CHAPTER 57: Eyes & Ear Problem

1. During the early postoperative period, a client who has undergone a cataract extraction complains of nausea and severe eye pain over the
operative site. What would be the initial nursing action?

1. Call the surgeon.

2. Reassure the client that this is normal.

3. Turn the client onto their operative side.

4. Administer the prescribed pain medication and antiemetic.

2. The nurse is developing a teaching plan for a client with glaucoma. Which instruction would the nurse include in the plan of care?

1. Avoid overuse of the eyes.

2. Decrease the amount of salt in the diet.

3. Eye medications will need to be administered for life.

4. Decrease fluid intake to control the intraocular pressure.

3. The nurse is performing an admission assessment on a client with a diagnosis of detached retina. Which sign or symptom is associated
with this eye problem?

1. Total loss of vision

2. Pain in the affected eye

3. A yellow discoloration of the sclera

4. A sense of a curtain falling across the field of vision

4. The nurse is performing an otoscopic examination on a client with mastoiditis. On examination of the tympanic membrane, which finding
would the nurse expect to observe?

1. A pink-colored tympanic membrane

2. A pearly colored tympanic membrane

3. A transparent and clear tympanic membrane

4. A red, dull, thick, and immobile tympanic mem- brane

5. A client is diagnosed with a problem involving the inner ear. Which is the most common client com- plaint associated with a problem
involving this part of the ear?

1. Pruritus

2. Tinnitus

3. Hearing loss

4. Burning in the ear

6. The nurse is performing an assessment on a client with a suspected diagnosis of cataract. Which clinical manifestation would the nurse
expect to note in the early stages of cataract formation?

1. Diplopia

2. Eye pain

3. Floating spots

4. Blurred vision

7. A client arrives in the emergency department following an automobile crash. The client's forehead hit the steering wheel, and a hyphema is
diagnosed. The nurse would place the client in which position?

1. Flat in bed

2. A semi-Fowler's position

3. Lateral on the affected side

4. Lateral on the unaffected side

8. The client sustains a contusion of the eyeball following a traumatic injury with a blunt object. Which intervention would be initiated immediately?

1. Apply ice to the affected eye.

2. Irrigate the eye with cool water.

3. Notify the primary health care provider (PHCP).

4. Accompany the client to the emergency department.

9. A client arrives in the emergency department with a penetrating eye injury from wood chips that occurred while cutting wood. The nurse
assesses the eye and notes a piece of wood protruding from the eye. What is the initial nursing action?

1. Apply an eye patch.

2. Perform visual acuity tests.

3. Irrigate the eye with sterile saline.

4. Remove the piece of wood using a sterile eye clamp.

10. The nurse is caring for a client following enucleation to treat an ocular tumor and notes the presence of bright red drainage on the
dressing. Which action would the nurse take at this time?

1. Document the finding.

2. Continue to monitor the drainage.

3. Notify the primary health care provider (PHCP).

4. Mark the drainage on the dressing and monitor for any increase in bleeding.

11. A client was working in the garden when insecticide accidentally sprayed into the right eye. The client calls the emergency department,
frantic and screaming for help. The nurse would instruct the client to take which immediate action?

1. Irrigate the eyes with water.

2. Come to the emergency department.

3. Call the primary health care provider (PHCP).

4. Irrigate the eyes with diluted hydrogen peroxide.

12. The nurse is preparing a teaching plan for a client who had a cataract extraction with intraocular implantation. Which home care
measures would the nurse include in the plan? Select all that apply.

1. Avoid activities that require bending over.

2. Contact the surgeon if eye scratchiness occurs.
3. Take acetaminophen for minor eye discomfort.
4. Expect episodes of sudden severe pain in the eye.
5. Place an eye shield on the surgical eye at bed- time.
6. Contact the surgeon if a decrease in visual acuity occurs.

13. Tonometry is performed on a client with a suspected diagnosis of glaucoma. The nurse looks at the documented test results and notes an
intraocular pressure (IOP) value of 23. What would be the nurse's initial action?

1. Apply normal saline drops.

2. Note the time of day the test was done.

3. Contact the primary health care provider (PHCP).

4. Instruct the client to sleep with the head of the bed flat.

14. The nurse is caring for a client following craniotomy for removal of an acoustic neuroma. Assessment of which cranial nerve would
identify a complication specifically associated with this surgery?

1. Cranial nerve I, olfactory 2. Cranial nerve IV, trochlear

3. Cranial nerve III, oculomotor

4. Cranial nerve VII, facial nerve

15. The nurse notes that the primary health care provider has documented a diagnosis of presbycusis on a client's chart. Based on this
information, what action would the nurse take?

1. Speak loudly but mumble or slur the words.

2. Speak loudly and clearly while facing the client.
3. Speak at normal tone and pitch, slowly and clearly.
4. Speak loudly and directly into the client's affect- ed ear.

16. A client with Ménière's disease is experiencing severe vertigo. Which instruction would the nurse give to the client to assist in controlling
the vertigo?

1. Increase sodium in the diet.

2. Avoid sudden head movements.

3. Lie still and watch the television.

4. Increase fluid intake to 3000 mL a day.

17. The nurse is preparing to test the visual acuity of a client, using a Snellen chart. Which identifies the accurate procedure for this visual
acuity test?

1. The right eye is tested, followed by the left eye, and then both eyes are tested.
2. Both eyes are assessed together, followed by assessment of the right eye and then the left eye.
3.The client is asked to stand at a distance of 40 feet (12 meters) from the chart and to read the largest line on the chart.

