Exam 3
A nurse is providing care to a patient with delirium. Which interventions would be most appropriate to implement? (Select all that apply) a. providing a calm, quiet environment b. supervising nutritional intake c. using familiar cues about the environment d. administering psychoactive drugs e. keeping the patient awake as much as possible
a, b, c
A nurse is receiving the medications of a client who lives alone and reports having difficulty remembering when to take them. To aid in medication compliance, which of the following measures would the nurse employ? (Select all that apply) a. write down the medication schedule for the client b. suggest that the client use a multiple-dose medication dispenser c. recommend to the client to use one pharmacy for all prescriptions d. encourage the client to use containers with safety lids e. remind the client to keep empty medication containers to demonstrate use
a, b, c
The nurse is developing a bowel training program for a patient. What education can the nurse provide for the patient that will increase the chance of success of the bowel program? (Select all that apply) a. set a daily defecation time that is within 15 minutes of the same time every day b. have an adequate intake of fiber containing foods c. have a fluid intake between 2 and 4 L/day d. take a retention enema daily e. take a laxative daily
a, b, c
An older adult in the hospital with a fractured hip is being prepared for surgical repair. The client left his bilateral hearing aids at home and is having difficulty hearing. To promote communication, which of the following actions should the nurse perform? (Select all that apply) a. talk directly to the client b. use a deeper tone of voice c. speak in a loud voice d. ask the client to repeat what was stated e. allow the television to remain on while talking to the client
a, b, d
A clinic nurse is meeting with a group of older adults living in a community that has been experiencing extremely hot summer days. Which of the following measures would the nurse encourage the clients to practice to protect their health during the hot summer days? (Select all that apply) a. wear lightweight shirts and shirts b. take cool showers c. decrease hot tub baths to three times each week d. increase fluid intake e. circulate air with a fan or air conditioner
a, b, d, e
A nurse is providing a fall prevention clinic for a group of older adults. What information should the nurse include? (Select all that apply) a. place grab bars in the shower and tub b. have routine vision and hearing screenings c. frequently change the furniture layout in the home d. wear nonslip shoes or socks when walking e. review medications routinely for side effects f. use scatter rugs on hard wood surfaces
a, b, d, e
The rehabilitation nurse is working closely with a patient who has a new orthosis following a knee injury. What are the nurse's responsibilities to this patient? (Select all that apply) a. help the patient learn to apply and remove the orthosis b. teach the patient how to care for the skin that comes in contact with the orthosis c. assist in the initial fitting of the orthosis d. assist the patient in learning how to move the affected body part correctly e. collaborate with the physical therapist to set goals for care
a, b, d, e
Falls, which are a major health problem in the elderly population, occur from multifactorial causes. When implementing a comprehensive plan to reduce the incidence of falls on a geriatric unit, what risk factors should the nurse identify? (Select all that apply) a. medication effects b. overdependence on assistive devices c. poor lighting d. sensory impairment e. ineffective use of coping strategies
a, c, d
The client with blindness is hospitalized following a MI. Which of the following care measures would the nurse take with this client? (Select all that apply) a. identify self when walking into the client's room b. speak in a slightly louder voice c. state when the nurse is leaving the room d. leave the bathroom door either completely open or closed e. pat the canine service animal immediately upon entering the client's room
a, c, d
A nursing instructor is preparing a class on pressure ulcers. Which of the following would the instructor most likely include as a possible risk factor? (Select all that apply) a. immobility b. enhanced sensory perception c. anemia d. increased tissue perfusion e. increased moisture
a, c, e
A nurse is completing an assessment of a client who has just been transferred to the rehabilitation facility. During the health history, the nurse asks about the client's activities of daily living (ADLs). About which areas would the nurse gather information? (Select all that apply) a. bathing b. cleaning c. cooking d. toileting e. eating
a, d, e
An 85 yo client diagnosed with a stroke is complaining of a severe headache. Which intervention should the nurse implement first? a. Complete a neurological assessment b. Administer a non-narcotic analgesic c. Prepare a stat MRI d. Start an IV with D5W at 100ml/hr
