Med Surg A Final 2.0

Family members are concerned because a client has been confused over the last few days. What is the best response by the nurse?

"Confusion can mean many things that should be evaluated."

What would the nurse include when teaching an adolescent about tinea pedis?

"Dry the area between your toes really well."

A teenage girl with psoriasis tells the nurse that she is so embarrassed by the plaque on her skin that she doesn't want to go to school. What is the best response by the nurse?

"It must be really difficult for you. Tell me how you are taking care of your skin on a daily basis."

A client with a seizure disorder asks the purpose of staying awake all night before having an electroencephalogram (EEG) in the morning. What should the nurse explain to this client?

"Sleep deprivation can cause a seizure, which will be helpful during the test."

Which statement by the patient regarding the treatment for cystic fibrosis indicates the need for further teaching?

"Taking CFTR modulators will cure my cystic fibrosis."

An older adult client asks why a wound is taking so long to heal. What is the nurse's best response?

"The amount of blood flow to the skin is slower with aging."

The nurse working in the community health clinic places a purified protein derivative (PPD, or Mantoux) test on an adult's forearm and instructs him to return when for reading of the response?

Between 48 and 72 hours after placement of the PPD

The nurse correlates which finding in a client's history as the highest risk for a stroke?

Blood pressure 182/90 mm Hg

The nurse monitors for which clinical manifestations in the client diagnosed with Parkinson's disease?

Bradykinesia

In administering bronchodilator therapy to a client with asthma, the nurse correlates the effectiveness of this classification of medication to which mechanism of action?

Bronchodilators widen the airways because they stimulate the sympathetic nervous system.

The nurse correlates which clinical manifestation in the client diagnosed with a basilar skull fracture?

Bruising around the ears

A client with a traumatic brain injury is leaking clear fluid from the nose. What action should the nurse take?

Collecting the fluid with gauze

The nurse monitors for which clinical manifestations in the client diagnosed with a left temporal node brain tumor?

Comprehensive speech difficulty

Pressure ulcers are directly caused by which condition at the site?

Compromised blood flow

The nurse is caring for a client newly diagnosed with asthma. Which assessment data indicate the need for an immediate intervention?

Diminished breath sounds

The nurse administers an antitussive/expectorant cough preparation to a client with bronchitis. Which response indicates to the nurse that the medication is effective?

Dry, unproductive cough is reduced, but voluntary coughing is more productive

The nurse correlates which diagnostic result as consistent with the diagnosis of cystic fibrosis?

Elevated sodium levels in sweat

A client has a stage 1 pressure injury on the left heel. What is the initial treatment for this pressure ulcer?

Elevation of the left heel off the bed

What aspect of nursing care will most assist a client with Alzheimer's to enhance bladder control?

Establish a timed voiding schedule

What diagnostic tool is used to assess level of consciousness for clients that have suffered blunt-force trauma to the head?

Glasgow Coma Scale

The nurse correlates which material as being used to treat the client requiring a secondary closure of a surgical wound?

Grafts

What is a major goal from an intradisciplinary team for a client with Parkinson's disease?

Maintain joint flexibility

In using the Braden Scale to assess a client's skin, which category does the nurse recognize as the most sensitive indicator for risk of pressure injury?

Mobility

Which client finding indicates the need for further monitoring after an outpatient surgical procedure?

Persistent nausea without vomiting

The results of a client's biopsy indicate a malignant growth. The nurse prepares the client for which treatment?

Surgical removal of the lesion

The nurse is teaching the parent of a child with cystic fibrosis about nutrition requirements for the child. What should be included in this teaching? Select all that apply.

B. "Give pancreatic enzymes with meals." D. "Feed your child foods that are high in protein." E. "Give your child high-calorie foods and snacks."

What intervention(s) should the nurse anticipate for treatment of hyperthermia in an unresponsive client following a closed-head injury? Select all that apply.

B. Give acetaminophen 500 mg rectal suppository C. Place ice packs to axilla and groin areas E. Place the client on a water-cooling blanket

The nurse is providing care to a client diagnosed with emphysema. Which clinical manifestation does the nurse correlate with this diagnosis?

Barrel chest

What condition is most likely represented by clear fluid draining from the nose of a client that suffered a trauma to the head several hours ago?

Basilar skull fracture

What is the therapeutic goal associated with levodopa in Parkinson's disease?

Decrease in muscle rigidity

A client recovering from an ischemic stroke is prescribed verapamil (Calan). The nurse teaches the client that this medication works by which action?

