ADhlth EX

The nurse assists an older man who has type 2 diabetes mellitus to improve his glucose control. Which of the following instructions does the nurse give to this individual when he plans to walk more than usual in 1 day?

Supplement caloric intake.

Which of the following is a true statement about joints in older adults?

Surgical joint replacement can cure OA.

Understand Parkinson's disease and life-threatening complications. Which of the following statements is true about Parkinson's disease (PD)?

older adults taking levodopa-carbidopa (Sinemet)must take it on an empty stomach.

An expected nursing diagnosis for a 30-year-old patient admitted to the hospital with symptoms of diabetes insipidus is

sleep pattern disturbance related to frequent waking to void.

When caring for a patient who has Guillain-Barré syndrome, which assessment data obtained by the nurse will require the most immediate action?

The patient has continuous drooling of saliva.

Which patient is most likely to need long-term nursing care management?

63-year-old with bilateral knee osteoarthritis who weighs 350 lb (159 kg)

Which patient seen by the nurse in the outpatient clinic is most likely to require teaching about ways to reduce risk for osteoarthritis (OA)?

A 56-year-old woman who works on an automotive assembly line

A patient is being evaluated for Alzheimer's disease (AD). The nurse explains to the patient's adult children that

A diagnosis of AD is made only after other causes of dementia are ruled out.

Which of the following is a true statement about osteoporosis (OA)?

A high risk of death follows an OA-related fracture.

Which action, if performed by a nurse who is assigned to take care of a patient with active tuberculosis (TB), would require an intervention by the nurse supervisor?

A surgical face mask is applied before visiting the patient.

A 23-year-old patient is admitted with diabetes insipidus. Which action will be most appropriate for the registered nurse (RN) to delegate to an experienced licensed practical/vocational nurse (LPN/LVN)?

Administer subcutaneous DDAVP

Which information about continuous bladder irrigation will the nurse teach to a patient who is being admitted for a transurethral resection of the prostate (TURP)?

ANSWER: Bladder irrigation prevents obstruction of the catheter after surgery.

A 46-year-old male patient with dermatomyositis is receiving long-term prednisone (Deltasone) therapy. Which assessment finding by the nurse is most important to report to the health care provider?

Acne is noted on the patients face.

Which information would the nurse include when teaching a patient who has an exacerbation of rheumatoid arthritis?

Applying cold packs before exercise may decrease joint pain.

After an acute exacerbation of chronic obstructive pulmonary disease (COPD), the nurse prepares an older adult for discharge to home. Which is the most important patient teaching for the nurse to include for the prevention of hospitalizations for exacerbations of COPD?

Avoid sick people and wash hands.

The nurse would anticipate the need to teach a patient who has osteoarthritis (OA) about which medication?

Capsaicin cream (Zostrix)

Which laboratory result will the nurse monitor to determine whether prednisone (Deltasone) has been effective for a 30-year-old patient with an acute exacerbation of rheumatoid arthritis?

C-reactive protein level

Which topic would the nurse plan to teach a 26-year-old patient who has been treated for pelvic inflammatory disease?

Potential complication of infertility

When the nurse brings medications to a patient with rheumatoid arthritis, the patient refuses the prescribed methotrexate. The patient tells the nurse, "My arthritis isn't that bad yet. The side effects of methotrexate are worse than the arthritis." Which information would be most important for the nurse to provide?

c. "It is important to start methotrexate early to decrease the extent of joint damage."

Which of the following statements is true about rheumatoid arthritis (RA)?

c. RA can affect body systems other than the joints.

A patient who had radical neck surgery to remove a malignant tumor developed hypoparathyroidism. The nurse should plan to teach the patient about

calcium supplements to normalize serum calcium levels.

When administering a mental status examination to a patient with delirium, the nurse should

choose a place without distracting stimuli.

When caring for a 58-year-old patient with persistent menorrhagia, the nurse will plan to monitor the

complete blood count (CBC).

A 54-yr-old woman who recently reached menopause and has a family history of osteoporosis is diagnosed with osteopenia. Which information would the nurse explain to the patient?

d. Calcium loss from bones can be slowed by increasing calcium intake and weight-bearing exercise.

