Exam 3 Flashcards by Ren Montooth

A nurse is assessing a patient with an acoustic neuroma who has been recently admitted
to an oncology unit. What symptoms is the nurse likely to find during the initial
assessment?
A) Loss of hearing, tinnitus, and vertigo
B) Loss of vision, change in mental status, and hyperthermia
C) Loss of hearing, increased sodium retention, and hypertension
D) Loss of vision, headache, and tachycardia

A) Loss of hearing, tinnitus, and vertigo

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A 25-year-old female patient with brain metastases is considering her life expectancy
after her most recent meeting with her oncologist. Based on the fact that the patient is
not receiving treatment for her brain metastases, what is the nurse’s most appropriate
action?
A) Promoting the patient’s functional status and ADLs
B) Ensuring that the patient receives adequate palliative care
C) Ensuring that the family does not tell the patient that her condition is terminal
D) Promoting adherence to the prescribed medication regimen

B) Ensuring that the patient receives adequate palliative care

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The nurse is writing a care plan for a patient with brain metastases. The nurse decides
that an appropriate nursing diagnosis is ìanxiety related to lack of control over the
health circumstances.î In establishing this plan of care for the patient, the nurse should
include what intervention?
A) The patient will receive antianxiety medications every 4 hours.
B) The patient’s family will be instructed on planning the patient’s care.
C) The patient will be encouraged to verbalize concerns related to the disease and its
treatment.
D) The patient will begin intensive therapy with the goal of distraction.

C) The patient will be encouraged to verbalize concerns related to the disease and its
treatment.

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A patient with suspected Parkinson’s disease is initially being assessed by the nurse.
When is the best time to assess for the presence of a tremor?
A) When the patient is resting
B) When the patient is ambulating
C) When the patient is preparing his or her meal tray to eat
D) When the patient is participating in occupational therapy

A) When the patient is resting

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The clinic nurse caring for a patient with Parkinson’s disease notes that the patient has
been taking levodopa and carbidopa (Sinemet) for 7 years. For what common side
effect of Sinemet would the nurse assesses this patient?
A) Pruritus
B) Dyskinesia
C) Lactose intolerance
D) Diarrhea

B) Dyskinesia

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The nurse is caring for a boy who has muscular dystrophy. When planning assistance
with the patient’s ADLs, what goal should the nurse prioritize?
A) Promoting the patient’s recovery from the disease
B) Maximizing the patient’s level of function
C) Ensuring the patient’s adherence to treatment
D) Fostering the family’s participation in care

B) Maximizing the patient’s level of function

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A 37-year-old man is brought to the clinic by his wife because he is experiencing loss
of motor function and sensation. The physician suspects the patient has a spinal cord
tumor and hospitalizes him for diagnostic testing. In light of the need to diagnose
spinal cord compression from a tumor, the nurse will most likely prepare the patient for
what test?
A) Anterior-posterior x-ray
B) Ultrasound
C) Lumbar puncture
D) MRI

D) MRI

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A patient with Parkinson’s disease is undergoing a swallowing assessment because she
has recently developed adventitious lung sounds. The patient’s nutritional needs should
be met by what method?
A) Total parenteral nutrition (TPN)
B) Provision of a low-residue diet
C) Semisolid food with thick liquids
D) Minced foods and a fluid restriction

C) Semisolid food with thick liquids

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While assessing the patient at the beginning of the shift, the nurse inspects a surgical
dressing covering the operative site after the patients’ cervical diskectomy. The nurse
notes that the drainage is 75% saturated with serosanguineous discharge. What is the
nurse’s most appropriate action?
A) Page the physician and report this sign of infection.
B) Reinforce the dressing and reassess in 1 to 2 hours.
C) Reposition the patient to prevent further hemorrhage.
D) Inform the surgeon of the possibility of a dural leak.

D) Inform the surgeon of the possibility of a dural leak

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A patient, diagnosed with cancer of the lung, has just been told he has metastases to the
brain. What change in health status would the nurse attribute to the patient’s metastatic
brain disease?
A) Chronic pain
B) Respiratory distress
C) Fixed pupils
D) Personality changes

D) Personality changes

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A patient has just been diagnosed with Parkinson’s disease and the nurse is planning the
patient’s subsequent care for the home setting. What nursing diagnosis should the nurse
address when educating the patient’s family?
A) Risk for infection
B) Impaired spontaneous ventilation
C) Unilateral neglect
D) Risk for injury

D) Risk for injury

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The nurse is caring for a patient with Huntington disease who has been admitted to the
hospital for treatment of malnutrition. What independent nursing action should be
implemented in the patient’s plan of care?
A) Firmly redirect the patient’s head when feeding.
B) Administer phenothiazines after each meal as ordered.
C) Encourage the patient to keep his or her feeding area clean.
D) Apply deep, gentle pressure around the patient’s mouth to aid swallowing.

D) Apply deep, gentle pressure around the patient’s mouth to aid swallowing.

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A patient has been admitted to the neurologic unit for the treatment of a newly
diagnosed brain tumor. The patient has just exhibited seizure activity for the first time.
What is the nurse’s priority response to this event?
A) Identify the triggers that precipitated the seizure.
B) Implement precautions to ensure the patient’s safety.
C) Teach the patient’s family about the relationship between brain tumors and
seizure activity.
D) Ensure that the patient is housed in a private room.

B) Implement precautions to ensure the patient’s safety.

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A patient diagnosed with a pituitary adenoma has arrived on the neurologic unit. When
planning the patient’s care, the nurse should be aware that the effects of the tumor will
primarily depend on what variable?
A) Whether the tumor utilizes aerobic or anaerobic respiration
B) The specific hormones secreted by the tumor
C) The patient’s pre-existing health status
D) Whether the tumor is primary or the result of metastasis

B) The specific hormones secreted by the tumor

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A male patient with a metastatic brain tumor is having a generalized seizure and begins
vomiting. What should the nurse do first?
A) Perform oral suctioning.
B) Page the physician.
C) Insert a tongue depressor into the patient’s mouth.
D) Turn the patient on his side.

D) Turn the patient on his side.

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The nurse in an extended care facility is planning the daily activities of a patient with
postpolio syndrome. The nurse recognizes the patient will best benefit from physical
therapy when it is scheduled at what time?
A) Immediately after meals
B) In the morning
C) Before bedtime
D) In the early evening

B) In the morning

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A patient newly diagnosed with a cervical disk herniation is receiving health education
from the clinic nurse. What conservative management measures should the nurse teach
the patient to implement?
A) Perform active ROM exercises three times daily.
B) Sleep on a firm mattress.
C) Apply cool compresses to the back of the neck daily.
D) Wear the cervical collar for at least 2 hours at a time.

B) Sleep on a firm mattress.

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A patient has just returned to the unit from the PACU after surgery for a tumor within
the spine. The patient complains of pain. When positioning the patient for comfort and
to reduce injury to the surgical site, the nurse will position to patient in what position?
A) In the high Fowler’s position
B) In a flat side-lying position
C) In the Trendelenberg position
D) In the reverse Trendelenberg position

B) In a flat side-lying position

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A patient with Huntington disease has just been admitted to a long-term care facility.
The charge nurse is creating a care plan for this patient. Nutritional management for a
patient with Huntington disease should be informed by what principle?
A) The patient is likely to have an increased appetite.
B) The patient is likely to required enzyme supplements.
C) The patient will likely require a clear liquid diet.
D) The patient will benefit from a low-protein diet.

