NSG 100 Exam #4 Review Questions
Bowel Alterations: Matching 1.Constipation 2.Diarrhea 3.Impaction 4.Incontinence 5.Hemorrhoids A.Results from unrelieved constipation B.Inability to control passage of feces and gas to the anus C.A symptom, not a disease D.Dilated, engorged veins in the lining of the rectum E.Fluid and electrolyte imbalances of primary concern
1.Constipation = C 2.Diarrhea = E 3.Impaction = A 4.Incontinence=B 5.Hemorrhoids = D
Review: Terminology 1.Defecation 2.Micturition 3.Continence 4.Incontinence 5.Retention A.passing of urine, urination B.loss of control of elimination of urine or feces or both C.keeping materials within the body that are normally expelled D.passing of bowel, bowel movement E.purposeful control of urine or fecal elimination
1.Defecation = D. passing of bowel, bowel movement 2.Micturition = A. passing of urine, urination 3.Continence = E. purposeful control of urine or fecal elimination 4.Incontinence = B. loss of control of elimination of urine or feces or both 5.Retention = C. keeping materials within the body that are normally expelled
Bowel Elimination Medication 1.Metamucil (bulking agent) 2.Senokot (stimulant laxative) 3.Imodium A-D (antispasmotic) 4.Miralax (osmotic laxative) Implication A.Decrease intestinal peristalsis B.Draw fluids into the intestine from other tissue and blood vessels C.Regular use is not recommended D.Absorb water to form soft stool
1.Metamucil (bulking agent) = D 2.Senokot (stimulant laxative) = C 3.Imodium A-D (antispasmotic) = A and C 4.Miralax (osmotic laxative) = B
Pain Physiology: Matching 1.Transduction 2.Transmission 3.Perception 4.Modulation A.Release of inhibitory neurotransmitters B.Nerve impulses travel along afferent peripheral nerve pathway C.Nociceptors respond to noxious stimuli D.Cerebral cortex and limbic systems
1.Transduction=C 2.Transmission=B 3.Perception=D 4.Modulation=A
Urinary Alterations: Matching 1.Stress 2.Urge 3.Overflow 4.Functional 5.Reflex A.Toileting programs, adaptive equipment B.Frequency, nocturia, small voids C.Neuropathy; trauma D.Urinary retention E.Kegel exercises
1=E: Treatment: Kegel exercises, α-adrenergic agonists 2= B: Presentation: Urinary urgency, frequency, nocturia, bladder contractures, small void 3= D: Etiology: Urinary retention 4= A: Treatment: Toileting programs, adaptive equipment 5= C: Etiology: Neuropathy; trauma
A client who is obese and who has Osteoarthritis is being managed pharmacologically with acetaminophen therapy. The nurse determines that additional teaching is needed when the client makes which statement? A."I take my acetaminophen when I have extreme pain or stiffness." B."I use heat sometimes to help reduce my pain and stiffness." C."I realize the importance of quality rest and sleep to feel my best." D."I started an exercise program to lose weight."
ANS: A Acetaminophen therapy is continuous and is effective only if therapeutic blood levels are reached. It is not taken intermittently. The other statements are appropriate self-care measures when taking acetaminophen for osteoarthritis.
The nurse is caring for a newborn infant who has not yet voided in the first 48 hours of life. Which action should the nurse take? A.Assess for bladder distention. B.Wait another 24 hours. C.Initiate IV fluid therapy. D.Insert a urinary catheter
ANS: A Bladder distention should be assessed in the newborn who has not yet voided in the first 48 hours of life. Actions should also include notifying the healthcare provider and assessing fluid status, not waiting another 24 hours. IV fluid and urinary catheterization would not be initiated without healthcare provider orders.
The teaching plan for a patient with diarrhea should include which intervention? A.Drinking at least eight glasses of fluid each day B.Eating foods low in sodium and potassium C.Limiting the amount of soluble fiber in the diet D.Eliminating whole-wheat and whole-grain breads and cereal
ANS: A Diarrhea is associated with high risk for dehydration, so the patient should increase the fluid intake. The patient may need increased sodium and potassium intake owing to loss of these electrolytes in the frequent stools. Fiber will add bulk and help form the stools so should be increased. Whole-grain products contain fiber.
A client with benign prostatic hyperplasia (BPH) asks the nurse if there are medications that can be used to prevent the need for surgery. Which response by the nurse is accurate? A."Yes, there are medications that can help control BPH symptoms and reduce the need for surgery." B."There are two classes of medications available for BPH, but they only address lower urinary tract symptoms and do not shrink the prostate." C."There are some medications available, but ultimately they just delay the need for surgery for a short time." D."There are medications, but most of them have serious adverse effects."
ANS: A Medications such as alpha-blockers and 5-alpha reductase inhibitors have significantly reduced the need for surgery to control symptoms of BPH. The medications do have several side effects, none of which would likely be considered terrible; in particular, finasteride has no serious adverse effects. The statement that they only delay the need for surgery for a short bit is not a valid statement. Finasteride and dutasteride both cause the enlarged prostate to shrink, thus the statement that they only address lower urinary tract symptoms is not valid.
