Medsurg Assignment #5

A recently hospitalized client with multiple sclerosis is concerned about generalized weakness and fluctuating physical status. What is the priority nursing intervention for this client? 1 Encourage bed rest. 2 Space activities throughout the day. 3 Teach the limitations imposed by the disease. 4 Have one of the client's relatives stay at the bedside.

2

An adult client is brought to the emergency department after an accident. The client has limitations in mental functioning related to Down syndrome. How can the nurse best assess the client's pain level? 1 Asking the client's parent 2 Using Wong's "Pain Faces" 3 Observing the client's body language 4 Explaining the use of a 0 to 10 pain scale

2

Soon after admission to the hospital with a head injury, a client's temperature increases to 102.2° F (39° C). The nurse considers that the client has sustained injury to which structure? 1 Thalamus 2 Hypothalamus 3 Temporal lobe 4 Globus pallidus

2

The nurse is educating new parents about circumcision. Which structure of the penis would this nurse tell the parents is removed during circumcision? 1 Glans 2 Prepuce 3 Epididymis 4 Vas deferens

2

The nurse is educating student nurses about the anatomy and physiology of the kidneys. What term does the nurse explain is used for the tip of the pyramid of a kidney? 1 Calyx 2 Papilla 3 Renal pelvis 4 Renal column

2

The nurse is teaching self-management techniques to a client newly diagnosed with polycystic kidney disease. Which statement of the client indicates a need for further teaching? 1 "I should monitor my bowel movements." 2 "I should weigh myself once a week." 3 "I should record my blood pressure daily." 4 "I should notify my healthcare provider if I have fever."

2

What is an acute, life-threatening complication for which a nurse should assess a client in the early postoperative period after a radical nephrectomy? 1 Sepsis 2 Hemorrhage 3 Renal failure 4 Paralytic ileus

2

Which is a primary glomerular disease? 1 Diabetic glomerulopathy 2 Chronic glomerulonephritis 3 Hemolytic-uremic syndrome 4 Systemic lupus erythematosus (SLE)

2

Which structure lies inside and parallel to the sclera? 1 Lens 2 Choroid 3 Conjunctiva 4 Ciliary processes

2

Which test is used to diagnose diseases of the vestibular system? 1 Rinne test 2 Caloric test stimulus 3 Pure-tone audiometry 4 Auditory brain stem response

2

A student nurse is caring for a client with chronic kidney failure who is to be treated with continuous ambulatory peritoneal dialysis (CAPD). Which statement by the student nurse indicates to the primary nurse that the student nurse understands the purpose of this therapy? 1 "It provides continuous contact of dialyzer and blood to clear toxins by ultrafiltration." 2 "It exchanges and cleanses blood by correction of electrolytes and excretion of creatinine." 3 "It decreases the need for immobility, because it clears toxins in short and intermittent periods." 4 "It uses the peritoneum as a semipermeable membrane to clear toxins by osmosis and diffusion."

4

A nurse reviews the history of a client who is hospitalized with a diagnosis of urinary calculi and identifies that which factor may have contributed to the development of the calculi? 1 Increased fluid intake 2 Urine specific gravity of 1.017 3 Jogging 3 miles (4.8 km) a day 4 History of hyperparathyroidism

4

When a disaster occurs, the nurse may have to first treat mass hysteria that is indicated by what response? 1 Panic 2 Coma 3 Euphoria 4 Depression

1

A client is diagnosed with a brain attack (cerebrovascular accident, CVA). The baseline vital signs are a pulse rate of 78 bpm and a blood pressure (BP) of 120/80 mm Hg. The nurse continues to monitor the vital signs and recognizes that which changes in vital signs indicate increased intracranial pressure (ICP)? 1 Pulse 50 bpm and BP 140/60 mm Hg 2 Pulse 56 bpm and BP 130/110 mm Hg 3 Pulse 60 bpm and BP 126/96 mm Hg 4 Pulse 120 bpm and BP 80/60 mm Hg