4. The client is asked to stand at a distance of 40 feet (12 meters) from the chart and to read the line that can be read 200 feet (60 meters) away by an
individual with unimpaired vision.

18. A client's vision is tested with a Snellen chart. The results of the tests are documented as 20/60. What action would the nurse implement
based on this finding?

1. Provide the client with materials on legal blind- ness.

2. Instruct the client that glasses may be needed when driving.

3. Inform the client of where to purchase a white cane with a red tip.

4. Inform the client that it is best to sit near the back of the room when attending lectures.

19. The nurse is caring for a hearing-impaired client. Which approach will facilitate communication?

1. Speak loudly.

2. Speak frequently.

3. Speak at a normal volume.

4. Speak directly into the impaired ear.

CHAPTER 58 Eyes & Ear Medication

1. Betaxolol hydrochloride eye drops have been pre- scribed for a client with glaucoma. Which nursing action is most appropriate related to
monitoring for side and adverse effects of this medication?

1. Assessing for edema

2. Monitoring temperature

3. Monitoring blood pressure

4. Assessing blood glucose level

2. The nurse is preparing to administer eye drops to a client being prepared for cataract surgery. Which actions would the nurse take to administer
the drops? Select all that apply.

1. Wash hands.
2. Put gloves on.
3. Place the drop in the conjunctival sac.
4. Pull the lower lid down against the cheekbone.
5. Instruct the client to squeeze the eyes shut after in- stilling the eye drop.
6. Instruct the client to tilt the head forward, open the eyes, and look down.
3. The nurse prepares a client for ear irrigation as pre- scribed by the primary health care provider. Which action would the nurse take when
performing the procedure?

1. Warm the irrigating solution to 0.6 deg * F(37 deg * C)

2. Position the client with the affected side up following the irrigation.

3. Direct a slow, steady stream of irrigation solution

toward the eardrum.

4. Assist the client to turn their head so that the ear to be irrigated is facing upward.

4. The nurse is providing instructions to a client who will be self-administering eye drops. To minimize systemic absorption of the eye drops,
the nurse would instruct the client to take which action?

1. Eat before instilling the drops.

2. Swallow several times after instilling the drops.

3. Blink vigorously to encourage tearing after instilling the drops.

4. Occlude the nasolacrimal duct with a finger after instilling the drops.

5. A client is prescribed an eye drop and an eye ointment for the right eye. How would the nurse best ad- minister the medications?

1. Administer the eye drop first, followed by the eye ointment.

2. Administer the eye ointment first, followed by the eye drop.

3. Administer the eye drop, wait 20 minutes, and ad- minister the eye ointment.

4. Administer the eye ointment, wait 20 minutes, and administer the eye drop.

6. Which medication, if prescribed for the client with glaucoma, would the nurse question?

1. Betaxolol

2. Pilocarpine

3. Erythromycin

4. Atropine sulfate

7. A miotic medication has been prescribed for the client with glaucoma, and the client asks the nurse about the purpose of the medication.
Which response would the nurse provide to the client?

1. "The medication will help dilate the eye to pre- vent pressure from occurring."

2. "The medication will relax the muscles of the eyes and prevent blurred vision."

3. "The medication causes the pupil to constrict and will lower the pressure in the eye."

4. "The medication will help block the responses that are sent to the muscles in the eye."

8. A client was just admitted to the hospital to rule out a gastrointestinal (GI) bleed. The client has brought several bottles of medications
prescribed by different specialists. During the admission assessment, the client states, "Lately, I have been hearing some noisy sounds in
my ears, especially when I am alone." Which medication would the nurse identify as the cause of the client's complaint?

1. Doxycycline

2. Atropine sulfate

3. Acetylsalicylic acid

4. Diltiazem hydrochloride

9. In preparation for cataract surgery, the nurse is to ad- minister cyclopentolate eye drops at 0900 for surgery that is scheduled for 0915.
What initial action would the nurse take in relation to the characteristics of the medication action?

1. Provide lubrication to the operative eye prior to giving the eye drops.

2. Call the surgeon, as this medication will further constrict the operative pupil.

3. Consult the surgeon, as there is not sufficient time for the dilative effects to occur.

4. Give the medication as prescribed; the surgeon needs optimal constriction of the pupil.
CHAPTER 59: Neurological Problem
1. The nurse is assessing the motor and sensory function of an unconscious client who sustained a head injury. The nurse would use which
technique to test the client's peripheral response to pain?

1. Sternal rub

2. Pressure on nail beds

3. Pressure on the orbital rim

4. Squeezing of the sternocleidomastoid muscle

2. The nurse is caring for a client with increased intracranial pressure as a result of a head injury. The nurse would note which trend in vital
signs if the intracranial pressure is rising?

1. Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure

2. Increasing temperature, decreasing pulse, de- creasing respirations, increasing blood pressure

3. Decreasing temperature, decreasing pulse, in- creasing respirations, decreasing blood pressure

4. Decreasing temperature, increasing pulse, de- creasing respirations, increasing blood pressure

3. A client recovering from a head injury is participating in care. The nurse determines that the client under- stands measures to prevent
elevations in intracranial pressure if the nurse observes the client doing which activity?

1. Blowing the nose

2. Isometric exercises

3. Coughing vigorously

4. Exhaling during repositioning

4. A client has clear fluid leaking from the nose following a basilar skull fracture. Which finding would alert the nurse that cerebrospinal fluid
is present?

1. Fluid is clear and tests negative for glucose.

2. Fluid is grossly bloody in appearance and has a pH of 6.

3. Fluid clumps together on the dressing and has a pH of 7.

4. Fluid separates into concentric rings and tests positive for glucose.

5. The nurse is caring for a client who begins to experience seizure activity while in bed. Which actions would the nurse take? Select all that
apply.

