n6420 midterm

T/F? The most accurate way to evaluate whether learning has taken place is to observe for a change in the patient's behavior.

True

A postoperative client begins coughing forcefully while eating jell-o. The nurse notices an evisceration of the intestines. What should the nurse do first? a. place the client in the low Fowler's position b. notify the surgeon c. cover the intestines with a sterile, moist dressing d. document the event

a. place the client in the low Fowler's position decreases further protrusion

The nurse applies a moisture- retentive dressing to a patient's wound. They understand that the main advantage of this dressing, rather than a wet-to-dry dressing, is its ability to: a. provide autolytic debridement b. decrease epidermal resurfacing c. promote formation of a protective scab that traps excess exudate d. enhance the absorption of topical medications

a. provide autolytic debridement

Which term refers to the inability to recognize objects through a particular sensory system? a) Ataxia b) Agnosia c) Aphasia d) Dysphasia

b) Agnosia

Which of the following is NOT a common complication/illness associated with HIV/AIDS? a) Kaposi sarcoma b) Squamous cell carcinoma c) B Cell lymphoma d) Cytomegalovirus

b) Squamous cell carcinoma

A patient comes to the clinic complaining of a red rash of small, fluid-filled blisters. The patient is suspected of having herpes zoster. What should the nurse know about the distribution of lesions of herpes zoster? a. Grouped vesicles occurring on lips and oral mucous membranes b. Grouped vesicles occurring on the genitalia c. Rough, fresh, or gray skin protrusions d. Grouped vesicles in linear patches along a dermatome

D

Older adults are at increased risk for disease and injury due to physiologic changes with age. These changes include: A) Increased physiologic reserves are available with age B) Fewer physiologic reserves are in use with age C) The body is able to adapt quickly to changes to maintain homeostasis D) Homeostenosis develops in which the older adult has fewer reserves available.

D) Homeostenosis develops in which the older adult has fewer reserves available.

A client recently diagnosed with late onset Alzheimer's Disease in the first stage has developed severe depression. What would be most important for the nurse to assess for? A) loss of bowel and bladder control B) emotional apathy C) increased appetite D) suicidal ideations

D) suicidal ideations

The nurse is planning to teach a patient about administering her new asthma medication. How can the nurse enhance the patient's ability to learn? A. Provide a list of websites that contain information related to the medication B. Exclude family members from the session to minimize distractions C. Use color-coded materials D. Make the information relevant to the patient's condition and needs

D. Make the information relevant to the patient's condition and needs

T/F: Delirium is a chronic, progressive condition.

False: Dementia is a chronic, progressive condition

A client who has suffered a compound fracture is preparing for discharge to home. During the teaching session, the client asks why he needs antibiotics fora broken bone. Which response by the nurse is most appropriate? A) "Antibiotic therapy has been prescribed as a precaution because your bone was exposed to the environment at the time of your injury." B) "You may discuss your prescriptions with your physician at your follow‐up appointment." C) "If your temperature is normal for 48 hours, you may discontinue the medication." D) "The antibiotics will help the bone to heal."

A) "Antibiotic therapy has been prescribed as a precaution because your bone was exposed to the environment at the time of your injury."

Which of the following is not a normal age-related change? A) Increased peristalsis B) Decreased cough reflex C) Decreased function of bone marrow D) Increased stiffening of blood vessels

A) Increased peristalsis

Which of the following is the least helpful intervention to help prevent patient falls? A) Keep the TV on when ambulating with assistance at night B) Ensure upper side rails are in upright position C) Have patient wear non-skid socks/shoes when out of bed D) Have patient dangle legs before standing

A) Keep the TV on when ambulating with assistance at night distracting

Older adults often do not adhere to a therapeutic regimen. What strategy is most likely to promote adherence to an older patient's therapeutic regimen after surgery? A. Demonstrate a dressing change and allow the patient to practice B. Provide a pamphlet on a dressing change C. Verbally instruct the patient how to change a dressing D. Have a family member change the dressing

A. Demonstrate a dressing change and allow the patient to practice

A client with a brain tumor may be at increased for aspiration. What does the nurse determine is the most important nursing intervention? A) monitoring vital signs B) Assisting with self-care C) Evaluation of gag reflex and ability to swallow D) frequent reorientation

C) Evaluation of gag reflex and ability to swallow think ABC: Airway, Breathing, Circulation

In a client with hypervolemia, what intervention is most important for the nurse to implement? A) Administration of anticholinergic medications B) Assess for dehydration C) Limit sodium and water intake D) Promote urinary retention/decreased urination

C) Limit sodium and water intake

Which geriatric assessment tool is most helpful for assessing an older adults nutritional status? A) MMSE B) Katz Index C) SCALES D) SPICES

C) SCALES

HIV is associated with which of the following? Select all that apply A) Increased CD4 count B) Decreased viral load C) Increased viral load D) Decreased CD4 count

