Quiz
Exam 3 Part 2
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Questions in this quiz (176)
1An 80-year-old man states that, although he adds a lot of salt to his food, it still does not have much taste. The nurse's response is based on the knowledge that the older adult
- Ashould not experience changes in taste.
- Bhas a loss of taste buds, especially for sweet and salt.
- Chas some loss of taste but no difficulty chewing food.
- Dloses the sense of taste because the ability to smell is decreased.
2When the nurse is assessing the health perception–health maintenance pattern as related to GI function, an appropriate question to ask is
- A“What is your usual bowel elimination pattern?”
- B“What percentage of your income is spent on food?”
- C“Have you traveled to a foreign country in the last year?”
- D“Do you have diarrhea when you are under a lot of stress?”
3During an examination of the abdomen the nurse should
- Aposition the patient in the supine position with the bed flat and knees straight.
- Blisten in the epigastrium and all four quadrants for 2 minutes for bowel sounds.
- Cuse the following order of techniques: inspection, palpation, percussion, auscultation.
- Ddescribe bowel sounds as absent if no sound is heard in the lower right quadrant after 2 minutes.
4A normal physical assessment finding of the GI system is/are (select all that apply)
- Anonpalpable liver and spleen.
- Bborborygmi in upper right quadrant.
- Ctympany on percussion of the abdomen.
- Dliver edge 2 to 4 cm below the costal margin.
- Efinding of a firm, nodular edge on the rectal examination.
5In preparing a patient for a colonoscopy, the nurse explains that
- Aa signed permit is not necessary.
- Bsedation may be used during the procedure.
- Conly one cleansing enema is necessary for preparation.
- Da light meal should be eaten the day before the procedure.
6A pt receives atropine, an anticholinergic drug, in preparation for surgery. The nurse expects the drug to affect the GI tract by doing what?
- AIncreasing gastric emptying
- BRelaxing pyloric and ileocecal sphincters
- CDecreasing secretions and peristaltic action
- DStimulating the nervous system of the GI tract
7When caring for a patient who has had most of the stomach surgically removed, what is important for the nurse to teach the patient?
- AExtra iron will need to be taken to prevent anemia.
- BAvoid foods with lactose to prevent bloating and diarrhea.
- CLifelong supplementation of cobalamin (vitamin B12) will be needed.
- DBecause of the absence of digestive enzymes, protein malnutrition is likely.
8A 68-year-old patient is in the office for a physical. She notes that she no longer has regular bowel movements. Which suggestion by the nurse would be most helpful to the patient?
- ATake an additional laxative to stimulate defecation
- BEat less acidic foods to enable the gastrointestinal system to increase peristalsis.
- CEat less food at each meal to prevent feces from backing up related to slowed peristalsis.
- DAttempt defecation after breakfast because gastrocolic reflexes increase colon peristalsis at that time.
9What problem should the nurse assess the patient for if the patient was on prolonged antibiotic therapy?
- ACoagulation problems
- BElevated serum ammonia levels
- CImpaired absorption of amino acids
- DIncreased mucus and bicarbonate secretion
10What is a clinical manifestation of age-related changes in the GI system that the nurse may find in an older patient?
- AGastric hyperacidity
- BIntolerance to fatty foods
- CYellowish tinge to the skin
- DReflux of gastric contents into the esophagus
11 What is a normal finding during physical assessment of the mouth?
- AA red, slick appearance of the tongue
- BUvular deviation to the side on saying “Ahh”
- CA thin, white coating of the dorsum of the tongue
- DScattered red, smooth areas on the dorsum of the tongue
12What is a normal finding on physical examination of the abdomen?
- AAuscultation of bruits
- BObservation of visible pulsations
- CPercussion of liver dullness in the left midclavicular line
- DPalpation of the spleen 1 to 2 cm below the left costal margin
13 A patient is admitted to the hospital with left upper quadrant (LUQ) pain. What may be a possible source of the pain?
- Aliver
- Bpancreas
- Cappendix
- Dgallbladder
14What characterizes auscultation of the abdomen?
- AThe presence of borborygmi indicates hyperperistalsis.
- BThe bell of the stethoscope is used to auscultate high-pitched sounds.
- CHigh-pitched, rushing, and tinkling bowel sounds are heard after eating.
- DAbsence of bowel sounds for 1 minute in each quadrant is reported as abnormal.
15 Following auscultation of the abdomen, what should the nurse’s next action be?
- ALightly percuss over all four quadrants
- BHave the patient empty his or her bladder
- CInspect perianal and anal areas for color, masses, rashes, and scars
- DPerform deep palpation to delineate abdominal organs and masses
16A patient’s serum liver enzyme tests reveal an elevated aspartate aminotransferase (AST). The nurse recognizes what about the elevated AST?
- AIt eliminates infection as a cause of liver damage.
- BIt is diagnostic for liver inflammation and damage
- CTissue damage in organs other than the liver may be identified.
- DNervous system symptoms related to hepatic encephalopathy may be the cause.
17Which nursing actions are indicated for a liver biopsy (select all that apply)?
- AObserve for white stools
- BMonitor for rectal bleeding
- CMonitor for internal bleeding
- DPosition to right side after test
- EEnsure bowel prep was done
- FCheck coagulation status before test
18Checking for the return of the gag reflex and monitoring for LUQ pain, nausea and vomiting are necessary nursing actions after which diagnostic procedure?
- AERCP
- BColonoscopy
- CBarium swallow
- DEsophagogastroduodenoscopy (EGD)
19A patient is receiving peripheral parenteral nutrition. The parenteral nutrition solution is completed before the new solution arrives on the unit. The nurse administers
- A20% intralipids.
- B5% dextrose solution.
- C0.45% normal saline solution.
- D5% lactated Ringer's solution.
20A patient with anorexia nervosa shows signs of malnutrition. During initial refeeding, the nurse carefully assesses the patient for
- Ahyperkalemia.
- Bhypoglycemia.
- Chypercalcemia.
- Dhypophosphatemia.
21What is the most common cause of secondary protein-calorie malnutrition in the United States?
- AThe unavailability of foods high in protein
- BA lack of knowledge about nutritional needs
- CA lack of money to purchase high-protein foods
- DAn alteration in ingestion, digestion, absorption, or metabolism
22 During assessment of the patient with protein-calorie malnutrition, what should the nurse expect to find (select all that apply)?
- Afrequent cold symptoms
- BDecreased bowel sounds
- CCool, rough, dry, scaly skin
- Da flat or concave abdomen
- Eprominent bony structures
- FDecreased reflexes and lack of attentio
23To evaluate the effect of nutritional interventions for a patient with protein-calorie malnutrition, what is the best indicator for the nurse to use?
- Aheight and weight
- BBMI
- CWeight in relation to ideal body weight
- DMid-upper arm circumference and triceps skinfold
24When considering tube feedings for a patient with severe protein-calorie malnutrition, what is an advantage of a gastrostomy tube versus a nasogastric (NG) tube?
- AThere is less irritation to the nasal and esophageal mucosa.
