Exam 1- Med Surg 1

The client reports chest pain. The nurse uses which of the following questions to assess the pain further. Select all answers that apply.

"How long have you experienced this pain?" "Please point to where you are experiencing pain." "Rate the pain on a scale of 0 to 10, with 10 being the worst possible pain." "What aggravates your chest pain?"

A teenage client is undergoing a dressing change to burns on the thigh. The client refuses pain medication and states, "I do not hurt, and I don't need it." He is withdrawn, grimaces, and turns away during the dressing change. He was last medicated 8 hours ago. What is the best statement by the nurse?

"I saw you grimacing during the dressing change. Please explain the reason you refused the pain medication."

The nurse is to administer meperidine 75 mg intramuscularly to a client. The medication is supplied in an ampule of 50 mg/mL. How many milliliters should the nurse administer to the client? Enter the correct number ONLY.

1.5

A waist circumference greater than which value indicates excess abdominal fat in men?

101.60 cm (40 in)

Normal BMI

18.5-24.9

overweight bmi

25-29.9

Obesity BMI

30 or greater

The prodromal phase of acute radiation exposure cost up to ______ Hours after exposure

48 - 72

When calculating ideal body weight for women, the health care professional adds how many pounds for each inch of height over 5 feet?

5

A nurse is providing discharge instruction to a victim who has been exposed to anthrax but does not have any symptoms. The nurse's teaching includes that prophylactic antibiotics must be taken for:

60 days.

A client who has lost weight asks a nurse about how much physical activity is needed to prevent regaining the weight. Which of the following would the nurse recommend?

60 minutes per day

What percentage of people older than 65 years of age has one or more chronic disease?

80

underweight BMI

<18.5

What underline focus is any definition of nursing is the registered nurses responsibility in practice? A. Appraise an enhance a person's health seeking perspective B. Coordinate a patient's total health management with all disciplines C. Diagnose acute pathology D. Treat acute clinical reactions to chronic illness

A

______ Is recognized as the most likely what a nice biologic agent available

Anthrax

Which health promotion model does the nurse identify is the reason some people choose actions to foster health and others refused to participate?

Health belief model

A client had a previous myocardial infarction and has been experiencing angina from occluded coronary arteries. What teaching should the nurse provide in the stable phase of the Trajectory Model of Chronic Illness?

Encourage the family to support the client's exercise plan.

Which substance reduces the transmission of pain?

Endorphins

The nurse is planning care for a client with a chronic leg ulcer. By including therapeutic touch as an intervention, the nurse is including which alternative therapies?

Energy therapy

A client being treated for rheumatoid arthritis has been prescribed a glucocorticosteroid. How should the nurse best ensure this client's safety during treatment?

Ensure the client knows to taper down the dose if it is discontinued by the care provider.

A client has been prescribed a fentanyl patch for pain control. The nurse understands that this patch should be replaced how often?

Every 48-72 hours

During a disaster, the nurse triages a victim with a fractured wrist. Which color triage tag should the nurse apply?

Green

A client presenting with symptoms of left-sided heart failure has been admitted to a health care center. Which statement accurately reflects the priority in this client's nursing care at admission and the days immediately after discharge from the acute care setting?

Initial nursing care at the hospital includes a respiratory assessment; after discharge, the home nurse provides education related to medical management of heart failure.

A patient is being brought into the ED who is probably infected with anthrax. The nurse should ensure what level of personal protective equipment to wear for everyone who will come in contact with the patient?

Level D

A client is reporting her pain as "8" on a 0-to-10 pain intensity scale. Then, the client states the pain is "3." Before the nurse leaves the room, the client states her pain is "6." The best action of the nurse is to

Obtain a pain scale with faces for the client to measure her pain.

A nurse working in an emergency department notes that several clients who have arrived at the emergency department within the past day are experiencing the same unusual signs and symptoms. All the clients have attended the same sporting event. Which of the following should the nurse do next?

Obtain an extensive history from each of the clients.

Opioid analgesics are effective pain management tools for many clients. A significant portion of a nurse's practice is older adults who suffer from chronic pain. What impact does a client's age have on initial dosing?

Older clients should receive a reduced dose.

The nurse is administering an analgesic to an older adult patient. Why is it important for the nurse to assess the patient carefully?