A) The patient is likely to have an increased appetite.

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A patient with amyotrophic lateral sclerosis (ALS) is being visited by the home health
nurse who is creating a care plan. What nursing diagnosis is most likely for a patient
with this condition?
A) Chronic confusion
B) Impaired urinary elimination
C) Impaired verbal communication
D) Bowel incontinence

C) Impaired verbal communication

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The nurse educator is discussing neoplasms with a group of recent graduates. The
educator explains that the effects of neoplasms are caused by the compression and
infiltration of normal tissue. The physiologic changes that result can cause what
pathophysiologic events? Select all that apply.
A) Intracranial hemorrhage
B) Infection of cerebrospinal fluid
C) Increased ICP
D) Focal neurologic signs
E) Altered pituitary function

C) Increased ICP
D) Focal neurologic signs
E) Altered pituitary function

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The nurse is caring for a patient newly diagnosed with a primary brain tumor. The
patient asks the nurse where his tumor came from. What would be the nurse’s best
response?
A) ìYour tumor originated from somewhere outside the CNS.
B) ìYour tumor likely started out in one of your glands.
C) ìYour tumor originated from cells within your brain itself.
D) ìYour tumor is from nerve tissue somewhere in your body.

C) ìYour tumor originated from cells within your brain itself.

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A gerontologic nurse is advocating for diagnostic testing of an 81-year-old patient who
is experiencing personality changes. The nurse is aware of what factor that is known to
affect the diagnosis and treatment of brain tumors in older adults?
A) The effects of brain tumors are often attributed to the cognitive effects of aging.
B) Brain tumors in older adults do not normally produce focal effects.
C) Older adults typically have numerous benign brain tumors by the eighth decade
of life.
D) Brain tumors cannot normally be treated in patient over age 75.

A) The effects of brain tumors are often attributed to the cognitive effects of aging.

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A patient who has been experiencing numerous episodes of unexplained headaches and
vomiting has subsequently been referred for testing to rule out a brain tumor. What
characteristic of the patient’s vomiting is most consistent with a brain tumor?
A) The patient’s vomiting is accompanied by epistaxis.
B) The patient’s vomiting does not relieve his nausea.
C) The patient’s vomiting is unrelated to food intake.
D) The patient’s emesis is blood-tinged.

C) The patient’s vomiting is unrelated to food intake.

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A male patient presents at the free clinic with complaints of impotency. Upon physical examination, the nurse practitioner notes the presence of hypogonadism. What diagnosis should the nurse suspect? A) Prolactinoma B) Angioma C) Glioma D) Adrenocorticotropic hormone (ACTH)ñproducing adenoma

A) Prolactinoma

The nurse is planning the care of a patient who has been recently diagnosed with a cerebellar tumor. Due to the location of this patient's tumor, the nurse should implement measures to prevent what complication? A) Falls B) Audio hallucinations C) Respiratory depression D) Labile BP

A) Falls

A patient has been admitted to the neurologic ICU with a diagnosis of a brain tumor. The patient is scheduled to have a tumor resection/removal in the morning. Which of the following assessment parameters should the nurse include in the initial assessment? A) Gag reflex B) Deep tendon reflexes C) Abdominal girth D) Hearing acuity

A) Gag reflex

A patient with a brain tumor has begun to exhibit signs of cachexia. What subsequent assessment should the nurse prioritize? A) Assessment of peripheral nervous function B) Assessment of cranial nerve function C) Assessment of nutritional status D) Assessment of respiratory status

C) Assessment of nutritional status

``` A patient with an inoperable brain tumor has been told that he has a short life expectancy. On what aspects of assessment and care should the home health nurse focus? Select all that apply. A) Pain control B) Management of treatment complications C) Interpretation of diagnostic tests D) Assistance with self-care E) Administration of treatments ```

A) Pain control B) Management of treatment complications D) Assistance with self-care E) Administration of treatments

An older adult has encouraged her husband to visit their primary care provider, stating that she is concerned that he may have Parkinson's disease. Which of the wife's descriptions of her husband's health and function is most suggestive of Parkinson's disease? A) ìLately he seems to move far more slowly than he ever has in the past. B) ìHe often complains that his joints are terribly stiff when he wakes up in the morning. C) ìHe's forgotten the names of some people that we've known for years. D) ìHe's losing weight even though he has a ravenous appetite.

A) ìLately he seems to move far more slowly than he ever has in the past.

A patient, brought to the clinic by his wife and son, is diagnosed with Huntington disease. When providing anticipatory guidance, the nurse should address the future possibility of what effect of Huntington disease? A) Metastasis B) Risk for stroke C) Emotional and personality changes D) Pathologic bone fractures

C) Emotional and personality changes

A patient who was diagnosed with Parkinson's disease several months ago recently began treatment with levodopa-carbidopa. The patient and his family are excited that he has experienced significant symptom relief. The nurse should be aware of what implication of the patient's medication regimen? A) The patient is in a ìhoneymoon periodî when adverse effects of levodopacarbidopa are not yet evident. B) Benefits of levodopa-carbidopa do not peak until 6 to 9 months after the initiation of treatment. C) The patient's temporary improvement in status is likely unrelated to levodopacarbidopa. D) Benefits of levodopa-carbidopa often diminish after 1 or 2 years of treatment.

D) Benefits of levodopa-carbidopa often diminish after 1 or 2 years of treatment.

``` The nurse caring for a patient diagnosed with Parkinson's disease has prepared a plan of care that would include what goal? A) Promoting effective communication B) Controlling diarrhea C) Preventing cognitive decline D) Managing choreiform movements ```

A) Promoting effective communication

The nurse is caring for a patient diagnosed with Parkinson's disease. The patient is having increasing problems with rising from the sitting to the standing position. What should the nurse suggest to the patient to use that will aid in getting from the sitting to the standing position as well as aid in improving bowel elimination? A) Use of a bedpan B) Use of a raised toilet seat C) Sitting quietly on the toilet every 2 hours D) Following the outlined bowel program

B) Use of a raised toilet seat

A patient with Parkinson's disease is experiencing episodes of constipation that are becoming increasingly frequent and severe. The patient states that he has been achieving relief for the past few weeks by using OTC laxatives. How should the nurse respond? A) ìIt's important to drink plenty of fluids while you're taking laxatives.î B) ìMake sure that you supplement your laxatives with a nutritious diet.î C) ìLet's explore other options, because laxatives can have side effects and create dependency.î D) ìYou should ideally be using herbal remedies rather than medications to promote bowel function.î

C) ìLet's explore other options, because laxatives can have side effects and create dependency.

A family member of a patient diagnosed with Huntington disease calls you at the clinic. She is requesting help from the Huntington's Disease Society of America. What kind of help can this patient and family receive from this organization? Select all that apply. A) Information about this disease B) Referrals C) Public education D) Individual assessments E) Appraisals of research studies

A) Information about this disease B) Referrals C) Public education

A patient with a new diagnosis of amyotrophic lateral sclerosis (ALS) is overwhelmed by his diagnosis and the known complications of the disease. How can the patient best make known his wishes for care as his disease progresses? A) Prepare an advance directive. B) Designate a most responsible physician (MRP) early in the course of the disease. C) Collaborate with representatives from the Amyotrophic Lateral Sclerosis Association. D) Ensure that witnesses are present when he provides instruction.

