FINAL EXAM (Nur 100)
1. The nurse has finished the receiving Answer: A. The patient with sclero-
shift report at 7:30am. Which patient derma who had an episode of dys-
should the nurse assess first? pnea during the night shift
A) The patient with scleroderma who
had an episode of dyspnea during the RATIONALE - The nurse must take
night shift. a systematic approach and decide
B) The patient diagonsed with OA who if any patient is experiencing a
complains of morning joint stiffness life-threatening or life-altering com-
C) The patient who needs to recive plication. Scleroderma can lead to
a scheduled 8am IV adrenal corticos- cardiopulmonary involvement and
teroid complications and an onset of dysp-
D) The pateint suspected of an acute nea is concerning. The nurse needs
gout attack who is scheduled for an to pay attention to pulmonary or car-
arthrocentesis diac symptoms. Morning joint stiff-
ness is an expected clinical mani-
festation. There is enough time to
assess the patient with scleroder-
ma before proceeding to the patient
scheduled for 8 am. medication or
arthrocentesis.
2. The nursing diagnosis identified for a Answer: C. Cold application to local-
patient with OA is acute pain. Which ized area for 30 minutes 4 to 5 times
action by the patient warrants inter- a day
vention by the visiting nurse?
A) Acetaminophen (Tylenol) taken PO Rationale - Cold application should
in doses no more than 3,000 mg/day be limited to no more than 20 min-
B) Capsaicin (Capsin) applied topical- utes. Other actions are appropriate
ly as needed 3 to 4 times a day and do not warrant the nurse to in-
C) Cold application to localized area tervene. Tylenol maximum dose is
for 30 minutes 4 to 5 times a day usually 1,000 mg every 6 hours with
D) Paraffin dips providing concentrat- a total of 4 mg in 24 hrs.. Capsaicin
ed heat applied to the wrist before to affected area provides temporary
bedtime pain relief, application no more than
4 times in 24 hours. Paraffin baths
are helpful to patients with wrist and
small-joint involvement.
3.
, FINAL EXAM (Nur 100)
When assessing a patient, the nurse Answer: D. Joint swelling, stiffness,
knows that which clinical manifesta- and pain
tions are shared by rheumatoid arthri-
tis and OA? Rationale - Joint swelling, stiff-
A) Joint space narrowing and a de- ness, and pain are manifestations
creased C4 level of rheumatoid arthritis (RA) and os-
B) Symmetrical knee involvement and teoarthritis (OA). Joint space nar-
joint effusions rowing is seen on x-ray in OA and
C) Tophi, joint enlargement, and se- RA, however, a decreased C4 level
vere pain is found only in RA, an autoimmune
D) Joint swelling, stiffness, and pain disorder. Osteoarthritis typically af-
fects joints asymmetrically, while RA
typically affects symmetrical joints
and more commonly results in ef-
fusions. Tophi are only found in pa-
tients with gout.
4. A patient with SLE is admitted to Answer: A. Elevated blood urea ni-
the hospital for evaluation and man- trogen (BUN)
agement of acute joint inflammation.
Which information obtained in the ad- RATIONALE - A patient with SLE is
mission laboratory testing results is at risk for developing nephropathy,
of most concern to the nurse? an elevation of blood urea nitrogen
A) Elevated blood urea nitrogen (BUN) warrants further diagnostic testing
B) Increased C-reactive protein of renal function. The other labora-
C) Positive ANA tory results are expected in patients
D) Positive RF with SLE.
5. Which statement indicates the patient Answer: C. "I need to follow a
requires further teaching regarding high-protein diet."
the nutritional management of gout?
A) "I need to limit my alcohol intake." RATIONALE - Many health care
B) "I need to avoid fad starvation di- providers believe that a person with
ets." gout needs to avoid trigger foods:
C) "I need to follow a high-protein foods high in protein such as red
diet." meat, lamb and pork; foods high
D) "I need to eliminate fructose in purines such as organ meats
drinks." and seafood especially shellfish;
limit alcohol such as beer and
, FINAL EXAM (Nur 100)
grain liquors; avoid starvation diets;
and avoid fructose drinks. Fructose
breaks down into purines in the
body that leads to uric acid forma-
tion and gout. It is also important to
drink plenty of fluids.
6. A 78-year-old woman is complaining Answer: A. Kyphosis
of neck and upper back pain. The
nurse's assessment reveals an abnor- Rationale - Kyphosis is an increased
mal convex curvature of the cervical forward curvature of the thoracic
and thoracic area. What is the termi- spine
nology for this finding?
A) Kyphosis
B) Lordosis
C) Kyphoscoliosis
D) Scoliosis
7. A 12-year-old girl complained to the Answer: D. Scoliosis
school nurse about back pain. The
nurse's assessment revealed a devi- Rationale - A lateral curvature of the
ation of the vertebrae to the right to spine
the right, with a raised shoulder and
hip. What is the terminology for this
finding?
A) Kyphosis
B) Lordosis
C) Osreoporosis
D) Scoliosis
8. A cast was applied to a patient's frac- Answer: A. Capillary refill of 5 sec-
tured leg 4 hours ago. Which finding is onds
associated with neurovascular com-
promise? Rationale - Capillary refill should be
A) Capillary refill of 5 seconds less than 2 seconds; a delay in cap-
B) Ability to move the toes without illary refill indicates impaired arterial
limitation perfusion.
