Reduction Of Risk Sensory Perception Mobility Rationales

Reduction of Risk-Sensory-Perception-Mobility 1. For a client with a neurological disorder, which nursing assessment will be most helpful in determining subtle changes in the clients level of consciousness? a. Client posturing b. Glasgow Coma Scale c. Client thinking pattern d. Occurrence of hallucinations The Glasgow Coma Coma Scale score best evaluates changes in a clients level of consciousness by evaluating eye opening, motor, and verbal responses. Option #1 indicates increased intracranial pressure. Options #3 and #4 are more appropriate for the psychiatric client. 2. The most important information for the nurse to obtain prior to a computerized axial tomography (CAT) scan concerns: a. problems being in closed spaces. b. allergies to aspirin. c. intact swallow and gag reflex. d. full range of motion of all extremities. If the client has claustrophobia, the scan may cause severe anxiety. Option #2 is incorrect because aspirin is not used for the scan. Options #3 and #4 are assessment data related to CVA but not necessary for CT scan. 3. Which clients pain should be assessed initially? a. A client experiencing pain 2 hours after a liver biopsy. b. A client with a long leg cast who was medicated for pain 45 min. earlier. c. A maternity client who experiences pain during breast feeding. d. A 4-year-old child who complains of a sore throat after a tonsillectomy. While it is important to evaluate any client's discomfort, this client could be developing compartmental syndrome and needs immediate attention. It is important to further evaluate the pulse, sensation, movement, color, and temperature. Options #1, #3, and #4 are not a priority to #2. A client will experience discomfort after a liver biopsy. There is a release of oxytocin during breast feeding which will cause some discomfort. 4. Which nursing response indicates an understanding of a toddler that is drowsy after a grandmal seizure? a. This is an expected finding after a seizure. Maintain bedrest and neurological assessments. b. This indicates cortical damage. Assess for impaired motor and sensory function. c. Another seizure will shortly occur. Precautions should be taken. d. There is decreased sensory stimulation. Ambulate the child to initiate an increased response. The postictal state sometimes leaves a client unresponsive, drowsy, and difficult to arouse. Options #2 and #3 are not correct. Option #4 is incorrect because an individual needs to rest after a seizure of this type. 5. At the time of diagnosis, a client with Bell's Palsy is given a supply of eye patches. The client should be cautioned against: a. allowing the cornea of the eye to become dry. b. photosensitivity regarding light on the retina. c. sudden movement of the head when bending over. d. contamination from the affected eye to the other eye. Paralysis of the eyelid allows the cornea to dry. Patches can be used to keep the eyelid closed to prevent damage. Drops and/or ointments are also used to reduce the chance of corneal damage. Option #2 is incorrect because the problem, properly managed, should not result in a problem with light. Option #3 is for clients with increased intraocular pressure. Option #4 is incorrect because Bells Palsy is not contagious. 6. Which action should the nurse take if a CBC of a client receiving Cephalexin (Keflex) intravenously reflects a significant decrease in red cells and platelets? a. Withhold drug pending notification of physician regarding lab results. b. Administer medication for next 2 scheduled doses and notify physician of CBC changes. c. Discontinue drug until another CBC can be performed. d. Proceed with administration of dose without delay. Cephalexin is an antibiotic associated with the development of aplastic anemia. The physician should be notified as soon as the problem is identified. Options #2, #3, and #4 are not appropriate nursing decisions regarding this medication.

