HESI NUR 314
Which disease conditions are associated with hard, nontender Heberden and Bouchard nodules? a. Osteoporosis b. Osteoarthritis c. Carpal tunnel syndrome d. Scoliosis
b. Osteoarthritis
Normally, a person should be able to recognize two points separated by
2 to 8 mm on fingertips.
Is the cure rate for testicular cancer low or high?
High rate
Early symptoms of testicular cancer are
Painless
Obtunded
Pt. won't wake up, Pt. will moan and will not be able to have a conversation
Menorrhagia
abnormally heavy or prolonged bleeding from periods *Heavy period*
Amenorrhea
absence of menstruation
Oral contraceptives are effective for birth control and may benefit
dysmenorrhea or menorrhagia
Acute pyelonephritis
is a sudden and severe kidney infection, causes the kidneys to swell and may permanently damage them.
The registered nurse (RN) is assisting the healthcare provider (HCP) with the removal of a chest tube. Which intervention has the highest priority and should be anticipated by the RN after removal of the chest tube? A. Prepare the client for chest x-ray at the bedside. B. Review arterial blood gases after removal. C. Elevate the head of the bed to 45 degrees. D. Assist with disassembling the drainage system.
A. Prepare the client for chest x-ray at the bedside.
During an interview, a woman says, "I have decided that I can no longer allow my children to live with their father's violence, but I just can't seem to leave him." *Using interpretation*, which would be the best response by the nurse? a. "You are going to leave him?" b. "If you are afraid for your children, then why can't you leave?" C. "It sounds as if you might be afraid of how your husband will respond." d. "It sounds as though you have made your decision. I think it is a good one."
"It sounds as if you might be afraid of how your husband will respond." (Taking what the pt. originally stated and took your spin on it and interpret what the pt. stated)
Cryptorchidism
*undescended testicles* - A condition in which one or both of the testes fail to descend from the abdomen into the scrotum.
During interpretation during an interview, what should you never do?
- be judgmental - say the word 'why' - Parroting back - express your opinion
The registered nurse (RN) places an ice pack on a middle school student who comes to the school clinic complaining of a sprained ankle. Which therapeutic response should the RN anticipate? A. Reduced pain and minimized bruising. B. Lowering of body core temperature. C. Increased circulation around injury. D. Reabsorption of edema at injury.
A. Reduced pain and minimized bruising.
The registered nurse (RN) palpates a weak pedal pulse on the client's right foot. Which assessment findings should the RN document that are consistent with diminished peripheral circulation (Select all that apply.) A. Diminished hair on legs. B. Bruising on extremities. C. Skin cool to touch. D. Capillary refill 1-2 seconds. E. Darkened skin on extremities
A. Diminished hair on legs. C. Skin cool to touch.
The registered nurse (RN) is caring for a client with peptic ulcer disease (PUD). What assessment should the RN identify that is consistent with PUD? (Select all that apply) A. Hematemesis- vomiting of blood B. Gastric pain on an empty stomach C. Colic-like pain with fatty food ingestion D. Intolerance of spicy foods E. Diarrhea and stearrhea
A. Hematemesis- vomiting of blood B. Gastric pain on an empty stomach D. Intolerance of spicy foods
The registered nurse (RN) is interviewing a female client who states she has a persistent cough during the winter caused by bronchitis. Which additional finding should the RN assess for bronchitis?
A. Phlegm production and wheezing - common finding with bronchitis B. Smoking history C. Hemoptysis D. Night sweats
An 86-year-old client is admitted with a diagnosis of syncope (temporary loss of conscious). He tells the nurse, "When I get up in the morning, I feel dizzy." The nurse replies, "You feel dizzy when you get out of bed in the morning?" What communication strategy is this nurse using? A. Reflection B. Facilitation C. Confirmation D. Summarization
A. Reflection
The registered nurse (RN) is caring for a client with tuberculosis (TB) who is taking a combination drug regimen. The client complains about taking "so many pills." What information should the RN provide to the client about the prescribed treatment? A. The development of resistant strains of TB are decreased with a combination of drugs. B. Compliance to the medication regimen is challenging but should be maintained. C. Side effects are minimized with the use of a single medication but is less effective. D. The treatment time is decreased from 6 months to 3 months with this standard regimen.
