Nursing 3 FInal

What is fibromyalgia syndrome?

Musculoskeletal chronic pain syndrome of unknown etiology

The nursing instructor would share with students which statement(s) regarding the effects of aging on the renal system? (Select all that apply.)

Older men are at risk for urinary retention because of prostatic hypertrophy. Urinary tract infections in older adults are often associated with diabetes, neurologic disorders, and procedures (e.g., catheterization). Older women are at risk for stress incontinence because of weakened pelvic musculature.

The nurse is caring for a patient with Addison disease. What signs and laboratory values would the nurse expect to see in this patient?

Postural hypotension

The nurse teaches care of the umbilical cord to a new mother. What instruction will the nurse provide?

apply alcohol on the cord stump

Which of the following medications would be the most effective in treating a duodenal ulceration caused by Helicobacter pylori?

Amoxicillin

The nurse is caring for a patient with acute renal failure (oliguric phase). What would the nurse expect to assess on a patient with this diagnosis?

Anorexia, nausea, vomiting, and decreased urine output

The nurse is caring for a 42-year-old female being treated for infertility. She has a 5-year-old daughter, whom she and her husband conceived without medical intervention, and they would like another child. The woman is expressing frustration about not being able to conceive. Which statement accurately describes infertility and its treatment?

Approximately 50% of couples who undergo assessment and treatment for infertility are able to conceive.

Which actions by the nursing mother will support milk production and promote infant comfort? (Select all that apply.)

Drink 8 to 10 glasses of fluids daily. Continue her prenatal vitamins and minerals until they are gone. Avoid spicy foods, chocolate, and onions.

The father's behavior when introduced to his new baby is typically an intense fascination. What is this behavior considered?

Engrossment

During a postpartum check, the nurse assesses the new mother's uterus and notes it to be boggy. What is the nurse's first intervention?

Gently instruct the patient to void

A patient with a chronic musculoskeletal disorder and is asking the nurse about alternative therapies for her condition. On what knowledge does the nurse base the response?

Glucosamine supplements have been linked with reduced articular pain, lessened joint tenderness, and less restricted joint movement in persons with arthritis.

Which physical signs and symptoms might the postpartum patient experience following delivery? (Select all that apply.)

Increased urination beginning 4 to 6 hours after delivery Increased diaphoresis, most commonly at night A normal bowel movement within 2 to 3 days

The nurse is caring for a patient in labor. While assessing the patient's vital signs, the nurse notes a drop in the patient's blood pressure. To prevent supine hypotension, the nurse should encourage the patient to be in what position?

Left Lateral side lying

The largest glandular organ in the body, which functions as an accessory organ of digestion, is the:

Liver

A patient is going for a diagnostic test. The nurse listens as the physician explains the procedure to the patient. The physician states that the test involves the use of differential signal characteristics of flowing blood to evaluate extracranial and intracranial blood vessels. In preparing to answer the patient's questions further, what diagnostic test will the nurse address?

Magnetic resonance angiography (MRA)

A postpartum patient is experiencing weakness and says that she is sick to her stomach. When the nurse performs an assessment, the patient has a pulse rate of 120 and a 60/48 blood pressure, and when touched the skin is cool and clammy. Which interventions should the nurse institute?

Massage the fundus Elevate legs 30 degrees Give oxygen if prescribed Maintain intravenous (IV) fluids

The nurse is caring for a patient who is taking digoxin once a day for treatment of congestive heart failure. He now has a new order to begin taking spironolactone (Aldactone). Which nursing intervention is most appropriate for this patient?

Monitor the patient for signs and symptoms of digoxin toxicity

The nurse is caring for a patient who is 24 hours postoperative following a modified radical mastectomy of the left breast. Which nursing intervention is most appropriate for this patient?

Monitor the patient for signs of shock or hemorrhage

What is the autoimmune disease of the neuromuscular junction characterized by fluctuating weakness of certain muscle groups?

