SAUNDERS COMPREHENSIVE REVIEW FOR NCLEX THREE

SAUNDERS COMPREHENSIVE REVIEW FOR NCLEX THREE 1) The nurse performs an assessment on a client admitted with contact dermatitis. Which signs and symptoms should the nurse look for? Lesions with well-defined geometric margins 2) The nurse is providing home care instructions to the client who just had surgery for squamous cell carcinoma. The nurse provides follow-up teaching and explains to the client to watch for which characteristics of this type of skin carcinoma? Firm, nodular lesion topped with a crust or with a central area of ulceration 3) The nurse is teaching the client about risk factors for skin cancer. Which statements by the client indicate that teaching was successful? Select all that apply. "I have to avoid excessive exposure to sunlight." "I am at higher risk for skin cancer because my mother had one." 4) The nurse is assessing a dark-skinned client for signs of anemia. The nurse should focus the assessment on which structures? Select all that apply. Lips Conjunctiva Mucous membranes 5) The nurse is providing teaching to a client who will undergo chemotherapy for cancer, and alopecia is expected from the chemotherapeutic agent. Which statement made by the client indicates a need for further teaching? "I can't believe my hair loss will be permanent." 6) The nurse is caring for a client with full-thickness circumferential burns of the entire trunk of the body. Which finding suggests that an escharotomy may be necessary? High pressure alarm keeps sounding on the ventilator 7) A client with chloasma is extremely stressed about the change in her facial appearance. Which integumentary change observed by the nurse is consistent with this problem? Blotchy brown macules across the cheeks and forehead 8) The nurse is planning care for a client who suffered a burn injury and has a negative self-image related to keloid formation at the burn site. The keloid formation is indicative of which condition? Hypertrophy of collagen fibers 9) The nurse observes the client's sacrum and notes the following. How will the nurse document this in the client's medical record? Refer to figure. View Figure Stage IV pressure ulcer 10) A client recently diagnosed with chronic kidney disease requiring hemodialysis has an arteriovenous fistula for access. The client asks the nurse what complications can occur with the access site. What complications should the nurse inform the client about? Select all that apply. Hepatitis Infection 11) The nurse has completed discharge teaching for a client who was admitted for reticular skin lesions. Which statement by the client indicates understanding of the discharge instructions? "I need to assess my skin for lesions that appear net-like." 12) A client exhibits erythema of the skin. The nurse plans care, knowing that which factors are responsible for this finding? Select all that apply. Fever Vasodilation Inflammation Excessively high environmental temperature 13) An older client's physical examination reveals the presence of a fiery star-shaped marking with a circular, solid center. The nurse recognizes that these findings, which are caused by capillary radiations extending from the central arterial body, are representative of which lesions? Spider angioma 14) An older client is lying in a supine position. The nurse understands that the client is at least risk for skin breakdown in which body area? Greater trochanter 15) In planning care for the client with psoriasis, the nurse understands that which represents a priority client problem? Altered body image 16) The nurse is performing an admission assessment on a client diagnosed with paronychia. The nurse should plan to assess which part of the integumentary system first? Nails 17) A client exhibits a purplish bruise to the skin after a fall. The nurse would document this finding in the health record most accurately using which term? Ecchymosis 18) A client is diagnosed with a full-thickness burn. What should the nurse anticipate will be used for final coverage of the client's burn wound? Autograft 19) The nurse is providing instructions to a client with psoriasis who will be receiving ultraviolet (UV) light therapy. Which statement would be most appropriate for the nurse to include in the client's instructions? "You will need to wear dark eye goggles during the treatment." 20) The nurse in the surgical care center will be assisting the health care provider to perform a punch biopsy of a client's skin lesion. Which interventions should be included in the preprocedure plan of care? Select all that apply. Obtain an informed consent. Prepare to apply direct pressure to the biopsy site after the procedure. Tell the client that a small piece of tissue will be removed for examination. 21) The nurse is developing a teaching plan for a group of adolescents regarding the causes of acne. The nurse develops the plan based on which characteristics associated with acne? Select all that apply. The exact cause of acne is unknown. Acne requires active treatment for control until it resolves. Oily skin and a genetic predisposition may be contributing factors for acne. The types of lesions in acne include comedones (open and closed), pustules, papules, and nodules. 22) The nurse is reviewing the health care records of clients scheduled to be seen at a health care clinic. The nurse determines that which client is at the greatest risk for development of an integumentary disorder? An outdoor construction worker 23) A client scheduled for a skin biopsy is concerned and asks the nurse how painful the procedure is. Which statement is the appropriate response by the nurse? "The local anesthetic may cause a burning or stinging sensation." 24) The nurse is preparing a client for punch biopsy. What should the nurse do to prepare for this procedure? Ensure that the consent form has been signed. 25) The nurse prepares to assist a health care provider who is examining a client's skin with a Wood's light. Which step should the nurse include in the plan for this procedure? Darken the room for the examination. 26) The nurse prepares to treat a client with frostbite of the toes. Which action should the nurse anticipate will be prescribed for this condition? Rapid and continuous rewarming of the toes in a warm water bath until flushing of the skin occurs 27) The presence of which finding leads the home health nurse to suspect infestation of a client with scabies? Multiple straight or wavy, threadlike lines beneath the skin 28) The nurse suspects herpes zoster (shingles) when which assessment finding is noted? Clustered skin vesicles 29) Ultraviolet (UV) light therapy is prescribed as a component of the treatment plan for a client with psoriasis, and the nurse provides instructions to the client regarding the treatment. Which statement by the client indicates a need for further instruction? "The UV light treatments are given on consecutive days." 30) The nurse prepares to care for a client with acute cellulitis of the lower leg. The nurse anticipates that which interventions will be prescribed for the client? Select all that apply. Antibiotic therapy Warm compresses to the affected area 31) Which individuals are most likely to be at risk for development of psoriasis? Select all that apply. A woman experiencing menopause A client with a family history of the disorder An individual who has experienced a significant amount of emotional distress 32) A 60-kg client has sustained third-degree burns over 40% of the body. Using the Parkland (Baxter) formula, the minimum fluid requirements are which during the first 24 hours after the burn? 9600 mL of lactated Ringer's solution 33) The nurse is evaluating fluid resuscitation attempts in the burn client. Which finding indicates adequate fluid resuscitation? Heart rate of 95 