NUR212 LIFE SPAN Quiz B Questions and Answers,100% CORRECT

NUR212 LIFE SPAN Quiz B Questions and Answers Infectious Disease A patient has an initial positive result for the enzyme-linked immunosorbent assay (ELISA) test for human immunodeficiency virus (HIV). The patient is upset and begins to cry. Which is the most appropriate response for the RN to make? "Be glad the disease was detected early." "This test is the best test for HIV diagnosis." "You do not have symptoms, so the test is not accurate." "Additional testing is needed before a definitive diagnosis is made." 1) HIV is not diagnosed with a single test. 2) Multiple tests are performed for an accurate diagnosis. 3) Patients do feel well in the early stages, but additional tests are necessary to confirm the diagnosis. *4) False positive results can occur, so multiple tests must be performed before a definitive diagnosis is made. Infectious Disease An RN is educating a new graduate RN on the symptoms of pneumonia in the older population. Which symptom does the RN distinguish as possibly being unique to this population? Rapid breathing or difficulty breathing Confusion or low alertness Chest pain Cough 1) Rapid and difficult breathing are not unique to the older population. *2) Older adults with pneumococcal pneumonia may experience confusion or low alertness, rather than the expected presenting signs of pneumonia such as rapid breathing, fever and chills, and chest pain. 3) Chest pain is not unique to the older population. 4) A cough is not unique to the older population. Infectious Disease Which is the most important personal protective equipment (PPE) an RN should use when obtaining an apical pulse on a patient with tuberculosis (TB)? N95 respirator Face shield Gloves Gown *1) An N95 respirator is a protective mask effective in trapping small, airborne droplets, thereby preventing their inhalation. Health care providers should wear an N95 respirator at all times when in the room with a patient hospitalized with tuberculosis. 2) A face shield protects the wearer against contamination with spatters of infected blood or body fluids. 3) Gloves protect from contact with patient secretions or excretions such as urine, fecal matter, blood, saliva, and drainage. 4) Gowns are worn to protect against contact contamination of clothing with any biologic material. Infectious Disease A patient is admitted with a diagnosis of tuberculosis (TB). An RN should implement which isolation procedure? Standard precautions Contact precautions Droplet precautions Airborne precautions 1) Standard precautions are used to prevent exposure to blood and body secretions. 2) Contact precautions are used for wounds. 3) Droplet precautions are used for infections spread by coughing or sneezing. *4) Tuberculosis is spread by air current; patient should be placed in negative air pressure rooms where air does not cross contaminate. Infectious Disease A 6-year-old patient has been diagnosed with acute conjunctivitis on three separate occasions over the last 4 months. When assessing the patient, what should be the nursing priority in educating the caregivers and patient? How to apply cool, moist, compresses to the affected eye Hpw to keep the affected eye covered at all times How and when to perform hand hygiene Proper nutrition to build up immunity 1) While this would help with any inflammation of the eye, it would not be a priority. 2) This helps prevent the infection from transferring to the unaffected eye, but it would not be a priority to prevent the reoccurring infection. *3) The child has had the same infection every month for 3 months. This eye infection is common in children who rub their eyes with their hands frequently. Therefore, a priority would be to make sure the parents and child understand how and when to perform hand hygiene. 4) While nutrition is important, it would not be a priority for this child. Infectious Disease Unlicensed assistive personnel (UAP) are assisting an RN in providing care to a patient who has an infection. What information should the RN direct the UAPs to report whenever it is noted? Systolic blood pressure that is less than 90 mm Hg Assessment of the central venous line insertion site Analysis of pending laboratory work Urinary output that is dark in color and less than what is expected *1) This is specific and is a sign that the patient is developing septic shock and requires immediate action. 2) This is out of the scope of practice of an unlicensed assistivepersonnel (UAP). 3) The UAP would not be analyzing lab work results. 4) This information is nonspecific and does not provide clear direction to the UAP. Infectious Disease A 20-year-old patient with meningitis is in critical condition and the patient's prognosis is guarded. Which action is most essential for the RN to include in the plan of care to support patient and family coping? Update the family on the patient's condition at regular intervals. Arrange for a family conference with social services. Request the chaplain meet with the family. Allow for periodic family visits. 1) Providing regular updates to the family on the patient's condition is important to family coping, but it does not directly impact the patient's coping. 2) A conference with social services may be needed and may be helpful to the family; it does not directly impact the patient's coping. 3) A meeting with the chaplain may be desired and helpful to the family, but it will not directly impact the patient's coping ability. *4) Periodic family visits can support both the patient and the family. Seeing, hearing, touching, even the very presence of a loved one is comforting and reassuring. Infectious Disease An RN is conducting a focused assessment for infection. Which laboratory test value would support the finding that an infection is present in the patient? Decreased international normalized ratio (INR) Elevated erythrocyte sedimentation rate (ESR) Decreased white blood cell (WBC) count Elevated blood urea nitrogen (BUN) 1) A decreased international normalized ratio (INR) does not indicate an infection. *2) An elevated erythrocyte sedimentation rate (ESR) indicates an infection. 3) A decreased white blood cell (WBC) count does not indicate an infection. 4) Elevated blood urea nitrogen (BUN) does not indicate an infection. Infectious Disease A community health nurse is completing a health assessment on a new patient. The RN asks the patient about their medications, occupation, sexual history, any cough or fever, history of travel, and vaccination history. Which risk is the nurse assessing? Ebola Hepatitis Lyme disease Infectious disease 1) While some of the assessments relate specifically to Ebola, not all do. 2) While some of the assessments relate specifically to hepatitis, not all do. 3) While some of the assessments relate specifically to Lyme disease, not all do. *4) All of the assessments relate to determining the risk of infectious disease. Infectious Disease The RN is providing education about the transmission of infectious diseases through the fecal-oral route to a group of unlicensed assistive personnel (UAP) who will be working on the pediatric unit. Which infections should be included in the teaching session? (Select all that apply.) Hepatitis A Hepatitis B Hepatitis C Hepatitis D Hepatitis E *1) In children, ways of spreading hepatitis A include ingestion of fecally contaminated water or shellfish; or day care center spread from contaminated changing tables. 2) Mode of transmission for hepatitis B includes transfusion of contaminated blood and plasma or semen; inoculation by a contaminated syringe or needle through intravenous (IV) drug use; or it may be spread to the fetus if the mother has an infection in third trimester of pregnancy. 3) Transmission, as with hepatitis B virus (HBV), is primarily by blood or blood products, intravenous (IV) drug use, or sexual contact. 