- BThe patient experiences the sights and smells associated with eating.
- CAspiration resulting from reflux of formulas into the esophagus is less common.
- DRoutine checking for placement is not required because gastrostomy tubes do not become displaced.
25 Before administering a bolus of intermittent tube feeding to a patient with a percutaneous endoscopic gastrostomy (PEG), the nurse aspirates 220 mL of gastric contents. How should the nurse respond?
- AReturn the aspirate to the stomach and recheck the volume of aspirate in an hour.
- BReturn the aspirate to the stomach and continue with the tube feeding as planned
- CDiscard the aspirate to prevent overdistending the stomach when the new feeding is given.
- DNotify the health care provider that the feedings have been scheduled too frequently to allow for stomach emptying
26What is an indication for parenteral nutrition that is not an appropriate indication for enteral tube feedings?
- AHead and neck cancer
- BHypermetabolic states
- CMalabsorption syndrome
- DProtein-calorie malnutrition
27 The nurse is caring for a patient receiving 1000 mL of parenteral nutrition solution over 24 hours. When it is time to change the solution, 150 mL remain in the bottle. What is the most appropriate action by the nurse?
- AHang the new solution and discard the unused solution.
- BOpen the IV line and rapidly infuse the remaining solution.
- CNotify the health care provider for instructions regarding the infusion rate.
- DWait to change the solution until the remaining solution infuses at the prescribed rate.
28Which statement best describes the etiology of obesity?
- AObesity primarily results from a genetic predisposition.
- BPsychosocial factors can override the effects of genetics in the etiology of obesity.
- CObesity is the result of complex interactions between genetic and environmental factors.
- DGenetic factors are more important than environmental factors in the etiology of obesity.
29The obesity classification that is most often associated with cardiovascular health problems is
- Aprimary obesity.
- Bsecondary obesity.
- Cgynoid fat distribution.
- Dandroid fat distribution.
30Health risks associated with obesity include (select all that apply)
- Acolorectal cancer.
- Brheumatoid arthritis.
- Cpolycystic ovary syndrome.
- Dnonalcoholic steatohepatitis.
- Esystemic lupus erythematosus.
31The best nutritional therapy plan for a person who is obese is
- Athe Zone diet.
- Bthe Atkins diet.
- CSugar Busters.
- Dfoods from the basic food groups.
32This bariatric surgical procedure involves creating a stoma and gastric pouch that is reversible, and no malabsorption occurs. What surgical procedure is this?
- AVertical gastric banding
- BBiliopancreatic diversion
- CRoux-en-Y gastric bypass
- DAdjustable gastric banding
33Which of the following criteria must be met for a diagnosis of metabolic syndrome (select all that apply)?
- AHTN
- BElevated triglycerides
- CElevated plasma glucose
- DIncreased waist circumference
- EDecreased low-density lipoproteins
34Which statement about obesity is explained by genetics?
- AOlder obese patients have exacerbated changes of aging.
- BAndroid body shape and weight gain are influenced by genetics.
- CWhite Americans have a higher incidence of obesity than African Americans.
- DMen have a harder time losing weight, as they have more muscle mass than women.
35Which patient is at highest risk for complications of obesity?
- AA 30-year-old woman who is 5 ft (151 cm) tall, weighs 140 lb (63.6 kg), and carries weight in her thighs
- BA 56-year-old woman with a BMI of 38 kg/m2, a waist measurement of 38 in (96 cm), and a hip measurement of 36 in (91 cm)
- CA 42-year-old man with a waist measurement of 36 in (91 cm) and a hip measurement of 36 in (91 cm) who is 5 ft, 6 in (166 cm) tall and weighs 150 lb (68.2 kg)
- DA 68-year-old man with a waist measurement of 38 in (96 cm) and a hip measurement of 42 in (76 cm) who is 5 ft, 11 in (179 cm) tall and weighs 200 lb (90.9 kg)
36Before selecting a weight reduction plan with an obese patient, what is most important for the nurse to first assess?
- AThe patient’s motivation to lose weight
- BThe length of time that the patient has been obese
- CWhether financial considerations will affect the patient’s choices
- DThe patient’s anthropometric measures of height, weight, BMI, waist-to-hip ratio, and skinfold thickness
37The nurse is teaching a moderately obese woman interventions for the management of obesity. Initially, which strategies will support restricting dietary intake to below energy requirements (select all that apply)?
- ALimit alcohol
- BRest when fatigued
- CDetermine portion sizes
- D1800- to 2200-calorie diet
- EAttend Overeaters Anonymous
38 Which explanation about weight reduction should be included when teaching the obese patient and her obese husband?
- AWeight gain is caused by psychologic factors.
- BDaily weighing is recommended to monitor weight loss.
- CFat is not burned until the glycogen-water pool is depleted.
- DMen lose weight less quickly than women because they have a higher percentage of metabolically less-active fat.
39A patient has been on a 1000-calorie diet with a daily exercise routine. In 2 months, the patient has lost 20 lb (9 kg) toward a goal of 50 lb (23 kg) but is now discouraged that no weight has been lost in the last 2 weeks. What should the nurse tell the patient about this?
- APlateaus where no weight is lost normally occur during a weight-loss program.
- BA weight considered by the body to be most efficient for functioning has been reached.
- CA return to former eating habits is the most common cause of not continuing to lose weight.
- DA steady weight may be due to water gain from eating foods high in sodium.
40When teaching a patient about weight reduction diets, the nurse teaches the patient that an appropriate single serving of a food is
- Aa 6-inch bagel.
- B1 cup of chopped vegetables.
- Ca piece of cheese the size of three dice.
- Da chicken breast the size of a deck of cards.
41 When medications are used in the treatment of obesity, what is most important for the nurse to teach the patient?
- AOver-the-counter (OTC) diet aids are safer than other agents and can be useful in controlling appetite.
- BDrugs should be used only as adjuncts to a diet and exercise program as treatment for a chronic condition
- CAll drugs used for weight control are capable of altering central nervous system (CNS) function and should be used with caution.
- DThe primary effect of the medications is psychologic, controlling the urge to eat in response to stress or feelings of rejection.
42A patient asks the nurse about taking phentermine and topiramate (Qsymia) for weight loss. To avoid side effects, it is important for the nurse to determine whether the patient has a history of
- Aglaucoma.
- BHTN
- Cvalvular heart disease.
- Dirritable bowel disease.
43 The nurse has completed initial instruction with a patient regarding a weight-loss program. Which patient comment indicates to the nurse that the teaching has been effective?
- A“I will keep a diary of daily weight to illustrate my weight loss.”
- B“I plan to lose 4 lb a week until I have lost the 60 lb I want to lose.”
- C“I should not exercise more than what is required so I don’t increase my appetite.”
- D“I plan to join a behavior modification group to help establish long-term behavior changes.”
44What characteristics describe adjustable gastric banding (select all that apply)?
- A85% of the stomach is removed.
- BStomach restriction can be reversed.
- CEliminates hormones that stimulate hunger.
- DMalabsorption of fat-soluble vitamins occurs.
