Final Exam 1212C
49. A woman gave birth to a healthy newborn 1 month ago. The patient now reports she cannot cope and is unable to sleep or eat. She says, "I don't know why I had this baby. This baby is the root of all my problems." The priority nursing diagnosis is: A. Risk for other-directed violence B. Insomnia C. Ineffective coping D. Situational low self-esteem
A. Risk for other-directed violence
56. The nurse is teaching about treatment with a SSRI antidepressant. Which teaching considerations are appropriate?(Select all that apply.) A. The patient should notify the prescriber before taking any over-the-counter medications. B. The patient should be instructed to use caution when standing up quickly from a sitting position. C. The patient should be told which foods contain tyramine and instructed to avoid these foods. D. The patient should avoid herbal products containing St. John's wort. E. This medication should not be stopped abruptly.
A. The patient should notify the prescriber before taking any over-the-counter medications. B. The patient should be instructed to use caution when standing up quickly from a sitting position. D. The patient should avoid herbal products containing St. John's wort. E. This medication should not be stopped abruptly.
45. The nurse is caring for a patient with benign prostatic hypertrophy who states that he feels a constant urge to urinate but cannot pass more than 30 to 60 mL of urine into the toilet at a time. The nurse performs a bladder scan and finds that there are 1100 mL of urine in the patient's bladder. What is the priority nursing diagnosis for this patient? A. Urinary retention r/t obstruction of urinary bladder outlet B. Toileting self-care deficit r/t inability to pass urine into the toilet C. Alteration in comfort r/t continual urge to urinate D. Overflow urinary incontinence r/t over-distention of the bladder
A. Urinary retention r/t obstruction of urinary bladder outlet
14. A nurse is caring for a patient with an exacerbation of irritable bowel disease. Which medications can be used for the treatment of Crohn's disease and/or Ulcerative colitis? (Select all that apply.) A. acetominophen (Tylenol) B. Sulfasalazine (Azulfidine) C. Furosemide (Lasix) D. Prednisone (methylprednisone) E. Infliximab (Remicade)
A. acetominophen (Tylenol) B. Sulfasalazine (Azulfidine) E. Infliximab (Remicade)
51. A client who has been started on an androgen deprivation therapy (ADT) for the treatment of prostate cancer. Which of the following side effect would be uncommon while taking male hormone suppressing medications? A. increased libido B. erectile dysfunction C. hot flashes D. gynecomastia
A. increased libido
15. Which medication should the nurse anticipate administrating for a client diagnosed with acute exacerbation of inflammatory bowel disease? A. methylprednisone (Solumedrol) B. phenytoin (Dilantin) C. ibuprofen (Motrin) D. Furosemide (lasix)
A. methylprednisone (Solumedrol)
35. A client is being interviewed for an assessment related to erectile dysfunction. Which of the following medications are used to treat erectile dysfunction? (Select all that apply.) A. sildenafil (Viagra) B. cimetidine (Tagamet) C. testosterone (Androgel) D. tadalafil (Cialis) E. metoprolol (Lopressor) F. finasteride (Proscar)
A. sildenafil (Viagra) D. tadalafil (Cialis)
10. The physician orders digoxin (Lanoxin) 125mcg daily. The nurse has digoxin (Lanoxin) 0.25 mg tablets on hand. How many tablet(s) should the nurse administer? ______tablet(s)
ANS: 0.5
21. A client is undergoing hemodialysis treatments three times per week. The client is to receive 2500 units of Epoetin (Procrit) following each treatment. The medication vial states epoetin (Procrit) 5000 units/1 mL. The client should receive ____mL for one dose.
ANS: 0.5
3. The client is ordered Heparin 4,000 units subcutaneous twice a day. It is available in 5,000 units/ml. How much will the nurse administer for the morning dose? ______mL (round to the nearest tenth)
ANS: 0.8
23. The physician orders Ampicillin 150 mg IM for a systemic infection. After reconstitution, the medication is available as 125 mg/mL. How many milliliters will the nurse administer?
ANS: 1.2
8. The physician orders furosemide (Lasix) 30 mg bid IV . The furosemide (Lasix) is available in 40 mg/2ml vials. How much Lasix should the nurse administer per dose? ______ mL
ANS: 1.5
32. The nurse is to administer an infliximab (Remicade) infusion to a client who weighs 110 lbs. The client is to receive 5mg/kg of the drug, which is available as a 100 mg/10ml solution. The nurse will draw up _____ milliliters of solution for the clients solution
ANS: 25
16. The nurse is caring for a client with Type I diabetes. It is 0630 and the client's blood glucose is 300 mg/dl. The physician has ordered 25 units of NPH to be given at 0630 and sliding scale coverage if needed. According to the sliding scale provided, how much total insulin should be administered? ____ units Blood Glucose Below 150 150 - 200 201 - 250 251 - 300 Regular Insulin 0 units2 units4 units 6 units
ANS: 31
12. A patient on a ventilator has an order for a continuous Versed drip at 4 mg/h. The Versed concentration is 50 mg/50 mL of NS. Using an IV controller, how many milliliters per hour should the Versed be infused?
