Adult Health 1 Final Exam

What are the s/s of right sided heart failure?

§ Jugular vein distention § Ascites § Hepatomegaly § Peripheral edema

What is the patient teaching needed for bariatric surgery?

· Pre-op teaching for post-op: stop eating when you feel full, if severe pain in the abdomen need to call MD, will lose weight very quickly in the first 6 months, cosmetic surgery can happen once weight has been stabilized for 1 year, make sure to be drinking 30 mL fluid every hour but not while eating, need to make lifestyle changes to keep the weight off

The nurse is caring for a client who reports seeing a reddish colored tint in the urine. Which of the following questions would be most appropriate for the nurse to ask?

"Do you take prescribed anticoagulants?"

A nurse has taught a client with allergic rhinitis about managing symptoms. Which of the following statements by the client would indicate to the nurse that teaching was effective?

"I will have carpets removed from the bedroom."

The nurse has taught a client with type I diabetes about exercise and glucose control. Which of the following statements by the client would indicate to the nurse more teaching is required?

"I will increase my daily exercise when ketones are present in my urine."

The nurse is collecting the health history of a client admitted with generalized myalgia and chills. Which of the following statements by the client would indicate that the client has influenza?

"My joints hurt really bad."

The nurse is preparing a staff education program about urinary tract infections (UTIs). Which of the following information should the nurse include in the education program? Select all that apply.

- "Uncomplicated UTIs can occur in a normal urinary tract." - "Diabetes mellitus is a risk factor for urinary tract infections." - "Nitrates on a urine dipstick can indicate the presence of a UTI."

Who needs to be vaccinated for meningitis?

- Adolescents and college freshman (dorm-living increases risk) - Service members going to live in barracks (close quarters)

The hospice nurse is reviewing the prescriptions of a client receiving palliative care. Which of the following prescriptions should the nurse expect? (Select all the apply)

- Apply moisture cream barrier to the skin - Administer artificial tear eyedrops - Perform mouth care every hour - Administer oxygen 2L via nasal cannula

What are nursing interventions for patients with brain damage from stroke?

- Assist the patient to eat with their non-dominant hand if dominant hand is affected - Ask yes or no questions for patients experiencing expressive aphasia - Develop a regular voiding schedule to prevent incontinence

What should you teach your patient with RA about managing ADLs?

- Avoid activities that require repetitive motions - Sit down while doing household chores (such as the dishes)

What do you need to teach you patient with SLE?

- Avoid fatigue by balancing exercise with rest - Severe skin reactions can occur with sun exposure so wear sunscreen or protective clothing - Oral contraceptives can lead to exacerbations so use another form of contraceptive

When is urinary catheterization indicated?

- Bladder distention and urinary retention - BPH - Elevated BUN and creatinine

What do you need to teach about for a patient with GERD?

- Educate not to eat until they're full right before bed and to sleep with their head elevated (pillows, recliner, raise head of bed) - Avoid foods that might irritate the stomach such as alcohol, fat, chocolate, caffeine, mints - Need to maintain a healthy weight

What are interventions for patients with bacterial meningitis?

- Encourage family members to remain at the bedside for comfort (patient may be disoriented and anxious) - Perform frequent assessments - Use touch and soothing voice - Dim lights (photophobia)

The nurse is presenting a class on urinary tract infections. Which of the following should be included in the presentation? (select all that apply)

- Males and females over the age of 65 are equally prone to UTIs - Women of menopausal age have an increased risk of UTIs - E. Coli is the most common cause of bacterial UTIs

How do you determine that someone has chronic insomnia?

- Subjective assessment (what symptoms do they report) - Evaluate a 1-2 week sleep diary - Sleep study

The nurse is assessing the level of risk for complications of a client with pneumonia. Which of the following findings would indicate to the nurse that the client will require admission to the hospital for treatment? (Select All)

- The client is A/O x 1 to self - The client has a BUN of 24 - The client has a respiratory rate of 33

How do you educate your patient to avoid future UTIs?

