Nursing 2: Exam 1
A nurse is assessing an 85-year-old client. Which of the following findings should the nurse report to the provider? a) A widened anterior-posterior chest diameter b) Presence of an S4 heart sound c) Differences in pulse strength between lower extremities d) Post-void residual of 75 mL
c) Differences in pulse strength between lower extremities
A patient who is in the last hours of life is experiencing the "death rattle" with increasing periods of apnea. The patient has a signed do-not-resuscitate (DNR)/do-not-intubate (DNI) in the chart. Which action should the nurse take? a) Preparing for intubation b) Notifying the provider c) Notifying the patient's family d) Administering a diuretic
c) Notifying the patient's family
When planning for a patient's palliative care needs, the nurse identifies the goals and values of the patient and family. The nurse is focusing on which domain of palliative care? a) Social aspects of care b) Psychologic and psychiatric aspects of care c) Structure and processes of care d) Cultural aspects of care
c) Structure and processes of care
A nurse is assessing an older adult client who has right-sided heart failure. Which of the following findings is the nurse's priority? a) Oxygen saturation is 92% on room air. b) The client consumes 20% of meals. c) Weight has increased 0.91 kg (2 lb) in 24 hr. d) The client has 1+ edema in the lower extremities.
c) Weight has increased 0.91 kg (2 lb) in 24 hr.
A nurse in an assisted living facility is assessing an older adult client who moved in 3 months ago following the death of his partner. The client reports awakening early in the morning and admits to feeling very sad. The nurse should identify that the client is experiencing which of the following types of grief? a) anticipatory grief b) delayed grief c) acute grief d) disenfranchised grief
c) acute grief
A nurse at a long term care facility is contributing to the plan of care for a client who has Alzheimer's disease and wanders at night. Which of the following interventions should the nurse include in the plan a) place the client in wrist restraints at night b) request a prescription for a psychotropic medication c) assign the client to a room closer to the nurse's station d) keep the television on at night
c) assign the client to a room closer to the nurse's station
A 16-year-old male patient who recently learned of having terminal leukemia wishes to withhold future care. Which response by the nurse is appropriate? a) "Unfortunately, I can't discuss your plan of care until I get permission from your parents." b) "I will get the appropriate paperwork for you to sign." c) "You can only be involved in making medical decisions after you turn 18." d) "Let's talk to your parents and healthcare provider. It's important for you to discuss this with them."
d) "Let's talk to your parents and healthcare provider. It's important for you to discuss this with them."
A nurse is providing teaching to a client who is to start taking alendronate sodium. Which of the following recommendations should the nurse include in the teaching? a) "the medication may be crushed if you have difficulty swallowing it" b) "drink a full glass of milk when you take the medication" c) "take the medication at bedtime" d) "discontinue the medication if you develop heartburn"
d) "discontinue the medication if you develop heartburn"
The nurse reviews the health status of a group of patients on an oncology care area. Which patient should the nurse identify as being eligible for hospice care? a) A 76-year-old female who is suffering from postsurgical infection b) A 54-year-old man with terminal prostate cancer who wishes to pursue experimental treatment c) A 92-year-old male with a new diagnosis of dementia d) A 30-year-old woman who was diagnosed with cervical cancer and 3 months to live
d) A 30-year-old woman who was diagnosed with cervical cancer and 3 months to live
A public health nurse is planning an immunization clinic for older adults. At which of the following times should an older adult client receive the influenza vaccine? a) Once during the client's lifetime b) Every 10 years c) Every 5 years d) Annually in the fall
d) Annually in the fall
A nurse is assessing an older adult client who reports feeling anxious about financial concerns and having difficulty sleeping for several months. Which of the following factors should the nurse identify as a factor in the client's sleep pattern? a) Older adults require much less sleep than young adults. b) Older adults seldom awake at night once they have fallen asleep. c) Older adults have an increase in stages III and IV of sleep. d) Anxiety can cause disturbed sleep patterns.
d) Anxiety can cause disturbed sleep patterns.
