NUR 332: EXAM 4
A patient has just been told he has a terminal illness. Which of the following statements supports a nursing diagnosis of spiritual distress related to diagnosis of terminal illness? A: "I have nothing to live for now." B: "What will happen to my wife when I die?" C: "How much longer do I have to live?" D: "I need to go to church and pray for a miracle."
A: "I have nothing to live for now."
A patient who is hospitalized with heart failure states that she sees her illness as an opportunity and a challenge. Despite her illness, she is still able to see that life is worth living. This is an example of: A: Hope. B: Faith. C: Values. D: Connectedness
A: Hope.
An older adult is receiving hospice care. Which nursing intervention(s) help the patient cope with feelings related to death and dying? (Select all that apply.) A: Teaching the patient how to use guided imagery B: Encouraging the family to visit the patient frequently C: Taking the patient's vital signs every time the nurse visits D: Teaching the patient how to manage pain and take pain medications E: Helping the patient put significant photographs in a scrapbook for the family
A: Teaching the patient how to use guided imagery B: Encouraging the family to visit the patient frequently E: Helping the patient put significant photographs in a scrapbook for the family
1. Which description best matches the role of a parish nurse? A. A spiritual leader, such as a minister, who is also a registered nurse. B. A nurse who works to reintegrate the healing tradition into the life of a faith community. C. A nurse who provides home health services similar to a visiting nurse. D. A trained layperson who provides for the spiritual needs of a congregation or parish.
B. A nurse who works to reintegrate the healing tradition into the life of a faith community.
Which of the following statements made by an older adult whose husband recently died most indicates the need for follow-up by the nurse? A: "I planted a tree at church in my husband's honor." B: "I have been unable to talk with my children lately." C: "My friends suggest that I go to a grief support group." D: "I believe that someday I'll meet my husband in heaven."
B: "I have been unable to talk with my children lately."
An emergency department nurse is caring for a patient who was severely injured in a car accident. The patient's family is in the waiting room, crying softly. The nurse sits down next to the family, takes the mother's hand, and says, "I can only imagine how you're feeling. What can I do to help you feel more at peace right now? " In this example the nurse is demonstrating: A: Prayer B: Presence C: Coaching D: Instilling hope
B: Presence
1. Which of the following would be the most appropriate outcome for a patient who has a nursing diagnosis of spiritual distress related to loneliness? A: Encourage the patient to meditate 2 to 3 times a week. B: The patient will set up a time to speak to a close friend in 1 week. C: Encourage the patient to phone his brother and set up a time to go out for dinner. D: The patient will experience greater connections with family members in 2 months.
B: The patient will set up a time to speak to a close friend in 1 week.
The parents of an infant who just died from sudden infant death syndrome (SIDS) are angry at God and refuse to see any members of the clergy. Which nursing diagnosis is most appropriate? A. Chronic sorrow B. Complicated grieving C. Spiritual distress D. Ineffective coping
C. Spiritual distress
A client admitted for treatment of a colon tumor, asks, "Do I have cancer?" Which response by the nurse would be best? A. "Your physician can discuss this in more detail." B. "You'll have to have some tests before the physician can rule out cancer." C. "Most people your age develop some type of colon problem." D. "You sound concerned about what's happening."
D. "You sound concerned about what's happening."
A client with chronic renal failure was recently told by the healthcare provider of being a poor candidate for a transplant because of chronic uncontrolled hypertension and diabetes mellitus. Now the client tells the nurse, "I want to go off dialysis. I'd rather not live than be on this treatment for the rest of my life." Which responses are appropriate? Select all that apply. A. Say, "We all have days when we don't feel like going on." B. Say, "The treatments are only 3 days a week. You can live with that." C. Leave the room to allow the client privacy to collect thoughts. D. Say, "You're feeling upset about the news you got about the transplant." E. Take a seat next to the client and sit quietly to reflect on what was said.
D. Say, "You're feeling upset about the news you got about the transplant." E. Take a seat next to the client and sit quietly to reflect on what was said.
