NURSING 21 NCLEX-RN EXAM TEST BANK WITH RATIONALE

NURSING 21 NCLEX-RN EXAM TEST BANK WITH RATIONALENURSING 21 NCLEX-RN EXAM TEST BANK 1001 Which electrolyte abnormalities would the nurse expect to occur while working with a client who just sustained partial- and full-thickness burns? 1) Decreased sodium and increased potassium 2) Increased calcium and decreased potassium 3) Decreased magnesium and increased sodium 4) Increased sodium and decreased potassium 1002 The nurse provides teaching to a client after the removal of a short leg cast. The nurse should include which of the following in discussions with the client? 1) Wash the skin with undiluted hydrogen peroxide. 2) Vigorously scrub the legs to remove dead skin. 3) Gently wash and lubricate the leg. 4) Avoid touching the leg for 2 weeks. 1003 Which of the following nursing diagnoses would be the priority for a client with Paget’s disease? 1) Risk for noncompliance 2) Disturbed sleep pattern 3) Impaired physical mobility 4) Disturbed body image 1004 A client with a right arm cast for fractured humerus states, “I haven’t been able to extend the fingers on my right hand since this morning.” What action should the nurse take next? 1) Assess neurovascular status. 2) Ask the client to massage the fingers. 3) Encourage the client to take the prescribed analgesics as ordered. 4) Elevate the right arm on a pillow to reduce edema. 1005 A client with an open fracture is at risk for developing osteomyelitis. Which of the following classic symptoms would the nurse assess for to detect development of this complication? 1) Low bone density 2) Elevated temperature 3) Acute respiratory distress 4) Shortening of the affected extremity 1006 An obese client with degenerative joint disease is being managed pharmacologically with aspirin therapy. The nurse knows that additional client teaching is necessary when the client makes which of the following statements? 1) “I take my aspirin only when I have extreme pain and stiffness.” 2) “I use heat sometimes to help decrease my pain and joint stiffness.” 3) “I frequently examine my stools for bleeding.” 4) “I started an exercise program to lose weight.” CRRECT ANSWER: 1 RATIONALE: Aspirin therapy for this condition is continuous and is effective only after a therapeutic level is reached. It should not be taken intermittently (option 1). The other options are correct statements about self-care measures when taking aspirin for degenerative joint disease. COGNITIVE LEVEL: Application CLIENT NEED: Physiological Integrity: Physiological Adaptation INTEGRATED PROCESS: Nursing Process: Evaluation CONTENT AREA: Adult Health: Musculoskeletal STRATEGY: The core issue of the question is the knowledge of appropriate self-management techniques for degenerative joint disease. Use nursing knowledge and the process of elimination to make a selection. 1007 A client underwent a lumbar laminectomy today. Which nursing diagnosis has highest priority for this client? 1) Disturbed body image disturbance 2) Social isolation 3) Ineffective role performance 4) Impaired physical mobility CORRECT ANSWER: 4 RATIONALE: Immediately after surgery, the client will be inclined not to move because of pain and fear of disturbing the operative site. Minimal scarring results from this surgery, so body image disturbance is not likely to be appropriate (option 1). The psychosocial diagnoses in options 2 and 3 have less priority than option 4 because option 4 is a physiological concern. COGNITIVE LEVEL: Analysis CLIENT NEED: Physiological Integrity: Physiological Adaptation INTEGRATED PROCESS: Nursing Process: Analysis CONTENT AREA: Fundamentals STRATEGY: The core issue of the question is the knowledge of priority nursing diagnoses following musculoskeletal surgery. Use nursing knowledge and the process of elimination to make a selection. 1008 A client had a left above-the-knee amputation today. For the first 24 hours postoperatively, the nurse makes it a priority to do which of the following to properly manage the surgical site? 1) Elevate the residual limb on a pillow. 2) Loosen the stump dressing every 4 hours. 3) Maintain the residual limb in a dependent position. 4) Change dressings as often as needed. CORRECT ANSWER: 1 RATIONALE: Elevating the limb on a pillow facilitates venous return, decreases swelling, and promotes comfort. The stump dressing is usually a compression type to mold the stump and to decrease the edema associated with inflammation, so option 2 is an inappropriate intervention. The other options are also inappropriate because option 3 increases risk of edema and option 4 is done as ordered. COGNITIVE LEVEL: Application CLIENT NEED: Physiological Integrity: Physiological Adaptation INTEGRATED PROCESS: Nursing Process: Implementation CONTENT AREA: Adult Health: Musculoskeletal STRATEGY: The core issue of the question is the knowledge of postoperative stump care and positioning. Use nursing knowledge and the process of elimination to make a selection. 1010 A truck driver presents to the primary care provider with complaints of persistent back pain. The nurse explains that which client activity documented during the nursing history may contribute to further back injury? 1) Lifting objects close to the body 2) Shifting positions often when sitting for prolonged periods 3) Providing back support with a pillow when sitting 4) Prolonged standing or sitting CORRECT ANSWER: 4 RATIONALE: Prolonged sitting or standing aggravates back injury because of the additional stress placed on the structures supporting the back. Lifting objects close to the body, shifting positions frequently, and providing back support are appropriate actions to maintain good body mechanics. COGNITIVE LEVEL: Analysis CLIENT NEED: Physiological Integrity: Physiological Adaptation INTEGRATED PROCESS: Nursing Process: Assessment CONTENT AREA: Adult Health: Musculoskeletal STRATEGY: The core issue of the question is the knowledge of risk factors and aggravating factors of low back pain. Use nursing knowledge and the process of elimination to make a selection. 1011 A client underwent a lumbar laminectomy. Which of the following activities would be best 4 hours postoperatively? 1) Sitting up in a chair to watch television 2) Sitting at the side of the bed 3) Lying in bed in good alignment with the head of bed flat 4) Using the side-rails for support to get out of bed CORRECT ANSWER: 3 RATIONALE: The physician orders the client’s activity after a laminectomy. After a laminectomy procedure, a client should be assisted to logroll from side to side. The principle is to maintain the alignment of the vertebral column at all times. Clients with lumbar laminectomy should be kept flat or with head of bed slightly elevated to minimize stress on the suture line. Using the side-rails to get out of bed causes shifting of the vertebral column. Sitting up in a chair or on the side of the bed is usually done the evening of the surgery or the first day following surgery, and it is for brief periods only. COGNITIVE LEVEL: Application CLIENT NEED: Safe Effective Care Environment: Safety and Infection Control INTEGRATED PROCESS: Nursing Process: Implementation CONTENT AREA: Adult Health: Musculoskeletal STRATEGY: The core issue of the question is the knowledge of activity levels after surgery that will not cause harm to the surgical area following laminectomy. Use nursing knowledge and the process of elimination to make a selection. 1012 The nurse provides teaching to a 50-year-old male Caucasian client with chronic low back pain. The client weighs 200 pounds, works as a truck driver, sits for prolonged periods, and seldom participates in exercise activities. The client smokes one pack of cigarettes and drinks six cans of beer per day. What risk factors should the nurse include in the discussion? 