108 FINAL EXAM

A client who is legally blind is being admitted to the hospital. The client informs the nurse that she needs to have her guide dog present during her hospitalization. What is the nurse's best response to the client?

"Arrangements can be made for your guide dog to be at the hospital with you during your stay."

The staff development nurse is presenting a class on the importance of incorporating "people-first" language into daily practice as well as documentation. What is an example of the use of "people-first" language when giving a verbal report?

"The client with schizophrenia"

The nurse in a pediatric ICU is caring for a child who is dying of sickle cell disease. The child's mother has been unable to eat or sleep and can talk only about her impending loss and the guilt she feels about the child's pain and suffering. What intervention has the highest priority?

Allowing the client to express her feelings without judging her

A home health nurse makes a home visit to a 90-year-old client who has cardiovascular disease. During the visit the nurse observes that the client has begun exhibiting subtle and unprecedented signs of confusion and agitation. What should the home health nurse do?

Arrange for the client to see his primary care provider.

The nurse is providing care for an older adult client who has a diagnosis of shingles. The nurse is aware that this health problem is attributable to the varicella zoster virus. This belief is an example of which paradigm explaining the cause of disease and illness?

Biomedical

A client is scheduled for surgery the next day and the different phases of the client's surgical experience will require input from members of numerous health disciplines. How should the client's care best be coordinated?

By implementing an interdisciplinary approach to care

The nurse is admitting a client who is a recent immigrant from China and who has a diagnosis of adenocarcinoma. During the client's admission assessment, the client speaks of her beliefs related to health care and indirectly references the yin/yang theory. Based on her cancer diagnosis and her yin/yang beliefs, which meal will the client most likely order for lunch?

Chicken noodle soup with crackers, fruit crisp, and hot tea

The nurse walks into a client's room and finds the client sobbing uncontrollably. The client states, "I am so scared. I have never known anyone who goes into a hospital and comes out alive." On the client's care plan, the nurse reads that there is a pre-existing nursing diagnosis of Ineffective Coping related to stress. What outcome is most appropriate to this client's care?

Client will adopt coping mechanisms to reduce stress.

A client with hypertension has been prescribed hydrochlorothiazide. What nursing action will best reduce the client's risk for electrolyte disturbances?

Ensure the client has sufficient potassium intake

A home care nurse is teaching meal-planning to a client's son who is caring for his mother during her recovery from hip replacement surgery. Which of the following meals indicates that the son understands the concept of nutrition, based on the U.S. Department of Agriculture's MyPlate?

Ham sandwich with tomato on rye bread with peaches and yogurt

While assessing a newly admitted client, the nurse identifies impaired coordination, decreased muscle strength, limited range of motion, and reluctance to move. What nursing diagnosis do these signs and symptoms most clearly suggest?

Impaired physical mobility

An oncology nurse educator is providing health education to a client who has been diagnosed with skin cancer. The client's wife has asked about the differences between normal cells and cancer cells. What characteristic of a cancer cell should the educator cite?

Malignant cells contain proteins called tumor-associated antigens.

An elderly client, while being seen in an urgent care facility for a possible respiratory infection, asks the nurse if Medicare is going to cover the cost of the visit. What information can the nurse give the client?

Medicare has a copayment for many of the services it covers. This requires the client to pay a part of the bill.

The nursing profession and nurses as individuals have a responsibility to promote activities that foster well-being. What factor has most influenced nurses' abilities to play this vital role?

Nurses have long-established credibility with the public.

A nurse is collaborating with a team of community nurses to identify the vision and mission for community care. What is the central focus of community-based nursing?

Promoting and maintaining the health of individuals and families

The home health nurse is caring for a homebound client who is terminally ill. You are delivering a patient-controlled analgesia (PCA) pump to the client at your visit today. The family members will be taking care of the client. What would your priority nursing interventions be for this visit?

Provide client and family teaching regarding the operation of the pump, monitoring the IV site, and knowing the side effects of the medication.

A client who is receiving rehabilitation following a spinal cord injury has been diagnosed with reflex incontinence. The nurse caring for the client should include which intervention in this client's plan of care?

Regular perineal care to prevent skin breakdown

A medical nurse is providing end-of-life care for a client with metastatic bone cancer. The nurse notes that the client has been receiving oral analgesics for her pain with adequate effect, but is now having difficulty swallowing the medication. What should the nurse do?

