Block 2: Assessment 2 Quiz Questions

Which hormone is required to lower blood glucose levels?

Insulin

Which medication is appropriate for a client with hypothyroidism?

Levothyroxine

A nurse is conducting a class for nurses working in the postpartum unit about ways to reduce the risk of postpartum infections. The nurse determines that the teaching was effective when the group identifies which preventive measure as essential?

Meticulous handwashing

A hospital nurse is aware that hospital-acquired infections pose a significant threat to many clients' health status. In order to reduce the spread of these infections, the nurse should prioritize which action?

Vigilant and thorough hand hygeine

The nurse in a long-term-care facility is aware of the importance of preventing upper respiratory infections (URIs) among the residents of the facility. How is this best accomplished?

Vigilant handwashing by staff and residents

A nurse is caring for a client who is 2 days postoperative after abdominal surgery. What nursing intervention would be important to promote wound healing at this time?

assisting the client in moving to prevent strain on the suture line

A patient is being treated with an antibiotic for an infected orthopedic injury. What explanation should the nurse give to the patient about this medication?

"An antibiotic helps to kill the infection causing the inflammation."

The nurse notes multiple elevated masses with irregular transient borders that are superficial, raised, and erythematous in a client who complains of an "itching rash." Which question would be most important for the nurse to ask?

"Are you allergic to foods, medications, or other substances?"

While assisting an older adult with morning hygiene, the nurse notes a lesion on the client's coccyx region. How should the nurse best document this objective assessment finding?

"Area of non-blanching erythema noted over client's coccyx, 2 cm × 2 cm."

The nurse is giving an educational talk to a local parent-teacher association. A parent asks how to help the family avoid community-acquired infections. What would be the nurse's best response to help prevent and control community-acquired infections?

"Make sure your family has all their childhood immunizations."

The nurse is discharging a 4-year-old client from the emergency department. The client was seen for an insect bite that became swollen, reddened, warm, and painful to touch. The client's vital signs are all within normal range for age. While the nurse is giving discharge instructions to the client's parent, the parent asks why the child is not going to get antibiotics for the infected insect bite. What would be the nurse's best response?

"This is a local inflammatory response to the insect bite; it is not an infection, so antibiotics will not help."

The nurse is taking a client's health history. Which question would the nurse ask to collect data about infection control?

"When did you complete your immunizations?"

The nurse is caring for a hospitalized, 1-week-old infant who appears very ill. Which assessment finding(s) will the nurse report to the health care provider? Select all that apply.

- petechiae - heart rate 190 beats/min - axillary temperature 100.4F - weak cry and lethargy

The clinic nurse is caring for a client diagnosed with leukopenia. What does the nurse know this client has?

A general reduction in all white blood cells

A client recovered from influenza 2 days ago and informs the nurse that she is feeling better but now has a fever, chills, pain when breathing, and a productive cough. What complication does the nurse anticipate the client will be treated for?

A secondary bacterial pneumonia

During a mumps outbreak at a local school, a patient, who is a school teacher, is exposed. She has previously been immunized for mumps. What type of immunity does she possess?

Acquired immunity

The thyroid gland produces and secretes which in direct response to serum calcium levels?

Calcitonin

The nurse's review of a client's laboratory results indicates that inflammation is absent and platelet levels are low. Which test was performed to provide the platelet count?

Complete blood count

A client received 2 units of packed red blood cells while in the hospital with rectal bleeding. Three days after discharge, the client experienced an allergic response and began to itch and break out with hives. What type of reaction does the nurse understand could be occurring?

Delayed hypersensitivity response

The nurse is caring for a client who just received a dose of insulin. The client is found to be sweaty, confused, and pale. What is the priority intervention?

Draw a glucose level

The nurse's assessment of an adult female client reveals the presence of excessive hair on her face and chest. The nurse should plan further evaluation of which body system?

Endocrine

What would a nurse monitor in a client with decreased adrenal function?

Fluid status

The nurse is caring for a client and completing a health history. The client states he has lost 30 pounds in the last couple months without really trying. The client also states he feels warm all the time and sometimes feels like he has heart palpitations. What would the nurse expect the client to be evaluated for?

Hyperthyroidism

The nurse is caring for a woman with gestational diabetes who has just given birth. While caring for this neonate, the nurse is aware that the child is risk for which complication?

