Adult Health Modules

Front 1

A 72-year-old patient hospitalized with pneumonia is disoriented and confused 2 days after admission. Which assessment information obtained by the nurse about the patient indicates that the patient is experiencing delirium rather than dementia?
a. The patient is disoriented to place and time but oriented to person.
b. The patient has a history of increasing confusion over several years.
c. The patient’s speech is fragmented and incoherent.
d. The patient was oriented and alert when admitted.

Back 1

D

Rationale: The onset of delirium occurs acutely. The degree of disorientation does not differentiate between delirium and dementia. Increasing confusion for several years is consistent with dementia. Fragmented and incoherent speech may occur with either delirium or dementia.

Front 2

hen developing a plan of care for a hospitalized patient with moderate dementia, which intervention will the nurse include?
a. Reminding the patient frequently about being in the hospital
b. Placing suction at the bedside to decrease the risk for aspiration
c. Providing complete personal hygiene care for the patient
d. Repositioning the patient frequently to avoid skin breakdown

Back 2

Correct Answer: A
Rationale: The patient with moderate dementia will have problems with short- and long-term memory and will need reminding about the hospitalization. The other interventions would be used for a patient with severe dementia, who would have difficulty with swallowing, self-care, and immobility.

Front 3

To protect a patient from injury during an episode of delirium, the most appropriate action by the nurse is to
a. have a close family member remain with the patient and provide reassurance.
b. assign a staff member to stay with the patient and offer frequent reorientation.
c. ask the health care provider about ordering an antipsychotic drug.
d. secure the patient in bed with a soft chest restraint.

Back 3

Correct Answer: B
Rationale: The priority goal is to protect the patient from harm, and a staff member will be most experienced in providing safe care. Visits by family members are helpful in reorienting the patient, but families should not be responsible for protecting patients from injury. Antipsychotic medications may be ordered, but only if other measures are not effective because these medications have multiple side effects. Restraints are sometimes used but tend to increase agitation and disorientation.

Front 4

A 71-year-old patient is diagnosed with moderate dementia as a result of multiple strokes. During assessment of the patient, the nurse would expect to find
a. excessive nighttime sleepiness.
b. variable ability to perform simple tasks.
c. difficulty eating and swallowing.
d. loss of recent and long-term memory.

Back 4

Correct Answer: D
Rationale: Loss of both recent and long-term memory is characteristic of moderate dementia. Patients with dementia have frequent nighttime awakening. Dementia is progressive, and the patient’s ability to perform tasks would not have periods of improvement. Difficulty eating and swallowing is characteristic of severe dementia.

Front 5

The nurse has identified the nursing diagnosis of disturbed thought processes related to effects of dementia for a patient with late-stage Alzheimer’s disease (AD). An appropriate intervention for this problem is to
a. maintain a consistent daily routine for the patient’s care.
b. encourage the patient to discuss events from the past.
c. reorient the patient to the date and time every few hours.
d. provide the patient with current newspapers and magazines.

Back 5

Correct Answer: A
Rationale: Providing a consistent routine will decrease anxiety and confusion for the patient. In late-stage AD, the patient will not remember events from the past. Reorientation to time and place will not be helpful to the patient with late-stage AD. The patient with late-stage AD will not be able to read.

Front 6

A patient with Alzheimer’s disease (AD) is hospitalized with a urinary tract infection. The spouse tells the nurse, “I am just exhausted from the constant care and worry. We don’t have any children and we can’t afford a nursing home. I don’t know what to do.” The most appropriate nursing diagnosis for the spouse is
a. anxiety related to limited financial resources.
b. ineffective health maintenance related to stress.
c. caregiver role strain related to limited resources for caregiving.
d. social isolation related to unrelieved caregiving responsibilities.

Back 6

Correct Answer: C
Rationale: The spouse’s statements are most consistent with caregiver role strain. The other diagnoses each address one aspect of the spouse’s problem, but caregiver-role strain related to limited resources for caregiving addresses all the information the nurse has about this situation.

Front 7

A long-term care patient with moderate dementia develops increased restlessness and agitation. The nurse’s initial action should be to
a. administer the PRN dose of lorazepam (Ativan).
b. reorient the patient to time and place.
c. assess the patient for anything that might be causing discomfort.
d. have a nursing assistant stay with the patient to ensure safety.

Back 7

Correct Answer: C
Rationale: Increased motor activity in a patient with dementia is frequently the patient’s only way of responding to factors like pain, so the nurse’s initial action should be to assess the patient for any precipitating factors. Administration of sedative drugs may be indicated, but this should not be done until assessment for precipitating factors has been completed and any of these factors have been addressed. Reorientation is unlikely to be helpful for the patient with moderate dementia. Assigning a nursing assistant to stay with the patient may also be necessary, but any physical changes that may be causing the agitation should be addressed first.

Front 8

During the morning change-of-shift report, the nurse learns that the patient with dementia has had sundowning. Which nursing action should the nurse take while caring for the patient?
a. Move the patient to a quieter room at night.
b. Open the blinds in the patient’s room and provide frequent activities.
c. Have the patient take a brief mid-morning nap.
d. Provide hourly orientation to time of day.

Back 8

Correct Answer: B
Rationale: The most likely cause of sundowning is a disruption in circadian rhythms and keeping the patient active and in daylight will help to reestablish a more normal circadian pattern. Moving the patient to a different room might increase confusion. Taking a nap will interfere with nighttime sleep. Hourly orientation will not be helpful in a patient with memory difficulties.

Front 9

1. A diabetic patient who has had vomiting and diarrhea for the past 3 days is admitted to the hospital with a blood glucose of 748 mg/ml (41.5 mmol/L) and a urinary output of 120 ml in the first hour. The vital signs are blood pressure (BP) 72/62; pulse 128, irregular and thready; respirations 38; and temperature 97° F (36.1° C). The patient is disoriented and lethargic with cold, clammy skin and cyanosis in the hands and feet. The nurse recognizes that the patient is experiencing the
a. progressive stage of septic shock.
b. compensatory stage of diabetic shock.
c. refractory stage of cardiogenic shock.
d. progressive stage of hypovolemic shock.

Back 9

Correct Answer: D
Rationale: The patient’s history of hyperglycemia (and the associated polyuria), vomiting, and diarrhea is consistent with hypovolemia, and the symptoms are most consistent with the progressive stage of shock. The patient’s temperature of 97° F is inconsistent with septic shock. The history is inconsistent with a diagnosis of cardiogenic shock, and the patient’s neurologic status is not consistent with refractory shock.

Front 10

2. A patient with hypovolemic shock has a urinary output of 15 ml/hr. The nurse understands that the compensatory physiologic mechanism that leads to altered urinary output is
a. activation of the sympathetic nervous system (SNS), causing vasodilation of the renal arteries.
b. stimulation of cardiac β-adrenergic receptors, leading to increased cardiac output.
c. release of aldosterone and antidiuretic hormone (ADH), which cause sodium and water retention.
d. movement of interstitial fluid to the intravascular space, increasing renal blood flow.

Back 10

Correct Answer: C
Rationale: The release of aldosterone and ADH lead to the decrease in urine output by increasing the reabsorption of sodium and water in the renal tubules. SNS stimulation leads to renal artery vasoconstriction. β-receptor stimulation does increase cardiac output, but this would improve urine output. During shock, fluid leaks from the intravascular space into the interstitial space.

Front 11

While caring for a seriously ill patient, the nurse determines that the patient may be in the compensatory stage of shock on finding
a. cold, mottled extremities.
b. restlessness and apprehension.
c. a heart rate of 120 and cool, clammy skin.
d. systolic BP less than 90 mm Hg.

Back 11

Correct Answer: B
Rationale: Restlessness and apprehension are typical during the compensatory stage of shock. Cold, mottled extremities, cool and clammy skin, and a systolic BP less than 90 are associated with the progressive and refractory stages.

Front 12

A patient who has been involved in a motor-vehicle crash is admitted to the ED with cool, clammy skin, tachycardia, and hypotension. All of these orders are written. Which one will the nurse act on first?
a. Insert two 14-gauge IV catheters.
b. Administer oxygen at 100% per non-rebreather mask.
c. Place the patient on continuous cardiac monitor.
d. Draw blood to type and crossmatch for transfusions.

Back 12

Correct Answer: B
Rationale: The first priority in the initial management of shock is maintenance of the airway and ventilation. Cardiac monitoring, insertion of IV catheters, and obtaining blood for transfusions should also be rapidly accomplished, but only after actions to maximize oxygen delivery have been implemented.

Front 13

A patient with massive trauma and possible spinal cord injury is admitted to the ED. The nurse suspects that the patient may be experiencing neurogenic shock in addition to hypovolemic shock, based on the finding of
a. cool, clammy skin.
b. shortness of breath.
c. heart rate of 48 beats/min
d. BP of 82/40 mm Hg.

Back 13

Correct Answer: C
Rationale: The normal sympathetic response to shock/hypotension is an increase in heart rate. The presence of bradycardia suggests unopposed parasympathetic function, as occurs in neurogenic shock. The other symptoms are consistent with hypovolemic shock

Front 14

The nurse caring for a patient in shock notifies the health care provider of the patient’s deteriorating status when the patient’s ABG results include
a. pH 7.48, PaCO2 33 mm Hg.
b. pH 7.33, PaCO2 30 mm Hg.
c. pH 7.41, PaCO2 50 mm Hg.
d. pH 7.38, PaCO2 45 mm Hg.

Back 14

Correct Answer: B
Rationale: The patient’s low pH in spite of a respiratory alkalosis indicates that the patient has severe metabolic acidosis and is experiencing the progressive stage of shock; rapid changes in therapy are needed. The values in the answer beginning “pH 7.48” suggest a mild respiratory alkalosis (consistent with compensated shock). The values in the answer beginning “pH 7.41” suggest compensated respiratory acidosis. The values in the answer beginning “pH 7.38” are normal.

Front 15

A patient in septic shock has not responded to fluid resuscitation, as evidenced by a decreasing BP and cardiac output. The nurse anticipates the administration of
a. nitroglycerine (Tridil).
b. dobutamine (Dobutrex).
c. norepinephrine (Levophed).
d. sodium nitroprusside (Nipride).

Back 15

Correct Answer: C
Rationale: When fluid resuscitation is unsuccessful, administration of vasopressor drugs is used to increase the systemic vascular resistance (SVR) and improve tissue perfusion. Nitroglycerin would decrease the preload and further drop cardiac output and BP. Dobutamine will increase stroke volume, but it would also further decrease SVR. Nitroprusside is an arterial vasodilator and would further decrease SVR.

Front 16

A patient who is receiving chemotherapy is admitted to the hospital with acute dehydration caused by nausea and vomiting. Which action will the nurse include in the plan of care to best prevent the development of shock, systemic inflammatory response syndrome (SIRS), and multiorgan dysfunction syndrome (MODS)?
a. Administer all medications through the patient’s indwelling central line.
b. Place the patient in a private room.
c. Restrict the patient to foods that have been well-cooked or processed.
d. Insert a nasogastric (NG) tube for enteral feeding.

Back 16

Correct Answer: B
Rationale: The patient who has received chemotherapy is immune compromised, and placing the patient in a private room will decrease the exposure to other patients and reduce infection/sepsis risk. Administration of medications through the central line increases the risk for infection and sepsis. There is no indication that the patient is neutropenic, and restricting the patient to cooked and processed foods is likely to decrease oral intake further and cause further malnutrition, a risk factor for sepsis and shock. Insertion of an NG tube is invasive and will not decrease the patient’s nausea and vomiting.

Front 17

The nurse evaluates that fluid resuscitation for a 70 kg patient in shock is effective on finding that the patient’s
a. urine output is 40 ml over the last hour.
b. hemoglobin is within normal limits.
c. CVP has decreased.
d. mean arterial pressure (MAP) is 65 mm Hg.

Back 17

Correct Answer: A
Rationale: Assessment of end-organ perfusion, such as an adequate urine output, is the best indicator that fluid resuscitation has been successful. The hemoglobin level is not useful in determining whether fluid administration has been effective unless the patient is bleeding and receiving blood. A decrease in CVP indicates that more fluid is needed. The MAP is at the low normal range, but does not clearly indicate that tissue perfusion is adequate.

Front 18

10. The nurse is caring for a patient admitted with a urinary tract infection and sepsis. Which information obtained in the assessment indicates a need for a change in therapy?
a. The patient is restless and anxious.
b. The patient has a heart rate of 134.
c. The patient has hypotonic bowel sounds.
d. The patient has a temperature of 94.1° F.

Back 18

Correct Answer: D
Rationale: Hypothermia is an indication that the patient is in the progressive stage of shock. The other data are consistent with compensated shock.

Front 19

11. While assessing a patient in shock who has an arterial line in place, the nurse notes a drop in the systolic BP from 92 mm Hg to 76 mm Hg when the head of the patient’s bed is elevated to 75 degrees. This finding indicates a need for
a. additional fluid replacement.
b. antibiotic administration.
c. infusion of a sympathomimetic drug.
d. administration of increased oxygen.

Back 19

Correct Answer: A
Rationale: A postural drop in BP is an indication of volume depletion and suggests the need for additional fluid infusions. There are no data to suggest that antibiotics, sympathomimetics, or additional oxygen are needed.

Front 20

12. The best nursing intervention for a patient in shock who has a nursing diagnosis of fear related to perceived threat of death is to
a. arrange for the hospital pastoral care staff to visit the patient.
b. ask the health care provider to prescribe a sedative drug for the patient.
c. leave the patient alone with family members whenever possible.
d. place the patient’s call bell where it can be easily reached.

Back 20

Correct Answer: D
Rationale: The patient who is fearful should feel that the nurse is immediately available if needed. Pastoral care staff should be asked to visit only after checking with the patient to determine whether this is desired. Providing time for family to spend with the patient is appropriate, but patients and family should not feel that the nurse is unavailable. Sedative administration is helpful but does not as directly address the patient’s anxiety about dying.

Front 21

13. A patient outcome that is appropriate for the patient in shock who has a nursing diagnosis of decreased cardiac output related to relative hypovolemia is
a. urine output of 0.5 ml/kg/hr.
b. decreased peripheral edema.
c. decreased CVP.
d. oxygen saturation 90% or more.

Back 21

Correct Answer: A
Rationale: A urine output of 0.5 ml/kg/hr indicates adequate renal perfusion, which is a good indicator of cardiac output. The patient may continue to have peripheral edema because fluid infusions may be needed despite third-spacing of fluids in relative hypovolemia. Decreased central venous pressure (CVP) for a patient with relative hypovolemia indicates that additional fluid infusion is necessary. An oxygen saturation of 90% will not necessarily indicate that cardiac output has improved.

Front 22

14. When caring for a patient with cardiogenic shock and possible MODS, which information obtained by the nurse will help confirm the diagnosis of MODS?
a. The patient has crackles throughout both lung fields.
b. The patient complains of 8/10 crushing chest pain.
c. The patient has an elevated ammonia level and confusion.
d. The patient has cool extremities and weak pedal pulses.

Back 22

Correct Answer: C
Rationale: The elevated ammonia level and confusion suggest liver failure in addition to the cardiac failure. The crackles, chest pain, and cool extremities are all consistent with cardiogenic shock and do not indicate that there are failures in other major organ systems.

Front 23

15. To monitor a patient with severe acute pancreatitis for the early organ damage associated with MODS, the most important assessments for the nurse to make are
a. stool guaiac and bowel sounds.
b. lung sounds and oxygenation status.
c. serum creatinine and urinary output.
d. serum bilirubin levels and skin color.

Back 23

Correct Answer: B
Rationale: The respiratory system is usually the system to show the signs of MODS because of the direct effect of inflammatory mediators on the pulmonary system. The other assessment data are also important to collect, but they will not indicate the development of MODS as early.

