practice question exam 1

Which supplement will the nurse recommend to a client who wants to enhance eye health? A. Lutein B. Vitamin D C. Magnesium D. Saw palmetto

A. Lutein

The nurse assesses a client with a diagnosis of early stage Alzheimer's disease. Which assessment finding would the nurse expect for this client? Select all A. Forgetfulness B. Hallucinations C. Wandering D. Urinary incontinence E. Difficulty eating F. Personality changes

A- forgetfulness F- personality changes

The nurse is preparing to teach a client who has been prescribed a levodopa-carbidopa preparation for Parkinson's disease. What health teaching will the nurse include for the client and family? Select all A. Move slowly when changing positions from sitting to standing B. Take your medication after meals to help prevent nausea. C. Report any hallucinations that the client may have. D. Note any changes in mental or emotional status. E. Pay attention to whether your tremors improve or worsen.

A- move slowly when changing positions from sitting to standing C- report any hallucinations that the client may have D- note any changes in mental or emotional status E- pay attention to whether your tremors improve or worsen.

A client experiences a seizure that is observed by the nurse. What will the nurse document in the clients medical record? Select all A. Time that seizure began and ended B. Whether the seizure was preceded by an aura C. What the client does after the seizure D. How long it takes for the client to return to preseizure status E. The drugs that are administered during the seizure

A- time thay seizure began and ended B- whether the seizure was preceded by an anura C- what the client does after the seizure D- how long it takes for the client to return to preseizure status

Which symptom will the nurse teach the client who just has surgery to correct a retinal detachment to immediately report to the eye care provider? Select all A. Pain in the affected eye B. Pus in the affected eye C. Decreased visual acuity D. Temperature of 99.0 f E. Pupil that constricts in response to light

A. Pain in the affected eye B. Pus in the affected eye C. Temperature of 99.0

The nurse assesses a client who was admitted 8 hours after stroke symptoms began and documents the following findings. Which assessment findings would the nurse report immediately to the primary health care provider? Select all A. Blood pressure increases to 196/100 mm hg B. Heart rate of 88 beats/min C. Respiratory rate of 22 breaths/min D. New onset headache reported as 8/10 pain intensity E. Increased drowsiness and dozing frequently F. Urine output of 360 ml since admission

A. Blood pressure increases to 196/100 mm hg D. New onset headache reported as 8/10 pain intensity E. Increased drowsiness and dozing frequently

The nurse performs an initial neurologic assessment on an older client. Which assessment findings would the nurse expect to be the result of normal physiologic aging? Select all A. Decreased coordination B. Hearing loss C. Long term memory loss D. Recent memory loss E. Decreased balance control

A. Decreased coordinaton B. Hearing loss. D. Recent memory loss E. Decreased balance control

Which client statement regarding a new diagnosis of tinnitus requires nursing teaching? Select all A. I am so glad this condition will go away permanently B. It is important that I do not drive when I have tinnitus C. Watching my diet will make a difference in my condition D. Surgery is the only treatment that is available for tinnitus E. I have found a couple of support groups that I like to attend

A. I am so glad this condition will go away permanently C. Watching my diet will make a difference in my condition D. Surgery is the only treatment that is available for tinnitus

Which statement by a client who had a transient ischemic attack (TIA) and is at risk for stroke indicates a need for further health teaching by the nurse? A. Im glad I can keep eating protein like red meat. B. I'll try to walk at least 20 to 30 minutes each day C. Im going to talk to my doctor about weight loss plan D. I plan to include more fruits and vegetables in my diet

A. Im glad i can keep eating protein like red meat.

Which assessment data do the nurse anticipate when a client presents to the emergency department reporting the sensation of a foreign body in the eye? Select all A. Pain B. Fever C. Tearing D. Photophobia E. Blurred vision

A. Pain C. Tearing D. Photophobia E. Blurred vision

A nurse is caring for a client who has halo fixator device with vest for a complex cervical spinal cord injury. Which assessment finding will the nurse report to the primary health care provider! A. Purulent drainage from the pin sites on the clients forehead B. Painful pressure injury under the collar C. Inability to move legs or feet D. Oxygen saturation of 95% on room air

