Adult Health II

The nurse is conducting a functional assessment for an older adult client. The client reports to the nurse, "I often forget where I put my keys, but that is expected at my age." Which of the following is the most appropriate response by the nurse? a. "How often do you think you forget where items are located?" b. "Yes, short term memory loss does occur as you get older." c. "What do you do to remember where your keys are?" d. "I lose my keys all the time, as long as you find the keys it is not a problem."

"How often do you think you forget where items are located?"

The nurse is providing pre-operative teaching regarding autologous blood transfusion to a 60-year old client in preparation for surgery. Which of the following statements by the client would indicate correct understanding of the teaching? a. "I do not think I can develop a reaction if I receive my old blood." b. "I need to donate blood for the transfusion 5 weeks before my surgery." c. "I cannot receive autologous transfusion since I am a Jehovah's Witness." d. "I cannot donate blood for autologous transfusion because of my age"

"I need to donate blood for the transfusion 5 weeks before my surgery."

The nurse is teaching a client who is postoperative abdominal surgery the purpose of the incentive spirometer. Which of the following statements by the nurse would indicate a correct understanding of the procedure? a. "The spirometer can help you cough out the secretions in your lungs." b. "The spirometer can prevent formation of blood clots in your lungs." c. "The spirometer can prevent the development of fever after surgery." d. "The spirometer can help the expansion of your lungs after surgery."

"The spirometer can help the expansion of your lungs after surgery."

The nurse in the ambulatory surgical center is assessing a client scheduled for surgery requiring general anesthesia. The client states, "I ate a light breakfast about 2 hours ago." Which of the following statements by the nurse would be appropriate? a. "You may experience more nausea than usually expected after the surgery." b. "We will have to wait another two hours to do your surgery." c. "We will give you medication to prevent you from vomiting during the surgery." d. "There is a possibility that your surgery will be rescheduled."

"There is a possibility that your surgery will be rescheduled."

The evening shift nurse received report that a signed consent is needed before the client goes to surgery in the morning. The nurse was not present when the surgeon explained the procedure to the client. Which of the following statements by the nurse would be most appropriate before asking the client to sign the consent form? a. "You have the right to change your mind at any time." b. "What were you told about your surgical procedure?" c. "Do you have any questions about your surgery tomorrow?" d. "Your surgeon asked me to ensure that you sign the consent form."

"What were you told about your surgical procedure?"

The nurse is collecting the health history of a client who reports daytime drowsiness. Which of the following statements would indicate to the nurse that the client is experiencing restless leg syndrome? a. "When I lie down at night, I feel like I need to keep moving my legs." b. "My legs feel heavy in the morning." c. "If I keep my legs still, the crawling sensation goes away." d. "I noticed that the color of my toes often change color."

"When I lie down at night, I feel like I need to keep moving my legs."

A nurse is talking with an older adult client who has an elevated risk for osteoporosis about strategies for preventing bone loss. Which of the following instructions should the nurse provide? A. Take a brisk walk every day B. Take 800 mg of calcium daily C. Drink plenty of sparkling water D. Drink 8 ounces of red wine every day

A

A nurse is teaching a client who has rheumatoid arthritis about increasing physical rest as part of her treatment plan. Which of the following outcomes of this intervention should the nurse document as a goal for this client? A.Reduced joint stress B.Maintenance of joint function C.Suppression of the inflammatory process D.Decreased stiffness

A

Which assessment finding found while assessing a patient with a fracture who has traction requires immediate intervention? A. The weights are touching the floor or bed. B. Pin sites are free from drainage. C. Patient uses the overhead trapeze bar to move around in the bed. D. Patient's extremities have a capillary refill of less than 2 seconds.

A

A patient is suspected of having multiple sclerosis. The neurologist orders various test. The patient's MRI results are back and show lesions on the cerebellum and optic nerve. What signs and symptoms below would correlate with this MRI finding in a patient with multiple sclerosis? A. Blurry vision B. Pain when moving eyes C. Dysarthria D. Balance and coordination issues E. "Pill rolling" of fingers and hands G. Heat intolerance H. Dark spots in vision I. Ptosis

A B C D H FYI Pill rolling" of the fingers and hands is found in Parkinson's disease. Ptosis is common in myasthenia gravis, and heat intolerance in thyroid issues.