1) Lack of exercise, obesity, sitting for long periods, smoking, sedentary occupation 2) Degenerative disk disease, gender, race, smoking 3) Degenerative disk disease, race, alcohol use, smoking, inactivity 4) Age, obesity, lack of exercise, genetic factors CORRECT ANSWER: 1 RATIONALE: Smoking has been found to contribute to disc deterioration. Lack of exercise predisposes the muscles of the back to strain. The extra weight of obese individuals imposes more strain on the back and also interferes in maintaining good body mechanics in lifting. Occupations that require prolonged sitting or standing predispose those individuals to exacerbation of back pain. Option 1 is the only answer that accurately reflects risk factors associated with chronic low back pain for the client described in the question. COGNITIVE LEVEL: Analysis CLIENT NEED: Physiological Integrity: Physiological Adaptation INTEGRATED PROCESS: Nursing Process: Planning CONTENT AREA: Adult Health: Musculoskeletal STRATEGY: The core issue of the question is the knowledge of factors that aggravate low back pain. Use nursing knowledge and the process of elimination to make a selection. 1013 The nurse is teaching a postmenopausal client about the use of calcium to prevent the effects of osteoporosis. The client asks: “Why do I have to take Vitamin D with my calcium?” Which of the following is the nurse’s best response? 1) “Vitamin D prevents osteoporosis.” 2) “Vitamin D increases intestinal absorption of calcium.” 3) “You are most likely to be deficient in Vitamin D.” 4) “Calcium and Vitamin D supplementation is the only way to prevent osteoporosis.” CORRECT ANSWER: 2 RATIONALE: A combination of calcium and Vitamin D is recommended for the prevention of osteoporosis. Vitamin D increases the intestinal absorption of calcium and mobilizes calcium and phosphorus into the bone. Vitamin D alone does not prevent osteoporosis (option 2). Whereas some elderly might be deficient in Vitamin D, a postmenopausal state does not necessarily cause the deficiency (option 3). There are other interventions for the prevention of osteoporosis, including lifestyle modifications (e.g., smoking cessation), which makes option 4 inaccurate. COGNITIVE LEVEL: Application CLIENT NEED: Health Promotion and Maintenance INTEGRATED PROCESS: Communication and Documentation CONTENT AREA: Adult Health: Musculoskeletal STRATEGY: The core issue of the question is the knowledge of risk factors for and prevention of osteoporosis. Use nursing knowledge and the process of elimination to make a selection. 1014 The nurse is caring for a client with a week-old cast. The client asks why the nurse palpates the casted area when doing the assessment. Which of the following is the most appropriate response by the nurse? 1) “I am making sure that the cast has dried.” 2) “I am evaluating the strength of the cast.” 3) “I am feeling for hot spots that might indicate infection.” 4) “I am making sure that the cast is not too tight.” CORRECT ANSWER: 3 RATIONALE: A complication of cast application is skin breakdown underneath the cast. If this occurs, infection can set in and can cause the area over the breakdown to be warmer than other areas. A bad odor coming from the area may also be noted. Option 1 is inaccurate because generally plaster casts dry in 48 hours or less and erglass casts in 30 minutes to 1 hour. If a cast is too tight, symptoms associated with neurovascular compromise will be noted, which include pain, paresthesia, pallor, diminished pulse distal to the cast, and paralysis (option 4). COGNITIVE LEVEL: Application CLIENT NEED: Physiological Integrity: Physiological Adaptation INTEGRATED PROCESS: Communication and Documentation CONTENT AREA: Adult Health: Musculoskeletal STRATEGY: The core issue of the question is the knowledge of various complications of casts. Use nursing knowledge and the process of elimination to make a selection. 1015 A client is placed on continuous passive motion (CPM) machine postoperatively after a total knee replacement. The nurse observes that the client’s knee is externally rotating during flexion. What should the nurse do next? 1d, loss of the limb may occur. The nurse needs to ensure that the leg is not above heart level so no further damage occurs. The physician needs to be notified immediately so medical interventions can be instituted before irreversible tissue and nerve damage occurs. COGNITIVE LEVEL: Application CLIENT NEED: Physiological Integrity: Physiological Adaptation INTEGRATED PROCESS: Nursing Process: Implementation CONTENT AREA: Adult Health: Musculoskeletal STRATEGY: The core issue of the question is the knowledge of adverse neurovascular changes to a client in a cast. Recall principles of gravity and blood flow to aid in answering the question. Use nursing knowledge and the process of elimination to make a selection. 1017 A nurse receives a client from the emergency department in Buck’s traction following a fracture of the right femur. The nurse documents which of the following as a priority in the client medical record? 1) Status of skin underneath the traction and over bony prominences 2) Type of pin, wire, or tongs used 3) The effectiveness of pain medication given in the field 4) Medications given in the emergency department CORRECT ANSWER: 1 RATIONALE: It is essential to monitor the condition of the skin under traction, as well as bony prominences, because these areas are at risk for breakdown due to continuous friction and pressure from the skin traction device. Option 2 is incorrect because Buck’s traction is a type of skintraction. Skeletal tractions use pins, wires, or tongs to aid in realignment. Option 3 is appropriate, but the most essential assessment to be documented for a client with skin traction is the condition of the skin underneath the straps. COGNITIVE LEVEL: Analysis CLIENT NEED: Physiological Integrity: Physiological Adaptation INTEGRATED PROCESS: Communication and Documentation CONTENT AREA: Adult Health: Musculoskeletal STRATEGY: The critical word in the question is priority, which tells you that all or more than one options are correct and that the most essential one is the correct answer. Use nursing knowledge about skin traction and the process of elimination to make a selection. 1018 The nurse planning for the care of a client admitted with balanced suspension traction explains to the family that an advantage of balanced suspension is which of the following? 1) It eliminates the risk for skin breakdown. 2) It allows the client to raise the buttocks off the bed for bedpan use and skin care. 3) It is more effective in reducing hip contracture. 4) It requires only one weight to maintain traction. CORRECT ANSWER: 2 RATIONALE: Balanced suspension allows for ease with bedpan use and skin care without disturbing the line of traction. In this type of traction, the client’s injured extremity is lifted off the bed and a straight pull is accomplished by the application of several forces and several weights. Skin breakdown is not eliminated with this type of traction because any immobile client can be at risk. COGNITIVE LEVEL: Application CLIENT NEED: Physiological Integrity: Physiological Adaptation INTEGRATED PROCESS: Nursing Process: Implementation CONTENT AREA: Adult Health: Musculoskeletal STRATEGY: The core issue of the question is the knowledge of Buck’s traction as a skin traction and the need to assess the underlying skin. Use nursing knowledge and the process of elimination to make a selection. 