Final Exam -- AH2
A patient has been admitted to a burn intensive care unit with extensive deep-full-thickness burns over 25% of the body. What would be the nurse's priority concern about this patient? A. Fluid status B. Risk for infection C. Body image D. Lebel of pain
A
A patient in the emergent/resuscitative phase of a burn injury has had her lab work drawn. Upon analysis of the patient's laboratory studies, the nurse will expect the results to indicate what? A. Hyperkalemia, hyponatremia, elevated hematocrit, metabolic acidosis B. Hypokalemia, hypernatremia, decreased hematocrit, metabolic acidosis C. Hyperkalemia, hypernatremia, decreased hematocrit, metabolic acidosis D. Hypokalemia, hyponatremia, elevated hematocrit, metabolic acidosis
A
A patient on your unit is in an Addisonian crisis. You now the patient requires immediate treatment with what? A. Vasopressors B. Oral fluids C. Calcium channel blockers D. Antihypertensives
A
An emergency room nurse cares for a patient admitted with a 50% burn injury at 10AM. The patient weighs 90 kg. Using the Parkland formula, calculate the rate at which the nurse would infuse IV fluid resuscitation when started at Noon A. 1500 mL/hr B. 1800 mL/hr C. 2400 mL/hr D. 3600 mL/hr
A
A spinal cord patient is ready to be discharged home. A family member asks the nurse to go over potential complications one more time. What are the potential complications that should be monitored for this patient? Select All that Apply A. Orthostatic hypotension B. Autonomic dysreflexia C. DVT D. Cerebral salt-wasting syndrome E. Increased ICP
A, B, C
A nurse cares for a client who reports pain related to eczematous dermatitis. Which nonpharmacologic comfort measures should the nurse implement? A. Cool, moist compresses B. Topical corticosteroids C. Heating pad D. Tepid bath with cornstarch E. Back rub with baby oil
A, D
A patient has experienced a stroke in the left cerebral hemisphere. What clinical presentation does the nurse expect? (Select all that apply.) A. Aphasia B. Decreased proprioception C. Disoriented to time and place D. Agraphia E. Difficulty with math calculation
A, D, E The right cerebral hemisphere is more involved with visual and spatial awareness and proprioception (sense of body position). A person who has a stroke involving the right cerebral hemisphere is often unaware of any deficits and may be disoriented to time and place. Personality changes include impulsivity (poor impulse control) and poor judgment. The left cerebral hemisphere, the dominant hemisphere in all but about 15% to 20% of the population, is the center for language, mathematical skills, and analytic thinking. Therefore a left hemisphere stroke may result in: Aphasia: inability to speak or comprehend language Alexia or dyslexia: difficulty with reading Agraphia: difficulty with writing Acalculia: difficulty with mathematical calculation
A patient ith Cushing's Syndrome has been hospitalized after a fall. The dietician is consulted and works with the patient to improve the nutritional intake of the patient. What foods should a patient with Cushing's Syndrome eat to optimize health? Select ALL that Apply. A. Foods high in Vitamin D B. Foods high in calories C. Foods high in protein D. Foods high in calcium E. Foods high in sodium
A,B,D
Which patient is at greatest risk of developing primary angle-closure glaucoma? A. 52-year-old Asian female B. 32-year-old Caucasian female C. 42-year-old Hispanic male D. 64-year-old African-American male
A. 52-year-old Asian female The risk of glaucoma begins after age 40 for all races. Primary angle-closure glaucoma (also called PACG or acute glaucoma) is more common in women and Asians. African-Americans and Hispanics have a greater tendency for developing primary open-angle glaucoma than do people of other ethnicities.
When developing a postoperative plan of care for a patient after a total thyroidectomy, the nurse knows the plan should include which intervention? A. Avoiding extending the patient's neck B. Assessing the patient's voice once per shift C. Encouraging the patient to be out of bed in a chair D. Administering oxygen via nasal cannula as needed
A. Avoiding extending the patient's neck Manifestations of hyperparathyroidism may present as bone lesions, pathologic fractures, bone cysts, and osteoporosis. Preventing falls is a priority nursing intervention. Fluid hydration may be used to treat hypercalcemia. Small frequent meals can assist with nutritional need.
