med surg 3 final
A patient who is taking a monoamine oxidase inhibitor (MAOI) asks the nurse about the addition of St. John's wort to help with his depression. What would be the best response of the nurse?
"Did you know that St. John's wort can raise your blood pressure dramatically?"
Which patient statement indicates the need for additional teaching for a patient with rheumatoid arthritis who is taking meloxicam (Mobic)?
"I take aspirin before I go to bed."
The patient has been diagnosed as having gouty arthritis. The patient asks the nurse to explain the cause of the inflammation of the great toe. What is the most appropriate nursing response?
"The inflammation is from small accumulations of uric acid crystals, which are called tophi."
The 14-year-old boy who is scheduled for left leg amputation says to the nurse, "What in the world am I going to do with only one leg?" What is the nurse's most therapeutic response?
"What are you thinking about right now?"
How would a nurse record the behavior when a patient with Alzheimer's disease attempts to eat using a napkin rather than a fork?
Agnosia
A patient has been casted to stabilize a fracture of the right radius and ulna. The nurse assesses a capillary refill of 5 seconds and cold fingers of the right hand. Which initial intervention should the nurse deploy?
Elevate the right hand to heart level to maintain arterial pressure.
Which event in the mental health care movement occurred first?
Establishment of Pennsylvania Hospital
Why is otitis media found more frequently in children 6 to 36 months?
Eustachian tubes in children are shorter and straighter.
What is the nurse assessing when asking the patient, "Who is the president of the United States?" during a level of consciousness assessment?
Fund of knowledge
What should the nurse instruct the patient before the initiation of the antimalarial drug hydroxychloroquine (Plaquenil)?
Get an eye examination.
What is the prognosis for a schizophrenic patient who is exhibiting positive behaviors?
Good
The nurse alters the care plan for a patient with depression to include what type of activity?
Group outing to view wildflowers
The patient talks with his dead brother and arranges furniture so that his brother will have a place to sit. How should the nurse document this behavior?
Hallucination
A home health nurse has a patient who is taking lithium. What should be included in the teaching plan?
Have her drug blood level checked every month.
Four hours after a stapedectomy, the patient complains that hearing has not improved at all. What knowledge would the nurse use to shape a response?
Hearing will not return until edema subsides.
During the 17th and 18th centuries, care of patients with mental illness often was cruel. What type of care was used by Dr. Philippe Pinel to bring about change?
Humane care
The newly admitted patient to the emergency room 30 minutes ago after a fall off a ladder has gradually decreased in consciousness and has slowly reacting pupils, a widening pulse pressure, and verbal responses that are slow and unintelligible. What is the most appropriate position for the patient?
Neck placed in a neutral position.
A 14-year-old survivor of a school shooting screams and dives under a table when firecrackers go off. What does this behavior represent?
Posttraumatic stress disorder
Which of the following are the main purposes of traction? (Select all that apply.)
Prevent deformities. Align and stabilize a fracture. Relieve muscle spasms.
When the patient with a psychosis is thought to be a danger to self or others, by what method should the patient be admitted to the hospital?
Probating
What is the term used for the beginning stage of schizophrenia, characterized by a lack of energy and complaints of multiple physical problems?
Prodromal
Which foods should the home health nurse suggest for the patient with osteoporosis to help slow the disease?
Leafy green vegetables
What would a nurse do when the patient arrives in the PACU after a left stapedectomy? (Select all that apply.)
Leave the bed flat. Medicate immediately on the complaint of nausea. Turn the patient to his right side.
How should the nurse advise a patient who has severe vertigo from labyrinthitis?
Lie immobile and hold the head in one position until the vertigo lessens.
The office nurse has noted the presence of an increase in lumbar curvature in a 20-year-old female patient. What is this condition known as?
Lordosis
What are the three vital functions muscles perform when they contract? (Select all that apply.)
Maintenance of posture Production of heat Motion
Which foods should the person who suffers from migraine headaches avoid? (Select all that apply.)
Marinated foods Yogurt Caffeine
The Diagnostic and Statistical Manual of Psychiatric Disorders, V (DSM-V), is used by most hospitals and is the current tool used to examine mental health and illness. What approach does the DSM-V use to classify mental disorders?
