H&I FINAL, H&I FINAL

The nurse is caring for a client that is experiencing increasing shortness of breath. The client is pale and slight cicumoral cyanosis is developing. Which laboratory test best measures the adequacy of tissue oxygenation? A. arterial blood gas B. red blood cell C. hemoglobin D. pulmonary function test

A. arterial blood gas

An adolescent boy who is academically gifted is about to graduate from high school early since he has completed all course needed to earn a diploma. Within the last 3 months he has begun to experience panic attacks that have forced him to leave classes early and occasionally miss a day of school. He is concerned that these attacks may hinder is ability to pursue a college degree. What would be the best response by the school nurse who has been helping him deal with his panic attacks? A. "It sounds like you have a real concern about transitioning to college. I can refer you to a health care provider for assessment and treatment." B. "Its natural to be worried about going into a new environment. I'm sure with your abilities you'll do well once you get settled." C. You're putting too much pressure on yourself. You just need to relax more and things will be alright." D. "It might be best for you to postpone going to college. You need to get these panic attacks controlled first."

A. "It sounds like you have a real concern about transitioning to college. I can refer you to a health care provider for assessment and treatment."

You are working in cardiac telemetry unit and are providing patient education regarding the importance of taking all prescribed cardiac medication. The patient appears annoyed with the new medication and states, "Well I am already taking aspirin and metoprolol. I dont understand how furosemide will help my heart." How would you describe the benefit of this medication? A. "This medication is a diuretic which will reduce blood volume and the workload of the heart" B. "This medication is an anticoagulant which will help to prevent blood clotting" C. "This is a vasopressor which will decrease the diameter of blood vessels." D. "This medication is an antidysrhythmic which will correct irregular electrical impulses of the heart."

A. "This medication is a diuretic which will reduce blood volume and the workload of the heart"

A 49-year-old patient tells the nurse he has smoked half of a pack of cigarettes a day since he was 19-years-old, for a total of 30 years. What does the nurse record for pack-year history? A. 15 B. 20 C. 25 D. 30

A. 15

The nurse assesses the family's ability to cope with the Childs cerebral palsy. Which action should alert the nurse to the possibility of their inability to cope with the disease? A. limiting interaction with extended family and friends B. learning measures to meet the Childs physical needs C. requesting teaching about cerebral palsy in general D. seeking advice on coping social media

A. limiting interaction with extended family and friends

A client comes to the emergency department reporting severe substernal chest pain radiating down the left arm. The client is admitted to the coronary care unit with a diagnosis of myocardial infarction (MI). Which should the nurse do first when the client is admitted to the coronary care unit ? A. Obtain health history B. Auscultate heart sounds C. Begin telemetry monitoring D. Evaluate the client's pain

C. Begin telemetry monitoring

An appropriate nursing intervention for a patient with fatigue related to cancer treatment includes teaching the patient to: A. Increase fluid intake B. Minimize naps or periods of rest during the day C. Conserve energy by prioritizing activities. D. Limit dietary intake high-fiber foods

C. Conserve energy by prioritizing activities.

The nurse caring for an infant with RSV is monitoring for signs of respiratory distress. Which one of the following is a cardinal late sign of respiratory distress? Poor I & O. Wheezing. Mild retractions. Cyanosis.

Cyanosis.

What does each zone consist of?

Green Zone is breathing is good, no cough or wheeze, can work and play normal, PF is personal best. Green= means Go- Use preventive medicine, Yellow = means Caution-Use quick relief medicine, Red= means Stop, Get help from a doctor Yellow Zone is when pt has cough, wheezing, tight chest, wakes up at night with symptoms, PF is 50-80% of personal best. Red zone is when the medication is not helping, breathing is rapid and hard, nose is flaring or wide open, pt can't walk or talk well, ribs show (+ retractions), Peak Flow (PF) is less than 50% of personal best.

A patient with iron deficiency anemia increased fatigue. The patient report, "I am even too tired to eat what I should." Based on this information, the most appropriate intervention to combat this nutritional problem is to: A. Eat three week- balanced meals per day B. Exercise 1 hours before each meal C. Put oxygen on at @L during meal time D. Divide daily food intake into five or six smaller meals

D. Divide daily food intake into five or six smaller meals

A patient has chronic obstructive pulmonary disease (COPD). In reviewing this patient's laboratory values. The nurse would not be surprised to see a/an: Decreased sedimentation rate. Elevated RBC count. Normochromic anemia. Therapeutic INR.

Elevated RBC count.

A patient with COPD is experiencing respiratory distress and has an O2 saturation of 86%. Which one of the following nursing diagnoses would be most appropriate? Impaired Gas Exchange. Ineffective Airway Clearance. Ineffective Breathing Pattern. Impaired Spontaneous Ventilation.

Impaired Gas Exchange.