beats/minute 34) The nurse is assessing a dark-skinned client for the presence of petechiae. Which body area is the best for the nurse to check in this client? Oral mucosa 35) The nurse is caring for a client who has vesicles filled with purulent fluid on the face and upper extremities. On the basis of these findings, the nurse should tell the client that the vesicles are consistent with which condition? Acne 36) The nurse is performing assessment of the client who is admitted with left leg cellulitis. What does the nurse anticipate finding on the assessment of the left lower extremity? Erythema 37) A client complains of chronic pruritus. Which diagnosis should the nurse expect to note documented in the client's medical record that would support this client's complaint? Chronic kidney disease 38) A client being seen in an ambulatory clinic for an unrelated complaint has a butterfly rash noted across the nose. The nurse interprets that this finding is consistent with early manifestations of which disorder? Systemic lupus erythematosus (SLE) 39) The nurse notes that an older adult has a number of bright, ruby-colored, round lesions scattered on the trunk and thighs. How should the nurse document these lesions in the medical record? Appears to have cherry angiomas on trunk and thighs 40) The nurse is teaching a client about changes in body image related to chronic obstructive pulmonary disease (COPD). Which statement by the client would indicate that teaching was successful? "My nails may become clubbed." 41) The nurse is teaching a client who is preparing for discharge from the hospital after having a stroke about prevention of pressure ulcers while the client has limited mobility. Which statement by the client indicates the need for further teaching? "I can sit in my favorite chair all day." 42) The nurse is caring for a client with a diabetic ulcer. What discharge instructions should the nurse provide to the client? Select all that apply. Use a mild soap when washing the feet. Use lanolin on the feet to prevent dryness. Exercise the feet daily by walking and flexing at the ankle. 43) An older client has been lying in a supine position for the past 3 hours. The nurse who is repositioning this client would be most concerned with examining which bony prominences of the client? Select all that apply. Heels Elbows Sacrum Back of the head 44) An adult client trapped in a burning house has suffered burns to the back of the head, the upper half of the posterior trunk, and the back of both arms. Using the rule of nines, what percentage does the nurse determine the extent of the burn injury to be? Fill in the blank. Correct Answer: 22.5 % 45) A hospitalized client is diagnosed with scabies. The health care provider (HCP) recommended that the client and the client's roommate be treated with lindane. Which finding, if noted on this client's chart, would alert the nurse to notify the HCP before the treatment with lindane? Client history of seizure disorders 46) Isotretinoin has been prescribed for an adolescent with a diagnosis of severe cystic acne. The nurse provides instructions to the adolescent regarding the use of the medication. Which statement, if made by the adolescent, indicates a need for further instruction? "I need to be sure to take my vitamin A supplement so that the treatment will work." 47) The clinic nurse is caring for a client with a diagnosis of scabies who has just been prescribed crotamiton. The nurse instructs the client to perform which action when applying this medication? Massage the medication into the skin from the chin downward. Apply a second application in 24 hours, followed by a cleansing bath 48 hours after the second application. 48) A client has been given diphenhydramine as a topical agent for allergic dermatitis. The nurse should instruct the client to observe for which intended medication effect? A decrease in urticaria 49) A home health nurse is visiting a client who has been started on therapy with clotrimazole. The nurse determines the effectiveness of the medication by noting a decrease in which problem? Rash 50) An outbreak of head lice infestation has occurred at a local school. The school nurse is providing instructions to the mothers of the children attending the school regarding the application of malathion. The nurse should tell the mothers to take which action? Leave the lotion on for 8 to 12 hours, and then wash the hair with nonmedicated shampoo. 51) A client is seen in the clinic for a complaint of scalp itching that has been persistent over the past several weeks. After an assessment, it is determined that the client has head lice. Permethrin shampoo is prescribed, and the nurse provides instructions to the client regarding the use of the medication. The nurse should tell the client to take which measure? Wash, rinse, and towel-dry the hair before applying. 52) Lindane is prescribed. The nurse reviews the client's record, knowing that this medication therapy would be contraindicated in which client? A child 53) The nurse is applying a topical glucocorticoid as prescribed for a client with psoriasis. The nurse would be concerned about the potential for systemic absorption of the medication if it were being applied in which situation? Applied to a reddened, itchy area underneath an occlusive dressing 54) A topical corticosteroid is prescribed for an infant with dermatitis in the gluteal area. The nurse provides instructions to the mother regarding the use of the medication. Which statement by the mother indicates an understanding of the use of the medication? "The medication will help relieve the inflammation." 55) A child with severe seborrheic dermatitis is receiving treatments of topical corticosteroid applied over an extensive area of the body, followed by the application of an occlusive dressing. The nurse should monitor the child closely, knowing that which systemic effect can occur as a result of this treatment? Growth retardation 56) A client with acute seborrheic dermatitis of the back, chest, and legs is receiving treatments with salicylic acid. The nurse should monitor the client for which symptom that indicates the presence of systemic toxicity from this medication? Increased respirations 57) Topical azelaic acid is prescribed for a client, and the clinic nurse provides instructions regarding the use of this medication. Which statement by the client indicates a need for further instruction? "The medication is used to treat my eczema." 58) Minoxidil is prescribed for a client to treat hair loss. The nurse provides instructions to the client regarding the application of the medication. Which statement by the client indicates that teaching is effective? "I will apply the prescribed amount of solution twice a day." 59) Minoxidil is prescribed for a client to treat hair loss. The client asks the nurse if the hair will continue to grow when the medication is stopped. What is the appropriate nursing response? "Newly gained hair is lost in 3 to 4 months." 60) The school nurse has provided instructions regarding the use of permethrin rinse to the parents of children diagnosed with pediculosis capitis (head lice). Which statement by one of the parents indicates a need for further instruction? "It is applied to the hair and then shampooed out." 61) A child is diagnosed with impetigo. The health care provider prescribes a topical medication for treatment. The nurse anticipates that which medication will be prescribed? Mupirocin 62) Coal tar has been prescribed for the client with psoriasis, and the nurse provides instructions to the client regarding this treatment. Which statement by the client indicates a need for further instruction? "The medication can cause diarrhea." 