BIOLOGY 102Medical-Surgical Nursing Critical Thinking in Client Care, CHAPTER 40-45

Medical-Surgical Nursing Critical Thinking in Client Care, 4th Edition Priscilla LeMon

CHAPTER   40-45

Chapter 40

1. A school nurse is reviewing properties of skeletal muscle cells with a sports team. Which comment made by a student indicates that further teaching is necessary?

1. “Excitability refers to the ability to receive and respond to a stimulus.”

2. “Contractibility is a response to a stimulus by forcibly lengthening a muscle.”

3. “Extensibility is a response to a stimulus by extending and relaxing a muscle.”

4. “Elasticity is the ability to resume resting length after shortening a muscle.”

2. Choose the normal movements allowed by synovial joints: (Select all that apply.)

1. Abduction

2. Extension

3. Pronation

4. Inversion

5. Protraction

6. Articulation

3. What would the nurse ask a client during a functional health pattern interview to elicit data pertaining to health perception/health management of the musculoskeletal system?

1. “How has having this condition affected your relationship with others?”

2. “Describe your usual activities for a 24-hour period.”

3. “Has having this condition created stress for you?”

4. “Do you take any herbal supplements for musculoskeletal problems?”

4. In what area of the physical assessment would the nurse expect to find crepitation when examining the musculoskeletal system?

1. Body posture assessment

2. Range-of-motion assessment

3. Joint assessment

4. Gait assessment

5. When assessing the fingers during a musculoskeletal examination, the nurse notes swollen fingers with a white chalky discharge, and documents this as:

1. Osteoporosis.

2. Chronic gout.

3. Carpal tunnel syndrome.

4. Rheumatoid arthritis.

6. The nurse teaching a class on the musculoskeletal system would emphasize that compact bone is stronger than spongy bone due its greater:

1. Density.

2. Size.

3. Volume.

4. Weight.

NCLEX: Health Promotion and Maintenance

7. Of the following clients scheduled for an MRI, for which would the nurse have no cause for concern related to safety during the test?

1. A client with a pacemaker for three years

2. A client with shrapnel from a military assault

3. A client with an open abdominal wound

4. A client with external hardware following a fracture repair

8. The nurse is aware of musculoskeletal changes associated with aging such as:

(Select all that apply.)

1. Decreased bone mass and minerals.

2. Increased calcium reabsorption.

3. Muscle fibers atrophy.

4. Vertebrae elongate.

5. Decreased range of motion.

6. Development of bone spurs.

9. A health-conscious young adult female asks the nurse what diagnostic test might help predict the likelihood for developing osteoporosis. The nurse recommends:

1. Arthroscopy.

2. An electromyogram (EMG).

3. Somatosensory evoked potential (SSEP).

4. Dual energy x-ray absorptiometry (DEXA).

10. The nurse would document “unable to assess” for which of the following clients in relation to performing Phalen’s test?

1. A client with a long leg cast

2. A client with an above-the-elbow amputation

3. A client wearing compression stockings

4. A client with osteoarthritis of the hips

Chapter 41

1. An Emergency Department nurse has provided discharge teaching for home care to a young adult male experiencing a sprain from playing softball. Based of the following statements, which indicates further teaching is necessary?

1. “I should put a heating pad on my leg as soon as I get home.”

2. “I should avoid weight bearing on this leg for a couple days.”

3. “I should make sure to keep the ace bandage on my leg.”

4. “I should prop this leg up when I’m sitting in a chair.”

2. Put the following stages of bone healing in the correct sequence in which they occur.

1. Fibrocartilaginous callus formation

2. Bone injury

3. Bone remodeling

4. Bony callus formation

3. The nurse is concerned about the possibility of compartment syndrome for a client wearing a long leg cast. In preparation for the physician to perform the necessary treatment, the nurse would gather what supplies or equipment?