A) Prepare an advance directive.

The nurse is caring for a patient who is scheduled for a cervical discectomy the following day. During health education, the patient should be made aware of what potential complications? A) Vertebral fracture B) Hematoma at the surgical site C) Scoliosis D) Renal trauma

B) Hematoma at the surgical site

The nurse responds to the call light of a patient who has had a cervical diskectomy earlier in the day. The patient states that she is having severe pain that had a sudden onset. What is the nurse's most appropriate action? A) Palpate the surgical site. B) Remove the dressing to assess the surgical site. C) Call the surgeon to report the patient's pain. D) Administer a dose of an NSAID.

C) Call the surgeon to report the patient's pain.

A nurse is planning discharge education for a patient who underwent a cervical diskectomy. What strategies would the nurse assess that would aid in planning discharge teaching? A) Care of the cervical collar B) Technique for performing neck ROM exercises C) Home assessment of ABGs D) Techniques for restoring nerve function

A) Care of the cervical collar

A patient with possible bacterial meningitis is admitted to the ICU. What assessment finding would the nurse expect for a patient with this diagnosis? A) Pain upon ankle dorsiflexion of the foot B) Neck flexion produces flexion of knees and hips C) Inability to stand with eyes closed and arms extended without swaying D) Numbness and tingling in the lower extremities

B) Neck flexion produces flexion of knees and hips

The nurse is planning discharge education for a patient with trigeminal neuralgia. The nurse knows to include information about factors that precipitate an attack. What would the nurse be correct in teaching the patient to avoid? A) Washing his face B) Exposing his skin to sunlight C) Using artificial tears D) Drinking large amounts of fluids

A) Washing his face

The nurse is caring for a patient with multiple sclerosis (MS). The patient tells the nurse the hardest thing to deal with is the fatigue. When teaching the patient how to reduce fatigue, what action should the nurse suggest? A) Taking a hot bath at least once daily B) Resting in an air-conditioned room whenever possible C) Increasing the dose of muscle relaxants D) Avoiding naps during the day

B) Resting in an air-conditioned room whenever possible

A patient with Guillain-BarrÈ syndrome has experienced a sharp decline in vital capacity. What is the nurse's most appropriate action? A) Administer bronchodilators as ordered. B) Remind the patient of the importance of deep breathing and coughing exercises. C) Prepare to assist with intubation. D) Administer supplementary oxygen by nasal cannula.

C) Prepare to assist with intubation.

A patient diagnosed with Bell's palsy is being cared for on an outpatient basis. During health education, the nurse should promote which of the following actions? A) Applying a protective eye shield at night B) Chewing on the affected side to prevent unilateral neglect C) Avoiding the use of analgesics whenever possible D) Avoiding brushing the teeth

A) Applying a protective eye shield at night

The nurse is working with a patient who is newly diagnosed with MS. What basic information should the nurse provide to the patient? A) MS is a progressive demyelinating disease of the nervous system. B) MS usually occurs more frequently in men. C) MS typically has an acute onset. D) MS is sometimes caused by a bacterial infection.

A) MS is a progressive demyelinating disease of the nervous system.

The nurse is creating a plan of care for a patient who has a recent diagnosis of MS. Which of the following should the nurse include in the patient's care plan? A) Encourage patient to void every hour. B) Order a low-residue diet. C) Provide total assistance with all ADLs. D) Instruct the patient on daily muscle stretching.

D) Instruct the patient on daily muscle stretching.

A patient with metastatic cancer has developed trigeminal neuralgia and is taking carbamazepine (Tegretol) for pain relief. What principle applies to the administration of this medication? A) Tegretol is not known to have serious adverse effects. B) The patient should be monitored for bone marrow depression. C) Side effects of the medication include renal dysfunction. D) The medication should be first taken in the maximum dosage form to be effective.

B) The patient should be monitored for bone marrow depression.

A male patient presents to the clinic complaining of a headache. The nurse notes that the patient is guarding his neck and tells the nurse that he has stiffness in the neck area. The nurse suspects the patient may have meningitis. What is another well-recognized sign of this infection? A) Negative Brudzinski's sign B) Positive Kernig's sign C) Hyperpatellar reflex D) Sluggish pupil reaction

B) Positive Kernig's sign

The nurse is developing a plan of care for a patient newly diagnosed with Bell's palsy. The nurse's plan of care should address what characteristic manifestation of this disease? A) Tinnitus B) Facial paralysis C) Pain at the base of the tongue D) Diplopia

B) Facial paralysis

The nurse caring for a patient diagnosed with Guillain-BarrÈ syndrome is planning care with regard to the clinical manifestations associated this syndrome. The nurse's communication with the patient should reflect the possibility of what sign or symptom of the disease? A) Intermittent hearing loss B) Tinnitus C) Tongue enlargement D) Vocal paralysis

D) Vocal paralysis

The nurse is preparing to provide care for a patient diagnosed with myasthenia gravis. The nurse should know that the signs and symptoms of the disease are the result of what? A) Genetic dysfunction B) Upper and lower motor neuron lesions C) Decreased conduction of impulses in an upper motor neuron lesion D) A lower motor neuron lesion

D) A lower motor neuron lesion

A patient with suspected Creutzfeldt-Jakob disease (CJD) is being admitted to the unit. The nurse would expect what diagnostic test to be ordered for this patient? A) Cerebral angiography B) ABG analysis C) CT D) EEG

D) EEG

To alleviate pain associated with trigeminal neuralgia, a patient is taking Tegretol (carbamazepine). What health education should the nurse provide to the patient before initiating this treatment? A) Concurrent use of calcium supplements is contraindicated. B) Blood levels of the drug must be monitored. C) The drug is likely to cause hyperactivity and agitation. D) Tegretol can cause tinnitus during the first few days of treatment.

B) Blood levels of the drug must be monitored.

A patient with herpes simplex virus encephalitis (HSV) has been admitted to the ICU. What medication would the nurse expect the physician to order for the treatment of this disease process? A) Cyclosporine (Neoral) B) Acyclovir (Zovirax) C) Cyclobenzaprine (Flexeril) D) Ampicillin (Prinicpen)

B) Acyclovir (Zovirax)

A middle-aged woman has sought care from her primary care provider and undergone diagnostic testing that has resulted in a diagnosis of MS. What sign or symptom is most likely to have prompted the woman to seek care? A) Cognitive declines B) Personality changes C) Contractures D) Difficulty in coordination

D) Difficulty in coordination

A nurse is planning the care of a 28-year-old woman hospitalized with a diagnosis of myasthenia gravis. What approach would be most appropriate for the care and scheduling of diagnostic procedures for this patient? A) All at one time, to provide a longer rest period B) Before meals, to stimulate her appetite C) In the morning, with frequent rest periods D) Before bedtime, to promote rest

C) In the morning, with frequent rest periods

The nurse is caring for a patient who is hospitalized with an exacerbation of MS. To ensure the patient's safety, what nursing action should be performed? A) Ensure that suction apparatus is set up at the bedside. B) Pad the patient's bed rails. C) Maintain bed rest whenever possible. D) Provide several small meals each day.

A) Ensure that suction apparatus is set up at the bedside.