63) Mafenide acetate is prescribed for a client with a burn injury to the hand. Which should the nurse include in the instructions to the client regarding the use of this medication? It is normal to experience local discomfort and stinging and burning after the medication is applied. 64) A burn-injured client is receiving treatments of topical mafenide acetate to the site of injury. The nurse should monitor the client for which systemic effect that can occur from the use of this medication? Acidosis 65) The nurse is planning care for a client returning from the operating room after having an autograft applied to the right lower extremity. Which nursing intervention is focused on promoting graft "take"? Leave the dressing intact for 3 to 5 days. 66) Sodium hypochlorite solution is prescribed for a client with a wound on the left foot that is draining purulent material. Which action should the nurse plan to take? Irrigate the wound with the solution. 67) Tretinoin is prescribed for a client with acne, and the nurse provides instructions to the client regarding the medication. Which statement by the client indicates a need for further instruction? "If my skin begins to peel, I will notify the health care provider (HCP)." 68) The nurse provides instructions to a client regarding the use of topical tretinoin. Which statement by the client indicates a need for further instruction? "I cannot use any cosmetics while I am using this medication." 69) Isotretinoin is prescribed for a client to treat severe cystic acne, and the nurse provides instructions to the client regarding the medication. Which statement by the client indicates a need for further instruction? "I cannot crush or chew the tablets if I have difficulty swallowing them whole." 70) Tetracycline is prescribed for a client with severe acne. The nurse instructs the client regarding the importance of reporting which finding if it occurs? Persistent diarrhea 71) A health care provider (HCP) prescribes isotretinoin for a client with severe acne. The nurse reviews the client's record 72) and notifies the HCP if which prescribed medication is noted on the medication record? Doxycycline 73) The health care provider has prescribed a topical antiinflammatory cream for a client with a muscular sprain. The nurse provides instructions to the client regarding the medication. Which statement by the client indicates an understanding of this prescribed treatment? "The medication will act as a local anesthetic." 74) Collagenase is prescribed for a client with a severe burn to the hand. The home care nurse provides instructions to the client regarding the use of the medication. Which client statement indicates an accurate understanding of the use of this medication? "I will apply the ointment once a day and cover it with a sterile dressing." 75) Which clients can safely receive lindane? Select all that apply. An 89-year-old client with dementia A 32-year-old client with renal stones A 42-year-old woman with osteoporosis A 52-year-old man with hypertension and high cholesterol 76) A hydrocolloid dressing is prescribed for a client with a leg ulcer. The home health nurse is preparing a plan of care for the client and should appropriately document which intervention? Change the hydrocolloid dressing every 3 to 5 days. 77) A client is prescribed mupirocin intranasally twice daily. The nurse correlates this prescription with the client's medical record and expects to note which result specifically related to the indication for this medication? Positive methicillin-resistant Staphylococcus aureas (MRSA) by polymerase chain reaction (PCR) 78) The health care provider has prescribed coal tar treatments for a client with psoriasis, and the nurse provides information to the client about the treatments. Which statement made by the client indicates a need for further education about the treatments? "The medication always causes systemic toxicity." 79) Sodium hypochlorite is prescribed for a client with a leg wound that is draining purulent material. The home health nurse 80) teaches a family member how to perform wound treatments. Which statement, if made by the family member, indicates a need for further teaching? "I will soak a sterile dressing with solution and pack it into the wound." 81) The nurse has provided instructions to a client regarding the use of tretinoin. Which statement made by the client indicates the need for further instruction? "I must apply it to wet to damp skin." 82) A client is seen in the clinic for complaints of skin itchiness that has persisted for several weeks. After an assessment, the client is determined to have scabies. Lindane is prescribed, and the nurse provides instructions to the client regarding the use of the medication. Which action should the nurse tell the client to take? Leave the cream on for 8 to 12 hours, and then remove it by washing. 83) A topical corticosteroid is prescribed for a client with dermatitis. The nurse provides instructions to the client regarding the use of the medication. Which statement by the client would indicate a need for further instruction? "I should place a bandage over the site after applying the medication." 84) A client has a wound with a moderate amount of drainage and is scheduled for a dressing change. Which dressing, if selected by the student nurse, requires further intervention by the nursing instructor? Semipermeable transparent film 85) The home health care nurse makes a home visit to a client who has an ulcer on the medial aspect of the left ankle. The wound is being treated with a hydrocolloid dressing. The nurse removes the hydrocolloid dressing, cleanses the wound as prescribed, and reapplies the hydrocolloid dressing. The nurse schedules the next visit for wound care and changing the hydrocolloid dressing in how many days, which is the maximum number of days? Fill in the blank. Correct Answer: 7 days 86) Isotretinoin is prescribed for a client with severe cystic acne. The nurse provides instructions to the client regarding administration of the medication. Which phrase stated by the client indicates a need for further teaching regarding this medication? "I need to continue to take my vitamin A supplements." 87) A burn client has been having 1% silver sulfadiazine applied to burns twice a day for the past 3 days. Which laboratory abnormality indicates that the client is experiencing a side or adverse effect of this medication? White blood cell count of 3000 mm3 (3 × 109/L) 88) The nurse is providing instructions to a mother of a child with atopic dermatitis (eczema) regarding the application of topical cortisone cream to the affected skin sites. Which statement made by the mother indicates an understanding of the use of this medication? "I need to wash the sites gently before I apply the medication." 89) A client with psoriasis is being treated with calcipotriene cream. Administration of high doses of this medication can cause which side or adverse effect? Hypercalcemia 90) Collagenase is prescribed for a client with a severe burn to the hand. The nurse is providing instructions to the client and spouse regarding wound treatment. Which should the nurse include in the instructions? Apply once a day and cover it with a sterile dressing. 91) The nurse is caring for a client at home with a diagnosis of actinic keratosis. The client tells the nurse that her skin is very dry and irritated. The treatment includes diclofenac sodium. The nurse teaches the client that this medication is from which class of medications? Nonsteroidal antiinflammatory drugs (NSAIDs) 92) A client with muscle aches and a diagnosis of rheumatism has been given a prescription for capsaicin topical cream. The nurse determines that the client understands the use of the medication if the client makes which statement? "The medication will act as a local analgesic." 