Karteikarten
Lifespan 3 excelsior
Karten in diesem Stapel (80)
- 1Which is a clinical manifestation of rubella in the prodromal stage?Mild conjunctivitis is present in the prodromal stage of German measles (rubella).
- 2A person who works at which occupation is at increased risk of acquiring hepatitis C?A phlebotomist is at greatest risk because hepatitis C is transmitted through infected blood.
- 3Which method most reliably indicates that a patient has active pulmonary tuberculosis?Sputum culture is the most reliable method to diagnose tuberculosis, since the bacteria are most easily transmitted via airborne vectors such as coughing, sneezing, and expectorating sputum.
- 4The nurse assesses a patient who has been admitted to the hospital with pyelonephritis. Which nursing diagnosis should receive initial priority?altered comfort related to inflammatory process
Rationale for Choice 1: According to Maslow's hierarchy of needs, providing comfort is a basic physical need that follows the needs of maintaining an airway, breathing, and circulation. - 5Which diagnostic test confirms lung consolidation in a patient with pneumonia?chest X ray
Rationale Chest X ray is the least invasive diagnostic procedure and is used to reveal an extensive pathological process in the lungs in the absence of symptoms. It is frequently used to diagnose lung consolidation in patients with pneumonia. - 6Which health problem may occur if streptococcal pharyngitis remains untreated?glomerulonephritis
Streptococcal pharyngitis is not a serious disease, but the risk for serious sequelae such as acute glomerulonephritis may occur. - 7Why is a one-year-old infant with an upper respiratory infection likely to develop diarrhea?An infant's response to infection tends to be generalized. Infants and young children, especially those between six months and three years old, react more severely than older children to acute respiratory tract infection. Younger children display a number of generalized signs and symptoms such as vomiting, diarrhea, and abdominal pain.
- 8Why are antidiarrheal agents contraindicated for patients with salmonellosis?These drugs can potentially extend the period of infection.
Rationale: The primary action of antidiarrheal drugs is to inhibit peristalsis and prolong transit time through the intestines. In salmonellosis, it is important for the body to rid itself of the infectious toxins as soon as possible. Antidiarrheal drugs will only slow this process down. - 9Which instruction should be included in the discharge plan for patients infected with the herpes simplex virus?Avoid situations that might result in stress. The virus lives in nerve ganglia and may cause recurrent lesions in response to injury or stress.
- 10Which drug decreases pain in patients with urinary tract infections (UTIs) by acting as a topical anesthetic?phenazopyridine hydrochloride (Pyridium)
is a urinary analgesic that exerts a local anesthetic action on the urinary mucosa. - 11What situation places a person at greatest risk for an infection transmitted by the fecal-oral route?eating shrimp salad at a picnic can put a person at great risk for an infection via the fecal-oral route, especially if it is not known how the salad was prepared, who prepared it, and whether safe, effective handwashing was used prior to the preparation.
- 12Why is it important to administer an antibiotic, such as penicillin, at equal time intervals?to maintain constant serum levels.
Antibiotics are most effective when given at equal time intervals so a constant serum level can be maintained. - 13Which clinical manifestation is most indicative of a urinary tract infection (UTI)?frequency.
Frequency is a common clinical manifestation most indicative of a urinary tract infection (UTI). - 14What is the etiology of rheumatic heart disease?Group A streptococci affect the heart. the most significant complication of rheumatic fever, is thought to occur as a result of a previous upper respiratory tract infection with group A streptococci.
- 15Zoster immune globulin is used as prophylaxis against which communicable disease?varicella.
Varicella vaccine, also known as zoster immune globulin, is recommended at or after age 12 months for susceptible children to prevent varicella. - 16What evidence indicates that trimethoprim and sulfamethoxazole (Bactrim) has been effective in the treatment of a patient with a urinary tract infection (UTI)?The urine bacterial colony count is <100,000/mL
is normal and is the goal of antibiotic therapy in the treatment of a UTI. - 17Opportunistic infection, such as oral candidiasis, is a common problem associated with which infectious disease?acquired immunodeficiency syndrome.