1. Loosening restrictive clothing

2. Restraining the client's limbs.

3. Removing the pillow and raising padded side rails.

4 Positioning the client to the side, if possible, with the head flexed forward.

5. Keeping the curtain around the client and the room door open so that when help arrives, they can quickly enter to assist.

6. The nurse is assigned to care for a client with complete right-sided hemiparesis from a stroke (brain attack). Which characteristics are
associated with this condition? Select all that apply.

1. The client is aphasic.

2. The client has weakness on the right side of the body.

3. The client has complete bilateral paralysis of the arms and legs.

4. The client has weakness on the right side of the face and tongue.

5. The client has lost the ability to move the right arm but is able to walk independently.
6. The client has lost the ability to ambulate in- dependently but is able to feed and bathe self without assistance

7. The nurse has instructed the family of a client with a stroke (brain attack) who has homonymous hemi- anopsia about measures to help
the client overcome the deficit. Which statement suggests that the family understands the measures to use when caring for the client?

1. "We need to discourage wearing eyeglasses."

2. "We need to place objects in the impaired field of vision."

3. "We need to approach from the impaired field of vision."

4. "We need to encourage head turning to scan the lost visual field."

8. The nurse is assessing the adaptation of a client to changes in functional status after a stroke (brain at- tack). Which observation indicates
to the nurse that the client is adapting most successfully?

1. Gets angry with family if they interrupt a task

2. Experiences bouts of depression and irritability

3. Has difficulty with using modified feeding utensils

4. Consistently uses adaptive equipment in dressing self

9. The nurse is teaching a client with myasthenia gravis about the prevention of myasthenic and cholinergic crises. Which client activity
suggests that teaching is most effective?

1. Taking medications as scheduled

2. Eating large, well-balanced meals

3. Doing muscle-strengthening exercises

4. Doing all chores early in the day while less fatigued

10. The nurse is instructing a client with Parkinson's disease about preventing falls. Which client state- ment reflects a need for further
teaching?
1. "I can sit down to put on my pants and shoes."

2. "I try to exercise every day and rest when I'm tired."

3. "My son removed all loose rugs from my bed- room."

4. "I don't need to use my walker to get to the bath- room."

11. The nurse has given suggestions to a client with trigeminal neuralgia about strategies to minimize episodes of pain. The nurse determines
that the client needs further teaching if the client makes which statement?

1. "I will wash my face with cotton pads."

2. "I'll have to start chewing on my unaffected side."

3. "I should rinse my mouth if toothbrushing is painful."

4. "I'll try to eat my food either very warm or very cold."

12. The client is admitted to the hospital with a diagnosis of Guillain-Barré syndrome. Which past medical history finding makes the client
most at risk for this disease?

1. Meningitis or encephalitis during the last 5 years

2. Seizures or trauma to the brain within the last year

3. Back injury or trauma to the spinal cord during the last 2 years

4. Respiratory or gastrointestinal infection during the previous month

13. A client with Guillain-Barré syndrome has ascending paralysis and is intubated and receiving mechanical ventilation. Which strategy
would the nurse incorporate in the plan of care to help the client cope with this illness?

1. Giving client full control over care decisions and restricting visitors

2. Providing positive feedback and encouraging active range of motion

3. Providing information, giving positive feedback, and encouraging relaxation

4. Providing intravenously administered sedatives, reducing distractions, and limiting visitors

14. A client has a neurological deficit involving the limbic system. On assessment, which finding is specific to this type of deficit?

1. Is disoriented to person, place, and time

2. Affect is flat, with periods of emotional lability.

3. Cannot recall what was eaten for breakfast today

4. Demonstrates inability to add and subtract; does not know who is the president of the United States

15. The nurse is instituting seizure precautions for a client who is being admitted from the emergency department. Which measures would the nurse
include in planning for the client's safety? Select all that apply.

1. Padding the side rails of the bed.

2. Placing an airway at the bedside.

3. Placing the bed in the high position.

4. Putting a padded tongue blade at the head of the bed.

5. Placing oxygen and suction equipment at the bedside.

6. Flushing the intravenous catheter to ensure that the site is patent.

16. The nurse is evaluating the status of a client who had a craniotomy 3 days ago. Which assessment finding would indicate that the client is
developing meningitis as a complication of surgery?
1. A negative Kernig's sign

2. Absence of nuchal rigidity

3. A positive Brudzinski's sign

4. A Glasgow Coma Scale score of 15

17. The nurse is admitting a client with Guillain-Barré syndrome to the nursing unit. The client has com- plaints of inability to move both legs
and reports a tingling sensation above the waistline. Knowing the complications of the disorder, the nurse would bring which most essential
items into the client's room?

1. Nebulizer and pulse oximeter

2. Blood pressure cuff and flashlight

3. Nasal cannula and incentive spirometer

4. Electrocardiographic monitoring electrodes and intubation tray

CHAPTER 60 Neurological Medication

1. Carbidopa-levodopa is prescribed for a client with Parkinson's disease. The nurse monitors the client for side and adverse effects of the
medication. Which finding indicates that the client is experiencing an adverse effect?

1. Pruritus

2. Tachycardia

3. Hypertension

4. Impaired voluntary movements

2. The home health nurse visits a client who is taking phenytoin for control of seizures. During the assessment, the nurse notes that the
client is taking birth control pills. Which information would the nurse include in the teaching plan?

