Exam 5- Adult Health- Review Questions

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Musculoskeletal Disorders A patient is suspected of having rheumatoid arthritis and her diagnostic regimen includes aspiration of synovial fluid from the knee for a definitive diagnosis. The nurse kn... ows that which of the following procedures will be involved? Angiography Myelography Paracentesis Arthrocentesis A nurse is providing care for a patient who has just been diagnosed as being in the early stage of rheumatoid arthritis. The nurse should anticipate the administration of which of the following? Hydromorphone (Dilaudid) Methotrexate (Rheumatrex) Allopurinol (Zyloprim) Prednisone A nurse is performing the initial assessment of a patient who has a recent diagnosis of systemic lupus erythematosus (SLE). What skin manifestation would the nurse expect to observe on inspection? Petechiae Butterfly rash Jaundice Skin sloughing A clinic nurse is caring for a patient with suspected gout. While explaining the pathophysiology of gout to the patient, the nurse should describe which of the following? Autoimmune processes in the joints Chronic metabolic acidosis Increased uric acid levels Unstable serum calcium levels A patients decreased mobility is ultimately the result of an autoimmune reaction originating in the synovial tissue, which caused the formation of pannus. This patient has been diagnosed with what health problem? Rheumatoid arthritis (RA) Systemic lupus erythematosus Osteoporosis Polymyositis A nurse is performing the health history and physical assessment of a patient who has a diagnosis of rheumatoid arthritis (RA). What assessment finding is most consistent with the clinical presentation of RA? Cool joints with decreased range of motion Signs of systemic infection Joint stiffness, especially in the morning Visible atrophy of the knee and shoulder joints A patient has a diagnosis of rheumatoid arthritis and the primary care provider has now prescribed cyclophosphamide (Cytoxan). The nurses subsequent assessments should address what potential adverse effect? Infection Acute confusion Sedation Malignant hyperthermia A nurse is assessing a patient for risk factors known to contribute to osteoarthritis. What assessment finding would the nurse interpret as a risk factor? The patient has a 30 pack-year smoking history. The patients body mass index is 34 (obese). The patient has primary hypertension. The patient is 58 years old. A patient is undergoing diagnostic testing to determine the etiology of recent joint pain. The patient asks the nurse about the difference between osteoarthritis (OA) and rheumatoid arthritis (RA). What is the best response by the nurse? OA is a considered a noninflammatory joint disease. RA is characterized by inflamed, swollen joints. OA and RA are very similar. OA affects the smaller joints such as the fingers, and RA affects the larger, weight-bearing joints like the knees. OA originates with an infection. RA is a result of your body's cells attacking one another. OA is associated with impaired immune function; RA is a consequence of physical damage. A patient with systemic lupus erythematosus (SLE) is preparing for discharge. The nurse knows that the patient has understood health education when the patient makes what statement? Ill make sure I get enough exposure to sunlight to keep up my vitamin D levels. Ill try to be as physically active as possible between flare-ups. Ill make sure to monitor my body temperature on a regular basis. Ill stop taking my steroids when I get relief from my symptoms. A nurse is caring for a 78-year-old patient with a history of osteoarthritis (OA). When planning the patients care, what goal should the nurse include? The patient will express satisfaction with her ability to perform ADLs. The patient will recover from OA within 6 months. The patient will adhere to the prescribed plan of care. The patient will deny signs or symptoms of OA. Allopurinol (Zyloprim) has been ordered for a patient receiving treatment for gout. The nurse caring for this patient knows to assess the patient for bone marrow suppression, which may be manifested by which of the following diagnostic findings? Hyperuricemia Increased erythrocyte sedimentation rate Elevated serum creatinine Decreased platelets A patient with rheumatic disease is complaining of stomatitis. The nurse caring for the patient should further assess the patient for the adverse effects of what medications? Corticosteroids Gold-containing compounds Antimalarials Salicylate therapy A nurse is planning patient education for a patient being discharged home with a diagnosis of rheumatoid arthritis. The patient has been prescribed antimalarials for treatment, so the nurse knows to teach the patient to self-monitor for what adverse effect? Tinnitus Visual changes Stomatitis Hirsutism A nurse is working with a patient with rheumatic disease who is being treated with salicylate therapy. What statement would indicate that the patient is experiencing adverse effects of this drug? I have this ringing in my ears that just wont go away. I feel so foggy in the mornings and it takes me so long to wake up. When I eat a meal thats high in fat, I get really nauseous. I seem to have lost my appetite, which is unusual for me. A nurse is educating a patient with gout about lifestyle modifications that can help control the signs and symptoms of the disease. What recommendation should the nurse make? Ensuring adequate rest Limiting exposure to sunlight Limiting intake of alcohol Smoking cessation A patients rheumatoid arthritis (RA) has failed to respond appreciably to first-line treatments and the primary care provider has added prednisone to the patients drug regimen. What principle will guide this aspect of the patients treatment? The patient will need daily blood testing for the duration of treatment. The patient must stop all other drugs 72 hours before starting prednisone. The drug should be used at the highest dose the patient can tolerate. The drug should be used for as short a time as possible. A patient with SLE has come to the clinic for a routine check-up. When auscultating the patients apical heart rate, the nurse notes the presence of a distinct scratching sound. What is the nurses most appropriate action? Reposition the patient and auscultate posteriorly. Document the presence of S3 and monitor the patient closely. Inform the primary care provider that a friction rub may be present. Inform the primary care provider that the patient may have pneumonia. A community health nurse is performing a visit to the home of a patient who has a history of rheumatoid arthritis (RA). On what aspect of the patients health should the nurse focus most closely during the visit? The patients understanding of rheumatoid arthritis The patients risk for cardiopulmonary complications The patients social support system The patients functional status A 21-year-old male has just been diagnosed with a spondyloarthropathy. What will be a priority nursing intervention for this patient? Referral for assistive devices Teaching about symptom management Referral to classes to stop smoking Setting up an exercise program A patient with SLE asks the nurse why she has to come to the office so often for check-ups. What would be the nurses best response? Taking care of you in the best way involves seeing you face to face. Taking care of you in the best way involves making sure you are taking your medication the way it is ordered. Taking care of you in the best way involves monitoring your disease activity and how well the prescribed treatment is working. Taking care of you in the best way involves drawing blood work every month. A patient with rheumatoid arthritis comes to the clinic complaining of pain in the joint of his right great toe and is eventually diagnosed with gout. When planning teaching for this patient, what management technique should the nurse emphasize? Take OTC calcium supplements consistently. Restrict consumption of foods high in purines. Ensure fluid intake of at least 4 liters per day. Restrict weight-bearing on right foot. A nurses plan of care for a patient with rheumatoid arthritis includes several exercise-based interventions. Exercises for patients with rheumatoid disorders should have which of the following goals? Maximize range of motion while minimizing exertion Increase joint size and strength Limit energy output in order to preserve strength for healing Preserve and increase range of motion while limiting joint stress A nurse is providing care for a patient who has a rheumatic disorder. The nurses comprehensive assessment includes the patients mood, behavior, LOC, and neurologic status. What is this patients most likely diagnosis? Osteoarthritis (OA) Systemic lupus erythematosus (SLE) Rheumatoid arthritis (RA) Gout A patient with rheumatoid arthritis comes into the clinic for a routine check-up. On assessment the nurse notes that the patient appears to have lost some of her ability to function since her last office visit. Which of the following is the most appropriate action? Arrange a family meeting in order to explore assisted living options. Refer the patient to a support group. Arrange for the patient to be assessed in her home environment. Refer the patient to social work. A nurse is assessing a patient with rheumatoid arthritis. The patient expresses his intent to pursue complementary and alternative therapies. What fact should underlie the nurses response to the patient? New evidence shows CAM to be as effective as medical treatment. CAM therapies negate many of the benefits of medications. CAM therapies typically do more harm than good. Evidence shows minimal benefits from most CAM therapies. A nurse is providing care for a patient whose pattern of laboratory testing reveals longstanding hypocalcemia. What other laboratory result is most consistent with this finding? An elevated parathyroid hormone level An increased calcitonin level An elevated potassium level A decreased vitamin D level A nurse is caring for a patient whose cancer metastasis has resulted in bone pain. Which of the following are typical characteristics of bone pain? A dull, deep ache that is boring in nature Soreness or aching that may include cramping Sharp, piercing pain that is relieved by immobilization Spastic or sharp pain that radiates A nurse is assessing a patient who is experiencing peripheral neurovascular dysfunction. What assessment findings are most consistent with this diagnosis? Hot skin with a capillary refill of 1 to 2 seconds Absence of feeling, capillary refill of 4 to 5 seconds, and cool skin Pain, diaphoresis, and erythema Jaundiced skin, weakness, and capillary refill of 3 seconds An older adult patient has symptoms of osteoporosis and is being assessed during her annual physical examination. The assessment shows that the patient will require further testing related to a possible exacerbation of her osteoporosis. The nurse should anticipate what diagnostic test? Bone densitometry Hip bone radiography Computed tomography (CT) Magnetic resonance imaging (MRI) An older adult patient has come to the clinic for a regular check-up. The nurses initial inspection reveals an increased thoracic curvature of the patients spine. The nurse should document the presence of which of the following? Scoliosis Epiphyses Lordosis Kyphosis The results of a nurses musculoskeletal examination show an increase in the lumbar curvature of the spine. The nurse should recognize the presence of what health problem? Osteoporosis Kyphosis Lordosis Scoliosis The human body is designed to protect its vital parts. A fracture of what type of bone may interfere with the protection of vital organs? Long bones Short bones Flat bones Irregular bones A patient has just had an arthroscopy performed to assess a knee injury. What nursing intervention should the nurse implement following this procedure? Wrap the joint in a compression dressing. Perform passive range of motion exercises. Maintain the knee in flexion for up to 30 minutes. Apply heat to the knee. While assessing a patient, the patient tells the nurse that she is experiencing rhythmic muscle contractions when the nurse performs passive extension of her wrist. What is this pattern of muscle contraction referred to as? Fasciculations Contractures Effusion Clonus A nurse is caring for an older adult who has been diagnosed with geriatric failure to thrive. This patients prolonged immobility creates a risk for what complication? Muscle clonus Muscle atrophy Rheumatoid arthritis Muscle fasciculations A clinic nurse is caring for a patient with a history of osteoporosis. Which of the following diagnostic tests best allows the care team to assess the patients risk of fracture? Arthrography Bone scan Bone densitometry Arthroscopy A nurse is performing a musculoskeletal assessment of a patient with arthritis. During passive range-of- motion exercises, the nurse hears an audible grating sound. The nurse should document the presence of which of the following? Fasciculations Clonus Effusion Crepitus A child is growing at a rate appropriate for his age. What cells are responsible for the secretion of bone matrix that eventually results in bone growth? Osteoblasts Osteocytes Osteoclasts Lamellae A nurse is explaining a patients decreasing bone density in terms of the balance between bone resorption and formation. What dietary nutrients and hormones play a role in the resorption and formation of adult bones? Select all that apply. Thyroid hormone Growth hormone Estrogen Vitamin B12 Luteinizing hormone Diagnostic tests show that a patients bone density has decreased over the past several years. The patient asks the nurse what factors contribute to bone density decreasing. What would be the nurses best response? For many people, lack of nutrition can cause a loss of bone density. Progressive loss of bone density is mostly related to your genes. Stress is known to have many unhealthy effects, including reduced bone density. Bone density decreases with age, but scientists are not exactly sure why this is the case. The nurse is assessing a patient for dietary factors that may influence her risk for osteoporosis. The nurse should question the patient about her intake of what nutrients? Select all that apply. Calcium Simple carbohydrates Vitamin D Protein Soluble fiber A nurse is performing a nursing assessment of a patient suspected of having a musculoskeletal disorder. What is the primary focus of the nursing assessment with a patient who has a musculoskeletal disorder? Range of motion Activities of daily living Gait Strength A nurses assessment of a teenage girl reveals that her shoulders are not level and that she has one prominent scapula that is accentuated by bending forward. The nurse should expect to read about what health problem in the patients electronic health record? Lordosis Kyphosis Scoliosis Muscular dystrophy A nurse is caring for a patient who has just had an arthroscopy as an outpatient and is getting ready to go home. The nurse should teach the patient to monitor closely for what post-procedure complication? Fever Crepitus Fasciculations Synovial fluid leakage A patient has had a cast placed for the treatment of a humeral fracture. The nurses most recent assessment shows signs and symptoms of compartment syndrome. What is the nurses most appropriate action? Arrange for a STAT assessment of the patients serum calcium levels. Perform active range of motion exercises. Assess the patients joint function symmetrically. Contact the primary care provider immediately. A patient has been experiencing an unexplained decline in knee function and has consequently been scheduled for arthrography. The nurse should teach the patient about what process? Injection of a contrast agent into the knee joint prior to ROM exercises Aspiration of synovial fluid for serologic testing Injection of corticosteroids into the patients knee joint to facilitate ROM Replacement of the patients synovial fluid with a synthetic substitute The nurses musculoskeletal assessment of a patient reveals involuntary twitching of muscle groups. How would the nurse document this observation in the patients chart? Tetany Atony Clonus Fasciculations A patient has been experiencing progressive increases in knee pain and diagnostic imaging reveals a worsening effusion in the synovial capsule. The nurse should anticipate which of the following? Arthrography Knee biopsy Arthrocentesis Electromyography A nurse is caring for a patient who has had a plaster arm cast applied. Immediately postapplication, the nurse should provide what teaching to the patient? The cast will feel cool to touch for the first 30 minutes. The cast should be wrapped snuggly with a towel until the patient gets home. The cast should be supported on a board while drying. The cast will only have full strength when dry. A patient broke his arm in a sports accident and required the application of a cast. Shortly following application, the patient complained of an inability to straighten his fingers and was subsequently diagnosed with Volkmann contracture. What pathophysiologic process caused this complication? Obstructed arterial blood flow to the forearm and hand Simultaneous pressure on the ulnar and radial nerves Irritation of Merkel cells in the patients skin surfaces Uncontrolled muscle spasms in the patients forearm A patient is admitted to the unit in traction for a fractured proximal femur and requires traction prior to surgery. What is the most appropriate type of traction to apply to a fractured proximal femur? Russells traction Dunlops traction Bucks extension traction Cervical head halter A nurse is caring for a patient who is in skeletal traction. To prevent the complication of skin breakdown in a patient with skeletal traction, what action should be included in the plan of care? Apply occlusive dressings to the pin sites. Encourage the patient to push up with the elbows when repositioning. Encourage the patient to perform