7. While the nurse is irrigating an ear to remove cerumen, the client comments that he is getting dizzy. The nurse would stop the procedure and: a. notify the physician immediately. b. monitor for changes in intracranial pressure c. warm the irrigant and resume the procedure. d. explore the canal with a cotton applicator. Water that is too cool can elicit dizziness when it comes in contact with the tympanic membrane. Option #1 is not necessary. Option #2 is incorrect because the client is not experiencing increased intraocular pressure. Option #4 could compact the cerumen against the membrane and is never recommended. 8. A client with a recent lumbar spinal cord injury must be repositioned. Nursing actions would include: a. having client raise his leg and turn to opposite side. b. removing the pillow between the clients legs. c. turning the client smoothly, maintaining straight alignment. d. moving the client to the middle of the bed. Maintaining straight alignment is necessary to keep the spine straight. Option #1 will increase the twisting of the trunk when the client turns. Option #2 will diminish support to the legs and possibly allow twisting of the hips. Option #4 will not allow the client to, he in the center of the bed after the turning. 9. A client with a closed head injury begins to vomit. Which assessment is the most important for the nurse to report when calling the physician? a. Increasing lethargy. b. Heart rate 80. c. Sodium level of 145. d. Presence of facial symmetry. Changes in level of consciousness, increasing drowsiness or difficulty in arousing (e.g., increasing lethargy), are initial signs of increased intracranial pressure. Options #2, #3, and #4 are normal findings. 10. A client returns to the unit after having plastic surgery for left hand reconstruction. The nurse would implement which action to the left hand? a. Apply heat. b. Apply cold packs. c. Alternate with heat and cold packs. d. Apply paraffin. Cold packs will cause vasoconstriction which will decrease the edema. Options #1 and #4 are incorrect. Option #3 is used for arthritis. 11. The nurse is observing a client for complications following a craniotomy. The client begins complaining of thirst and fatigue. Which nursing observation is most important to report to the physician? a. Specific gravity of urine is increased; urine is foul smelling. b. Fluid intake over past 24 hours has been 3000 cc. c. Urine output in excess of 4000 cc in 24 hours. d. Presence of diarrhea and excoriation of anal area. In diabetes insipidus, one of the first signs is a significant increase in urine output and pale colored urine. Option #1 is incorrect because the specific gravity is decreased, and foul smelling urine usually indicates infection. Option #2 is incorrect because intake is normal. Option #4 is associated with a client in chemotherapy, but not as often as Option #3. 12. Before teaching a CVA client about self-care, which plan would be a priority? a. Have the client identify perception of health status. b. Identify the clients strengths and weaknesses. c. Encourage client to discuss concerns with another CVA client. d. Provide client with a written plan of therapy. Before teaching or client learning can occur, the client must identify thoughts about his/her current status including concerns, fears, anxieties, etc. Option #2 is not a priority because the nurse is processing instead of the client. Option #3 is important, but is not a priority over #1. Option #4 will be done at a later time. 13. The nurse enters the room and discovers the client has slurred speech, right-sided paralysis, and unequal pupils. The most appropriate next step for the nurse is to: a. call the physician. b. assess the respiratory status. c. determine the level of consciousness.

d. perform a complete neurological evaluation. Assess the respiratory status and make sure the client has an open airway is the appropriate next step. Option #1 is incorrect because the physician will need to be notified after the nurse completes her assessment of vital signs. Option #3 will need to be determined, but is not the appropriate next step. Option #4 is not a priority over Option #2. Part of the neurological assessment has been given in the question. 14. The client is admitted via the emergency room with a possible cervical spinal cord injury. The most important information for the nurse to obtain is: a. history of accident and type of trauma. b. neurological functioning. c. respiratory status and tissue perfusion. d. allergies and pre-existing medical conditions. Respirations are a priority, especially with cervical injuries. Options #1, #2, and #4 are all important but are all secondary to respirations. 15. The nurse would identify which ocular response as desirable for the client using Pilocarpine eye drops? a. Pupillary constriction. b. Pupillary dilation. c. Corneal lubrication. d. Clearing of injected sclera. Pilocarpine is a miotic which constricts the pupils, allowing the aqueous humor to circulate more freely and reducing the intraocular pressure. Options #2, #3, and #4 are not therapeutic responses to Pilocarpine. 16. What would be the highest priority for a client 72 hours after having 2nd-degree burns to 20% of his body in the lower abdominal area, back, and both legs? a. Airway. b. Body image. c. Fluid and electrolytes. d. Pain. Second-degree burns create a lot of pain for the client. Option #1 would be a priority within the first few hours for upper extremity burns. However, these are on the lower body. Option #2 is a concern, but not a priority to pain. Option #3 is a major concern initially after the burns. 17. Which is the most important postoperative nursing action for the client following a sceleral buckling procedure for detached retina? a. Remove reading material to decrease eye strain. b. Closely assess for presence of nausea and prevent vomiting. c. Assess color of drainage from affected eye. d. Maintain sterility for q3h saline eye irrigations. It is important to prevent nausea and vomiting as this would increase the intraocular pressure and could cause damage to the area repaired. Option #1 would not be effective. Option #3 refers to an eye infection. This would be important after the initial operative day. Option #4 is incorrect because eye irrigations are not common following this procedure. 18. Which nursing intervention is important in the immediate postoperative period of a client who had a cataract removed from his left eye? a. Position on right side with head slightly elevated. b. Place client on his left side to protect the eye. c. Perform sensory neuro checks every two hours. d. Maintain complete bed rest for the first 48 hours. The client should be positioned on his back or on his unaffected side to prevent trauma to the surgical eye. Option #2 is positioning the client on his affected side. Options #3 and #4 are not necessary with the cataract client. 19. A client is admitted with a diagnosis of trigeminal neuralgia (Tic Douloureux) involving the maxillary branch of the affected nerve. The nurse would plan nursing care to assist the client with which problem? a. Intermittent blurred vision and tinnitus. b. Intense facial pain on affected side. c. Attacks of severe dizziness and vertigo. d. Impaired speech function due to muscle spasm. A characteristic of this condition is the intense facial pain experienced along the nerve tract. Nursing care should be directed toward preventing stimuli to the area and decreasing pain. Option #1 does not occur with this condition. Option #3 describes Menieres disease. Option #4 may occur, but Option #2 is a priority.