The nurse is caring for a patient who has just had a near-death experience (NDE) following a cardiac arrest. Which intervention by the nurse best promotes the spiritual well-being of the patient after the NDE? a. Allowing the patient to discuss the experience b. Referring the patient to pastoral care c. Having the patient talk to another patient who had an NDE d. Offering to pray for the patient
a. Allowing the patient to discuss the experience
What features of cancer cells distinguish them from normal cells (select all that apply)? a. Cells lack contact inhibition. b. Cells undergo rapid proliferation. c. Cells return to a previous undifferentiated state. d. Proliferation occurs when there is a need for more cells. e. New proteins characteristic of embryonic stage emerge on cell membrane.
a. Cells lack contact inhibition. c. Cells return to a previous undifferentiated state. e. New proteins characteristic of embryonic stage emerge on cell membrane.
It is important for the nurse to assess for which manifestation(s) in a patient who has just undergone a total thyroidectomy (select all that apply)? a. Confusion b. Weight gain c. Depressed reflexes d. Circumoral numbness e. Positive Chvostek's sign
a. Confusion d. Circumoral numbness e. Positive Chvostek's sign
A 70-year-old male patient has multiple myeloma. His wife calls to report that he sleeps most of the day, is confused when awake, and reports nausea and constipation. Which complication of cancer is this most likely caused by? a. Hypercalcemia b. Tumor lysis syndrome c. Spinal cord compression d. Superior vena cava syndrome
a. Hypercalcemia
A 59-yr-old man scheduled for a herniorrhaphy in 2 days reports that he takes ginkgo daily. What is the priority intervention? a. Inform the surgeon, since the procedure may have to be rescheduled. b. Notify the anesthesia care provider, since this herb interferes with anesthetics. c. Ask the patient if he has noticed any side effects from taking this herbal supplement. d. Tell the patient to continue to take the herbal supplement up to the day before surgery.
a. Inform the surgeon, since the procedure may have to be rescheduled.
A patient has recently been diagnosed with early stages of breast cancer. What is most appropriate for the nurse to focus on? a. Maintaining the patient's hope b. Preparing a will and advance directives c. Discussing replacement child care for the patient's children d. Discussing the patient's past experiences with her grandmother's cancer
a. Maintaining the patient's hope
After admitting a postoperative patient to the clinical unit, which assessment data require the most immediate attention? a. O2 saturation of 85% b. Respiratory rate of 13/min c. Temperature of 100.4°F (38°C) d. Blood pressure of 90/60 mm Hg
a. O2 saturation of 85%
Which factors would place a patient at a higher risk for prostate cancer (select all that apply)? a. Older than 65 years b. Asian or Native American c. Long-term use of an indwelling urethral catheter d. Father diagnosed and treated for early-stage prostate cancer e. Previous history of undescended testicle and testicular cancer
a. Older than 65 years d. Father diagnosed and treated for early-stage prostate cancer
The nurse is caring for a 50-year-old woman visiting the outpatient medicine clinic. The patient has had type 1 diabetes since age 13. She has numerous complications from her disease, including reduced vision, heart disease, and severe numbness and tingling of the extremities. Knowing that spirituality helps patients cope with chronic illness, which of the following principles should the nurse apply in practice? (Select all that apply.) a. Pay attention to the patient's spiritual identity throughout the course of her illness. b. Select interventions that you know scientifically support spiritual well-being. c. Listen to the patient's story each visit to the clinic, and offer a compassionate presence. d. When the patient questions the reason for her long-time suffering, try to provide answers. e. Consult with a spiritual care adviser, and have the adviser recommend useful interventions.
a. Pay attention to the patient's spiritual identity throughout the course of her illness. c. Listen to the patient's story each visit to the clinic, and offer a compassionate presence.
Teach the patient with fibromyalgia the importance of limiting intake of which foods? (select all that apply) a. Sugar b. Alcohol c. Caffeine d. Red meat e. Root vegetables
a. Sugar b. Alcohol c. Caffeine
The nurse is caring for a patient undergoing surgery for a knee replacement. What is critical to the patient's safety during the procedure (select all that apply)? a. Universal protocol is followed. b. The ACP is an anesthesiologist. c. The patient has adequate health insurance. d. The patient's family is in the surgery waiting area. e. The patient's allergies are conveyed to the surgical team.
a. Universal protocol is followed. e. The patient's allergies are conveyed to the surgical team.