Myasthenia Gravis

An off-duty LPN/LVN is buying groceries and observes a child sitting in the cart ahead. The child raises her shirt and picks at some scabs on her abdomen. The LPN/LVN recognizes that the wounds look like the result of cigarette burns. What is the best response as a health care professional?

Notify the appropriate agency that that there is reason to believe a child has been abused.

The nurse is caring for a patient who has undergone a thyroidectomy. Which signs or symptoms should be reported immediately to the RN/MD for further evaluation? (Select all that apply.)

Numbness in the fingers Heart rate of 160 Noticeable arm twitching while assessing blood pressure

When does Rh incompatibility occur?

Only when the mother is Rh negative and the fetus is Rh positive.

An 18-month-old child is having difficulty maintaining his respiratory status. The child's physician orders oxygen therapy per nasal cannula. Which statements are true regarding oxygen therapy for children? (Select all that apply.)

Oxygen flow by nasal cannula allows constant oxygen delivery even while eating and talking, because the mouth remains unobstructed. To assess adequate oxygenation, the nurse checks cannula placement and oxygen saturation using a pulse oximeter every 2 hours and PRN. Maintaining cannula placement may be difficult as the child is able to remove it from the nares.

A male patient has been recently diagnosed with Parkinson disease. His wife asks the nurse numerous questions about the disease. What information is correct in addressing this wife's questions?

Parkinson disease is a syndrome of bradykinesia, rigidity, tremor, and impaired postural reflexes

What type of liver cirrhosis is caused by viral hepatitis, exposure to hepatotoxins (e.g., industrial chemicals), or infection?

Postnecrotic cirrhosis

The nurse is caring for a patient who is being evaluated for a neurologic disorder. She is not able to comprehend the written or spoken word. Which term would the nurse use to document this problem?

Receptive aphasia

A patient has recently suffered through a bout of acute pancreatitis. He is asking for something to eat. The nurse finds each of the following choices in the kitchen. Which would be most appropriate for this patient? (Select all that apply.)

Reduced fat cheese and whole-wheat crackers Grilled chicken and a baked potato

A female patient has been diagnosed with gastroesophageal reflux disease (GERD). The nurse is beginning to teach the patient about lifestyle changes that can be implemented to minimize the symptoms of this disease. Which of the following will the nurse include?

Reducing caffeine and alcohol consumption may alleviate symptoms of the disease.

When caring for a patient who has just undergone a corneal transplant (keratoplasty), what is the most important nursing intervention?

Reporting any severe or progressive pain to the surgeon immediately

The nurse is performing patient teaching for a patient who has urolithiasis. This patient has been determined to be a "calcium stone former." What current research recommendation will the nurse base the answers to the patient's dietary questions?

Restricted animal protein

A patient delivered her infant 36 hours ago. She is sitting in bed when she feels a gush of warm fluid between her legs. She calls the nurse, who finds her bleeding. This is an example of late postpartum hemorrhage. What is the most common cause of late postpartum hemorrhage?

Retained fragments of the placenta

A pregnant patient asks the nurse about a darkened line that is seen on her abdomen. What would be the best response?

That is linea nigra, a darkened line from the pubis to the umbilicus, as a result of increased hormones.

When a pregnant patient is being monitored for preeclampsia, fetal condition is also monitored. If the physician requests a kick count, how many counts per hour would be considered to be a concern?

less than 3 counts per hour

A pregnant patient comes to the clinic for a prenatal visit. At how many weeks' gestation would the patient need to be to hear fetal heart tones using a Doppler scan?

10 weeks

What term most accurately describes age-related changes of the neurologic system?

As neurons are lost with aging, there is deterioration in neurologic function.

What are the signs and symptoms of maternal hyperglycemia? (Select all that apply.)

Fatigue Frequent urination Flush hot skin

What condition is associated with Dumping syndrome

Following gastric resection or peptic ulcer surgery

You are caring for a recently admitted patient who has suffered a pelvic fracture. Which of the following is the most serious physical assessment finding for the nurse to report?