20. A client with a head injury has an order for hourly neuro checks. During the evaluation, the nurse would anticipate which assessment indicating an early sign of increased intracranial pressure? a. An alteration in the clients ability to answer questions and respond to verbal stimuli. b. Cushings triad. c. Decorticate posturing d. The presence of dolls eyes. Option #1 is an indication in the alteration in the level of consciousness which is the earliest sign of neurological changes. Options #2, #3 and #4 occur later after #1 has occurred. Option #2 includes increased systolic pressure, decreased pulse rate, and irregular respirations. IICP is well-established when this occurs. 21. The physician orders a wet-to-dry dressing for your client with a venous stasis ulcer. The correct method of implementing this order is to: a. moisten the skin around the ulcer. Then apply a dry gauze dressing. b. apply antibacterial ointment to the wound. Then apply a dry gauze dressing. c. apply a wet dressing and allow to dry. Then wet again to remove. d. Apply a wet dressing. Allow to dry; then remove. This method aids wound debridement. Option #1 would not be effective. Option #2 will prevent adherence of gauze to wound debris and limit debridement. Option #3 before removal will defeat the purpose of wound debridement. 22. The nurse is caring for an elderly client with bilateral eye patches. Which nursing action would be most beneficial in preventing problems secondary to sensory deprivation? a. Maintain client sedation until eye patches are removed. b. Isolate client so others will not confuse him. c. Maintain a calm, dark environment conducive to rest. d. Speak to him frequently, and provide frequent touch. The nurse should always speak when entering the room of a client with decreased vision. This makes the client aware of the nurses presence. Options #1, #2, and #3 are incorrect because the client will become more confused with sensory deprivation. 23. Which statement made by the parents of a child with hydrocephalus indicates they understand how to care for a child with a ventriculoperitoneal shunt? a. "We will position our child on the operative side." b. "We will position our child in the semi-Fowlers position after surgery." c. "We will report if our child starts vomiting." d. "We will rely on the home health nurse to pump the shunt." The parents need to understand the importance of monitoring and reporting signs of increased intracranial pressure. Vomiting is a sign of IICP. Signs of infection would also be important to report. Options #1 and #2 are incorrect positions. Parents need to understand how to pump the shunt in order to maintain patency. 24. Which statement by the client best indicates an understanding of and preparedness for a scheduled magnetic resonance imaging (MRI)? a. “The dye used in the test will turn my urine green for about 24 hours." b. "I will be put to sleep for this procedure. I will return to my room in 2 hours." c. "This procedure will take about 1-1/2 hours to complete. It will be noisy." d. "The wires that will be attached to my head and chest will not cause me any pain." This procedure takes approximately 1-1/2 hours, and there is a lot of noise associated with the test. Option #1 is incorrect because there is no dye used for an MRI. Option #2 is incorrect because the client is not anesthetized for this procedure. Option #4 is inappropriate for this situation. 25. When caring for a client with myasthenia gravis, an important nursing consideration would be to: a. prevent accidents from falls as a result of vertigo. b. maintain fluid and electrolyte replacement. c. control situations that could increase intracranial pressure and cerebral edema. d. assess muscle groups that are affected as they tend to be weaker toward the end of the day. The client has increased muscle fatigue and needs more assistance towards the end of the day. Option #1 is incorrect because the client does not experience vertigo. Option #2 is incorrect because though fluid and electrolytes are important, they are not a priority over. Option #4. Option #3 is incorrect because increased intracranial pressure is not associated with my asthenia gravis. 26. The nurse would identify which response as the therapeutic one to mydriatic eye drops? a. Pupillary dilation. b. Decrease in ocular pain c. Resolution of sclera inflammation.