What is the priority nursing intervention when providing care to a patient with hearing loss? A. Creating a safe environment B. Providing written information regarding medications and disease processes C. Having the patient repeat instructions to evaluate additional teaching needs D. Ensuring that the patient can directly visualize you when you provide instructions
A. Creating a safe environment Safety concerns are always a priority b/c the pt may not hear warning sounds such as alarm in the room. All other interventions are subsequent to safety concern. A pt w/hearing loss will use other senses such as sight to help interpret communication; the nurse should sit in adequate light & face the pt to allow him/her to see the nurse speak. Written info & assessment of pt comprehension augments all teaching interventions completed by a nurse.
As the nurse is assessing a patient with Grave's disease, which finding requires immediate attention? A. Elevated temperature B. Elevated blood pressure C. Change in respiratory rate D. Irregular heart rate and rhythm
A. Elevated temperature Increases in temperature may indicate a rapid worsening of the patient's condition and the onset of "thyroid storm." Further evaluation of cardiovascular status is warranted.
What is the priority nursing intervention for an older female patient with a history of hyperparathyroidism? A. Implement fall precautions. B. Encourage oral fluid hydration. C. Encourage small frequent meals. D. Provide pain medications as prescribed
A. Implement fall precautions. Manifestations of hyperparathyroidism may present as bone lesions, pathologic fractures, bone cysts, and osteoporosis. Preventing falls is a priority nursing intervention. Fluid hydration may be used to treat hypercalcemia. Small frequent meals can assist with nutritional need.
A client had a myringotomy. The nurse provides which discharge teaching? a. Buy dry shampoo to use for a week. b. Drink liquids through a straw. c. Flying is not allowed for 1 month. d. Hot water showers will help the pain.
ANS: A The client cannot shower or get the head wet for 1 week after surgery, so using dry shampoo is a good suggestion. The other instructions are incorrect: straws are not allowed for 2 to 3 weeks, flying is not allowed for 2 to 3 weeks, and the client should not shower. DIF: Applying/Application REF: 995 KEY: Auditory system| auditory disorders| patient education
The nurse is completing a health assessment of a 42-yer-old female with suspected Graves' disease. When conducting a focused assessment, what should the nurse assess the client for? A. Anorexia B. Tachycardia C. Weight Gain D. Cold skin
B
An older adult in the family practice clinic reports a decrease in hearing over a week. What action by thenurse is most appropriate? a. Assess for cerumen buildup. b. Facilitate audiological testing. c. Perform tuning fork tests. d. Review the medication list
ANS: A. All options are possible actions for the client with hearing loss. The first action the nurse should take is to lookfor cerumen buildup, which can decrease hearing in the older adult. If this is normal, medications should beassessed for ototoxicity. Further auditory testing may be needed for this client.DIF: Applying/Application REF: 992KEY: Auditory system| auditory assessment| auditory disorders| nursing assessmentMSC: Integrated Process: Nursing Process: AssessmentNOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
A nurse is teaching a client about ear hygiene and health. What client statement indicates a need for furtherteaching? a. A soft cotton swab is alright to clean my ears with. b. I make sure my ears are dry after I go swimming. c. I use good earplugs when I practice with the band. d. Keeping my diabetes under control helps my ears.