4) Hepatitis D is a co-exister with hepatitis B. *5) The E form of hepatitis is entericallytransmitted similarly to hepatitis A (that is, through fecally contaminated water). Infectious Disease An RN is working with a nursing team that includes the RN, an LPN/LVN, and unlicensed assistive personnel (UAP) who are caring for several patients with infectious diseases. Which action performed by a team member would require the RN to intervene? Continually washing hands when entering and exiting each room Shutting the room door of a patient on airborne precautions Wearing the same mask and gown when taking vital signs for the group of patients Leaving the stethoscope when exiting a room with a contact precautions sign posted 1) Hands should be washed between rooms, even if the patient does not have an infectious disease. 2) The door should be closed when a patient is on airborne precautions. *3) The UAP should apply a separate mask and gown for each room and wash their hands between rooms. 4) Dedicated equipment is utilized when caring for patients on contact precautions so other patients are not placed at risk. Infectious Disease An order says to administer Amoxicillin orally (po) 20 to 40 mg/kg/day in 3 divided doses. If the patient weighs 99 lb, what would be a maximum safe single dose for this pediatric patient? 600 mg 660 mg 1320 mg 1800 mg *1) To calculate, first find kg = 99 lb/2.2 = 45 kg. Then, multiply 45 kg by 40 mg (maximum dose for the child) = 1800 mg. Then divide in 3 doses = 600 mg per single dose can be administered. 2) See 1). This answer is if one used 20 mg (minimum dose requirement), so it is not the answer. 3) See 1). In this answer, pounds were not converted to kg; this is a very common mistake. 4) See 1). This answer is for the whole 24 hrs; the question asked for a single dose. Infectious Disease An RN is reviewing the laboratory test results of a patient with acquired immunodeficiency syndrome (AIDS) who is on antiretroviral agents (ART). Which laboratory value would best determine the effectiveness of this group of medications? CD4+ T-cell count Complete blood count (CBC) Enzyme-linked immunosorbent assay (ELISA) Enzyme immunoassay (EIA) *1) The CD4 T-cell count serves as the major laboratory test of immune function. 2) The CBC determines the values of the red cells, white cells, and platelets. 3) The ELISA identifies antibodies directed against HIV. 4) EIA is a variant of the ELISA test. Infectious Disease A patient in the intensive care unit (ICU) with septic shock is showing signs of multiple organ dysfunction syndrome (MODS). The RN plans to increase which focused assessment, recognizing that organ system is first to show signs of dysfunction? Neurological Respiratory Cardiovascular Hepatic 1) The neurological response will progress to unresponsiveness or coma once the cardiovascular system is unresponsive to vasoactiveagents. *2) The lungs are typically the first to show signs of dysfunction with progressive dyspnea and respiratory failure. 3) The cardiovascular system usually follows the respiratory system and will require vasoactive agents to support the BP and cardiac output. 4) The hepatic system will show signs of dysfunction with an elevated bilirubin and liver function tests in less than 2 weeks from the onset. Infectious Disease A patient with tuberculosis (TB) is being admitted to the hospital. The RN knows the Centers for Disease Control and Prevention (CDC) has recommended interventions for the care of a patient with TB. Which of the following interventions does the CDC recommend using for a patient with TB? (Select all that apply.) Private positive pressure room Private negative pressure room Disposable particulate respirator facemasks Reusable acid-fast bacilli (AFB) respirator facemasks Television channel that shows infection control and prevention videos 1) AFB isolation precautions include the use of a private room with negative pressure (not positive) in relation to surrounding areas and a minimum of 6 air exchanges per hour. (CDC recommendations). *2) AFB isolation precautions include the use of a private room with negative pressure in relation to surrounding areas and a minimum of 6 air exchanges per hour. *3) Persons entering the AFB isolation room should use disposable particulate respirators that fit snugly around the face. (CDC recommendations). 4) Facemasks should be disposable particulate respirators that fit snugly around the face. (CDC recommendations). 5) While helpful, this is not required, and is not recommended by CDC. Infectious Disease A patient with multiple health problems including an open, weeping skin infection is admitted to the medical-surgical unit. Which action can the RN delegate to unlicensed assistive personnel (UAP) to assist with the patient's care? Teaching the patient and family members about ways to prevent transmission of scabies Communicating with other departments when the patient is transported for ordered tests Monitoring the results of ordered laboratory cultures and sensitivity tests Implementing contact precautions when providing care for the patient 1) This is out of the scope of practice for an unlicensed assistivepersonnel (UAP). 2) This should be done by the RN. 3) This is out of the scope of practice for an unlicensed assistivepersonnel (UAP). *4) Contact precautions should be implemented by all that provide care for this patient until it is determined whether the wound is not infectious. Infectious Disease An RN is admitting a patient who is experiencing manifestations of acquired immunodeficiency syndrome (AIDS). During the assessment, the RN would note which sign? Jaundice Bradypnea White patches in the mouth Urine specific gravity of 1.010 1) Jaundice is not present with AIDS. 2) Dyspnea occurs with AIDS. *3) White patches in the mouth indicate candidiasis, an opportunistic infection. 4) AIDS patients are frequently dehydrated, not adequately hydrated. Infectious Disease An RN is administering a skin test for tuberculosis (TB) to a patient. The patient asks how the test will reveal TB. The RN should base the response on which knowledge? A chest X ray will be done after the Mantoux test. A negative skin test excludes TB infection or disease. Induration does not have to be present to reveal a positive test. A positive reaction does not necessarily mean active disease is present in the body. 1) A chest X ray done with a positive skin test, blood test, or sputum culture for acid-fast bacilli. 2) A negative skin test does not exclude TB infection or disease because immunosuppression may cause the inability of the body to produce a positive skin test. 3) A reaction occurs when both induration and erythema are present. *4) A positive Mantoux test does not mean active disease. Over 90% of people who are tuberculin-positive reactors do not develop clinical TB. Additional test required for diagnosis. Tissue Trauma An RN manager overhears nursing personnel making unprofessional remarks about a bariatric surgery patient who was readmitted with wound complications, suggesting that the patient's current health status is self- inflicted. What should be the RN manager's priority in planning a response to these comments? Plan a staff development session on bias against obesity. Find out which members of the unit staff are responsible. Plan a staff development session on cultural sensitivity. Re-examine the unit's bariatric surgery discharge protocols. 1) This is a good secondary action for the nurse manager to plan. 2) This is a punitive action which will likely make the situation worse. *3) Staff behavior suggests that cultural bias may be the underlying problem. Planning a cultural sensitivity session is the priority action for the nurse manager. 