Multiaxial system
What is the term for a long-term and intense form of psychotherapy developed by Sigmund Freud that allows a patient's unconscious thoughts to be brought to the surface?
Psychoanalysis
What should the nurse stress to a patient who has had a hip replacement and is beginning strengthening exercises for the unaffected leg?
Push foot down against the footboard for a count of five.
What should the nurse stress to a post-hip replacement patient in quadriceps setting exercises?
Push knee down to mattress and raise heel off the bed.
What should the nurse instruct the patient before a magnetic resonance imaging (MRI) procedure?
Remove all metal, such as jewelry, glasses, and hair clips
What should the home health nurse include assessment for in the plan of care for an 82-year-old female with severe kyphosis from ankylosis?
Respiratory effort
What is the purpose of a "drug holiday" in the treatment of Parkinson disease?
Restart drugs at a lower dosage with favorable results.
How is rheumatoid arthritis distinguished from osteoarthritis?
Rheumatoid arthritis is an autoimmune, systemic disease; osteoarthritis is a degenerative disease of the joints.
A profound, disabling mental illness is characterized by bizarre, nonreality thinking. What is the illness?
Schizophrenia
A patient with a spinal cord injury at T1 complains of stuffiness of the nose and a headache. The nurse notes a flushing of the neck and "goose flesh." What should be the primary nursing intervention based on these assessments?
Sit upright and check blood pressure.
The 62-year-old home health patient who is recovering from eye surgery complains of a feeling of "grittiness" in the eye and is having blurred vision. The eyes are reddened and have stringy mucus. What do these complaints indicate?
Sjögren syndrome
The patient complains of recurrent, multiple physical ailments for which there is no organic cause. How should the nurse assess this?
Somatic symptom disorder
What does any event that requires change stimulate?
Stress
A patient admitted for delirium demonstrates increased disorientation and agitation only during the evening and nighttime. What is the term applied to this type of delirium?
Sundowning syndrome
What should the nurse include in the teaching plan for a patient who is taking alendronate (Fosamax)?
Take drug first thing in the morning
Why is the patient with suspected Guillain-Barre Syndrome (GBS) hospitalized immediately?
The disease can rapidly progress into respiratory failure
Adjunctive therapies are used for which reasons? (Select all that apply.)
To increase self-esteem To enhance reality orientation To promote positive interaction
The nurse is told that a patient believes he was born into the wrong body. What is the correct terminology for the desire to have the body of the opposite sex?
Transsexualism
A patient has recently suffered a stroke with left-sided weakness and has problems with choking, especially when drinking thin liquids. What nursing interventions would be most helpful in assisting this patient to swallow safely?
Tuck chin when swallowing.
Which may contribute to otitis media? (Select all that apply.)
Upper respiratory infections Allergies Exposure to cigarette smoke
Which instructions should the nurse include in a teaching plan for a person with gouty arthritis? (Select all that apply.)
Use bed cradle to support linens. Maintain rest and immobility while disease is symptomatic. Avoid excessive alcohol. Check urine and urine output for possible kidney stones.
What is the cranial nerve that supplies most of the organs in the thoracic and abdominal cavities and carries motor fibers to glands that produce digestive juices and other secretions?
Vagus nerve
What action by a student before taking a test should indicate to a nursing instructor that the student is demonstrating signs of moderate anxiety?
Vomits
The nurse weighs a patient at the same time of day with the same scale and same clothing. What is this a simple and accurate method of determining?
Water balance
When a patient recovering from a fractured tibia asks what callus formation is, the nurse tells her it is:
a part of the bone healing process after a fracture when new bone is being formed over the fracture site.
The patient that has a bipolar hip replacement following an intracapsular fracture has an order to be turned every 2 hours. The nurse understands that the correct nursing intervention is to keep the legs:
abducted so the prosthesis does not become dislocated.
Forty-eight hours after a patient sustained a fractured femur in a car accident, the nurse assessed a pulse of 110, respirations at 25, and labored crackles in both lung fields. The nurse immediately reports to the charge nurse the probability of a(n):
fat embolism.
The nurse is caring for a home health patient who had a spinal cord injury at C5 3 years ago. The nurse bases the plan of care on the knowledge that the patient will be able to:
feed self with setup and adaptive equipment.
An 83-year-old patient has had a stroke. He is right handed and has a history of hypertension and "little" strokes. He presents with right hemiplegia. To afford him the best visual field, the nurse should approach him:
from the left side.