A. The development of resistant strains of TB are decreased with a combination of drugs.
The registered nurse (RN) is caring for a client who developed oliguria (small amounts of urine) and was diagnosed with sepsis and dehydration 48 hours ago. Which assessment finding indicates to the RN that the client is stabilizing? A. Urine output of 40 ml/hour B. Apical pulse 100 and blood pressure 76/42. C. Urine specific gravity of 1.001. D. Tented skin on the dorsal surface of the hands.
A. Urine output of 40 ml/hour
A registered nurse (RN) is performing a mini-mental state examination (MMSE) for a client who is being admitted to an assisted living community. Which communication techniques should the RN implement to decrease anxiety in the client? (Select all that apply.) A. Use simple sentences during the examination. B. Move to another question if the client seems confused. C. Reduce environmental detractors during the examination. D. Allow the family to answer for the client to decrease frustration. E. Ask questions one at a time to decrease confusion.
A. Use simple sentences during the examination. C. Reduce environmental detractors during the examination. E. Ask questions one at a time to decrease confusion.
A 30-year-old client is brought to the emergency department with head injuries from a motorcycle accident. During the neurological assessment, the client displays positive Babinski's reflex. The nurse knows that this finding is: A. an abnormal response B. a normal response C. a hyperactive response D. a diminished response
A. an abnormal response - positive Babinski finding on a 30-yr. old is an abnormal finding
Testing for accommodation
Ask person to focus on distant object, which should dilate the pupils. Then have the person shift their gaze to a near object such of your finger held about 7 to 8 cm away from their nose. Normal response includes 1) pupillary constriction and 2) convergence of the axes of the eyes 3) record the normal response to these maneuvers as PERRLA
A nurse is inspecting a 58-year-old client's chest wall to locate the apical pulse. Where should the nurse look? A. At the fifth intercostal space medial to the left midclavicular line B. Over the base of the heart C. Over the aortic area D. At the third intercostal space to the left of the sternum
At the fifth intercostal space medial to the left midclavicular line - Apical pulse: 5th
How do you perform the two-point discrimination?
Apply the two points of an opened paper clip lightly to the skin in ever-closing distances. Note the distance at which the person no longer perceives two separate points. - *Fingertips are most sensitive to two-point discrimination (2 to 8mm)* - Least sensitive are the upper arms, thighs, and back (40 to 75mm).
While reviewing the client's electronic medical record (EMR), the registered nurse (RN) assesses a client who is at risk for possible interaction with an over-the-counter (OTC) decongestant. Which client health history should the RN report to the healthcare provider concerning the OTC medication? (Select all that apply) A. Type I diabetes mellitus (DM) B. Closed-angle glaucoma C. Chronic hypertension D. Rheumatoid arthritis E. Crohn's disease
B. Closed angle glaucoma C. Chronic hypertension
Which actions should the registered nurse (RN) implement to complete an assessment for a client using an interpreter? A. Ask close-ended questions with assistance of the interpreter. B. Maintain eye contact with the client while listening to the translation. C. Instruct interpreter to answer questions from the interpreter's point of view. D. Protect the client's privacy by asking a limited number of questions.
B. Maintain eye contact with the client while listening to the translation.
An older client is admitted to the hospital with severe diarrhea. The registered nurse (RN) is completing an assessment and notes the client has dry mucous membranes and poor skin turgor. Which assessment data should the RN gather to determine if the client has a fluid volume deficit? A. Bilateral pitting edema B. Orthostatic hypotension C. Jugular venous distention D. Cheyne Stokes respirations
B. Orthostatic hypotension
A client's muscle tone is assessed by performing: A. deep tendon reflex (DTR) testing B. Passive range-of-motion (ROM) exercises C. Romberg's test D. constructional ability testing
B. Passive range-of-motion (ROM) exercises- helps assess muscle tone
The registered nurse (RN) is evaluating a client who presents with symptoms of gastroenteritis. Which assessment finding should the RN report to the healthcare provider? A. Dry mucous membranes and lips. B. Rebound abdominal tenderness over the right lower quadrant. C. Dizziness when client ambulates from a sitting position. D. Poor skin turgor over the client's wrist.