1019 A client is taking colchicine for gout. The client complains of weakness, abdominal pain, nausea, vomiting, and diarrhea for the past 2 days. The nurse interprets these complaints indicating which of the following? 1) Therapeutic effects of the medication 2) Signs of toxicity 3) Expected side effects 4) An allergic response CORRECT ANSWER: 2 RATIONALE: Colchicine is used in treating the acute attack of gout. The symptoms described are signs of toxicity. The client should be instructed to stop the medication and be seen for follow-up treatment. The expected effect of colchicine is to diminish the joint pain associated with the acute attack. COGNITIVE LEVEL: Application CLIENT NEED: Physiological Integrity: Pharmacological and Parenteral Therapies INTEGRATED PROCESS: Nursing Process: Analysis CONTENT AREA: Adult Health: Musculoskeletal STRATEGY: The core issue of the question is the knowledge of actions and adverse effects of colchicines in the client with gout. Use nursing knowledge and the process of elimination to make a selection. 1020 An 87-year-old client sustained a right hip fracture. The client asks the nurse about the length of time needed for the fracture to heal. The nurse’s response includes consideration of which client factor that influences the rate of bone healing? 1) Frequency of physical therapy 2) Age of the client 3) Weight of the client 4) Early ambulation 1022 A child is admitted to the hospital with a diagnosis of osteomyelitis. Which of the following would the nurse likely find when gathering the nursing history? 1) History of an upper respiratory infection 2) History of gastroenteritis 3) History of Legg-Calve-Perthes disease 4) History of congenital hip dysplasia CORRECT ANSWER: 1 RATIONALE: The history of a child with osteomyelitis may include a recent upper respiratory infection (which may include an ear infection or sinus infection), skin infection, or blunt trauma to a bone. Gastroenteritis would not be found in the recent history of this child that would lead to this illness. LCPD and CHD do not lead to osteomyelitis. COGNITIVE LEVEL: Analysis CLIENT NEED: Physiological Integrity: Physiological Adaptation INTEGRATED PROCESS: Nursing Process: Assessment CONTENT AREA: Child Health STRATEGY: The core issue of the question is the knowledge of risk factors for osteomyelitis. Use nursing knowledge and the process of elimination to make a selection. 1023 Two hours after a child had a cast applied for a fractured radius, the nursing assessment reveals swelling in the hand, which is elevated higher than the heart. Ice has been applied continuously. The child does not complain of pain but does complain of numbness and tingling. Which should the nurse do first? 1) Medicate for pain. 2) Elevate the injured extremity even higher. 3) Call the physician. 4) Provide the child with diversional activities. CORRECT ANSWER: 3 RATIONALE: A very swollen hand despite application of ice and elevation is a grave concern, especially with the child complaining of numbness. Such swelling can lead to compartment syndrome, which can lead to neurological damage. This is a medical emergency, and the physician should be called immediately. The nurse can then provide diversional activities while waiting for definitive orders. COGNITIVE LEVEL: Analysis CLIENT NEED: Physiological Integrity: Physiological Adaptation INTEGRATED PROCESS: Nursing Process: Implementation CONTENT AREA: Child Health STRATEGY: The core issue of the question is recognition of a complication, compartment syndrome, that can lead to neurological damage. The correct answer is the one that provides for definitive treatment of the problem, which in this case is in the practice realm of the physician. 1024 The pediatric nurse interprets that which of the following infants is the least likely to be diagnosed with developmental dysplasia of the hip? 1) The infant with a family history of developmental dysplasia of the hip 2) The infant who weighs over 10 pounds 3) The infant carried on the mother’s hips 4) The infant who had breech position while in the uterus CORRECT ANSWER: 3 RATIONALE: The infant who is carried with the hips abducted is at decreased risk for developing developmental dysplasia of the hip. Options 1, 2, and 4 are all factors that would possibly increase the incidence of this defect. COGNITIVE LEVEL: Analysis CLIENT NEED: Physiological Integrity: Physiological Adaptation INTEGRATED PROCESS: Nursing Process: Analysis CONTENT AREA: Child Health STRATEGY: The core issue of the question is recognition of which situation allows the infant to keep the hips abducted. Evaluate each option according to this criteria to make a selection. 1025 Which of the following interventions would be essential for the nurse to implement to promote a stable respiratory status in the adolescent who recently had a spinal fusion for scoliosis? 1) Logrolling and repositioning every 4 hours 2) Coughing and deep-breathing every 2 hours during the day 3) Assessing pain status and ensuring adequate pain relief 4) Encouraging use of incentive spirometry every 4 hours while awake CORRECT ANSWER: 3 RATIONALE: Pain must be managed properly in the child after spinal fusion in order for the client to participate in respiratory exercises. Logrolling and repositioning, as well as coughing, deep-breathing, and use of incentive spirometry should be done every 2 hours around the clock with this postoperative client. Providing adequate pain relief will enable the client to carry out these important activities. COGNITIVE LEVEL: Analysis CLIENT NEE CLIENT NEED: Physiological Integrity: Physiological Adaptation INTEGRATED PROCESS: Nursing Process: Assessment CONTENT AREA: Child Health STRATEGY: The issue of the question is the ability of the nurse to analyze assessment data and compare it to typical data of childhood musculoskeletal problems. Note that the temperature is elevated to help choose the option related to infection. 1027 The nurse is preparing to help a client get up from a chair using crutches. Place in order the steps that the nurse outlines to the client to do this procedure correctly. Click and drag the options below to move them up or down. 1) Place unaffected leg slightly under or at the edge of the chair. 2) Grasp the arm of the chair using the hand on the unaffected side. 3) Grasp the crutches by the horizontal hand bars using the hand on the affected side. 4) Move forward to the edge of the chair. 5) Assume a tripod position. 6) Push down on the crutches and the chair armrest while raising the body out of the chair. CORRECT ANSWER: 4, 1, 3, 2, 6, 5 RATIONALE: The proper procedure is as follows:BR / 1. Move forward to the edge of the chair.BR / 2. Place unaffected leg slightly under or at the edge of the chair (this position helps the client to stand up from the chair and achieve balance, since the unaffected leg is supported against the edge of the chair).BR / 3. Grasp the crutches by the horizontal hand bars using the hand on the affected side.BR / 4. Grasp the arm of the chair using the hand on the unaffected side (the body weight is placed on the crutches and the hand on the armrest to support the unaffected leg when the client rises to stand).BR / 5. Push down on the crutches and the chair armrest while raising the body out of the chair.BR / 6. Assume a tripod position (crutches out laterally in front of feet, approximately 6 inches, with feet slightly apart, creating a wide base of support) for balance before moving. COGNITIVE LEVEL: Analysis CLIENT NEED: Physiological Integrity: Physiological Adaptation INTEGRATED PROCESS: Nursing Process: Implementation CONTENT AREA: Child Health STRATEGY: Visualize the procedure and think about principles of joint support and balance to complete the ordered steps. 