a. Complete a neurological assessment
The nurse is planning the care of a client diagnosed with Addison's disease. Which interventions should be included? a. administer steroid medications b. provide frequent stimulation c. consult physical therapy for gait training d. place the client on a fluid restricition
a. administer steroid medications
The client diagnosed with atrial fibrillation has experienced a TIA which medication would the nurse antivipate being ordered for the client on discharge? a. an oral anitcoagulant med b. a beta blocker med c. an anti-hyperuricemic med d. a thrombolytic med
a. an oral anitcoagulant med
The client diagnosed with OA is prescribed a NSAID. Which instruction should the nurse teach the client? a. notify the HCP if vomiting blood b. take the medication on an empty stomach c. apply the medication topically over the affected joints d. make sure to taper the medication when discontinuing
a. notify the HCP if vomiting blood
A 78 yo client is admitted to the ED with numbness and weakness of the left arm and slurred speech. Which nursing intervention is priority? a. schedule for a stat CT scan of the head b. notify the speech pathologist for an emergency consult c. prepare to administer recombinant tissue plasminogen activator (TPA) d. discuss the precipitating factors that caused the symptoms
a. schedule for a stat CT scan of the head
Which medication order should the nurse question in the client diagnosed with untreated hypothyroidism? a. laxatives b. oxygen c. sedatives d. thyroid hormones
a. sedatives
The client is diagnosed with OA. Which signs and symptoms should the nurse expect the client to exhibit? a. severe bone deformity b. swan-neck fingers c. waddling gait d. joint stiffness in the AM
a. severe bone deformity *the pt with OA will experience stiffness and pain with movement, not upon awakening
A client diagnosed with Addison's disease is admitted to the ER after a day at the lake. The client is lethargic, forgetful, and weak. Which intervention should the nurse implement? a. start an IV and infuse NS rapidly b. obtain a permit for the client to receive a blood transfusion c. have the client wait in the waiting room until a bed is available d. collect urinalysis and blood samples for a CBC and calcium level
a. start an IV and infuse NS rapidly
A client is scheduled for laser-assisted in situ keratomileusis (LASIK) surgery for severe myopia. Which instructions should the nurse discuss prior to the client's discharge from day surgery? a. teach the client how to instill corticosteroid ophthalmic drops b. wear corrective lenses until the follow-up visit c. do not read any material for at least one week d. wear bilateral eye patches for 3 days
a. teach the client how to instill corticosteroid ophthalmic drops
A nurse is going to assess which patient first? a. the client diagnosed with advanced RA who is receiving antineoplastic drugs IV b. the client diagnosed with scleroderma who has hard, wax like skin near the eyes c. the client diagnosed with SLE who has a rash across the bridge of the nose d. the client diagnosed with RA complaining of pain at a 3 on a scale of 1-10
a. the client diagnosed with advanced RA who is receiving antineoplastic drugs IV
The nurse is developing a care plan for a client with SLE. Which goal is priority for this client? a. the client will have no deterioration of organ function b. the client will maintain reproductive ability c. the client's skin will remain intact and have no irritation d. the client will verbalize feelings of body-image changes
a. the client will have no deterioration of organ function
The client with RA has nontender moveable nodules in the subcutaneous tissue over the elbows and shoulders. a. the nodules indicate a rapidly progressive destruction of the affected tissue b. the nodules present a favorable prognosis and mean the client is better c. the nodules are lymph nodes which have proliferated to try to fight the disease d. the nodules are small amounts of synovial fluid that have become crystallized
a. the nodules indicate a rapidly progressive destruction of the affected tissue
The nurse brings the older adult patient a dinner tray and observes the patient placing excess amounts of salt on the food. What suggestions for flavoring can the nurse provide to decrease the amount of salt the patient is placing on her food? (Select all that apply) a. drink water before the meal b. use low-sodium herbs and spices c. use an alcohol-based mouthwash prior to eating d. use pepper instead of salt e. use lemon instead of salt to flavor food
b, d, e
Which statement by the client supports the diagnosis of Guillian-Barre syndrome? a. "I just returned from a short trip to Japan" b. "I had a really bad cold a few weeks ago" c. "I think one of the people I work with had this" d. "I have been taking some herbs for more than a year"