A patient arrives in the emergency department with hemiparesis and dysarthria that started 2 hours previously. Health records show a history of several transient ischemic attacks (TIAs). Which interprofessional intervention would the nurse anticipate for this patient?

d. Tissue plasminogen activator (tPa) infusion

A 56-year-old patient who is disoriented and reports a headache and muscle cramps is hospitalized with possible syndrome of inappropriate antidiuretic hormone (SIADH). The nurse would expect the initial laboratory results to include a(n)

decreased serum sodium.

A patient who had surgery for creation of an ileal conduit 3 days ago will not look at the stoma and requests that only the ostomy nurse specialist does the stoma care. The nurse identifies a nursing diagnosis of

disturbed body image related to change in function.

A young adult patient who is in the rehabilitation phase after having deep partial thickness face and neck burns have a nursing diagnosis of disturbed body. image. Which statement by the patient indicates that the problem is resolved?

"Do you think dark beige makeup foundation would cover this scar on my cheek?"

Your patient has a sudden tonic clonic seizure. What do you do?A high school teacher who has been diagnosed with epilepsy after having a generalized tonic-clonic seizure tells the nurse, "I cannot teach any more. It will be too upsetting if I have a seizure at work." How would the nurse respond to specifically address the patient's concern?

"Epilepsy usually can be well controlled with medications."

Which patient statement to the nurse indicates a need for additional instruction in administering insulin?

"I Should inject the insulin into a muscle that I plan to exercise vigorously."

Which patient statement indicates to the nurse that further instruction is needed about chronic syndrome of inappropriate antidiuretic hormone (SIADH)?

"I need to shop for foods low in sodium and avoid adding salt to food"

The nurse would determine that teaching about migraine headaches has been effective when the patient says which of the following?

"I will lie down someplace dark and quiet when the headaches begin."

The nurse teaches a patient about the transmission of pulmonary tuberculosis (TB). Which statement by the patient indicates that teaching was effective?

"My spouse will sleep in another room."

An older person is admitted to the hospital with an exacerbation of congestive heart failure. The nurse notes that the patient complains of severe itching at night and has a red rash on her torso. The patient is diagnosed with scabies. The patient asks the nurse, "How did I get something like this?" The best response by the nurse is:

"Scabies is highly contagious and spreads easily through physical contact."

The nurse teaches a patient who is scheduled for a prostate needle biopsy about the procedure. Which statement by the patient indicates that teaching was effective?

"The biopsy will help guide the treatment choices for my enlarged prostate."

What should you include in your teaching concerning migraine headaches? The nurse is planning a teaching session with a patient who is newly diagnosed with migraine headaches. To assess the patient's readiness to learn, which question should the nurse ask first?

"What information do you think you need right now?"

In which order will the nurse perform the following actions when caring for a patient with possible C5 spinal cord trauma who is admitted to the emergency department? (Put a comma and a space between each answer choice [A, B, C, D, E].)

A. Infuse normal saline at 150 mL/hr. B. Monitor cardiac rhythm and blood pressure. C. Administer O2 using a non-rebreather mask. D. Immobilize the patient's head, neck, and spine. E. Transfer the patient to radiology for spinal computed tomography (CT). ANS: D, C, B, A, E

Which prescribed intervention would the emergency department nurse implement first for a patient who is experiencing continuous tonic-clonic seizures?

Administer lorazepam (Ativan) 4 mg IV.

What is your priority plan of care for a patient diagnosed with a stroke? After completing an admission assessment on a patient who recently hahoose which of the following nursing d a stroke, the nurse should cdiagnoses as a priority?

Altered cerebral perfusion.

What is the best intervention you should use when communicating with a hearing-impaired adult?

Always clearly identify yourself and others with you.

female patient being admitted with pneumonia has a history of neurogenic bladder as a result of a spinal cord injury. Which action will the nurse plan to take first?

Ask about the usual urinary pattern and any measures used for bladder control.

A 22-yr-old patient seen at the health clinic with a severe migraine headache tells the nurse about having similar headaches recently. Which initial action would the nurse take?

Ask the patient to keep a headache diary.

Which initial action would the nurse take for a patient with moderate dementia who develops increased restlessness and agitation?

Assess for factors that might be causing discomfort.

The nurse recording health histories in the outpatient clinic would plan a focused hearing assessment for adult patients taking which medication?