1028 The mother of a newborn is upset that her baby has congenital clubfoot. She asks the nurse what she did to cause her baby's deformity. Which of the following answers is the most appropriate? Select all that apply. 1) Abnormal uterine positioning could have caused this deformity 2) A lack of good nutrition during pregnancy could have caused this defect 3) Having the baby before the due date could have caused this problem 4) There are no known etiologies of this defect 5) Neuromuscular and vascular problems may have caused the problem CORRECT ANSWER: 1, 5 RATIONALE: The exact cause of clubfoot is unknown, though several possible etiologies exist. Abnormal intrauterine position may cause the deformity, along with neuromuscular or vascular problems. A positive family history increases the chance of this deformity. COGNITIVE LEVEL: Analysis CLIENT NEED: Physiological Integrity: Physiological Adaptation INTEGRATED PROCESS: Nursing Process: Implementation CONTENT AREA: Child Health STRATEGY: Knowledge of the etiology of clubfoot will help to determine the correct response. Consider which response, in addition to being accurate, would be most comforting for the mother. 1029 Which of the following are appropriate nursing interventions to include in the initial postoperative care of a child who has had surgery for clubfoot? Select all that apply. 1) Apply ice bags to the foot; keep the ankle and foot elevated on a pillow 2) Check for drainage or bleeding; observe for swelling around the cast edges 3) Administer pain medications routinely and maintain nasogastric intubation 4) Perform neurovascular status checks every 2 hours and provide diversional activities 5) Cover the surgical extremity with warm blankets CORRECT ANSWER: 1, 2, 4 RATIONALE: The postoperative care of the child undergoing repair of clubfoot includes elevation, application of ice, assessment for neurovascular status, bleeding and swelling, and pain. Nasogastric intubation is usually not needed and warm blankets are not indicated. COGNITIVE LEVEL: Application CLIENT NEED: Physiological Integrity: Reduction of Risk Potential INTEGRATED PROCESS: Nursing Process: Planning CONTENT AREA: Child Health STRATEGY: Knowledge of the postsurgical care of the infant with clubfoot will aid in choosing the correct answer. 1030 Which of the following does the nurse expect to find during assessment of a 5-year-old client who has developmental dysplasia of the hip (DDH)? 1) Asymmetry of gluteal and thigh fat folds 2) Positive Ortolani-Barlow maneuver 3) Telescoping of the femoral head into the pelvis 4) Limited abduction of the affected hip CORRECT ANSWER: 3 RATIONALE: All symptoms listed are clinical manifestations of developmental dysplasia of the hip, although the only one that would be found in a 5-year-old would be the telescoping of the femoral head into the pelvis. Other clinical signs in an older child would be lordosis, and a waddling gait with a marked limp. A positive Ortolani-Barlow maneuver is found in the infant younger than 2 to 3 months of age. Limited abduction is the sign most often used for an infant older than three months, along with asymmetry of thigh and gluteal folds. COGNITIVE LEVEL: Application CLIENT NEED: Physiological Integrity: Physiological Adaptation INTEGRATED PROCESS: Nursing Process: Assessment CONTENT AREA: Child Health STRATEGY: Knowledge of the assessment findings for a child with DDH will aid in choosing the correct answer. 1031 A 14-year-old boy is diagnosed with slipped capital femoral epiphysis (SCFE). He asks the nurse what caused this condition. Which of the following best answers his question? 1) SCFE is a result of an injury to the hip 2) SCFE may be caused by an endocrine disorder 3) SCFE may be caused by an abnormality of the muscles 4) SCFE is caused by abnormal intrauterine position CORRECT ANSWER: 2 RATIONALE: The exact cause of SCFE is unknown. Predisposing factors include obesity, a growth spurt resulting in a tall and thin stature, and endocrine disorders such as hypothyroidism and hypogonadism. There may be a genetic predisposition to this disorder. COGNITIVE LEVEL: Analysis CLIENT NEED: Physiological Integrity: Physiological Adaptation INTEGRATED PROCESS: Nursing Process: Implementation CONTENT AREA: Child Health STRATEGY: Knowledge of the possible etiology of SCFE will aid in choosing the correct answer. 1032 An adolescent is wearing a cast following a spinal fusion for scoliosis. The nurse would include which of the following interventions to address the nursing diagnosis of disturbed body image related to wearing a cast after spinal fusion? Select all that apply. 1) Encourage independence in daily activities 2) Encourage the adolescent to participate in community activities 3) Provide contact with a peer who has undergone the same treatment 4) Teach cast care as appropriate 5) Suggest the client change hairstyle or buy new clothes as a coping mechanism CORRECT ANSWER: 1, 2, 3 RATIONALE: All are appropriate interventions for the child who has undergone a spinal fusion, although only the first three are appropriate interventions directly aimed at the client experiencing an altered body image. Teaching cast care is important, but would be appropriate under the nursing diagnosis of knowledge deficit. The nurse would assist with coping, but this does not necessarily involve new hairstyle or clothes. COGNITIVE LEVEL: Analysis CLIENT NEED: Psychosocial Integrity INTEGRATED PROCESS: Nursing Process: Planning CONTENT AREA: Child Health STRATEGY: Knowledge of the interventions aimed at helping the adolescent in a cast with body image difficulties will help to choose the correct answers. 1033 Which of the following instructions would be appropriate for the nurse to include in the discharge teaching of an adolescent following a spinal fusion? 1) No sittins; it's just too dangerous for you." 2) "Have you thought about bowling? That is a sport that is allowed when you have this condition." 3) "Swimming is an activity that you can participate in and will improve overall muscle tone." 4) "How about trying wheelchair sports? Maybe you would enjoy wheelchair basketball." CORRECT ANSWER: 3 RATIONALE: Exercise such as swimming is allowed for clients with osteogenesis imperfecta and will help improve muscle tone and prevent obesity. Bowling and wheelchair sports would not be allowed, as the weight involved with both could cause fractures of the upper extremities. COGNITIVE LEVEL: Application CLIENT NEED: Health Promotion and Maintenance INTEGRATED PROCESS: Communication and Documentation CONTENT AREA: Child Health STRATEGY: Knowledge of the normal developmental needs and activities permitted for the adolescent with osteogenesis imperfecta will aid in choosing the correct answer. 1035 Which of the following assessment findings would the nurse expect to find in the school-age child with Duchenne's muscular dystrophy? 1) Enlargement of muscles 2) Bedridden 3) Weak cough reflex 4) Paralysis of lower muscles CORRECT ANSWER: 1 RATIONALE: A child with DMD would have enlargement of muscles as a result of fatty tissue infiltration. A school-aged child with DMD is generally still ambulatory. Muscles at this age are weak, not paralyzed. A weak cough reflex would occur as the disease progresses. COGNITIVE LEVEL: Application CLIENT NEED: Physiological Integrity: Physiological Adaptation INTEGRATED PROCESS: Nursing Process: Assessment CONTENT AREA: Child Health STRATEGY: Knowledge of the assessment findings for the school aged child with muscular dystrophy will aid in choosing the correct answer. 1036 The nurse concludes that a child in Bryant’s traction is in correct position after noting which of the following? 