ANS: 4
9. Zosyn 4.5 g IV every 6 hours is ordered for a patient. The Zosyn is dissolved in 50 mL of NS and should infuse over 1 hour. Using tubing with a drop factor of 60 gtt/mL, how many drops per minute should the Zosyn be infused?
ANS: 50
48. The physician orders pantoprazole Protonix 150mg IV. You received pantoprazole 150 mg in 250ml of solution. The tubing delivers 10 gtts/mL. What is the drip rate to infuse over 30 minutes?
ANS: 83
64. A client does not understand why vision loss due to glaucoma is irreversible. What explanation by the nurse is best? A. "Because eye pressure was too high, the nerve tissue died." B. "Glaucoma always leads to complete permanent blindness." C. "The infection occurs so quickly it can't be treated." D. "The traumatic damage to your eye was too great.
A. "Because eye pressure was too high, the nerve tissue died."
42.. Which statement by a client indicates the need for clarification after pre-operative laparoscopic gallbladder surgery teaching? A. "My liver will replace the function of the gallbladder after surgery." B. "After my gallbladder is removed I will not be able to eat any meat." C. "I will have 3-4 small incisions on my abdomen." D. "Removal of my gallbladder will decrease episodes of cholecystitis."
A. "My liver will replace the function of the gallbladder after surgery."
53 A client is being evaluated for possible gastric ulcers? Which of the following statements by the patient does not correlate to a diagnosis of gastric ulcers? A. "My pain seems to get better when I eat." B. "I have lost 15 pound over the past month." C. "My stomach hurts more when I eat." D. "I was told I have a bacterial in my stomach."
A. "My pain seems to get better when I eat."
52. A nurse assesses clients on a medical-surgical unit. Which client should the nurse identify as having the greatest risk for development of cholecystitis? A. A 30-year-old overweight woman with diabetes mellitus B. An 86-year-old man with a history of colitis C. A 53-year-old postmenopausal woman who is on hormone therapy D. A 32-year-old Asian-American man with colorectal cancer
A. A 30-year-old overweight woman with diabetes mellitus
30. A nurse on a medical unit is caring for several patients. Which of the following patients are at risk for developing pyelonephritis? (Select all that apply.) A. A patient with Type ll Diabetes B. A patient who has a urinary tract infection C. A patient with a GFR of 100 mL/min D. A patient with bladder urgency E. A patient with a suspected renal calculi
A. A patient with Type ll Diabetes D. A patient with bladder urgency E. A patient with a suspected renal calculi
6. A client with glaucoma is being seen for routine evaluation of intraocular pressure (IOP). The IOP has increased from 15 to 23 since the last visit. What action by the nurse is best? A. Assess adherence to the eye drop regimen. B. Schedule the client for eye drainage surgery. C. Schedule for re-evaluation in 1 year D. Chart the intraocular pressure as within normal limits
A. Assess adherence to the eye drop regimen.
18 You are caring for a patient who has been brought to the emergency department by concerned family. The patient has been exhibiting signs of extreme sadness and verbalizing feeling of despair. What is a nursing priority action? A. Assess for depression and ask directly about suicide thoughts. B. Focus on the presenting problems and refer the patient for a mental health evaluation. C. Interview the patient's family to identify their concerns about the patient's behaviors. D. Ask the care provider to prescribe blood lab work to assess for depression.