- Void every 3-4 hours during the day - Drink 2.5-3L of fluid per day - Avoid tight fitting clothing, breathable fabrics are best, and no wet clothes

The nurse is assessing the urinary system of an older adult female client. Which of the following findings would be an expected age related change? Select all that apply.

- palpable bladder after urination - stress incontinence - nocturia

What are complications of N/V?

-Dehyrdration -Lethargy -Aspiration of fluid -Electrolyte imbalances

Normal magnesium levels?

1.5-2.5

Normal sodium levels?

135-145

Normal phosphate levels?

2.5-4.4

Normal potassium levels?

3.5-5.0

What is the maximum dose of Tylenol (acetaminophen) per day?

4 g (4000 mg)

The nurse is assessing a group of assigned clients. Which of the following clients has the highest risk of developing a urinary tract infection?

56-year-old female client with poorly controlled type 2, diabetes mellitus.

What is a normal CD4+ count?

800-1200

A nurse is planning an education conference about fluid spacing. What should the nurse include as an example of third spacing?

Abdominal ascites

A nurse is performing a physical assessment of a client who is suspected of having an endocrine disorder. The nurse knows that hyperpigmentation on the client's knuckles, elbows, and knees are manifestations of what?

Addison's disease

You are caring for a patient with severe allergies who is having skin testing. A few minutes after the intradermal injection, the patient reports SOB, feeling anxious, and dizziness. What do you need to do first?

Administer epinephrine subcutaneously (0.3)

Who does the CDC recommend get tested routinely for HIV?

All patients between 13 and 64-years-old

The nurse is reviewing the medical record for a client with newly diagnosed psoriasis with a history of dysplastic nevi, the nurse should question what treatment?

Artificial Phototherapy

What do you need to do before taking a patient for a CT scan?

Ask about allergies to contrast dye

If a patient reports abnormal colored urine, what do you need to assess?

Ask about what medications they are on

For a patient who is having signs of a stoke, what do you need to do first?

Ask when the symptoms started (TPA can only be given within 4 hours of stroke)

The unlicensed personnel reports to the nurse that the client with type 2 diabetes has a bedside glucose of 65. Which of the following should be a priority by the nurse?

Assess LOC

You're performing skin allergy testing and the patient reports difficulty breathing. What is your first action?

Assess and maintain the airway

You have a patient who was prescribed atenolol 2 weeks ago and their BP is now higher than before. What do you need to ask them?

Assess for compliance (they probably weren't taking the medication)

What do you need to assess/do for a patient with IBS?

Assess for psychosocial stress and possibly refer for CBT

When caring for a patient with a left arm arteriovenous fistula, what should you assess?

Auscultate for a bruit at the fistula site

What diet is needed to prevent calcium-containing stones?

Avoid dairy products, legumes, and dried fruits

What should you teach your patient who is taking benadryl for allergic rhinitis?

Avoid driving or other activities that require wakefulness after taking this medication

What diet is needed to prevent uric acid renal calculi?

Avoid organ meats and sardines

The nurse is teaching a client who has a Chlamydia infection about newly prescribed Doxycycline. What should the nurse include in the teaching?

Avoid prolonged exposure to the sunlight

What diet is needed to prevent oxalate stones?

Avoid spinach, chocolate, and tomatoes

What do you teach your patient about preventing allergic rhinitis?

Avoid the source of the symptoms (grass, dust, etc.)

The nurse is teaching a client diagnosed with a urinary tract infection. An intervention that needs to be followed by the client includes?

Avoid tight-fitting pants or clothing

Which type of skin cancer results from sun exposure?

Basal cell carcinoma (usually on the face and other sun-exposed areas)

What are symptoms of lower UTI?

Bladder distention Foul smelling urine Suprapubic discomfort Dysuria Urinary frequency

Which of the following reported by the client would indicate that the client is experiencing Cataracts?