1) The lower leg is suspended in a padded sling 2) Leg is in extended position without hip flexion 3) The arm is kept flexed and is suspended horizontally 4) Hips are flexed at a 90 degree angle, with buttocks off the mattress CORRECT ANSWER: 4 RATIONALE: Bryant's traction is used specifically for children under 3 years of age and weighing less than 35 pounds who have developmental hip dysplasia or fractured femur. This bilateral traction is applied to the child's legs, with the hips flexed at 90 degree angle, with knees extended and buttocks slightly off the bed. The other distracters describe Russell, Buck, and Dunlop traction. COGNITIVE LEVEL: Analysis CLIENT NEED: Physiological Integrity: Physiological Adaptation INTEGRATED PROCESS: Nursing Process: Assessment CONTENT AREA: Child Health STRATEGY: Knowledge of Bryant’s traction will aid in choosing the correct answer. 1037 A child with Legg-Calve-Perthes disease is undergoing non-surgical treatment. Which of the following would indicate to the nurse that the parents understand such treatment? 1) "My child will need to wear a brace while he is sleeping." 2) "My child will need to wear a brace for two years or more." 3) "My child will not be able to attend school until healing has occurred." 4) "My child will develop hip dysfunction later in life." CORRECT ANSWER: 2 RATIONALE: To promote healing of the affected hip in LCPD, the femoral head is contained in the hip socket until ossification is complete, which may take up to two years or more. This is accomplished by keeping the hips abducted by continual use of Petrie casting, or Toronto and Scottish-Rite braces. The child should be encouraged to attend school during this time. Untreated LCPD clients may develop osteoarthritis and hip dysfunction. The other answers are incorrect statements of fact. COGNITIVE LEVEL: Application CLIENT NEED: Physiological Integrity: Physiological Adaptation INTEGRATED PROCESS: Nursing Process: Evaluation CONTENT AREA: Child Health STRATEGY: Knowledge of the care of the child with LCPD will help to choose the correct answer. 1038 Parents of an unborn infant have just learned that, based on ultrasound, their infant has clubfoot. They ask the nurse how clubfoot is treated. Which of the following treatments should the nurse discuss with the parents? 1) Weekly cast changes with manipulation 2) Probable surgery on the affected limb 3) Abduction device to keep the hip in full abduction 4) Use of a Denis Browne splint to achieve correction CORRECT ANSWER: 1 RATIONALE: The initial treatment for clubfoot begins immediately or shortly after birth and consists of weekly cast changes and manipulation. Surgery is completed only if nonsurgical intervention of serial casting is not effective. A Denis Browne splint may be used to maintain correction once it is achieved. Abduction devices are used for hip conditions. COGNITIVE LEVEL: Application CLIENT NEED: Physiological Integrity: Physiological Adaptation INTEGRATED PROCESS: Teaching and Learning CONTENT AREA: Child Health STRATEGY: Option 3 can be eliminated as it refers to the hip, not the foot. The other options are used in clubfoot, but the learner must choose the option that would be used immediately after birth. 1039 An infant is placed in a Pavlik harness for developmental dysplasia of the hip. The nurse has completed parent teaching, but the parents seem to be overwhelmed by the condition and make several statements indicating a lack of understanding. The statements that indicate more teaching is needed are: (Select all that apply.) 1) “The straps of the harness should be placed next to the skin.” 2) “The harness should be worn for 6 hours a day.” 3) “It will take a long time for my child to walk and crawl.” 4) “I should not lift the baby by his legs when changing his diaper.” 5) “Because my child’s defect was caught early, treatment will not usually require surgery.” CORRECT ANSWER: 1, 2, 3 RATIONALE: Diapers should be placed underneath the straps of a Pavlik harness; a t-shirt should be worn under the straps of the harness. The harness should be worn for 23 hours a day. The child quickly “catches up” once the device is no longer worn if developmental milestones are delayed because of the abduction device. Babies should never be lifted by their legs when changing diapers. Early treatment is usually successful without surgery. The treatment is not painful. COGNITIVE LEVEL: Analysis CLIENT NEED: Physiological Integrity: Physiological Adaptation INTEGRATED PROCESS: Nursing Process: Evaluation CONTENT AREA: Child Health STRATEGY: Knowledge of the care of the child in a Pavlik harness will aid in choosing the correct answer. The wording of the question guides you to eliminate responses that are correct information. 1040 A 4-year-old child with osteogenesis imperfecta (OI) is admitted to the hospital unit for an unrelated condition. The nurse determines that which nursing diagnosis has the highest priority for this child? 1) Impaired skin integrity related to cast 2) Pain related to fractures 3) Risk for injury related to disease state 4) Disturbed body image related to short stature CORRECT ANSWER: 3 RATIONALE: Because of their very fragile bones, children with OI experience countless fractures, and the prevention of injury takes highest priority in this child’s care. Pain would be important if a fracture actually occurs, but the key is prevention of fractures, making risk for injury more appropriate. Skin integrity impairment would also not be a concern unless a fracture actually occurred. COGNITIVE LEVEL: Analysis CLIENT NEED: Physiological Integrity: Physiological Adaptation INTEGRATED PROCESS: Nursing Process: Planning CONTENT AREA: Child Health STRATEGY: Option 4 can be eliminated as the child is 4 years old and body image is not a great concern. Of the three remaining, choose the option that would be a concern throughout the care of this child. 1041 A child is admitted to the hospital unit with a diagnosis of “rule out acute onset of Legg-Calve-Perthes (LCP) disease.” The symptom that would not be associated with LCP is: 1) Swelling and redness of the involved joint(s). 2) Stiffness in the morning or after rest. 3) Insidious limp after activities. 4) Referred pain to the knee. CORRECT ANSWER: 1 RATIONALE: Swelling and redness of involved joints is a symptom found in juvenile arthritis, not LCP disease. Stiffness in the morning or after rest, an insidious limp after activities, and referred pain to the knee are all consistent with this diagnosis. COGNITIVE LEVEL: Analysis CLIENT NEED: Physiological Integrity: Physiological Adaptation INTEGRATED PROCESS: Nursing Process: Assessment CONTENT AREA: Child Health STRATEGY: Knowledge of the signs and symptoms of LCP disease will help to choose the correct answer. Eliminate symptoms normally seen in LCP. That leaves only the correct response. 1042 A 12-year-old male is admitted to the adolescent unit with a diagnosis of slipped capital femoral epiphysis. Which of the following activities should not be allowed by the nurse prior to surgical correction? 1) Ambulation with crutches; avoid bearing weight on the affected leg 2) Sitting in a wheelchair 3) Moving on a stretcher 4) Maintaining bed rest CORRECT ANSWER: 2 RATIONALE: Once the diagnosis is made, the child should be non-weight-bearing on the affected hip, as weight-bearing can increase the amount of slippage. Wheelchair use should be avoided, as this also may increase the amount of slippage. COGNITIVE LEVEL: Analysis CLIENT NEED: Physiological Integrity: Physiological Adaptation INTEGRATED PROCESS: Nursing Process: Implementation CONTENT AREA: Child Health STRATEGY: Knowledge of the care of the client with slipped capital femoral epiphysis will help to answer the question correctly. After noting the critical word “not” in the question, select the option that places the affected joint at risk. 1043 An adolescent diagnosed with idiopathic structural scoliosis describes all of the following symptoms. Which one would the nurse conclude is not associated with this diagnosis? 