- EInflatable band allows for modification of gastric stoma size.
- FStomach with a gastric pouch surgically anastomosed to the jejunum.
45During care of the severely obese patient, what is most important for the nurse to do?
- AAvoid reference to the patient’s weight to avoid embarrassing the patient.
- BEmphasize to the patient how important it is to lose weight to maintain health
- CPlan for necessary modifications in equipment and nursing techniques before initiating care.
- DRecognize that a full assessment of each body system might not be possible because of numerous layers of skinfolds.
46 In preparing to care for the obese patient with cancer, what physiologic problems is this patient at a greater risk for having (select all that apply)?
- ATinnitus
- Bfractures
- Csleep apnea
- DTrousseau’s sign
- EType 2 diabetes mellitus
- FGERD
47 The nurse admitting a patient for bariatric surgery obtains the following information from the patient. Which finding should be brought to the surgeon’s attention before proceeding with further patient preparation?
- AHistory of hypertension
- BHistory of untreated depression
- CHistory of multiple attempts at weight loss
- DHistory of sleep apnea treated with continuous positive airway pressure (CPAP)
48What is a postoperative nursing intervention for the obese patient who has undergone bariatric surgery?
- AIrrigating and repositioning the nasogastric (NG) tube as needed
- BDelaying ambulation until the patient has enough strength to support sel
- CKeeping the patient positioned on the side to facilitate respiratory function
- DProviding adequate support to the incision during coughing, deep breathing, and turning
49Which female patient is most likely to have metabolic syndrome?
- ABP 128/78 mm Hg, triglycerides 160 mg/dL, fasting blood glucose 102 mg/dL
- BBP 142/90 mm Hg, high-density lipoproteins 45 mg/dL, fasting blood glucose 130 mg/dL
- CWaist circumference 36 in, triglycerides 162 mg/dL, high-density lipoproteins 55 mg/dL
- DWaist circumference 32 in, high-density lipoproteins 38 mg/dL, fasting blood glucose 122 mg/dL
50 Which teaching points are important when providing information to a patient with metabolic syndrome (select all that apply)?
- Astop smoking
- BMonitor weight daily.
- CIncrease level of activity.
- DDecrease saturated fat intake.
- EReduce weight and maintain lower weight.
- FCheck blood glucose each morning prior to eating.
51What is the main underlying risk factor for metabolic syndrome?
- Aage
- Bheart disease
- CInsulin resistance
- DHigh cholesterol levels
52The nurse explains to the patient with gastroesophageal reflux disease (GERD) that this disorder
- Aresults in acid erosion of the esophagus from frequent vomiting.
- Bwill require surgical wrapping or repair of the pyloric sphincter to control the symptoms.
- Cis the protrusion of a portion of the stomach into the esophagus through an opening in the diaphragm.
- Doften involves relaxation of the lower esophageal sphincter, allowing stomach contents to back up into the esophagus.
53The nurse is teaching the patient and family that peptic ulcers are
- Acaused by a stressful lifestyle and other acid-producing factors such as H. pylori.
- Binherited within families and reinforced by bacterial spread of Staphylococcus aureus in childhood.
- Cpromoted by factors that tend to cause oversecretion of acid, such as excess dietary fats, smoking, and H. pylori.
- Dpromoted by a combination of factors that may result in erosion of the gastric mucosa, including certain drugs and alcohol.
54The teaching plan for the patient being discharged after an acute episode of upper GI bleeding includes information concerning the importance of (select all that apply)
- Aonly taking aspirin with milk or bread products.
- Bavoiding taking aspirin and drugs containing aspirin.
- Conly taking drugs prescribed by the health care provider.
- Dtaking all drugs 1 hour before mealtime to prevent further bleeding.
- Ereading all OTC drug labels to avoid those containing stearic acid and calcium.
55The nurse is planning to teach the patient with gastroesophageal reflux disease (GERD) about foods or beverages that decrease lower esophageal sphincter (LES) pressure. What should be included in this list (select all that apply)?
- Aalcohol
- Broot beer
- Cchocolate
- Dcitrus fruits
- Efatty foods
- Fcola sodas
56How should the nurse teach the patient with a hiatal hernia or GERD to control symptoms?
- ADrink 10 to 12 oz of water with each meal
- BSpace six small meals a day between breakfast and bedtime.
- CSleep with the head of the bed elevated on 4- to 6-inch blocks
- DPerform daily exercises of toe-touching, sit-ups, and weight lifting.
57Duodenal and gastric ulcers have similar as well as differentiating features. What are characteristics unique to duodenal ulcers (select all that apply)?
- APain is relieved with eating food.
- BThey have a high recurrence rate
- CIncreased gastric secretion occurs.
- DAssociated with Helicobacter pylori infection.
- EHemorrhage, perforation, and obstruction may result.
- FThere is burning and cramping in the mid-epigastric area.
58Which patient is at highest risk for having a gastric ulcer?
- A55-year-old female, smoker, with nausea and vomiting
- B45-year-old female admitted for illicit drug detoxification
- C37-year-old male, smoker, who fell while looking for a job
- D27-year old male who is being divorced and has back pain
59What type of pain does the nurse expect a patient with an ulcer of the posterior portion of the duodenum to experience?
- APain that occurs after not eating all day
- BBack pain that occurs 2 to 4 hours following meals
- CMidepigastric pain that is unrelieved with antacids
- DHigh epigastric burning that is relieved with food intake
60What does the nurse include when teaching a patient with newly diagnosed peptic ulcer disease?
- AMaintain a bland, soft, low-residue diet.
- BUse alcohol and caffeine in moderation and always with food.
- CEat as normally as possible, eliminating foods that cause pain or discomfort.
- DAvoid milk and milk products because they stimulate gastric acid production.
61What is the rationale for treating acute exacerbation of peptic ulcer disease with NG intubation?
- AStop spillage of GI contents into the peritoneal cavity
- BRemove excess fluids and undigested food from the stomach
- CFeed the patient the nutrients missing from the lack of ingestion
- DRemove stimulation for hydrochloric acid and pepsin secretion by keeping the stomach empty
62Which medications are used to decrease gastric or hydrochloric acid secretion (select all that apply)?
- AFamotidine (Pepcid)
- BSucralfate (Carafate)
- COmeprazole (Prilosec)
- DMisoprostol (Cytotec)
- EAmoxicillin/clarithromycin/omeprazole
63 The nurse determines that teaching for the patient with peptic ulcer disease has been effective when the patient makes which statement?
- A“I should stop all my medications if I develop any side effects.”
- B“I should continue my treatment regimen as long as I have pain.”
- C“I have learned some relaxation strategies that decrease my stress.”
- D“I can buy whatever antacids are on sale because they all have the same effect.”
64 A patient with a history of peptic ulcer disease is hospitalized with symptoms of a perforation. During the initial assessment, what should the nurse expect the patient to report?