1. Pregnancy must be avoided while taking phenytoin.

2. The client may stop the medication if it is causing severe gastrointestinal effects.

3. There is the potential of decreased effectiveness of birth control pills while taking phenytoin.

4. There is the increased risk of thrombophlebitis while taking phenytoin and birth control pills together.

3. The nurse is caring for a client in the emergency department who has been diagnosed with Bell's palsy. The client has been taking
acetaminophen, and acetaminophen overdose is suspected. Which anti- dote would the nurse prepare for administration if prescribed?

1. Pentostatin
2. Auranofin

3. Fludarabine

4. Acetylcysteine

4. Oxycodone has been prescribed for a client to treat pain. Which side and adverse effects would the nurse monitor for? Select all that
apply.

1. Diarrhea

2. Tremors

3. Drowsiness

4. Hypotension 5. Urinary frequency

6. Increased respiratory rate

5. A client is taking the prescribed dose of phenytoin to control seizures. Results of a phenytoin blood level study reveal a level of 35 mcg/mL.
Which finding would be expected as a result of this laboratory result?

1. Hypotension

2. Tachycardia

3. Slurred speech

4. No abnormal finding

6. The client arrives at the emergency department, complaining of back spasms. The client states, "I have been taking 2 to 3 aspirin every 4
hours for the last week, and it hasn't helped my back." Since acetylsalicylic acid intoxication is suspected, the nurse would assess the client
for which manifestation?
1. Tinnitus

2. Diarrhea

3 . Constipation

4. Photosensitivity

7. A client with trigeminal neuralgia is being treated with carbamazepine, 400 mg orally daily. Which value indicates that the client is
experiencing an ad- verse effect to the medication?

1. Sodium level, 140 mEq/L (140 mmol/L)

2. Uric acid level, 4.0 mg/dL (240 mcmol/L)

3. White blood cell count, 3000 mm³ (3.0 x 109/L)

4. Blood urea nitrogen level, 10 mg/dl. (3.6 mmol/L)

8. The nurse is caring for a client with cancer. Morphine has been prescribed for the client. Specific to this medication, which intervention
would the nurse include in the plan of care while the client is taking this medication?

1. Monitor radial pulse.

2. Monitor bowel activity.

3. Monitor apical heart rate.

4. Monitor peripheral pulses.

9. The nurse has given medication instructions to a client receiving phenytoin. Which statement indicates that the client has an adequate
understanding of the instructions?

1. "Alcohol is not contraindicated while taking this medication."

2. "Good oral hygiene is needed, including brushing and flossing."

3. "The medication dose may be self-adjusted, de- pending on side effects."

4. "The morning dose of the medication needs to be taken before a medication level is drawn."
10. A client with myasthenia gravis has become increasingly weaker. The primary health care provider pre- pares to identify whether the
client is reacting to an overdose of the medication (cholinergic crisis) or an increasing severity of the disease (myasthenic crisis). An
injection of edrophonium is administered. Which finding would indicate that the client is in cholinergic crisis?

1. No change in the condition

2. Complaints of muscle spasms

3. An improvement of the weakness

4. A temporary worsening of the condition

11. A client with trigeminal neuralgia tells the nurse that acetaminophen is taken daily for the relief of generalized discomfort. Which
laboratory value would indicate toxicity associated with the medication?

1. Sodium level of 140mEq / L (140 mmol/L)

2. Platelet count of 400000m * m ^ 3 m * m ^ 3 * (40 * 10 ^ 9 / L)

3. Prothrombin time of 12 seconds (12 seconds)

4. Direct bilirubin level of 2mg / d * L (34 mcmol/L)

CHAPTER 61: Musculoskeletal Problem

1. The nurse is conducting health screening for osteo- porosis. Which client is at greatest risk of developing this problem?

1. A 25-year-old client who runs

2. A 36-year-old client who has asthma

3. A 70-year-old client who consumes excess alcohol

4. A sedentary 65-year-old client who smokes cigarettes

2. The nurse has given instructions to a client who sustained a ligament injury who is returning home after knee arthroscopy. Which
statement by the client indicates that the instructions are understood?

1. "I can resume regular exercise tomorrow."

2. "I can't eat food for the remainder of the day."

3. "I need to stay off the leg entirely for the rest of

the day."

4. "I need to report a fever, redness around my incisions, or persistent drainage to my health care provider."

3. The nurse witnessed a vehicle hit a pedestrian. The victim is dazed and tries to get up. A leg appears fractured. Which intervention would
the nurse take?

1. Try to reduce the fracture manually.

2. Assist the victim to get up and walk to the side- walk.

3. Leave the victim for a few moments to call an ambulance.

4. Stay with the victim and encourage the victim to remain still.

4. Which cast care instructions would the nurse pro- vide to a client who just had a plaster cast applied to the right forearm? Select all that
apply.

1. Keep the cast clean and dry.

2. Allow the cast 24 to 72 hours to dry.

3. Keep the cast and extremity elevated.

4. Expect tingling and numbness in the extremity.

5. Use a hair dryer set on a warm to hot setting to dry the cast.

6. Use a soft, padded object that will fit under the cast to scratch the skin under the cast.
5. The nurse is evaluating a client in skeletal traction. When evaluating the pin sites, the nurse would be most concerned with which finding?

1. Redness around the pin sites

2. Pain on palpation at the pin sites

3. Thick, yellow drainage from the pin sites

4. Clear, watery drainage from the pin sites

6. The nurse is assessing the casted extremity of a client. Which sign is indicative of infection?

1. Dependent edema

2. Diminished distal pulse

3. Presence of a "hot spot" on the cast

4. Coolness and pallor of the extremity

7. A client has sustained a closed fracture and has just had a cast applied to the affected arm. The client is complaining of intense pain. The
nurse elevates the limb, applies an ice bag, and administers an analgesic, with little relief. Which problem may be causing this pain?

