Nursing 113: Exam 1
When teaching the child with scoliosis being treated with a Boston brace about
exercises, the nurse explains that the exercises are performed primarily for what
reason?
to strengthen the back and abdominal muscles
When the nurse is conducting a preoperative interview with a client who is having
a vaginal hysterectomy, the client states that she forgot to tell her surgeon that
she had a total hip replacement 3 years ago. Why should the nurse communicate
this information to the perioperative nurse?
The client should not have her hip externally rotated when she is positioned for the
procedure.
A client is scheduled to undergo transurethral resection of the prostate. The
procedure is to be done under spinal anesthesia. What should the nurse assess
the client for after surgery?
respiratory paralysis
A client with respiratory complications of multiple sclerosis (MS) is admitted to
the intensive care unit. Which equipment is most important for the nurse to keep
at the client's bedside?
suction machine with catheters
A nurse is assessing a client for neurologic impairment after a total hip
replacement. Which finding would indicate impairment in the affected extremity?
inability to move
A 20-year-old seeks treatment at a local emergency care center after spraining an
ankle while playing ball with friends. The ankle is painful and swollen. Which
actions should the nurse perform, as ordered by the physician? Select all that
apply.
1)Initially apply cold pack.
2)Instruct the client to elevate the ankle for 48 to 72 hours.
3)Provide crutch-gait training.
4)If needed, apply an elastic bandage from the toes to midcalf.
A client who has had an above-the-knee amputation develops a dime-sized bright
red spot on the dressing after 45 minutes in the postanesthesia recovery unit.
What should the nurse do first?
Draw a mark around the site
A nurse is helping a client move up in the bed. Which action maintains good body
mechanics?
having the client help as much as possible
To promote early and efficient ambulation for a client after an above-the-knee
amputation, the nurse is aware that the leg will need to be positioned in which
way?
in functional alignment
A client is 4 days postoperative from a tibia fracture and has a long leg cast. The
nurse is conducting initial teaching for walking with crutches. What is the most
important activity for the nurse to encourage the client to do prior to discharge
from the hospital?
,conduct exercises in bed to strengthen the upper extremities, as this will assist the client
in crutch use.
The nurse enters the room to do an initial assessment on a client with a fracture
of the femoral head. What would be the expected findings on the affected limb?
shortening of the affected extremity with external rotation
The nurse is aware that frequent repositioning in bed will assist in the prevention
of which condition for a client?
pneumonia
The client was recently diagnosed with a musculoskeletal disorder and ordered
carisoprodol. The nurse completes teaching about the medication. Which
statement by the client indicates a need for more teaching about carisoprodol?
"I will stop the medication as soon as the muscle spasticity goes away."
Which positioning technique is most effective when there is only one person to
assist the client to move from the left side to the right side if the client has
hemiparalysis?
rolling the client onto the side
The nurse is caring for a client during the postoperative period. The client was
prescribed thigh high antiembolism stockings and pneumatic compression
devices for prevention of deep vein thrombosis. Assessment data reveal +3
pitting edema to the lower extremities bilaterally. What is the priority action by the
nurse?
Measure client's thighs and calves to ensure the antiembolism stockings are the correct
size.
The nurse is creating a plan of care for an older adult client with osteoarthritis.
Which nursing diagnosis is most appropriate?
risk for injury related to altered mobility
The school nurse is planning an educational session to prevent injuries in
children with juvenile arthritis. Which information should the nurse include in the
teaching?
Schedule the completion of daily range-of-motion exercises to support joint mobility.
A client is diagnosed with rheumatoid arthritis and is ordered oral indomethacin.
What should the nurse include in the client's teaching concerning the
administration of indomethacin? Select all that apply.
1)"Avoid any hazardous activity until you know how you react to this drug."
2)"Tell your health care provider immediately about changes in your hearing."
3)"Do not use aspirin while taking this drug."
Define contact dermatitis
The inflammation of skin characterized by damage to the dermis and epidermis
Is contact dermatitis chronic or acute?
Can be either/ or
What are the symptoms of contact dermatitis?
Bullae, Vesicles, Wheals
What kind of cells in the body cause the body to have the reaction of contact
dermatitis?
T Lymphocytes
What are some irritants of contact dermatitis?
, Plants (poison) Drugs acids Alkalies latex soaps perfumes deodorants, and materials.
Rubber cosmetics / hair dye.
What is the etiology of allergic contact dermatitis?