Front 24

16. An assessment finding indicating to the nurse that a 70-kg patient in septic shock is progressing to MODS includes
a. respiratory rate of 10 breaths/min.
b. fixed urine specific gravity at 1.010.
c. MAP of 55 mm Hg.
d. 360-ml urine output in 8 hours.

Back 24

Correct Answer: B
Rationale: A fixed urine specific gravity points to an inability of the kidney to concentrate urine caused by acute tubular necrosis. With MODS, the patient’s respiratory rate would initially increase. The MAP of 55 shows continued shock, but not necessarily progression to MODS. A 360-ml urine output over 8 hours indicates adequate renal perfusion.

Front 25

17. When caring for a patient who has just been admitted with septic shock, which of these assessment data will be of greatest concern to the nurse?
a. BP 88/56 mm Hg
b. Apical pulse 110 beats/min
c. Urine output 15 ml for 2 hours
d. Arterial oxygen saturation 90%

Back 25

Correct Answer: C
Rationale: The best data for assessing the adequacy of cardiac output are those that provide information about end-organ perfusion such as urine output by the kidneys. The low urine output is an indicator that renal tissue perfusion is inadequate and the patient is in the progressive stage of shock. The low BP, increase in pulse, and low-normal O2 saturation are more typical of compensated septic shock.

Front 26

he key factor in describing any type of shock is
a. hypoxemia.
b. hypotension.
c. vascular collapse.
d. inadequate tissue perfusion.

Back 26

Correct Answer: D
Rationale: Although all the factors may be present, regardless of the cause, the end result is inadequate supply of oxygen and nutrients to body cells from inadequate tissue perfusion.

Front 27

A patient with acute pancreatitis is experiencing hypovolemic shock. Which of the following initial orders for the patient will the nurse implement first?
a. Start 1000 mL of normal saline at 500 mL/hr.
b. Obtain blood cultures before starting IV antibiotics.
c. Draw blood for hematology and coagulation factors.
d. Administer high flow oxygen (100%) with a nonrebreather bag

Back 27

Correct Answer: D
Rationale: In every type of shock there is a deficiency of oxygen to the cells, and high-flow oxygen therapy is indicated. Fluids could be started next, blood cultures done before any antibiotic therapy, and lab specimens then could be drawn

Front 28

The most accurate assessment parameters for the nurse to use to determine adequate tissue perfusion in the patient with MODS are
a. blood pressure, pulse, and respirations.
b. breath sounds, blood pressure, and body temperature.
c. pulse pressure, level of consciousness, and pupillary response.
d. level of consciousness, urine output, and skin color and temperature.

Back 28

Correct Answer: D
Rationale: Adequate tissue perfusion in a patient with multiple organ dysfunction syn-drome is assessed by the level of consciousness, urine output, capillary refill, peripheral sensation, skin color, extremity skin temperature, and peripheral pulses.

Front 29

When assessing a patient with a head injury, the nurse recognizes that the earliest indication of increased intracranial pressure (ICP) is
a. vomiting.
b. headache.
c. change in level of consciousness (LOC).
d. sluggish pupil response to light.

Back 29

Correct Answer: C
Rationale: LOC is the most sensitive indicator of the patient’s neurologic status and possible changes in ICP. Vomiting and sluggish pupil response to light are later signs of increased ICP. A headache can be caused by compression of intracranial structures as the brain swells, but it is not unexpected after a head injury.

Front 30

2. When caring for a patient with a right-sided intracerebral hemorrhage, the nurse suspects possible supratentorial herniation and compression of the brainstem when the
a. corneal reflexes are absent.
b. patient develops nystagmus.
c. right pupil does not react to light.
d. left pupil is 10 mm in size.

Back 30

Correct Answer: C
Rationale: A dilated pupil on the ipsilateral side in a patient with an acute brain injury indicates herniation. Absent corneal reflexes and nystagmus are not symptoms of herniation. A nonreactive left pupil would be consistent with left-sided damage.

Front 31

When the nurse applies a painful stimulus to the nailbeds of an unconscious patient, the patient responds with internal rotation, adduction, and flexion of the arms. The nurse documents this as
a. decorticate posturing.
b. decerebrate posturing.
c. localization of pain.
d. flexion withdrawal.

Back 31

Correct Answer: A
Rationale: Internal rotation, adduction, and flexion of the arms in an unconscious patient is documented as decorticate posturing. Extension of the arms and legs is decerebrate posturing. Because the flexion is general, it does not indicate localization of pain or flexion withdrawal.

Front 32

When a patient’s intracranial pressure (ICP) is being monitored with an intraventricular catheter, which of these data obtained during the assessment is most important to communicate to the health care provider?
a. Oral temperature 101.6° F
b. Intracranial pressure 15 mm Hg
c. Mean arterial pressure 70 mm Hg
d. Apical pulse 106 beats/min

Back 32

Correct Answer: A
Rationale: Infection is a serious consideration with ICP monitoring, especially with intraventricular catheters; the temperature indicates the need for antibiotics or removal of the monitor. The ICP, arterial pressure, and apical pulse are all borderline high but require only ongoing monitoring at this time.

Front 33

A patient with a severe head injury has been maintained on IV fluids of 5% dextrose in water (D5W) at 50 ml/hr for 3 days. The nurse will anticipate the need to
a. continue the D5W to provide the needed glucose for brain function.
b. decrease the rate of IV infusion to avoid increasing cerebral edema.
c. insert an enteral feeding tube to provide nutritional replacement.
d. administer IV 5% albumin to increase serum protein levels.

Back 33

Correct Answer: C
Rationale: The patient is in a hypermetabolic and hypercatabolic state, and enteral feedings will provide nutrients for brain function and also for healing and immune function. 5% dextrose does not provide adequate nutrition to meet patient needs and can lead to lower serum osmolarity and cerebral edema. A total fluid intake of 1200 ml for 24 hours will not cause cerebral edema. Albumin administration will temporarily increase serum protein, but the patient also requires lipids, carbohydrate, and other nutrients that will be supplied through enteral feeding.

Front 34

When caring for a patient who has had a head injury, which assessment information is of most concern to the nurse?
a. The blood pressure increases from 120/54 to 136/62.
b. The patient is more difficult to arouse.
c. The patient complains of a headache at pain level 5 of a 10-point scale.
d. The patient’s apical pulse is slightly irregular.

Back 34

Correct Answer: B
Rationale: The change in level of consciousness (LOC) is an indicator of increased ICP and suggests that action by the nurse is needed to prevent complications. The change in BP should be monitored but is not an indicator of a need for immediate nursing action. Headache is not unusual in a patient after a head injury. A slightly irregular apical pulse is not unusual.

Front 35

The nurse identifies a nursing diagnosis of ineffective breathing pattern related to loss of central nervous system (CNS) integrative function for a patient who has posttraumatic brain swelling, based on the finding of
a. apneustic breathing.
b. crackles on inspiration.
c. Glasgow Coma Scale score of 7.
d. cerebral perfusion pressure of 56 mm Hg.

Back 35

Correct Answer: A
Rationale: Apneustic breathing is caused by loss of CNS integration in the pons and is not effective in maximizing gas exchange. Crackles on inspiration are abnormal, but they are not an indication of an abnormal breathing pattern. The Glasgow Coma Scale and cerebral perfusion pressure P are not useful in determining or documenting a patient’s respiratory patterns.

Front 36

An unconscious patient has a nursing diagnosis of ineffective tissue perfusion (cerebral) related to cerebral tissue swelling. An appropriate nursing intervention for this problem is to
a. maintain the patient in a head-up position.
b. position the patient with the knees and hips flexed.
c. cluster nursing interventions to provide uninterrupted periods of rest.
d. encourage coughing and deep-breathing to improve oxygenation.

Back 36

Correct Answer: A
Rationale: The patient with increased intracranial pressure (ICP) should be maintained in the head-up position to help reduce ICP. Flexion of the hips and knees increases abdominal pressure, which increases ICP. Because the stimulation associated with nursing interventions increases ICP, clustering interventions will progressively elevate ICP. Coughing increases intrathoracic pressure and ICP.

Front 37

The nurse notes that a patient with a head injury has a clear nasal drainage. The most appropriate nursing action for this finding is to
a. obtain a specimen of the fluid and send for culture and sensitivity.
b. take the patient’s temperature to determine whether a fever is present.
c. check the nasal drainage for glucose with a Dextrostik or Testape.
d. have the patient to blow the nose and then check the nares for redness.

Back 37

Correct Answer: C
Rationale: If the drainage is cerebrospinal fluid (CSF) leakage from a dural tear, glucose will be present. Fluid leaking from the nose will have normal nasal flora, so culture and sensitivity will not be useful. A dural tear does increase the risk for infections such as meningitis, but the nurse should first determine whether the clear drainage is CSF. Blowing the nose is avoided to prevent CSF leakage.

Front 38

10. A patient with right-sided weakness that started 1 hour ago is admitted to the emergency department and all these diagnostic tests are ordered. Which order should the nurse act on first?
a. Noncontrast computed tomography (CT) scan
b. Chest radiograph
c. Complete blood count (CBC)
d. Electrocardiogram (ECG)

Back 38

Correct Answer: A
Rationale: Rapid screening with a noncontrast CT scan is needed before administration of tissue plasminogen activator (tPA), which must be given within 3 hours of the onset of clinical manifestations of the stroke. The sooner the tPA is given, the smaller the area of brain injury. The other diagnostic tests give information about possible causes of the stroke and do not need to be completed as urgently as the CT scan.

Front 39

11. Aspirin is ordered for a patient who is admitted with a possible stroke. Which information obtained during the admission assessment indicates that the nurse should consult with the health care provider before giving the aspirin?
a. The patient has atrial fibrillation.
b. The patient has dysphasia.
c. The patient states, “I suddenly developed a terrible headache.”
d. The patient has a history of brief episodes of right hemiplegia.

Back 39

Correct Answer: C
Rationale: A sudden-onset headache is typical of a subarachnoid hemorrhage, and aspirin is contraindicated. Atrial fibrillation, dysphasia, and transient ischemic attack (TIA) are not contraindications to aspirin use, so the nurse can administer the aspirin.

Front 40

12. A patient with a stroke experiences right-sided arm and leg paralysis and facial drooping on the right side. When obtaining admission assessment data about the patient’s clinical manifestations, it is most important the nurse assess the patient’s
a. ability to follow commands.
b. visual fields.
c. right-sided reflexes.
d. emotional state.

Back 40

Correct Answer: A
Rationale: Because the patient with a left-sided brain stroke may also have difficulty with comprehension and use of language, so it is important to obtain baseline data about the ability to follow commands. This will impact on patient safety and nursing care. The visual fields are not typically affected by a left-sided stroke. Information about reflexes and emotional state will be collected but is not as high a priority as information about language abilities.

Front 41

13. The nurse identifies the nursing diagnosis of impaired verbal communication for a patient with expressive aphasia. An appropriate nursing intervention to help the patient communicate is to
a. ask simple questions that the patient can answer with “yes” or “no.”
b. develop a list of words that the patient can read and practice reciting.
c. have the patient practice facial and tongue exercises to improve motor control necessary for speech.
d. prevent embarrassing the patient by changing the subject if the patient does not respond in a timely manner.

Back 41

Correct Answer: A
Rationale: Communication will be facilitated and less frustrating to the patient when questions that require a “yes” or “no” response are used. When the language areas of the brain are injured, the patient might not be able to read or recite words, which will frustrate the patient without improving communication. Expressive aphasia is caused by damage to the language areas of the brain, not by the areas that control the motor aspects of speech. The nurse should allow time for the patient to respond.

Front 42

14. A patient with a stroke has progressive development of neurologic deficits with increasing weakness and decreased level of consciousness (LOC). The priority nursing diagnosis for the patient is
a. risk for impaired skin integrity related to immobility.
b. disturbed sensory perception related to brain injury.
c. risk for aspiration related to inability to protect airway.
d. impaired physical mobility related to weakness.

Back 42

Correct Answer: C
Rationale: Protection of the airway is the priority of nursing care for a patient having an acute stroke. The other diagnoses are also appropriate, but interventions to prevent aspiration are the priority at this time.

Front 43

15. A patient has a stroke affecting the right hemisphere of the brain. Based on knowledge of the effects of right brain damage, the nurse establishes a nursing diagnosis of
a. impaired physical mobility related to right hemiplegia.
b. impaired verbal communication related to speech-language deficits.
c. risk for injury related to denial of deficits and impulsiveness.
d. ineffective coping related to depression and distress about disability.

Back 43

Correct Answer: C
Rationale: Right-sided brain damage typically causes denial of any deficits and poor impulse control, leading to risk for injury when the patient attempts activities such as transferring from a bed to a chair. Right-sided brain damage causes left hemiplegia. Left-sided brain damage typically causes language deficits. Left-sided brain damage is associated with depression and distress about the disability.

Front 44

16. A patient has right-sided weakness and aphasia as a result of a stroke but is attempting to use the left hand for feeding and other activities. The patient’s wife insists on feeding and dressing him, telling the nurse, “I just don’t like to see him struggle.” A nursing diagnosis that is most appropriate in this situation is
a. situational low self-esteem related to increasing dependence on others.
b. interrupted family processes related to effects of illness of a family member.
c. disabled family coping related to inadequate understanding by patient’s spouse.
d. ineffective therapeutic regimen management related to hemiplegia and aphasia.

Back 44

Correct Answer: C
Rationale: The information supports the diagnosis of disabled family coping because the wife does not understand the rehabilitation program. There are no data supporting low self-esteem, and the patient is attempting independence. The data do not support an interruption in family processes because this may be a typical pattern for the couple. The patient’s attempts to use the left hand indicate that he is managing the therapeutic regimen appropriately.

Front 45

17. A patient with a paraplegia resulting from a T10 spinal cord injury has a neurogenic reflex bladder. When the nurse develops a plan of care for this problem, which nursing action will be most appropriate?
a. Teaching the patient how to self-catheterize
b. Assisting the patient to the toilet q2-3hr
c. Use of the Credé method to empty the bladder
d. Catheterization for residual urine after voiding

Back 45

Correct Answer: A
Rationale: Because the patient’s bladder is spastic and will empty in response to overstretching of the bladder wall, the most appropriate method is to avoid incontinence by emptying the bladder at regular intervals through intermittent catheterization. Assisting the patient to the toilet will not be helpful because the bladder will not empty. The Credé method is more appropriate for a bladder that is flaccid, such as occurs with a reflexic neurogenic bladder. Catheterization after voiding will not resolve the patient’s incontinence.

Front 46

18. A patient with a history of a T2 spinal cord tells the nurse, “I feel awful today. My head is throbbing, and I feel sick to my stomach.” Which action should the nurse take first?
a. Notify the patient’s health care provider.
b. Check the blood pressure (BP).
c. Give the ordered antiemetic.
d. Assess for a fecal impaction.

Back 46

Correct Answer: B
Rationale: The BP should be assessed immediately in a patient with an injury at the T6 level or higher who complains of a headache to determine whether autonomic dysreflexia is causing the symptoms, including hypertension. Notification of the patient’s health care provider is appropriate after the BP is obtained. Administration of an antiemetic is indicated after autonomic dysreflexia is ruled out as the cause of the nausea. The nurse may assess for a fecal impaction, but this should be done after checking the BP and lidocaine jelly should be used to prevent further increases in the BP.

Front 47

19. The nurse discusses long-range goals with a patient with a C6 spinal cord injury. An appropriate patient outcome is
a. transfers independently to a wheelchair.
b. drives a car with powered hand controls.
c. turns and repositions self independently when in bed.
d. pushes a manual wheelchair on flat, smooth surfaces.