Blurry vision

What are the classic signs of cataracts?

Blurry vision and light sensitivity (halos around lights)

What are symptoms of upper UTI?

CVA tenderness, flank pain, and nausea

What electrolyte is controlled by the parathyroid gland?

Calcium (high parathyroid hormone leads to high calcium, low parathyroid hormone leads to low calcium)

During peritoneal dialysis, the effluent starts to appear cloudy. What action should you take?

Call the provider immediately (sign of peritonitis, the patient needs to be started on antibiotics)

An admitted client states that "at midnight I am supposed to be observing my monthly fast for my religion". What is the appropriate response from the nurse?

Can you describe to me what occurs during your fast?

Cheyne Stokes breathing

Characterized by periods of apnea alternating with deep and rapid breaths.

What assessment do you need to do before administering labetalol?

Check BP and pulse, if HR is below 60 bpm hold the medication and call the MD

How do you test for suspected pyelonephritis?

Check for flank pain by percussion of the CVA and asking the patient about pain- strike a flat hand covering the costovertebral angle CVA

During routine hemodialysis, the 68-year-old patient complains of nausea and dizziness. Which action should the nurse take first?

Check the patient's BP

The nurse is caring for a client who is admitted with SOB, productive cough, and is suspected of having pneumonia. The nurse should understand that which of the following diagnostic test should be the priority for this client?

Chest x-ray

If the community health nurse is reviewing records of a group of clients, which client will the nurse identify as most likely to have the highest risk for health disparities?

Client who is a high school graduate who recently disclosed being gay

What is a common manifestation of hyponatremia?

Confusion (want to keep them close to the nurses station and restrict fluids)

The nurse is assessing a client diagnosed with acute pyelonephritis. Which of the following assessment findings should the nurse expect?

Costovertebral tenderness

What are the s/s of left sided heart failure?

Crackles, dyspnea, increased RR, shallow respirations, orthopnea, frothy pink sputum

What is the difference between stool in Crohn's and UC?

Crohn's - diarrhea, rectal bleeding (though not as common as in UC )UC - bloody diarrhea, rectal bleeding

A nurse is assessing the abdomen of a client and notes fragile skin and purple/blue striae across the abdomen. The nurse recognizes that this is a manifestation of what?

Cushing's

You are caring for a patient with weakness from stroke who is working well with physical therapy. When the spouse comes in, she does everything for the patient. What would be an appropriate nursing diagnosis?

Disabled family coping

For antibiotic therapy for STIs, what should you tell your patient?

Do not stop taking the medication once you start feeling better, need to take the full course

What would you document if you are assessing a patient and you cannot palpate their thyroid gland?

Document that it was non-palpable (this is a normal finding)

A nurse is assessing a client for fluid status and notices that the client's skin stays wrinkled for 3-4 seconds after pinching. What action should the nurse take?

Document the finding as normal

The nurse completing a physical assessment for a newly admitted patient is unable to feel either kidney on palpation. Which action should the nurse take?

Document the information on the assessment form

How do you teach your patients to prevent recurrence of renal calculi?

Drink 2000-3000 mL of fluid per day

If a patient has bloody diarrhea and a stool culture is ordered, what are you likely looking for?

E. coli

The nurse assesses the skin of a patient with a diagnosis of Psoriasis, what are the characteristics of this disorder?

Elevated plaques greater than 0.5 cm in diameter that are white in color, located on elbows and knees

Nectrotic, black, crusty tissue of a wound

Eschar

What does FAST stand for?

F- Face drooping A- Arm wekaness S- Speech difficulties T- Time

How is Lyme disease transferred?

From the bite of a blacklegged deer ticks .

What is the goal for treatment of chronic pain?

Get them to the point that they can do the things they want to do

Explain passive immunity

Getting antibodies from mother through breast milk (short term until they start to develop their own immunity, around 2 months)

What is the action of heparin?

Given to patients with non-ST-segment elevation to prevent new thrombus from forming

What do pleural friction rubs sound like?

