Medical-Surgical Nursing Week 2 Part 2

The nurse is administering chemotherapeutic drugs to the patient and notices excessive bruising on the patient's arms. The patient cannot recall injury to the area. The nurse knows that this bruising may indicate which condition?

Diminished clotting

The nurse should include questions about which factors when assessing a patient's sexuality? Select all that apply.

- Sexual activity - Sexual behaviors - Protection measures - History of sexually transmitted diseases

The nurse understands that which factors may put a patient at risk for decreased nutrition? Select all that apply.

- Thyroid disorder - Low socioeconomic status - Chronic obstructive pulmonary disease (COPD)

What easily observable physical signs may indicate malnutrition? Select all that apply.

- Very dry skin - Brittle hair and nails

What psychosocial complications does the nurse monitor for in a patient who is confined to bed? Select all that apply.

-Sensory deprivation - Changes in sleep-wake cycle

The patient presents with decreased hair distribution and cool, pale legs. What measurement is the nurse's priority?

Distal peripheral pulses

The nurse understands that which complication of decreased mobility in older patients affects the bones?

Disuse osteoporosis

The nurse may use the Confusion Assessment Method (CAM) to screen patients for impairment in what area?

Cognition

The nurse enters the room of an older patient and finds the patient in bed completing crossword puzzles. What is the nurse's most appropriate response?

"It's great that you enjoy crossword puzzles. They can help maintain brain functions like memory."

The nurse working in the neurology department sees a patient who has a meningioma. The patient asks the nurse why surgery is necessary if the mass is benign. What is the nurse's best response?

"While the cells from a benign mass cannot spread to other organs, there is a risk of increased intracranial pressure, which can be very dangerous."

The nurse understands that which laboratory tests are most useful in detecting autoimmune disease? Select all that apply.

- Rheumatoid factor - Antinuclear antibody

What might a patient with excessive immune response experience that a patient with decreased immune response is less likely to experience? Select all that apply.

- Allergies - Autoimmune diseases

The nurse should educate patients at risk for clotting to use what measures to decrease the risk of complications? Select all that apply.

- Avoid smoking. - Avoid crossing the legs. - Avoid prolonged sitting. - Observe symptoms in lower extremities.

To prevent hypokalemia, what foods should the nurse recommend to the patient with prolonged diarrhea? Select all that apply.

- Bananas - Oranges - Potatoes

During the clinical interview, the patient reports flare-ups of a previously diagnosed autoimmune condition. Which conditions are prone to this pattern? Select all that apply.

- Crohn disease - Lupus erythematous - Rheumatoid arthritis (RA)

Which conditions are among the most common risk factors for acid-base imbalance that indicate the nurse should closely monitor the patient's arterial blood pH? Select all that apply.

- Diarrhea - Poisoning - Chronic kidney disease

The nurse understands that a patient with fluid deficit may experience which physiological consequences? Select all that apply.

- Fever - Tachycardia - Hypotension

The nurse understands that a patient with an electrolyte deficit may experience which physiological consequences? Select all that apply.

- Hypokalemia - Hyponatremia

The nurse understands that which adult populations are at an increased risk for impaired immunity? Select all that apply.

- Nonimmunized adults - Low socioeconomic groups - Adults experiencing substance abuse disorder

The nurse is caring for a patient at high risk for decreased perfusion. What lifestyle interventions does the nurse teach the patient in order to decrease the risk? Select all that apply.

- Quitting smoking - Eating a high-fiber diet - Regular cardiovascular exercise

If the nurse finds that the patient's arterial blood pH is below 7.35, what term does the nurse document in the patient's electronic health record?

Acidosis

What body part loses elasticity as adults age, leading to a decrease in gas exchange?

Alveoli

The nurse understands that in patients with diminished clotting ability, continued bleeding may lead to which complication?

Anemia

For a patient with acid-base imbalance, what method should the nurse use to determine the type of acid-base imbalance the patient is experiencing?

Arterial blood gas monitoring

What assessment used by the nurse can be graded types I to IV?

Autoimmune reaction

When the nurse is monitoring the patient's fluid and electrolyte levels, what is the best measure of fluid volume changes?

Body weight

The nurse should teach the patient who is immobile to eat a diet high in which mineral to prevent bone loss?

Calcium

A patient being treated for pneumonia presents with a decrease in blood pH. What two components combine to produce the carbonic acid responsible for the acid-base imbalance?

Carbon dioxide and water

The nurse is caring for an older adult patient with limited mobility who takes an opioid drug for pain. For what change to normal elimination is this patient most at risk?

Constipation

Assisting the patient with reorientation is an appropriate intervention by the nurse in the case of which type of cognitive impairment?

Delirium

The nurse is caring for a patient whose cervical spinal cord was injured in a motor vehicle accident. The nurse understands that monitoring this patient for decreased gas exchange is necessary because of possible damage to spinal nerves that control what body part?

Diaphragm

Decreased function of which physiologic process causes inadequate transportation of oxygen to body cells and organs?

Gas exchange

How often should the nurse turn and reposition a patient who is immobile?

Every 1 to 2 hours

Decreased function of which physiologic process causes retention of carbon dioxide?

Gas exchange

Following surgery, a patient has limited mobility. The nurse observes the patient for localized redness, swelling, and warmth to assess for which complication?

Excessive clotting

The nurse is providing education to a patient with recurring constipation. What lifestyle intervention does the nurse suggest to the patient to stimulate peristalsis?

Exercising frequently

The nurse is treating a patient who has had prolonged diarrhea. What secondary concern is a priority for the nurse to monitor?

Fluid and electrolyte imbalances

What is the primary collaborative intervention for patients with fluid deficits?

Fluid replacement

The nurse is caring for a patient recovering from hip surgery. What exercise should the nurse teach the patient to prevent venous thromboembolism (VTE)?

Heel pump

The nurse uses which term to describe the inability to pass stool?

Obstipation

The nurse understands that signs of decreased peripheral perfusion most often occur where?

Lower extremities

For a patient with acid-base imbalance, what method should the nurse use to assess how well the kidneys are excreting or reabsorbing base as needed?

Measuring bicarbonate level

The nurse understands that a patient's sense of touch is most often affected by which type of conditions?

Neurological

Which patient has the highest risk for decreased perfusion?

Older adult with obesity and diabetes mellitus

In the patient with end-stage chronic kidney disease, how does the nurse expect the patient's urine to present?

Oliguria

The nurse should anticipate that the postoperative patient will most likely require what source of comfort?

Patient-controlled analgesia for continuous pain control

The nurse understands that older adults may experience urinary and bowel incontinence as a result of the weakening of which muscles?

Pelvic floor

What are the most common serum laboratory tests to assess for generalized malnutrition?

Prealbumin and albumin

What assessment used by the nurse can be measured on a scale of 0 to 5?

Range of motion

What is an example of secondary prevention to promote cellular regulation and prevent impaired cellular regulation?

Screening to identify early risks

The nurse is treating a patient who has urinary and bowel incontinence. What secondary concern is a priority for the nurse to monitor?

Skin irritation or infection

During a physical examination, the nurse identifies a palpable mass in the patient's breast. What type of assessment may be used to identify the type of cells that are present in the mass?

Tissue biopsy

The nurse understands that which complication of decreased mobility in older patients affects circulation?

Venous thromboembolism (VTE)

The nurse is caring for a patient with damage to cranial nerve II. The nurse understands that monitoring for changes to what sense is required?

Vision