Unit 3 Exam Review - Theory
Which blood gas result should the nurse expect an adolescent with diabetic ketoacidosis to exhibit? 1. pH 7.30, CO 2 40 mm Hg, HCO3 - 20 mEq/L (20 mmol/L) 2. pH 7.35, CO 2 47 mm Hg, HCO3 - 24 mEq/L (24 mmol/L) 3. pH 7.46, CO 2 30 mm Hg, HCO3 - 24 mEq/L (24 mmol/L) 4. pH 7.50, CO 2 50 mm Hg, HCO3 - 22 mEq/L (22 mmol/L)
1. pH 7.30, CO 2 40 mm Hg, HCO3 - 20 mEq/L (20 mmol/L)
A client's arterial blood gas report indicates that pH is 7.25, Pco 2 is 60 mm Hg, and HCO 3 is 26 mEq/L (26 mmol/L). Which client should the nurse consider is most likely to exhibit these blood gas results? 1. A 65-year-old with pulmonary fibrosis 2. A 24-year-old with uncontrolled type 1 diabetes 3. A 45-year-old who has been vomiting for 3 days 4. A 54-year-old who takes sodium bicarbonate for indigestion
1. A 65-year-old with pulmonary fibrosis
After cataract surgery, a client reports feeling nauseated. How can the nurse help relieve the nausea? 1. Administer the prescribed antiemetic drug. 2. Provide some dry crackers for the client to eat. 3. Explain that this is expected following surgery. 4. Teach how to breathe deeply until the nausea subsides.
1. Administer the prescribed antiemetic drug.
An 18-year-old high school student arrives at the local blood drive center to donate blood for the first time. As the site is being prepared for needle insertion, the student becomes agitated, starts to hyperventilate, and complains of dizziness and tingling of the hands. What should the nurse instruct the student to do? 1. Breathe into cupped hands. 2. Pant using rapid, shallow breaths. 3. Use a rapid deep-breathing pattern. 4. Hold the breath for as long as possible.
1. Breathe into cupped hands.
An older client with the diagnosis of dementia of the Alzheimer type is admitted to a long-term care facility. What should the nurse keep in mind regarding confusion when planning care for this client? 1. Confusion occurs with a transfer to new surroundings. 2. Confusion will be unchanged despite reality orientation. 3. Confusion is a common finding and is expected with aging. 4. Confusion results from brain changes that make interventions futile.
1. Confusion occurs with a transfer to new surroundings.
What type of an environment should the nurse provide for a confused client? 1. Familiar 2. Variable 3. Challenging 4. Nonstimulating
1. Familiar
The student nurse is learning about the developmental characteristics of vision. Which major developmental characteristics does an infant start exhibiting around age 6 weeks? Select all that apply. 1. Having binocular vision 2. Having doll's eye reflex 3. Having visual acuity 20/40 to 20/60 4. Having peripheral vision to 180 degree 5. Having strabismus if binocular vision is absent
1. Having binocular vision 4. Having peripheral vision to 180 degree
A client with colitis has had a hemicolectomy. Three days after surgery the nurse identifies that the client has abdominal distention and absent bowel sounds, and has vomited 300 mL of dark green viscous fluid. The nurse contacts the primary healthcare provider and recommends which intervention? 1. Nasogastric tube for decompression 2. Antiemetic for nausea/vomiting 3. Intravenous (IV) lactated Ringer for fluid replacement 4. Stat electrolytes to assess for probable electrolyte imbalance
1. Nasogastric tube for decompression
An older client with dementia of the Alzheimer type is residing in a nursing home. When in bed, the client consistently is found sleeping in the semi-Fowler position. What area of the client's body does the nurse determine has the most risk for developing a pressure ulcer? 1. Sacrum 2. Scapulae 3. Ischial spine 4. Greater trochanter
1. Sacrum
The primary objective of nursing intervention for clients with dementia, delirium, and other cognitive disorders is to maintain what? 1. Safety within the environment 2. Psychological faculties 3. Participation in educational activities 4. Face-to-face contact with other clients
1. Safety within the environment
When assessing a client's fluid and electrolyte status, the nurse recalls that the regulator of extracellular osmolarity is what? 1. Sodium 2. Potassium 3. Chloride 4. Calcium
1. Sodium
Which assessment finding is associated with depression? 1. The client has islands of intact memory. 2. The client has impaired recent and remote memory. 3. The client has impaired recent and immediate memory. 4. The client needs step-by-step instructions for simple tasks.
