Exam 3 review

THE NURSE IS PLANNING A TEACHING WORKSHOP AT THE LOCAL COMMUNITY CENTER FOR A GROUP OF 66-YEAR-OLD MEN AND WOMEN. WHAT INFORMATION IS MOST IMPORTANT TO INCLUDE AT THE WORKSHOP? a. A booklet on heart disease and diabetes b. Planning leisure activities and exercise c. How to stay connected with family members d. A list of doctor names in the community

B

A CLIENT HAS NOTICED A DECREASE IN TASTE SENSATION. WHICH OF THE FOLLOWING CRANIAL NERVES ARE MOST LIKELY INVOLVED? a. CN V and CN VII b. CN VII and CN IX c. CN V and CN VIII d. CN VI and CN X

B

A CLIENT IS ADMITTED TO THE HEALTH CARE FACILITY WITH BOWEL OBSTRUCTION SECONDARY TO COLON CANCER. THE NURSE OBTAINS A HEALTH HISTORY, MEASURES VITAL SIGNS, AND AUSCULTATES FOR BOWEL SOUNDS. WHICH STEP OF THE NURSING PROCESS IS SHE PERFORMING? A: PLANNING B: ASSESSMENT C: EVALUATION D: IMPLEMENTATION

B

A NURSE IS ASSESSING A CLIENT WHO REPORTS ABDOMINAL PAIN, NAUSEA, AND DIARRHEA. THE NURSE KNOWS THAT PALPATING THE ABDOMEN FIRST WOULD: A: BE AN APPROPRIATE INTERVENTION. B: ALTER ABDOMINAL SOUNDS FROM BASELINE. C: HELP THE CLIENT'S SYMPTOMS. D: MAKE IT EASIER TO HEAR THE BOWEL SOUNDS IN ALL FOUR QUADRANTS.

B

THE NURSE IS ASSESSING A CLIENT WITH COPD. WHICH REQUIRES IMMEDIATE INTERVENTION? A: DISTANT HEART SOUNDS B: DIMINISHED LUNG SOUNDS C: INABILITY TO SPEAK D: PURSED LIP BREATHING

C

A CLIENT IS ADMITTED TO THE PREOPERATIVE CLINIC FOR A BREAST BIOPSY. WHICH INFORMATION WOULD THE NURSE ENTER INTO THE MEDICAL RECORD AS OBJECTIVE DATA? A: LEFT BREAST IS TENDER TO TOUCH. B: CLIENT STATES, "I AM WORRIED ABOUT THE RESULTS." C: ANXIETY LEVEL OF CLIENT IS RATED AT 7 OUT OF 10. D: BLOOD PRESSURE 130/90 MM HG; PULSE 100 BPM; RESPIRATIONS 14 BREATHS/MIN

D

A NURSE CAN AUSCULTATE FOR HEART SOUNDS MORE EASILY IF THE CLIENT IS: A: SUPINE. B: ON HIS RIGHT SIDE. C: HOLDING HIS BREATH. D: LEANING FORWARD.

D

THE CORRECT PROCEDURE FOR AUSCULTATING THE CLIENT'S ABDOMEN FOR BOWEL SOUNDS IS TO: A: PALPATE THE ABDOMEN FIRST TO DETERMINE CORRECT STETHOSCOPE PLACEMENT. B: ENCOURAGE THE CLIENT TO COUGH TO STIMULATE MOVEMENT OF FLUID AND AIR THROUGH THE ABDOMEN. C: PLACE THE CLIENT ON THE LEFT SIDE TO AID AUSCULTATION. D: LISTEN FOR 5 MINUTES IN ALL FOUR QUADRANTS TO CONFIRM ABSENCE OF BOWEL SOUNDS.

D

WHICH STATEMENT REGARDING HEART SOUNDS IS CORRECT? A: S1 AND S2 SOUND EQUALLY LOUD OVER THE ENTIRE CARDIAC AREA. B: S1 AND S2 SOUND FAINTER AT THE APEX THAN AT THE BASE. C: S1 AND S2 SOUND FAINTER AT THE BASE THAN AT THE APEX. D: S1 IS LOUDEST AT THE APEX, AND S2 IS LOUDEST AT THE BASE.

D

PERRLA WHAT DOES THIS SAY?

PUPILS EQUAL ROUND AND REACTIVE TO LIGHT AND ACCOMMODATION

A NURSE IS CHANGING A CLIENT'S DRESSING. WHICH OBSERVATION OF THE WOUND WARRANTS IMMEDIATE PHYSICIAN NOTIFICATION? A: APPROXIMATED WOUND EDGES B: YELLOW, PURULENT DRAINAGE C: SUTURES IN PLACE D: PINK GRANULATION TISSUE

B

A 75-YEAR-OLD WHITE FEMALE PATIENT SAYS, "I'VE HEARD THAT WOMEN LIVE TO AN OLDER AGE THAN MEN DO. MY HUSBAND AND I ARE THE SAME AGE, SO I AM AFRAID I WILL HAVE TO SPEND SOME YEARS WITHOUT HIM. THAT REALLY WORRIES ME." WHICH ANSWER IS BASED ON CORRECT INFORMATION? A. "THAT IS A REALISTIC CONCERN, AS WOMEN DO HAVE A LONGER LIFE EXPECTANCY THAN MEN. BUT MANY THINGS CAN HAPPEN TO CHANGE THAT." B. "YOU NEED NOT WORRY BECAUSE BOTH YOU AND YOUR HUSBAND ARE WHITE. THAT STATISTIC IS TRUE ONLY FOR BLACK MEN AND WOMEN." C. "IT IS TRUE THAT WOMEN HAVE A LONGER LIFE EXPECTANCY AT BIRTH. HOWEVER, LIFE EXPECTANCY MEASURED AT AGE 65 IS ALMOST THE SAME FOR BOTH SEXES. YOU ARE BOTH WELL PAST 65." D. "THAT IS TRUE ONLY IN CERTAIN GEOGRAPHICAL AREAS, SUCH AS THOSE WITH A HIGH POPULATION OF NEWLY RETIRED PERSONS."

