N4010 Exam 1 | Questions and Answers (Complete Solutions)

N4010 Exam 1 | Questions and Answers (Complete Solutions) A nurse in a long-term care facility is caring for an older adult client who had a stroke 4 weeks ago and who is unable to move independently. The nurse should monitor for which of the following complications of immobility? A. A reddened area over the sacrum B. Stiffness in the lower extremities C. Difficulty moving the upper extremities D. Difficulty hearing some types of sounds A nurse is assessing a client who has carpal tunnel syndrome. The nurse should expect which of the following findings? A. Decreased radial pulse B. Positive Chvostek's sign C. Cool extremities D. Positive Phalen's sign A nurse is caring for a client who is postoperative following knee arthroplasty and has a continuous passive motion (CPM) machine. Which of the following actions should the nurse take? A. Store the CPM machine on the floor when not in use. B. Use a special pillow to rotate the affected knee internally. C. Set the CPM to fully flex the knee joint. D. Apply ice to the operative knee. A nurse is conducting a primary survey of a client who has sustained life-threatening injuries due to a motor-vehicle crash. Identify the sequence of actions the nurse should take. A. Perform a Glasgow Coma Scale assessment. B. Establish IV access. C. Open the airway using a jaw-thrust maneuver. D. Determine effectiveness of ventilator efforts. E. Remove clothing for a thorough assessment. C, D, B, A, E A nurse in the emergency department is monitoring a client who has a cervical spinal cord injury from a fall. The nurse should monitor the client for which of the following complications? (Select all that apply.) A. Hypotension B. Polyuria C. Hyperthermia D. Absence of bowel sounds E. Weakened gag reflex A nurse is teaching a client about risk factors for osteoarthritis. Which of the following factors should the nurse include in the teaching? (Select all that apply.) A. Bacteria B. Diuretics C. Aging D. Obesity E. Smoking A nurse caring for a client who had a right-sided stroke and is exhibiting homonymous hemianopsia when eating. Which of the following actions should the nurse take? A. Provide a nonskid mat to alleviate plate movement. B. Encourage the client to use his right hand when feeding himself. C. Remind the client to look for food on the left side of the tray. D. Encourage the use of the wide grip utensils. A rehabilitation nurse is caring for a client who has had a spinal cord injury that resulted in paraplegia. After a week on the unit, the nurse notes that the client is withdrawn and increasingly resistant to rehabilitative efforts by the staff. Which of the following actions should the nurse take? A. Inform the client that privileges are related to participation in therapy. B. Limit visiting hours until the client begins to participate in therapy. C. Allow the client to control the timing and frequency of the therapy. D. Establish a plan of care with the client that sets attainable goals. A nurse is providing nutritional teaching to a client who has osteoporosis. Which of the following foods should the nurse recommend as being the highest in calcium? A. 1 cup carrot strips B. 3 oz canned salmon C. 1 cup chopped chicken breast D. 1 plain baked potato A nurse is caring for a client who has had a stroke involving the right hemisphere. Which of the following alterations in function should the nurse expect? A. Difficulty reading B. Inability to recognize his family members C. Right hemiparesis D. Aphasia A nurse is teaching a client about the causes of osteoporosis. The nurse should include which of the following types of medication therapy as a risk factor for osteoporosis? A. Anticoagulants B. NSAIDs C. Cardiac glycosides D. Thyroid hormones A nurse is educating coworkers about how to minimize back strain and avoid repeated episodes of low back pain. Which of the following strategies should the nurse include? (Select all that apply.) A. Avoid prolonged sitting. B. Apply heat for 10 min every hour. C. Sleep in a side-lying position with flexed knees. D. Sleep on a soft mattress. E. Try padded shoe insoles. A nurse is teaching a client about risk factors for osteoporosis. Which of the following factors should the nurse include in the teaching? (Select all that apply.) A. Sedentary lifestyle B. Obesity C. Aging D. Caffeine intake E. Secondhand smoke A nurse is developing a plan of care to prevent skin breakdown for a client with a spinal cord injury and paralysis. Which of the following nursing actions are appropriate? (Select all that apply.) A. Massage over erythematous bony