Result of immune response to a subsequent response. Meaning the 1st time the body
does not react to it but the 2nd time the body reacts.
What are the expected outcomes of contact dermatitis?
1.Control of dermatitis
2.No infection occurs
3.Triggers identified and eliminated
4.Sleep is minimally disturbed by itching.
What is the nursing process for contact dermatitis?
1.Identify agent
2.Develop Strategy
3.Teach
A severely dehydrated adolescent admitted to the hospital with hypotension and
tachycardia undergoes evaluation for electrolyte disturbances. The client's
history includes anorexia nervosa and a 20-lb (9.1-kg) weight loss in the past
month. She is 5′ 7″ (1.7 m) tall and weighs 80 lb (36.3 kg). Which nursing
intervention takes highest priority?
initiating caloric and nutritional therapy as ordered
A client with severe inflammatory bowel disease is receiving total parenteral
nutrition (TPN). When administering TPN, the nurse must take care to maintain
the ordered flow rate because giving TPN too rapidly may cause
hyperglycemia
A student with type 1 diabetes tells the nurse she is feeling light-headed. The
student's blood sugar is 60 mg/dL (3.3 mmol/L). Using the 15-15 rule, what should
the nurse do to treat the blood glucose?
Administer 15 g of carbohydrate and retest the blood sugar in 15 minutes.
The nurse is planning care for a client with osteomyelitis. The client is taking an
antibiotic, but the infection has not resolved. What should the nurse advise the
client to do?
Eat a high diet in Vitamin C and Vitamin D
The client with Cushing's disease needs to modify dietary intake to control
symptoms. In addition to increasing protein, which strategy would be most
appropriate?
Restrict Sodium
When instructing the client with severe burns about proper nutrition, the nurse
should encourage the client to choose which menu for lunch?
Roast Beef sandwich, milkshake, and cottage cheese
A primiparous client is on a regular diet 24 hours postpartum. The client's mother
asks the nurse if she can bring her daughter some "special foods from home."
The nurse responds, based on the understanding about which principle?
A mother can bring anything the pt desires
A breastfeeding primiparous client who gave birth 8 hours ago asks the nurse,
"How will I know that my baby is getting enough to eat?" Which guideline should
the nurse include in the teaching plan as evidence of adequate intake?
When teaching the child with scoliosis being treated with a Boston brace about
exercises, the nurse explains that the exercises are performed primarily for what
reason?
to strengthen the back and abdominal muscles
When the nurse is conducting a preoperative interview with a client who is having
a vaginal hysterectomy, the client states that she forgot to tell her surgeon that
she had a total hip replacement 3 years ago. Why should the nurse communicate
this information to the perioperative nurse?
The client should not have her hip externally rotated when she is positioned for the
procedure.
A client is scheduled to undergo transurethral resection of the prostate. The
procedure is to be done under spinal anesthesia. What should the nurse assess
the client for after surgery?
respiratory paralysis
A client with respiratory complications of multiple sclerosis (MS) is admitted to
the intensive care unit. Which equipment is most important for the nurse to keep
at the client's bedside?
suction machine with catheters
A nurse is assessing a client for neurologic impairment after a total hip
replacement. Which finding would indicate impairment in the affected extremity?
inability to move
A 20-year-old seeks treatment at a local emergency care center after spraining an
ankle while playing ball with friends. The ankle is painful and swollen. Which
actions should the nurse perform, as ordered by the physician? Select all that
apply.
1)Initially apply cold pack.
2)Instruct the client to elevate the ankle for 48 to 72 hours.
3)Provide crutch-gait training.
4)If needed, apply an elastic bandage from the toes to midcalf.
A client who has had an above-the-knee amputation develops a dime-sized bright
red spot on the dressing after 45 minutes in the postanesthesia recovery unit.
What should the nurse do first?
Draw a mark around the site
A nurse is helping a client move up in the bed. Which action maintains good body
mechanics?
having the client help as much as possible
To promote early and efficient ambulation for a client after an above-the-knee
amputation, the nurse is aware that the leg will need to be positioned in which
way?
in functional alignment
A client is 4 days postoperative from a tibia fracture and has a long leg cast. The
nurse is conducting initial teaching for walking with crutches. What is the most
important activity for the nurse to encourage the client to do prior to discharge
from the hospital?
,conduct exercises in bed to strengthen the upper extremities, as this will assist the client
in crutch use.