4) This is a good secondary action for the nurse manager to plan. Tissue Trauma A patient has sustained a third-degree burn to the right forearm and received a skin graft. The patient's right fingers are pale and cool to touch, there is a moderate amount of serosanguinous strike through on the gauze dressing, lab results indicate elevated potassium levels and low sodium levels, and urinary output is less than 30 mL per hour. The patient states, "I don't have much pain, but I feel pins and needles." Which complication is indicated by the RN's assessment data presented here? Graft rejection Wound infection Compartment syndrome Fluid volume overload 1) There is no information about the appearance of the graft provided. 2) The data provided do not indicate wound infection. *3) Compartment syndrome is a common complication of a severe burn. Pale, cool fingertips, diminished sensation, decreased urinary output, and low serum sodium are all indications of compartment syndrome. 4) The data presented do not indicate fluid volume overload. Blood pressure is low and pulse is high. Tissue Trauma An RN is assessing a full-thickness burn patient over an extended period of time. While checking on the patient, the RN is told that the patient feels pain in their severely burned limb. What does the report of pain in the burned limb indicate to the RN about the patient's condition? In a full-thickness burn, nerve endings are activated and pain is severe. The feeling of pain would indicate the burn is healing normally. In a full-thickness burn, nerve endings are destroyed and numbness is felt. The feeling of pain would indicate the burn is healing normally. In a full-thickness burn, nerve endings are confused and don't read pain well. The feeling of pain would indicate the burn is healing normally. In a full-thickness burn, nerve endings are activated, but pain is not registered. The feeling of pain would indicate the burn is healing normally. 1) This is incorrect, the nerve endings are destroyed. *2) Superficial burns are very painful because the nerve endings are exposed, resulting in excruciating pain with exposure to temperature, pressure, and movement. In a full-thickness burn the nerve endings are destroyed, and upon admission there is numbness and decreased sensation in the area. The feeling of pain would indicate the burn is healing normally. 3) See 1). 4) See 1). Tissue Trauma A patient who was severely burned is being discharged. Under which circumstances should the RN consider a referral for home physical therapy for this patient? Extensive wound care is needed to prevent infection. Family coping is compromised and social support is limited. Patient is interested in resources to help improve perceptions of body image. Mobility is inadequate to allow performance of activities of daily living (ADLs). 1) Wound care is facilitated by home care nurses through direct assistance or teaching. 2) Coping needs can be addressed by referral to mental health counseling. 3) Home care nurses can provide information about resources that improve body image. *4) Physical therapy is necessary and effective to improve mobility and range of motion. Tissue Trauma An RN is assessing a burn victim who has a urine output greater than their fluid intake, and whose daily weight is 3 lb less than the day before. What action is most appropriate for the RN to implement? Call the health care provider immediately to report the findings. Continue to monitor the patient because the findings are expected. Consult with another RN about the findings before calling the health care provider. Plan to call the health care provider if the numbers don't improve over the next few hours. 1) Assessment shows fluid shift with burns, hypovolemia in first 2 hours, then hypervolemia after 48 hours. This is expected. *2) About 48 hours after the burn, as inflammation decreases, the extracellular fluid at the burn site begins to be reabsorbed into the bloodstream. Edema at the burn site begins to subside; diuresis begins, and the patient loses weight. 3) See 1). 4) See 1). Tissue Trauma A 10-year-old patient who is newly diagnosed with rheumatoid arthritis (RA) reports pain after 5 weeks of using ibuprofen (Motrin), as prescribed. What nursing education would the RN provide to the patient? Usually patients do not improve only on ibuprofen (Motrin). Ask the physician for methotrexate. Medication should be taken for at least 6 to 8 weeks to ensure affectiveness. Discuss with the health care provider about doubling the dose. Tell the patient to stop taking the Motrin and look for other options. 1) NSAIDS: Motrin or Naprosyn must be taken for at least 6 to 8 weeks to ensure effectiveness. This drug is a second drug prescribed, but the patient still did not finish appropriate therapy with Motrin. *2) NSAIDS: Motrin or Naprosyn must be taken for at least 6 to 8 weeks to ensure effectiveness. 3) NSAIDS: Motrin or Naprosyn must be taken for at least 6 to 8 weeks to ensure effectiveness. This is not appropriate teaching. 4) NSAIDS: Motrin or Naprosyn must be taken for at least 6 to 8 weeks to ensure effectiveness. This does not help a patient and it is not appropriate teaching. Tissue Trauma An adult patient has just signed an Informed Consent for excision of a right ankle lipoma. Which patient statement indicates that an Informed Consent principle may have been violated? "I understand the surgeon's answers to my questions." "I understand that I cannot change my mind." "I understand the benefits and alternatives." "I understand the procedure and the risks." 1) This reflects element of informed consent. *2) The patient should have received instructions that they may withdraw consent. Consent is a voluntary act. 3) See 1). 4) See 1). Tissue Trauma Edetate calcium disodium (CaEDTA) is ordered for a 22-month-old infant. Which laboratory values should the RN check before administering the drug to this patient? (Select all that apply.) Blood glucose Urinary protein Serum creatinine Prothrombin time Blood urea nitrogen (BUN) Aspartate aminotransferase (AST) 1) Blood glucose is not affected by CaEDTA. *2) BUN, serum creatinine, and protein in urine are assessed to ensure kidney function is adequate because CaEDTA can lead to nephrotoxicity or kidney damage if it cannot be excreted. *3) See 2). 4) Prothrombin time is not affected by CaEDTA. It can be prolonged in liver disease but CaEDTA is associated with kidney disease, not liver disease. *5) See 2). 6) The ratio of serum alanine aminotransferase to serum aspartateaminotransferase (AST/ALT) are serum aminotransferase enzyme studies. These are enzymes released by damaged liver cells. CaEDTA can cause kidney damage, not liver damage. Tissue Trauma An RN is providing nursing education to a preoperative bariatric surgery patient. Which comment made by the patient would cause the most concern to the RN, regarding how well the patient understands the teaching? "These lifestyle changes are unrealistic. I don't think anyone can really follow them." "The psychiatric evaluation wasn't needed, but it's good things are checked out." "I've cleaned out my kitchen and my family is supportive of the procedure." "I've been following all the guidelines, but I'm nervous about the procedure." *1) The patient has not followed the guidelines and is not ready for the procedure. 2) Because bariatric surgery involves such a drastic change in the functioning of the digestive system, patients need counseling before and after the surgery. 3) Different bariatric surgical procedures entail different lifestyle modifications, and patients must be well informed about the specific lifestyle changes, eating habits, and bowel habits that may result from a particular procedure. 4) See 3). Tissue Trauma A patient recently had open reduction and fixation to repair a fracture. Which is an appropriately written outcome for this patient? Actively participate in an exercise regimen. Not become constipated from pain medications. Have no signs or symptoms of infection at surgical site. Pain will be at a manageable level (a level 4 to 5 out of 10 on a pain scale) for 2 weeks. 1) This outcome is written without a time frame and is not measureable. 