1. Extra pillows, to elevate the casted extremity above the heart

2. A Doppler, to aid in assessing the strength of peripheral pulses

3. Ace bandages, to wrap around the bi-valved cast

4. A percussion hammer, to physically assess reflexes for damage

Nursing Process: Planning

NCLEX: Physiologic Integrity: Reduction of Risk Potential

4. An elderly woman was admitted to the orthopedic unit following a fall that resulted in a fractured left hip, and is placed in Buck’s traction. Which of the following is an appropriate nursing action?

1. Providing pin site care every shift as ordered by the MD

2. Placing an abduction pillow between her legs for alignment

3. Having another person hold the weights when pulling her up in bed

4. Turning her to the unaffected side every two hours

5. Choose the position the nurse should promote the first several days postoperatively for the client with an above-the-knee amputation.

1. Sims’ position as tolerated

2. Prone for one hour, several times a day

3. High Fowler’s position

4. Sitting in a chair while awake

6. The nurse is aware that which of the following occupations could put a client at risk for carpal tunnel syndrome? Select all that apply.

1. Farmer

2. Police officer

3. Barber

4. Computer technician

5. Carpet installer

6. Baker

7. A patient with a compound fracture has been admitted to the E.D., and is scheduled for immediate surgery. Which of the following nursing diagnoses would be most appropriate in the immediate postoperative period?

1. Transfer Ability, Impaired

2. Post-Trauma Syndrome, Risk for

3. Infection, Risk for

4. Falls, Risk for

8. The nurse should observe for signs that indicate compromised circulation in a client with a long leg cast, including:

1. Swelling of the toes.

2. Drainage on the cast.

3. Increased temperature.

4. Foul odor detected.

9. The nurse recognizes that the contractures that develop most frequently after fracture of the hip are:

1. Internal rotation with abduction.

2. External rotation with abduction.

3. Flexion and adduction of the hip with flexion of the knee.

4. Hyperextension of the knee joint with foot drop deformity.

Nursing Process: Evaluation

NCLEX: Physiological Integrity: Reduction of Risk Potential

10. The nurse cannot palpate a client’s pedal pulse following an ORIF procedure for a fractured tibia. Which action is the priority?

1. Notify the surgeon of the problem.

2. Check the lower extremity for pallor.

3. Use a Doppler to find the pedal pulse.

4. Assess the client’s pain rating.

CHAPTER 42

1. A 30-year-old female client reporting to the clinic for a sport physical is told by the physician she is demonstrating signs consistent with the early onset of osteoporosis. The client asks how she could be at risk for this disease, since she is so active. Which of the following responses by the nurse is most correct?

a. “You might have placed underlying stress on your skeleton from your frequent exercise.”

b. “You are at an age when your estrogen levels have begun to decline drastically, thus increasing your risk for the development of osteoporosis.”

c. “Do your bones feel weak?”

d. “Your dietary practices might be partially responsible.”

2. The client diagnosed with osteoporosis has been prescribed calcitonin. The client reports experiencing nausea and vomiting. What initial action is indicated by the nurse?

a. Hold the prescribed dosage.

b. Call the physician.

c. Monitor and record the frequency and amount of emesis.

d. Increase the amount of vitamin D in the diet.

3. Sodium fluoride rinse has been prescribed to the client. When preparing to administer the medication, what nursing implications will need to be implemented? Select all that apply.

a. Administer the medication immediately upon arising.

b. Administer the medication with milk.

c. Administer the medication after meals.

d. Monitor fluoride levels annually.

e. Avoid intake for 30 minutes after use.

4. A 88-year-old female client having a history of osteoporosis has been admitted to the long-term care facility. She has a history of falls and dementia. Which of the following interventions will best aid in the prevention of injuries?

a. The use of wrist restraints

b. Using furniture as obstacles to keep the client in the bed

c. Keeping the bed in a low position

d. Keeping a nightlight on in the room

5. The client with gout reports the presence of small “lumps” on his ear and big toe. After being advised the lumps are accumulations of uric acid, the client becomes worried these deposits can become lodged in his blood, resulting in a blood clot. Which of the following explanations by the nurse will be most accurate?

a. “These will not become problematic if you remain on the prescribed medications.”

b. “Unfortunately, this is a common complication associated with gout.”

c. “You will need to talk with the physician during your next visit.”

d. “These accumulations are more common in areas of the body having lower temperatures, and are not in danger of causing clot development.”

