Chapter 49 My Nursing Test Banks

Osborn, Medical-Surgical Nursing, 2e
Chapter 49

Question 1

Type: MCSA

A 65-year-old female admitted with a fractured hip tells the nurse that she was unaware that she has osteoporosis. What is the nurses best response?

1. Sometimes the first sign of the disorder is a fracture.

2. It is rare for someone your age to have osteoporosis.

3. There is no way to prevent the disorder.

4. Everyone has it now.

Correct Answer: 1

Rationale 1: The manifestations of osteoporosis may go undetected because many patients are asymptomatic. The first sign of the disorder may be a fracture.

Rationale 2: There are different types of osteoporosis that occur in postmenopausal women as a natural result of aging. It is not rare for a 65-year-old female to be diagnosed with the disorder.

Rationale 3: Osteoporosis can be prevented by sufficient intake of calcium and vitamin D, weight management, and exercise.

Rationale 4: Not everyone has osteoporosis.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 49-1

Question 2

Type: MCSA

A patient recovering from a total hip replacement develops a fever and redness at the surgical site. The nurses priority is to conduct additional assessment for which disorder?

1. Pathologic fracture

2. Osteomyelitis

3. Undiagnosed osteitis deformans

4. Subacute osteoporosis

Correct Answer: 2

Rationale 1: Pathologic fracture occurs in the absence of trauma. Fever and redness are not manifestations of pathologic fracture.

Rationale 2: Acute osteomyelitis results from direct trauma or surgery. It is the direct contact of bacteria or the implanting of bacteria from the outside environment during a surgical procedure. Symptoms of acute osteomyelitis include fever, edema at the surgical site, warmth, redness, tenderness, and limited mobility.

Rationale 3: Osteitis deformans is a chronic disorder that causes irregular bone breakdown and bone weakness.

Rationale 4: Subacute osteoporosis is not a clinical disorder.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 49-1

Question 3

Type: MCSA

A 55-year-old female patient with rheumatoid arthritis is diagnosed with osteoporosis. The nurse anticipates that the patient may be prescribed which medication to help with the treatment of this bone disorder?

1. Antihypertensive

2. Cardiac glycoside

3. Parathyroid hormone

4. Vitamins A and E

Correct Answer: 3

Rationale 1: An antihypertensive medication would not have a direct effect on the progression of osteoporosis.

Rationale 2: A cardiac glycoside would not have a direct effect on the progression of osteoporosis.

Rationale 3: Parathyroid hormone is used to reverse the inhibitory effects of bone formation in secondary osteoporosis resulting from the use of steroids.

Rationale 4: Vitamins A and E would not have a direct effect on the progression of osteoporosis.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 49-1

Question 4

Type: MCMA

The nurse is planning a community education program on osteoporosis prevention. Which topics should be included in this program?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Lack of hereditary link

2. Limiting alcohol intake

3. Higher incidence in both men and women who are obese

4. Lifetime adequate intake of calcium and vitamin D

5. Avoidance of cigarette smoking

Correct Answer: 2,4,5

Rationale 1: There is a higher incidence in those with a family history of fractures and osteoporosis. It is thought that the disorder is 70% dependent on genetic factors.

Rationale 2: The excessive use of alcohol increases the risk for developing osteoporosis.

Rationale 3: There is a higher incidence in small, thin-boned men and women.

Rationale 4: One way to prevent the onset of osteoporosis is to have an adequate intake of calcium and vitamin D throughout the lifetime.

Rationale 5: Cigarette smoking increases the risk for developing osteoporosis.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 49-1

Question 5

Type: MCSA

A 50-year-old female patient is concerned that she will develop osteoporosis because both her maternal aunts have been diagnosed with the disorder. The nurse would help the patient manage which intervention?

1. Prophylactic nonsteroidal anti-inflammatory medication

2. A DEXA test

3. Prescription for risedronate (Actonel)

4. Daily intake of 2,000 mg of calcium

Correct Answer: 2

Rationale 1: Nonsteroidal anti-inflammatory medication has no prophylactic effect against osteoporosis.