A nurse is caring for an older adult who has a terminal illness. The client tells the nurse, "I just want to live one more month so I can see my grandchild get married." Which of the following Kubler-Ross stages of grief should the nurse identify the client is experiencing? a) Depression b) Acceptance c) Denial d) Bargaining
d) Bargaining
A community health nurse is assessing an older adult client who lives alone. The nurse finds that, although the client is able to answer all questions appropriately, the client has a decreased attention span, expresses feelings of overwhelming sadness, and has a low energy level. The nurse should identify that the client is exhibiting manifestations of which of the following disorders? a) Delusions b) Dementia c) Delirium d) Depression
d) Depression
A nurse is reviewing the medical record of an older adult client. For which of the following medications should the nurse conduct a hearing assessment of the client? a) Omeprazole b) Ferrous sulfate c) Digoxin d) Furosemide
d) Furosemide
A nurse is reviewing the records of a group of older adult clients. Which of the following findings should the nurse identify as an unexpected manifestation of the aging process? a) Decreased absorption of nutrients b) Impaired excretion of medications c) High-pitched frequency hearing loss d) Obesity
d) Obesity
A patient who is nearing the end of life is restless. Which action should the nurse take at this time? a) Withhold pain medication to improve bladder continence. b) Encourage the consumption of oral fluids every 2 hours. c) Transfer the patient to a chair to reduce restlessness. d) Reposition the patient in the bed to aid in comfort.
d) Reposition the patient in the bed to aid in comfort.
A nurse is caring for an older adult client who is on bed rest. Which of the following foods should the nurse plan to include on the client's breakfast tray to prevent constipation? a) A banana b) Hash brown potatoes c) An egg and cheese omelet d) Stewed prunes
d) Stewed prunes
The nurse is evaluating outcomes of care for a patient from a non-American culture who dies in the hospital. Which outcome should the nurse identify that indicates that the patient received culturally competent care? a) The patient was bathed by the nurse after death. b) Medals and bracelets were removed from the patient after death. c) The patient was placed on a stretcher and covered with a clean sheet after death. d) The patient received care by the family after death.
d) The patient received care by the family after death.
An older adult patient with metastatic breast cancer is experiencing severe pain and skin irritation caused by radiation therapy. She has requested that no further treatments occur and wants to be permitted to die in peace. Which patient outcome should the nurse identify when planning care for this patient? a) The patient will resume radiation treatments. b) The patient will have minimal anxiety as death approaches. c) The patient will be aware of impending death. d) The patient will state that she is comfortable.
d) The patient will state that she is comfortable.
A Nurse is completing medication reconciliation for an older adult client who is receiving multiple medications. Which of the following actions should the nurse take first? a) clarify the client's list of medications with the pharmacist b) compare the current list against the new medication prescriptions c) investigate any discrepancies on the list d) ask the client about OTC medications she is taking
d) ask the client about OTC medications she is taking
A nurse is caring for an older adult client who reports that he has just retired and expresses feelings of loneliness due to the loss of daily interactions with coworkers. Which of the following responses should the nurse make? a) "do you know about the local senior citizens group?" b) "you need to take a vacation" c) "but now you can finally relax and enjoy your life" d) "why don't you go into work and visit with your old friends?"
a) "do you know about the local senior citizens group?"
A patient who is actively dying is experiencing severe muscle cramps in the back. Which action should the nurse implement to help this patient? a) Administering morphine via standing order b) Administering intravenous electrolyte solution c) Informing the provider and scheduling a Doppler ultrasound d) Performing a gentle back and leg massage
a) Administering morphine via standing order
A patient who is dying from congestive heart failure expresses sadness at the thought of not seeing his grandchildren grow up. The nurse should realize that the patient is experiencing which condition? a) Anticipatory grief b) Dysfunctional grief c) Depression d) Anxiety
a) Anticipatory grief
A home-health nurse is caring for a client who has cancer and is using a fentanyl transdermal patch for pain control. Which of the following actions should the nurse take when caring for this client? a) Avoid using a heating pad on the area with the patch. b) To decrease the dose, cut the patch in half. c) Dispose of the used patch by placing it in the trash can. d) Assess the client for urinary retention every 8 hr.
a) Avoid using a heating pad on the area with the patch.