93) A client with a burn injury is applying mafenide acetate cream to the wound. The client calls the health care provider's (HCP's) office and tells the nurse that the medication is uncomfortable and is causing a burning sensation. The nurse should instruct the client to take which action? Continue with the treatment, as this is expected. 94) A client with an infected leg wound that is draining purulent material has a prescription for sodium hypochlorite to be used in the care of the wound. The nurse should implement which action while using this solution? Rinse off immediately following irrigation. 95) An adolescent with severe cystic acne has been prescribed isotretinoin. Which statement by the client would suggest the need for further teaching? "I need to take my vitamin A supplement so that the treatment will work." 96) An ambulatory care client with allergic dermatitis has been given a prescription for a tube of diphenhydramine 1% to use as a topical agent. The nurse determines that the medication was effective if which finding was noted? Decrease in urticaria 97) The nurse has completed giving discharge instructions to a client who has had a total joint replacement (TJR) of the knee with a metal prosthetic system. The nurse determines that the client understands the instructions if the client makes which statement? "All caregivers should be told about the metal implant." 98) The nurse develops a plan of care for a client with a spica cast that covers a lower extremity and documents that the client is at risk for constipation. When planning for bowel elimination needs, the nurse should include which in the plan of care? Use a fracture pan for bowel elimination. 99) The nurse is preparing to teach a client how to safely use crutches. Before initiating the teaching, the nurse performs an assessment on the client. The priority nursing assessment should include which information? The client's vital signs, muscle strength, and previous activity level 100) The nurse is providing instructions to a client regarding ambulation after the application of a fiberglass cast to the lower leg. The nurse determines that the client understands the instructions if the client states that weight bearing on the casted leg can begin at which time period? Within 20 to 30 minutes of application 101) The nurse is caring for a client in skeletal leg traction with an overbed frame. Which nursing intervention will best assist the client with self- positioning in bed? Place a trapeze on the bed frame to provide a means for the client to lift the hips off the bed. 102) The nurse is caring for the client who has skeletal traction applied to the left leg. The client complains of severe left leg pain. The nurse checks the client's alignment in bed and notes that proper alignment is maintained. Which is the priority nursing action? Call the health care provider. 103) The home care nurse visits a client who has a cast applied to the left lower leg. On assessment of the client, the nurse notes the presence of skin irritation from the edges of the cast. Which nursing intervention is most appropriate? Petal the cast edges with appropriate material. 104) A client who has been taking high doses of acetylsalicylic acid to relieve pain from osteoarthritis now has more generalized joint pain and an elevated temperature. The nurse should assess for which complication to determine whether the client has other signs of aspirin toxicity? Ringing in the ears 105) The nurse is developing a plan of care for a client in Buck's traction. The plan of care should include assessing the client for which finding indicating a complication associated with the use of this type of traction? Weak pedal pulses 106) The nurse is caring for a client in skeletal traction. On assessing the pin sites, the nurse notes the presence of purulent drainage. Which nursing action is most appropriate? Notify the health care provider. 107) The nurse is caring for a client with a radius fractured across the shaft and bone splintered into fragments. Information about which type of fracture should be included by the nurse in the client's education? Comminuted fracture 108) The home care nurse is providing instructions to a client regarding the use of crutches. The client asks the nurse to demonstrate the method for going down the stairs with the crutches. How should the nurse accurately demonstrate this technique? Crutches and the affected leg down, followed by the unaffected leg 109) The home care nurse has instructed a client how to perform the three-point gait with the use of crutches. The nurse observes the client using this gait to ensure correct performance of the maneuvers. Which observation, if made by the nurse, would indicate that the client understands how to perform this type of gait? The client moves both crutches forward, along with the affected leg, and then moves the unaffected leg forward. 110) A male client arrives in the hospital emergency department and tells the nurse that he twisted his ankle while jogging. The client is seen by the health care provider and is diagnosed with a sprained ankle. The nurse provides instructions to the client regarding home care for the injury. Which statement, if made by the client, would indicate an understanding of appropriate care measures for the next 24 hours? "I should elevate my foot above the level of the heart." 111) The community health nurse is providing an educational session for community members regarding dietary measures that will assist in reducing the risk of osteoporosis. The nurse should instruct the community members to increase dietary intake of which food known to be helpful in minimizing this risk? Yogurt 112) The nurse is teaching a client with a right arm cast how to prevent stiff or frozen shoulder. What should the nurse instruct the client to do? Lift the shoulder of the casted arm over the head periodically throughout the day. 113) The nurse is preparing to perform pin site care for a client in skeletal traction. On assessment of the pin site, the nurse notes the presence of serous drainage. Which nursing action would be appropriate? Document the findings. 114) The nurse is performing a neurovascular assessment on a client with a cast on the left lower leg. The nurse notes the presence of edema in the foot below the cast. The nurse should make which interpretation about this finding? Impaired venous return 115) The nurse is caring for a client with a long bone fracture at risk for fat embolism. The nurse specifically monitors for the earliest signs of this complication by performing an assessment of which item(s)? The neurological and respiratory systems 116) The nurse is caring for a client who was just admitted to the hospital with a diagnosis of a fractured right hip sustained from a fall 5 hours earlier. The nurse creates a plan of care for the client and includes interventions related to monitoring for signs of fat embolism. Which findings should be listed in the care plan as a sign/symptom of fat embolism? Dyspnea and chest pain 117) The nurse is caring for a client at risk for fat embolism because of a fracture of the left femur and pelvis sustained in a fall. The client also sustained a head injury, is comatose, and is unable to communicate verbally. Which assessment findings should the nurse identify as early signs of possible fat embolism? Increased heart rate and adventitious breath sounds 118) The nurse is caring for a client with a fractured tibia and fibula. Eight hours after a long leg cast is applied, the client reports a significant increase in pain level even after administration of the prescribed dose of opioid analgesic. What is the initial nursing action? Check the neurovascular status of the toes on the casted leg. 119) The nurse is caring for a client after the application of a plaster cast for a fractured left radius. The nurse should suspect impairment with the neurovascular status of the client's casted extremity if which findings are noted? Select all that apply. Client report of severe, deep, unrelenting pain Client report of pain as nurse assesses finger movement Client report of numbness and tingling sensation in the fingers 120) The nurse has delegated the ambulation of a client to the unlicensed assistive personnel (UAP). Which actions by the UAP support a clear understanding of the appropriate steps to carry out this task safely? Select all that apply. Remove clutter that may interfere with ambulation. Assist client in applying nonskid shoes before ambulation. Instruct client to sit up on the bedside and dangle before ambulation. Observe the client for dizziness during ambulation and report immediately. 