Grating/rubbing sound on inspiration and expiration

What are the risk factors for gastritis?

H. pylori, alcohol, NSAIDs, stress

A nurse has taught a client with newly diagnosed hypertension about the DASH diet. Which of the following food choices by the client would indicate to the nurse that more teaching is required?

Hamburger and salad

What do wheezes sound like?

High-pitched whistling sounds on inspiration and expiration

What are the main physical assessment findings for patients with Addison's disease?

Hyper-pigmented skin (bronze/tan color) and hypotension

What are modifiable risk factors for stroke?

Hypertension Obesity Diabetes mellitus Sleep apnea Alcohol abuse

What can hyperaldosteronism lead to?

Hypertension (due to sodium retention)

How do you assess a patient's fluid status?

I/O and skin turgor (looking for tenting)

Which medication taken at home by a patient with decreased renal function will be of most concern to the nurse?

Ibuprofen (motrin)

A 72-yr-old patient with a history of benign prostatic hyperplasia (BPH) is admitted with acute urinary retention and elevated blood urea nitrogen (BUN) and creatinine levels. What action should the nurse take?

Insert a urinary catheter

Proper sequence of abdominal assessment?

Inspection, auscultation, percussion, palpation

The nurse manager is planning an educational in-service about managing stress for a group of new nurses. What should be included in the teaching?

Journaling about experiences

What do you need to teach your patient who is having trouble sleeping?

Keep a sleep diary Go to bed at the same time every night

What causes the pain of an MI?

Lactic acid buildup

What are the effects of left-sided brain damage from stroke that we need to know?

Language and speech deficits Depression Distress about disability

What laboratory work would be ordered to determine the cause of hypothyroidism?

Look for low TSH (this would indicate anterior pituitaru gland problem) or low T3 and T4 (thyroid gland problem)

The patient is actively dying, what should the nurse identify as the final finding at the end of life?

Loss of hearing

What will a patient with glaucoma report?

Loss of peripheral vision

Describe the DASH diet

Low sodium, increase calcium-rich foods, decrease caffeine, no canned soup (or any packaged food)

What do crackles sound like?

Low-pitched, bubbly sound on inspiration

How is viral meningitis diagnosed?

Lumbar puncture - PRIORITY is to obtain spinal fluid and blood cultures for the lab

What are non-modifiable risk factors for stroke?

Male, African American

Will you be able to palpate the bladder?

May be able to palpate a distended bladder above the symphysis pubis

What do you need to monitor in a patient with hypovolemia?

Monitor BP (hypotension is serious adverse effect) and HR

What is the important assessment you need to do for a patient who is post-op bronchoscopy?

Monitor frequently for aspiration (every 10-15 minutes)

What medication should be given first for patients with renal colic?

Morphine 2 mg every 4 hr PRN to control pain

A nurse is caring for a client with hypertension who recently started taking Lisinopril. Which of the following if reported by the client would require immediate follow up by the nurse?

My lips seem puffy

With use of high potency topical corticosteroids what will you assess for?

Need to assess the skin for atrophy and risk for tears/cuts

How do you diagnose TB in an immigrant who has had the BCG vaccine?

Need to do a chest x-ray because they will always test positive with the Mantoux test due to the vaccine

What do you need to watch for in patients taking spironolactone?

Need to monitor for hyperkalemia and watch for dehydration (this is a potassium-sparing diuretic so potassium levels can get high)

If you have a patient on hospice who is exhibiting Cheyne Stokes breathing, what do you do for them?

No life-saving measures, they are actively dying (no O2, no suctioning)

If a patient arrives to the ED with respiratory distress, should you obtain a complete health history?

No, do a brief focused assessment initially until they are stable

What do you need to ask a patient who is seeking treatment for obesity?

Obtain information about their perceptions of the reasons for their obesity to individualize the plan of care

The nurse is preforming discharge teaching with an Asian client who is looking down and nodding while the nursing is speaking. Which state made by the nurse would be appropriate?

