MED SURG

A patient has a family history of cataracts. He asked what symptom would be present if he begins to develop them. The nurse may respond that the first symptoms of a cataract is usually

Blurring of vision

Calcitriol (Rocsltrol) Is prescribed for the client with hypocalcemia. The nurse instruct the client to avoid excessive amounts of which of the following food items that interfere with calcium absorption?

Bran

When obtaining a health history from a patient with a neurological problem the nurses is likely to elicit the most valid response from the patient with which question?

Can you describe the sensation you're having in your head?

Which are signs and symptoms of fluid overload and a patient receiving diuretics? (Select all that apply)

Changes in cardiac in lung sounds increase in daily weight

When assessing the visual field, which actions should be performed by the examiner? (Select all that apply)

Cover his own right eye cover the patient's left eye asked the patient to report when the examiners finger is seen directs the patient to look directly into the examiner's eyes.

A patient visits the physician for a routine physical examination that involves testing distance vision. As she faces the snellen chart, the nurse is to instruct the patient to

Cover one eye while testing the other

A nurse is caring with a client with a head injury secondary to a motor vehicle accident the nurse observes the clients status regularly monitoring closely for which changes in the vital signs

Decreasing pulse, decreasing respiration's, increasing BP

A client who sustained a closed head injury has a new onset of copious urinary output. Urine output for the previous 8 hour shift was 3300 ML, 2800ML for the shift before that. The findings have been reported to the physician, and the nurse anticipate an order for which of the following medication.

Desmopressin (DDAVP)

The nurse caring for a patient with automatic dysreflexia assesses the patient for which condition or situation? (Select all that apply)

Distended bladder constipation wrinkles in bed linens abrupt environmental temperature changes.

Which nursing diagnosis is appropriate for a patient diagnosed with hypothyroidism as a result of a newly developed goiter?

Disturbed body image

Which assessment question should the nurse ask if stress incontinence ?

Do you experience urine leakage when you cough or sneeze

On the second post operative day, a 63-year-old patient who has had an abdominal hysterectomy complaints of gas pains in abdominal distention. She has not had a bowel movement since surgery. Which nursing intervention or best stimulate peristalsis and relieve distention?

Encourage ambulating at least four times per day

The nurse is reviewing the record of pregnant client knows that the physician has documented the presence of chadwick sign. The nurse determined that the hormone responsible for the development of this sign is which of the following?

Estrogen

A client who is recovering from a brain attack (stroke) has residual dysphasia. The license practical nurse instructed the nursing assistant to avoid which of the following at meal time?

Give the client then liquids

when reviewing laboratory results, the nurse should immediately notify the healthcare provider about which finding?

Glomerular filtration rate of 20 mL/min.

Which diagnostic test for diabetes mellitus provide a measure of glucose levels for the previous 8 to 12 weeks?

Glycosylated hemoglobin (HbA1c)

To obtain a clean voided urine specimen for a female patient, the nurse should teach the patient to?

Hold the labia apart awhile voiding into the specimen cup.

A client calls the physicians office to schedule an appointment because a home pregnancy test was performed and the results were positive. The nurse determines that the home pregnancy test identifies the presence of which of the following in the urine?

Human Chorionic Gonadotropion (HCG)

The nurse provides discharge teaching for a client regarding her activity level as she recovers from her Modified radical mastectomy. Which statement by her indicates to the nurse that the teaching has been successful?

I just sleep on the side opposite from mastectomy

A nurse is providing instructions to the client who has just been fitted for a halo best. Which statement by the client indicates the need for further instructions?

I will avoid driving at night

A nurse is providing instructions to the client who has just been fitted for a halo vest. Which statement by the client indicates they need for further instructions?

I will avoid driving at night because the vest limits the ability to turn the head

Signs and symptoms of hypoglycemia include; (select all that apply)

Irritability Tremors Personality changes

A client with newly diagnosed Cushing's syndrome expresses concern about personal appearance, specifically about the "buffalo hump" that has developed at the base of the neck. When counseling the client about this manifestation, the nurse should incorporate the knowledge that:

It may slowly improve with treatment of the disorder.