Rationale 2: Assessment of bone mass is the primary measurement for osteoporosis. The bone mineral density test, or DEXA test, uses a technique that measures any skeletal site and then compares bone density values with other values in a reference population of the same age, race, and gender.

Rationale 3: Actonel is prescribed for patients diagnosed with osteoporosis and is not used prophylactically.

Rationale 4: Total dietary intake of calcium should be 1,200 to 1,500 mg. Taking additional calcium is not indicated and could result in manifestations of hypercalcemia.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 49-1

Question 6

Type: MCSA

A patient is being discharged after treatment for a fracture. Which home management instructions would help ensure safety in the patients home environment?

1. Place a small rug in front of bathroom sink to reduce your risk of slipping on water.

2. Be certain that devices used for cooking work properly.

3. Be sure all walking paths through the house are clear of obstruction.

4. Move the furniture around so you have lots of things to hold on to for support.

Correct Answer: 3

Rationale 1: Scatter rugs increase the risk of slipping and falling and should be avoided in this patients environment.

Rationale 2: The functioning of cooking devices is important; however, it is not as important as another factor in the prevention of future fractures.

Rationale 3: The patients home should be assessed for a safe environment that would include safe walking paths.

Rationale 4: Paths should be clear of furniture, and the patient should use standard devices for support. Furniture can topple or break under pressure.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 49-2

Question 7

Type: MCSA

The nurse is preparing discharge instructions for a patient diagnosed with hypokalemic myopathy. What information should be included in these instructions?

1. When to take coenzyme Q-10

2. The need for rest periods between activities

3. Foods rich in potassium

4. When to take prescribed prednisone

Correct Answer: 3

Rationale 1: Coenzyme Q-10 is a supplement used to manage mitochondrial myopathy.

Rationale 2: A frequent rest period between activities is not indicated in the treatment of hypokalemic myopathy.

Rationale 3: Hypokalemic myopathy is common in the elderly and results from a low serum potassium level caused by long-term diuretic use. The patient should be encouraged to eat foods rich in potassium as part of discharge instructions.

Rationale 4: Prednisone is used to treat polymyositis, one type of inflammatory myopathy.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 49-4

Question 8

Type: MCSA

A patient is admitted with a purple rash on her eyelids and a slightly red rash on her face and neck. The patient tells the nurse that her muscles hurt and she fatigues easily. The nurse would conduct additional assessment for which condition?

1. Mitochondrial myopathy

2. Polymyositis

3. Dermatomyositis

4. Inclusion body myositis

Correct Answer: 3

Rationale 1: Symptoms of mitochondrial myopathy include muscle weakness, exercise intolerance, hearing loss, loss of balance and coordination, and seizures.

Rationale 2: Individuals diagnosed with polymyositis may have a rash, but the primary symptom is weakness in the upper and lower extremities.

Rationale 3: Dermatomyositis is an autoimmune disease that affects the small blood vessels and capillaries in muscles. A bluish-purple rash on the eyelids with redness of the face, chest, and neck are commonly seen. Muscle weakness and fatigue develop gradually over several months.

Rationale 4: Inclusion body myositis occurs primarily in men over age 50 and is characterized by asymmetrical muscle weakness.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 49-4

Question 9

Type: MCSA

A patient diagnosed with a myopathy is at risk for aspiration. Which intervention should be included in the plan of care for this patient?

1. Instruct the patient to avoid thick liquids.

2. Instruct the patient to eat small bites of food and chew thoroughly before swallowing.

3. Instruct the patient to avoid solid foods.

4. Instruct the patient to consume thin, watery liquids with meals.

Correct Answer: 2

Rationale 1: Thick liquids are easier to swallow than thin, watery liquids.

Rationale 2: The patient at risk for aspiration should be instructed to eat small bites of food and chew thoroughly before swallowing.

Rationale 3: The patient does not need to avoid solid foods.

Rationale 4: Thin, watery liquids increase the risk for aspiration.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 49-4

Question 10

Type: MCSA

A 30-year-old female patient diagnosed with early onset of osteoporosis asks the nurse how she could be at risk for this disease, as she is so active. Which response by the nurse is most accurate?

