Concept Exam 2.1

During an outpatient visit you are assessing the patient's understanding about the signs and symptoms associated with osteoporosis. Select all of the sings and symptoms stated by the patient that are correct?

- Dowager's Hump - Some patients are asymptomatic - Fractures most commonly in the hips, wrist, and spine

Which patient below is NOT at risk for osteoporosis?

A 30 year old make who drinks alcohol occasionally and has a BMI of 28. Risk: Post-menopause, glucocorticoids, seizures

Intravenous heparin therapy is prescribed for a client. While implementing this prescription, the nurse ensures which medication is available on the unit?

Protamine Sulfate

The home health nurse is monitoring a client with gestational hypertension who is at risk for preeclampsia. At each home care visit, the nurse assesses the client for which classical signs of preeclampsia? Select all that apply:

Proteinuria, Hypertension, Generalized edema

While reviewing the result of an intravenous pyelogram, the nurse discovers that the client has a shortened urethra. The client also complains of urinary incontinence. Which nursing intervention is beneficial for the client?

Providing thorough perineal care after each voiding

The nurse is caring for a client with peripheral arterial disease (PAD) for which symptoms does the nurse assess?

Reproducible leg pain with exercise

The nurse is reviewing a health care provider's order for a child with sickle cell anemia who was admitted to the hospital for the treatment of vaso-occlusive crisis. Which orders should the nurse question?

Restrict fluid intake

A patient who has a history of pulmonary valve stenosis tells the healthcare provider, "I don't have a lot of energy anymore, and both of my feet get swollen in the late afternoon." Which of these problems does the healthcare provided conclude is the likely cause of these clinical findings?

Right side heart failure- S/S of heart failure is bilateral peripheral edema and fatigue.

Bones play an important role in the body. Which of the following is NOT a function performed by the bones?

Secrete hormone calcitonin and store blood cells

A patient is diagnosed with heart failure and is prescribed digoxin (Lanoxin) and furosemide (Lasix). Before administration the furosemide to the patient, which laboratory result should the healthcare provider to review?

Serum potassium

Which instruction would be most beneficial for an aging African-American client with hypertension?

"Have an annual urinalysis."

When obtaining a health history of a patient admitted with a diagnosis of heart failure, which statement made by the patient supports the diagnosis of heart failure?

"I get short of breath when walking."

A patient is diagnosed with primary hypertension. When taking the patient's history, the healthcare provider anticipates the patient will report which of the following?

"I haven't noticed any changes in my health."

The nurse educates an obese adolescent about healthy dietary habits and risk associated with obesity. Which statement by the adolescent indicates the need for further counseling?

"I should watch more TV to reduce stress."

The nurse provides discharge instructions to a client who is taking warfarin sodium (Coumadin). Which statement, by the client, reflects the need for further teaching?

"I will take enteric-coated aspirin for my headache because it is coated."

A patient diagnosed with mild heart failure is prescribed hydrochlorothiazide. The healthcare provider should determine the teaching about the medication has been successful if the patient makes which of these statements?

"It is important for me to change positions slowly because I might become dizzy."- Caused by the diuretic effect and decrease in fluid volume.

Which statement should the nurse include when providing anticipatory guidance to the patents of a 3 year old client?

"It is important to set limits with your child."

The nursing leader is teaching the newly hired nurse about the use of an electronic medication administration record. Which statement of the newly hired nurse indicates effective learning?

"It will identify medication errors."

A nurse is caring for an obese client with diabetes mellitus. Which nursing actions satisfy the Quality and Safety Education for Nurses (QSEN) competency called teamwork and collaboration? Select all that apply:

- Engaging the physical therapist in managing the client's condition. - Explaining the client's medication routine tot he next shift nurse. - Consulting with the dietitian to help manage the client's condition.

Based on Virchow's Triad, select which patients below are at RISK for the development of a deep vein thrombosis? Select all that apply:

- A 70 year old female with severe sepsis - A 25 year old male who uses intravenous drugs - A 65 year old female who is post-op day 1 after joint replacement surgery

When caring for a client with a fractured hip, the nurse should place pillows around the injured leg to specifically maintain what?

Abduction

A client with an inflamed sciatic nerve is to have a conventional transcutaneous electrical nerve stimulation (TENS) device applied to the painful nerve pathway. When operating the TENS unit, which nursing action is appropriate?

Adjust the dial on the unit until the client states the pain is relieved

A client is admitted to the hospital with a diagnosis of renal calculi. The client is experiencing severe flank pain and nausea, the temperature is 100.6ºF. Which of the following would be a priority outcome for this client?

Alleviation of pain

A patient tells the healthcare provider, "I stopped taking my medication because it kept me up at night with a dry cough." When reviewing the patient's medical record, which of these antihypertensive medications will the healthcare provider identify as the likely cause of tis patient's report?

Angiotensin converting enzyme inhibitor (ACE I) - Not for COPD or Asthma

Which action will the nurse take in order to evaluate the effectiveness of Buck's traction for a patient who has an intracapsular fracture of the left femur?

Ask about left hip pain level

The nurse is caring for a client who is three days post-operative repair of a hip fracture. The client reports shortness of breath and difficultly breathing. What should the nurse's first action be?

Assess her vital signs, perform a respiratory assessment, and be prepared to start oxygen.

A pregnant woman was diagnosed with hypertension and was administered magnesium sulfate. What drug should be co-administered to prevent magnesium toxicity?

Calcium gluconate

A home care nurse visits a pregnant client who has a diagnosis of mild preeclampsia. Which assessment findings indicates a worsening of the preeclampsia and the need to notify the health care provider?

Client complains of headache and blurred vision

A nurse is teaching a group of clients with peripheral vascular disease about a smoking cessation program. Which physiologic effect of nicotine should the nurse explain to the group?

