141 Exam 3: Review
When providing care for a client with paraplegia secondary to a spinal cord injury, which potential complication may occur early during the recovery period?
- Bladder control issues
A nurse is caring for a client who is to start chemotherapy for advanced breast cancer. She tells the nurse she is worried about the adverse effects of the treatment. Which of the following responses should the nurse make?
-"What is it about the adverse effects that concerns you?"
Which nursing interventions enhance comfort in a dying client in the hospital? (Select all that apply.)
-Apply lotion tot he clients skin daily, maintaining oral hygiene in the client, frequently repositioning the client
A terminally ill client is receiving a morphine drip that exceeds the typical recommended dosage. The client's spouse tells the nurse that the client is again uncomfortable and needs the morphine increased. The prescription states to titrate the morphine to comfort level. Which action will the nurse take?
-Assess the client's pain before increasing the dose of morphine.
A nurse is teaching a client who is to begin long term therapy with prednisone to treat rhumatoid arthritis. The nurse should instruct the client to take which of the following supplements while taking this medication?
-Calcium and Vit. D
A client who had been receiving treatment for cancer has deteriorated and has decided on a "comfort measures only" order. The nurse identifies that which types of care will now be removed from the treatment plan? (Select four that apply.)
-Chemotherapy, radiation therapy, parenteral feedings, blood transfusions
A nurse is admitting a client who has a partial hearing loss. Which of the following is the priority action by the nurse?
-Determine if the client uses a hearing aid
Which clinical findings would the nurse expect when completing a health history and physical assessment for a client who has myasthenia gravis? (Select three that apply.)
-Difficulty swallowing saliva, drooping of the upper eyelids, double vision
Morphine has been prescribed for a client with frequent pain in a hospice home care program. Which information will the nurse provide regarding this pain management regimen?
-Dosages of the medication will be given automatically t regular intervals around the clock
The nurse provides education to a client about how to prevent constipation. The nurse concludes that the teaching is understood when the client makes which statements? (Select all that apply.)
-Drink at least 6-8 glasses of water every day, I will walk every day as part of my exercise regimen, I can include bran muffins in my breakfast daily
A nurse is caring for a middle adult female client who reports that her menstrual periods have become irregular, and she has been having hot flashes. The nurse should expect the client to have which of the following manifestations associated with early menopause?
-Dryness with intercourse: Because of the changes in the vagina, some women can have dryness, discomfort, or pain during sexual intercourse.
Which clinical manifestation would the nurse expect to find in a client with a new diagnosis of acute lymphocytic leukemia (ALL)?
-Ecchymosis
Which signs and symptoms are characteristic of Alzheimer dementia? (Select all that apply.)
-Expressive aphasia, forgetfulness
In distinguishing between dementia and delirium, which factors are unique to delirium? (Select all that apply.)
-Fluctuating level of consciousness, slurred speech, visual or tactile hallucinations
Which statement indicates a client understands transmission of the human immunodeficiency virus (HIV)? (Select all that apply.)
-HIV is contracted by using contaminated needle, Babies can contrast HIV because of contact with maternal blood during birth, I can contract HIV by participating in oral sex
An older client's colonoscopy reveals the presence of extensive diverticulosis. Which type of diet would the nurse encourage the client to follow?
-High fiber is recommended for diverticulosis
A nurse is completing discharge instructions with a client following an acute onset of gout. Which of the following client statements indicates an understanding of the treatment regimen?
-I should avoid alcohol because it can increase uric acid levels and exacerbate gout
The nurse gives the client with a history of constipation a list of foods to help prevent it. Which statement made by the client indicates that further teaching is needed?
-I should eat eggs
Which factors contribute to development of osteoporosis in female clients? (Select all that apply.)
-Inadequate intake of dietary calcium, Hx of anorexia nervosa, cigarette smoking, familial predisposition
Which information would the nurse consider when planning care for a group of clients with myasthenia gravis, Guillain-Barré syndrome, and amyotrophic lateral sclerosis (ALS)?
-Increased risk for respiratory complications
Which information would the nurse include in the teaching plan for a client diagnosed with epilepsy?
-Individuals taking phenytoin must floss their teeth regularly
Which educational topic is a high priority for the nurse providing education to a client with systemic lupus erythematosus?
-Instructing about ways to protect the skin
The nurse is assessing two clients. One client has ulcerative colitis, and the other client has Crohn disease. Which diagnostic finding is more likely to be identified in the client with ulcerative colitis than in the client with Crohn disease?
-Involvement starting distally with rectal bleeding that spreads continuously up the colon.
A client has a tentative diagnosis of Hodgkin disease. How would the nurse expect the diagnosis to be confirmed?
-Lymph node biopsy
A nurse is teaching the family of a client who has a new diagnosis of epilepsy about actions to take if the client experiences a seizure. Which of the following instructions should the nurse include in the teaching?
-Move objects away from the client
A nurse is caring for an older adult client who was alert and oriented at admission, but now seems increasingly restless and intermittently confused. Which of the following actions should the nurse take first to address the client's safety needs?