Back 47

Correct Answer: D
Rationale: The patient with a C6 injury will be able to use the hands to push a wheelchair on flat, smooth surfaces. Because flexion of the thumb and fingers is minimal, the patient will not be able to grasp a wheelchair during transfer, drive a car with powered hand controls, or turn independently in bed.

Front 48

20. A patient who sustained a T1 spinal cord injury a week ago refuses to discuss the injury and becomes verbally abusive to the nurses and other staff. The patient demands to be transferred to another hospital, where “they know what they are doing.” The best response by the nurse to the patient’s behavior is to
a. ask for the patient’s input into the plan for care.
b. clarify that abusive behavior will not be tolerated.
c. reassure the patient that the anger will pass and rehabilitation will then progress.
d. ignore the patient’s anger and continue to perform needed assessments and care.

Back 48

Correct Answer: A
Rationale: The patient is demonstrating behaviors consistent with the anger phase of the mourning process, and the nurse should allow expression of anger and seek the patient’s input into care. Expression of anger is appropriate at this stage and should be tolerated by the nurse. Refusal to acknowledge the patient’s anger by telling the patient that the anger is just a phase is inappropriate. Continuing to perform needed assessments and care is appropriate, but the nurse should seek the patient’s input into what care is needed.

Front 49

A patient who has just been diagnosed with type 2 diabetes is 5 ft 4 in (160 cm) tall and weighs 182 pounds (82 kg). A nursing diagnosis of imbalanced nutrition: more than body requirements is developed. Which patient outcome is most important for this patient?
a. The patient will have a diet and exercise plan that results in weight loss.
b. The patient will state the reasons for eliminating simple sugars in the diet.
c. The patient will have a glycosylated hemoglobin level of less than 7%.
d. The patient will choose a diet that distributes calories throughout the day.

Back 49

Correct Answer: C
Rationale: The complications of diabetes are related to elevated blood glucose, and the most important patient outcome is the reduction of glucose to near-normal levels. The other outcomes are also appropriate but are not as high in priority.

Front 50

A patient with type 1 diabetes has received diet instruction as part of the treatment plan. The nurse determines a need for additional instruction when the patient says,
a. “I may have an occasional alcoholic drink if I include it in my meal plan.”
b. “I will need a bedtime snack because I take an evening dose of NPH insulin.”
c. “I will eat meals as scheduled, even if I am not hungry, to prevent hypoglycemia.”
d. “I may eat whatever I want, as long as I use enough insulin to cover the calories.”

Back 50

Correct Answer: D
Rationale: Most patients with type 1 diabetes need to plan diet choices very carefully. Patients who are using intensified insulin therapy have considerable flexibility in diet choices but still should restrict dietary intake of items such as fat, protein, and alcohol. The other patient statements are correct and indicate good understanding of the diet instruction.

Front 51

When teaching a patient with type 2 diabetes about taking glipizide (Glucotrol), the nurse determines that additional teaching about the medication is needed when the patient says,
a. “Since I can take oral drugs rather than insulin, my diabetes is not serious and won’t cause many complications.”
b. “If I overeat at a meal, I will still take just the usual dose of medication.”
c. “If I become ill, I may have to take insulin to control my blood sugar.”
d. “I should check with my doctor before taking any other medications because there are many that will affect glucose levels.”

Back 51

Correct Answer: A
Rationale: The patient should understand that type 2 diabetes places the patient at risk for many complications and that good glucose control is as important when taking oral agents as when using insulin. The other statements are accurate and indicate good understanding of the use of glypizide.

Front 52

Cardiac monitoring is initiated for a patient in diabetic ketoacidosis (DKA). The nurse recognizes that this measure is important to identify
a. electrocardiographic (ECG) changes and dysrhythmias related to hypokalemia.
b. fluid overload resulting from aggressive fluid replacement.
c. the presence of hypovolemic shock related to osmotic diuresis.
d. cardiovascular collapse resulting from the effects of hyperglycemia.

Back 52

Correct Answer: A
Rationale: The hypokalemia associated with metabolic acidosis can lead to potentially fatal dysrhythmias such as ventricular tachycardia and ventricular fibrillation, which would be detected with ECG monitoring. Fluid overload, hypovolemia, and cardiovascular collapse are possible complications of DKA, but cardiac monitoring would not detect theses.

Front 53

A diabetic patient is admitted with ketoacidosis and the health care provider writes all of the following orders. Which order should the nurse implement first?
a. Start an infusion of regular insulin at 50 U/hr.
b. Give sodium bicarbonate 50 mEq IV push.
c. Infuse 1 liter of normal saline per hour.
d. Administer regular IV insulin 30 U.

Back 53

Correct Answer: C
Rationale: The most urgent patient problem is the hypovolemia associated with DKA, and the priority is to infuse IV fluids. The other actions can be accomplished after the infusion of normal saline is initiated.

Front 54

While hospitalized and recovering from an episode of diabetic ketoacidosis, the patient calls the nurse and reports feeling anxious, nervous, and sweaty. Based on the patient’s report, the nurse should
a. obtain a glucose reading using a finger stick.
b. administer 1 mg glucagon subcutaneously.
c. have the patient eat a candy bar.
d. have the patient drink 4 ounces of orange juice.

Back 54

Correct Answer: A
Rationale: The patient’s clinical manifestations are consistent with hypoglycemia and the initial action should be to check the patient’s glucose with a finger stick or order a stat blood glucose. If the glucose is low, the patient should ingest a rapid-acting carbohydrate, such as orange juice. Glucagon might be given if the patient’s symptoms become worse or if the patient is unconscious. Candy bars contain fat, which would slow down the absorption of sugar and delay the response to treatment.

Front 55

A patient recovering from DKA asks the nurse how acidosis occurs. The best response by the nurse is that
a. insufficient insulin leads to cellular starvation, and as cells rupture they release organic acids into the blood.
b. when an insulin deficit causes hyperglycemia, then proteins are deaminated by the liver, causing acidic by-products.
c. excess glucose in the blood is metabolized by the liver into acetone, which is acidic.
d. an insulin deficit promotes metabolism of fat stores, which produces large amounts of acidic ketones.

Back 55

Correct Answer: D
Rationale: Ketoacidosis is caused by the breakdown of fat stores when glucose is not available for intracellular metabolism. The other responses are inaccurate.

Front 56

Intramuscular glucagon is administered to an unresponsive patient for treatment of hypoglycemia. Which action should the nurse take after the patient regains consciousness?
a. Give the patient a snack of cheese and crackers.
b. Have the patient drink a glass of orange juice or nonfat milk.
c. Administer a continuous infusion of 5% dextrose for 24 hours.
d. Assess the patient for symptoms of hyperglycemia.

Back 56

Correct Answer: A
Rationale: Rebound hypoglycemia can occur after glucagon administration, but having a meal containing complex carbohydrates plus protein and fat will help prevent hypoglycemia. Orange juice and nonfat milk will elevate blood sugar rapidly, but the cheese and crackers will stabilize blood sugar. Administration of glucose intravenously might be used in patients who were unable to take in nutrition orally. The patient should be assessed for symptoms of hypoglycemia after glucagon administration.

Front 57

A type 1 diabetic patient who was admitted with severe hypoglycemia and treated tells the nurse, “I did not have any of the usual symptoms of hypoglycemia.” Which question by the nurse will help identify a possible reason for the patient’s hypoglycemic unawareness?
a. “Do you use any calcium-channel blocking drugs for blood pressure?”
b. “Have you observed any recent skin changes?”
c. “Do you notice any bloating feeling after eating?”
d. “Have you noticed any painful new ulcerations or sores on your feet?”

Back 57

Correct Answer: C
Rationale: Hypoglycemic unawareness is caused by autonomic neuropathy, which would also cause delayed gastric emptying. Calcium-channel blockers are not associated with hypoglycemic unawareness, although -adrenergic blockers can prevent patients from having symptoms of hypoglycemia. Skin changes can occur with diabetes, but these are not associated with autonomic neuropathy. If the patient can feel painful areas on the feet, neuropathy has not occurred.

Front 58

A patient with type 2 diabetes has sensory neuropathy of the feet and legs and peripheral vascular disease evidenced by decreased peripheral pulses and dependent rubor. The nurse teaches the patient that
a. the feet should be soaked in warm water on a daily basis.
b. flat-soled leather shoes are the best choice to protect the feet from injury.
c. heating pads should always be set at a very low temperature.
d. over-the-counter (OTC) callus remover may be used to remove callus and prevent pressure.

Back 58

Correct Answer: B
Rationale: The patient is taught to avoid high heels and that leather shoes are preferred. The feet should be washed, but not soaked, in warm water daily. Heating pad use should be avoided. Commercial callus and corn removers should be avoided; the patient should see a specialist to treat these problems.

Front 59

Amitriptyline (Elavil) is prescribed for a diabetic patient with peripheral neuropathy who has burning foot pain occurring mostly at night. Which information should the nurse include when teaching the patient about the new medication?
a. Amitriptyline will help prevent the transmission of pain impulses to the brain.
b. Amitriptyline will improve sleep and make you less aware of nighttime pain.
c. Amitriptyline will decrease the depression caused by the pain.
d. Amitriptyline will correct some of the blood vessel changes that cause pain.

Back 59

Correct Answer: A
Rationale: Tricyclic antidepressants decrease the transmission of pain impulses to the spinal cord and brain. Tricyclics also improve sleep quality and are used for depression, but that is not the major purpose for their use in diabetic neuropathy. The blood vessel changes that contribute to neuropathy are not affected by tricyclics.

Front 60

Which of these laboratory values noted by the nurse when reviewing the chart of a diabetic patient indicates the need for further assessment of the patient?
a. Fasting blood glucose of 130 mg/dl
b. Noon blood glucose of 52 mg/dl
c. Glycosylated hemoglobin of 6.9%
d. Hemoglobin A1C of 5.8%

Back 60

Correct Answer: B
Rationale: The nurse should assess the patient with a blood glucose level of 52 mg/dl for symptoms of hypoglycemia, and give the patient some carbohydrate-containing beverage such as orange juice. The other values are within an acceptable range for a diabetic patient.

Front 61

When assessing the patient experiencing the onset of symptoms of type 1 diabetes, which question should the nurse ask?
a. Have you lost any weight lately?
b. Do you crave fluids containing sugar?
c. How long have you felt anorexic?
d. Is your urine unusually dark-colored?

Back 61

Correct Answer: A
Rationale: In type 1 diabetes, the patient usually has a history of recent and sudden weight loss, as well as the classic symptoms of polydipsia (excessive thirst), polyuria (frequent urination), and polyphagia (excessive hunger).

Front 62

When teaching the patient with diabetes about insulin administration, the nurse instructs the patient to
a. pull back on the plunger after inserting the needle to check for blood.
b. clean the skin at the injection site with an alcohol swab before each injection.
c. consistently use the same size of the appropriate strength insulin syringe to avoid dosing errors.
d. rotate injection sites from arms to thighs to abdomen with each injection to prevent lipodystrophies

Back 62

Correct Answer: C
Rationale: U100 insulin must be used with a U100 syringe, but for those using low doses of insulin, syringes are available that have increments of 1 unit instead of 2 units. Errors can be made in dosing if patients switch back and forth between different sizes of syringes. Aspiration before injection of the insulin is not recommended, nor is the use of alcohol to clean the skin. Because the rate of peak serum concentration varies with the site selected for injection, injections should be rotated within a particular area, such as the abdomen.

Front 63

Lispro insulin (Humalog) and NPH insulin is ordered for a patient with newly diagnosed type 1 diabetes. The nurse knows that when rapid acting lispro insulin is used, it should be administered
a. only once a day.
b. 1 hour before meals.
c. 30 to 45 minutes before meals.
d. at mealtime or within 15 minutes of meals

Back 63

Correct Answer: D
Rationale: Lispro is a rapid-acting insulin that has an onset of action of 5 to 15 minutes and should be injected at the time of the meal to within 15 minutes of eating. Regular insulin is short acting with an onset of action in 30 to 60 minutes following administration and should be given 30 to 45 minutes before meals.

Front 64

To prevent hyperglycemia or hypoglycemia with exercise, the nurse teaches the patient using glucose-lowering agents that exercise should be undertaken
a. only after a 10- to 15-g carbohydrate snack is eaten.
b. about 1 hour after eating, when blood glucose levels are rising.
c. when glucose monitoring reveals that the blood glucose is in the normal range.
d. when blood glucose levels are high because exercise always has a hypoglycemic effect.

Back 64

Correct Answer: B
Rationale: During exercise, a diabetic person needs both adequate glucose to prevent exercise-induced hypoglycemia and adequate insulin because counterregulatory hormones are produced during the stress of exercise and may cause hyperglycemia. Exercise after meals is best, but a 10- to 15-g carbohydrate snack may be taken if exercise is performed before meals or is prolonged. Blood glucose levels should be monitored before, during, and after exercise to determine the effect of exercise on the levels.

Front 65

In nutritional management of all types of diabetes, it is important for the patient to
a. eat regular meals at regular times.
b. restrict calories to promote moderate weight loss.
c. eliminate sucrose and other simple sugars from the diet.
d. limit saturated fat intake to 30% of dietary calorie intake.

Back 65

Correct Answer: A
Rationale: The body requires food at regularly spaced intervals throughout the day, and omission or delay of meals can result in hypoglycemia, especially for the patient taking insulin or oral hypoglycemic agents. Weight loss may be recommended in type 2 diabetes if the individual is overweight, but many patients with type 1 diabetes are thin and require an increase in caloric intake. Fewer than 7% of total calories should be from saturated fats, and simple sugar should be limited, but moderate amounts can be used if counted as a part of total carbohydrate intake.

Front 66

The nurse assesses the diabetic patient’s technique of self-monitoring of blood glucose (SMBG) 3 months after initial instruction. An error in the performance of SMBG noted by the nurse that requires intervention is
a. doing the SMBG before and after exercising.
b. puncturing the finger on the side of the finger pad.
c. cleaning the puncture site with alcohol before the puncture.
d. holding the hand down for a few minutes before the puncture.

Back 66

Correct Answer: C
Rationale: Cleaning the puncture site with alcohol is not necessary and may interfere with test results and lead to drying and splitting of the fingertips. Washing the hands with warm water is adequate cleaning and promotes blood flow to the fingers. Blood flow is also increased by holding the hand down. Punctures on the side of the finger pad are less painful. Self-monitored blood glucose (SMBG) should be performed before and after exercise.

Front 67

A patient with diabetes calls the clinic because she is experiencing nausea and flulike symptoms. The nurse advises the patient to
a. administer the usual insulin dosage.
b. hold fluid intake until the nausea subsides.
c. come to the clinic immediately for evaluation and treatment.
d. monitor the blood glucose every 1 to 2 hours and call if the glucose rises over 150 mg/dL

Back 67

Correct Answer: A
Rationale: During minor illnesses, the patient with diabetes should continue drug therapy and food intake. Insulin is important because counterregulatory hormones may raise blood glucose during the stress of illness, and food or a carbohydrate liquid substitution is important because during illness the body requires extra energy to deal with the stress of the illness. Blood glucose monitoring should be done every 4 hours, and the health care provider should be notified if the level is >240 mg/dL or if fever, ketonuria, or nausea and vomiting occur.

Front 68

A diabetic patient is found unconscious at home, and a family member calls the clinic. After determining that no glucometer is available, the nurse advises the family member to
a. try to arouse the patient to drink some orange juice.
b. administer 10 U of regular insulin subcutaneously.
c. call for an ambulance to transport the patient to a medical facility.
d. administer glucagon 1 mg intramuscularly (IM) or subcutaneously.