2) See 1). There is no time frame nor indication of type of medication used to treat the pain. Constipation would only occur if opioid narcotics are used. 3) See 1). The signs and symptoms of infection should be stated and require a time frame. *4) This outcome is written correctly with a time frame. Tissue Trauma A 12-year-old patient presents at the emergency department (ED) with nausea, vomiting, and right-sided abdominal pain. A nursing assessment reveals a tense abdomen, shallow respirations, 80/40 mm Hg, 120 beats per minute (bpm), and a white blood cell (WBC) count of 22,000/mm3. What should be the initial priority action taken by the RN? Administer oral antibiotics. Initiate an intravenous (IV) line. Collaborate with the ultrasound technician. Provide pre-operative instructions to the parents. 1) The signs and symptoms indicate a strong possibility of appendicitis and possibly a ruptured appendix. Antibiotics may be administered intravenously, but nothing should be allowed by mouth in preparation for possible surgery. *2) Gastrointestinal symptoms, vital signs, and other assessments point to possible appendicitis with the need for intravenous fluids and antibiotics. 3) An ultrasound may be done to determine the cause of symptoms, but the priority is stabilization of fluid balance. 4) The diagnosis of appendicitis will need to be confirmed and then teaching will be required; initial priority is on physiological stabilization. Tissue Trauma An RN is assessing a patient who is obese and who had an open Roux-en-Y gastric bypass procedure 2 days earlier. The patient's weight is 420 lb and their height is 5' 6". The patient states, "I feel hot, shaky, and miserable. My stomach hurts." After assessing the patient's vital signs, the RN informs the health care provider that the patient is febrile and tachycardic. Which is the most appropriate response for the RN to give to the patient? "Are you allergic to contrast dye? Your health care provider has ordered an upper gastrointestinal (GI) series followed by a computed tomography (CT) scan with contrast dye to rule out a surgical complication." "I'm sorry you feel miserable. I've heard from the health care provider and you will have new orders to stay on bed rest until you are feeling better." "How has your appetite been? You may be able to advance to a solid diet; eating more calories will help you feel better." "Here is an ice pack to place over your incision. The cold will bring the swelling down." *1) The possibility of sepsis due to gastric contents leaking into the peritoneum is great in an older patient of large body mass. GI series followed by CT with contrast will determine whether this complication is present. 2) The symptoms (fever, pain, tachycardia) indicate possible sepsis, which could be the result of a gastric leak at the site of the anastomosis. Bed rest may be indicated, but it is not the best answer. 3) The symptoms would not support an advance in diet. If anything, this patient is to be given nothing by mouth (NPO). 4) Cold packs can provide some relief, but given the acute nature of the problem, ruling out a gastric leak is the best answer. Tissue Trauma A cognitively competent older patient is admitted to the hospital with an infected diabetic ulcer on the left ankle. The patient explains to the RN that they do not want surgery and that they would rather go home. The patient's caregiver and health care provider do not support the patient's decision. Which is the most appropriate initial action that should be taken by the RN? Tell the patient that surgery is in their best interest. Ask the health care provider to submit a referral for a psychiatric consult. Suggest that the situation be referred to the ethics committee. Encourage the patient to verbalize the reasons for not wanting surgery. 1) This is a violation of patient autonomy. 2) This is premature until the patient is fully assessed by members of the health team. 3) The patient is cognitively competent, so there isn't a moral/ethical dilemma. *4) This intervention will open up lines of communication for the nurse to better understand underlying patient issues, and aid in improving communication between the patient and the health team. Tissue Trauma An RN collaborates with a health care provider to adjust the fluid resuscitation for a patient in response to physiological findings. Why would the RN take this action? To liquify secretions and facilitate expectoration To minimize energy expenditure To prevent distribution shock To relieve gastric distention 1) The RN would provide humidified oxygen to help with liquefying secretions. 2) The RN would provide a warm environment to help with fluid resuscitation. *3) Optimal fluid resuscitation prevents distributive shock. 4) The RN would maintain a nasogastric tube (NG) to help with fluid resuscitation. Tissue Trauma A febrile patient requires nursing care for a complex, draining abdominal wound. The wound requires irrigation, a sterile dressing, and reapplication of Montgomery straps. Which nursing decision would provide the least fragmentation of care for this patient? The RN completes the wound care. The RN delegates the wound care to an LPN/LVN. The RN assigns the wound care to another RN to complete. The RN delegates the wound care to unlicensed assistive personnel (UAP). *1) The assigned RN can provide enhanced continuity of care by providing wound care for this febrile patient rather than delegating the task. 2) The wound care is too complex and the patient is too ill. The wound care should not be delegated to an LPN/LVN who does not have the needed professional judgment. 3) This leads to fragmentation of care. 4) Wound care may not be delegated to UAP. Tissue Trauma A 7-year-old patient is 3 hours postoperative from an open reduction with internal fixation of a left tibial fracture. A nursing diagnosis label in the patient's plan of care is Risk for Ineffective Peripheral Tissue Perfusion related to pressure from the cast. Which assessment findings would indicate that this is no longer a risk but rather an actual diagnosis? (Select all that apply.) Pallor of the left foot Left foot warmer than the right Absence of feeling in the left toes Pedal pulses equal but difficult to palpate Pins and needles sensation in the left foot *1) Absence of feeling, pallor, and paresthesias (such as pins and needles sensation) are defining characteristics of ineffective peripheral tissue perfusion 2) With ineffective peripheral tissue perfusion, the affected side would be cooler, not warmer than the unaffected side. *3) See 1). 4) With ineffective peripheral tissue perfusion related to pressure from the cast, the pedal pulse in the foot of the casted leg would be absent or weaker than the pedal pulse in the foot of the non-casted leg. *5) See 1). Tissue Trauma Which nursing intervention is the most effective method for preventing surgical wound infection when a break in the integrity of the skin occurs and there is an increased risk for infection? Antibiotic therapy Occlusive dressings Sterile dressing changes Appropriate hand hygiene 1) Antibiotic therapy is used when a bacterial infection is already present. 2) Occlusive dressings do not always prevent infections. 3) Hand hygiene is used first before performing either a sterile or clean technique dressing change. *4) Careful hand hygiene before caring for a wound is probably the single most effective method for preventing wound infections. Tissue Trauma A veteran who had an above-the-knee amputation to the right leg is seen at the clinic and is asking for additional medications for depression. In addition to consulting with the psychiatrist about the medication regimen, which action should the RN take to promote positive coping for this patient? Suggest the patient develop a hobby that will benefit others, like training service dogs. Discuss with the patient participation in a support group focused on veterans. Instruct family members to carefully monitor the patient's medication use. Teach the patient the dangers of increased doses of antidepressants. 