Med Surge Summative Exam2,3,4,6,24,25

A patient is scheduled for pulmonary function tests (PFTs) . What does the nurse tell the patient about the test?

PFT is useful to determine the cause of dyspnea

The nurse is preforming a skin assessment for a patient confined to bed and notes a reddened area over the ankle. How long does the nurse wait for the reddened area to fade before classifying it as pre ulcer or stage 1 pressure area.

3 min

When using McCaffrey and Pesaro's Hierarchy of pain measures which assessment data corresponds with behavioral signs

Frowning or grimacing doing repositioning

If a person retires between the age of 55 and 65 by what age are fun is most likely to become depleted causing strain on healthcare

80 to 85 years

Which group of older adults is classified as old old

85 to 99 years of age

A patient of Voice taking over the counter (OTC) medications unless the primary healthcare provider suggest the patient del Sol this is an example of what

A Health protecting behavior

Which statement about older adults and incontinence is correct

A bladder training program is often helpful in the management

Financial hardship, not insurance , I a source of stress and anxiety for older adult patients. Relocation, acute or chronic illness, and loss of significant others also causes stress and anxiety among older adults.

A health protecting behavior

The nurse is caring for patient who has a history of osteoarthritis and peptic ulcer disease which angalestic medication will the nurse anticipate administering to the patient.

Acetaminophen

Which nursing student response about frequent sources of stress and anxiety in older adult patients confirms the need for further teaching by the nursing instructor

Acute or chronic illness

A patient with chronic pain feels no relief with high dose Opiods and says 'I just can't manage living right now'. what intervention does the nurse anticipate the healthcare provider will order for the patient

Adding the duloxetine as adjuvant therapy

The nurse is caring for a patient who is receiving intravenous Hydromorephon. Prior to administration of the medication the patient's respiratory rate was 18 breaths per minute 10 minutes after receiving a dose of Hydro more phone the patient is on arousable and her respiratory rate is eight breaths per minute which action will the nurse implement immediately

Administer naloxone

The patient is receiving opioid analgesic medication via patient controlled analgesia (PCA) On occasion, the patient's spouse activates the PCA button. Which nursing action will the nurse implement immediately?

Advise the patient and his spouse that only the patient may activate the PCA

What might a patient with excessive immune response experience that a patient with decreased immune response is less likely to experience select all that apply

Allergies Autoimmune disease

Which group of drugs may cause delirium as an adverse side effect

Anticholinergic

The rehabilitation nurse at the hospital is also designated as a case manager for a patient which of the following is a duty of the nurse as a case manager

Assesses the layout of the patient's home

The nurse should educate patients at risk for clotting to use what measures to decrease the risk of complications? Select all that apply.

Avoid smoking Avoid crossing the legs. Avoid prolonged sitting . Observe symptoms in lower extremities .

In the role of patient advocate what does the nurse do first for the patient who reports pain

Believes the patient report of pain

Decreased function of which physiologic process calls retention of carbon dioxide

Gas exchange

What adverse effects will the nurse monitor for in patient taking nonsteroidal anti inflammatory drugs NSAIDS select all that apply

Gastric toxicity Thrombocytopenia Gastrointestinal ulcer

Which health problem dose rehabilitation programs most assist in

Cardiac

What is the most common problem faced by rehabilitation patients

Constipation

The nurse is performing a functional assessment for a patient what skills does the nurse classify as instrumental activities of daily living I ADLs

Cooking shopping housekeeping

Which term is used to describe pain quality

Cramping

What support is provided to a patient coping with a disability

Get counseling for the patient and family

What age related changes, Lee affect the metabolism of drugs in the body of older patient

Decrease in liver size

Patients who are late old and patience with alcoholism and/or disorders of Major body organs are at a higher risk of what

Delirium

Which condition places the patient at high risk for under treatment of pain

Delirium

Independence in bowel elimination requires cognition, manual dexterity, sensation, muscle control, and mobility. Good sleep, deep breathing, and nutritions diet are not factors that determine independence in bowel elimination.

Depression

Which Manifestations of Neglect does the nurse identify as most common in older adults

Depression

The Nurse is administering chemotherapeutic Drugs to the patient and noticed excessive bruising on the patient's arm the patient cannot recall injury to the area the nurse knows that this bruising may indicate which condition

Diminished clotting

An older adult patient is diagnosed with depression that the provider believes is due to insufficient serotonin in the brain this is described as what

Primary depression

What data indicatesWhat does static or postural hypotension in a patient

Drop of 10 MMHG in diastolic pressure between positions

Which nursing action reflects correct use of the Wong baker faces pain rating scale

Encouraging the patients to choose a cartoon face that best represents the pain

The nurse is establishing a plan of care for a hospitalized patient with chronic pain caused by fibromyalgia. Which nursing action does the nurse delegate to a nursing assistant?