- AVomiting of bright-red blood
- BProjectile vomiting of undigested food
- CSudden, severe upper abdominal pain and back pain
- DHyperactive stomach sounds and upper abdominal swelling
65When caring for a patient with an acute exacerbation of a peptic ulcer, the nurse finds the patient doubled up in bed with shallow, grunting respirations. Which action should the nurse take first?
- AIrrigate the patient’s NG tube.
- BNotify the health care provider.
- CPlace the patient in high-Fowler’s position.
- DAssess the patient’s abdomen and vital signs.
66Following a Billroth II procedure, a patient develops dumping syndrome. The nurse should explain that the symptoms associated with this problem are caused by
- Adistention of the smaller stomach by too much food and fluid intake.
- Bhyperglycemia caused by uncontrolled gastric emptying into the small intestine
- Cirritation of the stomach lining by reflux of bile salts because the pylorus has been removed.
- Dmovement of fluid into the small bowel because concentrated food and fluids move rapidly into the intestine.
67What type of bleeding will a patient with peptic ulcer disease with a slow upper GI source of bleeding have?
- Amelena
- BOccult blood
- Ccoffee-ground emesis
- DProfuse bright-red hematemesis
68 What should the nurse emphasize when teaching patients at risk for upper GI bleeding to prevent bleeding episodes?
- AAll stools and vomitus must be tested for the presence of blood.
- BThe use of over-the-counter (OTC) medications of any kind should be avoided.
- CAntacids should be taken with all prescribed medications to prevent gastric irritation.
- DMisoprostol (Cytotec) should be used to protect the gastric mucosa in individuals with peptic ulcers.
69When a 35-year-old female patient is admitted to the emergency department with acute abdominal pain, which possible diagnosis should you consider that may be the cause of her pain (select all that apply)?
- AGastroenteritis
- BEctopic pregnancy
- CGI bleed
- DIrritable bowel syndrome
- Einflammatory bowel disease
70Assessment findings suggestive of peritonitis include
- Arebound abdominal pain.
- Ba soft, distended abdomen.
- Cdull, continuous abdominal pain
- Dobserving that the pt is restless
71The nurse performs a detailed assessment of the abdomen of a patient with a possible bowel obstruction, knowing that manifestations of an obstruction in the large intestine are (select all that apply)
- Apersistent abdominal pain.
- Bmarked abdominal distention.
- Cdiarrhea that is loose or liquid
- Dcolicky, severe, intermittent pain.
- Eprofuse vomiting that relieves abdominal pain.
72A patient with stage I colorectal cancer is scheduled for surgery. Patient teaching for this patient would include an explanation that
- Achemotherapy will begin after the patient recovers from the surgery.
- Bboth chemotherapy and radiation can be used as palliative treatments.
- Cfollow-up colonoscopies will be needed to ensure that the cancer does not recur.
- Da wound, ostomy, and continence nurse will visit the patient to identify an abdominal site for the ostomy.
73The nurse explains to the patient undergoing ostomy surgery that the procedure that maintains the most normal functioning of the bowel is
- Aa sigmoid colostomy
- Ba transverse colostomy
- Ca descending colostomy
- Dan ascending colostomy
74In contrast to diverticulitis, the patient with diverticulosis
- Ahas rectal bleeding.
- Boften has no symptoms
- Chas localized cramping pain
- Dfrequently develops peritonitis
75A patient is admitted to the emergency department with acute abdominal pain. What nursing intervention should the nurse implement first?
- AMeasurement of vital signs
- BAdministration of prescribed analgesics
- CAssessment of the onset, location, intensity, duration, and character of the pain
- DPhysical assessment of the abdomen for distention, bowel sounds, and pigmentation changes
76 The patient has peritonitis, which is a major complication of appendicitis. What treatment will the nurse plan to include?
- APeritoneal lavage
- BPeritoneal dialysis
- CIV fluid replacement
- DIncreased oral fluid intake
77For the patient hospitalized with inflammatory bowel disease (IBD), which treatments would be used to rest the bowel (select all that apply)?
- ANPO
- BIV fluids
- Cbed rest
- DSedatives
- ENG suction
- FParenteral nutrition
78The medications prescribed for the patient with inflammatory bowel disease include cobalamin and iron injections. What is the rationale for using these drugs?
- AAlleviate stress
- BCombat infection
- CCorrect malnutrition
- DImprove quality of life
79 A patient with inflammatory bowel disease has a nursing diagnosis of imbalanced nutrition: less than body requirements related to decreased nutritional intake and decreased intestinal absorption. Which assessment data support this nursing diagnosis?
- APallor and hair loss
- BFrequent diarrhea stools
- CAnorectal excoriation and pain
- DHypotension and urine output below 30 mL/hr
80The patient comes to the emergency department with intermittent crampy abdominal pain, nausea, projectile vomiting, and dehydration. The nurse suspects a GI obstruction. Based on the manifestations, what area of the bowel should the nurse suspect is obstructed?
- ALarge intestine
- BEsophageal sphincter
- CUpper small intestine
- DLower small intestine
81An important nursing intervention for a patient with a small intestinal obstruction who has an NG tube is to
- Aoffer ice chips to suck PRN.
- Bprovide mouth care every 1 to 2 hours.
- Cirrigate the tube with normal saline every 8 hours
- Dkeep the patient supine with the head of the bed elevated 30 degrees.
82When obtaining a nursing history from the patient with colorectal cancer, the nurse should specifically ask the patient about
- Adietary intake
- Bsports involvement.
- Cenvironmental exposure to carcinogens.
- Dlong-term use of nonsteroidal antiinflammatory drugs (NSAIDs).
83What should the nurse teach the patient with diverticulosis to do?
- AUse anticholinergic drugs routinely to prevent bowel spasm.
- BHave an annual colonoscopy to detect malignant changes in the lesions.
- CMaintain a high-fiber diet and use bulk laxatives to increase fecal volume.
- DExclude whole grain breads and cereals from the diet to prevent irritating the bowel.
84An 82-year-old man is admitted with an acute attack of diverticulitis. What should the nurse include in his care?
- AMonitor for signs of peritonitis.
- BTreat with daily medicated enemas.
- CPrepare for surgery to resect the involved colon.
- DProvide a heating pad to apply to the left lower quadrant.
85For which patients is it most important for the nurse to refer to a dietitian for a complete nutritional assessment?
- AA 38-year-old diabetic who is undergoing laser eye surgery
- BA 55-year-old with a history of alcoholism who is hospitalized with a fractured femur resulting from a fall
- CA 24-year-old who has been taking a burst of corticosteroid therapy for 1 week for treatment of an asthma exacerbation
- DA 45-year-old hospitalized with nausea and abdominal pain who has had no oral intake and has received only IV fluids of D5½NS for 6 days
86The nurse is caring for a 74-year-old woman. What would be a normal age-related finding?
- Akyphosis
- Bback pain
- Closs of height
- DSpinal crepitation
87The nurse notices that a patient has a disturbed gait. To further assess this problem, which action should the nurse take?
- AMeasure the length of both legs
- BPerform deep palpation of the hip joints.
- CTest range of motion of the lower extremities
- DPerform muscle-strength testing of the legs.
