325 exam 1 review

A nurse is monitoring a client who took an overdose of acetaminophen 72 hr ago. The nurse should identify which of the following findings as a manifestation of acetaminophen poisoning?

Vomiting- also include diarrhea, sweating, abdominal distress, nausea

A nurse is caring for a client who is taking naproxen following an exacerbation of rheumatoid arthritis. Which of the following statements by the client requires further discussion by the nurse?

"I've been taking an antacid with indigestion"- NSAIDS can cause adverse GI reactions; this would be a warning manifestation

1) A patient tells the nurse, "I'm told that I should reduce the stress in my life, but I have no idea where to start." Which would be the best initial nursing response?

"Let's talk about what is going on in your life and then look at possible options"

1) A patient who is dehydrated has been experiencing confusion. The daughter is concerned about taking the patient home in a confused state. What statement by the nurse is correct?

"Once the dehydration is corrected, the patient's confusion should improve"

1) The nurse is sitting with the family of a patient who has just received the diagnosis of dementia. The family asks for information on what treatment will be needed to cure the condition. What is the nurse's best response?

"There is no treatment that reverses dementia"

1) The nurse is teaching primary prevention of cognitive impairment at a community health fair. Which topics would be included in the presentation? (Select all that apply.)

1. Do not use substances such as cannabis and alcohol 2. Wear a seat belt whenever riding in motorized vehicles 3. wear a helmet when riding bicycles and motorcycles

1) Which action should the nurse take to monitor the effects of an acute stressor on a hospitalized patient? (Select all that apply.)

1. observe for increased appetite 2. ask about epigastric pain 3. check for elevated glucose levels

A nurse is teaching a client who has a new prescription for aspirin to treat rheumatoid arthritis. The nurse should include to monitor for which of the following adverse effects of this medication?

Bleeding

1) An 80-year-old male patient is in the intensive care unit has suffered a fractured femur. You are making rounds and notice he is somnolent, with no response to verbal or physical stimulation. He has been on round the clock opioid doses q 4 hours. What is the nurse's first action?

Call the rapid response team to care for the patient immediately

A nurse is caring for a female client who has rheumatoid arthritis and asks the nurse if it is safe for her to take aspirin. The nurse should recognize which of the following findings in the client's history is a contraindication to this medication?

History of gastric ulcers- aspirin contraindicated for bleeding and decreases platelet aggregation

1) The nurse is reviewing the care plan for a patient experiencing difficulty coping with stress. Which action should the nurse implement to assist the patient?

Identifying the cause of fear- identifying causes of negative perception is the first step in helping with stress and coping

1) An older adult who is cognitively impaired is admitted to the hospital with pneumonia. Which sign or symptom would the nurse expect to be exhibited by the patient?

Increased confusion

A nurse is teaching a client who takes acetaminophen daily to manage mild knee pain. The nurse should instruct the client to monitor for which of the following adverse reactions to this medication?

Jaundice- liver toxicity, look for abdominal pain, fever, colored stool

1) A cognitively impaired patient newly admitted to the hospital is experiencing signs of sundown syndrome. Which intervention is best for the nurse to implement?

Leave a night light on in the room at all times

A nurse is assessing a client prior to the administration of morphine. The nurse should recognize that which of the following assessments is the priority?

Respiratory rate- opioids can cause respiratory depression, less than 12 resp/min

1) A 70-year-old retired patent is interested in nondrug, mind-body therapies, self-management, and alternative strategies to deal with joint discomfort from rheumatoid arthritis. What options should the nurse consider in the plan of care considering the patient's expressed wishes?

Mind- body therapies such as music therapy, distraction techniques, meditation, prayer, hypnosis, guided imagery, relaxation techniques, and pet therapy

A nurse is teaching a client who has a new prescription for aspirin to prevent cardiovascular disease. Which of the following instructions should the nurse include in the teaching?

Monitor for tinnitus- manifestation of aspirin

A nurse is preparing to administer morphine IV to a client. Which of the following medications should the nurse plan to have available?

Naloxone- Narcan, reversal agent for opioids

A nurse is planning to administer butorphanol to a client who is in labor. Which of the following medications should the nurse plan to have available to reverse the action of this medication?

Naloxone- reversal agent

1) A 19-year-old male has sustained a transection of C-7 in a motor vehicle crash rendering him a quadriplegic. He describes his pain as burning, sharp, and shooting. What type of pain is this patient describing?

Neuropathic pain- damage to the CNS

1) A 62-year-old male has fallen while trimming tree branches sustaining tissue injury. He describes his condition as an aching, throbbing back. This is characteristic of what type of pain?

Nociceptive pain- because it would be somatic pain; localized pain

1) An 82-year-old patient who is in the hospital awakens from sleep and is disoriented to where she is at the present time. The nurse reorients the patient to her surroundings and helps the patient return to sleep. What data does the nurse consider as a probable cause of the patient's confusion?

Pain medication received earlier in the night

1) The nurse is developing a care plan for a patient newly admitted to a unit that cares for patients with cognitive impairment. What is an important component of care for the patients on this unit?

Plan for a structured routine of events and caregivers

A nurse is caring for a client who is postoperative following abdominal surgery and reports incisional pain. The surgeon has prescribed morphine 4 mg IV bolus every 6 hr as needed. Before administering this medication, the nurse should complete which priority assessment?

Respiratory rate

1) A patient has not been sleeping well because he is worried about losing his job and not being able to support his family. The nurse takes the patient's vital signs and notes a pulse rate of 112 beats/min, respirations are 26 breaths/min, and his blood pressure is 166/88 instead his usual 110-120/76-84 range. Which nursing intervention or recommendation should be used first?

Slow and deepen breathing via use of positive, repeated words

1) The nurse is planning to teach a patient how to use relaxation techniques to prevent elevation of blood pressure and heart rate. The nurse is teaching the patient to control which physiological function?

Switch from the sympathetic mode of the autonomic nervous system to the parasympathetic nervous system

A nurse is caring for a client who is to start therapy with ibuprofen for hip pain. Which of the following information should the nurse provide about ibuprofen?

Take the medication with food

A nurse is teaching a client who has a new prescription for ibuprofen to treat hip pain. Which of the following instructions should the nurse include in the teaching?

Take the medication with food

1) The nurse is developing a care plan for a patient with ineffective coping skills. Which intervention would be an example of a problem-focused coping strategy?

identify a condiant to share feelings