Back 68

Correct Answer: D
Rationale: If a diabetic patient is unconscious, immediate treatment for hypoglycemia must be given to prevent brain damage, and IM or subcutaneous administration of 1 mg of glucagon should be done. If the unconsciousness has another cause, such as ketosis, the rise in glucose caused by the glucagon is not as dangerous as the low glucose level. Following administration of the glucagon, the patient should be transported to a medical facility for further treatment and evaluation. Insulin is contraindicated without knowledge of the patient’s glucose level, and oral carbohydrate cannot be given when patients are unconscious.

Front 69

During the nursing assessment of a patient with Graves’ disease, the nurse notes a bounding, rapid pulse and systolic hypertension. Based on these assessment data, which question is important for the nurse to ask the patient?
a. “Do you have any problem with frequent constipation?”
b. “Have you noticed any recent decrease in your appetite?”
c. “Do you ever have any chest pain?”
d. “Have you had recent muscle aches?”

Back 69

Correct Answer: C
Rationale: Angina is a possible complication of Graves’ disease, especially for a patient with tachycardia and hypertension. The other clinical manifestations are associated with hypothyroidism.

Front 70

While assessing a patient who has just arrived in the postanesthesia recovery unit (PACU) after a thyroidectomy, the nurse obtains these data. Which information is most important to communicate to the surgeon?
a. The patient is complaining of 7/10 incisional pain.
b. The patient’s cardiac monitor shows a heart rate of 112.
c. The patient has increasing swelling of the neck.
d. The patient’s voice is weak and hoarse sounding.

Back 70

Correct Answer: C
Rationale: The neck swelling may lead to respiratory difficulty, and rapid intervention is needed to prevent airway obstruction. The incisional pain should be treated but is not unusual after surgery. A heart rate of 112 is not unusual in a patient who has been hyperthyroid and has just arrived in the PACU from surgery. Vocal hoarseness is expected after surgery due to edema.

Front 71

A few hours after returning to the surgical nursing unit, a patient who has undergone a subtotal thyroidectomy develops laryngeal stridor and a cramp in the right hand. The nurse anticipates that intervention will include
a. administration of IV morphine.
b. administration of IV calcium gluconate.
c. endotracheal intubation with mechanical ventilation.
d. immediate tracheostomy and manual ventilation.

Back 71

Correct Answer: B
Rationale: The patient’s clinical manifestations are consistent with tetany caused by hypocalcemia resulting from damage to the parathyroid glands during surgery. Tracheostomy may be needed if the calcium does not resolve the stridor. There is no indication that morphine is needed. Endotracheal intubation may be done, but only if calcium is not effective in correcting the stridor.

Front 72

The nurse identifies a nursing diagnosis of risk for injury: corneal ulceration related to inability to close the eyelids secondary to exophthalmos for a patient with Graves’ disease. An appropriate nursing intervention for this problem is to
a. teach the patient to blink every few seconds to lubricate the cornea.
b. elevate the head of the patient’s bed to reduce periorbital fluid.
c. apply eye patches to protect the cornea from irritation.
d. place cold packs on the eyes to relieve pain and swelling.

Back 72

Correct Answer: B
Rationale: The patient should sit upright as much as possible to promote fluid drainage from the periorbital area. With exophthalmos, the patient is unable to close the eyes completely. Lubrication of the eyes, rather than eye patches, will protect the eyes from developing corneal scarring. The swelling of the eye is not caused by excessive blood flow to the eye, so cold packs will not be helpful.

Front 73

The first nursing action indicated when a patient returns to the surgical nursing unit following a thyroidectomy is to
a. check the dressing for bleeding.
b. assess respiratory rate and effort.
c. support the patient’s head with pillows.
d. take the blood pressure and pulse.

Back 73

Correct Answer: B
Rationale: Airway obstruction is a possible complication after thyroidectomy because of swelling or bleeding at the site or tetany, and the priority nursing action is to assess the airway. The other actions are also part of the standard nursing care post-thyroidectomy but are not as high in priority.

Front 74

A patient with hyperthyroidism is treated with radioactive iodine (RAI) at a clinic. Before the patient is discharged, the nurse instructs the patient
a. to monitor for symptoms of hypothyroidism, such as easy bruising and cold intolerance.
b. to discontinue the antithyroid medications taken before the radioactive therapy.
c. that symptoms of hyperthyroidism should be relieved in about a week.
d. about radioactive precautions to take with urine, stool, and other body secretions.

Back 74

Correct Answer: A
Rationale: There is a high incidence of post-radiation hypothyroidism after RAI, and the patient should be monitored for symptoms of hypothyroidism. RAI has a delayed response, with the maximum effect not seen for 2 to 3 months, and the patient will continue to take antithyroid medications during this time. The therapeutic dose of radioactive iodine is low enough that no radiation safety precautions are needed.

Front 75

A 72-year-old patient is diagnosed with hypothyroidism, and levothyroxine (Synthroid) is prescribed. During initiation of thyroid replacement for the patient, it is most important for the nurse to assess
a. mental status.
b. nutritional level.
c. cardiac function.
d. fluid balance.

Back 75

Correct Answer: C
Rationale: In older patients, initiation of levothyroxine therapy can increase myocardial oxygen demand and cause angina or dysrhythmias. The medication is also expected to improve mental status and fluid balance and will increase metabolic rate and nutritional needs, but these changes do not indicate a need to change the therapy.

Front 76

When teaching a patient with newly diagnosed hypothyroidism about management of the condition, the nurse should
a. delay teaching about the condition until the patient has responded to replacement therapy.
b. provide written handouts of all instructions for continued reference as the patient improves.
c. have a family member teach the patient about the condition when the patient is more alert.
d. arrange for daily home visits by home health nurses to repeat the necessary instructions.

Back 76

Correct Answer: B
Rationale: Written instructions will be helpful to the patient because initially the hypothyroid patient may be unable to remember to take medications and other aspects of self-care. Teaching should not be delayed, but family members or friends should be included in teaching to assist the patient. The nurse, not a family member, is responsible for patient teaching. Because thyroid replacement does not begin to improve alertness immediately, it is not appropriate to schedule daily home health visits for teaching.

Front 77

A nursing assessment of a patient with Cushing syndrome reveals that the patient has truncal obesity and thin arms and legs. An additional manifestation of Cushing syndrome that the nurse would expect to find is
a. chronically low blood pressure.
b. decreased axillary and pubic hair.
c. purplish red streaks on the abdomen.
d. bronzed appearance of the skin.

Back 77

Correct Answer: C
Rationale: Purplish-red striae on the abdomen are a common clinical manifestation of Cushing syndrome. Hypotension and bronzed-appearing skin are manifestations of Addison’s disease. Decreased axillary and pubic hair occur with androgen deficiency.

Front 78

A patient with Cushing syndrome is admitted to the hospital to have laparoscopic adrenalectomy. During the admission assessment, the patient tells the nurse, “The worst thing about this disease is how terrible I look. I feel awful about it.” The best response by the nurse is
a. “Let me show you how to dress so that the changes are not so noticeable.”
b. “I do not think you look bad. Your appearance is just altered by your disease.”
c. “Most of the physical and mental changes caused by the disease will gradually improve after surgery.”
d. “You really should not worry about how you look in the hospital. We see many worse things.”

Back 78

Correct Answer: C
Rationale: The most reassuring communication to the patient is that the physical and emotional changes caused by the Cushing syndrome will resolve after hormone levels return to normal postoperatively. The response beginning “Let me show you how to dress” indicates that the changes are permanent and that the patient’s appearance needs disguising. The response beginning, “I do not think you look bad” does not acknowledge the patient’s feelings and also fails to communicate that the changes will be resolved after surgery. And the response beginning “You really should not worry about how you look in the hospital” implies that the patient’s appearance is not good.

Front 79

When providing postoperative care for a patient who has had bilateral adrenalectomy, which assessment information obtained by the nurse is most important to communicate to the health care provider?
a. The blood glucose is 156 mg/dl.
b. The patient’s blood pressure is 102/50.
c. The patient has 5/10 incisional pain.
d. The lungs have bibasilar crackles.

Back 79

Correct Answer: B
Rationale: During the immediate postoperative period, marked fluctuation in cortisol levels may occur and the nurse must be alert for signs of acute adrenal insufficiency such as hypotension. The nurse should also address the elevated glucose, incisional pain, and crackles with appropriate collaborative or nursing actions, but prevention and treatment of acute adrenal insufficiency is the priority after adrenalectomy.

Front 80

A patient with Cushing syndrome returns to the surgical unit following an adrenalectomy. During the initial postoperative period, the nurse gives the highest priority to
a. monitoring for infection.
b. protecting the patient’s skin.
c. maintaining fluid and electrolyte status.
d. preventing severe emotional disturbances.

Back 80

Correct Answer: C
Rationale: After adrenalectomy, the patient is at risk for circulatory instability caused by fluctuating hormone levels, and the focus of care is to assess and maintain fluid and electrolyte status through the use of IV fluids and corticosteroids. The other goals are also important for the patient but are not as immediately life-threatening as circulatory collapse.

Front 81

A patient is hospitalized with acute adrenal insufficiency. The nurse determines that the patient is responding favorably to treatment upon finding
a. decreasing serum sodium.
b. decreasing serum potassium.
c. decreasing blood glucose.
d. increasing urinary output.

Back 81

Correct Answer: B
Rationale: Clinical manifestations of Addison’s disease include hyperkalemia and a decrease in potassium level indicates improvement. Decreasing serum sodium and decreasing blood glucose indicate that treatment has not been effective. Changes in urinary output are not an effective way of monitoring treatment for Addison’s disease.

Front 82

A patient is admitted to the hospital in addisonian crisis 1 month after a diagnosis of Addison’s disease. The nurse identifies the nursing diagnosis of ineffective therapeutic regimen management related to lack of knowledge of management of condition when the patient says,
a. “I double my dose of hydrocortisone on the days that I go for a run.”
b. “I had the stomach flu earlier this week and couldn’t take the hydrocortisone.”
c. “I frequently eat at restaurants, and so my food has a lot of added salt.”
d. “I do yoga exercises almost every day to help me reduce stress and relax.”

Back 82

Correct Answer: B
Rationale: The need for hydrocortisone replacement is increased with stressors such as illness, and the patient needs to be taught to call the health care provider because medication and IV fluids and electrolytes may need to be given. The other patient statements indicate appropriate management of the Addison’s disease.

Front 83

A patient who uses every-other-day prednisone therapy for rheumatoid arthritis complains of not feeling as well on the non-prednisone days and asks the nurse about taking prednisone daily instead. The best response to the patient is that
a. an every-other-day schedule mimics the normal pattern of cortisol secretion from the adrenal gland.
b. glucocorticoids are taken on a daily basis only when they are being used for replacement therapy.
c. if it improves the symptoms, it would be acceptable to take half the usual dose every day.
d. there is less effect on normal adrenal function when prednisone is taken every other day.

Back 83

Correct Answer: D
Rationale: An alternate-day regimen is given to minimize the impact of exogenous glucocorticoids on adrenal gland function. The normal pattern of cortisol secretion is diurnal. Glucocorticoids are taken daily when being used for replacement therapy, but this is not the only indication for daily use. Taking half the usual dose would not achieve the goal of minimizing adrenal gland suppression.

Front 84

A patient is taking high doses of prednisone to control the symptoms of an acute exacerbation of systemic lupus erythematosus. When teaching the patient about the use of prednisone, which information is most important for the nurse to include?
a. Call the doctor if you experience any mood alterations with the prednisone.
b. Do not stop taking the prednisone suddenly; it should be decreased gradually.
c. Weigh yourself daily to monitor for weight gain caused by water or increased fat.
d. Check your temperature daily because prednisone can hide signs of infection.

Back 84

Correct Answer: B
Rationale: Acute adrenal insufficiency may occur if exogenous glucocorticoids are suddenly stopped. Mood alterations and weight gain are possible adverse effects of glucocorticoid use, but these are not life-threatening effects. Glucocorticoids do mask the signs of infection, but temperature elevation tends to be suppressed, so other signs of infection should be monitored.

Front 85

A patient has an adrenocortical adenoma causing hyperaldosteronism and is scheduled for laparoscopic surgery to remove the tumor. During care before surgery, the nurse should
a. monitor blood glucose level every 4 hours.
b. provide a potassium-restricted diet.
c. monitor the blood pressure every 4 hours.
d. relieve edema by elevating the extremities.

Back 85

Correct Answer: C
Rationale: Hypertension caused by sodium retention is a common complication of hyperaldosteronism. Hyperaldosteronism does not cause elevation in blood glucose. The patient will be hypokalemic and require potassium supplementation prior to surgery. Edema does not usually occur with hyperaldosteronism.

Front 86

To determine the severity of the symptoms for a patient with benign prostatic hyperplasia (BPH), the nurse will ask the patient about
a. the presence of blood in the urine.
b. any erectile dysfunction (ED).
c. occurrence of a weak urinary stream.
d. lower back and hip pain.

Back 86

Correct Answer: C
Rationale: The American Urological Association (AUA) Symptom Index for a patient with BPH asks questions about the force and frequency of urination, nocturia, etc. Blood in the urine, ED, and back or hip pain are not typical symptoms with BPH.

Front 87

A patient scheduled for a transurethral resection of the prostate (TURP) for BPH tells the nurse that he has delayed having surgery because he is afraid it will affect his sexual function. When responding to his concern, the nurse explains that
a. with this type of surgery, erectile problems are rare, but retrograde ejaculation may occur.
b. information about penile implants used for ED is available if he is interested.
c. there are many methods of sexual expression that can be alternatives to sexual intercourse.
d. sterility will not be a problem after surgery because sperm production will not be affected.

Back 87

Correct Answer: A
Rationale: Erectile problems are rare, but retrograde ejaculation may occur after TURP. Erectile function is not usually affected by a TURP, so the patient will not need information about penile implants or reassurance that other forms of sexual expression may be used. Because the patient has not asked about fertility, reassurance about sperm production does not address his concerns.

Front 88

A 41-year-old man asks the nurse what he can do to decrease the risk of BPH. The nurse explains that
a. riding a bicycle raises prostate specific antigen levels and may increase BPH risk.
b. prevention is not possible because prostatic enlargement occurs with normal aging.
c. decreasing butter and margarine and increasing fruits in the diet may help.
d. taking a daily vitamin E supplement has reduced prostate size in some men.

Back 88

Correct Answer: C
Rationale: A diet high in saturated fats, found in foods like butter, is associated with an increased risk for BPH. Individuals who eat more fruits and vegetables may be at lower risk. Riding a bicycle does increase prostate-specific antigen (PSA) levels, but this is not associated with development of BPH. Dietary changes and increased exercise do appear to help prevent BPH. Vitamin E supplements do not decrease prostate size.

Front 89

A patient undergoing a TURP returns from surgery with a three-way urinary catheter with continuous bladder irrigation in place. The nurse observes that the urine output has decreased and the urine is clear red with multiple clots. The patient is complaining of painful bladder spasms. The most appropriate action by the nurse is to
a. administer the ordered IV morphine sulfate, 4 mg.
b. increase the flow rate of the continuous bladder irrigation.
c. give the ordered the belladonna and opium suppository.
d. manually instill 50 ml of saline and try to remove the clots.

Back 89

Correct Answer: D
Rationale: The assessment suggests that obstruction by a clot is causing the bladder spasms, and the nurse’s first action should be to irrigate the catheter manually and to try to remove the clots. IV morphine will not decrease the spasm, although pain may be reduced. Increasing the flow rate of the irrigation will further distend the bladder and may increase spasms. The belladonna and opium suppository will decrease bladder spasms but will not remove the obstructing blood clot.

Front 90

The wife of a patient who has undergone a TURP and has continuous bladder irrigation asks the nurse about the purpose of the continuous bladder irrigation. Which response by the nurse is appropriate?
a. “The bladder irrigation is needed to stop the postoperative bleeding in the bladder.”
b. “The irrigation is needed to keep the catheter from being occluded by blood clots.”
c. “Normal production of urine is maintained with the irrigations until healing occurs.”
d. “Antibiotics are being administered into the bladder with the irrigation solution.”