A. Assess for depression and ask directly about suicide thoughts.
36. A patient is prescribed prednisone for 60 days to manage a moderate flare up of Crohn's disease. What medication facts should be discussed with the client while on this medication regimen? (Select all that apply.) A. Avoid people who have an infection B. Temporary weight gain is common C. Take this medication with food D. Do not eat or drink 1-2 hours before or after taking this medication E. Do not suddenly stop this medication F. You may experience dizziness if you experience a drop in blood sugar
A. Avoid people who have an infection B. Temporary weight gain is common C. Take this medication with food E. Do not suddenly stop this medication
70. Which of the following schizophrenic manifestations can be categorized as a positive symptom?A. Hallucinations B. Dysphoria C. Catatonic state D. Poverty of Thought
A. Hallucinations
61. The nurse is caring for a client with an severe attack of diverticulitis with possible intestinal obstruction. Which intervention should the nurse be prepared to implement? A. Insertion of a nasogastric tube for decompression B. Increase client activity level C. Provide a heating pad to the abdomen D. Administer daily, medicated enemass
A. Insertion of a nasogastric tube for decompression
2. A patient is in the recovery phase of acute kidney injury as a result of acute post- streptococcal glomerulonephritis. Which of the following orders should be questioned? A. Preparation for a Renal CT scan with contrast B. Monitor strict intake and output C. Weigh patient daily D. Penicillin 250mg every 6 hours for 10 days
A. Preparation for a Renal CT scan with contrast
31. A patient is in the recovery phase of acute kidney injury as a result of acute post- streptococcal glomerulonephritis. Which of the following orders should be questioned? A. Preparation for a Renal CT scan with contrast B. Monitor strict intake and output C. Weigh patient daily D. Penicillin 250mg every 6 hours for 10 days
A. Preparation for a Renal CT scan with contrast
20. A client is being prepared for emergency surgery. The client's medication list includes warfarin (Coumadin) 5 mg once a day. Which of the following test would the nurse anticipate to be ordered before surgery? A. Protime and INR B. Protamine level C. Partial thromboplastin time D. Vitamin K level (This is the antidote for warfarin overdose)
A. Protime and INR
5. A client is newly admitted to hospice and will continue to use morphine for pain management. Which of the following need to be included in the patient's education? A. "Take your stool softener everyday as ordered." B. "Avoid activities that can cause breaks in the skin." C. "Always use sunscreen when going outside." D. "Make sure you have good oral hygiene."
B. "Avoid activities that can cause breaks in the skin."
26. A client calls the office complaining that the escitalopram (Lexapro) she was started on last week is not working to improve her mood. The nurse would provide which of the following instructions: A. "Stop taking the medication and come in tomorrow for re-evaluation." B. "Continue the medication as prescribed and come in for your evaluation in 2 weeks as planned." C. "Supplement your medication with a dose of St. John's Wort." D. "Stop the medication and use relaxation techniques until your re-evaluation in 2 weeks."
B. "Continue the medication as prescribed and come in for your evaluation in 2 weeks as planned."
53.. Which documentation indicates that the treatment plan for a patient experiencing acute mania has been effective? A. "Irritable, suggestible, distractible; napped for 10 minutes in afternoon."B. "Converses without interrupting; clothing matches; participates in activities." C. "Heavy makeup; seductive toward staff; pressured speech." D. "Attention span short; writing copious notes; intrudes in conversations.
B. "Converses without interrupting; clothing matches; participates in activities."
28. A nurse is preparing to administer prednisone (Solumedrol) IV. Which nursing intervention should the nurse implement, related to the side effects of this medication? A. Assess apical heart rate for one minute B. Blood glucose monitoring C. Restrict oral intake D. Pulse-oximeter monitoring with any activity
B. Blood glucose monitoring
7.A patient's care plan includes monitoring for paranoid delusions. Which assessment findings suggest the patient may be experiencing active delusions? A. Elevated mood, hyperactivity, distractibility B. Darting eyes, tilted head, mumbling to self C. Aloofness, haughtiness, suspicion D. Performing rituals, avoiding open places
B. Darting eyes, tilted head, mumbling to self
19. A nurse is assessing the severity of bowel mucosa changes for a client with Crohn's disease. Which of the following labs would indicate that the disease progression shows malabsorption issues. A. Increased white blood cells B. Decreased serum albumin C. Decreased red blood cells D. Decreased erythrocyte sedimentation rate
B. Decreased serum albumin
13. A patient is admitted with bulimia nervosa. Which findings would the nurse expect? (Select all that apply.) A. hyperkalemia B. Russell's sign C. enlarged parotid glands D. eroded teeth enamel E. cachexia
B. Russell's sign C. enlarged parotid glands D. eroded teeth enamel
25. A patient is scheduled to receive an antibiotic on call to the OR before colorectal surgery. He does not have any manifestations of infection. The patient asks, "Why am I getting this medication if I do not have an infection? The nurse's best response would be: A. To reduce the number of resistant microorganisms B. To provide prophylactic therapy C. To treat a superinfection and prevent diarrhea D. To decrease the viral load
B. To provide prophylactic therapy
44. A 65 year old male is inquiring about taking sildenafil (Viagra) for erectile dysfunction. Which of these factors stated in his medical history will contraindicate the use of this drug? A. History of HIV/AIDSB. Uses nitroglycerine medication on a prn basis for angina pectoris B. Uses nitroglycerine medication on a prn basis for angina pectoris C. Frequent urinary tract infections D. Hypertension controlled with hydrochlorothiazide
B. Uses nitroglycerine medication on a prn basis for angina pectoris
84. Which of the following is a priority step when administering finsetride (Proscar) to a patient with benign prostatic hyperplasia? A. use only a tuberculin syringe B. don gloves C. wash your hands D. give the medication with meals only
B. don gloves
37. The nurse is seeing a patient who has been in the clinic eight times in the past 6 months for injuries from an abusive partner. The patient states, "I don't see any way to get away from my partner, and I can't keep going on like this." What assessment question is most important for the nurse to ask? A. "Have you discussed this with anyone else? B. "Do you have any family in the area that can help?" C. "Have you thought about hurting yourself or someone else?" D. "Have you thought about moving to a different city?"