Request the physician to prescribe analgesics by an alternative route.

Nursing continues to recognize and participate in collaboration with other health care disciplines to meet the complex needs of the client. Which of the following is the best example of a collaborative practice model?

The nurse and the physician jointly making clinical decisions.

A client has completed the acute treatment phase of care following a stroke and the client will now begin rehabilitation. What should the nurse identify as the major goal of the rehabilitative process?

To restore the client's ability to function independently

The nurse is assessing a client with end-stage liver failure for the presence of hope. What should the nurse identify as a hope-fostering category?

Uplifting memories

The nurse is caring for a client who anticipates pain and anxiety following his prostatectomy. Which intervention will likely best assist in decreasing the client's pain and anxiety?

Use of guided imagery along with pain medication

A 16-year-old female client experiences alopecia resulting from chemotherapy, prompting the nursing diagnoses of disturbed body image and situational low self-esteem. The nurse should determine that the client is meeting the goal of improved body image and self-esteem when the client

requests that her family bring her makeup and wig.

A client tells the nurse that he has just been told that his computed tomography results were abnormal. The nurse expects that his sympathetic nervous system has stimulated his adrenal gland to release what?

Epinephrine

Prior to a client's scheduled surgery, the nurse has described the way that members of diverse health disciplines will collaborate in the client's care. What is the main rationale for organizing perioperative care in this collaborative manner?

Evidence-based practice

An adult client, estranged from his siblings, has begun showing signs of dementia and has been diagnosed with Alzheimer disease. The nurse tells him how important it is that he inform his siblings of his disease. He refuses stating, "I don't want them to know. Let them find out on their own." What should the nurse do?

Instruct the client on the importance of notifying the siblings and keep his information confidential

A couple wants to start a family and they are concerned that their child will be at risk for cystic fibrosis because they each have a cousin with cystic fibrosis. What should the nurse practitioner tell them about cystic fibrosis?

It is an autosomal recessive disorder.

An OR nurse will be participating in the intraoperative phase of a client's kidney transplant. What action will the nurse prioritize in this aspect of nursing care?

Monitoring the client's physiologic status

The mother of a client with cancer comes to the nurse concerned with her daughter's safety. She states that the dose of morphine that her daughter requires to control her pain is getting "higher and higher." As a result, the mother is afraid that her daughter will overdose. The nurse should educate the mother about what aspect of her pain management?

There is no absolute maximum opioid dose and her daughter is becoming more tolerant to the drug.

The nurse is caring for a client has just been given a 6-month prognosis following a diagnosis of extensive stage small-cell lung cancer. The client states that he would like to die at home, but the team believes that the client's care needs are unable to be met in a home environment. What might the nurse suggest as an alternative?

Discuss a referral for hospice care.

The nurse is admitting a Native American/First Nation client with uncontrolled hypertension and type 1 diabetes to the unit. During the initial assessment, the client informs the nurse that he has been seeking assistance and care from the shaman in his community. The nurse recognizes that the client's blood pressure and his blood sugar level are elevated upon admission. What is the nurse's best response to the client's indication that his care provider is a shaman?

"I understand that you value the care provided by the shaman, and we would like you to consider medications and dietary changes that may lower your blood pressure and blood sugar levels."

The nurse is reviewing the importance of preventative health care with a client who has a disability. The client describes intense financial pressures associated with being disabled. What is the nurse's best response?

"I'll look into federal assistance programs that provide financial assistance for health-related expenses for people with disabling conditions."

A client's most recent diagnostic imaging has revealed that his lung cancer has metastasized to his bones and liver. What is the most likely mechanism by which the client's cancer cells spread?

Apoptosis Angiogenesis Invasion Lymphatic circulation

The nurse is providing care for a client with chronic obstructive pulmonary disease. When describing the process of respiration the nurse explains how oxygen and carbon dioxide are exchanged between the pulmonary capillaries and the alveoli. The nurse is describing what process?

Diffusion

An adult client has survived an episode of shock and will be discharged home to finish the recovery phase. What aspect of his care should be prioritized by the home health nurse?