B. Rebound abdominal tenderness over right lower quadrant. (Indicating: Pelvic Pain, constipation, appendicitis, inflammatory, disease)
A 34-year-old client complains of pain and tingling in her right wrist. During the assessment, the client reports pain when the nurse flexes the wrist for 30 seconds. The nurse knows that this finding indicates: A. a fractured wrist B. carpal tunnel syndrome C. a stroke D. paralysis
B. carpal tunnel syndrome- indicated pain after flexing wrist for 30 seconds
An 84-year-old client complains of leg pain. A nurse assesses his legs and discovers an ulcerated area close to the ankle on his left leg. The nurse knows that this finding indicates: A. arterial insufficiency B. chronic venous insufficiency- ulcerated area close to the ankle on his left leg C. skin infection D. skin allergy
B. chronic venous insufficiency
A school nurse is performing an annual screening on a 12-year-old student. Toassess for scoliosis, the nurse should: A. Palpate for crepitus B. Measure the length of the spine from neck to waist. C. Ask the client to bend forward at the waist D. Palpate the spinous processes
C. Ask the client to bend forward at the waist- help determine is pt. has scoliosis
An 11-year-old child reports to the school nurse with an earache and sore throat. The nurse inspects the tympanic membrane using an otoscope. Which color suggests a normal eardrum? A. Pink B. White C. Gray D. red
C. Gray- indicates normal eardrum
During the examination of a 36-year-old client's right breast, the nurse palpates a lump. Which characteristic most suggests that the lump may be malignant? A. Softness B. Mobility C. Irregular shape D. Nontender
C. Irregular shape- indicates that a lump is malignant
Twenty-four hours after a client returns from a surgical gastric bypass, the registered nurse (RN) observes large amounts of blood in the nasogastric tube (NGT) cannister. Which assessment finding should the RN report as early signs of hypovolemic shock? A. Faint pedal pulses B. Decrease in blood pressure. C. Lethargy - lack of energy D. Slow breathing.
C. Lethargy - lack of energy - loss of blood therefore causing weakness
When the nurse is performing a testicular examination on a 25-year-old man, which finding is considered normal? A. Nontender subcutaneous plaques B. Scrotal area that is dry, scaly, and nodular C. Testes that feel oval and movable and are slightly sensitive to compression D. Single, hard, circumscribed, movable mass, less than 1 cm under the surface of the testes HARD or pain is abnormal
C. Testes that feel oval and movable and are slightly sensitive to compression
The registered nurse (RN) is caring for an Asian client who refuses to make eye contact during conversations. How should the RN assess this client's response? A. The client cannot understand the nurse. B. The client is uncomfortable with the nurse. C. The client is treating the nurse with respect. D. The client is purposefully disrespecting the nurse.
C. The client is treating the nurse with respect.
A nurse is performing an otoscopic examination on a 3-year-old child who has an earache and a fever. In which direction should the nurse pull the child's auricle to straighten the ear canal? A. Down and forward B. Up and forward C. Up and Back D. Down and back
C. Up and Back
A client with a urinary tract infection reports pain when the nurse percusses her back at the costovertebral angle. This finding suggests: A. A ureteral stone B. an ovarian cyst C. kidney inflammation D. bladder cancer
C. kidney inflammation- UTI & pain in the back (costovertebral angle)
During a routine physical examination, a 68-year-old client can't identify a pencil or a cotton ball when manipulating the object with his hands, keeping his eyes closed. The nurse knows that this abnormal finding indicates: A. Apraxia B. Aphasia C. Graphesthesia D. Impaired stereognosis (astereognosis)
D. Impaired stereognosis (astereognosis) - is the ability to perceive and recognize the form of an object in the absence of visual and auditory information
Which types of abuse are we obligated to report as Nurses ?
Child and elderly abuse
A 28-year-old client asks, "When should I perform breast self-examination (BSE)?" The best response from the nurse would be: A. "On the first day of your menstrual cycle each month." B. "On the last day of your menstrual cycle each month." C. "On the first day of every month." D. "Any time during the month. The important thing is that you do the exam every month"
D. "Any time during the month. The important thing is that you do the exam every month"
A male client is admitted after falling from his bed. The healthcare provider (HCP) tells the family that he has anincomplete fracture of the humerus. The family asks the nurse what this means. Which type of fracture should the RN explain from these findings? A. Straight fracture line that is also a simple, closed fracture. B. Nondisplaced fracture line that wraps around the bone. C. A complete fracture that also punctures the skin. D. A fracture that bends or splinters part of the bone.
D. A fracture that bends or splinters part of the bone. (incomplete fracture, refers to a bone that cracks and bends but does not completely break.)