b. "I had a really bad cold a few weeks ago"
The client is diagnosed with Meniere's disease. Which statement indicates the client understands the medical management of the disease? a. "After IV antibiotics, I will be cured" b. "I must adhere to a low-sodium diet, 2,000 mg/day" c. "I will have to use a hearing aid for the rest of my life" d. "I should sleep with the head of my bed elevated"
b. "I must adhere to a low-sodium diet, 2,000 mg/day"
The school nurse is assessing a teacher who has had pediculosis. Which statement by the teacher indicates that she did not comply with instructions provided by the nurse? a. "I washed my hair with Kwell shampoo" b. "I removed the sheets from my bed and washed them in cold water" c. "I did not share brushes with my daughter" d. "I used a comb to remove all the nits"
b. "I removed the sheets from my bed and washed them in cold water"
The school nurse is discussing impetigo with teachers in the elementary school. One of the teachers asks, "how can I prevent getting impetigo?" Which statement would be the most appropriate response? a. "wash your hands after using the bathroom" b. "do not touch any affected areas without gloves" c. "apply a topical antibiotic ointment to your hands" d. "keep the child with impetigo isolated in the room"
b. "do not touch any affected areas without gloves"
Which assessment data would indicate to the nurse that the client would be at risk for hemorrhagic stroke? a. blood glucose level os 480 b. BP 220/110 c. presence of bronchogenic carcinoma d. a right sided carotid bruit
b. BP 220/110
A 65 yo pt is diagnosed with macular degeneration. Which statement by the client indicates the client needs more discharge teaching? a. I am going to contact a low-vision center to evaluate my home b. I need to use low-watt light bulbs in my house c. I should use magnification devises as much as possible d. I will look at my Amsler grid at least twice a week
b. I need to use low-watt light bulbs in my house
What client problem is priority for a client diagnosed with RA? a. activity intolerance b. alteration in comfort c. fluid and electrolyte imbalance d. excessive nutritional intake
b. alteration in comfort
The client is complaining of burning, stabbing pain that radiates around the left rib cage area. The nurse cannot find any type of skin abnormality. Which action should the nurse implement? a. administer a nonnarcotic analgesic to the client b. ask the client if he or she has ever had chickenpox c. transfer the client to the ED for cardiac work-up d. inform the client that the nurse can't see anything
b. ask the client if he or she has ever had chickenpox
The client is scheduled for right-eye cataract removal surgery in five days. Which pre-op instruction should be discussed with the client? a. prior to surgery do not lift or push any objects heavier than 15 lbs b. avoid taking any type of medication which may cause bleeding, such as aspirin c. administer dilating drops on both eyes for 72 hours prior to surgery d. make arrangements for being in the hospital for at lest 3 days
b. avoid taking any type of medication which may cause bleeding, such as aspirin
The 26 yo female client is complaining of a low-grade fever, arthralgia, fatigue, and facial rash. Which lab test should the nurse expect the HCP to order if SLE is suspected? a. complete metabolic panel and liver function tests b. complete blood count and antinuclear antibody tests c. cholesterol and lipid profile tests d. blood urea nitrogen and glomerular filtration tests
b. complete blood count and antinuclear antibody tests
The client diagnosed with a right sided CVA is admitted to the rehab unit. Which intervention should be included in the nursing care plan? a. turn and reposition the client every shift b. encourage the client to move the affected side c. perform quadriceps exercises three times a day d. instruct the client to hold the fingers in a fist
b. encourage the client to move the affected side
The client received 10 units of Humulin R (regular) at 0700. At 1030, the UAP tells the nurse that the patient is acting "funny". What interventions should the nurse implement first? a. prepare to administer one ampule of D50 IV b. go to the client's room with a glucometer and a 6 oz glass of juice and assess the client for hypoglycemia c. instruct the UAP to obtain a blood glucose level d. have the client drink 8 oz of diet soda
b. go to the client's room with a glucometer and a 6 oz glass of juice and assess the client for hypoglycemia
The elederly client with NIDDM is admitted to the ICU with severe Hyperglycaemic Hyperosmolar non-ketotic Syndrome (HHNS). Which collaborative intervention should the nurse include in the plan of care? a. perform glucometer checks daily b. infuse 0.9% NS IV c. monitor ABG results d. administer intermediate acting insulin
b. infuse 0.9% NS IV
