Health and Illness Exam 1
After abdominal surgery, which question should the nurse ask the patient to determine whether peristaltic movement is returning? a. "Have you passed flatus?" b. "Are you hungry?" c. "Do you have any nausea?" d. "Is your pain level manageable?"
a. "Have you passed flatus?" Evidence indicates that the patient's report of passing flatus is the best indicator (above assessing bowel sounds) of whether peristaltic movement is returning after surgery.
The emergency department nurse is caring for a 78- year old patient whose daughter reports a decrease in cognition. Which nursing statement directed to the patient helps the nurse to assess cognition? a. "Tell me what this fable means to you" b. "Please count backward from 100 by 7s" c. "Tell me how you were transported to the hospital today" d. "I will write a word on this paper, and you copy it"
a. "Tell me what this fable means to you" Asking the patient about the meaning of various proverbs or fables assessesthe patient's abstract reasoning, which is part of cognition. Asking the patient about how he or she came to the hospital would assess memory. Counting backward from 100 by 7s would assess the patient's attention. Giving the patient a simple written command would assess language and copying skills.
The nurse is caring for a 30-year-old patient who experienced a frontal lobe infarction after a motorcycle accident. What is the appropriate nursing intervention? a. Enable the bed alarm safety system. b. Place all items directly in front of the patient. c. Use a picture board to assist with communication. d. Instruct the patient to use a call light proper to getting out of bed.
a. Enable the bed alarm safety system Frontal lobe injuries may interfere with the patient's ability to regulate behavior based on judgment and foresight and also may affect reasoning, concentration, andabstraction. Hemay not be able to reason through how to use the call light.Enabling the bed alarm is important to reduce fall risk. Placing items in front of the patient would be helpful for parietal injuries involving spatial perception deficits, and a communication board would be indicated for an injury to the temporal lobe.
Atrophic skin changes that occur with peripheral arterial insufficiency include: a. thin shiny skin with loss of hair b. brown discoloration c. thick leathery skin d. slow-healing blisters on the skin
a. thin shiny skin with loss of hair
The nurse is caring for four female patients. Which patient is identified as being at greatest risk for low bone density? a. 22 yr old Asian American b. 39 yr old Caucasian American c. 44 yr old Native American d. 50 yr old African American
b. 39 yr old caucasian american Caucasian women tend to have the least amount of bone density of any group, which makes them more likely to have osteoporosis and fractures.
A patient with kidney failure reports dyspnea. The patient's pulse oximeter reading is 95% on the room air, but is visibly distressed with a respiratory rate of 32 breaths/min. What is the priority intervention? a. Notify the respiratory therapist b. Administer oxygen by nasal cannula c. Elevate the head of bed to 90 degrees d. Administer a respiratory nebulizing treatment
b. Administer oxygen by nasal cannula Patients with kidney failure are anemic because they cannot produce the hormone erythropoietin. A high oxygen saturation in an anemic patient who is showing signs of respiratory distress may still be hypoxemic. Clients who have decreased hemoglobincould have a high percentage of the hemoglobin saturated with oxygen, but because they have a decreased hemoglobin level, not enough oxygen is provided. Administering oxygen is necessary.
When administering a new GI medication to an older patient, the nurse anticipates what? a. A higher-than-normal dose may be needed b. Close monitoring is needed because toxic levels may develop c. Older adults always require a lower-than-normal dose than younger patients d. Nausea and vomiting may develop rapidly and are common side effects in older adults
b. Close monitoring is needed because toxic levels may develop The older patient should be monitored closely for adverse effects of all medications, even those administered in normal doses, because toxic levels can develop rapidly. Medications should never be increased to greater-than-normal levels because age-related changes in the liver and intestinal absorption may cause development of toxic drug levels. The patient also should not receive drug doses that are lower than normal. Nausea and vomiting in response to medication are not expected side effects of a patient's use of prescribed medication in appropriate dosages.