1. The client has islands of intact memory.
What important step should the community nurse take when dealing with older adults with a confusional states problem? Select all that apply. 1. The nurse should provide a protective environment. 2. The nurse should monitor blood pressure and weight. 3. The nurse should recommend applicable community resources. 4. The nurse should demonstrate proper hygiene to the primary caretaker. 5. The nurse should educate about polypharmacy and drug-drug and drug-food interactions.
1. The nurse should provide a protective environment. 3. The nurse should recommend applicable community resources. 4. The nurse should demonstrate proper hygiene to the primary caretaker.
A client with dementia who feels highly anxious and confused believes that the current day is actually different than what it is. Which statement made by the nurse is an example of validation therapy? 1. "No, try to be in your sense of reality." 2. "Yes, today is the day that you just mentioned." 3. "You should try improving your awareness level." 4. "Try to recall your past memories associated with the day."
2. "Yes, today is the day that you just mentioned."
What would the nurse tell the parents is the acceptable range of heart beats per minute for a preschooler? 1. 60-100 2. 80-110 3. 75-100 4. 90-140
2. 80-110
A nurse is caring for an infant whose vomiting is intractable. Which complication is most likely to occur? 1. Acidosis 2. Alkalosis 3. Hyperkalemia 4. Hypernatremia
2. Alkalosis
A nurse in the mental health clinic concludes that a client is using confabulation when the client does what? 1. The flow of thoughts is interrupted. 2. Imagination is used to fill in memory gaps. 3. Speech flits from one topic to another with no apparent meaning. 4. Connections between statements are so loose that only the speaker understands them.
2. Imagination is used to fill in memory gaps.
A client with chronic obstructive pulmonary disease (COPD) states, "I have had steady weight loss, and I am often too tired to eat." Which nursing diagnosis would be most appropriate for this client? 1. Fatigue related to weight loss secondary to COPD 2. Imbalanced nutrition: less than body requirements, related to fatigue 3. Imbalanced nutrition: less than body requirements, related to COPD 4. Ineffective breathing pattern, related to alveolar hypoventilation
2. Imbalanced nutrition: less than body requirements, related to fatigue
A client in a mental health facility is demonstrating manic-type behavior by being demanding and hyperactive. What is the nurse's major objective? 1. Easing the client's feelings of guilt 2. Maintaining a supportive, structured environment 3. Pointing out reality through continued communication 4. Broadening the client's contacts with other people on the unit
2. Maintaining a supportive, structured environment
A nurse teaches a client about the dangers of using bicarbonate of soda regularly. What effect of bicarbonate of soda is the nurse trying to prevent? 1. Gastric distention 2. Metabolic alkalosis 3. Chronic constipation 4. Cardiac dysrhythmias
2. Metabolic alkalosis
A client with hepatic cirrhosis begins to develop slurred speech, confusion, drowsiness, and a flapping tremor. Which diet can the nurse expect will be prescribed for this client based upon the assessment? 1. No protein 2. Moderate protein 3. High protein 4. Strict protein restriction
2. Moderate protein
A nurse is caring for a male client who was admitted to the mental health unit with the diagnosis of schizophrenia. The client is hostile and experiencing auditory hallucinations and states that the voices are saying that they are going to poison him because he is bad. What type of schizophrenic behavior does the nurse identify? 1. Residual 2. Paranoid 3. Catatonic 4. Disorganized
2. Paranoid
After an automobile collision involving a fatality and a subsequent arrest for speeding, a client has amnesia regarding the events surrounding the accident. Which defense mechanism is being used by the client? 1. Projection 2. Repression 3. Suppression 4. Rationalization
2. Repression
What should a nurse who is caring for a hospitalized older client with dementia consider before planning care? 1. Physical contact will increase dependency needs. 2. Routines provide stability for clients with dementia. 3. Regressive behavior should be interrupted immediately. 4. Procedures do not have to be explained to clients with dementia.