1

A client with the diagnosis of chronic kidney disease develops hypocalcemia. Which clinical manifestations should the nurse expect the client with hypocalcemia to exhibit? Select all that apply. 1 Acidosis 2 Lethargy 3 Fractures 4 Osteomalacia 5 Eye calcium deposits

3, 4, 5

A client is scheduled for a lumbar puncture. What nursing care should be implemented after the procedure? 1 Maintaining the client in the supine position for several hours 2 Encouraging the client to ambulate every hour for at least 6 hours 3 Keeping the client in the Trendelenburg position for at least 2 hours 4 Placing the client in the high-Fowler position immediately after the procedure

1

A client newly diagnosed with myasthenia gravis is concerned about fluctuations in physical condition and generalized weakness. When caring for this client it is most important for the nurse to plan which intervention? 1 Space activities throughout the day. 2 Restrict activities and encourage bed rest. 3 Teach the client about limitations imposed by the disorder. 4 Have a family member stay at the bedside to give the client support.

1

A client with hemiparesis is reluctant to use a cane. How does the nurse explain the cane's purpose to the client? 1 Maintain balance to improve stability 2 Relieve pressure on weight-bearing joints 3 Prevent further injury to weakened muscles 4 Aid in controlling involuntary muscle movements

1

A nurse finds a victim under the wreckage of a collapsed building. The individual is conscious, supine, breathing satisfactorily, and reports back pain and an inability to move the legs. Which action should the nurse take first? 1 Leave the individual lying on the back with instructions not to move, and seek additional help. 2 Roll the individual onto the abdomen, place a pad under the head, and cover with any material available. 3 Gently raise the individual to a sitting position to determine whether the pain either diminishes or increases in intensity. 4 Gently lift the individual onto a flat piece of lumber and, using any available transportation, rush to the closest medical institution.

1

A nurse is caring for a client with Guillain-Barré syndrome. The nurse should prepare the client for what essential care related to rehabilitation? 1 Physical therapy 2 Speech exercises 3 Fitting with a vertebral brace 4 Follow-up on cataract progression

1

A nurse is evaluating the practice of a home health aide who is caring for a client who has paraplegia. Which behavior indicates understanding about the nursing team's responsibility in relation to pressure ulcers? 1 Inspecting the skin daily 2 Providing a rubber cushion on which to sit 3 Massaging body lotion over reddened areas 4 Applying a heating pad to bony prominences

1

A young man who sustained a spinal cord injury at the cervical level expresses concern about sexual functioning. What should the nurse do when counseling this client? 1 Consider that the client most likely will be able to have reflex penile erections. 2 Arrange for the client to see the healthcare provider because sexual performance is unlikely. 3 Discourage the client from forming sexual relationships because little pleasure will be possible. 4 Reassure the client that he will be able to have sexual relationships with the ability to reproduce.

1

An older client with dementia of the Alzheimer type is residing in a nursing home. When in bed, the client consistently is found sleeping in the semi-Fowler position. What area of the client's body does the nurse determine has the most risk for developing a pressure ulcer? 1 Sacrum 2 Scapulae 3 Ischial spine 4 Greater trochanter

1

The nurse is performing a physical examination of a client by placing the left hand on the back and supporting the client's right side between the rib cage and the iliac crest. Which physical assessment maneuver is the nurse performing on this client? 1 Palpation 2 Inspection 3 Percussion 4 Auscultation

1

The nurse provides discharge instructions to a male client who had an ureterolithotomy. The client has a history of recurrent urinary tract infections (UTIs). For which indicators of a UTI should the nurse instruct the client? 1 Urgency or frequency of urination 2 An increase of ketones in the urine 3 The inability to maintain an erection 4 Pain radiating to the external genitalia

1

The urinalysis report of a client reveals cloudy urine. What does a nurse infer from the client's report? 1 The client has a urinary infection. 2 The client has a biliary obstruction. 3 The client has diabetic ketoacidosis. 4 The client has been on a starvation diet.