A 17-yr-old patient with a leg fracture who is scheduled for surgery is an emancipated minor. She has a statement from the court for verification. Which intervention is most appropriate? a. Witness the permit after the surgeon obtains consent. b. Call a parent or legal guardian to sign the permit since the patient is under 18. c. Notify the hospital attorney that an emancipated minor is consenting for surgery. d. Obtain verbal consent since written consent is not necessary for emancipated minors.
a. Witness the permit after the surgeon obtains consent.
You are a community health nurse planning a program on breast cancer screening guidelines for women in the neighborhood. Which recommendations you would include? (select all that apply) a. Women over age 55 may have biennial screening. b. Screening should end when the women reaches age 65. c. Women aged 45 to 54 years should be screened annually. d. Regular screening mammography should start at age 45 years. e. Clinical breast examinations can be used if the woman has average risk.
a. Women over age 55 may have biennial screening. c. Women aged 45 to 54 years should be screened annually. d. Regular screening mammography should start at age 45 years.
When discussing risk factors for breast cancer with a group of women, you emphasize that the greatest known risk factor for breast cancer is a. being a woman over age 60. b. experiencing menstruation for 30 years or more. c. using hormone therapy for 5 years for menopausal symptoms. d. having a paternal grandmother with postmenopausal breast cancer.
a. being a woman over age 60.
The nurse's primary responsibility for the care of the patient undergoing surgery is a. developing an individualized plan of nursing care for the patient. b. carrying out specific tasks related to surgical policies and procedures. c. ensuring that the patient has been assessed for safe administration of anesthesia. d. performing a preoperative history and physical assessment to identify patient needs.
a. developing an individualized plan of nursing care for the patient.
The nursing care for a patient with hyponatremia and fluid volume excess includes a. fluid restriction. b. administration of hypotonic IV fluids. c. administration of a cation-exchange resin. d. placement of an indwelling urinary catheter.
a. fluid restriction.
After a hypophysectomy for acromegaly, immediate postoperative nursing care should focus on a. frequent monitoring of serum and urine osmolarity. b. parenteral administration of a GH-receptor antagonist. c. keeping the patient in a recumbent position at all times. d. patient teaching about the need for lifelong hormone therapy.
a. frequent monitoring of serum and urine osmolarity.
To prevent capsular formation after breast reconstruction with implants, teach the patient to a. gently massage the area around the implant. b. bind the breasts tightly with elastic bandages. c. avoid strenuous exercise until the implant has healed. d. exercise the arm on the affected side to promote drainage.
a. gently massage the area around the implant.
To control the side effects of corticosteroid therapy, the nurse teaches the patient who is taking corticosteroids to a. increase calcium intake to 1500 mg/day. b. perform glucose monitoring for hypoglycemia. c. obtain immunizations due to high risk for infections. d. avoid abrupt position changes because of orthostatic hypotension.
a. increase calcium intake to 1500 mg/day.
The lungs act as an acid-base buffer by a. increasing respiratory rate and depth when CO2 levels in the blood are high, reducing acid load. b. increasing respiratory rate and depth when CO2 levels in the blood are low, reducing base load. c. decreasing respiratory rate and depth when CO2 levels in the blood are high, reducing acid load. d. decreasing respiratory rate and depth when CO2 levels in the blood are low, increasing acid load.
a. increasing respiratory rate and depth when CO2 levels in the blood are high, reducing acid load.
When positioning a patient in preparation for surgery, the nurse understands that injury to the patient can occur because of (select all that apply) a. loss of pain perception. b. incorrect musculoskeletal alignment. c. vasoconstriction of the peripheral vessels. d. hypovolemia contributing to decreased perfusion. e. inability to sense pressure over bony prominences.
a. loss of pain perception. b. incorrect musculoskeletal alignment. d. hypovolemia contributing to decreased perfusion. e. inability to sense pressure over bony prominences.
During administration of a hypertonic IV solution, the mechanism involved in equalizing the fluid concentration between ECF and the cells is a. osmosis. b. diffusion. c. active transport. d. facilitated diffusion
a. osmosis.
An overweight patient (BMI 28.1 kg/m2) is scheduled for a laparoscopic cholecystectomy at an outpatient surgery setting. The nurse knows that a. surgery will involve multiple small incisions. b. this setting is not appropriate for this procedure. c. surgery will involve removing a part of the liver. d. the patient will need special preparation because of obesity
a. surgery will involve multiple small incisions.