C. "Have you thought about hurting yourself or someone else?"
68. A newly admitted patient diagnosed with schizophrenia says, "The voices are bothering me. They yell and tell me I'm bad. I have got to get away from them." Select the nurse's most helpful reply. A. "Do you hear the voices often?" B. "Forget the voices. Ask some other patients to sit and talk with you." C. "I will stay with you. Focus on what we are talking about, not the voices." D. "Do you have a plan for getting away from the voices?"
C. "I will stay with you. Focus on what we are talking about, not the voices."
57. A patient who is post-op after an amputation of a the distal foot due to a diabetic foot ulcer is prescribed pantoprazole (Protonix) IV push. The patient states, "I have never taken that medication before. Why are you giving it to me now?" The nurses best response would be: A. "This is a medication that will help prevent post op infections." B. "It must have been prescribed in error. I will call your HCP." C. "It is commonly prescribed with surgery or trauma to help prevent stress ulcers." D. "It is in the Healthcare providers orders, so I need to give it to you now."
C. "It is commonly prescribed with surgery or trauma to help prevent stress ulcers."
67. A patient diagnosed with schizophrenia has auditory hallucinations. The patient anxiously tells the nurse, "The voice is telling me to do things." Select the nurse's priority assessment question. A. "Do you recognize the voice speaking to you?" B. "Do the messages from the voice frighten you?" C. "What is the voice telling you to do?" D. "How long has the voice been directing your behavior?"
C. "What is the voice telling you to do?"
38. Which client being managed for dehydration does the nurse consider at greatest risk for possible reduced kidney function? A. A 45-year-old man receiving oral and IV fluid therapy B. A 48-year-old woman with established urinary incontinence C. An 80-year-old man who has benign prostatic hyperplasia D. A 62-year-old woman with a known allergy to contrast media
C. An 80-year-old man who has benign prostatic hyperplasia
69. A patient has progressive memory deficit associated with dementia. Which nursing intervention would best help the individual function in the environment? A. Reduce frustration by performing activities of daily living for the patient. B. Promote the use of the patient's sense of humor by telling jokes. C. Assist the patient to perform simple tasks by giving step-by-step directions. D. Stimulate intellectual function by discussing new topics with the patient.
C. Assist the patient to perform simple tasks by giving step-by-step directions.
33. The nurse understands that the patient with acute glomerulonephritis has had an immune complex response to which of the following? A. H-Pylori infection B. Mitral valve stenosis C. Beta-hemolytic strep A infection D. Acute hepatic dysfunction
C. Beta-hemolytic strep A infection
59. A nurse assesses a client who is 1 day post operative bowel resection with ileostomy placement. Which clinical manifestation should alert the nurse to urgently contact the health care provider? A. Ostomy pouch disconnection B. Liquid stool C. Pale and bluish stoma D. Blood-smeared output
C. Pale and bluish stoma
41. the nurse is working in an urgent care clinic that has standardized treatment protocols for implementation by nursing staff. After reviewing the history, physical assessment, and vital signs for a 60-year-old patient. Information is as indicated: History of Diabetes type 2 for 5 years; History of mild hearing loss; Sudden loss of left eye peripheral vision today; PERRLA; Extraocular movements intact; Cerumen obstructs view of tympanic membranes; Pulse 102, B/P 146/90 on the Right arm, respirations 24 and Temperature 97.9 F (36.6C). Which action should the nurse take first? A. Use an irrigating syringe to clean the ear canals. B. Check the patient's blood glucose level. C. Report the vision change to the health care provider. D. Take the blood pressure on the left arm.