During a well child visit, the mother of a 3-year-old child asks the nurse how many hours of sleep the child requires each night. Which response by the nurse is appropriate? A."A 3-year-old child needs 10 to 13 hours of sleep each night." B."A 3-year-old child needs 7 to 9 hours of sleep each night." C."A 3-year-old child needs 12 to 15 hours of sleep each night." D."A 3-year-old child needs 8 to 10 hours of sleep each night."
ANS: A Rationale: Growing children require more sleep than adults. The 3-year-old child requires 10 to 13 hours of sleep each night. Infants need 12 to 15 hours of sleep in 24 hours. Adolescents require 8 to 10 hours of sleep each night. Adults need 7 to 9 hours of sleep each night.
The nurse is assessing an older adult client who presents with fecal incontinence. Which statement by the nurse indicates understanding of the etiology of fecal incontinence? A."Fecal incontinence is abnormal and should be addressed in clients who are cognitively intact and physically able." B."Older adults with fecal incontinence are not candidates for treatment to alleviate their condition." C."Older adults are not at an increased risk for fecal incontinence." D."Fecal incontinence is a normal response to the aging process."
ANS: A The causes of fecal incontinence are multifactorial. Fecal incontinence is abnormal and should never be considered a normal part of the aging process. Older adults are at increased risk for fecal incontinence due to chronic disease, polypharmacy, inactivity, immobility, and decreased fluid intake. Older adults who are cognitively intact and physically able should be considered for treatment to alleviate the psychosocial effects associated with fecal incontinence.
Which nursing intervention would be the highest priority when caring for a patient complaining of voiding small amounts of urine in relation to his fluid intake? A. Palpating the patient's bladder for distention before scanning for possible retention. B. Placing a disposable waterproof pad on the patient's bed before he goes to sleep. C. Documenting in the patient's electronic health record that he is complaining of anuria. D. Notifying the patient's primary care provider (PCP) of the need for intermittent catherization.
ANS: A The highest priority nursing intervention for a patient experiencing oliguria (reduced urine volume) is to check the patient for bladder distention and retention. Placing a waterproof pad on the patient's bed at bedtime would be more appropriate if the patient was incontinent or experiencing nocturia (excessive urination at night). Documentation of anuria (excretion of 50-100 mL or less of urine each day) would be erroneous since the patient is complaining of repeatedly passing small amounts of urine. Notifying the primary care provider may be necessary, but only after the patient is assessed for distention and retention that is not resolved by other less invasive methods of relief.
The nurse is planning care for a patient experiencing acute pain. Which should the nurse include in the health history portion of the nursing assessment? A.A developmentally appropriate assessment tool B.Assessing facial expressions C.Inspecting injuries D.Monitoring vital signs
ANS: A The nurse should use a developmentally appropriate pain assessment tool during the health history portion of the nursing assessment. Monitoring vital signs, assessing facial expressions, and inspecting injuries occur during the physical examination portion of the nursing assessment.
A client fell down some stairs and broke the humerus. Upon admission, the client is experiencing limited range of motion and severe pain. Which kind of pain should the nurse recognize this client is experiencing? A.Somatic nociceptive pain B.Chronic pain C.Visceral nociceptive pain D.Idiopathic pain
ANS: A This is considered acute pain due to the injury specifically Somatic nociceptive pain. Any pain that lasts for more than 6 months and progressively worsens is considered chronic pain. Visceral pain is pain arising from an organ, while idiopathic pain is a pain with no known cause.
The nurse is providing care to a client at a sleep disorder clinic. Which assessment finding does the nurse expect during REM sleep (Select all that apply) A.Tachypnea B.Decrease in voluntary muscle tone C.Decrease in eye movement D.Bradycardia
ANS: A,B During REM sleep, the body and brain are highly active. Distinctive eye movements occur; breathing becomes more rapid, irregular, and shallow; and voluntary muscle tone is dramatically decreased. The heart rate increases, blood pressure rises.
The nurse is preparing a teaching session about nutrition for a community health fair. Which information should the nurse include about obesity? (Select all that apply.) A.Portion sizes help control body weight. B.Food choices contribute to the development of obesity. C.Refined foods, animal proteins, and fats contribute to obesity. D.The prevalence of obesity has declined over recent years. E.Preventing obesity lowers the risk of developing hypertension
ANS: A,B,C,E Portion sizes and food choices both help control body weight and may help reduce the incidence of obesity. Refined foods, animal proteins, and fat intake contribute to obesity. Obesity is linked to the development of hypertension. The prevalence of obesity has increased 25% in adults and doubled in children and adolescents.
The nurse is providing care to older adult clients at a long-term care facility. Which factor places these clients at risk for urinary incontinence? (Select all that apply.) A.Age B.Stroke C.Depression D.Frequent travel E.Multiple urinary tract infections (UTIs) in a year
ANS: A,B,C,E Risk factors for urinary incontinence include age, gender (women are more susceptible than are men), obesity, smoking, diabetes, inactivity, pregnancy, depression, neurologic disorders (e.g., stroke), two or more UTIs per year, and medications (medications affecting the adrenergic system, diuretics, and calcium channel blockers). Frequent travel is not a risk factor for Urinary incontinence.
