Question

A nurse is planning care for an older adult client who has a history of dementia and is admitted following surgical repair of a hip fracture. Which of the following actions should the nurse plan to take?

Answer 1

Correct Answers:

Play serene soothing music.

Rationale :

💠Clients with dementia are prone to agitation, confusion, and delirium, especially in the hospital after surgery.

💠Non-pharmacological interventions such as playing calm, soothing music are effective in promoting relaxation and reducing agitation.

💠Serene music helps create a therapeutic environment, supporting orientation, decreasing anxiety, and improving sleep quality.

💠Keeping the over-bed light on can actually increase confusion and agitation, especially at night, by disrupting circadian rhythm.

💠Frequent visits may overwhelm a client with dementia and worsen disorientation.

💠Physical restraints are contraindicated unless absolutely necessary, as they increase the risk of injury, agitation, and functional decline in clients with dementia.

💠Therefore, calm background music is the most appropriate and least invasive intervention to support recovery and comfort.

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Answer 2

Correct Answers

Blank 1 Correct Option: Cirrhosis
Blank 2 Correct Option: Teach the client about restricting sodium intake and Measure the abdominal girth
Blank 3 Correct Option: Ammonia levels and Unintentional weight loss.

Rationale :

Cirrhosis

🔷The cluster of ascites (tense, distended abdomen with dilated veins and protruding umbilicus), hepatomegaly, and peripheral pitting edema indicates portal hypertension and sodium–water retention, classic for cirrhosis.

🔷History of alcohol use disorder is a leading etiology for hepatic fibrosis progressing to cirrhosis, aligning with this presentation.

🔷Orthopnea, crackles, tachypnea, and inability to lie supine are explained by ascites elevating the diaphragm and third‑spacing, which worsen respiratory mechanics.

🔷Low‑grade fever may reflect inflammation/infection risk (e.g., SBP) in the setting of ascitic fluid, further supporting a decompensated hepatic picture.

🔷The hemodynamics (HTN, tachycardia) plus hypoactive bowel sounds and fluid signs all point away from primary GI inflammatory disease and toward decompensated chronic liver disease with fluid overload.

Actions:

Measure the abdominal girth

🔷 Serial abdominal‑girth measurements at the same anatomical landmark (usually at the umbilicus) provide an objective trend of ascites volume and response to therapy (salt restriction, diuretics, paracentesis).

🔷 Girth trending is essential for early detection of rapid fluid reaccumulation, which can compromise ventilation and herald complications (e.g., SBP, renal hypoperfusion).

🔷 When paired with daily weights and I&O, girth helps tailor diuretic dosing and need for therapeutic paracentesis.

🔷 Accurate trending reduces unnecessary imaging and supports timely escalation when conservative measures fail.

🔷 Consistent technique (same tape, same patient position) ensures reliable comparisons day to day.

Teach the client about restricting sodium intake

🔷Sodium restriction (commonly ≤2 g/day) is first‑line to control ascites and edema because sodium drives renal water retention via RAAS in cirrhosis.

🔷Lowering dietary sodium decreases intravascular and third‑spaced volume, improving dyspnea and abdominal discomfort.

🔷Education focuses on hidden sodium sources (processed foods, canned soups, deli meats) and label reading, which meaningfully affects outcomes.

🔷Sodium restriction augments the effect of loop ± aldosterone‑antagonist diuretics and can reduce need/frequency of paracentesis.

🔷Consistent adherence is a modifiable factor that lowers hospital readmissions for fluid overload in cirrhosis.

Parameters:

Ammonia levels

🔷Impaired hepatic ammonia detoxification predisposes to hepatic encephalopathy—manifesting as confusion, asterixis, somnolence—especially in decompensation.

🔷Trending ammonia alongside mental‑status exams guides therapy with lactulose/rifaximin and helps assess precipitating factors (GI bleed, infection, electrolyte shifts).

🔷Rising levels or clinical decline warn of impending airway risk and need for higher‑level care.

🔷Monitoring supports timely titration of lactulose to 2–3 soft stools/day, the therapeutic target.

🔷Close surveillance reduces morbidity from cerebral edema and aspiration in advanced cases.

Unintentional weight loss

🔷Cirrhosis is catabolic; sarcopenia and protein‑energy malnutrition are common due to anorexia, early satiety from ascites, malabsorption, and altered metabolism.