A patient with chronic renal failure reverses a do-not-resuscitate (DNR)order so that a diagnostic test can be performed the next day. Overnight, the patient goes into cardiac arrest. Which action should the nurse take at this time? a) Begin cardiopulmonary resuscitation (CPR). b) Call the family and ask them what to do. c) Avoid resuscitating the patient. d) Call the healthcare provider and ask what direction to take.
a) Begin cardiopulmonary resuscitation (CPR).
A nurse is performing an assessment on an older adult client who has chronic pain. Which of the following effects of unrelieved pain should the nurse identify as a priority finding to report? a) Impaired mobility b) Decreased independence c) Decreased self-esteem d) Impaired socialization
a) Impaired mobility
A nurse is caring for an older adult client who is expressing feelings of grief and longing for his earlier life. Which of the following actions should the nurse take? a) Listen attentively and allow the client to talk about the past. b) Change the topic of conversation. c) Let the client know that this is a common issue for older adult clients. d) Tell the client about some younger clients who are in worse shape than he is.
a) Listen attentively and allow the client to talk about the past.
A nurse is caring for a client who has aphasia following a stroke. Which of the following actions should the nurse take? a) Present one idea in a sentence. b) Avoid using nonverbal communication techniques. c) Speak loudly. d) Use simplified language.
a) Present one idea in a sentence.
A pediatric patient with a terminal illness is nearing death. Which intervention should the nurse implement to meet the needs of the patient and family at this time? a) Providing timely, sensitive, and open communication b) Assigning a private nursing aide c) Pursuing aggressive treatment at all costs d) Providing continuous privacy
a) Providing timely, sensitive, and open communication
A nurse working in a community health center is completing an assessment of an older adult female client. Which of the following findings should the nurse identify as a priority? a) Rales heard in the bases of the lungs b) Constipation c) Urinary frequency d) Painful intercourse
a) Rales heard in the bases of the lungs
The nurse provides a patient who is receiving end-of-life care with morphine to help with shortness of breath. Which position should the nurse suggest to help the patient breathe more comfortably? a) Supine with the head elevated b) Trendelenburg c) Prone d) Left side-lying
a) Supine with the head elevated
A nurse is caring for an older adult client who is unresponsive following a stroke. Which of the following actions should the nurse take while providing oral care? a) Turn the client on his side before starting oral care. b) Use the thumb and index finger to keep the client's mouth open. c) Cleanse the client's oral mucosa with a toothbrush. d) Perform oral care using sterile gloves.
a) Turn the client on his side before starting oral care.
A nurse is performing skin assessments for a group of older adult clients. Which of the following findings should the nurse identify as a benign, age-related skin change commonly seen in older adult clients? a) liver spots b) nevi c) atopic dermatitis d) psoriasis
a) liver spots
Before assessing a new patient with terminal cancer, the nurse reads in the chart that the patient and family are using mutual pretense awareness. The patient reports back pain. Which statement by the nurse best respects the patient and family's awareness preferences? a) "Terminal cancer can be very painful. The doctor has ordered an extra dose of morphine." b) "I can give you an extra dose of pain medication if you would like." c) "I can give you an extra dose of morphine. We'll help you wean off the opiates when you are better." d) "How is your pain being managed? We want to be sure that you are comfortable during the time you have left."
b) "I can give you an extra dose of pain medication if you would like."
A nurse is teaching a client who has chronic obstructive pulmonary disease (COPD) and has been losing weight about ways to improve his nutritional intake. Which of the following statements by the client indicates an understanding of the teaching? a) "I will choose hot foods to decrease the sense of fullness when eating." b) "I should add grated cheese to sauces and vegetables." c) "I will eat my largest meal of the day in the evening." d) "I should consume a diet high in carbohydrates."
b) "I should add grated cheese to sauces and vegetables."