Older people are more sensitive to drugs.

A client is receiving morphine through a patient-controlled analgesia (PCA) system following surgery. The nurse states to the client

Only you are to push the button for medication."

During review of a plan of care for a client, the nurse determines that the outcomes have not been achieved. The nurse believes an error may have been made during the planning phase of the nursing process. Based on this belief, what will the nurse consider during this evaluation step? Select all that apply.

Was the appropriate nursing diagnosis chosen? Do the nursing interventions need revision? What factors led to the achievement of the outcomes? Have new problems evolved requiring different interventions? Were the time frames appropriate to achieve the expected outcomes?

A client has just returned to the unit following abdominal surgery and is in significant pain. According to the nursing process, how frequently will the nurse perform assessments on this client?

as often as needed

The nurse working in the clinic has had several incidences of positive chlamydia cultures return in women with pelvic pain. The nurse understands that early diagnosis and treatment are essential measures in which to reduce contagion and limit the complications related to this infection. What type of prevention will the nurse use when these infections are treated?

Secondary prevention

A client has designated her daughter as a person to make healthcare decisions for the client if he is not able to do so. What type of advance directive is this considered?

Durable power of attorney (DPOA) for healthcare

A nursing instructor is discussing the causes of the increasing number of people with chronic conditions. Which of the following would the nurse correctly identify as a cause?

Early detection and treatment of diseases

During a nutritional assessment, the nurse measures a woman's waist at 38.5 inches (98 cm). Based on this finding, which of the following is a priority intervention?

Educate the client regarding her increased risk for hypertension and diabetes.

The advance nurse practitioner, who is treating a client diagnosed with neuropathic pain, decides to start adjuvant analgesic agent therapy. Which medication is appropriate for the nurse practitioner to prescribe?

Gabapentin

Choose the nursing statement that would best reflect the final component of the "ask tell ask close" technique of communication demonstration

"Can you repeat for me the information I just reviewed about weighing food portions?"

The nurse moves a confused, disruptive patient to a private room at the end of the hall so that other patients can rest, even though the confused patient becomes more agitated. The nurse's intervention is consistent with what moral theory?

"Consequentialism," by which good consequences for the greatest number are maximized

The nurse applies a transdermal patch of fentanyl for a client with pain due to cancer of the pancreas. The client puts the call light on 1 hour later and tells the nurse that it has not helped. What is the best response by the nurse?

"It will take approximately 12 to 18 hours for the medication to begin to work, so I will give you something else now to relieve the pain."

The advance practice nurse is treating a client experiencing a neuropathic pain syndrome. Which statements by the client demonstrates an understanding of concepts related to neuropathic pain?

"My phantom limb pain serves no purpose, and I may need to take antidepressants to help."

A nurse educator for a local home care company is teaching staff nurses on the use of the Outcome and Assessment Information Set (OASIS). What statement will the nurse include when teaching about the OASIS?

"Results are used to improve overall quality improvement efforts."

The nurse is caring for an older adult patient recently diagnosed with pancreatic cancer. The family has been informed of the diagnosis and states to the nurse we don't want any want to tell our parent with a diagnosis is we are just going to say that it is a stomach issue that will get better with time. And the family leaves the patient asked the nurse, what is wrong with me? What strategies can the nurse use to respect the patients rights? Select all that apply. A. Provide all information related to nursing procedures and diagnosis. B. Avoid lying to the patient when asked a direct question C. Make a referral to the institutions ethics committee D. Act as an advocate for the patients rights E. Encourage the family to make decisions for the patient

A, b, c, d

A 65-year-old client was diagnosed with multiple sclerosis 10 years ago. The client has difficulty ambulating and is seeking a prescription for a wheelchair. The nurse assesses the type of disability the client has is

Acquired

Myocardial infarction is an example of which type of disability?

Acute nontraumatic

The nurse is obtaining data regarding medications the client is taking on a regular basis. The client states he is taking duloxetine, an antidepressant for the treatment of neuropathic pain. What type of therapy does the nurse understand the client is receiving?

Adjuvant drug therapy

A client with end-stage dementia is admitted to the orthopedic unit after undergoing internal fixation of the right hip. How should the nurse manage the client's postoperative pain?

Administer analgesics around the clock.