Hypotension, tachycardia, and hematuria

A pregnant patient comes into the clinic complaining of constipation. Which statement by the patient indicates the need for further teaching?

I can stop taking my vitamins if I have hemorrhoids

A pregnant patient complains of having to go to the bathroom frequently and sometimes even has stress incontinence. What can the nurse teach the patient to do to increase the tone of the perineum muscles?

Kegal Exercises

After which of the following diagnostic studies is it important that the patient lie quietly in a semi-Fowler position for approximately 8 hours (12 hours if oil-based dye is used)?

Myelogram

The nurse is taking care of a patient who suddenly begins to have a seizure. What is the appropriate nursing response?

Observe and record the seizure activity.

A patient with rheumatoid arthritis asks the nurse about her condition. On what knowledge does the nurse base patient teaching?

Rheumatoid arthritis is thought to be an autoimmune disorder.

Malabsorption can be a major problem with Crohn's disease when what portion of the intestine is involved?

The small intestine

The nurse assesses jaundice in a newly admitted patient. What is there an excess amount of in the bloodstream that causes jaundice?

Billirubin

What is the disorder caused by secretion of insufficient amounts of antidiuretic hormone (ADH)?

Diabetes insipidus

What is a characteristic of hyperparathyroidism?

Increased Serum calcium

What is the most serious type of female reproductive infection?

Pelvic inflammatory disease

A patient with a family history of PIH asks the nurse if there is a cure. What information will the nurse give to this patient?

Termination of the pregnancy

The nurse is instructing a new mother about treatment for mastitis. Which statement by the patient indicates the need for further teaching?

"I will need to stop breastfeeding until the infection is gone."

The nurse is caring for a patient who reports that she has premenstrual syndrome (PMS). Which statement would be most useful to the patient?

"Some research suggests that a diet high in complex carbohydrates, moderate in protein, and low in refined sugar and sodium may help ease the symptoms."

While in the clinic, a first-time pregnant patient asks the nurse when she should be able to feel the fetus move. What is the nurse's best response?

14 to 16 weeks gestation

A nurse is collecting data on a patient who is 28 weeks pregnant. What would the nurse expect the fundal height to measure in centimeters?

28 cm

A patient has been admitted with preeclampsia. Following an assessment, the nurse notes the patient has edema of the face, hand, and abdomen. How would the nurse document this finding?

3+

What diagnostic test is useful for diagnosing cervical cancer and is recommended after a woman turns age 18?

A Papanicolaou (Pap) test

A patient is scheduled to have a total abdominal hysterectomy with bilateral salpingo-oophorectomy (TAH-BSO). She has verbalized anxiety and has stated, "I won't be a woman anymore." In formulating a response, the nurse keeps in mind which facts about a TAH-BSO? (Select all that apply.

A TAH-BSO involves removal of the entire uterus, fallopian tubes, and ovaries. The incidence of urinary retention postoperatively is greater with a hysterectomy than with any other type of surgery. This surgery will induce menopause.

The nurse is caring for a patient who has had functional blindness for 10 years. Which statement is true?

A comprehensive approach to patient care is essential with blind patients.

What is the ability of the eye to focus on objects at various distances?

Accommodation

The nurse is caring for a patient diagnosed with alcoholic cirrhosis of the liver. Which of the following items written on the nursing Kardex would you question the RN about before implementing?

Acetaminophen prn pain

The nurse is caring for a patient with toxic shock syndrome (TSS). She has a temperature of 102.5° F, and complains of feeling "awful." Which nursing intervention should receive the highest priority?

Administering the antibiotics on time

Diabetic retinopathy occurs more frequently in patients with long-standing, poorly controlled diabetes mellitus

Age-related macular degeneration

What factors have been associated with the formation of cataracts? (Select all that apply.)

Aging Ultraviolet light Exposure to maternal rubella Smoking Diabetes mellitus

A female patient diagnosed with osteoarthritis has numerous questions for the nurse about the disorder. In answering her questions, what does the nurse relay regarding osteoarthritis?