isometric exercises once a shift. Assess the pin insertion site every 8 hours. A nurse is caring for a patient who is postoperative day 1 right hip replacement. How should the nurse position the patient? Keep the patients hips in abduction at all times. Keep hips flexed at no less than 90 degrees. Elevate the head of the bed to high Fowlers. Seat the patient in a low chair as soon as possible. While assessing a patient who has had knee replacement surgery, the nurse notes that the patient has developed a hematoma at the surgical site. The affected leg has a decreased pedal pulse. What would be the priority nursing diagnosis for this patient? Risk for Infection Risk for Peripheral Neurovascular Dysfunction Unilateral Neglect Disturbed Kinesthetic Sensory Perception A patient was brought to the emergency department after a fall. The patient is taken to the operating room to receive a right hip prosthesis. In the immediate postoperative period, what health education should the nurse emphasize? Make sure you dont bring your knees close together. Try to lie as still as possible for the first few days. Try to avoid bending your knees until next week. Keep your legs higher than your chest whenever you can. A patient with a fractured femur is in balanced suspension traction. The patient needs to be repositioned toward the head of the bed. During repositioning, what should the nurse do? Place slight additional tension on the traction cords. Release the weights and replace them immediately after positioning. Reposition the bed instead of repositioning the patient. Maintain consistent traction tension while repositioning. A patient with a total hip replacement is progressing well and expects to be discharged tomorrow. On returning to bed after ambulating, he complains of a new onset of pain at the surgical site. What is the nurses best action? Administer pain medication as ordered. Assess the surgical site and the affected extremity. Reassure the patient that pain is a direct result of increased activity. Assess the patient for signs and symptoms of systemic infection. The nurse is caring for a patient who underwent a total hip replacement yesterday. What should the nurse do to prevent dislocation of the new prosthesis? Keep the affected leg in a position of adduction. Have the patient reposition himself independently. Protect the affected leg from internal rotation. Keep the hip flexed by placing pillows under the patients knee. A patient is complaining of pain in her casted leg. The nurse has administered analgesics and elevated the limb. Thirty minutes after administering the analgesics, the patient states the pain is unrelieved. The nurse should identify the warning signs of what complication? Subcutaneous emphysema Skin breakdown Compartment syndrome Disuse syndrome The nurse educator on an orthopedic trauma unit is reviewing the safe and effective use of traction with some recent nursing graduates. What principle should the educator promote? Knots in the rope should not be resting against pulleys. Weights should rest against the bed rails. The end of the limb in traction should be braced by the footboard of the bed. Skeletal traction may be removed for brief periods to facilitate the patients independence. The orthopedic surgeon has prescribed balanced skeletal traction for a patient. What advantage is conferred by balanced traction? Balanced traction can be applied at night and removed during the day. Balanced traction allows for greater patient movement and independence than other forms of traction. Balanced traction is portable and may accompany the patients movements. Balanced traction facilitates bone remodeling in as little as 4 days. The nursing care plan for a patient in traction specifies regular assessments for venous thromboembolism (VTE). When assessing a patients lower limbs, what sign or symptom is suggestive of deep vein thrombosis (DVT)? Increased warmth of the calf Decreased circumference of the calf Loss of sensation to the calf Pale-appearing calf An elderly patients hip joint is immobilized prior to surgery to correct a femoral head fracture. What is the nurses priority assessment? The presence of leg shortening The patients complaints of pain Signs of neurovascular compromise The presence of internal or external rotation A nurse is caring for a patient who has had a total hip replacement. The nurse is reviewing health education prior to discharge. Which of the patients statements would indicate to the nurse that the patient requires further teaching? Ill need to keep several pillows between my legs at night. I need to remember not to cross my legs. Its such a habit. The occupational therapist is showing me how to use a sock puller to help me get dressed. I will need my husband to assist me in getting off the low toilet seat at home. A nurse is admitting a patient to the unit who presented with a lower extremity fracture. What signs and symptoms would suggest to the nurse that the patient may have aperoneal nerve injury? Numbness and burning of the foot Pallor to the dorsal surface of the foot Visible cyanosis in the toes Inadequate capillary refill to the toes A patient has suffered a muscle strain and is complaining of pain that she rates at 6 on a 10-point scale. The nurse should recommend what action? Taking an opioid analgesic as ordered Applying a cold pack to the injured site Performing passive ROM exercises Applying a heating pad to the affected muscle A patient has had a brace prescribed to facilitate recovery from a knee injury. What are the potential therapeutic benefits of a brace? Select all that apply. Preventing additional injury Immobilizing prior to surgery Providing support Controlling movement Promoting bone remodeling A physician writes an order to discontinue skeletal traction on an orthopedic patient. The nurse should anticipate what subsequent intervention? Application of a walking boot Application of a cast Education on how to use crutches Passive range of motion exercises A patient has just begun been receiving skeletal traction and the nurse is aware that muscles in the patients affected limb are spastic. How does this change in muscle tone affect the patients traction prescription? Traction must temporarily be aligned in a slightly different direction. Extra weight is needed initially to keep the limb in proper alignment. A lighter weight should be initially used. Weight will temporarily alternate between heavier and lighter weights. A nurse is caring for a patient receiving skeletal traction. Due to the patients severe limits on mobility, the nurse has identified a risk for atelectasis or pneumonia. What intervention should the nurse provide in order to prevent these complications? Perform chest physiotherapy once per shift and as needed. Teach the patient to perform deep breathing and coughing exercises. Administer prophylactic antibiotics as ordered. Administer nebulized bronchodilators and corticosteroids as ordered. A patient is scheduled for a total hip replacement and the surgeon has explained the risks of blood loss associated with orthopedic surgery. The risk of blood loss is the indication for which of the following actions? Use of a cardiopulmonary bypass machine Postoperative blood salvage Prophylactic blood transfusion Autologous blood donation The nurse is helping to set up Bucks traction on an orthopedic patient. How often should the nurse assess circulation to the affected leg? Within 30 minutes, then every 1 to 2 hours Within 30 minutes, then every 4 hours Within 30 minutes, then every 8 hours Within 30 minutes, then every shift A nurse is caring for a patient in skeletal traction. In order to prevent bony fragments from moving against one another, the nurse should caution the patient against which of the following actions? Shifting ones weight in bed Bearing down while having a bowel movement Turning from side to side Coughing without splinting A nurse is caring for an older adult patient who is preparing for discharge following recovery from a total hip replacement. Which of the following outcomes must be met prior to discharge? Patient is able to perform ADLs independently. Patient is able to perform transfers safely. Patient is able to weight-bear equally on both legs. Patient is able to demonstrate full ROM of the affected hip. A patient has recently been admitted to the orthopedic unit following total hip arthroplasty. The patient has a closed suction device in place and the nurse has determined that there were 320 mL of output in the first 24 hours. How should the nurse best respond to this assessment finding? Inform the primary care provider promptly. Document this as an expected assessment finding. Limit the patients fluid intake to 2 liters for the next 24 hours. Administer a loop diuretic as ordered. A 91-year-old patient is slated for orthopedic surgery and the nurse is integrated gerontologic considerations into the patients plan of care. What intervention is most justified in the care of this patient? Administration of prophylactic antibiotics Total parenteral nutrition (TPN) Use of a pressure-relieving mattress Use of a Foley catheter until discharge A nurse is providing a class on osteoporosis at the local seniors center. Which of the following statements related to osteoporosis is most accurate? Osteoporosis is categorized as a disease of the elderly. A nonmodifiable risk factor for osteoporosis is a persons level of activity. Secondary osteoporosis occurs in women after menopause. Slow discontinuation of corticosteroid therapy can halt the progression of the osteoporosis. A nurse is reviewing the pathophysiology that may underlie a patients decreased bone density. What hormone should the nurse identify as inhibiting bone resorption and promoting bone formation? Estrogen Parathyroid hormone (PTH) Calcitonin Progesterone An older adult womans current medication regimen includes alendronate (Fosamax). What outcome would indicate successful therapy? Increased bone mass Resolution of infection Relief of bone pain Absence of tumor spread A nursing educator is reviewing the risk factors for osteoporosis with a group of recent graduates. What risk factor of the following should the educator describe? Recurrent infections and prolonged use of NSAIDs High alcohol intake and low body mass index Small frame, female gender, and Caucasian ethnicity Male gender, diabetes, and high protein intake An elderly female with osteoporosis has been hospitalized. Prior to discharge, when teaching the patient, the nurse should include information about which major complication of osteoporosis? Bone fracture Loss of estrogen Negative calcium balance Dowagers hump A nurse admits a patient who has a fracture of the nose that has resulted in a skin tear and involvement of the mucous membranes of the nasal passages. The orthopedic nurse is aware that this description likely indicates which type of fracture? Compression Compound Impacted Transverse A patient has sustained a long bone fracture and the nurse is preparing the patients care plan. Which of the following should the nurse include in the care plan? Administer vitamin D and calcium supplements as ordered. Monitor temperature and pulses of the affected extremity. Perform passive range of motion exercises as tolerated. Administer corticosteroids as ordered. A nurse is writing a care plan for a patient admitted to the emergency department (ED) with an open fracture. The nurse will assign priority to what nursing diagnosis for a patient with an open fracture of the radius? Risk for Infection Risk for Ineffective Role Performance Risk for Perioperative Positioning Injury Risk for Powerlessness A nurse is caring for a patient who has suffered an unstable thoracolumbar fracture. Which of the following is the priority during nursing care? Preventing infection Maintaining spinal alignment Maximizing function Preventing increased intracranial pressure Six weeks after an above-the-knee amputation (AKA), a patient returns to the outpatient office for a routine postoperative checkup. During the nurses assessment, the patient reports symptoms of phantom pain. What should the nurse tell the patient to do to reduce the discomfort of the phantom pain? Apply intermittent hot compresses to the area of the amputation. Avoid activity until the pain subsides. Take opioid analgesics as ordered. Elevate the level of the amputation site. The orthopedic nurse should assess for signs and symptoms of Volkmanns contracture if a patient has fractured which of the following bones? Femur Humerus Radial head Clavicle A nurse is performing a shift assessment on an elderly patient who is recovering after surgery for a hip fracture. The nurse notes that the patient is complaining of chest pain, has an increased heart rate, and increased respiratory rate. The nurse further notes that the patient is febrile and hypoxic, coughing, and producing large amounts of thick, white sputum. The nurse recognizes that this is a medical emergency and calls for assistance, recognizing that this patient is likely demonstrating symptoms of what complication? Avascular necrosis of bone Compartment syndrome Fat embolism syndrome Complex regional pain syndrome A young patient is being treated for a femoral fracture suffered in a snowboarding accident. The nurses most recent assessment reveals that the patient is uncharacteristically confused. What diagnostic test should be performed on this patient? Electrolyte assessment Electrocardiogram Arterial blood gases Abdominal ultrasound Which of the following is the most appropriate nursing intervention to facilitate healing in a patient who has suffered a hip fracture? Administer analgesics as required. Place a pillow between the patients legs when turning. Maintain prone positioning at all times. Encourage internal and external rotation of the affected leg. A nurse is planning the care of an older adult patient who will soon be discharged home after treatment for a fractured hip. In an effort to prevent future fractures, the nurse should encourage which of the following? Select all that apply. Regular bone density testing A high-calcium diet Use of falls prevention precautions Use of corticosteroids as ordered Weight-bearing exercise An emergency department patient is diagnosed with a hip dislocation. The patients family is relieved that the patient has not suffered a hip fracture, but the nurse explains that this is still considered to be a medical emergency. What is the rationale for the nurses statement? The longer the joint is displaced, the more difficult it is to get it back in place. The patients pain will increase until the joint is realigned. Dislocation can become permanent if the process of bone remodeling begins. Avascular necrosis may develop at the site of the dislocation if it is not promptly resolved. The surgical nurse is admitting a patient from postanesthetic recovery following the patients below-the- knee amputation. The nurse recognizes the patients high risk for postoperative hemorrhage and should keep which of the following at the bedside? A tourniquet A syringe preloaded with vitamin K A unit of packed red blood cells, placed on ice A dose of protamine sulfate A 25-year-old man is involved in a motorcycle accident and injures his arm. The physician diagnoses the man with an intra-articular fracture and splints the injury. The nurse implements the teaching plan developed for this patient. What sequela of intra-articular fractures should the nurse describe regarding this patient? Post-traumatic arthritis Fat embolism syndrome (FES) Osteomyelitis Compartment syndrome A patient is admitted to the orthopedic unit with a fractured femur after a motorcycle accident. The patient has been placed in traction until his femur can be rodded in surgery. For what early complications should the nurse monitor this patient? Select all that apply. Systemic infection Complex regional pain syndrome Deep vein thrombosis Compartment syndrome Fat embolism A patient has come to the orthopedic clinic for a follow-up appointment 6 weeks after fracturing his ankle. Diagnostic imaging reveals that bone union is not taking place. What factor may have contributed to this complication? Inadequate vitamin D intake Bleeding at the injury site Inadequate immobilization Venous thromboembolism An older adult patient has fallen in her home and is brought to the emergency department by ambulance with a suspected fractured hip. X-rays confirm a fracture of the left femoral neck. When planning assessments during the patients presurgical care, the nurse should be aware of the patients heightened risk of what complication? Osteomyelitis Avascular necrosis Phantom pain Septicemia A patient is being treated for a fractured hip and the nurse is aware of the need to implement interventions to prevent muscle wasting and other complications of immobility. What intervention best addresses the patients need for exercise? Performing gentle leg lifts with both legs Performing massage to stimulate circulation Encouraging frequent use of the overbed trapeze Encouraging the patient to log roll side to side once per hour A patient who has had an amputation is being cared for by a multidisciplinary rehabilitation team. What is the primary goal of this multidisciplinary team? Maximize the efficiency of care Ensure that the patients health care is holistic Facilitate the patients adjustment to a new body image Promote the patients highest possible level of function The nurse is providing care for a patient who has had a below-the-knee amputation. The nurse enters the patients room and finds him resting in bed with his residual limb supported on pillow. What is the nurses most appropriate action? Inform the surgeon of this finding. Explain the risks of flexion contracture to the patient. Transfer the patient to a sitting position. Encourage the patient to perform active ROM exercises with the residual limb. A patient has returned to the postsurgical unit from the PACU after an above-the-knee