Once I am done with the teaching, I will give you time to ask questions

When do you know a patient is ready to learn?

Once they start asking questions or express a desire to learn

What medication taken by diabetics would interfere with wound healing?

Oral hypoglycemics

How do you assess vision?

PERRLA, visual acuity, EOM, Snellen chart (20 ft away)

What is an expected assessment finding for osteoarthritis?

Pain with movement of the joints

A 61-year-old female is admitted with a total serum calcium level of 13.3. The nurse will anticipate the need to teach the patient about testing what blood levels?

Parathyroid hormone

After receiving the daily shift report and electrolyte levels of patients, which patient should the nurse assess first?

Patient with a serum magnesium of 1.1 who has tremors and hyperactive reflexes.

Change-of-shift report, which patient would you see first?

Patient with chest pain

The nurse is assessing a client who states, "I feel like I am not emptying my bladder completely." Which of the following would be the best action for the nurse to take?

Percuss for dullness over the area of the symphysis pubis.

What are the airway clearance techniques that need to be performed for patients with CF?

Percussion and vibration

A nurse is concerned that a client's external wound is at risk for dehiscence. What intervention would help prevent this complication?

Placing a pillow over the incision when they need to sneeze or cough

The nurse is assessing a client with chest pain with inspiration. The nurse notices a friction rub when auscultating breath sounds. Which of the following should the nurse suspect the client is experiencing?

Pleurisy

What are the effects of right-sided brain damage from stroke that we need to be watching for?

Poor impulse control leading to risk for injury (safety issue) Patient may deny any deficits

What is the main physical assessment finding of Cushing's syndrome?

Purple striae on the abdomen

What diagnostic test is performed for TIA (stroke)?

Rapid screening with non-contrast CT scan

A nurse is caring for a client with type 1 diabetes who is experiencing nausea, vomiting, abdominal pain, Kussmual respirations and a fruity scented breath. Which of the following actions by the nurse should be a priority?

Rapidly administering prescribed 0.9% normal saline IV fluids

If you are assessing the BP of an older adult and you get a sudden high reading, what should you do?

Reconfirm the BP manually and need to look for secondary causes

A nurse is caring for a client with diabetic ketoacidosis who has a prescription for IV infusion of insulin. Which of the following insulins should the nurse anticipate administering to the patient?

Regular insulin

A patient is anxious about having a biopsy, which relaxation technique would help the patient?

Relaxation breathing

What do you need to tell your patient about pain with osteoarthritis?

Rest will relieve the pain but regular exercise is still important

For a patient with a femoral vein catheter, what should their activity level be?

Restrict physical activity to bed rest to prevent trauma to the vein

What is a common manifestation of hypomagnesemia?

Seizures

How do you set goals with your patient who has fibromyalgia?

Set functional goals rather than 1-10 pain scale goal, if their goal is to play golf then set a goal of pain level being reduced enough for them to play golf

What is the most common way HIV is transmitted?

Sexual transmission

Yellow, friable tissue of a wound

Slough

The nurse is implementing nutritional interventions for a client with pneumonia. Which of the following should the nurse include in the plan of care for this client?

Small frequent meals

What is an appropriate nursing diagnosis for SLE (lupus)?

Social isolation

The nurse has taught nutrition management for a client diagnosed with oxalate kidney stones. Which of the following food choices by the client would indicate that the client requires more teaching?

Spinach salad and rhubarb pie

How is meningitis spread and what precautions do you need to take?

Spread by respiratory secretions, maintain respiratory isolation and make sure to wear a mask when working with the patient

What should you teach your patient about headphone usage?

Suggest using over the ear headphones to avoid hearing loss

The nurse administers which of the following prescribed medications to a client with recurrent UTIs caused by E. Coli?

Sulfamethoxazole and Trimethaprim (Bactrim DS)

Your patient with RA asks you about interventions for their rheumatoid nodules, what should you say?

