Nursing Board Review: Medical Surgical Nursing Practice Test Part 2

Pain in the calf while pulling up on the toes is abnormal and indicates a positive test. If the client feels nothing or just feels like the calf muscle is stretching, it is considered negative. A tourniquet test is used to measure for varicose veins.

Nosocomial, or hospital-acquired are infections acquired during hospitalization for which the patient isn’t being primarily treated. Community acquired or opportunistic infections may not be acquired during hospitalization. An iatrogenic infection is caused by the doctor or by medical therapy. And an opportunistic infection affects a compromised host.

Hyperglycemia is defined as a blood glucose level greater than 120 mg/dl. Blood glucose levels of 120 mg/dl, 130 mg/dl and 150 mg/dl are considered hyperglycemic. A blood glucose of 100 mg/dl is normal.

Chvostek’s sign is a spasm of the facial muscles elicited by tapping the facial nerve and is associated with hypocalcemia. Clinical signs of hypokalemia are muscle weakness, leg cramps, fatigue, nausea and vomiting. Muscle cramps, anorexia, nausea and vomiting are clinical signs of hyponatremia. Clinical manifestations associated with hypophosphatemia include muscle pain, confusion, seizures and coma.

Typically, a patient with cataracts experiences painless, gradual loss of vision. Although both eyes may develop at different rates.

Heavy lifting is one factor that leads to development of a hiatal hernia. Dietary factors involve limiting fat intake, not restricting client to soft foods. It is more prevalent in individuals who are middle-aged or older. Fair-skinned individuals are not prone to this condition.

Flapping tremors associated with hepatic encephalophaty are asterixis. Aphasia is the inability to speak. Ascites is an accumulation of fluid in the peritoneal cavity. Astacia is the inability to stand or sit still.

Cerebral tissue hypoxia is commonly associated with dizziness. The greatest potential risk to the client with dizziness is injury, especially with changes in position. Planning for periods of rest and conserving energy are important with someone with anemia because of his or her fatigue level but most important is safety.

when opening an envelop-wrapped sterile package, reaching across the package and using the first motion to open the top cover away from the body eliminates the need to later reach across the steri9le field while opening the package. To remove equipment from the package, opening the first portion of the package toward, to the left, or to the right of the body would require reaching across a sterile field.

The Lanoxin should be held for a pulse of 60 bpm. Nurses cannot arbitrarily give half of a dose without a physician’s order. Unless specific parameters are given concerning pulse rate, most resources identify 60 as the reference pulse.

A dissecting thoracic aneurysm may cause loss of radical pulses and severe chest and back pain. An MI typically doesn’t cause loss of radial pulses or severe back pain. CVA and dissecting abdominal aneurysm are incorrect responses.

Although option D is correct, it is not a strong indicator of cirrhosis. Pruritus can occur for many reasons. Options A and C are incorrect, fluid accumulations is usually in the form of ascites in the abdomen. Hepatomegaly is an enlarged liver, which is correct. The spleen may also be enlarged.

Caffeine and alcohol can increase bladder spasms and mucosal irritation, thus increase the signs and symptoms of UTI. All antibiotics should be taken completely to prevent resistant strains of organisms.

SIADH results in fluid retention and hyponatremia. Correction is aimed at restoring fluid and electrolyte balance. Anxiety and risk for injury should be addressed following fluid volume excess.

A burn face, neck or chest may cause airway closure because of the edema that occurs within hours. Remember the ABC’s: airway, breathing and circulation. Airway always comes first, even before pain. The nurse will also assess options B and D, but these are not the highest priority assessments.

A mediastinal shift is indicative of a tension pneumothorax along with the other symptoms in the question. Since the individual was involved in a MVA, assessment would be targeted at acute traumatic injuries to the lungs, heart or chest wall rather than other conditions indicated in the other answers. Option A is common with pneumonia; values in option B are not alarming; and option D is typical of someone with COPD.

Narrow-angle glaucoma develops abruptly and manifests with acute face and eye pain and is a medial emergency. Halo vision, dull eye pain and impaired night vision are symptoms associated with open-angle glaucoma.

Alzheimer’s disease is the most common cause of dementia in the elderly population. AIDS, brain tumors and vascular disease are all less common causes of progressive loss of mental function in elderly patients.

Herpes is a virus and is spread through direct contact. An antifungal would not be useful; bed rest and temperature measurement are usually not necessary.

A stage 3 ulcer is full thickness involving the subcutaneous tissue. A stage 1 ulcer has a defined area of persistent redness in lightly pigmented skin. A stage 2 ulcer involves partial thickness skin loss. Stage 4 ulcers extend through the skin and exhibit tissue necrosis and muscle or bone involvement.

Central tissue hypoxia is commonly associated with dizziness. Recognition of cerebral hypoxia is critical since the body will attempt to shunt oxygenated blood to vital organs.

The 50% dextrose is given to counteract the effects of insulin. Insulin drives the potassium into the cell, thereby lowering the serum potassium levels. The dextrose doesn’t directly cause potassium excretion or any movement of potassium.

Options B, C and D are appropriate nursing interventions when caring for a client diagnosed with osteomyelitis. The application of heat can increase edema and pain in the affected area and spread bacteria through vasodilation.

The BUN is primarily used as indicator of kidney function because most renal diseases interfere with its excretion and cause blood vessels to rise. Creatinine is produced in relatively constant amounts, according to the amount of muscle mass and is excreted entirely by the kidneys making it a good indicator of renal function.

DVT, is the most probable complication for postoperative patients on bed rest. Options A, B and D aren’t likely complications of the post operative period.