Herzing University NSG 223 Med Surg II Exam 3
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The nurse is caring for the patient with a recent lower extremity injury.
During the physical assessment, the nurse would include which
components in the inspection and palpation of the injury? Select all that
apply. - ANSWER-Pallor
Pulselessness
Movement
Sensation
The nurse is seeing a patient in the emergency department with a severe
sprain to the left ankle. The nurse would include which information in
the discharge teaching? Select all that apply. - ANSWER-Rest the injury.
Elevate the extremity.
Use a compression wrap to the injury.
How would the nurse explain to the patient the difference between a
strain and a sprain? - ANSWER-"A sprain is the stretching or tearing of
a ligament; a strain is the stretching or tearing of a muscle or tendon."
The nurse is caring for a patient who was involved in a crush injury of
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the lower extremity and is complaining of severe flank pain and the
Which assessment findings would provide an indication of increased
intracranial pressure? Select all that apply.
Oxygen saturation
Decreased alertness
Increased blood pressure
Personality changes
Swelling of the optic disc - SOLUTION=Decreased alertness
Personality changes
Swelling of the optic disc
What common complications should the nurse assess for in a client with
a brain tumor? Select all that apply.
Bleeding
Seizures
Venous thrombus embolism
Decline in kidney function
Cerebral edema - SOLUTION=Bleeding
Seizures
Venous thrombus embolism
Cerebral edema
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The nurse is caring for a patient undergoing chemotherapy for a brain
tumor. Which is the most important nursing intervention for this patient?
Encourage use of sunscreen lotion.
Provide nutritional supplements.
Teach importance of frequent handwashing.
Encourage use of skin emollients. - SOLUTION=Teach importance of
frequent handwashing.
Which intervention should the nurse implement for the patient with
increased intracranial pressure following a brain tumor resection?
Administer stool softeners.
Position the patient in a supine position at all times.
Apply sequential compression devices.
Encourage the patient to use a non-alcohol containing mouth wash. -
SOLUTION=Administer stool softeners.
The computed tomography reports of a patient show a glioma located
near the brainstem. Which grade of brain tumor does the patient have?
Grade I
Grade II
Grade III
Grade IV - SOLUTION=Grade IV
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presence of dark, tea-colored urine. The nurse is aware of the potential
for which serious complication? - ANSWER-Rhabdomyolysis
The nurse is aware that a serious complication of an open fracture is
osteomyelitis. If the osteomyelitis is not treated promptly, which further
complications can occur? Select all that apply. - ANSWER-Gas
gangrene
Tetanus
The nurse is caring for a client with a blunt trauma and tissue injury to
the lower extremity. Which signs could develop in a client with
compartment syndrome?
Increased pain in the affected extremity upon ambulation
Numbness in the toes of the affected extremity
Passive pain at rest in the affected extremity
Absence of pain in the affected extremity - ANSWER-Passive pain at
rest in the affected extremity
The nurse is caring for an older client who has been diagnosed with
osteoporosis. The nurse explains to the client that vertebral compression
fractures are common with osteoporosis and can result in which
condition?
Lordosis