ADN 301 Module 3 DECK

While examining the lymph nodes during physical assessment, the nurse would be most concerned about a. a 2-cm nontender supraclavicular node. b. a 1-cm mobile and nontender axillary node. c. an inability to palpate any superficial lymph nodes. d. firm inguinal nodes in a patient with an infected foot.

a. a 2-cm nontender supraclavicular node.

A patient admitted with metastatic lung cancer is ordered to receive morphine sulfate for pain. Which side effect of this medication should the nurse try to prevent with oral intake and medication? Diarrhea Agitation Constipation Urinary frequency

Constipation

After a patient died of severe injuries from a motor vehicle crash, the nurse who provided care is feeling helpless and powerless. What intervention would be most appropriate to help this nurse deal with these emotions and the death of this patient? Maintain daily contact with the adolescent's family for the next 2 to 3 months. Request a prescription for an anxiolytic to aid in dealing with the death of this patient. Attend a debriefing session with interprofessional team to allow expression of feelings. Avoid caring for any other patients who are terminally ill until the feelings of grief subside.

Attend a debriefing session with interprofessional team to allow expression of feelings.

13. A patient with type 1 diabetes uses 20 U of Novolin 70/30 (NPH/regular) in the morning and at 6:00 pm. When teaching the patient about this regimen, what should the nurse emphasize? a. Hypoglycemia is most likely to occur before the noon meal. b. A set meal pattern with a bedtime snack is necessary to prevent hypoglycemia. c. Flexibility in food intake is possible because insulin is available 24 hours a day. d. Premeal glucose checks are required to determine needed changes in daily dosing.

B

In type 1 diabetes, glucose has an osmotic effect when insulin deficiency prevents the use of glucose for energy. Which classic symptom is caused by the osmotic effect of glucose? a. Fatigue b. Polydipsia c. Polyphagia d. Recurrent infections

B

Which nursing assessment of a 70-yr-old patient is most important to make during initiation of thyroid replacement with levothyroxine (Synthroid)? a. Fluid balance b. Apical pulse rate c. Nutritional intake d. Orientation and alertness

ANS: B In older patients, initiation of levothyroxine therapy can increase myocardial oxygen demand and cause angina or dysrhythmias. The medication also is expected to improve mental status and fluid balance and will increase metabolic rate and nutritional needs, but these changes will not result in potentially life-threatening complications.

Which laboratory value reported to the nurse by the unlicensed assistive personnel (UAP) indicates the most urgent need for the nurse's assessment of the patient? a. Bedtime glucose of 140 mg/dL b. Noon blood glucose of 52 mg/dL c. Fasting blood glucose of 130 mg/dL d. 2-hr postprandial glucose of 220 mg/dL

ANS: B The nurse should assess the patient with a blood glucose level of 52 mg/dL for symptoms of hypoglycemia and give the patient a carbohydrate-containing beverage such as orange juice. The other values are within an acceptable range or not immediately dangerous for a diabetic patient.

After obtaining the information shown in the accompanying figure regarding a patient with Addison's disease, which prescribed action will the nurse take first? a. Give 4 oz of fruit juice orally. b. Recheck the blood glucose level. c. Infuse 5% dextrose and 0.9% saline. d. Administer O2 therapy as needed.

ANS: C The patient's poor skin turgor, hypotension, and hyponatremia indicate an Addisonian crisis. Immediate correction of the hypovolemia and hyponatremia is needed. The other actions may also be needed but are not the initial action for the patient.

You are giving a report in your pathophysiology class. The subject of your report is cancer cells. In differentiating between benign and malignant cells, what characteristics would you cite? (Mark all that apply.) A) Rate of growth B) Ability to cause death C) Size of cells D) Cell contents E) Ability to spread

A, B, E

10. During routine health screening, a patient is found to have fasting plasma glucose (FPG) of 132 mg/dL (7.33 mmol/L). At a follow-up visit, a diagnosis of diabetes would be made based on which laboratory results (select all that apply)? a. A1C of 7.5% b. Glycosuria of 3 + c. FPG ≥ 127 mg/dL (7.0 mmol/L). d. Random blood glucose of 126 mg/dL (7.0 mmol/L) e. A 2-hour oral glucose tolerance test (OGTT) of 190 mg/dL (10.5 mmol/L)

A, C

The patient is admitted with hypercalcemia, polyuria, and pain in the pelvis, spine, and ribs with movement. Which hematologic problem would most likely cause these manifestations? Multiple myeloma Thrombocytopenia Megaloblastic anemia Myelodysplastic syndrome

Multiple myeloma

Unless contraindicated, postoperative surgical patients should be given alternating doses of acetaminophen and which medication throughout the postoperative course?

NSAIDS

The nurse is caring for a patient receiving morphine sulfate 10 mg IV push when necessary for pain. Upon assessment, the nurse finds the patient obtunded with a respiratory rate of 8 breaths/min. Which medication would the nurse prepare to administer to treat these symptoms? Atropine Naloxone Protamine sulfateIncorrect Answer Neostigmine bromide

Naloxone

A 38-year-old male patient is admitted to the hospital in Addisonian crisis. Which patient statement supports a nursing diagnosis of ineffective self-health management related to lack of knowledge about management of Addison's disease? a. "I frequently eat at restaurants, and my food has a lot of added salt." b. "I had the stomach flu earlier this week, so I couldn't take the hydrocortisone." c. "I always double my dose of hydrocortisone on the days that I go for a long run." d. "I take twice as much hydrocortisone in the morning dose as I do in the afternoon."

b. "I had the stomach flu earlier this week, so I couldn't take the hydrocortisone."

A patient is being admitted with a diagnosis of Cushing syndrome. Which findings will the nurse expect during the assessment? a. Chronically low blood pressure b. Bronzed appearance of the skin c. Purplish streaks on the abdomen d. Decreased axillary and pubic hair

c. Purplish streaks on the abdomen

It is important for the nurse providing care for a patient with sickle cell crisis to a. limit the patient's intake of oral and IV fluids. b. evaluate the effectiveness of opioid analgesics. c. encourage the patient to ambulate as much as tolerated. d. teach the patient about high-protein, high-calorie foods.

b. evaluate the effectiveness of opioid analgesics

Charcot-Marie Tooth disease is a type of __________________ peripheral neuropathy a. acquired b. communal c. idiopathic d. hereditary

d. hereditary

post thyroidectomy, what would you act on first? a. dry mouth b. incisional pain 6/10 c. oxygen at 95% d. manual bp of 79/48

d. manual bp of 79/48

In reviewing a 55-year-old patient's medical record, the nurse notes that the last eye examination revealed an intraocular pressure of 28 mm Hg. The nurse will plan to assess a. visual acuity.b. pupil reaction. c. color perception.d. peripheral vision

d. peripheral vision

The primary purpose of hospice is to a. allow patients to die at home b. provide better quality of care than the family can c. coordinate care for dying patients and their families d. provide comfort and support for dying patients and their families

d. provide comfort and support for dying patients and their families

The nurse is caring for a patient admitted to the hospital with a head injury who requires frequent neurologic assessment. Which components are assessed using the Glasgow Coma Scale (GCS)? (Select all that apply.) Judgment Eye opening Abstract reasoning Best motor response Best verbal response Cranial nerve function

Eye opening Best motor response Best verbal response

The nurse assesses a patient for signs of meningeal irritation. Which finding indicates nuchal rigidity is present? Tonic spasms of the legs Curling in a fetal position Arching of the neck and back Resistance to flexion of the neck

Resistance to flexion of the neck

How do generalized seizures differ from focal seizures? Group of answer choices a. Focal seizures are confined to one side of the brain and never spread to the rest of the brain b. Generalized seizures result in loss of consciousness, whereas focal seizures do not c. Generalized seizures result in temporary residual deficits during the postictal phase d. Generalized seizures have bilateral synchronous epileptic discharges affecting the whole brain at onset of the seizure

d. Generalized seizures have bilateral synchronous epileptic discharges affecting the whole brain at onset of the seizure

A 48-year-old male patient screened for diabetes at a clinic has a fasting plasma glucose level of 120 mg/dL (6.7 mmol/L). The nurse will plan to teach the patient about a. self-monitoring of blood glucose. b. using low doses of regular insulin. c. lifestyle changes to lower blood glucose. d. effects of oral hypoglycemic medications.

c. lifestyle changes to lower blood glucose.

A postoperative 68-year-old opioid naïve patient is receiving morphine by patient controlled analgesia (PCA) for postoperative pain. What is the reason for not starting the PCA analgesic with a basal dose of analgesic as well? a. Opioid overdose d. Adverse respiratory outcomes c. Lack of pain control b. Nausea and itching

d. Adverse respiratory outcomes

During change-of-shift report, the nurse learns that a patient with a head injury has decorticate posturing to noxious stimulation. Which positioning shown in the accompanying figure will the nurse expect to observe? a. (1) hands curled up to chest. b.(2) hands flexed and externally rotated to side of torso. c.(3) one hand on chest and one hand on the side of the torso. d.(4)Torso prosturing

ANS: A With decorticate posturing, the patient exhibits internal rotation and adduction of the arms with flexion of the elbows, wrists, and fingers. The other illustrations are of decerebrate, mixed decorticate and decerebrate posturing, and opisthotonic posturing.DIF: Cognitive Level: Understand (comprehension)

A patient has been diagnosed with acute myelogenous leukemia (AML). What should the nurse educate the patient that care will focus on? Leukapheresis Attaining remission One chemotherapy agent Waiting with active supportive care

Attaining remission

The thrombocytopenic patient has had a bone marrow biopsy taken from the posterior iliac crest. What intervention is the priority for this patient after this procedure? Position the patient prone. Apply a pressure dressing. Administer analgesic for pain. Return metal objects to the patient.

Apply a pressure dressing

The provider orders intracranial pressure (ICP) readings every hour for a patient with a traumatic brain injury from a motor vehicle crash. The patient's ICP reading is 21 mm Hg. It is most important for the nurse to take which action? Document the ICP reading in the chart. Determine if the patient has a headache. Assess the patient's level of consciousness. Position the patient with head elevated 60 degrees.

Assess the patient's level of consciousness.

Collaboration: The following interventions are planned for a patient with diabetes. Which intervention can the nurse delegate to unlicensed assistive personnel (UAP)? a. Discuss complications of diabetes. b. Check that the bath water is not too hot. c. Check the patient's technique for drawing up insulin. d. Teach the patient to use a meter for self-monitoring of blood glucose.

B

Cortisol, glucagon, epinephrine, and growth hormone are referred to as counterregulatory hormones because they a. Decrease glucose production b. Stimulate glucose output by the liver c. Increase glucose transport into the cells d. Independently regulate glucose level in the blood

B

When teaching the patient with diabetes about insulin administration, the nurse should include which instruction? a. Pull back on the plunger after inserting the needle to check for blood. b. Consistently use the same size of insulin syringe to avoid dosing errors. c. Clean the skin at the injection site with an alcohol swab before each injection. d. Rotate injection sites from arms to thighs to abdomen with each injection to prevent lipodystrophies.

B

Which treatment strategy would be most effective for an obese patient who has had type 2 diabetes for more than four years who has a body mass index (BMI) of 40 kg/m 2 and 8% A1C? a. Insulin therapy b. Bariatric surgery c. Nutritional therapy d. Pancreas transplantation

B

Priority Decision: A patient with diabetes calls the clinic because she has nausea and flu-like symptoms. Which advice from the nurse will be the best for this patient? a. Administer the usual insulin dosage. b. Hold fluid intake until the nausea subsides. c. Come to the clinic immediately for evaluation and treatment. d. Monitor the blood glucose every 1 to 2 hours and call if it rises over 150 mg/dL (8.3 mmol/L). Harding, Mariann M.. Study Guide for Lewis' Medical-Surgical Nursing - E-Book (p. 95). Elsevier Health Sciences. Kindle Edition.

A

A patient who has been treated for status epilepticus in the emergency department will be transferred to the medical nursing unit. Which equipment should the nurse have available in the patient's assigned room (select all that apply)? a. Side-rail pads b. Tongue blade c. Oxygen mask d. Suction tubing e. Urinary catheter f. Nasogastric tube

A,C,D

Previous administrations of chemotherapy agents to a patient with cancer have resulted in diarrhea. Which dietary modification should the nurse recommend? A bland, low-fiber diet A high-protein, high-calorie diet A diet high in fresh fruits and vegetables A diet emphasizing whole and organic foods

A bland, low-fiber diet

What assessment findings occur with diabetic ketoacidosis (DKA) (select all that apply)? a. Thirst b. Ketonuria c. Dehydration d. Metabolic acidosis e. Kussmaul respirations f. Sweet, fruity breath odor

A, B, C, D, E, F

The patient with diabetes has been diagnosed with autonomic neuropathy. What problems should the nurse assess for in this patient (select all that apply)? a. Painless foot ulcers b. Erectile dysfunction c. Burning foot pain at night d. Loss of fine motor control e. Vomiting undigested food f. Painless myocardial infarction

B, E, F

A patient with a large stomach tumor attached to the liver is scheduled for a debulkingprocedure. Which information should the nurse teach the patient about the outcome of thisprocedure? a. Pain will be relieved by cutting sensory nerves in the stomach b. Relief of pressure in the stomach will promote better nutrition. c. Decreasing the tumor size will improve the effects of other therapy. d. Tumor growth will be controlled by the removal of malignant tissue.