1. Your frequent exercise might have placed underlying stress on your skeleton.

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

3. Do your bones feel weak or painful?

4. Dietary practices have some influence on the development of osteoporosis.

Correct Answer: 4

Rationale 1: Exercise is beneficial in the prevention of osteoporosis. It does not increase the likelihood of osteoporosis.

Rationale 2: At 30 years of age, this is unlikely.

Rationale 3: The patient is seeking information. She is not requiring an assessment at this time.

Rationale 4: It is estimated that development of osteoporosis is about 30% dependent on environmental factors. Decreased dietary intake of calcium is implicated in the development of osteoporosis.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 49-1

Question 11

Type: MCMA

A patient who has been diagnosed with Pagets disease in the hip is admitted to the hospital for treatment of another condition. Which assessment findings would the nurse attribute to Pagets disease?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Pain and aching in the hip at night

2. Edema over the hip

3. Difficulty hearing

4. Elevation of serum phosphorus

5. Nausea and vomiting

Correct Answer: 1,2,3

Rationale 1: The pain of Pagets disease is often worse at night.

Rationale 2: Edema over the affected joint may occur with Pagets disease.

Rationale 3: Pagets disease may affect the ossicles of the ear, causing hearing loss.

Rationale 4: Hypercalcemia, not hyperphosphatemia, is common with Pagets disease.

Rationale 5: Nausea and vomiting are not associated with Pagets disease.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 49-1

Question 12

Type: MCMA

Which instruction should the nurse include when teaching a patient about the medication alendronate (Fosamax)?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Report new or worsening heartburn and difficult or painful swallowing.

2. Take the medication with orange juice 1 hour after eating.

3. Do not lie down for 30 minutes after taking the medication.

4. Take vitamin C supplements as instructed for bone mineralization.

5. Chew the medication well before swallowing.

Correct Answer: 1,3

Rationale 1: New or worsening heartburn and difficult or painful swallowing are adverse reactions to the medication.

Rationale 2: Alendronate should be administered with water 30 minutes before eating or taking other medications.

Rationale 3: Lying down within 30 minutes of ingestion of the medication may precipitate adverse gastrointestinal reactions.

Rationale 4: Vitamin D supplements should be taken as well as calcium, not vitamin C.

Rationale 5: The medication should not be chewed.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 49-2

Question 13

Type: MCMA

The nurse is instructing a patient on foods high in calcium. The nurse knows the teaching was effective when the patient chooses which foods for a meal?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Chicken

2. Kale

3. Bananas

4. Salmon

5. Low-fat milk

Correct Answer: 2,4,5

Rationale 1: Chicken is not high in calcium.

Rationale 2: Green, leafy vegetables such as kale are high in calcium.

Rationale 3: Bananas are not a source of calcium.

Rationale 4: Salmon is a good dietary source of calcium.

Rationale 5: Milk and milk products are good sources of calcium. The patient should choose low-fat products.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 49-1

Question 14

Type: MCSA

A patient diagnosed with osteomyelitis has a fever of 101.2F, a white blood cell count of 22,000, and is complaining of severe leg pain. Which physicians order should the nurse implement first?

1. Start IV D51/2 NS at 125 ml/hr

2. Blood cultures 2 at different sites

3. Rocephin 1 gram IV twice a day

4. Acetaminophen 650 mg PO for temperature above 100F

5. Morphine 4 mg IV for pain

Correct Answer: 1

Rationale 1: The nurses priority is to start an IV line so that medications and fluids can be administered. Depending on agency policy, one blood culture may be drawn when this IV line is started.

Rationale 2: Drawing blood cultures is the second priority.

Rationale 3: Once the intravenous line is established, the pain medication can be provided and the antibiotic can be started.

Rationale 4: Acetaminophen is not a priority at this time and can be provided at any point in the process.

Rationale 5: Once the intravenous line is established, the pain medication can be provided and the antibiotic can be started.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 49-1

Question 15

Type: FIB

A patient diagnosed with Pagets disease has been prescribed the bisphosphonate medication pamidronate 90 mg over 3 days. Medication instructions state to mix 30 mg of the drug in 500 mL NS and administer over 4 hours. This administration should be repeated for 3 days for a total of 90 mg of drug. The nurse should run this infusion at an IV rate of ________ mL/hr.

