Health and Illness Exam 2

The nurse is caring for a patient who has discomfort related to dermatitis. Which of the following is a non-pharmacologic measure that the nurse should implement for this patient? a. cool, moist compress b. heating pad c. topical corticosteroids d. rub with baby oil

a

The client is admitted with possible sepsis. Which action should the nurse perform first? a. give an antipyretic b. obtain specified cultures c. place the patient in isolation d. administer antibiotics

b

The nurse is caring for a long-term care resident who was unable to transfer to the chair without assitance of staff has stool in his briefs. Which of the following disorders best characterizes the problem? a. fecal incontinence b. functional incontinence c. encopresis d. fecal impaction

b

This patient came to the ER with facial pain, swelling, redness, fever and chills. Which of the following therapies would the nurse expect to administer? a. antihistamine b. antibiotics c. aspirin d. steroid cream

b

Which actions should the nurse implement when caring for a client with a stage 4 pressure wound on the leg? a. maintain a dry wound b. cleanse the wound with antibacterial soap daily c. administer analgesics before wound care d. position the leg above the level of the heart

c

Which client would benefit from anticholinergic medications? a. a client who is pregnant and leaking urine b. a client with prostate issues c. a client with pelvic floor weakness and stress incontinence d. a client with constipation

c

A client with benign prostatic hyperplasia (BPH). Asked the nurse why he should avoid taking cold medications. These medications should be avoided because they are associated with a. urinary retention b. incidence of bladder cancer c. impotence d. increases the size of the prostate

a

A nurse cares for a client who has severe dementia from Alzheimer's disease. Which communication techniques would the nurse implement? a. validate client feelings b. provide multiple choices c. avoid using pictures when giving instructions d. ask open questions

a

A nurse is teaching home safety to the family of a client with Alzheimer's disease. The client has begun wandering around the house as night. Which of the following statements made by the family indicates an understanding of the teaching? a. "I have new locks at the tops of all outside doors." b. "I will keep the room dark at night to improve sleep." c. "I will make sure he knows his address in case he wanders outside." d. "I will place restraints to remind him not to get out of bed."

a

A patient has been placed on Contact Precautions. Their family is very afraid to visit for fear of "catching something" from the patient. What action by the nurse is best? a. teach the family how to follow Contact precautions (hand hygiene and appropriate PPE use) using demonstration and teach back b. tell the family they will never get an infection from the patient c. remind the family that the patient is depressed because they won't visit him d. explain that family members reduce their risk for infection by following contact precautions when they visit

a

The heat index is well over 100 degrees Fahrenheit and the emergency room has several patient with heat related problems. Which patient should be seen first? a. a marathon runner with altered muscle coordination, confusion and hot dry skin b. a homeless person looking for a cool place to stay c. an obese adult whose air conditioner is not working d. an older adult who has a mild headache after watching a parade outside

a

The nurse in urgent care has four patients waiting to be seen. Which one should be seen first? a. client with increased trouble breathing after pneumonia diagnosis b. client with diarrhea that started two hours ago c. client with a ringworm rash on their arm d. client needing a medication refill

a

The nurse is instructing a 28-year-old married female with a urinary tract infection how to prevent them. Which statement indicates a lack of understanding of this teaching? a. "It's okay to soak in the tub with a bubble bath to make sure I am properly cleaned." b. "I will drink 2 liters of fluid every day." c. "I will empty my bladder regularly, even if I don't have the urge to go." d. "I will drink cranberry juice daily in an attempt to decrease the number of bacteria in my bladder."

a

The nurse working in memory care is caring for a patient with dementia who has periodic episodes of incontinence of the bowel and bladder. Which intervention is most important for improving elimination? a. Toilet the patient upon waking, at bedtime, after meals, and every two hours b. establish a bedtime ritual for the patient c. speak with the patient's family about food choices d. speak with the family about past elimination habits

a

What is the treatment for a stage 3 pressure ulcer with lots of exudate? a. cover with an absorbent dressing b. debridement c. protect with a non-adherent dressing d. wet to dry dressing

a

When assessing patients for pressure injuries, which of the following patients is at greatest risk? a. a 65 year old with a stroke and incontinence b. a 26 year old with a fractured leg from a motor vehicle accident c. a 78 year old requiring assistance to ambulate with a walker d. a 44 year old with pneumonia