The primary protective role of the immune system related to malignant cells is a. surveillance for cells with tumor-associated antigens. b. binding with free antigens released by all cancer cells. c. producing blocking factors that immobilize cancer cells. d. reacting to a new set of antigenic determinants on cancer cells.
a. surveillance for cells with tumor-associated antigens.
An older woman is admitted to the medical unit with GI bleeding. Assessment findings that indicate fluid volume deficit include (select all that apply) a. weight loss. b. dry oral mucosa. c. full bounding pulse. d. engorged neck veins. e. decreased central venous pressure.
a. weight loss. b. dry oral mucosa. e. decreased central venous pressure.
A patient with breast cancer has a lumpectomy with sentinel lymph node biopsy that is positive for cancer. You explain that, of the other tests done to determine the risk for cancer recurrence or spread, the results that support the more favorable prognosis are (select all that apply) a. well-differentiated tumor. b. estrogen receptor-positive tumor. c. overexpression of HER-2 cell marker. d. involvement of two to four axillary nodes. e. aneuploidy status from cell proliferation studies.
a. well-differentiated tumor. b. estrogen receptor-positive tumor.
A 44-year-old male patient has just been told that his wife and child were killed in an auto accident while coming to visit him in the hospital. Which of the following statements are assessment findings that support a nursing diagnosis of Spiritual Distress related to loss of family members? (Select all that apply.) a. "I need to call my sister for support." b. "I have nothing to live for now." c. "Why would my God do this to me?" d. "I need to pray for a miracle." e. "I want to be more involved in my church."
b. "I have nothing to live for now." c. "Why would my God do this to me?"
The health care provider prescribes levothyroxine for a patient with hypothyroidism. After teaching about this drug, the nurse determines that further instruction is needed when the patient says a. "I can expect the medication dose may need to be adjusted." b. "I only need to take this drug until my symptoms are improved." c. "I can expect to return to normal function with the use of this drug." d. "I will report any chest pain or difficulty breathing to the doctor right away."
b. "I only need to take this drug until my symptoms are improved."
When administering medications to the patient with chronic gout, the nurse recognizes which drug is used as a treatment for this disease? a. Colchicine b. Allopurinol c. Sulfasalazine d. Cyclosporine
b. Allopurinol
The patient tells the nurse in the preoperative setting that she has noticed she has a reaction when wearing rubber gloves. What is the most appropriate action? a. Notify the surgeon so that the surgery can be cancelled. b. Ask additional questions to assess for a possible latex allergy. c. Notify the OR staff at once so they can use latex-free supplies. d. No action is needed because the patient's rubber sensitivity has no bearing on surgery.
b. Ask additional questions to assess for a possible latex allergy.
A nurse is preparing to teach an older adult who has chronic arthritis how to practice meditation. Which of the following strategies are appropriate? (Select all that apply.) a. Encourage family members to participate in the exercise. b. Have patient identify a quiet room in the home that has minimal interruptions. c. Suggest the use of a quiet fan running in the room. d. Explain that it is best to meditate about 5 minutes 4 times a day. e. Show the patient how to sit comfortably with the limitation of his arthritis and focus on a prayer.
b. Have patient identify a quiet room in the home that has minimal interruptions. c. Suggest the use of a quiet fan running in the room. e. Show the patient how to sit comfortably with the limitation of his arthritis and focus on a prayer.
A patient has just learned she has been diagnosed with a malignant brain tumor. She is alone; her family will not be arriving from out of town for an hour. The nurse has been caring for her for only 2 hours but has a good relationship with her. What is the most appropriate intervention for support of her spiritual well-being at this time? a. Make a referral to a professional spiritual care adviser. b. Sit down and talk with the patient; have her discuss her feelings and listen attentively. c. Move the patient's Bible from her bedside cabinet drawer to the top of the over-bed table. d. Ask the patient whether she would like to learn more about the implications of having this type of tumor.
b. Sit down and talk with the patient; have her discuss her feelings and listen attentively.
To prevent fever and shivering during an infusion of rituximab (Rituxan), the nurse should premedicate the patient with a. aspirin. b. acetaminophen. c. sodium bicarbonate. d. meperidine (Demerol).
b. acetaminophen.