Almost considered to be an inevitable consequence of aging

Which of the following maternal changes are presumptive signs of pregnancy? (Select all that apply.)

Amenorrha Breast Changes Chadwick Sign

While assessing a pregnant patient during the 28th week of pregnancy, the nurse finds that the primary health care provider has recommended a biophysical profile test to the patient. What parameters are assessed in the patient during the test?

Amniotic Fluid Volume Fetal tone and posture Accelerations associated with maternal palpation

A woman comes to the clinic for her first prenatal visit. The nurse asks when her first day of her last menstrual cycle was. The woman reports July 10, 2004. What would the nurse calculate her estimated date of delivery to be using the Naegele rule?

April 17, 2005

An LPN/LVN hears a 1-year-old Vietnamese patient crying shortly after the parents enter the room. The LPN/LVN enters and observes an object in the mother's hand and bright red welts on the toddler's skin. What is the appropriate nursing intervention?

Ask the parent to explain what is occuring

Some infants and children require gavage feedings. What is the best technique to check placement of the feeding tube before initiating the feeding?

Aspirate for stomach contents and then inject air into the feeding tube while listening for gurgling sounds per policy and procedure.

The LPN/LVN is assessing a postpartum patient when the patient reports pain in her right calf. The LPN/LVN notes the area is reddened and edematous. What is the LPN/LVN's next intervention?

Assess for a positvie homan sign

A patient has been diagnosed with diverticulosis as a result of muscle thickening and increased intracolonic pressure. Which of the following recommendations would the nurse give her regarding food choices?

Bran, fruits, and vegetables

What is the earliest sign of increased intracranial pressure?

Change in level of consciousness (LOC)

Which characteristics are indications of true labor? (Select all that apply.)

Contractions follow a regular pattern. The cervix softens, effaces, and dilates Contractions get stronger with ambulation

A pregnant patient comes to the hospital saying she thinks her water has broken. The nurse checks the fluid with Nitrazine test paper to determine if the fluid is amniotic fluid or vaginal secretions. What color will the nurse expect the paper to turn if the fluid is amniotic?

Deep

When taking care of a patient with newly diagnosed type 1 diabetes mellitus, the nurse notes the patient is expressing some fears about long-term complications of the disease. She states, "I know I'll go blind within 10 years. Why should I bother controlling my blood sugar?" On what knowledge can the nurse's best response be based?

Diabetic retinopathy occurs more frequently in patients with long-standing, poorly controlled diabetes mellitus

A patient is undergoing a diagnostic tests to rule out carcinoma of the oral cavity. Which of the following symptoms have been associated with the disease? (Select all that apply.

Difficulty chewing, speaking, coughing chronic cough constant earache toothache mouth edema numbness or loss of sensation in part of the mouth dysphagia

What neurotransmitter primarily affects motor function and is involved in gross subconscious movements of the skeletal muscles?

Dopamine

A pregnant patient comes to the clinic for a prenatal visit. She complains of being frequently awakened at night by leg cramps. What instructions should the nurse give this patient

Dorsiflex her foot when the cramp occurs.

The hospital environment can be frightening and traumatic for children. How can the pediatric nurse help alleviate these stressors?

During preadmission, offer the parents and child a tour of the pediatric unit and inviting the parents to room-in with the child during hospitalization.

The nurse addresses the local PTA about accident prevention for adolescents. What is most important for the nurse to highlight during the session?

Education and review of basic first aid; setting consequences for substance abuse, especially drinking; and discussing the dangers of swimming alone

A patient is undergoing a diagnostic procedure in which needle electrodes are inserted into skeletal muscles to record electrical activity. What is this test called?

Electromyogram (EMG)

Which intervention would be most appropriate for the patient with hypothyroidism?

Encourage fluids

The nurse observes a new mother turning away from her infant and sighing deeply. Which intervention would be most appropriate for the nurse?

Encourage the new mother to discuss her feelings by sitting next to her and stating, "Having a baby can be overwhelming."

The nurse is caring for a patient with multiple sclerosis. What appropriate nursing care should be implemented?

