H&I 2 Quiz 2
A client with depression is receiving electroconvulsive therapy (ECT). Which interventions should the nurse plan when caring for this client? a. Maintain nothing-by-mouth status until fully awake. b. Administer intravenous fluids for 8 hours post procedure. c. Place in the supine position with the head flat for best recovering. d. Provide oral fluids immediately after the procedure.
A
At the conclusion of a health interview and physical assessment, the nurse suspects that an older client is experiencing hyperthyroidism. Which assessment finding supports the nurse's conclusion? a. Presence of exophthalmos b. Lower extremity parathesias c. Decreased deep tendon reflexes d. Weight gain
A
The nurse is assessing a patient for an endocrine problem. During the health assessment interview, it is essential that the nurse ask the patient which question about the skin to determine whether the patient is experiencing hypothyroidism? a. "Is your skin rough and dry?" b. "Is your skin smooth?" c. "Is your skin often clammy?" d. "Do you have brown shiny patches on your legs?"
A
The nurse is caring for a patient who was admitted with potential hepatic failure. The patient is at risk for developing ascites. Which of the following assessment finding would indicate this development? a. Increased abdominal girth b. Yellow-tinged skin c. Bleeding and bruising easily d. Gallbladder pain
A
The nurse is planning care for an adolescent client experiencing the manic phase of bipolar disorder. He is hearing voices and asks the nurse if she is hearing voices. Which response will be most appropriate? a. tell the client that she/he does not hear voices. b. Discuss a homework assignment. c. Let's go to the quiet room. d. Let's go spending time with others.
A
The nurse is preparing to discharge an older patient who was recently diagnosed with diabetes mellitus. The nurse knows that which of the following is the priority outcome goal for this patient? a. Maintain proper blood glucose levels b. Yearly eye examinations c. Keeping appointments with podiatrists for foot care d. Recognizing the symptoms of myocardial infarction
A
The nurse observes a client being treated for depression sitting with the head down and avoiding conversation with peers. Which nursing intervention is appropriate for this client? a. Be patient waiting for a reply and ask open-ended questions about the client's feelings b. Tell the client that lack of involvement leads to more depression. c. Encourage a peer to sit with the client and the nurse. d. Ask the client close-ended questions.
A
While teaching a 32-year-old client about colostomy care, the nurse notes the client has tears in his eyes. The client states, "I can't believe I have to live with this thing for the rest of my life." Which nursing response best reflects the nurse's understanding of factors that inhibit learning? a. "Let's reschedule this teaching session for later. I'll check back with you to pick a time. Right now, please tell me more about what you're feeling." b. "I'm sorry you have to go through this. Understanding how to take care of yourself should make it a little easier for you, so let's talk a little more about how to clean your colostomy site." c. "I hear you saying that you're upset. I'll reschedule your teaching for tomorrow morning. Now, please tell me more about how you feel." d. "You've been through a lot. As soon as we're finished, I'd like to ask your nurse practitioner to give you a counseling referral."
A
A nurse is providing education to a patient with new onset diabetes. Which of the following are appropriate teach-back delivery methods? Select all that apply. a. Talk back b. Demo back c. Teach back methods are not necessary d. Discussing new onset diabetes
A, B
A client in the manic phase of bipolar disorder will not sit down to eat. Which can the nurse do to ensure adequate nutrition and improved self-care of this client? a. Use a jacket restraint at meal times. b. Ask the healthcare provider if intravenous feedings would be applicable. c. Discuss finger-food options with the dietitian. d. Provide a sedative before meals.
C
During an interview, a patient with mania demonstrates very rapid speech and talks continuously and loudly. The patient's speech pattern is best documented as: a. persevaration. b.labile. c. pressured. d. tangential.
C
The nurse is conducting a health history on a patient who has come to the clinic for an annual physical. The nurse plans to assess the patient for signs of osteoporosis. Which of the following assessment questions would be most appropriate for the nurse to ask this 70-year-old post-menopausal female patient? a. "Have you experienced any palpitations?" b. "Have you experienced issues with constipation?" c. "Are you having any low back pain?" d. "Are you having problems with swelling in your feet?"
C
The nurse is planning care for a patient who was recently diagnoses with hyperthyroidism. The nurse must teach the patient about certain food-drug interactions that are associated with the medications prescribed. The nurse teaches the patient to avoid which of the following foods? a. High calorie foods b. Caffeine free soda c. High iodine foods d. Dairy products
C
The nurse is preparing to discharge a 58-year-old patient who is newly diagnosed with type 2 diabetes. The nurse wants to teach the patient ways to optimize health outcomes. The patient has smoked for 30 years. The nurse tells the patient that smoking cessation is especially important for patients with diabetes because smoking: a. Promotes weight gain b. Is a major factor in the development of diabetic neuropathy c. Accelerates arteriosclerotic changes in blood vessels d. Increases insulin resistance
C
A nurse is caring for a 35-year-old female patient who was recently diagnosed with hypothyroidism. After reviewing the nursing admission assessment, the nurse plans care for this patient based on which of the following documented findings? (Select all that apply.) a. Hot flashes b. Tachycardia c. Fatigue d. Depression e. Hypothermia
C, E
The home health nurse is teaching an older adult client how to use an automatic blood pressure monitoring device. Which teaching strategy reflects the nurse's correct application of lifespan considerations for this client? a. Encouraging the client to rest as opposed to asking her to perform a return demonstration of skills b. Using written materials that feature small print, black ink, and reflective, bright white paper c. Scheduling the session as a one-on-one meeting between the nurse and the client without family present d. Designing content that targets individuals with a fifth- to sixth-grade reading level
D
The nurse is caring for an adolescent with bipolar disorder who has expressed the desire to harm self. What is the priority nursing diagnosis for this client? a. Impaired Social Interaction b. Social Isolation related to disorder c. Powerlessness related to mood instability d. Risk for Suicide
D
The nurse is providing care to a client who is exhibiting clinical manifestations of bipolar disorder. Which assessment findings support that the client is at an increased risk for this disorder? a. Blood pressure 120/80 mmHg b. Works out at the gym every week c. Currently employed d. Mother diagnosed with bipolar disorder
D
The nurse is teaching an older adult client how to use an incentive spirometer. The client has unsuccessfully attempted to use the device several times. Which is the best response by the nurse? a. Asking the charge nurse to assume the role of teacher b. Concluding the teaching session the client is hopeless c. Encouraging the client to continue to practice using the spirometer d. Praising the client for his attempts to use the incentive spirometer and repeating the instructions for its use
D
Which client observation indicates that interventions provided to a client in the manic phase of bipolar disorder has improved self-care activities? a. Brushes own teeth every time when reminded b. Cleaned liquid spilled on floor but did not change clothes c. Washes hands most of the time after using the toilet d. Completed morning bath and changed clothes
D