskeletal assessment

C

Which of the following signs and symptoms in a patient with a T4 spinal cord injury should alert the nurse to the possibility of autonomic dysreflexia?
A) a. Headache and rising blood pressure
B) b. Irregular respirations and shortness of breath
C) c. Decreased level of consciousness or hallucinations
D) d. Abdominal distention and absence of bowel sounds

A

Which of the following interventions should the nurse perform in the acute care of a patient with autonomic dysreflexia?
A) a. Urinary catheterization
B) b. Administration of benzodiazepines
C) c. Suctioning of the patient's upper airway
D) d. Placement of the patient in the Trendelenburg position

A

Because the most common cause of autonomic dysreflexia is bladder irritation, immediate catheterization to relieve bladder distention may be necessary.

A 54-year-old patient admitted with cellulitis and probable osteomyelitis has just received an injection of radioisotope at 9:00 am before a bone scan. The nurse should plan to send the patient for the bone scan at which of the following times?
A) a. 9:30 pm
B) b. 10:00 am
C) c. 11:00 am
D) d. 1:00 pm

C

A technician usually administers a calculated dose of a radioisotope 2 hours before a bone scan. If the patient was injected at 9:00 am, the procedure should be done at 11:00 am.

A 54-year-old patient is about to have a bone scan. In teaching the patient about this procedure, the nurse will include which of the following information?
A) a. Two additional follow-up scans will be required.
B) b. There will be only mild pain associated with the procedure.
C) c. The procedure takes approximately 15 to 30 minutes to complete.
D) d. The patient will be asked to drink increased fluids after the procedure.

D

Patients are asked to drink increased fluids after the procedure to aid in excretion of the radioisotope, if not contraindicated by another condition.

Musculoskeletal assessment is an important component of care for patients on long-term therapy of
A) a. Corticosteroids.
B) b. Antiplatelet aggregators.
C) c. b-Adrenergic blockers.
D) d. Calcium-channel blockers.

A

A female patient with a long-standing history of rheumatoid arthritis has sought care because of increasing stiffness in her right knee that has culminated in complete fixation of the joint. The nurse would document the presence of which of the following problems?
A) a. Atrophy
B) b. Ankylosis
C) c. Crepitation
D) d. Contracture

B

The nurse is performing a musculoskeletal assessment of an 81-year-old female patient whose mobility has been progressively decreasing in recent months. How should the nurse best assess the patient's range of motion (ROM) in the affected leg?
A) a. Perform passive ROM, asking the patient to report any pain.
B) b. Ask the patient to lift progressive weights with the affected leg.
C) c. Observe the patient's unassisted ROM in the affected leg.
D) d. Move both of the patient's legs from a supine position to full flexion.

C

While completing an admission history for a 73-year-old man with osteoarthritis admitted for knee arthroplasty, the nurse asks about the patient's perception of the reason for admission. The nurse expects the patient to relate which of the following responses to this question?
A) a. Recent knee trauma
B) b. Debilitating joint pain
C) c. Repeated knee infections
D) d. Onset of "frozen" knee joint

B

The nurse is caring for a patient with osteoarthritis who is about to undergo total left knee arthroplasty. The nurse assesses the patient carefully to be sure that there is no evidence of which of the following in the preoperative period?
A) a. Pain
B) b. Left knee stiffness
C) c. Left knee infection
D) d. Left knee instability

C

The nurse formulates a nursing diagnosis of impaired physical mobility related to decreased muscle strength for a 78-year-old patient following left total knee replacement. Which of the following would be an appropriate nursing intervention for this patient?
A) a. Promote vitamin D and calcium intake in the diet.
B) b. Provide passive range of motion to all of the joints q4hr.
C) c. Encourage isometric quadriceps-setting exercises at least qid.
D) d. Keep the left leg in extension and abduction to prevent contractures.

C


Great emphasis is placed on postoperative exercise of the affected leg, with isometric quadriceps setting beginning on the first day after surgery.