1

What instruction regarding sample collection should the nurse give a client who is ordered a clean-catch urine specimen? 1 Urinate small amount, stop flow, fill half of cup 2 Collect the last urine sample voided in the night 3 Keep the urine sample in dry warm area if delay is anticipated 4 Send the urine sample to the laboratory within 6 hours of collection

1

What is the cup-like structure that collects a client's urine and is located at the end of each papilla? 1 Calyx 2 Capsule 3 Renal cortex 4 Renal columns

1

What should the nurse infer from the given figure? 3204036169 1 Used for self-administration of eye drops. 2 Used for determination of long sightedness. 3 Used for slit-lamp ocular examination. 4 Used for measurement of intraocular pressure.

1

When completing a neurologic assessment, the nurse determines that a client has a positive Romberg test. Which finding supports the nurse's conclusion? 1 Inability to stand with feet together when eyes are closed 2 Fanning of toes when the sole of the foot is firmly stroked 3 Dilation of pupils when focusing on an object in the distance 4 Movement of eyes toward the opposite side when head is turned

1

Which anatomical area in the brain regulates a client's verbal expression? 1 Broca's area 2 Wernicke's area 3 Association area 4 Supplemental area

1

Which cranial nerve damage may lead to a decrease in the client's olfactory acuity? 1 Cranial nerve I 2 Cranial nerve X 3 Cranial nerve V 4 Cranial nerve VIII

1

Which electrolyte deficiency triggers the secretion of renin? 1 Sodium 2 Calcium 3 Chloride 4 Potassium

1

Which phase of the woman's sexual response is characterized by elevation of the uterus? 1 Plateau phase 2 Orgasmic phase 3 Excitation phase 4 Resolution phase

1

Which structure indicated in the figure is the primary reproductive organ of the female? 3204932525 1 A 2 B 3 C 4 D

1

Which type of cranial surgery involves opening the cranium with a drill? 1 Burr hole 2 Craniotomy 3 Craniectomy 4 Cranioplasty

1

A client with end-stage renal disease is hospitalized. For which complications should the nurse monitor the client? Select all that apply. 1 Anemia 2 Dyspnea 3 Jaundice 4 Hyperexcitability 5 Hypophosphatemia

1, 2

Which hormone elevations indicate Turner syndrome? Select all that apply. 1 Lutropin 2 Prolactin 3 Follitropin 4 Testosterone 5 Progesterone

1, 3

A nurse expects a client with a herniated intervertebral disk to report a sudden increase in pain with which activities? Select all that apply. 1 Coughing or sneezing 2 Sitting on cold surfaces 3 Standing for extended periods 4 Lying supine while flexing the knees 5 Straining when having a bowel movement

1, 5

A client has a permanent colostomy. During the first 24 hours there is no drainage from the colostomy. How should the nurse interpret this finding? 1 Edema after the surgery is causing this. 2 Absence of intestinal peristalsis is causing this. 3 Decrease in fluid intake before surgery is causing this. 4 Effective functioning of the nasogastric tube is causing this.

2

A nurse identifies that a client exhibits the characteristic gait associated with Parkinson disease. When recording on the client's record, what term does the nurse use to document this gait? 1 Ataxic 2 Shuffling 3 Scissoring 4 Asymmetric

2

A nurse is caring for a client with chronic kidney failure. What should the nurse teach the client to limit the intake of to help control uremia associated with end-stage renal disease (ESRD)? 1 Fluid 2 Protein 3 Sodium 4 Potassium

2

A nurse is performing range-of-motion exercises with a client who had a cerebrovascular accident (CVA). The nurse places the client's hand in the position exhibited in the picture. What is the term for this position?3030987232 1 Flexion 2 Extension 3 Adduction 4 Circumduction