prominences. B. Implement turning schedule every 4 hr. C. Use pillows to keep heels off the bed surface. D. Keep the client's skin dry with powder. E. Minimize skin exposure to moisture. A nurse is assessing a client who reports numbness and pain in his right palm, index finger, and middle finger. The client reports working with a keyboard most of the time while at work. The nurse suspects carpal tunnel syndrome. Which of the following tests should the nurse request that the client perform? A. Hold the right arm straight. B. Hold the wrist at a 90-degree flexion. C. Flex the right arm at the elbow. D. Extend the right arm upward. A nurse is caring for a client who has right-sided acoustic neuroma resulting in impairment of cranial nerves IX and X. Which of the following actions should the nurse take? A. Place suction equipment at the client's bedside. B. Apply an eye patch to the client's right eye. C. Avoid the use of warm water to wash the client's face. D. Provide range-of-motion exercises to the client's neck and shoulders. A nurse is teaching an older adult client who has osteoporosis about beginning a program of regular physical activity. Which of the following recommendations should the nurse make? A. High-impact aerobics B. Walking briskly C. Riding a bicycle D. Stretching exercises A nurse is providing teaching to the family of a client who has Parkinson's disease. Which of the following information should the nurse include in the teaching? A. Provide client supervision. B. Limit client physical activity. C. Speak loudly to the client. D. Leave the television on continuously. A nurse is providing care for four clients on a medical-surgical unit. Which of the following clients should the nurse identify as being at risk for the development of pressure ulcers? (Select all that apply.) A. A client who is ambulatory following a cardiac catheterization 4 hr ago B. A client who has type 1 diabetes mellitus and is hyperglycemic C. A client who has protein calorie malnutrition D. A client who has right-sided heart failure and 4+ edema to the lower extremities E. A client who has postoperative delirium A nurse is caring for a client who has Parkinson's disease and is taking diphenhydramine 25 mg PO TID. Which of the following therapeutic outcomes should the nurse expect to see? A. Delay in disease progression B. Improved bladder function C. Relief of depression D. Decreased tremors A nurse is teaching a client who has a prosthetic limb due to a right below-the-knee amputation about prosthesis and stump care. Which of the following instructions should the nurse include in the teaching? A. Keep the prosthesis in direct contact with the residual limb. B. Apply a moisturizing lotion or oil to the stump daily. C. Dry the prosthesis socket completely before applying it to the limb. D. Expect some skin irritation from the prosthesis. A nurse is planning care for a female client who has a T4 spinal cord injury and is at risk for acquiring urinary tract infections. Which of the following actions should the nurse include in the client's plan of care? A. Cleanse the perineum from back to front. B. Obtain a prescription for an indwelling urinary catheter. C. Encourage fluid intake at and between meals. D. Offer the client the bedpan every 2 hours. A nurse is caring for a client who has paraplegia following an automobile accident. The client is on an intermittent urinary catheterization program. Which of the following findings indicates the need for catheterization? A. Urge incontinence B. Dribbling of urine C. Weight gain D. Rectal distention A nurse in a provider's office is assessing a client who reports shoulder pain. Which of the following findings by the nurse indicates rotator cuff injury? A. Alteration in the contour of the joint B. Inability to abduct the arm at the shoulder C. Negative drop arm test D. A positive Tinel's sign A nurse is teaching a client who is starting to take alendronate effervescent tablets to treat osteoporosis. Which of the following information should the nurse include? A. "Sit upright or stand for at least 30 minutes after taking this medication." B. "Take this medication with food." C. "Take this medication with orange juice." D. "Chew or suck on the tablet." A nurse caring for a client who is scheduled for an arthroplasty. The nurse asks client to state if he understands the procedure that is being performed. Which of the following statements by the client indicates an understanding of the procedure? A. "This procedure determines the extent of joint damage." B. "This procedure will fuse my joint to reduce my pain." C. "This procedure will prevent