ANS: C A debulking surgery reduces the size of the tumor and makes radiation and chemotherapymore effective. Debulking surgeries do not control tumor growth. The tumor is debulkedbecause it is attached to the liver, a vital organ (not to relieve pressure on the stomach).Debulking does not sever the sensory nerves, although pain may be lessened by the reductionin pressure on the abdominal organs.DIF: Cognitive Level: Understand (comprehension) REF: 245TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

A client has a sickle cell crisis with extreme lower extremity pain. What comfort measure does the nurse delegate to the unlicensed assistive personnel (UAP)? a. Apply ice packs to the clients legs. b. Elevate the clients legs on pillows. c. Keep the lower extremities warm. d. Place elastic bandage wraps on the clients legs.

ANS: C During a sickle cell crisis, the tissue distal to the occlusion has decreased blood flow and ischemia, leading to pain. Due to decreased blood flow, the clients legs will be cool or cold. The UAP can attempt to keep the clients legs warm. Ice and elevation will further decrease perfusion. Elastic bandage wraps are not indicated and may constrict perfusion in the legs.

Which instruction will the nurse plan to include in discharge teaching for the patient admitted with a sickle cell crisis? a. Take a daily multivitamin with iron. b. Limit fluids to 2 to 3 quarts per day. c. Avoid exposure to crowds when possible. d. Drink only two caffeinated beverages daily.

ANS: C Exposure to crowds increases the patient's risk for infection, the most common cause of sickle cell crisis. There is no restriction on caffeine use. Iron supplementation is generally not recommended. A high-fluid intake is recommended

A nurse working in an outpatient clinic plans a screening program for diabetes. What recommendations for screening should be included? a. OGTT for all minority populations every year b. FPG for all persons at age 45 years and then every 3 years c. Testing people under the age of 21 years for islet cell antibodies d. Testing for type 2 diabetes in all overweight or obese persons

B

What causes the anemia of sickle cell disease? a. intracellular hemolysis of sickled RBCs b. Accelerated breakdown of abnormal RBCs c. Autoimmune antibody destruction of RBCs d. Isoimmune antibody-antigen reactions with RBCs

B

A patient with a seizure disorder is being evaluated for surgical treatment of the seizure. The nurse recognizes that what is one of the requirements for surgical treatment? A. ID of scar tissue that is able to be removed B. An adequate trial of drug therapy that had unsatisfactory results C. Development of toxic syndromes from long-term use of anti-seizure meds D. The presence of symptoms of cerebral degeneration from repeated seizures

B. An adequate trial of drug therapy that had unsatisfactory results

A client is having a bone marrow biopsy and is extremely anxious. What action by the nurse is best? A. Assess client fears and coping mechanisms. B. Reassure the client this is a common test. C. Sedate the client prior to the procedure. D. Tell the client he or she will be asleep

Answer: A - Assessing the clients specific fears and coping mechanisms helps guide the nurse in providing holistic care that best meets the clients needs. Reassurance will be helpful but is not the best option. Sedation is usually used. The client may or may not be totally asleep during the procedure.

A nurse is assessing a dark-skinned client for pallor. What action is best? A. Assess the conjunctiva of the eye. B. Have the client open the hand widely. C. Look at the rook of the clients mouth. D. Palpate for areas of mild swelling.

Answer: A - To assess pallor in dark-skinned people, assess the conjunctiva of the eye or the mucous membranes. Looking at the roof of the mouth can reaveal jaundice. Opening of the hand widley is not related to pallor, nor is palpating for mild swelling.

Priority Decision: A patient taking insulin has recorded fasting glucose levels above 200 mg/dL (11.1 mmol/L) on awakening for the last 5 mornings. What should the nurse have the patient to do first? a. Increase the evening insulin dose to prevent the dawn phenomenon. b. Use a single-dose insulin regimen with an intermediate-acting insulin. c. Monitor the glucose level at bedtime, between 2:00 am and 4:00 am, and on arising. d. Decrease the evening insulin dosage to prevent night hypoglycemia and the Somogyi effect. Harding, Mariann M.. Study Guide for Lewis' Medical-Surgical Nursing - E-Book (p. 95). Elsevier Health Sciences. Kindle Edition.

C

The nurse assesses the technique of the patient with diabetes for self-monitoring of blood glucose (SMBG) 3 months after initial instruction. Which error in the performance of SMBG noted by the nurse requires intervention? a. Doing the SMBG before and after exercising b. Puncturing the finger on the side of the finger pad c. Cleaning the puncture site with alcohol before the puncture d. Holding the hand down for a few minutes

C

What describes the primary difference in treatment for diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic syndrome (HHS)? a. DKA requires administration of bicarbonate to correct acidosis. b. Potassium replacement is not necessary in management of HHS. c. HHS requires greater fluid replacement to correct the dehydration. d. Glucose is withheld in HHS until the blood glucose reaches a normal level.

C

Which patient should the nurse plan to teach how to prevent or delay the development of diabetes? a. An obese 40-year-old Hispanic woman b. A 20-year-old man whose father has type 1 diabetes c. A 34-year-old woman whose parents both have type 2 diabetes d. A 12-year-old boy whose father has maturity-onset diabetes of the young (MODY)

C

The nurse in an acute care setting is caring for a patient experiencing pain and a pain management plan of care has been implemented. What is the minimal interval of time and/or instance when the nurse should reassess the patient's pain? (Select all that apply.)

Before and after administration of analgesics With each new report of pain

A patient with diabetes is found unconscious at home, and a family member calls the clinic. After determining that a glucometer is not available, what should the nurse advise the family member to do? a. Have the patient drink some orange juice. b. Administer 10 U of regular insulin subcutaneously. c. Call for an ambulance to transport the patient to a medical facility. d. Administer glucagon 1 mg intramuscularly (IM) or subcutaneously.

D

Which parameter is best for the nurse to monitor to determine whether the prescribed IV mannitol (Osmitrol) has been effective for an unconscious patient? a. Hematocrit b. Blood pressure c. Oxygen saturation d. Intracranial pressure

D

Treatment for thyroid storm includes A. iodine B. Synthroid C. Inderal D. Levothyroxine

A. Iodine

An infant born with hydrocephalus is to be discharged after insertion of a ventriculoperitoneal shunt. Knowing the most common complication of this type of surgery, what clinical manifestations should the nurse instruct the home caregivers to monitor for at home? Violent involuntary muscle contractions Excessive fluid accumulation in the abdomen Eyes with sclera visible above the irises Fever accompanied by decreased responsiveness

Fever accompanied by decreased responsiveness

When caring for the patient after a head injury, the nurse would be most concerned with assessment findings which included respiratory changes, a. hypertension, and bradycardia. b. hypertension, and tachycardia. c. hypotension, and bradycardia. d. hypotension, and tachycardia.

a. hypertension, and bradycardia.

The nurse should question an order written for acetaminophen with oxycodone for a patient exhibiting which clinical manifestation? Severe jaundice Oral candidiasis Increased urine output Elevated blood glucose

Severe jaundice

The nurse collects a nutritional history from a 22-yr-old woman who is planning to conceive a child in the next year. Which foods reported by the woman would indicate that her diet is high in folate and iron? Crab, fish, and tuna Milk, cheese, and yogurt Spinach, beans, and liver White rice, potatoes, and pasta

Spinach, beans, and liver

A patient with cancer is having chemotherapy treatments and has now developed neutropenia. What care should the nurse expect to provide and teach the patient about? (Select all that apply.) Strict hand washing. Daily nasal swabs for culture. Monitor temperature every hour. Daily skin care and oral hygiene. Encourage the patient to eat all foods to increase nutrients. Private room with a high-efficiency particulate air (HEPA) filter

Strict hand washing. Daily skin care and oral hygiene. Private room with a high-efficiency particulate air (HEPA) filter

A patient has been diagnosed with Burkitt's lymphoma. In the initiation stage of cancer, the cells genetic structure is mutated. Exposure to what may have functioned as a carcinogen for this patient? Bacteria Sun exposure Most chemicals Epstein-Barr virus

Epstein-Barr virus

What can the nurse do to facilitate cancer prevention for the patient in the promotion stage of cancer development? A. Teach the patient to exercise daily. B. Teach the patient promoting factors to avoid. C. Tell the patient to have the cancer surgically removed now. D. Teach the patient which vitamins will improve the immune system.

B. Teach the patient promoting factors to avoid.

The patient is told that an adenoma tumor is not encapsulated but has normally differentiated cells and surgery will be needed. The patient asks the nurse what this means. What should the nurse's response be to the patient? It will recur. It has metastasized. It is probably benign. It is probably malignant.

It is probably benign.

What is the drug of choice for a 45-year-old patient who has a body mass index (BMI) of 30 kg/m2, random blood glucose of 200 mg/dL, and a history of hypertension? a. Glipizideb. Acarbosec. Metformind. Pioglitazone

Metformin

The patient's MRI showed the presence of a brain tumor. The nurse anticipates which treatment modality? Surgery Chemotherapy Radiation therapy Biologic drug therapy

Surgery

The nurse is caring for a patient with a diagnosis of disseminated intravascular coagulation (DIC). What is the first priority of care? Administer heparin. Administer whole blood. Treat the causative problem. Administer fresh frozen plasma.

Treat the causative problem.

What is a nursing intervention that is indicated for the patient during a sickle cell crisis? a. Frequent ambulation b. Application of antiembolism hose c. Restriction of sodium and oral fluids d. Administration of large doses of continuous opioid analgesics

d. Administration of large doses of continuous opioid analgesics

A patient with type 2 diabetes is scheduled for a follow-up visit in the clinic several months from now. Which test will the nurse schedule to evaluate the effectiveness of treatment for the patient? a. Urine dipstick for glucose b. Oral glucose tolerance test c. Fasting blood glucose level d. Glycosylated hemoglobin level

d. Glycosylated hemoglobin level

A client presents to the emergency department in sickle cell crisis. What intervention by the nurse takes priority? a. Administer oxygen. b. Apply an oximetry probe. c. Give pain medication. d. Start an IV

a. Administer oxygen.

While the nurse performs ROM on an unconscious patient with increased ICP, the patient experiences severe decerebrate posturing reflexes. The nurse should a. use restraints to protect the patient from injury b. administer CNS depressants to lightly sedate the patient c. perform the exercises less frequently because posturing can increase ICP d. continue the exercises because they are necessary to maintain musculoskeletal function

C. Perform the exercises less frequently because posturing can increase ICP- If reflex posturing occurs during ROM or positioning of the patient, these activities should be done less frequently until the patient's condition stabilizes, because posturing can case increases in ICP. Neither restraints nor CNS depressants would be indicated.

The nurse teaches the patient taking anti-seizure meds that this method is most commonly used to measure compliance and monitor for toxicity A. A daily seizure log B. Urine testing for drug levels C. Blood testing for drug levels D. Monthly electroencephalopathy (EEG)

C. Blood testing for drug levels

A patient with leukemia is admitted for severe hypovolemia after prolonged diarrhea. The platelet count is 43,000/µL. It is most important for the nurse to take which action? Insert two 18-gauge IV catheters. Administer prescribed enoxaparin. Monitor the patient's temperature every 2 hours. Check stools for presence of frank or occult blood.

Check stools for presence of frank or occult blood.

A patient asks the nurse why a dose of hydromorphone (Dilaudid) by IV push is given before starting the medication via PCA. Which response is most appropriate? "PCA will never be effective unless a loading dose is given first." "The IV push dose will enhance the effects of the PCA for the next 8 hours." "The IV push dose will provide for immediate pain relief, which can be maintained by using the PCA." "PCA takes at least 2 hours to begin working, so the IV push dose will provide pain relief in the interim."

"The IV push dose will provide for immediate pain relief, which can be maintained by using the PCA."

A patient with terminal cancer tells the nurse, "I know I am going to die pretty soon, perhaps in the next month." What is the most appropriate response by the nurse? "What are your feelings about being sick and thinking you may die soon?" "None of us know when we are going to die. Is this a particularly difficult day?" "Would you like for me to call your spiritual advisor so you can talk about your feelings?" "Perhaps you are depressed about your illness. I will speak to the doctor about getting some medications for you."

"What are your feelings about being sick and thinking you may die soon?"

The patient has osteosarcoma of the right leg. The unlicensed assistive personnel (UAP) reports that the patient's vital signs are normal, but the patient says he still has pain in his leg, and it is getting worse. Which question would best determine treatment measures for the patient's pain? "Where is the pain?" "Is the pain getting worse?" "What does the pain feel like?" "Do you use medications to relieve the pain?"

"What does the pain feel like?"

The nurse teaches a black man with sickle cell disease about symptom management and prevention of sickle cell crisis. The nurse determines further teaching is necessary if the patient makes which statement? "When I take a vacation, I should not go to the mountains." "I should avoid being with anyone who has a respiratory infection." "I may have severe pain during a crisis and need opioid analgesics." "When my vision is blurred, I will close my eyes and rest for an hour."

"When my vision is blurred, I will close my eyes and rest for an hour."

The nurse should teach a patient to avoid which medication while taking ibuprofen? Aspirin Furosemide Nitroglycerin Morphine sulfate

aspirin

Patient-Centered Care: The patient with type 2 diabetes is being put on acarbose (Precose) and wants to know about taking it. What should the nurse include in this patient's teaching (select all that apply)? a. Take it with the first bite of each meal. b. It is not used in patients with heart failure. c. Endogenous glucose production is decreased. d. Effectiveness is measured by 2-hour postprandial glucose. e. It delays glucose absorption from the gastrointestinal (GI) tract.

A, D, E

1. In addition to promoting the transport of glucose from the blood into the cell, what does insulin do? a. Enhances the breakdown of adipose tissue for energy b. Stimulates hepatic glycogenolysis and gluconeogenesis c. Prevents the transport of triglycerides into adipose tissue d. Increases amino acid transport into cells and protein synthesis

D

Lispro insulin (Humalog) with NPH (Humulin N) insulin is ordered for a patient with newly diagnosed type 1 diabetes. When should the nurse administer lispro insulin? a. Only once a day b. 1 hour before meals c. 30 to 45 minutes before meals d. At mealtime or within 15 minutes of meals

D

The nurse determines that a patient with a 2-hour OGTT of 152 mg/dL has a. diabetes. b. elevated A1C. c. impaired fasting glucose. d. impaired glucose tolerance.