A client is newly diagnosed with diverticulosis. The registered nurse (RN) is assessing the client's basic knowledge about the disease process. Which statement by the client conveys the client's understanding of the etiology of diverticula? A. Over use of laxatives for bowel regularity result in loss of peristaltic tone. B. Inflammation of the colon mucosa that cause growths that protrude into the lumen. C. Diverticulosis is the result of high fiber diet and sedentary life style. D. Chronic constipation causes weakening of colon wall which result in out-pouching sacs.
D. Chronic constipation causes weakening of colon wall which result in out-pouching sacs.
During an interview, a client has episodes in which she jumps abruptly from topic to topic. Which identifies this type of speech? A. Neologisms B. Echolalia C. Confabulation D. Flight of ideas
D. Flight of ideas- jumping abruptly from topic to topic
The registered nurse (RN) is caring for a client who has taken atenolol for 2 years. The healthcare provider recently changed the medication to enalapril to manage the client's blood pressure. Which instruction should the RN provide the client regarding the new medication? A. Take the medication at bedtime. B. Report presence of increased bruising. C. Check pulse before taking medication. D. Rise slowly when getting out of bed or chair.
D. Rise slowly when getting out of bed or chair.
A 19-year-old college student is brought to the emergency department with dyspnea (labored breathing) and asymmetrical breathing patterns after falling down a flight of steps at a party. His admission chest X-ray shows right-sided pneumothorax. During inspection, what other characteristic of pneumothorax might the nurse observe? A. Funnel chest B. Barrel chest C. Intercostal retractions D. Tracheal deviation- trachea is pushed to one side of your neck by abnormal pressure in your chest cavity or neck.
D. Tracheal deviation- trachea is pushed to one side of your neck by abnormal pressure in your chest cavity or neck.
Broca aphasia
Expressive aphasia *( The person can understand language but cannot express himself or herself using language.)*
What is the Tinetti Balance Assessment Tool used for?
It's an easily administered test that measures balance & gait based on a numeric scoring system to assess for ataxia in the elderly.
The nurse is caring for a patient who was in an accident. The *nurse notices that the patient has clear, watery drainage from the ear*. What is the priority *nursing intervention in this situation*? a. Irrigate the patient's ear canal with a warm solution b. Report to the primary health care provider about the patient c. Instill antibiotic solution into the patient's ear d. Instill 2% acetic acid solution in the patient's ear
b. Report to the primary health care provider about the patient
Wernicke's area in the temporal lobe is associated with?
Language comprehension. When damaged in the person's dominant hemisphere, *receptive aphasia* results. - The person hears sounds, but it has no meaning, like hearing a foreign language.
The nurse takes special care while checking a patient's *tail of Spence*. What is the reason for this intervention? a. To detect supernumerary nipple b. To detect breast cancer c. To detect Paget's disease d. To detect skin retraction
b. To detect breast cancer
The two- point discrimination test for?
Patient's ability to discriminate two concurrent points - used when testing for the sensory system
Orientation X 4 refers to:
Person Place Time Situation
Wernicke aphasia
Receptive aphasia The person can hear sounds and words but cannot relate them to previous experiences *-Speech is fluent, effortless, and well-articulated but has many paraphasias; word substitutions that are malformed or wrong.*
Elderly with dementia, first memories to go are
Short term
Stuporous state
Unaware of his or her surroundings *requires continuous stimulation to get the pt. talking and awake but pt. will still be confused and not be able to have a conversation*
Hyperthyroidism
Weight loss Sensitivity to cold sweating insomnia heart palpations heat intolerance fine, brittle hair *infertility*
Testicular Self-Exam
T = timing, once a month S = shower, warm water relaxes scrotal sac E = examine, check for changes, report changes immediately Encourage self-care by teaching every male (from 13 to 14 years old through adulthood) how to examine his own testicles. - Testicular cancer is not common, but it has no early symptoms - A good time to examine the testicles is during the shower or bath, when your hands are warm and soapy and the scrotum is warm. Abnormal: But, if you ever notice a firm, painless lump; a hard area; or an overall enlarged testicle, you must call a physician.
global aphasia
When both production and understanding of language is damaged - The most common and severe form. Spontaneous speech is absent or reduced to a few stereotyped words or sounds. - Comprehension is absent or reduced to only the person's own name and a few select words. *Repetition, reading, and writing are severely impaired.* **Prognosis for language recovery is poor. Caused by a large lesion that damages most of the combined anterior and posterior language areas.**
What do you do if a patient is anxious, what should be your first nursing priority?
