Med Surg Midterm
A nurse is assisting with teaching a group of clients about monitoring for diabetic peripheral neuropathy. Which of the following client statements indicates understanding of the information?
"I might lose awareness of when I'm stepping on a harmful object."
A nurse is caring for a client who just had cataract surgery. Which of the following comments from the client should the nurse report to the provider?
"I need something for the horrible pain in my eye."
A nurse is reinforcing discharge teaching with a client who is postoperative following a cataract extraction. Which of the following statements by the client indicates understanding of the teaching?
"I will bend at my knees if I need to pick something up off the floor."
A nurse is reinforcing teaching with a client who has a new prescription for phenytoin. The nurse should recognize that which of the following statements by the client indicates a need for further teaching.
"I'll be glad when my seizures stop so I can quit taking this medication."
A nurse is caring for a client who develops a pulmonary embolism. Which of the following interventions is the priority for the nurse to take?
Administer oxygen therapy.
A nurse is reinforcing discharge teaching with a client who has a prescription for phenytoin. Which of the following instructions should the nurse include in the teaching?
Alcohol increases the chance of phenytoin toxicity.
A patient who had an enucleation of the right eye has been admitted to PACU. What should the nurse include in the plan of care?
Apply a pressure dressing over the right eye socket.
A nurse is collecting data from a school age child who is undergoing a neurological assessment following a head injury. The nurse should document gross incoordination when walking as which of the following findings?
Ataxia
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.
Which diagnostic test for diabetes mellitus provides a measure of glucose levels for the previous 8-12 weeks?
Glycosylated hemoglobin. HbA 1c.
A nurse is collecting data from a client who has open-angle glaucoma. Which of the following findings should the nurse expect?
Gradual loss of peripheral vision.
The nurse assures an anxious family member of a 92-year-old patient who is demonstrating signs of dementia that many causes of dementia are reversible and preventable. What is one example?
Hypotension.
What is the first sign of Bell's Palsy?
Inability to wrinkle forehead and pucker lips on affected side.
A home health patient in with end stage renal disease (ESRD) has a patient problem of powerlessness related to life altering disease. Which nursing intervention would be most helpful?
Include the patient in making the plan of care.
What should the nurse encourage, barring any other contraindication, when teaching the patient how to decrease the chance of further problems with urolithiasis?
Increase his fluid intake.
A patient, age 69, has emphysema. On assessment, the nurse notes the presence of a "barrel chest." What does this pathology result from?
Increased anteroposterior diameter caused by overinflation of the alveoli.
A nurse is assisting with the plan of care for a client who is postoperative following repair of a detached retina. Which of the following interventions should the nurse include in the plan of care?
Instruct the client to avoid reading for long periods of time.
A nurse is assisting with the care of a client who has adult respiratory distress syndrome (ARDS). Which of the following actions should the nurse take?
Position the client in supine for ventilatory support.
A nurse is assisting with the care of a client who has adult respiratory distress syndrome (ARDS). Which of the following actions should the nurse take?
Position the client supine for ventilatory support.
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.
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?
Sjogren Syndrome.
The older adult patient with long-term emphysema complains of a sharp pleuritic pain after a severe period of coughing. The patient's heart rate and respiratory rate have increased. Auscultation reveals no breath sounds of left side. These are signs and symptoms of what condition?
Spontaneous Pneumothorax
What information should be obtained from the patient before an iodine-131 test?
Status of possible pregnancy.
A patient with cystitis is receiving phenazopyridine (Pyridium) for pain and is voiding a bright red-orange urine. What should the nurse do?
Tell the patient it's normal.
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.
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.
A nurse is caring for a client who has Meniere's Disease. When asked by the client if he is allowed to ambulate independently, which of the following responses should the nurse make?
"Please call for assistance when you wish to get out of bed."
The health care provider orders an 1800 calorie diabetic diet and 40 units of (Humulin N) insulin U-100 subcutaneously daily for a patient with diabetes mellitus. Why would a mid-afternoon snack of milk and crackers be given?
To prevent an insulin reaction.
What extra equipment should the nurse provide at the bedside of a new postoperative thyroidectomy patient?
Tracheotomy Tray.
Which precaution(s) should the nurse take when caring for a patient who is being treated with radioactive iodine 131 (RAIU)?
Wait three days after assigning a pregnant nurse to care for this patient.
A nurse is reinforcing preoperative teaching with a client who is scheduled for cataract surgery. Which of the following statements should the nurse make?
Watch of intraocular hemorrhage. Bend at the knees.
Four hours of 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.
What is the master gland of the endocrine system?
pituitary gland
What are surgical navigational systems?