The nurse is caring for a group of clients. What priority nursing intervention illustrates planned nursing care prioritized according to Maslow's hierarchy of needs?

Administer pain medication to a client before transportation to physical therapy for crutch-walking exercises.

How should the administration of analgesics be scheduled to provide a uniform level of pain relief to a client?

Administering the analgesics every three hours

When working in an acute care facility as part of a disaster response team, a nurse is preparing to care for clients requiring level C protection. Which of the following would the nurse need to wear?

Air-purified respirator

The nurse is caring for a client diagnosed with botulism. Which medication classification does the nurse anticipate?

Antitoxins

A patient who adheres to the dietary laws of Judaism is in traction and confined to bed. The patient needs assistance with the evening meal of chicken, rice, beans, a roll, and a carton of milk. Which nursing approach is most representative of promoting wellness?

Ask whether the patient would like to make any substitutions in the foods and fluids received.

In which situation is the nurse providing appropriate discharge planning?

Assessing the client's support system at home during the admission assessment

What does the nurse identify as the primary purpose of CQI? A. Identify measures to ensure minimal expectations of care B. Assess the impact of financial decisions on patient care delivery C. Examine processes that affect patient care in the need for improvement D. Review medication errors for individual patients

B

The nurse is caring for a client who expresses the belief that her illness (cellulitis) is a result of bacteria that has caused an infection. To which of the following views of disease/illness does this client allude?

Biomedical and/or scientific

Which area for assessing the client profile should be addressed last?

Body image

The nurse is caring for an older adult patient recently diagnosed with pancreatic cancer. The family has been informed of the diagnosis and states to the nurse we don't want any want to tell our parent with a diagnosis is we are just going to say that it is a stomach issue that will get better with time. And the family leaves the patient asked the nurse, what is wrong with me? The nurse talks with family members about the patient's desire to be informed of the diagnosis. The patient's family states, we just don't know what the right words to say. What is the best response by the nurse? A. Maybe it would be better to postpone telling the patient until you can say it correctly B. Would you like me to contact your clergy to be present with you C. I will wait outside of the room, and you can call me when you are finished. D. Would you like me to give the patient a sedative prior to the discussion

C

The nurse is caring for an older adult patient recently diagnosed with pancreatic cancer. The family has been informed of the diagnosis and states to the nurse we don't want any want to tell our parent with a diagnosis is we are just going to say that it is a stomach issue that will get better with time. And the family leaves the patient asked the nurse, what is wrong with me? What is the best response by the nurse to address the ethical dilemma? A. I don't know so it would be best to ask your family what the healthcare provider said. B. Your family would rather you not know what the diagnosis is and I can't say without permission. C. I will talk with your family and healthcare provider and inform them of your request for a diagnosis. D. Don't worry about your diagnosis right now let's just help you get better and take care of the pain.

C

The nurse is caring for a client with diabetes. Which of the following is a characteristic of chronic illness?

Chronic illness affects the entire family.

A patient was suspected of being in direct contact with anthrax but is exhibiting no signs or symptoms. What type of prophylaxis does the nurse know this patient will have to take?

Ciprofloxacin (Cipro) for 60 days

The nurse case manager is planning care for a 5-year-old client recently diagnosed with asthma. The client's mother informs the nurse that her child had shown similar symptoms in the past and was diagnosed with asthma at age 2 years. The nurse noted the client's symptoms and medical history. What information is appropriate for the case manager to share with the client's mother related to community resources and referrals? Select all that apply.

Community support groups for parents of children with asthma Asthma camp enrollment age requirements The Web address to the Allergy & Asthma Network Mothers of Asthmatics A list of pharmaceutical company assistance programs that may help pay for EpiPens

When using transdermal Fentanyl, the nurse and patient should be aware of which sign or symptom of Fentanyl overdose?

Confusion

The home health nurse has been working with an elderly client with limited means who required long-term wound care. The client's wound is almost healed and the client tells the nurse that he will be sorry when she no longer comes around. He reveals that he no longer has anyone to take him to the grocery store and he just can't keep the house up like he used to. He also tells the nurse that he would like to be able to participate in some social activities. The nurse knows that what type of healthcare setting would be most appropriate for this client at this time?