A nurse at a long term care facility is reinforcing teaching with an older adult client about ambulating with a quad cane. Which one of the following statements should the nurse include in the teaching? a) "adjust the height of the cane so that you can flex you elbow at 45 degrees" b) "hold the cane in the hand on the stronger side of your body" c) "place the flat side of the cane away from your foot" d) "move the cane and your stronger leg at the same time"
b) "hold the cane in the hand on the stronger side of your body"
The nurse is caring for a patient who is in the last few hours of life. The patient's level of consciousness is altered, and the patient is pulling at the indwelling urinary catheter and intravenous line. Which prescription should the nurse anticipate from the healthcare provider? a) Remove the intravenous line and indwelling urinary catheter. b) Administer morphine. c) Apply soft restraints. d) Administer haloperidol.
b) Administer morphine.
A patient receiving palliative care for terminal cancer is experiencing apneic periods and increasing confusion. Which action should the nurse take to ensure the patient's social needs are met? a) Review the medical record for resuscitation orders. b) Contact the family to be with the patient. c) Administer pain medication as prescribed. d) Notify the patient's clergy of the change in health status.
b) Contact the family to be with the patient.
A community health nurse is visiting the home of an older adult client and her caregiver. The client has excoriations to her wrists and ankles. Which of the following actions should the nurse take first? a) Refer the caregiver to a support group. b) Interview the client in private. c) Document the client's wounds. d) Contact adult protective services.
b) Interview the client in private.
A nurse is caring for a client who is using a continuous passive motion (PCM) device following a right total knee replacement. Which of the following actions should the nurse take when applying the CPM device? a) Apply the CPM device in the flexed position. b) Line up the frame joints of the CPM device with the client's knee. c) Check the range-of-motion settings on the CPM device daily. d) Place the head of the client's bed at 45º during CPM use.
b) Line up the frame joints of the CPM device with the client's knee.
A nurse is caring for an older adult client who has a hip fracture and is rating his pain at 8 on a scale of 0 to 10. Which of the following medications should the nurse administer? a) Capsaicin topical gel b) Oxycodone/acetaminophen 7.5/325 tablet PO c) Celecoxib 200 mg capsule PO d) Aspirin 325 mg tablet PO
b) Oxycodone/acetaminophen 7.5/325 tablet PO
The nurse is planning care for a patient with terminal bone cancer who is experiencing altered consciousness and skin weeping of the lower extremities. Which nursing diagnosis should the nurse use as the priority to guide this patient's care? a) Tissue Perfusion: Peripheral, Ineffective b) Pain, Acute c) Anxiety, Death d) Tissue Integrity, Impaired, Risk for
b) Pain, Acute
A patient nearing the end of life slept throughout the day but is wide awake at midnight. Which action should the nurse take to support this patient's needs? a) Offer the patient reading material. b) Provide sleeping medication as prescribed. c) Turn on the television to keep the patient stimulated. d) Provide pain medication earlier than prescribed.
b) Provide sleeping medication as prescribed.
An older adult patient with end-stage renal disease has no desire to eat and has stopped taking oral fluids. Which intervention should the nurse implement to support the patient at this time? a) Inserting a feeding tube to maintain adequate hydration and nutrition b) Providing around-the-clock oral care c) Asking the healthcare provider to prescribe an appetite stimulant d) Consulting with a dietitian to determine the best nutritional approach for the patient
b) Providing around-the-clock oral care
The nurse reviews medications prescribed for a patient who is approaching end of life. The nurse identifies which goal for pharmacological therapy for this patient? a) Managing the patient's body-system symptoms b) Providing the highest quality of life for the patient c) Supporting the family's desires d) Easing the patient's transition to hospice care
b) Providing the highest quality of life for the patient
A nurse is caring for an older adult who has moderate hearing loss. Which of the following actions should the nurse take to enhance communication? a) Speak with exaggerated lip movement. b) Speak at a moderate rate. c) Speak in a louder voice. d) Speak using a higher pitch.
b) Speak at a moderate rate.