Which nursing intervention should be included in the plan of care for the client diagnosed with hyperthyroidism? a. decrease the client's fluid intake to 1,000mL/day b. provide six small, well-balanced meals a day c. reduce the amount of fiber in the diet d. encourage a low-calorie, low protein diet
b. provide six small, well-balanced meals a day
The nurse is discussing ways to prevent DKA with the client with type 1 diabetes. Which instruction is most important to discuss with the client? a. explain the need to get annual flu and pneumonia vaccines b. take the prescribed insulin even when unable to eat because of illness c. do not take any OTC medications d. refer the client to the American Diabetes Association
b. take the prescribed insulin even when unable to eat because of illness
The nurse is caring for clients on a medical unit. After shift report, which client should the nurse assess first? a. the 34 yo who is quadriplegic and cannot move his arms b. the 78 yo client with pressure ulcers who has a T 102.3 F c. the young adult who is unhappy with the care that was provided last shift d. the elderly client diagnosed with a CVA who is weak on the right side
b. the 78 yo client with pressure ulcers who has a T 102.3 F
The nurse is assessing the feet of a client with Type 2 diabetes. Which of the assessment data warrant immediate intervention by the nurse? a. the client has tinea pedis (athletes foot) b. the client has a necrotic big toe c. the client has crumbling toenails d. the client has thickened toenails
b. the client has a necrotic big toe
The client with skin lesions is experiencing pruritus. Which statement would be an appropriate long-term goal? a. the client will have relief from itching b. the client will not develop a secondary bacterial infection c. the client will refrain from scratching the skin d. the client will maintain skin integrity
b. the client will not develop a secondary bacterial infection
The client diagnosed with an acute exacerbation of SLE is prescribed high dose steroids. Which statement best explains the scientific rationale for using high dose steroids in the treatment of SLE? a. the steroids will prevent scarring of skin tissues with SLE b. the steroids will suppress tissue inflammation, which reduces damage to organs c. the steroids will decrease the chance of SLE spreading to other organs d. the steroids will increase the body's ability to fight the infection
b. the steroids will suppress tissue inflammation, which reduces damage to organs
When assessing a client's risk for pressure ulcer development, which finding would alert the nurse to an increased risk? (Select all that apply). a. constipation b. sensory overload c. edema d. anemia e. diaphoresis
c, d, e
The nurse is discharging a client who had a total hip replacement. Which statement indicates further teaching is needed? a. "I will call my HCP if a sudden increase in pain" b. "I will sit on a chair with arms and a firm seat" c. "After 3 weeks, I don't have to worry about infection" d. "I should not cross my legs because my hip can come out of the socket"
c. "After 3 weeks, I don't have to worry about infection"
A client with a subarachnoid hemorrhage has undergone a craniotomy fo repair of a ruptured aneurysm. Which intervention will the intensive care nurse implement? a. monitor neurological status every shift b. maintain the dopamine drip to keep BP at 160/90 c. administer a stool softener d. encourage the client to cough hourly
c. administer a stool softener
Which signs and symptoms should the nurse expect to assess in the client diagnosed with Sjogrens Syndrome? a. complaints of muscle weakness b. complaints of peripheral joint pain c. complaints of dry mouth and eyes d. complaints of severe itching
c. complaints of dry mouth and eyes
The client is experiencing ringing in the ears. Which data is most appropriate for the nurse to document in the client's chart? a. complaints of presbycusis b. complaints of otorrhea c. complaints of tinnitus d. complaints of vertigo
c. complaints of tinnitus
The male client is sitting in a chair and his entire body is rigid with his arms and legs contracting and relaxing. The client is not aware of what is going on and is making guttural sounds. Which action should the nurse implement first? a. place the client on his side b. assess the client's VS c. ease the client to the floor d. push aside any furniture
c. ease the client to the floor
The client diagnosed with an acute exacerbation of MS is placed on high-dose IV injections of a corticosteroid medication. Which nursing intervention should be implemented? a. provide supplemental dietary sodium with the client's meals b. hold the medications until all cultures have been obtained c. monitor the client's serum blood glucose levels d. discuss continuing the proton pump inhibitor with the HCP
c. monitor the client's serum blood glucose levels