Back 90

Correct Answer: B
Rationale: The purpose of bladder irrigation is to remove clots from the bladder and to prevent obstruction of the catheter by clots. The irrigation does not decrease bleeding or maintain urine production. Antibiotics are given by the IV route, not through the bladder irrigation.

Front 91

A patient with symptomatic BPH is scheduled for visual laser ablation of the prostate (VLAP) at an outpatient surgical center. The nurse will plan to teach the patient
a. how to care for an indwelling urinary catheter.
b. that the urine will appear bloody for several days.
c. to expect an immediate improvement in urinary force.
d. that an intraprostatic urethral stent will be placed.

Back 91

Correct Answer: A
Rationale: The patient will have indwelling catheter for up to a week and will need to be instructed on catheter care to avoid problems such as infection. There is minimal bleeding with this procedure. It will take several weeks before the full benefits of the procedure take effect. Stent placement is not included in the procedure.

Front 92

The health care provider orders a blood test for prostate-specific antigen (PSA) when an enlarged prostate is palpated during a routine examination of a 56-year-old man. When the patient asks the nurse the purpose of the test, the nurse’s response is based on the knowledge that
a. elevated levels of PSA are indicative of metastatic cancer of the prostate.
b. PSA testing is the “gold standard” for making a diagnosis of prostate cancer.
c. baseline PSA levels are necessary to determine whether treatment is effective.
d. PSA levels are usually elevated in patients with cancer of the prostate.

Back 92

Correct Answer: D
Rationale: PSA levels are usually elevated above the normal in patients with prostate cancer. PSA testing does not determine whether metastasis has occurred. A biopsy of the prostate is needed for a definitive diagnosis of prostate cancer. Success of treatment is determined by a fall in PSA to an undetectable level; the patient’s baseline PSA is not needed to determine the success of treatment.

Front 93

A 64-year-old man undergoes a perineal radical prostatectomy for stage C prostatic cancer. Postoperatively, the nurse establishes the nursing diagnosis of risk for infection related to
a. urinary stasis.
b. urinary incontinence.
c. possible fecal contamination of the surgical wound.
d. placement of a suprapubic catheter into the bladder.

Back 93

Correct Answer: C
Rationale: The perineal approach increases the risk for infection because the incision is located close to the anus and contamination with feces is possible. Urinary stasis and incontinence do not occur because the patient has a retention catheter in place for 1 to 2 weeks. A urethral catheter is used after the surgery.

Front 94

Following discharge teaching for a patient who has had a transurethral prostatectomy for benign prostatic hyperplasia (BPH), the nurse determines that additional instruction is needed when the patient says,
a. “I will increase fiber and fluids in my diet to prevent constipation.”
b. “I should call the doctor if I have any incontinence at home.”
c. “I will avoid heavy lifting or driving until I get approval from my health care provider.”
d. “I should continue to schedule yearly appointments for prostate exams.”

Back 94

Correct Answer: B
Rationale: Incontinence is common for several weeks after a TURP. The other patient statements indicate that the patient has a good understanding of post-TURP instructions.

Front 95

Leuprolide (Lupron), an LH-RH Agonist, and bicalutamide (Casodex), an androgen receptor blocker, are prescribed for a patient with cancer of the prostate. In teaching the patient about these drugs, the nurse informs the patient that side effects may include

a. low blood pressure.
b. decreased sexual drive.
c. urinary incontinence.
d. frequent infections.

Back 95

Correct Answer: B
Rationale: Hormonal therapy blocks the effects of testosterone and decreases libido. Hypotension is associated with the -blockers used for BPH. Urinary incontinence may occur after prostate surgery, but it is not an expected medication side effect. Risk for infection is increased in patients receiving chemotherapy.

Front 96

11. A 32-year-old man scheduled for a unilateral orchiectomy for testicular cancer is admitted to the hospital the morning of surgery. He is accompanied by his wife but does not talk to her and does not initiate interaction with the nurse. The most appropriate action by the nurse is to
a. ask the patient if he has any questions or concerns about the diagnosis and treatment.
b. tell the patient’s wife that concerns about sexual function are common with this diagnosis.
c. teach the patient that impotence is rarely a problem after unilateral orchiectomy.
d. document the patient’s lack of communication on the chart and continue preoperative care.

Back 96

Correct Answer: A
Rationale: The initial action by the nurse should be assessment for any anxiety or questions about the surgery or postoperative care. The nurse should address the patient, not the spouse, when discussing the diagnosis and any possible concerns. Without further assessment of patient concerns, it is inappropriate for the nurse to initiate teaching. It would be inappropriate for the nurse to provide patient teaching without further assessment of the patient’s teaching needs and concerns. Documentation of the patient’s lack of interaction is not an adequate nursing action in this situation.

Front 97

When taking a nursing history from a patient with BPH, the nurse would expect the patient to report
a. nocturia, dysuria, and bladder spasms.
b. urinary frequency, hematuria, and perineal pain.
c. urinary hesitancy, postvoid dribbling, and weak urinary stream.
d. urinary urgency with a forceful urinary stream and cloudy urine.

Back 97

Correct Answer: C
Rationale: Classic symptoms of uncomplicated BPH are those associated with urinary obstruction and include diminished caliber and force of the urinary stream, hesitancy, difficulty initiating voiding, intermittent urination, dribbling at the end of urination, and a feeling of incomplete bladder emptying because of urinary retention. Irritative symptoms, including nocturia, frequency, dysuria, urgency, or hematuria, occur if infection results from urinary retention.

Front 98

On admission to the ambulatory surgical center, a patient with BPH informs the nurse that he is going to have a laser treatment of his enlarged prostate. The nurse plans patient teaching with the knowledge that the patient will need
a. monitoring for postoperative urinary retention.
b. teaching about the effects of general anesthesia.
c. to be informed of the possibility of short-term incontinence.
d. instruction about home management of an indwelling catheter.

Back 98

Correct Answer: D
Rationale: Because of edema, urinary retention, and delayed sloughing of tissue that occurs with a laser prostatectomy, the patient will have postprocedure catheterization for up to 7 days. The procedure is done under local anesthetic, and incontinence is not usually a problem.

Front 99

1. When counseling an older patient about ways to prevent fractures, which information will the nurse include?
a. Tacking down scatter rugs in the home is recommended.
b. Occasional weight-bearing exercise will improve muscle and bone strength.
c. Most falls happen outside the home.
d. Buying shoes that provide good support and are comfortable to wear is recommended.

Back 99

Correct Answer: D
Rationale: Comfortable shoes with good support will help to decrease the risk for falls. Scatter rugs should be eliminated, not just tacked down. Regular weight-bearing exercise will improve strength, but occasional exercise is not helpful in improving strength. Falls inside the home are responsible for many injuries.

Front 100

A patient is seen at the urgent care center after falling on the right arm and shoulder. It will be most important for the nurse to determine
a. whether there is bruising at the shoulder area.
b. whether the right arm is shorter than the left.
c. the amount of pain the patient is experiencing.
d. how much range of motion (ROM) is present.

Back 100

Correct Answer: B
Rationale: A shorter limb after a fall indicates a possible dislocation, which is an orthopedic emergency. The nurse will expect bruising and pain at the area, even without an injury that requires surgery. The shoulder should be immobilized until it is evaluated by the health care provider.

Front 101

patient arrives in the emergency department with ankle swelling and severe pain after twisting the ankle playing soccer. All of the following orders are written by the health care provider. Which one will the nurse act on first?
a. Administer naproxen (Naprosyn) 500 mg PO.
b. Wrap the ankle and apply an ice pack.
c. Give acetaminophen with codeine (Tylenol #3).
d. Take the patient to the radiology department for x-rays.

Back 101

Correct Answer: B
Rationale: Immediate care after a sprain or strain injury includes the application of cold and compression to the injury to minimize swelling. The other actions should be taken after the ankle is wrapped with a compression bandage and ice is applied.

Front 102

4. Following x-rays of an injured wrist, the patient is informed that it is badly sprained. In teaching the patient to care for the injury, the nurse tells the patient to
a. apply a heating pad to reduce muscle spasms.
b. wear an elastic compression bandage continuously.
c. use pillows to keep the arm elevated above the heart.
d. gently exercise the joint to prevent muscle shortening.

Back 102

Correct Answer: C
Rationale: Elevation of the arm will reduce the amount of swelling and pain. For the first 24 to 48 hours, cold packs are used to reduce swelling. Compression bandages are not left on continuously. The wrist should be rested and kept

Front 103

5. A 22-year-old patient started an exercise regimen 2 months ago that includes running 3 to 4 miles a day. The patient tells the nurse, “I enjoy my daily runs, but now I have shin splints.” Which response by the nurse is appropriate?
a. “You may be increasing your running time too quickly and need to cut back a little bit.”
b. “You need to have x-rays of your lower legs to be sure you do not have stress fractures.”
c. “You should expect some leg pain while running.”
d. “You should try speed-walking rather than running.”

Back 103

Correct Answer: A
Rationale: The patient’s information about running 3 to 4 miles daily after starting an exercise program only 2 months previously suggests that the shin splints are caused by overuse. Radiographs are not indicated for the type of injury described by the patient. Shin splints are not a normal or expected response to running. Because the patient expresses enjoyment of running, it would not be appropriate for the nurse to suggest a different sport.

Front 104

6. A patient with a fractured pelvis is initially treated with bed rest with no turning from side to side permitted. The second day after admission, the patient develops chest pain, tachypnea, and tachycardia. The nurse determines that the patient’s symptoms are most likely related to fat embolism when assessment of the patient reveals
a. a blood pressure of 100/65 mm Hg.
b. anxiety, restlessness, and confusion.
c. warm, reddened areas in the calf.
d. pinpoint red areas on the upper chest.

Back 104

Correct Answer: D
Rationale: The presence of petechiae helps distinguish fat embolism from other problems. The other symptoms might occur with fat embolism but could also occur with other postoperative complications such as bleeding, myocardial infarction, venous thrombosis, or hypoxemia.

Front 105

7. After falling at home, a patient is admitted to the emergency department, where x-rays confirm the presence of an extracapsular fracture of the femur. When assessing the patient, the nurse would expect to find
a. bruising of the left hip and thigh.
b. numbness in the left leg and hip.
c. outward pointing toes on the left leg.
d. weak or nonpalpable left leg pulses.

Back 105

Correct Answer: C
Rationale: External rotation of the leg is a classic sign associated with a hip fracture. Bruising does not always appear rapidly, and bruising extending to the thigh might indicate hemorrhage. Numbness and decreased pulses are not typical of a hip fracture unless there is associated tissue swelling and trauma to blood vessels.

Front 106

8. A patient who has severe peripheral arterial disease and ischemic foot ulcers is upset with the health care provider’s recommendation to have an above-the-knee amputation. The patient tells the nurse, “If they want to cut off my leg, they should just shoot me instead.” The most appropriate response to the patient’s statement is,
a. “Let’s talk about how you feel this surgery will affect you.”
b. “If you do not want the surgery, you do not have to have it.”
c. “I understand why you are upset, but there really is no choice because your leg is so badly diseased.”
d. “Many people are able to function normally with a prosthesis after amputation, and you can too.”

Back 106

Correct Answer: A
Rationale: The initial nursing action should be to assess how the patient feels about the amputation and what the patient knows about the procedure and rehabilitation process. Discussion about the patient’s option to not have the procedure, the reason the procedure is needed, or rehabilitation after the procedure may be appropriate after the nurse knows more about the patient’s current level of knowledge and emotional state.

Front 107

9. On the first postoperative day, a patient with a below-the-knee amputation complains of pain in the amputated limb. An appropriate action by the nurse is to
a. administer prescribed opioids to relieve the pain.
b. explain the reasons for phantom limb pain.
c. loosen the compression bandage to decrease incisional pressure.
d. remind the patient that this phantom pain will diminish over time.

Back 107

Correct Answer: A
Rationale: Phantom limb pain is treated like any other type of postoperative pain would be treated. Explanations of the reason for the pain may be given, but the nurse should still medicate the patient. The compression bandage is left in place except during physical therapy or bathing. Although the pain may decrease over time, it still requires treatment now.

Front 108

10. When giving home-care instructions to a patient who has multiple forearm fractures and a long-arm cast on the right arm, which information should the nurse include?
a. Keep the hand immobile to prevent soft tissue swelling.
b. Call the health care provider for increased swelling or numbness.
c. Keep the right shoulder elevated on a pillow or cushion.
d. Avoid the use of NSAIDs for the first 48 hours after the injury.

Back 108

Correct Answer: B
Rationale: Increased swelling or numbness may indicate increased pressure at the injury, and the health care provider should be notified immediately to avoid damage to nerves and other tissues. The patient should be encouraged to move the joints above and below the cast to avoid stiffness. There is no need to elevate the shoulder, although the forearm should be elevated to reduce swelling. NSAIDs are appropriate to treat pain after a fracture.

Front 109

11. A patient who has a proximal humerus fracture that is immobilized with a left-sided long-arm cast, and a sling is admitted to the medical-surgical unit. Which nursing intervention will be included in the plan of care?
a. Use surgical net dressing to hang the arm from an IV pole.
b. Immobilize the fingers on the left hand with gauze dressings.
c. Assess the left axilla and change absorbent dressings as needed.
d. Assist the patient in passive range of motion (ROM) for the right arm.

Back 109

Correct Answer: C
Rationale: The axilla can become excoriated when a sling is used to support the arm, and the nurse should check the axilla and apply absorbent dressings to prevent this. A patient with a sling would not have traction applied by hanging. The patient will be encouraged to move the fingers on the injured arm to maintain function and to help decrease swelling. The patient will do active ROM on the uninjured side.

Front 110

12. A 26-year-old woman has been diagnosed with early systemic lupus erythematosus (SLE) involving her joints. In teaching the patient about the disease, the nurse includes the information that SLE is a(n)
a. hereditary disorder of women but usually does not show clinical symptoms unless a woman becomes pregnant.
b. autoimmune disease of women in which antibodies are formed that destroy all nucleated cells in the body.
c. disorder of immune function, but it is extremely variable in its course, and there is no way to predict its progression.
d. disease that causes production of antibodies that bind with cellular estrogen receptors, causing an inflammatory response.

Back 110

Correct Answer: C
Rationale: SLE has an unpredictable course, even with appropriate treatment. Women are more at risk for SLE, but it is not confined exclusively to women. Clinical symptoms may worsen during pregnancy but are not confined to pregnancy or the perinatal period. All nucleated cells are not destroyed by the antinuclear antibodies. The inflammation in SLE is not caused by antibody binding to cellular estrogen receptors.

Front 111

13. A patient with an acute exacerbation of systemic lupus erythematosus (SLE) is hospitalized with incapacitating fatigue, acute hand and wrist pain, and proteinuria. The health care provider prescribes prednisone (Deltasone) 40 mg twice daily. Which nursing action should be included in the plan of care?
a. Institute seizure precautions.
b. Reorient to time and place PRN.
c. Monitor intake and output.
d. Place on cardiac monitor.

Back 111

Correct Answer: C
Rationale: Lupus nephritis is a common complication of SLE, and when the patient is taking corticosteroids, it is especially important to monitor renal function. There is no indication that the patient is experiencing any nervous system or cardiac problems with the SLE.

Front 112

14. A patient with systemic lupus erythematosus (SLE) who has a facial rash and alopecia tells the nurse, “I hate the way I look! I never go anyplace except here to the health clinic.” An appropriate nursing diagnosis for the patient is
a. activity intolerance related to fatigue and inactivity.
b. impaired skin integrity related to itching and skin sloughing.
c. social isolation related to embarrassment about the effects of SLE.
d. impaired social interaction related to lack of social skills.