121) A client has had surgery to repair a fractured left hip. When repositioning the client from side to side in the bed, what should the nurse plan to use as the most important item for this maneuver? Abductor splint 122) A client with a 4-day-old lumbar vertebral fracture is experiencing muscle spasms. Which are interventions to aid the client in relieving the spasm? Select all that apply. Heat Analgesics Muscle relaxers Intermittent traction 123) The nurse has reviewed activity restrictions with a client who is being discharged after insertion of a femoral head prosthetic system. What statement by the client will help the nurse determine that the client understands the material presented? Use a raised toilet seat. 124) The nurse is talking to a client who had a below-the- knee amputation 2 days earlier. The client states, "I hate looking at this; I feel that I'm not even myself anymore." What client problem should the nurse incorporate in the plan of care based on the statement by this client? Altered body image 125) The home health nurse is planning to teach a client with osteoporosis about home modifications to reduce the risk of falls. Which recommendations would be necessary to include in the teaching plan? Select all that apply. Use night lights. Remove scatter rugs. Use staircase railings. Place hand rails in the bathroom. 126) A client immobilized in skeletal leg traction complains of being bored and restless. Based on these complaints, the nurse identifies which client problem as the priority? Inability to entertain self 127) A client with a fractured femur experiences sudden dyspnea, tachypnea, and tachycardia. A set of arterial blood gas tests reveals the following: pH, 7.35 (7.35); Paco2, 43 mm Hg (43 mm Hg); Pao2, 58 mm Hg (58 mm Hg); HCO3, 23 mEq/L (23 mmol/L). The nurse interprets that the client probably has experienced fat embolus because of the result of which parameter? o Pao2 128) The nurse is planning discharge teaching for a client diagnosed and treated for compartment syndrome. Which information should the nurse include in the teaching? o "Bleeding and swelling caused increased pressure in an area that couldn't expand." 129) The nurse is repositioning a client who has been returned to the nursing unit after internal fixation of a fractured right hip with a femoral head replacement. The nurse should use which method to reposition the client? o A pillow to keep the right leg abducted during turning 130) The nurse has completed giving discharge instructions to a client after total knee arthroplasty and replacement with a prosthetic system. The nurse teaches the client about weight-bearing status. What information should the nurse include? o "You will use full weight bearing by discharge." 131) The nurse is planning to teach the client with below- the-knee amputation about care to prevent skin breakdown. Which point should the nurse include in developing the teaching plan? o The socket of the prosthesis must be dried carefully before it is used. 132) A client has just undergone spinal fusion after experiencing herniation of a lumbar disk. The nurse should include which interventions to maintain client safety after this procedure? Select all that apply. o Keep the head of the bed flat. o Place pillows under the length of the legs. o Use logrolling technique for repositioning. o Assist the client with eating meals and drinking fluids. 133) A client has several fractures of the lower leg, which has been placed in an external fixation device. The client is upset about the appearance of the leg, which is edematous. The nurse documents which client problem in the plan of care? o Body image alteration 134) A client has been placed in Buck's extension traction. The nurse can provide for countertraction to reduce shear and friction by performing which action? o Slightly elevating the foot of the bed 135) The nurse is reviewing the postprocedure plan of care formulated by a nursing student for a client scheduled for a bone biopsy. The nurse determines that the student needs additional information about postprocedure care if which inaccurate intervention is documented? o Administering opioid analgesics intramuscularly 136) A client has had a bone scan done. The nurse determines that the client demonstrates understanding of postprocedure care when the client makes which statement? "I need to drink plenty of water for 1 to 2 days after the procedure." 137) A client seeks treatment in the hospital emergency department for a lower leg injury. Deformity of the lower portion of the leg is evident, and the injured leg appears shorter than the other. The area is painful, swollen, and beginning to become ecchymotic. The nurse interprets that this client has experienced which injury? Fracture 138) The nurse is caring for a client who is an athlete and has sustained an injury to the anterior cruciate ligament. The nurse is providing education to the client regarding the potential treatment measures for this injury. What should the nurse include in the teaching? Select all that apply. Physical therapy Knee immobilizer Aspiration of joint fluid Antiinflammatory medications 139) The nurse is evaluating a client's use of a cane for left-sided weakness. The nurse should intervene and correct the client if the nurse observed that the client performs which action? Moves the cane when the right leg is moved 140) The nurse is planning to teach a client how to stand on crutches. The nurse will incorporate into written instructions that the client should be told to place the crutches in what manner? 6 inches (15 cm) to the front and side of the toes 141) A client is admitted to the nursing unit after a left below-the-knee amputation after a crush injury to the foot and lower leg. The client tells the nurse, "I think I'm going crazy. I can feel my left foot itching." How should the nurse interpret this client statement? A normal response that indicates the presence of phantom limb sensation 142) The nurse has provided instructions to a client with a diagnosis of rheumatoid arthritis about measures to protect the joints. Which statement by the client indicates a need for further instruction? "Pain or fatigue is expected, and I should try to continue with the activity if this occurs." 143) The nurse has provided discharge instructions to a client after a total hip replacement. Which statement by the client indicates a need for further instruction? "I should sit in my recliner when I get home." 144) The community health nurse is providing a teaching session on osteoporosis to women living in the community. The nurse informs these community residents that which is a risk factor for this disorder? A diet low in vitamin D 145) The nurse is performing an assessment on a client with suspected Paget's disease. On assessment the nurse would expect the client to report which as the most common symptom of this disease? Bone pain 146) Diagnostic studies are prescribed for a client with suspected Paget's disease. In reviewing the client's record, the nurse would expect to note that the health care provider has prescribed which laboratory study? Alkaline phosphatase 147) A hospitalized client has been diagnosed with osteomyelitis of the left tibia. The nurse determines that this condition is most likely a result of which event in the client's recent history? Open trauma to the left leg 148) A nursing student is providing health maintenance education to a client with osteitis deformans (Paget's disease). Which statement by the client indicates a need for further education? "Because I have no symptoms, my disease is not progressing." 