Decreases blood pressure

The nurse is providing care to a client who is diagnosed with rhinosinusitis and prescribed azelastine. The nurse recognizes that the rationale for this medication is which of the following actions?

Decreasing inflammation

What is the rationale for rapid completion of computed tomography (CT) scanning in clients presenting with stroke-like symptoms?

Determining the type of stroke

In collecting a wound culture, what action does the nurse need to take prior to obtaining the specimen?

Flush the wound bed with sterile saline

The client tells the nurse, "I'm so nervous. I want to be knocked out for the surgery so that I don't know what is going on." When the nurse communicates with the surgeon and anesthetist, which type of surgery should the nurse report that the client desires?

General anesthesia

The nurse is educating the parents of a 7-year-old boy with asthma about the medications that have been prescribed. Which drug would the nurse identify as an adjunct to a β2-adrenergic agonist for treatment of bronchospasm?

Ipratropium

The nurse is caring for a client who is admitted to the unit with tuberculosis (TB). The client is placed in isolation. To protect the caregivers and other clients on the unit, which type of isolation room is most appropriate?

Isolation room with an anteroom and negative air flow (air flows into the room)

When using sterile technique to perform tracheostomy care of a new tracheostomy, which action is correct?

Place the client in semi-Fowler's position, if possible

Which finding in a client with dyspnea requires an immediate intervention by the nurse? Select all that apply.

Tachypnea Cyanosis Accessory muscle use

The nurse is planning discharge instructions for a client recovering from surgery to debulk a brain tumor. What is the rationale for teaching the client about self-monitoring of capillary blood glucose level?

Taking steroid medication

The nurse teaches a client who is prescribed carbamazepine (Tegretol) for the treatment of seizure activity. Which client statement indicates a need for additional teaching?

"I can crush the pill and eat it in applesauce because it is so big."

What is an early sign of increased intracranial pressure (ICP)?

Disorientation and restlessness

The nurse provides education to a client who is prescribed an aerochamber for the treatment of asthma. Which client statement indicates the need for additional teaching?

"I should hear a whistling sound as I inhale the medication."

Which client statement regarding the use of a normal saline nasal rinse requires intervention by the nurse?

"I will allow fluid to drain out the upper nostril to remove excess mucous from my nose."

The nurse teaches a client how to implement pursed-lip breathing. Which client statement indicates a need for additional instruction?

"I will inhale through my mouth while slowly counting.

The nurse provides education to a client who is being treated for rhinitis. Which client statement indicates the need for further teaching?

"I will use my nasal decongestant spray every day."

A child is in the emergency department with an asthma exacerbation. Upon auscultation the nurse is unable to hear air movement in the lungs. What action should the nurse take first?

Administer a beta-2 adrenergic agonist

Which information does the post-anesthesia care unit (PACU) nurse receive from the operating room nurse during hand-off communication? Select all that apply.

1. Estimated blood loss 3. The surgical procedure 4. Fluid intake during the procedure 5. Names of family members in the waiting room

Why is an accurate description of the location of a wound important? Select all that apply.

1. Influences the rate of healing 4. Affects client movement and mobility Answers:

The nurse in the operating room is preparing a client for a surgical procedure. What action will the nurse take to prepare the client's skin? Select all that apply.

1. Remove the hair 2. Cleanse the surgical site 5. Assess the skin for rashes or areas of breakdown

The nurse working on the medical-surgical unit has received a client from the post-anesthesia care unit (PACU). Which clinical manifestations are indicative of pain in the postoperative client? Select all that apply.

1. Restlessness 2. Diaphoresis 5. Piloerection

Which are actions the nurse implements during the informed consent process when providing client care? Select all that apply.

1. Reviewing the consent form 2. Witnessing the client's signature on the consent form 5. Validating client understanding of the information presented for the procedure

The nurse correlates which data from a client's history to a diagnosis of bronchitis?

A history of progressive dyspnea

The nurse notes that a client has a prescription for a peak expiratory flow meter. For which health problem should the nurse prepare teaching for this client?

Asthma

The nurse is assessing several clients at a community clinic. The nurse questions administration of the annual influenza vaccination in which client?

A 35-year-old man with a severe allergy to eggs

What nursing intervention(s) is/are appropriate for a client presenting with status epilepticus? Select all that apply.

A. Remove nearby objects to prevent possible injury B. Provide supplemental oxygen therapy C. Administer lorazepam intravenously or rectally

The nurse provides care to a client who is diagnosed with Parkinson's disease (PD). Which client data support the implementation of fall precautions in the plan of care? Select all that apply.