d. Pinpoint pupils with decreased response. Mydriatic eye drops are administered to dilate the pupil frequently for ocular surgery. Options #2 and #3 will not occur as a result of the drops. Option #4 is the response of miotic eye drops. 27. Which observation by the nurse would indicate the client is beginning to accept blindness? a. Walking in hall without a walking cane. b. Asking sister to fix her hair. c. Surveying her room, touching furniture. d. Not listening to TV or radio when alone. Acceptance of blindness would be exhibited by an exploration of their world. Option #1 demonstrates denial. Option #2 exhibits dependence. Option #4 could be a result of depression. 28. In planning the care of a client with an acute episode of Menieres Syndrome, the nurse would outline teaching to include: a. adding salt to food. b. avoiding sudden motion of the head. c. restricting fluids to 3-4 glasses daily. d. keeping cotton in affected ear. Avoiding sudden motion of the head will reduce incidence of vertigo, nausea, and vomiting. Option #1 is incorrect because salt should be restricted. Option #3 is incorrect because fluids should not be restricted. Option #4 is incorrect because cotton will not help the condition. 29. Which instruction would the nurse include in a discharge teaching plan for the client with a diagnosis of glaucoma? a. Decrease intake of saturated fats and potassium. b. Eye pain and nausea should be reported to the physician. c. Anticipate gradual increase in visual field. d. Eye drops may be discontinued after two weeks. Eye pain and nausea may be indicative of increased intraocular pressure. Option #1 is for a client with hypertension and atherosclerosis. Option #3 is incorrect because the client may not experience any improvement in vision, but further deterioration may be prevented. Option #4 is incorrect because the eye drops may be continued indefinitely. 30. Which communication technique would be appropriate for a nurse to implement when caring for a client with a hearing loss? a. Irrigate the ear with warm water to remove any wax obstruction. b. Always touch the client prior to speaking to him. c. Encourage the client to purchase a hearing aid. d. Stand in front of him and speak clearly and slowly. The nurse should always stand in front of the hearing impaired client, and raising the voice is not as effective as clear, slow speech. Option #1 is not necessary. Option #2 is incorrect because it is important that a sensory-impaired client be aware of someone’s presence before they are touched. 31. Which statement made by a client with a left-sided hemiparesis from a CVA indicates an understanding of how to transfer out of the bed? a. "The wheel chair should be on the right side of the bed." b. "The wheel chair should be on the left side of the bed." c. "I will use a cane." d. "I will wait for the physical therapist to lift me out of the bed." When teaching paralyzed clients how to transfer themselves, it is important for them to understand that the strong side leads. Options #2, #3, and #4 are ineffective. 32. Which client would have the highest potential for skin breakdown? a. A client with functional incontinence. b. A client in Buck's traction. c. A new postoperative hip replacement. d. Two-hour postoperative knee replacement. Option #1 would be the highest risk for skin breakdown due to the inability to get to the bathroom. Options #2, #3, and #4 are possibilities but are not priorities to Option #1. 33. A client with a long leg cast on his right leg has a foot that is pale and cool to touch. An analgesic has offered no relief to severe leg pain after 45 minutes. The first action of the nurse should be to: a. apply a heating pad to the right toes. b. repeat the dose of analgesic stat.