1) Hobbies can be helpful in dealing with depression. Assessment of the patient's interests must precede suggestion of specific activities. *2) Social support is strongly related to positive coping, especially if contact includes a group of individuals who have shared a common experience. 3) Family members can contribute to social support but there is no indication that the adult patient is unable to manage medication administration appropriately. 4) Antidepressant medication is an element of treatment for depression; while the nurse should teach about medications, focusing on the dangers of medication use will not promote positive coping. Tissue Trauma An RN is assessing a 23-month-old infant who was brought in to the emergency department (ED) by the parent for an electric shock sustained when the infant bit the end of an extension cord. During the assessment, the RN notices a white blister on the hard palate, a dark area on center of the infant's tongue, and bleeding on the right buccal membrane. Based on the location of the infant's burns, which information should the RN provide to the parent? It is common for children of this age to bite electrical cords. They will heal quickly. Electrical burns in the mouth may cause swelling that may affect breathing. Because the burn is in the mouth, saliva will prevent it from becoming infected. Sips of milk and ginger ale will be enough to cleanse the wounds in his mouth. 1) Accidental electric shock is common; however, stating that the patient will heal quickly is not necessarily accurate. *2) The damage to the surrounding tissue may cause edema and impact the airway. This is the correct response. 3) Electrical burns in the oral cavity are susceptible to infection, so this statement is incorrect. 4) Sips of milk and flat ginger ale may be well tolerated; however, these will not prevent infections. Neurological Dysfunction A newborn diagnosed with epilepsy is experiencing a tonic-clonic seizure. The patient weighs 7 lb, 8 oz. The physician's orders are to administer Diazepam 0.3 mg/kg intravenously (IV). Diazepam is available as a 5 mg/mL injection. How many milligrams (mg) should the RN administer? (Provide your answer to 1 decimal place in the input box below.) Rationale: Convert weight lb to kg: 7 lb 8 oz = 7.5 lb divided by 2.2 (there are 2.2 kg/lb) = 3.4 kg. The doctor's order is 0.3 mg/kg, therefore multiply 0.3 x 3.4 = 1.0 mg diazepam is the dose. Neurological Dysfunction An older patient with Huntington's disease is being seen by a neurologist. The patient's son expresses concern over the chances that his own children may develop Huntington's disease in the future. The most appropriate response by the RN would be based on which fact, regarding Huntington's disease? Huntington's disease is an autosomal recessive trait and causes a third- degree pedigree of disease carriers. Huntington's disease is a multifactorial genetic condition and does not always result in characteristic patterns. Huntington's disease is an X-linked recessive inherited condition. This type of condition can present as either autosomal recessive or autosomal dominant. Huntington's disease is an autosomal dominant trait and there is a 50% chance for each child to develop the disease if one parent has a disease carrying this allele. 1) Huntington's disease is not an autosomal recessive trait. It is an autosomal dominant trait. 2) Huntington's disease is not a multifactorial genetic condition. It is an autosomal dominant trait. 3) Huntington's disease is not an X-linked inherited condition. It is an autosomal dominant trait. *4) Huntington's disease is an autosomal dominant trait. Neurological Dysfunction A patient is recovering from a craniotomy for a pituitary tumor. The physician's orders are to administer Vasopressin 5 units subcutaneous (SQ) immediately. The drug availability is Vasopressin 20 units/mL injection. How many milliliters (mL) should the RN administer? (Provide your answer to 2 decimal places in the input box below.) Rationale: 20 units/mL = 5 units/ x mL Cross multiply: 20x = 5 Solve for x: x/20 = 5/20; x = 5/20 = 0.25 mL Neurological Dysfunction A patient is 1 hour post-laminectomy. What should be included in the immediate postoperative nursing intervention for this patient? Assessing the surgical dressing every shift Performing hourly neurovascular assessments Elevating the head of bed to 30 degrees Positioning the patient on the side, straight, without neck, waist, or knees flexed 1) The surgical dressing should be assessed frequently immediately following a laminectomy operation. *2) Neurovascular assessments should be done frequently post- laminectomy to detect alterations in neurologic or circulatory status to extremities. 3) The head of the bed is not elevated after laminectomy surgery. The patient's head remains flat. Knees do get elevated slightly to reduce tension on the back. 4) When a patient who has had a laminectomy is lying on the side, the knees should be slightly bent to reduce tension on the back. Neurological Dysfunction A patient weighing 176 lb has intracranial pressure (ICP) that is elevated beyond the normal level. The orders are to immediately administer Mannitol 0.5 gm/kg intravenously (IV). The drug availability is Mannitol 25 gm/100 mL. How many milliters (mL) will the RN administer? (Provide your answer to the nearest whole number in the input box below.) Rationale: Convert 176 lb to kg 1276/2.2 = 80 kg weight. 176/2.2 = 80 kg: 80 x .5 = 40 gm/kg. 40 gm/25 gm x 100 = 160 mL. Neurological Dysfunction In response to a painful stimulus, an unconscious patient flexes both arms over their chest and rotates the lower extremities inward with feet in plantar flexion. What should the RN recognize about this response? Decorticate posturing Decerebrate response Purposeful withdrawal Minimally conscious state *1) Flexion of the upper extremities with extension of the feet into plantar flexion is decorticate posturing. 2) The upper extremities extend and straighten in the decerebrateresponse to painful stimuli. 3) Purposeful withdrawal is seen when the patient can cross the midline of the body as the patient attempts to withdraw from the pain. 4) Minimally conscious state occurs when the patient has inconsistent but reproducible signs of awareness. This posturing indicates coma, which is not purposeful response to external stimuli. Neurological Dysfunction A patient is admitted with Guillain-Barré syndrome. Which assessment by the RN is the priority when caring for this patient? Assess for renal dysfunction. Assess for respiratory difficulty. Monitor level of consciousness frequently. Check papillary size and reactivity every 2 hours. 1) Renal dysfunction is not usually a problem with Guillain-Barrésyndrome. *2) Demyelination of the nerves innervating the diaphragm and intercostal muscles results in neuromuscular respiratory failure. 3) Patients with Guillain-Barré syndrome do not have problems with changes in level of consciousness. 4) Papillary size and reactivity may be affected if the optic nerve is affected, but this is not the priority. Assessing respiratory status is the priority. Neurological Dysfunction An RN is the preceptor for a new staff RN in the intensive care unit (ICU) who is caring for a patient diagnosed with bacterial meningitis. Which action by the new staff RN requires the preceptor RN to intervene immediately? Instructing the caregiver to limit visits to short periods Entering the room without putting on a mask Evaluating neurological checks every hour Giving the patient a cold drink 1) It is important that the patient rests and has quiet. *2) The patient requires isolation and respiratory control precautions for 24 hours after the start of antibiotics. This requires a mask be worn. 3) Neurological checks are done at least every hour. 4) This is not contraindicated with meningitis. Neurological Dysfunction A 9-year-old child has been having frequent falls, followed by a brief period of unresponsiveness. The child is diagnosed with tonic-clonic seizures and has started on anti-seizure medication. Which parental statement indicates a need for further education? "I'll keep a record to be sure the medication is taken at the same time each day." "I have scheduled the follow-up appointment with the primary physician in 2 weeks." "I'll work with my other children to be sure they do not treat their sibling any differently than before." "I'll be sure to notify the school so my child can be excused from gym classes that require vigorous activity." 