Physiological Adaption Quiz

A nurse is caring for a client who has reported difficulty sleeping. Which statement made by the client requires further assessment?

a. "I drink a cup of chamomile tea to help relax at bedtime." b. "I have been really stressed out at work lately." c. "I try not to nap during the day, even though I'm tired." d. "I make a point of getting to bed at the same time every night." Answer: b.

A nurse is teaching lifestyle modifications to a client diagnosed with hypertension. Which of the following statements made by the client indicates a need for further teaching?

a. "I don't like to walk, but I do aerobics and work out at the gym during the week." b. "We have a glass of wine a couple of times a week with dinner." c. "Losing weight is so hard, but so far I am losing 2 pounds a week." d. "I will substitute mushrooms for the bacon in my daily omelets." Answer: d.

A client is prescribed Warfarin daily. Which of the following statement made by the client indicates to the nurse a need for further teaching?

a. "I will report any sign of Purple Syndrome to my physician." b. "I have been eating more salads and other green, leafy vegetables to prevent constipation." c. "Instead of a safety razor, I have been using an electric razor to shave." d. "I have two pairs of anti-embolic stockings so that one pair can be washed each day." Answer: b.

A nurse is caring for a client diagnosed with diabetes. The nurse notes that the client has a mild tremor, slight diaphoresis and is fully oriented. Which of the following nursing actions should have the highest priority?

a. Administer 50% Dextrose via IV push. b. Assess the client's blood glucose level. c. Call the lab for a stat glucose level. d. Give the client 4 ounces of orange juice Answer: b.

A nurse is caring for a client who is intubated and receiving ventilatory assistance. The high pressure alarm is sounding on the ventilator. Which of the following would have the highest priority?

a. Assess the ETT cuff for proper inflation. b. Administer sedation to calm the client's fears. c. Assess the clients need for suctioning. d. Check the endotracheal tube (ETT) to be sure there is no disconnection. Answer: c.

A nurse is caring for a client on the telemetry unit who is two days post coronary artery bypass grafting (CABG). The nurse recognizes a cardiac rhythm change from normal sinus rhythm to atrial fibrillation. Which of the following should be completed first?

a. Assess the client's blood pressure. b. Notify the health care provider. c. Prepare a diltizem drip. d. Prepare the client for cardio-version. Answer: a.

A nurse is caring for a client who has had a gastric resection to treat peptic ulcer disease. What is the priority intervention when caring for the client in the immediate postoperative period?

a. Auscultate the lungs for adventitious sounds. b. Assess NG tube for patency. c. Inspect the operative site for redness or swelling. d. Monitor pain levels. Answer: b.

A nurse is reviewing a client's lab results. Which finding would lead the nurse to suspect the client is experiencing dehydration?

a. BUN 20mg/100mL b. Serum sodium 130 mEq/L c. Hematocrit 55% d. Urine specific gravity of 1.025 Answer: c.

A nurse is caring for a client with diabetes insipidus (DI) who has been prescribed aqueous vasopressin. Which of the following outcomes indicates that treatment has been effective?

a. Blood pressure of 90/50 mm Hg b. Fluid intake of 2,400mL in 24 hours c. Urine output of 200mL per hour d. Pulse rate of 126 beats/minute Answer: b.

A nurse is caring for a client who is experiencing a sodium level of 119 mEq/L. Which nursing action would be most appropriate at this time?

a. Encourage water and other fluids. b. Monitor for diminished breath sounds. c. Administer 0.9% Normal Saline. d. Provide oral hygiene and comfort measures. Answer: c.

A client diagnosed with atrial fibrillation has a pacemaker set at a ventricular rate of 70 beats per minute. Which of the following findings should the nurse immediately report to the provider?

a. HR= 76 beats/minute and irregular b. HR= 60 beats /minute and regular c. HR= 96 beats /minute and regular d. HR= 96 beats/minute and irregular Answer: b.

A nurse is caring for a client with a partial hearing impairment. The nurse understands which of the following is the best way to communicate with this client?

a. Have a family member present. b. Provide assessment questions in a written format. c. Conduct only the physical assessment at this time. d. Speak slowly in a low-pitched voice. Answer: d.

A nurse is caring for a client with Addison's disease. Which of the following diets should the nurse teach the client to follow?

a. High Sodium, low potassium and increased fluids. b. High Sodium, low calcium and increased fluids. c. Low Sodium, high potassium and decreased fluids. d. Low Sodium, high calcium and decreased fluids. Answer: a.

A nurse is caring of a client recently diagnosed with diabetes mellitus (DM). Which of the following is the physiologic basis for the polyuria manifested by individuals with untreated DM?

a. Hyperosmolarity of the extracellular fluids secondary to hyperglycemia b. Early-stage renal failure causes a loss of urine concentrating capacity c. Chronic stimulation of the detrusor muscle by the ketone bodies in the urine d. Inadequate secretion of antidiuretic hormone (ADH) Answer: a.

A nurse is caring for a client following a spinal cord injury (SCI). Which of the following findings would alert the nurse to the development of neurogenic shock?

a. Hypotension b. Hypoglycemia c. Hypertension d. Hyperglycemia Answer: a.