D

The nurse has administered 4 oz of orange juice to an alert patient whose blood glucose was 62 mg/dL. Fifteen minutes later, the blood glucose is 67 mg/dL. Which action should the nurse take next? a. Give the patient 4 to 6 oz more orange juice. b. Administer the PRN glucagon (Glucagon) 1 mg IM. c. Have the patient eat some peanut butter with crackers. d. Notify the health care provider about the hypoglycemia.

A. The "rule of 15" indicates that administration of quickly acting carbohydrates should be done 2 to 3 times for a conscious patient whose glucose remains less than 70 mg/dL before notifying the health care provider. More complex carbohydrates and fats may be used once the glucose has stabilized. Glucagon should be used if the patient's level of consciousness decreases so that oral carbohydrates can no longer be given.

The nurse working in the vision and hearing clinic receives telephone calls from several patients who want appointments in the clinic as soon as possible. Which patient should be seen first? a. 71-year-old who has noticed increasing loss of peripheral vision b. 74-year-old who has difficulty seeing well enough to drive at night c. 60-year-old who has difficulty hearing clearly in a noisy environment d. 64-year-old who has decreased hearing and ear "stuffiness" without pain

ANS: A Increasing loss of peripheral vision is characteristic of glaucoma and the patient should be scheduled for an examination as soon as possible. The other patients have symptoms commonly associated with aging: presbycusis, possible cerumen impaction, and impaired night vision

Admission vital signs for a brain-injured patient are blood pressure of 128/68 mm Hg, pulse of 110 beats/min, and of respirations 26 breaths/min. Which set of vital signs, if taken 1 hour later, will be of most concern to the nurse? a. Blood pressure of 154/68 mm Hg, pulse of 56 beats/min, respirations of 12 breaths/min b. Blood pressure of 134/72 mm Hg, pulse of 90 beats/min, respirations of 32 breaths/min c. Blood pressure of 148/78 mm Hg, pulse of 112 beats/min, respirations of 28 breaths/min d. Blood pressure of 110/70 mm Hg, pulse of 120 beats/min, respirations of 30 breaths/min

ANS: A Systolic hypertension with widening pulse pressure, bradycardia, and respiratory changes represent Cushing's triad. These findings indicate that the intracranial pressure (ICP) has increased, and brain herniation may be imminent unless immediate action is taken to reduce ICP. The other vital signs may indicate the need for changes in treatment, but they are not indicative of an immediately life-threatening process.DIF: Cognitive Level: Apply (application)

Ten days after receiving a bone marrow transplant, a patient develops a skin rash. What would the nurse suspect is the cause of the rash? a. The donor T cells are attacking the patient's skin cells. b. The patient needs treatment to prevent hyperacute rejection. c. The patient's antibodies are rejecting the donor bone marrow. d. The patient is experiencing a delayed hypersensitivity reaction.

ANS: A The patient's history and symptoms indicate that the patient is experiencing graft-versus-host disease, in which the donated T cells attack the patient's tissues. The history and symptoms are not consistent with rejection or delayed hypersensitivity.

An older client has decided to give up driving due to cataracts. What assessment information is most important to collect? a. Family history of visual problems b. Feelings related to loss of driving c. Knowledge about surgical options d. Presence of family support

ANS: B Loss of driving is often associated with loss of independence, as is decreasing vision. The nurse should assess how the client feels about this decision and what its impact will be. Family history and knowledge about surgical options are not related as the client has made a decision to decline surgery. Family support is also useful information, but it is most important to get the client's perspective on this change.DIF: Applying/Application REF: 983KEY: Visual system| visual disorders| cataracts| older adult| coping| psychosocial responseMSC: Integrated Process: Nursing Process: AssessmentNOT: Client Needs Category: Psychosocial Integrity

After suctioning, the nurse notes that the intracranial pressure for a patient with a traumatic head injury has increased from 14 to 16 mm Hg. Which action should the nurse take first? a. Document the increase in intracranial pressure. b. Assure that the patient's neck is not in a flexed position. c. Notify the health care provider about the change in pressure. d. Increase the rate of the prescribed propofol (Diprovan) infusion.

ANS: B Since suctioning will cause a transient increase in intracranial pressure, the nurse should initially check for other factors that might be contributing to the increase and observe the patient for a few minutes. Documentation is needed, but this is not the first action. There is no need to notify the health care provider about this expected reaction to suctioning. Propofol is used to control patient anxiety or agitation; there is no indication that anxiety has contributed to the increase in intracranial pressure.DIF: Cognitive Level: Application REF: 1426 | 1435-1437 | 1436-1437

A client admitted for sickle cell crisis is distraught after learning her child also has the disease. What response by the nurse is best? a. Both you and the father are equally responsible for passing it on. b. I can see you are upset. I can stay here with you a while if you like. c. Its not your fault; there is no way to know who will have this disease. d. There are many good treatments for sickle cell disease these days

ANS: B The best response is for the nurse to offer self, a therapeutic communication technique that uses presence. Attempting to assign blame to both parents will not help the client feel better. There is genetic testing available, so it is inaccurate to state there is no way to know who will have the disease. Stating that good treatments exist belittles the clients feelings.

A 37-yr-old patient has just arrived in the postanesthesia recovery unit (PACU) after a thyroidectomy. Which information about the patient is most important to communicate to the surgeon? a. Difficult to awaken .b. Increasing neck swelling. c. Reports 7/10 incisional pain. d. Cardiac rate 112 beats/minute.

ANS: B The neck swelling may lead to respiratory difficulty, and rapid intervention is needed to prevent airway obstruction. The incisional pain should be treated but is not unusual after surgery. A heart rate of 112 beats/min is not unusual in a patient who has been hyperthyroid and has just arrived in the PACU from surgery. Sleepiness in the immediate postoperative period is expected.

Which action should the nurse take after a 36-year-old patient treated with intramuscular glucagon for hypoglycemia regains consciousness? a. Assess the patient for symptoms of hyperglycemia. b. Give the patient a snack of peanut butter and crackers. c. Have the patient drink a glass of orange juice or nonfat milk. d. Administer a continuous infusion of 5% dextrose for 24 hours.

b. Give the patient a snack of peanut butter and crackers.

A patient has a systemic BP of 108/51 mm Hg and an intracranial pressure (ICP) of 14 mm Hg. Which action should the nurse take first?a. Elevate the head of the patient's bed to 60 degrees. b. Document the BP and ICP in the patient's record. c. Report the BP and ICP to the health care provider. d. Continue to monitor the patient's vital signs and ICP.

ANS: C The patient's cerebral perfusion pressure is 56 mm Hg, below the normal of 60 to 100 mm Hg and approaching the level of ischemia and neuronal death. Immediate changes in the patient's therapy such as fluid infusion or vasopressor administration are needed to improve the cerebral perfusion pressure. Adjustments in the head elevation should only be done after consulting with the health care provider. Continued monitoring and documentation also will be done, but they are not the first actions that the nurse should take.

A 54-year-old woman with acute myelogenous leukemia (AML) is considering treatment with a hematopoietic stem cell transplant (HSCT). The best approach for the nurse to assist the patient with a treatment decision is to a. emphasize the positive outcomes of a bone marrow transplant. b. discuss the need for adequate insurance to cover post-HSCT care. c. ask the patient whether there are any questions or concerns about HSCT. d. explain that a cure is not possible with any other treatment except HSCT.

ANS: C Offering the patient an opportunity to ask questions or discuss concerns about HSCT will encourage the patient to voice concerns about this treatment and also will allow the nurse to assess whether the patient needs more information about the procedure. Treatment of AML using chemotherapy is another option for the patient. It is not appropriate for the nurse to ask the patient to consider insurance needs in making this decision.

The nurse is providing health promotion teaching to a group of older adults. Which information will the nurse include when teaching about routine glaucoma testing? a. A Tono-pen will be applied to the surface of the eye. b. The test involves reading a Snellen chart from 20 feet. c. Medications will be used to dilate the pupils for the test. d. The examination involves checking the pupil's reaction to light.

A Glaucoma is caused by an increase in intraocular pressure, which would be measured using the Tono-pen. The other techniques are used in testing for other eye disorders

Which patient is most likely to develop anemia related to an increased destruction of red blood cells? A 23-yr-old black man who has sickle cell disease A 59-yr-old man whose alcohol use caused folic acid deficiency A 13-yr-old child with impaired growth and development due to thalassemia A 50-yr-old woman with a history of "heavy periods" accompanied by anemia

A 23-yr-old black man who has sickle cell disease

The nurse is assigned to care for several patients on a medical unit. Which patient should the nurse assess first? A 60-yr-old patient with a blood pressure of 92/64 mm Hg and hemoglobin of 9.8 g/dL A 50-yr-old patient with a respiratory rate of 26 breaths/minute and an elevated D-dimer A 40-yr-old patient with a temperature of 100.8°F (38.2°C) and a neutrophil count of 256/µL A 30-yr-old patient with a pulse of 112 beats/min and a white blood cell count of 14,000/µL

A 40-yr-old patient with a temperature of 100.8°F (38.2°C) and a neutrophil count of 256/µL

Which patient is statistically and medically at the highest risk of developing cancer? A 68-yr-old white woman who has BRCA-1 gene and is obese A 56-yr-old black man with hepatitis C who drinks alcohol daily An 18-yr-old Hispanic man who eats fast food once per week and drinks alcohol An 80-yr-old Asian woman with coronary artery disease on blood pressure medication.

A 56-yr-old black man with hepatitis C who drinks alcohol daily

he patient was told that he would have intraperitoneal chemotherapy. He asks the nurse when the IV will be started for the chemotherapy. What should the nurse teach the patient about this type of chemotherapy delivery? It is delivered via an Ommaya reservoir and extension catheter. It is instilled in the bladder via a urinary catheter and retained for 1 to 3 hours. A Silastic catheter will be percutaneously placed in the abdomen for chemotherapy administration. The arteries supplying the tumor are accessed with surgical placement of a catheter connected to an infusion pump.

A Silastic catheter will be percutaneously placed in the abdomen for chemotherapy administration.

The nurse is teaching the patient with prediabetes ways to prevent or delay the development of type 2 diabetes. What information should be included (select all that apply)? a. Exercise regularly. b. Maintain a healthy weight. c. Have BP checked regularly. d. Assess for visual changes on a monthly basis. e. Monitor for polyuria, polyphagia, and polydipsia.

A, B, C

An early sign of increased ICP is? Cushing's triad Unexpected vomiting Decreased level of consciousness (LOC) Dilated pupil with sluggish response

Decreased level of consciousness (LOC)

The patient is receiving fentanyl patch for control of chronic cancer pain. What should the nurse observe for in the patient as a potential life-threatening adverse effect of this medication? Tachycardia Hypertension Pupillary dilation Decreased respiratory rate

Decreased respiratory rate

The nurse is caring for a patient with a diagnosis of immune thrombocytopenic purpura (ITP). What is a priority nursing action in the care of this patient? Administration of packed red blood cells Administration of oral or IV corticosteroids Administration of clotting factors VIII and IX Maintenance of reverse isolation and application of standard precautions

Administration of oral or IV corticosteroids

When going to the hospital, which forms should patients be taught to bring with them in case end-of-life care becomes an ethical or legal issue? Euthanasia Organ donor card Advance directives Do not resuscitate (DNR)

Advance directives

The most common type of leukemia in older adults is A. acute myelocytic leukemia. B. acute lymphocytic leukemia. C. chronic myelocytic leukemia. D. chronic lymphocytic leukemia.

D. chronic lymphocytic leukemia.

The patient has chronic pain that is no longer relieved with oral morphine. Which medication would the nurse expect to be ordered to provide better pain relief for this patient? Hydrocodone Fentanyl Intranasal butorphanol Morphine sustained-release

Fentanyl

When a brain-injured patient responds to nail bed pressure with internal rotation, adduction, and flexion of the arms, the nurse reports the response as a. flexion withdrawal. b. decorticate posturing. c. localization of pain. d. decerebrate posturing.

b. decorticate posturing.

Priority Decision: The nurse is assessing a newly admitted patient with diabetes. Which observation should be addressed as the priority by the nurse? a. Bilateral numbness of both hands b. Rapid respirations with deep inspiration c. Stage II pressure injury on the right heel d. Areas of lumps and dents on the abdomen

B

The strict vegetarian diet is at highest risk for the development of which anemia? a. Thalassemia B. Iron-deficiency anemia C. Folic acid deficiency anemia D. Cobalamin deficiency anemia

B

Which statement best describes atherosclerotic disease affecting the cerebrovascular, cardiovascular, and peripheral vascular systems in patients with diabetes? a. It can be prevented by tight glucose control. b. It occurs with a higher frequency and earlier onset than in the nondiabetic population. c. It is caused by hyperinsulinemia related to insulin resistance common in type 2 diabetes. d. It cannot be modified by reducing risk factors, such as smoking, obesity, and high fat intake.

B

The nurse cares for a patient with lung cancer in a home hospice program. Which action by the nurse is most appropriate? a.Discuss cancer risk factors and appropriate lifestyle modifications. b.Encourage the patient to discuss past life events and their meaning. c.Teach the patient about the purpose of chemotherapy and radiation. d.Accomplish a thorough head-to-toe assessment several times a week.

B The role of the hospice nurse includes assisting the patient with the important end-of-life task of finding meaning in the patient's life. Frequent head-to-toe assessments are not needed for hospice patients and may tire the patient unnecessarily. Patients admitted to hospice forego curative treatments such as chemotherapy and radiation for lung cancer. Discussion of cancer risk factors and therapies is not appropriate.