COGNITIVE LEVEL: Analysis

6. When providing care to the client with an exacerbation of gout, resulting in foot pain, which of the following interventions will aid in promoting comfort?

a. Wrap the extremity in an ace bandage.

b. Encourage liberal fluid intake.

c. Provide range-of-motion exercises to the involved area to promote flexibility.

d. Elevate the extremity using a cradle.

7. The client with osteoarthritis reports achieving pain relief when using an over-the-counter ointment on the affected areas. When assessing the client’s knowledge of safe administration practices, which of the following principles should the nurse plan to include in the teaching?

a. Apply heat to the affected area after applying ointment.

b. Use caution when using a heating pad and ointment together.

c. Limit the use of ointment to 3–4 times per day.

d. Initial skin irritation is common, and will subside within a few weeks of initiating treatment.

 8. A client is scheduled to undergo a hip replacement to manage osteoarthritis. A review of the client’s history reflects overall health. When providing education concerning the procedure, the client asks if she should be concerned about complications. What information should be included concerning the occurrence of complications?

a. “Complications are variable.”

b. “You may ask your physician about complications before the procedure is initiated.”

c. “You are healthy, and should have an uneventful recovery.”

d. “Complications can happen with any surgical procedure, and we will discuss their potential.”

9. The day after surgery to replace a hip joint, the client states he is not ready to ambulate, and will consider it tomorrow. Which of the following actions by the nurse is indicated first?

a. Ask the client why he is resistant to ambulating at this time.

b. Contact the physician.

c. Call nursing assistants to assist with ambulation anyway.

d. Document the client’s refusal.

10. A client with a history of osteoarthritis reports discomfort unrelieved by the medications. Which of the following nonpharmacological interventions might assist the client in managing the discomfort? Select all that apply.

a. Suggest the use of ice to the painful joints.

b. Encourage rest of the painful joints.

c. Discuss the use of relaxation techniques.

d. Encourage distraction techniques.

e. Advise the client to perform range-of-motion exercises to reduce the cramping sensation.

Chapter 43

1. A nurse working in a long-term care facility cares for a client with Parkinson’s disease. When giving L-dopa, which of the following statements made to the client’s family shows the nurse’s understanding of the client’s medication?

a)      “This medicine increases the ability to have clearer thoughts.”

b)      “We need to give this medicine to help movement become smoother.”

c)       “We need to make sure that there are no seizures.”

d)      “This pill will help with pain control.”

1. A client’s family asks the nurse “What does damage to Broca’s area mean?” just after the physician leaves the client’s room. The best response by the nurse is:

a)      “The way you communicate will have to change.”

b)      “You’ll have to speak very loudly when you talk.”

c)       “Make sure there are no obstacles in the room, because sight will be a problem.”

d)      “Perhaps you would like to learn how to provide range-of-motion exercises.”

1. A parasympathetic response that the nurse can assess would include: (Select all that apply.)

1. Decrease in heart rate.

2. Increase in heart rate.

3. Dilation of coronary vessels.

4. Hyperactive bowel sounds.

5. Hypoactive bowel sounds.

1. When taking a health history of an elderly client, which statement by the nurse would best focus on function of the central nervous system?

a) “Do you get dizzy when moving from a sitting to standing position?”

b) “Do you have difficulty adjusting to a change in temperature?”

c) “Can you describe your sleep pattern?”

d) “Have you had any weight loss?”

1. A client states that he has been hearing noises. The nurse should:

a)      Make sure the client is referred to a psychiatrist.

b)      Document that the client has a mental illness.

c)       Ask the client if he has any visual disturbances.

d)      Explain to the client that this is not unusual.

1. An ED nurse receives a report that an incoming client has a Glascow Coma Scale (GCS) score of 8. The nurse should be prepared to:

a)      Treat the client’s pain.

b)      Assess airway, breathing, and circulation.

c)       Get a complete history from the client.

d)      Triage with the other ED clients.