1. Infection under the cast

2. The anxiety of the client

3. Impaired tissue perfusion

4. The recent occurrence of the fracture

8. The nurse is admitting a client with multiple trauma injuries to the nursing unit. The client has a leg fracture and had a plaster cast applied.
Which position would be best for the casted leg?

1. Elevated for 3 hours, then flat for 1 hour

2. Flat for 3 hours, then elevated for 1 hour

3. Flat for 12 hours, then elevated for 12 hours

4. Elevated on pillows continuously for 24 to 48 hours

9. A client is being discharged to home after application of a plaster leg cast. Which statement indicates that the client understands proper
care of the cast?

1. "I need to avoid getting the cast wet."

2. "I need to cover the casted leg with warm blankets."

3. "I need to use my fingertips to lift and move my leg."

4. "I need to use something like a padded coat hanger end to scratch under the cast if it itches."

10. A client being measured for crutches asks the nurse why the crutches cannot rest up underneath the arm for extra support. The nurse
responds, knowing that which would most likely result from this improper crutch measurement?

1. A fall and further injury

2. Injury to the brachial plexus nerves

3. Skin breakdown in the area of the axilla

4. Impaired range of motion while the client ambulates

11. The nurse has given the client instructions about crutch safety. Which statements indicate that the client understands the instructions?
Select all that apply.

1. "I would not use someone else's crutches."

2. "I need to remove any scatter rugs at home."

3. "I can use crutch tips even when they are wet."

4.I need to have spare crutches and tips avail able"

5. "When I'm using the crutches, my arms need to be completely straight."

12. The nurse is caring for a client being treated for fat embolus after multiple fractures. Which data would the nurse evaluate as the most
favorable indication of resolution of the fat embolus?

1. Clear mentation

2. Minimal dyspnea

3. Oxygen saturation of 85%

4. Arterial oxygen level of 78 mm Hg

13. The nurse has conducted teaching with a client in an arm cast about the signs and symptoms of compartment syndrome. The nurse
determines that the client understands the information if the client states that they will report which early symptom of compartment
syndrome?

1. Cold, bluish-colored fingers

2. Numbness and tingling in the fingers

3. Pain that increases when the arm is dependent

4. Pain that is out of proportion to the severity of the fracture

14. A client with diabetes mellitus has had a right below-knee amputation. Given the client's history of diabetes mellitus, which
complication is the client at most risk for after surgery?

1. Hemorrhage

2. Edema of the residual limb

3. Slight redness of the incision

4. Separation of the wound edges

15. The nurse is caring for a client who had an above- knee amputation 2 days ago. The residual limb was wrapped with an elastic
compression band- age, which has come off. Which immediate action would the nurse take?

1. Apply ice to the site.

2. Call the primary health care provider (PHCP).

3. Rewrap the residual limb with an elastic com- pression bandage.

4. Apply a dry, sterile dressing, and elevate the residual limb on one pillow.

16. A client is complaining of low back pain that radiates down the left posterior thigh. The nurse would ask the client if the pain is worsened
or aggravated by which factor?

1. Bed rest

2. Ibuprofen

3. Bending or lifting

4. Application of heat

17. The nurse is caring for a client who has had spinal fusion, with insertion of hardware. The nurse would be most concerned with which
assessment finding?

1. Temperature of 0.6 deg * F(38.7 deg * C) orally

2. Complaints of discomfort during repositioning

3. Old bloody drainage outlined on the surgical dressing

4. Discomfort during coughing and deep-breathing exercises

18. The nurse is caring for a client with a diagnosis of gout. Which laboratory value would the nurse expect to note in the client?

1. Calcium level of 9mg / d * L ( 2.25 mmol/L)

2. Uric acid level of 9mg / d * L ( 540 mcmol/L)

3. Potassium level of 4.1 mEq / L (4.1 mmol/L)

4. Phosphorus level of 3.1mg / d * L ( 1 mmol/L)

19. A client with a hip fracture asks the nurse what is involved with Buck's (extension) traction, which is being applied before surgery. The
nurse would pro- vide which information to the client?

1. Allows bony healing to begin before surgery and involves pins and screws

2. Provides rigid immobilization of the fracture site and involves pulleys and wheels

3. Lengthens the fractured leg to prevent severing of blood vessels and involves pins and screws

4. Provides comfort by reducing muscle spasms, provides fracture immobilization, and involves pulleys and wheels

CHAPTER 62: Musculoskeletal Medication

1. A client has been on treatment for rheumatoid arthritis for 3 weeks. During the administration of etanercept, which is most important for
the nurse to assess?

1. The injection site for itching and edema

2. The white blood cell counts and platelet counts

3. Whether the client is experiencing fatigue and joint pain

4. Whether the client is experiencing a metallic taste in the mouth and a loss of appetite

2. Allopurinol is prescribed for a client and the nurse provides medication instructions to the client. Which instruction would the nurse
provide?

1. Drink 3000 mL of fluid a day.

2. Take the medication on an empty stomach.

3. The effect of the medication will occur immediately.

4. Any swelling of the lips is a normal expected response.

3. Colchicine is prescribed for a client with a diagnosis of gout. The nurse reviews the client's record, knowing that this medication would be
used with caution in which disorder?

1. Myxedema

2. Kidney disease

3. Hypothyroidism

4. Diabetes mellitus

4. Alendronate is prescribed for a client with osteoporosis, and the nurse is providing instructions on administration of the medication.
Which instruction would the nurse provide?