A 33-year-old patient presents at the clinic with complaints of weakness, incoordination, dizziness, and loss of balance. The patient is hospitalized and diagnosed with MS. What sign or symptom, revealed during the initial assessment, is typical of MS? A) Diplopia, history of increased fatigue, and decreased or absent deep tendon reflexes B) Flexor spasm, clonus, and negative Babinski's reflex C) Blurred vision, intention tremor, and urinary hesitancy D) Hyperactive abdominal reflexes and history of unsteady gait and episodic paresthesia in both legs

C) Blurred vision, intention tremor, and urinary hesitancy

The nurse is developing a plan of care for a patient with Guillain-BarrÈ syndrome. Which of the following interventions should the nurse prioritize for this patient? A) Using the incentive spirometer as prescribed B) Maintaining the patient on bed rest C) Providing aids to compensate for loss of vision D) Assessing frequently for loss of cognitive function

A) Using the incentive spirometer as prescribed

A 69-year-old patient is brought to the ED by ambulance because a family member found him lying on the floor disoriented and lethargic. The physician suspects bacterial meningitis and admits the patient to the ICU. The nurse knows that risk factors for an unfavorable outcome include what? Select all that apply. A) Blood pressure greater than 140/90 mm Hg B) Heart rate greater than 120 bpm C) Older age D) Low Glasgow Coma Scale E) Lack of previous immunizations

B) Heart rate greater than 120 bpm C) Older age D) Low Glasgow Coma Scale

The critical care nurse is caring for 25-year-old man admitted to the ICU with a brain abscess. What is a priority nursing responsibility in the care of this patient? A) Maintaining the patient's functional independence B) Providing health education C) Monitoring neurologic status closely D) Promoting mobility

C) Monitoring neurologic status closely

A patient is being admitted to the neurologic ICU with suspected herpes simplex virus encephalitis. What nursing action best addresses the patient's complaints of headache? A) Initiating a patient-controlled analgesia (PCA) of morphine sulfate B) Administering hydromorphone (Dilaudid) IV as needed C) Dimming the lights and reducing stimulation D) Distracting the patient with activity

C) Dimming the lights and reducing stimulation

A patient is admitted through the ED with suspected St. Louis encephalitis. The unique clinical feature of St. Louis encephalitis will make what nursing action a priority? A) Serial assessments of hemoglobin levels B) Blood glucose monitoring C) Close monitoring of fluid balance D) Assessment of pain along dermatomes

C) Close monitoring of fluid balance

The nurse is caring for a 77-year-old woman with MS. She states that she is very concerned about the progress of her disease and what the future holds. The nurse should know that elderly patients with MS are known to be particularly concerned about what variables? Select all that apply. A) Possible nursing home placement B) Pain associated with physical therapy C) Increasing disability D) Becoming a burden on the family E) Loss of appetite

A) Possible nursing home placement C) Increasing disability D) Becoming a burden on the family

You are the clinic nurse caring for a patient with a recent diagnosis of myasthenia gravis. The patient has begun treatment with pyridostigmine bromide (Mestinon). What change in status would most clearly suggest a therapeutic benefit of this medication? A) Increased muscle strength B) Decreased pain C) Improved GI function D) Improved cognition

A) Increased muscle strength

The critical care nurse is admitting a patient in myasthenic crisis to the ICU. The nurse should prioritize what nursing action in the immediate care of this patient? A) Suctioning secretions B) Facilitating ABG analysis C) Providing ventilatory assistance D) Administering tube feedings

C) Providing ventilatory assistance

The nurse caring for a patient in ICU diagnosed with Guillain-BarrÈ syndrome should prioritize monitoring for what potential complication? A) Impaired skin integrity B) Cognitive deficits C) Hemorrhage D) Autonomic dysfunction

D) Autonomic dysfunction

The nurse is teaching a patient with Guillain-BarrÈ syndrome about the disease. The patient asks how he can ever recover if demyelination of his nerves is occurring. What would be the nurse's best response? A) ìGuillain-BarrÈ spares the Schwann cell, which allows for remyelination in the recovery phase of the disease.î B) ìIn Guillain-BarrÈ, Schwann cells replicate themselves before the disease destroys them, so remyelination is possible.î C) ìI know you understand that nerve cells do not remyelinate, so the physician is the best one to answer your question.î D) ìFor some reason, in Guillain-BarrÈ, Schwann cells become activated and take over the remyelination process.î

A) ìGuillain-BarrÈ spares the Schwann cell, which allows for remyelination in the recovery phase of the disease.î

A patient diagnosed with myasthenia gravis has been hospitalized to receive plasmapheresis for a myasthenic exacerbation. The nurse knows that the course of treatment for plasmapheresis in a patient with myasthenia gravis is what? A) Every day for 1 week B) Determined by the patient's response C) Alternate days for 10 days D) Determined by the patient's weight

B) Determined by the patient's response

The nurse is discharging a patient home after surgery for trigeminal neuralgia. What advice should the nurse provide to this patient in order to reduce the risk of injury? A) Avoid watching television or using a computer for more than 1 hour at a time. B) Use OTC antibiotic eye drops for at least 14 days. C) Avoid rubbing the eye on the affected side of the face. D) Rinse the eye on the affected side with normal saline daily for 1 week.

C) Avoid rubbing the eye on the affected side of the face.

A patient diagnosed with Bell's palsy is having decreased sensitivity to touch of the involved nerve. What should the nurse recommend to prevent atrophy of the muscles? A) Blowing up balloons B) Deliberately frowning C) Smiling repeatedly D) Whistling

D) Whistling

A patient with diabetes presents to the clinic and is diagnosed with a mononeuropathy. This patient's nursing care should involve which of the following? A) Protection of the affected limb from injury B) Passive and active ROM exercises for the affected limb C) Education about improvements to glycemic control D) Interventions to prevent contractures

A) Protection of the affected limb from injury

A patient diagnosed with MS has been admitted to the medical unit for treatment of an MS exacerbation. Included in the admission orders is baclofen (Lioresal). What should the nurse identify as an expected outcome of this treatment? A) Reduction in the appearance of new lesions on the MRI B) Decreased muscle spasms in the lower extremities C) Increased muscle strength in the upper extremities D) Decreased severity and duration of exacerbations

B) Decreased muscle spasms in the lower extremities

A 35-year-old woman is diagnosed with a peripheral neuropathy. When making her plan of care, the nurse knows to include what in patient teaching? Select all that apply. A) Inspect the lower extremities for skin breakdown. B) Footwear needs to be accurately sized. C) Immediate family members should be screened for the disease. D) Assistive devices may be needed to reduce the risk of falls. E) Dietary modifications are likely necessary.

A) Inspect the lower extremities for skin breakdown. B) Footwear needs to be accurately sized. D) Assistive devices may be needed to reduce the risk of falls.

A 73-year-old man comes to the clinic complaining of weakness and loss of sensation in his feet and legs. Assessment of the patient shows decreased reflexes bilaterally. Why would it be a challenge to diagnose a peripheral neuropathy in this patient? A) Older adults are often vague historians. B) The elderly have fewer peripheral nerves than younger adults. C) Many older adults are hesitant to admit that their body is changing. D) Many symptoms can be the result of normal aging process.

D) Many symptoms can be the result of normal aging process.

A patient with MS has been admitted to the hospital following an acute exacerbation. When planning the patient's care, the nurse addresses the need to enhance the patient's bladder control. What aspect of nursing care is most likely to meet this goal? A) Establish a timed voiding schedule. B) Avoid foods that change the pH of urine. C) Perform intermittent catheterization q6h. D) Administer anticholinergic drugs as ordered.

