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15 NCLEX and increased ICP

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115 NCLEX and increased ICP Empty 15 NCLEX and increased ICP on Thu Nov 03, 2011 11:44 pm


Fosamax is prescribed for a client with osteoporosis. The nurse instructs the client to:
1. take the medication at bedtime
2. take the medication in the morning with breakfast
3. lie down for 30 min after taking the medication
4. take the medication with a full glass of water after rising in the morning

A nurse conducting a health screening for osteoporosis. Which of the follwing clients is at greatest risk of developing this disorder
1. a 25 y.o woman who jogs
2. a 36 y.o man who has asthma
3. a 70 y.o man who consumes excess alcohol
4. a sedentary 65 y.o woman who smokes cigarettes
Answer: 4

The nurse prepares a client for a bone scan. What priority assessment should the nurse perform for this client?
1.hx of claustrophobia
2.presence of IV access
3.current VS
4.presence of metallic implants such as a pacemaker or aneurysm clips
answer: 2

A retired 66 y.o female client is being evaluated for osteoporosis as part of a yearly physical. The client states that she is a smoker, watches TV most of the day, and has been hospitalized with three different fractures within the last year. Based on this info, the nurse suspects which of the following
1. low bone mass leading to increased bone fragility
2. degeneration of the articular cartilage
3. recurrent attacks of acute arthritis
4. personality changes caused by chronic nature of illness
Answer: 1

The primary care provider determines that a 55 y.o female client is experiencing menopause and is also at risk for osteoporosis. What foods other than milk can the nurse suggest to this client to increase her calcium intake
1.seafood, wheat, corn, green vegs
2.chicken, green vegs, sardines, broccoli vegs, sardines, salmon with the bone, broccoli
4.eggs, cheese, sardines, fish
answer: 3

Fosamax is ordered for a client with osteoporosis. Which info should the nurse include in teaching the client about this drug is a selective estrogen receptor modulator increases bone mass may be obtained as a nasal spray prevents bone resorption and is taken orally
answer: 4

A home health nurse is planning to teach a client with osteoporosis about home modifications to reduce the risk of falls. Which of the following recommendations would be necessary to include in the teaching plan? Select all that apply.
1. use of staircase railings
2. use of nightlights
3. removal of wall-to-wall carpeting
4. removal of scatter rugs
4. placement of handrails in the bathroom
Answer: 1,2,4,5

A community health nurse is providing a teaching session on osteoporosis to women living in the community. The nurse informs these community residents that which of the following is a risk factor for this disorder
1. a large skeletal frame
2. a high dietary intake of calcium
3. low thyroid hormone levels
4. a diet low in vit D
Answer: 4

An older female is dx with osteoporosis. The nurse teaches the client about self-care measures, knowing that the client is most at risk for which of the following as a result of this disorder of the bones?
1.loss of appetite
3.nutritional deficiencies
answer: 2

A nurse is obtaining a health hx from a client and is assessing for risk factors associated with osteoporosis. Which of the following assessment findings are risk factors? Select all that apply
1. high-calcium diet
2. postmenopausal age
3. long-term use of corticosteroids
4. family hx of osteoporosis
5. active lifestyle
Answer: 2,3,4

A nurse is providing instructions to a client with osteoporosis regarding appropriate food items to include in the diet. The nurse tells the client that which food item provides the least amount of calcium
1. plain yogurt
2. seafood
3. sardines
4. pork
Answer: 4

An immobile client is at risk for disuse osteoporosis. The nurse understands that which of the following substances plays an important role in the bone remodeling process?
1. Vit C
2. Vit A
3. Calcitonin
4. Thyroid hormone
Answer: 3

A nurse is lecturing to a group of women who are at high risk for osteoporosis. What is the most important intervention that the nurse can inform the women about?
1. limit protein in the diet because it contributes to the incidence of bone demineralizatiom
2. limit participation in activities such as walking and swimming
3. limit caffeine intake
4. limit intake of vit D
Answer: 3

Which of the following is the major mechanism for maintaing calcium balance in the body
1.appropriate body alignment
2.bone remodeling and passive exercises
answer: 2

Osteoporosis can be defined as:
1.loss of bone matrix, weaker bone growth
3.loss of bone density
4.increased phagocytic activity
answer: 3

five signs earliest to latest of increased ICP
1. altered LOC
2. blurred vision
3. headache
4. rise in blood pressure with widening pulse pressure
5. slowing of pulse

three positions that are contraindicated with increased ICP:
1. Trendelenburg position
2. flexion of the neck and hips
3. supine/prone
For the client with increased ICP,elevate the HOB 30 to 40 degrees.

Sources: Medical-Surgical Nursing Reviews & Rationales, 2 ed.

Saunders Comprehensive Review NCLEX-RN examination, 5 ed.

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