88Which patient would be at greatest risk for developing osteoporosis
- AA 73-year-old man who has five alcoholic drinks per week and limits sun exposure to prevent recurrence of skin cancer.
- BAn 84-year-old man who has recently been diagnosed with hypothyroidism and is prescribed levothyroxine (Synthroid).
- CA 69-year-old woman who had a renal transplant 5 years ago and has been taking prednisone to prevent organ rejection
- DA 55-year-old woman who recently had a hysterectomy with bilateral salpingo-oophorectomy and refuses estrogen therapy
89A plaster splint is applied with an elastic bandage to the leg of a patient with a fractured tibia in preparation for open reduction and internal fixation. The patient complains of increasing pain in the affected leg and foot that is not relieved by loosening of the elastic bandage. The most appropriate action by the nurse is to
- Aelevate the leg on two pillows
- Bapply ice over the fracture site
- Cnotify the health care provider.
- Dperform neurovascular assessment of the foot
90During the administration of total parenteral nutrition (TPN), an assessment of the client reveals a bounding pulse, distended jugular veins, dyspnea, and cough. What is the priority nursing intervention?
- ARestart the client's infusion at another site
- BSlow the rate of the client's infusion of the TPN.
- CInterrupt the client's infusion and notify the healthcare provider
- DObtain the vital signs and continue monitoring the client's status.
91A client with gastroesophageal reflux disease (GERD) receives a prescription for an H2 receptor antagonist. Which medications are within the classification of an H2 receptor antagonist? Select all that apply.
- ANizatidine
- BRanitidine
- CFamotidine
- DLansoprazole
- EMetoclopramide
92A client diagnosed with gastroesophageal reflux disease (GERD) is being treated with antacid therapy. When teaching the client about the therapy, what does the nurse reinforce?
- AAntacids should be taken 1 hour before meals
- BThese should be scheduled at 4-hour intervals.
- CAntacid tablets are just as fast and effective as the liquid form
- DAntacids commonly interfere with the absorption of other drugs.
93A client with gastroesophageal reflux disease (GERD) should make diet and lifestyle changes. Which instructions should the nurse include in the client's discharge teaching? Select all that apply.
- AEncourage to quit smoking
- BElevate the foot of the bed
- CAvoid caffeine-containing products
- DEat three large, evenly spaced meals daily
- EAvoid lying down for 2 to 3 hours after eating
94A client with gastroesophageal reflux disease (GERD) is being treated with dietary management. The client states, "I like to have a glass of juice every day." Which juice will the nurse recommend?
- Aapple
- Borange
- Ctomato
- Dgrapefruit
95A client who has gastroesophageal reflux disease (GERD) is unable to tolerate a back rest elevation. The nurse should place the client in what position in the illustration?
- AA
- BB
- CC
- DD
96A client has a history of gastroesophageal reflux disease (GERD). Why should the nurse also monitor the client for clinical manifestations of heart disease?
- AEsophageal pain may imitate the symptoms of a heart attack.
- BGERD may predispose to heart disease
- CStrenuous exercise may exacerbate both cardiac and reflux problems
- DSimilar changes in laboratory studies may occur in both cardiac and reflux problems
97A nurse teaches a client about limiting the discomfort associated with a hiatal hernia. Which statement from the client indicates teaching by the nurse is effective?
- A"After meals I will take a 10-minute walk."
- B"After meals I will drink 8 oz (240 mL) of water."
- C"After meals I will rest in a sitting position for one hour."
- D"After meals I will lie down in bed for at least 20 minutes."
98Famotidine (Pepcid) is prescribed for a client with peptic ulcer disease. The client asks the nurse what this medication does. Which action does the nurse mention when replying?
- AIncreases gastric motility
- BNeutralizes gastric acidity
- CFacilitates histamine release
- DInhibits gastric acid secretion
99A nurse is obtaining a health history from a client with the diagnosis of peptic ulcer disease. Which client statement provides evidence to support the identification of a possible contributory factor?
- A"My blood type is A positive."
- B"I smoke one pack of cigarettes a day."
- C"I have been overweight most of my life."
- D"My blood pressure has been high lately."
100A nurse provides a list of suggested food choices to a client who has peptic ulcer disease. Which foods should be included on the list?
- AOrange juice, fried eggs, and sausage
- BTomato juice, raisin bran cereal, and tea
- CApplesauce, cream of wheat, and apple juice
- DSliced oranges, pancakes with syrup, and coffee
101A teenager is admitted with an acute onset of right lower quadrant pain at McBurney point. Appendicitis is suspected. For which clinical indicator should the nurse assess the client to determine if the pain is secondary to appendicitis?
- AUrinary retention
- BGastric hyperacidity
- CRebound tenderness
- DIncreased lower bowel motility
102A client develops acute appendicitis. Prior to arrival to the hospital, the client attempted self-care at home. Which self-care measures could potentially lead to rupture of the appendix?
- ARefusing food and liquids
- BApplying an ice pack to the abdomen
- CTaking a small volume enema
- DTaking acetaminophen (Tylenol) for pain
103A client is admitted to the hospital with the diagnosis of intestinal obstruction and has an intestinal tube inserted. The plan of care includes a prescription to instill 30 mL of normal saline into the tube as needed to maintain patency. When considering the normal saline that is instilled, how should the nurse proceed?
- ASubtract the 30 mL from the gastric output
- BRecord the 30 mL on the intake and output record
- CUnderstand that the amount instilled equals insensible losses
- DConsider the amount too small to document on the intake and output record
104A client had surgery for a perforated appendix with localized peritonitis. In which position should the nurse place this client?
- ASims
- BSemi-Fowler
- CTrendelenburg
- DDorsal recumbent
105An older client's colonoscopy reveals the presence of extensive diverticulosis. Which type of diet should the nurse encourage the client to follow?
- ALow-fat
- BHigh-fiber
- CHigh-protein
- DLow-carbohydrate
106The diet prescribed for a client with diverticulosis includes 30 grams of fiber a day. Which breakfast items should the nurse encourage the client to select?
- ACream of wheat, milk, and cranberry juice
- BUnstrained orange juice, pancakes, and bacon
- COatmeal, sliced bananas, whole wheat toast, and milk
- DPoached eggs on whole wheat toast, tomato juice, and tea
107A client with Crohn disease is admitted to the hospital with a history of chronic, bloody diarrhea, weight loss, and signs of general malnutrition. The client has anemia, a low serum albumin level, and signs of negative nitrogen balance. The nurse concludes that the client's health status is related to what major deficiency?
- AFerrous sulfate
- Bprotein
- CAscorbic acid
- DLinoleic acid
108A client has a body mass index (BMI) of 35 and verbalizes the need to lose weight. The nurse encourages the client to lose weight safely by changing which dietary habits?
- ADecrease portion size and fat intake
- BIncrease protein and vegetable intake
- CDecrease carbohydrate and fat intake
- DIncrease fruits and limit fluid intake
109A client admitted to the hospital with a diagnosis of malabsorption syndrome exhibits signs of tetany. The nurse concludes that the tetany was precipitated by the inadequate absorption of which electrolyte?