A. Rigidity B. Tremors E. Orthostatic hypotension

A client recovering from abdominal surgery has an incision has been closed by primary intention, and the staples are intact. To provide more support to the incision site and decrease the risk of dehiscence, what would be appropriate to apply?

Abdominal binder

What assessment must be completed prior to a client completing magnetic resonance imaging (MRI) of the head?

Ability of the client to tolerate an enclosed space

The circulating nurse is assisting the anesthesiologist with client monitoring during a surgical procedure. When documenting the administration of propofol, which terminology does the nurse use?

An intravenous anesthetic

The nurse is caring for a client admitted for treatment of a subarachnoid hemorrhage caused by a cerebral aneurysm who has a wide neck and tortuous vascular anatomy. The client is hemodynamically stable with Glasgow Coma Scale of 14. Based on this data, the client is most likely to have which procedure?

Aneurysm clipping

The nurse is caring for an infant with candidal diaper rash. Which topical agent would the nurse expect the healthcare provider to order?

Antifungals

What is the nurse's best intervention for preventing injury for a client with a head injury that has become increasingly agitated?

Ask a friend or family member to sit with the client.

What nursing intervention is most appropriate during administration of phenobarbital?

Assess for signs of drowsiness

A child has been prescribed a nasal cannula for oxygen delivery. What should the nurse do before applying the cannula?

Assess patency of the nares

A child has been prescribed a nasal cannula for oxygen delivery. What should the nurse do beforeapplying the cannula?

Assess patency of the nares

The staff development trainer is preparing orientation materials for new staff hired to care for clients with seizure disorders. Which data are included in this presentation? Select all that apply.

C. Myoclonic seizures involve sudden brief, involuntary contractions. D. Tonic-clonic seizures include rigidity followed by jerking movements. E. Tonic seizures are sustained muscle contractions lasting a few seconds to minutes.

A client is admitted with a stroke. The nurse correlates which predisposing factor in the client's history places as placing this client at greatest risk for embolic stroke?

Carotid plaque

The nurse monitors for which assessment data in the client diagnosed with a Staphylococcusskin infection?

Creamy, yellow pus drainage

A client in the operating room develops malignant hyperthermia. The nurse prepares which medication for administration to treat this medical emergency?

Dantrolene

"The amount of blood flow to the skin is slower with aging."

Exceed the typical healing time

The nurse assesses a client who is admitted after a traumatic brain injury (TBI) to the frontal lobe. The nurse correlates which clinical manifestations to damage to this area of the brain?

Expressive speech difficulty

The nurse recognizes which client at greatest risk for chronic rhinosinusitis?

Female client with history of nasal polyps

A client developed a stage 4 pressure injury to the sacrum 6 weeks ago, and now the ulcer appears to be a shallow crater involving only partial skin loss. How should the nurse now classify this pressure injury?

Stage 4 pressure injury, healing

The nurse monitors for which clinical manifestation as indication that a client's Alzheimer's disease is progressing?

Inability to recall the word for "car"

What trends in vital signs would indicate an increased intracranial pressure (ICP)?

Increasing temperature, decreasing pulse, decreasing respirations, and increasing blood pressure

A client recovering from reconstructive surgery is experiencing unrelenting postoperative pain. The nurse correlates this finding to which potential complication?

Infection

A client scheduled for surgery does not have a signed consent form on the chart. The healthcare provider directs the nurse to have the client sign the consent before reviewing the type of surgery. What should the nurse do?

Inform the surgeon that the consent form will be provided after the surgery is discussed with the client.

A client's pulse oximetry reading is 90%. What action should the nurse take first?

Move the sensor to another area

During a home visit the nurse is concerned that the client with Alzheimer's disease is deteriorating. What client observation caused the nurse to have this concern?

No recognition of bowel incontinence during the visit

What information does the nurse teach the client regarding NPO status before a surgical procedure?

Nothing solid by mouth for 6 to 8 hours before surgery

The nurse administers the preoperative medication to the client 1 hour before elective surgery and then discovers the preoperative consent is not signed. Which action by the nurse is the most appropriate?

Notify the healthcare provider that surgery will need to be canceled.

Chest percussion and postural drainage would be an appropriate intervention for which condition?

Pneumonia

Which diagnostic study is the most effective in determining whether a client has obstructive sleep apnea?