The nurse on an adult med-surg unit has received a change-of-shift report about their patients with respiratory problems. Which patient should the nurse assess first? Patient with asthma who has expiratory wheezes. Patient with COPD who has a productive cough of thick, green sputum. Patient with asthma who has a respiratory rate of 38. Patient with COPD who has JVD and peripheral edema.

Patient with asthma who has a respiratory rate of 38.

Which of the following is NOT a characteristic of infants and young children that put them at increased risk for respiratory disease? Small airway size. Underdeveloped respiratory muscles. Immunologic immaturity. Relatively less oxygen consumption per body weight than an adult.

Relatively less oxygen consumption per body weight than an adult.

What position should the nurse use for the client with venous insufficiency to enhance blood supply? A. Supine with legs elevated B. Prone with head turned to the right side C. Fowler's position with legs dependent D. Semi-fowlers position with legs neutral

A. Supine with legs elevated

A child with asthma is having pulmonary function tests. Which of the following explains the main purpose of the peak expiratory flow rate (Peak flow)? A. To assess the severity of asthma. B. To determine the cause of asthma. C. To identify asthma 'triggers.' D. To confirm diagnosis of asthma.

A. To assess the severity of asthma.

Which symptom should the nurse teach the client with unstable angina to report immediately to the health care provider (HCP)? A. A change in the pattern of the chest pain B. Pain during sexual activity C. Pain during an argument D. Pain during or after physical exertion

A. A change in the pattern of the chest pain

A patient is admitted with fatigue, SOB, pale skin, and dried crackled lips, tongue and mouth. The hemoglobin is 9g/dL and red blood cell count is 3.5. Which of the following foods should the nurse teach this patient to include in the diet? A. Beef, beets, and cabbage B. Lamb, applesauce and mint jelly C. Chicken, dumplings and biscuits D. Fish, wine and apples

A. Beef, beets, and cabbage

Cara is a six-week-old who arrives in the ED by ambulance with her mother Wendy. The patient has had a 2-day history of cold symptoms. Today, she became limp, cyanotic, and stopped breathing. She was tested and positive for RSV. The emergency medical technician (EMT) stabilized Cara before transporting the infant to the Emergency Center. This information is reported to the nurse by the EMT upon the infant's arrival to the Emergency Center. What nursing diagnosis has the highest priority for Cara? A. Ineffective Airway Clearance. B. Activity Intolerance. C. Risk for Fluid Volume Deficit. D. Interrupted Family Processes.

A. Ineffective Airway Clearance.

A nurse is seeing a patient to discharge after being admitted to hospital for suicidal ideation. As the nurse begins the discharge process, the patient closes her eyes and begins rapid, shallow breathing. The patient also begins to shake and perspire profusely. Which action should the nurse take? Select all that apply A. Reassure the patient of being safe B. Take the client to a quiet space C. Assess the patient for suicidal ideation D. Talk to the patient in a comforting manner E. Leave the room to provide the patient with some space

A. Reassure the patient of being safe B. Take the client to a quiet space D. Talk to the patient in a comforting manner

When evaluating the red cells indices of a patient, the nurse knows that a low mean corpuscular volume (MCV) indicates: A. Small size of the RBCs B. Inadequate number of RBCs C. Low hemoglobin in the RBCs D. Hypochromic RBCs

A. Small size of the RBCs

A 45-year-old single mother of three teenaged boys has metazoic breast cancer. Her parents live 750 miles away and have only been able to visit twice since her initial diagnosis 14 months ago. The progression of her disease has forced the patient to consider high-dose chemotherapy. She is concerned about her children welfare during treatment. When assessing the patient's present and future needs, the nurse will be most concerned about which potential problem? A. support system and coping strategies B. transportation and money for the boys C. Decision- making abilities D. Denial as a primary coping mechanism

A. support system and coping strategies

A nurse is teaching a patient with mononucleosis about how to manage the fatigue associated with this disease. Which statement by the patient indicates she understands how to manage the fatigue? A. "I sleep for 8 to 10 hours every night so that I'll have the energy to care for my children during the day." B. "I schedule afternoon rest periods for myself in addition to sleeping 10 hours every night." C. "I spend one weekend day a week resting in bed while my husband cares for the children.:" D. "I get up early in the morning and get all my household chores complete before my children wake up."

B. "I schedule afternoon rest periods for myself in addition to sleeping 10 hours every night."

A nurse is providing discharge instructions to a patient with peripheral vascular disease that include stress-reduction techniques. The patient asks the nurse "why is reducing stress so important?" What is the nurses best response? A. "Reducing stress is helpful because it will assist in smoking cessation." B. "Stress reduction techniques are helpful because stress stimulates the release of vasoconstricting catecholamines." C. Stress reduction techniques will distract you from focusing on claudication pain in your feet." D. "reducing stress will help decreased the amount of medication you take peripheral vascular disease."