149) An older client is diagnosed with osteoporosis. The nurse teaches the client about self-care measures, knowing that the client is most at risk for which problem as a result of this disorder of the bones? Fractures 150) The nurse provides instructions to a client with bilateral deformities of the joints of the fingers due to rheumatoid arthritis. When providing teaching about the disease process, the nurse should inform the client that the changes are most likely due to what type of response? Autoimmune 151) A client has been diagnosed with osteomalacia, or adult rickets. The nurse should anticipate that the health care provider will include a new prescription for which vitamin supplement? D 152) A client is having a plaster cast placed on the lower extremity that will extend from mid-thigh to the center of the foot. Which instruction should be given to the client before hospital discharge? The need to notify the health care provider immediately if the client notices numbness or swelling or if the foot becomes cold and pale 153) A client is complaining of knee pain. The knee is swollen, reddened, and warm to the touch. The nurse interprets that the client's signs and symptoms are compatible with which conditions? Select all that apply. Infection Recent injury Inflammation 154) The nurse witnesses a client sustain a fall and suspects that the right leg may be broken. The nurse should take which priority action? Immobilize the right leg before moving the client. 155) The nurse in the hospital emergency department is caring for a client with a fractured arm and is preparing the client for a reduction of the fracture that will be done in the casting room in the emergency department. The nurse should take which actions? Select all that apply. Administer a prescribed analgesic. Explain the procedure to the client. Obtain informed consent for the procedure. 156) The nurse teaches a client who is going to have a plaster cast applied about the procedure. Which statement by the client indicates a need for further teaching? "I can bear weight on the cast in one-half hour." 157) The nurse has suggested specific leg exercises for a client immobilized in right skeletal lower leg traction. The nurse determines that the client needs further instruction if the nurse observes the client performing which action? Performing active range of motion to the right ankle and knee 158) The nurse is giving a client with a left leg cast crutch-walking instructions using the three-point gait. The client is allowed touch-down of the affected leg. The nurse should tell the client to perform which action? Advance the crutches along with the left leg, and then advance the right leg. 159) A client has slight weakness in the right leg. On the basis of this assessment finding, the nurse determines that the client would benefit most from the use of which item? A straight leg cane 160) A client who has experienced a stroke has partial hemiplegia of the left leg. The nurse interprets that the client could benefit from the support and stability provided by which item? Quad cane 161) A client who is learning to use a cane is afraid it will slip with ambulation, causing a fall. The nurse provides the client with the most reassurance by making which statement? "The cane has a flared tip with concentric rings to give stability." 162) The nurse is caring for a client who has just had a plaster leg cast applied. The nurse should plan to prevent the development of compartment syndrome by performing which action? Elevate the limb slightly. 163) A client has undergone fasciotomy to treat compartment syndrome of the leg. The nurse should anticipate that which type of wound care to the fasciotomy site will be prescribed? Moist sterile saline dressings 164) The nurse is assessing a client with a shortened, adducted, and externally rotated left leg. On the basis of this finding, which condition should the nurse anticipate? Fracture of the femoral neck 165) A client who has had a total knee arthroplasty tells the nurse that there is pain with extension of the knee. The nurse should perform which action? Administer an analgesic. 166) The nurse has taught a client with a below-the-knee amputation about prosthesis and residual limb care. The nurse determines that the client has understood the instructions if the client makes which statement? Use a mirror to inspect all areas of the residual limb each day. 167) The nurse is caring for a client admitted for a herniated intervertebral lumbar disk who is complaining about stabbing pain radiating to the lower back and the right buttock. The nurse determines that the client's signs/symptoms are most likely due to which condition? Muscle spasm in the area of the herniated disk 168) The nurse has a prescription to place a client with a herniated lumbar intervertebral disk on bed rest in Williams' position to minimize the pain. The nurse should put the bed in what position? In semi Fowler's position, with the knees slightly flexed 169) A client who has had spinal fusion and insertion of hardware is extremely concerned with the perceived lengthy rehabilitation period. The client expresses concerns about finances and the ability to return to prior employment. The nurse understands that the client's needs could best be addressed by referral to which member of the health care team? A social worker 170) The nurse is planning to teach proper use of a thoracolumbosacral orthosis to a client who has had spinal fusion with instrumentation. The nurse should include which teaching point in the discussion with the client? The device is applied before getting out of bed in the morning. 171) A client is being transferred to the nursing unit from the postanesthesia care unit after spinal fusion with rod insertion. The nurse should prepare to transfer the client from the stretcher to the bed by using which best method? A transfer (slider) board and the assistance of three people 172) A client is being discharged to home after spinal fusion with insertion of instrumentation (rod). The unit nurse should consult with the continuing care nurse regarding the need for modification of the home environment if the client makes which statement? "My bedroom and bathroom are on the second floor of my home." 173) The nurse in the hospital emergency department is assessing a client with an open leg fracture. The nurse should inquire about the last time the client had which done? Tetanus vaccine 174) A client who has experienced nonunion of a fracture is scheduled for bone grafting using cadaver bone. The client appears restless and anxious about the procedure. After determining that the client understands the surgical procedure, the nurse should explore which item next? Potential worry about contracting hepatitis or possibly human immunodeficiency virus infection 175) A client has just been admitted to the hospital with a fractured femur and pelvic fractures. The nurse should plan to carefully monitor the client for which signs/symptoms? Tachycardia and hypotension 176) A client is complaining of pain underneath a cast in the area of a bony prominence. The nurse interprets that this client may need which intervention? To have a window cut in the cast 177) A client is fearful about having an arm cast removed. Which action by the nurse would be the most helpful? Showing the client the cast cutter and explaining how it works 178) A client has just had a cast removed, and the underlying skin is yellow-brown and crusted. The nurse gives the client instructions for skin care. The nurse determines that the client needs further teaching of the directions if he or she makes which statement? "I need to scrub the skin vigorously with soap and water." 