A. Purulent drainage from the pin sites on the clients forehead.

During a clients neurologic assessment, the nurse finds that the client is arousable only with vigorous or painful stimulation. How does the nurse document this clients LOC? A. Stuporous B. Lethargic C. Comatose D. Alert

A. Stuporous

Which communication method is appropriate when the nurse is interacting with a client who is deaf? A. Use pictures and writing B. Speak with enunciated words C. Ask the client to read the nurses lips D. Dialogue with the clients caregivers

A. Use pictures and writing

The nurse is admitting a client with a probable diagnosis of meningitis. What signs and symptoms might the nurse expect when assessing the client? Select all A. Photophobia B. Nystagmus C. Decreased LOC D. Decreased movement, such a Hemiparesis E. Disorientation to person, place, and time

ALL

1. A client scheduled for a percutaneous transhepatic cholangiography (PTC) denies allergies to medication. What action by the nurse is best?

Ask the client about shellfish allergies.

1. A client is recovering from an esophagogastroduodenoscopy (EGD) and requests something to drink. What action by the nurse is best?

Assess the clients gag reflex

1. The nurse knows that a client with prolonged prothrombin time (PT) values (not related to medication) probably has dysfunction in which organ?

a. Liver

The nurse is preparing a teaching plan for a client with migraine headaches. Which of these foods or food additives that may trigger a migraine and should be avoided will the nurse include in the teaching? Select all A. Sugar B. Beer C. Smoked sausage D. Pickles E. Caffeine F. Wine

B- beer C- smoked sausage D- pickles E- caffeine F- wine

Which client statement affirms that nurse teaching about instillation of multiple different eye drops has been effective? Select all A. It will be very easy for me to instill all of the drops at one time B. A schedule will help me remember when to instill the eye drops C. If i have trouble instilling the drops, there are devices that can be helpful. D. I can label the eye drops by color to help me easily distinguish which one is which. E. I will not touch the droppers to my eyes as this can cause contamination and infection.

B. A schedule will help me remember when to instill the eye drops C. If I have trouble instilling the drops, there are devices that can be helpful D. I can label the eye drops by color to help me easily distinguish which one is which E. I will not touch the droppers to my eyes as this can cause contamination and infection

The nurse is caring for a client following a cerebral angiography. Which assessment finding will the nurse report immediately to the primary health care provider? A. Discomfort at the injection site B. Bleeding from the injection site C. Fatigue and weakness D. Mild headache

B. Bleeding from the injection site

The nurse is caring for a client treated with alteplase following a stroke. Which assessment finding is the highest priority for the nurse to report to the primary health care provider? A. Client has a new onset mild headache B. Clients blood pressure is 194/120 mm hg C. Client has left hemiparesis D. Client continues to be drowsy

B. Clients blood pressure is 194/120 mm hg

A client returns from the PACU after a surgical removal of a frontal lobe tumor. In what position will the nurse place the client at this time? A. Turn the client from side to side to prevent aspiration B. Elevate the head of the bed to at least 30 degrees at all times. C. Keep the client flat in bed or up 10 degrees and reposition from side to side D. Keep the client in a high fowler position in bed at all times

B. Elevare the head of the bed to at least 30 degrees at all times.

A client is admitted with a suspected cervical spinal cord injury. What is the nurses priority action for this client? A. Assess cardiac sounds. B. Manage the clients airway C. Check oxygen saturation level. D. Perform a neurologic assessment.

B. Manage the clients airway

A nurse is assessing a client with a suspected diagnosis of multiple sclerosis. Which assessment findings will the nurse expect? Select all A. Resting tremors B. Memory loss C. Muscle spasticity D. Fatigue E. Diplopia F. Dysarthria

B. Memory loss C. Muscle spasticity D. Fatigue E. Diplopia F. Dysarthia

The nurse is preparing to conduct a focused neurologic assessment for a client who had a traumatic brain injury. Which assessment finding is the immediate concern of the nurse? A. Disorientation B. Numbness in both arms C. Decreased LOC D. Report of headache