C. Report the vision change to the health care provider.
11. A 62-year-old patient presents to her provider for a yearly physical. The provider notes a family history of prostate cancer in the patient's father. The provider schedules the patient for a PSA testing. The nurse recognizes this as what level of prevention? A. Holistic B. Tertiary C. Secondary D. Primary
C. Secondary
46. The patient has been started on an antipsychotic medication and is asks the nurse how they will recognize tardive dyskinesia. Which of the following best describes this side effect? A. A focal seizure without loss of consciousness B. Skin eruptions, similar to hives, that are red and raised C. Uncontrollable movements, chewing or jaw tightening D. Unsteady gait, difficulty with balance
C. Uncontrollable movements, chewing or jaw tightening
29. A nurse assesses a client who has stage 4 lung cancer with metastasis. When discussing care options the client states "I will really quit smoking and follow all the doctors recommendations. I just want to live until my daughter's wedding next year." This statement best represents which stage of grief? A. anger B. denial C. bargaining D. acceptance
C. bargaining
60. The periorbital edema and body edema in a child with Nephrotic syndrome is primarily the result of which metabolic imbalance? A. hyperkalemia B. hypoproteinuria C. hypoalbuminemia D. hypolipidemia
C. hypoalbuminemia
4. The adult children of an actively dying woman calls the on-call nurse very upset because their mother's respirations are irregular, wet and she sounds like she is drowning. She is unresponsive but seems to be comfortable. Which of the following instructions would be appropriate at this time? A. transfer her out of bed to a reclining chair B. administer an acetaminophen (Tylenol) suppository C. teach the family to deep suction her as needed D. apply a scopolamine patch
C. teach the family to deep suction her as needed
17. Sulfasalazine (Azulfidine) has been ordered for a client admitted with an exacerbation of ulcerative colitis. Which question by the admitting nurse takes priority? A. "Are you a diabetic?" B. "Do you primarily work indoors or outdoors?" C. "When is the last time that you had something to eat?" D. "Are you allergic to sulfa drugs?"
D. "Are you allergic to sulfa drugs?"
58. A client with peripheral neuropathy is ordered to receive gabapentin (Neurontin). The patient states: "The pharmacist told me this was an anti-seizure medication, but I do not have a seizure disorder." What is the nurses best response? A. "Peripheral neuropathy can lead to seizure activity." B. "I will contact the pharmacist to get you more information." C. "This medication will decrease inflammation in the extremities." D. "This medication can ease pain by decreasing nerve irritability."
D. "This medication can ease pain by decreasing nerve irritability."
62. Which instruction is appropriate following the instillation of eye drops for glaucoma? A. "Close your eye gently and keep closed for about 1 minute." B. "Irrigate the eye surface with sterile water 5 minutes after instilling the drops." C. "Wait for at least 30 minutes to instill your other prescribed eye drops." D. "Wait at least 5 minutes before you instill your other prescribed eye drop"
D. "Wait at least 5 minutes before you instill your other prescribed eye drop"
39.. The nurse is caring for a client who just had an esophagogastroduodenoscopy (EGD) completed. The client tells the nurse that her mouth is very dry after the procedure. What is the nurse's first action? A. Give the client a cup of ice chips to suck on. B. Offer the client sips of clear liquids C. Keep the client NPO (nothing by mouth) D. Check the client's gag reflex.
D. Check the client's gag reflex.
24. The nurse is caring for a client preparing to have a laparoscopic cholecystectomy in the morning. Which statement by the client indicates a need for further teaching?A. I will have three or four small incisions on the abdomen. B. I may have gas pains after the procedure. C. I will need to be on strict bed rest for 24-48 hours after surgery D. I will need to perform deep breathing exercises every hour while awake.
D. I will need to perform deep breathing exercises every hour while awake.
63. An older adult who is cognitively impaired is admitted to the hospital with an upper respiratory infection that has progressed to pneumonia. Which manifestations would the nurse expect to be exhibited by the patient? A. Severe headache B. Flank pain C. Decreased blood glucose D. Increased confusion
D. Increased confusion
65. A client is hospitalized for an acute manic phase. What goal takes priority during this phase? A. Allow the patient to act out his or her feelings. B. Teach strategies to help balance work, interpersonal, and family problems C. Restrain the patient to reduce hyperactivity and aggression. D. Set limits on the patient's behavior to maintain a safe situation
D. Set limits on the patient's behavior to maintain a safe situation
50. A client with Crohns desease is recovering from descending colon resection surgery. Which of the following is true regarding the clients post op recovery? A. The client is likely to develop ulcerative colitis B. The client may experience future exacerbations. C. The client will no longer experience bowel flare-ups D. The client is likely to experience dumping syndrome
D. The client is likely to experience dumping syndrome
22 A patient is being discharged with a T-tube following an open cholecystectomy. After receiving care instruction, which of the following statements by the patient indicates the need for clarification? A. The tube will remain in place until the duct inflammation subsides B. The bag should be emptied when 1/2 full C. The area around the insertion site needs to be gently cleaned with water D. The drainage will be clear blood tinged watery stool
D. The drainage will be clear blood tinged watery stool
76. The nurse is providing medication teaching to a patient prescribed phenazopyrim (Pyridium). Which statement made by the patient indicates an understanding of the medication? a. This medication will treat my urinary tract infection b. This medication will decrease the size of my prostate c. This medication will increase my urine output D. This medication will relieve the irritation in my bladder
D. This medication will relieve the irritation in my bladder
55. A nurse performs an assessment of pain/tactile sensory discrimination on an older adult client. The client correctly identifies, with eyes closed, a sharp sensation on the right hand when touched with a pin. Which action should the nurse take next? A. Continue the assessment on the client's feet. B. Contact the provider with the assessment results. C. Ask the client about current medications. D. Touch the pin on the same area of the left hand.