amputation of the right leg. Results of the nurses initial postsurgical assessment were unremarkable but the patient has called out. The nurse enters the room and observes copious quantities of blood at the surgical site. What should be the nurses initial action? Apply a tourniquet. Elevate the residual limb. Apply sterile gauze. Call the surgeon. A patient who has undergone a lower limb amputation is preparing to be discharged home. What outcome is necessary prior to discharge? Patient can demonstrate safe use of assistive devices. Patient has a healed, nontender, nonadherent scar. Patient can perform activities of daily living independently. Patient is free of pain. An older adult patient experienced a fall and required treatment for a fractured hip on the orthopedic unit. Which of the following are contributory factors to the incidence of falls and fractured hips among the older adult population? Select all that apply. Loss of visual acuity Adverse medication effects Slowed reflexes Hearing loss Muscle weakness The nurse is conducting health screening for osteoporosis. Which client is at greatest risk of developing this disorder? A 36-year-old man who has asthma A 25-year-old woman who runs A 70-year-old man who consumes excess alcohol A sedentary 65-year-old woman who smokes cigarettes The nurse is evaluating a client in skeletal traction. When evaluating the pin sites, the nurse would be most concerned with which finding? Redness around the pin sites Pain on palpation at the pin sites Thick, yellow drainage from the pin sites Clear, watery drainage from the pin sites The nurse is assessing the casted extremity of a client. Which sign is indicative of infection? Dependent edema Diminished distal pulse Presence of a “hot spot” on the cast Coolness and pallor of the extremity A client has sustained a closed fracture and has just had a cast applied to the affected arm. The client is complaining of intense pain. The nurse elevates the limb, applies an ice bag, and administers an analgesic, with little relief. Which problem may be causing this pain? Infection under the cast Anxiety of the client Impaired tissue perfusion Recent occurrence of the fracture The nurse is caring for a client being treated for fat embolus after multiple fractures. Which data would the nurse evaluate as the most favorable indication of resolution of the fat embolus? Clear mental status Minimal dyspnea Oxygen saturation of 85% Arterial oxygen level of 78mmHg The nurse has conducted teaching with a client in an arm cast about the signs and symptoms of compartment syndrome. The nurse determines that the client understands the information if the client states that he or she should report which early symptom of compartment syndrome? Cold, bluish-colored fingers Numbness and tingling in the fingers Pain that increases when the arm is dependent Pain that is out of proportion to the severity of the fracture A client is complaining of low back pain that radiates down the left posterior thigh. The nurse should ask the client if the pain is worsened or aggravated by which factor? Bed rest Ibuprofen Bending or lifting Application of heat The nurse is caring for a client who has had spinal fusion, with insertion of hardware. The nurse would be most concerned with which assessment finding? Temperature of 101.6°F (38.7°C) orally Complaints of discomfort during repositioning Old bloody drainage outlined on the surgical dressing Discomfort during coughing and deep-breathing exercises The nurse is caring for a client with a diagnosis of gout. Which laboratory value would the nurse expect to note in the client? Calcium level of 9.0 mg/dL Uric acid level of 9.0 mg/dL Potassium level of 4.1 mEq/L Phosphorus level of 3.1 mg/dL A client with a hip fracture asks the nurse about Buck's (extension) traction that is being applied before surgery and what is involved. The nurse should provide which information to the client? Allows bony healing to begin before surgery and involves pins and screws Provides rigid immobilization of the fracture site and involves pulleys and wheels Lengthens the fractured leg to prevent severing of blood vessels and involves pins and screws Provides comfort by reducing muscle spasms, provides fracture immobilization, and involves pulleys and wheels The nurse is assigned to care for a client in traction. The nurse creates a plan of care for the client and should include which action in the plan? Ensure that the knots are at the pulleys. Check the weights to ensure that they are off of the floor. Ensure that the head of the bed is kept at a 45- to 90-degree angle. Monitor the weights to ensure that they are resting on a firm surface. The nurse is creating a plan of care for a client in skin traction. The nurse should monitor for which priority finding in this client? Urinary incontinence Signs of skin breakdown Presence of bowel sounds Signs of infection around pin sites The nurse is caring for a client in skeletal leg traction with an overbed frame. Which nursing intervention will best assist the client with self-positioning in bed? Use the assistance of four nurses to reposition the client. Place a draw sheet on the mattress for pulling the client up in bed. Place a trapeze on the bed frame to provide a means for the client to lift the hips off the bed. Encourage the client to push with the unaffected leg on the bed mattress to help with repositioning. The nurse is caring for the client who has skeletal traction applied to the left leg. The client complains of severe left leg pain. The nurse checks the client's alignment in bed and notes that proper alignment is maintained. Which is the priority nursing action? Provide pin care Medicate the client Call HCP Remove weight of traction system A client who has been taking high doses of acetylsalicylic acid to relieve pain from osteoarthritis now has more generalized joint pain and an elevated temperature. The nurse should assess for which complication to determine whether the client has other signs of aspirin toxicity? Diarrhea Constipation Double vision Ringing of the ears The nurse is developing a plan of care for a client in Buck's traction. The plan of care should include assessing the client for which finding indicating a complication associated with the use of this type of traction? Hypotension Weak pedal pulses Redness at pin sites Drainage at pin sites The nurse is caring for a client with a radius fractured across the shaft and bone splintered into fragments. Information about which type of fracture should be included by the nurse in the client's education? Simple fracture Greenstick fracture Compound fracture Comminuted fracture A male client arrives in the hospital emergency department and tells the nurse that he twisted his ankle while jogging. The client is seen by the health care provider and is diagnosed with a sprained ankle. The nurse provides instructions to the client regarding home care for the injury. Which statement, if made by the client, would indicate an understanding of appropriate care measures for the next 24 hours? "I should place hot packs on my ankle." "I should wrap my ankle with blankets." "I should elevate my foot above the level of the heart." “I should try to ambulate at least 10 minutes out of every hour." The nurse is performing a neurovascular assessment on a client with a cast on the left lower leg. The nurse notes the presence of edema in the foot below the cast. The nurse should make which interpretation about this finding? Arterial insufficiency Impaired venous return Impaired arterial circulation Presence of an infection The nurse is caring for a client with a long bone fracture at risk for fat embolism. The nurse specifically monitors for the earliest signs of this complication by performing an assessment of which item(s)? Client’s mobility status Renal and endocrine systems Cardiovascular and renal systems Neurological and respiratory systems The nurse is caring for a client who was just admitted to the hospital with a diagnosis of a fractured right hip sustained from a fall 5 hours earlier. The nurse creates a plan of care for the client and includes interventions related to monitoring for signs of fat embolism. Which findings should be listed in the care plan as a sign/symptom of fat embolism? Fever and chills Dyspnea and chest pain External rotation of the right leg Pallor, paresthesia, pulselessness of right lower leg Which assessment findings should the nurse identify as early signs of possible fat embolism? Decreased heart rate and increased restlessness Decreased heart rate and decreased respiratory rate Increased heart rate and adventitious breath sounds Increased heart rate and increased oxygen saturation The nurse should suspect impairment with the neurovascular status of the client's casted extremity if which findings are noted? Select all that apply. Capillary refill is less than 3 seconds Pulses present and with swollen, pink fingers. Client reports severe, deep, unrelenting pain Client reports pain as nurse assess finger movement Client reports numbness and tingling sensations in the fingers. A client has had surgery to repair a fractured left hip. When repositioning the client from side to side in the bed, what should the nurse plan to use as the most important item for this maneuver? Bed pillow Abductor splint Adductor splint Overhead trapeze A client with a 4-day-old lumbar vertebral fracture is experiencing muscle spasms. Which are interventions to aid the client in relieving the spasm? Select all that apply. Ice Heat Analgesics Muscle relaxers Intermittent traction The nurse is planning discharge teaching for a client diagnosed and treated for compartment syndrome. Which information should the nurse include in the teaching? "A bone fragment has injured the nerve supply in the area." "An injured artery caused impaired arterial perfusion through the compartment." "Bleeding and swelling caused increased pressure in an area that couldn't expand." "The fascia expanded with injury, causing pressure on underlying nerves and muscles." The nurse is repositioning a client who has been returned to the nursing unit after internal fixation of a fractured right hip with a femoral head replacement. The nurse should use which method to reposition the client? A trochanter roll to prevent abduction during turning A pillow to keep the right leg abducted during turning A pillow to keep the right leg adducted during turning A trochanter roll to prevent external rotation during turning A client has been placed in Buck's extension traction. The nurse can provide for countertraction to reduce shear and friction by performing which action? Using a footboard Providing an overhead trapeze Slightly elevating the foot of the bed Slightly elevating the head of the bed The nurse is reviewing the postprocedure plan of care formulated by a nursing student for a client scheduled for a bone biopsy. The nurse determines that the student needs additional information about postprocedure care if which inaccurate intervention is documented? Elevating the limb Monitoring vital signs every 4 hours Administering opioid analgesics intramuscularly Monitoring the biopsy site for swelling, bleeding, or hematoma A client seeks treatment in the hospital emergency department for a lower leg injury. Deformity of the lower portion of the leg is evident, and the injured leg appears shorter than the other. The area is painful, swollen, and beginning to become ecchymotic. The nurse interprets that this client has experienced which injury? Strain Sprain Fracture Contusion A client is admitted to the nursing unit after a left below-the-knee amputation after a crush injury to the foot and lower leg. The client tells the nurse, "I think I'm going crazy. I can feel my left foot itching." How should the nurse interpret this client statement? A normal response that indicates the presence of phantom limb pain A normal response that indicates the presence of phantom limb sensation An abnormal response that indicates that the client is in denial about the limb loss An abnormal response that indicates that the client needs more psychological support A hospitalized client has been diagnosed with osteomyelitis of the left tibia. The nurse determines that this condition is most likely a result of which event in the client's recent history? Sprained left ankle Decreased calcium intake Open trauma to the left leg Starting to smoke cigarettes An older client is diagnosed with osteoporosis. The nurse teaches the client about self-care measures, knowing that the client is most at risk for which problem as a result of this disorder of the bones? Anemia Fractures Infection Muscle spasms A client has been diagnosed with osteomalacia, or adult rickets. The nurse should anticipate that the health care provider will include a new prescription for which vitamin supplement? Vitamin A Vitamin D Vitamin E Vitamin K A client is complaining of knee pain. The knee is swollen, reddened, and warm to the touch. The nurse interprets that the client's signs and symptoms are compatible with which conditions? Select all that apply. Infection Recent injury Inflammation Degenerative disease Developmental retardation A client has undergone fasciotomy to treat compartment syndrome of the leg. The nurse should anticipate that which type of wound care to the fasciotomy site will be prescribed? Dry sterile dressings Hydrocolloid dressings Moist sterile saline dressings One-half strength povidone-iodine dressings The nurse is assessing a client with a shortened, adducted, and externally rotated left leg. On the basis of this finding, which condition should the nurse anticipate? Fractured knee Dislocated knee Fracture of the femoral neck Fracture of the midshaft of the femur A client who has had a total knee arthroplasty tells the nurse that there is pain with extension of the knee. The nurse should perform which action? Administer an analgesic. Notify the health care provider. Immobilize the knee temporarily. Put the client's knee through full passive range of motion. The nurse is caring for a client admitted for a herniated intervertebral lumbar disk who is complaining about stabbing pain radiating to the lower back and the right buttock. The nurse determines that the client's signs/symptoms are most likely due to which condition? Pressure on the spinal cord Pressure on the spinal nerve root Muscle spasm in the area of the herniated disk Excess cerebrospinal fluid production in the area The nurse has a prescription to place a client with a herniated lumbar intervertebral disk on bed rest in Williams' position to minimize the pain. The nurse should put the bed in what position? Flat with the knees raised In high Fowler's position, with the foot of the bed flat In semi Fowler's position, with the foot of the bed flat In semi Fowler's position, with the knees slightly flexed The nurse in the hospital emergency department is assessing a client with an open leg fracture. The nurse should inquire about the last time the client had which done? Tuberculin test Tetanus vaccine Chest radiograph Physical examination A client has just been admitted to the hospital with a fractured femur and pelvic fractures. The nurse should plan to carefully monitor the client for which signs/symptoms? Fever and bradycardia Fever and hypertension Tachycardia and hypotension Bradycardia and hypertension The nurse is obtaining a health history from a client and is assessing for risk factors associated with osteoporosis. The nurse would be most concerned if which data were obtained? Select all that apply. The client reports that she doesn't exercise much at all. The client reports that she smokes a few cigarettes a day The client reports that she is taking phenytoin to treat a seizure disorder The client reports that she consumes calcium and vitamin foods and supplements daily. The client reports that she takes a daily low dose of prednisone to treat a chronic respiratory condition. The home health nurse visits a client who is having an acute attack of gout. The nurse determines that the client needs further instruction regarding the treatment of gout if the client states to take which action? Restricting fluids Maintaining bed rest Eating a low-purine diet Taking NSAIDs The clinic nurse is performing an assessment on a client with a diagnosis of rheumatoid arthritis (RA). The nurse checks for which assessment finding that is associated with RA? Age of onset is generally 65 years of age or older Complaints of pain that is more severe after activity Systemic symptoms such as fatigue, anorexia, and weight loss Joint pain is asymmetrical and associated with past injuries to the joint The nurse is performing an assessment on a client after a closed reduction of a fractured right humerus and application of a plaster cast. To assess for signs of compartment syndrome, the nurse should perform which action? Assess the client's cognitive level. Assess the temperature of the cast. Monitor for the presence of drainage or odors on or beneath the cast. Assess capillary refill, temperature, color, and amount of pain in the right hand. The nurse is caring for a client admitted for a fractured hip status post fall at home. On assessment of the client's affected lower extremity, which signs/symptoms would most likely be noted? Shortening and abduction Abduction and internal rotation Shortening and internal rotation Shortening and external rotation The nurse is preparing a plan of care for a client who is scheduled to return from the recovery room after a left total knee arthroplasty. The nurse includes in the plan of care to assess the client's neurovascular status the monitoring of which parameter? The pain level of the client Blood pressure and respiratory rate Capillary refill, sensation, color, and pulse of the left foot The range of motion of the left knee when a continuous passive motion machine is used The nurse is preparing instructions for a client who is diagnosed with osteomalacia. Which