🔷Tracking unintentional weight loss (interpreted with fluid status) identifies nutritional decline that increases infection risk, reduces functional status, and worsens survival.

🔷Detection prompts early dietitian referral, high‑protein, frequent small meals (unless contraindicated), and late‑evening carbohydrate/protein snacks to blunt overnight catabolism.

🔷Weight trends complement girth and edema assessment to discern true lean mass changes versus fluid shifts.

🔷Nutritional optimization improves candidacy for procedures and decreases readmissions.

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Answer 3

Correct Answers

Blank 1 Correct Option: compartment syndrome
Blank 2 Correct Option: neurovascular assessment

Rationale :

⏺️Compartment syndrome is a surgical emergency that occurs when increased pressure within a closed muscle compartment impairs circulation and nerve function.

⏺️In this case, the client presents with hallmark findings: taut skin, severe pain (moaning, grimacing), cool tender skin, weak (+1) pulse, delayed capillary refill (>3 sec), and inability to move fingers despite cues.

⏺️These neurovascular changes indicate ischemia in the affected limb, which, if untreated, can progress to permanent nerve and muscle damage within hours.

⏺️Unlike infection (osteomyelitis), the client’s afebrile status (36.9°C) and nonpurulent drainage do not suggest systemic infection.

⏺️Similarly, there are no findings of respiratory distress or petechiae that would suggest a fat embolism.

⏺️The neurovascular assessment (pulse, movement, sensation, color, cap refill, temperature) is the critical evidence here showing deterioration and confirming the risk of compartment syndrome.

⏺️Urgent action (notify provider immediately, prepare for fasciotomy if indicated, and avoid elevating the extremity above heart level) is required to prevent irreversible limb damage.

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Answer 4

Correct Answers

Blank 1 Correct Option: Rheumatoid arthritis
Blank 2 Correct Option: Assess joints for warmth and redness and Collect a 24-hr urine sample.
Blank 3 Correct Option: Cervical neck pain and Decreased immunity

Rationale :

Condition — Rheumatoid Arthritis (RA):

💠The client’s symmetrical joint pain, stiffness worse in the morning, bilateral swelling of hands and feet, and subcutaneous nodules are hallmark findings of RA.

💠Systemic symptoms — fatigue, weight loss, low-grade fever, and weakness — further distinguish RA from osteoarthritis or gout, which are more localized.

💠Laboratory results support inflammatory autoimmune disease: positive ANA, elevated ESR (38) and CRP (4), all markers of systemic inflammation.

💠Normal uric acid rules out gout, while normal calcium and vitamin D argue against metabolic bone disease such as osteoporosis.

💠Therefore, the most likely condition is RA — a chronic, progressive autoimmune inflammatory arthritis.

Actions

Assess joints for warmth and redness:

💠Warmth, redness, and swelling are indicators of active synovial inflammation in RA.

💠Ongoing joint assessments help determine disease activity and effectiveness of therapy.

💠Early recognition of flares allows timely provider notification and treatment adjustment.

💠This assessment helps prevent permanent joint deformity and disability by guiding aggressive control of inflammation.

💠Nurses play a key role in tracking inflammatory changes during each encounter.

Collect a 24-hr urine sample:

💠RA clients are often treated with DMARDs (e.g., methotrexate) and NSAIDs, which can affect renal function.

💠A 24-hr urine collection provides a measure of kidney clearance and protein excretion, important in monitoring for drug toxicity or renal involvement.

💠Detecting early renal impairment supports dose adjustments or drug changes to prevent complications.

💠Since autoimmune disease can also cause secondary renal manifestations, this test provides a baseline and follow-up measure.

💠This aligns with safe, comprehensive monitoring in chronic RA management.

Parameters

Cervical neck pain:

💠In advanced RA, cervical spine involvement can occur due to erosion and instability at C1-C2, placing clients at risk for spinal cord compression.

💠Symptoms of neck pain, neurological changes, or restricted motion require immediate evaluation, sometimes even surgical stabilization.

💠Ongoing assessment is essential because cervical spine disease is a serious, potentially life-threatening complication.

💠Monitoring ensures early referral to neurology or orthopedics if instability develops.

💠This surveillance is part of standard RA complication management.

Decreased immunity:

💠Clients with RA are immunocompromised due to both the disease process (autoimmune dysfunction) and immunosuppressive therapy (methotrexate, biologics, corticosteroids).