ANS: A. Clients should be taught not to put anything larger than their fingertip into their ears. Using a cotton swab,although soft, can cause damage to the ears and cerumen buildup. The other statements are accurate.DIF: Evaluating/Synthesis REF: 993KEY: Auditory system| auditory assessmentMSC: Integrated Process: Nursing Process: EvaluationNOT: Client Needs Category: Health Promotion and Maintenance
A nurse assesses a client who is recovering from anterior cervical diskectomy and fusion. Whichcomplication should alert the nurse to urgently communicate with the health care provider? a. Auscultated stridor b. Weak pedal pulses c. Difficulty swallowing d. Inability to shrug shoulders
ANS: A. Postoperative swelling can narrow the trachea, cause a partial airway obstruction, and manifest as stridor. Theclient may also have trouble swallowing, but maintaining an airway takes priority. Weak pedal pulses and aninability to shrug the shoulders are not complications of this surgery.DIF: Applying/Application REF: 899KEY: Back surgery| spinal cord/back injuryMSC: Integrated Process: Nursing Process: AssessmentNOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
A client had a retinal detachment and has undergone surgical correction. What discharge instruction is mostimportant? a. Avoid reading, writing, or close work such as sewing. b. Dim the lights in your house for at least a week. c. Keep the follow-up appointment with the ophthalmologist. d. Remove your eye patch every hour for eyedrops.
ANS: AAfter surgery for retinal detachment, the client is advised to avoid reading, writing, and close work becausethey cause rapid eye movements. Dim lights are not indicated. Keeping a postoperative appointment isimportant for any surgical client. The eye patch is not removed for eyedrops.
A client does not understand why vision loss due to glaucoma is irreversible. What explanation by the nurse is best? a. Because eye pressure was too high, the tissue died. b. Glaucoma always leads to permanent blindness. c. The traumatic damage to your eye was too great. d. The infection occurs so quickly it cant be treated
ANS: AGlaucoma is caused when the intraocular pressure becomes too high and stays high long enough to cause tissueischemia and death. At that point, vision loss is permanent. Glaucoma does not have to cause blindness.Trauma can cause glaucoma but is not the most common cause. Glaucoma is not an infection.DIF: Understanding/Comprehension REF: 976KEY: Visual system| visual disorders| glaucoma| patient education| pathophysiologyMSC: Integrated Process: Teaching/LearningNOT: Client Needs Category: Physiological Integrity: Physiological Adaptation A clients intraocular pressure
A client has a foreign body in the eye. What action by the nurse takes priority? a. Administering ordered antibiotics b. Assessing the clients visual acuity c. Obtaining consent for enucleation d. Removing the object immediately
ANS: ATo prevent infection, antibiotics are provided. Visual acuity in the affected eye cannot be assessed. The clientmay or may not need enucleation. The object is only removed by the ophthalmologist.DIF: Applying/Application REF: 983KEY: Visual system| visual disorders| antibioticsMSC: Integrated Process: Nursing Process: ImplementationNOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
A client is brought to the emergency department after a car crash. The client has a large piece of glass inthe left eye. What action by the nurse takes priority? a. Administer a tetanus booster shot. b. Ensure the client has a patent airway. c. Prepare to irrigate the clients eye. d. Turn the client on the unaffected side.