Which intervention is an example of a secondary nursing intervention when discussing osteoporosis? a. perform non-weight bearing exercises regularly b. obtain a bone density test c. refer clients to a smoking cessation program d. increase the intake of dietary calcium
c. refer clients to a smoking cessation program
The client is admitted to the outpatient surgery for removal of a malignant melanoma. Which assessment data indicate the lesion is a malignant melanoma? a. the lesion has a waxy appearance with pearl-like borders b. the lesion has a thickened scaly appearance c. the lesion is asymmetrical with irregular borders d. the lesion appears as a thickened area after an injury
c. the lesion is asymmetrical with irregular borders
The nurse is performing discharge teaching for a client diagnosed with Cushing's disease. Which statement by the client demonstrates an understanding of the instructions? a. "I will abruptly withdraw the prednisone treatment as soon as I feel better" b. "It is fine to play in weekend games of tackle football" c. "If I get weak and shaky, I will need to eat some hard candy or drink some juice" d. "I will not abruptly withdraw from my prednisone treatment, I will taper off as directed"
d. "I will not abruptly withdraw from my prednisone treatment, I will taper off as directed"
The client with a C6 SCI is admitted to the ER complaining of a severe pounding headache and has a BP of 180/110. Which intervention should the ER nurse implement first? a. keep the client flat in bed b. administer a narcotic analgesic c. dim the lights in the room d. assess for bladder distension
d. assess for bladder distension
The client is taken to the ER with an injury to the left arm. Which intervention should the nurse implement first? a. remove the client's clothing from the arm b. call radiology for a STAT x-ray of the extremity c. prepare the client for the application of a cast d. assess the nailbeds for capillary refill time
d. assess the nailbeds for capillary refill time
The client diagnosed with Parkinson's Disease is admitted with a fever and patchy infiltrates in the lung on cxr. Which clinical manifestations of PD would explain these assessment data? a. lack of arm swing and bradykinesia b. masklike facies and shuffling gait c. pill rolling of fingers and flat affect d. difficulty swallowing and immobility
d. difficulty swallowing and immobility
The client is being admitted to rule out a brain tumor. Which classic triad of symptoms supports a diagnosis of brain tumor? a. abrupt loss of motor function, diarrhea, and change in taste b. nervousness, metastasis to lungs, and seizures c. hypotension, tachycardia, and tachypnea d. headache, vomiting, and papilledema
d. headache, vomiting, and papilledema
The client comes to the emergency department after splashing chemicals into the eyes. Which intervention should the nurse implement first? a. have the client move the eyes in all directions b. determine when the client had a tetanus shot c. administer a broad-spectrum antibiotic d. irrigate the eyes with normal saline solution
d. irrigate the eyes with normal saline solution
The client is admitted to the medical floor with a diagnosis of a closed head injury. Which nursing intervention has priority? a. initiate an IV access b. assess neurological status c. monitor pulse, respirations, and blood pressure d. maintain an adequate airway
d. maintain an adequate airway
The client diagnosed with an acute exacerbation of SLE is being discharged with a prescription for an oral steroid will be discontinued gradually. Which statement is the scientific rationale for this type of medication gradually? a. tapering the med prevents the client form having withdrawal symptoms b. so thyroid gland starts working, because this med stops it from working c. this is a health care providers personal choice in prescribing this medication d. tapering the dose allows the adrenal glands to begin to produce cortisol again
d. tapering the dose allows the adrenal glands to begin to produce cortisol again
The client diagnosed with hypothyroidism is prescribed levothyroxine (Synthorid). Which assessment data is of most concern? a. the client has a pulse rate of 62 bpm b/ the client's temperature is WNL c. the client denies any diaphoresis d. the client has a 3 lb weight gain
d. the client has a 3 lb weight gain
The client has undergone a craniotomy for a brain tumor. Which data indicate a complication of this surgery? a. the client complains of dizziness when trying to get up too quickly b. the client complains of a raspy throat c. the client complains of a headache at 3 or 4 out of 1-10 d. the client has an intake of 1000 ml and an output of 3500 ml
d. the client has an intake of 1000 ml and an output of 3500 ml
the client diagnosed with type 1 diabetes had a HgA1C level of 8.1%. Which interpretation should the nurse make based on this result? a. the result is below normal levels b. the result is within acceptable levels c. the result is above recommended levels d. the result is dangerously high
d. the result is dangerously high