C- decreased LOC

A client with moderate dementia asks the nurse to find her son who is deceased. What is the nurses most appropriate response? A. We can call him in a little while if you want B. Your son died over 20 years ago C. What did you son look like D. I'll ask you husband to find him when he visits

C- what did your son look like

Which patient does the nurse identify at highest risk for development of dry age macular degeneration? A. 55 year old client who recently began wearing glasses B. 59 year old client who has controlled hypertension C. 62 year old client with hypothyroidism D. 65 year old client with diabetes

C. 62 year old client with hypothyroidism

When teaching a community group of older adults, what information will the nurse include regarding normal hearing changes associated with aging? Select all A. Hair in the ear thins and falls out B. Hearing acuity changes in all older adults C. Cerumen dries and becomes impacted more easily D. The ability to hear low frequency pitches diminishes first E. Sounds such as f, s, sh, and pa May be more difficult to discern

C. Cerumen dries and becomes impacted more easily E. Sounds such as f, s, sh, and pa May be more difficult to discern

What finding does the nurse anticipate when assessing a client with a new diagnosis of glaucoma? A. Seeing shooting stars B. Decrease central vision C. Gradual loss of visual fields D. Abrupt onset of excruciating pain

C. Gradual loss of visual fields

A client who sustained a recent cervical spinal cord injury reports having a throbbing headache and feeling flushed. The clients blood pressure is 190/110 mm hg. What is the nurses priority action at this time? A. Perform a bladder assessment B. Insert an indwelling urinary catheter C. Place the patient in a sitting position D. Turn on a fan to cool the patient

C. Place the patient in a sitting position

The nurse is caring for an older client with receptive (sensory) aphasia. Which nursing action is most appropriate for communicating with the client? A. Refer the client to the speech-language pathologist (SLP) B. Speak loudly to help the client interpret what is being said C. Provide pictures to help the client understand. D. Ask the client to read messages on a whiteboard.

C. Provide pictures to help the client understand

What teaching will the nurse provide to a client who continues to experience more frequent episodes associated with meniere disease? Select all A. Reducing activity can reduce frequency of episodes B. Episodes will eventually decrease in severity and number C. Reducing sodium, caffeine, and alcohol intake can be beneficial D. The only treatment that is effective is to undergo labyrinthectomy E. When moving from sitting to standing, be cautious and take your time.

C. Reducing sodium, caffeine, and alcohol intake can be beneficial E. When moving from sitting to standing, be cautious and take your time.

The nurse is caring for a client who is diagnosed with early stage Alzheimer's disease who has periods of lucidity. What is the best principle for the nurse to Use when communicating with this client? A. Use validation therapy to prevent upsetting the client B. Encourage pet therapy to help allay the clients anxiety C. Use aromatherapy and other integrative therapies to relax the client. D. Reorient the client frequently to foster reality.

D- reorient the client frequently to foster reality

What is the appropriate nursing response when a 66 year old healthy client asks how often a visit to the eye care provider is recommended? A. Annually B. Every 6 months C. Only if you have vision problems D. Every 1-2 years If you have no eye problems

D. "Every 1-2 years if you have no eye problems."

When caring for four clients, which client does the nurse report to the health care provider who should not receive an otoscopic examination? A. 25 year old with throat and ear pain B. 39 year old experiencing dizziness C. 46 year old has a type 2 diabetes D. 60 year old experiencing delirium

D. 60 year old experiencing delirium

The primary health care provider started a client with multiple sclerosis on mitoxantrone therapy. Which statement will the nurse include in teaching the client about this drug? A. Report changes in urinary and bowel elimination immediately B. Follow up for annual lab testing to monitor for liver toxicity C. Rotate the sites for your self administered injections. D. Avoid crowded places such as malls and large public gatherings

D. Avoid crowded places such as malls and large public gatherings

What teaching will the nurse provide to a client who has just been fitted for new hearing aids? A. Turn off the hearing aid when not using it B. Immerse the ear mold in alcohol to fully clean it C. Sore throat hearing aid in a warm, humid bathroom when not in use D. Avoid using hair spray, makeup, and personal care products around the device

D. Avoid using hair spray, makeup, and personal care products around the device

A client was admitted to the hospital unit a few minutes ago with a new diagnosis of right hemiparesis and aphasia, which resulted from a traumatic brain injury. Which of the following interventions is a priority for the client at this time? A. Contact the physical therapist to plan care to increase the clients mobility B. Contact the occupational therapist to assess the clients ADL's C. Contact the unit social worker to talk with the family about the clients discharge D. Contact the speech language pathologist to schedule a swallowing study.