2

A nurse is teaching the client about cerumen when irrigating the ear. Which area will the nurse indicate to the client in the given image that is an example of cerumen? 3204029378 1 1 2 2 3 3 4 4

2

A nurse uses a dull object to stroke the lateral side of the underside of a client's left foot and moves upward to the great toe. What reflex is the nurse testing? 1 Moro 2 Babinski 3 Stepping 4 Cremasteric

2

Which ophthalmic conditions can cause a client to have photophobia? Select all that apply. 1 Nystagmus 2 Chalazion 3 Trachoma 4 Hordeolum 5 Keratoconjunctivitis sicca

2, 3, 5

A client is newly diagnosed with multiple sclerosis. The client is obviously upset with the diagnosis and asks, "Am I going to die?" Which is the nurse's best response? 1 "Most individuals with your disease live a normal life span." 2 "Is your family here? I would like to explain your disease to all of you." 3 "The prognosis is variable; most individuals experience remissions and exacerbations." 4 "Why don't you speak with your healthcare provider? You probably can get more details about your disease."

3

A client is suspected of having myasthenia gravis. What are the most significant initial nursing assessments that should be performed? 1 Ability to chew and speak distinctly 2 Capacity to smile and close the eyelids 3 Effectiveness of respiratory exchange and ability to swallow 4 Degree of anxiety and concern about the suspected diagnosis

3

A nurse is caring for a client who is scheduled to have a paracentesis. Immediately before the procedure, the nurse asks the client to void. What is the rationale for asking the client to void? 1 A full bladder decreases the intraabdominal pressure. 2 A full bladder decreases the amount of fluid in the abdominal cavity. 3 A full bladder increases the danger of puncture during the procedure. 4 A full bladder increases the presence of urea in the intraabdominal fluid.

3

A nurse is caring for a client with a diagnosis of benign prostatic hyperplasia (BPH). Which information about this condition is important for the nurse to consider when caring for this client? 1 It is a congenital abnormality. 2 A malignancy usually results. 3 It predisposes to hydronephrosis. 4 Prostate-specific antigen decreases.

3

A primary healthcare provider prescribed an indwelling urinary catheter for a client. Which catheter should the nurse use to implement this prescription? 3142355346 1 A 2 B 3 C 4 D

3

A registered nurse teaches a nursing student about cluster headaches. Which statement made by the nursing student indicates a need for further teaching? 1 "Each episode of a cluster headache may last up to 3 hours." 2 "Pupillary constriction occurs during the period of cluster headaches." 3 "Pulsating pain is the characteristic type of pain that occurs in cluster headaches." 4 "Cluster headaches occur for weeks to months followed by a period of remission."

3

After a transurethral prostatectomy, a client returns to the postanesthesia care unit with a three-way indwelling catheter with continuous bladder irrigation. Which nursing action is the priority? 1 Observing the suprapubic dressing for drainage 2 Maintaining the client in the semi-Fowler position 3 Monitoring for bright red blood in the drainage bag 4 Encouraging fluids by mouth as soon as the gag reflex returns

3

Postoperatively, a client complains about a variety of minor environmental factors, frequently changes positions, and avoids eye contact. The nurse responds to these observations by stating, "Let me get you some cold water and your pain pill, and you'll be much better." What does the nurse's response demonstrate? 1 An empathic recognition of anxiety 2 Addressing of the client's needs 3 An inappropriate interpretation of the assessment findings 4 Advanced problem solving and critical thinking skills

3

The magnetic resonance image (MRI) of a client who sustained brain trauma reveals injury to the occipital lobe. Which disability might be anticipated in the client? 1 Loss of perception 2 Loss of learning ability 3 Loss of visual capability 4 Loss of auditory sensation

3

The nurse is providing care to a client who has had a transurethral resection of the prostate (TURP). Which goal is the priority? 1 Maintain patency of the cystostomy tube. 2 Prevent wound hemorrhage and infection. 3 Maintain patency of the indwelling catheter. 4 Prevent the abdominal dressing from draining.