The nurse expects the long-term treatment of a patient with hyperphosphatemia from renal failure will include a. fluid restriction. b. calcium supplements. c. magnesium supplements. d. increased intake of dairy products.
b. calcium supplements.
A patient scheduled for a radical prostatectomy for prostate cancer expresses the fear that he will have erectile dysfunction. In responding to this patient, the nurse should keep in mind that a. PD5 inhibitors are not recommended in prostatectomy patients. b. erectile dysfunction can occur even with a nerve-sparing procedure. c. the most common complication of this surgery is bowel incontinence. d. the provider will place a penile implant during surgery to treat any dysfunction.
b. erectile dysfunction can occur even with a nerve-sparing procedure.
A patient who normally takes 40 units of glargine insulin (long acting) at bedtime asks the nurse what to do about her dose the night before surgery. The best response would be to have her a. skip her insulin altogether the night before surgery. b. get instructions from her surgeon or HCP on any insulin adjustments. c. take her usual dose at bedtime and eat a light breakfast in the morning. d. eat a moderate meal before bedtime and then take half her usual insulin dose.
b. get instructions from her surgeon or HCP on any insulin adjustments.
The nurse receives an order for a patient with lung cancer to receive influenza vaccine and pneumococcal vaccines. The nurse will a. call the health care provider to question the order. b. give both vaccines at the same time in different arms. c. give the pneumococcal vaccine and obtain a nasal influenza vaccine. d. give the flu shot and tell the patient to come back in 1 week to have the pneumococcal vaccine.
b. give both vaccines at the same time in different arms.
In assessing the joints of a patient with osteoarthritis, the nurse understands that Bouchard's nodes a. are often red, swollen, and tender. b. indicate osteophyte formation at the PIP joints. c. are the result of pannus formation at the DIP joints. d. occur from deterioration of cartilage by proteolytic enzymes.
b. indicate osteophyte formation at the PIP joints.
A patient with rheumatoid arthritis has articular involvement. The nurse recognizes these characteristic changes include (select all that apply) a. bamboo-shaped fingers. b. metatarsal head dislocation in feet. c. noninflammatory pain in large joints. d. asymmetric involvement of small joints. e. morning stiffness lasting 60 minutes or more.
b. metatarsal head dislocation in feet. e. morning stiffness lasting 60 minutes or more.
Important nursing intervention(s) when caring for a patient with Cushing syndrome include (select all that apply) a. restricting protein intake. b. monitoring blood glucose levels. c. observing for signs of hypotension. d. administering medication in equal doses. e. protecting patient from exposure to infection.
b. monitoring blood glucose levels. e. protecting patient from exposure to infection.
Activities that the nurse might perform in the role of a scrub nurse during surgery include (select all that apply) a. checking electrical equipment. b. preparing the instrument table. c. assisting with draping the patient. d. passing instruments to the surgeon and assistants. e. documenting activities occurring in the operating room
b. preparing the instrument table. c. assisting with draping the patient. d. passing instruments to the surgeon and assistants.
The nurse should teach the patient with ankylosing spondylitis the importance of a. avoiding extremes in environmental temperatures b. regularly exercising and maintaining proper posture. c. maintaining patient's usual physical activity during flares. d. applying hot and cool compresses for relief of local symptoms.
b. regularly exercising and maintaining proper posture.
The nurse explains to a patient undergoing brachytherapy of the cervix that she a. must undergo simulation to locate the treatment area. b. requires the use of radioactive precautions during nursing care. c. may have desquamation of the skin on the abdomen and upper legs. d. requires shielding of the ovaries during treatment to prevent ovarian damage.
b. requires the use of radioactive precautions during nursing care.