further joint damage." D. "This procedure will replace my joint to improve function." A nurse is caring for an older adult client who has dementia and handles anxiety by confabulating. The nurse should recognize confabulation when the client. A. displays compulsive and ritualistic behaviors. B. reminisces about the past. C. makes up stories when he is unable to remember actual events. D. refuses to leave home to see a provider. A nurse is teaching a client about medications that prevent osteoporosis. The nurse should instruct the client that which of the following medications is prescribed to prevent osteoporosis? A. Levothyroxine B. Calcitonin C. Raloxifene D. Allopurinol A nurse is teaching a client at high risk for osteoporosis about dietary measures she can take to increase her calcium level. Which of the following foods should the nurse advise the client to increase in her diet? A. Carrots B. Broccoli C. Cabbage D. Potatoes A nurse is preparing to administer PO medication to a client who has myasthenia gravis. Which of the following actions should the nurse take prior to administering the client medication? A. Have the client empty his bladder. B. Put up the side rails on the client's bed. C. Ask the client to take a few sips of water. D. Place the client in a low Fowler's position A nurse is teaching a client who will receive a prosthetic leg. Which of the following statements should the nurse identify as an indication that the client needs further instruction? A. "I will need to war a sock over the residual portion of the leg." B. "The technician will complete the prosthesis fitting at the time the surgeon removes the staples." C. "I'll need to wear a sturdy pair of shoes for the prosthesis fitting." D. "I can apply elastic bandages to help shrink my residual leg." A nurse is modifying the diet of a client who has Parkinson's disease and is prescribed selegiline, an MAOI. Which of the following foods should the nurse eliminate? A. Fresh fish B. Cheddar cheese C. Cherries D. Chicken A nurse is assessing a client who has a herniated cervical intervertebral disc. Which of the following findings should the nurse expect? (Select all that apply.) A. Tingling in the arms B. Low-back pain C. Shoulder pain D. Muscle spasms E. Stiff neck A nurse is assessing a client who has a spinal cord injury. Which of the following actions should the nurse take to monitor C4 function? A. Apply downward pressure while the client shrugs his shoulders upward. B. Apply resistance while the client lifts his legs from the bed. C. Ask the client to grasp an object and form a fist. D. Apply resistance while the client flexes his arms. A nurse is teaching a client who is taking benzotropine to treat Parkinson's disease. The nurse should instruct the patient to report which of the following adverse effects? A. Excess salivation B. Difficulty voiding C. Diarrhea D. Slow pulse A nurse is developing a plan of care for a client who has a spinal fracture and complete spinal cord transection at the level of C5. Which of the following rehabilitation goals should the nurse add to the client's plan of care? A. Ability to achieve independent transfer from bed to wheelchair. B. Independent control of bowel and bladder function. C. Use of a wheelchair with a chin or mouth stick. D. Ability to self-feed with the use of adaptive equipment A nurse is teaching a client about preventing osteoporosis. Which of the following statements by the client indicates a need for further teaching? A. "I will reduce my intake of sodium." B. "I will decrease my intake of caffeine." C. "I will limit my intake of soft drinks." D. "I will reduce my intake of vitamin K-rich foods." A nurse is caring for a client who is taking aspirin for arthritis. The nurse should identify which of the following findings as an adverse effect of this medication? A. Tinnitus B. Clay colored stools C. Nystagmus D. Respiratory depression A nurse in a provider's office is providing teaching to a client about modifiable risk factors for osteoporosis. Which of the following factors should the nurse include? (Select all that apply.) A. Sedentary lifestyle B. Obesity C. Carbonated beverages D. Caffeine intake E. Smoking tobacco products A nurse is assessing a client who has Paget's disease of the bone. Which of the following findings should the nurse expect? (Select all that apply.) A. Cranial enlargement B. Skeletal pain C. Waddling gait D. Cold extremities E. Vision deficits A nurse is assessing a client who has Parkinson's disease. Which of the following manifestations should the nurse expect? A. Pruritus B. Hypertension C. Bradykinesia D. Xerostomia