Encouraging a well-balanced diet high in fiber and adequate fluids

What is the diagnostic test that involves visualization of the esophagus, stomach, and duodenum via a flexible endoscope?

Esophagogastroduodenoscopy

When assessing cultural preferences of a laboring patient, the nurse remembers to ask about traditional birth practices. Which birth practice is most common in non-American cultures?

Father is not present

What is the preferred diagnostic test for visualizing the biliary tree in a patient with jaundice?

Gallbladder ultrasound

Based on the definitions of gravida and para, what documentation best describes a woman in the clinic who is currently pregnant and has had two prior children?

Gravida III, para II

What is the most common form of hepatitis today, which has an incubation period of 10 to 40 days

Hepatitis A

What is the term for a chemical messenger that travels throughout the bloodstream to its target organ?

Hormone

A nurse is writing a care plan for a diagnosis of imbalanced nutrition: less than body requirements. What is the most common nutrition-related discomfort of pregnancy?

Hyperemesis gravidarum

A new mother reports feeling weak, light-headed, and being sick to her stomach. The LPN/LVN also notes that the patient's perineal pad is soaked since she last checked it 15 minutes ago. The patient's skin is cool and clammy. The pulse is 110 bpm and the blood pressure is 80/60. What complication do these symptoms indicate?

Hypovolemic shock

What are the most appropriate nursing diagnoses for a breastfeeding mother? (Select all that apply.)

Imbalanced nutrition: less than body requirements related to the demands during lactation Anxiety related to lactation expectations Potential for infection related to dry, cracked nipples

A patient who is 9 weeks pregnant comes to the hospital complaining of vaginal bleeding. An ultrasound reveals no heartbeat or uterine growth. The patient is to be scheduled for a D & C. What type of abortion is this?

Incomplete spontaneous abortion

The nurse is caring for a 75-year-old patient who has experienced some sensory deficits. What change might be explained by age-related changes of the sensory system?

Increased difficulty focusing on close ojects

What is a feature of Cushing syndrome?

Increased susceptibility to infection

In caring for a patient with diabetes mellitus who is experiencing an acute hyperglycemic reaction (diabetic ketoacidosis), which intervention would be most appropriate?

Insulin IV via infusion pump

A patient is scheduled to undergo T-tube cholangiography. Before administration of contrast dye, what allergy should the nurse check the patient for?

Iodine

Which statement is correct in regard to menopause?

It is recommended that menopausal women take the lowest effective dose of hormone replacement therapy for the shortest amount of time possible to relieve menopausal symptoms.

The physician is performing the Leopold maneuver on a laboring patient to check for fetal position. What is the most common position for delivery?

LOA

While assessing a laboring patient, which fetal heart tone (FHT) would the nurse consider cause for further or constant monitoring?

Late Decelerations

After delivery, a newborn is classified according to weight at any given gestational age. What would a newborn weighing 2500 g or less be classified as?

Low birth weight (LBW)

The laboring patient has just had membranes ruptured by the physician. The amniotic fluid is greenish-brown in color. What does this abnormal finding indicate?

Passage of meconium stool by the fetus

What is the most lethal complication of a peptic ulcer

Perforation

What is considered the "master gland," which exerts control over the other glands?

Pituitary gland

A female patient has undergone a needle liver biopsy 15 minutes ago. The nurse enters her room to discover her sitting up in bed reading the newspaper. What is the first action the nurse should take?

Place her on her right side

The nurse will implement which of these nursing interventions for the patient with increased intracranial pressure? (Select all that apply.)

Place neck in neutral position. Keep head of the bed angled 10° to 20°. Force fluids up to 2 L/day unless otherwise contraindicated. Teach patient to avoid Valsalva maneuver. Position patient to avoid flexion of hips, waist, and neck. Suction only as necessary, but no longer than 10 seconds.

A transrectal ultrasound is done to look at which structure?

Prostate

What anatomic part of the male reproductive system often hypertrophies with age

Prostate gland

What is the top priority when managing a patient with a ruptured esophageal varix?