During an office visit, a client reports infrequent and difficult bowel movements. Which teaching topic should the nurse include when developing the client's plan of care? (Select all that apply.) A.The importance of staying active B.The use of laxatives or stool softeners C.The importance of cooking and storing food correctly D.The importance of consuming adequate amounts of fluid and fiber E.The avoidance of raw fruit, vegetables, and meat when traveling abroad
ANS: A,B,D Being active and consuming adequate fluids and fiber in the diet can prevent constipation. Clients at high risk of constipation may prevent it by taking daily laxatives or stool softeners. Cooking and storing food properly and avoiding raw foods during travel would address diarrhea, not constipation
Which factors may influence the expression of pain regardless of culture, and is important for the nurse to consider for all patients? (Select all that apply.) A.Client's ability to cope with pain B.Previous pain experiences C.Family members perception of pain D.Client's skills at reporting pain and discomfort
ANS: A,B,D The patient's ability to cope with pain, skills at reporting pain and discomfort, and previous pain experiences are important factors to consider for all patients. The family members perception of pain is not vital to understanding how patients express pain.
The nurse should anticipate conducting which assessment when preparing to provide care for a client experiencing alterations in bowel function? (Select all that apply.) A.Client interview B.Skin assessment C.Renal assessment D.Abdominal assessment E.Inguinal area assessment
ANS: A,B,D,E Client interview, abdominal assessment, and inguinal area assessment are used to assess clients experiencing alterations in bowel function. A skin assessment should be conducted to the anal, perineum, and buttocks if the alteration involves diarrhea or frequent loose stool. A renal assessment is more appropriate for alterations in urinary elimination.
The nurse should anticipate conducting which assessment when preparing to provide care for a client experiencing alterations in Urinary function? (Select all that apply.) A.Client interview B.Bladder assessment C.Pulmonary assessment D.Renal assessment E.Skin assessment
ANS: A,B,D,E Client interview, bladder, renal and skin assessment are used to assess clients experiencing alterations in urinary function. A pulmonary assessment is more appropriate for alterations in gas exchange.
The nurse is planning to teach a class regarding factors that influence food choices. Which factor should the nurse include? (Select all that apply.) A.Emotion B.Availability C.Level of hunger D.Convenience E.Cost
ANS: A,B,D,E Factors that affect food choices include cost, emotion, availability, and convenience. Additional factors include taste, smell, habits, packaging, body image, health, and cultural influences. Level of hunger is not identified as a factor that influences food choices
Which of the following is a risk factor for constipation? (Select all that apply.) A.Immobility B.Lack of privacy C.Intake of high levels of dietary fiber D.Suppressing the urge to defecate E.Chronic laxative use
ANS: A,B,D,E Rationale: Lack of privacy and immobility can lead to constipation. Ignoring the urge to defecate causes the muscles and mucosa in the rectal area to become insensitive to the presence ofstool, which becomes more difficult to expel. Chronic use of laxatives and the dilation of the bowel with loss of smooth muscle tone in the colon can cause constipation. High levels of dietary fiber and high fluid intake decrease the chance of constipation.
The nurse is caring for a client who is in pain because of a back spasm. Which independent nursing intervention should the nurse use for this client? (Select all that apply.) A.Positioning the client to promote comfort B.Providing distractions C.Ordering physical therapy for the client D.Administering analgesics as ordered E.Applying heat or cold as appropriate
ANS: A,B,E Independent nursing interventions for a client in discomfort include applying heat or cold as appropriate, providing distractions, and positioning the client to promote comfort. Administering analgesics and ordering physical therapy are physician initiated and collaborative interventions.
´The nurse is teaching a community-based group about reproductive health. Which information should the nurse include when discussing benign prostatic hyperplasia (BPH)? (Select all that apply.) ´ A.BPH is the most common benign tumor in men. B.BPH is considered a precursor to prostate cancer. C.Almost all men will develop BPH if they live long enough. D.Caucasian American men develop symptoms of BPH later than all other races. E.Antioxidant and anti-inflammatory supplements can reduce the risk of BPH.
ANS: A,C BPH is the most common benign tumor in men and almost all men will develop BPH if they live long enough. Therefore, the nurse would include these statements in the teaching session. BPH is not considered a precursor to prostate cancer. There is no evidence to support the use of antioxidant or anti-inflammatory supplements to reduce the risk of BPH. Caucasian American men do not develop symptoms of BPH later than all other races. Asian American men develop symptoms later than Caucasian American men.
The nurse is planning to collect anthropometric data from a client who is being evaluated for undernutrition. Which information should the nurse include? (Select all that apply.) A.Weight B.Food allergies C.Skinfold thickness D.Height E.Capillary blood glucose level
ANS: A,C,D Anthropometric data include the client's height, weight, and skinfold thickness. Food allergies are a part of the physical history of digestive problems. Capillary blood glucose level is a laboratory test used to measure the amount of glucose in the client's blood.
The nurse suspects that a client is experiencing chronic pain. Which finding caused the nurse to make this clinical determination? (Select all that apply.) A.Says the pain varies in intensity and location B.Causes changes in vital signs C.Demonstrates depression D.Describes the pain as persistent E.Has been occurring for 2 months
ANS: A,C,D Chronic pain is also referred to as persistent pain. It is pain that lasts longer than 6 months. The pain may vary in intensity and location. Acute, not chronic, pain triggers a sympathetic nervous response which includes a change in vital signs. Chronic pain may cause depression.