D. Touch the pin on the same area of the left hand.
43. A client experiencing nephrolithiasis is being prepared for extracorporeal shock wave lithotripsy. The patient should contact the health care provider if which of the following symptoms are noted? A. Gravel-like particles are found in the urine B. Bruising and tenderness are noted on the flank area C. Urine shows traces of blood D. Urine output has a foul odor
D. Urine output has a foul odor
47. A nurse cares for a client who has chronic heart failure, "The patients cardiac output has decreased significantly over the past 6 months? For which of the following conditions is the patient at increase risk due to the drop in cardiac output? A. intrarenal acute kidney injury B. pre-renal acute kidney injury C. post renal acute kidney injury D. acute nephrotic syndrome
D. acute nephrotic syndrome
27.A client with schizophrenia has been receiving long term treatment with risperidone (Risperdal). Which of the following symptoms might indicate the onset of a potentially permanent extrapyramidal side effect of tardive dyskinesia? A. aphasia B. urinary retention C. waxy flexibility D. persistent twitchy face movements
D. persistent twitchy face movements
90. A client with obsessive-compulsive anxiety disorder tells you that they have heard that there are multiple ways to manage this condition. The nurse assesses the need for reeducation and when the client identifies which of the following as an effective long term intervention for OCD. a. Use of benzodiazepine for daily anxiety reduction b. Exposure response prevention therapy c. Relaxation techniques like yoga and exercise d. Use of SSRI's like fluoxetine (Prozac) daily
a. Use of benzodiazepine for daily anxiety reduction
96. The nurse notices her 50-year-old patient is holding his lunch menu at arm's length while trying to read his choices. This is an indication of: a. Presbyopia b. Retinopathy c. Macular degeneration d. Cataracts
a. Presbyopia
100. Mrs. J, a 62-year-old woman, walks into the emergency department with complaints of "not feeling well" and has an open wound on the bottom of her foot, but the patient states she was not aware of this. The nurse interprets this response as: a. a pathologic impairment of sensory responses. b. a side effect of anti-hypertensive medication. c. a need for the patient to be evaluated for cognitive impairment. d. a normal finding the older adult.
a. a pathologic impairment of sensory responses.
102. Outpatient treatment is planned for a patient diagnosed with anorexia nervosa. Select the most important outcome related to the nursing diagnosis: Imbalance nutrition: less than body requirements. Within 1 week, the patient will: a. gain 1 to 2 pounds b. limit exercise to less than 2 hours daily c. select clothing that fits properly d. weigh self accurately using balance scales
a. gain 1 to 2 pounds
86. A nurse is completing a teaching to a client who has a new prescription for famotidine (Pepcid). Which of the following statements by the patient indicates understanding of the teaching? a. "This medication coats the lining of my stomach." b. "I will take this medication at mealtime." c. "I will monitor any bleeding from my nose." d. "This should stop the pain right away."
b. "I will take this medication at mealtime."
66. A patient diagnosed with bipolar disorder is in the maintenance phase of treatment. The patient asks, "Do I have to keep taking lithium even though my mood is stable now?" select the nurse's most appropriate response. a. "Your health care provider should have tapered you off this drug." b. "Taking this medication every day helps prevent relapses and recurrences." c. "You will be able to stop the medication and use it as needed." d. "This medication is usually taken for approximately 6 months after discharge."
b. "Taking this medication every day helps prevent relapses and recurrences."
