Nokea
While reviewing a client's medical record who has fallen twice in the past month, which medications should the nurse recommend be discontinued to lower the client's risk for future falls?
- A. Fluoxetine
- B. Temazepam
- C. Bupropion
- D. Ferrous sulfate
- E. Hydrocodone-acetaminophen
- F. Hydroxyzine
- G. Docusate
Correct Answer: B, E, F
Rationale: Temazepam (sedative), hydrocodone-acetaminophen (opioid), and hydroxyzine (sedating antihistamine) increase fall risk via drowsiness or dizziness. Fluoxetine, bupropion, ferrous sulfate, and docusate have lower fall risk.
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The following scenario applies to the next 6 items
The nurse in the medical-surgical unit is caring for a newly admitted client.
Item 1 of 6
History and Physical
1930: Client is a 45-year-old male who has a one-and-a-half-week history of pain, redness, and swelling in his right foot. He reported that the symptoms began after he accidentally cut his foot while walking barefoot in his backyard. Over the next few days, he developed pain and swelling around the cut, accompanied by redness and warmth. He went to urgent care two days later and was diagnosed with cellulitis in his right foot. He was prescribed antibiotics but could not afford the treatment. Three days ago, the pain escalated and was described as throbbing and constant, with a severity rating of 7/10 on the Numerical Pain Rating Scale. He states, "the pain is now in the bone of my foot; I don't know how else to describe it." He also noted occasional fever 101°F (38.3°C), chills, and general malaise. On physical examination, his right foot was erythematous, swollen, and warm to the touch. A 3 cm ulcer was noted on the plantar aspect of the right foot, with moderate purulent discharge present. The ulcer appeared deep, and palpation of the surrounding tissue elicited tenderness. There was limited range of motion in the right ankle due to pain. The distal pulses were palpable 2+, and there were signs of neuropathy in the feet (decreased sensation to light touch and pinprick). He has a medical history of uncontrolled diabetes mellitus (type two), obesity, peripheral neuropathy in all extremities, hypertension, hyperlipidemia, and epilepsy.
Which of the following findings in the history and physical requires follow-up?
- A. Sensation in the feet
- B. Drainage from wound
- C. Peripheral pulses
- D. Pain characteristics
- E. Medical history
Correct Answer: A, B, D, E
Rationale: Decreased sensation (neuropathy) risks further injury, purulent drainage suggests infection, pain characteristics indicate severity and progression, and uncontrolled diabetes and other conditions increase complication risk. Peripheral pulses are normal at 2+.
A nurse is taking care of a client that is status-post hand arthroplasty. When creating the care plan, which of the following nursing interventions should be avoided to prevent complications?
- A. Encourage the client to perform finger and wrist exercises ten times per hour, using a full range of flexion and extension.
- B. Place the client's personal items within reach of the client's non-operative arm.
- C. Place the client's operative arm on a pillow to rest and keep it elevated.
- D. Encourage the client to use the non-operative arm as much as possible.
Correct Answer: A
Rationale: Excessive full range of motion exercises shortly after hand arthroplasty can strain the surgical site, risking damage or delayed healing. Elevation, using the non-operative arm, and placing items within reach are appropriate.
The following scenario applies to the next 1 items
The nurse in a urgent care facility cares for a 46-year-old male
Item 1 of 1
Triage Note
1400: 46-year-old man reports right ankle pain that started one hour ago while playing soccer with his children. He states that he was getting ready to kick the ball and lost his footing on wet grass. Focused assessment: swelling over the lateral malleolus down to the area of the fourth and fifth metatarsals is present, and pedal pulses are 2+ bilaterally. Pain is endorsed with movement, and the range of motion of the right ankle is very limited. No gross deformity of the ankle was observed. Pain is rated 9 on a scale of 0 (no pain) to 10 (severe pain). T 97.5° F (36.4° C), P 98, RR 18, BP 144/90, pulse oximetry reading 96% on room air. The client reports allergies to erythromycin with an unknown reaction. Medical history included a myocardial infarction 8 months ago, irritable bowel syndrome, and plaque psoriasis. Current medications include clopidogrel and atenolol.
Physician Orders
• Discharge home with an orthopedic referral
• Ketorolac 15 mg intramuscular (IM) x 1 dose
• Apply ace wrap to the right ankle
• Home prescription: Ketorolac 10 mg by mouth twice a day PRN pain for three days
• Home prescription: Oxycodone 5 mg by mouth twice a day PRN pain for three days
• Home prescription: Docusate 50 mg by mouth once a day for three days
• Home prescription: Crutches, no weight bearing to the right lower extremity until seen by orthopedics
Diagnostics
Right Ankle X-Ray
No obvious fracture is seen. Bones show normal alignment and architecture. Joint spaces and articular margins are intact. Soft tissue swelling noted.
The nurse implements the physician's orders. Complete the sentences below by choosing from the list of options. The nurse reviews the prescriptions and should question the prescribed……….. with the physician based on the client's medical history of…….The nurse is gathering the prescribed crutches and plans on teaching the client to ambulate using the……..The nurse should instruct the client that the crutches should be………To promote comfort and to reduce swelling, the nurse should instruct the client to apply…………..compresses to the ankle for no greater than………..
- A. Ketorolac
- B. Recent myocardial infarction.
- C. Three point gait.
- D. 6 inches (15 cm) in front of their feet while standing.
- E. Cold
- F. 20 minutes at a time.
Correct Answer: A, B,C,D,E,F
Rationale: A, B: Ketorolac, an NSAID, increases bleeding risk, concerning with a recent myocardial infarction and clopidogrel use. Other options relate to crutch use and swelling management, which are appropriate.
The nurse is assessing a client who is newly diagnosed with rheumatoid arthritis (RA). Which of the following findings is consistent with this diagnosis?
- A. Janeway lesions
- B. Tophi
- C. Unilateral joint pain
- D. Low-grade fever
Correct Answer: D
Rationale: Low-grade fever is consistent with rheumatoid arthritis, a systemic inflammatory condition. Janeway lesions are linked to endocarditis, tophi to gout, and RA typically involves bilateral joint pain.
While training a new RN in the emergency department, the nurse attends to a client with Guillain-Barre Syndrome. The new RN asks what may have caused this condition. Which of the following occurrences in the patient's history is most likely a contributing factor?
- A. A spinal cord injury at age 12
- B. An upper respiratory infection about a month ago
- C. Hydrocephaly as an infant
- D. A joint injury as a teenager
Correct Answer: B
Rationale: Guillain-Barre Syndrome is often triggered by a recent infection, commonly an upper respiratory infection, leading to an autoimmune response against peripheral nerves. Spinal cord injury, hydrocephaly, and joint injury are unrelated.