1) Maintaining a consistent blood level is important in controlling seizures, so a record of when medication is being taken is recommended. 2) Follow-up care with the primary care provider will ensure coordination of medications and treatment for all health issues. 3) Parents are advised to treat children with seizures the same as other family members, so this statement is appropriate and does not require further teaching. *4) Children with seizures should attend regular physical education classes. Neurological Dysfunction A patient is admitted to the emergency department (ED) after a fall. The patient reports feeling the worst headache they have ever experienced. Upon assessment, the RN recognizes the need to collaborate with the interprofessional team regarding which potential complication? Ischemic stroke Intracerebral bleed Epidural hematoma Subarachnoid hemorrhage 1) Signs and symptoms of an ischemic stroke may include unilateral weakness, facial droop, difficulty ambulating, difficulty speaking, confusion, and visual disturbances. 2) Intracerebral bleeding has a variety of signs and symptoms because the bleeding is diffuse throughout the brain; however, there is never a short period of unconsciousness, followed by a brief period of lucidity, further followed by unconsciousness again. 3) Epidural bleeding and hematomas are accompanied by a loss of consciousness, followed by a brief period when the patient is awake, alert, and oriented. Then, they rapidly deteriorate and become unconscious again. This indicates a rapid, arterial bleed. *4) Subarachnoid hemorrhages cause intracranial bleeding that is most often accompanied by a severe headache, due to meningeal irritation. Neurological Dysfunction A pediatric patient with epilepsy weighs 60 lb. The health care provider orders lamotrigine (Lamictal) 300 mg 2 times a day. The RN reads the drug dosage requirements and finds that the safe dose is a maximum of 15 mg/kg/day. What is the appropriate action for the RN to take? Collaborate with the health care provider regarding the order. Assess the vital signs prior to administering the medication. Review the complete blood count for evidence of anemia. Administer the medication as prescribed. *1) Convert lb to kg 60 lb/2.2 = 27.3 kg weight of the patient Find safe dose for that patient based on weight: 15mg/27.3 kg/day = 409.5 mg/day Health care provider orders 500 mg twice a day. 300 x 2 = 600 mg per day 600 mg/day would be OVER the maximum safe dose of 409.5 mg/day. 2) See 1). 3) See 1). 4) See 1). Neurological Dysfunction A patient is 24 hours post-craniotomy for a benign brain tumor. Which action should the RN delegate to the unlicensed assistive personnel (UAP)? Keep the patient's head of bed flat. Assist the patient out of bed to a chair. Keep the bed in Trendelenburg position. Keep the bed in reverse Trendelenburg position. 1) The patient's head of bed following craniotomy should be 30 to 45 degrees to assist in venous drainage. *2) The patient should get out of bed as soon as possible after surgery to prevent venous thrombosis, atelectasis and other complications. 3) Trendelenburg would be contraindicated, because the patient's head would be lower than his feet and body. This could cause increased intracranial pressure. 4) Reverse Trendelenburg position is not necessary (upper part of bed higher than the lower part of bed.); the patient's head of bed can be raised 30 to 45 degrees. Neurological Dysfunction A school-aged child falls 2 feet off of playground equipment and hits their head on the ground. The child's level of consciousness is assessed as awake and alert. A minor bump on the head is treated with an ice pack. Which instruction should the school RN provide to the parents of the child? (Select all that apply.) Keep the child on bed rest for 24 hours. Check the child's pupils every hour for 24 hours. Take the child to the emergency department (ED) immediately. Wake the child up at least once during the night to assess level of consciousness. Assess the child's level of consciousness every 1 to 2 hours for 24 hours, while awake. 1) Bed rest is not necessary for a minor head injury of this type. 2) Pupil check is not a skill that lay persons would carry out. Pupillary dilation is a late sign of progressing brain injury. 3) A head injury of minor severity does not necessitate a trip to the emergency department (ED). *4) Level of consciousness needs to be checked during the night in order to assess for progressing brain injury. *5) Level of consciousness is the best and earliest sign of progressing brain injury. Neurological Dysfunction How should the RN assess venous thromboembolism in a patient with paraplegia from a complete spinal cord injury following a motor vehicle accident? Measure and record thigh and calf circumference. Monitor range of motion and sensation in arms and legs. Check and document strength and equality of pedal pulses. Assess for spasticity and hyperreflexia in lower extremities. *1) Following complete SCI, a patient would not perceive pain. Change in calf or thigh circumference would result from obstructed venous return due to VTE in the leg veins and is routinely measured. 2) Movement and sensation would not be affected by impaired venous circulation from VTE. 3) Venous thromboemboli would not affect arterial circulation, so pedal pulses would not change. 4) Spasticity and hyperrreflexia would result from neurologicimpairment rather than circulatory problems such as VTE. Neurological Dysfunction To advocate for a patient with epilepsy, an RN educates the patient and family about support groups and counseling available in their community. The RN should also provide teaching on which topic? The patient should take tub baths, not showers. Blood work is not required after the patient is free from seizures for 6 months. The patient should discontinue medications if there is no seizure activity. The patient should wear a medical alert bracelet and carry a medical identification card. 1) The patient should take showers to avoid drowning in case of a seizure. 2) Blood work should be checked on a regular basis even when seizure-free. 3) Medications should be continued to remain seizure-free. *4) The patient should wear a bracelet and carry identification that specifies the seizure medication and the name of the physician caring for them. Neurological Dysfunction Which changes in vital signs indicate increased intracranial pressure (ICP) in a comatose patient? Decreased respiratory rate with increased pulse rate Increased pulse rate with increased temperature Decreased systolic blood pressure with increased pulse rate Increased systolic blood pressure with decreased pulse rate 1) Both pulse and respiratory rates decrease in Cushing's triad, indicating increased ICP. 2) Pulse rate decreases when ICP increases. 3) Systolic pressure with bradycardia indicates increased ICP. *4) Cushing's response (reflex) is seen as an increased blood pressure with a reflexive decrease in pulse in response to decreased blood flow from cerebral edema. Neurological Dysfunction An adult patient with cerebral subdural hematoma is experiencing increased intracranial pressure (ICP). Which nursing interventions would be a priority? Hold the administration of stool softeners and monitor bowel sounds. Lower head of bed from 30 degrees to a flat position. Ensure midline head position, utilizing a cervical collar. Change body position every 1 hour instead of every 2 hours. 