Back 112

Correct Answer: C
Rationale: The patient’s statement about not going anyplace because of hating the way he or she looks supports the diagnosis of social isolation because of embarrassment about the effects of the SLE. Activity intolerance is a possible problem for patients with SLE, but the information about this patient does not support this as a diagnosis. The rash with SLE is nonpruritic. There is no evidence of lack of social skills for this patient.

Front 113

A patient with polyarthralgia with joint swelling and pain is being evaluated for systemic lupus erythematosus (SLE). The nurse knows that the serum test result that is the most specific for SLE is the presence of
a. rheumatoid factor.
b. anti-Smith antibody (Anti-Sm).
c. antinuclear antibody (ANA).
d. lupus erythematosus (LE) cell prep.

Back 113

Correct Answer: B
Rationale: The anti-Sm is antibody found almost exclusively in SLE. The other blood tests are also used in screening but are not as specific to SLE.

Front 114

16. Following instruction for a patient with newly diagnosed systemic lupus erythematosus (SLE), the nurse determines that teaching about the disease has been effective when the patient says,
a. “I should expect to have a low fever all the time with this disease.”
b. “I need to restrict my exposure to sunlight to prevent an acute onset of symptoms.”
c. “I should try to ignore my symptoms as much as possible and have a positive outlook.”
d. “I can expect a temporary improvement in my symptoms if I become pregnant.”

Back 114

Correct Answer: B
Rationale: Sun exposure is associated with SLE exacerbation, and patients should use sunscreen with an SPF of at least 15 and stay out of the sun between 11:00 AM and 3:00 PM. Low-grade fever may occur with an exacerbation but should not be expected all the time. A positive attitude may decrease the incidence of SLE exacerbations, but patients are taught to self-monitor for symptoms that might indicate changes in the disease process. Symptoms may worsen during pregnancy and especially during the postpartum period.

Front 115

A patient is admitted to the emergency department with possible fractures of the bones of the left lower extremity. The initial action by the nurse should be to
a. Splint the lower leg.
b. Elevate the left leg.
c. Check the popliteal, dorsalis pedis, and posterior tibia pulses.
d. Obtain information about the patient’s tetanus immunization status.

Back 115

Correct Answer: C
Rationale: The initial nursing action should be assessment of the neurovascular status of the injured leg. After assessment, the nurse may need to splint and elevate the leg, based on the assessment data. Information about tetanus immunizations should be done if there is an open wound.

Front 116

A patient hospitalized with multiple fractures has a long-arm plaster cast applied for immobilization of a fractured left radius. Until the cast has completely dried, the nurse should
a. Keep the left arm in a dependent position.
b. Handle the cast with the palms of the hands.
c. Place gauze around the cast edge to pad any roughness.
d. Cover the cast with a small blanket to absorb the dampness.

Back 116

Correct Answer: B
Rationale: Until a plaster cast has dried, placing pressure on the cast should be avoided to prevent creating areas inside the cast that could place pressure on the arm. The left arm should be elevated to prevent swelling. The edges of the cast may be petaled once the cast is dry, but padding the edges before that may cause the cast to be misshapen. The cast should not be covered until it is dry because heat builds up during drying.

Front 117

The nurse provides discharge instructions to a patient with an above-the-knee amputation who will be fitted with a prosthesis when healing is complete and the residual limb is well molded. The nurse determines that teaching has been effective when the patient says,
a. “I should change the limb sock when it becomes soiled or stretched out.”
b. “I should use lotion on the stump to prevent drying and cracking of the skin.”
c. “I should elevate my residual limb on a pillow 2 or 3 times a day.”
d. “I should lay on my abdomen for 30 minutes 3 or 4 times a day.”

Back 117

Correct Answer: D
Rationale: The patient lies in the prone position several times daily to prevent flexion contractures of the hip. The limp sock should be changed daily. Lotion should not be used on the stump. The residual limb should not be elevated because this would encourage flexion contracture

Front 118

An older adult woman is admitted to the emergency department after falling at home. The nurse cautions the patient not to put weight on the leg after finding
a. inability to move the toes and ankle.
b. edema of the thigh extending to the knee.
c. internal rotation of the leg with groin pain.
d. shortening and external rotation of the leg.

Back 118

Correct Answer: D
Rationale: The classic signs of a hip fracture are shortening of the leg and external rotation accompanied by severe pain at the fracture site, and additional injury could be caused by weight bearing on the extremity. The patient may not be able to move the hip or the knee, but movement in the ankle and toes is not affected.

Front 119

A patient with an extracapsular hip fracture is admitted to the orthopedic unit and placed in Buck’s traction. The nurse explains to the patient that the purpose of the traction is to
a. pull bone fragments back into alignment.
b. immobilize the leg until healing is complete.
c. reduce pain and muscle spasms before surgery.
d. prevent damage to the blood vessels at the fracture site.

Back 119

Correct Answer: C
Rationale: Although surgical repair is the preferred method of managing intracapsular and extracapsular hip fractures, initially patients frequently may be treated with skin traction, such as Buck’s extension or Russell’s traction, to immobilize the limb temporarily and to relieve the painful muscle spasms before surgery is performed. Prolonged traction would be required to reduce the fracture or immobilize it for healing, creating a very high risk for complications of immobility.

Front 120

A patient with a fractured right hip has an open reduction and internal fixation of the fracture with compression screw and plate. Postoperatively the nurse plans to
a. get the patient up in the chair the first postoperative day.
b. position the patient only on the back and unoperative side.
c. keep leg abductor splints on the patient except when bathing.
d. ambulate the patient with partial weight bearing by discharge.

Back 120

Correct Answer: A
Rationale: Because the fracture site is internally fixed with pins or plates, the fracture site is stable, and the patient is moved from the bed to the chair on the first postoperative day, with ambulation beginning on the first or second postoperative day, without weight bearing on the affected leg. Weight bearing on the affected extremity is usually restricted for 6 to 12 weeks until adequate healing is evident on x-ray. The patient may be positioned on the operative side following internal fixation, and abductor pillows are used for patients who have femoral head prosthesis or total hip replacements.

Front 121

Discharge instructions for the patient following a hip fracture with femoral head prosthesis include
a. restricting walking for 2 to 3 months.
b. taking a bath rather than a shower to prevent falling.
c. keeping the leg internally rotated while sitting and standing.
d. having a family member put on the patient’s shoes and socks.

Back 121

Correct Answer: D
Rationale: Patients with hip prostheses or a total hip arthroplasty must avoid extreme flexion, adduction, or internal rotation for at least 6 weeks to prevent dislocation of the prosthesis. Gradual weight bearing on the limb is allowed, and ambulation should be encouraged.

Front 122

A 65-year-old patient has undergone a right total hip arthroplasty with a cemented prosthesis for treatment of severe osteoarthritis of the hip. Patient activity that the nurse anticipates on the patient’s first or second postoperative day includes
a. transfer from bed to chair twice a day only.
b. turning from the back to the unaffected side q2hr only.
c. crutch walking with non–weight bearing on the operative leg.
d. ambulation and weight bearing on the right leg with a walker.

Back 122

Correct Answer: D
Rationale: Physical therapy is initiated 1 day postoperatively with ambulation and weight bearing using a walker for a patient with a cemented prosthesis and non–weight bearing on the operative side for an uncemented prosthesis. In addition, the patient is turned to both sides and back with support of the operative leg and sits in the chair at least twice a day

Front 123

When positioning the patient with a total hip arthroplasty, it is important that the nurse maintain the affected extremity in
a. adduction and flexion.
b. extension and abduction.
c. abduction and internal rotation.
d. adduction and external rotation.

Back 123

Correct Answer: B
Rationale: Following a total hip arthroplasty, extremes of internal rotation, adduction, and 90-degree flexion of the hip must be avoided for 4 to 6 weeks postoperatively to prevent dislocation of the prosthesis. During hospitalization an abduction pillow is placed between the legs to maintain abduction, and the leg is extended.

Front 124

Following a knee arthroplasty, a patient has a continuous passive-motion machine for the affected joint. The nurse explains to the patient that this device is used to
a. relieve edema and pain at the incision site.
b. promote early joint mobility and increase knee flexion.
c. prevent venous stasis and the formation of a deep venous thrombosis.
d. improve arterial circulation to the affected extremity to promote healing.

Back 124

Correct Answer: B
Rationale: Continuous passive motion machines are frequently used following knee surgery to promote earlier joint mobility. Because joint dislocation is not a problem with knee replacements, early exercise with straight leg raises and gentle ROM is also encouraged postoperatively.

Front 125

Priority Decision: Following change-of-shift handoff, which patient should the nurse assess first?
a. a 58-year-old male experiencing phantom pain and requesting analgesic
b. a 72-year-old male being transferred to a skilled nursing unit following repair of a hip fracture
c. a 25-year-old female in left leg skeletal traction asking for the weights to be lifted for a few minutes
d. a 68-year-old male with a new lower leg cast complaining that the cast is too tight and he can’t feel his toes

Back 125

Correct Answer: D
Rationale: The patient with a tight cast may be at risk for neurovascular compromise (impaired circulation and peripheral nerve damage) and should be assessed first. The other patients should be seen as soon as possible. Providing analgesia for the patient with phantom pain would be the next priority. The patient in skeletal traction needs explanation of the purpose and functioning of the traction. She may need analgesia or muscle relaxants to help tolerate the traction.

Front 126

1. The nurse is assessing a patient with gastroesophageal reflux disease (GERD) who is experiencing increasing discomfort. Which patient statement indicates that additional patient education about GERD is needed?
a. “I take antacids between meals and at bedtime each night.”
b. “I quit smoking several years ago, but I still chew a lot of gum.”
c. “I sleep with the head of the bed elevated on 4-inch blocks.”
d. “I eat small meals throughout the day and have a bedtime snack.”

Back 126

Correct Answer: D
Rationale: GERD is exacerbated by eating late at night, and the nurse should plan to teach the patient to avoid eating at bedtime. The other patient actions are appropriate to control symptoms of GERD.

Front 127

2. When admitting a patient with a stroke who is unconscious and unresponsive to stimuli, the nurse learns from the patient’s family that the patient has a history of GERD. The nurse will plan to do frequent assessment of the patient’s
a. bowel sounds.
b. breath sounds.
c. apical pulse.
d. abdominal girth.

Back 127

Correct Answer: B
Rationale: Because GERD may cause aspiration, the unconscious patient is at risk for developing aspiration pneumonia. Bowel sounds, abdominal girth, and apical pulse will not be affected by the patient’s stroke or GERD and do not require more frequent monitoring than the routine.

Front 128

3. When admitting a patient with a stroke who is unconscious and unresponsive to stimuli, the nurse learns from the patient’s family that the patient has a history of GERD. The nurse will plan to do frequent assessment of the patient’s
a. bowel sounds.
b. breath sounds.
c. apical pulse.
d. abdominal girth.

Back 128

Correct Answer: B
Rationale: Because GERD may cause aspiration, the unconscious patient is at risk for developing aspiration pneumonia. Bowel sounds, abdominal girth, and apical pulse will not be affected by the patient’s stroke or GERD and do not require more frequent monitoring than the routine.

Front 129

4. A patient with recurring heartburn receives a new prescription for esomeprazole (Nexium). In teaching the patient about this medication, the nurse explains that this drug
a. reduces the reflux of gastric acid by increasing the rate of gastric emptying.
b. coats and protects the lining of the stomach and esophagus from gastric acid.
c. treats gastroesophageal reflux disease by decreasing stomach acid production.
d. neutralizes stomach acid and provides relief of symptoms in a few minutes.

Back 129

Correct Answer: C
Rationale: The proton pump inhibitors decrease the rate of gastric acid secretion. Promotility drugs such as metoclopramide (Reglan) increase the rate of gastric emptying. Cryoprotective medications such as sucralfate (Carafate) protect the stomach. Antacids neutralize stomach acid and work rapidly.

Front 130

5. After the nurse teaches a patient with GERD about recommended dietary modifications, which diet choice for a snack 2 hours before bedtime indicates that the teaching has been effective?
a. Chocolate pudding
b. Glass of low-fat milk
c. Peanut butter sandwich
d. Cherry gelatin and fruit

Back 130

Correct Answer: D
Rationale: Gelatin and fruit are low fat and will not decrease lower esophageal sphincter (LES) pressure. Foods like chocolate are avoided because they lower LES pressure. Milk products increase gastric acid secretion. High-fat foods such as peanut butter decrease both gastric emptying and LES pressure.

Front 131

6. Which information will the nurse include when teaching a patient with newly diagnosed GERD?
a. “Peppermint tea may be helpful in reducing your symptoms.”
b. “You will need to keep the head of your bed elevated on blocks.”
c. “You should avoid eating between meals to reduce acid secretion.”
d. “Vigorous physical activities may increase the incidence of reflux.”

Back 131

Correct Answer: B
Rationale: Elevating the head of the bed will reduce the incidence of reflux while the patient is sleeping. Peppermint will lower LES pressure and increase the chance for reflux. Small, frequent meals are recommended to avoid abdominal distension. There is no need to make changes in physical activities because of GERD.

Front 132

7. A patient with chronic gastritis associated with the presence of Helicobacter pylori is treated with triple-drug therapy. The nurse explains to the patient that the drugs commonly included in this regimen include
a. famotidine (Pepcid), magnesium hydroxide (Mylanta), and pantoprazole (Protonix).
b. amoxicillin (Amoxil ), clarithromycin (Biaxin), and omeprazole (Prilosec).
c. sucralfate (Carafate), mycostatin (Nystatin), and bismuth subsalicylate (Pepto-Bismol).
d. metoclopramide (Reglan), bethanecol (Urecholine), and promethazine (Phenergan).

Back 132

Correct Answer: B
Rationale: The drugs used in triple-drug therapy include a proton pump inhibitor such as omeprazole and the antibiotics amoxicillin and clarithromycin. The other combinations listed are not included in the protocol for H. pylori infection.

Front 133

8. A patient with a bleeding duodenal ulcer has an NG tube in place, and the health care provider orders 30 ml of aluminum hydroxide/magnesium hydroxide (Maalox) to be instilled through the tube every hour. To evaluate the effectiveness of this treatment, the nurse
a. periodically aspirates and tests gastric pH.
b. measures the amount of residual stomach contents hourly.
c. monitors arterial blood gas values on a daily basis.
d. checks each stool for the presence of occult blood.

Back 133

Correct Answer: A
Rationale: The purpose for antacids is to increase gastric pH; checking gastric pH is the most direct way of evaluating the effectiveness of the medication. Arterial blood gases may change slightly, but this does not directly reflect the effect of antacids on gastric pH. Because the patient has upper GI bleeding, occult blood in the stools will appear even after the acute bleeding has stopped. The amount of residual stomach contents is not a reflection of resolution of bleeding or of gastric pH.

Front 134

9. A patient with a peptic ulcer who has an NG tube develops sudden, severe upper abdominal pain, diaphoresis, and a very firm abdomen. Which action should the nurse take next?
a. Irrigate the NG tube.
b. Obtain the vital signs.
c. Give the ordered antacid.
d. Listen for bowel sounds.

Back 134

Correct Answer: B
Rationale: The patient’s symptoms suggest acute perforation, and the nurse should assess for signs of hypovolemic shock. Irrigation of the NG tube, administration of antacids, or both would be contraindicated because any material in the stomach will increase the spillage into the peritoneal cavity. The nurse should assess the bowel sounds, but this is not the first action that the nurse should take.

Front 135

10. The nurse implements discharge teaching for a patient following a gastroduodenostomy for treatment of a peptic ulcer. Which patient statement indicates that the teaching has been effective?
a. “I will need to choose foods that are low in fat and high in carbohydrate.”
b. “I will try to drink liquids along with my meals.”
c. “Vitamin injections may be needed to prevent problems with anemia.”
d. “The surgery has cured my peptic ulcer disease.”