Oral candidiasis is a fungal infection that occurs in nearly all patients with AIDS. - 18The nurse instructs a father regarding care of his six-month-old infant who has viral nasopharyngitis. Which statement by the father indicates the need for further instruction?"I'm going to ask the doctor to prescribe an antibiotic to help my baby get well."
Antibiotics are not effective in treating viral infections. The father needs further instruction. - 19A child has a family history of convulsions. Which medication should be administered along with the diphtheria and tetanus toxoid, pertussis (DTP) immunization?acetaminophen.
The most common side effect experienced by children receiving DTaP immunization is low grade fever. Acetaminophen is the safest medication to treat fever and prevent it from causing convulsions. - 20Which data should the nurse expect to find when assessing a female patient who is in the primary stage of syphilis?a painless chancre on the genitalia
The primary stage of syphilis is characterized by the appearance of a chancre on the genitalia. Little or no pain accompanies this warning sign. - 21Which data should the nurse expect to find when assessing a female patient who is in the secondary stage of syphilis?aching joints and muscles
Bone and joint aches as well as myalgia are present during the secondary stage of syphilis. - 22A fiery red throat is a common sign of which problem?acute pharyngitis.
Signs of acute pharyngitis include a fiery red throat, enlarged, tender cervical lymph nodes, fever, and malaise. - 23Which disease should the nurse suspect when a child exhibits a white tongue with red papillae and a diffuse red rash under the folds of the joints?scarlet fever
In scarlet fever, most of the symptoms occur in the mouth and pharynx, beginning with enlarged tonsils covered with exudate. The tongue is coated and papillae become red and swollen, resembling strawberries. - 24Which observation is indicative of the onset of sepsis in a patient with a gram-negative infection?hyperthermia
The first phase of gram-negative sepsis is characterized by vasodilation with vascular dehydration, hyperthermia, hypotension, tachycardia, and anxiety. - 25The nurse assessing a 9-month-old infant notes paroxysmal cough, wheezing, and a 37.8° C (100.1° F) temperature. The infant's parents state that they have observed episodes of apnea. Which condition should the nurse suspect?respiratory syncytial virus
Respiratory syncytial virus begins as an upper respiratory infection with a mild fever. It gradually develops into increasing respiratory distress with tachypnea, paroxysmal cough, wheezing, and episodes of apnea. - 26How is the hepatitis A virus transmitted?fecal-oral route
- 27After three weeks of taking naproxen bid for osteoarthritis in the hands, a patient tells the nurse that the medication is not effective in controlling the pain. Which information should the nurse use as a basis for responding to the patient?Another type of NSAID agent may be indicated due to variations in individual responses to individual medications.
- 28Which finding is normal when a patient's arm is put in a cast?There is mild discomfort in the fingers.
Mild discomfort is to be expected with a cast. - 29Which observation of a 13-year-old patient is most indicative of scoliosis?One side of the rib cage is higher when the patient bends forward.
This finding is a common indication of scoliosis. - 30The nurse teaches the family of a patient with an above-the-knee amputation about methods to prepare the patient for prosthesis fitting. Which action by the family indicates that the teaching was successful?wrap the residual limb with elastic dressings.
Wrapping the residual limb with elastic dressings keeps the muscles firm and helps to shape the limb. - 31An emergency department nurse is delivering discharge instructions to the mother of a five-year-old child with a severely sprained ankle. Which would be most appropriate for the nurse to include in the instruction?Place ice on the injury for the first 24 hours.
Ice is the home therapy of choice for the first 24 hours after a sprain - 32Which finding indicates that drug therapy for a patient with chronic gout has been effective?normal serum uric acid
Gout involves excess serum uric acid. A finding that the level is normal indicates effective drug therapy. - 33Which suggestion by the nurse is appropriate to improve the self-concept of a patient with systemic lupus erythematosus (SLE)?Consult a cosmetologist, to select cosmetics to cover the facial rash.