1) Constipation can occur without stool softeners and increase intrathoracic pressure, which increases intracranial pressure. 2) Changing the head of bed to a flat position would decrease venous drainage and potentially increase intracranial pressure. *3) This intervention will promote venous drainage and help decrease intracranial pressure. 4) Body position changes can increase intracranial pressure. An increased frequency in position change can increase this risk. Question 55 1 / 1 pts Neurological Dysfunction A patient with myasthenia gravis is admitted with severe weakness and acute respiratory insufficiency. Which response to the Tensilon test is most likely to occur if the patient is in myasthenic crisis? Pupillary miosis Ptosis improvement Increased bronchial secretions Increased weakness and dyspnea 1) See 2). *2) The initial manifestation of myasthenia gravis in 80% of patients involves the ocular muscles. Diplopia and ptosis (drooping of the eyelids) are common. Many patients also experience weakness of the muscles of the face and throat (bulbar symptoms) and generalized weakness. Weakness of the facial muscles results in a bland facial expression. Laryngeal involvement produces dysphonia (voice impairment) and dysphagia, which increases the risk of choking and aspiration. Generalized weakness affects all extremities and the intercostal muscles, resulting in decreasing vital capacity and respiratory failure. Myasthenia gravis is purely a motor disorder with no effect on sensation or coordination. An acetylcholinesterase inhibitor test, called the Tensilon test, is used to diagnose myasthenia gravis. The acetylcholinesterase inhibitor stops the breakdown of acetylcholine, thereby increasing availability at the neuromuscular junction. Edrophonium chloride (Tensilon), a fast- acting acetylcholinesterase inhibitor, is administered intravenously (IV) to diagnose myasthenia gravis. Thirty seconds after injection, facial muscle weakness and ptosisshould resolve for about 5 minutes. Immediate improvement in muscles strength after administration of this agent represents a positive test and usually confirms the diagnosis. 3) See 2). 4) See 2). Neurological Dysfunction An RN is supervising an LPN/LVN caring for a patient with Guillain-Barré syndrome. Which observation would the RN instruct the LPN/ LVN to report immediately? Heart rate of 100 beats/min Weakness of the lower extremities Shallow and decreased breath sounds Urinary output of less than 400 mL of urine in 8 hours 1) This heart rate is within normal limits. 2) This is an expected observation. *3) Ineffective breathing could be a sign that the paralysis is ascending and respiratory failure could occur. Respiratory failure is a major cause of death with this disease. 4) This is normal output. Musculoskeletal Dysfunction An RN is caring for a patient in skeletal traction. What is the standard of care when providing care to a patient requiring skeletal traction? Removing weights from the traction only in life-threatening conditions Assessing neurovascular status every 8 hours Cleaning pin sites with soap and water Encouraging patient movement, using elbows and heel of unaffected leg *1) Weights should not be removed unless it is a life-threatening emergency. 2) Neurovascular assessments are completed every 4 hours for a patient in traction. 3) Pin sites should be cleaned with Chlorhexidine. 4) To encourage movement without using the elbows or heel, a trapeze can be suspended overhead within easy reach of the patient. Not using the elbows or heels for movement prevents skin breakdown in these areas. Musculoskeletal Dysfunction An RN is assigning patients to a staff of 3 RNs and an LPN/LVN. After comparing patients' conditions, the RN decides that which patient should be assigned to the LPN/LVN? A patient who is 2 days postoperational surgery for a hip fracture who is being discharged today A patient who is requesting information about diet restrictions for a new diagnosis of gout A patient with compartment syndrome receiving intravenous pain medication A patient with systemic lupus erythematosus (SLE) who is receiving corticosteroids 1) An RN's scope of practice includes responsibility for teaching, including discharge teaching. This task should not be delegated. 2) An RN's scope of practice includes responsibility for patient education, and this task should not be delegated. 3) Administering intravenous pain medication is not within the scope of practice for an LPN. *4) It is within the scope of practice for an LPN to administer corticosteroids to patients. Musculoskeletal Dysfunction An RN is caring for a patient who has had a left, below-the-knee amputation. Which nursing intervention would be included in the plan of care for the nursing diagnosis label Impaired Physical Mobility? Bed rest for 72 hours All patient self-care activities to be performed by RN Range of motion (ROM) exercises Pain control with nonsteroidal anti-inflammatory agents (NSAIAs) 1) Active movement is called for, so the patient should be out of bed in 24 hours to prevent respiratory complications of surgery. 2) The patient should be allowed to have control over self-care activities. *3) Range of motion (ROM) exercises prevent contractures. Contractures develop rapidly. 4) Pain would be controlled with opioid analgesics. Musculoskeletal Dysfunction A patient recovering from chemical burns of the esophagus is being discharged. In preparing discharge plans, which action by the RN would promote tissue healing for this patient? Consulting with a registered dietician for nutritional assessment and planning Making an appointment with a respiratory therapist for oxygenation needs Providing a referral to a mental health professional for assessment of self- harm Arranging interaction with a peer group for coping support *1) Chemical burns of the esophagus result in difficulty with oral intake. Enteral or parenteral feeding may be needed to provide adequate nutrition for healing. 2) Respiratory distress is more likely in the acute phase following chemical burns of the esophagus. Nutritional support is the primary need in the rehabilitative phase. 3) Chemical burns may be the result of self-harm; however, the situation does not indicate this has happened. Actions of a mental health professional do not directly affect tissue healing. 4) Peer support may be helpful to cope with pain and emotional distress related to chemical burns of the esophagus, but does not directly affect tissue healing. Musculoskeletal Dysfunction An RN is educating a patient who has been newly diagnosed with osteoarthritis (OA) on how to manage the symptoms. Which self-care activities should the RN include in the teaching plan? (Select all that apply.) Follow a purine-free diet. Follow a therapeutic weight loss program. Rest a painful joint when acutely inflamed. Plan exercise when pain is at the minimum. Be sure to taper off the cortisone pills over several days. 1) A purine-free diet is used in patients with gout and is not necessary in the care of a patient with osteoarthritis. *2) The most prominent modifiable risk factor for OA is obesity. The patient will need to be involved in a therapeutic weight loss program. *3) The main clinical manifestations of OA include pain, stiffness, and functional impairment. The joint pain is usually aggravated by movement or exercise and relieved by rest. *4) Patients should plan their daily exercise for a time when the pain is least severe or plan to use an analgesic agent, if appropriate, before exercising. 