Congregate housing

While taking a nursing history, the nurse is made to feel uncomfortable when a client positions himself very close to the nurse. The nurse should do which of the following?

Consider that the client's cultural preferences for space and distance may be a reason for this behavior.

Which stage of the trans theoretical model occurs when the patient has serious consideration of change, but it is sometime in the future?

Contemplation

The registered nurse has a responsibility to practice nursing according to the social policy statement of the American nurses association. What definition of the ANA best describes the role of registered nurses? A. To diagnose and treat medical conditions B. To prescribe medications in order to treat a variety of medical conditions C. To prevent illness and maintain health D. To diagnose and treat the human responses to health and illness

D

Using the concept of the wellness-illness continuum, what would the nurse include in the development of a nursing care plan for a chronically ill patient. A. Educate the patient with every possible complication associated with that specific illness B. Encourage positive health characteristics within the limits of the specific illness C. Limit all activities because of the progressive deterioration associated with all chronic illnesses D. Recommend activity beyond the scope of tolerance to prevent early deterioration

D

Which term refers to a process by which an individual receives education about recognition of stress reactions and management strategies?

Defusing

In disaster triage, patients with injuries that are significant and require medical care I can wait hours without threat to life or limb are in the ______ category

Delayed and yellow

During a mass casualty incident a person who is injuries are significant they can wait hours without threat to life or limb a triage as a priority to and tagged with the color green

False

The physician has ordered a mu opioid analgesic for a patient with pain. What drug does the nurse anticipate administering?

Fentanyl

Which is a cause related to the increasing number of people with chronic conditions?

Improved screening and diagnostic procedures

Which of the following is an example of adherence to treatment

Maintaining a healthy diet Self monitoring for signs and symptoms of illness Taking prescribed medication's Increasing daily activities

A soldier is preparing to enter an area in which there is a high risk for chemical exposure to a nerve agent. What should the soldier be given prior to entering this area?

Mark I automatic injectors that contain 2 mg atropine and 600 mg pralidoxime chloride

The nurse understands that one of the characteristics of critical thinking is flexibility. What can the nurse do to achieve this characteristic?

Modify priorities and adapt to change.

Which statement provides accurate information related to chronic illness?

Most people with chronic conditions do not consider themselves sick or ill.

The Home Health nurse is planning teaching for a client with COPD and a history of noncompliance to the medication regimen. What factor does the nurse recognize as having the most influence on enabling complete adherence to the health regimen?

Motivation

The nurse knows that a framework that uses a language common to all aspects of nursing, regardless of the classification system, is desirable. In 2001, a taxonomy of nursing practice was developed and includes which of the following? Choose all that apply.

NANDA NIC NOC

A client, who had an above the knee amputation of the left leg related to peripheral vascular disease from uncontrolled diabetes, complains of pain in the left lower extremity. What type of pain is the client experiencing?

Neuropathic pain

Which chemical is a vesicant?

Nitrogen mustard

Which element is least likely to be a characteristic of an expected outcome of a nursing intervention?

Nurse-centered

The nurse is developing a health promotion program at a company in which many employees are women in their 20s and 30s. For this population, the nurse plans to include information about

Parenting issues

Which phase of the nursing process encompasses the establishment of expected outcome?

Planning

The nurse is preaparing to use the trans theoretical model of change with a client who smokes 2 packs of cigarettes per day. Place in order how the nurse will implement the stages of the model.

Precontemplative Contemplative Decision making Action Maintenance Termination

A client comes to the ED after ingesting cyanide. What is the first thing the nurse should anticipate doing?

Prepare the client for intubation.

Last long and Tim panic membrane rupture or two injuries that are common during the ______ phase of a blast injury

Primary

A nurse documents the presence of chronic pain on an electronic health record. Choose a description that could be used. The pain can be:

Prolonged in duration.

Which of the following describes the role of the nurse as defined by Florence Nightingale?

Putting the client in the best condition for nature to act upon him or her

The nurse is caring for a 12 year old client. When teaching the client, what tone of teaching should the nurse implement?

Relevant

A nurse is preparing keychain for a client with an auditory perceptual disorder. Which educational strategy will be most effective?

Repeat and reinforce words frequently

The client had a cerebrovascular accident with drooping of the face. Speech is slurred. The nurse is obtaining the admission assessment data. It would be best for the nurse to

Repeat back what the client states.