B. "Stress reduction techniques are helpful because stress stimulates the release of vasoconstricting catecholamines."

The nurse assesses a child after heart surgery to correct tetralogy of Fallot. Which finding would the nurse report to the provider as an indication that the client has low cardiac output? A. Bounding pulses and mottled skin B. Altered level of consciousness and thready pulse C. Capillary refill of 2 seconds and blood pressure of 96/67 mmHg D. Extremities warm to touch and pale skin

B. Altered level of consciousness and thready pulse

The client has been managing angina episodes with nitroglycerin. Which finding indicates that the therapeutic effect of the drug has been achieved? A. Decreased blood pressure B. Decreased chest pain C. Increased blood pressure D. Decreased heart rate

B. Decreased chest pain

A client tell the nurse is experiencing dyspnea. Which action by the nurse is most appropriate? A. Placing client in Trendenlenburg position B. Placing the client in high Fowler's position C. Placing the client in Sim's Position D. Placing the client in the supine position

B. Placing the client in high Fowler's position

Perfusion is best defined as: A. The movement of oxygen through the respiratory tract into the alveoli and the diffusion of oxygen from the lungs into the blood B. The movement of oxygen and nutrients into and metabolic wastes out of the cell C. The process of regulating the pH, bicarbonate concentration and partial pressure of carbon dioxide in body fluids D. The biochemical processes occurring in the body cells that are necessary to produce growth, generate energy, and maintain life

B. The movement of oxygen and nutrients into and metabolic wastes out of the cell

A client is scheduled for a treadmill stress test. Prior to the stress test, the nurse reviews the results of the laboratory reports. The nurse should report which elevated lab result to the health care provider prior to the stress test? A. Cholesterol B. Troponin C. Prothrombin time D. Erythrocyte sedimentation rate

B. Troponin

After stabilization of Addison's disease, the nurse teaches the client about stress management. What should the nurse instruct the client to do? A. Remove all sources of stress from daily life B. Use relaxation techniques such as music C. Avoid discussing stressful experiences D. Take anti anxiety drugs daily

B. Use relaxation techniques such as music

You are caring for a 10 year old with a history of Asthma. He has the following sign and symptoms: wheezing for 24 hours, cough, complains of chest feeling tight, awakened from sleeping the last two nights, and had Peak Flow values (PF= peak flow) that are 60 % of his personal best. In what Zone on his Asthma Action Medication Plan, is this patient? A. Green zone. B. Yellow Zone. C. Red Zone.

B. Yellow Zone. - Yellow Zone is when pt has cough, wheezing, tight chest, wakes up at night with symptoms, PF is 50-80% of personal best.

A client with a specific phobia of spiders is seeing a therapist for the first session of treatment. The therapist hands the client a clear container with a large house spider inside. The activity is repeated continuously until the client's fear subsides. Which strategy is being used to treat the client's specific phobia? A. Systemic desensitization B. Flooding C. Decatastrophizing D. Assertive training

C. Decatastrophizing

When doing a physical assessment of a patient, the nurse should expect which of these findings related to mononucleosis? A. Temperature of 37.4 C B. Petechiae C. Enlarged lymph nodes D. Pustular rash

C. Enlarged lymph nodes

Which manifestation is characteristically associated with anemia? A. Pruritus B. Rash C. Fatigue D. Ruddy skin color

C. Fatigue

Which one of the following nursing diagnoses would be the most appropriate for a patient with mononucleosis? A. Chronic pain B. Impaired physical mobility C. Fatigue D. Noncompliance

C. Fatigue

The client is caring for a patient with asthma. The nurse should conduct a focused assessment to detect: A. Increased forced expiratory volume B. Normal breath sounds C. Inspiratory and expiratory wheezing D. Morning headaches

C. Inspiratory and expiratory wheezing

The nurse is assessing a 4-month old client. For what finding will the nurse take immediate action? A. Respiratory rate between 30 to 35 breaths/minute B. Abdominal wall rising with inspiration C. Intercostal retractions on inspiration D. Temperature is 99.4 F

C. Intercostal retractions on inspiration

The nurse is caring for an infant with RSV and monitoring for signs an symptoms of respiratory distress. Which one of the following is an early sign of respiratory distress? A. Wheezing B. Cyanosis C. Restlessness D. Mild retractions

C. Restlessness Restlessness is an early sign of distress.

During physical assessment of a patient, the nurse suspects a chronic, severe iron-deficiency anemia on finding: A. Yellow- tinged sclerae B. Gum bleeding and tenderness C. Shiny, smooth beefy tongue D. Numbness of the extremities