information should the nurse include in the teaching? "Avoid exposure to sunlight." "Avoid weight-bearing exercise." "Ensure adequate intake of vitamin D fortified foods. "Osteomalacia and osteoporosis are interchangeable terms." The nurse provides instructions to a client diagnosed with osteoporosis. Education about prevention of which complication is the most important? Fractures Weight loss Hypocalcemia Muscle atrophy The nurse is caring for a client diagnosed with osteomyelitis. Which mechanism of the disease process can result in necrosis of the bone? Devascularization Infection of the bone Decreased bone mass Decreased bone density The nurse is gathering subjective and objective data from a client with a diagnosis of suspected rheumatoid arthritis (RA). The nurse would expect to note which early signs and symptoms of RA? Select all that apply. Fatigue Weight gain Restlessness Morning stiffness Pain with movement only The nurse is performing a musculoskeletal assessment of an immobile client for disuse osteoporosis. Which should the nurse assess to obtain the best information about the bone remodeling process? Vitamin C Vitamin A Calcitonin Thyroid hormone The nurse is planning discharge teaching for a client admitted with a fracture of the leg that does not extend all the way through the bone. The nurse should include information about which types of fractures? Open Displaced Complete Incomplete A client has been diagnosed with subluxation of the shoulder. The nurse explains to the client that which injury has occurred to the joint? It is strained It is contused It is completely dislocated It is incompletely dislocated. A client who suffered a contusion after being hit on the thigh with a racquetball has been told that it is acceptable to apply heat to the area 72 hours after the injury. The nurse explains the rationale for this treatment to the client, stating that which is the physiological benefit of heat in this case? It induces muscle relaxation It prevents abscess formation. It reduces the likelihood of strain as a complication. It promotes reabsorption of blood from the injured tissue. The nurse is caring for a client with a swollen left ankle who has difficulty bearing weight on this leg and states that he twisted his ankle. Based on these findings, which condition does the nurse determine the client has most likely experienced? Strain Sprain Fracture Contusion Which tests can be used to diagnose gout? Select all that apply. Renal ultrasound Serum uric acid level Bone marrow biopsy Urinalysis with culture Synovial fluid aspiration 24-hour urine uric acid level The nurse is preparing a client for an arthroscopy of the knee. When providing teaching, which information is essential for the nurse to include? It will drain fluid that has accumulated below the knee. It is used to obtain a muscle biopsy for pathology studies It will determine the degree of range of motion of the joint. It will identify if there is joint injury and provide a route for surgical repair if indicated The nurse is creating a plan of care for a client in skin traction. Which frequent assessment should the nurse include in the plan as a priority intervention? Urinary incontinence Signs of skin breakdown Presence of bowel sounds Signs of infection around the pin sites The nurse is caring for a client with osteoarthritis. The nurse performs an assessment knowing that which clinical manifestations are associated with the disorder? Select all that apply. Elevated white blood cell count A decreased sedimentation rate Joint pain that diminishes after rest Elevated antinuclear antibody levels Joint pain that intensifies with activity The nurse is caring for a client diagnosed with osteomyelitis. Which data noted in the client's record are supportive of this diagnosis? Select all that apply.t Pyrexia Elevated potassium level Elevated white blood cell count Elevated erythrocyte sedimentation rate Bone scan impression indicative of infection A client was admitted to the hospital 2 hours ago following multiple fractures to the pelvis and soft tissue injury to the abdomen. Diagnostic studies have ruled out perforation of abdominal organs. The nurse places highest priority on monitoring this client for which changes in vital signs? Fever, bradycardia Fever, hypertension Tachycardia, hypotension Bradycardia, hypertension The nurse is caring for a client who had surgery to repair a fractured left-sided hip using a posterior approach. In implementing hip precautions, which action should the nurse teach the client to avoid? Crossing legs at the ankle Using an elevated toilet seat Placing a pillow between the legs Keeping the legs abducted from the midline Neurological & Cognitive-Perceptual Disorders The clinic nurse caring for a patient with Parkinson's disease notes that the patient has been taking levodopa and carbidopa (Sinemet) for 7 years. For what common side effect of Sinemet would the nurse assesses this patient? Pruritus Dyskinesia Lactose intolerance Diarrhea The nurse is caring for a boy who has muscular dystrophy. When planning assistance with the patients ADLs, what goal should the nurse prioritize? Promoting the patients recovery from the disease Maximizing the patients level of function Ensuring the patients adherence to treatment Fostering the family’s’ participation in care A patient with Parkinson’s disease is undergoing a swallowing assessment because she has recently developed adventitious lung sounds. The patients nutritional needs should be met by what method? Total parenteral nutrition (TPN) Provision of a low-residue diet Semisolid food with thick liquids Minced foods and a fluid restriction While assessing the patient at the beginning of the shift, the nurse inspects a surgical dressing covering the operative site after the patients cervical discectomy. The nurse notes that the drainage is 75% saturated with serosanguineous discharge. What is the nurses most appropriate action? Page the physician and report this sign of infection. Reinforce the dressing and reassess in 1 to 2 hours. Reposition the patient to prevent further hemorrhage. Inform the surgeon of the possibility of a dural leak. A patient has just been diagnosed with Parkinson's disease and the nurse is planning the patients subsequent care for the home setting. What nursing diagnosis should the nurse address when educating the patients family? Risk for infection Impaired spontaneous ventilation Unilateral neglect Risk for injury A male patient with a metastatic brain tumor is having a generalized seizure and begins vomiting. What should the nurse do first? Perform oral suctioning. Page the physician. Insert a tongue depressor into the patients mouth. Turn the patient on his side. A patient newly diagnosed with a cervical disk herniation is receiving health education from the clinic nurse. What conservative management measures should the nurse teach the patient to implement? Perform active ROM exercises three times daily. Sleep on a firm mattress. Apply cool compresses to the back of the neck daily. Wear the cervical collar for at least 2 hours at a time. A patient has just returned to the unit from the PACU after surgery for a tumor within the spine. The patient complains of pain. When positioning the patient for comfort and to reduce injury to the surgical site, the nurse will position to patient in what position? In the high Fowlers position In a flat side-lying position In the Trendelenberg position In the reverse Trendelenberg position An older adult has encouraged her husband to visit their primary care provider, stating that she is concerned that he may have Parkinson's disease. Which of the wifes descriptions of her husbands health and function is most suggestive of Parkinson's disease? Lately he seems to move far more slowly than he ever has in the past. He often complains that his joints are terribly stiff when he wakes up in the morning. He is forgotten the names of some people that weve known for years. He is losing weight even though he has a ravenous appetite. A patient who was diagnosed with Parkinson's disease several months ago recently began treatment with levodopa-carbidopa. The patient and his family are excited that he has experienced significant symptom relief. The nurse should be aware of what implication of the patients medication regimen? The patient is in a honeymoon period when adverse effects of levodopa-carbidopa are not yet evident. Benefits of levodopa-carbidopa do not peak until 6 to 9 months after the initiation of treatment. The patients temporary improvement in status is likely unrelated to levodopa-carbidopa. Benefits of levodopa-carbidopa often diminish after 1 or 2 years of treatment. The nurse caring for a patient diagnosed with Parkinson's disease has prepared a plan of care that would include what goal? Promoting effective communication Controlling diarrhea Preventing cognitive decline Managing choreiform movements The nurse is caring for a patient diagnosed with Parkinson's disease. The patient is having increasing problems with rising from the sitting to the standing position. What should the nurse suggest to the patient to use that will aid in getting from the sitting to the standing position as well as aid in improving bowel elimination? Use of a bedpan Use of a raised toilet seat Sitting quietly on the toilet every 2 hours Following the outlined bowel program A patient with Parkinson's disease is experiencing episodes of constipation that are becoming increasingly frequent and severe. The patient states that he has been achieving relief for the past few weeks by using OTC laxatives. How should the nurse respond? Its important to drink plenty of fluids while you're taking laxatives. Make sure that you supplement your laxatives with a nutritious diet. Lets explore other options, because laxatives can have side effects and create dependency. You should ideally be using herbal remedies rather than medications to promote bowel function. The nurse is caring for a patient who is scheduled for a cervical discectomy the following day. During health education, the patient should be made aware of what potential complications? Vertebral fracture Hematoma at the surgical site Scoliosis Renal trauma The nurse responds to the call light of a patient who has had a cervical diskectomy earlier in the day. The patient states that she is having severe pain that had a sudden onset. What is the nurses most appropriate action? Palpate the surgical site. Remove the dressing to assess the surgical site. Call the surgeon to report the patients pain. Administer a dose of an NSAID. A nurse is planning discharge education for a patient who underwent a cervical diskectomy. What strategies would the nurse assess that would aid in planning discharge teaching? Care of the cervical collar Technique for performing neck ROM exercises Home assessment of ABGs Techniques for restoring nerve function A patient is receiving ongoing nursing care for the treatment of Parkinson's disease. When assessing this patients gait, what finding is most closely associated with this health problem? Spastic hemiparesis gait Shuffling gait Rapid gait Steppage gait A patient is being admitted to the neurologic ICU following an acute head injury that has resulted in cerebral edema. When planning this patients care, the nurse would expect to administer what priority medication? Hydrochlorothiazide (HydroDIURIL) Furosemide (Lasix) Mannitol (Osmitrol) Spirolactone (Aldactone) The nurse is providing care for a patient who is unconscious. What nursing intervention takes highest priority? Maintaining accurate records of intake and output Maintaining a patent airway Inserting a nasogastric (NG) tube as ordered Providing appropriate pain control The nurse is caring for a patient in the ICU who has a brain stem herniation and who is exhibiting an altered level of consciousness. Monitoring reveals that the patients mean arterial pressure (MAP) is 60 mm Hg with an intracranial pressure (ICP) reading of 5 mm Hg. What is the nurses most appropriate action? Position the patient in the high Fowlers position as tolerated. Administer osmotic diuretics as ordered. Participate in interventions to increase cerebral perfusion pressure. Prepare the patient for craniotomy. The nurse is caring for a patient who is postoperative following a craniotomy. When writing the plan of care, the nurse identifies a diagnosis of deficient fluid volume related to fluid restriction and osmotic diuretic use. What would be an appropriate intervention for this diagnosis? Change the patients position as indicated. Monitor serum electrolytes. Maintain NPO status. Monitor arterial blood gas (ABG) values. A patient with a documented history of seizure disorder experiences a generalized seizure. What nursing action is most appropriate? Restrain the patient to prevent injury. Open the patients jaws to insert an oral airway. Place patient in high Fowlers position. Loosen the patients restrictive clothing. A patient who has been on long-term phenytoin (Dilantin) therapy is admitted to the unit. In light of the adverse of effects of this medication, the nurse should prioritize which of the following in the patients plan of care? Monitoring of pulse oximetry Administration of a low-protein diet Administration of thorough oral hygiene Fluid restriction as ordered While completing a health history on a patient who has recently experienced a seizure, the nurse would assess for what characteristic associated with the postictal state? Epileptic cry Confusion Urinary incontinence Body rigidity A patient with increased ICP has a ventriculostomy for monitoring ICP. The nurses most recent assessment reveals that the patient is now exhibiting nuchal rigidity and photophobia. The nurse would be correct in suspecting the presence of what complication? Encephalitis CSF leak Meningitis Catheter occlusion The nurse is participating in the care of a patient with increased ICP. What diagnostic test is contraindicated in this patients treatment? Computed tomography (CT) scan Lumbar puncture Magnetic resonance imaging (MRI) Venous Doppler studies The nurse is caring for a patient who is in status epilepticus. What medication does the nurse know may be given to halt the seizure immediately? Intravenous phenobarbital (Luminal) Intravenous diazepam (Valium) Oral lorazepam (Ativan) Oral phenytoin (Dilantin The nurse has created a plan of care for a patient who is at risk for increased ICP. The patients care plan should specify monitoring for what early sign of increased ICP? Disorientation and restlessness Decreased pulse and respirations Projectile vomiting Loss of corneal reflex The neurologic ICU nurse is admitting a patient following a craniotomy using the supratentorial approach. How should the nurse best position the patient? Position the patient supine. Maintain head of bed (HOB) elevated at 30 to 45 degrees. Position patient in prone position. Maintain bed in Trendelenberg position. A clinic nurse is caring for a patient diagnosed with migraine headaches. During the patient teaching session, the patient questions the nurse regarding alcohol consumption. What would the nurse be correct in telling the patient about the effects of alcohol? Alcohol causes hormone fluctuations. Alcohol causes vasodilation of the blood vessels. Alcohol has an excitatory effect on the CNS. Alcohol diminishes endorphins in the brain. A patient has developed diabetes insipidus after having increased ICP following head trauma. What nursing assessment best addresses this complication? Vigilant monitoring of fluid balance Continuous BP monitoring Serial arterial blood gases (ABGs) Monitoring of the patients airway for patency What should the nurse suspect when hourly assessment of urine output on a patient post-craniotomy exhibits a urine output from a catheter of 1,500 mL for two consecutive hours? Cushing syndrome Syndrome of inappropriate antidiuretic hormone (SIADH) Adrenal crisis Diabetes insipidus During the examination of an unconscious patient, the nurse observes that the patients pupils are fixed and dilated. What is the most plausible clinical significance of the nurses finding? It suggests onset of metabolic problems. It indicates paralysis on the right side of the body. It indicates paralysis of cranial nerve X. It indicates an injury at the midbrain level. The nurse caring for a patient in a persistent vegetative state is regularly assessing for potential complications. Complications of neurologic dysfunction for which the nurse should assess include which of the following? Select all that apply. Contractures Hemorrhage Pressure ulcers Venous thromboembolism Pneumonia The nurse is caring for a patient with a brain tumor. What drug would the nurse expect to be ordered to reduce the edema surrounding the tumor? Solumedrol Dextromethorphan Dexamethasone Furosemide The nurse is caring for a patient who sustained a moderate head injury following a bicycle accident. The nurses most recent assessment reveals that the patients respiratory effort has increased. What is the nurses most appropriate response? Inform the care team and assess for further signs of possible increased ICP. Administer bronchodilators as ordered and monitor the patients LOC. Increase the patients bed height and reassess in 30 minutes. Administer a bolus of normal saline as ordered. A patient has experienced a seizure in which she became rigid and then experienced alternating muscle relaxation and contraction. What type of seizure does the nurse recognize? Unclassified seizure Absence seizure Generalized seizure Focal seizure When caring for a patient with increased ICP the nurse knows the importance of monitoring for possible secondary complications, including syndrome of inappropriate antidiuretic hormone (SIADH). What nursing interventions would the nurse most likely initiate if the patient developed SIADH? Fluid restriction Transfusion of platelets Transfusion of fresh frozen plasma (FFP) Electrolyte restriction A patient is