You're assessing your patient load for the patients who are at MOST risk for seizures. Select all the patients below that are at risk: A. A 32-year-old with a blood glucose of 20 mg/dL. B. A 63-year-old whose CT scan shows an ischemic stroke. C. A 72-year-old who is post opt day 5 from open heart surgery. D. A 16-year-old with bacterial meningitis. E. A 58-year-old experiencing ETOH withdrawal.

A B D E Remember all the risk factors: illness (especially CNS types like bacterial meningitis), fever, electrolyte/metabolic issues (low blood sugar, acidosis etc.), ETOH (alcohol) withdraw, brain injury, STROKE, congenital brain defects, tumors etc.

A patient with osteoarthritis is describing their signs and symptoms. Which signs and symptoms below are NOT associated with osteoarthritis? Select-all-that-apply: A. Morning stiffness greater than 30 minutes B. Experiencing grating during joint movement C. Fever and Anemia D. Symmetrical joint involvement E. Pain and stiffness tends to be worst at the end of the day

A C D

A patient is being discharged with a plaster cast. What education would the nurse give? Select all that apply: A.You can apply an ice pack over the cast for relief B.You can shower with this type of cast C.You can add more padding at the openings if needed D.You do not want to move your extremities until the cast is removed E.You can tap the cast to relieve itching F.You can put an object inside the cast to relieve itching G.You can dry the cast with a hair dryer on high if it gets wet

A C E

A nurse is caring for a client who is in Buck's traction. Which of the following actions should the nurse take? Select all that apply: •A. Monitor peripheral pulses in the affected extremity. •B. Position weights against the foot of the bed. •C. Adjust the prescribed weights every shift. •D. Examine the skin under the traction splint. •E. Assess the temperature of the affected extremity.

A D E

Your patient is scheduled for a lumbar puncture to help diagnose multiple sclerosis.What interventions does the nurse encourage the patient to do? A. Drink fluids B. Lay on their side C. Ambulate to the bathroom D. Use the Incentive Spirometer

A. Nurse will instruct patient to: Increase fluids - replace fluid loss Monitor sensations - check for paralysis Lay on back for 4 to 6 hours - keep pressure low Administer Zofran - prevent nausea

A nurse is caring for a client who is 1-day postoperative following total hip arthroplasty. It is 0830 and the client is schedule for physical therapy (PT) at 0900. Which of the following interventions should the nurse take? A. Encourage the client to use full weight bearing. B. Identify the client's pain level and medicate if needed. C. Teach the client which positions to avoid during PT. D. Perform the client's morning care.

B

A patient is recovering from surgery. The patient is very restless, heart rate is 120 bpm and blood pressure is 70/53, skin is cool/clammy. As the Nurse you would do? A. Continue to monitor the patient B. Notify the MD C. Obtain an EKG D. Check the patient's blood glucose

B

An 85-year-old patient has an accidental fall while going to the bathroom without assistance. It appears the patient has sustained a bone fracture to the left leg. The leg's shape is deformed and the patient is unable to move it. The patient is alert and oriented but in pain. What will you do FIRST after confirming the patient is safe and stable? A. Apply an ice pack covered with a towel to the site. B. Immobilize the fracture with a splint. C. Administer pain medication. D. Elevate the extremity above heart level.

B

Which statement by a patient, who just received a cast on the right arm for a fracture, requires you to notify the physician immediately? A. "It is really itchy inside my cast!" B. "My pain is so severe that it hurts to stretch or elevate my arm." C. "I can feel my fingers and move them." D. "I've been using ice packs to reduce swelling."

B

You're a home health nurse providing care to a patient with myasthenia gravis. Today you plan on helping the patient with bathing and exercising. When would be the best time to visit the patient to help these tasks? A. Mid-afternoon B. Morning C. Evening D. Before bedtime

B

The nurse is caring for a patient with a fractured fibula. Which assessment prompts immediate action by the nurse? Select all: A. Reported Pain of 4/10 B. Numbness and tingling in the extremity C. Swollen extremity where the injury occurred D. Reports being cold in bed

B D

You're providing diet education to a patient with Parkinson's Disease. Which statement below demonstrates the patient understood your teaching? Select all that apply: A. "I will limit foods high in fiber like fruits and vegetables in my diet." B. "I will be sure to drink 2 Liter of fluid per day." C. "It is very common for me to experience diarrhea with this disease." D. "I will avoid taking Carbidopa/Levodopa with a protein rich meal."