ANS: BAirway always comes first. After ensuring a patent airway and providing cervical spine precautions (do notturn the client to the side), the nurse provides other care that may include administering a tetanus shot. Theclients eye may or may not be irrigated.DIF: Applying/Application REF: 983KEY: Visual system| visual disturbances| primary surveyMSC: Integrated Process: Nursing Process: ImplementationNOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
The staff educator is precepting a nurse new to the unit when a patient with a T2 cord injury is admitted. The patient is soon exhibiting manifestations of neurogenic shock. What would the staff educator and the new nurse monitor this patient for? A. Increased cardiac markers B. Hypotension C. Tachycardia D. Excessive sweating
B
Which medication should be available to provide emergency treatment if a client develops tetany after a subtotal thyroidectomy? A. Sodium phosphate B. Calcium gluconate C. Echothiophate iodide D. Sodium bicarbonate
B
A client is seen in the ophthalmology clinic with bacterial conjunctivitis. Which statements by the clientindicate a good understanding of home management of this condition? (Select all that apply.) a. As long as I dont wipe my eyes, I can share my towel. b. Eye irrigations should be done with warm saline or water. c. I will throw away all my eye makeup when I get home. d. I wont touch the tip of the eyedrop bottle to my eye. e. When the infection is gone, I can use my contacts again
ANS: C, DBacterial conjunctivitis is very contagious, and re-infection or cross-contamination between the clients eyes ispossible. The client should discard all eye makeup being used at the time the infection started. When instillingeyedrops, the client must be careful not to contaminate the bottle by touching the tip to the eye or face. Theclient should be instructed not to share towels. Eye irrigations are not needed. Contacts being used when theinfection first manifests also need to be discarded
A client has external otitis. On what comfort measure does the nurse instruct the client? a. Applying ice four times a day b. Instilling vinegar-and-water drops c. Use of a heating pad to the ear d. Using a home humidifier
ANS: C. A heating pad on low or a warm moist pack can provide comfort to the client with otitis externa. The otheroptions are not warranted.DIF: Remembering/Knowledge REF: 992KEY: Auditory system| auditory disorders| comfort measuresMSC: Integrated Process: Teaching/LearningNOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort
A client with Mnires disease is in the hospital when the client has an attack of this disorder. What action by the nurse takes priority? a. Assess vital signs every 15 minutes. b. Dim or turn off lights in the clients room. c. Place the client in bed with the upper siderails up. d. Provide a cool, wet cloth for the clients face.
ANS: C. Clients with Mnires disease can have vertigo so severe that they can fall. The nurse should assist the client intobed and put the siderails up to keep the client from falling out of bed due to the intense whirling feeling. Theother actions are not warranted for clients with Mnires disease.DIF: Applying/Application REF: 996KEY: Auditory system| auditory disorders| patient safetyMSC: Integrated Process: Nursing Process: ImplementationNOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
The nurse works with clients who have hearing problems. Which action by a client best indicates goals foran important diagnosis have been met? a. Babysitting the grandchildren several times a week b. Having an adaptive hearing device for the television c. Being active in community events and volunteer work d. Responding agreeably to suggestions for adaptive devices
ANS: C. Clients with hearing problems can become frustrated and withdrawn. The client who is actively engaged in thecommunity shows the best evidence of psychosocial adjustment to hearing loss. Babysitting the grandchildrenis a positive sign but does not indicate involvement outside the home. Having an adaptive device is not thesame as using it, and watching TV without evidence of other activities can also indicate social isolation.Responding agreeably does not indicate the client will actually follow through.DIF: Evaluating/Synthesis REF: 990KEY: Auditory system| auditory disorders| psychosocial response| copingMSC: Integrated Process: Nursing Process: EvaluationNOT: Client Needs Category: Psychosocial
The clients chart indicates a sensorineural hearing loss. What assessment question does the nurse ask todetermine the possible cause? a. Do you feel like something is in your ear? b. Do you have frequent ear infections? c. Have you been exposed to loud noises? d. Have you been told your ear bones dont move?
ANS: C. Sensorineural hearing loss can occur from damage to the cochlea, the eighth cranial nerve, or the brain.Exposure to loud music is one etiology. The other questions relate to conductive hearing loss.DIF: Remembering/Knowledge REF: 989KEY: Auditory system| auditory assessment| auditory disordersMSC: Integrated Process: Nursing Process: AssessmentNOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
A client is in the preoperative holding area waiting for cataract surgery. The client says Oh, yeah, I forgot totell you that I take clopidogrel, or Plavix. What action by the nurse is most important? a. Ask the client when the last dose was. b. Check results of the prothrombin time (PT) and international normalized ratio (INR). c. Document the information in the chart. d. Notify the surgeon immediately.