C, D

Nursing interventions can be very effective in preventing and treating pressure ulcers. Which of the following actions are recommended? Select all that apply. a. Reposition the patient every 3 hours when in bed b. Assist the patient into the semi-fowler's position when in bed c. Relieve any pressure if redness is noted on the skin d. Massage erythematous areas to improve circulation e. Encourage a high-protein diet f. Prevent the continuous presence of moisture on the skin

C, E, F

Which of the following is the best example of health promotion teaching? A. Demonstrating an injection technique to a patient for anticoagulant therapy B. Explaining the side effects of a medication to an adult patient C. Discussing the importance of preventing sexually transmitted infections to a group of high school students D. Instructing an adolescent patient about her allergies

C. Discussing the importance of preventing sexually transmitted infections to a group of high school students

Which of the following interventions is LEAST appropriate for the patient with pneumonia? A. Promoting fluid B. Providing Venous Thromboembolism (VTE) prophylaxis C. Encouraging strict bedrest D. Administering oxygen as ordered

C. Encouraging strict bedrest

When interpreting the results of a Mantoux test, the nurse explains to the client that a reaction occurs when the intradermal injection site shows Redness and induration Drainage Tissue Sloughing Bruising

Redness and induration

A client presents in the emergency department with complaints of cough, headache, and generalized aches and pains. Upon assessment, the nurse documents a temperature of 102.5 °F (39.2°C) and redness on the arms, legs, and upper chest. She also notes that the client takes eight different medications each day. What nursing diagnosis is the priority for this client? a. Impaired physical mobility b. Impaired tissue integrity c. Impaired thermoregulation d. Ineffective therapeutic regimen

B - if you don't have tissue integrity, can't thermoregulate

Which of the following is NOT an appropriate intervention for a patient with suspected C.Diff infection? (SELECT ALL THAT APPLY) A) Encourage PRN use of Lomotil agents B) Encourage increased fluid intake as tolerated C) Educate visitors on handwashing with soap and water D) Wearing appropriate PPE of face mask and shield

B, C

A patient has intermittent asthma attacks. Which of the following therapies does the nurse teach the client to use at home when experiencing an asthma attack? A. Oxygen Therapy B. Inhaled SABA C. Oral LABA D. Inhaled LABA

B. Inhaled SABA

The defining difference between Type I and Type II diabetes is: a) Type I diabetes can sometimes be managed with diet & exercise while Type II requires insulin therapy b) Type I diabetes involves complete destruction of beta cells while with Type II there is still some insulin production c) Type I diabetes is diagnosed in children while Type II diabetes is diagnosed later in life d) Type II diabetics do not experience hypoglycemic episodes while Type I diabetics do

b) Type I diabetes involves complete destruction of beta cells while with Type II there is still some insulin production

The nurse recognizes which of the following as a true statement regarding oxygenation in the patient with COPD? a. The target O2 saturation for most patients with COPD is >95% b. Low O2 level is the stimulus to breath in a patient with COPD c. Bradypnea is typical of the patient with COPD d. The higher the patient's FEV, the sicker he/she is

b. Low O2 level is the stimulus to breath in a patient with COPD

The nurse is assessing a 20 year-old patient experiencing the onset of symptoms of Type I diabetes. To which question would the nurse anticipate a positive response? a) "Are you experiencing loss of appetite?" b) "Is your urine dark in color?" c) "Have you lost weight lately?" d) "Do you crave sugar?"

c) "Have you lost weight lately?"

Which of the following is true about Hyperglycemic Hyperosmolar Nonketotic State (HHNS)? a) Is characterized by fruity breath b) Is characterized by moderate hyperglycemia with blood glucose levels >300 c) Is more common in type II diabetes d) Is more common in young adults and children

c) Is more common in type II diabetes

Which statement indicates a misunderstanding of coronavirus testing? a) "A positive test means I currently have the virus" b) "A negative antibody test means I have not developed antibodies" c) "If I have positive antibodies, I am permanently immune" d) "I can test negative for the viral test but still have COVID‐19"

c)"If I have positive antibodies, I am permanently immune"

Which statement indicates a characteristic of a basal cell carcinoma (BCC)? a. It is more invasive that squamous cell carcinoma (SCC) b. It metastasizes through blood or the lymphatic system c. It begins as a small, waxy nodule with rolled, translucent pearly borders d. It is a malignant proliferation arising from the epidermis

c. It begins as a small, waxy nodule with rolled, translucent pearly borders

The nurse is assessing the periwound skin of an African American client for inflammation. The nurse determines that inflammation is present when which characteristic is noted? a. red coloration b. blue-green hue c. purple-gray cast d. white patches

c. purple-gray cast

Which activity places a patient at risk for hyperthermia? a. Snowmobiling in Canada b. Scuba diving in the Caribbean c. Hiking Alaskan mountains d. Running a marathon in high humidity

d. Running a marathon in high humidity