72. A nurse is assessing the severity of bowel mucosa changes for a client with Crohn's disease. Which of the following labs would indicate that the disease progression shows malabsorption issues. a. Increased white blood cells b. Decreased serum albumin c. Decreased red blood cells d. Decreased erythrocyte sedimentation rate
b. Decreased serum albumin
80. A patient has been resistant to treatment with antidepressant therapy. The care provider prescribes phenelzine (Nardil), a monoamine oxidase inhibitor (MAOI) medication. What teaching is critical for the nurse to give the patient? a. Serum blood levels must be regularly monitored to assess for toxicity. b. Eating foods such as blue cheese or red wine will cause an increase in side effects. c. The medication should be administered as an intramuscular injection d. This medication class may only be used safely for a few days at a time.
b. Eating foods such as blue cheese or red wine will cause an increase in side effects.
97. A disheveled patient with severe depression and psychomotor retardation has not bathed for several days. The nurse should: a. Avoid forcing the issue by allowing the client to stay as they are. b. Firmly and neutrally guide and assist the patient with the bathing and grooming. c. Calmly tell the patient, "Facility rules state, you must bathe daily." d. Bring up the issue at the group milieu meeting.
b. Firmly and neutrally guide and assist the patient with the bathing and grooming.
1. A client with Crohn's disease develops a fever and symptoms of a urinary tract infection (UTI) with tan, fecal-smelling urine. What information will the nurse add to a general teaching plan about UTI's in order to individualize the teaching for this patient? a. Bacteria in the perianal area can enter the urethra. b. Fistulas can form between the bowel and bladder. c. Drink adequate fluids to maintain normal hydration. d. Empty the bladder before and after sexual intercourse.
b. Fistulas can form between the bowel and bladder.
81. A nurse witnesses a client begin to experience a tonic-clonic seizure and loss of consciousness. Which action should the nurse take first? a. Initiate intravenous fluid bolus b. Position the patient on their side c. Prepare to intubate the client d. Administer IV push diazepam
b. Position the patient on their side
83. What is the nurse's legal responsibility if child abuse or neglect is suspected? a. Discuss the findings with the child's teacher, principal, and school psychologist. b. Report the suspected abuse or neglect according to state regulations. c. Document the observations and speculations in the medical record. d. Confront the parent or guardian about what is suspected.
b. Report the suspected abuse or neglect according to state regulations.
95. A nurse reviews the chart of a client who has Crohn's disease and a draining fistula. Which documentation should alert the nurse to urgently contact the provider for additional orders? a. Client's weight decreased by 3 pounds b. Serum potassium of 2.6 mEq/L c. White blood cell count of 8200/mm3 d. Client ate 20% of breakfast meal
b. Serum potassium of 2.6 mEq/L
99. A middle-aged client with diabetes mellitus is being treated for the third episode of acute pyelonephritis in the past year, asks what can be done to help prevent these infections. Which is the nurse's best response? a. "Test your urine daily for the presence of ketone bodies and proteins." b. "Be careful with your diet to keep your hemoglobin A1c under 9%." c. "Drink more water and empty your bladder every 2 to 3 hours during the day." d. "Use tampons rather than sanitary napkins during menstrual period."
c. "Drink more water and empty your bladder every 2 to 3 hours during the day."
85. After teaching a client newly diagnosed with epilepsy, the nurse assesses the client's understanding. Which statement by the client indicates a need for additional teaching? a. "I will wear my medical alert bracelet at all times." b. "While taking my epilepsy medications, I will not drink any alcoholic beverages." c. "If I am nauseated, I will not take my epilepsy medication." d. "I will tell my doctor about my prescription and over-the-counter medications."
c. "If I am nauseated, I will not take my epilepsy medication."
88 A nurse who is applying eyedrops to a client holds pressure against the corner of the eye nearest the nose after instilling the drops. The client asks what the nurse is doing. What response by the nurse is best? a. "Doing this allows time for absorption." b. "I am stopping you from rubbing your eye." c. "This prevents systemic absorption." d. "I am keeping the drops in the eye."
c. "This prevents systemic absorption."
78. The nurse is planning to assess the structure of a family. Which question should the nurse ask? a. "Who provides financial support to your family?" b. "Who does the grocery shopping and cleaning?" c. "Who lives with you?" D. "How old are the members of your family?"
c. "Who lives with you?"
75. A nurse sits with a patient diagnosed with schizophrenia. The patient starts to laugh uncontrollably, although the nurse has not said anything funny. Select the nurse's best response. a. "I don't think I said anything funny."b. "Please share the joke with me." c. "You are laughing. Tell me what's happening." d. "Why are you laughing?"
c. "You are laughing. Tell me what's happening."