3

Upon assessment, the nurse finds the following (see image). The nurse will prepare the client for which type of surgery? 3204034183 1 Keratoplasty 2 Trabeculoplasty 3 Cataract removal 4 Laser in situ keratomileusis (LASIK)

3

What is the middle layer of the eyeball? 1 Sclera 2 Retina 3 Uveal tract 4 Transparent cornea

3

Which condition is characterized with an involuntary and rapid twitching of the client's eyeball? 1 Ptosis 2 Anisocoria 3 Nystagmus 4 Enophthalmos

3

Which hormone is released in response to low serum levels of calcium? 1 Renin 2 Erythropoietin 3 Parathyroid hormone 4 Atrial natriuretic peptide

3

A client fears pregnancy despite the use of oral contraceptives. Which blood test would the primary healthcare provider order for the client? 1 Prolactin test 2 Testosterone test 3 Progesterone test 4 Human chorionic gonadotropin (hCG) test

4

A client in a nursing home is diagnosed with urethritis. What should the nurse plan to do before initiating antibiotic therapy prescribed by the primary healthcare provider? 1 Start a 24-hour urine collection. 2 Prepare for urinary catheterization. 3 Teach the client how to perform perineal care. 4 Obtain a urine specimen for culture and sensitivity.

4

A client scheduled for a hemicolectomy because of ulcerative colitis asks if having a hemicolectomy means wearing a pouch and having bowel movements in an abnormal way. Which is the best response by the nurse? 1 "Yes, hemicolectomy is the same as a colostomy." 2 "Yes, but it will be temporary until the colitis is cured." 3 "No, that is necessary when a tumor is blocking the rectum." 4 "No, only part of the colon is removed and the rest reattached."

4

A client sustains a crushing injury of the spinal cord above the level of origin of the phrenic nerve. As a result of this injury, the nurse expects what client response? 1 Ventricular fibrillation 2 Dysfunction of the vagus nerve 3 Retention of sensation but paralysis of the lower extremities 4 Respiratory paralysis and cessation of diaphragmatic contractions

4

A client who has been told she needs a hysterectomy for cervical cancer is upset about being unable to have a third child. Which action should the nurse take next? 1 Evaluate her willingness to pursue adoption. 2 Encourage her to focus on her own recovery. 3 Emphasize that she does have two children already. 4 Ensure that other treatment options for her will be explored.

4

A nurse is caring for a client who is admitted to the hospital with a severe head injury. Which action is priority? 1 Place the client in a supine position. 2 Prevent contractures and deformities. 3 Monitor the blood pressure frequently. 4 Maintain respiratory exchange and ventilation.

4

A nurse is caring for a client who is scheduled for surgery for a detached retina. Which goal of surgery identified by the client indicates that the preoperative teaching is effective? 1 Promote growth of new retinal cells. 2 Adhere the sclera to the choroid layer. 3 Graft a healthy piece of retina in place. 4 Create a scar that aids in healing retinal holes.

4

A nurse is caring for a client who sustained a transection of the spinal cord with no other injuries. The nurse continually monitors this client for which medical emergency? 1 Hemorrhage 2 Hypovolemic shock 3 Gastrointestinal atony 4 Autonomic hyperreflexia

4

A nurse is preparing for an unconscious client with a head injury to be transferred from the emergency department to a neurologic trauma unit. Which nursing action is the priority? 1 Notifying the receiving unit of the transfer 2 Having the client's records ready for the transfer 3 Verifying that the family has been notified of the transfer 4 Checking that a bag-valve mask is available during the transfer

4

A nurse is teaching a client with a diagnosis of open-angle glaucoma. The nurse explains that the chief aim of treatment is to meet which goal? 1 Rest the eye. 2 Dilate the pupil. 3 Prevent secondary infections. 4 Control the intraocular pressure.