Computerized devices that guide the surgeon
What is the cardinal sign of increased intracranial pressure in a brain injured patient?
Decrease in the level of consiousness.
The purpose of the use of radioactive iodine in the treatment of hyperthyroidism is to:
Destroy some of the thyroid tissue.
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.
What is an appropriate patient problem for a patient who has recently been diagnosed with acromegaly?
Risk for trauma.
What is the postoperative position for a person who has had a thyroidectomy?
Semi-Fowlers.
A nurse is reinforcing teaching with a client who has a prescription for oral suspension phenytoin. Which of the following information should the nurse include in the teaching?
Shake the suspension vigorously prior to pouring the medication.
The nurse is assessing an 11-year-old who is having an asthma attack expects to hear adventitious sounds of:
Sibilant Wheezes
A nurse is collecting data from a client who has a suspected cataract. The nurse should collect date from which of the following areas to confirm the diagnosis?
The lens in the client's eye.
What is a major advantage of video-assisted thoracoscopic surgery (VATS)?
The surgeon can remove tumors of the lungs through a small keyhole incision.
The home health nurse suggests the use of complementary and alternative therapies to prevent and/or treat urinary tract infections (Utis). Which of the following is an example of such therapies?
Cranberry Juice.
A nurse is reinforcing teaching with a client who has Parkinson's disease. The client tells the nurse that he gets nausea when he takes his prescribed levodopa/carbidopa. Which of the following foods should the nurse recommend the client take with his medication?
1 cup (8 oz) of applesauce.
What Glasgow Coma Scale (GCS) score would you assign to a patient who opens the eyes spontaneously, but has incomprehensible speech and obeys commands for movement?
12
The nurse cautions the patient who is being instructed on self-medication with insulin to be aware that there are 25-, 30-, 50-, and 100-unit syringes. How is the 100- unit syringe marked?
2- unit increments.
The nurse is aware that the drug t-PA (Activase), a tissue plasminogen activator, must be given in hours of onset symptoms to have maximum benefit.
3 hours.
A nurse is reinforcing discharge teaching with a client following a cataract extraction. Which of the following should the nurse include in the teaching?
Avoid bending at the waist.
What instructions should a nurse give to a diabetic patient to prevent injury to the feet?
Avoid going barefoot and always wear shoes with soles.
A nurse is collecting data from an 8-month-old infant who has increased intracranial pressure (ICP). Which of the following manifestations should the nurse expect?
Bulging Fontanel.
The nurse is caring for a patient who has a closed chest drainage system notes that there is fluctuation (tidaling) in the water seal chamber. What is the most appropriate nursing action based on this assessment?
Document the Tidaling.
A male patient, age 71, has benign prostatic hypertrophy. He is recovering from a trans-urethral prostatic resection. The health care provider orders removal of the indwelling catheter 2 days after the TURP procedure. What might the patient experience after the catheter is removed?
Dribbling of urine.
The nurse is caring for a patient who is receiving calcium gluconate for treatment of hypo parathyroid tetany. Which assessment would indicate an adverse reaction to the drug?
Drop in blood pressure.
The nurse explains that the two divisions of the autonomic nervous system work to maintain homeostasis. Which is the first autonomic event?
Extremely stressful or frightening event.
How does pursed lip breathing assist patients with asthma during an attack.
It opens bronchioles by backflow air pressure.
A nurse is caring for a client who has a chest tube connected to a water-seal drainage system. Which of the following actions should the nurse take?
Keep drainage below chest level.
A nurse is assisting with the plan of care for a client who has a chest tube connected to a closed chest drainage system. Which of the following interventions should the nurse include in the plan of care?
Keep the collection device upright at all times.
A patient has undergone tests that indicate a deficiency of the parathyroid hormone secretion. She should be informed of which potential complication?
Laryngeal Spasms.
To which diet should a patient with Cushing syndrome adhere?
Less sodium.
The nurse takes in consideration that the Weber test indicated a conductive hearing loss in a patient because the patient reported hearing the tone:
Louder in his affected ear.
The nurse is caring for a client who has a pneumothorax and a water-seal chest tube drainage system to suction. Which of the following actions should the nurse take?
Maintain the drainage containers below the level of the client's chest.
A 56-year-old patient with cancer of the bladder is recovering from a cystectomy with an ileal conduit. What is an important aspect in nursing interventions of a patient with an ileal conduit?
Maintaining skin integrity.
What is the basic problem that prompts most of the early signs of Alzheimer's disease?
Memory loss that disrupts daily life.
The newly admitted patient to the emergency room 30 minutes ago after a fall off a ladder has gradually decreased in consiousness 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 neutral position.