B D

A nurse is discussing the differences between skeletal and skin traction with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates understanding? A. "Skeletal traction has less risk for infection than skin traction." B. "Clients with skin traction have more mobility than those with skeletal traction." C. "Skeletal traction is more appropriate than skin traction for reducing a fracture." D. "Clients with skin traction have more discomfort than those with skeletal traction."

C

A patient is taking Aspirin 325 mg PO by mouth daily. The patient is scheduled for surgery in a week. What education do you provide the patient with before surgery? A. Educate the patient to take the scheduled dose of Aspirin the day of surgery to help prevent blood clots B. To hold his morning dose of Aspirin because the nurse will give it to him before surgery C. The medication should be discontinued for 48 hours prior to the scheduled surgery date D. None of the above are correct

C

A patient with Parkinson's Disease has slow movements that affects their swallowing, facial expressions, and ability to coordinate movements. As the nurse you will document the patient has: A. Akinesia B. "Freeze up" tremors C. Bradykinesia D. Pill-rolling

C

A patient with myasthenia gravis will be eating lunch at 1200. It is now 1000 and the patient is scheduled to take Pyridostigmine. At what time should you administer this medication so the patient will have the maximum benefit of this medication? A. As soon as possible B. 1 hour after the patient has eaten (at 1300) C. 1 hour before the patient eats (at 1100) D. at 1200 right before the patient eats

C

Which meal option would be the most appropriate for a patient with myasthenia gravis? A.Roasted potatoes and cubed steak B.Hamburger with baked fries C.Clam chowder with mashed potatoes D.Fresh veggie tray with sliced cheese cubes

C

Which patient below is NOT at risk for osteoporosis? A. 50 year old female whose last menstrual period was 7 years ago. B. A 45 year old male patient who has been taking glucocorticoids for the last 6 months. C. A 30 year old male who drinks alcohol occasionally and has a BMI of 28. D. A 35 year old female who has a history of seizures and takes Dilantin regularly

C

Your patient has entered the post ictus stage for seizures. The patient's seizure presented with an aura followed by body stiffening and then recurrent jerking. The patient had incontinence and bleeding in the mouth from injury to the tongue. What is an expected finding in this stage based on the type of seizure this patient experienced? A. Crying and anxiety B. Immediate return to baseline behavior C. Sleepy, headache, and soreness D. Unconsciousness

C

You are completing the history on a patient who is scheduled to have surgery. What health history increases the risk for surgery for the patient?Select All: A. Urinary Tract infections B. History of Premature Ventricular Beats C. Abuse of street drugs D. Latex Allergy

C D

A nurse is caring for a client following a hip arthroplasty. The nurse places an aBduction pillow on the client for which of the following purposes? A. To raise the sheets off the clients feet to prevent plantar flexion B. To keep the clients heels of the bed to prevent pressure ulcers C. To position the client off the post operative site D. To prevent hip dislocation during position changes or movement

D

A nurse is caring for an older adult client who has rheumatoid arthritis (RA) and is taking aspirin 650 mg every 4 hours. Which of the following diagnostic tests should the nurse monitor to evaluate the effectiveness of this medication? A. White blood cell (WBC) count B. Rheumatoid factor (RF) C. Antinuclear antibody (ANA) D, Erythrocyte sedimentation rate (ESR)

D

A nurse is developing a care plan for a patient who is at risk for developing pneumonia after surgery. Which of the following is not an appropriate nursing intervention? A. Encourage patient intake of 3000 ml/day of fluids if not contraindicated B. Encourage patient to use the incentive spirometer device 10 times every 1-2 hours while awake C. Encourage early ambulation and patient to eat meals in beside chair D. Repositioning every 3-4 hours

D

A nurse is teaching a client about preventing osteoporosis. Which of the following statements by the client indicates a need for further teaching? A. "I will reduce my intake of sodium." B. "I will decrease my intake of caffeine." C. "I will limit my intake of soft drinks." D. "I will reduce my intake of vitamin K-rich foods."