Standard Text:

Correct Answer: 125

Rationale : Pamidronate (Aredia), which inhibits bone resorption, is among the primary treatments for severe Pagets disease. Pamidronate is given as an intravenous infusion for 3 successive days. 500 mL/4 hours = 125 mL/hour

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 49-1

Question 16

Type: MCMA

A 50-year-old woman is diagnosed with a small malignant tumor in her spine. The nurse anticipates which interventions?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Surveillance for the primary cancer site

2. Removal of the womans ovaries because these cancers are almost always estrogen dependent

3. Pharmacologic treatment of severe pain

4. Involvement of a multidisciplinary team in designing the patients care

5. Surgical removal of the tumor, which will facilitate rapid recovery

Correct Answer: 1,3,4

Rationale 1: Most bone cancer diagnosed after age 30 is due to metastasis from a primary tumor in another organ system.

Rationale 2: There is no evidence that these cancers are estrogen dependent.

Rationale 3: Bone pain is typically very severe and requires pharmacological intervention.

Rationale 4: Bone cancer requires input from a multidisciplinary team to best manage the complexities of the patients care.

Rationale 5: Surgical removal of a tumor in the spine may be very difficult or impossible. Recovery is not likely to be rapid.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 49-1

Question 17

Type: MCSA

Review of a 7-year-old boys chart reveals a diagnosis of Duchenne muscular dystrophy made after the patient began to exhibit Gowers maneuver. Which movements would the nurse expect to assess?

1. The child rocks backward and forward several times before being able to get up from a chair.

2. The child extends both arms out to the sides for balance while walking.

3. The child gets onto the hands and knees before achieving a standing position from the floor.

4. The child must roll to the side and push up from the floor with the hands.

Correct Answer: 3

Rationale 1: This movement does not describe Gowers maneuver.

Rationale 2: This movement does not describe Gowers maneuver.

Rationale 3: Gowers maneuver involves the child getting on the hands and knees, raising the rear end, and then walking the hands up the legs until the child reaches a standing position.

Rationale 4: This movement does not describe Gowers maneuver.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 49-3

Question 18

Type: MCSA

A young boy has just been diagnosed with Duchenne muscular dystrophy (DMD). The nurse evaluates that teaching has been effective when the parent makes which statement?

1. We should avoid getting a wheelchair for as long as possible.

2. He should improve over time as the medication begins to take effect.

3. He should not have an influenza vaccine.

4. Even though his body is weak, his cognitive abilities should be normal.

Correct Answer: 1

Rationale 1: It is desirable to encourage the child to remain mobile for as long as possible.

Rationale 2: Children with DMD generally get worse over time, despite medical treatment.

Rationale 3: Influenza and pneumonococcal vaccinations are an essential part of this childs therapy.

Rationale 4: About a third of boys with DMD have some progressive learning disability. Some develop mental retardation.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 49-3

Question 19

Type: MCSA

A patient diagnosed with oculopharyngeal muscular dystrophy has been admitted for ankle surgery. What interventions should the nurse plan?

1. Provide eye patches for times when the patient cannot close the eyes.

2. Modify food consistency to allow for easier swallowing.

3. Notify anesthesiology about the patients history.

4. Monitor for the development of fluid in the lungs.

Correct Answer: 2

Rationale 1: Inability to open and close the eyes is associated with facioscapulohumeral disease.

Rationale 2: Patients with oculopharyngeal MD have difficulty swallowing. Modifying food consistency helps protect quality of life.

Rationale 3: Persons with myotonic muscular dystrophy may have adverse reaction to anesthesia.

Rationale 4: Fluid in the lungs is common with some forms of MD, but less so with oculopharnyngeal MD.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 49-3

Question 20

Type: MCMA

The nurse has chosen the nursing diagnosis Ineffective Breathing for a patient with muscular dystrophy. Which interventions are indicated?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Assess the gag reflex before administering food or fluids.

2. Encourage frequent rest periods during daily activities.

3. Teach pursed-lip breathing.

4. Assess capillary refill.

5. Observe for use of accessory muscles.

Correct Answer: 2,3,5

Rationale 1: The gag reflex is associated with Risk for Aspiration.