You first find a way to calm the patient down and relive anxiety
Pupils with unequal size occur with
a central nervous system injury
The nurse is obtaining a history from a 30-year-old male patient and is concerned about health promotion activities. Which of these questions would be appropriate to use to assess *health promotion* activities for this patient? a. "Do you perform testicular self-examinations?
a. "Do you perform testicular self-examinations? b. "Have you ever noticed any pain in your testicles?" c. "Have you had any problems with passing urine?" d. "Do you have any history of sexually transmitted infections?"
A 75-year-old woman is at the office for a preoperative interview. The nurse is aware that the interview may take longer than interviews with younger people. What is the reason for this? a. An aged person has a longer story to tell. b. An aged person is usually lonely and likes to have someone with whom to talk. c. Aged people lose much of their mental abilities and require a longer time to complete an interview. d. As a person ages, he or she is unable to hear; thus the interviewer usually needs to repeat much of what is said.
a. An aged person has a longer story to tell.
→ During a *head-to-toe assessment* on a patient with a possible urinary tract infection, you perform *costovertebral angle percussion*. The costovertebral angle is found? a. Between the bottom of the 12th rib and spine b. between the right upper quadrant and umbilicus c. between the sternal notch and angle of Louis d. between the ischial spine and umbilicus
a. Between the bottom of the 12th rib and spine ( Looking for any kidney inflammation and infection) - located on the back
The nurse is *teaching a patient with diabetes about foot care*. Which instructions should the nurse include about maintaining blood flow to the feet? a. Curl and spread out the toes frequently. b. Dry feet carefully after a shower or bath. c. Apply a thin coat of lotion on the skin. d. Keep the toenails trimmed and straight.
a. Curl and spread out the toes frequently.
A client is admitted for dehydration, weight loss, and a flat affect. After reviewing the client's history, the registered nurse (RN) discovers that the client's spouse died 2 weeks ago. Which nursing interventions should the RN implement to help the client begin the process of dealing with loss? a. Establish trust by creating a safe atmosphere for sharing. b. Share personal stories about how other clients dealt with grief. c. Help the client identify ways to adapt lifestyle to accommodate the loss. d. Assure the client that their grief will last a short period of time. e. Explore ways to assist the client to make new emotional investments.
a. Establish trust by creating a safe atmosphere for sharing. c. Help the client identify ways to adapt lifestyle to accommodate the loss. e. Explore ways to assist the client to make new emotional investments.
A patient *drifts off to sleep when she is not being stimulated*. The *nurse can easily arouse her by calling her name, but the patient remains drowsy during the conversation*. What is the best description of this patient's level of consciousness? a. Lethargic b. Obtunded c. Stuporous d. Semi-coma
a. Lethargic Sleepy and can wake up and has the ability to have a conversation - When the conversation is over pt. goes right back to sleep.
The nurse documents observations about the light reflex seen on the tympanic membrane during an otoscopic examination. Which observation signifies that the ears are normal? a. The light reflection is at the 5 o'clock position on the right tympanic membrane, and the 7 o'clock position on the left. b. The light reflection is amber yellow in color. c. The light reflection is at the 7 o'clock position in both the ears.
a. The *light reflection is at the 5 o'clock position* on *the right tympanic membrane*, and the *7 o'clock position on the left.*
What is the primary purpose of interviewing a patient? a. To get the patient's health history and current health status. b. To allow the patient to become acquainted with the nurse. c. To teach preventive health care methods to the patient. d. To correlate the patient's complaints with objective signs.