D

A nurse is teaching a client who has a new prescription for alendronate for the treatment of osteoporosis. Which of the following statements by the client indicates an understanding of the teaching? A. I will take the medication in the evening B. I will drink a full glass of milk with the medication C. I will take the medication with lunch D. I will sit upright after taking the medication

D

After surgery your patient is semi comatose with vital signs within normal limits. As the nurse, what position would be best for this patient? A. Semi-Fowler's B. Prone C. Low-Fowler's D. Side positioning, preferable on the left side

D

A 7-year-old male patient is being evaluated for seizures. While in the child's room talking with the child's parents, you notice that the child appears to be daydreaming. You time this event to be 10 seconds. After 10 seconds, the child appropriately responds and doesn't recall the event. This is known as what type of seizure? A. Focal Impaired Awareness (complex partial) B. Atonic C. Tonic-Clonic D. Absence

D This is an absence seizure and is most common in children. The hallmark of it is staring that appears to be like a daydreaming state. It is very short and the post ictus stage of this type of seizure is immediate.

The nurse is caring for a client who had an open reduction internal fixation 2 hours ago to correct a fractured hip. Which of the following assessment findings would require immediate follow-up? a. Pain rated 6 on a scale of 0-10 b. Hemovac drainage of 125 mL c. Poor nutritional status d. Absence of leg immobilizer

Hemovac drainage of 125 mL

A nurse is assessing a client who has rotator cuff injury. Which of the following findings should the nurse expect to observe? a. Inability to maintain abduction of the arm at the joint. b. Difficulty performing circumduction of the joint c. Unable to shrug shoulders. d. Alteration in the contour of the joint.

Inability to maintain abduction of the arm at the joint.

The nurse is performing a neurological assessment for a client with a head trauma. Which of the following actions by the nurse would assess the function of the client's cranial nerve III. a. Have client stand with eyes closed and touch their nose. b. Ask the client to shrug shoulders against passive resistance. c. Instruct the client to look up and down without moving their head. d. Observe the client's ability to smile and frown.

Instruct the client to look up and down without moving their head.

The evening shift nurse is caring for a client who is scheduled for surgery. The client states "I once got a rash from wearing rubber gloves." Which of the following actions should the nurse take? a. Notify the operating room staff that the client has an allergy to sulfur-containing products. b. Notify the surgeon so that the surgery can be cancelled. c. No intervention is needed since the client will not be wearing gloves. d. Note in the medical record that the client has a latex allergy.

Note in the medical record that the client has a latex allergy.

The nurse is reviewing the laboratory data of a client with rheumatoid arthritis who is taking prescribed methotrexate. Which of the following results would indicate to the nurse the client is experiencing an adverse effect of the medication? a. Blood glucose of 125 d/L b. ALT of 30 U/L c. WBC of 10,000 mm3 d. Platelet count of 100 μL

Platelet count of 100 μL

When assessing a 53-yr-old client with bacterial meningitis, the nurse obtains the following data. Which finding requires the most immediate intervention? a. The client has a positive Kernig's sign b. The client exhibits nuchal rigidity c. The client's temperature is 101° F (38.3° C) d. The client's blood pressure is 88/42 mm Hg

The client's blood pressure is 88/42 mm Hg

A client has been admitted with meningococcal meningitis. Which observation by the nurse requires action? a. The client receives a regular diet tray b. Staff have turned off the lights in the client's room c. Staff have entered the client's room without a mask d. The bedrails on both sides of the bed are elevated

Staff have entered the client's room without a mask

Which action will the nurse take when caring for a client with osteomalacia? a. Emphasize the importance of sunscreen use when outside b. Educate about the need for weight-bearing exercise c. Teach about the use of vitamin D supplements d. Discuss the use of medications such as bisphosphonates

Teach about the use of vitamin D supplements

The nurse advises a client with myasthenia gravis (MG) to: a. anticipate the need for weekly plasmapheresis treatments b. perform physically demanding activities early in the day c. do frequent weight-bearing exercise to prevent muscle atrophy d. protect the extremities from injury due to poor sensory perception

perform physically demanding activities early in the day

The nurse is assessing a client with a spinal cord injury following a skiing accident. Which of the following techniques should the nurse use to test the function of the spinothalamic tract? a. ask the client to push the lower extremity against an opposing force b. apply light pressure from a sharp object to the client's lower extremity c. strike the client's patella tendon with a hammer d. instruct the client to perform straight leg raise

apply light pressure from a sharp object to the client's lower extremity

The nurse is assessing a client who has a suspected right hip fracture following a fall. Which of the following findings would require immediate follow up by the nurse? a. edema and ecchymosis over the right hip b. diminished pedal pulse and capillary refill greater than 3 seconds in affected extremity c. right leg appears shorter than the left leg and client reports pain level of 6 d. adduction of the affected extremity is noted

diminished pedal pulse and capillary refill greater than 3 seconds in affected extremity