Rationale 2: Frequent rest periods are needed to facilitate respiration.

Rationale 3: Pursed-lip breathing helps to expand lungs for maximum oxygen intake and helps expel carbon dioxide.

Rationale 4: Capillary refill is related to tissue perfusion and cardiac output.

Rationale 5: The use of accessory muscles indicates respiratory dysfunction.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 49-3

Question 21

Type: MCMA

A patient with a musculoskeletal disorder is prescribed carbamazepine (Tegretol). What medication education should the nurse provide?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Take your medication with food.

2. You may be more sensitive to the sun, so be certain to wear protective clothing or sunscreen.

3. If mouth ulcers appear, notify the prescriber.

4. Avoid touching the pill with your fingers.

5. If fever occurs, notify the prescriber.

Correct Answer: 1,2,3,5

Rationale 1: Carbamazepine may cause gastric upset unless it is taken with food.

Rationale 2: Carbamazepine may cause photosensitivity.

Rationale 3: Mouth ulcers may occur in those taking carbamazepine and should be reported.

Rationale 4: There is no reason to avoid skin contact with the medication.

Rationale 5: Fever is a possible adverse reaction in those taking carbamazepine and should be reported.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 49-4

Question 22

Type: MCMA

A patient diagnosed with polymyositis has been prescribed azathioprine (Imuran.) What medication education should the nurse provide?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. This therapy increases your risk for infections.

2. Take this medication at least 4 hours prior to or after eating.

3. Do not drink alcohol while taking the medication.

4. Wear sunscreen if you are outside.

5. You may need folic acid supplementation while on this drug.

Correct Answer: 1,3

Rationale 1: Azathioprine is an immunosuppressant.

Rationale 2: Azathioprine can cause stomach upset and should be taken with meals.

Rationale 3: CNS depressants such as alcohol should be avoided while taking azathioprine.

Rationale 4: Increased photosensitivity is not associated with taking azathioprine.

Rationale 5: There is no indication that folic acid supplementation is needed because the patient is taking this drug.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 49-4

Question 23

Type: MCSA

A patient has been diagnosed with inclusion body myositis (IBM.) Which instruction should the nurse provide?

1. Be certain to keep your appointment to fit your foot brace.

2. You can expect to be cured from this disorder if you take your medications as directed.

3. Taking steroids will help you maintain long-term remission from this illness.

4. You may be unable to drive due to weakness in your neck.

Correct Answer: 1

Rationale 1: Prevention of foot drop and wrist drop are important aspects of maintaining the patients quality of life.

Rationale 2: There is no known cure for IBM.

Rationale 3: Sustained remission has not been demonstrated.

Rationale 4: The most common areas of weakness in IBM are the wrists, finger flexors, and knee extensors.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 49-4

Question 24

Type: MCMA

A patient is admitted to the hospital after being found on the floor at home. It appears that the patient had a seizure and may have been in the floor for 10 to 12 hours before being discovered. Which assessment findings would be critical for the nurse to report?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Urine is dark.

2. Low CK levels

3. Potassium level of 4.8 mEq/L

4. Complaints of new-onset muscle pain

5. Complaints of extreme hunger

Correct Answer: 1,3,4

Rationale 1: Dark-colored urine, along with the history of being immobile, raise suspicion of rhabdomyolysis.

Rationale 2: The nurse would report high CK levels.

Rationale 3: Hyperkalemia is a complication associated with rhabdomyolysis.

Rationale 4: Complaints of muscle pain are associated with rhabdomyolysis. New-onset pain, given this patients history, should be reported.

Rationale 5: Hunger is not associated with any apparent risk of pathology.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 49-3

Question 25

Type: FIB

A woman who emigrated from a Third World country has just delivered a baby. The woman says, In my country, many babies die from polio. I want my baby immunized as soon as possible. The nurse responds, Your baby will receive the first polio immunization at age _______ months.

Standard Text:

Correct Answer: 2

Rationale : Children receive four doses of injected polio vaccine. These immunizations are scheduled at 2 months, 4 months, 6 to 18 months, and 4 to 6 years.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 49-3

Question 26

Type: MCSA

A patient has been diagnosed with fibromyalgia. Which statement would indicate that the patient understands the nurses instruction about the disease?