1. Take the medication at bedtime.

2. Take the medication in the morning with break- fast.

3. Lie down for 30 minutes after taking the medication.

4. Take the medication with a full glass of water after rising in the morning.

5. The nurse is preparing discharge instructions for a client who sustained a skeletal muscle injury and is receiving baclofen. Which
instruction would be included in the teaching plan?

1. Restrict fluid intake.

2. Avoid the use of alcohol.

3. Stop the medication if diarrhea occurs.

4. Notify the primary health care provider (PHCP) if fatigue occurs.

6. The nurse is analyzing the laboratory studies on a client receiving dantrolene to treat muscle spasms from an injury. Which laboratory test
would identify an adverse effect associated with the administration of this medication?

1. Platelet count

2. Creatinine level

3. Liver function tests

4. Blood urea nitrogen level

7. Cyclobenzaprine is prescribed for a client for muscle spasms, and the nurse is reviewing the client's record. Which disorder, if noted in the
record, would indicate a need to contact the primary health care provider about the administration of this medication?

1. Glaucoma

2. Emphysema

3. Hypothyroidism

4. Diabetes mellitus

8. In monitoring a client's response to disease- modifying antirheumatic drugs (DMARDs), which assessment findings would the nurse
consider accept- able responses? Select all that apply.

1. Control of symptoms during periods of emotional stress

2. Normal white blood cell, platelet, and neutrophil counts

3. Radiological findings that show no progression of joint degeneration

4. An increased range of motion in the affected joints 3 months into therapy

5. Inflammation and irritation at the injection site 3 days after the injection is given

6. A low-grade temperature on rising in the morning that remains throughout the day

9. The nurse is administering an intravenous dose of methocarbamol to a client with a musculoskeletal in- jury. For which adverse effect
would the nurse monitor?

1. Tachycardia

2. Rapid pulse

3. Bradycardia

4. Hypertension

CHAPTER 63: Immune Problems

1. The nurse prepares to give a bath and change the bed linens of a client with cutaneous Kaposi's sarcoma lesions. The lesions are open and
draining a scant amount of serous fluid. Which would the nurse incorporate into the plan during the bathing of this client?

1. Wearing gloves

2. Wearing a gown and gloves

3. Wearing a gown, gloves, and a mask

4. Wearing a gown and gloves to change the bed linens, and gloves only for the bath

2. The nurse provides home care instructions to a client with systemic lupus erythematosus and tells the client about methods to manage
fatigue. Which statement by the client indicates a need for further instruction?

1. "I need to take hot baths because they are relaxing."

2. "I need to sit whenever possible to conserve my energy."

3. "I need to avoid long periods of rest because it causes joint stiffness."

4. "I need to do some exercises, such as walking, when I am not fatigued."

3. A client develops an anaphylactic reaction after receiving morphine. The nurse would take which actions? Select all that apply.

1. Administer oxygen.

2. Quickly assess the client's respiratory status.

3. Document the event, interventions, and client's response.

4. Leave the client briefly to contact a primary health care provider (PHCP).

5. Keep the client supine regardless of the blood pressure readings.

6. Start an intravenous (IV) infusion of DSW and administer a 500-ml bolus.

4. The nurse is conducting a teaching session with a client on their diagnosis of pemphigus. Which state- ment by the client indicates that
the client under- stands the diagnosis?

1. "My skin will have tiny red vesicles."

2. "The presence of the skin vesicles is caused by a virus."

3. "I have an autoimmune disease that causes blistering in the skin."

4. "Red, raised papules and large plaques covered by silvery scales will be present on my skin."

5. The nurse is assisting in planning care for a client with a diagnosis of immunodeficiency and would incorporate which action as a priority in
the plan?

1. Protecting the client from infection

2. Providing emotional support to decrease fear 3. Encouraging discussion about lifestyle changes

4. Identifying factors that decreased the immune function

6. A client calls the nurse in the emergency department and reports being just stung by a bumblebee while gardening. The client is afraid of a
severe reaction because the client's neighbor experienced such a reaction just 1 week ago. Which action would the nurse take?

1. Advise the client to soak the site in hydrogen per- oxide.

2. Ask the client if they ever sustained a bee sting in the past.

3. Tell the client to call an ambulance for transport to the emergency department.

4. Tell the client not to worry about the sting unless difficulty with breathing occurs.

7. The community health nurse is conducting a re- search study and is identifying clients in the com- munity at risk for latex allergy. Which
client population is most at risk for developing this type of allergy?

1. Hairdressers

2. The homeless

3. Children in day care centers

4. Individuals living in a group home

8. Which interventions apply in the care of a client at high risk for an allergic response to a latex allergy? Select all that apply.

1. Use nonlatex gloves.

2. Use medications from glass ampules.

3. Place the client in a private room only.

4. Keep a latex-safe supply cart available in the client's area.

5. Avoid the use of medication vials that have rubber stoppers.

6. Use only a blood pressure cuff from an electronic device to measure the blood pressure.

9. A client presents at the primary health care provider's office with complaints of a ringlike rash on the upper leg. Which question would the
nurse ask first?

1. "Do you have any cats in your home?"

2. "Have you been camping in the last month?"

3. "Have you or close contacts had any flulike symptoms within the last few weeks?"

4. "Have you been in physical contact with anyone who has the same type of rash?"