The nurse clarifies to a patient who is being evaluated for possible rheumatoid arthritis that the elevated erythrocyte sedimentation rate indicates the presence of:
increased inflammatory reaction in the body.
When the patient with rheumatoid arthritis complains about the daily exercise, the nurse encouragingly reminds the patient that exercises:
keeps the joints from "freezing."
A 16-year-old male patient presents in the emergency room with a pathologic fracture of the left femur and complains of pain on weight-bearing. These are cardinal indicators of:
osteogenic sarcoma.
The nurse explains to a patient who has had a knee replacement that warfarin (Coumadin) is ordered to:
prevent formation of emboli.
The characteristics of osteoarthritis that should be included in a teaching plan would include that osteoarthritis: (Select all that apply.)
results from wear and tear. will cause the formation of Heberden nodes. may affect only one side of the body.
Following a myelogram the nurse should include in the postprocedure care assessment for
sensation in lower extremities.
The nurse is aware that the characteristic gait of the person with Parkinson disease is a propulsive gait, which causes the patient to:
shuffle with arms flexed.
The nurse instructs the patient who is to have a unicompartmental knee replacement that a major advantage of this partial knee replacement is that:
the patient will be up and walking 2 to 3 hours after the operation.
What is the most interior part of the eye?
Choroid
What should the nurse do when assisting a blind person to walk in an unfamiliar hospital environment? (Select all that apply.)
Describe the surroundings. Encourage the patient to ask for verbal cues. Place patient hand on nurse's shoulder or elbow.
When the patient in the emergency room complains of seeing flashing lights and a curtain down over his right eye, the nurse recognizes this as a symptom of which condition?
Detached retina
The nurse takes into consideration that a healing fracture progresses through several healing stages. Which is the third healing stage?
Development of fibrin meshwork
A patient who has had a right below the knee amputation continues to complain of unpleasant sensation in the right foot. What can the nurse explain about this "phantom pain"?
It is related to the severed nerves that are still sending messages to the brain.
What must a patient do following a left vitrectomy?
Position self in a face-down position for 4 to 5 days.
Calcium is a mineral found in many foods that can slow bone loss during the aging process. Which food is high in calcium?
Spinach
What are considered warning signs of suicide? (Select all that apply.)
Talking about suicide Drug or alcohol abuse Personality changes Difficulty concentrating on work or school
When a patient is experiencing a panic attack, how should the nurse best assist the patient?
Coach in deep breathing.
What are surgical navigational systems?
Computerized devices that guide the surgeon
What does a tympanoplasty correct?
Conductive hearing loss
How should the nurse document the behavior of a patient with mental illness?
Differing from socially acceptable behavior
The patient, age 58, is diagnosed with osteoporosis after densitometry testing. She has been menopausal for 5 years and has been concerned about her risk for osteoporosis because her mother has osteoporosis. In teaching her about her osteoporosis, which information does the nurse include?
Even with a family history of osteoporosis, the calcium loss from bones can be slowed by increased calcium intake and exercise.
Sodium is the most abundant electrolyte in the body. The location of electrolytes is important for maintaining homeostasis. Sodium is the major electrolyte in which fluid compartment?
Extracellular
The patient is concerned about confidentiality and asks the nurse not to tell anyone what is said. What is the best response by the nurse?
. "I am required to report any intent to hurt yourself or others."
What is the typical schedule for electroconvulsive therapy (ECT)?
10 treatments over several weeks
What Glasgow Coma Scale rating would a patient receive who opens the eyes spontaneously, but has incomprehensible speech and obeys commands for movement?
12
When was psychiatric training for nurses initially offered?
1882
The nurse is aware that the patient has 20/40 vision. This means that the patient can see at 20 ft what the normal eye can see at _______ ft.
20
The nurse encourages a patient who has been vomiting to drink fluids because the body fluid lost daily must match the amount of fluid taken in to maintain homeostasis. What is the recommended daily amount of fluid for an adult?
2500 mL
The nurse must keep an accurate intake and output record to assess kidney efficiency. In order for the kidneys to remove waste, what is the least amount of hourly urine output the kidneys must produce to remove waste?
30 mL
What percentage of an adult's body weight consists of water?