1. This disease should run its course in about 18 months.

2. Because my muscles are so painful, I should avoid exercise.

3. Following a very low-fat diet has been proven to reduce the symptoms of fibromyalgia.

4. I need to work on reducing my anxiety about things I cannot control.

Correct Answer: 4

Rationale 1: Fibromyalgia is a chronic syndrome.

Rationale 2: Exercise helps to increase circulation to the muscles and is recommended therapy for fibromyalgia.

Rationale 3: There is no particular diet that has been shown to improve fibromyalgia.

Rationale 4: Anxiety and depression must be controlled in order to control fibromyalgia.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 49-5

Question 27

Type: MCMA

A patient diagnosed with fibromyalgia is interested in alternative and complementary therapies to treat the disorder. The nurse suggests the patient examine which types of therapy?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Acupuncture

2. Reflexology

3. Prescription antidepressants

4. Electrical stimulation

5. Prayer

Correct Answer: 1,2,4,5

Rationale 1: Acupuncture is used in the treatment of fibromyalgia.

Rationale 2: Reflexology has been used to treat fibromyalgia.

Rationale 3: Prescription antidepressants are standard medical treatment for fibromyalgia.

Rationale 4: Transcutaneous electrical nerve stimulation (TENS) is used in the treatment of fibromyalgia.

Rationale 5: Meditation and prayer have been helpful in the treatment of fibromyalgia.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 49-5

Question 28

Type: MCSA

A patient states, I am in such pain. Do you think I might have fibromyalgia? Which response by the nurse is indicated?

1. Have you been in pain over 2 months?

2. You must stop smoking before a diagnosis of fibromyalgia can be made.

3. Have you considered having the blood test for fibromyalgia?

4. In which areas do you have pain?

Correct Answer: 4

Rationale 1: Fibromyalgia is diagnosed when pain has continued over 3 months.

Rationale 2: Symptoms of fibromyalgia are aggravated by smoking, but it is not required that a patient stop smoking before the diagnosis can be made.

Rationale 3: There is no specific test for fibromyalgia.

Rationale 4: The main signs and symptoms of fibromyalgia are pain in the back, neck, forearms, and knees.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 49-5

Question 29

Type: MCSA

A patient diagnosed with fibromyalgia has been prescribed pregabalin (Lyrica). Which patient statement about the drug is correct?

1. Pregabalin will cure my fibromyalgia.

2. I should not drive until I see how this drug affects me.

3. It is okay for me to relax with a glass of wine in the evening before bed.

4. If this drug doesnt help me, I can quit taking it and try something else.

Correct Answer: 2

Rationale 1: There is no cure for fibromyalgia. Pregabalin will help control symptoms.

Rationale 2: Pregabalin can make the patient dizzy or drowsy, so driving should be avoided until the effects of the drug are known.

Rationale 3: Pregabalin should not be taken with other CNS depressants.

Rationale 4: Pregabalin use can result in physical and psychological addiction.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 49-5

Question 30

Type: MCSA

A male patient, one day postoperative from a total hip replacement, tells the nurse that he does not want to ambulate and will consider it tomorrow. What should the nurse do first to assist this patient?

1. Determine the reason he is resistant to ambulating at this time.

2. Contact the physician.

3. Call additional personnel to assist with ambulation anyway.

4. Document the patients refusal.

Correct Answer: 1

Rationale 1: Determining the reason the patient is declining to participate is beneficial in the patients care.

Rationale 2: It is premature to contact the physician.

Rationale 3: Forcing the patient to get out of bed would constitute a crime.

Rationale 4: Documentation of the exchange is needed, but it should be done once the reason for the refusal is known.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 49-1

Question 31

Type: MCSA

A 60-year-old man asks the nurse if he should consume sports drinks while mowing the lawn in the summer to prevent dehydration. What response by the nurse is indicated?

1. As long as you are drinking fluids, it doesnt really matter what they are.

2. If you drink only one sports drink a day, there should be no problem.

3. Let me review your lab results from last week before I reply.

4. You should drink only water.

Correct Answer: 3

Rationale 1: This is not correct information. The nurse should be more specific about what is safe for this patient to drink.