10. A client is diagnosed with scleroderma. Which intervention would the nurse anticipate to be prescribed?

1. Maintain bed rest as much as possible.

2. Administer corticosteroids as prescribed for inflammation.

3. Advise the client to remain supine for 1 to 2 hours after meals.

4. Keep the room temperature warm during the day and cool at night.

11. A client arrives at the health care clinic and tells the nurse that they were just bitten by a tick and would like to be tested for Lyme
disease. The client tells the nurse that the tick was removed and flushed down the toilet. Which actions are most appropriate? Select all that
apply.

1. Tell the client that testing is not necessary un- less arthralgia develops.

2. Tell the client to avoid any woody, grassy areas that may contain ticks.

3. instruct the client to immediately start to take the antibiotic that was prescribed

4. Inform the client to plan to have a blood test 4 to 6 weeks after a bite to detect the presence of the disease.

5. Tell the client that if this happens again, to never remove the tick but to vigorously scrub the area with an antiseptic.

12. The client with acquired immunodeficiency syn- drome is diagnosed with cutaneous Kaposi's sarcoma. Based on this diagnosis, the
nurse understands that this has been confirmed by which finding?

1. Swelling in the genital area

2. Swelling in the lower extremities

3. Positive punch biopsy of the cutaneous lesions

4. Appearance of reddish-blue lesions noted on the skin

13. The nurse is conducting allergy skin testing on a client. Which post procedure interventions are most appropriate? Select all that apply.

1. Record site, date, and time of the test.

2. Give the client a list of potential allergens if identified.

3. Estimate the size of the wheal and document the finding.

4. Tell the client to return to have the site inspect- ed only if there is a reaction.

5. Have the client wait in the waiting room for at least 1 to 2 hours after injection.

14. The nurse is performing an assessment on a client who has been diagnosed with an allergy to latex. In determining the client's risk
factors, the nurse would question the client about an allergy to which food item?

1. Eggs

2. Milk

3. Yogurt

4. Bananas

CHAPTER 45: Oncological & Hematological Problem

1. The nurse is reviewing the laboratory results of a client diagnosed with multiple myeloma. Which would the nurse expect to note
specifically in this disorder?

1. Increased calcium level

2. Increased white blood cells

3. Decreased blood urea nitrogen level

4. Decreased number of plasma cells in the bone marrow

2. The nurse is creating a plan of care for the client with multiple myeloma and includes which priority intervention in the plan?

1. Encouraging fluids

2. Providing frequent oral care

3. Coughing and deep breathing

4. Monitoring the red blood cell count

3. When caring for a client with cervical cancer who has an internal radiation implant, the nurse would observe which principles? Select all
that apply.

1. Limiting the time with the client to 1 hour per shift.

2. Keeping pregnant persons out of the client's room.

3. Placing the client in a private room with a private bath.

4. Wearing a lead shield when providing direct client care.

5. Removing the dosimeter film badge when entering the client's room.

6. Allowing individuals younger than 16 years old in the room as long as they are 6 feet away from the client.

4. While giving care to a client with cervical cancer who has an internal cervical radiation implant, the nurse finds the implant in the bed. The
nurse would take which initial action?

1. Call the primary health care provider (PHCP).

2. Reinsert the implant into the vagina.

3. Pick up the implant with gloved hands and flush it down the toilet.

4. Pick up the implant with long-handled forceps and place it in a lead container.

5. The nurse would plan to implement which intervention in the care of a client experiencing neutropenia as a result of chemotherapy?

1. Restrict all visitors.

2. Restrict fluid intake.

3. Teach the client and family about the need for hand hygiene

4. Insert an indwelling urinary catheter to prevent skin breakdown.

6. The home health care nurse is caring for a client with cancer who is complaining of acute pain. The most appropriate determination of the
client's pain needs to include which assessment?

1. The client's pain rating

2. Nonverbal cues from the client

3. The nurse's impression of the client's pain

4. Pain relief after appropriate nursing intervention

7. The nurse is caring for a client who is postoperative following a pelvic exenteration, and the surgeon changes the client's diet from NPO
(nothing by mouth) status to clear liquids. The nurse would check which priority item before administering the diet?

1. Bowel sounds

2. Ability to ambulate

3. Incision appearance

4. Urine specific gravity

8. A client is admitted to the hospital with a suspected diagnosis of Hodgkin's disease. Which assessment finding would the nurse expect to
note specifically in the client?

1. Fatigue

2. Weakness

3. Weight gain

4. Enlarged lymph nodes

9. During the admission assessment of a client with advanced ovarian cancer, the nurse recognizes which manifestation as typical of the
disease?

1. Diarrhea

2. Hypermenorrhea

3. Abnormal bleeding
4. Abdominal distention

10. The nurse is caring for a client with lung cancer and bone metastasis. What signs and symptoms would the nurse recognize as
indications of a possible oncological emergency? Select all that apply.

1. Facial edema in the morning

2. Weight loss of 20 lb (9 kg) in 1 month
3. Serum calcium level of 12 mg/dl. (3.0 mmol/L)
4. Serum sodium level of 136 mg/dL (136 mmol/L)
5. Serum potassium level of 3.4 mg/dL (3.4 mmol/L)
6. Numbness and tingling of the lower extremities

11. A client who has been receiving radiation therapy for bladder cancer states to the nurse. "I feel like 1 am urinating through my vagina." The
nurse interprets that the client may be experiencing which condition?

1. Rupture of the bladder

2. The development of a vesicovaginal fistula

3. Extreme stress caused by the diagnosis of cancer

4. Altered perineal sensation as a side effect of radiation therapy

12. The nurse is instructing a client to perform a testicular self-examination (TSE). The nurse would provide the client with which information
about the procedure?