Constriction of the peripheral vessels increases the force of flow

Which intrinsic factors may contribute to falls in older adults? Select all that apply:

Deconditioning, Impaired vision

After abdominal surgery a client reports pain. What action should the nurse take first?

Determine the characteristics of the pain

Which diagnostic study is used to detect deep vein thrombosis in the client's lower extremities?

Duplex venous doppler

Health promotion efforts for a chronically ill client should include interventions related to primary prevention. What should this include?

Encouraging daily physical exercise

Which are extrinsic factors responsible for falls in older adults? Select all that apply:

Environmental hazards, Inappropriate footwear, Improper use of assistive devices

What medication does a nurse expect to administer to control bleeding in a child with hemophilia A?

Factor VIII concentrate

True or False: Assessment of Homan's Sign is the most reliable indicator of deep vein thrombosis.

False

A patient is prescribed a calcium channel blocker to treat primary hypertension. When teaching the patient about the medication, which of these foods will the healthcare provider advise the patient to avoid?

Grapefruit

The nurse is providing care to a client with chronic pain. During assessment, what findings would the nurse expect?

Heart rate, blood pressure, and pulse rate may be normal while the client is experiencing pain.

What is contact precautions?

Prevents transmission of disease by direct or indirect contact. Ex: diarrhea, draining wound

The nurse is planning to administer hydrochlorothiazide. The nurse understands that which is a concern related to the administration of this medication?

Hypokalemia, hyperglycemia, sulfa allergy

When discussing hypertension with a student, which of the following will the healthcare provider identify as a factor related to hypertension?

Increased afterload

A patient is being assessed for possible heart failure. Which of these laboratory results will provide support for this diagnosis?

Increased brain natriuretic peptide (BNP)

The nurse provides education related to the relationship between aerobic exercise and weight loss to an obese client. The nurse evaluates that teaching is effective when the client states which effect of exercise?

Increases my lean body mass

When assessing a patient with chronic heart failure, the healthcare provider would expect to identify which of these clinical manifestations?

Inspiratory crackles - When there is decreased pumping ability of the heart, fluid backs up into the pulmonary system.

After a deep vein thrombosis developed in a postpartum client, an intravenous (IV) infusion of heparin therapy was instituted 2 days ago. The client's activated partial thromboplastin time (aPTT) is now 98 seconds. What should the nurse do next?

Interrupt the infusion and notify the primary healthcare provided of the aPTT result- Normal clotting time is 25 to 36 seconds.

The school nurse is assessing a 10-year-old boy with hemophilia who has fallen while playing in the schoolyard. At which site does the nurse expect to find internal bleeding?

Joints

What is droplet precautions?

Organisms that can be spread by large-particle droplets. Ex: Influenza

An infant is admitted to the hospital with gastroenteritis. The infant vomits shortly after admission. Under standard precautions, what protective equipment should the nurse wear when cleaning the infant after the vomiting episode?

Pair of gloves

The nurse analyzes the laboratory results of a child with hemophilia. The nurse understands that which result will most likely be abnormal in this child?

Partial thromboplastin time

A patient has been admitted to the cardiac unit with a diagnosis of right ventricular failure. Which of the following assessment findings would the healthcare provider expect to observe by the healthcare provider?

Peripheral edema and juglar vein distention

A 16-year-old girl with sickle cell anemia is experiencing a painful episode (vaso-occlusive crisis) and has a patient-controlled analgesia (PCA) pump. She complains of pain (5 on a scale of 1 to 10) in her right elbow. The nurse observes that the pump is "locked out" for another 10 minutes. What action should the nurse implement?

Placing the prescribed as-needed warm, wet compress on the elbow

A client in sinus bradycardia with a heart rate of 45 beats/minutes, complains of dizziness and has a blood pressure of 82/60 mm Hg. Which prescription should the nurse anticipate will be prescribed?

Prepare for transcutaneous pacing

The nursing student is teaching a client who has undergone hip replacement surgery. Which instructions from the nursing student indicate a need for correction? Select all that apply:

Sit on chairs without arms, Cross legs at the knees or ankles

Which physiologic changes of the musculoskeletal system are related to aging? Select all that apply:

Slowed movement, Cartilage degenerations, Increased bone prominence

A client with heart failure is to receive digoxin and asks the nurse why the medication is necessary. What physiologic response will the nurse include when answering the client's question?

Slows and strengthens cardiac contractions

The nurse is providing home care instructions to the parents of a 10 year old boy with hemophilia. Which sport activity should the nurse suggest?

Swimming

The nurse is providing education for an individual receiving treatment with a transcutaneous electrical nerve stimulation (TENS) unit. What information should the nurse include in the teaching?

The client can adjust both voltage and pulsation

When providing nutritional counseling for patients at risk for coronary artery disease, which foods would the nurse encourage patients to include in their diet? Select all that apply:

Tofu, Walnuts, Tuna fish - All are rich in Omega-3 Fatty acids

A patient who is newly diagnosed with stage 1 hypertension is being evaluated by a healthcare provider. Which of the following laboratory test would indicate organ damage that mat result from hypertension?

Urinalysis

What is neutropenic precautions?

Used with patients who are immunocompromised. Ex: AIDS, chemotherapy

During a follow-up visit, a nurse finds that flexion contractures have developed in a client with osteoarthritis (OA). Which factor may have led to this condition?

Using large pillows under the knees or head

The nurse is caring for an elderly client who has a right hip fracture. Which priority intervention should be included in the plan of care?

Venous thromboembolism (VTE) prevention

A client with coronary artery disease is scheduled for a cardiac catheterization. What should the client be able to describe if the nurse's preoperative teaching is considered effective?

What will be expected during the procedure