a

Which action by the infection control nurse would be most effective in reducing the incidence of healthcare associated infections? a. have hand sanitizer available inside and outside of every patient room b. require full PPE before entering any patient room c. screen all patients for MRSA d. develop a policy on antibiotic therapy

a

Which patient population is at greatest risk for life-threatening complications from diarrhea because a greater portion of their bodies are made from water? a. infants b. school-age child c. older adult d. adult

a

Which type of healing is represented by the picture below? (wound with stitches) a. primary intention healing b. non healing wound c. tertiary intention healing d. secondary intention healing

a

A hospitalized child with an infection has a moderate-grade fever. Which actions by the nurse help promote the child's comfort? Select all that apply. a. change the child's gown when it becomes damp b. administer antipyretics for comfort as needed c. place ice bags in the armpits and groin d. sponge bathe the child with rubbing alcohol

a, b

A nurse is teaching older adults at a senior care center about changes to the ears and hearing that can occur with aging. What statements should the nurse include? Select all that apply. a. hearing function may be reduced because cerumen is drier and impacts more easily b. hearing aids can contribute to cerumen impaction c. all adults may have some degree of hearing loss d. use cotton swabs to clean the ears or remove cerumen

a, b, c

A patient has cellulitis on the right forearm. Which of the following should the nurse expect to be ordered? Select all that apply. a. elevate right forearm above the level of the bed b. notify the provider for increased area of redness, swelling, and warmth c. administer antibiotics as prescribed d. limit use of antipyretics

a, b, c

Which of the following clinical manifestations are associated with small bowel obstruction? Select all that apply. a. vomiting b. abnormal electrolytes values c. high pitched bowel sounds d. non-distended abdomen

a, b, c

Which of the following is a potential cause of Constipation for older adults? Select all that apply. a. medical conditions b. slowed peristalsis c. anticholinergics d. opioids e. gastroenteritis

a, b, c, d

Which of the following are factors that affect bowel elimination? Select all that apply. a. neuromuscular disorders b. privacy c. laxative use d. exercise e. fiber intake f. age

a, b, c, d, e, f

A student asks the nurse why older adults are at greater risk for getting COVID infection than younger adults. Which explanation about infections is accurate? Select all that apply. a. older adults have decreased cough and gag reflexes b. older adults have a higher rate of chronic illnesses, placing them at greater risk c. older adults are less likely to wear a mask in public d. older adults have a decrease immune function

a, b, d

The nurse is caring for a client in long term care who has been receiving antibiotics for a urinary tract infection. The client complains of watery, odorous diarrhea. Which intervention should the nurse plan for this client? Select all that apply. a. place the client on contact isolation b. encourage client to push fluids c. insert a catheter to obtain a urine specimen d. monitor for signs of dehydration e. wash hands thoroughly with hand sanitizer

a, b, d

A nurse is caring for a client whose Braden Scale score indicates a high risk for pressure ulcer development. Which interventions are evidence-based practices (EBP) to prevent or treat skin breakdown? Select all that apply. a. use barrier cream for incontinence b. perform perineal cleansing every two hours c. keep the head of the bed elevated d. request a referral to the nutritionist e. assess the skin daily

a, b, d, e

Which of the following interventions are appropriate when caring for patients with wounds? Select all that apply. a. cleanse around the wound with normal saline b. consider recommending a wound vac for wounds that have a significant amount of drainage c. soak wounds to remove dead tissue d. consult with the wound nurse for therapies that are not promoting healing e. assess for pain f. consult with a dietitian to increase protein in the diet

a, b, d, e, f

The most common causes for delirium in an older person include: (select all that apply). a. Foley catheter b. opioid analgesic medications c. exposure to air pollution d. urinary tract infection e. pneumonia f. recent hip fracture g. being placed in a new environment

a, b, d, e, f, g

An in-home care nurse is giving patient teaching safety to an older diabetic client. Which of the following instructions should the nurse include? Select all that apply. a. use adaptive devices as needed b. inspect feet once a month c. wearing proper footwear will reduce the risk of trauma d. place cold fingers in hot water to warm them