Which statement regarding comfort is true? (Select all that apply.) A.It can be associated with sleep and rest. B.It is objective. C.It is subjective. D.It varies from one individual to another.
ANS: A,C,D Comfort can be associated with sleep and rest, is subjective, and varies from one individual to another.
The nurse is speaking at a school to pre-teens on the topic of healthy lifestyles. What information would the nurse include in her presentation? (Select all that apply) A.Limit television, computer, and video game time. B.Limit sugar-sweetened beverages to three per day. C.Include 30 minutes of aerobic activity in the day. D.Eat a healthy diet with whole grains, lean meat, vegetables, and fruits.
ANS: A,C,D Sugar-sweetened beverages are empty calories and can easily add up throughout the day, providing no nutritional benefit. These drinks should be limited to special occasions only and not for everyday use. Water consumption should be encouraged. Limiting time on devices when the student is inactive is important. The student should attempt to include 30 minutes of daily aerobic activity. A healthy diet is the cornerstone of a healthy lifestyle.
´Which diagnostic tests should the nurse expect to be prescribed for a client with symptoms of benign prostatic hyperplasia (BPH)? (Select all that apply.) A.Urinalysis B.Urine specific gravity test C.Digital rectal examination D.Prostate-specific antigen (PSA) level E.Ultrasound or postvoid catheterization
ANS: A,C,D,E Urinalysis is done to identify the presence of white and red blood cells or bacteria in the urine. An ultrasound or postvoid catheterization is performed to determine residual urine volume. A PSA test screens for prostate cancer, and a digital rectal exam assesses the external surface of the prostate. A urine specific gravity test is not a part of the diagnostic screening for BPH.
Which tool is available to the nurse to assess a client's eating habits? (Select all that apply.) A.Mini-Nutritional Assessment B.Body mass index C.Waist-to-height ratio D.Food dairy E.Food frequency questionnaire
ANS: A,D,E Requesting the client keep a food diary for 3 days or more, conducting a food frequency questionnaire including a 24-hour recall of food intake, or performing the six-item Mini-Nutritional Assessment all provide important insight to what and when the client is eating. The nurse can then teach about replacements or changes in food choice, as well as timing of meals. Body mass index and waist-to-height ratio are methods of evaluating under- or over-nutrition but do not provide information about what and when the client is eating.
´Which clinical manifestations should the nurse expect to observe when assessing a client with benign prostatic hyperplasia (BPH)? (Select all that apply.) A.Hesitancy B.Incontinence C.Empty bladder D.Nocturia E.Weak or intermittent urinary stream
ANS: A,D,E Symptoms of BPH include difficulty starting urination (hesitancy), incomplete bladder emptying, increased frequency of urination at night (nocturia), weak or intermittent urinary stream, dribbling at the end of urination, and straining during urination. Incontinence is not a clinical manifestations of BPH.
The nurse is providing education to the client on the effect of lifestyle factors on sleep. Which should the nurse include as a factor that negatively influences sleep? (Select all that apply.) A.Evening exercise B.Relaxation C.Regular nighttime schedule D.Morning exercise E.Irregular work schedule
ANS: A,E Rationale: Factors that negatively impact sleep include evening exercise and an irregular work schedule. Morning exercise, relaxation, and regular nighttime schedule are known to enhance sleep.
Which of the following is a necessary component of a nutritional assessment? (Select all that apply) A.Anthropometrics B.A nutritional screen C.Medication history D.Recent BUN lab value
ANS: All are correct Data that should be included in a patient's nutritional assessment: Dietary Medical Socioeconomic Anthropometric Clinical Laboratory
Which of the following direct visualization tests uses a long, flexible, fiber-optic lighted scope to visualize the rectum, colon, and distal small bowel? A.Esophagogastroduodenoscopy (EGD) B.Colonoscopy C.Sigmoidoscopy D.UGI series
ANS: B A colonoscopy visualizes the rectum, colon, and bowel using a lighted scope. An EGD examines the esophagus, stomach, and upper duodenum through an optic scope. A sigmoidoscopy examines the distal sigmoid colon, rectum, and anal canal through a flexible or rigid sigmoidoscope. UGI series involves fluoroscopic examination of the esophagus, stomach, and small intestine after ingestion of barium sulfate.
Which of the following direct visualization tests uses a long, flexible, fiber-optic lighted scope to visualize the rectum, colon, and distal small bowel? A.Esophagogastroduodenoscopy (EGD) B.Colonoscopy C.Sigmoidoscopy D.UGI series
ANS: B A colonoscopy visualizes the rectum, colon, and bowel using a lighted scope. An esophagogastroduodenoscopy examines the esophagus, stomach, and upper duodenum through an optic scope. A sigmoidoscopy examines the distal sigmoid colon, rectum, and anal canal through a flexible or rigid sigmoidoscope. UGI series involves fluoroscopic examination of the esophagus, stomach, and small intestine after ingestion of barium sulfate.
The father of a 3-year-old boy is concerned that his child still wets the bed at night. Which explanation by the nurse is most appropriate regarding bedwetting? A."By 24 months, children are capable of holding urine beyond the urge to void." B."Children often achieve daytime bladder control prior to nighttime control." C."Oliguria is not uncommon in children." D."Sometimes children experience nocturia."