ANS: DClopidogrel is an antiplatelet aggregate and could increase bleeding. The surgeon should be notifiedimmediately. The nurse should find out when the last dose of the drug was, but the priority is to notify theprovider. This drug is not monitored with PT and INR. Documentation should occur but is not the priority.DIF: Applying/Application REF: 974KEY: Visual system| visual disorders| cataracts| preoperative nursing| communicationMSC: Integrated Process: Communication and DocumentationNOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
A nurse assesses a client who has psoriasis. Which action should the nurse take first? A. Don gloves and an isolation gown B. Shake the client's hand and introduce self C. Assess for signs and symptoms of infection D. Ask the client if she might be pregnant
B
A nurse cares for a patient who possibly has syndrome of inappropriate antidiuretic hormone (SIADH). The patient's serum sodium level is 114 mEq/L. Physical exam reveals Hypertension distended neck veins and crackels in the lung fields. What action would the nurse take first? A. Consult with the dietician about increased dietary sodium B. Restrict the patient's fluid intake to 600 mL/day C. Handle the patient gently by using turn sheets for repositioning D. Instruct unlicensed personnel to measure intake and output
B
A nurse is caring for a patient with autonomic dysreflexia. What clinical manifestations would the nurse expect in this patient? A. Tachycardia and hypotension B. Bradycardia and hypertension C. Tachycardia and hypertension D. Bradycardia and hypotension
B
After teaching a client who has psoriasis, a nurse assesses the clients understanding. Which statement indicates the client needs additional teaching? A. At the next family reunion, I'm going to ask my relatives if they have psoriasis B. I have to make sure I keep my lesions covered, so I do not spread this to others C. I expect that these patches will get smaller when I lie out in the sun D. I should continue to use the cortisone ointment as the patches shrink and dry out
B
A 34-year-old female is diagnosed with hypothyroidism. What information should the nurse obtain from conducting a focused assessment? Select ALL that Apply? A. Rapid pulse B. Decreased energy and fatigue C. Weight gain of 10 lbs. in 3 weeks D. Fine, thin hair with hair loss E. Constipation F. Menorrhagia
B, C, D, E, F
During the physical assessment, the nurse notices that the patient's right external ear is deformed. What is the appropriate nursing action? A. Ask the patient about hearing deficits. B. Assess for kidney or urinary tract problems. C. Ask the patient to provide information about his or her hearing. D. Speak in a lower-toned voice and ensure good visual contact with the patient.
B. Assess for kidney or urinary tract problems. The external ear develops in the embryo @ the same time as the kidneys & urinary tract. Thus any person w/a defect of the external ear should be examined for possible problems of the kidneys & urinary systems.
A patient with a TBI has nonreactive and dilated pupils. What would the nurse anticipate? A. Loss of vision B. Brain stem herniation C. Intense headache D. Projectile vomiting
B. Brain stem herniation Asymmetric (uneven) pupils, loss of light reaction, or unilateral or bilateral dilated pupils are treated as herniation of the brain from increased ICP until proven differently. Pupils that are fixed (nonreactive) and dilated are a poor prognostic sign. Patients with this problem are sometimes referred to as having "blown" pupils.
The nurse is caring for a patient who is admitted to the ED with burns to the lower legs and hands. During the initial management, what is the priority nursing care? A. Assess and treat pain. B. Evaluate airway and circulation. C. Place two IV catheters and initiate fluid resuscitation. D. Use the rule of nines to estimate the percent of body surface area burned.
B. Evaluate airway and circulation. Initial management of a burn-injured patient focuses on assessing the patient's airway, breathing, and circulation. Other priorities include keeping the patient warm, elevating extremities to reduce edema, preparing for fluid resuscitation, estimating the total body percent of burn injury, and administering tetanus toxoid prophylaxis.
Which postoperative outcome would the nurse anticipate for a patient who has undergone surgery for cataract removal? A. Yellowish drainage and photophobia B. Mild itching and bloodshot appearance C. Pain early after surgery accompanied by nausea and vomiting D. Change in visual acuity accompanied by tearing and redness
B. Mild itching and bloodshot appearance Mild itching and bloodshot appearance are considered to be normal postoperative outcomes for this patient. Pain early after surgery may indicate increased intraocular pressure or hemorrhage. Change in visual acuity accompanied by tearing and redness and any yellowish drainage and photophobia can be signs of infection.