50% to 60%
Which patient is most likely to develop osteoporosis?
57-year-old white woman
The nurse recognizes that researchers have identified that hereditary factors account for what percentage of mood disorders?
60% to 80%
What is the movement of an extremity away from the midline of the body called?
Abduction
What coping mechanism demonstrated by a patient should indicate to the nurse that the patient is seeking ways to deal with and resolve stress?
Adaptation
What is the first priority nursing intervention for an impending fat embolism?
Administer oxygen in a respiratory emergency.
The nurse is sensitive to the fact that patients lose control over their lives when admitted to the hospital. In what does this loss of control frequently result?
Anxiety
The nurse is assessing a female patient who has become rapidly and exceedingly anxious because her fingernail polish is chipped. What type of anxiety should the nurse conclude that the patient is exhibiting?
Anxiety traits
A patient who had an enucleation of the right eye has been admitted PACU. What should the nurse include in the plan of care?
Apply a pressure dressing over the right eye socket.
The nurse is educating a patient regarding the need to avoid foods high in potassium. What food choices led the nurse to conclude that teaching was not effective?
Apricots and asparagus
What should the nurse advise the 20 year old to do who has been put on cefaclor (Ceclor) for a resistant otitis media?
Avoid alcoholic beverages.
A patient has undergone a bipolar hip repair (hemiarthroplasty). Which is the most appropriate instruction?
Avoid crossing the legs.
What is the basis for classifying a person as having a mental illness?
Behavior exhibited and the context
Why is it important for the nurse to be observant of patient behavior?
Behavior is learned
In order for a patient to flex the lower leg, which muscle must be contracted?
Biceps femoris
A 56-year-old female patient is being seen for osteoarthritis of the knee in the clinic. What should the nurse recommend when discussing strengthening exercises?
Bicycling
For the past 3 weeks, the nurse has observed a patient interacting with staff and other patients, helping decorate the dining room for a party, and leading the singing in the activity room. Today, the patient tearfully refuses to dress or get out of bed. The nurse recognizes these behaviors as evidence of which psychiatric disorder?
Bipolar disorder
Certain foods may increase the pain associated with gout. Which foods have the highest concentration of purines?
Brain, liver, kidney
What does diabetes retinopathy result from?
Capillaries in retina hemorrhage
What is the nurse closely assessing for in a patient with hypokalemia?
Cardiac complications
What are the two divisions of the nervous system?
Central and the peripheral
Dementia is an organic mental disease secondary to what problem?
Cerebral disease
A family member of a patient who has just suffered a tonic-clonic seizure is concerned about the patient's deep sleep. What is this behavior called?
Postictal period
What is the cardinal sign of increased intracranial pressure in a brain injured patient?
Decrease in the level of consciousness
A nurse tearfully confides to the head nurse that being assigned to care for eight patients is stressful and overwhelming. What demonstrates the use of a healthy coping mechanism?
Delegating appropriate care assignments to unlicensed assistive personnel
After finding the patient with diabetes eating candy, the nurse reminds the patient that the candy will elevate blood sugar levels. The patient's response is: "It's only a little bit, and it won't do anything." Which defense mechanism is the patient using?
Denial
What is the first sign of Bell's palsy?
Inability to wrinkle forehead and pucker lips on affected side
What should the nurse do when a patient with osteomyelitis is admitted with an open wound that is draining?
Initiate drainage and secretion precautions.
What is the reticular activating system (RAS) essential to? (Select all that apply.)
Introspection Concentration Attention Wakefulness
One of the housekeepers splashes a chemical in the eyes. What should be the first priority?
Irrigate with normal saline solution for 20 minutes.
A frantic family member is distressed about the flaccid paralysis of her son following a spinal cord injury several hours ago. What does the nurse know about this condition?
It is possibly a temporary condition and will clear.
How many people in the United States will develop a mental disorder during their lifetime?
One in two
What does prolonged bed rest put the older adult at risk for?
Pathologic fractures
What is a nursing intervention that helps to build trust, encourages the patient to have faith in the care being received, and meets psychosocial needs?
Patient education
Which finding would delay a computed tomography (CT) scan?
Patient's allergy to shellfish
What is the large, fan-shaped muscle that covers the anterior chest from the sternum to the proximal end of the humerus and acts on the joint of the shoulder to flex, adduct, and rotate?