- ANa
- BCa
- CK
- DPhosphorus
110A nurse is assessing a client for possible malabsorption syndrome. Which stool assessment finding will support this diagnosis?
- Amelena
- Bfrank blood
- CFat globules
- DCurrant jelly consistency
111A nurse is assessing two clients. One client has ulcerative colitis, and the other client has Crohn disease. Which is more likely to be identified in the client with ulcerative colitis than in the client with Crohn disease?
- AInclusion of transmural involvement of the small bowel wall
- BHigher occurrence of fistulas and abscesses from changes in the bowel wall
- CPathology beginning proximally with intermittent plaques found along the colon
- DInvolvement starting distally with rectal bleeding that spreads continuously up the colon
112A client is experiencing an exacerbation of ulcerative colitis. A low-residue, high-protein diet and IV fluids with vitamins have been prescribed. When implementing these prescriptions, which goal is the nurse trying to achieve?
- AReduce gastric acidity
- BReduce colonic irritation
- CReduce intestinal absorption
- DReduce bowel infection rate
113A nurse is teaching a client with an acute exacerbation of ulcerative colitis about the most appropriate diet. Which food selected by the client indicates that the dietary teaching is effective?
- AOJ
- BScrambled eggs
- CVanilla milkshake
- DCreamed potato soup
114A client with Crohn disease is admitted to the hospital with abdominal pain, fever, poor skin turgor, and diarrhea, with 10 stools in the past 24 hours. Which signs are evidence that the client most likely is dehydrated? Select all that apply.
- AMoist skin
- BSunken eyes
- CDecreased apical pulse
- DDry mucous membranes
- EIncreased blood pressure
115A nurse is assessing several clients. Which client will require parenteral nutrition?
- AA client with brain neoplasm
- BA client with anorexia nervosa
- CA client with inflammatory bowel disease
- DA client with severe malabsorption disorder
116A client is receiving total parenteral nutrition (TPN) through a central venous access device. The nurse discovers that the TPN bag is empty and the next bag has not been received yet from the pharmacy. What is the most appropriate action for the nurse to take?
- APerform a finger stick glucose test and call the primary healthcare provider with the results.
- BHang a bag of 10% dextrose at the ordered TPN rate and place an urgent request for the next TPN bag
- CDiscontinue the infusion and flush the IV line with saline solution until the next TPN bag is ready.
- DHang a bag of 5% dextrose at a keep-open rate and notify the nurse manager of the occurrence
117A nurse is teaching a client about gastroesophageal reflux disease (GERD). Which statement made by the client indicates correct understanding of GERD management?
- A"Three meals per day is the best regimen to avoid GERD symptoms."
- B"I can reduce my GERD symptoms through a high-carbohydrate, low-fat diet."
- C"A snack at bedtime will help reduce the acidity of my stomach during the night."
- D"I will place a 6-inch (15 cm) block under the head of my bed to help with digestion."
118A healthcare provider prescribes dietary and medication therapy for a client with the diagnosis of gastroesophageal reflux disease (GERD). What is most appropriate for the nurse to teach the client about meal management?
- ASnack daily in the evenings
- BDivide food into four to six meals a day
- CEat the last of three daily meals by 8:00 PM
- DSuck a peppermint candy after each meal
119A nurse is caring for a client with a hiatal hernia. Which risk factor should the nurse assess for in this client?
- AObesity
- BAlcoholism
- CChronic bronchitis
- DEsophageal varices
120An obese client with a hiatal hernia asks the nurse how to prevent esophageal reflux. Which is the nurse's best response?
- A"Lie down after eating."
- B"Eat less food at each meal."
- C"Increase your intake of fat."
- D"Drink more fluid with each meal."
121A client is prescribed ranitidine 150 mg daily to treat peptic ulcer disease (PUD). Which instruction would the nurse give to the client about when to take this medication?
- AAs needed
- BWith meals
- CAt bedtime
- DWhen indigestion occurs
122Which information should be included in the teaching plan for the elderly client with peptic ulcer disease who is taking an antacid and sucralfate?
- AAntacids should be taken 30 minutes before a meal
- BSucralfate should be taken on an empty stomach one hour before meals.
- CSucralfate is prescribed for the long-term maintenance of peptic ulcer disease.
- DSodium bicarbonate is an inexpensive over-the-counter antacid with few adverse effects
123A client with a history of Crohn disease develops an intestinal obstruction. A nasogastric tube is inserted and connected to low continuous suction. The nurse monitors the client for fluid volume deficit. What clinical finding does the nurse expect if the client becomes dehydrated?
- ARestlessness
- Bconstipation
- CInelastic skin turgor
- DIncreased blood pressure
124A client develops peritonitis and sepsis after the surgical repair of a ruptured diverticulum. What signs should the nurse expect when assessing the client? Select all that apply.
- Afever
- BTachypnea
- CHTN
- DAbdominal rigidity
- EIncreased bowel sounds
125Four days after abdominal surgery a client has not passed flatus and there are no bowel sounds. Paralytic ileus is suspected. What does the nurse conclude is the most likely cause of the ileus?
- ADecreased blood supply
- BImpaired neural functioning
- CPerforation of the bowel wall
- DObstruction of the bowel lumen
126A nurse is caring for a client who is scheduled for a gastric bypass to treat morbid obesity. Which diet should the nurse teach the client to maintain because it will help minimize clinical manifestations of dumping syndrome?
- ALow-residue, bland diet
- BFluid intake below 500 mL
- CSmall, frequent feeding schedule
- DLow-protein, high-carbohydrate diet
127The nurse is caring for a client who is scheduled for a gastric bypass to treat morbid obesity. Which statement by the client indicates a good understanding of preventing dumping syndrome after meals? Select all that apply.
- A"I will eat a bland diet."
- B"I will not drink fluids when I eat meals."
- C"I will avoid sweetened and spicy foods."
- D"I will eat a low-protein, high-carbohydrate diet."
- E"I will eat small, frequent meals instead of three large meals a day."
128A client develops steatorrhea with malabsorption syndrome. How will the nurse document this finding in the client’s medical record?
- ADry and rock-hard
- BClay-colored and pasty
- CBulky and foul-smelling
- DBlack and blood-streaked
129A client with severe Crohn disease develops a small bowel obstruction. Which clinical finding should the nurse expect the client to report?
- ABloody vomitus
- BProjectile vomiting
- CBleeding with defecation
- DPain in the left lower quadrant
130You are initiating a nursing care plan for a patient with osteoporosis. All of these nursing interventions apply to the nursing diagnosis Risk for Falls. Which intervention should you delegate to the UAP?
- AIdentifying environmental factors that increase risk for falls
- BMonitoring gait, balance, and fatigue level with ambulation
- CCollaborating with the physical therapist (PT) to provide the patient with a walker
- DAssisting the patient with ambulation to the bathroom and in the halls
131You are preparing to teach a patient with a new diagnosis of osteoporosis about strategies to prevent falls. Which teaching points will you be sure to include? (Select all that apply.)