It has been 12 hours since a patient has been admitted for burns to the face and neck with associated inhalation injuries. The patient had been wheezing audibly and the wheezing has now stopped. What nursing action is appropriate? A. Check the patient's Spo2 level. B. Notify the physician immediately. C. Re-assess breathing in 1 hour. D. Document improvement in patient's condition.
B. Notify the physician immediately if the patient with an inhalation injury becomes more breathless or audible wheezes disappear. This could indicate a worsening of the patient's respiratory injuries, including possible loss of the patient's airway.
A patient with a spinal cord injury at C5-C6 reports a sudden severe headache. The patient is flushed. Vital signs include a blood pressure of 190/100 mm Hg and heart rate of 52 beats/min. What is the priority nursing intervention? A. Notify the health care provider. B. Place the patient in a sitting position. C. Check the patient for fecal impaction. D. Check the urinary catheter for kinks or obstruction.
B. Place the patient in a sitting position. Autonomic dysreflexia is an excessive, uncontrolled sympathetic output and is a neurologic emergency in patients with spinal cord injury T6 and above. The first priority of care is to place the patient in a sitting position. Then contact the health care provider to treat the increased blood pressure. The cause of this syndrome is a noxious stimulus—most often a distended bladder or constipation. Rapid treatment is essential to prevent a stroke.
A nurse caring for a patient with diabetes insipidus is reviewing laboratory results. What is an expected urinalysis finding? A. Glucose I the urine B. Albumin in the urine C. Urine specific gravity below 1.005 D. Leukocytes in the urine
C
A patient is admitted to the Neuro ICU with a spinal cord injury. When assessing the patient the nurse notes there is a sudden depression of the reflex activity in the spinal cord below the level of injury. What does this nurse suspect? A. Hypoactivity in reflexes B. Hypertension C. Spinal Shock D. Hypovolemia
C
Following a subtotal thyroidectomy, the nurse asks the client to speak immediately upon regaining consciousness. The client is not able to make a sound. The nurse determines that the client us experiencing which complication of the surgery? A. Internal hemorrhage B. Decreasing level of consciousness C. Laryngeal nerve damage D. Upper airway obstruction
C
The emergency department nurse is caring for a client who has been brought in by ambulance after sustaining a fall at home. The patient is exhibiting an altered level of consciousness. Following a skill x-ray, the patient is diagnosed with a basilar skull fracture. Which sign should alert the nurse to this type of fracture? A. Babinski sign B. Kernig's sign C. Battle sign D. Brudzinski sign
C
The nursing instructor is teaching the senior nursing class Addison's Disease. What symptom would the instructor tech the student's is characteristic of Addison's Disease? A. Truncal obesity B. Hypertension C. Muscle weakness D. "Moon" face
C
The triage nurse in the emergency department (ED) receives a phone call from a frantic father who saw his 4-year-old child tip a pot of boiling water onto her chest. The father has called an ambulance. What would the nurse in the ED receiving the call instruct the father to do? A. Cover the burn with ice and secure with a towel B. Apply butter to the area that is burned C. Immerse the child in a cool bath D. Avoid touching the burned area and seek medical attention
C
The nurse understands which symptom is the earliest indicator of increased intracranial pressure when caring for a patient with a head injury? A. Increased pupil size B. Nausea and vomiting C. Agitation and confusion D. Elevated blood pressure
C. Agitation and confusion The first sign of increased intracranial pressure (ICP) is a declining or changing level of consciousness (LOC). Patients may be agitated and slightly confused before progressing to difficult to arouse as an early assessment variable of increased ICP. Changes in vital signs, nausea and vomiting, and pupillary response occur as ICP increases.