a, c

The nurse is caring for a client who is prescribed habit training to manage incontinence. Which of the following interventions should the nurse implement? Select all that apply. a. implementing a toileting schedule b. encourage the use of incontinence briefs instead of toileting the patient c. encourage the client to drink fluids d. recording the client's incontinence episodes

a, c, d

The nurse is teaching members of the community how to prevent heat related illnesses. Which of the following statements should the nurse include in the teaching? Select all that apply. a. check on older people during extremely hot weather b. use sunscreen with SPF 8 at minimum c. drink plenty of fluids throughout the day d. take cool baths or showers after outdoor activities e. wear dark colored clothing

a, c, d

A nurse plans care for several patients who are immobile. Which intervention should the nurse include to prevent pressure injuries for this group of patients? Select all that apply. a. avoid shearing when moving patients b. only turn/reposition the patient if they are awake to promote sleep c. ask the patient to "offload" their weight while sitting in a chair d. limit fluid and protein in the diet e. place a pillow under the lower extremities to elevate the heels

a, c, e

A 76 year old woman with Alzheimer's disease was admitted to a memory care facility. After falling at home, the family states she has a history of dementia with wandering and cannot be trusted alone. On the first few days, she is restless and agitated, sleeping only two to three hours a night. Which interventions would help her to function at the highest level possible? Select all that apply. a. avoid unfamiliar situations whenever possible b. vary the timing of the day-to-day activities c. furnishing her room with familiar possessions d. encourage her to perform cognitive skills above her level of ability e. reducing over stimulation f. having her take part in activities that distract her

a, c, e, f

A client has a wound that is healing by secondary intention. Which statement best describes this type of wound? a. the wound is contaminated with debris and cannot be closed at all b. the wound is an open cavity that will fill with granulation tissue c. the wound edges are well approximated d. the wound was stapled together after an infection was cleared up

b

A nurse assesses an older client who has a rash on both hands and complaints of itching. What should the nurse do first? a. administer an antihistamine b. ask the patient what they were doing when they developed the rash c. apply moisturizing lotion d. applied gloves to minimize friction

b

A nurse is caring for a client who has a non-healing pressure injury. Which assessment finding indicates that it is a non-healing wound? a. color of the wound is red and beefy b. increased size in the length and width of the wound c. decrease in the depth of the wound d. patient is requesting more pain medication

b

A nurse is teaching a new nursing assistant about caring for older adults and sensory perception. Which statement should the nurse include in this teaching? a. "Assess the client's hearing with the whisper test." b. "Face the client when you are talking to them." c. "You always need to check for ear wax." d. "Stand over the client and talk down to them."

b

A nurse teaching a client with functional urinary incontinence. Which statements would the nurse include in the client's teaching? a. "You will need to be on medication for the rest of your life." b. "You may want to get pants with elastic waistbands." c. "Operations to repair your bladder are available." d. "You must clean around your catheter daily with soap and water."

b

A patient has a sacral ulcer that measures 4x5x2cm and requires mechanical debridement. Which dressing is most appropriate for this wound? a. autolytic debridger b. wet to moist dressing c. hydrocolloid dressing d. alginate dressing

b

A patient who was diagnosed with dementia has become incontinent of urine. When the patient's daughter asks the nurse why this is happening. What is the nurse's best response? a. "She doesn't want to use the commode because it is unfamiliar." b. "The brain doesn't send the message for the need to urinate." c. "She is uncooperative because of the dementia." d. "She is angry about the dementia diagnosis."

b

How would the nurse stage this pressure injury? a. stage 1 b. stage 2 c. stage 3 d. stage 4

b

Which client is at greatest risk for developing delirium? a. a 59 year old man with a history of heart disease who just had surgery b. a 70 year old woman who was just admitted to the hospital for pneumonia who has a history of dementia c. a 65 year old man taking opioid analgesics for pain after a motor vehicle accident d. a 10 year old child on the pediatric floor who has a Foley catheter in place

b

Which isolation precaution is necessary for a patient with a MRSA skin infection? a. droplet b. contact c. standard d. airborne

b

Which of the following is the most important barrier to infection? a. inflammatory processes b. skin and mucous membranes c. gastrointestinal secretions d. colonization by host bacteria