After providing education, which patient statement does the nurse identify that reflects an older patient's understanding of musculoskeletal health interventions? a. "I should use a cane when I walk" b. "I should drink 8 oz of orange juice daily" c. "I should try to exercise at least five times a week" d. "I should ignore my pain and adapt to moving more slowly"
c. "I should try to exercise at least five times a week" It is important to prevent falls in older adults. Regular exercise is the most important element in healthy musculoskeletal aging. Assistive devices may be needed for ambulation. A nutrient-rich diet is an important part of maintaining musculoskeletal health. Assessment of pain can present many challenges. Pain can be related to bone, muscle, or joint problems and may be described as acute or chronic. Patients should not ignore changes in musculoskeletal pain.
A patient is scheduled for an electromyography (EMG) to evaluate diffuse or localized muscle weakness. What question will the nurse ask the patient before the test? a."When did you last eat or drink?" b. "Have you completed your exercise for the day?" c. "What herbs and over-the-counter medicines do you take?" d. "Did you take your cyclobenzaprine (Flexeril) this morning?"
c. "What herbs and over-the-counter medicines do you take?" EMG helps in the diagnosis of neuromuscular, lower motor neuron, and peripheral nerve disorders. This test is contraindicated for patients undergoing anticoagulant therapy. If a patient has taken herbal or over-the-counter medications that interfere with clotting, the test may need to be delayed or rescheduled. Invasive/needle test is involved.
The nurse is caring for an older adult who is usually alert and oriented. When the patient exhibits a change in mental status, for which most cause does the nurse initially assess? a. Infection b. Use of sedatives c. Oxygen insufficiency d. Electrolyte imbalance
c. Oxygen insufficiency Many things influence transmission of nerve impulses affecting mental state. In the older adult, a lack of oxygen often causes mental status changes. The airway should always be assessed first. Changes in extracellular electrolytes, specifically sodium, can also alter mental status, as can hypnotic, anesthetic, and sedating agents. Confusion or change in mental status such as agitationmay also be associated with infection. These can all beassessed after adequate oxygenation is ensured.
Inspection of a person's right hand reveals a red, swollen area. To further assess for infection, you would palpate the: a. cervical node b. axillary node c. epitrochlear node d. inguinal node
c. epitrochlear node
Which patient statement alerts the nurse to perform a thorough GI history and focused assessment? a. "I don't like the taste of spicy foods" b. "I got dentures four years ago" c. "I experience occasional constipation" d. "I take ibuprofen three times daily for arthritis"
d. "I take ibuprofen three times daily for arthritis" Large amounts of aspirin or other nonsteroidal anti-inflammatory drugs (NSAIDS) such as ibuprofen can predispose the patient to peptic ulcer disease and GI bleeding.
Which patient is most likely to experience renal compromise assessed by decreased urine production? a. 10-year history of diabetes mellitus b. White blood cell count of 12,000/mm3 c. Recent history of myocardial infarction d. Blood pressure of 92/46 mm Hg for 12 hours
d. Blood pressure of 92/46 mmHG for 12 hours The ability of the kidneys to self-regulate renal blood pressure and renal blood flow keeps the glomerular filtration rate (GFR) constant. A blood pressure of 92/48 mm Hg is a mean arterial pressure of 62 mm Hg. The kidney has a difficult time regulating GFR with a mean arterial blood pressure less than 65 mm Hg.
A patient with a history of kidney disease is admitted with acute shoulder pain. Which order should the nurse question? a. Digoxin 0.125 mg by mouth daily b. Metoprolol 50 mg by mouth twice daily c. Pan cultures for a temperature >38.5 degrees C d. Ibuprofen 800 mg by mouth every 4 hours as needed for pain
d. Ibuprofen 800 mg by mouth every 4 hours as needed for pain High-dose or long-term use of nonsteroidal antiinflammatory drugs (NSAIDs) can seriously reduce kidney function. Explore the past and current use of over-the-counter (OTC) drugs or agents, including dietary supplements, vitamins and minerals, herbal agents, laxatives, analgesics, acetaminophen, and NSAIDs.
While reviewing a medical record, a notation of 4+ of the right leg is noted. The best description of this type of edema is: a. mild pitting, no perceptible swelling of the leg b. moderate pitting, indentation subsides rapidly c. deep pitting, leg looks swollen d. very deep pitting, indentation last a long time
d. very deep pitting, indentation lasts a long time