Rationale 2: This statement could easily be misinterpreted to mean that the patient only needs the fluid from one sports drink while exerting himself in the sun. The patient may need additional fluids in forms other than sports drinks.

Rationale 3: The use of sports drinks can be contraindicated in some older adults, depending on their electrolyte balance.

Rationale 4: Sports drinks and other drinks may help to keep the patient hydrated.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 49-6

Question 32

Type: MCSA

An 82-year-old woman with fibromyalgia reports that she is not sleeping well at night. The nurse realizes that this patient is at particular risk for which complication of fibromyalgia?

1. Falling

2. Point tenderness

3. Becoming addicted to pain medications

4. Respiratory difficulties

Correct Answer: 1

Rationale 1: The muscle pain and weakness of fibromyalgia, coupled with fatigue, put the patient at greater risk of falling.

Rationale 2: Point tenderness is already associated with fibromyalgia, and less sleep does not increase the risk.

Rationale 3: There is no reason that fatigue would make a patient more likely to become addicted to pain medications.

Rationale 4: Respiratory difficulties are not specifically associated with fibromyalgia, nor is fatigue particularly causative of respiratory difficulty.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 49-6

Question 33

Type: MCSA

A patient has fallen in his room. The nurse who admitted the patient says, But when I assessed his fall status, he was only moderate risk. How should the nurse manager interpret this situation?

1. The fall assessment was not completed correctly.

2. Fall assessment alone is not sufficient to protect patients.

3. Something must have changed in the patients condition since the assessment was completed.

4. The patient must be confused.

Correct Answer: 2

Rationale 1: The nurse reports the patient was at moderate risk for fall, so there is no reason to think the assessment was incorrect.

Rationale 2: Fall assessment alone does not prevent falls. The nurse must interpret the information and intervene to keep the patient as safe as possible.

Rationale 3: The nurse reports that the patient was at moderate risk for fall. There may have been changes in the patients condition, but because moderate risk already existed, there is no reason to believe this must have occurred.

Rationale 4: There is nothing to indicate that the patient is confused. Patients who are cognitively clear may fall if they have muscle weakness or other conditions.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 49-2

Question 34

Type: MCMA

The nurse is providing discharge instructions to a patient recovering from a total hip replacement. Which information should the nurse include in these instructions?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Follow the use and weight-bearing instructions provided by the surgeon.

2. Do not do exercises if experiencing discomfort.

3. Report possible complications such as infection or dislocation.

4. Continue pain medications for only 2 days after discharge.

5. Eat protein foods with high biologic value such as meat, eggs, and dairy products.

Correct Answer: 1,3,5

Rationale 1: Patient education should focus on the continued progression of exercise and ambulation.

Rationale 2: The patient will feel some degree of discomfort when exercising the affected limb, but this can be controlled with mild analgesics.

Rationale 3: The patient should be instructed to report increasing pain, redness, swelling, fever, or deformity of the hip.

Rationale 4: Postoperative pain medication will be necessary for longer than 2 days. Without proper pain control, the patient may not progress with exercise and ambulation.

Rationale 5: The patient needs proteins that supply high biologic value to support the healing of the bone and surgical incisions.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 49-1

Question 35

Type: MCMA

A nursing unit has adopted the Four P strategy to reduce fall rates. Which components of patient care will this plan emphasize?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Position

2. Pain assessment

3. Personal needs

4. Prevention

5. Placement

Correct Answer: 1,2,3,5

Rationale 1: Frequent repositioning of the patient is important for comfort. It also allows frequent observation of the patient and assessment for changes in skin integrity, pain level, mental status, and physical status.

Rationale 2: Pain is a frequent reason that patients fall, and pain management medications may increase the risk of falling.

Rationale 3: If personal needs are taken care of, it is less likely the patient will attempt to get out of bed alone and fall. Nearly half of falls that occur in hospitals are related to toileting.

Rationale 4: The entire plan is preventive; prevention is not a separate component of the Four Ps.

Rationale 5: Checking for placement of frequently used items such as telephones, call bells, and the television remote can help reduce falls.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 49-2

 

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