Back 135

Correct Answer: C
Rationale: Cobalamin deficiency may occur after partial gastrectomy, and the patient may need to receive cobalamin injections. Foods that have moderate fat and low carbohydrate should be chosen to prevent dumping syndrome. Ingestion of liquids with meals is avoided to prevent dumping syndrome. Peptic ulcer disease (PUD) is a chronic problem, and the patient will need to continue lifestyle changes and perhaps medications to prevent recurrence.

Front 136

11. A patient recovering from a gastrojejunostomy (Billroth II) for treatment of a duodenal ulcer develops dizziness, weakness, and palpitations, with an urge to defecate about 20 minutes after eating. To avoid recurrence of these symptoms, the nurse teaches the patient to
a. increase the amount of fluid intake with meals.
b. lie down for about 30 minutes after eating.
c. drink sugared fluids or eat candy after each meal.
d. choose foods that are high in carbohydrates.

Back 136

Correct Answer: B
Rationale: The patient is experiencing symptoms of dumping syndrome, which may be reduced by lying down after eating. Increasing fluid intake and choosing high carbohydrate foods will increase the risk for dumping syndrome. Having a sweet drink or hard candy will correct the hypoglycemia that is associated with dumping syndrome but will not prevent dumping syndrome.

Front 137

12. While obtaining a nursing history from a 55-year-old patient scheduled for a colonoscopy, the nurse will be most concerned about
a. lifelong constipation.
b. nausea and vomiting.
c. history of an appendectomy.
d. recent blood in the stools.

Back 137

Correct Answer: D
Rationale: Rectal bleeding is associated with colorectal cancer. Recent changes in bowel patterns are a clinical manifestation of colorectal cancer, but lifelong constipation is not an indication. Nausea and vomiting are not common clinical manifestations of problems with the distal GI tract. An appendectomy is not a risk factor for cancer of the colon

Front 138

13. During preoperative preparation for a patient scheduled for an abdominal-perineal resection, the nurse will
a. give IV antibiotics starting 24 hours before surgery to reduce the number of bowel bacteria.
b. teach the patient that activities such as sitting at the bedside will be started the first postoperative day.
c. instruct the patient that another surgery in 8 to 12 weeks will be used to create an ileal-anal reservoir.
d. administer enemas and laxatives to ensure that the bowel is empty before the surgery.

Back 138

Correct Answer: D
Rationale: A bowel-cleansing agent is used to empty the bowel before surgery to reduce the risk for infection. Oral antibiotics are given to reduce colonic and rectal bacteria. Sitting is contraindicated after an abdominal-perineal resection. A permanent colostomy is created with this surgery.

Front 139

14. A patient returns from surgery following an abdominal-perineal resection with a sigmoid colostomy and abdominal and perineal incisions. The colostomy is dressed with petroleum jelly gauze and dry gauze dressings. The perineal incision is partially closed and has two drains attached to Jackson-Pratt suction. On the first postoperative day, the nurse gives the highest priority to
a. teaching about a low-residue diet.
b. monitoring drainage from the stoma.
c. assessing the perineal drainage and incision.
d. encouraging acceptance of the colostomy site.

Back 139

Correct Answer: C
Rationale: Because the perineal wound is at high risk for infection, the initial care is focused on assessment and care of this wound. Teaching about diet is best done closer to discharge from the hospital. There will be very little drainage into the colostomy until peristalsis returns. The patient will be encouraged to assist with the colostomy, but this is not the highest priority in the immediate postoperative period.

Front 140

15. During the initial postoperative assessment of a patient’s stoma formed with a transverse colostomy, the nurse finds it to be red with moderate edema and a small amount of bleeding. The nurse should
a. document the stoma assessment.
b. notify the surgeon about the stoma appearance.
c. monitor the stoma every 30 minutes.
d. place an ice pack on the stoma to reduce swelling.

Back 140

Correct Answer: A
Rationale: The stoma appearance indicates good circulation to the stoma. There is no indication that surgical intervention is needed or that frequent stoma monitoring is required. Swelling of the stoma is normal for 2 to 3 weeks after surgery, and an ice pack is not needed.

Front 141

16. When implementing the initial plan of care for a patient admitted with acute diverticulitis, the nurse will
a. administer IV fluids.
b. order a diet high in fiber and fluids.
c. give stool softeners.
d. prepare the patient for colonoscopy.

Back 141

Correct Answer: A
Rationale: A patient with acute diverticulitis will be NPO with parenteral fluids. A diet high in fiber and fluids will be implemented before discharge. Bulk-forming laxatives, rather than stool softeners, are usually given, and these will be implemented later in the hospitalization. The patient with acute diverticulitis will not have colonoscopy because of the risk for perforation and peritonitis.

Front 142

17. A patient with a gunshot wound to the abdomen undergoes surgery, and a colostomy is formed as illustrated. The nurse explains to the patient that

a. this type of colostomy is usually temporary.
b. soft, formed stool can be expected as drainage.
c. the drainage is liquid at this site but less odorous than at higher sites.
d. colostomy irrigations can help regulate the drainage from the proximal stoma.

Back 142

Correct Answer: A
Rationale: A loop or double-barrel stoma is usually temporary

Front 143

18. The nurse is obtaining a history for a 23-year-old woman who is being evaluated for acute lower abdominal pain and vomiting. Which question will be most useful in determining the cause of the patient’s symptoms?
a. “Is it possible that you are pregnant?”
b. “Can you tell me more about the pain?”
c. “What type of foods do you usually eat?”
d. “What is your usual elimination pattern?”

Back 143

CORRECT ANS: B
A complete description of the pain provides clues about the cause of the problem. The usual diet and elimination patterns are less helpful in determining the reason for the patient’s symptoms. Although the nurse should ask whether the patient is pregnant to determine whether the patient might have an ectopic pregnancy and before any radiology studies are done, this information is not the most useful in determining the cause of the pain.

Front 144

19. Two days after an exploratory laparotomy with a resection of a short segment of small bowel, a patient complains of gas pains and abdominal distention. Which nursing action is best to take at this time?
a. Give a return-flow enema.
b. Assist the patient to ambulate.
c. Administer the ordered IV morphine sulfate.
d. Insert the ordered promethazine (Phenergan) suppository.

Back 144

ANS: B
Ambulation will improve peristalsis and help the patient eliminate flatus and reduce gas pain. Morphine will further reduce peristalsis. A return-flow enema may decrease the patient’s symptoms, but ambulation is less invasive and should be tried first. Promethazine (Phenergan) is used as an antiemetic rather than to decrease gas pains or distention.

Front 145

20. A patient is admitted to the hospital for evaluation of right lower quadrant abdominal pain with nausea and vomiting. Which action should the nurse take?
a. Check for rebound tenderness.
b. Assist the patient to cough and deep breathe.
c. Apply an ice pack to the right lower quadrant.
d. Encourage the patient to take sips of clear liquids.

Back 145

ANS: C
The patient’s clinical manifestations are consistent with appendicitis, and application of an ice pack will decrease inflammation at the area. The patient should be NPO in case immediate surgery is needed. Checking for rebound tenderness frequently is unnecessary and uncomfortable for the patient. The patient will need to know how to cough and deep breathe postoperatively, but coughing will increase pain at this time.

Front 146

21. A patient hospitalized with an acute exacerbation of ulcerative colitis is having 14 to 16 bloody stools a day and crampy abdominal pain associated with the diarrhea. The nurse will plan to
a. place the patient on NPO status.
b. administer IV metoclopramide (Reglan).
c. teach the patient about total colectomy surgery.
d. administer cobalamin (vitamin B12) injections.

Back 146

ANS: A
An initial therapy for an acute exacerbation of inflammatory bowel disease (IBD) is to rest the bowel by making the patient NPO. Cobalamin (vitamin B12) is absorbed in the ileum, which is not affected by ulcerative colitis. Although total colectomy is needed for some patients, there is no indication that this patient is a candidate. Metoclopramide increases peristalsis and will worsen symptoms.

Front 147

22. A patient who has an exacerbation of ulcerative colitis is having 15 to 20 stools daily and has excoriated perianal skin. Which patient behavior indicates that teaching regarding maintenance of skin integrity has been effective?
a. The patient uses incontinence briefs to contain loose stools.
b. The patient asks for antidiarrheal medication after each stool.
c. The patient uses witch hazel compresses to decrease anal irritation.
d. The patient cleans the perianal area with soap and water after each stool.

Back 147

ANS: C
Witch hazel compresses are suggested to reduce anal irritation and discomfort. Incontinence briefs may trap diarrhea and increase the incidence of skin breakdown. Antidiarrheal medications are not given 15 to 20 times a day. The perianal area should be washed with plain water after each stool.

Front 148

23. When caring for a patient who has a new diagnosis of Crohn’s disease after having frequent diarrhea and a weight loss of 10 pounds (4.5 kg) over 2 months, the nurse will plan to teach the patient about
a. medication use.
b. fluid restriction.
c. enteral nutrition.
d. activity restrictions.

Back 148

ANS: A
Medications are used to induce and maintain remission in patients with inflammatory bowel disease (IBD). Decreased activity level is indicated only if the patient has severe fatigue and weakness. Fluids are needed to prevent dehydration. There is no advantage to enteral feedings.

Front 149

24. A patient with Crohn’s disease develops a fever and symptoms of a urinary tract infection (UTI) with tan, fecal-smelling urine. The nurse will teach the patient
a. to clean the perianal area carefully after any stools.
b. about fistula formation between the bowel and bladder.
c. to empty the bladder before and after sexual intercourse.
d. about the effects of corticosteroid use on immune function.

Back 149

ANS: B
Fistulas between the bowel and bladder occur in Crohn’s disease and can lead to UTI. There is no information indicating that the patient’s risk for UTI is caused by poor cleaning or not voiding before and after intercourse. Steroid use may increase the risk for infection, but the characteristics of the patient’s urine indicate that a fistula has occurred.

Front 150

25. A patient has a large bowel obstruction that occurred as a result of diverticulosis. When assessing the patient, the nurse will plan to monitor for
a. referred back pain.
b. metabolic alkalosis.
c. projectile vomiting.
d. abdominal distention.

Back 150

ANS: D
Abdominal distention is seen in lower intestinal obstruction. Metabolic alkalosis is common in high intestinal obstruction because of the loss of HCl acid from vomiting. Referred back pain is not a common clinical manifestation of intestinal obstruction. Bile-colored vomit is associated with higher intestinal obstruction.

Front 151

26. Which nursing action is most important to include in the plan of care for a patient who had an abdominal-perineal resection the previous day?
a. Teach about a low-residue diet.
b. Monitor output from the stoma.
c. Assess the perineal drainage and incision.
d. Encourage acceptance of the colostomy stoma.

Back 151

ANS: C
Because the perineal wound is at high risk for infection, the initial care is focused on assessment and care of this wound. Teaching about diet is best done closer to discharge from the hospital. There will be very little drainage into the colostomy until peristalsis returns. The patient will be encouraged to assist with the colostomy, but this is not the highest priority in the immediate postoperative period.

Front 152

27. When interviewing a patient with abdominal pain and possible irritable bowel syndrome, which question will be most important for the nurse to ask?
a. “Have you been passing a lot of gas?”
b. “What foods affect your bowel patterns?”
c. “Do you have any abdominal distention?”
d. “How long have you had abdominal pain?”

Back 152

ANS: D
One criterion for the diagnosis of irritable bowel syndrome (IBS) is the presence of abdominal discomfort or pain for at least 3 months. Abdominal distention, flatulence, and food intolerance also are associated with IBS, but are not diagnostic criteria.

Front 153

28. Following an exploratory laparotomy and bowel resection, a patient who has a nasogastric tube to suction complains of nausea and stomach distention. The first action by the nurse should be to
a. auscultate for hypotonic bowel sounds.
b. notify the patient’s health care provider.
c. reposition the tube and check for placement.
d. remove the tube and replace it with a new one.

Back 153

C
Repositioning the tube will frequently facilitate drainage. Because this is a common occurrence, it is not appropriate to notify the health care provider. Information about the presence or absence of bowel tones will not be helpful in improving drainage. Removing the tube and replacing it are unnecessarily traumatic to the patient.

Front 154

29. After receiving change-of-shift report, which of the following patients should the nurse assess first?
a. A patient whose new ileostomy has drained 800 mL over the previous 8 hours
b. A patient with familial adenomatous polyposis who has occult blood in the stool
c. A patient with ulcerative colitis who has had six liquid stools in the previous 4 hours
d. A patient who has abdominal distention and an apical heart rate of 136 beats/minute

Back 154

ANS: D
The patient’s abdominal distention and tachycardia suggest hypovolemic shock caused by problems such as peritonitis or intestinal obstruction, which will require rapid intervention. The other patients also should be assessed as quickly as possible, but the data do not indicate any life-threatening complications associated with their diagnoses.

Front 155

30. A patient has had an esophagogastroduodenoscopy with local anesthetic spray to the throat during the procedure. The assessment that determines whether the patient can have fluids after the procedure is
a. Ability to swallow without discomfort
b. Presence of gag reflex when a tongue blade touches the back of the throat
c. Absence of nausea or abdominal distention
d. Presence of active bowel sounds

Back 155

Answer: B
Rationale: If local anesthetic spray is used on the throat the patient should remain NPO until the gag reflex returns. Gently tickle the back of the throat to determine if the gag reflex is present. Fluids should not be given to test for the gag reflex. Options C and D do not give information about the gag reflex.

Front 156

31. In preparing a patient for a colonoscopy, the nurse explains that
a. a signed permit is not necessary.
b. sedation may be used during the procedure.
c. only one cleansing enema is necessary for preparation.
d. a regular diet may be eaten the day before the procedure.

Back 156

Answer: B
Rationale: IV sedation will be used during the procedure. The patient will be asked to sign a consent for this invasive procedure. Bowel preparation may involve laxative pills and drinking 1 gallon of GoLytely (polyethylene glycol) the day before to cleanse the bowel. In addition, a liquid diet is recommended for 1-2 days before the procedure.

Front 157

32. The nurse explains to the patient undergoing ostomy surgery that the procedure that maintains the most normal functioning of the bowel is
a. A sigmoid colostomy
b. A transverse colostomy
c. An ileostomy
d. An ascending colostomy

Back 157

Answer: A
Rationale: A sigmoid colostomy is most likely to have formed stool and may be regulated by irrigation. Stool from an ileostomy will be liquid to semiliquid. Stool from an ascending or transverse colostomy will be semiliquid.

Front 158

After the insertion of an arteriovenous graft (AVG) in the right forearm, a patient complains of pain and coldness of the right fingers. Which action should the nurse take?
a. Elevate the patient’s arm above the level of the heart.
b. Report the patient’s symptoms to the health care provider.
c. Remind the patient about the need to take a daily low-dose aspirin tablet.
d. Educate the patient about the normal vascular response after AVG insertion.

Back 158

ANS: B
The patient’s complaints suggest the development of distal ischemia (steal syndrome) and may require revision of the AVG. Elevation of the arm above the heart will decrease perfusion. Pain and coolness are not normal after AVG insertion. Aspirin therapy is not used to maintain grafts.

Front 159

A patient with acute kidney injury (AKI) has an arterial blood pH of 7.30. The nurse will assess the patient for
a. vasodilation.
b. poor skin turgor.
c. bounding pulses.
d. rapid respirations.

Back 159

ANS: D
Patients with metabolic acidosis caused by AKI may have Kussmaul respirations as the lungs try to regulate carbon dioxide. Bounding pulses and vasodilation are not associated with metabolic acidosis. Because the patient is likely to have fluid retention, poor skin turgor would not be a finding in AKI.