Engagement in conversation about the patient's family to distract the patient

Which did the National Institute for occupational Saftey and Health NIOSH establish

Evidence based guidelines for saftey patient handling

Following surgery a patient has limited mobility. The nurse observes the patient for localized redness, swelling, and warmth to assess for which complication

Excessive clotting

The nurse is providing education to patient with recurring constipationWhat lifestyle intervention does the nurse suggest to the patient to stimulate peristalsis

Exercising frequently

A patient is brought to the hospital in a state of delirium which indicators on the checklist of nonverbal pain indicators see NPI does the nurse used to assess this patient's level of pain select all that apply

Facial expression Mental status changes Changes in interpersonal interactions

What is the most prominent hindrance to the rehabilitation of patients with cardiac disorders

Fear

What is the primary collaborative intervention for patients with fluid deficits?

Fluid replacement

A patient has lost weight since admission into the rehabilitation center one week ago there is a decrease in the serum prealbumin level. What nutritional recommendation does the nurse expect from the register dietitian for this patient

Hi Protein and high carbohydrate diet

What does the nurse infer if a patient scores a 2 on the Wong-Baker FACES pain rating scale ?

Hurts a little bit

The registered nurse is teaching a nursing student about interventions to prevent sleep disorders in an older patient. Which nursing student statement indicates a need for further teaching by the nurse?

I should encourage the patient to sleep langer during the daytime.

The nurse preceptor is teaching a nursing student about minimizing the effects of relocation trauma in Older adults which of the nursing student statements indicate a need for further teaching by the nurse preceptor

I should not involve the older patient in decision making

Which strategy represents correct use of behavioral signs as part of pain assessment

Identifying specific pain behaviors that are unique to the patient

Which patients are generally in capable of reporting their pain using self-report assessment tools

Immediately dying patients

What is the other term use for subarachnoid analegesia

Intrathecal

A postoperative patient is vomiting and states, 'I am having a lot of pain about a 7 on a scale of to 10. Which route of administration does the nurse choose to administer an analgesic to the patient?

Intravenous

A registered nurse ask a nursing student about the minimum data set MDS required by Medicare and Medicaid certified nursing homes which nursing student statement indicates a need for further teaching

It is evaluated specifically by the mobility of the resident patient

Fentanyl is a opioid which can be administered through the transdermal route to relieve pain which factors are considered disadvantages of the trans terminal route of OPiod administration

It needs to be supplemented with other analgesics analogically initially

Which factor affects the ability of older patients to process new information

Loss of vision

The nurse understands that signs of decreased peripheral perfusion most often occur where?

Lower extremities

Which term describes pain produced by Inflammation of the trigeminal nerve that is the fuse in nature extending across the various nerves that intervate the face

Projected

What is one way in which the baby boomer generation health affected the United States

Mark negative impact on the country's economy

Following a falla 62-year-old patient is admitted to the rehabilitation unit with a broken collarbone and a full leg brace. Which transfer technique is indicated for this patient?

Mechanical lift

For which do older adults pay to cover prescription drug costs

Medicare part D

which cognitive behavioral distractions can be useful in reducing a patient's focus on pain select all that apply

Medication Biofeedback Guided imagery

Which medication is listed on the beers criteria for potentially inappropriate medication use in older adults

Meperidine

Which type of drugs are appropriate for the nurse to recommend to patients experiencing constipation select all that apply

Mild laxatives Stool softeners Bulk forming agents

During which process of pain transition does an opioid analgesic medication inhibits pain by affecting central mechanism

Modulation

Which patient statement is consistent with the experience of visceral pain

My entire abdomen is cramping

Which is risk factor for opioid induced respiratory depression

Obstructive sleep apnea

The patient is struggling with use of eating utensilsWhich rehabilitation team member is brought in to help the patient with this problem?