179) A client has skeletal traction applied to the right leg and has an overhead trapeze available for use. The nurse should assess which area as high risk for pressure and breakdown? Left heel 180) The nurse is planning measures to increase bed mobility for a client in skeletal leg traction. Which item should the nurse consider to be most helpful for this client? Overhead trapeze 181) The nurse is evaluating goal achievement for a client in traction with impaired physical mobility. The nurse determines that the plan of care needs to be revised if which outcome is noted? Bowel movement every 4 days 182) The nurse is obtaining a health history from a client and is assessing for risk factors associated with osteoporosis. The nurse would be most concerned if which data were obtained? Select all that apply. The client reports that she doesn't exercise much at all. The client reports that she smokes a few cigarettes a day. The client reports that she is taking phenytoin to treat a seizure disorder. The client reports that she takes a daily low dose of prednisone to treat a chronic respiratory condition. 183) The home health nurse visits a client who is having an acute attack of gout. The nurse determines that the client needs further instruction regarding the treatment of gout if the client states to take which action? Restricting fluids 184) The clinic nurse is performing an assessment on a client with a diagnosis of rheumatoid arthritis (RA). The nurse checks for which assessment finding that is associated with RA? Systemic symptoms such as fatigue, anorexia, and weight loss 185) A client who had a body cast applied 2 days earlier begins to complain of anorexia, nausea, and abdominal discomfort. The nurse should take which immediate action? Notify the health care provider. 186) The nurse is performing an assessment on a client after a closed reduction of a fractured right humerus and application of a plaster cast. To assess for signs of compartment syndrome, the nurse should perform which action? Assess capillary refill, temperature, color, and amount of pain in the right hand. 187) The nurse is caring for a client admitted for a fractured hip status post fall at home. On assessment of the client's affected lower extremity, which signs/symptoms would most likely be noted? Shortening and external rotation 188) The nurse is preparing a plan of care for a client who is scheduled to return from the recovery room after a left total knee arthroplasty. The nurse includes in the plan of care to assess the client's neurovascular status the monitoring of which parameter? Capillary refill, sensation, color, and pulse of the left foot 189) The nurse is preparing instructions for a client who is diagnosed with osteomalacia. Which information should the nurse include in the teaching? "Ensure adequate intake of vitamin D fortified foods." 190) The nurse provides instructions to a client diagnosed with osteoporosis. Education about prevention of which complication is the most important? Fractures 191) The nurse is caring for a client diagnosed with osteitis deformans (Paget's disease). Which does the nurse identify as the cause of the client's stooped posture and bowing of lower extremities? Bone resorption and regeneration 192) The nurse is caring for a client diagnosed with osteomyelitis. Which mechanism of the disease process can result in necrosis of the bone? Devascularization 193) The nurse is providing dietary instructions to a client with osteoporosis and is discussing appropriate food items to include in the diet. Which food items should the nurse recommend as being high in calcium? Select all that apply. Tofu Spinach Sardines Salmon 194) A client is seen in the health care provider's office for complaints of wrist pain. A diagnosis of carpal tunnel syndrome is made. In explaining this disorder to the client, the nurse states that it is caused by compression of which nerve? Median 195) The nurse is caring for a client diagnosed with the rotator cuff lesion. The nurse assesses the client knowing that the client most likely has which structure affected? Tendon 196) The nurse is gathering subjective and objective data from a client with a diagnosis of suspected rheumatoid arthritis (RA). The nurse would expect to note which early signs and symptoms of RA? Select all that apply. Fatigue Morning stiffness 197) The nurse is performing a musculoskeletal assessment of an immobile client for disuse osteoporosis. Which should the nurse assess to obtain the best information about the bone remodeling process? Calcitonin 198) The nurse is planning discharge teaching for a client admitted with a fracture of the leg that does not extend all the way through the bone. The nurse should include information about which types of fractures? Incomplete 199) A client has been diagnosed with subluxation of the shoulder. The nurse explains to the client that which injury has occurred to the joint? It has incompletely dislocated. 200) A client who suffered a contusion after being hit on the thigh with a racquetball has been told that it is acceptable to apply heat to the area 72 hours after the injury. The nurse explains the rationale for this treatment to the client, stating that which is the physiological benefit of heat in this case? It promotes reabsorption of blood from the injured tissue. 201) The nurse is caring for a client admitted for a torn meniscus. What is the focus of the nurse's immediate assessment? The knee 202) The nurse is caring for a client with a swollen left ankle who has difficulty bearing weight on this leg and states that he twisted his ankle. Based on these findings, which condition does the nurse determine the client has most likely experienced? Sprain 203) A client with a short-leg plaster cast complains of an intense itching under the cast. The nurse provides instructions to the client regarding relief measures for the itching. Which client statement indicates an understanding of appropriate measures to relieve the itching? "I can use a hair dryer on the low setting and allow the cool air to blow into the cast." 204) A client has been experiencing muscle weakness over a period of several months. The health care provider suspects polymyositis. Which client statement correctly identifies a confirmation of test results and this diagnosis? "I will know I have polymyositis if the muscle fibers are inflamed." 205) Which tests can be used to diagnose gout? Select all that apply. Serum uric acid level Synovial fluid aspiration 24-hour urine uric acid level 206) The nurse is preparing a client for an arthroscopy of the knee. When providing teaching, which information is essential for the nurse to include? It will identify if there is joint injury and provide a route for surgical repair if indicated. 207) The nurse is creating a plan of care for a client scheduled for a left total hip arthroplasty. Which interventions should the nurse include in the plan to prevent complications of the surgery? Select all that apply. Keep the leg slightly abducted. Teach leg exercises to the client. Use aseptic technique for wound care. Prevent hip flexion beyond 90 degrees. 