Assisting the client and family to identify and mobilize community resources??? Providing supervision to home health aides in providing necessary client care

A nurse is working with a teenage boy who was recently diagnosed with asthma. During the current session, the nurse has taught the boy how to administer his bronchodilator by metered-dose inhaler. How should the nurse best evaluate the teaching-learning process?

Directly observe the boy using his inhaler to give himself a dose

A nurse practicing in an oncology clinic has the goal of improving client outcomes and nursing care by influencing the client, the nurse, and the health care system. What is this nurse's most likely role?

Clinical nurse specialist

The nurse is preparing an elderly client for a scheduled removal of orthopedic hardware, a procedure to be performed under general anesthetic. For which adverse effect should the nurse most closely monitor the client?

Hypothermia

The nurse is caring for a client who has terminal lung cancer and is unconscious. Which assessment finding would most clearly indicate to the nurse that the client's death is imminent?

Mottling of the lower limbs

The nurse is performing wound care on a postsurgical client. Which of the following practices violates the principles of surgical asepsis?

Pouring solution onto a sterile field cloth

The nurse is assessing a client who is experiencing stress because of a recent hip fracture and the exacerbation of chronic heart failure. What is an example of a bodily function that restores homeostasis by negative feedback when conditions shift out of normal range?

Pupil dilation Body temperature Diuresis

The nurse is assessing an 80-year-old client who has presented because of an unintended weight loss of 10 lb over the past 8 weeks. During the assessment, the nurse learns that the client has ill-fitting dentures and a limited intake of high-fiber foods. The nurse should assess the client's risk for what problem?

Constipation

Staff nurses in an ICU setting have noticed that their clients required lower and fewer doses of analgesia when noise levels on the unit were consciously reduced. They informed an advanced practice RN of this and asked the APRN to quantify the effects of noise on the pain levels of hospitalized clients. How does this demonstrate the role of the APRN?

Contributing to the scientific basis of nursing practice

The nurse is providing care for a client who is in shock after massive blood loss from a workplace injury. The nurse recognizes that many of the findings from the most recent assessment are due to compensatory mechanisms. What compensatory mechanism will increase the client's cardiac output during the hypovolemic state?

Tachycardia Dysrhythmias Third spacing of fluid Gastric hypermotility

A 60-year-old client who has diabetes had a below-knee amputation 1 week ago. The client asks, "Why does it still feel like my leg is attached, and why does it still hurt?" The nurse explains neuropathic pain in terms that are accessible to the client. The nurse should describe what pathophysiologic process?

The abnormal reorganization of the nervous system

The nurse in a pain clinic caring for a client who is suffering from long-term, intractable pain. The pain team feels that first-line pharmacologic and nonpharmacologic methods of pain relief have been ineffective. What recommendation should guide this client's subsequent care?

The client may benefit from referral to a neurologist or neurosurgeon to discuss pain-management options.

The nurse is providing care for a 90-year-old client whose severe cognitive and mobility deficits result in the nursing diagnosis of risk for impaired skin integrity due to lack of mobility. When planning relevant assessments, the nurse should prioritize inspection of what area?

The client's knees The soles of the client's feet The client's elbows The client's heels

The nurse is receiving an older adult client from the PACU. Part of the report had been passed on from the preoperative assessment where it was noted that the client has been agitated in the past following opioid administration. What principle should guide the nurse's management of the client's pain?

The elderly may require lower doses of medication and are easily confused with new medications.

The PACU nurse is caring for a client who has arrived from the OR. During the initial assessment, the nurse observes that the client's skin has become blue and dusky. The nurse looks, listens, and feels for breathing, and determines the client is not breathing. What is the priority intervention?

Treat the possible airway obstruction by tilting the head back and pushing forward on the angle of the lower jaw.

The nurse is caring for a client who is withdrawing from heavy alcohol use and who is consequently combative and confused, despite the administration of benzodiazepines. The client has a fractured hip that he suffered in a traumatic accident and is trying to get out of bed. What is the most appropriate action for the nurse to take?

Obtain a physician's order to restrain the client

A nurse is planning discharge teaching for an older adult client with mild short-term memory loss. The discharge teaching will include how to perform basic wound care for the venous ulcer on the client's lower leg. When planning the necessary health education for this client, the nurse should

keep teaching periods short.