What disorders and diseases are related to macrovascular complications of diabetes (select all that apply)? a. Chronic kidney disease b. Coronary artery disease c. Microaneurysms and destruction of retinal vessels d. Ulceration and amputation of the lower extremities e. Capillary and arteriole membrane thickening specific to diabetes

B, D

The nurse is caring for a patient admitted with a subdural hematoma after a motor vehicle accident. What change in vital signs would the nurse interpret as a manifestation of increased intracranial pressure (ICP)? Tachypnea Bradycardia Hypotension Narrowing pulse pressure

Bradycardia

Mr. K, an 80-year-old patient, is being discharged after he was diagnosed with diabetes mellitus and retinopathy. His daughter has been part of the discharge instruction process. Understanding of the instructions is evident in when the daughter says which of the following? a. "I will make sure that Dad always wears warm socks. "b. "Dad needs to wear his glasses so he can delay the onset of macular degeneration." c. "I will ask the home health aide to carefully inspect Dad's feet every day when she helps him bathe." d. "We will give him only warm foods, so that he doesn't burn his mouth."

C

When caring for the patient with cancer, what does the nurse understand is the response of the immune system to antigens of the malignant cells? Metastasis Tumor angiogenesis Immunologic escape Immunologic surveillance

Immunologic surveillance

The patient diagnosed with anemia had laboratory tests done. Which results indicate a lack of nutrients needed to produce new red blood cells (RBCs)? (Select all that apply.) Increased homocysteine Decreased reticulocyte count Decreased cobalamin (vitamin B12) Increased methylmalonic acid (MMA) Elevated erythrocyte sedimentation rate (ESR)

Increased homocysteine Decreased cobalamin (vitamin B12) Increased methylmalonic acid (MMA)

When evaluating a patient's nutritional-metabolic pattern related to hematologic health, what priority assessment should the nurse perform? Inspect the skin for petechiae. Ask the patient about joint pain. Assess for vitamin C deficiency. Determine if the patient can perform activities of daily living.

Inspect the skin for petechiae

What features of cancer cells distinguish them from normal cells (select all that apply)? a. Cells lack contact inhibition. b. Oncogenes maintain normal cell expression. 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.

Correct answers: a, c, e Rationale: Two major dysfunctions in the process of cancer are defective cell proliferation (i.e., growth) and defective cell differentiation. Cancer cells lack contact inhibition and are poorly differentiated. Cancer cell growth is infiltrative and expansive, and cancer cells are abnormal and become more unlike parent cells.

Following the teaching of foot care to a patient with diabetes, the nurse determines that additional instruction is needed when the patient makes which statement? a. "I should wash my feet daily with soap and warm water." b. "I should always wear shoes to protect my feet from injury." c. "If my feet are cold, I should wear socks instead of using a heating pad." d. "I'll know if I have sores or lesions on my feet because they will be painful."

D

The home care nurse should intervene to correct a patient whose insulin administration includes a. warming a prefilled refrigerated syringe in the hands before administration. b. storing syringes prefilled with NPH and regular insulin needle-up in the refrigerator. c. placing the insulin bottle currently in use in a small container on the bathroom countertop. d. mixing an evening dose of regular insulin with insulin glargine in 1 syringe for administration.

D

The patient with type 2 diabetes has had trouble controlling his blood glucose with several OAs but wants to avoid the risks of insulin. The health care provider (HCP) told him a medication will be prescribed that will increase insulin synthesis and release from the pancreas, inhibit glucagon secretion, and slow gastric emptying. Which medication will have to be injected? a. Dopamine receptor agonist, bromocriptine (Cycloset) b. Dipeptidyl peptidase-4 (DPP-4) inhibitor, sitagliptin (Januvia) c. Sodium-glucose co-transporter 2 (SGLT2) inhibitor, canagliflozin (Invokana) d. Glucagon-like peptide-1 receptor agonist, exenatide extended release (Bydureon)

D

Which laboratory results indicate the patient has prediabetes? a. Glucose tolerance result of 132 mg/dL (7.3 mmol/L) b. Glucose tolerance result of 240 mg/dL (13.3 mmol/L) c. Fasting blood glucose result of 80 mg/dL (4.4mmol/L) d. Fasting blood glucose result of 120 mg/dL (6.7 mmol/L)

D

The health care provider performs a bone marrow aspiration from the left posterior iliac crest on a patient with pancytopenia.Following the procedure, the nurse should a. elevate the head of the bed to 45 degrees. b. apply a sterile Band-Aid at the aspiration site .c. use half-inch sterile gauze to pack the wound. d. have the patient lie on the left side for an hour.

D To decrease the risk for bleeding, the patient should lie on the left side for 30 to 60minutes. The wound after bone marrow biopsy is small and will not be packed withgauze. A pressure dressing is used to cover the aspiration site. There is no indication thatthe head needs to be elevated for this patient.

After receiving change-of-shift report about the following four patients, which patient should the nurse assess first? a. A 31-yr-old female patient with Cushing syndrome and a blood glucose level of 244 mg/dL b. A 70-yr-old female patient taking levothyroxine (Synthroid) who has an irregular pulse of 134 c. A 53-yr-old male patient who has Addison's disease and is due for a prescribed dose of hydrocortisone (Solu-Cortef). d. A 22-yr-old male patient admitted with syndrome of inappropriate antidiuretic hormone (SIADH) who has a serum sodium level of 130 mEq/L

ANS: B Initiation of thyroid replacement in older adults may cause angina and cardiac dysrhythmias. The patient's high pulse rate needs rapid investigation by the nurse to assess for and intervene with any cardiac problems. The other patients also require nursing assessment and/or actions but are not at risk for life-threatening complications.

An elderly Chinese woman is interested in biologically based therapies to relieve osteoarthritis pain (OA). You are preparing a plan of care for her OA. Options most conducive to her expressed wishes may include a. Pilates, breathing exercises, and aloe vera. b. Guided imagery, relaxation breathing, and meditation. c. Herbs, vitamins, and tai chi. d. Alternating ice and heat to relieve pain and inflammation.

c. Herbs, vitamins, and tai chi.

The nurse is assigned a group of patients. Which patient would the nurse identify as being at increased risk for impaired gas exchange? A patient a. with a blood glucose of 350 mg/dL b. who has been on anticoagulants for 10 days c. with a hemoglobin of 8.5 g/dL d. with a heart rate of 100 beats/min and blood pressure of 100/60

c. with a hemoglobin of 8.5 g/dL

Which prescribed intervention will the nurse implement first for a patient in the emergency department who is experiencing continuous tonic-clonic seizures? a. Give phenytoin (Dilantin) 100 mg IV. b. Monitor level of consciousness (LOC). c. Obtain computed tomography (CT) scan. d. Administer lorazepam (Ativan) 4 mg IV.

d. Administer lorazepam (Ativan) 4 mg IV.

The postoperative patient is receiving epidural fentanyl for pain relief. For which common side effects should the nurse monitor the patient? (Select all that apply.) Ataxia Itching Nausea Urinary retention Gastrointestinal bleeding

Itching Nausea Urinary retention

Which drug treatment helps decrease ICP by expanding plasma and osmotic effect to move fluid? a. Dexamethasone b. Oxygen administration c. Pentobarbital d. Mannitol (Osmitrol)

d. Mannitol (Osmitrol)

The nurse knows that hemolytic anemia can be caused by which extrinsic factors? Trauma or splenic sequestration crisis Abnormal hemoglobin or enzyme deficiency Macroangiopathic or microangiopathic factors Chronic diseases or medications and chemicals

Macroangiopathic or microangiopathic factors

A patient who has sickle cell disease has developed cellulitis above the left ankle. What is the nurse's priority for this patient? Start IV fluids. Maintain oxygenation. Maintain distal warmth. Check peripheral pulses.

Maintain oxygenation.

A patient has been receiving scheduled doses of phenytoin (Dilantin) and begins develops diplopia. Which additional findings should the nurse expect? Nystagmus or confusion An aura or focal seizure Abdominal pain or cramping Irregular pulse or palpitations

Nystagmus or confusion

The nurse is planning care for a patient with hypercalcemia secondary to bone metastasis. Which interventions should be included in the plan of care? (Select all that apply.) Increasing oral fluids Monitoring for Chvostek's sign Observation for muscle weakness Hyperactive reflex assessment Implementing seizure precautions Placement of an oral airway at the bedside

Observation for muscle weakness Increasing oral fluids

Which manifestation should the nurse attribute to adverse effects of morphine sulfate administered via PCA? Diarrhea Urinary frequency Nausea and vomiting Increased blood pressure

Nausea and vomiting

The nurse is caring for a patient receiving morphine sulfate via PCA. Which patient assessment data demonstrate the most therapeutic effect of this medication? Pain rating 3/10, awake and alert, respirations 24 Pain rating 2/10, awake and alert, respirations 18 Pain rating 2/10, drowsy but arousable, respirations 18 Pain rating 1/10, drowsy but arousable, respirations 16

Pain rating 2/10, awake and alert, respirations 18

A patient who is receiving radiation to the head and neck as treatment for an invasive cancer reports mouth sores and pain. Which intervention should the nurse add to the plan of care? Provide ice chips to soothe the irritation. Weigh the patient every month to monitor for weight loss. Cleanse the mouth every 2 to 4 hours with hydrogen peroxide. Provide high-protein and high-calorie, soft foods every 2 hours.

Provide high-protein and high-calorie, soft foods every 2 hours.

Which assessment finding would support the presence of a hemostasis abnormality? Purpura Pruritus Weakness Pale conjunctiva

Purpura

Which assessment is of highest priority for the nurse to complete before administering morphine? Pain rating Blood pressure Respiratory rate Level of consciousness

Respiratory rate

Which problem is of most concern for a patient with myelosuppression secondary to chemotherapy for cancer treatment? Acute pain Hypothermia Powerlessness Risk for infection

Risk for infection

Which information will the nurse teach a patient who has been newly diagnosed with Graves' disease? a. Exercise is contraindicated to avoid increasing metabolic rate. b. Restriction of iodine intake is needed to reduce thyroid activity. c. Antithyroid medications may take several months for full effect. d. Surgery will eventually be required to remove the thyroid gland.

c. Antithyroid medications may take several months for full effect.

Which instruction will the nurse plan to include in discharge teaching for the patient admitted with a sickle cell crisis? a. Take a daily multivitamin with iron. b. Limit fluids to 2 to 3 quarts per day. c. Avoid exposure to crowds when possible. d. Drink only two caffeinated beverages daily.

c. Avoid exposure to crowds when possible.

The nurse recognizes the presence of Cushing's triad in the patient with which vital sign changes? a. Increased pulse, irregular respiration, decreased systolic BP b. Decreased pulse, increased respiration, decreased systolic BP c. Decreased pulse, irregular respiration, widened pulse pressure d. Increased pulse, decreased respiration, widened pulse pressure

c. Decreased pulse, irregular respiration, widened pulse pressure

A college student is newly diagnosed with type 1 diabetes. She now has a headache, changes in her vision, and is anxious, but does not have her portable blood glucose monitor with her. Which action should the campus nurse advise her to take? a. Eat a piece of pizza. b. Drink some diet pop. c. Eat 15 g of simple carbohydrates. d. Take an extra dose of rapid-acting insulin.

c. Eat 15 g of simple carbohydrates.

The nurse is caring for a patient with microcytic, hypochromic anemia. What teaching should the nurse provide about medication therapy? Take enteric-coated iron with each meal. Take cobalamin with green leafy vegetables. Take the iron with orange juice 1 hour before meals. Decrease the intake of the antiseizure medications to improve.

Take the iron with orange juice 1 hour before meals

A patient is receiving morphine sulfate via patient-controlled analgesia (PCA). What nursing action is most effective to reduce the risk of adverse effects? Tell the patient not to push the button too frequently. Teach the caregiver not to push the button for the patient. Ask the patient to do deep breathing exercises every hour. Administer medications to prevent the occurrence of diarrhea.

Teach the caregiver not to push the button for the patient.

The patient with a brain tumor is being monitored for increased intracranial pressure (ICP) with a ventriculostomy. What nursing intervention is priority? Administer IV mannitol as ordered. Ventilator use to hyperoxygenate the patient. Use strict aseptic technique with dressing changes. Be aware of changes in ICP related to cerebrospinal fluid leaks.

Use strict aseptic technique with dressing changes.

Myxedema is associated: Graves disease Thyrotoxic crisis hypothyroidism hyperthyroidism

hypothyroidism

Following a generalized tonic-clonic seizure, the patient is tired and sleepy. What care should the nurse provide? a. Suction the patient before allowing him to rest. b. Allow the patient to sleep as long as he feels sleepy. c. Stimulate the patient to increase his level of consciousness. d. Check the patient's level of consciousness every 15 minutes for an hour.

b. Allow the patient to sleep as long as he feels sleepy.In the postictal phase of generalized tonic-clonic seizures, patients are usually very tired and may sleep for several hours and the nurse should allow the patient to sleep for as long as necessary. Suctioning is performed only if needed and decreased level of consciousness is not a problem postictally unless a head injury has occurred during the seizure.

An unconscious patient has a nursing diagnosis of ineffective cerebral tissue perfusion related to cerebral tissue swelling. Which nursing intervention will be included in the plan of care? a. Keep the head of the bed elevated to 30 degrees. b. Position the patient with the knees and hips flexed. c. Encourage coughing and deep breathing to improve oxygenation. d. Cluster nursing interventions to provide uninterrupted rest periods.

a. Keep the head of the bed elevated to 30 degrees.