Polysomnography

During morning care a client with a seizure disorder asks why the room has suddenly turned green. What should the nurse do?

Prepare for a seizure to begin.

A client has been experiencing a tonic-clonic seizure for 5 minutes. What should the nurse do first?

Prepare to insert an airway.

What is the rationale for a client being placed on stool softeners following the repair of a cerebral aneurysm?

Prevention of straining, which increases intracranial pressure (ICP)

The nurse is examining a 5-year-old. Which sign or symptom is a reliable first indication of respiratory illness in children?

Rapid, shallow breathing

In assessing neurological status on an older client, the nurse needs to consider which age-related change of the neurological system?

Reaction time is slower

While assessing a new wound, the nurse notes red, watery drainage. What type of drainage will the nurse document this as?

Serosanguineous

A child is diagnosed with atopic dermatitis. Which laboratory test would the nurse expect the child to undergo to provide additional evidence for this condition?

Serum immunoglobulin E (IgE) level

The nurse correlates which potential risk factors to the development of several lacerations over the coccyx area?

Shearing

When conducting a skin assessment for a client, which term does the nurse use to document soft, moist, tan- or green-colored devitalized tissue?

Slough

The nurse monitors for which gastrointestinal clinical manifestations in the client diagnosed with cystic fibrosis?

Steatorrhea

The nurse needs to provide a strong stimulus to illicit a response; however, the client drifts back to unresponsiveness. What term should the nurse use to document this client's level of responsiveness?

Stupor

The nurse is caring for a 3-year-old girl with a respiratory disorder. The nurse anticipates the need for providing supplemental oxygen to the child when performing which action?

Suctioning a tracheostomy tube

What clinical manifestations should the nurse most anticipate in a client experiencing a hemorrhagic stroke following the rupture of a cerebral aneurysm?

Sudden and severe headache

The nurse reads tuberculin skin test (TST) results for a group of clients. Which client does the nurse document as a positive result in the medical record?

The client who uses intravenous (IV) drugs whose induration is 11 mm.

When teaching a client about the healing process of an open wound after surgery, which point should the nurse make?

The client will have more scar tissue formation than for a wound closed at surgery.

A client is experiencing scaly, patchy skin changes on the upper back, chest, and arms. In some areas the skin is either red, dark in color, or lighter in color. The nurse correlates these findings to which type of fungal infection?

Tinea versicolor

What is the primary goal that the nurse should establish for a client with an open wound?

The wound will remain free of infection throughout the healing process.

The nurse is providing care to a child with folliculitis. What would the nurse expect to administer?

Topical mupirocin

A client with Parkinson's disease is prescribed carbidopa/levodopa (Sinemet). Which clinical manifestation should the nurse expect to be most affected with this medication?

Tremors

Which structure of the respiratory system is responsible for filtering, warming, and humidifying inhaled air?

Turbinates

A client has a pressure injury on the coccyx measuring 5 cm by 3 cm that is covered with eschar. How should the nurse classify this wound?

Unstageable pressure injury

What medication should the nurse anticipate for a client recently admitted to the hospital following a transient ischemic attach (TIA) secondary to atrial fibrillation?

Warfarin

A nurse is assessing the skin of a child with cellulitis. What would the nurse expect to find?

Warmth at skin disruption site

The nurse caring for a homeless client at risk for tuberculosis (TB) includes which clinical manifestations of the disease when educating the client? Select all that apply

Weight loss Night sweats Fatigue

The nurse is assessing a client's postoperative wound and finds it has separated from the suture line with extrusion of the bowel through the opening. How does the nurse document this finding?

Wound evisceration

Which is an applicable goal/outcome for the client with a stage 4 pressure injury?

Wound will close with no evidence of infection within 6 weeks.

Which statement describes the difference between dehiscence and evisceration?

With dehiscence, there is a separation of one or more layers of wound tissue; evisceration involves the protrusion of internal viscera from the incision site.

A client is undergoing a surgical procedure. Based on the figure, which intraoperative position does this represent?

Reverse Trendelenburg

A client returns to the community clinic after being diagnosed with Parkinson's disease. What should the nurse expect to see documented in the client's medical record to support this diagnosis?

Rigidity with ambulation

The nurse monitors for which clinical manifestation in the client admitted with tuberculosis?

Rust-colored sputum

A client is recovering from surgery for a ruptured appendix. Because the surgeon did not surgically close the wound, what wound healing process will occur?

Secondary intention

In caring for a client scheduled for a hip replacement surgical procedure, the nurse recognizes this procedure is an example of which surgical category?