A nurse is assisting and admitting a client who experienced seizure activity in the emergency department the nurse avoids doing which of the following when managing this clients environment

Keeping the bed position raised to the nurse's waist level

A patient has fallen several times in the past week when attempting to get up to go to the restroom. The patient informs the nurse that he gets up three or four times a night to urinate. Which recommendation by the nurse is most appropriate in correcting this urinary problem?

Limit fluid and caffeine intake before bed

The type and size of urinary catheter or determined by the (select all that apply)

Location of the urinary track problem cause of the urinary track problem

Chvostek's and Trousseau's signs are test to determine

Low Levels of blood calcium

A client has been diagnosed with glaucoma. The nurse who is teaching the client principles of self care would encourage the client to limit or refrain from which of the following usual activities on a repeated basis?

Picking objects up off the floor

A client has been diagnosed with glaucoma. The nurse who is teaching the client principles self-care would encourage the client to limit or refrain from which of the following usual activities on a repeated basis?

Picking objects up off the floor

A male patient brings home a note from The occupation her nurse that states, you have acute bacterial conjunctivitis this condition is more commonly called

Pink eye

When a patient on Lasix, a loop diuretics, complains of weakness and a irregular pulse, there may be an electrolyte deficiency of

Potassium

A 69-year-old patient with diabetes mellitus is admitted with cellulitis of the right foot. In apply moist packs to his ulcerated foot, the nurse should use aseptic techniques to:

Prevent the introduction of microorganisms

The nurse is caring for a patient in acute respiratory distress. The patient has multiple monitoring systems on that constantly beep and make noise. The patient is becoming agitated and frustrated over inability to sleep. Which action by the nurse is most appropriate for this patient?

Provide the patient with earplugs.

The nurse is preparing the client who is schedule for an intravenous pylegram (IVP). The nurse would take which take which most important action before the test

Question about allergies to iodine or shellfish

The nurse is caring for a patient who is having difficulty understanding written and spoken words ? The nurse suspects the patient has _____________ aphasia

Receptive

A nurse is collecting data from a female client who is suspected of having mittleschmerz. Which of the following with a nurse expect to note on to get a collection of the client?

Sharp pain located on the right side of the pelvis

A nursing intervention to assess the patient with chronic renal failure (CRF) in learning about available community resources would be a consultation with

Social services

The nurse is caring for a patient with conductive hearing lost from prolonged serum impaction. Which intervention by the nurse is most important in establishing effective communication with the patient.

Speaking with hands and face expressions

The nurse is explaining how sound is conducted from the middle ear to the inner ear in teaching a client who is experiencing hearing loss. The nurse plans to use a diagram that illustrates how how which of the following bones connects to the Cochlea at the oval window?

Stapes

What preparing to teach a patient about continuous bladder irrigation the nurses notes that the most frequently use irrigation is

Sterile isotonic saline

A client who return to the nursing unit eight hours ago after hypophysectomy has clear drainage saturating the nasal dressing. The nurse should take which action first?

Test the drainage for glucose

A client has been newly diagnosed with glaucoma. As part of the discharge instructions, the nurse should plan to include which of the following?

The need for lifelong medication therapy

A nurse is establishing a relationship with the patient who is visually impaired. Which is the most appropriate method to teach the patient how to contact the nurse for assistance? a. Place a raised Braille sticker on the call button, and instruct the patient to press for assistance. b. Instruct the patient to yell at the top of his lungs to get the attention of the staff. c. Explain to the patient that a staff person will stop by once an hour to see if the patient needs anything. d. Share cell phone numbers with the patient so he can call the nurse if he needs her

a. Place a raised Braille sticker on the call button, and instruct the patient to press for assistance. The nurse should devise a plan of care that is accommodating of the patient's visual deficit. Placing a sticker on the call light allows the patient to page the nurse for assistance as needed. Yelling at the top of the lungs is stressful for the patient and for surrounding patients. Making hourly rounds is not sufficient; the nurse needs to ensure that the patient can get in touch with her at any time. Sharing personal phone numbers with the patient is inappropriate.