To determine whether treatment is effective for a patient with primary open-angle glaucoma (POAG), the nurse can evaluate the patient for improvement by a. questioning the patient about blurred vision. b. noting any changes in the patient's visual field. c. asking the patient to rate the pain using a 0 to 10 scale. d. assessing the patient's depth perception when climbing stairs.

b. noting any changes in the patient's visual field.

Anti-thyroid meds are used to treat _______________ and may take up to ______________ to reach the full effect

hyperthyroidism; a few months

Manifestation of peripheral neuropathy

numbness

The patient with a documented history of opioid use just had surgery. The nurse is concerned about the high dose of opioid analgesic prescribed for this patient. What is the best action for the nurse to take? Remember that pain can be observed in patients. Relieve this patient's pain to avoid adverse consequences. Be sure the patient is really in pain before giving the analgesic. This patient has the right to appropriate assessment and management of pain.

This patient has the right to appropriate assessment and management of pain.

During the promotion stage of cancer development, which statement by the nurse most facilitates patient cancer prevention? "Exercise every day for 30 minutes." "Follow smoking cessation recommendations." "Following a vitamin regime is highly recommended." "I recommend excision of the cancer as soon as possible."

"Follow smoking cessation recommendations."

A patient is being treated for non-Hodgkin's lymphoma (NHL). What should the nurse first teach the patient about the treatment? Skin care that will be needed Method of obtaining the treatment Treatment type and expected side effects Gastrointestinal tract effects of treatment

Treatment type and expected side effects

A patient with metastatic cancer of the colon experiences severe vomiting after each administration of chemotherapy. Which action, if taken by the nurse, is appropriate? a. Have the patient eat large meals when nausea is not present. b. Offer dry crackers and carbonated fluids during chemotherapy. c. Administer prescribed antiemetics 1 hour before the treatments. d. Give the patient a glass of a citrus fruit beverage during treatments.

c. Administer prescribed antiemetics 1 hour before the treatments.

Which action should the nurse take when providing patient teaching to a 76-year-old with mild presbycusis? a.Use patient education handouts rather than discussion. b.Use a higher-pitched tone of voice to provide instructions. c.Ask for permission to turn off the television before teaching d.Wait until family members have left before initiating teaching.

c.Ask for permission to turn off the television before teaching

Which statement by a patient indicates good understanding of the nurse's teaching about prevention of sickle cell crisis? a. "Home oxygen therapy is frequently used to decrease sickling." b. "There are no effective medications that can help prevent sickling." c. "Routine continuous dosage narcotics are prescribed to prevent a crisis." d. "Risk for a crisis is decreased by having an annual influenza vaccination."

d. "Risk for a crisis is decreased by having an annual influenza vaccination."

The nurse finds a patient in bed having a generalized tonic-clonic seizure. During the seizureactivity, what actions should the nurse take (select all that apply)? a. Loosen restrictive clothing. b. Turn the patient to the side. c. Protect the patient's head from injury. d. Place a padded tongue blade between the patient's teeth. e. Restrain the patient's extremities to prevent soft tissue and bone injury.

a, b, c. The focus is on maintaining a patent airway and preventing patient injury. The nurse should not place objects in the patient's mouth or restrain the patient.

A patient who has sickle cell disease has developed cellulitis above the left ankle. What is the nurse's priority for this patient? 1. Start IV fluids. 2. Maintain oxygenation. 3. Maintain distal warmth. 4. Check peripheral pulses.

2. Maintain oxygenation.

Why is the Glasgow Coma Scale (GCS) used? Group of answer choices a. To quickly assess the LOC b. To assess the patient's ability to communicate c. To assess the patient's ability to respond to commands d. To assess the patient's coordination with motor responses

a. To quickly assess the LOC

A 55-year-old female patient with type 2 diabetes has a nursing diagnosis of imbalanced nutrition: more than body requirements. Which goal is most important for this patient? a. The patient will reach a glycosylated hemoglobin level of less than 7%. b. The patient will follow a diet and exercise plan that results in weight loss. c. The patient will choose a diet that distributes calories throughout the day. d. The patient will state the reasons for eliminating simple sugars in the diet.

a. The patient will reach a glycosylated hemoglobin level of less than 7%.

The patient with diabetes has a blood glucose level of 248 mg/dL. Which assessment findings would be related to this blood glucose level (select all that apply)? a. Headache b. Unsteady gait c. Abdominal cramps d. Emotional changes e. Increase in urination f. Weakness and fatigue

A, C, E, F

A 19-year old male has sustained a transaction of C-7 in an MVA reddening his quadriplegic. He describes his pain as burning, sharp, and shooting. This is characteristic of A. Neuropathic pain B. Ghost pain C. Mixed pain syndrome D. Nociceptive pain

A. Neuropathic pain Damage to the brain, spinal cord, peripheral nerves resulting in burning or shooting sensation

A patient reports feeling numbness and tingling of the left arm before experiencing a tonic-clonic seizure. The nurse determines that this history is consistent with what type of seizure? a. Focal b. Atonic c. Absence d. Myoclonic

ANS: A The initial symptoms of a focal seizure involve clinical manifestations that are localized to a particular part of the body or brain. Symptoms of an absence seizure are staring and a brief loss of consciousness. In an atonic seizure, the patient loses muscle tone and (typically) falls to the ground. Myoclonic seizures are characterized by a sudden jerk of the body or extremities.DIF: Cognitive Level: Understand (comprehension) REF: 1421TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

Which topic will the nurse teach after a patient has had outpatient cataract surgery and lens implantation? a. Use of oral opioids for pain control b. Administration of corticosteroid eye drops c. Importance of coughing and deep breathing exercises d. Need for bed rest for the first 1 to 2 days after the surgery

b. Administration of corticosteroid eye drops

A patient is receiving care to manage symptoms of a terminal illness when the disease no longer responds to treatment. What is this type of care known as? a. Terminal care c. Supportive care b. Palliative care d. Maintenance care

b. Palliative care is aimed at symptom management rather than curative treatment for diseases that no longer respond to treatment and is focused on caring interventions rather than curative treatments. "Palliative care" and "hospice" are frequently used interchangeably.

A patient is receiving care to manage symptoms of a terminal illness when the disease no longer responds to treatment. What is this type of care known as? a. Terminal care b. Supportive care c. Palliative care d. Maintenance care

C. Palliative care is aimed at symptom management rather than curative treatment for diseases that no longer respond to treatment and is focused on caring interventions rather than curative treatments. "Palliative care" and "hospice" are frequently used interchangeably.su

A patient admitted to the hospital following a geeralized tonic-clonic seizure asks the nurse what caused the seizure. Whats the best response? A. "so many factors can cause epilepsy that it is impossible to say what caused it" B. "Epilepsy is an inherited disorder. Does anyone in your family have a seizure disorder?" C. "In seizures, some type of trigger causes sudden, abnormal firing of electrical brain activity" D. "scar tissue in the brain alters the chemical balance, creating uncontrolled electrical discharges"

C. "In seizures, some type of trigger causes sudden, abnormal firing of electrical brain activity"

A patient has been prescribed a nonsteroidal antiinflammatory medication (NSAID). Which effect should the nurse teach the patient to immediately report? Blurred vision Nasal stuffiness Urinary retention Black or tarry stools

Black or tarry stools

Which components can change to adapt to small increases in intracranial pressure (ICP)? Select all that apply. Blood Skull Bone Brain Tissue Scalp Tissue Cerebrospinal fluid (CSF)

Blood Brain Tissue CSF

A patient newly diagnosed with glaucoma asks the nurse what has made the pressure in the eyes so high. Which is the nurse's most accurate response? A) Back pressure from cardiac congestion causes corneal edema. B) Cerebral venous dilation prevents normal interstitial fluid resorption. C) Increased production of aqueous humor or blocked drainage increases pressure. D) Congenital anomalies of the lacrimal gland or duct obstruct the passage of tears.

C) Increased production of aqueous humor or blocked drainage increases pressure.

The patient's neuropathic pain is not well controlled with the opioid analgesic prescribed. What medications may be added for a multimodal approach to treat the patient's pain (select all that apply)?A. NSAIDs B. Fentanyl C. Antiseizure drugs D. β-adrenergic agonists E. Tricyclic antidepressants

C. Antiseizure drugs E. Tricyclic antidepressants Antiseizure drugs, tricyclic antidepressants, SNRIs, transdermal lidocaine, and α2-adrenergic agonists will be used for multimodal treatment when opioid analgesics alone do not control neuropathic pain.

During the assessment of a patient with cobalamin deficiency, what manifestation would the nurse expect to find in the patient? a. Icteric sclera b. Hepatomegaly c. Paresthesia of the hands and feet d. Intermittent heartburn with acid reflux

c. Paresthesia of the hands and feet

A client's intraocular pressure (IOP) is 28 mm Hg. What action by the nurse is best? a. Educate the client on corneal transplantation. b. Facilitate scheduling the eye surgery. c. Plan to teach about drugs for glaucoma. d. Refer the client to local Braille classes.

c. Plan to teach about drugs for glaucoma.

When assisting a blind patient in ambulating to the bathroom, the nurse should a. take the patient by the arm and lead the patient slowly to the bathroom. b. have the patient place a hand on the nurse's shoulder and guide the patient. c. stay beside the patient and describe any obstacles on the path to the bathroom. d. walk slightly ahead of the patient and allow the patient to hold the nurse's elbow.

ANS: D When using the sighted-guide technique, the nurse walks slightly in front and to the side of the patient and has the patient hold the nurse's elbow. The other techniques are not as safe in assisting a blind patient

The patient is receiving immunotherapy and targeted therapy for ovarian cancer. What medication should the nurse expect to administer before therapy to combat the most common side effects of these medications? Morphine sulfate Ibuprofen (Advil) Ondansetron (Zofran) Acetaminophen (Tylenol)

Acetaminophen (Tylenol)

When teaching a patient with a seizure disorder about the medication regimen, what is it most important for the nurse to emphasize? a. The patient should increase the dosage of the medication if stress is increased. b. Most over-the-counter and prescription drugs are safe to take with antiseizure drugs. c. Stopping the medication abruptly may increase the intensity and frequency of seizures. d. If gingival hypertrophy occurs, the drug should be stopped and the health care provider notified.

c. Stopping the medication abruptly may increase the intensity and frequency of seizures.If antiseizure drugs are discontinued abruptly, seizures can be precipitated. Missed doses should be made up if the omission is remembered within 24 hours and patients should not adjust medications without professional guidance because this can also increase seizure frequency and may cause status epilepticus. Antiseizure drugs have numerous interactions with other drugs and the use of other medications should be evaluated by health professionals. If side effects occur, the physician should be notified and drug regimens evaluated.

When teaching the patient with type 1 diabetes, what should the nurse emphasize as the major advantage of using an insulin pump? a. Tight glycemic control can be maintained. b. Errors in insulin dosing are less likely to occur. c. Complications of insulin therapy are prevented. d. Frequent blood glucose monitoring is unnecessary.

A

Cushing syndrome symptoms

purplish streaks

The nurse cares for a terminally ill patient who has 20-second periods of apnea followed by periods of deep and rapid breathing. Which action by the nurse would be most appropriate? a.Suction the patient. b.Administer oxygen via face mask. c.Place the patient in high Fowler's position. d.Document the respirations as Cheyne-Stokes.

d.Document the respirations as Cheyne-Stokes.

A terminally ill patient is unresponsive and has cold, clammy skin with mottling on the extremities. The patient's husband and two grown children are arguing at the bedside about where the patient's funeral should be held. What should the nurse do first? a. Ask the family members to leave the room if they are going to argue. b. Take the family members aside and explain that the patient may be able to hear them. c. Tell the family members that this decision is premature because the patient has not yet died. d. Remind the family that this should be the patient's decision and to ask her if she regains consciousness.

b. Hearing is often the last sense to disappear with declining consciousness and conversations can distress patients even when they appear unresponsive. Conversation around unresponsive patients should never be other than that which one would maintain if the patients were alert.

A patient displays jerky muscle movements of the extremities and is incontinent of bowel and bladder. The nurse recognizes that these clinical manifestations are associated with: 1.Aura seizures 2.Postictal seizures 3.Generalized seizures 4.Simple partial seizures

3.Generalized seizures

When assessing a patient receiving morphine sulfate 2 mg every 10 minutes via PCA pump, the nurse should act as soon as the patient's respiratory rate drops down to or below which parameter? 10 breaths/min 12 breaths/min 14 breaths/min 16 breaths/min

12 breaths/min

Calculate the CPP of a patient whose BP is 106/52 and ICP is 14 mmHg Just type the number not mmHg

56

A patient with an intracranial problem does not open his eyes to any stimulus, has no verbal response except moaning and muttering when stimulated and flexes his arm in response to painful stimuli. What should the nurse record as the patient's GCS score? Group of answer choices a. 6 b. 7 c. 9 d. 11

7

A 72-year-old woman is diagnosed with diabetes. What does the nurse recognize about managing diabetes in the older adult? a. It is harder to achieve strict glucose control than in younger patients. b. Treatment is not warranted unless the patient develops severe hyperglycemia. c. It does not include treatment with insulin because of limited dexterity and vision. d. It usually requires that a younger family member be responsible for care of the patient.

A

Priority Decision: Two days after a self-managed hypoglycemic episode at home, the patient tells the nurse that his blood glucose levels since the episode have been between 80 and 90 mg/dL. Which is the best response by the nurse? a. "That is a good range for your glucose levels." b. "You should call your HCP because you need to have your insulin increased." c. "That level is too low in view of your recent hypoglycemia and you should increase your food intake." d. "You should take only half your insulin dosage for the next few days to get your glucose level back to normal."