The nurse is preparing the teacher client about newly prescribed medication. The client lacks insurance. The medication cost approximately $100 per month. The client states "I can't afford it." The nurse assesses a variable to successful education and health promotion for this client based on the health belief model is

Resources

The emergency department nurse is caring for clients involved in a chlorine exposure accident at a local chemical plant. The nurse is aware that permanent damage can occur to which body systems?

Respiratory

The nurse is performing a focused assessment on a client. Which body system will the nurse examine first, according to the correct sequence of the complete physical examination?

Skin

A client reports abdominal pain as "8" on a pain intensity scale of 0-10 thirty minutes after receiving an opioid intravenously. Her past medical history includes partial-thickness burns to approximately 60% of her body several years ago. The nurse assesses.

That the client's past experiences with pain may influence her perception of current pain.

A nurse is planning discharge instructions for a client from another culture. What does the nurse understand about the relationship of values and beliefs and the client's readiness to learn?

The Client will be less likely to accept health education unless values and beliefs are respected

A nurse is evaluating the clients motivation to make decisions that promote healthy behavior change, using the trans theoretical model of change. Which description best describes the decision making stage of this model

The client constructs a plan to change behavior

A client has a nursing diagnosis of "Feeding self-care deficit related to right-sided weakness. Which of the following would be the most appropriate expected outcome for this client?

The client will demonstrate an ability to feed himself with a spoon at the morning meal.

Which is defined as the potential of an agent to cause injury to the body?

Toxicity

A disaster tag should be securely affixed to the patient's bed or stretcher during an emergency to facilitate identification and treatment

True

In the event of a natural disaster, loss of communications, portable water, and electricity is usually the greatest obstacle to a well coordinated emergency response, and preparatory planning as essential

True

Level a of the environmental protection agency's regulations concerning personal protective equipment for healthcare personnel requires use of a self-contained breathing apparatus and a chemical-resistant suit with gloves and boots

True

Smallpox and botulism are two examples of category a biological agents that may be weaponized

True

Which term refers to the tendency for a chemical to become a vapor?

Volatility

A client who will undergo emergency surgery suffers from chronic depression. The nurse is performing client teaching prior to the surgery. To make the client more comfortable, which of the following actions should the nurse take? Select all answers that apply.

Wait for the client to complete speaking even when answers are slow. Face the client when speaking to the client. Address the client by title and last name. Allow extra time for this client.

The nurse listens to a client explain that she is receiving manipulations from a health care provider. The nurse documents in the client's chart that the client is using which therapy?

chiropractic

A male client recovering from a stroke is receiving anticoagulant therapy. Which item will the nurse instruct the client to use for self-care?

electric razor

A cause related to the increasing number of people with chronic conditions is

improved screening and diagnostic procedures.

A client is prescribed methadone 10 mg three times a day for neuralgia following chemotherapy treatment. The client reports that he is experiencing constipation and asks the nurse for information about preventing constipation. The nurse recommends

increasing the amount of bran and fresh fruits and vegetables

When functioning in the practitioner role, the nurse would be involved in which of the following? Select all that apply.

providing direct care Collaborating with other disciplines Prescribing medications Teaching clients and families

The community health nurse is teaching a health care group levels of prevention. What is the nurse's foci with primary prevention? Select all that apply.

self-care promotion prevention of illness continuity of care collaboration with health care providers

A nurse is preparing to provide discharge teaching for a hospitalized 19-year-old client who is hearing impaired with functioning hearing aides. The television is on, and several of the client's fraternity brothers are present. What are potential teaching barriers for the nurse? Select all that apply.

television in use fraternity brothers

A longterm care facility's newest client refuses to attend group activities or social events offered by the facility. Which level of Maslow's hierarchy do social events address?

third: love and belonging needs

You are caring for clients who have been exposed to a toxic nerve agent. You will need to use diazepam with these clients. Why is diazepam given when managing the effects of toxic nerve agent toxicity?

to control possible seizures

A client is admitted with generalized abdominal pain, nausea, vomiting, and hypotension. The client has not passed stool in over 1 week and has been in pain for the past 4 days. Which type of pain would you expect the client to be experiencing?

visceral