5) Pain management in OA does not require the use of oral corticosteroids. Acetaminophen, NSAIDs and COX-2 enzyme blocker are used to decrease pain and stiffness associated with OA. Intra-articular corticosteroid injections may be an option but do not require tapering. CAM therapies have been found to be just as effective as pharmacologic treatments. Musculoskeletal Dysfunction An RN suspects that a patient with a leg cast has developed compartment syndrome. What should be the RN's first action? Elevate the extremity at the heart level Perform range of motion exercises Palpate peripheral pulses Assess for petechiae *1) Compartment syndrome is managed by keeping the extremity at the heart level (not above heart level), and opening and bivalvingthe cast. 2) Motor weakness may occur as a late sign of nerve ischemia. 3) Pulselessness is a very late sign that may signify lack of distal tissue perfusion. 4) Petechiae occurs with fat embolism syndrome, not compartment syndrome. Musculoskeletal Dysfunction To lower the risk of venous thromboembolism in a patient who is postoperative for repair of ligaments in the knee, which action should be taken by the RN? Assist with deep breathing and use of incentive spirometer. Maintain use of the continuous passive motion machine. Provide pain medication before pain is severe. Encourage ankle and calf pumping exercises. 1) This activity lowers the risk of atelectasis, not venous thromboembolism. 2) The continuous passive motion machine maintains joint mobility but does not provide active motion in calf muscles. 3) Pain relief is important and may encourage mobility, but does not directly limit the risk of venous thromboembolism. *4) Active use of muscles in the calf prevents venous stasis that can lead to venous thromboembolus. Musculoskeletal Dysfunction An RN is orienting in the Operating Room (OR). During the pre-operative timeout, prior to a joint replacement surgery, the circulating RN is observed making jokes and haphazardly completing patient and site identification. Which action should the orienting RN take? Talk with the circulating RN at the end of the day. Interrupt the timeout process to bring focus back to the patient. Discuss the situation with the nursing supervisor immediately after the surgery. Allow the other staff members to address the behavior with the circulating RN. 1) The orienting RN has an obligation to take action to protect the patient and cannot wait until the end of the day. *2) If quality care is not being delivered, all staff members must speak up and take action to protect the patient. 3) The orienting RN has an obligation to take actions to protect the patient and cannot wait until after the surgery. 4) RNs have an obligation to take actions to protect the patient and cannot rely on the actions of others. Musculoskeletal Dysfunction A patient has undergone a fasciotomy after being diagnosed with compartment syndrome. An RN should provide wound care instruction that includes which action? Betadine dressing Dry sterile dressing Hydrocolloid dressing Wet sterile saline dressings 1) The incision is not infected, so there is no need for a betadinesolution, which could burn the tissue. 2) The area needs to remain moist at all times to facilitate healing. 3) Hydrocolloid dressing is not indicated for clean, open incisions. *4) Moist, sterile saline dressings are applied post fasciotomy. Musculoskeletal Dysfunction A patient who is diabetic is admitted to the nursing unit with acute osteomyelitis, secondary to a left foot wound. Which clinical manifestation should be expected in this patient? Nausea, vomiting, and blood pressure of 190/100 mm Hg A temperature of 37.5°C (99.5°F) and pain in the right foot A temperature of 38.0°C (102.1°F) and a blood sugar of 156 Flexion contracture in the left foot and a heart rate of 100 beats per minute 1) In the event of a systemic infection, a patient may have symptoms of nauseousness and vomiting; however, the blood pressure is abnormal, which is not an expected finding of osteomyelitis. 2) A patient with osteomyelitis will display systemic manifestations of infection, including a fever. In this option, the patient with a 37.5°C (99.5°F) is in the high range of normal. The patient may have pain from neuropathy in the opposite foot from diabetes; however, it would not be an expected manifestation of a patient with osteomyelitis on the left foot. *3) Although the infection stems from the bone, patients with osteomyelitis present systemic symptoms, including a high fever. The diabetic patient with a non-healing wound is most likely to present with an elevated blood sugar, especially in the presence of infection. 4) A patient with a systemic infection may have an elevated heart rate and decreased range of motion (ROM) due to pain in the effected extremity; however, a flexion contracture is not an expected finding of osteomyelitis and may require additional intervention. Musculoskeletal Dysfunction An RN is assessing a patient diagnosed with impingement syndrome. The RN should expect the assessment to show which symptoms? (Select all that apply.) Muscle spasms Wrist tenderness Fluid around the joint Edema from hemorrhage Full range of motion (ROM) *1) Muscle spasms are expected in a patient with impingement syndrome. 2) Wrist tenderness does not come from having impingement syndrome. 3) This does not occur in impingement syndrome. *4) An early sign of impingement is edema from hemorrhage. 5) A patient with impingement service will not have full range of motion (ROM). Musculoskeletal Dysfunction A patient is admitted to the hospital after being found approximately 48 hours earlier at home lying on the kitchen floor. X rays confirm a femoral neck fracture. Upon assessment, the RN discovers pain, deformity, and ischemia to the hip region. The RN recognizes that these assessment findings indicate which potential priority complication for this patient? Sprain Contusion Contractures Avascular necrosis 1) These are not the manifestations of a sprain, and furthermore, a sprain is not a priority complication. 2) Although important, a contusion is not a priority complication. The patient is not exhibiting the manifestations of a contusion. 3) Contractures are not a priority complication. The patient is not exhibiting the manifestations of contractures. *4) Avascular necrosis (tissue death caused by insufficient blood supply) is a priority complication for which this client is exhibiting clinical manifestations. Musculoskeletal Dysfunction An RN is planning a community education program about osteoporosis prevention at a local assisted living facility. Which teaching point should the RN include in the program? Take 1,000 mg of vitamin C daily. Maintain a diet high in foods containing phosphorus. Get involved with the assisted living facility's daily walking program. Take a daily supplement containing 500 mg of calcium and 200 IU of vitamin D. 1) A diet rich in calcium and vitamin D throughout life, with an increased calcium intake during adolescence and the middle years, protects against skeletal demineralization. Vitamin C does not have bone-protecting actions and will not prevent osteoporosis; however, a beverage that contains vitamin C can be taken to promote absorption of calcium. 2) To prevent bone loss, phosphorus should be limited. *3) Daily weight-bearing exercises, such as the walking program offered by the assisted living facility, promotes bone formation and thereby prevents osteoporosis. 4) The recommended adequate intake level of calcium for adults is 1,000 to 1,300 mg daily and the recommended vitamin D intake for adults 50 years and older is 800 to 1,000 IU daily. 500 mg of calcium and 200 IU of vitamin D is not enough. Musculoskeletal Dysfunction Following a below-the-knee amputation surgery, a patient reports a dull, burning sensation at the surgical site and is prescribed propranolol (Inderal). Which priority should the RN assess for, before administering this prescribed medication to the patient? Pain Blood pressure Respiratory Neurovascular 1) A pain assessment is necessary prior to the administration of any medication that will alter pai