A

Priority Decision: When caring for a patient with metabolic syndrome, the nurse should give the highest priority to teaching the patient about which treatment plan? a. Achieving a normal weight b. Performing daily aerobic exercise c. Eliminating red meat from the diet d. Monitoring the blood glucose periodically

A

To prevent hyperglycemia or hypoglycemia related to exercise, what should the nurse teach the patient using glucose-lowering agents about the best time for exercise? a. Plan activity and food intake related to blood glucose levels b. When blood glucose is greater than 250 mg/dL and ketones are present c. When glucose monitoring reveals that the blood glucose is in the normal range d. When blood glucose levels are high, because exercise always has a hypoglycemic effect

A

A 54-year-old woman with acute myelogenous leukemia (AML) is considering treatment with a hematopoietic stem cell transplant (HSCT). The best approach for the nurse to assist the patient with a treatment decision is to a. emphasize the positive outcomes of a bone marrow transplant .b. discuss the need for adequate insurance to cover post-HSCT care. c. ask the patient whether there are any questions or concerns about HSCT. d. explain that a cure is not possible with any other treatment except HSCT.

c. ask the patient whether there are any questions or concerns about HSCT.

You are caring for a patient who has just been told that her stage IV colon cancer has recurred and metastasized to the liver. The oncologist offers the patient the option of surgery to treat the progression of this disease. What type of surgery does the oncologist offer? A) Palliative B) Reconstructive C) Salvage D) Prophylactic

A. Palliative

The most concerning assessment finding after the patient has a thyroidectomy is: A. Laryngeal stridor B. temp of 96.9 F C. pain at 4/10 in throat D. Hoarseness when speaking

A. laryngeal stridor

The nurse is caring for a group of patients on a medical unit. After receiving report, which patient should the nurse see first? A 42-yr-old patient with multiple sclerosis who was admitted with sepsis A 72-yr-old patient with Parkinson's disease who has aspiration pneumonia. A 38-yr-old patient with myasthenia gravis who declined prescribed medications A 45-yr-old patient with amyotrophic lateral sclerosis who refuses enteral feedings.

A 38-yr-old patient with myasthenia gravis who declined prescribed medications

The nurse is reviewing laboratory results for the clinic patients to be seen today. Which patient meets the diagnostic criteria for diabetes mellitus? A 48-yr-old woman with a hemoglobin A1C of 8.4% A 58-yr-old man with a fasting blood glucose of 111 mg/dL A 68-yr-old woman with a random plasma glucose of 190 mg/dL A 78-yr-old man with a 2-hour glucose tolerance plasma glucose of 184 mg/dL

A 48-yr-old woman with a hemoglobin A1C of 8.4%

Which patient is most at risk for respiratory depression related to opioid administration for pain relief? A. 82-year-old patient who had abdominal surgery 4 hours ago B. 24-year-old patient who had a vaginal delivery 12 hours ago C. 32-year-old patient with chronic neuropathic pain for 6 months D. 20-year-old patient with a closed reduction of a fractured right arm

A. 82-year-old patient who had abdominal surgery 4 hours ago Patients most at risk for respiratory depression include those who are older, have underlying lung disease, have a history of sleep apnea, or are receiving other central nervous system depressants. For postoperative patients the greatest risk is in the first 24 hours after surgery. Respiratory depression related to opioid administration is higher in hospitalized patients who are opioid naïve.

Which patient action indicates a good understanding of the nurse's teaching about the use of an insulin pump? a. The patient programs the pump for an insulin bolus after eating. b. The patient changes the location of the insertion site every week. c. The patient takes the pump off at bedtime and starts it again each morning. d. The patient plans for a diet that is less flexible when using the insulin pump.

A. In addition to the basal rate of insulin infusion, the patient will adjust the pump to administer a bolus after each meal, with the dosage depending on the oral intake. The insertion site should be changed every 2 or 3 days. There is more flexibility in diet and exercise when an insulin pump is used. The pump will deliver a basal insulin rate 24 hours a day.

Which finding indicates to the nurse that the current therapies are effective for a patient with acute adrenal insufficiency? a. Increasing serum sodium levels b. Decreasing blood glucose levels c. Decreasing serum chloride levels d. Increasing serum potassium levels

ANS: A Clinical manifestations of Addison's disease include hyponatremia and an increase in sodium level indicates improvement. The other values indicate that treatment has not been effective.

A patient who had a subtotal thyroidectomy earlier today develops laryngeal stridor and a cramp in the right hand upon returning to the surgical nursing unit. Which collaborative action will the nurse anticipate next? a. Suction the patient's airway. b. Administer IV calcium gluconate. c. Plan for emergency tracheostomy. d. Prepare for endotracheal intubation.

B

The nurse administers an IV vesicant chemotherapeutic agent to a patient. Which action is most important for the nurse to take? a. Infuse the medication over a short period of time .b. Stop the infusion if swelling is observed at the site. c. Administer the chemotherapy through a small-bore catheter. d. Hold the medication unless a central venous line is available.

B

What should the goals of nutrition therapy for the patient with type 2 diabetes include? a. Ideal body weight b. Normal serum glucose and lipid levels c. A special diabetic diet using dietetic foods d. Five small meals per day with a bedtime snack

B

Which class of oral glucose-lowering agents (OA) is most commonly used for people with type 2 diabetes because it reduces hepatic glucose production and enhances tissue uptake of glucose? a. Insulin b. Biguanide c. Meglitinide d. Sulfonylurea

B

A patient with a head injury opens his eyes to verbal stimulation, curses when stimulated, and does not respond to a verbal command to move but attempts to push away a painful stimulus. The nurse records the patient's Glasgow Coma Scale score as a. 9. b. 11. c. 13. d. 15.

ANS: B The patient has scores of 3 for eye opening, 3 for best verbal response, and 5 for best motor response. DIF: Cognitive Level: Apply (application)

A patient with leukemia is considering whether to have hematopoietic stem cell transplantation (HSCT). The nurse will include which information in the patient's teaching plan? a. Donor bone marrow is transplanted through a sternal or hip incision. b. Hospitalization is required for several weeks after the stem cell transplant. c. The transplant procedure takes place in a sterile operating room to minimize the risk for infection. d. Transplant of the donated cells can be very painful because of the nerves in the tissue lining the bone.

ANS: B The patient requires strict protective isolation to prevent infection for 2 to 4 weeks after HSCT while waiting for the transplanted marrow to start producing cells. The transplanted cells are infused through an IV line so the transplant is not painful, nor is an operating room or incision required. DIF: Cognitive Level: Understand (comprehension) REF: 261TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

A female patient is having chemotherapy for brain metastasis. She is concerned about how she will look when she loses her hair. What is the best response by the nurse to this patient? "When your hair grows back, it will be patchy." "Use your curling iron since that will slow down the loss." "You can get a wig now to match your hair so you will not look different." "You should contact "Look Good, Feel Better" to figure out what to do about this."

"You can get a wig now to match your hair so you will not look different."

The nurse is caring for a 36-yr-old patient receiving phenytoin (Dilantin) to treat seizures resulting from a traumatic brain injury as a teenager. It is most important for the nurse to observe for which hematologic adverse effect of this medication? Anemia Leukemia Polycythemia Thrombocytosis

Anemia

During the assessment of a pt with cobalamin deficiency, what manifestation would the nurse expect to find in the pt? a. Icteric sclera b. Hepatomegaly c. Paresthesia of the hands and feet d. Intermitten heartburn with acid reflux

C

The nurse should observe the patient for symptoms of ketoacidosis when a. illnesses causing nausea and vomiting lead to bicarbonate loss with body fluids. b. glucose levels become so high that osmotic diuresis promotes fluid and electrolyte loss. c. an insulin deficit causes the body to metabolize large amounts of fatty acids rather than glucose for energy. d. the patient skips meals after taking insulin, leading to rapid metabolism of glucose and breakdown of fats for energy.

C

In addition to altered red blood cells (RBCs), which laboratory finding does the nurse expect for the patient with sickle cell disease?A. Leukocytosis B. Hypouricemia C. Hyperbilirubinemia D. Hypercholesteremia

C. Hyperbilirubinemia

Which nursing intervention is most appropriate when preparing to administer an opioid analgesic agent to a patient in pain? Give the medication on an empty stomach. Count the number of doses on hand before administration. Give the medication with a glass of juice or cold beverage. Assess the patient for allergies to aspirin before administration.

Count the number of doses on hand before administration.

Which type of seizure is most likely to cause death for the patient? A. Subclinical seizures B. Myoclonic seizures C. psychogenic seizures D. Tonic-clonic status epilepticus

D. Tonic-clonic status epilepticus

The patient with leukemia has acute disseminated intravascular coagulation (DIC) and is bleeding. What diagnostic findings should the nurse expect to find? Elevated D-dimers Elevated fibrinogen Reduced prothrombin time (PT) Reduced fibrin degradation products (FDPs)

Elevated D-dimers

The patient with type 1 diabetes is having a seizure. Which medication should the nurse anticipate will be administered first? IV dextrose solution IV diazepam (Valium) IV phenytoin (Dilantin) Oral carbamazepine (Tegretol)

IV dextrose solution

Patients with Cushings disease are at risk for bone fractures. What should you do?

Move with lift sheet and 2 staff members

PERRLA stands for

Pupils Equal Round Reactive to Light and Accommodation

A patient has just arrived on the unit after a thyroidectomy. Which action should the nurse take first? a. Observe the dressing for bleeding. b. Check the blood pressure and pulse. c. Assess the patient's respiratory effort. d. Support the patient's head with pillows.

ANS: C Airway obstruction is a possible complication after thyroidectomy because of swelling or bleeding at the site or tetany. The priority nursing action is to assess the airway. The other actions are also part of the standard nursing care postthyroidectomy but are not as high of a priority.

The nurse is evaluating whether a hospice referral is appropriate for a patient with end-stage liver failure. What is one of the two criteria necessary for admission to a hospice program? The hospice medical director certifies admission to the program. The physician guarantees the patient has less than 6 months to live. The patient has completed both advance directives and a living will. The patient wants hospice care and agrees to terminate curative care.

The patient wants hospice care and agrees to terminate curative care.

Which characteristic should the nurse associate with a focal seizure? The patient lost consciousness during the seizure. The seizure involved both sides of the patient's brain. The seizure involved lip smacking and repetitive movements. The patient fell to the ground and became stiff for 20 seconds.

The seizure involved lip smacking and repetitive movements.

The patient is being treated with brachytherapy for cervical cancer. What factors must the nurse be aware of to protect herself when caring for this patient? The medications the patient is taking The nutritional supplements that will help the patient How much time is needed to provide the patient's care The time the nurse spends at what distance from the patient

The time the nurse spends at what distance from the patient

Understanding classifications of pain helps nurses develop a plan of care. A 62-year old male has fallen while trimming tree branches sustaining tissue injury. He describes his condition as an aching, throbbing back. This is characteristic of A. Neuropathic pain B. Nociceptive pain C. Chronic pain D. Mixed pain syndrome

B. Nociceptive pain Normal function of the somatosensory system: eudynic= throbbing, aching, cramping

What characterizes type 2 diabetes (select all that apply)? a. β-cell exhaustion b. Insulin resistance c. Genetic predisposition d. Altered production of adipokines e. Inherited defect in insulin receptors f. Inappropriate glucose production by the liver

A, B, C, D, E, F

What is an appropriate nursing intervention for a patient with cerebral edema and increased ICP? Group of answer choices a. Avoid positioning the patient with neck and hip flexion b. Maintain hyperventilation to a paCO2 of 15-20 mmHg c. Cluster nursing activities to provide periods of uninterrupted rest d. Routinely suction to prevent accumulation respiratory secretions

a. Avoid positioning the patient with neck and hip flexion

A nurse caring for a client with sickle cell disease (SCD) reviews the clients laboratory work. Which finding should the nurse report to the provider? a. Creatinine: 2.9 mg/dL b. Hematocrit: 30% c. Sodium: 147 mEq/L d. White blood cell count: 12,000/mm3

a. Creatinine: 2.9 mg/dL

A patient with advanced colorectal cancer has continuous, poorly localized abdominal pain at an intensity of 5 on a scale of 0 to 10. How does the nurse teach the patient to use pain medication? a. On an around the clock schedule b. As often as necessary to keep the pain controlled c. By alternating two different types of drugs to prevent tolerance d. When the pain cannot be controlled with distraction or relaxation

a. On an around the clock schedule

Which of the following processes have the strongest links to intracranial regulation? (Select all that apply.)

Mobility Oxygenation Perfusion Hormonal Regulation Cognition

The nurse is caring for an 18-yr-old patient with acute lymphocytic leukemia who is scheduled for hematopoietic stem cell transplantation (HSCT). Which patient statement indicates a correct understanding of the procedure? "I understand the transplant procedure has no dangerous side effects." "After the transplant, I will feel better and can go home in 5 to 7 days." "My brother will be a 100% match for the cells used during the transplant." "Before the transplant, I will have chemotherapy and possibly full-body radiation."

"Before the transplant, I will have chemotherapy and possibly full-body radiation."

The nurse assesses a patient with chronic myeloid leukemia receiving chemotherapy using a kinase inhibitor medication. Which question is most important for the nurse to ask? "Have you had a fever?" "Have you lost any weight?" "Has diarrhea been a problem?" "Have you noticed any hair loss?"

"Have you had a fever?"

Which type of seizure occurs in children, is also known as a petit mal seizure, and consists of a staring spell for a few seconds? A. Atonic B. Simple focal C. Typical absence D. Atypical absence

C. Typical absence

Clinical manifestations of hypothyroidism include: Hair thinning constipation diarrhea Finger clubbing Big tongue Bulging eyes Lethargy

Hair thinning constipation big tongue lethargy

A 70-yr-old man who has end-stage lung cancer is admitted to the hospital with confusion and oliguria for 2 days. Which finding would the nurse report immediately to the health care provider? Weight gain of 6 lb Nausea and vomiting Urine specific gravity of 1.004 Serum sodium level of 118 mEq/L

Serum sodium level of 118 mEq/L

A 36-yr-old patient suspected of having leukemia is scheduled for a bone marrow aspiration. What statement in the patient's health history requires immediate follow-up by the nurse? "I had a bad reaction to iodine before and almost died." "I am taking an antibiotic to treat a urinary tract infection." "I have rheumatoid arthritis and take aspirin for joint pain." "I have dialysis for chronic renal failure three times a week."