208) The nurse has given activity guidelines to a client with chronic low back pain. The nurse determines that the client understands the instructions if the client states to do which activities? Select all that apply. Sitting using a lumbar roll or pillow Standing with one foot on a step or stool 209) The nurse is assigned to care for a client who is in Buck's traction. The nurse prepares a plan of care for the client and includes which nursing action in the plan? Inspect the skin under the boot at least every 8 hours. 210) The nurse is creating a plan of care for a client in skin traction. Which frequent assessment should the nurse include in the plan as a priority intervention? Signs of skin breakdown 211) The nurse has developed a plan of care for a client in traction and documents a problem of inability to perform self-care independently. The nurse evaluates the plan of care and determines that which observation indicates a successful outcome? The client assists in self-care as much as possible. 212) The nurse is caring for a client with osteoarthritis. The nurse performs an assessment knowing that which clinical manifestations are associated with the disorder? Select all that apply. Joint pain that diminishes after rest Joint pain that intensifies with activity 213) A client is treated in a health care provider's office for a sprained ankle after a fall. Radiographic examination has ruled out a fracture. Before sending the client home, the nurse plans to teach the client to avoid which activity in the next 24 hours? Applying a heating pad 214) A client has Buck's extension traction applied to the right leg. Which intervention should the nurse plan to prevent complications of the device? Inspect the skin on the right leg. 215) The client is complaining of skin irritation from the edges of a cast applied the previous day. Which action should the nurse take? Petal the cast edges with adhesive tape. 216) The nurse determines that a client's skeletal traction needs correction if which observation is made? Traction ropes rest against the footboard. 217) The nurse is lecturing to a group of women who are at high risk for osteoporosis. The nurse should inform the women about which most important measure? Limit caffeine intake. 218) A client is admitted to the emergency department with an open fracture of the right tibia. What intervention is most appropriate for this client? Check the neurovascular status of the area distal to the extremity. 219) The nurse is caring for a client with a hip fracture who has just been placed in Buck's traction. What intervention is most important for the nurse to perform? Inspect the skin at least every 8 hours for signs of irritation or inflammation. 220) The nurse is caring for a client diagnosed with osteomyelitis. Which data noted in the client's record are supportive of this diagnosis? Select all that apply. Pyrexia Elevated white blood cell count Elevated erythrocyte sedimentation rate Bone scan impression indicative of infection 221) The nurse provides information to a client scheduled for a dual x-ray absorptiometry (DEXA) test. Which information should the nurse provide to the client? Select all that apply. It is a painless test. Metallic objects such as jewelry or belt buckles may interfere with the test and need to be removed. 222) The nurse is providing care for a client admitted 3 days ago with a severe left ankle contusion. The nurse determines that heat application to the area has been effective if which has occurred? There is reabsorption of blood noted at the injured site. 223) The nurse is assisting in performing a physical assessment of a right-handed client's musculoskeletal system. Which would be an abnormal finding? Presence of fasciculations 224) A client was admitted to the hospital 2 hours ago following multiple fractures to the pelvis and soft tissue injury to the abdomen. Diagnostic studies have ruled out perforation of abdominal organs. The nurse places highest priority on monitoring this client for which changes in vital signs? Tachycardia, hypotension 225) Which teaching point is the priority when the nurse is teaching the client about caring for a plaster cast? Immediately report any increase in drainage or interruption in cast integrity. 226) The nurse is receiving a client from the postanesthesia care unit following left above-knee amputation. Which is the priority nursing action at this time? Elevate the foot of the bed. 227) A client has been diagnosed with gout, and the nurse provides dietary instructions. The nurse determines that the client needs additional teaching if the client states that it is acceptable to eat which food? Chicken liver 228) The nurse is caring for a client with acute back pain. Which are the most likely causes of this problem? Select all that apply. Twisting of the spine Hyperflexion of the spine Herniation of an intervertebral disk 229) A client who sustained a severe sprain of the ankle is told by the health care provider that the pain experienced is caused by muscle spasm and swelling in the area of the injury. Which interventions should the nurse anticipate will be included in the client's initial plan of care? Select all that apply. Ice bags Elevation Compression bandage 230) The nurse is collecting data related to a client's risk factors associated with osteoporosis. Which data should the nurse include? Select all that apply. Thin body build Smoking history Postmenopausal age Chronic corticosteroid use Family history of osteoporosis 231) The nurse is caring for a client who had surgery to repair a fractured left-sided hip using a posterior approach. In implementing hip precautions, which action should the nurse teach the client to avoid? Crossing legs at the ankle 232) A client is taking large doses of acetylsalicylic acid for rheumatoid arthritis. Which assessment findings indicate that the client is experiencing ototoxicity as a result of the medication? Tinnitus, hearing loss, dizziness, and ataxia 233) A client is seen in the hospital emergency department after injury to the right ankle. The client tells the nurse that she twisted her ankle while playing volleyball. The health care provider (HCP) has prescribed a topical analgesic cream for the injury. The nurse providing instruction about the medication should provide the client with which information? That the medication contains a combination of medications, one of which is an analgesic 234) The client is given medication instructions for maintenance therapy for oral dantrolene sodium for the treatment of spasticity. Which client statement indicates understanding of the instructions? "I will take 100 mg twice a day." 235) A client with gout has begun to take allopurinol. The nurse informs the client that which medication may also be necessary during the beginning phase of medication therapy with allopurinol? Select all that apply. Naproxen Colchicine Indomethacin 236) The home health nurse is providing dietary instructions to a client who is taking probenecid for the treatment of gout. Which food should the nurse instruct the client to continue to eat? Spinach 237) Auranofin has been prescribed for a client with rheumatoid arthritis. The nurse provides instructions to the client about the medication and tells the client to notify the health care provider if which occurs? Metallic taste in the mouth 238) An older client with rheumatoid arthritis has been instructed by the health care provider to take ibuprofen 400 mg orally (PO) three times daily. The home care nurse reading the medication prescription knows that the instruction has been effective when the client states the instructed dose is which? The normal adult dose 239) A client with multiple sclerosis is receiving baclofen. The nurse assessing the client monitors for which finding as an indication of a primary therapeutic response to the medication? Decreased muscle spasms 240) The nurse is providing medication instructions to a client with multiple sclerosis receivi