A new nurse is caring for a patient who is undergoing chemotherapy for cancer. The patient is becoming malnourished because nothing tastes good. Which recommendation by the nurse would be most appropriate for this patient? a. "Rinse your mouth several times a day to hydrate your taste buds." b. "Blend foods together in interesting flavor combinations." c. "Eat soft foods that are easy to chew and swallow." d. "Avoid adding spices or aromatic ingredients to food to prevent nausea."

a. "Rinse your mouth several times a day to hydrate your taste buds." Good oral hygiene is important to stimulate and hydrate taste buds. Having an unpleasant taste in the mouth discourages the patient from eating. Avoid blending foods together because this confuses the ability to discriminate flavors and taste. Texturized, spicy, and aromatic foods stimulate and make eating more enjoyable

The priority nursing responsibility while caring for a patient with a vertigo is

safety

Common early signs and symptoms of diabetic ketoacidosis include

thirst and drowsiness.

Which of the following is the primary function of the kidney?

maintaining fluid and electrolyte balance

One method of monitoring for signs and symptoms of fluid overload when administering direct is

Record daily morning weights

A license practical nurse is assisting a high school nurse in conducting a session with female adolescence regarding the menstrual cycle. The LPN tells the adolescence that the normal duration of the menstrual cycle is about;

28 days

The patient is a newly diagnosed diabetic. Until he has his diabetes under control, which test would furnish valuable immediate feedback information?

A fingerstick blood glucose

The nurse is aware that which patient is most at risk for sensory deprivation?

A patient on the unit with tuberculosis on airborne precautions

A tumor of the pituitary has caused the syndrome of inappropriate secretion of anti-diuretic hormone the nurse plans interventions for (Select all that apply)

A) Assisting with activities of daily living because of weakness B) recording accurate urine output because of oliguria C) weighing daily to assess edema D) assessing for changes in level of conscious because of confusion and seizures.

The nurse properly obtains a 24-hour urine specimen collection by (Select all that apply.) a. Asking the patient to void and to discard the first sample. b. Keeping the urine collection container on ice. c. Withholding all patient medications for the day. d. Asking the patient to notify the staff before and after every void.

A)Asking the patient to void and to discard the first sample. B)Keeping the urine collection container on ice.

What are the major senses (select all that apply)

A)Taste B) touch C)smell D)sight E)hearing/balance

female infertility is most often related to:

Infections of the reproductive tract.

Which of the following symptoms are closely associated with uremic syndrome: (select all that apply)

Nausea and vomiting headache altered mental status

A nurse is discussing foot care with a diabetic client and spouse. The nurse includes which of the following during the informational session?

The toenails should be cut straight across

Diabetes insipidus, clinical manifestations are caused by a deficiency of

antidiuretic hormone (ADH)

Rapid onset of decreased vision, halos around lights, and severe eye pain are indications of

closed angle glaucoma

A 32-year-old construction worker has suffered a penetrating wound to his right eye. The best intervention for anyone to perform at the scene while waiting to be transported to the hospital is to

cover both eyes with a paper cup and tape.

The nurse points out that the person with disorders of the inner ear can be injured by falls because of (select all that apply)

dizziness. vertigo. loss of balance. ataxia.

A nurse-midwife is conducting a session on the process of fertilization with a group of nursing students. The nurse-midwife asks a student to identify the structure where fertilization of an ovum takes place. Which of the following, if identified by the student, indicates an understanding of this process?

fallopian tube

The physician orders a urinalysis and urine culture. To obtain the urine specimen, the nurse would first instruct the patient about

obtaining a clean-catch specimen

A patient has an infectious/inflammatory process of the eyelid. The primary goal of nursing intervention is

preventing further infection

The patient is scheduled for a transurethral resection of the prostate. During preoperative teaching it is important to emphasize that after surgery he should expect

red drainage from the catheter

Often blindness occurs during childhood. Which health preventative measure is most appropriate to prevent vision impairment? a. Screen young children early for visual impairments. b. Instruct parents to report reduced eye contact from their child immediately. c. Include rubella and syphilis screening in the preconception care plan.

Include rubella and syphilis screening in the preconception care plan

An 86 year old patient asks the nurse what lifestyle changes will reduce the Chance of urinary tract infection. Which response is accurate ?

Increasing consumption of acidic foods such as cranberry juice will reduce the chance of infection.

After an older adult falls, the nurse suspects the development of a subdural hematoma based on which finding(s)? (Select all that apply.)