c. remove the cast immediately. d. notify the physician immediately. These are symptoms of compartmental syndrome which must be relieved as soon as possible. The only action within the realm of the nurse is to document observations and secure the physicians intervention immediately. Option #1 is inappropriate response to the symptoms observed. Option #2 is not likely to be ordered q45 min., and it is only palliative. Option #3 is beyond the scope of practice though bivalving is desirable. 34. Three days postoperative above-the-knee amputation, a client complains about phantom limb pain in his lower leg. Which nursing response would be best? a. "That should improve within a year." b. "I'll call the physician." c. "Keep your leg on this pillow." d. "Staying active will help decrease the episodes." Activity helps reduce frequency and degree of phantom pain. Option #1 may be true for 2% of amputees, but for the majority, pain occurs for a few months. Option #2 is not necessary. Option #3 is contraindicated more than 24 hours after an amputation because of the possibility of causing contractures 35. A toddler in traction and receiving chloral hydrate (Noctec) for sedation has become irritable and extremely restless. Which nursing action is most appropriate? a. Recognize the toddler needs more sedation, and give the next dose of chloral hydrate early. b. Recognize that this restlessness may be caused by the chloral hydrate, and recommend the use of another sedative. c. Realize that the toddler is upset about being in traction, and give the next dose of chloral hydrate as scheduled. d. Take the toddler out of traction for thirty minutes, and give the next dose of chloral hydrate as scheduled. Chloral hydrate can have the opposite effect on a toddler and cause excitability. Options #1 and #3 would probably increase the restlessness and worsen the condition by giving the toddler more medication. Option #4 is incorrect because the toddler would remain in traction until ordered out by a physician. 36. Which nursing assessment suggests a complication of a plaster-of-paris cast application on the arm? a. The client states that the wet cast feels warm. b. The client is able to move his fingers and thumb freely. c. The client states that his little finger feels asleep. d. The wet cast appears gray and smells slightly musty. A wet plaster of Paris cast will generate heat while hardening, appear gray, and smell slightly musty. Loss of sensation may indicate nerve compression. Options #1 and #2 are incorrect because these are normal findings. Option #4 indicates a later sign of complication. 37. On the second day following a lumbar disc excision, the client complains of mild pain in both legs. The nurses response is based on which understanding of leg pain in the early postoperative period? a. Should delay early ambulation. b. Can result from swelling which compresses the nerve. c. Is common for months after surgery. d. Indicates surgery was unsuccessful. The surgical inflammation can cause some temporary leg pain after disc excision. Option #1 is incorrect because early ambulation should be encouraged and sitting for long times is contraindicated. Option #3 may occur, but a prediction is not made at this time. Option #4 is inaccurate. 38. An 18-year-old immobilized for trauma to the spinal cord, has periods of diaphoresis, a draining abdominal wound, and diarrhea. An appropriate priority nursing diagnosis is: a. potential constipation related to immobilization. b. impaired skin integrity related to immobilization and secretions. c. potential for wound infection related to involuntary bowel secretions. d. potential fluid volume deficit related to secretions. Because of the immobility and the bodily secretions, the clients skin's very susceptible to breakdown and needs numerous nursing interventions to prevent this from happening. Options #1, #3, and #4 are not current problems. 39. The nursing assessment in a client exhibiting symptoms of myxedema should reveal: a. increased pulse rate b. decreased temperature. c. fine tremors. d. increased radioactive iodine uptake level.

With myxedema, there is a slowing of all body functions. Options #1, #3, and #4 are associated with hyperthyroidism. 40. A client with Parkinson's disease has the nursing diagnosis: potential for injury related to tremors. To promote safety, the nurse would instruct the client about: a. the use of crutches. b. over-filling cup of hot liquids. c. care of contractures. d. methods to prevent decubitus formation. A full cup of hot liquids may be spilled due to hand tremors, and the client may be burned. Option #1 is inappropriate. Options #3 and #4 are related to the potential for injury but are related to rigidity not tremors. 41. Which nursing assessment is the most important regarding proper fitting of crutches? a. With the client standing, the top of the crutch should be approximately 2 below the axillary area. b. The bottom of the crutches should be positioned next to the heel of the foot. c. The arms should be fully extended to the crutch hand grips. d. The crutches should fit snugly under the arm for weight-bearing. The crutches should be positioned about 2 under the axillary area to prevent nerve damage to the brachial plexus area which would result in arm paralysis or numbness. Options #2, #3, and #4 are incorrect positions. 