A) Establish a timed voiding schedule.

A patient with MS has developed dysphagia as a result of cranial nerve dysfunction. What nursing action should the nurse consequently perform? A) Arrange for the patient to receive a low residue diet. B) Position the patient upright during feeding. C) Suction the patient following each meal. D) Withhold liquids until the patient has finished eating.

B) Position the patient upright during feeding.

A 48-year-old patient has been diagnosed with trigeminal neuralgia following recent episodes of unilateral face pain. The nurse should recognize what implication of this diagnosis? A) The patient will likely require lifelong treatment with anticholinergic medications. B) The patient has a disproportionate risk of developing myasthenia gravis later in life. C) The patient needs to be assessed for MS. D) The disease is self-limiting and the patient will achieve pain relief over time.

C) The patient needs to be assessed for MS.

A patient presents at the clinic complaining of pain and weakness in her hands. On assessment, the nurse notes diminished reflexes in the upper extremities bilaterally and bilateral loss of sensation. The nurse knows that these findings are indicative of what? A) Guillain-BarrÈ syndrome B) Myasthenia gravis C) Trigeminal neuralgia D) Peripheral nerve disorder

D) Peripheral nerve disorder

A patient is brought to the ER following a motor vehicle accident in which he sustained head trauma. Preliminary assessment reveals a vision deficit in the patient's left eye. The nurse should associate this abnormal finding with trauma to which of the following cerebral lobes? A) Temporal B) Occipital C) Parietal D) Frontal

B) Occipital

A patient scheduled for magnetic resonance imaging (MRI) has arrived at the radiology department. The nurse who prepares the patient for the MRI should prioritize which of the following actions? A) Withholding stimulants 24 to 48 hours prior to exam B) Removing all metal-containing objects C) Instructing the patient to void prior to the MRI D) Initiating an IV line for administration of contrast

B) Removing all metal-containing objects

A gerontologic nurse planning the neurologic assessment of an older adult is considering normal, age-related changes. Of what phenomenon should the nurse be aware? A) Hyperactive deep tendon reflexes B) Reduction in cerebral blood flow C) Increased cerebral metabolism D) Hypersensitivity to painful stimuli

B) Reduction in cerebral blood flow

The nurse has admitted a new patient to the unit. One of the patient's admitting orders is for an adrenergic medication. The nurse knows that this medication will have what effect on the circulatory system? A) Thin, watery saliva B) Increased heart rate C) Decreased BP D) Constricted bronchioles

B) Increased heart rate

A nurse is assessing reflexes in a patient with hyperactive reflexes. When the patient's foot is abruptly dorsiflexed, it continues to beat two to three times before settling into a resting position. How would the nurse document this finding? A) Rigidity B) Flaccidity C) Clonus D) Ataxia

C) Clonus

The nurse is doing an initial assessment on a patient newly admitted to the unit with a diagnosis of cerebrovascular accident (CVA). The patient has difficulty copying a figure that the nurse has drawn and is diagnosed with visual-receptive aphasia. What brain region is primarily involved in this deficit? A) Temporal lobe B) Parietal-occipital area C) Inferior posterior frontal areas D) Posterior frontal area

B) Parietal-occipital area

What term is used to describe the fibrous connective tissue that hugs the brain closely and extends into every fold of the brain's surface? A) Dura mater B) Arachnoid C) Fascia D) Pia mater

D) Pia mater

The nurse is caring for a patient with an upper motor neuron lesion. What clinical manifestations should the nurse anticipate when planning the patient's neurologic assessment? A) Decreased muscle tone B) Flaccid paralysis C) Loss of voluntary control of movement D) Slow reflexes

C) Loss of voluntary control of movement

The nurse is admitting a patient to the unit who is diagnosed with a lower motor neuron lesion. What entry in the patient's electronic record is most consistent with this diagnosis? A) Patient exhibits increased muscle tone. B) Patient demonstrates normal muscle structure with no evidence of atrophy. C) Patient demonstrates hyperactive deep tendon reflexes. D) Patient demonstrates an absence of deep tendon reflexes.

D) ìPatient demonstrates an absence of deep tendon reflexes.

An elderly patient is being discharged home. The patient lives alone and has atrophy of his olfactory organs. The nurse tells the patient's family that it is essential that the patient have what installed in the home? A) Grab bars B) Nonslip mats C) Baseboard heaters D) A smoke detector

D) A smoke detector

The patient in the ED has just had a diagnostic lumbar puncture. To reduce the incidence of a post-lumbar puncture headache, what is the nurse's most appropriate action? A) Position the patient prone. B) Position the patient supine with the head of bed flat. C) Position the patient left side-lying. D) Administer acetaminophen as ordered.

A) Position the patient prone.

The nurse is conducting a focused neurologic assessment. When assessing the patient's cranial nerve function, the nurse would include which of the following assessments? A) Assessment of hand grip B) Assessment of orientation to person, time, and place C) Assessment of arm drift D) Assessment of gag reflex

D) Assessment of gag reflex

A nurse is caring for a patient diagnosed with MÈniËre's disease. While completing a neurologic examination on the patient, the nurse assesses cranial nerve VIII. The nurse would be correct in identifying the function of this nerve as what? A) Movement of the tongue B) Visual acuity C) Sense of smell D) Hearing and equilibrium

D) Hearing and equilibrium

A patient exhibiting an uncoordinated gait has presented at the clinic. Which of the following is the most plausible cause of this patient's health problem? A) Cerebellar dysfunction B) A lesion in the pons C) Dysfunction of the medulla D) A hemorrhage in the midbrain

A) Cerebellar dysfunction

A patient is being given a medication that stimulates her parasympathetic system. Following administration of this medication, the nurse should anticipate what effect? A) Constricted pupils B) Dilated bronchioles C) Decreased peristaltic movement D) Relaxed muscular walls of the urinary bladder

A) Constricted pupils

A patient with lower back pain is scheduled for myelography using metrizamide (a water-soluble contrast dye). After the test, the nurse should prioritize what action? A) Positioning the patient with the head of the bed elevated 45 degrees B) Administering IV morphine sulfate to prevent headache C) Limiting fluids for the next 12 hours D) Helping the patient perform deep breathing and coughing exercises

A) Positioning the patient with the head of the bed elevated 45 degrees

A patient is having a fight or flight response after receiving bad news about his prognosis. What affect will this have on the patient's sympathetic nervous system? A) Constriction of blood vessels in the heart muscle B) Constriction of bronchioles C) Increase in the secretion of sweat D) Constriction of pupils

C) Increase in the secretion of sweat

The nurse educator is reviewing the assessment of cranial nerves. What should the educator identify as the specific instances when cranial nerves should be assessed? Select all that apply. A) When a neurogenic bladder develops B) When level of consciousness is decreased C) With brain stem pathology D) In the presence of peripheral nervous system disease E) When a spinal reflex is interrupted

B) When level of consciousness is decreased C) With brain stem pathology D) In the presence of peripheral nervous system disease

A patient in the OR goes into malignant hyperthermia due to an abnormal reaction to the anesthetic. The nurse knows that the area of the brain that regulates body temperature is which of the following? A) Cerebellum B) Thalamus C) Hypothalamus D) Midbrain

C) Hypothalamus

The nurse is planning the care of a patient with Parkinson's disease. The nurse should be aware that treatment will focus on what pathophysiological phenomenon? A) Premature degradation of acetylcholine B) Decreased availability of dopamine C) Insufficient synthesis of epinephrine D) Delayed reuptake of serotonin