recovering from intracranial surgery that was performed using the transsphenoidal approach. The nurse should be aware that the patient may have required surgery on what neurologic structure? Cerebellum Hypothalamus Pituitary gland Pineal gland A school nurse is called to the playground where a 6-year-old girl has been found unresponsive and staring into space, according to the playground supervisor. How would the nurse document the girls activity in her chart at school? Generalized seizure Absence seizure Focal seizure Unclassified seizure A neurologic nurse is reviewing seizures with a group of staff nurses. How should this nurse best describe the cause of a seizure? Sudden electrolyte changes throughout the brain A dysrhythmia in the peripheral nervous system A dysrhythmia in the nerve cells in one section of the brain Sudden disruptions in the blood flow throughout the brain The nurse is caring for a patient who has undergone supratentorial removal of a pituitary mass. What medication would the nurse expect to administer prophylactically to prevent seizures in this patient? Prednisone Dexamethasone Cafergot Phenytoin A patient has had an ischemic stroke and has been admitted to the medical unit. What action should the nurse perform to best prevent joint deformities? Place the patient in the prone position for 30 minutes/day. Assist the patient in acutely flexing the thigh to promote movement. Place a pillow in the axilla when there is limited external rotation. Place patients hand in pronation. When caring for a patient who had a hemorrhagic stroke, close monitoring of vital signs and neurologic changes is imperative. What is the earliest sign of deterioration in a patient with a hemorrhagic stroke of which the nurse should be aware? Generalized pain Alteration in level of consciousness (LOC) Tonic-clonic seizures Shortness of breath The nurse is performing stroke risk screenings at a hospital open house. The nurse has identified four patients who might be at risk for a stroke. Which patient is likely at the highest risk for a hemorrhagic stroke? White female, age 60, with history of excessive alcohol intake White male, age 60, with history of uncontrolled hypertension Black male, age 60, with history of diabetes Black male, age 50, with history of smoking A patient who just suffered a suspected ischemic stroke is brought to the ED by ambulance. On what should the nurses primary assessment focus? Cardiac and respiratory status Seizure activity Pain Fluid and electrolyte balance A patient with a cerebral aneurysm exhibits signs and symptoms of an increase in intracranial pressure (ICP). What nursing intervention would be most appropriate for this patient? Range-of-motion exercises to prevent contractures Encouraging independence with ADLs to promote recovery Early initiation of physical therapy Absolute bed rest in a quiet, nonstimulating environment The nurse is assessing a patient with a suspected stroke. What assessment finding is most suggestive of a stroke? Facial droop Dysrhythmias Periorbital edema Projectile vomiting The nurse is caring for a patient diagnosed with an ischemic stroke and knows that effective positioning of the patient is important. Which of the following should be integrated into the patients plan of care? The patients hip joint should be maintained in a flexed position. The patient should be in a supine position unless ambulating. The patient should be placed in a prone position for 15 to 30 minutes several times a day. The patient should be placed in a Trendelenberg position two to three times daily to promote cerebral perfusion. The nurse is preparing health education for a patient who is being discharged after hospitalization for a hemorrhagic stroke. What content should the nurse include in this education? Mild, intermittent seizures can be expected. Take ibuprofen for complaints of a serious headache. Take antihypertensive medication as ordered. Drowsiness is normal for the first week after discharge. A patient is brought by ambulance to the ED after suffering what the family thinks is a stroke. The nurse caring for this patient is aware that an absolute contraindication for thrombolytic therapy is what? Evidence of hemorrhagic stroke Blood pressure of 180/110 mm Hg Evidence of stroke evolution Previous thrombolytic therapy within the past 12 months When caring for a patient who has had a stroke, a priority is reduction of ICP. What patient position is most consistent with this goal? Head turned slightly to the right side Elevation of the head of the bed Position changes every 15 minutes while awake Extension of the neck A patient who suffered an ischemic stroke now has disturbed sensory perception. What principle should guide the nurses care of this patient? The patient should be approached on the side where visual perception is intact. Attention to the affected side should be minimized in order to decrease anxiety. The patient should avoid turning in the direction of the defective visual field to minimize shoulder subluxation. The patient should be approached on the opposite side of where the visual perception is intact to promote recovery. A patient who has experienced an ischemic stroke has been admitted to the medical unit. The patients family in adamant that she remain on bed rest to hasten her recovery and to conserve energy. What principle of care should inform the nurses response to the family? The patient should mobilize as soon as she is physically able. To prevent contractures and muscle atrophy, bed rest should not exceed 4 weeks. The patient should remain on bed rest until she expresses a desire to mobilize. Lack of mobility will greatly increase the patients risk of stroke recurrence. A patient has recently begun mobilizing during the recovery from an ischemic stroke. To protect the patients safety during mobilization, the nurse should perform what action? Support the patients full body weight with a waist belt during ambulation. Have a colleague follow the patient closely with a wheelchair. Avoid mobilizing the patient in the early morning or late evening. Ensure that the patients family members do not participate in mobilization. After a subarachnoid hemorrhage, the patients laboratory results indicate a serum sodium level of less than 126 mEq/L. What is the nurses most appropriate action? Administer a bolus of normal saline as ordered. Prepare the patient for thrombolytic therapy as ordered. Facilitate testing for hypothalamic dysfunction. Prepare to administer 3% NaCl by IV as ordered. The nurse is reviewing the medication administration record of a female patient who possesses numerous risk factors for stroke. Which of the womans medications carries the greatest potential for reducing her risk of stroke? Naproxen 250 PO b.i.d. Calcium carbonate 1,000 mg PO b.i.d. Aspirin 81 mg PO o.d. Lorazepam 1 mg SL b.i.d. PRN A preceptor is discussing stroke with a new nurse on the unit. The preceptor would tell the new nurse which cardiac dysrhythmia is associated with cardiogenic embolic strokes? Ventricular tachycardia Atrial fibrillation Supraventricular tachycardia Bundle branch block After a major ischemic stroke, a possible complication is cerebral edema. Nursing care during the immediate recovery period from an ischemic stroke should include which of the following? Positioning to avoid hypoxia Maximizing PaCO2 Administering hypertonic IV solution Initiating early mobilization The nurse is caring for a patient recovering from an ischemic stroke. What intervention best addresses a potential complication after an ischemic stroke? Providing frequent small meals rather than three larger meals Teaching the patient to perform deep breathing and coughing exercises Keeping a urinary catheter in situ for the full duration of recovery Limiting intake of insoluble fiber A patient with a new diagnosis of ischemic stroke is deemed to be a candidate for treatment with tissue plasminogen activator (t-PA) and has been admitted to the ICU. In addition to closely monitoring the patients cardiac and neurologic status, the nurse monitors the patient for signs of what complication? Acute pain Septicemia Bleeding Seizures A nurse is caring for a critically ill patient with autonomic dysreflexia. What clinical manifestations would the nurse expect in this patient? Respiratory distress and projectile vomiting Bradycardia and hypertension Tachycardia and agitation Third-spacing and hyperthermia The nurse is caring for a patient with increased intracranial pressure (ICP) caused by a traumatic brain injury. Which of the following clinical manifestations would suggest that the patient may be experiencing increased brain compression causing brain stem damage? Hyperthermia Tachycardia Hypertension Bradypnea A patient is brought to the ED by her family after falling off the roof. A family member tells the nurse that when the patient fell she was knocked out, but came to and seemed okay. Now she is complaining of a severe headache and not feeling well. The care team suspects an epidural hematoma, prompting the nurse to prepare for which priority intervention? Insertion of an intracranial monitoring device Treatment with antihypertensives Emergency craniotomy Administration of anticoagulant therapy The staff educator is precepting a nurse new to the critical care unit when a patient with a T2 spinal cord injury is admitted. The patient is soon exhibiting manifestations of neurogenic shock. In addition to monitoring the patient closely, what would be the nurses most appropriate action? Prepare to transfuse packed red blood cells. Prepare for interventions to increase the patients BP. Place the patient in the Trendelenberg position. Prepare an ice bath to lower core body temperature. An ED nurse has just received a call from EMS that they are transporting a 17-year-old man who has just sustained a spinal cord injury (SCI). The nurse recognizes that the most common cause of this type of injury is what? Sports-related injuries Acts of violence Injuries due to a fall Motor vehicle accidents A patient with spinal cord injury has a nursing diagnosis of altered mobility and the nurse recognizes the increased the risk of deep vein thrombosis (DVT). Which of the following would be included as an appropriate nursing intervention to prevent a DVT from occurring? Placing the patient on a fluid restriction as ordered Applying thigh-high elastic stockings Administering an antifibrinolyic agent Assisting the patient with passive range of motion (PROM) exercises Paramedics have brought an intubated patient to the RD following a head injury due to acceleration- deceleration motor vehicle accident. Increased ICP is suspected. Appropriate nursing interventions would include which of the following? Keep the head of the bed (HOB) flat at all times. Teach the patient to perform the Valsalva maneuver. Administer benzodiazepines on a PRN basis. Perform endotracheal suctioning every hour. A patient who suffered a spinal cord injury is experiencing an exaggerated autonomic response. What aspect of the patients current health status is most likely to have precipitated this event? The patient received a blood transfusion. The patients analgesia regimen was recent changed. The patient was not repositioned during the night shift. The patients urinary catheter became occluded A patient with a C5 spinal cord injury is tetraplegic. After being moved out of the ICU, the patient complains of a severe throbbing headache. What should the nurse do first? Check the patients indwelling urinary catheter for kinks to ensure patency. Lower the HOB to improve perfusion. Administer analgesia. Reassure the patient that headaches are expected after spinal cord injuries. A patient is admitted to the neurologic ICU with a spinal cord injury. When assessing the patient the nurse notes there is a sudden depression of reflex activity in the spinal cord below the level of injury. What should the nurse suspect? Epidural hemorrhage Hypertensive emergency Spinal shock Hypovolemia An elderly woman found with a head injury on the floor of her home is subsequently admitted to the neurologic ICU. What is the best rationale for the following physician orders: elevate the HOB; keep the head in neutral alignment with no neck flexion or head rotation; avoid sharp hip flexion? To decrease cerebral arterial pressure To avoid impeding venous outflow To prevent flexion contractures To prevent aspiration of stomach contents A patient with a T2 injury is in spinal shock. The nurse will expect to observe what assessment finding? Absence of reflexes along with flaccid extremities Positive Babinskis reflex along with spastic extremities Hyperreflexia along with spastic extremities Spasticity of all four extremities A nurse is reviewing the trend of a patients scores on the Glasgow Coma Scale (GCS). This allows the nurse to gauge what aspect of the patients status? Reflex activity Level of consciousness Cognitive ability Sensory involvement The nurse is caring for a patient who is rapidly progressing toward brain death. The nurse should be aware of what cardinal signs of brain death? Select all that apply. Absence of pain response Apnea Coma Absence of brain stem reflexes Absence of deep tendon reflexes An 82-year-old man is admitted for observation after a fall. Due to his age, the nurse knows that the patient is at increased risk for what complication of his injury? Hematoma Skull fracture Embolus Stroke The school nurse is giving a presentation on preventing spinal cord injuries (SCI). What should the nurse identify as prominent risk factors for SCI? Select all that apply. Young age Frequent travel African American race Male gender Alcohol or drug use The nurse is caring for a patient whose spinal cord injury has caused recent muscle spasticity. What medication should the nurse expect to be ordered to control this? Baclofen (Lioresal) Dexamethasone (Decadron) Mannitol (Osmitrol) Phenobarbital (Luminal) A patient with a spinal cord injury has experienced several hypotensive episodes. How can the nurse best address the patients risk for orthostatic hypotension? Administer an IV bolus of normal saline prior to repositioning. Maintain bed rest until normal BP regulation returns. Monitor the patients BP before and during position changes. Allow the patient to initiate repositioning. A nurse on the neurologic unit is providing care for a patient who has spinal cord injury at the level of C4. When planning the patients care, what aspect of the patients neurologic and functional status should the nurse consider? The patient will be unable to use a wheelchair. The patient will be unable to swallow food. The patient will be continent of urine, but incontinent of bowel. The patient will require full assistance for all aspects of elimination. The nurse is providing health education to a patient who has a C6 spinal cord injury. The patient asks why autonomic dysreflexia is considered an emergency. What would be the nurses best answer? The sudden increase in BP can raise the ICP or rupture a cerebral blood vessel. The suddenness of the onset of the syndrome tells us the body is struggling to maintain its normal state. Autonomic dysreflexia causes permanent damage to delicate nerve fibers that are healing. The sudden, severe headache increases muscle tone and can cause further nerve damage. The nurse caring for a patient with a spinal cord injury notes that the patient is exhibiting early signs and symptoms of disuse syndrome. Which of the following is the most appropriate nursing action? Limit the amount of assistance provided with ADLs. Collaborate with the physical therapist and immobilize the patients extremities temporarily. Increase the frequency of ROM exercises. Educate the patient about the importance of frequent position changes. A patient who is being treated in the hospital for a spinal cord injury is advocating for the removal of his urinary catheter, stating that he wants to try to resume normal elimination. What principle should guide the care teams decision regarding this intervention? Urinary retention can have serious consequences in patients with SCIs. Urinary function is permanently lost following an SCI. Urinary catheters should not remain in place for more than 7 days. Overuse of urinary catheters can exacerbate nerve damage. A patient with spinal cord injury is ready to be discharged home. A family member asks the nurse to review potential complications one more time. What are the potential complications that should be monitored for in this patient? Select all that apply. Orthostatic hypotension Autonomic dysreflexia DVT Salt-wasting syndrome Increased ICP The nurse recognizes that a patient with a SCI is at risk for muscle spasticity. How can the nurse best prevent this complication of an SCI? Position the patient in a high Fowlers position when in bed. Support the knees with a pillow when the patient is in bed. Perform passive ROM exercises as ordered. Administer NSAIDs as ordered. A patient is admitted to the neurologic ICU with a C4 spinal cord injury. When writing the plan of care for this patient, which of the following nursing diagnoses would the nurse prioritize in the immediate care of this patient? Risk for impaired skin integrity related to immobility and sensory loss Impaired physical mobility related to loss of motor function Ineffective breathing patterns related to weakness of the intercostal muscles Urinary retention related to inability to void spontaneously The nurse is caring for the client with increased intracranial pressure. The nurse would note which trend in vital signs if the intracranial pressure is rising? Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure A client recovering from a head injury is participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure if the nurse observes the client doing which activity? Blowing the nose Isometric exercises Laughing vigorously Exhaling during repositioning A client has clear fluid leaking from the nose following a basilar skull fracture. Which finding would alert the nurse that cerebrospinal fluid is present? Fluid is clear and tests negative for glucose. Fluid is grossly bloody in appearance and has a pH of 6. Fluid clumps together on the dressing and has a pH of 7 Fluid separates into concentric rings and tests positive for glucose. A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse should include which measures in the plan of care to minimize the risk of occurrence? Select all that apply. Keeping the linens wrinkle-free under the client Preventing unnecessary pressure on the lower limbs Limiting bladder catheterization to once every 12 hours Turning and repositioning the client at least every 2 hours Ensuring that the client has a bowel movement at least once a week. The nurse is evaluating the neurological signs of a client in spinal shock following spinal cord injury. Which observation indicates that spinal shock persists? Hyperreflexia Positive reflexes Flaccid paralysis Reflex emptying of the bladder The nurse is assigned to care for a client with complete right-sided hemiparesis from a stroke (brain attack). Which characteristics are associated with this condition? Select all that apply. The client is aphasic. The client has weakness on the right side of the body. The client has complete bilateral paralysis of the arms and legs. The client has weakness on the right side of the face and tongue. The client has lost the ability to move the right arm but is able to walk independently. The client has lost the ability to ambulate independently but is able to feed and bathe himself or herself without assistance. The nurse is assessing the adaptation of a client to changes in functional status after a stroke (brain attack). Which observation indicates to the nurse that the client is adapting most successfully? Gets angry with family if they interrupt a task Experiences bouts of depression and irritability Has difficulty with using modified feeding utensils Consistently uses adaptive equipment in dressing self The nurse is evaluating the status of a client who had a craniotomy 3 days ago. Which assessment finding would indicate that the client is developing meningitis as a complication of surgery? A negative Kernig's sign Absence of nuchal rigidity A positive Brudzinski's sign A Glasgow Coma Scale score of 15 The nurse has just admitted to the nursing unit a client with a basilar skull fracture who is at risk for increased intracranial pressure. Pending specific health care provider prescriptions, the nurse should safely place the client in which positions? Select all that apply. Head in midline Neck in neutral position HOB at 30-45 degrees Head turned to the side when flat in bed Neck and jaw flexed forward when opening the mouth The nurse in the neurological unit is caring for a client who was in a motor vehicle crash and sustained a blunt head injury. On assessment of the client, the nurse notes the presence of bloody drainage from the nose. Which nursing action is most appropriate? Insert nasal packing Document the findings Contact the HCP Monitor the client's blood pressure and check for signs of increased intracranial pressure. The nurse is caring for a client who has undergone a craniotomy and has a supratentorial incision. The nurse should place the client in which position postoperatively? HOB, head and neck midline HOB flat, head turned to the non-operative side HOB elevated 30 to 45 degrees, head and neck midline HOB elevated 3- to 45, head turned to the operative side The nurse is assessing fluid balance in a client who has undergone a craniotomy. The nurse should assess for which finding as a sign of overhydration, which would aggravate cerebral edema? Unchanged weight Shift intake 950mL, output 900mL BUN 10mg/dL Serum osmolarity 280mOsm/kg H2O A client with a spinal cord injury at the level of C5 has a weakened respiratory effort and ineffective cough and is using accessory neck muscles in breathing. The nurse carefully monitors the client and suspects the presence of which problem? Altered breathing pattern Increased likelihood of injury Ineffective oxygen consumption Increased susceptibility to aspiration The nurse is assessing the client's gait and notes it is unsteady and staggering. Which description should the nurse use when documenting the assessment finding? Spastic Ataxic Festinating Dystrophic or broad-based Which intervention should the nurse include in a postoperative teaching plan for a client who underwent a spinal fusion and will be wearing a brace? Tell the client to inspect the environment for safety hazards Inform the client about the importance of sitting as much as possible. Inform the client that lotions and body powders can be used for skin breakdown. Instruct the client to tighten the brace during meals and to loosen it for the first 30 minutes after each meal. The nurse is preparing to care for a client after a lumbar puncture. The nurse should plan to place the client in which best position following the procedure? Prone in semi Fowler's position Supine in semi Fowler's position Prone with a small pillow under the abdomen Lateral with the head slightly lower than the rest of the body The student nurse develops a plan of care for a client after a lumbar puncture. The nursing instructor corrects the student if the student documents which incorrect intervention in the plan? Maintain the client in a flat position. Restrict fluid intake for a period of 2 hours. Assess the client's ability to void and move the extremities. Inspect the puncture site for swelling, redness, and drainage. The nurse is monitoring a client who has returned to the nursing unit after a myelogram. Which client complaint would indicate the need to notify the health care provider (HCP)? Backache Headache Neck stiffness Feelings of fatigue The nurse is caring for a client with a head injury. The client's intracranial pressure reading is 8 mm Hg. Which condition should the nurse document? ICP is normal ICP is elevated ICP is borderline ICP is too low The nurse in the neurological unit is monitoring a client for signs of increased intracranial pressure (ICP). The nurse reviews the assessment findings for the client and notes documentation of the presence of Cushing's reflex. The nurse determines that the presence of this reflex is obtained by assessing which item? Blood pressure Motor response Pupillary response Level of consciousness The nurse is performing the oculocephalic response (doll's eyes maneuver) on an unconscious client. The nurse turns the client's head and notes movement of the eyes in the same direction as the head. How should the nurse document these findings? Normal Abnormal Insignificant Inconclusive The nurse is reviewing the medical records of a client admitted to the nursing unit with a diagnosis of a thrombotic brain attack (stroke). The nurse would expect to note that which is documented in the assessment data section of the record? Sudden loss of consciousness occurred. Signs and symptoms occurred suddenly. The client experienced paresthesias a few days before admission to the hospital The client complained of a severe headache, which was followed by sudden onset of paralysis. The nurse in the health care clinic is providing medication instructions to a client with a seizure disorder who will be taking divalproex sodium. The nurse should instruct the client about the importance of returning to the clinic for monitoring of which laboratory study? Electrolyte panel Liver function studies Renal function studies Blood glucose level determination The nurse assesses a client who is diagnosed with a stroke (brain attack). On assessment, the client is unable to understand the nurse's commands. Which condition should the nurse document? Occipital lobe impairment Damage to the auditory association areas Frontal lobe and optic nerve tracts damage Difficulty with concept formation and abstraction areas The nurse is creating a plan of care for a client with dysphagia following a stroke (brain attack). Which should the nurse include in the plan? Select all that apply. Thicken liquids. Assist the client with eating Assess for the presence of a swallow reflex. Place the food on the affected side of the mouth. Provide ample time for the client to chew and swallow. The nurse in the neurological unit is caring for a client with a supratentorial lesion. The nurse assesses which measurement as the most critical index of central nervous system (CNS) dysfunction? Temperature Blood pressure Ability to speak Level of consciousness The nurse is caring for a client after a craniotomy and monitors the client for signs of increased intracranial pressure (ICP). Which finding, if noted in the client, would indicate an early sign of increased ICP? Confusion Bradycardia Sluggish pupils Widened pulse pressure The nurse is planning discharge teaching for a client started on acetazolamide for a supratentorial lesion. Which information about the primary action of the medication should be included in the client's education? It will prevent hypertension. It will prevent hyperthermia. It decreases cerebrospinal fluid production. It maintains adequate blood pressure for cerebral perfusion. The nurse is preparing for the admission to the unit of a client with a diagnosis of seizures and asks the nursing student to institute full seizure precautions. Which item if noted in the client's room would need to be removed and warrants the need to review seizure precautions with the student? Oxygen course Suction machine Padded tongue blade Padding for the side rails The clinic nurse is reviewing the record of a client scheduled to be seen in the clinic. The nurse notes that the client is taking selegiline hydrochloride. The nurse suspects that the client has which disorder? Diabetes mellitus Parkinson’s disease Alzheimer's disease Coronary artery disease The nurse is creating a plan of care for a client with a diagnosis of stroke (brain attack). On reviewing the client's record, the nurse notes an assessment finding of anosognosia. The nursing care plan should address which manifestation related to this finding? Patient will be easily fatigues Patient will have difficulty speaking Patient will have difficulty swallowing Patient will exhibit neglect of the affected side The nurse is caring for a client who sustained a spinal cord injury. During administration of morning care, the client begins to exhibit signs and symptoms of autonomic dysreflexia. Which initial nursing action should the nurse take? Elevate the HOB Examine the rectum digitally Assess the client’s blood pressure Place the cline in the prone position The home care nurse is visiting a client with a diagnosis of Parkinson's disease. The client is taking benztropine mesylate orally daily. The nurse provides information to the spouse regarding the side effects of this medication and should tell the spouse to report which side effect if it occurs? Shuffling gait Inability to urinate Decreased appetite Irregular bowel movements The nurse is documenting nursing observations in the record of a client who experienced a tonic-clonic seizure. Which clinical manifestation did the nurse most likely note in the clonic phase of the seizure? Body stiffening Spasms of the entire body Sudden loss of consciousness Brief flexion of the extremities At 8:00 a.m., A client who has had a stroke (brain attack) was awake and alert with vital signs of temperature 98°F (37.2°C) orally, pulse 80 beats/min, respirations 18 breaths/min, and blood pressure 138/80 mm Hg. At noon, the client is confused and only responsive to tactile stimuli, and vital signs are temperature 99°F (36.7°C) orally, pulse 62 beats/min, respirations 20 breaths/min, and blood pressure 166/72 mm Hg. The nurse should take which action? Reorient the client Retake the vital signs Call the HCP Administer an antihypertensive medication as needed A client had a transsphenoidal resection of the pituitary gland. The nurse notes drainage on the nasal dressing. Suspecting cerebrospinal fluid (CSF) leakage, the nurse should look for drainage that is of which characteristic? Serosanguineous Bloody with small clots Sanguineous with no clots Serosanguineous, surrounded by clear to straw-colored liquid A client who has a spinal cord injury that resulted in paraplegia experiences a sudden onset of severe headache and nausea. The client is diaphoretic with piloerection and has flushing of the skin. The client's systolic blood pressure (BP) is 210 mm Hg. What should the nurse immediately suspect? Return of spinal shock Malignant hypertension Impending brain attack (stroke) Autonomic dysreflexia The nurse is assessing a client who is experiencing seizure activity. The nurse understands that it is necessary to determine information about which items as part of routine assessment of seizures? Select all that apply. Postictal status Duration of the seizure Changes in pupil size or eye deviation Seizure progression and type of movements What the client ate in the 2 hours preceding seizure activity The nurse has a prescription to administer a medication to a client who is experiencing shivering as a result of hyperthermia. Which medication should the nurse anticipate to be prescribed? Buspirone Fluphenazine Chlorpromazine Prochlorperazine The nurse is caring for a client with an intracranial pressure (ICP) monitoring device. The nurse should become most concerned if the ICP readings drifted to and stayed in the vicinity of which finding? 5mmHg 8mmHg 14mmHg 22mmHg A client with a traumatic brain injury is on mechanical ventilation. The nurse promotes normal intracranial pressure (ICP) by ensuring that the client's arterial blood gas (ABG) results are within which ranges? PaO2 60 to 100mmHg (60 to 100mmHg), PaCo2 25 to 30mmHg (25 to 30mmHg) PaO2 60 to 100mmHg (60 to 100mmHg), PaCo2 30 to 35mmHg (30 to 35mmHg) PaO2 80 to 100mmHg (80 to 100mmHg), PaCo2 25 to 30mmHg (25 to 30mmHg) PaO2 80 to 100mmHg (80 to 100mmHg), PaCo2 35 to 38mmHg (35 to 38mmHg) A client was seen and treated in the hospital emergency department for a concussion. The nurse determines that the family needs further teaching if they verbalize to call the health care provider (HCP) for which client sign or symptom? Vomiting Minor headache Difficulty speaking Difficulty awakening The nurse is caring for a client with an intracranial aneurysm who has been alert. Which signs and symptoms are an early indication that the level of consciousness (LOC) is deteriorating? Select all that apply. Mild drowsiness Drooping eyelids Ptosis of left eyelid Slight slurring of speech Less frequent spontaneous speech A client has sustained damage to Wernicke's area from a stroke (brain attack). On assessment of the client, which sign or symptom would be noted? Difficulty speaking Problem with understanding language Difficulty controlling voluntary motor activity Problem with articulating events from the remote past A client has suffered damage to Broca's area of the brain. Which priority assessment should the nurse perform? Speech Hearing Balance Level of consciousness The nurse is caring for a client diagnosed with Alzheimer's disease. The nurse should anticipate that the client has changes in which component of the nervous system? Glia Peripheral nerves Neuronal dendrites Monoamine oxidase To promote optimal cerebral tissue perfusion in the postoperative phase following cranial surgery, the nurse should place the client with an incision in the anterior or middle fossa, in which position? 