A client is admitted to the surgical unit after sustaining a compound fracture of the left femur. The client is alert and oriented with the following vital signs: T 99.4 F, P 88, R 20, B/P 94/58. The nurse notes a 4 cm. area of bright red blood on the pressure dressing on the left lower extremity. The client is receiving intravenous fluids of normal saline at 150 ml/hr. One hour after being admitted to the unit, the nurse finds the client confused and combative. Which of the following is the most likely cause of the change in the client's condition?

a. Hypoxia related to fat embolism from the fractured bone. b. Infectious process related to contamination of the open wound. c. Hypovolemic shock related to hemorrhage from the open wound d. Fluid overload related to aggressive isotonic volume replacement Answer: a.

A client is admitted to the hospital for treatment of an acute asthma attack. The client is receiving an aminophylline infusion. Which of the following assessment findings indicate the client is experiencing the desired effect of aminophylline?

a. Increased blood pressure. b. Decreased heart rate c. Decreased wheezing. d. Increased mucous production. Answer: c.

A client is admitted to the medical unit from the convalescent center for treatment of urosepsis. The client's adult daughter reports to the nurse, "I don't know what to do. I love my mom and would like to have her live in my home, but I just can't be with her every minute, and that's what she needs now." Which of the following would be the best approach to improve integration of the elderly mother into the family structure?

a. Offer to refer the daughter to a counselor in an effort to better deal with her feelings of guilt. b. Determine if the daughter would consider having the client visit in her home one day a week. c. Assist the daughter in finding a caregiver who can assist the client in the convalescent center. d. Suggest that the daughter move the client into the family home on a trial basis for several weeks. Answer: b.

A client presents to the emergency department with an abdominal stab wound. The nurse visualizes intestines protruding through the wound. Which of the following is an appropriate action for the nurse?

a. Place sterile gauze and an abdominal binder over the wound. b. Apply pressure to the wound with wet sterile sponges. c. Irrigate the wound with a normal saline solution. d. Cover the wound with warm saline-soaked gauze. Answer: d.

A client is admitted to the emergency room after frequent, repeated falls. The client is restless and intermittently losses consciousness. Vital signs are BP 168/98; pulse 56; and respiratory rate 10. An x-ray of the head confirms a skull fracture. What data is most important for the nurse to collect?

a. Reflexes b. Respiratory Status c. Level of consciousness d. Pupillary changes Answer: b.

The nurse is planning care for a client who is prescribed antiembolic stocking following abdominal surgery. Which of the following interventions should the nurse include?

a. Remove stockings one to three times per day for skin care and inspection. b. Ensure stockings are loose fitting over client's calves. c. Encourage client to only wear stockings when out of bed. d. Remove stocking every 2 hours then reapply after 1 hour off. Answer: a.

One hour ago, a nurse administered morphine sulfate 4 mg IVP to a client who reported pain of 9 on a scale of 10. The client now reports pain of a 7 on a scale of 10. What is the priority intervention at this time?

a. Reposition the client. b. Administer antiemetic as prescribed. c. Notify the provider of client's report. d. Reassess pain level in 30 minutes. Answer: c.

Which of the following should the nurse use to determine the neurological status of a client with a head injury?

a. Respiratory rate b. Manifestations of seizure activity c. Client's reported pain scale d. The Glasgow Coma Scale Answer: d.

A nurse is caring for a client who has just undergone a bone marrow transplant. Neutropenic precautions are implemented to prevent infection. Which is not a precautionary neutropenic measure?

a. Screen visitors b. Restrict foods that may be contaminated with bacteria c. Monitor platelets d. Frequent, thorough hand hygiene Answer: c.

A client has undergone an aortofemoral bypass for the treatment of peripheral arterial disease. Which of the following findings should be reported to the surgeon immediately?

a. Systolic blood pressure 110 mmHg b. Edema of the affected limb c. Systolic blood pressure 160 mmHg d. Redness of the incision line Answer: c.

A client with chronic obstructive pulmonary disease (COPD) has oxygen therapy ordered. Which principle should guide the nurse in managing the delivery of oxygen to this client?

a. The concentration of oxygen should be high since the stimulus to breathe in clients with COPD is an elevated PaCO2. b. Clients with COPD should receive low concentrations (2-3 L) of oxygen since the stimulus to breathe is their low PaO2. c. Clients with COPD require higher concentrations (6-8 L) of oxygen since hypoxemia is their stimulus to breathe. d. The concentration of oxygen should be low since the stimulus to breathe in clients with COPD is an elevated PaCO2. Answer: b.

During a home visit, a 10-day postpartum client reports pain and tenderness with redness and swelling to her right breast. A localized hard mass is also noted upon palpation. How should the nurse respond to this client?

a. This is normal breast engorgement and should subside within another week or two. b. You will need to stop breastfeeding immediately until the swelling and redness subside c. Please mention this to your provider at your 2-week check-up. d. These symptoms suggest an inflammatory or infectious process and require immediate notification to your provider. Answer: d.

A nurse is caring for a client recovering from an abdominal aortic aneurysm (AAA) repair. Which of the following findings would have the highest priority?

a. Urine output 28 ml/hour b. Blood pressure 136/90 mmHg c. Pedal pulse amplitude 2+. d. Respiratory rate 12 breaths/minute. Answer: b.

A nurse is caring for a toddler who is being treated for hypovolemia. Which of the following demonstrates to the nurse the desired response to fluid replacement?

a. Urine output 48 ml for the past 4 hours b. Apical heart rate 130 beats/min c. Central Venous Pressure 2 mm Hg d. Specific Gravity 1.025 Answer: d.

A client comes to the emergency department reporting epistaxis. Which of the following medications should the nurse suspect as contributing to the epistaxis?

a. furosemide b. ibuprofen c. alprazolam d. montelukast Answer: b.