ANS: B Bladder control is usually attained by ages 24-30 months. By approximately age 5 years, most if not all children with normal bladder function should have acquired this ability. Oliguria is scant urine output, and the other statements by the nurse do not address the father's concern.
The daughter of a wheelchair-bound older adult client is concerned because her mother has been experiencing urinary incontinence. Which statement should the nurse use to explain the condition to the daughter? A."Renal blood flow and ability to concentrate urine decrease in older adults." B."Mobility issues may cause urinary incontinence. " C."The kidneys reach maximum size at ages 35 to 40." D."The frequency of voiding varies in older adults."
ANS: B Both mobility and neurological issues may cause urinary incontinence. The other explanations do not address the daughter's concern regarding her mother's urinary incontinence. Kidney size is unrelated to urinary incontinence. The excretory function of the kidneys diminishes with age, but not significantly enough below normal levels unless caused by a contributing disease process. The frequency of voiding varies for all individuals.
A patient present with complaints of lower abdominal pain. The patient describes the pain as vague deep ache that is poorly localized. The nurse recognizes that the patient is most likely experiencing which type of pain? A.Somatic pain B.Visceral pain C.Neuropathic pain D.Breakthrough pain
ANS: B Characteristics of visceral pain include - often poorly localized, may feel like a vague deep ache, sometimes being cramping or colicky in nature.
The patient talks with the nurse about bladder health. What is one of the most important recommendations the nurse can make for this patient? A.Eat foods high in fiber. B.Drink six to eight glasses of noncaffeinated fluids daily. C.Exercise in the morning and evening D.Visit the urologist once yearly.
ANS: B Drinking six to eight glasses of noncaffeinated fluids daily helps with bladder health because urine is not stagnating in the bladder. Exercising and eating foods high in fiber help with bowel elimination but do not have an effect on urination. Visiting the urologist is good if there is a problem, but this is not the most important recommendation from the nurse.
´The nurse is preparing health education for men about urinary retention and urinary incontinence. Which statement should the nurse include? A. "Urinary retention is more common in women than it is in men." B."Urinary incontinence is often associated with treatment for prostate enlargement." C."Urinary incontinence is less common than is urinary retention." D. "Urinary incontinence and retention are indications of kidney failure."
ANS: B More than half of men over 60 report urinary incontinence with treatment of prostate enlargement. Urinary retention is more common in men than it is in women and less common than is urinary incontinence. Urinary retention and incontinence are often associated with prostate issues in the male, not kidney failure, which may manifest as oliguria or anuria.
Which of the following signs or symptoms in an opioid-naïve patient is of greatest concern to the nurse when assessing the patient 1 hour after administering an opioid? A. Oxygen saturation of 95% B. Difficulty arousing the patient C. Respiratory rate of 10 breaths/min D. Pain intensity rating of 5 on a scale of 0 to 10
ANS: B Opioid-naive patients may develop a rare adverse effect of respiratory depression, and sedation always occurs before respiratory depression.
The nurse collects data from a client with suspected osteoarthritis. The nurse elicits information that will confirm which manifestations of osteoarthritis? A.Elevated sedimentation rate B.Pain and stiffness associated with prolonged inactivity C.Elevated white blood cell count D.Positive rheumatoid factor
ANS: B Pain and stiffness associated with prolonged inactivity is characteristic of osteoarthritis. An elevated sedimentation rate and positive rheumatoid factor are characteristics of rheumatoid arthritis. There are no lab tests that diagnose osteoarthritis. An elevated white blood cell count is not characteristic of this disease.
The nurse assesses a client for manifestations associated with a sleep rest disorder. Which should the nurse include when completing the psychosocial assessment? A.Appearance B.Life stressors C.Reflexes D.Muscle tone
ANS: B Rationale: Life stressors are included as part of the psychosocial assessment for sleep rest disorders. Reflexes, muscle tone, and appearance are components of a physical assessment.
The nurse caring for a client with stress incontinence should identify which condition as a cause? A.There is an inability to respond to the need to urinate. B.Pelvic muscle relaxation, a weak urethra, and surrounding tissues cause decreased urethral resistance. C.An overactive detrusor muscle increases bladder pressure. D.The lack of normal detrusor muscle function causes bladder overfilling and increased bladder pressure.
ANS: B Stress incontinence occurs when the pelvic muscle relaxes, and a weak urethra and surrounding tissues cause decreased urethral resistance. Urge incontinence is when an overactive detrusor muscle increases bladder pressure. Overflow incontinence is when the lack of normal detrusor muscle function causes bladder overfilling and increased bladder pressure. Functional incontinence occurs when the client is unable to respond to the need to urinate.
The nurse is reviewing the physiology of the gastrointestinal tract with a new employee. The nurse knows that the employee understands basic physiology when they state, most nutrient absorption occurs in the: A.Stomach B.Jejunum C.Liver D.Ascending Colon
ANS: B The small intestine is primarily responsible for nutrient absorption. The jejunum is the middle part of the small intestine, between the duodenum and ileum. Most digestion and nutrient absorption takes place in the jejunum. The absorption of carbohydrates and protein occurs in the jejunum; and the ileum absorbs water, fats, and bile salts.