Hypoglycemia

A client arrives in the orthopedic clinic with complaints of twisting the right ankle while playing softball. The nurse collects data including complaints of pain and swelling in the right ankle. What intervention will the nurse provide that will decrease vasodilation and reduce localized swelling?

Ice bag

A client has come to the clinic for an allergy shot. The client asks the nurse what immunoglobulin (Ig) is located in the body's tissues and is thought to be responsible for allergic reactions. What is the nurse's appropriate response?

IgE is thought to be responsible for allergic reactions.

A nurse is preparing to palpate the thyroid gland. Where would the nurse expect to find this gland?

In the lower neck, anterior to the trachea

The nurse is developing a plan of care for an 84-year-old client who has been diagnosed with diabetes and is receiving oral hydrocortisone 40 mg daily for treatment of arthritis. What is the priority nursing action?

Increase carbohydrates in the client's diet.

The course of any infectious disease progresses through several distinct stages after the pathogen enters the host. Although the duration may vary, which sign/symptom is the hallmark of the prodromal stage?

Initial appearance of symptoms

A client presented to the emergency department of the hospital with a swollen, reddened, painful leg wound and has been diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) cellulitis. The client's physician has ordered a complete blood count and white cell differential. Which blood component would the physician most likely anticipate to be elevated?

Neutrophils

Following an injury resulting in a small cut from a knife, the first cells to go to the area of the cut would be the:

Neutrophils

While reviewing the phases of wound healing, the students note that the first cells to arrive after the injury are the:

Neutrophils

A nursing instructor is teaching a group of nursing students about chronic hyperglycemia. The instructor determines the session is successful when the students correctly choose which as a risk factor for chronic hyperglycemia?

Obesity

What is a classic symptom of hyperthyroidism?

Protruding eyes

While providing care to a client admitted to the health care facility, the client states that she has "a burning sensation when urinating." After further questioning, the nurse inspects the client's perineal area. Which sign/symptom would the nurse document as an abnormal finding?

Reddened perineal skin

Which condition is associated with impaired immunity relating to the aging client?

Renal function decreases

The nurse is assessing a patient at risk for the development of a pressure ulcer. What laboratory test will assist the nurse in determining this risk?

Serum albumin

The anatomy and physiology instructor is explaining a cell-mediated response to the pre-nursing students. What actions would the instructor explain occur in a cell-mediated response?

T-cell lymphocytes survey proteins in the body and attack the invading antigens.

The nurse is assessing a client with joint pain and is trying to decide whether it is inflammatory or non-inflammatory. Which of the following symptoms is consistent with an inflammatory process?

Tenderness

The nurse is preparing a care plan for a 4-year-old client newly diagnosed with severe immune deficiency. What is the priority goal for this client?

The client will remain free from infection.

Which laboratory test result would be most important for the nurse to assess in a child who is suspected of having a urinary tract infection?

Urinalysis

The nurse's assessment of a postop client reveals a temperature of 103.2°F (39.5°C), tachycardia, and client complaints of increased incisional pain. What does the nurse recognize that this client is experiencing?

Wound infection

While providing client teaching relative to inflammatory disorders, the nurse would explain the presence of inflammation as:

an attempt by the body to remove the damaging agent and repair the damaged tissue

The nurse is teaching a class to pregnant adolescents and young adults. What does the nurse explain is the most important reason for breastfeeding instead of bottle feeding?

breastfeeding provides protection against infections

A nursing diagnosis of Risk for impaired tissue integrity would be most appropriate for which client?

client having reconstructive breast surgery

An 81-year-old resident of an elder care facility is immobile and has been restricted to bed for the past 6 weeks. The health care provider recently discovered a decubitus injury on the left buttock. Which etiology is most likely?

ischemia from prolonged pressure

A pediatric client is admitted to the hospital. The primary health care provider suspects a problem with the child's immune system. The nurse anticipates preparing this client for which test initially?

serum blood testing

What does the clinical presentation of an inflammatory reaction include? (Select all that apply.)

swelling, pain, heat, redness

A client who has received a heart transplant has been given a prescription for medications that block T-cell activity. What is the rationale behind this order?

to prevent an inflammatory reaction against the transplanted heart

A nurse assessing a client's wound documents the finding of purulent drainage. What is the composition of this type of drainage?

white blood cells, debris, bacteria