What is a common mistake that hinders communication when communicating with the hearing impaired?
Over accentuating words.
A patient has come to the clinic because of enlarged hands and feet, amenorrhea, and increased hair growth. These symptoms most likely indicate problems with the:
Pituitary gland.
A nurse is caring for a client who is unconscious and has lost the corneal reflex. Which of the following actions should the nurse take?
Place a eye patch over the eye.
A nurse is caring for a child who has a suspected diagnosis of bacterial meningitis. Which of the following actions is the nurse's priority?
Place the child in isolation.
What should the nurse do when the child arrives on the floor with the dianosis of bacterial meningitis?
Place the child in respiratory isolation.
A nurse is assisting with the care of a newborn who has a myelomeningocele. Which of the following actions by the nurse is appropriate?
Place the newborn in a prone-kneeling position.
An intravenous pyelogram confirms the presence of a large renal calculus in the proximal left ureter of a newly admitted patient. The patient is not a candidate for conservative measures, so surgical correction is ordered. A temporary stent is inserted. In addition to observing the patient for hemorrhage, what should the nurses post-surgical interventions include for this patient?
Providing aseptic care of the surgical site.
The nurse clarifies that the difference between a photorefractive keratectomy (PRK) and a laser in-situ keratomileusis (LASIK) is that LASIK
Removes some internal layers of the cornea.
Why would the nurse encourage a group of teenagers to protect their eyes with dark sunglasses while using a UV lamp?
The lamp can cause cataracts.
The patient with long-term emphysema is admitted with a secondary diagnosis of cor pulmonale. What should the nurse anticipate?
The patient will present with edema of the lower extremities and extended neck veins due to hypertension.
The nurse explains that the negative feedback inhibition controls hormone release by communication between:
The pituitary and the target organ.
How would the nurse explain the purpose of photocoagulation to a diabetic patient with diabetic retinopathy?
The procedure will destroy new blood cells, seal leaking vessels, and help prevent retinal edema.
What are the two divisions of the nervous system?
central nervous system and peripheral nervous system
What is the most interior part of the eye?
choroid
A nurse is evaluating discharge instructions for a client following a right cataract extraction. Which of the following statements indicate the teaching is effective?
"I will take stool softener until my eye is healed."
How would the nurse examining a patient with pleurisy document a low-pitched grating lung sound?
Friction Rub
The young man who had a bronchoscopy 1 hour ago asks when he can eat. Which response would be most helpful?
As soon as the gag reflex returns, usually in 2 hours.
How should the nurse administer insulin to prevent lipohypetrophy?
At room temperature.
A nurse is caring for a client who is conscious and has an airway obstruction. Which of the following actions should the nurse take?
Begin the Heimlich maneuver.
What does the cataract treatment of phacoemulsification involve?
Breaking the cataract with ultrasound.
A nurse is reinforcing discharge teaching on actions that improve gas exchange to a client diagnosed with emphysema. Which of the following instructions should be included in the teaching?
Breathing in through her nose and out through pursed lips.
A 27-year-old patient with hypothyroidism is referred to the dietician for dietary consultation. What should nutritional interventions include?
Calorie restricted meals.
What should the nurse counsel the young man with chronic prostatitis to avoid?
Cessation of intercourse.
A patient who is receiving continuous bladder-irrigation following a transurethral resection of the prostate (TURP) complains of "spasm-like" pain over his lower abdomen. What should the initial intervention be by the nurse?
Check the catheter and drainage system for obstruction.
What happens when there is a decrease in the oxygen level in the blood?
Chemoreceptors in the carotid body and aortic body stimulate the respiratory center to modify respiratory rates.
The patient, 43, has cancer of urinary bladder. He has received a cystectomy with an ileal conduit. Which characteristics would be considered normal for his urine?
Clear amber with mucus shreds.
A patient as returned to his room after a thyroidectomy with signs of thyroid crisis. During thyroid crisis, exaggerated hyperthyroid manifestations may lead to the development of the potentially lethal complication of:
Congestive Heart Failure.
What do miotic eyedrops do for a patient with glaucoma?
Constrict the pupil and open the canal of Schlemm.
The patient being treated for hypothyroidism shoud be instructed to eat well-balanced meals including intake of iodine. Which of the following foods contains iodine?
Eggs.
A patient is on postoperative day 2 after undergoing a total hip replacement. The patient suddenly complains of chest pain and is coughing up blood-tinged sputum. What should be the nurse's initial intervention?
Elevate head of bed and administer oxygen.
A home health nurse is visiting a client who has COPD and is receiving oxygen at 2 L/min via nasal cannula. The client tells the nurse she has been having difficulty breathing. Which of the following actions should the nurse take?