A nurse is teaching an older adult client who had a total hip arthroplasty about ambulating with a standard walker. Which of the following actions by the client indicates an understanding of the teaching? a) The client adjusts the height of the walker so the hand grips are at the level of his waist. b) The client moves the walker ahead about 15.24 cm (6 in) and then steps into the walker. c) The client uses the walker to pull himself up from a sitting to a standing position. d) The client uses the walker to climb the stairs.
b) The client moves the walker ahead about 15.24 cm (6 in) and then steps into the walker.
A nurse at a long-term care facility is planning care for an older adult client who has dementia. Which of the following interventions should the nurse include in the plan? a) vary the staff members caring for the client b) use photographs as memory triggers c) provide a minimum of three activity choices to the client d) break the tasks down to three or four steps at a time
b) use photographs as memory triggers
A nurse is teaching an older client about osteoporosis. Which of the following statements should the nurse include in the teaching? a) "Cottage cheese is a good source of calcium." b) "Increase your caffeine intake." c) "Brisk walking will help prevent bone loss." d) "Hormone replacement therapy with estrogen will increase your risk of osteoporosis."
c) "Brisk walking will help prevent bone loss."
A nurse is conducting an in-service for a group of assistive personnel about the basic needs of older adult clients. Which if the following statements should the nurse include in the teaching? a) "Caloric needs are increased." b) "Renal function is increased." c) "Deep sleep is decreased." d) "Exercise needs are decreased."
c) "Deep sleep is decreased."
A nurse is providing teaching to a client who is to start taking finasteride. Which of the following statements by the client indicates an understanding of the teaching? a) "I will see improvement in my symptoms within one week" b) "I can expect an increased libido with this medication" c) "I should see a decrease in my PSA levels" d) "I must take this medication within 60 min of sexual activity"
c) "I should see a decrease in my PSA levels"
A nurse is teaching an older adult client who is healthy and has chronic constipation about establishing a bowel retraining program. Which of the following statements should the nurse include in the teaching? a) "Limit physical activity during the day." b) "Set a time limit of 10 minutes when attempting to defecate." c) "Increase the fiber content of your diet." d) "Increase your fluid intake to 5,000 milliliters per day."
c) "Increase the fiber content of your diet."
A nurse is admitting an older adult client who has urinary incontinence and smells strongly of urine. The client's partner, who has been caring for her at home, states that he is sorry and embarrassed about the unpleasant smell. Which of the following responses should the nurse make? a) "A lot of clients who are cared for at home have the same problem." b) "Don't worry about it. She will get a bath, and that will take care of the odor." c) "It must be difficult to care for someone who has incontinence." d) "When was the last time that she had a bath?"
c) "It must be difficult to care for someone who has incontinence."
A nurse is caring for an older adult client who is having a stroke. After assessing airway, breathing, and circulation, which of the following assessments is the nurse's priority? a) Level of consciousness b) Muscle tone c) Sensory changes d) Gag reflex
a) Level of consciousness
The nurse is caring for a patient who is actively dying from colon cancer. Which intervention should be a priority for this patient? a) Blood pressure support b) Adequate pain management c) Maintaining airway and oxygenation d) Improving nutritional status
b) Adequate pain management
A young mother who has three children at home is dying from cervical cancer. The nurse finds the patient crying and stating that she will never see her daughters get married or have children. Which intervention is the best for the nurse to provide? a) Ensuring that the patient's will and healthcare proxy are up to date b) Assisting the patient in writing letters for her children to look at one day c) Arranging for a psychiatric consult d) Administering an anti-anxiety medication to help the patient feel calmer
b) Assisting the patient in writing letters for her children to look at one day
A nurse is teaching a group of healthy, older adult clients about expected age-related changes and sexual response. Which of the following changes should the nurse include as an age-related change? a) Decreased refractory time b) Decreased vaginal lubrication c) Loss of female clients' orgasm ability d) Premature ejaculation
b) Decreased vaginal lubrication
A nurse managing an adult day care is developing treatment plans for older adult clients. Which of the following therapeutic strategies should the nurse use to help the clients achieve Erikson's developmental task for this age group? a) Music therapy b) Reminiscence therapy c) Meditation therapy d) Pet therapy
b) Reminiscence therapy
A nurse is transferring a client who has right-sided weakness from the bed to a wheelchair. Which of the following actions should the nurse take to provide a safe transer? a) Keep the client at arm's length while performing the transfer. b) Bend at the waist to get down to the client's level. c) Maintain a straight back and bend at the knees. d) Place the wheelchair at the head of the bed on the client's right side.
c) Maintain a straight back and bend at the knees.