Increasing irritability Complaint of a dull headache Frequent "nodding off" in chair during the day

A client with acute glomerulonephritis is admitted to the nursing unit. The nurse should plan to do which of the following immediately on admission?

Remove the water pitcher from the bedside

A client who suffered a cervical spine injury had crutchfield tongs applied in the emergency department. The nurse would avoid which of the following actions in the care the client.

Removing the weights when repositioning the client

Which body system with the nurse choose to closely monitor any patient diagnosed with Gillians bar syndrome

Respiratory

A nurse is attempting to inspect the lacrimal apparatus of a client's eye. Because of its anatomical location, the nurse should do which of the following?

Retract the upper eyelid and ask the client to look down.

The nurse is creating a plan of care for a patient with Glaucoma which nursing diagnosis addresses the complication of the sensory deficit that places the patient at greatest risk for injury?

Risk for falls

The nurse uses a visual aid to show the hormones the anterior pituitary secretes, including (select all that apply)

- Growth hormone (GH) - Thyroid-stimulating hormone (TSH) - Follicle-stimulating hormone (FSH) - Luteinizing hormone (LH)

A long-term complications of diabetes mellitus is

-Blindness, Cardiovascular problems and renal failure

When discussing exercise programs with the diabetic, the nurse should stress that the patient should (select all that apply)

A)Delay the exercise program until glucose is under control C)have a quick source of glucose available while exercising D)begin slowly and build up to 30 to 45 minutes E)use abdomen only for injection site for insulin

The nurse list the functions of kidney, which include (select all that apply)

A)Regulation of electrolytes B)elimination of metabolic waste C)regulation of fluid volume D)regulation of blood pressure E)secretion of crythropoietin

The patient considering a vasectomy tells the nurse he is afraid he will be impotent after the surgery. The nurse list the expected outcomes of the procedure as ( select all that apply)

A)Remaining potent, but sterile C)incurring no effects on performance D)having no effect on amounts of ejaculation E)retaining some sperm for several weeks

A client has just been admitted with a diagnoses of Myxedema coma. If all of the following interventions were prescribed, the nurse would place highest priority on completing which of the following first?

Administering oxygen as ordered

A client with spinal cord injury has experienced more than one episode of automatic dysreflexia. The nurse will plan to avoid which of the following that could trigger an episode of this complication

Allowing the clients bladder to become distended

The client has she has undergone a renal biopsy. And planning care for this client, the nurse would avoid which intervention?

Ambulate in the room and hall right after biopsy

A nurse has an order to collect 24 hour urine specimen from a client. The nurse should avoid which of the following errors in technique while completing this procedure?

Ask the client to void and save the specimen

While receiving a shift report on a patient, the nurse is informed that the patient has urinary incontinence. Upon assessment, the nurse would expect to find a. An indwelling Foley catheter b. Reddened irritated skin on the buttocks. c. Tiny blood clots in the patient's urine. d. Foul-smelling discharge indicative of a UTI.

B. Reddened irritated skin on the buttocks.

A client is diagnosed with hyphenated after experiencing a traumatic blow to the eye. The nurse explains to the client that which activity limitations need to be implemented following this type of injury?

Bed rest with the head in semi-Fowler's position

A client arrives to the emergency department with an eye injury due to metal fragments that hit the eye while the client was drilling into metal. The nurse assesses the eye and notes small pieces of metal floating on the eyeball. Which action should the nurse take first?

Irrigate the eye with sterile saline.

What nursing action can the nurse implement to comfort an elderly patient with sensory deprivation to improve meaningful stimuli?

Offering the patient a back rub

The nurse answered the call light of a newly admitted patient. The patient tells the nurse she is and asks the nurse to assisst her to the bathroom. Which action by the nurse is most appropriate?

Walk slightly ahead of the patient and allow the patient to hold the nurses elbow

Many individuals have difficulty voiding in a bedpan or urinal while lying in bed because they.

Would feel more comfortable assuming a normal voiding position.

A patient age 46, is recovering from an abdominal hysterectomy. Postoperative nursing interventions for her would include a. Force fluids b. Report urinary retention to the charge nurse c. Milk the urinary catheter d. Turn the patient onto her right side

b. Report urinary retention to the charge nurse