15 degrees of Trendelenburg's Side-lying with the head of the bed flat With the head of the bed elevated at least 30 degrees With the head of the bed elevated no more than 10 degrees A client with myasthenia gravis arrives at the hospital emergency department in suspected crisis. The health care provider plans to administer edrophonium to differentiate between myasthenic and cholinergic crises. The nurse ensures that which medication is available in the event that the client is in cholinergic crisis? Atropine sulfate Morphine sulfate Protamine sulfate Pyridostigmine bromide The nurse is caring for a client who has just been admitted to the hospital with a diagnosis of a hemorrhagic stroke. The nurse should place the client in which position? Prone Supine Semi Fowler's with the hip and the neck flexed HOB elevated 30 degrees with the head in midline position The nurse is preparing to care for a client who had a supratentorial craniotomy. The nurse should plan to place the client in which position? Prone Supine Side-lying Semi Flower’s The nurse has just admitted to the nursing unit a client with a basilar skull fracture who is at risk for increased intracranial pressure (ICP). Pending specific health care provider prescriptions, the nurse should plan to place the client in which positions? Select all that apply. Head midline Neck in neutral position Flat, with head turned to the side Head of bed elevated 30 to 45 degrees Head of bed elevated with the neck extended The nurse is caring for a client who is at risk for increased intracranial pressure (ICP) after a stroke. Which activities performed by the nurse will assist with preventing increases in ICP? Select all that apply. Clustering nursing activities Hyperoxygenating before suctioning Maintaining 20 degree flexion of the knees Maintaining the head and neck in midline position Maintaining the head of the bed (HOB) at 30 degrees elevation The nurse is caring for the client who suffered a spinal cord injury 48 hours ago. What should the nurse assess for when monitoring for gastrointestinal complications? History of diarrhea Flattened abdomen Hyperactive bowel sounds Hematest-positive NGT drainage The client with a head injury opens eyes to sound, has no verbal response, and localizes to painful stimuli when applied to each extremity. How should the nurse document the Glasgow Coma Scale (GCS) score? GCS=3 GCS=6 GCS=9 GCS=11 The client with a spinal cord injury at the level of T4 is experiencing a severe throbbing headache with a blood pressure of 180/100 mm Hg. What is the priority nursing intervention? Notify HCP Loosen tight clothing on the client. Place the client in a sitting position. Check the urinary catheter tubing for kinks or obstruction. A client is newly admitted to the hospital with a diagnosis of stroke (brain attack) manifested by complete hemiplegia. Which item in the medical history of the client should the nurse be most concerned about? Glaucoma Emphysema Hypertension Diabetes mellitus The nurse caring for a client following craniotomy who has a supratentorial incision understands that the client should most likely be maintained in which position? Prone position Supine position Semi Fowler’s position Dorsal recumbent position The nurse is planning to perform an assessment of the client's level of consciousness using the Glasgow Coma Scale. Which assessments should the nurse include in order to calculate the score? Select all that apply. Eye opening Reflex response Best verbal response Best motor response Pupil size and reaction A client with a traumatic closed head injury shows signs of secondary brain injury. What are some manifestations of secondary brain injury? Select all that apply. Fever Seizures Hypoxia Ischemia Hypotension ICP A patient with a SCI at T5 begins to complain of a severe headache and is diaphoretic and nauseated. Which nursing intervention would not be appropriate? Place the patient immediately in a sitting position Lower the patient to a flat, side-lying position. Assess for bladder distention. Assess the rectum for a fecal mass. When assessing the client with a cord transection above T5 for possible complications, which of the following should the nurse expect as least likely to occur? Diarrhea Paralytic ileus Stress ulcers Intra-abdominal bleeding Which of the following should the nurse use as the best method to assess for the development of lower extremity DVT in a client with a spinal cord injury? Homan’s sign Pain Tenderness Leg girth During the period of spinal shock, the nurse should expect the client’s bladder function to be which of the following? Spastic Normal Atonic Uncontrolled When the client has a cord transection at T4, which of the following is the primary focus of the nursing assessment? Renal status Vascular status GI function Biliary function Which of the following will the nurse observe in the client in the ictal phase of a generalized tonic-clonic seizure? Jerking in one extremity that spreads gradually to adjacent areas Vacant staring and abruptly ceasing all activity Facial grimaces, patting motions, and lip smacking Loss of consciousness, body stiffening, and violent muscle contractions You see someone having a seizure. What is the order you do the following? Maintain a patent airway Record the seizure activity observed Ease the client to the floor Obtain vital signs Which of the following is an initial sign of Parkinson disease? Second? Third? Rigidity Tremor Bradykinesia Akinesia Which of the following is the second sign of Parkinson disease? Rigidity Tremor Bradykinesia Akinesia Which of the following is an the third sign of Parkinson disease? Rigidity Tremor Bradykinesia Akinesia Which of the following is an the fourth sign of Parkinson disease? Rigidity Tremor Bradykinesia Akinesia Which nursing approach is most helpful to a patient with PD who is experiencing a freezing gait with difficulty initiating movement? Pull the patient forward to initiate movement Instruct the patient to use a wheelchair Have the patient remain still Tell the patient to march in place The nurse develops a teaching plan for a patient newly diagnosed with PD. Which topic is most important to include in the plan? Maintaining a balanced nutritional diet Enhancing the immune system Maintaining a safe environment Engaging in diversional activities A patient with PD is prescribed levodopa (L-dopa) therapy. Improvement in which area indicates effective therapy? Mood Muscle rigidity Appetite Alertness A 50 yo man develops sudden expressive aphasia and left sided motor weakness. This information tells the RN that the lesion is likely located: In the cerebellum Right frontal lobe Left temporal lobe Occipital lobe A patient with a TBI is positioned with HOB at 45 degrees with the neck in a neutral position. The RN knows that the reason for this position is: To prevent aspiration To improve ventilation preventing atelectasis To reduce intracranial pressure To prevent a DVT A patient is admitted with an ischemic stroke. The RN knows that the best position for this patient is: HOB elevated and neck in neutral position Supine or Lateral with HOB less than 30 degrees High Fowler’s Position Trendelenberg Endocrine Disorders A patient diagnosed with a pituitary adenoma has arrived on the neurologic unit. When planning the patients care, the nurse should be aware that the effects of the tumor will primarily depend on what variable? Whether the tumor utilizes aerobic or anaerobic respiration The specific hormones secreted by the tumor The patients pre-existing health status Whether the tumor is primary or the result of metastasis The nurse is caring for a patient diagnosed with hypothyroidism secondary to Hashimoto's thyroiditis. When assessing this patient, what sign or symptom would the nurse expect? Fatigue Bulging eyes Palpitations Flushed skin A patient has been admitted to the post-surgical unit following a thyroidectomy. To promote comfort and safety, how should the nurse best position the patient? Side-lying (lateral) with one pillow under the head Head of the bed elevated 30 degrees and no pillows placed under the head Semi-Fowlers with the head supported on two pillows Supine, with a small roll supporting the neck A patient with thyroid cancer has undergone surgery and a significant amount of parathyroid tissue has been removed. The nurse caring for the patient should prioritize what question when addressing potential complications? Do you feel any muscle twitches or spasms? Do you feel flushed or sweaty? Are you experiencing any dizziness or lightheadedness? Are you having any pain that seems to be radiating from your bones? The nurse is caring for a patient with a diagnosis of Addison's disease. What sign or symptom is most closely associated with this health problem? Truncal obesity Hypertension Muscle weakness Moon face The nurse is caring for a patient with Addison's disease who is scheduled for discharge. When teaching the patient about hormone replacement therapy, the nurse should address what topic? The possibility of precipitous weight gain The need for lifelong steroid replacement The need to match the daily steroid dose to immediate symptoms The importance of monitoring liver function The nurse is teaching a patient that the body needs iodine for the thyroid to function. What food would be the best source of iodine for the body? Eggs Shellfish Table salt Red meat A patient is prescribed corticosteroid therapy. What would be the priority information for the nurse to give the patient who is prescribed long-term corticosteroid therapy? The patients diet should be low protein with ample fat. The patient may experience short-term changes in cognition. The patient is at an increased risk for developing infection. The patient is at a decreased risk for development of thrombophlebitis and thromboembolism. A nurse caring for a patient with diabetes insipidus is reviewing laboratory results. What is an expected urinalysis finding? Glucose in the urine Albumin in the urine Highly dilute urine Leukocytes in the urine The nurse caring for a patient with Cushing syndrome is describing the dexamethasone suppression test scheduled for tomorrow. What does the nurse explain that this test will involve? Administration of dexamethasone orally, followed by a plasma cortisol level every hour for 3 hours Administration of dexamethasone IV, followed by an x-ray of the adrenal glands Administration of dexamethasone orally at 11 PM, and a plasma cortisol level at 8 AM the next morning Administration of dexamethasone intravenously, followed by a plasma cortisol level 3 hours after the drug is administered The home care nurse is conducting patient teaching with a patient on corticosteroid therapy. To achieve consistency with the body's natural secretion of cortisol, when would the home care nurse instruct the patient to take his or her corticosteroids? In the evening between 4 PM and 6 PM Prior to going to sleep at night At noon every day In the morning between 7 AM and 8 AM A patient presents at the walk-in clinic complaining of diarrhea and vomiting. The patient has a documented history of adrenal insufficiency. Considering the patients history and current symptoms, the nurse should anticipate that the patient will be instructed to do which of the following? Increase his intake of sodium until the GI symptoms improve. Increase his intake of potassium until the GI symptoms improve. Increase his intake of glucose until the GI symptoms improve. Increase his intake of calcium until the GI symptoms improve. While assisting with the surgical removal of an adrenal tumor, the OR nurse is aware that the patients vital signs may change upon manipulation of the tumor. What vital sign changes would the nurse expect to see? Hyperthermia and tachypnea Hypertension and heart rate changes Hypotension and hypothermia Hyperthermia and bradycardia A patient has returned to the floor after having a thyroidectomy for thyroid cancer. The nurse knows that sometimes during thyroid surgery the parathyroid glands can be injured or removed. What laboratory finding may be an early indication of parathyroid gland injury or removal? Hyponatremia Hypophosphatemia Hypocalcemia Hypokalemia The nurse is planning the care of a patient with hyperthyroidism. What should the nurse specify in the patients meal plan? A clear liquid diet, high in nutrients Small, frequent meals, high in protein and calories Three large, bland meals a day A diet high in fiber and plant-sourced fat A patient with hypofunction of the adrenal cortex has been admitted to the medical unit. What would the nurse most likely find when assessing this patient? Increased body temperature Jaundice Copious urine output Decreased BP The nurse is assessing a patient diagnosed with Graves disease. What physical characteristics of Graves disease would the nurse expect to find? Hair loss Moon face Bulging eyes Fatigue A patient with suspected adrenal insufficiency has been ordered an adrenocorticotropic hormone (ACTH) stimulation test. Administration of ACTH caused a marked increase in cortisol levels. How should the nurse interpret this finding? The patients pituitary function is compromised. The patients adrenal insufficiency is not treatable. The patient has insufficient hypothalamic function. The patient would benefit from surgery. The physician has ordered a fluid deprivation test for a patient suspected of having diabetes insipidus. During the test, the nurse should prioritize what assessments? Temperature and oxygen saturation Heart rate and BP Breath sounds and bowel sounds Color, warmth, movement, and sensation of extremities A nurse works in a walk-in clinic. The nurse recognizes that certain patients are at higher risk for different disorders than other patients. What patient is at a greater risk for the development of hypothyroidism? A 75-year-old female patient with osteoporosis A 50-year-old male patient who is obese A 45-year-old female patient who used oral contraceptives A 25-year-old male patient who uses recreational drugs A patient with a recent diagnosis of hypothyroidism is being treated for an unrelated injury. When administering medications to the patient, the nurse should know that the patients diminished thyroid function may have what effect? Anaphylaxis Nausea and vomiting Increased risk of drug interactions Prolonged duration of effect A patient has been admitted to the critical care unit with a diagnosis of thyroid storm. What interventions should the nurse include in this patients immediate care? Select all that apply. Administering diuretics to prevent fluid overload Administering beta blockers to reduce heart rate Administering insulin to reduce blood glucose levels Applying interventions to reduce the patients temperature Administering corticosteroids The nurses assessment of a patient with thyroidectomy suggests tetany and a review of the most recent blood work corroborate this finding. The nurse should prepare to administer what intervention? Oral calcium chloride and vitamin D IV calcium gluconate STAT levothyroxine Administration of parathyroid hormone (PTH) A patient has been taking prednisone for several weeks after experiencing a hypersensitivity reaction. To prevent adrenal insufficiency, the nurse should ensure that the patient knows to do which of the following? Take the drug concurrent with levothyroxine (Synthroid). Take each dose of prednisone with a dose of calcium chloride. Gradually replace the prednisone with an OTC alternative. Slowly taper down the dose of prednisone, as ordered. A 30 year-old female patient has been diagnosed with Cushing syndrome. What psychosocial nursing diagnosis should the nurse most likely prioritize when planning the patients care? Decisional conflict related to treatment options Spiritual distress related to changes in cognitive function Disturbed body image related to changes in physical appearance Powerlessness related to disease progression A patient with pheochromocytoma has been admitted for an adrenalectomy to be performed the following day. To prevent complications, the nurse should anticipate preoperative administration of which of the following? IV antibiotics Oral antihypertensives Parenteral nutrition IV corticosteroids A patient is undergoing testing for suspected adrenocortical insufficiency. The care team should ensure that the patient has been assessed for the most common cause of adrenocortical insufficiency. What is the most common cause of this health problem? Therapeutic use of corticosteroids Pheochromocytoma Inadequate secretion of ACTH Adrenal tumor The nurse providing care for a patient with Cushing syndrome has identified the nursing diagnosis of risk for injury related to weakness. How should the nurse best reduce this risk? Establish falls prevention measures. Encourage bed rest whenever possible. Encourage the use of assistive devices. Provide constant supervision. A patient with Cushing syndrome has been hospitalized after a fall. The dietician consulted works with the patient to improve the patients nutritional intake. What foods should a patient with Cushing syndrome eat to optimize health? Select all that apply. Foods high in vitamin D Foods high in calories Foods high in protein Foods high in calcium Foods high in sodium A patient on corticosteroid therapy needs to be taught that a course of corticosteroids of 2 weeks duration can suppress the adrenal cortex for how long? Up to 4 weeks Up to 3 months Up to 9 months Up to 1 year A patient with Cushing syndrome as a result of a pituitary tumor has been admitted for a transsphenoidal hypophysectomy. What would be most important for the nurse to monitor before, during, and after surgery? Blood glucose Assessment of urine for blood Weight Oral temperature What should the nurse teach a patient on corticosteroid therapy in order to reduce the patients risk of adrenal insufficiency? Take the medication late in the day to mimic the body's natural rhythms. Always have enough medication on hand to avoid running out. Skip up to 2 doses in cases of illness involving nausea. Take up to 1 extra dose per day during times of stress. The nurse is caring for a patient at risk for an addisonian crisis. For what associated signs and symptoms should the nurse monitor the patient? Select all that apply. Epistaxis Pallor Rapid respiratory rate Bounding pulse Hypotension A patient has been assessed for aldosteronism and has recently begun treatment. What are priority areas for assessment that the nurse should frequently address? Select all that apply. Pupillary response Creatinine and BUN levels Potassium level Peripheral pulses BP A patient who has been taking corticosteroids for several months has been experiencing muscle wasting. The patient has asked the nurse for suggestions to address this adverse effect. What should the nurse recommend? Activity limitation to conserve energy Consumption of a high-protein diet Use of OTC vitamin D and calcium supplements Passive range-of-motion exercises 40. The nurse is providing care for an older adult patient whose current medication regimen includes levothyroxine (Synthroid). As a result, the nurse should be aware of the heightened risk of adverse effects when administering an IV dose of what medication? A fluoroquinolone antibiotic A loop diuretic A proton pump inhibitor (PPI) A benzodiazepine The nurse is caring for a client after hypophysectomy and notes clear nasal drainage from the client's nostril. The nurse should take which initial action? Lower the head of the bed. Test the drainage for glucose. Obtain a culture of the drainage. Continue to observe the drainage. A client is admitted to an emergency department, and a diagnosis of myxedema coma is made. Which action should the nurse prepare to carry out initially? Warm the client. Maintain a patent airway. Administer thyroid hormone. Administer fluid replacement. The nurse is completing an assessment on a client who is being admitted for a diagnostic workup for primary hyperparathyroidism. Which client complaint would be characteristic of this disorder? Select all that apply. Polyuria Headache Bone pain Nervousness Weight gain The nurse is teaching a client with hyperparathyroidism how to manage the condition at home. Which response by the client indicates the need for additional teaching? "I should limit my fluids to 1 liter per day." “I should use my treadmill or go for walks daily." "I should follow a moderate-calcium, high-fiber diet." “My alendronate helps to keep calcium from coming