When obtaining a health history and physical assessment for a 36-yr-old female client with possible multiple sclerosis (MS), the nurse should: a. inquire about urinary tract problems b. inspect the skin for rashes or discoloration c. assess for the presence of chest pain d. ask the client about any increase in libido

inquire about urinary tract problems

A nurse in a medical clinic is providing teaching to an older adult client who has osteoarthritis that is affecting her knees. Which of the following client statements indicates an understanding of the teaching? A. "I can use either heat or ice to help relieve the discomfort." B. "Ibuprofen is the first step in medication therapy for osteoarthritis." C. "I should limit physical activity to prevent further injury." D. "I will elevate my legs by placing two pillows under my knees when I go to bed."

A

A nurse is preparing a client for ambulation. Which of the following actions should the nurse take to determine the client's level of strength? A.Assess the patient's weight bearing status. B.Ask the client to touch her finger to her nose. C.Palpate the client's pedal pulses. D.Ask the client to push her feet against the nurse's palms. E.Give medication right before ambulating

A

A patient is taking Phenytoin for treatment of seizures. Which statement by the patient requires you to re-educate the patient about this medication? A."Every morning I take this medication with a full glass of milk with my breakfast." B."I know it is important to have my drug levels checked regularly." C."I will report a skin rash immediately to my doctor." D."This medication can lower my body's ability to clot and fight infection."

A

After surgery your patient starts to shiver uncontrollably. What nursing intervention would you do FIRST? A. Apply warm blankets & continue oxygen as prescribed B. Take the patient's rectal temperature C. Page the doctor for further orders D. Adjust the thermostat in the room

A

As a nurse, which statement is incorrect regarding an informed consent signed by a patient? A. The nurse is responsible for obtaining the consent for surgery B. Patients under 18 years of age may need a parent or legal guardian to sign a consent form C. The nurse can witness the client signing the consent form D. It is the nurse's responsibility to ensure the patient has been educated by the physician about the procedure before informed consent is obtained

A

A nurse is assessing a client for early manifestations of rheumatoid arthritis (RA). Which of the following changes is an early manifestation of RA? A.Morning stiffness B.Fatigue C.Temporomandibular joint pain D.Baker's cysts

B

The nurse is assessing a client who has Parkinson's disease. Which of the following findings should the nurse expect with this client? a. Flaccid muscles b. Bradykinesia c. Dry skin d. Xerostomia

Bradykinesia

A nurse in an acute care facility is preparing to admit a client who has myasthenia gravis. Which of the following supplies should the nurse place at the client's bedside? A. metered-dose inhaler B. Continuous passive motion machine C. Oral-nasal suction equipment D. External defibrillator pads

C

The nurse in the post-anesthesia care unit (PACU) is caring for a female client who had an abdominal cholecystectomy. The client states "I think I am going to vomit." Which of the following interventions should the nurse perform? a. Position the client in the lateral recumbent position. b. Tilt the client's head back and elevate the jaw. c. Administer beta-adrenergic drugs as prescribed. d. Increase the client's IV fluids

Position the client in the lateral recumbent position.

The nurse is caring for a client who is postoperative appendectomy who has a prescription to ambulate. Which of the following actions should the nurse take first before ambulating the client? a. Position the client on the side of the bed b. Provide the client with additional oral fluids c. Have the client do deep breathing exercises d. Encourage the client to stand up quickly to alleviate abdominal pain.

Position the client on the side of the bed

Match the Terms a. Abduction b. Adduction c. Flexion d. Extension e. Internal Rotation f. External Rotation ____ is rotation towards the center of the body ____ refers to a movement that decreases the angle between two body parts. ____ movement towards the midline. ____ is rotation away from the center of the body ____ movement away from the midline ____ refers to a movement that increases the angle between two body parts.

__e__ is rotation towards the center of the body __c__ refers to a movement that decreases the angle between two body parts. __b__ movement towards the midline. __f__ is rotation away from the center of the body __a__ movement away from the midline __d__ refers to a movement that increases the angle between two body parts.