The nurse is caring for a female client who complains of urine leakage when lifting moderate to heavy items at home. Which intervention should the nurse recommend to the client? A.Yoga B.Pelvic floor (Kegal) exercises C.Abdominal exercises D.Walking around the block daily
ANS: B This client is experiencing urinary incontinence that may be reduced through the strengthening of the pelvic floor muscles with pelvic floor exercises. Yoga, abdominal exercises, and walking are all good for general health but do not directly help reduce stress incontinence.
The nurse is assessing an undernourished client. Which manifestation of the integumentary system should the nurse consider an expected finding? (Select all that apply.) A.Muscle wasting B.Petechiae C.Dry brittle hair D.Poor wound healing E.Constipation
ANS: B,C,D Effects of undernutrition of the integumentary system include petechiae, dry brittle hair and nails, poor wound healing, and spoon-shaped nails. Constipation is an effect on the gastrointestinal system. Muscle wasting is an effect of undernutrition on the musculoskeletal system.
Which of the following laboratory values if decreased is indicative of protein malnutrition? A.Blood glucose B.Creatinine C.Albumin D.Hemoglobin levels
ANS: C
A registered nurse (RN) is providing medication teaching to a client who was prescribed an antispasmodic. Which of the following topics should the RN include in the teaching? A.Take with plenty of water or other liquids B.Take with an iron supplement C.Stop taking the medication as soon as stools thicken. D.Continue to take the medication until the stool softens.
ANS: C Antispasmodic antidiarrheal products such as Loperamide-Opiod (active ingredient in Imodium A-D) slow the intestine. Long-term use is not recommended. To avoid constipation, stop taking antidiarrheal medicines as soon as stools thicken.
The nurse is determining if a client is experiencing acute pain. Which finding should the nurse identify as being consistent with this type of pain? A.Pulse rate and respiratory rate are decreased, and blood pressure is increased. B.Respiratory rate and blood pressure are normal. C.Pulse rate, respiratory rate, and blood pressure are increased. D.The client is calm; pupils are constricted.
ANS: C In acute pain, the sympathetic nervous system increases the client's pulse rate, respiratory rate, and blood pressure. The client may become diaphoretic, and the pupils will dilate. The client may also be restless and anxious.
A client is taking morphine for chronic pain. Which instruction should the nurse give the client to minimize adverse effects of this medication? A.Decrease the amount of fluid intake. B.Eat large frequent meals to increase food intake. C.Increase fiber in the diet. D.Decrease the intake of protein.
ANS: C Morphine can cause constipation; therefore, fiber should be increased in the diet to counter this. Decreasing the amount of protein is not necessary. Clients would be encouraged to increase fluid intake to assist with constipation. Large frequent meals would be avoided due to nausea.
The nurse prepares to assess a client for pain. Which structures, as per the nurse's recollection, receive pain impulses from the site of injury? A.Muscles and spinal cord B.Brain and muscles C.Spinal cord and brain D.Tendons and ligaments
ANS: C Nociceptors, or sensory receptors that respond to pain, send a signal along the sensory neurons to the spinal cord, where the signal is transmitted to the brain for interpretation. The brain then sends a signal back to the site of pain via motor neurons, causing the body to respond to the painful stimuli.
Which sleep rest disorder should the nurse identify as being the most common? A.Parasomnia B.Hypersomnia C.Insomnia D.Dyssomnia
ANS: C Rationale: Insomnia is the most common sleep rest disorder. Insomnia is the inability to fall or stay asleep. Hypersomnia is extreme daytime drowsiness despite getting sufficient sleep. Parasomnias are abnormal actions during sleep. Dyssomnia is also known as restless leg syndrome.
During a home visit, the family caregiver asks what can be done to help the older client get a good night's sleep. Which should the nurse suggest? A.Wear light-weight clothing. B.Withhold fluids to decrease the need to void. C.Use flannel sheets to maintain warmth. D.Play relaxing music at bedtime.
ANS: C Rationale: Interventions to promote warmth and sleep for older adults include the use of flannel sheets to maintain warmth. Physiological changes that may contribute to sleep disorders in older adults are changes in circulation, metabolism, and body tissue density. These changes limit the older adult's ability to generate heat and maintain a comfortable body temperature. For this reason, the nurse would also suggest that the older adult client wear warmer clothing for sleep. Withholding fluids to decrease the need for the older adult to void may result in dehydration and hypotension. The physiological changes in the older adult result in nocturia
The nurse notices that a patient has received oxycodone/acetaminophen (Percocet) (5/325) two tablets PO every 3 hours for the past 3 days. What concerns the nurse the most? A. The patient's level of pain B. The potential for addiction C. The amount of daily acetaminophen D. The risk for gastrointestinal bleeding
ANS: C The major adverse effect of acetaminophen is hepatotoxicity. The maximum 24-hour dose is 4 grams It is often combined with opioids (e.g., oxycodone [Percocet]) because it reduces the dose of opioid needed to achieve successful pain control. Note-Less in older adults and for those taking on a regular basis Max dose 3grams
A nursing assessment of a 14-year-old client reveals a BMI in the 90th percentile and a lifestyle that includes spending 4 hours a day playing video games and eating supper while watching television. What is the priority nursing diagnosis? A.Disturbed Body Image related to distorted perception of body size and shape B.Delayed Growth and Development related to inappropriate intake C.Imbalanced Nutrition: More Than Body Requirements related to sedentary lifestyle D.Fatigue related to malnutrition
ANS: C The most appropriate nursing diagnosis is the one that focuses on the core of the problem. The child is overweight because of poor eating habits and a sedentary lifestyle. Fatigue and altered development would be more appropriate with a child who is not receiving enough calories. While the teen might have altered body image, there are no data given that support that. This nursing diagnosis would be more appropriate with the diagnosis of anorexia nervosa.