Atenolol (Tenormin) taken to prevent angina

A nurse is teaching an older adult who is experiencing an acute attack of gout. Which of the following should the nurse include in the teaching?

Avoid foods high in purine.

Which information about continuous bladder irrigation will the nurse teach to a patient who is being admitted for a transurethral resection of the prostate (TURP)?

Bladder irrigation prevents obstruction of the catheter after surgery.

A home health nurse is completing an admission on a patient who recently experienced a transient ischemic attack (TIA). During the assessment, the patient begins to complain of a severe headache and numbness in his left arm. Which action should the nurse take next?

Call 9-1-1.

What is the best way to prevent contractures in an elderly patient? The nurse is caring for a patient who has had a stroke. The nurse is concerned the patient will develop contractures. Which intervention should the nurse implement?

Conduct passive range-of-motion movements to the affected extremities.

Which of the following should the nurse use to assess a nonverbal older adult for delirium?

Confusion Assessment Method (CAM)

A patient who has type 1 diabetes plans to swim laps for an hour daily at 1:00 PM. Which advice would the clinic nurse plan to give the patient?

Check glucose level before, during, and after swimming.

Which information will the nurse include for a patient contemplating a cochlear implant?

Cochlear implants require training in order to receive the full benefit.

Which of the following nursing interventions are suitable for a patient who has gout?

Colchicine (Colsalide) by mouth

The nurse is administering a thrombolytic agent to a patient having an acute myocardial infarction. Which patient data indicates that the nurse should stop the drug infusion?

Decreased level of consciousness

A patient who is disoriented and reports a headache and muscle cramps is hospitalized with syndrome of inappropriate antidiuretic hormone (SIADH). Which initial laboratory result would the nurse expect?

Decreased serum sodium

Which of the following statements is true about diabetes mellitus?

Diabetes is diagnosed after two fasting plasma glucose readings over 125 mg/dL.

A 73-year-old patient with a stroke experiences facial drooping on the right side and right-sided arm and leg paralysis. When admitting the patient, which clinical manifestation will the nurse expect to find?

Difficulty comprehending instructions

A patient being admitted with a stroke has right-sided facial drooping and right-sided arm and leg paralysis. Which other finding would the nurse expect?

Difficulty comprehending instructions

The registered nurse (RN) is caring for a patient who is living with HIV and admitted with tuberculosis. Which task can the RN delegate to assistive personnel (AP)?

Stock the patient's room with the necessary personal protective equipment.

Which finding would the nurse expect when assessing a patient who has osteoarthritis (OA) of the knee?

Discomfort with joint movement

To decrease the risk for future hearing loss, which action should the nurse implement with college students at the on-campus health clinic?

Discuss exposure to amplified music.

A 19-year-old patient has genital warts around her external genitalia and perianal area. She tells the nurse that she has not sought treatment until now because of the warts. are so disgusting. Which nursing diagnosis is most appropriate?

Disturbed body image related to feelings about the genital warts.

74-yr-old patient is seen in the health clinic with new development of a stooped posture, shuffling gait, and pill rolling-type tremor. Which topic would the nurse anticipate explaining? to the patient?

Dopaminergic drugs

A patient with Parkinson's disease (PD) has bradykinesia. Which action would the nurse include in the plan of care?

Suggest that the patient use the arms of the chair to help push up to standing.

Which finding by the nurse when assessing a patient with Hashimoto's thyroiditis and a goiter will require the most immediate action?

Elevation in the patient's T3 and T4 levels

Which action would the nurse include in the plan of care for a patient with a new diagnosis of rheumatoid arthritis (RA)?

Encourage the patient to take a nap in the afternoon.

An overweight female patient who had enjoyed active outdoor activities is stressed because she is limited in what she can do because she has osteoarthritis in her hips. Which action by the nurse will best assist the patient to cope with this situation?

Encourage the patient to think about how weight loss might improve symptoms.

Which diagnostic test would the nurse anticipate for an older patient who is vomiting "coffee-ground" emesis?

Endoscopy

An older nursing home resident reports that her hearing loss is getting worse. What is the first action of the nurse?

Examine the resident's ears for cerumen impaction.

