NURS - 220 Exam 1

Which term describes involuntary, jerking, rhythmic movements of the eyes? A. Diplopia B. Exophthalmus C. Nystagmus D. Blepharitis

C

Which of the following is the most reliable method for assessing nasogastric tube placement? A. Capnometry B. Measuring the tube that extends from the body C. Injecting air into the tube and auscultating over the stomach D. Measuring pH of the aspirate

D

Which term best describes one or more joint being totally out of place? A. Contracture B. Subluxation C. Joint mobility D. Dislocation

D

You are assessing a client's level of consciousness. You begin by speaking to the client, but the client does not respond. Which of the following should you do next in your assessment? A. Wave at the client to get his attention B. Pass smelling salts beneath the client's nose C. Tap on the client's hand D. Shout the client's name

C

A nurse performs a neurologic assessment on a patient complaining of headaches and dizziness. Which assessment technique help assess the motor function of cranial nerve VII? A. Asking the patient to clench his jaw B. Testing the gag reflex by placing an applicator against the pharynx C. Asking the patient to swallow D. Asking the patient to smile, frown, and raise his eyebrows

D

A nurse who works nightshift eats a meal at 2 o'clock in the morning. Which factor has the greatest influence on his/her nutrition? A. Gender B. Ethnicity and culture C. Religious practices D. Lifestyle

D

A comatose patient needs a nasopharyngeal airway for suctioning. After the airway is placed, he gags and coughs. Which action should the nurse take? A. Remove the airway and insert a shorter one B. Reposition the airway C. Leave the airway in place until the patient gets used to it D. Remove the airway and attempt to suction without it

A

An elderly patient with pneumonia may appear with which symptoms first? A. Altered mental status and dehydration B. Fever and chills C. Hemoptysis and dyspnea D. Pleuritic chest pain and cough

A

When auscultating the chest of a patient with pneumonia, the nurse should expect to hear which type of sounds over the area of consolidation? A. Bronchial B. Bronchovesicular C. Tubular D. Vesicular

A

Which of the following could put a nurse or healthcare worker at risk for sustaining a back injury? A. Lifting a box of IV supplies up and over the head to place on a shelf B. Placing the feet 2 feet apart before sliding a patient up in bed C. Squatting to measure chest tube drainage D. Raising the bed to waist level when starting an IV

A

Which respiratory disorder is most common in the first 24-48 hours after surgery? A. Atelectasis B. Bronchitis C. Pneumonia D. Pneumothorax

A

You are caring for a client with macular degeneration who lives alone. Which of the following nursing diagnoses would be most appropriate for this client? A. Risk for falls r/t visual impairment B. Risk for injury r/t reduced tactile sensation C. Bathing self-care deficit r/t kinesthetic impairment D. Deficient diversional activity r/t reluctance to be in social situations because of hearing impairment

A

You are to get a patient with right-sided weakness up in a chair. On what side of the bed will you place the chair? A. On the patient's left side B. On the patient's weak side C. Either side, because you are assisting the patient D. On whichever side the patient prefers

A

Before transferring Mrs. Hughes from the bed to a stretcher, which assessment data does the nurse need to gather? Select all that apply A. Weight B. Level of cooperation C. Ability to assist D. Presence of medical equipment E. 24-hour calorie intake

A B C D

When conducting a history on the musculoskeletal system, which questions would be important to include? Select all that apply A. Do you have any muscle pain? B. What kind of work do you do? C. When was your last bowel movement? D. Do you have any difficulty combing your hair? E. Is there a temperature difference between your hands and the rest of your body? F. What kind of exercise do you do?

A B D F

When taking a health history on the integument system, which questions should be included? Select all that apply A. Have you noticed any changes in any moles? B. Do you have a past history of skin problem? C. Do you have any pets at home? D. What did you have for breakfast today? E. Have you noticed dryness or itchiness of your skin?

A B E

Which of the following indicates a patient is not tolerating the tube feeding? Select all that apply A. Complaints of nausea or bloating B. Crackles when auscultating the lung fields C. A residual of 75 mL after a feeding D. Soft formed bowel movement every other day E. Abdominal distention

A B E

Which of the following is a normal age related skin change in the older adult? Select all that apply A. Skin loses its elasticity and sags B. The skin color darkness C. The adhesion between skin layers weakens D. Fat is redistributed to the extremities E. Fewer sweat glands can lead to overheating

A C E

A patient calls the office and states that she just twisted her ankle. What instruction should the nurse give to treat this injury? Select all that apply A. Rest the injured extremity B. Apply heat to the injury C. Range of motion exercise will prevent stiffness D. Ibuprofen will alleviate the pain E. Elevate the injury above the level of the heart F. Wrap the ankle with an ACE bandage

