Basic Exam 1 (this one)

A hospitalized client is experiencing "fight versus flight," a stress-mediated physiologic response. As a result, the nurse should assess the client for which symptom?

.increased blood glucose

. The home health nurse is visiting a client for the first time. While assessing the client's medication history, it is noted that there are 19 prescriptions and several over-the-counter medications that the client has been taking. Which intervention would the nurse take first?

1. Determine whether there are medication duplications. 2. Check for medication interactions 3. Determine whether a family member supervises medication administration. 4. Call the prescribing primary health care provider and report polypharmacy

A client has been admitted with severe abdominal pain that has lasted for the past 4 hours. Place in chronological order the correct sequence for conducting an abdominal assessment.

1. ask client to urinate 2. auscultate the clients abd 3.percuss the clients abd 4. perform light palpation

Autosomal recessive

25%

Autosomal dominant

50%

Wellness-

Capacity to perform to the best of one's ability Reported feeling of well-being Feeling that "everything is together" and harmonious

Primary

prevention (PCP)

Health-

state of complete physical, mental, and social well-being and not merely the absence of disease and infirmity (physical or mental weakness)

When breaking confidentiality for life- threatening situation:

Date, person told, reason for disclosure, reason why consent not obtained, what exactly was said to person

The nurse is giving a 40-year-old client with limited English language skills printed information about postoperative dressing care. The nurse is using the interpreter to explain the printed information. What should the nurse do to determine that the client understands the procedure?

Have the client demonstrate how to change the dressing

Secondary

Immunizations, mammogram, colonoscopy

The nurse is providing medication instructions to an older client with chronic heart failure who is taking digoxin daily. The nurse explains to the client that decreased lean body mass and decreased glomerular filtration rate, which are age-related body changes, could place the client at risk for which complication with medication therapy?

Increased risk for digoxin toxicity

What personal safety precautions should the nurse utilize in the home health care environment?

Learn, or preprogram a phone with, the telephone numbers of the agency police, and emergency services. Carry agency Identification and a charged phone know where patient lives before leaving to make the visit, and either carry a map or use the navigation syster in your car or the GPS software on your smartphone for quick referral. Keep your car in good working order (gas) Park the car near the patiants home, and lock the car during the visit. Do not drive an expensive car or wear expensive Jewery when making visits. When making visits in high-crime areas, visit with another person rather than alone (if possible). Try to schedule visits during daylight hours (when possible). Never walk into a patents home uninvited; be vigiant for unrestrained pets. If you do not feel safe entering a patient's home, leave theаrea Become familar with the layout of the house, including exits from the house. If a patient or family member is visibly Intoxicated, under the Influence, or hostile, leave and reschedule the visit. it a family is having a serious argument or abusing the patient or anyone else in the household, leave, reschedule the visit, contact your supervisor, and report the abuse to the appropriate authorites.

A client who does not speak English arrives at the triage desk in the emergency department and states to the nurse that an interpreter is needed. Which is the best action for the nurse to take?

Page an interpreter from the hospital's interpreter services.

Tertiary

Rehab, AA

. Two days following a colon resection, an elderly client shows new onset of confusion. When contacting the health care provider, the nurse should make which recommendation?"

Shall I collect and send a urine sample for culture and sensitivity?

What is the significance of "people-first" language?

The person, not illness or disability, is most important ex: patient w/ copd NOT copd pt

A client has stress incontinence. Which data from the client's history contribute to the client's incontinence?

the client's history of three full-term pregnancies

Acquired-

came on later in life // ex:lose leg in car crash

Age related

happens with old age //ex: dementia

. A client has urge incontinence. When obtaining the health history, the nurse should ask the client about which factors that could precipitate incontinence?

involuntary urination

The nurse at an outpatient surgical clinic witnesses client signatures. When obtaining signatures, which clients are able to sign their own consent for a procedure/surgery? Select all that apply.

-A 62-vear-old with macular degeneration who is ordered a routine colonoscopy -A married 17-year-old who requires a chole-cystectomy for relief of nausea and pain

The nurse is caring for a 15-year-old client with anorexia nervosa and a body mass index (BMI) of 17. Which statement made by the client would indicate to the nurse that the North America Nursing Diagnosis Association (NANDA) diagnosis or patient priority of Body image altered is appropriate?

"I'm too ugly and fat."

Developmental

was born w it //ex: down syndrome

X-linked

50% for sons Have it 50% for daughters to carry

Which action by the nurse will best facilitate adherence to the treatment regimen for a client with a chronic illness?

arranging for home health care

The family of a hospitalized client demonstrates understanding of the teaching about legal documents related to end-of-life care such as "advance directive" and "power of attorney" when they make which statements? Select all that apply. CHECK

-Advance directives give instructions about future medical care and treatment." -"If people are not capable of communicating their wishes, health care providers and family together can agree on measures or actions that will be taken." -"Medical power of attorney or durable power of attorney for health care is a document that lists who can make health care decisions should a person be unable to make an informed decision for himself or herself."

The nurse is making a home visit to an older adult who is living with his son's family. The client has scald burns on the hands, both forearms, and on the neck (10% first- and second-degree burns). What should the nurse do? Select all that apply.

-Cleanse the wounds with cool water. -Remove clothing near the area. -Call for transport to a hospital. -Investigate the possibility of elder abuse.

The long-term care nurse is performing assessments on several of the residents. Which are normal age-related physiological changes the nurse would expect to note? Select all that apply.

-Decline in visual acuity -Increased susceptibility to urinary tract infections -Increased incidence of awakening after sleep onset

. A college student asks the nurse about the student's grandfather, who just received a diagnosis of Huntington's disease. The student wants to know if the student will have the disease too. What should the nurse tell the student? Select all that apply.

-Huntington's disease is an autosomal dominant disease. -Huntington's disease doesn't skip a generation."

The nurse is asked to develop an in-service to explain documents guiding professional nursing practice on the obstetrical unit. One of the documents included is the Code of Ethics. The nurse correctly explains that the Code of Ethics asks nurses to demonstrate which behaviors? Select all that apply.

-Maintain the integrity of practice and shape social policy. -Develop, maintain, and improve health care environments. -Be responsible and accountable for individual practice. -Increase professional competence and personal growth

A client is being seen in the clinic after returning from military service abroad. The nurse documents restlessness at night with nightmares leaving the veteran irritable and fatigued during the day. When discussing the possibility of posttraumatic stress disorder (PTSD), which statements about PTSD are accurate? Select all that apply.

-PTSD is characterized by nightmares and flashbacks. -Hypervigilance is characteristic of clients with PTSD. -Substance abuse is a common coping mechanism used by clients with PTSD. -Psychotic episodes can occur in clients with PTSD. -Clients with PTSD may complain of feeling empty inside

The health care provider writes an order that a client may have 12 oz of clear liquids at each meal and may supplement this with an additional 10 oz at each shift (7 to 3, 3 to 11, and 11 to 7). How many milliliters would the nurse document for the day shift (7 to 3) if the client took in all of the ordered volumes? Record your answer using a whole number.

1020 (30 oz=1 oz)

The nurse is providing instructions to the assistive personnel (AP) regarding care of an older client with hearing loss. What would the nurse tell the AP about older clients with hearing loss?

they respond to low-pitched sounds