C

TO EVALUATE A CLIENT'S REASON FOR SEEKING CARE, A NURSE PERFORMS DEEP PALPATION. WHAT IS THE NURSE ASSESSING? A: Dehydration B: Skin Turgor C: Organs D: Temperature

C

A CLIENT HAD A LIVER BIOPSY 1 HOUR AGO. THE NURSE SHOULD FIRST A: AUSCULTATE LUNG SOUNDS. B: CHECK FOR FEVER. C: OBTAIN A CBC. D: APPLY PACKING TO THE BIOPSY SITE.

A

THE JOINT COMMISSION'S NATIONAL SPEAK UP® CAMPAIGN ENCOURAGES PATIENTS TO BECOME ACTIVE AND INFORMED PARTICIPANTS ON THE HEALTHCARE TEAM. THE GOAL IS TO: a. Prevent healthcare errors b. Help control the cost of healthcare c. Reduce the number of automobile accidents d. Provide a forum for people without health insurance

A

THE NURSE IS INSPECTING THE CLIENT'S ABDOMEN (SEE THE ACCOMPANYING IMAGE). THE NURSE SHOULD DOCUMENT THAT THE CLIENT'S ABDOMEN: A: IS FLAT AND SYMMETRICAL. B: HAS AN AORTIC PULSATION. C: REVEALS A HERNIA. D: SHOWS STRIAE.

A

WHICH CLINICAL SIGNS WOULD INDICATE TO A NURSE CARING FOR A TERMINALLY ILL CLIENT THAT DEATH MAY BE IMMINENT? A: DIMINISHED URINE OUTPUT AND CHEYNE-STOKES RESPIRATIONS B: NARROW PULSE PRESSURE AND A BODY TEMPERATURE OF 98.6°F (37°C) C: SWALLOWING REFLEX AND BOWEL SOUNDS PRESENT D: RESPIRATIONS REGULAR AT 18 BREATHS/MIN AND WEAK PEDAL PULSES

A

A CLIENT IS CONCERNED ABOUT THE AGE-RELATED CHANGES OF HER MOTHER, WHO IS 80 YEARS OLD. WHICH STATEMENT(S) MADE BY THE CLIENT WOULD LIKELY REPRESENT A NORMAL CHANGE OF AGING? SELECT ALL THAT APPLY. A. "MY MOTHER SEEMS TO GET COLD VERY EASILY." B. "MY MOTHER COMPLAINS OF HER MOUTH BEING DRY." C. "MOTHER GOES AROUND THE HOUSE TURNING ON ALL THE LIGHTS." D. "MOTHER COMPLAINS OF LEAKING URINE WHEN SHE COUGHS."

ABC

AFTER A PATIENT HAS AN ARGUMENT WITH HER HUSBAND, SHE BECOMES VERBALLY ABUSIVE TO THE NURSE WHO IS CARING FOR HER. WHICH COPING MECHANISM IS THIS PATIENT EXHIBITING? A. REACTION FORMATION B. DISPLACEMENT C. DENIAL D. CONVERSION

B

An 18-year-old woman comes to the obstetrician's office and is informed that she is 6 weeks pregnant. Which statement by the woman is the nurse most concerned about? a. "I eat a pretty healthy diet with lots of fruits and vegetables, so I think I'm okay with my diet." b. "With my current job, I won't be able to keep up with prenatal visits so I will read some books on prenatal care." c. "Is it too early to think about babysitting arrangements or should I start looking now?" d. "Some people may think I am too young to be a mother. What do you think?"

B

THE NURSE IS ASSESSING A CLIENT'S NUTRITIONAL STATUS BEFORE SURGERY. WHICH OBSERVATION WOULD INDICATE POOR NUTRITION IN A 5-FOOT 7-INCH (170 CM) FEMALE CLIENT WHO IS 21 YEARS OF AGE? A: POOR POSTURE B: BRITTLE NAILS C: DULL EXPRESSION D: WEIGHT OF 128 LB (58.1 KG)

B

A nurse is preparing a client for a physical assessment. The client appears anxious about the assessment. Which statement by the nurse would be most appropriate? A. "This is nothing to worry about. I won't hurt you." B. "Some of the examination may be painful, but I will be gentle." C. "Let me tell you what I will be doing. It should not be painful." D. "I have to do this, so just relax and it won't last long."

C

TO ASSESS THE EFFECTIVENESS OF CARDIAC COMPRESSIONS DURING ADULT CARDIOPULMONARY RESUSCITATION (CPR), A NURSE SHOULD PALPATE WHICH PULSE SITE? A: RADIAL B: APICAL C: CAROTID D: BRACHIAL

C