The admissions department at a local hospital is registering a male older adult for an outpatient diagnostic test. The admissions nurse asks the man if he has an advanced directive. The man responds that he does not want to complete an advance directive because he does not want anyone controlling his finances. What would be appropriate information for the nurse to share with this client?

"Advance directives are limited only to health care instructions and directives."

An adult client with leukemia will soon begin chemotherapy. What would the nurse do to combat the most common adverse effects of chemotherapy?

Administer an antiemetic

The nurse is caring for an older adult client who has been involved in a motor vehicle accident. The client's labs indicate minimally elevated serum creatinine levels. The nurse should assess for signs of what change?

Substantially reduced renal function

Which client is most likely to benefit from the principles of precision medicine?

A client newly diagnosed with non-Hodgkin lymphoma

The nurse is planning an educational event for the nurses on a subacute medical unit on the topic of normal, age-related physiologic changes. What phenomenon should the nurse address?

A decrease in muscle mass and bone density

A presurgical client asks, "Why will I go to the PACU instead of just going straight up to the postsurgical unit?" What is the nurse's best response?

"The PACU allows you to recover from the effects of anesthesia, and you'll stay in the PACU until you're oriented, have stable vital signs, and are without complications."

A client has been hospitalized for a wedge resection of the left lower lung lobe after a routine chest x-ray shows carcinoma. The client states that he is anxious and asks if he can smoke. Which statement by the nurse would be most therapeutic?

"You are anxious about the surgery. Do you see smoking as helping

A nurse has been studying research that examines the association between stress levels and negative health outcomes. Which relationship between stress and other factors should inform the nurse's teaching plan?

Stress decreases immune function.

The clinic nurse is caring for an adult oncology client who reports extreme fatigue and weakness after the first week of radiation therapy. Which response by the nurse would best reassure this client?

"These symptoms usually result from radiation therapy; however, we will continue to monitor your laboratory and studies and test results."

The nurse in a rural nursing outpost will be receiving a client in hypovolemic shock due to a massive postpartum hemorrhage after her home birth. What principle should guide the nurse's administration of intravenous fluid?

Whatever fluid is most readily available in the clinic should be given, due to the nature of the emergency

The emergency department nurse is obtaining a health history from a client who has earlier told the triage nurse that she is experiencing intermittent abdominal pain. What question should the nurse ask to elicit the probable reason for the visit and identify her chief complaint?

"What brings you to the hospital today?"

To explain the concept of autosomal recessive inheritance, a nurse is using the example of two parents with two recessive genes each for six toes. What is the chance that this couple will have a child with six toes?

25% 100% 50% 75%

A community health nurse is aware that restoration of health often depends on appropriate interventions performed early in the course of a disease. Which client is most likely to seek health care late in the course of his or her disease process and deteriorate more quickly than other clients?

A client who has been homeless for an extended period of time

A public health nurse is preparing to hold a series of health promotion classes for middle-aged adults that will address a variety of topics. Which location would best meet the learning needs of this population?

A large, local workplace

A client is in a hospice receiving palliative care for lung cancer which has metastasized to the client's liver and bones. For the past several hours, the client has been experiencing dyspnea. What nursing action is most appropriate?

Administer bronchodilators and corticosteroids, as prescribed.

An elderly client is brought to the emergency department with a fractured tibia. The client appears malnourished, and the nurse is concerned about the client's healing process related to insufficient protein levels. What laboratory finding would the floor nurse prioritize when assessing for protein deficiency?

Albumin

A nurse will conduct an influenza vaccination campaign at an extended care facility. The nurse will be administering intramuscular (IM) doses of the vaccine. Of what age-related change should the nurse be aware when planning the appropriate administration of this drug?

An older client has less subcutaneous tissue and less muscle mass than a younger client.

The nurse is caring for a client who lives with chronic pain. During the initial health interview, the client tells the nurse that she has begun a regimen of herbal remedies in order to control her pain. What is the nurse's priority action?

Ensure that the client has informed the primary provider about these supplements

A client admitted with right leg thrombophlebitis is to be discharged from an acute care facility. Following treatment with a heparin infusion, the nurse notes that the client's leg is pain free, without redness or edema. Which step of the nursing process does this reflect?