a. To get the *patient's health history and current health status.*
A female patient does not speak English well, and the nurse needs to choose *an interpreter*. Which of the following would be the most appropriate choice? a. Trained interpreter b. Male family member c. Female family member d. Volunteer college student from the foreign language studies department
a. Trained interpreter
The registered nurse (RN) is caring for a client with a newly placed nasogastric tube (NGT). Once the placement of the NG tube is verified by x-ray, which technique should the RN use as a reliable method to ensure the NGT is not displaced?a. check the pH of aspirated stomach contents obtained from the NGT b. auscultate over the epigastrium while injecting air into the NGT c. disconnect and place the end of NGT in water to see if bubbles appear d. listen for hyperactive bowel sounds in all four quadrants in the abdomen
a. check the pH of aspirated stomach contents obtained from the NGT
pupil accommodation
always advance the light in from the side to test the light reflex, and note the response. - Normally you will see constriction of the pupils on the same side ( a direct light reflex) - simultaneously constriction of the other pupil ( a consensual light reflex)
breast self-examination
an essential self-care procedure for the early detection of breast cancer - Self-breast exam do it any time of the month as long as you do it monthly
The nurse is performing a *functional assessment* on an 82-year-old patient who recently had a stroke. Which of these questions would be most important to ask? a. "Do you wear glasses?" b. "Are you able to dress yourself?" c. "Do you have any thyroid problems?" d. "How many times a day do you have a bowel movement?"
b. "Are you able to dress yourself?"
Which of the following symptoms do you expect to see in a patient diagnosed with *acute pyelonephritis*? a. Jaundice and flank pain b. Costovertebral angle tenderness and chills c. Burning sensation on urination d. Polyuria and nocturia
b. *Costovertebral angle tenderness and chills*
The registered nurse (RN) notifies the spouse of a client who was admitted to hospice with shallow respirations, of a change in the client's condition. Over the past hour, the client's respiratory pattern has changed to a *Cheyne Stokes pattern*. After receiving this information, the client's spouse begins vacuuming around the bed. Which stage of grief is the spouse displaying during the visit? A. Acceptance B. Denial C. Bargaining D. Depression
b. Denial
Which intervention helps the nurse to listen to the lung sounds in a young child? a. Encouraging the child to exercise prior to auscultation b. Giving the child a pinwheel and asking the child to blow c. Allowing the child to listen to a parent's lung sounds d. Allowing the child to examine the tongue blade
b. Giving the child a pinwheel and asking the child to blow
Which condition is associated with venous pooling (chronic venous insufficiency- veins are not working effectively, making it difficult for the blood from the legs to return to the heart)? a. Diabetes b. Obesity c. Smoking d. Arteriosclerosis
b. Obesity
The unit in which you work has a team nursing delivery system. This delivery system is characterized by all of the following EXCEPT: a. Each team is led by a nurse team leader. b. One primary nurse is responsible for managing and coordinating the client's care. c. The registered nurse assumes total responsibility for planning and delivering care to a client. d. The team leader determines the work assignment.
b. One primary nurse is responsible for managing and coordinating the client's care. c. The registered nurse assumes total responsibility for planning and delivering care to a client.
The nurse is assessing a patient who has an *unsteady gait and lacks coordination*. The nurse finds that the *patient abuses alcohol*. What should be the first question the nurse asks during the interview? a. Has anyone asked you to quit drinking? b. When did you have your last drink? c. Have you injured anyone due to your drinking? d. With whom did you drink last?
b. When did you have your last drink?
The nurse is describing how to perform a testicular self-examination to a patient. Which statement is most appropriate? a. "A good time to examine your testicles is just before you take a shower." b. "The testicle is egg-shaped and movable. It feels firm and has a lumpy consistency." c. "If you notice an enlarged testicle or a painless lump, call your health care provider." d. "Perform a testicular examination at least once a week to detect the early stages of testicular cancer
c. "If you notice an enlarged testicle or a painless lump, call your health care provider."
An elderly patient with insomnia has been prescribed hypnotics and sedatives. What does the nurse inform the patient about the side effects of these medications? a. "You may develop hypoglycemia." b. "You may have decreased appetite." c. "You may increase the risk of delirium." d. "You may experience nausea."
c. "You may increase the risk of delirium."
The nurse has assessed the patients on the unit. Which patient requires immediate attention? a. A patient with a heart rate of 84 beats per minute and oxygen saturation of 99% b. A patient who reports amber-colored urine after a ureteroscopy procedure c. A patient with a blood pressure of 180/110 and urine output of 30 mL/hour d. A patient with a respiratory rate of 16 bpm and a temperature of 98.6°F (37° C)
c. A patient with *blood pressure of 180/110 and urine output of 30 mL/hour*
The home care nurse determines that a 78-year-old client is unable to remain in his current resident alone. The nurse determines this by what? a. The goals set for the client. b. The learning level of the client. c. Assessing the home environment. d. The distractions in the home of the client.
c. Assessing the home environment.