B) Decreased availability of dopamine

A patient is admitted to the medical unit with an exacerbation of multiple sclerosis. When assessing this patient, the nurse has the patient stick out her tongue and move it back and forth. What is the nurse assessing? A) Function of the hypoglossal nerve B) Function of the vagus nerve C) Function of the spinal nerve D) Function of the trochlear nerve

A) Function of the hypoglossal nerve

A trauma patient was admitted to the ICU with a brain injury. The patient had a change in level of consciousness, increased vital signs, and became diaphoretic and agitated. The nurse should recognize which of the following syndromes as the most plausible cause of these symptoms? A) Adrenal crisis B) Hypothalamic collapse C) Sympathetic storm D) Cranial nerve deficit

C) Sympathetic storm

Assessment is crucial to the care of patients with neurologic dysfunction. What does accurate and appropriate assessment require? Select all that apply. A) The ability to select mediations for the neurologic dysfunction B) Understanding of the tests used to diagnose neurologic disorders C) Knowledge of nursing interventions related to assessment and diagnostic testing D) Knowledge of the anatomy of the nervous system E) The ability to interpret the results of diagnostic tests

B) Understanding of the tests used to diagnose neurologic disorders C) Knowledge of nursing interventions related to assessment and diagnostic testing D) Knowledge of the anatomy of the nervous system

When caring for a patient with an altered level of consciousness, the nurse is preparing to test cranial nerve VII. What assessment technique would the nurse use to elicit a response from cranial nerve VII? A) Palpate trapezius muscle while patient shrugs should against resistance. B) Administer the whisper or watch-tick test. C) Observe for facial movement symmetry, such as a smile. D) Note any hoarseness in the patient's voice.

C) Observe for facial movement symmetry, such as a smile.

The nurse is caring for a patient who exhibits abnormal results of the Weber test and Rinne test. The nurse should suspect dysfunction involving what cranial nerve? A) Trigeminal B) Acoustic C) Hypoglossal D) Trochlear

B) Acoustic

The nurse caring for an 80 year-old patient knows that she has a pre-existing history of dulled tactile sensation. The nurse should first consider what possible cause for this patient's diminished tactile sensation? A) Damage to cranial nerve VIII B) Adverse medication effects C) Age-related neurologic changes D) An undiagnosed cerebrovascular accident in early adulthood

C) Age-related neurologic changes

A 72-year-old man has been brought to his primary care provider by his daughter, who claims that he has been experiencing uncharacteristic lapses in memory. What principle should underlie the nurse's assessment and management of this patient? A) Loss of short-term memory is normal in older adults, but loss of long-term memory is pathologic. B) Lapses in memory in older adults are considered benign unless they have negative consequences. C) Gradual increases in confusion accompany the aging process. D) Thorough assessment is necessary because changes in cognition are always considered to be pathologic.

D) Thorough assessment is necessary because changes in cognition are always considered to be pathologic.

A gerontologic nurse educator is providing practice guidelines to unlicensed care providers. Because reaction to painful stimuli is sometimes blunted in older adults, what must be used with caution? A) Hot or cold packs B) Analgesics C) Anti-inflammatory medications D) Whirlpool baths

A) Hot or cold packs

A trauma patient in the ICU has been declared brain dead. What diagnostic test is used in making the determination of brain death? A) Magnetic resonance imaging (MRI) B) Electroencephalography (EEG) C) Electromyelography (EMG) D) Computed tomography (CT)

B) Electroencephalography (EEG)

A patient is scheduled for CT scanning of the head because of a recent onset of neurologic deficits. What should the nurse tell the patient in preparation for this test? A) ìNo metal objects can enter the procedure room. B) ìYou need to fast for 8 hours prior to the test. C) ìYou will need to lie still throughout the procedure. D) ìThere will be a lot of noise during the test.

C) ìYou will need to lie still throughout the procedure.

A patient for whom the nurse is caring has positron emission tomography (PET) scheduled. In preparation, what should the nurse explain to the patient? A) The test will temporarily limit blood flow through the brain. B) An allergy to iodine precludes getting the radio-opaque dye. C) The patient will need to endure loud noises during the test. D) The test may result in dizziness or lightheadedness.

D) The test may result in dizziness or lightheadedness.

A patient is scheduled for a myelogram and the nurse explains to the patient that this is an invasive procedure, which assesses for any lesions in the spinal cord. The nurse should explain that the preparation is similar to which of the following neurologic tests? A) Lumbar puncture B) MRI C) Cerebral angiography D) EEG

A) Lumbar puncture

The physician has ordered a somatosensory evoked responses (SERs) test for a patient for whom the nurse is caring. The nurse is justified in suspecting that this patient may have a history of what type of neurologic disorder? A) Hypothalamic disorder B) Demyelinating disease C) Brainstem deficit D) Diabetic neuropathy

B) Demyelinating disease

A patient had a lumbar puncture performed at the outpatient clinic and the nurse has phoned the patient and family that evening. What does this phone call enable the nurse to determine? A) What are the patient's and family's expectations of the test B) Whether the patient's family had any questions about why the test was necessary C) Whether the patient has had any complications of the test D) Whether the patient understood accurately why the test was done

C) Whether the patient has had any complications of the test

A patient is currently being stimulated by the parasympathetic nervous system. What effect will this nervous stimulation have on the patient's bladder? A) The parasympathetic nervous system causes urinary retention. B) The parasympathetic nervous system causes bladder spasms. C) The parasympathetic nervous system causes urge incontinence. D) The parasympathetic nervous system makes the bladder contract.

D) The parasympathetic nervous system makes the bladder contract.

The nurse is performing a neurologic assessment of a patient whose injuries have rendered her unable to follow verbal commands. How should the nurse proceed with assessing the patient's level of consciousness (LOC)? A) Assess the patient's vital signs and correlate these with the patient's baselines. B) Assess the patient's eye opening and response to stimuli. C) Document that the patient currently lacks a level of consciousness. D) Facilitate diagnostic testing in an effort to obtain objective data.

B) Assess the patient's eye opening and response to stimuli.

In the course of a focused neurologic assessment, the nurse is palpating the patient's major muscle groups at rest and during passive movement. Data gleaned from this assessment will allow the nurse to describe which of the following aspects of neurologic function? A) Muscle dexterity B) Muscle tone C) Motor symmetry D) Deep tendon reflexes

B) Muscle tone

The neurologic nurse is testing the function of a patient's cerebellum and basal ganglia. What action will most accurately test these structures? A) Have the patient identify the location of a cotton swab on his or her skin with the eyes closed. B) Elicit the patient's response to a hypothetical problem. C) Ask the patient to close his or her eyes and discern between hot and cold stimuli. D) Guide the patient through the performance of rapid, alternating movements.

D) Guide the patient through the performance of rapid, alternating movements.

During the performance of the Romberg test, the nurse observes that the patient sways slightly. What is the nurse's most appropriate action? A) Facilitate a referral to a neurologist. B) Reposition the patient supine to ensure safety. C) Document successful completion of the assessment. D) Follow up by having the patient perform the Rinne test.

C) Document successful completion of the assessment.