"I have rheumatoid arthritis and take aspirin for joint pain."

The nurse is teaching a patient about timolol eye drops for the treatment of glaucoma. What statement made by the patient demonstrates that teaching was effective? "I may feel some palpitations after instilling these eye drops." "I should withhold this medication if my blood pressure becomes elevated." "I should keep my eyes closed for 15 minutes after instilling these eye drops." "I may have some temporary blurring of vision after instilling these eye drops."

"I may have some temporary blurring of vision after instilling these eye drops."

The nurse provides information to the caregiver of a 68-yr-old man with epilepsy who has tonic-clonic seizures. Which statement by the caregiver indicates a need for further teaching? "The jerking movements may last for 30 to 40 seconds" "It is normal for a person to be sleepy after a seizure." "I should call 911 if breathing stops during the seizure." "Objects should not be placed in the mouth during a seizure."

"I should call 911 if breathing stops during the seizure."

Upon entering the room, the nurse finds the patient, who has just had a mastectomy, crying. When the nurse asks about her crying, the patient states, "I know I shouldn't cry because this surgery may well save my life." What is the nurse's best response? "It is okay to cry; mourning the loss of your breast is important for getting past this." "Would you like to talk to someone who also has had a mastectomy?" "How have you coped with difficult situations in the past?" "I know this is hard, but chances of survival are greatly improved now."

"It is okay to cry; mourning the loss of your breast is important for getting past this."

A patient has recently been diagnosed with stage II cervical cancer. Which statement by the nurse best explains the diagnosis? "The cancer is found at the point of origin only." "Tumor cells have been identified in the cervical region." "The cancer has been identified in the cervix and the liver." "Your cancer was identified in the cervix and has limited local spread."

"Your cancer was identified in the cervix and has limited local spread."

When providing oral care to a patient with metastatic cancer who is at risk for oral tissue injury secondary to chemotherapy, what would be most beneficial to teach the patient to use? Firm-bristle toothbrush Hydrogen peroxide rinse Alcohol-based mouthwash 1 tsp salt in 1 L water mouth rinse

1 tsp salt in 1 L water mouth rinse

A patient with a head injury has admission vital signs of blood pressure 128/68, pulse 110, and respirations 26. Which of these vital signs, if taken 1 hour after admission, will be of most concern to the nurse? a. Blood pressure 156/60, pulse 55, respirations 12 b. Blood pressure 130/72, pulse 90, respirations 32 c. Blood pressure 148/78, pulse 112, respirations 28 d. Blood pressure 110/70, pulse 120, respirations 30

A

Individualized nutrition therapy for patients using conventional, fixed insulin regimens should include teaching the patient to a. eat regular meals at regular times. b. restrict calories to promote moderate weight loss. c. eliminate sucrose and other simple sugars from the diet. d. limit saturated fat intake to 30% of dietary calorie intake.

A

The nurse is providing instructions to a client with a seizure disorder who will be taking phenytoin (Dilantin). Which statement, if made by the client, would indicate an understanding of the information about this medication? 1."I need to perform good oral hygiene, including flossing and brushing my teeth." 2."I should try to avoid alcohol, but if I'm not able to, I can drink alcohol in moderation." 3."I should take my medication before coming to the laboratory to have a blood level drawn. "4."I should monitor for side effects and adjust my medication dose depending on how severe the side effects are."

1."I need to perform good oral hygiene, including flossing and brushing my teeth. "The client should perform good oral hygiene, including flossing and brushing the teeth. The client also should see a dentist at regularly scheduled times because gingival hyperplasia is a side effect of this medication. The client should avoid alcohol while taking this medication. The client should also be instructed that follow-up serum blood levels are important and that, on the day of the scheduled laboratory test, the client should avoid taking the medication before the specimen is drawn. The client should not adjust medication dosages.

A patient with diabetes is learning to mix regular insulin and NPH insulin in the same syringe. The nurse determines that additional teaching is needed when the patient does what? a. Withdraws the NPH dose into the syringe first b. Injects air equal to the NPH dose into the NPH vial first c. Removes any air bubbles after withdrawing the first insulin d. Adds air equal to the insulin dose into the regular vial and withdraws the dose

A

The nurse in the health care clinic is providing medication instructions to a client with a seizure disorder who will be taking divalproex sodium (Depakote). The nurse should instruct the client about the importance of returning to the clinic for monitoring of which laboratory study? 1.Electrolyte panel 2.Liver function studies 3.Renal function studies 4.Blood glucose level determination

2.Liver function studies Divalproex sodium, an anticonvulsant, can cause fatal hepatotoxicity. The nurse should instruct the client about the importance of monitoring the results of liver function studies and ammonia level determinations. Options 1, 3, and 4 are not studies that are required with the use of this medication.

The nurse is documenting nursing observations in the record of a client who experienced a tonic-clonic seizure. Which clinical manifestation did the nurse most likely note in the clonic phase of the seizure? 1.Body stiffening 2.Spasms of the entire body 3.Sudden loss of consciousness 4.Brief flexion of the extremities

2.Spasms of the entire body The clonic phase of a seizure is characterized by alternating spasms and momentary muscular relaxation of the entire body, accompanied by strenuous hyperventilation. The face is contorted and the eyes roll. Excessive salivation results in frothing from the mouth. The tongue may be bitten, the client sweats profusely, and the pulse is rapid. The clonic jerking subsides by slowing in frequency and losing strength of contractions over a period of 30 seconds. Options 1, 3, and 4 identify the tonic phase of a seizure.

A patient who is diagnosed with cervical cancer classified as Tis, N0, M0 asks the nurse what the letters and numbers mean. Which response by the nurse is accurate a. "The cancer involves only the cervix." b. "The cancer cells look like normal cells." c. "Further testing is needed to determine the spread of the cancer." d. "It is difficult to determine the original site of the cervical cancer."

A

A client hospitalized with sickle cell crisis frequently asks for opioid pain medications, often shortly after receiving a dose. The nurses on the unit believe the client is drug seeking. When the client requests pain medication, what action by the nurse is best? a. Give the client pain medication if it is time for another dose. b. Instruct the client not to request pain medication too early. c. Request the provider leave a prescription for a placebo. d. Tell the client it is too early to have more pain medication.

ANS: A Clients with sickle cell crisis often have severe pain that is managed with up to 48 hours of IV opioid analgesics. Even if the client is addicted and drug seeking, he or she is still in extreme pain. If the client can receive another dose of medication, the nurse should provide it. The other options are judgmental and do not address the clients pain. Giving placebos is unethical.

Which menu choice indicates that the patient understands the nurse's teaching about best dietary choices for iron-deficiency anemia? a. Omelet and whole wheat toast b. Cantaloupe and cottage cheese c. Strawberry and banana fruit plate d. Cornmeal muffin and orange juice

ANS: A Eggs and whole grain breads are high in iron. The other choices are appropriate for other nutritional deficiencies but are not the best choice for a patient with iron-deficiency anemia.

When the nurse applies a painful stimulus to the nail beds of an unconscious patient, the patient responds with internal rotation, adduction, and flexion of the arms. The nurse documents this as a. flexion withdrawal. b. localization of pain. c. decorticate posturing. d. decerebrate posturing.

ANS: C Internal rotation, adduction, and flexion of the arms in an unconscious patient is documented as decorticate posturing. Extension of the arms and legs is decerebrate posturing. Because the flexion is generalized, it does not indicate localization of pain or flexion withdrawal.DIF: Cognitive Level: Comprehension REF: 1429-1430

Which statement by a patient indicates good understanding of the nurse's teaching about prevention of sickle cell crisis? a. "Home oxygen therapy is frequently used to decrease sickling." b. "There are no effective medications that can help prevent sickling." c. "Routine continuous dosage narcotics are prescribed to prevent a crisis." d. "Risk for a crisis is decreased by having an annual influenza vaccination."

ANS: D Because infection is the most common cause of a sickle cell crisis, influenza, Haemophilus influenzae, pneumococcal pneumonia, and hepatitis immunizations should be administered. Although continuous dose opioids and oxygen may be administered during a crisis, patients do not receive these therapies to prevent crisis. Hydroxyurea (Hydrea) is a medication used to decrease the number of sickle cell crises.

When obtaining a health history from a 49-year-old patient, which patient statement is most important to communicate to the primary health care provider? a. "My eyes are dry now." b. "It is hard for me to see at night." c. "My vision is blurry when I read." d. "I can't see as far over to the side."

ANS: D The decrease in peripheral vision may indicate glaucoma, which is not a normal visual change associated with aging and requires rapid treatment. The other patient statements indicate visual problems (presbyopia, dryness, and lens opacity) that are considered a normal part of aging

Which prescribed medication should the nurse expect will have rapid effects on a patientadmitted to the emergency department in thyroid storm? a. Iodine b. Methimazole c. Propylthiouracil d. Propranolol (Inderal)

ANS: D β-Adrenergic blockers work rapidly to decrease the cardiovascular manifestations of thyroid storm. The other medications take days to weeks to have an impact on thyroid function.

The nurse is caring for a patient with anorexia secondary to chemotherapy. Which strategy would be most appropriate to increase the patient's nutritional intake? Increase intake of liquids at mealtime to stimulate the appetite. Serve three large meals per day plus snacks between each meal. Avoid the use of liquid protein supplements to encourage eating at mealtimes. Add items such as skim milk powder, cheese, honey, or peanut butter to selected foods.

Add items such as skim milk powder, cheese, honey, or peanut butter to selected foods.

A patient with osteoarthritis has been taking ibuprofen 400 mg every 8 hours. The patient states that the drug does not seem to work as well as it used to in controlling the pain. The most appropriate response to the patient is based on what knowledge? Another NSAID may be indicated because of individual variations in response to drug therapy. It may take several months for NSAIDs to reach therapeutic levels in the blood and thus be effective. If NSAIDs are not effective in controlling symptoms, systemic corticosteroids are the next line of therapy. The patient may not be taking the drug correctly, so the nurse must assess the patient's knowledge base and provide teaching.

Another NSAID may be indicated because of individual variations in response to drug therapy.

The nurse is preparing to administer celecoxib to a patient. What medication taken by the patient should the nurse monitor because of an increased risk of adverse effects? Aspirin Scopolamine Theophylline Acetaminophen

Aspirin

A dying patient is experiencing confusion, restlessness, and skin breakdown. What nursing interventions will best meet this patient's needs? Encourage more physical activity. Assess for pain, constipation, and urinary retention. Assess for spiritual distress and restrain in varying positions. Assess for quality, intensity, location, and contributing factors of discomfort.

Assess for pain, constipation, and urinary retention.

The nurse is caring for a patient with polycythemia vera. What is an important action for the nurse to initiate? Encourage deep breathing and coughing. Assist with or perform phlebotomy at the bedside. Teach the patient how to maintain a low-activity lifestyle. Perform thorough and regularly scheduled neurologic assessments.

Assist with or perform phlebotomy at the bedside.

A patient with breast cancer is having teletherapy radiation treatments after surgery. What should the nurse teach the patient about skin care? Use Dial soap to feel clean and fresh. Scented lotion can be used on the area. Avoid heat and cold to the treatment area. Wear the new bra to comfort and support the area.

Avoid heat and cold to the treatment area.

A patient with newly diagnosed type 2 diabetes has been given a prescription to start an oral hypoglycemic medication. The patient tells the nurse she would rather control her blood sugar with herbal therapy. Which action should the nurse take? a. Teach the patient that herbal therapy is not safe and should not be used. b. Advise the patient to discuss using herbal therapy with her HCP before using it. c. Encourage the patient to give the prescriptive medication time to work before using herbal therapy. d. Teach the patient that if she takes herbal therapy, she will have to monitor her blood sugar more often.

B

Priority Decision: The patient with diabetes is brought to the emergency department by his family members, who say that he has had an infection, is not acting like himself, and he is more tired than usual. Number the nursing actions in the order of priority for this patient. _______ a. Establish IV access. _______ b. Check blood glucose. _______ c. Ensure patent airway. _______ d. Begin continuous regular insulin drip. _______ e. Administer 0.9% NaCl solution at 1 L/hr. _______ f. Establish time of last food and medication(s). Harding, Mariann M.. Study Guide for Lewis' Medical-Surgical Nursing - E-Book (p. 95). Elsevier Health Sciences. Kindle Edition.

C B A E D F 1 2 3 4 5 6

Which tissues require insulin to enable movement of glucose into the tissue cells (select all that apply)? a. Liver b. Brain c. Adipose d. Blood cells e. Skeletal muscle

C, E

You are caring for a 39-year-old woman with a family history of breast cancer. She has requested a breast tumor marking test and the results are positive. The patient is requesting a bilateral mastectomy. What is this surgery an example of? A) Salvage surgery B) Palliative surgery C) Prophylactic surgery D) Reconstructive surgery

C. prohylactic

A patient with suspected bacterial meningitis just had a lumbar puncture in which cerebrospinal fluid was obtained for culture. Which medication should the nurse give first? Codeine Phenytoin Ceftriaxone Acetaminophen

Ceftriaxone

The laboratory reports that the cells from the patient's tumor biopsy are grade II. What should the nurse know about this histologic grading? Cells are abnormal and moderately differentiated. Cells are very abnormal and poorly differentiated. Cells are immature, primitive, and undifferentiated. Cells differ slightly from normal cells and are well-differentiated.