- AWear a hip protector when ambulating.
- BRemove throw rugs and other obstacles at home.
- CExercise to help build your strength.
- DExpect a few bumps and bruises when you go home.
- ERest when you are tired.
132As charge nurse, you are making assignments for the day shift. Which patient would you assign to the nurse who was floated from the postanesthesia care unit (PACU) for the day?
- A35-year-old with osteomyelitis who needs teaching before hyperbaric oxygen therapy
- B62-year-old with osteomalacia who is being discharged to a long-term care facility
- C68-year-old with osteoporosis given a new orthotic device whose knowledge of its use must be assessed
- D72-year-old with Paget disease who has just returned from surgery for total knee replacement
133You delegate the measurement of vital signs to an experienced UAP. Osteomyelitis has been diagnosed in a patient. Which vital sign value would you instruct the UAP to report immediately?
- ATemperature of 101° F (38.3° C)
- BBlood pressure of 136/80 mm Hg
- CHeart rate of 96 beats/min
- DRespiratory rate of 24 breaths/min
134You are caring for a patient with carpal tunnel syndrome (CTS) who has been admitted for surgery. Which intervention should you delegate to the UAP?
- AInitiating placement of a splint for immobilization during the day
- BAssessing the patient’s wrist and hand for discoloration and brittle nails
- CAssisting the patient with daily self-care measures such as bathing and eating
- DTesting the patient for painful tingling in the four digits of the hand
135You observe a UAP performing all of these interventions for a patient with CTS. Which action requires that you intervene immediately?
- AArranging the patient’s lunch tray and cutting his meat
- BProviding warm water and assisting the patient with his bath
- CReplacing the patient’s splint in hyperextension position
- DReminding the patient not to lift very heavy objects
136A patient is scheduled for endoscopic carpal tunnel release surgery in the morning. What would you be sure to teach the patient?
- APain and numbness will be experienced for several days to weeks.
- BImmediately after surgery, the patient will no longer need assistance.
- CAfter surgery, the dressing will be large and there will be lots of drainage.
- DThe patient’s pain and paresthesia will no longer be present.
137As charge nurse, you assign the nursing care of a patient who has just returned from open carpal tunnel release surgery to an experienced LPN/LVN, who will perform under the supervision of an RN. Which instructions would you provide for the LPN/LVN? (Select all that apply.)
- ACheck the patient’s vital signs every 15 minutes in the first hour.
- BCheck the dressing for drainage and tightness.
- CElevate the patient’s hand above the heart.
- DThe patient will no longer need pain medication.
- ECheck the neurovascular status of the fingers every hour.
138You are preparing the patient who had carpal tunnel release surgery for discharge. Which information is important to provide to this patient?
- AThe surgical procedure is a cure for CTS.
- BHand movements will be restricted for 4 to 6 weeks after surgery.
- CFrequent doses of pain medication will no longer be necessary.
- DThe health care provider should be notified immediately if there is any pain or discomfort.
139When receiving discharge instructions, a patient with osteoporosis makes all of these statements. Which statement indicates to you that the patient needs additional teaching?
- A“I take my ibuprofen every morning as soon as I get up.”
- B“My daughter removed all of the throw rugs in my home.”
- C“My husband helps me every afternoon with range-of-motion exercises.”
- D“I rest in my reclining chair every day for at least an hour.”
140A patient has a fractured femur. Which finding would you instruct the UAP to report immediately?
- AThe patient reports pain.
- BThe patient appears confused.
- CThe patient’s blood pressure is 136/88 mm Hg.
- DThe patient voided using the bedpan
141After you receive the change-of-shift report, which patient should you assess first?
- A42-year-old with CTS who reports pain
- B64-year-old with osteoporosis awaiting discharge
- C28-year-old with a fracture who reports that the cast is tight
- D56-year-old with a left leg amputation who reports phantom pain
142A patient with a fractured fibula is receiving skeletal traction and has skeletal pins in place. What would you instruct the UAP to report immediately?
- AThe patient wants to change position in bed.
- BThere is a small amount of clear fluid at the pin sites.
- CThe traction weights are resting on the floor.
- DThe patient reports pain and muscle spasm.
143The nursing diagnosis for a patient with a fracture of the right ankle is Impaired Physical Mobility. As charge nurse, you observe a newly-graduated RN perform all of these interventions. For which action should you intervene?
- AEncouraging the patient to go from a lying to a standing position
- BAdministering pain medication before the patient begins exercises
- CExplaining to the patient and family the purpose of the exercise program
- DReminding the patient about the correct use of crutches
144The charge nurse is assigning the nursing care of a patient who had a left below-the-knee amputation 1 day ago to an experienced LPN/LVN, who will function under your supervision. What will you tell the LPN/LVN is the major focus for the patient’s care today?
- ATo attain pain control over phantom pain
- BTo monitor for signs of sufficient tissue perfusion
- CTo assist the patient to ambulate as soon as possible
- DTo elevate the residual limb when the patient is supine
145A patient with a right above-the-knee amputation asks you why he has phantom limb pain. What is your best response?
- A“Phantom limb pain is not explained or predicted by any one theory.”
- B“Phantom limb pain occurs because your body thinks your leg is still present.”
- C“Phantom limb pain will not interfere with your activities of daily living.”
- D“Phantom limb pain is not real pain but is remembered pain.”
146During morning care, a patient with a below-the-knee amputation asks the UAP about prostheses. How will you instruct the UAP to respond?
- A“You should get a prosthesis so that you can walk again.”
- B“Wait and ask your doctor that question the next time he comes in.”
- C“It’s too soon to be worrying about getting a prosthesis.”
- D“I’ll ask the nurse to come in and discuss this with you.”
147During assessment of a patient with fractures of the medial ulna and radius, you find all of these data. Which assessment finding should you report to the health care provider immediately?
- AThe patient reports pressure and pain.
- BThe cast is in place and is dry and intact.
- CThe skin is pink and warm to the touch.
- DThe patient can move all the fingers and the thumb.
148A patient who underwent a right above-the-knee amputation 4 days ago also has a diagnosis of depression. Which order would you clarify with the health care provider?
- AGive fluoxetine (Prozac) 40 mg once a day.
- BAdminister acetaminophen with codeine (Tylenol-Codeine) 1 or 2 tablets every 4 hours as needed.
- CAssist the patient to the bedside chair every shift.
- DReinforce the dressing to the right residual limb as needed.
149The increased risk for falls in the older adult is most likely due to
- Achanges in balance.
- Bdecrease in bone mass.
- Closs of ligament elasticity.
- Derosion of articular cartilage.
150A patient with tendonitis asks what the tendon does. The nurse's response is based on the knowledge that tendons
- Aconnect bone to muscle.
- Bprovide strength to muscle.
- Clubricate joints with synovial fluid.
- Drelieve friction between moving parts.
151While obtaining subjective assessment data related to the musculoskeletal system, it is particularly important to ask a patient about other medical problems such as
- AHTN
- Bthyroid problems.