The nurse enters the room to do an initial assessment on a client with a fracture
of the femoral head. What would be the expected findings on the affected limb?
shortening of the affected extremity with external rotation
The nurse is aware that frequent repositioning in bed will assist in the prevention
of which condition for a client?
pneumonia
The client was recently diagnosed with a musculoskeletal disorder and ordered
carisoprodol. The nurse completes teaching about the medication. Which
statement by the client indicates a need for more teaching about carisoprodol?
"I will stop the medication as soon as the muscle spasticity goes away."
Which positioning technique is most effective when there is only one person to
assist the client to move from the left side to the right side if the client has
hemiparalysis?
rolling the client onto the side
The nurse is caring for a client during the postoperative period. The client was
prescribed thigh high antiembolism stockings and pneumatic compression
devices for prevention of deep vein thrombosis. Assessment data reveal +3
pitting edema to the lower extremities bilaterally. What is the priority action by the
nurse?
Measure client's thighs and calves to ensure the antiembolism stockings are the correct
size.
The nurse is creating a plan of care for an older adult client with osteoarthritis.
Which nursing diagnosis is most appropriate?
risk for injury related to altered mobility
The school nurse is planning an educational session to prevent injuries in
children with juvenile arthritis. Which information should the nurse include in the
teaching?
Schedule the completion of daily range-of-motion exercises to support joint mobility.
A client is diagnosed with rheumatoid arthritis and is ordered oral indomethacin.
What should the nurse include in the client's teaching concerning the
administration of indomethacin? Select all that apply.
1)"Avoid any hazardous activity until you know how you react to this drug."
2)"Tell your health care provider immediately about changes in your hearing."
3)"Do not use aspirin while taking this drug."
Define contact dermatitis
The inflammation of skin characterized by damage to the dermis and epidermis
Is contact dermatitis chronic or acute?
Can be either/ or
What are the symptoms of contact dermatitis?
Bullae, Vesicles, Wheals
What kind of cells in the body cause the body to have the reaction of contact
dermatitis?
T Lymphocytes
What are some irritants of contact dermatitis?
, Plants (poison) Drugs acids Alkalies latex soaps perfumes deodorants, and materials.
Rubber cosmetics / hair dye.
What is the etiology of allergic contact dermatitis?
Result of immune response to a subsequent response. Meaning the 1st time the body
does not react to it but the 2nd time the body reacts.
What are the expected outcomes of contact dermatitis?
1.Control of dermatitis
2.No infection occurs
3.Triggers identified and eliminated
4.Sleep is minimally disturbed by itching.
What is the nursing process for contact dermatitis?
1.Identify agent
2.Develop Strategy
3.Teach
A severely dehydrated adolescent admitted to the hospital with hypotension and
tachycardia undergoes evaluation for electrolyte disturbances. The client's
history includes anorexia nervosa and a 20-lb (9.1-kg) weight loss in the past
month. She is 5′ 7″ (1.7 m) tall and weighs 80 lb (36.3 kg). Which nursing
intervention takes highest priority?
initiating caloric and nutritional therapy as ordered
A client with severe inflammatory bowel disease is receiving total parenteral
nutrition (TPN). When administering TPN, the nurse must take care to maintain
the ordered flow rate because giving TPN too rapidly may cause
hyperglycemia
A student with type 1 diabetes tells the nurse she is feeling light-headed. The
student's blood sugar is 60 mg/dL (3.3 mmol/L). Using the 15-15 rule, what should
the nurse do to treat the blood glucose?
Administer 15 g of carbohydrate and retest the blood sugar in 15 minutes.
The nurse is planning care for a client with osteomyelitis. The client is taking an
antibiotic, but the infection has not resolved. What should the nurse advise the
client to do?
Eat a high diet in Vitamin C and Vitamin D
The client with Cushing's disease needs to modify dietary intake to control
symptoms. In addition to increasing protein, which strategy would be most
appropriate?
Restrict Sodium
When instructing the client with severe burns about proper nutrition, the nurse
should encourage the client to choose which menu for lunch?
Roast Beef sandwich, milkshake, and cottage cheese
A primiparous client is on a regular diet 24 hours postpartum. The client's mother
asks the nurse if she can bring her daughter some "special foods from home."
The nurse responds, based on the understanding about which principle?
A mother can bring anything the pt desires
A breastfeeding primiparous client who gave birth 8 hours ago asks the nurse,
"How will I know that my baby is getting enough to eat?" Which guideline should
the nurse include in the teaching plan as evidence of adequate intake?