An older woman seeks advice from the nurse about preventing further bone loss after being diagnosed with osteopenia. To achieve the woman's goal, which of the following patient teachings should the nurse provide to enhance the activity of the osteoblasts?

Exercise with weights.

A patient with Parkinson 's disease is admitted to the hospital for treatment of pneumonia. Which interventions would the nurse include in the plan of care? (Select all that apply.)

Provide an elevated toilet seat. Cut the patient 's food into small pieces. Place an armchair at the patient 's bedside.

Which topics will the nurse NOT include when preparing to teach a patient with recurrent genital herpes simplex.

Genital herpes can be cured by consistent use of antiviral medications.

An older woman is recovering from a bowel resection in the intensive care unit (ICU) but remained intubated and on a mechanical ventilator. Which of the following should the nurse implements to help prevent delirium in this woman?

Provide uninterrupted periods of rest and sleep.

51-year-old patient with a small immobile breast lump is considering having a fine-needle aspiration (FNA) biopsy. The nurse explains that an advantage to this procedure is that

FNA is done in the outpatient clinic and results are available in 1 to 2 days.

Which infection control actions would the nurse include in the use of standard precautions?

Gloving before wiping pink sputum off the bed rail.

A patient with type 2 diabetes is scheduled for a follow-up visit in the clinic several months from now. Which test will the nurse schedule to evaluate the effectiveness of treatment for the patient?

Glycosylated hemoglobin

According to the Center for Disease Control and Prevention (CDC) guidelines, which personal protective equipment will the nurse put on before assessing a patient who is on contact precautions for Clostridium difficile diarrhea? (Select all that apply.)

Gown and Gloves

A 39-year-old patient whose work involves frequent lifting has a history of chronic back pain. After the nurse has taught the patient about correct body mechanics, which patient statement indicates that the teaching has been effective?

I will begin doing exercises to strengthen the muscles of my back.

The nurse recording health histories in the outpatient clinic would plan a focused hearing assessment for adult patients taking which medication?

Ibuprofen (Advil) taken for 20 years to treat osteoarthritis

What is important to assess in a patient with possible MS? Which action would the nurse include in completing a health history and physical assessment for a 36-yr-old female patient with possible multiple sclerosis (MS)?

Inquire about urinary tract problems.

After the nurse assesses a 78-year-old who uses naproxen (Aleve) daily for hand and knee osteoarthritis management, which information is most important to report to the healthcare provider?

Laboratory results indicate blood urea nitrogen (BUN) is elevated.

A patient who has severe Alzheimer's disease (AD) is being admitted to the hospital for surgery. Which intervention will the nurse include in the plan of care?

Maintain a consistent daily routine for the patient's care.

The nurse is admitting a patient diagnosed with an acute exacerbation of chronic obstructive pulmonary disease (COPD). How would the nurse determine the appropriate O2 flow rate?

Maintain the pulse oximetry level at 90% or greater.

Are blood clots in the catheter bag after a TURP something to worry about and if so, how would you treat this?After a transurethral resection of the prostate (TURP), a 64-year-old patient with continuous bladder irrigation complains of painful bladder spasms. The nurse observes. clots in the urine. Which action should the nurse take first?

Manually instill and then withdraw 50 mL of saline into the catheter.

A 32-year-old patient who has had an open reduction and internal fixation (ORIF) of left lower leg fractures continues to complain of severe pain in the leg 15 minutes after receiving the prescribed IV morphine. Pulses are faintly palpable and the foot is cool. Which action should the nurse take next?

Notify the health care provider

Which patient problem would the nurse identify as of highest priority for a patient who has Parkinson 's disease and is unable to move the facial muscles?

Nutritionally compromised.

The nurse administers prescribed therapies for a patient with cor pulmonale and right-sided heart failure. Which assessment would best evaluate the effectiveness? of the therapies?

Observe for distended neck veins.

A patient is hospitalized with a new onset of Guillain-Barré syndrome. Which assessment would the nurse recognize as the most essential to complete?

Observing respiratory rate and effort

(Laminectomy is surgery that creates space by removing bone spurs and tissues associated with arthritis of the spine. It usually involves removing a small piece of the back part (lamina) of the small bones of the spine (vertebrae). Laminectomy enlarges the spinal canal to relieve pressure on the spinal cord or nerves.) (Diskectomy = Discectomy is the surgical removal of the damaged portion of a herniated disk in the spine.) *** A nurse who works on the orthopedic unit has just received the change-of-shift report. Which patient should the nurse assess first?