A nurse plans care for a patient with Cushing's disease. Which action would the nurse include in this patient's plan of care to prevent injury? A. Pa the side rails of the patient's bed B. Assist the patient to change positions slowly C. Use a lift/turning sheet to change the patient's position D. Keep suctioning equipment at the patient's bedside
C cortisol increases bone demineralization and increases the risk for pathological fractures
A client with hyperthyroidism is to be treated with radioactive iodine (RAI, I-131). Following treatment, what should the nurse tech the client to do? A. Monitor for signs and symptoms of hyperthyroidism B. Rest for 1 week to prevent complications of the medication C. Take thyroxine replacement for the remainder of the client's life D. Assess for hypertension and tachycardia resulting from altered thyroid activity
C radioactive iodine depletes functioning of thyroid making the client hypothyroid
A nurse assesses a patient who is recovering from a lumbar laminectomy. Which complications would alert the nurse to urgently communicate with the health care provider? Select All that Apply A. Surgical discomfort B. Redness and itching at the incision site C. Incisional bulging D. Clear drainage on the dressing E. Sudden and severe headache
C, D, E all signs of CSF leakage
A nurse cares for a patient with elevated free T4 and decreased thyroid stimulating hormone. What action does the nurse take? Select All that Apply A. Administer levothyroxine (Synthroid) B. Administer propranolol (Inderal) C. Monitor the apical pulse D. Assess for trousseau's sign E. Initiate telemetry monitoring
C, E lab values for hyperthyroidism
Which priority question should the nurse ask a patient with a pituitary tumor? A. "Have you had an unexpected weight loss?" B. "Have you noticed a change in your libido?" C. "Do you have any changes in your visual acuity?" D. "Have you experienced a change in growth of your facial hair?"
C. "Do you have any changes in your visual acuity?" Changes in vision are frequently the first and most common symptom associated with hypopituitarism as a result of tumor growth. Changes in weight, hair growth patterns, and secondary sex characteristics should also be assessed.
In assessing a patient with low back pain, which priority assessment question or statement will the nurse provide? A. "How long have you had back pain?" B. "How does your back pain affect your activities of daily living?" C. "Tell me about your pain and what interventions are helpful in managing your pain." D. "Have you ever had magnetic resonance imaging to find a cause for your back pain?"
C. "Tell me about your pain and what interventions are helpful in managing your pain." Obtaining a thorough assessment of the patient's pain level and effective interventions to treat pain is an important element of the nursing assessment. The priority assessment question helps the nurse more fully understand the patient's experience with pain, and how the patient has attempted to address the pain. All other questions can be asked as follow-ups to the priority question.
The nurse understands that a patient with a long history of heart failure is at risk for developing hearing loss if: A. Heart failure alters tissue perfusion, which may affect hearing. B. The patient uses topical medications, which may be ototoxic. C. The patient has received multiple doses of furosemide. D. There is a genetic predisposition to developing hearing loss.
C. The patient has received multiple doses of furosemide. The pt who has a hx of HF will likely be using large amounts of diuretics, most commonly furosemide, which has been shown to be ototoxic. The pt who has a hx of of HF may use topical medications, but there's no evidence that any of them are ototoxic. It's true that HF affects tissue perfusion, which can affect comprehension of what's heard.
What priority teaching will the nurse provide to a patient who has received a corneal transplant? A. Keep the eye moist. B. Watch the eye for signs of infection. C.Avoiding straining to have a bowel movement. D. Keep the eye covered for the first 24 hours postoperatively.