💠Monitoring for signs of infection (fever, elevated WBC, new cough, wounds) is critical to prevent sepsis.

💠Clients require education about infection prevention strategies (hand hygiene, vaccinations, avoiding sick contacts).

💠Routine labs (CBC) help detect bone marrow suppression or leukopenia from medications.

💠By monitoring immune status, nurses protect clients from the most common cause of RA morbidity — serious infections.

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Answer 5

Correct Answers:

Peripheral pulses

Rationale :

💠After a long leg cast, the client is at risk for neurovascular compromise due to swelling, tightness, or impaired circulation beneath the cast.

💠Assessing peripheral pulses is the priority, as it directly evaluates arterial blood flow to the extremity.

💠A diminished or absent pulse can indicate compartment syndrome or ischemia, which requires immediate intervention to prevent permanent damage or limb loss.

💠While pain and swelling are important, they can occur for many reasons and are subjective/secondary signs, whereas a pulse check is an objective, critical measure of perfusion.

💠Wound drainage is also important, but it does not carry the same immediate threat to tissue viability as loss of circulation.

💠Therefore, the first priority is confirming adequate blood supply by assessing peripheral pulses (along with color, temperature, capillary refill, sensation, and movement).

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Answer 6

Correct Answers

Blank 1 Correct Option: infection
Blank 2 Correct Option: WBC count

Rationale :

💠The client’s WBC count has declined from 4,500/mm³ to 4,100/mm³, which is below the normal range (5,000–10,000/mm³).

💠A low WBC count reflects leukopenia, which compromises the body’s ability to mount an effective immune response.

💠In the context of HIV-1, immune suppression is progressive because the virus specifically targets CD4+ T lymphocytes, increasing susceptibility to opportunistic infections.

💠While the platelet count and electrolytes remain within normal range, the primary abnormality is leukopenia, which places this client at higher infection risk.

💠Nurses should emphasize infection prevention strategies (hand hygiene, avoiding crowds/sick contacts, staying current with vaccines, and monitoring for fever, cough, or new lesions).

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Answer 7

Correct Answers:

Lie down when taking the medication.

Rationale :

💠Sublingual nitroglycerin causes vasodilation, which can result in sudden hypotension, dizziness, or syncope.

💠Clients are instructed to sit or lie down before taking the medication to prevent falls or injury.

💠The tablet should be placed under the tongue to dissolve—not chewed or swallowed—to allow rapid absorption into the bloodstream.

💠Nitroglycerin should be stored in its original dark glass container, not in the refrigerator, to preserve potency.

💠The client should check the expiration date monthly, as nitroglycerin loses effectiveness quickly.

💠Proper education helps ensure both safety and therapeutic effect during angina episodes.

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Answer 8

Correct Answers:

Wear a lead apron when providing client care.

Rationale :

💠Clients receiving internal radiation (brachytherapy) emit radiation that poses exposure risk to staff.

💠The nurse must use time, distance, and shielding to minimize exposure.

💠A lead apron provides effective shielding when direct client care is required, particularly if close contact is necessary.

💠The room door should remain closed to reduce radiation exposure to others, not open.

💠A dosimeter badge is worn by the nurse (not placed on the client) to measure cumulative radiation exposure.

💠Gloves during routine care do not need to be sterile; standard precautions suffice unless otherwise indicated.

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Answer 9

Correct Answers

Blank 1 Correct Option: Infection
Blank 2 Correct Option: WBC count

Rationale :

💠The client’s WBC count decreased from 4,500/mm³ at diagnosis to 4,100/mm³ at the 3-month follow-up, which is below the normal range (5,000–10,000/mm³).

💠This indicates leukopenia, a reduced ability of the immune system to fight pathogens.

💠In the context of HIV-1, the virus primarily targets CD4+ T-lymphocytes, leading to progressive immune suppression.

💠Even though CD4 count isn’t listed here, the drop in total WBC count reflects early compromise in immune defense mechanisms.

💠Infection risk is the greatest threat to people living with HIV because opportunistic pathogens (fungi, viruses, bacteria, protozoa) can invade easily when the immune system is weakened.

💠Other lab values (platelets, potassium, sodium, BUN) remain within normal limits, so risks like bleeding or dysrhythmias are not the immediate concern here.

💠Therefore, the primary nursing focus should be on infection prevention education—hand hygiene, avoiding exposure to sick contacts, keeping vaccinations current, safe food handling, and monitoring/reporting early signs of infection.