Which patient is at greatest risk for developing hypermagnesemia? a. 83-year-old man with lung cancer and hypertension b. 65-year-old woman with hypertension taking β-adrenergic blockers c. 42-year-old woman with systemic lupus erythematosus and renal failure d. 50-year-old man with benign prostatic hyperplasia and a urinary tract infection
c. 42-year-old woman with systemic lupus erythematosus and renal failure
What are the priority interventions the nurse performs when admitting a patient to the PACU? a. Assess the surgical site, noting presence and character of drainage. b. Assess the amount of urine output and the presence of bladder distention. c. Assess for airway patency and quality of respirations and obtain vital signs. d. Review results of intraoperative laboratory values and medications received.
c. Assess for airway patency and quality of respirations and obtain vital signs
A nurse is caring for a patient who is Muslim and has diabetes. Which of the following items does the nurse need to remove from the meal tray when it is delivered to the patient? a. Small container of vanilla ice cream b. A dozen red grapes c. Bacon and eggs d. Garden salad with ranch dressing
c. Bacon and eggs
In teaching a patient with Sjögren's syndrome about drug therapy for this disorder, the nurse includes instruction about the use of which drug? a. Pregabalin (Lyrica) b. Etanercept (Enbrel) c. Cyclosporine (Restasis) d. Cyclobenzaprine (Flexeril)
c. Cyclosporine (Restasis)
A nurse used spiritual rituals as an intervention in a patient's care. Which of the following questions is most appropriate to evaluate its efficacy? a. Do you feel the need to forgive your wife over your loss? b. What can I do to help you feel more at peace? c. Did either prayer or meditation prove helpful to you? d. Should we plan on having your family try to visit you more often in the hospital?
c. Did either prayer or meditation prove helpful to you?
A nursing student is developing a plan of care for a 74-year-old-female patient who has spiritual distress over losing a spouse. As the nurse develops appropriate interventions, which characteristics of older adults should be considered? (Select all that apply.) a. Older adults do not routinely use complementary medicine to cope with illness. b. Older adults dislike discussing the afterlife and what might have happened to people who have passed on. c. Older adults achieve spiritual resilience through frequent expressions of gratitude. d. Have the patient determine whether her husband left a legacy behind. e. Offer the patient her choice of rituals or participation in exercise.
c. Older adults achieve spiritual resilience through frequent expressions of gratitude. d. Have the patient determine whether her husband left a legacy behind. e. Offer the patient her choice of rituals or participation in exercise.
A patient on chemotherapy and radiation for head and neck cancer has a WBC count of 1.9 × 103/μL, hemoglobin of 10.8 g/dL, and a platelet count of 99 × 103/μL. Based on the CBC results, what is the most serious clinical finding? a. Cough, rhinitis, and sore throat b. Fatigue, nausea, and skin redness at site of radiation c. Temperature of 101.9° F, fatigue, and shortness of breath d. Skin redness at site of radiation, headache, and constipation
c. Temperature of 101.9° F, fatigue, and shortness of breath
The nurse should be alert for which manifestations in a patient receiving a loop diuretic? a. Restlessness and agitation b. Paresthesias and irritability c. Weak, irregular pulse and poor muscle tone d. Increased blood pressure and muscle spasms
c. Weak, irregular pulse and poor muscle tone
The goals of cancer treatment are based on the principle that a. surgery is the single most effective treatment for cancer. b. initial treatment is always directed toward cure of the cancer. c. a combination of treatment modalities is effective for controlling many cancers. d. although cancer cure is rare, quality of life can be increased with treatment modalities.
c. a combination of treatment modalities is effective for controlling many cancers.
An important preoperative nursing intervention before an adrenalectomy for hyperaldosteronism is to a. monitor blood glucose levels. b. restrict fluid and sodium intake. c. administer potassium-sparing diuretics. d. advise the patient to make postural changes slowly.
c. administer potassium-sparing diuretics.
Trends in the incidence and death rates of cancer include the fact that a. a higher percent of women than men have lung cancer. b. lung cancer is the most common type of cancer in men. c. blacks have a higher death rate from cancer than whites. d. breast cancer is the leading cause of cancer deaths in women.
c. blacks have a higher death rate from cancer than whites.
IV induction for general anesthesia is the method of choice for most patients because a. the patient is not intubated. b. the agents are nonexplosive. c. induction is rapid and controlled. d. emergence is longer but with fewer complications.
c. induction is rapid and controlled.
The typical fluid replacement for the patient with a fluid volume deficit is a. dextran. b. 0.45% saline. c. lactated Ringer's solution. d. 5% dextrose in 0.45% saline.
c. lactated Ringer's solution.