C.Avoiding straining to have a bowel movement. The patient should avoid activities that increase intraocular pressure (IOP) because they can interfere with corneal graft take. Activities such as straining to have a bowel movement, sneezing, coughing, vomiting, and bending over should be avoided. Other postoperative considerations include keeping the eye moist and covered with a protective eye patch, and daily assessment for signs of bleeding, infection, or graft rejection
A nurse assesses a patient who has burn injuries and notes crackles in bilateral lung bases, a respiratory rate of 40 breaths/min, and a productive cough with blood-tinged sputum. What action would the nurse take next? A. Administer furosemide B. Perform chest physiotherapy C. Document and reassess in an hour D. Place the patient in an upright position
D
A nurse cares for a patient who is recovering from a parathyroidectomy. When taking the patient's blood pressure, the nurse notes that the patient's hand has gone into flexion contractions. Which laboratory result does the nurse correlate with this condition? A. Hypokalemia B. Hyponatremia C. Hypomagnesemia D. Hypocalcemia
D
A patient arrives in the emergency department after being burned in a house fire. The patient's burns cover the face and head, and the entire left arm from shoulder to finger tips. What percentage of burn does the patient have? A. 10% B. 25% C. 9% D. 18%
D
A patient is brought to the Emergency department from the site of a chemical fire. The paramedics report that the patient has a burn that involves the epidermis, dermis, and the muscle and bone of the right arm. When you assess the patient he verbalizes no pain in the right arm and the skin appears charred. Based upon these assessment findings, what is the depth of the burn on the patient's right arm? A. Superficial partial-thickness B. Deep partial-thickness C. Full thickness D. Deep Full-thickness
D
You are caring for a burn patient who is in the later stges of the acute phase of the burn injury. What is an important factor in your care of the patient? A. Immobilizing the patient B. Maintaining splints and functional devices C. Maintaining ongoing discussion about the patient with a psychologist D. Prevention of DVT
D
The nurse knows which patient with Cushing's disease is at greatest risk for developing heart failure? A. 60-year-old with pneumonia B. 59-year-old with a history of hypertension C. 32-year-old with a history of hepatitis B infection D. 42-year-old with a serum creatinine level of 3.7 mg/dL
D. 42-year-old with a serum creatinine level of 3.7 mg/dL The 42-year-old patient has compromised kidney function evidenced by an elevated serum creatinine level. Preventing fluid overload that may quickly lead to pulmonary edema and heart failure is a primary concern for patients with Cushing's disease. Any patient with Cushing's disease is at risk for developing fluid overload, regardless of age. However, the older adult or one who has coexisting cardiac problems, kidney problems, pulmonary problems, or liver problems is at greater risk.
The nurse understand which of the following is a risk factor associated with the development of multiple sclerosis? A. Smoking B. High-fat diet C. Age greater than 70 D. Gender
D. Gender MS affects women two to three times more often than men, suggesting a possible hormonal role in disease development. Some studies show that the disease occurs up to four times more often in women than men (National Multiple Sclerosis Society, 2016).
A patient has been receiving dressing changes with silver sulfadiazine (Silvadene) for burn injuries over both lower arms. The nurse notices that the patient's white blood cell count has dropped significantly over the past 4 days. How does the nurse interpret this finding? A. Electrolyte imbalance B. Infection is improving C. Impending kidney disease D. Possible allergic reaction to silver sulfadiazine (Silvadene)
D. Possible allergic reaction to silver sulfadiazine (Silvadene) During therapy with silver sulfadiazine (Silvadene), a drop in the patient's white blood cell count indicates an allergic reaction. Silvadene does not cause kidney disease, infection, or electrolyte imbalance.
The nurse is caring for a patient diagnosed with small cell lung cancer. The nurse understands the patient may also present with which endocrine disorder? A. Adrenal crisis B. Cushing's syndrome C. Diabetes insipidus (DI) D. Syndrome of inappropriate antidiuretic hormone (SIADH)
D. Syndrome of inappropriate antidiuretic hormone (SIADH) Cancer (especially lung cancers) increases the risk of the patient developing SIADH. Other risk factors include recent head trauma, cerebrovascular disease, and tuberculosis or other pulmonary disease. A review of past and current medications is also important in searching for the cause of SIADH.
A nurse assesses a client who presents with an increase in psoriatic lesions. Which questions should the nurse ask to identify a possible trigger for worsening of this clients psoriatic lesions? SATA A. Have you eaten a large amount of chocolate lately? B. Have you been under a lot of stress lately? C. Have you recently used a public shower? D. Have you been out of the country lately? E. Have you recently had any other health problems? F. Have you changed any medications recently?
b, e, f