C. Shiny, smooth beefy tongue

A nurse is caring for a patient admitted with pernicious anemia. Which set of findings should the nurse expect when assessing the patient? A. Jaundice, bradycardia, and reduced pulse pressure B. Sore throat, dyspnea, and weight gain C. Sore tongue, paresthesias, and pailor D. Tremor, double vision and bradypnea

C. Sore tongue, paresthesias, and pailor

Which of the following clients should the nurse assess first? A. The client with chronic obstructive pulmonary disease in a tripod position B. The client with audible wheezing throughout the lung fields C. The client who is a child with stridor and nasal flaring D. The client with rhonchi

C. The client who is a child with stridor and nasal flaring

The nurse is interviewing a patient who is being treated for obsessive-compulsive disorder. The patient's compulsions involve cleanliness rituals, which the patient justifies by describing contaminants in great detail. The nurse interprets the patient's statement as implying that: A. The patient may develop more serious obsessions and compulsions over time B. The patient's fear can likely be alleviated by presenting evidence about the safety of water C. The patient may lack insight to the diagnosis D. The patient would likely benefit from inpatient treatment

C. The patient may lack insight to the diagnosis

The nurse recognized that which client is most likely experiencing generalized anxiety disorder (GAD)? A. 30 -year-old business executive who reports being anxious about attending the meetings and social events that are the executive's job responsibilities. B. 70-year-old whose spouse died 1 year ago who has "no desire to leave my house" and reports severe fatigue C. 22-year-old soldier who served in the Middle East who "cannot sleep" and is facing criminal charges for hurting someone in a barroom brawl D. 40-year-old who has reported numerous absences from work, muscle aches, and difficulty falling asleep for the last 8 months

D. 40-year-old who has reported numerous absences from work, muscle aches, and difficulty falling asleep for the last 8 months

A client experiencing an acute panic attach develops respiratory alkalosis. Vital signs are as follows; respiratory rate 46, heart rate 110, blood pressure 162/90, and temp of 98.6. Which action will the nurse implement first to help improve respiratory alkalosis? A. Apply oxygen via nasal cannula B. Administer albuterol inhaler C. Administer sodium bicarbonate intravenously D. Instruct the client to breathe into a paper bag

D. Instruct the client to breathe into a paper bag

A female client who is 32 years of age has been diagnosed with stage 1 hypertension. The client's heigh is 5 ft 5 inches and her weight is recorded as 125 pounds; she reports that she frequently eats at "fast food" restaurants and enjoys a glass of wine to relax on weekends. In developing a teaching plan for this client, the nurse should address which topic? A. Potential use of nitroglycerin B. Adverse effects of alcohol C. Decreasing calorie intake D. Low sodium food choices

D. Low sodium food choices

A healthcare provider has entered orders for a client with chronic obstructive pulmonary disease (COPD). Which order should the nurse question ? A. Oxygen via nasal canula at 2L/Min B. Head of the bed 30-45 degrees C. Albuterol nebulizer treatments every 4 hours as needed D. Oxygen increased to 3L min if oxygen saturation is less than 94% on room air

D. Oxygen increased to 3L min if oxygen saturation is less than 94% on room air

An adolescent who is immobilized in a cast to stabilize a recent fractured femur suddenly develops chest pain, dyspnea, diaphoresis, and tachycardia. The nurse should further assess the client for what condition? A. Atelectasis B. Pneumonia C. Pulmonary edema D. Pulmonary emboli

D. Pulmonary emboli

An attorney who throws books and furniture around the office after losing a case is referred to the psychiatric nurse in the law firm's employee assistance program. The nurse knows that the clients behavior most likely represents the use of which defense mechanism? A. Intellectualization B. Reaction formation C. Projection D. Regression

D. Regression

Tetralogy of Fallot is a combination of which four cardiac defects? A. Pulmonary stenosis, right ventricular hypertrophy, atrial septal defect, and overriding of the aorta B. Left ventricular hypertrophy, atrial septal defect, ventricular septal defect, and aortic stenosis C. Right ventricular hypertrophy, patent ductus arterioles, transposition of the great vessels, and ventricular septal defects D. Ventricular septal defect, pulmonary stenosis, overriding of the aorta, and right ventricular hypertrophy

D. Ventricular septal defect, pulmonary stenosis, overriding of the aorta, and right ventricular hypertrophy

A client is admitted to a healthcare facility for treatment of chronic obstructive pulmonary disease. Which nursing diagnosis is most important for this client? A. activity intolerance related to shortness of breath B. anxiety related to difficulty breathing C. risk for infection related to retained secretions D. impaired gas exchange related to airflow obstruction

D. impaired gas exchange related to airflow obstruction

Which of the following information given by an adult patient indicates they are at risk for developing oxygenation problems? Has two dogs and one cat. History of working as a local news reporter. Smoke marijuana a few times when in their teens. Lives in a large urban area with a high smog index.

Lives in a large urban area with a high smog index.