2. Routines provide stability for clients with dementia.
What developmental skills does a preschooler exhibit? Select all that apply. 1. Personal identity 2. Specific reasoning 3. Increased curiosity 4. Causal relationships 5. Understanding of others
2. Specific reasoning 3. Increased curiosity 4. Causal relationships
A client has a pulse deficit. Which documentation by the nurse supports this finding? 1. Blood pressure of 130/70 mm Hg indicating pulse deficit of 60. 2. Capillary refill greater than 3 seconds indicating pulse deficit. 3. Apical pulse 86 and radial pulse 78 indicating pulse deficit of 8. 4. Radial pulse 80 and pedal pulse 70 indicating pulse deficit of 10.
3. Apical pulse 86 and radial pulse 78 indicating pulse deficit of 8.
A nurse is teaching a group of parents why it is so important to prevent lead poisoning. The nurse notes that which problem is most associated with infants who are exposed to lead in the environment? 1. Chronic pain 2. Dental caries 3. Cognitive impairment 4. Compromised nutrition
3. Cognitive impairment
An 84-year-old woman is admitted to the hospital with a diagnosis of dementia of the Alzheimer type. What does the nurse know about this disorder? 1. Problem that first emerges in the third decade of life 2. Nonorganic disorder that occurs in the later years of life 3. Cognitive problem that is a slow and relentless deterioration of the mind 4. Disorder that is easily diagnosed through laboratory and psychological tests
3. Cognitive problem that is a slow and relentless deterioration of the mind
A nurse administers oxygen at 2 L/min via nasal cannula to a client with chronic obstructive pulmonary disease (COPD). By administering a low concentration of oxygen to this client, the nurse is preventing which physiologic response? 1. Decrease in red cell formation 2. Rupture of emphysematous bullae 3. Depression in the respiratory center 4. Excessive drying of the respiratory mucosa
3. Depression in the respiratory center
A mother comes for a well-child visit of her 4-year-old child. Which psychosocial developmental skill is the nurse likely to notice in the child? 1. Self-evaluation 2. Logical thinking 3. Increased curiosity 4. Understand others
3. Increased curiosity
What should the nurse include in the plan of care for a client with dementia of the Alzheimer type, stage 2 (moderate dementia)? 1. Discuss recent current events. 2. Teach the client new social skills. 3. Maintain a daily routine of living. 4. Encourage the client to talk about past experiences.
3. Maintain a daily routine of living.
A 65-year-old man is admitted to a mental health facility with a diagnosis of substance-induced persisting dementia resulting from chronic alcoholism. When conducting the admitting interview, the nurse determines that the client is using confabulation. What does the nurse recall precipitates the client's use of confabulation? 1. Ideas of grandeur 2. Need for attention 3. Marked memory loss 4. Difficulty in accepting the diagnosis
3. Marked memory loss
A client is hospitalized after four days of epigastric pain, nausea, and vomiting. The nurse reviews the laboratory test results: plasma pH 7.51, Pco 2 50 mm Hg, bicarbonate 58 mEq/L (58 mmol/L), chloride 55 mEq/L (55 mmol/L), sodium 132 mEq/L (132 mmol/L), and potassium 3.8 mEq/L (3.8 mmol/L). What condition does the nurse determine the results to indicate? 1. Hypernatremia 2. Hyperchloremia 3. Metabolic alkalosis 4. Respiratory acidosis
3. Metabolic alkalosis
The laboratory data for a client with prolonged vomiting reveal arterial blood gases of pH 7.51, Pco 2 of 50 mm Hg, HCO 3 of 58 mEq/L (59 mmol/L), and a serum potassium level of 3.8 mEq/L (3.8 mmol/L). The nurse concludes that the findings support what diagnosis? 1. Hypocapnia 2. Hyperkalemia 3. Metabolic alkalosis 4. Respiratory acidosis
3. Metabolic alkalosis
A client asks about the purpose of a pulse oximeter. The nurse explains that it is used to measure what? 1. Respiratory rate 2. Amount of oxygen in the blood 3. Percentage of hemoglobin-carrying oxygen 4. Amount of carbon dioxide in the blood
3. Percentage of hemoglobin-carrying oxygen
A client with chronic obstructive pulmonary disease (COPD) has a blood pH of 7.25 and a PCO 2 of 60 mm Hg. What complication does the nurse conclude the client is experiencing? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis
3. Respiratory acidosis
A 14-month-old toddler is able to recognize the shapes of objects and fit smaller boxes into larger boxes. Which type of cognitive development does this action indicate? 1. Domestic mimicry 2. Causal relationship 3. Spatial relationship 4. Object permanence
3. Spatial relationship
The serum ammonia level of a client with hepatic cirrhosis and ascites is elevated. What nursing intervention is the priority? 1. Weigh the client daily. 2. Restrict the client's oral fluid intake. 3. Measure the client's urine specific gravity. 4. Observe the client for increasing confusion.