Patient who has not voided 10 hours after having a laminectomy.

After a change-of-shift report on the neurology unit, which patient would the nurse assess first?

Patient with Guillain-Barré syndrome who is drooling and having difficulty swallowing.

A 71-year-old patient with Alzheimer's disease (AD) who is being admitted to a long-term care facility has had several episodes of wandering away from home. Which action will the nurse include in the plan of care?

Place the patient in a room close to the nurse's station.

A patient with Alzheimer's disease (AD) who is being admitted to a long-term care facility has had several episodes of wandering away from home. Which action will the nurse include in the plan of care?

Place the patient in a room close to the nurses' station.

Which action would the nurse take after assisting with a needle biopsy of the liver at a patient's bedside?

Place the patient on the right side with the bed flat.

Which is the best goal when planning nursing care for an older patient with diabetes mellitus?

Prevent disease progression.

Which topic will the nurse include in the preoperative teaching for a patient admitted for an abdominal hysterectomy?

Purpose of ambulation and leg exercises

Which is the most likely reason that type 2 diabetes mellitus is often difficult to diagnose in older adults?

The classic symptoms may not be present in older adults.

What are the signs and symptoms of abnormal side effect to prednisone?v

The increased glucose, skin change, and hypertension are possible side effects of the prednisone and should be addressed

A 44-year-old female patient with Cushing syndrome is admitted for adrenalectomy. Which intervention by the nurse will be most helpful for a nursing diagnosis of disturbed body image related to changes in appearance?

Remind the patient that most of the physical changes caused by Cushing syndrome will resolve after surgery

An older woman has a wound infection 5 days after a below-the-knee amputation brought about by diabetes mellitus. Which of the following is the nurse's priority? intervention to prevent cognitive dysfunction and postoperative complications in this older adult?

Remove invasive devices as soon as possible

An older woman has a wound infection 5 days after a below-the-knee amputation brought about by diabetes mellitus. Which of the following is the nurse's priority intervention to prevent cognitive dysfunction and postoperative complications in this older adult?

Remove invasive devices as soon as possible.

A patient with pelvic inflammatory disease (PID) is being treated with oral antibiotics as an outpatient. Which information will the nurse include in patient teaching?

Return for a follow-up appointment in 2 to 3 days.

A patient who has a small cell cancer of the lung develops syndrome of inappropriate antidiuretic hormone (SIADH). The nurse would notify the health care provider about which assessment finding?

Serum sodium of 120 mg/dL

A patient is hospitalized with active tuberculosis (TB). Which assessment finding indicates to the nurse that prescribed airborne precautions are likely to be discontinued?

Sputum smears for acid-fast bacilli are negative.

A nurse is teaching an older adult who is experiencing an acute attack of gout. Which of the following instructions should the nurse NOT include in the teaching?

Take ASA to relieve pain

Which action will the nurse take when caring for a patient with osteomalacia?

Teach about the use of vitamin D supplements.

Which action would the nurse take when caring for a patient who has osteomalacia?

Teach about the use of vitamin D supplements.

A patient with a left-brain stroke suddenly bursts into tears when family members visit. How would the nurse respond?

Teach the family that emotional outbursts are common after strokes.

Which action would the nurse plan to take for a patient with multiple sclerosis who has urinary retention caused by a flaccid bladder?

Teach the patient how to self-catheterize.

Which information is most important for the nurse to communicate rapidly to the health care provider about a patient admitted with possible syndrome of inappropriate antidiuretic hormone (SIADH)?

The patient has a serum sodium level of 118 mEq/L

Which information is most important for the nurse to communicate rapidly to the health care provider about a patient admitted with possible syndrome of inappropriate antidiuretic hormone (SIADH)

The patient has a serum sodium level of 118 mEq/L.

(Heberden's nodes are small bony growths that appear on the joint closest to the tip of your finger. Along with Bouchard's nodes, Heberden's nodes are a symptom of osteoarthritis of the hands. They can cause pain and limited motion in your hands.) ***Which assessment finding about a patient who has been using naproxen (Naprosyn) for 6 weeks to treat osteoarthritis is most important for the nurse to report to the health care provider?