- CDM
- Dchronic bronchitis
152When grading muscle strength, the nurse records a score of 3, which indicates
- Ano detection of muscular contraction.
- Ba barely detectable flicker of contraction.
- Cactive movement against full resistance without fatigue.
- Dactive movement against gravity but not against resistance.
153A normal assessment finding of the musculoskeletal system is
- Ano deformity or crepitation.
- Bmuscle and bone strength of 4.
- Culnar deviation and subluxation.
- Dangulation of bone toward midline.
154The patient is told by the health care provider that the size of the patient’s muscle has decreased. How should the nurse document this occurrence?
- AHyaline
- Batrophy
- CIsometric
- DHypertrophy
155An older patient is describing increased rigidity in the shoulders, back, and hips. The loss of elasticity in what tissue contributes to this?
- AActin
- BFascia
- CMyosin
- DCartilage
156What is the best description of the periosteum?
- ALining of a joint capsule
- BA characteristic of skeletal muscle
- CMost common type of cartilage tissue
- DFibrous connective tissue covering bone
157In performing range of motion (ROM) with a patient, the nurse puts each joint through its full movement. Which joints are capable of abduction and adduction (select all that apply)?
- Ahip
- Bknee
- Cwrist
- Delbow
- Ethumb
- Fshoulder
158While having his height measured during a routine health examination, a 79-year-old man asks the nurse why he is “shrinking.” How should the nurse explain the decreased height that occurs with aging?
- ADecreased muscle mass results in a stooped posture.
- BLoss of cartilage in the knees and hip joints causes a loss of height.
- CLong bones become less dense and shorten as bone tissue compacts.
- DVertebrae become more compressed with thinning of intervertebral discs.
159 A 78-year-old woman has a physiologic change related to aging in her joints. What is an appropriate nursing intervention related to common changes of aging in the musculoskeletal system?
- AEncourage rest to eliminate fatigue.
- BProvide all care for the patient to ensure that care is completed.
- CEncourage eating enough calories to avoid the risk for impaired skin integrity.
- DHave the patient exercise to maintain muscle strength and avoid the risk for falls.
160When obtaining information about the patient’s use of medications, the nurse recognizes that both bone and muscle function may be impaired when the patient reports taking what type of drug?
- ACorticosteroids
- BOral hypoglycemic agents
- CPotassium-depleting diuretics
- DNonsteroidal antiinflammatory drugs (NSAIDs)
161During muscle strength testing, the patient has active movement against gravity and some resistance to pressure. What score should the nurse give this finding?
- A2
- B3
- C4
- D5
162 On observation of the patient, the nurse notes the presence of a gait disturbance. How should the nurse further evaluate the patient?
- APalpate the hips for crepitation.
- BMeasure the length of the limbs.
- CEvaluate the degree of leg movement.
- DCompare the muscle mass of one leg with the other.
163A patient with severe joint immobility is receiving physical and exercise therapy. To evaluate the effect of the treatment, the nurse may assess joint range of motion with what equipment?
- AErgometer
- BMyometer
- CGoniometer
- DArthrometer
164The patient was referred to the office by the school nurse for a lateral curvature of the spine. The nurse knows this is called
- Alordosis.
- Bscoliosis.
- Cankylosis.
- Dkyphosis.
165In report, the nurse is told that the patient has a contracture of the right arm. What does the nurse know this means?
- AA fluid-filled cyst
- BGeneralized muscle pain
- CShortening of a muscle or ligament
- DGrating sensation between bones with movement
166 What is the most common diagnostic test used to assess musculoskeletal disorders?
- AMyelogram
- BArthroscopy
- CStandard x-ray
- DMRI
167What test provides fast, precise measurement of the bone mass of the spine, forearm, and total body to evaluate osteoporosis?
- Abone scan
- BDiskogram
- CQuantitative ultrasound (QUS)
- DDual energy x-ray absorptiometry (DXA)
168Which serologic tests would be done to evaluate rheumatoid arthritis (select all that apply)?
- AUric acid
- BAnti-DNA antibody
- CRheumatoid factor (RF)
- DAntinuclear antibody (ANA)
- EErythrocyte sedimentation rate (ESR)
169The nurse suspects an ankle sprain when a patient at the urgent care center relates
- Abeing hit by another soccer player during a game.
- Bhaving ankle pain after sprinting around the track.
- Cdropping a 10-lb weight on his lower leg at the health club.
- Dtwisting his ankle while running bases during a baseball game
170The nurse explains to a patient with a fracture of the distal shaft of the humerus who is returning for a 4-week checkup that healing is indicated by
- Aformation of callus.
- Bcomplete bony union.
- Chematoma at fracture site.
- Dpresence of granulation tissue.
171A patient with a comminuted fracture of the tibia is to have an open reduction with internal fixation (ORIF) of the fracture. The nurse explains that ORIF is indicated when
- Athe patient is unable to tolerate prolonged immobilization.
- Bthe patient cannot tolerate the surgery of a closed reduction.
- Ca temporary cast would be too unstable to provide normal mobility.
- Dadequate alignment cannot be obtained by other nonsurgical methods.
172An indication of a neurovascular problem noted during assessment of the patient with a fracture is
- Aexaggeration of strength with movement.
- Bincreased redness and heat below the injury.
- Cdecreased sensation distal to the fracture site.
- Dpurulent drainage at the site of an open fracture.
173A patient with a stable, closed fracture of the humerus caused by trauma to the arm has a temporary splint with bulky padding applied with an elastic bandage. The nurse suspects compartment syndrome and notifies the physician when the patient experiences
- Aincreasing edema of the limb.
- Bmuscle spasms of the lower arm.
- Crebounding pulse at the fracture site.
- Dpain when passively extending the fingers.
174During the postoperative period, the nurse instructs the patient with an above-the-knee amputation that the residual limb should not be routinely elevated because this position promotes
- Ahip flexion contractures.
- Bskin irritation and breakdown.
- Cclot formation at the incision site.
- Dincreased risk of wound dehiscence.
175A patient with osteoarthritis is scheduled for a total hip arthroplasty. The nurse explains that the purpose of this procedure is to (select all that apply)
- Afuse the joint.
- Breplace the joint.
- Cprevent further damage.
- Dimprove or maintain ROM.
- Edecrease the amount of destruction in the joint.
176A 72-year-old man tells the nurse that he cannot perform most of the physical activities he could do 5 years ago because of overall joint aches and pains. What can the nurse do to assist the patient to prevent further deconditioning and decrease the risk for developing musculoskeletal problems?
- ALimit weight-bearing exercise to prevent stress on fragile bones and possible hip fractures.
- BAdvise the patient to avoid the use of canes and walkers because they increase dependence on ambulation aids.
- CAdvise the patient to increase his activity by more frequently climbing stairs in buildings and other environments with steps.
- DDiscuss use of over-the-counter (OTC) medications to decrease inflammation and pain so that exercise can be maintained.
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- Med/Surg 1 Quiz on Exam 3 Part 2, created by Nicole Buda on 08/02/2017.
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- Nicole Buda
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