A E F

What effect can thoracic kyphoscoliosis have on lung function? A. Improve lung expansion B. Obstructs lung deflation C. Reduces aveolar compression during expiration D. Restricts lung expansion

D

Which of the following is included in the normal range of motion for the knee joint? A. Rotation B. Abduction C. Flexion D. Circumduction E. Adduction

C

A name-brand ice cream contains the following nutrition information for each serving: 30g carbohydrates, 19g fat, 5g protein. The total number of calories in a serving would be ... A. 366 B. 311 C. 435 D. 176

B

A patient needs to have a chest tube inserted in the right upper chest. Which action is part of the nurse's role? A. The nurse isn't needed B. Prepare the chest tube drainage system C. Bring the X-Ray machine into the patient room D. Insert the chest tube as ordered

B

An 87 year old patient requires long term ventilator therapy. He has a tracheostomy and requires frequent suctioning. Which is the proper technique? A. Using intermittent suction while advancing the catheter B. Using continuous suction for no longer than 10 seconds while withdrawing the catheter C. Using the continuous suction for no longer than 20 seconds while withdrawing the catheter D. Using the continuous suction while advancing the catheter

B

An elderly patient had a stroke and can only see the nasal visual field on one side and the temporal portion on the opposite side. Which term correctly describes this condition? A. Astereognosis B. Homonymous hemianopia C. Oculogyric crisis D. Receptive aphasia

B

The nurse assess muscle strength on a patient and finds that the patient can lift his arm against gravity but not against resistance. How should the nurse document this finding? A. MS 5, normal B. MS 3, fair C. MS 1, trace D. MS 0, zero

B

The nurse knows that the primary reason for the application of a sequential compression device (SCD) on the legs of an immobile patient is to ... A. Stimulate circulation in the deep arterial vascular system B. Help prevent the formation of deep vein thrombosis (DVT) C. Aid in peripheral circulation to minimize the risk of skin breakdown D. Assist in passive range of motion exercise of the patient's lower extremities

B

The term "Kussmaul" refers to a high-pitched, harsh, crowing inspiratory sound that occurs due to partial obstruction of the larynx A. True B. False

B

To maintain proper posture, it is important to ... A. Sleep on the softest mattress possible B. Avoid arching shoulders forward when sitting C. Keep your knees locked when standing upright D. Keep your stomach muscles relaxed to prevent back spasms

B

When using a Snellen alphabet chart, a nurse records a patient's vision as 20/40. Which statement best describes 20/40 vision? A. The patient has alterations in near vision and is legally blind B. The patient can see at 20 feet what the person with normal vision can see at 40 feet C. The patient can see at 40 feet what the person with normal vision can see at 20 feet D. The patient has a 20% decrease in one eye and a 40% decrease in the other eye

B

Which additional assessment data should immediately be gathered to determine the status of a patient with a respiratory rate of 4 bpm? A. Arterial blood gas and breath sounds B. Level of consciousness and pulse oximetry value C. Breath sounds and pulses D. Pulse oximetry and heart sounds

B

While you are performing a focused nursing assessment of a patient's hearing, he mentions that lately he has begun to hear a ringing sound in his ear at night when he lies down to sleep. Which of the following hearing deficits is this client most likely experiencing? A. Presbycusis B. Tinnitus C. Nerve deafness D. Otitis media

B

Which of the following questions should be included when taking a history of the mouth and oropharynx? Select all that apply A. Do you have any difficulty breathing? B. Do your gum bleed when you brush? C. Have you noticed any difficulty swallowing? D. Are you feeling more fatigued than usual E. Do you smoke or drink alcohol?

B C E

Which of the following are included in the care of a patient at risk for aspiration during the meals? Select all that apply A. Position patient on their side when feeding B. Flex head with chin down C. Offer liquids after each bite of food D. Sit upright E. Talk to the patient to improve socialization during the meals

B D

You are using the Glasgow Coma Scale to assess a client's level of consciousness (LOC). Which of the following responses to stimuli does this scale assess? Select all that apply A. Brainstem reflexes B. Eye responses C. Respirations D. Motor responses E. Verbal responses

B E

Which of the following patients should be allowed to lie back down? A. A patient who was just transferred to a chair and states that she was more comfortable in bed. Physician's orders are to be up in the chair twice daily B. A patient whose blood pressure was 120/80 prior to transfer, and is now 112/78 C. A patient who complaints of feeling dizzy and slightly nauseous when dangling on the bedside D. A patient whose blood pressure was 110/70 prior to transfer and she is now 125/80

C

Which patient is most likely to have a negative nitrogen balance? A. A 65 year old man admitted for diagnostic testing abdominal pain B. A 23 year old woman who is 35 weeks pregnant C. A 15 year old boy who has burns to his arms, chest, and face from a fire cracker D. A 2 month old being seen for immunizations and a well baby check