Elevate the client's respiratory status.
What should the nurse include in the plan of care following a tympanoplasty?
Elevating head of the bed with operative side facing upward.
A nurse is assisting with the care of a client who is postoperative following a pneumonectomy. Which of the following actions should the nurse take?
Encourage the client to splint the incision when coughing.
Why is Otitis media found more frequently in children 6 to 36 months?
Eustachian tubes in children are shorter and straighter.
Why are pediatric patients, especially girls, susceptible to urinary tract infections?
Females have a short and proximal urethra in relation to the vagina.
The nurse is aware that as a person ages there is a loss of the [blank] mechanisms of the kidney due to the decrease in blood supply to the kidneys and loss of nephrons.
Filtering.
It is 2 days after a 42 year old male patient's urinary diversion surgery. He continues to be critical of the hospital and the nursing care even though the staff has spent time explaining the care to him. What is the most likely explanation for his behavior?
He is reacting to the loss of self-esteem and altered body image.
The nurse discovers the type 1 diabetic (IDDM) patient drowsy and tremulous, the skin is cool and moist, and the respirations are 32 and shallow. These are signs of:
Hypoglycemic reaction, Give 6oz of orange juice.
The patient is on postoperative day 1 after having undergone a TURP procedure. He has continuous bladder irrigation (CBI). Actual urine output during continuous bladder irrigation is calculated by:
Measuring total output and deducting the amount of irrigating solution used.
How should the newly diagnosed patient who has been prescribed isoniazid (INH) for the treatment of active tuberculosis (TB) be advised.
Monitor Renal Function Every several months.
How should a patient be positioned after a thoracentesis is completed and the dressing applied?
Placed in a side-lying position on the unaffected side.
The patient has advanced emphysema and complains of dyspnea and fatigue. What would the most appropriate nursing intervention be for the patient problem activity intolerance related to an imbalance between oxygen supply and demand.
Plan care to provide optimum rest.
A nurse is caring for a client who is scheduled to undergo thoracentesis. In which of the following positions should the nurse place the client for the procedure?
Position the client in an upright position, leaning over the bedside table.
The nurse is caring for a 75-year-old man who has developed diabetes insipidus following a head injury will include in the plan of care provisions for:
Protecting Patient from injury.
A patient problem for the patient with a new laryngectomy would be a Social Isolation related to impaired verbal communication related to removal of the larynx. What is an appropriate nursing intervention?
Provide a pad and pencil or magic slate.
The patient is scheduled for a transurethral resection of the prostate. During preoperative teaching, what should the nurse empathize about what the patient can expect after the procedure?
Red Drainage from the catheter.
What is a long-term complication of diabetes mellitus?
Renal Failure.
A nurse is caring for a client whose arterial blood gas results show the following results: pH: 7.2, PaCO2: 50mm Hg, HICO3: 24 mEq/L. The nurse should identify the client is experiencing which of the following acid-base conditions?
Respiratory Acidosis
A nurse is reviewing the laboratory results of a client who is postoperative and has a respiratory rate of 7/min. The arterial blood gas (ABG) values include: pH 7.22, PaCO2 68 mmHg, Base excess -2, PaO2 78 mm Hg, Oxygen Saturation 80%, Bicarbonate 28 mEq/L Which of the following interpretations of the ABG values should the nurse make?
Respiratory Acidosis
A nurse is collecting data from a client who has shallow respirations and a respiratory rate of 9/min. Which the following acid-base imbalances should the nurse expect?
Respiratory Acidosis.
A nurse is caring for a client whose arterial blood gas results show the following results: pH: 7.2, PaC02: 50mm Hg, HCO3:24mEq/l,. The nurse should identify the client is experiencing which of the following acid-base conditions?
Respiratory acidosis
A home health nurse is assisting with the plan of care for an older adult client who had cataract surgery recently. Which of the following information should the nurse include in the plan of care?
Rest in semi-fowlers position.
How will the kidneys behave in respiratory acidosis?
Retain bicarbonate to increase PH.
Because the kidneys are located in proximity to the vertebrae and are protected by the ribs, their location in documentation is referred to as:
Retroperitoneal.
Which patient assessment indicates the most severe respiratory distress?
Substernal retraction, SaO2 84%
A patient with a history of Graves disease is admitted to the unit with shortness of breath. The nurse notes the patient's vital signs: T 103, P 160, BP 160/80. The nurse also notes distended neck veins. What does the patient most likely have?
Thyroid Storm.
Why would a patient with hypothyroidism be prescribed the drug methimazole (Tapa-zole)?
To block the production of thyroid hormones.