The nurse is caring for a 76-year-old man who has undergone left knee arthroplasty with prosthetic replacement of the knee joint to relieve the pain of severe osteoarthritis. Postoperatively the nurse expects which of the following will be included in the care of the affected leg?
A) a. Progressive leg exercises to obtain 90-degree flexion
B) b. Early ambulation with full weight bearing on the left leg
C) c. Bed rest for 3 days with the left leg immobilized in extension
D) d. Immobilization of the left knee in 30-degree flexion for 2 weeks to prevent dislocation

A

The nurse is caring for a 75-year-old woman who underwent left total knee arthroplasty and has a new physician order to be "up in chair today before noon." Which of the following actions would the nurse take to protect the knee joint while carrying out the order?
A) a. Administer a dose of prescribed analgesic before completing the order.
B) b. Ask the physical therapist for a walker to limit weight bearing while getting out of bed.
C) c. Keep the continuous passive motion machine in place while lifting the patient from bed to chair.
D) d. Put on a knee immobilizer before moving the patient out of bed and keep the surgical leg elevated while sitting.

D

The nurse is completing discharge teaching with an 80-year-old male patient who underwent right total hip arthroplasty. The nurse identifies a need for further instruction if the patient states the need to do which of the following?
A) a. Avoid crossing his legs.
B) b. Use a toilet elevator on toilet seat.
C) c. Notify future caregivers about the prosthesis.
D) Maintain hip in adduction and internal rotation.

D

The nurse interprets that which of the following prescribed medications is being used to treat osteomyelitis for a 54-year-old patient admitted to the nursing unit?
A) a. Thiamine (vitamin B1)
B) b. Gentamicin (Garamycin)
C) c. Chlordiazepoxide (Librium)
D) d. Oxycodone with acetaminophen (Percocet)

B

During a public health screening day, which of the following assessment findings would alert the nurse to the presence of osteoporosis in a 61-year-old female?
A) a. The presence of bowed legs
B) b. A measurable loss of height
C) c. Poor appetite and aversion to dairy products
D) d. The development of unstable, wide-gait ambulation

B

The nurse is reinforcing health teaching about osteoporosis with a 72-year-old patient admitted to the hospital. In reviewing this disorder, the nurse explains which of the following to the patient?
A) a. With a family history of osteoporosis, there is no way to prevent or slow bone resorption.
B) b. Continuous, low-dose corticosteroid treatment is effective in stopping the course of osteoporosis.
C) c. Estrogen replacement therapy must be maintained to prevent rapid progression of the osteoporosis.
D) d. Even with a family history of osteoporosis, the calcium loss from bones can be slowed by increased calcium intake and exercise.

D

The nurse determines that dietary teaching for a 75-year-old patient with osteoporosis has been most successful when the patient selects which of the following highest-calcium meals?
A) a. Chicken stir-fry with 1 cup each onions and snap peas, and 1 cup of steamed rice
B) b. Ham and Swiss cheese sandwich on whole wheat bread, steamed broccoli, and an apple
C) c. A sardine (3 oz) sandwich on whole wheat bread, 1 cup of fruit yogurt, and 1 cup of skim milk
D) d. A two-egg omelet with 2 oz of American cheese, one slice of whole wheat toast, and a half grapefruit

C

The highest calcium content is present in this lunch containing milk and milk products, and small fish with bones (sardines).

The nurse is caring for a 49-year-old patient admitted to the nursing unit with osteomyelitis. Which of the following symptoms will the nurse most likely find on physical examination of the patient?
A) a. Nausea and vomiting
B) b. Localized pain and redness
C) c. Paresthesia in the affected extremity
D) d. Generalized bone pain throughout the leg

B

Osteomyelitis is an infection of bone and bone marrow that can occur with trauma, surgery, or extension of nearby infection. Because it is an infection, the patient will exhibit typical signs of inflammation and infection, including localized pain and redness.

A 54-year-old patient with acute osteomyelitis asks the nurse how this problem will be treated. Which of the following responses by the nurse is most appropriate?
A) a. "Oral antibiotics are often required for several months."
B) b. "Intravenous antibiotics are usually required for several weeks."
C) c. "Surgery is almost always necessary to remove the dead tissue that is likely to be present."
D) d. "Drainage of the foot and instillation of antibiotics into the affected area is the usual therapy."

B

A 67-year-old patient hospitalized with osteomyelitis has an order for bed rest with bathroom privileges with the affected foot elevated on two pillows. The nurse would place highest priority on which of the following interventions?
A) a. Ambulate the patient to the bathroom every 2 hours.
B) b. Ask the patient about preferred activities to relieve boredom.
C) c. Allow the patient to dangle legs at the bedside every 2 to 4 hours.
D) d. Perform frequent position changes and range-of-motion exercises.