Occupational therapist

Which evidence based nursing interventions should the nurse include in a plan of care in order to prevent agency associated pressure ulcers as per the National Patient Safety Goals (NPSGs) Salei all that apply

Offer nutritional support Reposition and provide support surfaces Avoid skin injury caused by friction or shearing forces

What is the fastest growing sub group of older adults

Old old

Which necessitates help a patient maintain healthy skin select all that apply

Oxygen Sensation Adequate food

The nurse is conducting a pain assessment which assessment data is the most reliable indicator of the patient's pain

Pain rating of 3 on 0 to 10 scale

The medical surgical nurse is coordinating transfer from acute care to community base care for a patient who requires rehabilitation which interdisciplinary team member will be the primary decision-maker in this transition

Patient

An older patient tells the nurse his son sometimes hit him with the patient does not keep his bedroom tidy. what problem does this indicate

Physical abuse

A patient who is using patient control analgesia PCA Is Ashley the nurse observes a family member pushing the PCA button for a sleeping patient what does the nurse say to the visitor

Please allow the patient to push the button when needed

The nurse is performing a pain assessment on an alert mechanically vented patient which patient behavior has the potential to provide the most useful assessment data for determining patient intensity

Plinking

The nurse is mentoring a nursing student about best practices for safe patient handling SPH what practice does the nurse teach the student

Put the beer at waist level for Care and Hip level for movement of the patient

The nurse is caring for a patient at high risk for decreased perfusion what lifestyle Interventions does the nurse teach the patient in order to decrease the risk select all that apply

Quitting smoking Maintaining bed rest Regular cardiovascular exercise

Which term describes pain that occurs along a specific nerve or nerves

Radiating

Which term describes pain that originates at the site of a herniated cervical disc and extends into the arm hand and fingers

Radiating

Which pain is felt alone a specific nerve or nerves

Radiation pain

Which chronic condition does the nurse expect to find in a 70-year-old patient Salei all that apply

Stroke Arthritis Coronary heart disease

Which data is most reliable for use in assessment of a patient's pain

Subject patient report

The nurse understands that which laboratory test are most useful in detecting auto immune disease Select all that apply

Rheumatoid factor Antinuclear antibody

Which tool is available to help the nurse focus on factors that increase an older persons risk for falling

STRATIFY

The nurse is caring for a patient with flaccid bowel caused by lower motor neuron spinal cord injury. How does the nurse encourage bowel movements and prevent constipation in the patient

Schedule a bowel program as per the patients previous routine

The nurse is preparing a care plan for a patient with lower back pain and hypothyroidism who has been prescribed acetaminophen Which instruction would the nurse give regarding this medication

Schedule regular renal and liver function test number one

What behaviors differentiate a social smoker from an active smoker?

Social smokers claim to prefer the company of non-smokers

The nurse is teaching a patient about the administration of a prescribed liquid form of acetaminophen what information does the nurse include when advising this patient

Take a maximum up to 4000 MG/ day

If the nurse working in the hospital suspects physical abuse or neglect of another patient who should the nurse notify

The hospital social worker

A patient rates they're paying at a two or three on the pain rating scale on a calibrated 0 to 10 how does the nurse interpret this finding

The patient has mild pain

Members of the clergy may be part of the rehabilitation team that helps restore and maintain the patients function to the greatest extent possible what role do they play

They help in spiritual assessments and care of the patient.

During a physical examination, the nurse identifies palpable mass in the patient's breast. What type of assessment may be used to identify the type of cells that are present in the mass?

Tissue biopsy

What should the nurse include in the assessment when looking for signs of skin breakdown including pressure ulcers

Tissue integrity

Why was the Americans with disability act passed Select all that apply

To make employers offer assistance to the disabled employee So encourage disabled people to resume normal activities in the workplace

Which time is used to describe pain duration

Transient

A soldiers returning from overseas after sustaining injuries from a roadside bomb explosion which condition does the nurse expect to see in this patient

Traumatic brain injury

An older adult patient is being treated for depression following a recent major loss which type of treatment would be contradicted in this patient

Tricyclics antidepressant drugs

What easily observable physical signs may indicate malnutrition select all that apply

Very dry skin Brittle hair and nails

After administering a dose of opioids, the nurse evaluates the patient using the Pashto Opioid Sedation Scale (POSS) and documents a . What patient behavior does this indicate?

Wake and alert

The physical therapist is teaching a paraplegic patient to become independent and transfer from the bed to the chair which equipment does the nurse expect the physical therapist to use

Wheelchair with removable arms

Which pain scale is most appropriate for the nurse to use my necessity pay in a six year old child

Wong baker faces

The nurse is attending to an Asian American patient who cannot communicate in English what all does the nurse use when assessing the Painof the patient

Wong baker faces pain rating scale

What is the nature of sputum in a smoker with chronic bronchitis?

mucoid