The butterfly facial rash of SLE often contributes to body image disturbance, which in turn affects the patient's self-concept. This is an appropriate suggestion. - 34When transporting a patient in skeletal traction, the nurse should give the transport team which instruction?Allow the weights to hang freely when moving the patient.
Traction must be maintained at all times. Letting the weights hang freely accomplishes this. - 35How should the nurse position a patient immediately following a total left hip replacement?legs in abduction with a pillow .
The legs should be in abduction after total hip replacement. - 36Which complication is associated with Paget's disease of the bone?pathologic fracture
Pathologic fractures (fractures caused by disease) are the primary complication of Paget's disease of the bone. - 37A patient who has rheumatoid arthritis (RA) is diagnosed with appendicitis. Which laboratory test result should the nurse anticipate?elevated erythrocyte sedimentation rate (ESR) is typical in patients with inflammatory connective tissue disease (such as rheumatoid arthritis). The ESR also rises in response to infection-caused inflammation, such as that involved in appendicitis.
- 38When reviewing discharge instructions for a patient who had a total knee replacement five days ago, the nurse discusses with the patient and family which priority diagnosis?knowledge deficit related to potential complications . : The ability to recognize and prevent complications is essential if the patient is going home. Addressing a knowledge deficit in this area is the first priority.
- 39Following replacement surgery, a patient has a dislocated prosthetic hip as a result of a fall. The nurse should take which initial action?Offer medication for pain relief. Dislocation of the prosthesis is likely to cause acute pain. Pain relief is the first priority.
- 40Two days after fracturing a femur, a patient exhibits respirations of 32, a shallow pulse of 136, crackles on auscultation, confusion, and production of thick white sputum. What is the nurse's immediate response?administers oxygen. The nurse suspects pulmonary complications, which are especially common in older adult patients who have fractured a hip. Administering oxygen is the appropriate first response.
- 41Which type of exercise helps to maintain muscle tone in the forearm of a patient who is in a shoulder-to-waist cast?isometric . The purpose of isometric exercise is to maintain strength in a muscle when the joint is immobilized. This is correct for a patient in a shoulder-to-waist cast.
- 42What should the nurse do to assess a patient for the presence of pain related to carpal tunnel syndrome?Tap lightly over the medial nerve. Tapping lightly over the medial nerve will cause Tinel's sign (tingling, numbness, and pain) in a patient with carpal tunnel syndrome.
- 43Why might a patient be placed in Buck's traction prior to surgery for the repair of a fractured hip?to reduce muscle spasms. Buck's traction is used to reduce muscle spasm, to immobilize the leg, and to relieve pain.
- 44An infant has had bilateral casts applied for the correction of clubfeet. Which nursing measure will help prevent an infection from developing under the casts?Petal the edges of the casts with adhesive tape or Band-Aids. Petaling the edges of the cast protects skin from irritation that makes it more vulnerable to infection.
- 45The nurse performs daily pin site care for a patient in skeletal traction. Which assessment of the site is most indicative that an infection has developed?foul odor . A foul odor is a definite indication of infection at the pin site.
- 46While assessing a patient on the first day following a total hip replacement, the nurse notes that the affected leg is shorter than the other leg. Which action should the nurse take?Notify the physician immediately. The physician or surgeon must be notified immediately, because dislocation of the hip prosthesis requires reduction and stabilization.
- 47Why does the nurse use the palms of the hands when handling a wet cast?to avoid denting the cast. Using the palms of the hands minimizes the chance of denting the cast. Dents can result in pressure areas on the casted limb.
- 48A patient is two days postoperative from a total hip replacement and no longer on a PCA pump. The patient is complaining of moderate pain. What medication should the nurse expect to administer?oral opioid analgesic . Immediately after surgery, the patient may receive opioid analgesics parenterally, and an oral opiod like Percocet or Lortab will continue this level of relief as the patient begins to participate in activities.