D. Contact the speech language pathologist to schedule a swallowing study

Which statement by the client indicates a need for further teaching by the nurse about preventing back injuries? A. I need to lose weight because I'm too big B. I should no stand or sit for a long period of time C. It would be best if I could get ergonomic office furniture D. Exercise is not going to help my back very much.

D. Exercise is not going to help my back very much

The nurse is teaching a client about what to expect immediately after a cerebral angiographic examination. Which statement by the client indicates a need for further teaching? A. I'll have a pressure dressing on my groin for a couple of hours B. I'll have to keep my leg straight for a while after the procedure C. The nurses will check circulation in my injected leg frequently D. I can use heat on my groin to decrease any discomfort

D. I can use heat on my groin to decrease any discomfort

1. A client presents to the emergency department reporting severe abdominal pain. On assessment, the nurse finds a bulging, pulsating mass in the abdomen. What action by the nurse is the priority?

Notify the provider immediately

1. A nurse is examining a client reporting right upper quadrant (RUQ) abdominal pain. What technique should the nurse use to assess this clients abdomen?

Palpate the RUQ last.

1. The nurse working with clients who have gastrointestinal problems knows that which laboratory values are related to what organ dysfunctions? (Select all that apply.)

a. Ammonia: liver d. Lipase: pancreas

1. An older client has had an instance of drug toxicity and asks why this happens, since the client has been on this medication for years at the same dose. What response by the nurse is best?

a. Changes in your liver cause drugs to be metabolized differently.

1. A client had an endoscopic retrograde cholangiopancreatography (ERCP). The nurse instructs the client and family about the signs of potential complications, which include what problems? (Select all that apply.)

a. Cholangitis b. Pancreatitis c. Perforation e. Sepsis

1. The nurse working in the gastrointestinal clinic sees clients who are anemic. What are common causes for which the nurse assesses in these clients? (Select all that apply.)

a. Colon cancer b. Diverticulitis c. Inflammatory bowel disease d. Peptic ulcer disease

1. The nurse is aware of the 2014 American Cancer Society Screening Guidelines for colon cancer, which include which testing modalities for people over the age of 50? (Select all that apply.)

a. Colonoscopy every 10 years c. Computed tomography (CT) colonography every 5 years

1. The nurse working with older clients understands age-related changes in the gastrointestinal system. Which changes does this include? (Select all that apply.)

a. Decreased hydrochloric acid production b. Diminished sensation that can lead to constipation c. Fat not digested as well in older adults e. Pancreatic vessels become calcified

1. A client who has been taking antibiotics reports severe, watery diarrhea. About which test does the nurse teach the client?

a. Enzyme-linked immunosorbent assay (ELISA) toxin A+B

1. A client is scheduled for a colonoscopy and the nurse has provided instructions on the bowel cleansing regimen. What statement by the client indicates a need for further teaching?

a. Its a good thing I love orange and cherry gelatin.

1. To promote comfort after a colonoscopy, in what position does the nurse place the client?

a. Left lateral

1. The student nurse studying the gastrointestinal system understands that chyme refers to what?

a. Liquefied food ready for digestion

1. A client is having an esophagogastroduodenoscopy (EGD) and has been given midazolam hydrochloride (Versed). The clients respiratory rate is 8 breaths/min. What action by the nurse is best?

a. Provide physical stimulation.

1. A client presents to the family practice clinic reporting a week of watery, somewhat bloody diarrhea. The nurse assists the client to obtain a stool sample. What action by the nurse is most important?

a. Put on gloves prior to collecting the sample.

1. A client had a colonoscopy and biopsy yesterday and calls the gastrointestinal clinic to report a spot of bright red blood on the toilet paper today. What response by the nurse is best?

a. Remind the client that a small amount of bleeding is possible.