A patient with a long-standing history of diabetes mellitus is voicing concerns about kidney disease. The patient asks the nurse where urine is formed in the kidney. The nurse's response is the: A.Bladder B.Kidney C.Nephron D.Ureter
ANS: C The nephron is the functional unit of the kidney that forms the urine. It is composed of the glomerulus, Bowman's capsule, proximal convoluted tubule, loop of Henle, distal tubule, and collecting duct.
´The client complains of abdominal pain and distention. Upon questioning, you learn that your client takes daily doses of opiates for chronic back pain. Her last voluntary bowel movement was 5 days ago, although she admits to having involuntary leakage of liquid stool now. You suspect: A.constipation. B.perceived constipation. C.bowel obstruction. D.bowel incontinence
ANS: C The nurse should suspect bowel obstruction (impaction) when a client has abdominal distention with small amounts of liquid stool and has not had a bowel movement for several days.
The nurse is assessing a client for physical problems that affect food intake. Which factor should the nurse consider? (Select all that apply.) A.Lactose intolerance B.Financial resources C.Trouble swallowing D.Use of supplements E.Problems with dentition
ANS: C,E Physical problems that limit or affect food intake include dentition problems and trouble swallowing. Lactose intolerance is an absorption problem that may affect food intake. Financial resources help determine food security. Use of supplements assists in determining the current nutritional status.
The nurse is assessing a patient's urine output. Which of the following assessment findings would be of concern? A.Amber yellow color B.Faint ammonia like odor C.Clear appearance D.Output of 120mL in 8 hours
ANS: D Expected urine characteristics include color that is a light straw to amber yellow. Urine doesn't usually have a strong odor but may be described as ammonia like. Urine should be clear in appearance or clarity. Normal urinary output is approximately equal to fluid intake. Rane of 1200-1500 mL in 24 hours (adult). Output of less than 30 mL/hr may indicate decreased blood flow to the kidneys and should be reported immediately.
A breastfeeding mother of a 2-month-old infant is concerned that her son defecates too frequently. Which response by the nurse should address this mother's concern? A."Feces containing less water may be difficult for infants to expel." B. "The increased frequency in defecation means your baby is at risk of weight loss." C."Your baby should be able to control defecation by now." D."Frequent bowel movements can occur with breastfeeding."
ANS: D Frequent bowel movements often occur with breastfeeding; therefore, this response is the most appropriate. There is no indication that the infant is losing weight. Control of defecation is not expected at 2 months of age. While feces that contain less water may be difficult to pass, the infant is not experiencing hard stools.
The nurse knows that the teaching for a patient who was recently diagnosed with constipation has been effective if the patient's meal request specifies which food choice? A.Hot dog on a bun B.Grilled chicken C.Tuna sandwich on white bread D.Spinach salad with dressing
ANS: D Green leafy vegetables are high in fiber. None of the other options are high in fiber but could be modified by using or adding whole-grain products
A patient returning to the nursing unit after knee surgery is verbalizing pain at the surgical site. The nurse's first action is to: A. Call the patient's health care provider. B. Administer pain medication as ordered. C. Check the patient's vital signs. D. Assess the characteristics of the pain.
ANS: D It is necessary to monitor pain on a regular basis along with other vital signs. It is important for the nurse to understand that pain assessment is not simply a number. •Ask about pain regularly. Assess pain systematically. •Choose pain control options appropriate for the patient, family, and setting. •Deliver interventions in a timely, logical, and coordinated fashion.
The nurse is preparing health education for men about urinary retention and urinary incontinence. Which statement should the nurse include? A."Urinary incontinence is less common than is urinary retention." B."Urinary retention is more common in women than it is in men." C."Urinary incontinence and retention are indications of kidney failure." D."Urinary incontinence is often associated with treatment for prostate enlargement."
ANS: D More than half of men over 60 report urinary incontinence with treatment of prostate enlargement. Urinary retention is more common in men than it is in women and less common than is urinary incontinence. Urinary retention and incontinence are often associated with prostate issues in the male, not kidney failure, which may manifest as oliguria or anuria.
A patient with chronic low back pain who took an opioid around-the-clock (ATC) for the past year decided to abruptly stop the medication for fear of addiction. He is now experiencing shaking chills, abdominal cramps, and joint pain. The nurse recognizes that this patient is experiencing symptoms of: A. Addiction. B. Tolerance. C. Pseudoaddiction. D. Physical dependence.