1) Back pain 2) Skirts that hang unevenly 3) Unequal shoulder heights 4) Uneven waist angles CORRECT ANSWER: 1 RATIONALE: Back pain is not identified as a symptom of idiopathic structural scoliosis. Skirts that hang unevenly, unequal shoulder height, and uneven waist level are all positive symptoms of this disorder. COGNITIVE LEVEL: Application CLIENT NEED: Physiological Integrity: Physiological Adaptation INTEGRATED PROCESS: Nursing Process: Analysis CONTENT AREA: Child Health STRATEGY: Determine which options are symptoms of scoliosis. Eliminate these, leaving only the correct answer. 1044 A 15-year-old who has a diagnosis of scoliosis is being seen in the outpatient clinic. The nurse is planning care for this adolescent and develops the following nursing diagnoses. Which nursing diagnosis should take highest priority? 1) Disturbed body image related to treatment of scoliosis 2) Diversional activity deficit related to treatment of scoliosis 3) Anxiety related to outcome of treatment for scoliosis 4) Fear related to treatment and unknown outcomes CORRECT ANSWER: 1 RATIONALE: Adolescents are greatly concerned about their physical appearance as part of their growth and development. Unless there is a clear priority based on physiological need, attention to developmental concerns such as body image is important when caring for the adolescent client. COGNITIVE LEVEL: Analysis CLIENT NEED: Psychosocial Integrity INTEGRATED PROCESS: Nursing Process: Planning CONTENT AREA: Child Health STRATEGY: Eliminate options 3 and 4 because they are so similar. Then, consider the developmental period of the child, which is key to determining the correct response. All adolescents worry about body image and being different. This child will appear different and may be encased in a brace or cast. 1045 An adolescent is returning to the hospital unit after surgical spinal fusion for scoliosis. The nurse would include which of the following in the immediate postoperative care of this client? (Select all that apply.) 1) Oral analgesia for pain 2) Logrolling every 2 hours 3) Nasogastric intubation 4) Straight catheterization every 4 hours 5) Use of an incentive spirometer every two hours while awake CORRECT ANSWER: 2, 3, 5 RATIONALE: There is some degree of paralytic ileus following a spinal fusion; therefore, nasogastric intubation is required along with frequent assessment of return of bowel function. The pain experienced by this client is severe and requires intravenous medication, preferably with patient-controlled analgesia (PCA). Logrolling must be done every 2 hours, once allowed, to prevent the accumulation of secretions in the lungs. Urinary retention is common, and an indwelling catheter is used if present rather than repeated straight catheterization. Monitoring the child’s respiratory status is crucial as is the use of an incentive spirometer. COGNITIVE LEVEL: Application CLIENT NEED: Physiological Integrity: Reduction of Risk Potential INTEGRATED PROCESS: Nursing Process: Implementation CONTENT AREA: Child Health STRATEGY: Look carefully at each option to make sure the option is totally correct. Eliminate those that are either incorrect or only partially correct. 1046 A 3-year-old child is suspected of having Duchenne’s muscular dystrophy. Which of the following assessment findings by the nurse would support this diagnosis? 1) A history of delayed crawling 2) Outward rotation of the hips 3) Difficulty climbing stairs 4) Wasted muscle appearance CORRECT ANSWER: 3 RATIONALE: The child with Duchenne’s muscular dystrophy (MD) has a history of meeting early developmental milestones. Symptoms usually begin at around 3 years of age and include difficulty climbing stairs, running, and pedaling. Duchenne’s MD is also called pseudohypertrophic MD as the muscles appear enlarged. The appearance of the hips is normal. COGNITIVE LEVEL: Analysis CLIENT NEED: Physiological Integrity: Physiological Adaptation INTEGRATED PROCESS: Nursing Process: Analysis CONTENT AREA: Child Health STRATEGY: Knowledge of Duchenne’s muscular dystrophy will aid in choosing the correct answer. Eliminate option 4 as it is the opposite of the findings of Duchenne’s MD. Also, children develop normally until there is onset of symptoms, so option 1 would be incorrect. 1047 A child is admitted to the hospital with a diagnosis of “rule out osteomyelitis.” Which of the following serum laboratory values noted by the nurse supports this diagnosis? 1) Decreased white blood cell (WBC) count 2) Positive blood cultures 3) Increased hematocrit (HCT) 4) Increased BUN CORRECT ANSWER: 2 RATIONALE: Serum laboratory studies in a child with osteomyelitis will reveal an increased WBC count, C-reactive protein, and sedimentation rate. The blood culture is usually positive. This disease process does not affect the HCT or BUN. COGNITIVE LEVEL: Application CLIENT NEED: Physiological Integrity: Reduction of Risk Potential INTEGRATED PROCESS: Nursing Process: Analysis CONTENT AREA: Child Health STRATEGY: Option 1 can be eliminated because with infections the WBC is elevated. Two of the other tests have no relation to infections. 1048 A 6-year-old child has a cast applied for a fractured radius. The nurse completes an orthopedic assessment on this child. Which of the following symptoms requires immediate attention and should be reported to the physician? 1) Capillary refill of 4 seconds in the affected hand 2) Edema in the affected fingers that improves with elevation 3) Child describing feeling of the affected hand being “asleep” 4) Skin surrounding the cast is warm CORRECT ANSWER: 3 RATIONALE: The sensation of numbness or tingling is a sign of neurovascular impairment. Neurovascular impairment can lead to nerve ischemia and destruction, with possible permanent paralysis of the extremity. Any symptom of neurovascular impairment, such as paresthesia, lack of pulses, edema that does not improve with elevation, pallor, and pain, needs immediate attention. COGNITIVE LEVEL: Analysis CLIENT NEED: Physiological Integrity: Physiological Adaptation INTEGRATED PROCESS: Nursing Process: Analysis CONTENT AREA: Child Health STRATEGY: Determine which finding is abnormal. All others are expected findings. 1049 Which of the following nursing care measures takes highest priority in caring for a child in skeletal traction? 1) Assessing bowel sounds every shift 2) Assessing temperature every 4 hours 3) Providing adequate nutrition 4) Providing age-appropriate activities CORRECT ANSWER: 2 RATIONALE: The child with skeletal traction has a pin that passes through the skin into the end of a long bone. This procedure provides an entrance for microorganisms. Frequent monitoring of the pin site, pin care according to institutional policy, and frequent monitoring for signs of infection take priority over the other nursing interventions listed. COGNITIVE LEVEL: Analysis CLIENT NEED: Physiological Integrity: Physiological Adaptation INTEGRATED PROCESS: Nursing Process: Analysis CONTENT AREA: Child Health STRATEGY: The key concept is monitoring for complications of skeletal traction. 1050 A nurse performs triage in a pediatric orthopedic clinic. Which of the following should the nurse recognize as a symptom of slipped capital femoral epiphysis? 