4. Observe the client for increasing confusion.
While performing the physical assessment of an infant, the nurse notices the infant has developed a color preference for red and yellow. What is most likely to be the age of the infant? 1. 4 weeks 2. 8 weeks 3. 15 weeks 4. 20 weeks
4. 20 weeks
Corrective surgery for hypertrophic pyloric stenosis is completed, and the infant is returned to the pediatric unit with an intravenous (IV) infusion in progress. What is the priority nursing action? 1. Applying adequate restraints 2. Administering a mild sedative 3. Removing the nasogastric tube 4. Assessing the IV site for infiltration
4. Assessing the IV site for infiltration
The nurse hears a series of long, discontinuous low-pitched sounds similar to blowing through a straw under water while auscultating the lungs of a client with chronic obstructive pulmonary disease. What should the nurse document in the client's assessment record based on this finding? 1. Rhonchi 2. Wheezes 3. Fine crackles 4. Coarse crackles
4. Coarse crackles
The nurse is caring for a client with Alzheimer disease who exhibits behaviors associated with hyperorality. To meet the client's need for a safe milieu, what instructions will the nurse give the staff to monitor the client? 1. At meals to help prevent choking 2. For the presence of mouth ulcers 3. To prevent injury caused by hot foods 4. For attempts at eating inedible objects
4. For attempts at eating inedible objects
A client with moderate dementia often assaults nursing staff, and the staff members decide to develop a plan to minimize this behavior. What should the plan include? 1. Limiting the time staff and the client spend together 2. An outline of the consequences for uncooperative behavior 3. The client's preferences for use as a reward or a punishment 4. Identification of nursing staff members whom the client prefers
4. Identification of nursing staff members whom the client prefers
What is the priority nursing objective of the therapeutic psychiatric environment for a confused client? 1. Helping the client relate to others 2. Making the hospital atmosphere more homelike 3. Helping the client become accepted in a controlled setting 4. Maintaining the highest level of safe, independent function
4. Maintaining the highest level of safe, independent function
The nurse recognizes that which is the mental process most sensitive to deterioration with aging? 1. Judgment 2. Intelligence 3. Creative thinking 4. Short-term memory
4. Short-term memory
While assessing an older adult in the emergency department the nurse notes that the client is upset. The nurse asks what is wrong, and the client describes the current situation and then offers information that goes further and further off the topic. What pattern of communication does this conversation reflect? 1. Perseveration 2. Thought blocking 3. Overcompensation 4. Tangential thinking
4. Tangential thinking
A patient has a severe blockage in his right coronary artery. Which heart structures are most likely to be affected by this blockage (select all that apply)? a. AV node b. Left ventricle c. Coronary sinus d. Right ventricle e. Pulmonic valve
a. AV node b. Left ventricle d. Right ventricle
4. When teaching a patient about the most important respiratory defense mechanism distal to the respiratory bronchioles, which topic would the nurse discuss? a. Alveolar macrophages b. Impaction of particles c. Reflex bronchoconstriction d. Mucociliary clearance mechanism
a. Alveolar macrophages
A patient is admitted with a headache, fever, and general malaise. The HCP has asked that the patient be prepared for a lumbar puncture. What is a priority nursing action to avoid complications? a. Ensure that CT scan is performed prior to lumbar puncture. b. Assess laboratory results for changes in the white cell count. c. Provide acetaminophen for the headache and fever before the procedure. d. Administer antibiotics before the procedure to treat the potential meningitis.
a. Ensure that CT scan is performed prior to lumbar puncture.