The nurse caring for a child who has recently been diagnosed with terminal leukemia attends a care consultation. The healthcare provider does not mention options for advance care planning during the meeting with the parents. Which action should the nurse implement next? a) Wait for the healthcare provider to address the option when appropriate. b) Give the parents reading material about palliative care so that they can ask the healthcare provider if they are interested. c) Remind the healthcare provider to bring up palliative care during the next meeting. d) Discuss palliative and hospice care options with the parents.
d) Discuss palliative and hospice care options with the parents.
During a consultation with the parents of a young child with a terminal diagnosis, the physician mentions an experimental medication but, due to the severe side effects associated with the treatment, believes that the child should be placed in hospice care. The mother of the child says, "That's great news! There's another treatment that will save our child!" Which response by the nurse is appropriate? a) "The physician believes that this might be the best option for a full recovery." b) "I really don't think it's in the best interest of your child to be subjected to this medication." c) "Why don't we give you some time to weigh the risks and benefits of this medication." d) "If the side effects get too bad, we can always stop the medication."
c) "Why don't we give you some time to weigh the risks and benefits of this medication."
Which action should the nurse perform to meet a dying patient's circulatory needs? a) Provide passive range of motion. b) Administer oxygen. c) Gently rub the extremities. d) Provide oral care.
c) Gently rub the extremities.
A patient recently learns of having terminal breast cancer and will most likely pass away in a few months. Which referral should the nurse request to ensure this patient's quality of life? a) Physical therapist b) Long-term rehabilitation facility c) Hospice d) Pain management clinic
c) Hospice
The nurse is present when the healthcare provider tells the parents that their 9-year-old has leukemia. Which subject should the nurse discuss with the parents at this time? a) The need to begin hospice care b) The writing of an advance directive c) The value of palliative care d) The identification of a healthcare proxy
c) The value of palliative care
A patient nearing end of life is experiencing anorexia. Which action should the nurse take to support this patient's needs? a) Implementing nothing-by-mouth status b) Inserting a central line to administer parenteral nutrition c) Inserting a nasogastric tube for supplemental feedings d) Encouraging to try to eat a favorite meal
d) Encouraging to try to eat a favorite meal
A patient is diagnosed with terminal cancer. The nurse suggests that the patient consider a living will, but the patient does not want anyone else making healthcare decisions right now. Which statement should the nurse provide to the patient? a) "A living will is put into place when you are not able to make your own decisions and dictate what type of care you will receive." b) "Living wills are only used if you use opioid pain relievers because you will no longer be competent to make decisions." c) "Living wills are only necessary if you decide that you no longer want to make decisions for yourself." d) "Make sure that you think very carefully about whom you appoint because their decisions will override yours."
a) "A living will is put into place when you are not able to make your own decisions and dictate what type of care you will receive."
A nurse is teaching an older adult client about methods to improve sleep. Which of the following statements should the nurse include in the teaching? a) "Go to bed at the same time every night." b) "Watch television in bed until you are sleepy." c) "Drink a glass of wine before going to bed." d) "Engage in physical activity in the evenings."
a) "Go to bed at the same time every night."
A nurse is teaching a group of older clients about dietary needs. Which of the following dietary recommendations should the nurse include in the teaching? a) "You should consume 1,200 milligrams of calcium daily." b) "Consume 4 percent of your diet as fat." c) "You should drink 1,500 milliliters of fluid daily." d) "Consume 40 percent of your diet as protein."
a) "You should consume 1,200 milligrams of calcium daily."