1. In reviewing a client’s chart, the nurse notices that the client has had damage to the trigeminal nerve (CN V). Before bringing in the meal tray, the nurse should:

a)      Tell the client what food is on the tray.

b)      Assess the client’s ability to swallow.

c)       Make sure to speak loudly and with eye contact.

d)      Assist the client in identifying where items are on the tray.

1. The nurse tells the client “Stick out your tongue” and notices the client’s tongue deviates to the right side. How should the nurse document the findings?

a)      Abnormal hypoglossal nerve response

b)      Findings consistent with first cranial nerve damage

c)       Sluggish oculomotor response

d)      Absent Homans’ sign

1. The nurse asks the client to stand with his feet together and eyes closed. The client sways, and the nurse reaches to steady the client to prevent a fall. The nurse documents this as:

a)      A normal finding.

b)      Abnormal graphesthesia.

c)       Positive Romberg’s test.

d)      Clonus.

1.  A client has dysphagia. The nurse should:

a)      Bring a paper and pencil into the room for communication.

b)      Turn the radio off when speaking to the client.

c)       Provide foods that are easy to swallow.

d)      Bring the client a walker.

Chapter 44

1. The priority nursing intervention for the client with increasing ICP (intracranial pressure) is:

                a) Controlling pain.

                b) Monitoring for nausea and vomiting.

                c) Ensuring adequate oxygenation.

                d) Maintaining a calm environment.

2. A client with increased intracranial pressure is being repositioned. Of the following, which are appropriate? Select all that apply.

1.        Clients with ICP should remain in a stationary position.

2.        Slow, gentle movements with repositioning

3.        The client should be returned to supine position.

4.        Repositioning every hour

5.        Head of bed elevated

Learning Outcome 1

3. The client has a history of headaches. In order to differentiate between tension-type headaches and migraines, the nurse should ask which of the following?

                a) “Do you feel cold or hot before your headache?”

                b) “Do your headaches occur for weeks or months at a time?”

                c) “Which treatments seem to help your headaches when they do occur?”

                d) “Do you take a lot of ibuprofen?”

4. A child presents to the unit with a history of petit mal seizures. After one such episode, the nurse correctly documents which of the following? “The client:

a)      “Became unconscious, and all four extremities were jerking uncontrollably for two minutes.”

                b) “Was sitting very still, and stared off into space for a period of two minutes.”

c) “Repeatedly moved from the chair to the bed while touching her arms for a length of two minutes.”

d) “Pulled her arms in toward her body and flexed her hands over her chest. This lasted two minutes.”

5. A football player is discharged from the Emergency Department after being diagnosed with a closed head injury. Client teaching regarding complications should include monitoring for:

                a) Stiff neck after several weeks.

                b) Leakage of CSF immediately after discharge.

                c) Changes in mental status for 2 to 3 days after the injury.

                d) Increase in anxiety or difficulty sleeping.

6. A client has been diagnosed with a malignant brain tumor. When asked about metastasis, the best response by the nurse is:

                a) “You should ask your physician about this.”

                b) “Brain tumors usually stay in the central nervous system.”

                c) “The most likely organs will be the liver and GI system.”

                d) “You need to think positively about your future.”

7. A client is being monitored for increased ICP. Using the Monro-Kellie hypothesis as a basis for explanation, the nurse makes which comment to the client’s family?

                a) “The pressure in the brain is increasing because the brain is swelling.”

                b) “Increasing brain pressure decreases the amount of blood flow to the brain itself.”

                c) “Because there is more pressure in the brain, the blood flow is also increasing.”

                d) “There is nothing that can be done.”

8. A client with ICP is going to be evaluated by a neurosurgeon. The nurse identifies which of the following as priority results to be present on the chart for review? Select all that apply.

1.        MRI result

2.       Complete blood count of the cerebrospinal fluid

3.        Arterial blood gases

4.        Bronchoscopy results

5.        Serum osmolality

9. A client with altered consciousness is brought to the Emergency Department. The client is lethargic, and has decreased respirations and slow motor movements. Upon physical examination, the nurse finds several narcotic analgesic patches on the client’s torso. The next intervention would include:

a). Infusion of a hypotonic IV solution.

b) Administration of naloxone.

c) Removal of the patches.

d) ICP monitoring.