Protection of airway

The nurse is admitting a patient to the unit who has been diagnosed with a urinary tract infection (UTI). The patient is acutely ill, with a temperature of 102.5° F and chills. She is grabbing her left side and complaining of severe pain. The urine specimen appears concentrated with a cloudy appearance and the nurse knows that this symptom is most associated with what type of UTI?

Pyelonephritis

The vital signs of a newborn baby girl are: T-97.9, P-140, R-34 with brief periods of apnea, and B/P-80/40 with an increase in systolic pressure when crying. What is the nurse's next intervention?

Realize these vital signs are normal for a newborn and document the data on the flow sheet.

What is the thick, white, opaque connective tissue that is part of the outermost layer of the eyeball?

Sclera

What type of hearing loss involves normal sound conduction through the external and middle ear, but distortion in the inner ear, making discrimination difficult?

Sensorineural hearing loss

What blood test is done to evaluate for impaired renal function, which is affected very little by dehydration, malnutrition, or hepatic function?

Serum creatinine

What is a true statement regarding illness and sexuality?

Sexual dysfunction of a patient with diabetes mellitus can occur when the disease is not well-controlled.

What is an example of a flat bone?

Skull and sternum

When caring for a patient with hydronephrosis, what would be the most appropriate nursing interventions? (Select all that apply.)

Strict intake and output recording Assessment and management of pain Observing for signs and symptoms of infection

What is a true statement about diabetes mellitus type 2?

The main problem in this disease seems to be abnormal resistance to insulin action.

The nurse must know how to compute medication doses correctly for children. Which is correct regarding the dosage calculation for children?

The proportional amount of BSA to body weight is calculated.

Which statement is true regarding the anatomy and physiology of the renal system

The three phases of urine formation are filtration, reabsorption, and secretion

When the delivery of the placenta is complete, which stage of labor is complete?

Third stage

What is an imaging technique in which deep structures of the body are visualized by recording reflections or echoes of ultrasonic waves directed into the tissues?

Ultrasonography

The LPN/LVN is reading over the nursing care plan for a newly admitted female patient. One nursing diagnosis written is "impaired urinary elimination." The LPN/LVN is not certain exactly what that means, but upon further reading of the care plan, discovers nursing interventions listed as including "remind patient to perform Kegel exercises four times per shift" and "assist patient to toilet every 2 hours." Considering the care plan information, what is the patient most likely experiencing?

Urinary Incontinence

Because pain is often underestimated in children, how will the nurse best assess a child's pain?

Use accepted pain assessment tools, such as the Wong-Baker FACES scale.

The nurse uses many communication strategies when talking with children. Which strategies would be appropriate for the pediatric nurse? (Select all that apply.)

Using a calm, unhurried voice in a positive way to give directions or information. Avoid phrases that may be misinterpreted or provide more information than the child can understand. As a general guide, use sentences whose sum of words is equal to the child's age in years plus one

A 3-month-old at the clinic is to receive an intramuscular injection. What is the most appropriate site for this injection?

Vastus lateralis muscle

What are the most appropriate nursing care and patient teaching for the patient with external otitis?

Washing hands before and after changing cotton plug

A patient with carcinoma of the esophagus is about to undergo surgery, an esophagogastrectomy, and is very anxious about what to expect immediately after surgery. Which of the following statements would be appropriate to help calm his anxiety?

When you wake up, we will be monitoring you very closely. We will give you pain medication and do everything we can to keep you as comfortable as possible

Which of the following are risk factors for osteoporosis? (Select all that apply.)

White or Asian woman High intake of caffine steroid use postmenopausal females anticonvulsant therapy for seizure disorder

What will the nurse include in postoperative nursing care for a patient who has undergone a hip fracture repair?

Wound assessment with special attention paid to color, amount, and odor of exudate; frequent monitoring of vital signs; suture line assessment; and accurate intake and output recording

What is the term for shortening and thinning of the cervix during the first stage of labor?

effacement