Which nursing responsibilities are priorities when caring for a patient returning from a cardiac catheterization (select all that apply)? a. Monitoring vital signs and ECG b. Checking the catheter insertion site and distal pulses c. Assisting the patient to ambulate to the bathroom to void d. Informing the patient that he will be sleepy from the general anesthesia e. Instructing the patient about the risks of the radioactive isotope injection
a. Monitoring vital signs and ECG b. Checking the catheter insertion site and distal pulses
The nurse is preparing the patient for a diagnostic procedure to remove pleural fluid for analysis. The nurse would prepare the patient for which test? a. Thoracentesis b. Bronchoscopy c. Pulmonary angiography d. Sputum culture and sensitivity
a. Thoracentesis
5. A student nurse asks the RN what can be measured by arterial blood gas (ABG). The RN tells the student that the ABG can measure (select all that apply) a. acid-base balance. b. oxygenation status. c. acidity of the blood. d. bicarbonate (HCO3−) in arterial blood.
a. acid-base balance. b. oxygenation status. c. acidity of the blood. d. bicarbonate (HCO3−) in arterial blood.
When a person's blood pressure rises, the homeostatic mechanism to compensate for an elevation involves stimulation of a. baroreceptors that inhibit the sympathetic nervous system, causing vasodilation. b. chemoreceptors that inhibit the sympathetic nervous system, causing vasodilation. c. baroreceptors that inhibit the parasympathetic nervous system, causing vasodilation. d. chemoreceptors that stimulate the sympathetic nervous system, causing an increased heart rate.
a. baroreceptors that inhibit the sympathetic nervous system, causing vasodilation.
Stimulation of the parasympathetic nervous system results in (select all that apply) a. constriction of the bronchi. b. dilation of skin blood vessels. c. increased secretion of insulin. d. increased blood glucose levels. e. relaxation of the urinary sphincters.
a. constriction of the bronchi. b. dilation of skin blood vessels. c. increased secretion of insulin. e. relaxation of the urinary sphincters.
When assessing activity-exercise patterns related to respiratory health, the nurse inquires about a. dyspnea during rest or exercise. b. recent weight loss or weight gain. c. ability to sleep through the entire night. d. willingness to wear O2 equipment in public.
a. dyspnea during rest or exercise.
When assessing a patient, you note a pulse deficit of 23 beats. This finding may be caused by a. dysrhythmias. b. heart murmurs. c. gallop rhythms. d. pericardial friction rubs.
a. dysrhythmias.
A patient's eyes jerk while the patient looks to the left. The nurse will record this finding as a. nystagmus. b. CN VI palsy. c. ophthalmic dyskinesia. d. oculocephalic response.
a. nystagmus.
1. To promote the release of surfactant, the nurse encourages the patient to a. take deep breaths. b. cough five times per hour to prevent alveolar collapse. c. decrease fluid intake to reduce fluid accumulation in the alveoli. d. sit with head of bed elevated to promote air movement through the pores of Kohn.
a. take deep breaths.
The auscultatory area in the left midclavicular line at the level of the fifth ICS is the best location to hear sounds from which heart valve? a. Aortic b. Mitral c. Tricuspid d. Pulmonic
b. Mitral
A P wave on an ECG represents an impulse arising at the a. SA node and repolarizing the atria. b. SA node and depolarizing the atria. c. AV node and depolarizing the atria. d. AV node and spreading to the bundle of His.
b. SA node and depolarizing the atria.
When collecting subjective data related to the cardiovascular system, which information should be obtained from the patient (select all that apply)? a. Annual income b. Smoking history c. Religious preference d. Number of pillows used to sleep e. Blood for basic laboratory studies
b. Smoking history c. Religious preference d. Number of pillows used to sleep
A patient is seen in the emergency department after diving into the pool and hitting the bottom with a blow to the face that hyperextended the neck and scraped the skin off the nose. The patient also described "having double vision" when looking down. During the neurologic exam, the nurse finds the patient is unable to abduct either eye. The nurse recognizes this finding is related to a. a basal skull fracture. b. a stretch injury to bilateral CN VI. c. a stiff neck from the hyperextension injury. d. facial swelling from the scrape on the bottom of the pool.
b. a stretch injury to bilateral CN VI.
6. To detect early signs or symptoms of inadequate oxygenation, the nurse would examine the patient for a. dyspnea and hypotension. b. apprehension and restlessness. c. cyanosis and cool, clammy skin. d. increased urine output and diaphoresis.
b. apprehension and restlessness.