A patient with a head injury develops SIADH. Manifestations the nurse would expect to find include a. hypernatremia and edema. b. muscle spasticity and hypertension. c. low urine output and hyponatremia. d. weight gain and decreased glomerular filtration rate.
c. low urine output and hyponatremia.
Discharge criteria for the Phase II patient include (select all that apply) a. no nausea or vomiting. b. ability to drive self home. c. no respiratory depression. d. written discharge instructions understood. e. opioid pain medication given 45 minutes ago.
c. no respiratory depression. d. written discharge instructions understood. e. opioid pain medication given 45 minutes ago.
Preoperatively, to meet the psychologic needs of a woman scheduled for a simple mastectomy, you would a. discuss the limitations of breast reconstruction. b. include her significant other in all conversations. c. promote an environment for expression of feelings. d. explain the importance of regular follow-up screening.
c. promote an environment for expression of feelings.
Preoperative considerations for older adults include (select all that apply) a. using only large-print educational materials. b. speaking louder for patients with hearing aids. c. recognizing that sensory deficits may be present. d. providing warm blankets to prevent hypothermia. e. teaching important information early in the morning.
c. recognizing that sensory deficits may be present. d. providing warm blankets to prevent hypothermia.
Proper attire for the semirestricted area of the surgery department is a. street clothing. b. surgical attire and head cover. c. scrub attire, head cover, shoe covers. d. street clothing with the addition of shoe covers.
c. scrub attire, head cover, shoe covers.
Which statement made by a patient who is recovering after recently experiencing third-degree burns shows connectedness? a. "My pain medicine helps me feel better." b. "I know I will get better if I just keep trying." 738 c. "I see God's grace and become relaxed when I watch the sun set at night." d. "I feel so much closer to God after I read my Bible and pray."
d. "I feel so much closer to God after I read my Bible and pray."
A patient on chemotherapy for 10 weeks started at a weight of 121 lb. She now weighs 118 lb and has no sense of taste. Which nursing intervention would be a priority? a. Discuss with the provider the need for parenteral nutrition. b. Teach the patient to eat foods that are fatty, fried, or high in calories. c. Tell the patient to drink a nutritional supplement beverage three times a day. d. Have the patient try various spices and seasonings to enhance the flavor of food.
d. Have the patient try various spices and seasonings to enhance the flavor of food.
A patient is scheduled for surgery requiring general anesthesia at an ambulatory surgical center. The nurse asks him when he ate last. He replies that he had a light breakfast a couple of hours before coming to the surgery center. What should the nurse do first? a. Tell the patient to come back tomorrow, since he ate a meal. b. Have the patient void before giving any preoperative medications. c. Proceed with the preoperative checklist, including site identification. d. Notify the anesthesia care provider of when and what the patient last ate.
d. Notify the anesthesia care provider of when and what the patient last ate.
You are caring for a patient with breast cancer following a simple mastectomy. Postoperatively, to restore arm function on the affected side, you would a. apply heating pads or blankets to increase circulation. b. place daily ice packs to minimize the risk for lymphedema. c. teach passive exercises with the affected arm in a dependent position. d. emphasize regular exercises for the affected shoulder to increase range of motion.
d. emphasize regular exercises for the affected shoulder to increase range of motion.
A 70-kg postoperative patient has an average urine output of 25 mL/hr during the first 8 hours. The priority nursing intervention(s) given this assessment would be to a. notify the surgeon and expect obtaining blood work to evaluate renal function. b. perform a straight catheterization to measure the amount of urine in the bladder. c. continue to monitor the patient because this is a normal finding during this time period. d. evaluate the patient's fluid volume status since surgery and obtain a bladder ultrasound.
d. evaluate the patient's fluid volume status since surgery and obtain a bladder ultrasound.
A priority nursing intervention to aid a preoperative patient in coping with fear of postoperative pain would be to a. inform the patient that pain medication will be available. b. teach the patient to use guided imagery to help manage pain. c. describe the type of pain expected with the patient's particular surgery. d. explain the pain management plan, including the use of a pain rating scale.
d. explain the pain management plan, including the use of a pain rating scale
You are caring for a young woman who has painful fibrocystic breast changes. Management of this patient would include a. scheduling a biopsy to rule out the presence of breast cancer. b. teaching that symptoms will subside if she stops using oral contraceptives. c. preparing her for surgical removal of the lumps, since they will become larger and more painful. d. explaining that restricting coffee and chocolate and supplementing with vitamin E may relieve some discomfort.
d. explaining that restricting coffee and chocolate and supplementing with vitamin E may relieve some discomfort.