- 49Which procedure determines bone density, erosion, texture, and alterations in bone relationships?X ray . X ray is used to examine bone density, erosion, texture, and alterations in bone relationships.
- 50Which nursing intervention should be given priority in the plan of care for a patient with osteoporosis? The nurseexplains the need for supplemental calcium. Ensuring adequate calcium intake is the most important intervention for osteoporosis, and supplementation is usually required to achieve the desired levels.
- 51Which behavior by a patient who has gout indicates the need for further instruction related to the treatment plan?Patient consumes liver twice a week. A patient with gout should avoid foods that are high in purine. Organ meats like liver are especially in high in purine and should be avoided entirely.
- 52Which finding in a five-day-old infant indicates a normal Babinski reflex?fan out and draw together.
- 53What alleviates the headache resulting from a lumbar puncture?analgesics
: Pain medication (analgesic) is recommended along with bed rest and hydration to manage the headache after lumbar puncture. - 54The community health nurse arrives at a patient's home to find the patient lying on the floor. The patient is oriented to person, time, and place. The patient's right leg is shorter than the left and is adducted. The nurse suggests that the patient be transported by ambulance to the hospital. What is the rationale for the nursing action?The nurse suspects a fracture of the femoral neck.
In a fracture of the femoral neck, the affected leg is shortened and adducted. Such a fracture is confirmed by X ray, and transportation to the hospital by ambulance is advisable. - 55Which are primary goals for a patient scheduled for orthopedic surgerypain relief, tissue perfusion, health maintenance, improved mobility, and improved self-concept Orthopedic surgery is usually performed to relieve pain, improve tissue health, and restore motion and stability, thereby improving health maintenance and self-concept.
- 56Which laboratory blood test result supports a diagnosis of systemic lupus erythematosus (SLE)?positive for antinuclear antibodies
A positive result on the antinuclear antibodies test supports the diagnosis of SLE, and can be confirmed by findings of moderate to severe anemia, thrombocytopenia, and leukocytosis or leukopenia. - 57After teaching a patient with osteoporosis about nutritional needs, the nurse determines the patient understands high-calcium foods when the patient selects which meal?tuna sandwich on whole wheat bread, one cup of fruit yogurt, and one cup of skim milk
Each course of this meal provides some calcium. - 58The nurse teaches an adolescent client about management of scoliosis with a body brace. Which client statement indicates that the teaching was effective?"Wearing the brace 23 hours a day will be hard for me." The brace should be worn as much as possible, ideally 23 hours a day. The statement indicates that the patient understands and is trying to accept the teaching.
- 59A patient complains of pain in the right great toe 24 hours after a right above-the-knee amputation. What is the nurse's first action?Administer the prescribed narcotic analgesic. This action recognizes that phantom limb pain, caused by altered sensory perceptions, is very real pain for the patient.
- 60Which is an alternative means to reduce the perception of pain?back massage Back massage is an alternative method that provides physical relaxation and reduces the perception of pain.
- 61The presence of a diseased bone would make a patient more prone to which type of fracture?pathologic The word pathologic refers to the involvement of a disease process in the fracture.
- 62What will cause a pressure bandage to become saturated with blood immediately following a below-the-knee amputation?bleeding from a loosened suture This degree of bleeding indicates hemorrhage from a loosened suture. The surgeon should be notified.
- 63A nurse has given home care instructions to the husband of a 78-year-old woman who is going home after an open reduction and internal fixation of a hip fracture. The nurse realizes that the patient's husband needs further instruction when the husband makes which comment?I have put a hospital bed in the dining room so that I do everything for her more easily. The patient should be active and mobile. This comment indicates that the husband does not understand this.
- 64Which instruction should the nurse give to a patient who is receiving prophylactic probenecid-colchicine (ColBENEMID) therapy?Drink eight glasses of water a day. : Because probenecid-colchicine (ColBENEMID) increases excretion of uric acid through urine, the patient should be advised to maintain adequate water intake to flush through the uric acid.