When auscultating the chest of an older patient in respiratory distress, it is best to a. begin listening at the apices. b. begin listening at the lung bases. c. begin listening on the anterior chest. d. Ask the patient to breathe through the nose with the mouth closed.
b. begin listening at the lung bases.
The portion of the vascular system responsible for hemostasis is the a. thin capillary vessels. b. endothelial layer of the arteries. c. elastic middle layer of the veins. d. smooth muscle of the arterial wall.
b. endothelial layer of the arteries.
During the admitting neurologic examination, the nurse determines the patient has speech difficulties as well as weakness of the right arm and lower face. The nurse would expect a CT scan to show pathology in the distribution of the a. basilar artery. b. left middle cerebral artery. c. right anterior cerebral artery. d. left posterior communicating artery.
b. left middle cerebral artery.
The nurse is assessing the muscle strength of an older adult patient. The nurse knows the findings cannot be compared with those of a younger adult because a. nutritional status is better in young adults. b. muscle bulk and strength decrease in older adults. c. muscle strength should be the same for all adults. d. most young adults exercise more than older adults.
b. muscle bulk and strength decrease in older adults.
3. The nurse can best determine adequate arterial oxygenation of the blood by assessing a. heart rate. b. hemoglobin level. c. arterial oxygen partial pressure. d. arterial carbon dioxide partial pressure.
c. arterial oxygen partial pressure.
When assessing the cardiovascular system of a 79-year-old patient, you may expect to find a. a narrowed pulse pressure. b. diminished carotid artery pulses. c. difficulty in isolating the apical pulse. d. an increased heart rate in response to stress.
c. difficulty in isolating the apical pulse.
7. During the respiratory assessment of an older adult, the nurse would expect to find (select all that apply) a. a vigorous reflex cough. b. increased chest expansion. c. increased residual volume. d. diminished lung sounds at base of lungs. e. increased anteroposterior (AP) chest diameter.
c. increased residual volume. d. diminished lung sounds at base of lungs. e. increased anteroposterior (AP) chest diameter.
A patient with a tricuspid valve disorder will have impaired blood flow between the a. vena cava and right atrium. b. left atrium and left ventricle. c. right atrium and right ventricle. d. right ventricle and pulmonary artery.
c. right atrium and right ventricle.
During neurologic testing, the patient is able to perceive pain elicited by pinprick. Based on this finding, the nurse may omit testing for a. position sense. b. patellar reflexes. c. temperature perception. d. heel-to-shin movements.
c. temperature perception.
Which assessment finding of the respiratory system does the nurse interpret as abnormal? a. Inspiratory chest expansion of 1 inch b. Symmetric chest expansion and contraction c. Resonance (to percussion) over the lung bases d. Bronchial breath sounds in the lower lung fields
d. Bronchial breath sounds in the lower lung fields
Drugs or diseases that impair the function of the extrapyramidal system may cause loss of a. sensations of pain and temperature. b. regulation of the autonomic nervous system. c. integration of somatic and special sensory inputs. d. automatic movements associated with skeletal muscle activity.
d. automatic movements associated with skeletal muscle activity.
2. A patient with a respiratory condition asks, "How does air get into my lungs?" The nurse bases her answer on knowledge that air moves into the lungs because of a. increased CO2 and decreased O2 in the blood. b. contraction of the accessory abdominal muscles. c. stimulation of the respiratory muscles by the chemoreceptors. d. decrease in intrathoracic pressure relative to pressure at the airway.
d. decrease in intrathoracic pressure relative to pressure at the airway.
The nurse is caring for a patient with peripheral neuropathy who is scheduled for EMG studies tomorrow morning. The nurse should a. ensure the patient has an empty bladder. b. instruct the patient about the risk of electric shock. c. ensure the patient has no metallic jewelry or metal fragments. d. instruct the patient that pain may be experienced during the study.
d. instruct the patient that pain may be experienced during the study.
In a patient with a disease that affects the myelin sheath of nerves, such as multiple sclerosis, the glial cells affected are the a. microglia. b. astrocytes. c. ependymal cells. d. oligodendrocytes.
d. oligodendrocytes.