42. Following a left above-the-knee amputation, the nurse is teaching a client regarding positioning. Which response by the client indicates an understanding of the importance of the prone position postoperatively? a. "I need to lie on my stomach to keep from getting a flexion contracture at my left hip." b. "Lying flat keeps my blood flowing and prevents my stump from swelling." c. "I need to lie on my stomach to prevent a pressure sore on my hips." d. "I will always elevate my stump when I am in a chair to keep it from swelling." The prone position provides maximum extension of the hip joint and prevents hip flexion contracture. If hip flexion contracture occurs, then it is very difficult to correctly fit or utilize a prosthesis. Option #2 contains incorrect information. Option #3 is not a priority. Option #4 can result in contractures. 43. Which nursing goal is the highest priority in the plan of care for a client with a stroke? a. Maintain adduction of affected shoulder. b. Prevent flexion of the affected extremities. c. Provide active range of motion daily to all extremities. d. Maintain external rotation of affected hip. Prevention of flexion of the extremities is a priority. Options #1, #3, and #4 are incorrect because the nurse needs to prevent adduction of the affected shoulder, external rotation of the hip joint, and foot drop (plantar flexion) as well as place the hand in slight supination so that the fingers are barely flexed. 44. Which nursing measure would be the most appropriate in preventing complications of immobility with an elderly client? a. Consistent use of bedrails b. Physical restraints c. Encourage isometric muscle contraction. d. Encourage as much assistance from the caregiver with activities of daily living as needed. This will prevent atrophy of the flexor and extensor muscle groups which will result in optimizing mobility. Options #1 and #2 are inappropriately restraining the client which will result in complications of immobility. Option #4 should say encourage independence versus as much assistance. 45. Which statement made by a client with hypothyroidism started on levothyroxine sodium (Synthroid) indicates a need for further teaching? a. "This medicine might affect my diabetes." b. "I'll take this little pill every day before I have breakfast" c. "I'll be able to quit taking this pill when I start feeling better." d. "This medicine will affect the action of my heart pill Lanoxin." Thyroid hormone replacement is usually continued for life. A sudden discontinuing of the medication may cause a myxedema crisis. Option #1 is a correct statement because thyroid hormones may produce hyperglycemia due to the increased rate of carbohydrate breakdown. Option #2 is a correct statement because taking it before breakfast will prevent insomnia. Option #4 is a correct statement because thyroid hormones enhance toxic effects of digoxin preparations. 46. To evaluate the desired response of calcium gluconate in treating acute hypoparathyroidism, the nurse would monitor the client most closely for: a. intake and output.

b. confusion. c. tetany. d. bone deformities. Tetany is the major sign of hypoparathyroidism. Options # 1 and #4 are important to monitor but are not top priority. Option #2 is incorrect because bone deformities are most frequently observed with hyperparathyroidism. 47. In planning discharge teaching for a postoperative client after a lumbar laminectomy. which muscles would the nurse instruct the client to exercise regularly? a. Anal sphincter b. Abdominal c. Trapezius d. Rectus femoris Strengthening the abdominal muscles adds support for the muscles supporting the lumbar spine. Options #1 and #4 do not contribute significantly. Option #3 would be secondary. 48. The nurse would caution the client with hypothyroidism about avoiding: a. warm environmental temperatures. b. narcotic sedatives. c. increased physical exercise. d. numbness and tingling of fingers. The client with hypothyroidism is very sensitive to narcotics, barbiturates, and anesthetics. Option #1 is incorrect because the client with hypothyroidism cannot tolerate cold temperatures. Options #3 and #4 do not require caution. 49. Which nursing measure would be least helpful in maintaining skin integrity? a. Measure lesion size using the two greatest perpendicular diameters and lesion depth or elevation, and document in record. b. Use an air-supported mattress or bed. c. Educate client regarding how to safely take his iron supplement. d. Encourage foods high in protein. This does not address the question. Options #2, #3, and #4 are very helpful in maintaining skin integrity 50. The client with newly diagnosed multiple sclerosis is preparing to go home. The nurse should caution the client about: a. ambulating every day. b. over-exposure to heat or cold. c. stretching and strengthening exercises. d. participating in social activities. Overexposure to heat or cold may cause damage related to the changes in sensation. Options #1 and #3 are incorrect because the client is encouraged to ambulate as tolerated and participate in an exercise program to include ROM, stretching, and strengthening exercises. Option #4 is inappropriate because a client with multiple sclerosis is encouraged to continue usual activities as much as possible, including social activities. 51. Which client would require primary prevention for skin breakdown? a. A client with iron-deficiency anemia. b. A client with a pressure sore over the coccyx. c. A client with absence of erythema over an area that has recently been subjected to pressure. d. A client with a mobility deficit. An anemic client will have a lack of blood flow which is a critical factor in wound development. Option #2 presents with tertiary prevention for skin breakdown. Options #3 and #4 present with a secondary prevention for skin breakdown. 52. In planning care for the client with hyperthyroidism, the nurse would anticipate the client to require: a. extra blankets for warmth. b. ophthalmic drops on a regular basis. c. increased sensory stimulation. d. frequent low calorie snacks. Clients with hyperthyroidism frequently exhibit exophthalmos which requires ophthalmic drops on a regular basis. Option #1 is incorrect because the client is usually sensitive to heat. Option #3 is incorrect because the care would include a calm, restful environment with low levels of sensory stimulation. Option #4 is incorrect since these clients need to increase their caloric intake. 53. Based on the nursing assessment, an appropriate nursing diagnosis for the client with Parkinson's disease would be:

a. body image disturbance related to tremors b. altered tissue perfusion related to decreased blood supply. c. pain related to headaches. d. potential for injury related to seizures. Body image disturbance related to tremors is correct. Option #2 is incorrect because the blood supply is not decreased. Option #3 is incorrect because the client may experience pain, but' it is usually related to rigidity and tremors. Option #4 is incorrect. Although there is a potential for injury, the client does not experience seizures. 54. Which nursing intervention is inappropriate in helping a depressed client to sleep more hours per night? a. Teach deep breathing and relaxation techniques. b. Explore what client is thinking and feeling when unable to sleep. c. Help client express her feelings more clearly. d. Administer a sedative-hypnotic medication at bedtime. Medication which produces dependence, should be used only if other nursing measures and antidepressant medications have not worked, and the client is exhausted. Options #1, #2, and #3 are therapeutic interventions to help the client learn how to create an environment conducive to sleep. 55. Which statement made by the client indicates a correct understanding of steroid therapy for Addison's Disease? a. "I'll take the medicine in the morning because if I take it at night, it might keep me awake." b. "I'll take the same amount from now on." c. "I'll increase my potassium by eating more bananas." d. "This medicine probably won't affect my blood pressure." If steroids are taken at night, they may cause sleeplessness. Option #2 is incorrect because the dosage has to be regulated according to stress. Option #3 is incorrect because the client with Addisons disease has hyperkalemia. Option #4 is incorrect because steroids cause fluid retention which can increase the blood pressure. 56. Which statement made by the client with Cushing's syndrome indicates a need for further teaching? a. "I realize I'll have to begin an exercise program slowly and gradually." b. "I'm going to have to keep a close eye on my blood pressure." c. "I'm not really worried about getting pneumonia this winter." d. "I'll be eating foods low in carbohydrates and salt." This statement does not indicate the client realizes that there is an increased susceptibility to infections. Option #1 is a correct statement. Option #2 is a correct statement because these clients may develop hypertension related to sodium and water retention. Option #4 is a correct statement since the diet should be low carbohydrate, low sodium, and high protein. 57. In planning care for the client with Cushing's syndrome, which nursing action would be highest priority? a. Prevent skin breakdown b. Prevent infections. c. Teach client signs and symptoms of hyperglycemia. d. Prevent fluid overload. Respirations are the first priority. Clients with Cushing’s syndrome are prone to fluid overload and CHF due to sodium and water retention. Options #1 and #2 are incorrect because these clients are susceptible to skin breakdown and infections. Option #3 is incorrect because the hyperglycemia due to the impaired glucose tolerance is not the top priority. 58. A nursing assessment of a client with hyperthyroidism is most likely to reveal: a. weight gain. b. Bradycardia. c. hypotension. d. heat intolerance. Clients with hyperthyroidism are very sensitive to heat. Option #1 is incorrect since weight loss is common although the client has an increased appetite. Option #2 is incorrect because hyperthyroid clients will experience tachycardia. Option #3 is incorrect because hypertension is a symptom of hyperthyroidism. 59. Nursing care specific for an adult in Buck's traction would include: a. checking site of pins for bleeding or infection. b. applying topical or antibiotic ointment as ordered. c. assessing that the elastic bandages are not too loose or too tight. d. removing the bandages daily to lubricate the skin. Assessment is needed to make sure circulation is not being compromised. Option #1 is incorrect because Bucks traction is a type of skin traction. Therefore, there are no pins. Option #2 is incorrect because skin traction has no

need for topical ointment. Option #4 is incorrect because the skin is not lubricated under the bandages. 60. For an elderly client who has just had a prosthetic hip implant, which postoperative position should be maintained? a. The affected hip should be internally rotated and flexed. b. The affected hip should be adducted when turning the client. c. In the supine position, the knees should be elevated 90 degrees. d. When side-lying, the affected hip should be in a position of abduction. A position of abduction should be maintained. Flexion beyond 60 degrees and internal rotation should be avoided in the early postoperative period. Options #1, #2, and #3 are incorrect.