Front 160

A patient with severe heart failure develops elevated blood urea nitrogen (BUN) and creatinine levels. The nurse will plan care to meet the goal of
a. replacing fluid volume.
b. preventing hypertension.
c. maintaining cardiac output.
d. diluting nephrotoxic substances.

Back 160

ANS: C
The primary goal of treatment for acute kidney injury (AKI) is to eliminate the cause and provide supportive care while the kidneys recover. Because this patient’s heart failure is causing AKI, the care will be directed toward treatment of the heart failure. For renal failure caused by hypertension, hypovolemia, or nephrotoxins, the other responses would be correct.

Front 161

A patient who has acute glomerulonephritis is hospitalized with acute kidney injury (AKI) and hyperkalemia. Which information will the nurse obtain to evaluate the effectiveness of the prescribed calcium gluconate IV?
a. Urine output
b. Calcium level
c. Cardiac rhythm
d. Neurologic status

Back 161

ANS: C
The calcium gluconate helps prevent dysrhythmias that might be caused by the hyperkalemia. The nurse will monitor the other data as well, but these will not be helpful in determining the effectiveness of the calcium gluconate.

Front 162

Which statement by a patient with stage 5 chronic kidney disease (CKD) indicates that the nurse’s teaching about management of CKD has been effective?
a. “I need to try to get more protein from dairy products.”
b. “I will try to increase my intake of fruits and vegetables.”
c. “I will measure my urinary output each day to help calculate the amount I can drink.”
d. “I need to take the erythropoietin to boost my immune system and help prevent infection.”

Back 162

ANS: C
The patient with end-stage renal disease is taught to measure urine output as a means of determining an appropriate oral fluid intake. Erythropoietin is given to increase the red blood cell count and will not offer any benefit for immune function. Dairy products are restricted because of the high phosphate level. Many fruits and vegetables are high in potassium and should be restricted in the patient with CKD.

Front 163

Before administering sodium polystyrene sulfonate (Kayexalate) to a patient with hyperkalemia, the nurse should assess the
a. blood urea nitrogen (BUN) and creatinine.
b. blood glucose level.
c. patient’s bowel sounds.
d. level of consciousness (LOC).

Back 163

ANS: C
Sodium polystyrene sulfonate (Kayexalate) should not be given to a patient with a paralytic ileus (as indicated by absent bowel sounds) because bowel necrosis can occur. The BUN and creatinine, blood glucose, and LOC would not affect the nurse’s decision to give the medication.

Front 164

The nurse has instructed a patient who is receiving hemodialysis about appropriate dietary choices. Which menu choice by the patient indicates that the teaching has been successful?
a. Scrambled eggs, English muffin, and apple juice
b. Oatmeal with cream, half a banana, and herbal tea
c. Split-pea soup, whole-wheat toast, and nonfat milk
d. Cheese sandwich, tomato soup, and cranberry juice

Back 164

ANS: A
Scrambled eggs would provide high-quality protein, and apple juice is low in potassium. Cheese is high in salt and phosphate, and tomato soup would be high in potassium. Split-pea soup is high in potassium, and dairy products are high in phosphate. Bananas are high in potassium, and the cream would be high in phosphate.

Front 165

Which information will be most useful to the nurse in evaluating improvement in kidney function for a patient who is hospitalized with acute kidney injury (AKI)?
a. Blood urea nitrogen (BUN) level
b. Urine output
c. Creatinine level
d. Calculated glomerular filtration rate (GFR)

Back 165

ANS: D
GFR is the preferred method for evaluating kidney function. BUN levels can fluctuate based on factors such as fluid volume status. Urine output can be normal or high in patients with AKI and does not accurately reflect kidney function. Creatinine alone is not an accurate reflection of renal function.

Front 166

A patient needing vascular access for hemodialysis asks the nurse what the differences are between an arteriovenous (AV) fistula and a graft. The nurse explains that one advantage of the fistula is that it
a. is much less likely to clot.
b. increases patient mobility.
c. can accommodate larger needles.
d. can be used sooner after surgery.

Back 166

ANS: A
AV fistulas are much less likely to clot than grafts, although it takes longer for them to mature to the point where they can be used for dialysis. The choice of an AV fistula or a graft does not have an impact on needle size or patient mobility.

Front 167

When caring for a patient with a left arm arteriovenous fistula, which action will the nurse include in the plan of care to maintain the patency of the fistula?
a. Check the fistula site for a bruit and thrill.
b. Assess the rate and quality of the left radial pulse.
c. Compare blood pressures in the left and right arms.
d. Irrigate the fistula site with saline every 8 to 12 hours.

Back 167

ANS: A
The presence of a thrill and bruit indicates adequate blood flow through the fistula. Pulse rate and quality are not good indicators of fistula patency. Blood pressures should never be obtained on the arm with a fistula. Irrigation of the fistula might damage the fistula, and typically only dialysis staff would access the fistula.

Front 168

When a patient who has had progressive chronic kidney disease (CKD) for several years is started on hemodialysis, which information about diet will the nurse include in patient teaching?
a. Increased calories are needed because glucose is lost during hemodialysis.
b. Unlimited fluids are allowed since retained fluid is removed during dialysis.
c. More protein will be allowed because of the removal of urea and creatinine by dialysis.
d. Dietary sodium and potassium are unrestricted because these levels are normalized by dialysis.

Back 168

ANS: C
Once the patient is started on dialysis and nitrogenous wastes are removed, more protein in the diet is encouraged. Fluids are still restricted to avoid excessive weight gain and complications such as shortness of breath. Glucose is not lost during hemodialysis. Sodium and potassium intake continues to be restricted to avoid the complications associated with high levels of these electrolytes.

Front 169

Which action by a patient who is using peritoneal dialysis (PD) indicates that the nurse should provide more teaching about PD?
a. The patient slows the inflow rate when experiencing pain.
b. The patient leaves the catheter exit site without a dressing.
c. The patient plans 30 to 60 minutes for a dialysate exchange.
d. The patient cleans the catheter while taking a bath every day.

Back 169

ANS: D
RATIONALE: Patients are encouraged to take showers rather than baths to avoid infections at the catheter insertion side. The other patient actions indicate good understanding of peritoneal dialysis.

Front 170

When the nurse is taking a history for a patient who is a possible candidate for a kidney transplant, which information about the patient indicates that the patient is not an appropriate candidate for transplantation?
a. The patient has metastatic lung cancer.
b. The patient has poorly controlled type 1 diabetes.
c. The patient has a history of chronic hepatitis C infection.
d. The patient is infected with the human immunodeficiency virus.

Back 170

ANS: A
Disseminated malignancies are a contraindication to transplantation. The conditions of the other patients are not contraindications for kidney transplant.

Front 171

The nurse is caring for a patient who had kidney transplantation several years ago. Which assessment finding may indicate that the patient is experiencing adverse effects to the prescribed corticosteroid?
a. Joint pain
b. Tachycardia
c. Postural hypotension
d. Increase in creatinine level

Back 171

ANS: A
Aseptic necrosis of the weight-bearing joints can occur when patients take corticosteroids over a prolonged period. Increased creatinine level, orthostatic dizziness, and tachycardia are not caused by corticosteroid use.

Front 172

In a patient with acute kidney injury (AKI) who requires hemodialysis, a temporary vascular access is obtained by placing a catheter in the left femoral vein. Which intervention will be included in the plan of care?
a. Place the patient on bed rest.
b. Start continuous pulse oximetry.
c. Discontinue the retention catheter.
d. Restrict the patient’s oral protein intake.

Back 172

ANS: A
The patient with a femoral vein catheter must be on bed rest to prevent trauma to the vein. Protein intake is likely to be increased when the patient is receiving dialysis. The retention catheter is likely to remain in place because accurate measurement of output will be needed. There is no indication that the patient needs continuous pulse oximetry.

Front 173

Which information about a patient who was admitted 10 days previously with acute kidney injury (AKI) caused by dehydration will be most important for the nurse to report to the health care provider?
a. The blood urea nitrogen (BUN) level is 67 mg/dL.
b. The creatinine level is 3.0 mg/dL.
c. Urine output over an 8-hour period is 2500 mL.
d. The glomerular filtration rate is <30 mL/min/1.73m2.

Back 173

ANS: C
The high urine output indicates a need to increase fluid intake to prevent hypovolemia. The other information is typical of AKI and will not require a change in therapy.

Front 174

After noting lengthening QRS intervals in a patient with acute kidney injury (AKI), which action should the nurse take first?
a. Document the QRS interval.
b. Notify the patient’s health care provider.
c. Look at the patient’s current blood urea nitrogen (BUN) and creatinine levels.
d. Check the chart for the most recent blood potassium level.

Back 174

ANS: D
The increasing QRS interval is suggestive of hyperkalemia, so the nurse should check the most recent potassium and then notify the patient’s health care provider. The BUN and creatinine will be elevated in a patient with AKI, but they would not directly affect the electrocardiogram (ECG). Documentation of the QRS interval also is appropriate, but interventions to decrease the potassium level are needed to prevent life-threatening bradycardia.

Front 175

When caring for a dehydrated patient with acute kidney injury who is oliguric, anemic, and hyperkalemic, which of the following prescribed actions should the nurse take first?
a. Insert a urinary retention catheter.
b. Place the patient on a cardiac monitor.
c. Administer epoetin alfa (Epogen, Procrit).
d. Give sodium polystyrene sulfonate (Kayexalate).

Back 175

ANS: B
Since hyperkalemia can cause fatal cardiac dysrhythmias, the initial action should be to monitor the cardiac rhythm. Kayexalate and Epogen will take time to correct the hyperkalemia and anemia. The catheter allows monitoring of the urine output, but does not correct the cause of the renal failure.

Front 176

The nurse is assessing a patient who is receiving peritoneal dialysis with 2 L inflows. Which information should be reported immediately to the health care provider?
a. The patient has an outflow volume of 1800 mL.
b. The patient’s peritoneal effluent appears cloudy.
c. The patient has abdominal pain during the inflow phase.
d. The patient complains of feeling bloated after the inflow.

Back 176

ANS: B
Cloudy appearing peritoneal effluent is a sign of peritonitis and should be reported immediately so that treatment with antibiotics can be started. The other problems can be addressed through nursing interventions such as slowing the inflow and repositioning the patient.

Front 177

Two hours after a kidney transplant, the nurse obtains all of the following data when assessing the patient. Which information is most important to communicate to the health care provider?
a. The urine output is 900 to 1100 mL/hr.
b. The blood urea nitrogen (BUN) and creatinine levels are elevated.
c. The patient’s central venous pressure (CVP) is decreased.
d. The patient has level 8 (on a 10-point scale) incisional pain.

Back 177

ANS: C
The decrease in CVP suggests hypovolemia, which must be rapidly corrected to prevent renal hypoperfusion and acute tubular necrosis. The other information is not unusual in a patient after a transplant.

Front 178

A patient in the oliguric phase of acute renal failure has a 24-hour fluid output of 150 mL emesis and 250 mL urine. The nurse plans a fluid replacement for the following day of ___ mL.
a. 400
b. 800
c. 1000
d. 1400

Back 178

ANS: C
Usually fluid replacement should be based on the patient’s measured output plus 600 mL/day for insensible losses.

Front 179

During hemodialysis, a patient complains of nausea and dizziness. Which action should the nurse take first?
a. Slow down the rate of dialysis.
b. Obtain blood to check the blood urea nitrogen (BUN) level.
c. Check the patient’s blood pressure.
d. Give prescribed PRN antiemetic drugs.

Back 179

ANS: C
The patient’s complaints of nausea and dizziness suggest hypotension, so the initial action should be to check the BP. The other actions also may be appropriate, based on the blood pressure obtained.

Front 180

Which parameter will be most important for the nurse to consider when titrating the IV fluid infusion rate immediately after a patient has had kidney transplantation?
a. Heart rate
b. Blood urea nitrogen (BUN) level
c. Urine output
d. Creatinine clearance

Back 180

ANS: C
Fluid volume is replaced based on urine output after transplant because the urine output can be as high as a liter an hour. The other data will be monitored but are not the most important determinants of fluid infusion rate.

Front 181

A patient complains of leg cramps during hemodialysis. The nurse should first
a. reposition the patient.
b. massage the patient’s legs.
c. give acetaminophen (Tylenol).
d. infuse a bolus of normal saline.

Back 181

ANS: D
Muscle cramps during dialysis are caused by rapid removal of sodium and water. Treatment includes infusion of normal saline. The other actions do not address the reason for the cramps.

Front 182

1. For the patient with Crohn’s Disease, what signs and symptoms indicate a Nursing Diagnosis of Imbalanced Nutrition: Less than Body Requirements?

-What patient signs and symptoms?

-What lab values?

Back 182

Signs and Symptoms:
wt loss, follow oral intake, monitor weight

Lab values:
Albumin, protein, low hgb and hematocrit

Front 183

2. What acid-base imbalance can result from nasogastric (NG) suctioning?

Back 183

Metabolic Alkalosis

Front 184

1. A patient has a high potassium level of 6.0 (normal 3.5-5.0) and the physician orders IV glucose and insulin for treatment. How will you evaluate the effectiveness of this treatment?

Back 184

Recheck the K level

Front 185

4. Which actions should be avoided in neurologic patients because they may cause increased intracranial pressure (ICP)?

Back 185

clustering interventions
coughing
suctioning
have the bed at 30 degrees

Front 186

5. When a patient is vomiting bright red blood, what are you concerned about? __________________________.
What assessment should you do first? _____________________________.

Back 186

hypovolemic shock, BP and pulse

Front 187

6. A patient is 12 hours postop from having a Billroth I partial gastrectomy surgery. You note 175 cc of bright red blood in the NG drainage.

-What are you concerned about? _________________________________________

-What are your nursing actions? __________________________________________

Back 187

post-op hemorrhage, call MD/check vitals

Front 188

7. How is fluid therapy determined for a postop kidney transplant patient?

Back 188

based on their urine output

Front 189

8. A patient on peritoneal dialysis (PD) has 2 liters of fluid into the PD catheter and 1200 cc drains out. What should you do first?

Back 189

reposition pt

Front 190

9. What is Graves Disease?

Back 190

over secretion of thyroid hormone

Front 191

What is the treatment for Graves Disease?
How long does it take for the treatment to take effect?

Back 191

anti-thyroid medications and 1-2 weeks to 4-8 weeks to be full effect

Front 192

10. For a patient who is immediately postop from thyroidectomy

What are you concerned about?________________________________________

What is your priority nursing assessment?________________________________

Back 192

airway edema, airway/breathing

Front 193

11. What are the signs and symptoms of compartment syndrome? (6P’s)



Which of these are the early signs/symptoms that you should identify in your patients?

Which patients are at risk?

Back 193

Pain, Pallor, Pressure, Parathesia, paralysis, pulselessness

**pain, pallor, pressure, parathesia

crush injuries, cast, soft tissue damage

Front 194

1. Which patient movements are contraindicated for a patient who has had either a total hip arthroplasty (THA) or a femoral head prosthesis? (See Patient Teaching Guide for femoral head prosthesis or THA posted in D2L content for Mod 17-Musculoskeletal)

Back 194

dont cross legs
bend down to tie shoes
nothing greater than 90 degrees flexion
no internal rotation of the foot
no feet together (adduction)

Front 195

13. What should you teach patients about self care following amputation? (See Patient Teaching Guide following Amputation posted in D2L Content for Mod 17-Musculoskeletal)

Back 195

no lotion on residual limb
wear limb sock
shouldn't elevate leg on pillow
lay prone for 30 min 3-4 times a day

Front 196

14. A patient with right sided weakness has intracerebral bleeding identified on the CT scan. Which medications are contraindicated for this type of stroke?

Back 196

anticoagulants, thrombolytics