Restorative

In teaching the client about post-operative pain management, which statement by the nurse isbest?

"It is important that you request pain medication before the pain gets too severe."

The nurse is providing care for a 14-year-old girl with severe acne. The girl expresses sadness and distress about her appearance. Which response by the nurse would be most appropriate?

"Many people feel this way; I know someone who can help."

Which statement by the client recently diagnosed with a meningioma indicates understanding of the diagnosis?

"My tumor can be removed, but I can still have damage because of pressure in my brain."

A 62-year-old man with emphysema does not understand the need to stop smoking at this age because lung problems already exist. Which would be the best response to his statement?

"Once you stop smoking, your body will begin to repair some of the damage to your lungs.

A 62-year-old man with emphysema does not understand the need to stop smoking at this age because lung problems already exist. Which would be the best response to his statement?

"Once you stop smoking, your body will begin to repair some of the damage to your lungs."

After teaching a class about the differences in the skin of infants and adults, the nurse determines that additional teaching is necessary when the class states:

"The infant has a lower risk for damage from ultraviolet radiation because the skin is more pigmented."

Which statements by a client with asthma indicates effective teaching?

"We will replace the carpet in our bedroom with tile."

The nurse is monitoring a client who is receiving triple H therapy for vasospasm secondary to a subarachnoid hemorrhage. Which finding requires the nurse to immediately contact the healthcare provider?

Blood pressure 100/60

Which task is inappropriate for the nurse to delegate to the unlicensed assistive personnel (UAP) during the intraoperative period of care?

Identifying the client before the procedure

The community health nurse is preparing an educational program for local residents. Which information does the nurse include about chronic obstructive pulmonary disease (COPD)? Select all that apply.

Less than 5% of all COPD cases are caused by deficiency in alpha-1 antitrypsin. Approximately 80% to 90% of deaths from COPD are related to smoking. Cigarette smoking is the leading cause of COPD.

The nurse receives care of a postoperative client in the post-anesthesia care unit (PACU). Which is the priority action by the nurse?

Monitoring oxygen saturation

The nurse correlates that a positron emission tomography (PET) scan is indicated to confirm which diagnosis?

Brain tumor

What is the most appropriate action of the nurse to promote safety for a client that is attempting to ambulate post-ischemic stroke?

Have a staff member follow closely with a wheelchair

The nurse is caring for a client who is experiencing dyspnea. Which position would be most effective if incorporated into the client's care?

Head of bed elevated 80°

During morning rounds, the nurse notes that the unlicensed assistive personnel is assisting a client with Parkinson's disease with breakfast. Which observation requires an immediate intervention?

Head of the bed raised to 30 degrees

Which statement by the client being discharged after hospitalization for influenza indicated the need for further teaching?

I do not need to get a flu shot next year because I am now immune.

The nurse assesses a client who is sleepy, with slowed responses to stimuli. Which term does the nurse use when documenting this client's level of consciousness (LOC)?

Lethargic

What are the most common clinical findings in a client during the ictal phase of a generalized tonic-clonic seizure?

Loss of consciousness, body stiffening, and violent muscle contractions

A client with a seizure disorder is prescribed a 1,900-calorie ketogenic diet of which 80% should be consumed as fat. How many calories should the client consume as fat? Record your answer as a whole number. _____

1520

A child is hospitalized with pneumonia. The nurse assesses an increase in the work of breathing and in the respiratory rate. What intervention should the nurse do first to help this child?

Elevate the head of the bed

A client has a leg wound that has beige exudate and a fishy odor. The nurse correlates this assessment data to which microorganism?

Proteus

A client with a cerebral vasospasm is receiving triple H therapy. What parameter should the nurse use to determine adequacy of hemodilution?

Hemoglobin level 30 g/dL

An infant with a high respiratory rate is NPO and is receiving IV fluids. What assessment(s) will the nurse make to assure this infant is hydrated

Measure skin turgor Palpate anterior fontanel Determine urine output

A client is suspected of having Alzheimer's disease. The nurse correlates the results from which diagnostic evaluation to a presumptive diagnosis of this disorder?

History and physical examination

The nurse notes that a client's surgical wound is healing slowly. What should the nurse suggest to improve this client's tissue integrity?

Instruct on increasing the intake of protein

What medication should the nurse anticipate administering for a client with a traumatic head injury exhibiting signs of increasing intracranial pressures (ICP)?

Mannitol 25%