1) Pain in the hip of a preadolescent child 2) Acute onset of knee pain 3) Presence of a limp in a school-age child 4) Painful external rotation of the affected leg CORRECT ANSWER: 1 RATIONALE: Slipped capital femoral epiphysis is a slipping of the femoral head that occurs most frequently before or during the rapid adolescent growth spurt. The onset of symptoms is gradual, and symptoms include limp, holding the leg in external rotation to relieve pain, restricted and painful internal rotation, and knee and hip pain. COGNITIVE LEVEL: Analysis CLIENT NEED: Physiological Integrity: Physiological Adaptation INTEGRATED PROCESS: Nursing Process: Assessment CONTENT AREA: Child Health STRATEGY: First consider the age of the child most frequently seen with this condition. This will rule out one of the responses. Option 4 can be eliminated as the symptoms are not associated with rotation. 1051 Which of the following statements made by the parent of a child being discharged with osteomyelitis requires further teaching by the nurse? 1) “I can stop the antibiotics when I see that my child is afebrile for one week” 2) “We will make sure that our child’s diet has plenty of calcium and protein.” 3) “I will look at the intravenous site for signs of infection a couple of times a day.” 4) “My child won’t take physical education at school until allowed by the doctor.” CORRECT ANSWER: 1 RATIONALE: The therapeutic management of the child with osteomyelitis includes limiting weight-bearing on the affected part, immobilization, and administration of antibiotics. Antibiotic therapy may continue intravenously for 3 to 6 weeks, and orally for another 2 weeks depending on duration of symptoms, response to treatment, and sensitivity of the organism. Discharge teaching needs to include follow-up antibiotic care at home, care of the IV site, and continuing antibiotic therapy even though it may seem as if all the symptoms are gone. Food sources such as calcium and protein should be provided for bone healing. COGNITIVE LEVEL: Analysis CLIENT NEED: Physiological Integrity: Physiological Adaptation INTEGRATED PROCESS: Nursing Process: Evaluation CONTENT AREA: Child Health STRATEGY: Determine the right answer by eliminating any choice that is obviously correct information. 1052 A 5-month-old infant is being assessed for developmental dysplasia of the hip. The nurse concludes that positive signs and symptoms that indicate this disorder include: (Select all that apply) 1) Ortolani sign. 2) Barlow sign. 3) Allis sign. 4) Trendelenburg sign. 5) Asymmetric thigh and gluteal folds. CORRECT ANSWER: 3, 5 RATIONALE: All four of the signs are assessment tests for developmental dysplasia of the hip. Ortolani and Barlow signs disappear after 2 to 3 months. Trendelenburg sign will be seen in the child who is able to stand. Allis sign, shortening of the affected limb on the affected side, is a reliable test at 4 months of age. Asymmetric folds would be a positive sign at any age. The child is too young to walk, so a limp would not be observed. COGNITIVE LEVEL: Application CLIENT NEED: Physiological Integrity: Physiological Adaptation INTEGRATED PROCESS: Nursing Process: Analysis CONTENT AREA: Child Health STRATEGY: The core concept is the age of the child at the time of diagnosis. Wrong answers can be eliminated based on age. 1053 A newborn is being admitted to the newborn nursery. The nurse would assess the infant for congenital defects. In addition to the abnormal position of the foot, the nurse would note which of the following if clubfoot is present? 1) Affected foot is larger and longer. 2) Affected limb is longer. 3) There is calf muscle atrophy of the affected limb. 4) Affected foot is cooler. CORRECT ANSWER: 3 RATIONALE: Clubfoot is apparent at birth, with the affected foot fixed in an abnormal position. The affected foot is usually smaller, shorter, with an empty heel pad. The affected limb is usually shorter and has some calf muscle atrophy. COGNITIVE LEVEL: Application CLIENT NEED: Physiological Integrity: Physiological Adaptation INTEGRATED PROCESS: Nursing Process: Assessment CONTENT AREA: Child Health STRATEGY: Eliminate option 4 first as clubfoot does not affect circulation. Basically options 1 and 2 are the same, so they can be eliminated. 1054 A child is admitted with osteogenesis imperfecta (OI). In reviewing laboratory findings, the nurse would expect to find abnormal levels of: 1) Calcium. 2) Phosphorus. 3) Precollagen type I. 4) Vitamin D. CORRECT ANSWER: 3 RATIONALE: Children with this disorder have normal calcium and phosphorus and abnormal precollagen type I. This prevents the formation of collagen, the major component of connective tissue. The precollagen remains relatively unstable and unable to undergo final transformation into collagen. COGNITIVE LEVEL: Application CLIENT NEED: Physiological Integrity: Physiological Adaptation INTEGRATED PROCESS: Nursing Process: Analysis CONTENT AREA: Child Health STRATEGY: Three of the tests listed are common tests. One is uncommon. 1055 Which of the following statements made by a parent of a child with osteogenesis imperfecta (OI) needs clarification by the nurse? 1) “My child may be able to participate in sports.” 2) “There are no medications available to help this disease process.” 3) “Surgery may be needed to place rods in the bone for stability.” 4) “My child will need to be home schooled to protect him from injury.” CORRECT ANSWER: 4 RATIONALE: Children with mild OI may be able to participate in sports, and many are able to participate in swimming. There are no current medications that stop this disease process. There are a variety of surgical procedures that may be done to help strengthen the bones; one is the insertion of intermedullary rods to provide for stability. The child with OI may participate in school, though care needs to be provided to protect this child from injury. COGNITIVE LEVEL: Analysis CLIENT NEED: Physiological Integrity: Physiological Adaptation INTEGRATED PROCESS: Nursing Process: Evaluation CONTENT AREA: Child Health STRATEGY: The goal of treatment for all children is to promote growth and development. The one action that would limit growth and development would be home schooling. 1056 The physician has written the following orders for a child with Duchenne muscular dystrophy hospitalized for a respiratory infection. The nurse should question the order for: 1) Physical therapy. 2) Antibiotic therapy. 3) Passive range of motion exercises. 4) Strict bed rest. CORRECT ANSWER: 4 RATIONALE: Children with muscular dystrophy quickly suffer from complications of immobility. Therefore, when hospitalized, these children should have physical therapy, range-of-motion exercises, and bed-to-chair activity as soon as possible. Children with respiratory infections are treated with vigorous antibiotic therapy, as well as postural drainage and cupping. COGNITIVE LEVEL: Analysis CLIENT NEED: Safe Effective Care Environment: Management of Care INTEGRATED PROCESS: Nursing Process: Planning CONTENT AREA: Child Health STRATEGY: The core concept is Duchenne muscular dystrophy. It is important with these children that function be maintained, and bed rest will promote disability. 1057 A 14-year-old adolescent has just been fitted for a Milwaukee brace. Which of the following should the nurse include in teaching about this brace? 1) The brace should be worn only when the adolescent is sleeping or in the recumbent position. 2) The brace should be worn next to the skin. 3) Exercises to increase pelvic tilt should be done several times per day while in the brace. 