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Answer 10

Correct Answers:

Ensure client is NPO.
Prepare to insert a nasogastric tube.
Ensure the client is on bed rest.

Rationale :

Ensure client is NPO

💠Clients with acute diverticulitis must be placed NPO to allow the inflamed bowel to rest, preventing further irritation and risk of perforation.

💠Oral intake can exacerbate pain, distention, and bowel activity, worsening the inflammatory process.

💠NPO status also prepares the client in case surgical intervention is required if complications such as perforation or abscess develop.

💠Once inflammation subsides, the client can progress gradually to clear liquids → low-fiber diet → high-fiber diet for prevention.

Prepare to insert a nasogastric tube

💠Severe abdominal distention, pain, nausea, and vomiting suggest possible bowel obstruction or ileus from inflammation.

💠An NG tube helps decompress the bowel, relieve vomiting, and reduce pressure, lowering the risk of perforation.

💠NG suction supports bowel rest by removing gastric contents and preventing further distention.

💠This intervention is commonly ordered in acute diverticulitis with obstruction symptoms.

Ensure the client is on bed rest

💠Activity restriction/bed rest reduces intra-abdominal pressure, limits bowel stimulation, and helps relieve discomfort.

💠Movement can exacerbate peritoneal irritation and worsen pain and inflammation.

💠Bed rest provides close monitoring opportunities for worsening signs such as rigidity, rebound tenderness, or sepsis, which require urgent escalation.

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RN Adult Medical surgical 2023(August-2025)

No.

1 :
A nurse is planning care for an older adult client who has a history of dementia and is admitted following surgical repair of a hip fracture. Which of the following actions should the nurse plan to take?

2 :
A nurse in an emergency department (ED) is caring for a client.

Correct Answers

3 :
A nurse is caring for a client on rehabilitation care unit.

Correct Answers

4 :
A nurse is caring for a client in a provider’s office.

Correct Answers

5 :
A nurse is assessing a client who has a long leg cast. Which of the following assessments is the nurse's priority?

6 :
A nurse in a health clinic is caring for a client.

Correct Answers

7 :
A nurse is teaching a client who has angina about sublingual nitroglycerin. Which of the following instructions should the nurse include?

8 :
A nurse caring for a client who is receiving a prescribed dose of internal radiation therapy. Which of the following actions should the nurse plan to perform?

9 :
A nurse in a health clinic is caring for a client.

Correct Answers

10 :
A nurse is caring for a client who reports abdominal pain.

Answer Options

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RN Adult Medical surgical 2023(August-2025)

No.

1 : A nurse is planning care for an older adult client who has a history of dementia and is admitted following surgical repair of a hip fracture. Which of the following actions should the nurse plan to take?

2 : A nurse in an emergency department (ED) is caring for a client.

Correct Answers

3 : A nurse is caring for a client on rehabilitation care unit.

Correct Answers

4 : A nurse is caring for a client in a provider’s office.

Correct Answers

5 : A nurse is assessing a client who has a long leg cast. Which of the following assessments is the nurse's priority?

6 : A nurse in a health clinic is caring for a client.

Correct Answers

7 : A nurse is teaching a client who has angina about sublingual nitroglycerin. Which of the following instructions should the nurse include?

8 : A nurse caring for a client who is receiving a prescribed dose of internal radiation therapy. Which of the following actions should the nurse plan to perform?

9 : A nurse in a health clinic is caring for a client.

Correct Answers

10 : A nurse is caring for a client who reports abdominal pain.

Answer Options

1 :
A nurse is planning care for an older adult client who has a history of dementia and is admitted following surgical repair of a hip fracture. Which of the following actions should the nurse plan to take?

2 :
A nurse in an emergency department (ED) is caring for a client.

3 :
A nurse is caring for a client on rehabilitation care unit.

4 :
A nurse is caring for a client in a provider’s office.

5 :
A nurse is assessing a client who has a long leg cast. Which of the following assessments is the nurse's priority?

6 :
A nurse in a health clinic is caring for a client.

7 :
A nurse is teaching a client who has angina about sublingual nitroglycerin. Which of the following instructions should the nurse include?

8 :
A nurse caring for a client who is receiving a prescribed dose of internal radiation therapy. Which of the following actions should the nurse plan to perform?

9 :
A nurse in a health clinic is caring for a client.

10 :
A nurse is caring for a client who reports abdominal pain.