-Move the client to a room near the nurses station
A nurse in a provider's clinic is caring for a client who reports erectile dysfunction and requests a prescription for sildenafil. Which of the following medications currently prescribed for the client is a contraindication to taking sildenafil?
-Nitroglycerin: due to a potentially fatal interaction causing severe hypotension.
The nurse is caring for a client with chronic inflammation of the bowel. For which most serious complication would the nurse monitor in this client?
-Perforation: Because of chronic inflammation, the colon becomes thin and may perforate, causing peritonitis.
Which procedure would the nurse expect as a treatment option for a client newly diagnosed with Guillain-Barré syndrome?
-Plasmapheresis: is the removal of plasma from withdrawn blood followed by the reconstitution of its cellular components in an isotonic solution and the reinfusion of this solution
A nurse is caring for the client who has Meniere's disease who asks if he is allowed to ambulate independently. Which of the following responses should the nurse make?
-Please ring and request assistance before attempting to get out of bed."
A nurse is caring for a client who had a stroke involving the right cerebral hemisphere. The nurse should monitor for which of the following findings?
-Poor impulse control
Which interventions would the nurse perform while caring for an actively dying client? (Select all that apply.)
-Provide client and family reassurance, perform symptom management for the client
Which manifestations are seen in an older adult with the diagnosis of dementia? (Select all that apply.)
-Resistance to change, Tendency to dwell on the past, inability to recognize familiar objects, inability to concentrate on new activities
The office nurse is reviewing the record of a client with a new diagnosis of osteoarthritis of the knees. Which facts from the client's history does the nurse note as risk factors for osteoarthritis? (Select all that apply.)
-Sedentary lifestyle, facility hx of osteoarthritis, age of 64, history of long term employment as a home health aid
Which explanation would the nurse give to the family when an older widow, who is in the terminal stages of lung cancer, exhibits mood changes and anger toward the family?
-She is trying to cope with her impending death
Which behaviors would the nurse include when teaching a family what to expect from a client who experienced a stroke on the left side of the brain? (Select all that apply.)
-Slow performance and caution, impaired speech/language aphasias, awareness of deficits with depression and anxiety
Which type of impairment does the nurse expect the client who has expressive aphasia to exhibit?
-Speaking or writing
Which factors can trigger a client's migraine attacks? (Select four that apply.)
-Specific foods like chocolate or cheese, sleep problems, hormonal fluctuations, fatigue
A client with a cervical injury reports the sudden onset of a severe headache and nasal congestion. For which clinical manifestations would the nurse assess?
-Suprapubic distention
The nurse plans to monitor for signs of autonomic dysreflexia in a client who sustained a spinal cord injury at the T2 level. Which statement explains the nurse's rationale?
-There is damage above the sixth thoracic vertebra
A nurse is talking with a client who is about to start using transcutaneous electrical nerve stimulation (TENS) to manage chronic pain. Which of the following statements should the nurse identify as an indication that the client needs further teaching?
-This is only a short term strategy for pain relief
The nurse reviews the medical record of a client who is eligible to receive hospice care. Which are the criteria for a client to receive this type of care? (Select all that apply.)
-When the expected death of the client is within 6 months, When the client seeks no aggressive disease management
A client is concerned about developing ovarian cancer and reports information about her personal history. Which of the following client characteristics places her at high risk of ovarian cancer?
BRCA 1 positive: Familial cancer syndromes linked to the BRCA 1 and BRCA2 mutations present a high risk for ovarian, breast, and other reproductive cancers.
A client who has had a leg amputated because of bone cancer begins to experience phantom limb sensations. How would the nurse respond to complaints of pain?
By acknowledging that the pain is real and administering medication to relieve it.
Which action would the nurse perform immediately according to priority of care for a client with tonic-clonic seizures?
Ensuring patent airway
What is the purpose of placing a client in cervical traction after sustaining a fractured cervical vertebra?
Immobilizing the area minimizes injury to the spinal cord
A nurse is caring for a client who has acute diverticular disease. When palpating the client's abdomen, in which of the following locations should the nurse expect the client to report abdominal pain?
Left lower quadrant -The nurse should expect the client to have abdominal pain in the lower left quadrant of the abdomen. The disease is usually found in the sigmoid colon, where high pressure to move fecal contents from the rectum causes pouch formation.
Which behavior indicates that an individual has successfully completed the grieving process after the death of a significant other?
Remembers the significant other realistically -Successful resolution means being able to remember the good as well as the bad qualities of the deceased and accepting them as part of the deceased.
A client who exhibits blurred and double vision and muscular weakness is informed of the diagnosis of multiple sclerosis (MS). The client becomes visibly upset. Which response would the nurse make?
That must have shocked you. Tell me what the health care provider told you about it."
Which would the nurse include when teaching a client with Parkinson disease about carbidopa-levodopa?
The medication should be taken with meals, on a strict schedule