Evaluation

A pregnant woman has a child at home who has been diagnosed with neurofibromatosis 1. She asks the nurse what she should look for in her new baby that would indicate that it also has neurofibromatosis 1. What sign should the nurse instruct the woman to look for in the new baby?

Café-au-lait spots

A client has had a total knee replacement and will need to walk with a two-wheeled walker for 6 weeks. The client is being discharged home with a referral for home health care. What assessment should the nurse prioritize during the initial nursing assessment in the home?

Characteristics of the home environment

The nurse has just received report on a client who is coming to the unit from the emergency department with a torn meniscus. The nurse reviews the PRN medications and sees that an NSAID (ibuprofen) is prescribed every 6 hours. How should the nurse best implement preventive pain measures?

Check for allergies, use a pain scale to assess the client's pain, and offer the ibuprofen every 6 hours until the client is discharged.

Baroreceptors in the left atrium and in the carotid and aortic arches, respond to changes in the circulating blood volume and regulate sympathetic and parasympathetic neural activity as well as endocrine activities. Sympathetic stimulation constricts renal arterioles, causing what effect?

Decrease in glomerular filtration

During the integumentary assessment of an adult female client, the nurse observes that the client has dry, dull, brittle hair and dry, flaky skin with poor turgor. When planning this client's nursing care, the nurse should prioritize interventions that address what problem?

Deficient nutritional status

A client has a diagnosis of breast cancer and is tearfully discussing her diagnosis with the nurse. The client states, "They tell me my cancer is malignant, while my coworker's breast tumor was benign. I just don't understand at all." When preparing a response to this client, the nurse should be aware of what characteristic that distinguishes malignant cells from benign cells of the same tissue type?

Different proteins in the cell membrane

The nurse is packing a client's abdominal wound with sterile, half-inch Iodoform gauze. During the procedure, the nurse drops some of the gauze onto the client's abdomen 2 inches (5 cm) away from the wound. What should the nurse do?

Discard the gauze packing and repack the wound with new Iodoform gauze.

A critical care nurse is aware of similarities and differences between the treatments for different types of shock. What intervention is used in all types of shock?

Early provision of nutritional support

The nurse is doing a preoperative assessment of an 87-year-old man who is slated to have a right lung lobe resection to treat lung cancer. What underlying principle should guide the nurse's preoperative assessment of an elderly client?

Elderly clients have less physiologic reserve than younger clients.

The nurse has been assigned to care for a client admitted with an opportunistic infection secondary to AIDS. The nurse informs the clinical nurse leader that she is refusing to care for him because he has AIDS. The nurse has an obligation to this client under which of the following?

Good Samaritan Act International Council of Nurses (ICN) Code of Ethics for Nurses The nurse practice act in the nurse's jurisdiction Nursing Interventions Classification (NIC)

The nurse is assessing a client and learns that the client and his wife were married just 3 weeks earlier. What principle should underlie the nurse's care planning for this client?

Happy events do not normally cause stress. The client and spouse should seek counseling to ease their transition. Marriage causes transition, which has the potential to cause stress.

An adult client has just been admitted to the PACU following abdominal surgery. As the client begins to awaken, he is uncharacteristically restless. The nurse checks his skin and it is cold, moist, and pale. The nurse concerned the client may be at risk for what?

Hemorrhage and shock

When planning the care of a client with a fluid imbalance, the nurse understands that in the human body, water and electrolytes move from the arterial capillary bed to the interstitial fluid. What causes this to occur?

Hydrostatic pressure resulting from the pumping action of the heart

As a case manager, the nurse oversees the multidisciplinary care of several clients living with chronic conditions. Two of the nurse's clients are living with spina bifida. The center of care for these two clients will typically exist where?

In the home

The nurse in the ED is caring for a client recently admitted with a likely myocardial infarction. The nurse understands that the client's heart is pumping an inadequate supply of oxygen to the tissues. For what health problem should the nurse assess?

Increase in heart rate Increase in blood pressure Decrease in oxygen demands Dysrhythmias

The nurse is assessing a client and palpates two enlarged supraclavicular lymph nodes. The nurse asks the client how long these nodes have noticeably enlarged. The client states, "I can't remember. A long time I think. Do I have cancer?" Which of the following is an immediate physiologic response to stress the nurse would expect this client to experience?