D

The patient is at risk for atelectasis of the lungs and for contractures because of prescribed bed rest. For this reason, the nurse should change the patient's position frequently to promote lung expansion and perform range-of-motion exercises to prevent contractures.

The nurse is working with a 73-year-old patient with osteoarthritis (OA). In assessing the patient's understanding of this disorder, the nurse concludes teaching has been effective when the patient describes the condition as which of the following?
A) a. Joint destruction caused by an autoimmune process
B) b. Degeneration of articular cartilage in synovial joints
C) c. Overproduction of synovial fluid resulting in joint destruction
D) d. Breakdown of tissue in non-weight-bearing joints by enzymes

B

The nurse is assessing the recent health history of a 63-year-old patient with osteoarthritis (OA). The nurse determines that the patient is trying to manage the condition appropriately when the patient describes which of the following activity patterns?
A) a. Bed rest with bathroom privileges
B) b. Daily high-impact aerobic exercise
C) c. A regular exercise program of walking
D) d. Frequent rest periods with minimal exercise

C

The nurse is admitting a patient who is scheduled for knee arthroscopy related to osteoarthritis (OA). Which of the following findings would the nurse expect to be present on examination of the patient's knees?
A) a. Ulnar drift
B) b. Pain with joint movement
C) c. Reddened, swollen affected joints
D) d. Stiffness that increases with movement

B

The nurse is caring for a patient who has osteoarthritis (OA) of the knees. The nurse teaches the patient that the most beneficial measure to protect the joints is to do which of the following?
A) a. Use a wheelchair to avoid walking as much as possible.
B) b. Eat a well-balanced diet to maintain a healthy body weight.
C) c. Use a walker for ambulation to relieve the pressure on her hips.
D) d. Sit in chairs that do not cause her hips to be lower than her knees.

B

The nurse is reinforcing general health teaching with a 64-year-old patient with osteoarthritis (OA) of the hip. Which of the following points would the nurse include in this review of the disorder (select all that apply)?
A) a. OA cannot be successfully treated with any current therapy options.
B) b. OA is an inflammatory disease of the joints that may present symptoms at any age.
C) c. Joint degeneration with pain and disability occurs in the majority of people by the age of 60.
D) d. OA is more common with aging, but usually it remains confined to a few joints and does not cause crippling.
E) e. OA can be prevented from progressing when well controlled with a regimen of exercise, diet, and medication.

D,E

When reinforcing health teaching about the management of osteoarthritis (OA), the nurse determines that the patient needs additional instruction after making which of the following statements?
A) a. "I should take the Celebrex as prescribed to help control the pain."
B) b. "I should try to stay standing all day to keep my joints from becoming stiff."
C) c. "I can use a cane if I find it helpful in relieving the pressure on my back and hip."
D) d. "A warm shower in the morning will help relieve the stiffness I have when I get up."

B

Which of the following patient statements most clearly suggests a need to assess the patient for ankylosing spondylitis (AS)?
A) a. "My right elbow has become red and swollen over the last few days."
B) b. "I wake up stiff every morning and my knees just don't want to bend."
C) c. "My husband tells me that my posture has become so stooped this winter."
D) d. "My lower back pain seems to be getting worse all the time and nothing seems to help."

D

AS primarily affects the axial skeleton. Based on this, symptoms of inflammatory spine pain are often the first clues to a diagnosis of AS. Knee or elbow involvement is not consistent with the typical course of AS. Back pain is likely to precede the development of kyphosis.

A female patient's complex symptomatology over the past year has culminated in a diagnosis of systemic lupus erythematosus (SLE). Which of the patient's following statements demonstrates the need for further teaching about the disease?
A) a. "I'll try my best to stay out of the sun this summer."
B) b. "I know that I probably have a high chance of getting arthritis."
C) c. "I'm hoping that surgery will be an option for me in the future."
D) d. "I understand that I'm going to be vulnerable to getting infections."

C

SLE carries an increased risk of infection, sun damage, and arthritis. Surgery is not a key treatment modality for SLE.

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