1. To examine the testicles while lying down

2. That the best time for the examination is after a shower

3. To gently feel the testicle with one finger to feel for a growth

4. That TSEs should be done at least every 6 months

13. The nurse is conducting a history and monitoring laboratory values on a client with multiple myeloma. What assessment findings would
the nurse expect to note? Select all that apply.

1. Pathological fracture

2. Urinalysis positive for Bence Jones protein

3. Hemoglobin level of 15.5 g/dL (155 mmol/L)

4. Calcium level of 9.0 mg/dl. (2.25 mmol/L)

5. Serum creatinine level of 2.0 mg/dL. (176.6 mcmol/L)

14. A gastrectomy is performed on a client with gastric cancer. In the immediate postoperative period, the nurse notes bloody drainage from
the nasogastric tube. The nurse would take which most appropriate action?

1. Measure abdominal girth

2. Irrigate the nasogastric tube.

3. Continue to monitor the drainage.

4. Notify the surgeon.

15. The nurse is teaching a client about the risk factors associated with colorectal cancer. The nurse deter- mines that further teaching is
necessary related to colorectal cancer if the client identifies which item as an associated risk factor?

1. Age younger than 50 years

2. History of colorectal polyps

3. Family history of colorectal cancer

4. Chronic inflammatory bowel disease

16. The nurse is assessing the perineal wound in a client who has returned from the operating room following an abdominal perineal
resection and notes serosanguineous drainage from the wound. Which nursing action is most appropriate?

1. Clamp the surgical drain.

2. Change the dressing as prescribed.

3. Notify the surgeon.

4. Remove and replace the perineal packing.

17. The nurse is assessing the colostomy of a client who has had an abdominal perineal resection for a bow el tumor. Which assessment
finding indicates that the colostomy is beginning to function?

1. The passage of flatus

2. Absent bowel sounds

3. The client's ability to tolerate food

4. Bloody drainage from the colostomy

18. The nurse is reviewing the history of a client with bladder cancer. The nurse expects to note documentation of which most common sign
or symptom of this type of cancer?

1. Dysuria

2. Hematuria

3. Urgency on urination

4. Frequency of urination

19. The nurse is assessing a client who has a new ureterostomy. Which statement by the client indicates the need for more education about
urinary stoma care?

1. "I change my pouch every week."

2. "I change the appliance in the morning."

3. "I empty the urinary collection bag when it is two-thirds full."

4. "When I'm in the shower, I direct the flow of water away from my stoma."

20. A client with carcinoma of the lung develops syn- drome of inappropriate antidiuretic hormone (SIADH) as a complication of the cancer.
The nurse anticipates that the primary health care provider will request which prescriptions? Select all that apply.

1. Radiation

2. Chemotherapy

3. Increased fluid intake

4. Decreased oral sodium intake

5. Serum sodium level determination

6. Medication that is antagonistic to antidiuretic hormone

21. The nurse is monitoring a client for signs and symptoms related to superior vena cava syndrome. Which is an early sign of this
oncological emergency?

1. Cyanosis

2. Arm edema

3. Periorbital edema

4. Mental status changes

22. The nurse manager is teaching the nursing staff about signs and symptoms related to hypercalcemia in a client with metastatic prostate
cancer and tells the staff that which is a late sign or symptom of this oncological emergency?

1. Headache

2. Dysphagia

3. Constipation

4. Electrocardiographic changes
23. As part of chemotherapy education, the nurse teach- es a client about the risk for bleeding and self-care during the period of greatest
bone marrow suppression (the nadir). The nurse understands that further teaching is needed if the client makes which statement?

1. "I should avoid blowing my nose."

2. "I may need a platelet transfusion if my platelet count is too low."

3. "I'm going to take aspirin for my headache as soon as I get home."

4. "I will count the number of pads and tampons I use when menstruating."

24. The community health nurse is instructing a group of young clients about breast self-examination. The nurse would instruct the clients to
perform the ex- amination at which time?

1.At the onset of menstruation

2. Every month during ovulation

3. Weekly at the same time of day

4. One week after menstruation begins

25. A client is diagnosed as having a intestinal tumor. The nurse would monitor the client for which com- plications of this type of tumor?
Select all that apply.

1. Flatulence

2. Peritonitis

3. Hemorrhage

4. Fistula formation

5. Bowel perforation

6. Lactose intolerance

26. The nurse is caring for a client after a mastectomy. Which nursing intervention would assist in preventing lymphedema of the affected
arm?

1. Placing cool compresses on the affected arm

2. Elevating the affected arm on a pillow above heart level

3. Avoiding arm exercises in the immediate postoperative period

4. Maintaining an intravenous site below the ante- cubital area on the affected side

27. The nurse is providing dietary teaching for a client with a diagnosis of chronic gastritis who is at risk for vitamin B12 deficiency. The nurse
instructs the client to include which foods rich in vitamin B12 in the diet? Select all that apply.

1. Meat

2. Corn

3. Liver

4. Apples

5. Bananas

28. The nurse is instructing a client with iron-deficiency anemia regarding the administration of a liquid oral iron supplement. Which
instruction would the nurse tell the client?

1. Administer the iron at mealtimes.

2. Administer the iron through a straw.

3. Mix the iron with cereal to administer.

4. Add the iron to apple juice for easy administration.

29. Laboratory studies are performed for a client suspected to have iron-deficiency anemia. The nurse reviews the laboratory results,
knowing that which result indicates this type of anemia?

1. Elevated hemoglobin level

2. Decreased reticulocyte count

3. Elevated red blood cell count

4. Red blood cells that are microcytic and hypochromic