- 65Which nursing action should receive priority for a patient who is recovering from a total hip replacement?Position the patient using an abductor pillow. An abductor pillow helps to prevent dislocation of the prosthetic hip.
- 66An abductor pillow helps to prevent dislocation of the prosthetic hip."Tuck a disposable diaper beneath the entire perineal opening of the cast to keep it clean." Applying a large diaper around the perineal opening is the best way to care for the cast and protect the child's skin.
- 67Which is the best indicator of circulatory complications in a patient who underwent a right total hip replacement 3 days ago? The patient experiences pain upondorsiflexion of the right ankle. This finding suggests circulatory complications. It should be noted that a positive Homans' sign is not the "gold standard" indicator it once was, but in the situation described, it is crucial.
- 68A 60-year-old patient is admitted to the hospital with a fracture of the right femur. Which assessment should the nurse be most concerned about?The patient pulls at the bed covers and talks to the wall. This finding indicates that serious confusion is developing.
- 69Which discharge instruction should the nurse provide to the parents of an 18-month-old child who is in a hip spica cast?"Tuck a disposable diaper beneath the entire perineal opening of the cast to keep it clean."Applying a large diaper around the perineal opening is the best way to care for the cast and protect the child's skin.
- 70Which condition has clinical manifestations similar to those of systemic lupus erythematosus (SLE)?rheumatoid arthritis Rheumatoid arthritis and SLE are both autoimmune disorders. Musculoskeletal manifestations are common in both.
- 71Which condition has clinical manifestations similar to those of systemic lupus erythematosus (SLE)?rheumatoid arthritis Rheumatoid arthritis and SLE are both autoimmune disorders. Musculoskeletal manifestations are common in both.
- 72Two days following multiple fractures, a patient reports shortness of breath and chest pain. Upon assessment, the nurse also finds the patient to be confused. The nurse should suspect which complication?fat embolism Fat embolism is signaled by shortness of breath, chest pain, and confusion.
- 73Which nursing goal should receive priority for a patient in a full leg cast who is on prolonged bed rest?Maintain skin integrity. The nursing diagnosis of Impaired skin integrity is primary among the four choices for a patient on prolonged bed rest, especially with the additional circumstance of a full leg cast.
- 74The nurse has provided pin site care for a patient in skeletal traction who has a Steinmann pin in place. Which observation should the nurse be certain to include in the nurse's report?heat and swelling at the pin site.Heat and swelling at the pin site indicates that an infection may be developing. This observation should be reported.
- 75Which action should the nurse take when caring for a patient with a newly applied cast?Keep the cast uncovered. Leaving the cast uncovered promotes drying. Drying of a plaster cast may take 24 to 72 hours.
- 76Which injury of a child is most suggestive of physical abuse?spiral fracture of the humerus. A spiral fracture of the humerus typically occurs as a result of abusive pulling or twisting of the arm.
- 77A nurse is caring for a 29-year-old patient who is admitted with a spiral fracture of the femur resulting from a motor vehicle accident. The patient's pain seemed to decrease during the night. In the morning, the patient is restless and irritable. What further assessment would be of high priority?Get an order to obtain blood gas values. The nurse suspects a fat embolism. This is confirmed by obtaining blood gases.
- 78Which nursing intervention is appropriate to include in a plan of care for a patient in Buck's traction?Remove the foam boot and inspect the skin three times daily.
- 79What is the appearance of normal synovial fluid?Normal synovial fluid is clear, scanty, and straw-colored.
- 80A patient with rheumatoid arthritis of the hands asks the nurse why resting splints are necessary. The nurse explains that resting splints are used for which purpose?Resting splints stabilize and immobilize joints in desired position when use of the hand is not required. Resting splints are designed to hold joints of the hand in a desirable position when the hand is at rest.