A nurse admits a patient who has a fracture of the nose that has resulted in a skin tear and involvement of the mucous membranes of the nasal passages. The orthopedic nurse is aware that this description likely indicates which type of fracture? A) Compression B) Compound C) Impacted D) Transverse

B) Compound

A patient has sustained a long bone fracture and the nurse is preparing the patient's care plan. Which of the following should the nurse include in the care plan? A) Administer vitamin D and calcium supplements as ordered. B) Monitor temperature and pulses of the affected extremity. C) Perform passive range of motion exercises as tolerated. D) Administer corticosteroids as ordered.

B) Monitor temperature and pulses of the affected extremity.

A nurse's assessment of a patient's knee reveals edema, tenderness, muscle spasms, and ecchymosis. The patient states that 2 days ago he ran 10 miles and now it really hurts to stand up.î The nurse should plan care based on the belief that the patient has experienced what? A) A first-degree strain B) A second-degree strain C) A first-degree sprain D) A second-degree sprain

B) A second-degree strain

A nurse is caring for a patient who has suffered a hip fracture and who will require an extended hospital stay. The nurse should ensure that the patient does which of the following in order to prevent common complications associated with a hip fracture? A) Avoid requesting analgesia unless pain becomes unbearable. B) Use supplementary oxygen when transferring or mobilizing. C) Increase fluid intake and perform prescribed foot exercises. D) Remain on bed rest for 14 days or until instructed by the orthopedic surgeon.

C) Increase fluid intake and perform prescribed foot exercises.

A nurse is caring for a patient who has suffered an unstable thoracolumbar fracture. Which of the following is the priority during nursing care? A) Preventing infection B) Maintaining spinal alignment C) Maximizing function D) Preventing increased intracranial pressure

B) Maintaining spinal alignment

The patient scheduled for a Syme amputation is concerned about the ability to eventually stand on the amputated extremity. How should the nurse best respond to the patient's concern? A) ìYou will eventually be able to withstand full weight-bearing after the amputation.î B) ìYou will have minimal weight-bearing on this extremity but you'll be taught how to use an assistive device.î C) ìYou likely will not be able to use this extremity but you will receive teaching on use of a wheelchair.î D) ìYou will be fitted for a prosthesis which may or may not allow you to walk.î

A) ìYou will eventually be able to withstand full weight-bearing after the amputation.î

A patient with a simple arm fracture is receiving discharge education from the nurse. What would the nurse instruct the patient to do? A) Elevate the affected extremity to shoulder level when at rest. B) Engage in exercises that strengthen the unaffected muscles. C) Apply topical anesthetics to accessible skin surfaces as needed. D) Avoid using analgesics so that further damage is not masked.

B) Engage in exercises that strengthen the unaffected muscles.

Six weeks after an above-the-knee amputation (AKA), a patient returns to the outpatient office for a routine postoperative checkup. During the nurse's assessment, the patient reports symptoms of phantom pain. What should the nurse tell the patient to do to reduce the discomfort of the phantom pain? A) Apply intermittent hot compresses to the area of the amputation. B) Avoid activity until the pain subsides. C) Take opioid analgesics as ordered. D) Elevate the level of the amputation site.

C) Take opioid analgesics as ordered.

A nurse is caring for a patient who had a right below-the-knee amputation (BKA). The nurse recognizes the importance of implementing measures that focus on preventing flexion contracture of the hip and maintaining proper positioning. Which of the following measures will best achieve these goals? A) Encouraging the patient to turn from side to side and to assume a prone position B) Initiating ROM exercises of the hip and knee 10 to 12 weeks after the amputation C) Minimizing movement of the flexor muscles of the hip D) Encouraging the patient to sit in a chair for at least 8 hours a day

A) Encouraging the patient to turn from side to side and to assume a prone position

A nurse is preparing to discharge an emergency department patient who has been fitted with a sling to support her arm after a clavicle fracture. What should the nurse instruct the patient to do? A) Elevate the arm above the shoulder 3 to 4 times daily. B) Avoid moving the elbow, wrist, and fingers until bone remodeling is complete. C) Engage in active range of motion using the affected arm. D) Use the arm for light activities within the range of motion.

D) Use the arm for light activities within the range of motion.

The orthopedic nurse should assess for signs and symptoms of Volkmann's contracture if a patient has fractured which of the following bones? A) Femur B) Humerus C) Radial head D) Clavicle

B) Humerus

An emergency department nurse is assessing a 17-year-old soccer player who presented with a knee injury. The patient's description of the injury indicates that his knee was struck medially while his foot was on the ground. The nurse knows that the patient likely has experienced what injury? A) Lateral collateral ligament injury B) Medial collateral ligament injury C) Anterior cruciate ligament injury D) Posterior cruciate ligament injury

A) Lateral collateral ligament injury

A school nurse is assessing a student who was kicked in the shin during a soccer game. The area of the injury has become swollen and discolored. The triage nurse recognizes that the patient has likely sustained what? A) Sprain B) Strain C) Contusion D) Dislocation

C) Contusion

Radiographs of a boy's upper arm show that the humerus appears to be fractured on one side and slightly bent on the other. This diagnostic result suggests what type of fracture? A) Impacted B) Compound C) Compression D) Greenstick

D) Greenstick

A nurse is performing a shift assessment on an elderly patient who is recovering after surgery for a hip fracture. The nurse notes that the patient is complaining of chest pain, has an increased heart rate, and increased respiratory rate. The nurse further notes that the patient is febrile and hypoxic, coughing, and producing large amounts of thick, white sputum. The nurse recognizes that this is a medical emergency and calls for assistance, recognizing that this patient is likely demonstrating symptoms of what complication? A) Avascular necrosis of bone B) Compartment syndrome C) Fat embolism syndrome D) Complex regional pain syndrome

C) Fat embolism syndrome

A young patient is being treated for a femoral fracture suffered in a snowboarding accident. The nurse's most recent assessment reveals that the patient is uncharacteristically confused. What diagnostic test should be performed on this patient? A) Electrolyte assessment B) Electrocardiogram C) Arterial blood gases D) Abdominal ultrasound

C) Arterial blood gases

Which of the following is the most appropriate nursing intervention to facilitate healing in a patient who has suffered a hip fracture? A) Administer analgesics as required. B) Place a pillow between the patient's legs when turning. C) Maintain prone positioning at all times. D) Encourage internal and external rotation of the affected leg.

B) Place a pillow between the patient's legs when turning.

A nurse is planning the care of an older adult patient who will soon be discharged home after treatment for a fractured hip. In an effort to prevent future fractures, the nurse should encourage which of the following? Select all that apply. A) Regular bone density testing B) A high-calcium diet C) Use of falls prevention precautions D) Use of corticosteroids as ordered E) Weight-bearing exercise

A) Regular bone density testing B) A high-calcium diet C) Use of falls prevention precautions E) Weight-bearing exercise

A patient is brought to the emergency department by ambulance after stepping in a hole and falling. While assessing him the nurse notes that his right leg is shorter than his left leg; his right hip is noticeably deformed and he is in acute pain. Imaging does not reveal a fracture. Which of the following is the most plausible explanation for this patient's signs and symptoms? A) Subluxated right hip B) Right hip contusion C) Hip strain D) Traumatic hip dislocation

D) Traumatic hip dislocation

An emergency department patient is diagnosed with a hip dislocation. The patient's family is relieved that the patient has not suffered a hip fracture, but the nurse explains that this is still considered to be a medical emergency. What is the rationale for the nurse's statement? A) The longer the joint is displaced, the more difficult it is to get it back in place. B) The patient's pain will increase until the joint is realigned. C) Dislocation can become permanent if the process of bone remodeling begins. D) Avascular necrosis may develop at the site of the dislocation if it is not promptly resolved.