ANS: D Physical dependence is a state of adaptation that is manifested by a drug class specific withdrawal syndrome produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist. Physical dependence does not imply addiction but rather is a state of adaptation manifested by a drug withdrawal syndrome. Addiction: A primary, chronic, neurobiological disease with genetic, psychosocial, and environmental factors influencing its development and manifestations Drug tolerance: A state of adaptation in which exposure to a drug induces changes that result in a decrease of one or more effects of the drug over time. Drug tolerance does not imply addiction. Instead, tolerance is the diminution of one or more of a drug's effects resulting from repeated use over time. Pseudoaddiction: A drug-seeking behavior that simulates true addiction, which occurs in patients with pain who are receiving inadequate pain medication
A caregiver of a 10-year-old fifth grader reports to the nurse about the current behavior of the child. The teacher reported to the caregiver that the student is falling asleep in class, is distracted in interactions with the peer group, and has trouble concentrating, leading to poor grades on assignments. The caregiver also reports that the child often plays video games late into the night. Which issue does the nurse suspect as the cause of the behavior? A.Sundown syndrome B.Nocturnal emissions C.Waking up frequently at night due to nightmares D.Screen time at night
ANS: D Rationale: School-age children need 9-11 hours of sleep per night. They may spend more time at the computer, playing video games, and watching TV, leading to difficulty falling asleep and fewer hours of sleep. A regular and consistent sleep schedule and bedtime routine need to be established. The client is not experiencing sundown syndrome. Nocturnal emissions and nightmares are not the cause of the client's symptoms.
The nurse is caring for a 5-year-old client experiencing difficulty with sleeping. Which should the nurse discuss with the parents before creating a plan of care for this client? A.The plan to initiate cognitive behavioral therapy B.The child's physiological delay in melatonin release C.A plan to implement stimulus therapy D.Principles of good sleep hygiene
ANS: D Rationale: The nurse should review sleep hygiene with the parents. Sleep hygiene is a critical component for developing healthy sleep habits. Stimulus therapy is used for adults and involves using the bed only for sleep and sex, and not for other activities such as watching TV, reading, or working. Cognitive behavioral therapy is used for chronic insomnia. A delay in melatonin release that delays sleep is applicable for adolescent children.
The nurse is caring for a client in the emergency department who is complaining of severe gas pain. The nurse should anticipate the administration of which medication to the client? A.Bulk-forming agent, such as methylcellulose B.Stool softener, such as ducosate sodium C.Antidiarrheal agent, such as loperamide D.Antiflatuent, such as simethicone
ANS: D Simethicone is an antiflatulence agent that breaks up gas bubbles and facilitates their passage. This medication will likely be ordered to address the client's discomfort. Docusate sodium is a stool softener that adds moisture to the stool and can be used to promote bowel movement and reduce constipation. Loperamide is an antidiarrheal agent that promotes absorption of excess fluid in the intestines and reduces diarrhea. Methylcellulose is a bulk-forming agent that increases the amount of water in the stool, making it easier to pass.
A 63-year-old client has recently been diagnosed with osteoarthritis (OA) and the nurse is teaching the client about activities to manage the disease. The nurse includes which teaching? A.Ice painful joints for 60 minutes. B.Perform vigorous exercise. C.Take cod liver oil as a supplement. D.Do not overuse affected joints.
ANS: D Symptoms of joint pain and swelling will increase if the affected joint is overused or stressed. To avoid skin injury, application of hot packs should not exceed 20 minutes, and cold packs should be applied for no more than 10-30 minutes. Mild exercise balanced with rest is best for the affected areas.
The nurse plans outcomes with a client recovering from knee replacement surgery. Which outcome should the nurse identify as appropriate for this client? A.The nurse will utilize a pain scale assessment. B.The client will have improved physical mobility. C.The nurse will administer analgesia when requested. D.The client will report pain of 1 on a scale of 0-10.
ANS: D The client's report of pain is a measurable outcome. The nurse utilizing a pain scale is an assessment and administering analgesia is an intervention. Improved physical mobility is not a measurable outcome.
The nurse plans to assess a client for pain. Which self-reporting tool should the nurse consider using for this assessment? A.Braden scale B.Cage assessment C.SPICES assessment D.Visual analog scale
ANS: D The visual analog scale is a self-reporting tool that is used to diagnose pain. The Braden scale is used to assess skin status. Fulmer SPICES is an efficient and effective instrument for obtaining the information necessary to prevent health alterations in the older adult patient. The Cage assessment is used to evaluate the use of alcohol.
Review: Terminology 1.Oliguria 2.Nocturia 3.Polyuria 4.Urgency 5.Dysuria A.Awakening to void one or more times at night. B.Strong desire to void C.painful or difficult urination D.An excessive output of urine. E.A decrease in urinary output in spite of adequate fluid intake.
•Oliguria=E is a decreased urinary output in spite of adequate fluid intake. Another method for identifying oliguria is urine output that is less than less than 1ml/kg/h in infants or 0.5ml/kg/h (milliliters per kilogram of body weight per hour) in children and adults or less than 500 mL daily in adults. •Nocturia = A is awakening to void one or more times at night. •Polyuria = D is an excessive output of urine. Polyuria: The excessive passage of urine (at least 2.5 liters per day for an adult) resulting in profuse urination and urinary frequency (the need to urinate frequently). •Urgency=B •Dysuria=C is painful or difficult urination •Anuria refers to very low or no urine production (a daily output less than 100ml) Rarely is there a total absence of urine output. Anuria is synonymous with kidney shutdown or renal failure. •Glycosuria is the presence of sugar in the urine. •Pyuria is pus in the urine.