Cells are abnormal and moderately differentiated.

A characteristic of the stage of progression in the development of cancer 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.

Correct answer: d Rationale: Progression is the final stage of cancer. This stage is characterized by increased growth rate of the tumor, increased invasiveness, and spread of the cancer to a distant site (i.e., metastasis). Progression occurs as a result of the following characteristics of cancer cells: rapid proliferation and decreased cell adhesion.

A patient has been receiving palliative care for the past several weeks in light of her worsening condition following a series of strokes. The caregiver has rung the call bell, stating that the patient now "stops breathing for a while, then breathes fast and hard, and then stops again." The nurse would recognize that the patient is experiencing A. Apnea. B. Bradypnea. C. Death rattle. D. Cheyne-Stokes respirations.

D. Cheyne-Stokes respirations.

Which sign or symptom would you recognize as a unique characteristic specific to hemolytic anemia? A. Tachycardia B. Weakness C. Decreased RBCs D. Jaundice

D. Jaundice Jaundice is likely because the increased destruction of RBCs causes an elevation in bilirubin levels. The spleen and liver may enlarge because of their hyperactivity, which is related to macrophage phagocytosis of the defective erythrocytes. The other symptoms are common to all types of anemia.Reference: 672

When caring for a patient with metastatic cancer, the nurse notes a hemoglobin level of 8.7 g/dL and hematocrit of 26%. What associated clinical manifestations does the nurse anticipate observing? Thirst Fatigue Headache Abdominal pain

Fatigue

The nurse is caring for a patient receiving an initial dose of chemotherapy to treat a rapidly growing metastatic colon cancer. The nurse is aware that the patient is at risk for tumor lysis syndrome (TLS) and will monitor for which abnormality associated with this oncologic emergency? Hypokalemia Hypercalcemia Hyperuricemia Hypophosphatemia

Hyperuricemia

The patient and his family are upset that the patient is going through procedures to diagnose cancer. What nursing actions should the nurse use first to facilitate their coping with this situation? (Select all that apply.) Maintain hope. Exhibit a caring attitude. Plan realistic long-term goals. Give them antianxiety medications. Be available to listen to fears and concerns. Teach them about the type of cancers that could be diagnosed.

Maintain hope. Exhibit a caring attitude. Be available to listen to fears and concerns

A patient sustained a diffuse axonal injury from a traumatic brain injury. Why are IV fluids being decreased and enteral feedings started? Free water should be avoided. Sodium restrictions can be managed. Dehydration can be better avoided with feedings. Malnutrition promotes continued cerebral edema.

Malnutrition promotes continued cerebral edema.

What nursing intervention should be implemented for a patient with increased intracranial pressure (ICP)? Monitor fluid and electrolyte status carefully. Position the patient in a high Fowler's position. Administer vasoconstrictors to maintain cerebral perfusion. Maintain physical restraints to prevent episodes of agitation.

Monitor fluid and electrolyte status carefully.

A patient will receive a hematopoietic stem cell transplant (HSCT). What is the nurse's priority after the patient receives combination chemotherapy before the transplant? Prevent patient infection. Avoid abnormal bleeding. Give pneumococcal vaccine. Provide companionship while isolated.

Prevent patient infection

Patients may reduce the risk of developing cancer using health promotion strategies. Identify modifiable strategies which can reduce the risk of developing cancer. (Select all that apply.) Stop smoking Use sunscreen Limit alcohol use Undergo genetic testing Maintain a healthy weight Receive appropriate immunizations

Stop smoking Use sunscreen Limit alcohol use Maintain a healthy weight Receive appropriate immunizations

Which aspects of anticipatory grief are associated with positive outcomes for the caregiver of a palliative patient? (Select all that apply.) Strong spiritual beliefs Advanced age of the patient Medical diagnosis of the patient Acceptance of the expected death of the patient Adequate time for the caregiver to prepare for the death

Strong spiritual beliefs Acceptance of the expected death of the patient Adequate time for the caregiver to prepare for the death

A patient is recovering from a motor vehicle crash that resulted in blindness. The patient is withdrawn and refuses to get out of bed. What is the nurse's priority goal for this patient? Use suitable coping strategies to reduce stress. Identify patient's strengths and support system. Verbalize feelings related to visual impairment. Transition successfully to the sudden vision loss.

Verbalize feelings related to visual impairment.

Analyze the following diagnostic findings for your patient with type 2 diabetes. Which result will need further assessment? a) A1C 9% b) BP 126/80 mmHg c) FBG 130 mg/dL (7.2 mmol/L) d) LDL cholesterol 100 mg/dL (2.6 mmol/L)

a) A1C 9%

The nurse at the eye clinic advises all patients to wear sunglasses that protect the eyes from ultraviolet light because ultraviolet sunlight exposure is associated with the development of a.cataracts. b.glaucoma. c.anisocoria. d.exophthalmos.

a.cataracts.

A client had cataract surgery. What instructions should the nurse provide? (Select all that apply.) a. Call the doctor for increased pain. b. Do not bend over from the waist. c. Do not lift more than 10 pounds. d. Sexual intercourse is allowed. e. Use stool softeners to avoid constipation.

a. Call the doctor for increased pain. b. Do not bend over from the waist. c. Do not lift more than 10 pounds. e. Use stool softeners to avoid constipation.

After administering acetaminophen with oxycodone (Percocet) for pain, which intervention would be of highest priority for the nurse to complete before leaving the patient's room? a. Ensure that the side rails are raised. b. Leave the overbed light on at low setting. c. Offer to turn on the television to provide distraction. d. Ensure that documentation of intake and output is accurate.

a. Ensure that the side rails are raised.

The nursing management of a patient in sickle cell crisis includes (select all that apply) a. monitoring CBC. b. optimal pain management and O2 therapy. c. blood transfusions if required and iron chelation. d. rest as needed and deep vein thrombosis prophylaxis. e. administration of IV iron and diet high in iron content.

a. monitoring CBC. b. optimal pain management and O2 therapy. c. blood transfusions if required and iron chelation. d. rest as needed and deep vein thrombosis prophylaxis.

The nurse admits a patient to the hospital in Addisonian crisis. Which patient statement supports the need to plan additional teaching? a. "I frequently eat at restaurants, and my food has a lot of added salt." b. "I had the flu earlier this week, so I couldn't take the hydrocortisone." c. "I always double my dose of hydrocortisone on the days that I go for a long run." d. "I take twice as much hydrocortisone in the morning dose as I do in the afternoon."

b. "I had the flu earlier this week, so I couldn't take the hydrocortisone."

A patient with glaucoma who has been using timolol (Timoptic) drops for several days tells the nurse that the eye drops cause eye burning and visual blurriness for a short time after administration. The best response to the patient's statement is a. "Those symptoms may indicate a need for an increased dosage of the eye drops." b. "The drops are uncomfortable, but it is important to use them to retain your vision." c. "These are normal side effects of the drug, which should be less noticeable with time." d. "Notify your health care provider so that different eye drops can be prescribed for you."

b. "The drops are uncomfortable, but it is important to use them to retain your vision."

After the family members of a postoperative patient leave, the patient tells the nurse that his family gave him a headache by fussing over him so much. What is an appropriate intervention by the nurse? a. Administer the PRN analgesic prescribed for his postoperative pain b. Ask the patient's permission to use acupressure to ease his headache c. Reassure the patient that his headache will subside now that his family is gone d. Teach the patient biofeedback methods to relieve his headaches by controlling cerebral blood flow

b. Ask the patient's permission to use acupressure to ease his headache

During the diagnosis and long-term management of a seizure disorder, what should the nurse recognize as one of the major needs of the patient? a. Managing the complicated drug regimen of seizure control b. Coping with the effects of negative social attitudes toward epilepsy c. Adjusting to the very restricted lifestyle required by a diagnosis of epilepsy d. Learning to minimize the effect of the condition in order to obtain employment

b. Coping with the effects of negative social attitudes toward epilepsy One of the most common complications of a seizure disorder is the effect it has on the patient's lifestyle. This is because of the social stigma attached to seizures, which causes patients to hide their diagnosis and to prefer not to be identified as having epilepsy. Medication regimens usually require only once-or twice-daily dosing and the major restrictions of the lifestyle usually involve driving and high-risk environments. Job discrimination against the handicapped is prevented by federal and state laws and patients only need to identify their disease in case of medical emergencies.

Which prescribed medication should the nurse give first to a patient who has just been admitted to a hospital with acute angle-closure glaucoma? a. Morphine sulfate 4 mg IV b. Mannitol (Osmitrol) 100 mg IV c. Betaxolol (Betoptic) 1 drop in each eye d. Acetazolamide (Diamox) 250 mg orally

b. Mannitol (Osmitrol) 100 mg IV

Vigorous control of fever in the patient with meningitis is needed to prevent complications of increased cerebral edema, seizure frequency, neurologic damage, and fluid loss. What nursing care should be included? a. Administer analgesics as ordered b. Monitor LOC related to increased brain metabolism c. Rapidly decrease temperature with a cooling blanket. d. Assess for peripheral edema from rapid fluid infusion

b. Monitor LOC related to increased brain metabolism

While caring for an unconscious patient, the nurse discovers a stage 2 pressure injury on the patient's heel. During care of the ulcer, what is the nurse's understanding of the patient's perception of pain? a. The patient will have a behavioral response if pain is perceived b. The area should be treated as a painful lesion, using gentle cleansing and dressing d. All nociceptive stimuli that are transmitted to the brain result in the perception of pain c. The area can be thoroughly scrubbed because the patient is not able to perceive pain

b. The area should be treated as a painful lesion, using gentle cleansing and dressing

A patient has been diagnosed with stage 1A Hodgkin's lymphoma. The nurse knows that which chemotherapy regimen is most likely to be prescribed for this patient? a. Brentuximab vedotin (Adcetris) b. Two to four cycles of ABVD: doxorubicin (Adriamycin), bleomycin, vinblastine, and dacarbazine c. Four to six cycles of ABVD: doxorubicin (Adriamycin), bleomycin, vinblastine, and dacarbazine d.BEACOPP: bleomycin, etoposide, doxorubicin (Adriamycin), cyclophosphamide, vincristine (Oncovin), procarbazine, and prednisone

b. Two to four cycles of ABVD: doxorubicin (Adriamycin), bleomycin, vinblastine, and dacarbazine

The patient is diagnosed with complex focal seizures. Which characteristics are related to complex focal seizures (select all that apply)? a. Formerly known as grand mal seizure b. Often accompanied by incontinence or tongue or cheek biting c. Psychomotor seizures with repetitive behaviors and lip smacking d. Altered memory, sexual sensations, and distortions of visual or auditory sensations e. Loss of consciousness and stiffening of the body with subsequent jerking of extremities f. Often involves behavioral, emotional, and cognitive functions with altered consciousness

c, d, f. Complex focal seizures are psychomotor seizures with automatisms such as lip smacking. They cause altered consciousness or loss of consciousness producing a dreamlike state and may involve behavioral, emotional, or cognitive experiences without memory of what was done during the seizure. In generalized tonic-clonic seizures (previously known as grand mal seizures) there is loss of consciousness and stiffening of the body with subsequent jerking of extremities. Incontinence or tongue or cheek biting may also occur.

Which patient should the nurse refer for hospice care? a.60-year-old with lymphoma whose children are unable to discuss issues related to dying b.72-year-old with chronic severe pain as a result of spinal arthritis and vertebral collapse c.28-year-old with AIDS-related dementia who needs palliative care and pain management d.56-year-old with advanced liver failure whose family members can no longer provide care in the home

c. 28-year-old with AIDS-related dementia who needs palliative care and pain management

Pain has been defined as "whatever the person experiencing the pain says it is, existing whenever the patient says it does." This definition is problematic for the nurse when caring for which type of patient? c. A patient with decreased cognitive function a. A patient on a ventilator d. A patient with pain resulting from severe trauma b. A patient with a history of opioid addiction

c. A patient with decreased cognitive function

A patient who has severe pain associated with terminal pancreatic cancer is being cared for at home by family members. Which finding by the nurse indicates that teaching regarding pain management has been effective? a. The patient uses the ordered opioid pain medication whenever the pain is greater than 5 (0 to 10 scale). b. The patient agrees to take the medications by the IV route in order to improve analgesic effectiveness. c. The patient takes opioids around the clock on a regular schedule and uses additional doses when breakthrough pain occurs. d. The patient states that nonopioid analgesics may be used when the maximal dose of the opioid is reached without adequate pain relief.

c. The patient takes opioids around the clock on a regular schedule and uses additional doses when breakthrough pain occurs.

endocrine issues: adequate oxygenation, hypotension, tachycardia, hyponatremia, hypoglycemia. nursing intervention: a. wait lab results and inform provider b. provide oral hydration and nutrition c. administer iv fluids and dextrose d. monitor respiratory status

c. administer iv fluids and dextrose

A patient with chronic back pain is seen in the pain clinic for follow-up. In order to evaluate whether the pain management is effective, which question is best for the nurse to ask? a. "Can you describe the quality of your pain?" b. "Has there been a change in the pain location?" c. "How would you rate your pain on a 0 to 10 scale?" d. "Does the pain keep you from doing things you enjoy?"

d. "Does the pain keep you from doing things you enjoy?" The goal for the treatment of chronic pain usually is to enhance function and quality of life. The other questions also are appropriate to ask, but information about patient function is more useful in evaluating effectiveness.

What does mononeuropathy multiplex mean? a. Nerve damage caused by trauma b. nerve damage caused by alcoholism c. damage to a nerve area outside brain and spinal cord d. damage to at least two separate nerve areas

d. damage to at least two separate nerve areas