out of my bones." A client with a diagnosis of Addisonian crisis is being admitted to the intensive care unit. Which findings will the interprofessional health care team focus on? Select all that apply. Hypotension Leukocytosis Hyperkalemia Hypercalcemia Hypernatremia The nurse is performing an assessment on a client with pheochromocytoma. Which assessment data would indicate a potential complication associated with this disorder? A urinary output of 50 mL/hour A coagulation time of 5 minutes A heart rate that is 90 beats/minute and irregular A blood urea nitrogen level of 20 mg/dL (7.1 mmol/L) The nurse is preparing a client with a new diagnosis of hypothyroidism for discharge. The nurse determines that the client understands discharge instructions if the client states that which signs and symptoms are associated with this diagnosis? Select all that apply. Tremors Weight loss Feeling cold Loss of body hair Persistent therapy Puffiness of face A client has just been admitted to the nursing unit following thyroidectomy. Which assessment is the priority for this client? Hypoglycemia Level of hoarseness Respiratory distress Edema at surgical site A client has been diagnosed with hyperthyroidism. The nurse monitors for which signs and symptoms indicating a complication of this disorder? Select all that apply. Fever Nausea Lethargy Tremors Confusion Bradycardia The nurse is caring for a client scheduled for a transsphenoidal hypophysectomy. The preoperative teaching instructions should include which statement? "Your hair will need to be shaved." "You will receive spinal anesthesia." "You will need to ambulate after surgery." "Brushing your teeth needs to be avoided for at least 2 weeks after surgery.” The nurse should include which interventions in the plan of care for a client with hypothyroidism? Select all that apply. Provide a cool environment for the client. Instruct the client to consume a high-fat diet. Instruct the client about thyroid replacement therapy. Encourage the client to consume fluids and high-fiber foods in the diet. Inform the client that iodine preparations will be prescribed to treat the disorder. Instruct the client to contact the health care provider (HCP) if episodes of chest pain occur. The nurse is caring for a client after thyroidectomy. The nurse notes that calcium gluconate is prescribed for the client. The nurse determines that this medication has been prescribed for which purpose? To treat thyroid storm To prevent cardiac irritability To treat hypocalcemic tetany To stimulate release of parathyroid hormone The nurse should include which interventions in the plan of care for a client with hyperthyroidism? Select all that apply. Provide a warm environment for the client Instruct the client to consume a low-fat diet. A thyroid-releasing inhibitor will be prescribed. Encourage the client to consume a well-balanced diet. Instruct the client that thyroid replacement therapy will be needed. Instruct the client that episodes of chest pain are expected to occur. The nurse is reviewing the laboratory test results for a client with a diagnosis of Cushing's syndrome. Which laboratory finding would the nurse expect to note in this client? A platelet count of 200,000 mm3 (200 × 109/L) A blood glucose level of 110 mg/dL (6.28 mmol/L) A potassium (K+) level of 3.0 mEq/L (3.0 mmol/L) A white blood cell (WBC) count of 6000 mm3 (6 × 109/L) The nurse caring for a client with a diagnosis of hypoparathyroidism reviews the laboratory results of blood tests for this client and notes that the calcium level is extremely low. The nurse should expect to note which finding on assessment of the client? Unresponsive pupils Positive Trousseau's sign Negative Chvostek's sign Hypoactive bowel sounds The nurse is caring for a client with a diagnosis of Addison's disease and is monitoring the client for signs of addisonian crisis. The nurse should assess the client for which manifestation that would be associated with this crisis? Agitation Diaphoresis Restlessness Severe abdominal pain The nurse is developing a plan of care for a client who is scheduled for a thyroidectomy. The nurse focuses on psychosocial needs, knowing that which is likely to occur in the client? Infertility Gynecomastia Sexual dysfunction Body image changes The nurse is reviewing the record of a client admitted to the hospital with a diagnosis of pheochromocytoma. The nurse reads the assessment findings and expects to note documentation of which major symptom associated with this condition? Glycosuria Diaphoresis Weight loss Hypertension The nurse is performing an assessment on a client with a diagnosis of Cushing's syndrome. Which should the nurse expect to note on assessment of the client? Skin atrophy The presence of sunken eyes Drooping on 1 side of the face A rounded "moonlike" appearance to the face The nurse is performing an assessment on a client with a diagnosis of myxedema (hypothyroidism). Which assessment finding should the nurse expect to note in this client? Dry skin Thin, silky hair Bulging eyeballs Fine muscle tremors The nurse is performing an assessment on a client with a diagnosis of hyperthyroidism. Which assessment finding should the nurse expect to note in this client? Dry skin Bulging eyeballs Periorbital edema Coarse facial features The nurse is developing a plan of care for a client with Cushing's syndrome. The nurse documents a client problem of excess fluid volume. Which nursing actions should be included in the care plan for this client? Select all that apply. Monitor daily weight. Monitor intake and output. Assess extremities for edema. Maintain a high-sodium diet. Maintain a low-potassium diet. The nurse is caring for a client who has had an adrenalectomy and is monitoring the client for signs of adrenal insufficiency. Which signs and symptoms indicate adrenal insufficiency in this client? Hypotension and fever Mental status changes and hypertension Subnormal temperature and hypotension Complaints of weakness and hypertension The nurse is providing home care instructions to the client with a diagnosis of Cushing's syndrome and prepares a list of instructions for the client. Which instructions should be included on the list? Select all that apply. The signs and symptoms of hypoadrenalism The signs and symptoms of hyperadrenalism Instructions to take the medications exactly as prescribed The importance of maintaining regular outpatient follow-up care A reminder to read the labels on over-the-counter medications before purchase The nurse is developing a plan of care for a client with Addison's disease. The nurse has identified a problem of risk for deficient fluid volume and identifies nursing interventions that will prevent this occurrence. Which nursing interventions should the nurse include in the plan of care? Select all that apply. Monitor for changes in mentation. Encourage an intake of low-protein foods. Encourage an intake of low-sodium foods. Encourage fluid intake of at least 3000 mL per day. Monitor vital signs, skin turgor, and intake and output The nurse has developed a postoperative plan of care for a client who had a thyroidectomy and documents that the client is at risk for developing an ineffective breathing pattern. Which nursing intervention should the nurse include in the plan of care? Maintain a supine position. Monitor neck circumference every 4 hours. Maintain a pressure dressing on the operative site. Encourage deep-breathing exercises and vigorous coughing exercises. The nurse is monitoring a client for signs of hypocalcemia after thyroidectomy. Which sign or symptom, if noted in the client, would most likely indicate the presence of hypocalcemia? Bradycardia Flaccid paralysis Tingling around the mouth Absence of Chvostek’s sign The nurse is monitoring a client with Graves' disease for signs of thyrotoxic crisis (thyroid storm). Which signs or symptoms, if noted in the client, will alert the nurse to the presence of this crisis? Fever and tachycardia Pallor and tachycardia Agitation and bradycardia Restlessness and bradycardia The nursing instructor asks a nursing student to identify the risk factors associated with the development of thyrotoxicosis. The student demonstrates understanding of the risk factors by identifying an increased risk for thyrotoxicosis in which client? A client with hypothyroidism A client with Graves' disease who is having surgery A client with diabetes mellitus scheduled for a diagnostic test A client with diabetes mellitus scheduled for debridement of a foot ulcer The home care nurse visits a client with a diagnosis of hyperparathyroidism who is taking furosemide and provides dietary instructions to the client. Which statement by the client indicates a need for additional instruction? "I need to eat foods high in potassium." "I need to drink at least 2 to 3 L of fluid daily." "I need to eat small, frequent meals and snacks if nauseated." "I need to increase my intake of dietary items that are high in calcium." A nurse is reviewing the assessment findings and laboratory data for a client with the syndrome of inappropriate antidiuretic hormone secretion (SIADH). The nurse understands that which symptoms are associated characteristics of this disorder? Select all that apply. Hypernatremia Signs of water deficit High urine osmolality Low urine osmolality Hypotonicity of body fluids Continued release of antidiuretic hormone (ADH) A nurse is reviewing the assessment findings for a client who was admitted to the hospital with a diagnosis of diabetes insipidus. The nurse understands that which manifestations are associated with this disorder? Select all that apply. Polyuria Polydipsia Concentrated urine Complaints of excessive thirst Specific gravity lower than 1.005 A client has been hospitalized for impaired function of the posterior pituitary gland. The nurse plans to monitor for signs and symptoms of which hormone imbalance? Growth hormone (GH) Luteinizing hormone (LH) Antidiuretic hormone (ADH) Follicle stimulating hormone (FSH) The nurse is admitting a client diagnosed with pheochromocytoma. The client is complaining of a pounding headache and palpitations and the blood pressure is 170/90 mm Hg. The nurse is aware that which substance is responsible for these clinical manifestations? Cortisol Androgens Aldosterone Epinephrine A client has a tumor that is interfering with the function of the hypothalamus. The nurse should monitor for signs and symptoms related to which imbalance? Melatonin excess or deficit Glucocorticoid excess or deficit Mineralocorticoid excess or deficit Antidiuretic hormone (ADH) excess or deficit A client with an endocrine disorder has experienced recent weight loss and exhibits tachycardia. Based on the clinical manifestations, the nurse should suspect dysfunction of which endocrine gland? Thyroid Pituitary Parathyroid Adrenal cortex A client has abnormal amounts of circulating thyronine (T3) and thyroxine (T4). While obtaining the health history, the nurse asks the client about dietary intake. Lack of which dietary element is most likely the cause? Iodine Calcium Phosphorous Magnesium A client with medullary carcinoma of the thyroid has an excess function of the C cells of the thyroid gland. When reviewing the most recent laboratory results, the nurse should expect which electrolyte abnormality? Sodium Calcium Potassium Magnesium A client has overactivity of the thyroid gland. The nurse should expect which finding? Weight gain Nutritional deficiencies Low blood glucose levels Increased body fat stores A client is diagnosed with Cushing's syndrome. When reviewing the recent laboratory results, the nurse should expect an excess of which substance? Calcium Cortisol Epinephrine Norepinephrine The nurse is caring for a client with a new diagnosis of hypothyroidism. Which clinical manifestations might the nurse expect to note on examination of this client? Select all that apply. Irritability Periorbital edema Coarse, brittle hair Slow or slurred speech Abdominal distention Soft, silky, thinning hair A nurse is reviewing the health care provider's prescriptions for a client diagnosed with hypothyroidism. Which medication prescription should the nurse question and verify? Acetaminophen Docusate sodium Morphine sulfate Levothyroxine sodium A preoperative client is scheduled for adrenalectomy to remove a pheochromocytoma. The nurse would most closely monitor which item in the preoperative period? Vital signs Fluid balance Anxiety level Creatinine levels A client is admitted to the hospital with a diagnosis of Addison's disease. The nurse would assess for which problem as a manifestation of this disorder? Edema Obesity Hirsutism Hypotension A client with suspected primary hyperparathyroidism is undergoing diagnostic testing. The nurse would assess for which as a manifestation of this disorder? Polyuria Diarrhea Polyphagia Weight gain A nurse is assessing the status of a client who returned to the surgical nursing unit after a parathyroidectomy procedure. The nurse would place highest priority on which assessment finding? Laryngeal stridor Difficulty voiding Mild incisional pain Absence of bowel sounds A client is admitted to the hospital with a diagnosis of pheochromocytoma. The nurse would check which item to detect the primary manifestation of this disorder? Weight Urine ketones Blood pressure Skin temperature A nurse is caring for a client with thyrotoxicosis who is at risk for the development of thyroid storm. To detect this complication, the nurse should assess for which sign or symptom? Bradycardia Constipation Hypertension Low grade temperature During routine nursing assessment after hypophysectomy, a client complains of thirst and frequent urination. Knowing the expected complications of this surgery, what should the nurse assess next? Serum glucose Blood pressure Respiratory rate Urine specific gravity A client has been diagnosed with Cushing's syndrome. The nurse should assess the client for which expected manifestations of this disorder? Dizziness Weight loss Hypoglycemia Truncal obesity A client has returned to the nursing unit after a thyroidectomy. The nurse notes that the client is complaining of tingling sensations around the mouth, fingers, and toes. On the basis of these findings, the nurse should next assess the results of which serum laboratory study? Sodium Calcium Potassium Magnesium A client visits the health care provider's office for a routine physical examination and reports a new onset of intolerance to cold. Since hypothyroidism is suspected, which additional information would be noted during the client's assessment? Weight loss and tachycardia Complaints of weakness and lethargy Diaphoresis and increased hair growth Increased heart rate and respiratory rate A 33-year-old female client is admitted to the hospital with a tentative diagnosis of Graves' disease. Which symptom related to the menstrual cycle would the client be most likely to report during the initial assessment? Amenorrhea Menorrhagia Metrorrhagia Dysmenorrhea The nurse is instructing a client with Cushing's syndrome on follow-up care. Which of these client statements would indicate a need for further instruction? "I should avoid contact sports." "I should check my ankles for swelling." "I need to avoid foods high in potassium." "I need to check my blood glucose regularly." The nurse is caring for a postoperative client who has had an adrenalectomy. What should the nurse check for during the client's focused assessment? Peripheral edema Bilateral exophthalmos Signs of hypovolemia Signs of hypocalcemia The nurse is caring for a client with Addison's disease. The client asks the nurse about the risks associated with this disease, specifically about addisonian crisis. Regarding prevention of this complication, how should the nurse inform the client? "You can take either hydrocortisone or fludrocortisone for replacement. "You need to take your fludrocortisone 3 times a day to prevent a crisis." “You need to increase salt in your diet, particularly during stressful situations." "You need to decrease your dosages of glucocorticoids and mineralocorticoids during stressful situations." The nurse is assessing a client who has a diagnosis of goiter. Which should the nurse expect to note during the assessment of the client? An enlarged thyroid gland The presence of heart damage Client complaints of chronic fatigue Client complaints of slow wound healing A health care provider has prescribed propylthiouracil for a client with hyperthyroidism. The nurse recalls that first-line treatment calls for methimazole for medication therapy. The nurse should question the client about her past medical history, specifically regarding which condition? Pregnancy Renal failure Prolonged QT interval Adverse reactions to thyroxine During physical examination of a client, which finding is characteristic of hypothyroidism? Periorbital edema Flushed, warm skin Hyperactive bowel sounds Heart rate of 120 bpm A client's laboratory results indicate the serum calcium is 12 mg/dL (3 mmol/L) and the serum phosphorous is 2.1 mg/dL (0.697 mmol/L). Based on these findings, the nurse suspects imbalance of which hormone? Thyroid hormone Parathyroid hormone Follicle stimulating hormone Adrenocorticotropic hormone A nurse is caring for a client with a dysfunctional thyroid gland and is concerned that the client will exhibit a sign of thyroid storm. Which is an early indicator of this complication? Bradycardia Constipation Hyperreflexia Low grade temp The nurse is caring for a client with a diagnosis of Cushing's syndrome. Which expected signs and symptoms should the nurse monitor for? Select all that apply. Anorexia Dizziness Weight loss Moon face Hypertension Truncal obesity A client has begun medication therapy with propylthiouracil. The nurse should assess the client for which condition as an adverse effect of this medication? Joint pain Renal toxicity Hyperglycemia Hypothyroidism [Show More]

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