1. A client with a brain abscess is admitted for acute care. Along with an antibiotic, the nurse can expect to administer which of the following?

a)      Morphine

b)      Decadron

c)       Valium

d)      Ativan

Chapter 45

1. A client was diagnosed with a left cerebral hemorrhage. To meet the needs of the client and family, the nurse will include teaching in the following areas: (Select all that apply.)

                1. How to use a sign board

                2. Transfer techniques

                3. Information about impulse control

                4. Time adjustment to complete activities

Implementation

Physiological Integrity

Application

Learning Outcome 2

2. A client has the nursing diagnosis: Swallowing, Impaired, and complains of frequent heartburn. The nurse should:

a). Assist the client in maintaining a sitting position for 30 minutes after the meal.

b). Teach the client the “chin tuck” technique when swallowing.

c). Check the client’s mouth for pocketing of food.

d). Assist the client to a 90-degree sitting position, or as high as tolerated, during meals.

3. A nurse is teaching a wellness class, and is covering the warning signs of stroke. A client asks “What’s the most important thing for me to remember?” The nurse states:

                a) “Know your family history.”

                b) “Keep a list of your medications.”

                c) “Be alert for sudden weakness or numbness.”

                d) “Call 911 if you notice a gradual onset of paralysis or confusion.”

Learning Outcome 1

45-4.         A client with a spinal cord injury at the T1 level complains of a severe headache and an “anxious feeling.” The nurse initially should:

a)      Try to calm the client and make the environment soothing.

b)      Assess for a full bladder.

c)       Notify the physician.

d)      Prepare the client for diagnostic radiography.

45-5.         A client hospitalized with a known AV malformation begins to complain of a headache, and becomes disorientated. The nurse should:

a)      Recommend to the family that they start to look for a long-term care facility.

b)      Prepare to give aspirin or a “clot buster.”

c)       Ready the client for surgery.

d)      Document the changes and monitor closely.

45-6.         A nurse at a family gathering witnesses an adult relative drop her plate, become disoriented, and have noticeable changes in her speech. Nursing actions include the following. Organize them in order of priority, starting with the top priority.

1.       Call 911.

2.       Call ahead to the hospital.

3.       Assist the client to a safe position.

4.       Comfort the client’s spouse.

5.       Assess the client’s respiratory effort.

45-7.         A school nurse is called after a student falls down a flight of stairs. The student is breathing, but unconsciousness. After the ambulance is called, the nurse should:

a)      Protect the client’s neck and head from any movement.

b)      Place the client on his side to prevent aspiration.

c)       Open the airway using the head tilt maneuver.

d)      Try to rouse the client by gently shaking his shoulders.

46-8. A hospitalized client with a C7 cord injury begins to yell “I can’t feel my legs anymore.” The nurse should:

                a) Remind the client of her injury and try to comfort her.

                b) Call the physician and get an order for radiologic evaluation.

                c) Prepare the client for surgery, as her condition is worsening.

                d) Explain to the client that this could be a common, temporary problem.

Application

Learning Outcome 4

45-9.         A post-stroke client is going home on oral Coumadin (warfarin). During discharge teaching, which statement by the client would reflect an understanding of the effects of this medication?

a)      “I will stop taking this medicine if I notice any bruising.”

b)      “I will not eat spinach while I’m taking this medicine.”

c)       “It will be OK for me to eat anything, as long as it is low-fat.”

d)      “I’ll check my blood pressure frequently while taking this medication.”

45-10.      A client with a spinal cord injury was given IV Decadron (dexamethasone) after arriving in the Emergency Department. The client also has a history of hypoglycemia. During the hospital stay, the nurse would expect to see:

a)      Increased episodes of hypoglycemia.

b)      Possible episodes of hyperglycemia.

c)       No change in the client’s glycemic parameters.

d)      Both hyper- and hypoglycemic episodes.