Surgery or injections are not an option because they will just come back

What is angioedema?

Swelling of the eyelids, lips, and tongue due to inflammatory reaction to allergies or medication

What medication is given to treat TIA?

TPA - breaks up thrombus

What does accommodation test?

The ability of the lens to adjust to focus on objects at various distances

The nurse is developing a care plan for a group of assigned clients. Which of the following clients should the nurse identify as having the highest risk of developing aspiration pneumonia?

The client who has had a cerebral vascular accident

The nurse is developing the plan of care for a client with urge incontinence. Which of the following should the nurse understand when developing the plan of care for this client?

The client will have the inability to stop urine flow long enough to get to the toilet

What do you teach your patient who is post acute MI about resuming sexual activity?

They can resume sexual activity once they are able to climb 2 flights of stairs

If a person has recurrent STIs, what could be the possible cause?

They may not have informed their sexual partner

What do you need to teach female patients taking methotrexate for RA?

This drug has teratogenic effects so they need to be on some form of contraception

What do you need to teach your patients about taking aspirin for stroke?

This is taken to prevent future strokes, you are not taking this for a headache

A nurse is assessing a newly admitted client for risk of hyperphosphatemia. The nurse should ask the client about what when obtaining a medical history?

Thyroid surgery

The nurse instructs a client with pyelonephritis to drink 2.5 to 3L of fluid per day. The nurse understands the rationale for this self care intervention as?

To prevent stasis of urine

Your patient has an abdominal wound that is getting deeper, what is this called?

Underming (need to measure with a cotton-tipped applicator)

A patient is suspected to have a UTI. Which lab tests are appropriate in the diagnosis?

Urinalysis for culture and sensitivity

What is the most common cause of healthcare associated infections?

Urinary catheterization

What are antimicrobials used for?

Used for partial and full-thickness wounds over incisions or trachs

You have a patient taking ramipril (Altace), what is your priority assessment?

Watch for angioedema (ACE inhibitors), need to call the MD right away if the patient develops angioedema

Your patient is taking bumetanide (loop diuretic), what do you need to watch for?

Watch for cardiac dysrhythmias

Patient taking clopidogrel (Plavix), what do you need to watch for?

Watch for signs of GI bleeding (inhibits plately aggregation)

For a diabetic patient who is post-up from abdominal surgery, what do you need to watch for? What do you do?

Wound dehiscence because wound healing is slowed, call surgeon immediately if this happens

Do STIs need to be reported?

YES (genital herpes, chlamydia)

A nurse is talking to a client at a public health clinic. The client asks, "The doctor said that my CD4+ is 450, is that good?" What response should the nurse make?

Your count is a bit low and you are susceptible to infection

Stage 3 pressure ulcer

full thickness skin loss extending into subcutaneous tissue, may see subq fat but not muscle, bone, or tendon, slough or eschar may be present

Unstageable pressure ulcer

full thickness tissue loss with depth unknown due to slough or eschar in the wound bed, depth cannot be determined

stage 4 pressure ulcer

full thickness tissue loss with exposed muscle, tendon, or bone, slough or eschar may be present

The nurse is assessing a client who reports having a sharp pain along the costovertebral angles. The nurse recognizes that this assessment finding might be due to which of the following?

kidney inflammation

Stage 1 pressure ulcer

non-blanchable erythema, skin is not broken but is red or discolored, area may be warm or cool

What are non-modifiable risk factors for CAD?

o Caucasian, middle-aged, males are most at risk o Elderly o African American o Genetic predisposition

What are modifiable risk factors for CAD?

o Elevated serum lipids o Hypertension o Tobacco use o Stressful lifestyle o Physical inactivity o Obesity o Diabetes o Metabolic syndrome o Substance abuse

Stage 2 pressure ulcer

partial thickness skin erosion, superficial shallow ulcer like an abrasion or open blister with a red-pink wound bed