The nurse is unable to flush a central venous access device and suspects occlusion. The best nursing intervention would be to a. apply warm moist compresses to the insertion site. b. try to force 10 mL of normal saline into the device. c. place the patient on the left side with the head down. d. have the patient change positions, raise arm, and cough.
d. have the patient change positions, raise arm, and cough.
When scrubbing at the scrub sink, the nurse should a. scrub from elbows to hands. b. scrub without mechanical friction. c. scrub for a minimum of 10 minutes. d. hold the hands higher than the elbows.
d. hold the hands higher than the elbows.
After thyroid surgery, the nurse suspects damage or removal of the parathyroid glands when the patient develops a. muscle weakness and weight loss. b. hyperthermia and severe tachycardia. c. hypertension and difficulty swallowing. d. laryngospasms and tingling in the hands and feet.
d. laryngospasms and tingling in the hands and feet.
The nurse is caring for a 59-year-old woman who had surgery 1 day ago to remove an ovarian cancer mass. The patient is awaiting the pathology report. She is tearful and says that she is scared to die. The most effective nursing intervention at this point is to use this opportunity to a. motivate change in an unhealthy lifestyle. b. teach her about the 7 warning signs of cancer. c. discuss healthy stress relief and coping practices. d. let her communicate about the meaning of this experience.
d. let her communicate about the meaning of this experience.
The nurse counsels the patient receiving radiation therapy or chemotherapy that a. effective birth control methods should be used for the rest of the patient's life. b. after successful treatment, patients can expect a return to their previous level of function. c. the cycle of fatigue-depression-fatigue that may occur during treatment may be reduced by restricting activity. d. nausea and vomiting can usually be managed with antiemetic drugs, diet modification, and other interventions.
d. nausea and vomiting can usually be managed with antiemetic drugs, diet modification, and other interventions.
A patient is admitted to the PACU after major abdominal surgery. During the initial assessment the patient tells the nurse he thinks he is going to "throw up." A priority nursing intervention is to a. increase the rate of the IV fluids. b. give antiemetic medication as ordered. c. obtain vital signs, including O2 saturation. d. position patient in lateral recovery position.
d. position patient in lateral recovery position.
A characteristic of the stage of progression in cancer development is a. oncogenic viral transformation of target cells. b. a reversible steady growth facilitated by carcinogens. c. a period of latency before clinical detection of cancer. d. proliferation of cancer cells despite host control mechanisms.
d. proliferation of cancer cells despite host control mechanisms.
A patient has the following arterial blood gas results: pH 7.52, PaCO2 30 mm Hg, HCO3− 24 mEq/L. The nurse determines that these results indicate a. metabolic acidosis. b. metabolic alkalosis. c. respiratory acidosis. d. respiratory alkalosis
d. respiratory alkalosis
During the postoperative care of a 76-year-old patient, the nurse monitors the patient's intake and output carefully, knowing that the patient is at risk for fluid and electrolyte imbalances primarily because a. older adults have an impaired thirst mechanism and need reminding to drink fluids. b. water accounts for a greater percentage of body weight in the older adult than in younger adults. c. older adults are more likely than younger adults to lose extracellular fluid during surgical procedures. d. small losses of fluid are significant because body fluids account for 45% to 50% of body weight in older adults.
d. small losses of fluid are significant because body fluids account for 45% to 50% of body weight in older adults.
In teaching a patient with systemic lupus erythematosus about the disorder, the nurse knows the pathophysiology includes a. circulating immune complexes formed from IgG autoantibodies reacting with IgG. b. an autoimmune T-cell reaction that results in destruction of the deep dermal skin layer. c. immunologic dysfunction leading to chronic inflammation in the cartilage and muscles. d. the production of a variety of autoantibodies directed against components of the cell nucleus.
d. the production of a variety of autoantibodies directed against components of the cell nucleus.
The most effective method of administering a chemotherapy agent that is a vesicant is to a. give it orally. b. give it intraarterially. c. use an Ommaya reservoir. d. use a central venous access device.
d. use a central venous access device.