Pectoralis major
What should the nurse include in the plan of care for a patient following a myelogram?
Position in a semi-Fowler's position for 8 hours to reduce potential of headache.
What should a patient who has had a cataract repair avoid?
The lifting of heavy objects
What is the mental health nurse referring to when using the term behavior?
The manner in which a person performs
A variety of factors influence the level of anxiety experienced by the patient faced by a stressful situation. Which would the nurse outline? (Select all that apply.)
The number of stressors present at one time Present role assumption Degree of change the stressors require Previous experience with a similar situation
The patient tells the nurse that he is legally blind. How would this information impact the nurse's plan of care for this patient?
The nurse would need to determine how this patient's visual impairment affects normal functioning.
The nurse cautions a patient to watch his step. What response indicates concrete thinking?
The patient fixedly begins to watch his feet.
How would the nurse explain the purpose of photocoagulation to a diabetic patient with diabetic retinopathy?
The procedure will destroy new blood vessels, seal leaking vessels, and help prevent retinal edema.
Which symptom is specific to migraine headaches?
They are preceded by an aura
The home health nurse assesses a patient who creates elaborate excuses for not leaving home. Further questioning reveals the patient had not left home for 6 months. How should this be documented?
Agoraphobia
When the newly blind male home health patient asks the nurse how he might get assistance, who might the nurse suggest he contact?
American Foundation for the Blind for a list of agencies
What disorder is a severe form of self-starvation that can lead to death?
Anorexia nervosa
A patient, age 68, has suffered an intertrochanteric fracture of the right hip. Before surgery, to provide support and comfort, an immobilizing device of a ______ is applied
Buck traction
What should the nurse preparing a patient for a scheduled appointment for electroconvulsive therapy (ECT) remind the patient to do?
Arrange for transportation to and from the appointment.
The nurse is aware that when assessing a patient by the FOUR score coma scale, the patient is assessed in four categories: eye response, brainstem reflexes, motor response, and respiration. How are these results reported?
As individual scores in each category
What does the cataract treatment of phacoemulsification involve?
Breaking the cataract with ultrasound
The newly admitted patient to the emergency room after a motorcycle accident has serosanguineous drainage coming from the nose. What is the most appropriate nursing response to this assessment?
Gently wipe nose with absorbent gauze.
Using Freud's personality theory, what action by a patient indicates a strong ego?
Laughs at himself for being foolish.
What is the first nursing intervention step for the immediate care of a patient with a penetrating wound of the eye?
Lay the patient down flat.
A patient believes himself to be the president of the United States and that terrorists are trying to kidnap him. The nurse records these observations as which type of behavior?
Positive behavior
The patient complains to the nurse that the health care provider does not like him and wants him to fail at following the diet prescribed. The nurse recognizes that the patient is using which defense mechanism?
Projection
Why are the drugs neostigmine (Prostigmin) and pyridostigmine (Mestinon) helpful to the person with myasthenia gravis?
Promotes nerve impulse transmission.
As the result of a stroke, a patient has difficulty discerning the position of his body without looking at it. In the nurse's documentation, which would best describe the patient's inability to assess spatial position of his body?
Proprioception
When the patient who overeats insists that weight gain is related to retained fluids, the nurse recognizes the patient is using which defense mechanism?
Rationalization
When assisting the older adult who is despondent about the need to leave his home, what technique should the nurse use?
Reminisce with the patient and review his life
A patient is in which stage of Alzheimer's disease when she demonstrates "sundowning"?
Second stage
The nurse uses a diagram to show how the four parts of "self" fit together. What are the four parts? (Select all that apply.)
Self-esteem Identity Role Body image
A patient had an open reduction with internal fixation (ORIF) for a compound fracture of the left tibia and has been placed in a long leg cast. The assessments by the nurse are: left foot warm/pink, pedal pulse weaker than right, capillary refill 3 seconds, and small 1 cm area of blood on cast. What should the nurse do?
Document that all assessments are within normal limits.
The majority of people function in a relatively healthy manner. What can diminish their functional capacity?
Periods of crisis
A patient, age 45, is to have a myelogram to confirm the presence of a herniated intervertebral disk. Which nursing action should be planned with respect to this diagnostic test?
Obtain an allergy history before the test.