89. The nurse is caring for a male patient who reports an urgent need to urinate but is unable to pass more than a few drops of urine in the toilet. What priority assessment should be performed by the nurse? a. Auscultation to assess circulation through the right and left renal arteries b. Calculate the patient's intake and output to check for fluid volume deficit c. Bladder scan to determine the amount of urine in the bladder d. Bimanual palpation to assess for possible enlargement of the kidneys
c. Bladder scan to determine the amount of urine in the bladder
94. Which is a behavioral change that may indicate a person is making a plan to commit suicide? a. Manipulative behaviors b. Impulsive actions c. Giving away personal possessions d. Difficult focusing on a task
c. Giving away personal possessions
93. The nurse admitting a patient with acute diverticulitis explains that the initial plan care will include: a. order a diet high in fiber and fluids b. give stool softeners and enemas c. starting an IV and administering IV fluids d. prepare the patient for an upper endoscopy
c. starting an IV and administering IV fluids
92. The nurse is providing discharge teaching for a client who has peptic ulcer disease cause by Helicobacter pylori infection. Which statement by the client indicates that additional teaching is needed? a. "I will try to cut down and quit smoking cigarettes." b. "I will avoid coffee and cola drinks." c. "I will take a multivitamin every morning with breakfast." d. "I will take my antibiotics every day until my heartburn is gone."
d. "I will take my antibiotics every day until my heartburn is gone."
77. A nurse cares for a client who has a family history of colon cancer. The client states, "My father and my brother had colon cancer. What is the chance that I will get cancer? How should the nurse respond? a. "If you eat a low-fat and low-fiber diet, your chances decrease significantly." b. "You are safe, this is an autosomal dominant disorder that skips generations." c. Preemptive surgery and chemotherapy will remove cancer cells and prevent cancer." d. "You should have a colonoscopy more frequently to identify any abnormal polyps early."
d. "You should have a colonoscopy more frequently to identify any abnormal polyps early."
73. A family member asks the nurse, "I know my uncles Alzheimer's disease has progressed but is there any medication that could help him now?" Which response by the nurse is best? a. "I'm sorry there are no medications that help with sever Alzheimer's disease." b. "There are medications that can help. Let's talk with the health care provider." c. "Alzheimer's disease sometimes stabilizes, let's hope that happens." d. "Your Uncle's disease is not treatable. Let's talk about your feelings?"
d. "Your Uncle's disease is not treatable. Let's talk about your feelings?"
82. Several children are seen in the emergency department for treatment of illnesses and injuries. Which finding would create a high index of suspicion for abuse for a 2 year old child? The child who has: a. Knee and elbow abrasions b. Repeated middle ear infections c. Sever colic and feeding problems d. Bruises at various stages over back and torso
d. Bruises at various stages over back and torso
87. The nurse is caring for a postoperative patient who underwent bowel resection surgery that morning. The nurse assesses the patient's abdomen and notes that there are hypoactive bowel sounds. The patient is resting quietly without nausea or vomiting. What is the appropriate action of the nurse? a. Insert a Salem sump nasogastric tube to low continuous suction. b. Notify the surgeon and prepare the patient to return to surgery. c. Administer a laxative suppository to stimulate peristalsis. d. Keep the patient NPO and document the findings in the chart.
d. Keep the patient NPO and document the findings in the chart.
79. The nurse is caring for a client with peptic ulcer disease who reports sudden onset abdominal pain. On palpation, the client's abdomen is tense and rigid. What action takes priority? a. Percuss all four abdominal quadrants. b. Administer a prescribed mild laxative c. Administer the prescribed pain medication d. Notify the health care provider immediately
d. Notify the health care provider immediately
101. A client with peptic ulcer disease is in the emergency department and reports the pain has gotten much worse over the last several days. The client's blood pressure when lying down was 122/80 mm Hg and when standing was 98/52 mm Hg. What action by the nurse is most appropriate? a. Start oxygen at 5 liter via nasal cannula b. Administer ibuprofen (Motrin) c. Insert an indwelling catheter d. Obtain physician order to start an IV with normal saline
d. Obtain physician order to start an IV with normal saline
74. A patient diagnosed with borderline personality disorder is hospitalized several times after self-inflicted lacerations. The patient remains impulsive. Which nursing diagnosis is the focus of this therapy?a. Impaired skin integrity b. Risk for injury c. Powerlessness d. Risk for self-mutilation
d. Risk for self-mutilation
98. Which of the following aspects for health teaching regarding acute and chronic conjunctivitis is the most important information to be emphasized to a group of preschool parents? a. reducing eye discomfort b. consistent use of eye drops c. application of warm eye compresses d. methods to reduce transmission to classmates
d. methods to reduce transmission to classmates
91. The nurse is assessing the client's abdomen post bowel surgery, what is the best indicator of intestinal activity? a. detection of bowel sounds upon auscultation b. abdominal cramping with distention c. client's report of peristalsis d. passage of flatus or stool
d. passage of flatus or stool