4

A nurse prepares a client with kidney dysfunction for a cystoscopy. Which nursing intervention would be beneficial? 1 Asking the client to have an adequate evening meal 2 Instructing the client to take oral fluids to increase urine output 3 Performing a bowel preparation with enema the morning before the procedure 4 Asking the client to be NPO (nil per os) after midnight on the night before the procedure

4

A nurse providing care in a hospital witnesses a client's spouse shaking the client vigorously because the client has had an episode of incontinence. Because of the suspicion of physical abuse, legally the nurse should discuss the concerns with which party? 1 The client 2 The client's spouse 3 The client's primary healthcare provider 4 Adult Protective Services

4

After prostate surgery a client's indwelling catheter and continuous bladder irrigation (CBI) are to be removed. The nurse discusses with the client the procedure and what to expect after the removal. Which statement by the client indicates teaching by the nurse is understood? 1 "I probably will have dilute urine." 2 "I probably will be unable to urinate." 3 "I probably will produce dark red urine." 4 "I probably will experience some burning on urination."

4

The nurse is educating a couple concerning the process of fertilization. The nurse explains to the couple that which component stimulates the release of estrogen and progesterone after fertilization? 1 Inhibin 2 Testosterone 3 Follicle-stimulating hormone (FSH) 4 Human chorionic gonadotropin (hCG)

4

The nurse is teaching a client receiving peritoneal dialysis about the reason dialysis solution is warmed before it is instilled into the peritoneal cavity. Which information will the nurse share with the client? 1 Because it forces potassium back into the cells, thereby decreasing serum levels 2 Because it adds extra warmth to the body because metabolic processes are disturbed 3 Because it helps prevent cardiac dysrhythmias by speeding up removal of excess potassium 4 Because it encourages removal of serum urea by preventing constriction of peritoneal blood vessels

4

The nurse providing postoperative care for a client who had kidney surgery reviews the client's urinalysis results. Which urinary finding should the nurse conclude needs to be reported to the primary healthcare provider? 1 Acidic pH 2 Glucose negative 3 Bacteria negative 4 Presence of large proteins

4

The spouse of a client who had a brain attack (cerebrovascular accident) tells the home health nurse that the client cries easily and without provocation. The spouse asks why the client is so emotionally fragile. What is the nurse's best response? 1 This is a way of getting attention that should be ignored. 2 The client can remember only depressing events from the past. 3 The client feels guilty about the demands being placed on the family. 4 This behavior is a common response over which the client has very little control.

4

What does the presence of ketones in the urine of a client with renal dysfunction indicate? 1 Cystitis 2 Heart failure 3 Urinary calculi 4 Anorexia nervosa

4

What should the nurse instruct the client to do to limit triggering the pain associated with trigeminal neuralgia? 1 Drink iced liquids. 2 Avoid oral hygiene. 3 Apply warm compresses. 4 Chew on the unaffected side.

4

Which cerebral lobe includes the speech area that allows the client to process words into coherent thoughts? 1 Limbic lobe 2 Frontal lobe 3 Occipital lobe 4 Temporal lobe

4

Which health problem does the nurse identify from an older client's history that increases the client's risk factors for a cerebrovascular accident (CVA, also known as "brain attack")? 1 Glaucoma 2 Hypothyroidism 3 Continuous nervousness 4 Transient ischemic attacks (TIAs)

4

Which part of the brain contains the client's "central switchboard" of the central nervous system? 1 Cerebrum 2 Brain stem 3 Cerebellum 4 Diencephalon

4

A client with an indwelling catheter is prescribed a urinalysis test. Arrange the steps involved in the collection of the urine sample in correct order. 1. Aspirate the urine 2. Remove the clamp 3. Attach a sterile syringe 4. Clamp drainage tubing

clamp, attach, aspirate, remove