b

Which patient goal (outcome) should the nurse focus on for the patient with dermatitis from Poison Ivy? a. preventing pressure ulcers b. decreasing pruritis c. decreasing pain d. promoting drying of lesions

b

Which of the following statements about elimination across the lifespan are true? Select all that apply. a. the risk of functional incontinence increases with age because of slowed peristalsis b. constipation is common with pregnancy due to the elevated progesterone c. older male adults are more likely to develop benign prostatic hyperplasia d. school aged children who have a busy schedule will often forget to use the bathroom e. newborns are at high risk for constipation

b, c, d

A client has been diagnosed with C. diff. Which personal protective equipment PPE will the nurse need to put on when preparing to assess the patient? Select all that apply. a. N95 respirator b. gloves c. goggles d. gown

b, d

The nurse is caring for a client with functional urinary incontinence. Which of the following instructions are appropriate for the client's condition? Select all that apply. a. the potential side effects of antispasmodic medications b. have scheduled toileting practices c. avoid drinking more than 2 liters per day d. the importance of having a commode near the client at night

b, d

A 76 year old woman with Alzheimer's disease was admitted to a memory care facility. After falling at home, the family states she has a history of dementia with wandering and cannot be trusted alone. On the first few days, she is restless and agitated, sleeping only two to three hours a night. As you develop a plan for her care, which of the following has the highest priority? a. chronic confusion b. impaired communication c. safety d. elimination

c

A client on antibiotics develops diarrhea three times a day for three days. Which action by the nurse is most important? a. delegate skin care to the nursing assistant b. notify the provider and recommend Imodium c. notify the provider and recommend stool cultures d. place the client in NPO until the diarrhea resolves

c

A nurse assesses the patient with a mechanical bowel obstruction who reports intermittent abdominal pain. An hour later, the patient reports constant abdominal pain. Which action would the nurse take next? a. insert a urinary catheter b. position the patient with knees to chest c. insert a nasogastric tube for gastric decompression per provider orders d. administer intravenous opioid medication

c

A nurse witnesses a client with dementia eat breakfast afterwards, the client states, "I'm hungry and want breakfast." How would the nurse respond? a. "Your family will be here soon. Let's get dressed." b. "It appears you are confused this morning." c. "I see that you're still hungry. I'll get you some toast." d. "You ate your breakfast 30 minutes ago."

c

A patient asks why it was so important for oral care to be completed at least twice a day. What is the nurse's best response? a. "Oral care is important to everyone." b. "Oral care is performed mostly for comfort." c. "It keeps the bacteria in the oral cavity under control to prevent infection." d. "Cleaning the surface of the teeth will prevent discoloration."

c

A patient has progressive cognitive impairment and personality changes. Is this behavior associated with dementia or delirium? a. dementia b. delirium c. both d. neither

c

A patient is admitted for heat stroke which intervention should the nurse include in the patient's plan of care? a. administer ibuprofen as ordered b. administer aspirin as ordered c. administer intravenous fluids as ordered d. cool the patient rapidly

c

An industrial nurse surveys a job site and identifies flying wood debris as a potential hazard. Which of the following should the nurse emphasize to all workers at this job site? a. follow workplace policies for handling chemicals b. know where the emergency was stations are located at work c. protective eyewear should always be worn d. have a first aid kit available in your locker

c

The nurse assesses a client in the ER who presents with lower abdominal bladder distention. Which question would the nurse ask first? a. "Are you drinking plenty of water?" b. "What medications are you taking?" c. "When was the last time you voided?" d. "Have you tried laxatives or enemas?"

c

What effect does shivering have on the body? a. it has no effect on the temperature b. it decreases the temperature c. it increases the temperature d. it both increases and decreases the temperature depending on the environmental temperature

c

What is an expected outcome for an adult patient using continuous positive airway pressure (CPAP) machine for obstructive sleep apnea (OSA)? a. the patient will have fewer than 3 awakenings a night b. the patient has a blood pressure of 150/80 c. the patient has no periods of apnea d. the patient requires 2 naps per day instead of three

c

When caring for residents with severe dementia, which of the following interventions should be avoided? a. adjust your approach if the resident seems upset b. talk calmly c. use restraints d. don't argue with the resident