Increased blood pressure

The nurse is evaluating a newly admitted client's laboratory results, which include several values that are outside of reference ranges. Which of the following alterations would cause the release of antidiuretic hormone (ADH)?

Increased serum sodium

Verification that all required documentation is completed is an important function of the intraoperative nurse. The intraoperative nurse should confirm that the client's accompanying documentation includes which of the following?

Informed consent

An emergency department nurse is caring for a 7-year-old child suspected of having meningitis. The client is to have a lumbar puncture performed, and the nurse is doing preprocedure teaching with the child and the mother. The nurse's action is an example of which therapeutic communication technique?

Informing

The nurse is caring for a client admitted with cardiogenic shock. The client is experiencing chest pain and there is an order for the administration of morphine. In addition to pain control, what is the main rationale for administering morphine to this client?

It dilates the blood vessels.

The nurse is caring for a client in shock who is receiving enteral nutrition. What is the basis for enteral nutrition being the preferred method of meeting the body's needs?

It promotes GI function through direct exposure to nutrients.

The nurse in the ICU is caring for a 47-year-old, obese male client who is in shock following a motor vehicle accident. What would be the main challenge in meeting this client's elevated energy requirements during prolonged rehabilitation?

Loss of skeletal muscle

A female client, 47 years old, visits the clinic because she has been experiencing stress incontinence when she sneezes or exercises vigorously. What is the best instruction the nurse can give the client?

Perform Kegel exercises four to six times per day

The nurse is caring for a client who is postoperative day 2 following a colon resection. While turning him, wound dehiscence with evisceration occurs. What should be the nurse's first response?

Place saline-soaked sterile dressings on the wound.

A client is on call to the OR for an aortobifemoral bypass and the nurse administers the prescribed preoperative medication. After administering a preoperative medication to the client, what should the nurse do?

Place the bed in a low position with the side rails up.

A client on the medical unit is dying and the nurse has determined that the family's psychosocial needs during the dying process need to be addressed. What is a cause of many client care dilemmas at the end of life?

Poor communication between the family and the care team

The nurse is caring for an 82-year-old female client in the PACU. The woman begins to awaken and responds to her name, but is confused, restless, and agitated. What principle should guide the nurse's subsequent assessment?

Postoperative confusion is common in the older adult client, but it could also indicate a significant blood loss.

A client is scheduled for a bowel resection in the morning and the client's orders include a cleansing enema tonight. The client wants to know why this is necessary. The nurse should explain that the cleansing enema will have what therapeutic effect?

Preventing potential contamination of the peritoneum

The nurse is caring for a male client who has had spinal anesthesia. The client is under a physician's order to lie flat postoperatively. When the client asks to go to the bathroom, you encourage him to adhere to the physician's order. What rationale for complying with this order should the nurse explain to the client?

Preventing the onset of a headache

The nurse is caring for a client with a history of chronic angina. The client states that after breakfast he usually takes a shower and shaves. It is at this time, the client says, that he tends to experience chest pain. What should the nurse counsel the client to do to decrease the likelihood of angina in the morning?

Shower in the evening and shave before breakfast Shower once a week and shave prior to breakfast Take a nitroglycerin tab prior to breakfast Skip breakfast and eat an early lunch

A school nurse works with a diverse population of students in a large school. Which students are known to particularly benefit from interaction with a school nurse?

Students from low-income families

A client comes into the emergency department (ED) by ambulance after slipping on a small carpet in his home. The client fell on his hip with a resultant fracture. He is alert and oriented; his pupils are equal and reactive to light and accommodation. His heart rate is elevated, he is anxious and thirsty, a Foley catheter is placed, and 40 mL of urine is present. What is the nurse's most likely explanation for the low urine output?

The man is having a sympathetic reaction, which has stimulated the renin-angiotensin-aldosterone system that results in diminished urine output.

A newly graduated nurse is admitting a client with a long history of emphysema. The nurse learns that the client's PaCO2 has been between 56 and 64 mm Hg for several months. Why should the nurse be cautious administering oxygen?

Using oxygen may result in the client developing carbon dioxide narcosis and hypoxemia.

The nurse is performing a preadmission assessment of a client scheduled for a bilateral mastectomy. The nurse should be aware of what purpose of the preadmission assessment?

Verifies completion of preoperative diagnostic testing