C) Full sensation
D) Toes warm to touch
1. The nurse has finished the receiving Answer: A. The patient with sclero-
shift report at 7:30am. Which patient derma who had an episode of dys-
should the nurse assess first? pnea during the night shift
A) The patient with scleroderma who
had an episode of dyspnea during the RATIONALE - The nurse must take
night shift. a systematic approach and decide
B) The patient diagonsed with OA who if any patient is experiencing a
complains of morning joint stiffness life-threatening or life-altering com-
C) The patient who needs to recive plication. Scleroderma can lead to
a scheduled 8am IV adrenal corticos- cardiopulmonary involvement and
teroid complications and an onset of dysp-
D) The pateint suspected of an acute nea is concerning. The nurse needs
gout attack who is scheduled for an to pay attention to pulmonary or car-
arthrocentesis diac symptoms. Morning joint stiff-
ness is an expected clinical mani-
festation. There is enough time to
assess the patient with scleroder-
ma before proceeding to the patient
scheduled for 8 am. medication or
arthrocentesis.
2. The nursing diagnosis identified for a Answer: C. Cold application to local-
patient with OA is acute pain. Which ized area for 30 minutes 4 to 5 times
action by the patient warrants inter- a day
vention by the visiting nurse?
A) Acetaminophen (Tylenol) taken PO Rationale - Cold application should
in doses no more than 3,000 mg/day be limited to no more than 20 min-
B) Capsaicin (Capsin) applied topical- utes. Other actions are appropriate
ly as needed 3 to 4 times a day and do not warrant the nurse to in-
C) Cold application to localized area tervene. Tylenol maximum dose is
for 30 minutes 4 to 5 times a day usually 1,000 mg every 6 hours with
D) Paraffin dips providing concentrat- a total of 4 mg in 24 hrs.. Capsaicin
ed heat applied to the wrist before to affected area provides temporary
bedtime pain relief, application no more than
4 times in 24 hours. Paraffin baths
are helpful to patients with wrist and
small-joint involvement.
3.
, FINAL EXAM (Nur 100)
When assessing a patient, the nurse Answer: D. Joint swelling, stiffness,
knows that which clinical manifesta- and pain
tions are shared by rheumatoid arthri-
tis and OA? Rationale - Joint swelling, stiff-
A) Joint space narrowing and a de- ness, and pain are manifestations
creased C4 level of rheumatoid arthritis (RA) and os-
B) Symmetrical knee involvement and teoarthritis (OA). Joint space nar-
joint effusions rowing is seen on x-ray in OA and
C) Tophi, joint enlargement, and se- RA, however, a decreased C4 level
vere pain is found only in RA, an autoimmune
D) Joint swelling, stiffness, and pain disorder. Osteoarthritis typically af-
fects joints asymmetrically, while RA
typically affects symmetrical joints
and more commonly results in ef-
fusions. Tophi are only found in pa-
tients with gout.
4. A patient with SLE is admitted to Answer: A. Elevated blood urea ni-
the hospital for evaluation and man- trogen (BUN)
agement of acute joint inflammation.
Which information obtained in the ad- RATIONALE - A patient with SLE is
mission laboratory testing results is at risk for developing nephropathy,
of most concern to the nurse? an elevation of blood urea nitrogen
A) Elevated blood urea nitrogen (BUN) warrants further diagnostic testing
B) Increased C-reactive protein of renal function. The other labora-
C) Positive ANA tory results are expected in patients
D) Positive RF with SLE.
5. Which statement indicates the patient Answer: C. "I need to follow a
requires further teaching regarding high-protein diet."
the nutritional management of gout?
A) "I need to limit my alcohol intake." RATIONALE - Many health care
B) "I need to avoid fad starvation di- providers believe that a person with
ets." gout needs to avoid trigger foods:
C) "I need to follow a high-protein foods high in protein such as red
diet." meat, lamb and pork; foods high
D) "I need to eliminate fructose in purines such as organ meats
drinks." and seafood especially shellfish;
limit alcohol such as beer and
, FINAL EXAM (Nur 100)
grain liquors; avoid starvation diets;
and avoid fructose drinks. Fructose
breaks down into purines in the
body that leads to uric acid forma-
tion and gout. It is also important to
drink plenty of fluids.
6. A 78-year-old woman is complaining Answer: A. Kyphosis
of neck and upper back pain. The
nurse's assessment reveals an abnor- Rationale - Kyphosis is an increased
mal convex curvature of the cervical forward curvature of the thoracic
and thoracic area. What is the termi- spine
nology for this finding?
A) Kyphosis
B) Lordosis
C) Kyphoscoliosis
D) Scoliosis
7. A 12-year-old girl complained to the Answer: D. Scoliosis
school nurse about back pain. The
nurse's assessment revealed a devi- Rationale - A lateral curvature of the
ation of the vertebrae to the right to spine
the right, with a raised shoulder and
hip. What is the terminology for this
finding?
A) Kyphosis
B) Lordosis
C) Osreoporosis
D) Scoliosis
8. A cast was applied to a patient's frac- Answer: A. Capillary refill of 5 sec-
tured leg 4 hours ago. Which finding is onds
associated with neurovascular com-
promise? Rationale - Capillary refill should be
A) Capillary refill of 5 seconds less than 2 seconds; a delay in cap-
B) Ability to move the toes without illary refill indicates impaired arterial
limitation perfusion.
C) Full sensation
D) Toes warm to touch