C

Which result shows a chest tube insertion was done properly? A. Bronchial breath sounds heard at both bases B. Vesicular breath sounds heard over the upper lung field C. Bronchovesicular sounds heard over both lung fields D. Crackles heard on the affected side

C

Which term describes diminished near vision that occurs with aging? A. Myopia B. Hyperopia C. Presbyopia D. Hyopia

C

A nurse is working in a walk in clinic. She has been alerted that there is an outbreak of TB. Which patient entering the clinic today is most likely to have TB? A. A 16 year old female high school student B. A 33 year old day-care worker C. A 43 year old homeless man with a history of alcoholism D. A 54 year old business man

C

A patient diagnosed with active TB would be hospitalized primarily for which reason? A. To evaluate his condition B. To determine compliance C. To prevent the spread of the infection D. To determine the need for antibiotics

C

A patient must place his hand on the wall to keep his balance when walking. He leans when sitting and has difficulty knowing when his body is vertical and sensing the position of his body in space. Which type of receptor is probably involved? A. Photoreceptors B. Chemoreceptors C. Proprioceptors D. Thermoreceptors

C

Identify the client with the greatest risk for developing protein-calorie malnutrition A. A client who has multiple sclerosis and is in a wheelchair B. A client weighing 300 lb who has entered the hospital for cardiac bypass surgery C. A client with a broken arm and femur from trauma who is running a fever of 101.5 F (38.6 C) D. A client who is of Native American heritage

C

Mrs. Hughes calls for the nurse. You enter her room, she tells you "it hurts when I try to breathe, and I can't catch my breath." What should be the nurse's first action? A. Call the health care provider to report this change in condition B. Give the patient a paper bag to breath into to decrease her anxiety C. Assess her vital signs, perform a respiratory assessment, and be prepared to start oxygen D. Explain that this is normal after such trauma and administer the ordered pain medication

C

Of the following interventions for the client who is immobile, the nurse will give priority to ... A. Encouraging a diet high in fiber and extra fluids B. Administering the PRN medication for sleep C. Having the client use his or her incentive spirometer q2hrs D. Massaging the client's legs every hour

C

What type of therapeutic diet would be best for an older adult patient who has difficulty of swallowing? A. Clear fluids B. High fiber C. Pureed D. NPO

C

When inspecting a joint during the musculoskeletal exam which of the following is important to include? A. Assessing full range of motion and muscle strength B. Assessing for tenderness in the joint C. Assessing both sides of the body for comparison D. Assessing for muscle tone

C

When offering health promotion education on the mouth and oropharynx what information os most important to include? A. Regular brushing and flossing will reduce bad breath and increase self esteem B. Tooth loss is a normal part of aging, so older adults will need dentures C. Smoking, smokeless tobacco and alcohol increase the risk of cancer D. Regular dental check ups are not needed if the person wears dentures

C

When performing an assessment of the eye, which test assessment the patient's peripheral vision? A. The Snellen chart B. The pupillary light response C. The confrontation test D. The Ishihara plates

C

During pregnancy, the women has increased nutritional needs. Which of the following need to be increased during the pregnancy. Select all that apply A. Carbohydrates B. Water C. Iron D. Protein E. Calcium

C D E

When assessing a patient's nails for the shape and contour by performing the profile sign. Which of the following findings would indicate prolonged hypoxia? A. Nail plate angle of about 160 degrees B. Nail plate of 180 degrees C. Nail plate angle less than 140 degrees D. Nail plate angle greater than 180 degrees

D

Which action or condition is the number one cause of lung cancer? A. Genetics B. Smoking pipe C. Occupational exposure D. Cigarette smoking

D

Which measure can reduce or prevent the incidence of atelectasis in a post operative patient? A. Chest physiotherapy B. Mechanical ventilation C. Reducing oxygen requirements D. Use of an incentive spirometer

D

Which method would be used to test for pupil accommodation? A. Assessing peripheral vision? B. Touching the cornea with a wisp of cotton C. Having the patient follow an object downward, upward, obliquely and horizontally D. Observing the pupil constriction and convergence while focusing on an object coming toward the patient

D

A 20 year old patient is being treated for pneumonia. He has a persistent cough and complains of severe pain with coughing. What type of instruction should be given to help reduce the discomfort he is having? A. "Hold your cough for as long as possible" B. "Place the head of your bed flat to help with the coughing" C. "Restrict your fluids to help decrease the amount of sputum" D. "Splint your chest wall with a pillow when coughing"

D

A nurse is speaking to a group of residents in a nursing home about health promotion of the musculoskeletal system. What information would be important to include in the presentation? A. Adequate vitamin D and calcium will prevent rickets B. Osteopenia is a normal part of the aging process C. Swimming is the best exercise for the older adults D. Screening for osteoporosis should start at age 40 E. Weight bearing exercise, calcium, and vitamin D help prevent bone loss

E