D) Avascular necrosis may develop at the site of the dislocation if it is not promptly resolved.

The surgical nurse is admitting a patient from postanesthetic recovery following the patient's below-the-knee amputation. The nurse recognizes the patient's high risk for postoperative hemorrhage and should keep which of the following at the bedside? A) A tourniquet B) A syringe preloaded with vitamin K C) A unit of packed red blood cells, placed on ice D) A dose of protamine sulfate

A) A tourniquet

An elite high school football player has been diagnosed with a shoulder dislocation. The patient has been treated and is eager to resume his role on his team, stating that he is not experiencing pain. What should the nurse emphasize during health education? A) The need to take analgesia regardless of the short-term absence of pain B) The importance of adhering to the prescribed treatment and rehabilitation regimen C) The fact that he has a permanently increased risk of future shoulder dislocations D) The importance of monitoring for intracapsular bleeding once he resumes playing

B) The importance of adhering to the prescribed treatment and rehabilitation regimen

A patient has presented to the emergency department with an injury to the wrist. The patient is diagnosed with a third-degree strain. Why would the physician order an x-ray of the wrist? A) Nerve damage is associated with third-degree strains. B) Compartment syndrome is associated with third-degree strains. C) Avulsion fractures are associated with third-degree strains. D) Greenstick fractures are associated with third-degree strains.

C) Avulsion fractures are associated with third-degree strains.

A 20 year-old is brought in by ambulance to the emergency department after being involved in a motorcycle accident. The patient has an open fracture of his tibia. The wound is highly contaminated and there is extensive soft-tissue damage. How would this patient's fracture likely be graded? A) Grade I B) Grade II C) Grade III D) Grade IV

C) Grade III

A 25-year-old man is involved in a motorcycle accident and injures his arm. The physician diagnoses the man with an intra-articular fracture and splints the injury. The nurse implements the teaching plan developed for this patient. What sequela of intraarticular fractures should the nurse describe regarding this patient? A) Post-traumatic arthritis B) Fat embolism syndrome (FES) C) Osteomyelitis D) Compartment syndrome

A) Post-traumatic arthritis

A nurse is planning the care of a patient with osteomyelitis that resulted from a diabetic foot ulcer. The patient requires a transmetatarsal amputation. When planning the patient's postoperative care, which of the following nursing diagnoses should the nurse most likely include in the plan of care? A) Ineffective Thermoregulation B) Risk-Prone Health Behavior C) Disturbed Body Image D) Deficient Diversion Activity

C) Disturbed Body Image

A patient is admitted to the orthopedic unit with a fractured femur after a motorcycle accident. The patient has been placed in traction until his femur can be rodded in surgery. For what early complications should the nurse monitor this patient? Select all that apply. A) Systemic infection B) Complex regional pain syndrome C) Deep vein thrombosis D) Compartment syndrome E) Fat embolism

C) Deep vein thrombosis D) Compartment syndrome E) Fat embolism

A patient has come to the orthopedic clinic for a follow-up appointment 6 weeks after fracturing his ankle. Diagnostic imaging reveals that bone union is not taking place. What factor may have contributed to this complication? A) Inadequate vitamin D intake B) Bleeding at the injury site C) Inadequate immobilization D) Venous thromboembolism (VTE)

C) Inadequate immobilization

An older adult patient has fallen in her home and is brought to the emergency department by ambulance with a suspected fractured hip. X-rays confirm a fracture of the left femoral neck. When planning assessments during the patient's presurgical care, the nurse should be aware of the patient's heightened risk of what complication? A) Osteomyelitis B) Avascular necrosis C) Phantom pain D) Septicemia

B) Avascular necrosis

A patient is being treated for a fractured hip and the nurse is aware of the need to implement interventions to prevent muscle wasting and other complications of immobility. What intervention best addresses the patient's need for exercise? A) Performing gentle leg lifts with both legs B) Performing massage to stimulate circulation C) Encouraging frequent use of the overbed trapeze D) Encouraging the patient to log roll side to side once per hour

C) Encouraging frequent use of the overbed trapeze

A patient who has had an amputation is being cared for by a multidisciplinary rehabilitation team. What is the primary goal of this multidisciplinary team? A) Maximize the efficiency of care B) Ensure that the patient's health care is holistic C) Facilitate the patient's adjustment to a new body image D) Promote the patient's highest possible level of function

D) Promote the patient's highest possible level of function

A rehabilitation nurse is working with a patient who has had a below-the-knee amputation. The nurse knows the importance of the patient's active participation in selfcare. In order to determine the patient's ability to be an active participant in self-care, the nurse should prioritize assessment of what variable? A) The patient's attitude B) The patient's learning style C) The patient's nutritional status D) The patient's presurgical level of function

A) The patient's attitude

The nurse is providing care for a patient who has had a below-the-knee amputation. The nurse enters the patient's room and finds him resting in bed with his residual limb supported on pillow. What is the nurse's most appropriate action? A) Inform the surgeon of this finding. B) Explain the risks of flexion contracture to the patient. C) Transfer the patient to a sitting position. D) Encourage the patient to perform active ROM exercises with the residual limb.

B) Explain the risks of flexion contracture to the patient.

A patient has returned to the postsurgical unit from the PACU after an above-the-knee amputation of the right leg. Results of the nurse's initial postsurgical assessment were unremarkable but the patient has called out. The nurse enters the room and observes copious quantities of blood at the surgical site. What should be the nurse's initial action? A) Apply a tourniquet. B) Elevate the residual limb. C) Apply sterile gauze. D) Call the surgeon.

A) Apply a tourniquet.

A nurse in a busy emergency department provides care for many patients who present with contusions, strains, or sprains. Treatment modalities that are common to all of these musculoskeletal injuries include which of the following? Select all that apply. A) Massage B) Applying ice C) Compression dressings D) Resting the affected extremity E) Corticosteroids F) Elevating the injured limb

B) Applying ice C) Compression dressings D) Resting the affected extremity F) Elevating the injured limb

A patient who has undergone a lower limb amputation is preparing to be discharged home. What outcome is necessary prior to discharge? A) Patient can demonstrate safe use of assistive devices. B) Patient has a healed, nontender, nonadherent scar. C) Patient can perform activities of daily living independently. D) Patientis free of pain.

A) Patient can demonstrate safe use of assistive devices.

An older adult patient experienced a fall and required treatment for a fractured hip on the orthopedic unit. Which of the following are contributory factors to the incidence of falls and fractured hips among the older adult population? Select all that apply. A) Loss of visual acuity B) Adverse medication effects C) Slowed reflexes D) Hearing loss E) Muscle weakness

A) Loss of visual acuity B) Adverse medication effects C) Slowed reflexes E) Muscle weakness

A patient was fitted with an arm cast after fracturing her humerus. Twelve hours after the application of the cast, the patient tells the nurse that her arm hurts. Analgesics do not relieve the pain. What would be the most appropriate nursing action? A) Prepare the patient for opening or bivalving of the cast. B) Obtain an order for a different analgesic. C) Encourage the patient to wiggle and move the fingers. D) Petal the edges of the patient's cast.

A) Prepare the patient for opening or bivalving of the cast.