c

Which nursing intervention would be most appropriate to meet safety needs when caring for an older adult with sensory change? a. use minimal touch with an older adult because touch may feel uncomfortable b. use care when administering an injection because older adults experience more pain c. assist with preparing a bath because the client may be less able to feel the temperature d. massage with abdominal pressure because perception is diminished

c

Which of the following interventions help to improve communication with a people who have dementia? a. give long explanations with a lot of detail to the resident b. ask questions while the resident is completing a task c. speak calmly and clearly to the resident d. keep the television on all day to help reorient them

c

Which of the following is a potential consequence of diabetic neuropathy? a. sensorineural hearing loss b. cataracts c. infection d. glaucoma

c

Which of the following is an accurate statement about the differences between dementia and delirium? a. dementia has early onset and delirium has a late onset b. dementia can be caused by infection and delirium is hereditary c. delirium is acute and dementia is chronic d. delirium is permanent and dementia is temporary

c

Which option correctly describes the type of pressure injury? a. stage 3 may have a pink or red wound bed b. stage 4 wound is obscured with eschar or slough c. stage 1 non-blanchable tissue d. stage 2 may have visible adipose tissue and slough

c

Which statement best describes the clinical manifestations associated with late hypothermia? a. skin that is cool and has fast capillary refill b. flush diaphoretic skin c. confusion, stupor, and coma d. delirium and shivering

c

Which interventions prevent infection in the hospital setting? Select all that apply. a. screen all emergency room patients for MRSA b. monitor white blood cell counts for patients on the unit c. screen all visitors for symptoms of infection prior to visiting patients d. disinfect all frequently touched surfaces

c, d

The nurse understands which factors must by present to transmit infection. Select all that apply. a. colonization b. poor hygiene c. host d. portal of entry e. mode of transmission f. reservoir

c, d, e, f

A 90 year old patient is hospitalized with a history of 10 liquid stools per day for 3 days in a row. What is the priority nursing concept to consider when planning interventions? a. tissue integrity b. elimination c. pain d. fluid and electrolytes

d

A client is disoriented to person, place and time. Which of the following observations made by the nurse indicate the client is experiencing delirium? a. the client's pupils are 4mm in diameter and respond equally to light b. the confusion began 5 months ago c. the client remains awake and alert d. the client has disorganized thinking

d

A female patient who has a history of delivering four babies is now diagnosed with stress incontinence. Which intervention is most appropriate for this condition? a. perform a bladder scan b. insert an indwelling catheter c. place a commode next to the bedside at night d. teach the patient Kegel exercises

d

A hospitalized patient is on contact precautions for MRSA. The physician ordered a CT scan. What action by the nurse is most appropriate? a. have the aid go with the patient to the CT scan b. no special precautions are needed when this patient leaves the unit c. notify the physician that the patient cannot leave the room d. notify the CT scan staff about the isolation precautions

d

A nurse in a long-term care facility is caring for a client with Alzheimer's disease who says she saw a little child under the bed when clearly there was no little child under the bed. How should the nurse respond? a. state "I do not see the child under the bed." b. explain to the client that she needs her eyes rechecked c. verify you see the child is under the bed, although you do not actually see it d. ask the client about her past to distract her from what she believes she is seeing

d

How would the nurse describe black tissue at the center of a wound? a. granulation b. slough c. stage 2 pressure ulcer d. necrosis

d

The nurse is caring for a postsurgical patient who is being discharged with antibiotics, oral opioid analgesics, and stool softeners. Which of the following is important to include in the discharge instructions? a. decrease fluid intake b. maintain a low fiber diet c. take a laxative if constipated d. monitor for both constipation and diarrhea

d

What type of dressing is needed for a stage 3 pressure injury wound with a large amount of exudate a. wet-to-dry saline gauze dressing b. a large band-aid c. tegaderm (transparent dressing) d. an absorbent dressing

d

Which of the following clinical manifestations is associated with glaucoma? a. eye itching b. cloudy central vision c. increased depth perception d. loss of peripheral vision

d

Which of the following statements is true about fever? a. younger children are less likely to develop a fever when ill b. immunocompromised individuals are more likely to develop a fever c. adults are likely to have fever with every infection d. older adults are less likely to develop a fever when ill

d