4) The adolescent should experience no pain as a result of wearing this brace. CORRECT ANSWER: 3 RATIONALE: The Milwaukee brace is worn for scoliosis, when the degree of curve is greater than 20 but less than 40 degrees. It is worn for 23 hours a day. Exercises to increase pelvic tilt, for lateral strengthening, and to correct lordosis should be done several times a day while in the brace. The brace should be worn over a T-shirt to minimize skin irritation. The adolescent may experience muscle aches resulting from new alignment. COGNITIVE LEVEL: Analysis CLIENT NEED: Physiological Integrity: Physiological Adaptation INTEGRATED PROCESS: Teaching and Learning CONTENT AREA: Child Health STRATEGY: The goal of therapy is to prevent progression of the scoliosis. To be successful in answering this question, the learner must understand the treatment plan. 1058 The nurse has completed instructions on health maintenance for a client diagnosed with osteoarthritis. The nurse verifies that the client understood the instructions if the client states that participation in which of the following sports would be beneficial? 1) Tennis 2) Jogging 3) Swimming 4) Volleyball CORRECT ANSWER: 3 RATIONALE: Aerobic exercises such as swimming help the client to maintain maximum range of motion (ROM) and mobility while minimizing strain on joints. Isotonic exercises such as tennis, jogging, and volleyball place excessive strain on diseased joints. COGNITIVE LEVEL: Application CLIENT NEED: Health Promotion and Maintenance INTEGRATED PROCESS: Nursing Process: Evaluation CONTENT AREA: Adult Health: Musculoskeletal STRATEGY: Choose the odd option of the four, noting that swimming is the only non-weight bearing exercise on the list. 1059 A health history and physical assessment on a client with rheumatoid arthritis (RA) may reveal which of the following assessment data? 1) Heberden's nodes 2) Morning stiffness no longer than 30 minutes 3) Asymmetric joint swelling 4) Swan neck deformities CORRECT ANSWER: 4 RATIONALE: Swan neck deformities of the hand are classic deformities associated with rheumatoid arthritis secondary to the presence of rous connective tissue within the joint space. Clients with RA do experience morning stiffness, but it can last from 30 minutes up to several hours. RA is characterized by symmetrical joint involvement, and Heberden's nodes are characteristic of osteoarthritis. COGNITIVE LEVEL: Application CLIENT NEED: Physiological Integrity: Physiological Adaptation INTEGRATED PROCESS: Nursing Process: Assessment CONTENT AREA: Adult Health: Musculoskeletal STRATEGY: This question requires differentiation of osteoarthritis and rheumatoid arthritis. 1060 Which of the following over-the-counter (OTC) agents should the client on uricosuric drugs be instructed to avoid? 1) Acetaminophen (Tylenol) 2) Ibuprofen (Motrin) 3) Aspirin (ASA) 4) Naproxen (Naprosyn) CORRECT ANSWER: 3 RATIONALE: Aspirin interferes with the action of uricosuric drugs. Acetaminophen, naproxen, or ibuprofen may be used effectively as an analgesic in the treatment of pain associated with acute gout, and they do not interfere with the action of uricosuric drugs. COGNITIVE LEVEL: Application CLIENT NEED: Physiological Integrity: Reduction of Risk Potential INTEGRATED PROCESS: Nursing Process: Implementation CONTENT AREA: Pharmacology STRATEGY: Be cautious with choosing ASA as a medication choice due to the high number of side and adverse effects associated with it, especially in the presence of a chronic illness. 1061 Which of the following nursing interventions is contraindicated in the care of a client with acute osteomyelitis? 1) Apply heat compresses to the affected area 2) Immobilize the affected area 3) Administer narcotic analgesics for pain 4) Administer OTC analgesics for pain CORRECT ANSWER: 1 RATIONALE: Options 2, 3, and 4 are appropriate nursing interventions when caring for a client diagnosed with osteomyelitis. The application of heat can increase edema and pain in the affected area and spread bacteria through vasodilatation. COGNITIVE LEVEL: Application CLIENT NEED: Safe Effective Care Environment: Safety and Infection Control INTEGRATED PROCESS: Nursing Process: Implementation CONTENT AREA: Adult Health: Musculoskeletal STRATEGY: Remember not to use heat with infection; it will increase circulation and the dissemination of the infection. 1062 Which of the following lab data would be most significant in the client with Paget's disease? 1) Elevated white blood count (WBC) 2) Elevated erythrocyte sedimentation rate (ESR) 3) Positive tissue biopsy for Staphylococcus 4) Elevated serum alkaline phosphatase CORRECT ANSWER: 4 RATIONALE: Serum alkaline phosphatase is elevated because of increased activity of bone cells. Inflammation is in the bone and usually doesn't reveal an elevated serum WBC, ESR, or the presence of Staphylococcus. COGNITIVE LEVEL: Application CLIENT NEED: Physiological Integrity: Physiological Adaptation INTEGRATED PROCESS: Nursing Process: Assessment CONTENT AREA: Adult Health: Musculoskeletal STRATEGY: This question requires knowledge of the diagnostics associated with the illness. 1063 Which of the following individuals is at greatest risk for developing an osteosarcoma? 1) Male, age 42 2) Female, age 52 3) Female, age 20 4) Male, age 15 CORRECT ANSWER: 4 RATIONALE: Osteosarcomas are most commonly seen in males during optimal growth years. Middle-aged males (option 1), females age 50 to 60 (option 2), and females of childbearing age (option 3) are less likely to develop osteosarcoma. COGNITIVE LEVEL: Application CLIENT NEED: Health Promotion and Maintenance INTEGRATED PROCESS: Nursing Process: Assessment CONTENT AREA: Adult Health: Musculoskeletal STRATEGY: Make sure when answering this question that the gender and age are both correct. 1064 A drug history is important in a client with systemic lupus erythematosus (SLE) because the disease may be associated with use of which of the following drugs? 1) Procainamide (Procan SR) 2) Acetylsalicylic acid (aspirin) 3) Diazepam (Valium) 4) Azathioprine (Imuran) CORRECT ANSWER: 1 RATIONALE: Although the etiology of SLE is unknown, certain environmental factors have been associated with the onset of symptoms. The administration of procainamide (Procan SR) and hydralazine (Apresoline) have been associated with SLE symptoms, which usually subside after the drug is discontinued. COGNITIVE LEVEL: Application CLIENT NEED: Physiological Integrity: Pharmacological and Parenteral Therapies INTEGRATED PROCESS: Nursing Process: Analysis CONTENT AREA: Adult Health: Musculoskeletal STRATEGY: Recall that valium and aspirin are common medications and that Imuran is an immunosuppressant. Use the process of elimination to choose Procan. 1065 To prevent occurrences of Raynaud's phenomenon, what should the client diagnosed with systemic Scleroderma be instructed to do? 1) Wear gloves 2) Perform range-of-motion exercises daily 3) Limit sodium intake 4) Avoid warm temperature CORRECT ANSWER: 1 RATIONALE: Raynaud's disease is characterized by spasms of the blood vessels within the fingers of the hands resulting in diminished circulation. Gloves protect the hands from cold temperatures and provide warmth, which promotes blood flow to the affected areas. Raynaud's phenomenon is in the CREST syndrome, a type of scleroderma. COGNITIVE LEVEL: Application CLIENT NEED: Physiological Integrity: Reduction of Risk Potential INTEGRATED PROCESS: Nursing Process: Implementation CONTENT AREA: Adult Health: Musculoskeletal STRATEGY: Recall that vasoconstriction occurs in response to cold, which then exacerbates the client’s pain. 1066 Which of the following occurs during the remodeling phase of bone healing? 1) Callus formation occurs. 2) Callus is replaced with mature bone. 3) Osteoclasts resorb excess callus to return the bone to its original shape. 4) Proliferation of osteoblast and roblasts occurs within the hematoma at the fracture site. CORRECT ANSWER: 3 RATIONALE: Duri