The patient has dark-colored stools.

A 28-year-old male patient with type 1 diabetes reports how he manages his exercise and glucose control. Which behavior indicates that the nurse should implement additional teaching?

The patient increases daily exercise when ketones are present in the urine

What would you include in your education to an older person with diabetes before exercising?

The patient increases daily exercise when ketones are present in the urine.

The nurse is caring for a patient admitted with diabetes insipidus (DI). Which information is most important to report to the health care provider?

The patient is confused and lethargic.

The nurse is assessing a 55-yr-old female patient with type 2 diabetes who has a body mass index (BMI) of 32 kg/m2 .Which goal in the plan of care is most important for this patient?

The patient will reach a glycosylated hemoglobin level of less than 7%.

Which assessment information obtained by the nurse indicates that a patient with an exacerbation of rheumatoid arthritis (RA) is experiencing a side effect of prednisone (Deltasone)?

The patient's blood glucose is 165 mg/dL.

The nurse assesses a patient who had a total abdominal hysterectomy 2 days ago. Which information about thepatient is most important to communicate to thehealth care provider?

The patient's calf is swollen and warm to touch.

Which assessment information would indicate to the nurse that a patient with an exacerbation of rheumatoid arthritis (RA) is experiencing a side effect of prednisone?

The patient's fasting blood glucose is 90 mg/dL. or 165

The nurse is administering IV fluid boluses and nasogastric irrigation to a patient with acute gastrointestinal (GI) bleeding. Which assessment finding is most important for the nurse to communicate to the health care provider?

The patient's lungs have crackles audible to the midchest.

An older adult with type 2 diabetes who is being treated with insulin wants to increase his activity level and begin a walking program. What recommendations should the nurse provide to this patient?

The walking regimen needs to be done on a regularly scheduled basis.

A 38-year-old patient who had a kidney transplant 8 years ago is receiving the immunosuppressants tacrolimus (Prograf), cyclosporine (Sandimmune), an prednisone (Deltasone). Which assessment data will be of most concern to the nurse?

There is a non-tender axillary lump.

While the nurse is transporting a patient on a stretcher to the radiology department, the patient begins having a tonic-clonic seizure. Which action would the nurse take?

Time and observe and record the details of the seizure and postictal state.

A patient arrives in the emergency department with hemiparesis and dysarthria that started 2 hours previously. Health records show a history of several transient ischemic attacks (TIAs). Which interprofessional intervention would the nurse anticipate for this patient?

Tissue plasminogen activator (tPa) infusion

A patient is being treated with carbidopa/levodopa (Sinemet) for Parkinson 's disease. Which assessment finding would indicate to the nurse that a change in the medication or dosage may be needed?

Uncontrolled head movement

Which finding indicates to the nurse that demeclocycline has been effective for a patient with syndrome of inappropriate antidiuretic hormone (SIADH)?

Urinary output has increased.

During the change of shift report a nurse is told that a patient has an occluded left posterior cerebral artery. The nurse will anticipate that the patient may have

Visual deficits.

An assessment finding for a 55-year-old patient that alerts the nurse to the presence of osteoporosis is-

a measurable loss of height.

A female patient who had a stroke 24 hours ago has expressive aphasia. The nurse identifies the nursing diagnosis of impaired verbal communication. An appropriate nursing intervention to help the patient communicate is to

ask questions that the patient can answer with yes or no.

A patient in the clinic reports a recent episode of dysphasia and left-sided weakness at home that resolved after 2 hours. The nurse will anticipate teaching the patient about

aspirin (Ecotrin).

Which intervention will the nurse include in the plan of care for a patient with moderate dementia who had an appendectomy 2 days ago?

b. Remind the patient frequently about being in the hospital.

An appropriate nursing intervention for a patient who has acute low back pain and muscle spasms is to teach the patient to

keep the head elevated slightly and flex the knees when resting in bed.

When a patient who takes metformin (Glucophage) to manage type 2 diabetes develops an allergic rash from an unknown cause, the health care provider prescribes prednisone (Deltasone). The nurse will anticipate that the patient may

require administration of insulin while taking prednisone.