After reviewing the prescription of a patient, *the nurse warns the patient about the possibility of insomnia*. Which *medication* would have this effect? a. Hypnotics b. Barbiturates c. Diuretics d. Antihypertensives
c. Diuretics
A patient with *congestive heart failure* reports to the nurse a *ringing sensation in the ears*. After reviewing the medication reports, the nurse suspects the patient is having *side effects from one of the prescribed medications*. Which medication is likely to cause these symptoms in the patient? a. Mannitol (Osmitrol) b. Digitalis (Digoxin) c. Ethacrynic acid (Edecrin) d. Captopril (Capoten)
c. Ethacrynic acid (Edecrin)
The nurse is *assessing* a *75-year-old man*. What should the nurse *expect* when performing the *mental status portion of the assessment*? a. Will have no decrease in any of his abilities, including response time. b. Will have difficulty with tests of remote memory because this ability typically decreases with age c. It may take a little longer to respond, but his general knowledge and abilities should not have declined. d. Will exhibit a decrease in his response time because of the loss of language and a decrease in general knowledge.
c. It may take a little longer to respond, but his general knowledge and abilities should not have declined.
Hypothyroidism
condition of hyposecretion of the thyroid gland causing low thyroid levels in the blood that result in *sluggishness, fatigue, slow pulse, and often obesity/ Weight gain.* - Everything slows down - *Also causes irregular menses & an increased risk of a miscarriage*
A 23-year-old patient in the clinic appears *anxious*. Her *speech is rapid*, and she is *fidgety and in constant motion*. Which of these questions or statements would be most appropriate for the nurse to use in this situation? a. "How do you usually feel? Is this normal behavior for you?" b. "I am going to say four words. In a few minutes, I will ask you to recall them." c. "Describe the meaning of the phrase, 'Looking through rose-colored glasses.'" d. "Pick up the pencil in your left hand, move it to your right hand, and place it on the table."
d. "Pick up the pencil in your left hand, move it to your right hand, and place it on the table." - *Center her and have her follow directions* - *Get her out of her head to help her with her anxiety*
During an interview, a woman has answered "yes" to two of the Slapped, Threatened, and Throw (STaT) questions. What *should the nurse say* next? a. "So you were abused?" b. "Do you know what caused this abuse?" c. "I need to report this abuse to the authorities." d. "Tell me about the abuse in your relationship."
d. "Tell me about the abuse in your relationship." -(She has stated that she has been ⅔ hurt)
The nurse is aware that which *statement is true regarding the incidence of testicular cancer*? a. The cure rate for testicular cancer is low. b. Testicular cancer is the most common cancer in men aged 30 to 50 years. c. The early symptoms of testicular cancer are pain and induration. d. Men with a history of cryptorchidism are at the greatest risk for the development of testicular cancer
d. Men with a history of cryptorchidism are at the greatest risk for the development of testicular cancer
The student nurse is *caring for a patient with a urinary catheter*. The nurse instructs the student to assess vital signs every hour. What other parameters should the nursing student assess every hour? a. Skin integrity b. Blood glucose levels c. Hemoglobin levels d. Quantity and quality of urine
d. Quantity and quality of urine
While assessing an *older adult*, the nurse finds that the patient *does not speak or understand English*. What should be the most important nursing intervention in this situation? a. Report to the primary healthcare provider. b. Request that family members translate. c. Schedule another day for the assessment. d. Use interpreters for better communication.
d. Use interpreters for better communication
The registered nurse (RN) is caring for a client who has a closed head injury from a motor vehicle collision. Which finding should the RN assess the client for the risk of diabetes insipidus (DI)? a. high fever b. low blood pressure c. muscle rigidity d. polydipsia/ excessive thirst or excessive drinking
d. polydipsia/ excessive thirst or excessive drinking
Assessment of limb symmetry
legs should be symmetrical - 1 cm difference between the legs is okay - Hip to the inside of knee down There will be a little difference
Broca's area in the frontal lobe mediates
motor speech - When injured in the dominant hemisphere, *expressive aphasia results*; the person cannot talk. - The person can understand language and knows what he or she wants to say but can produce only a garbled sound.
dysmenorrhea
pain caused by uterine cramps during a menstrual period *Painful menses*
When assessing the sensory system what test do we perform?
screening procedures include: testing superficial pain light touch vibration in a few distal locations stereognosis - *The person's eyes should be closed, in each test.* - Take time to explain the procedure and what you will expect the patient to respond to.
