Health & Illness Exam 1

You are caring for a patient in the post op period. Using your clinical judgment, prioritize these nursing diagnoses n the sequence from highest to lower priority a) impaired gas exchange b) fluid volume deficit c) risk for infection d)anxiety e) altered comfort

A, B, E, D, C

The nurse is providing preoperative care to a client who is anxious about total hip replacement surgery. "What if I can never walk again? I don't want to end up like my father." What are some ways the nurse might help alleviate the clients anxiety? Select all that apply a. make sure the client understands what will happen during the surgery b. listen empathetically to the client's concerns about the procedure c. remind the client that the chances of something goes wrong are statistically low d. offer a sedative to help the client relax and feel more comfy e. review the client's postoperative goals following the procedure f. ask the client if he would like to speak with clergy person

A, B, E, F

A nurse researcher examines the risk factors of obesity. Which statements does the nurse find true? Select all that apply. a. obesity decreases overall life expectancy b. risk factors that identify the odds of being diagnosed with obesity are predictable and defined c. obesity increases the risk of mortality d. Causes of obesity are complex and multifactorial

A, C, D

An elderly patient is being discharged home after a minor joint surgery to her foot. Which PRIORITY education should the nurse provide to prevent injury? a. remove all small rugs and trip hazards from the home b. participate in weight-bearing exercises c. ensure understanding of medication side effects d. increase calcium and vitamin D in the diet

A.

A nurse is performing discharge teaching for an elderly client diagnosed with osteoporosis. Which statement about home safety should the nurse include? a. Most accidental injuries among the elderly are automobile-related. Elderly clients should have visions testing every 6 months while they're still driving b. Most falls among the elderly occur in the home. These clients should remove throw rugs and install bathroom grab bars. c. Because of the increase in home burglaries involving the elderly, these clients should have burglar bars on every window in the home d. most falls among the elderly occur outside the home. clients should confine themselves to their homes as much as practical

B

The client arrives at the emergency room reporting symptoms of heart palpitations, tightness in the chest, and epigastric pain after a stressful event. What system will the nurse correlate with the client symptoms? a. respiratory b. autonomic nervous system c. cardiopulmonary system d. central nervous system

B

A patient with his left arm in a cast continues to complain of unrelieved throbbing pain even after receiving a dose of opioid medication. Which is the priority action by the nurse? A. Review the chart for history of opioid abuse B. Reposition the patient for comfort C. Assess the arm for complications D. teach the patient relaxation techniques

C

Nurses assist clients to make knowledgeable choices about their health care by: a. encouraging the experimentation with alternative therapies regardless of regulations b. discouraging clients from making informed decisions about their health care; rather they should trust the care provider's recommendations c. helping the client get full disclosure about their treatment options d. ignoring possible adverse effects if there seems to be benefit

C

A 19-yr-old male has sustained a transection of C-7 in an MVA rendering him quadriplegic. He describes his pain as burning, sharp, and shooting. This is characteristics of: a. mixed pain syndrome b. nociceptive pain c. ghost pain d. neuropathic pain

D

The nurse is preparing to discharge an adolescent with sickle cell anemia. Which patient need should the nurse emphasize in the discharge planning? a. The need for adequate support structure b. the need to have pain medication available c. the need to maintain adequate hydration d. the need to follow up with physician visits

A

The overall goals of care for an individuals experiencing a stress response are to focus on interventions to develop a. positive social support b. positive coping skills c. reappraisal d. cognitive appraisal

B

While assessing a newly admitted client, the nurse identifies impaired coordination, decreased muscle strength, limited range of motion, and reluctance to move. What nursing diagnosis do these signs and symptoms most clearly suggest? a. ineffective health maintenance b. impaired physical mobility c. disturbed sensory perception d. ineffective coping

B

A patient who has been in the hospital for several weeks is about to be discharged. The patient is weak from the hospitalization and asks the nurse to explain why this is happening. The nurse's best response is, "You are weak because... a. your iron level is low, this is known as anemia. b. of your poor appetite. This is known as malnutrition. c. of your immobility in the hospital. This is known as deconditioning." d. of your medications. This is known as drug-induced weakness.

C

A nurse is caring for an older adult client who has become increasingly frail and unsteady on her feet. During the assessment, the client indicates that she has fallen three times in the month, though she has not yet suffered an injury. The nurse should take action in the knowledge that this client is at a high risk for what health problem? a. femoral fracture b. pelvic dysplasia c. medial meniscus tear d. hip fracture

D

A patient is seen in the ER with severe pain related to sickle cell crisis. What does the nurse understand is occurring with this patient? a. the patient has decreased pain tolerance due to the chronic nature of the illness. b. bone marrow decreases erythrocyte production causes decrease in hypoxia c. over hydration enlarging the red blood cells d. vascular occlusion of small vessels decreasing oxygen and blood flow to the tissues

D

A patient is talking with the nurse about hip fractures. The patient would like to know the best approach to strengthen the bones. The nurse's best response is which of the following? a. Walk at least 5 miles everyday for exercise. b. Stand up slowly so you don't feel faint. c. wear proper fitting shoes to prevent tripping d. talk to your physician about a calcium supplement

D

An 80-yr-old male patient is on your unit with a fractured tibia/fibula post traumatic fall. You are making rounds and notice he is somnolent, with no response to verbal or physical stimulation. He has been on round the clock opioids doses q 4 hours. The best immediate course of nursing action is to: a. call the anesthesia provider on call b. call a code blue c. call the primary hospitalist in charge of the patient d. stop opioid; consider administering naloxone, call Rapid Response team

D

Harmful effects of unrelieved pain include all of the following except: a. hyperglycemia b. hypertension c. increased cortisol secretion d. bradycardia

D

the nurse is conducting a community education program on hip fracture risk. the nurse evaluates that the participants understand the program when the participants determine that client at highest risk for a hip fracture is a: a. high school athlete b. 30-year-old pregnant women c. toddler just starting to walk d. 80-year-old man recently widowed

D

The patient is being treated for fracture hip and the nurse is aware of the need to respond with interventions to prevent muscle wasting and other complications related to immobility. What intervention best addresses the patient need for exercise? a. Performing gentle leg lifts with both legs b. performing massage to stimulate circulation c. encoring frequent use of the overbid trapeze d. encouraging the patient to logrolling side to side once per hour

C

Which of the following are PRIORITY nursing concerns for the immobilized patient? select all that apply: a. constipation b. loneliness c. DVT/VTE d. pressure ulcer

C, D

A 75 year old patient had surgery for hip fracture yesterday. After using clinical judgement skills of noticing and interpreting, the nurse should response by assessing the patient for which potential complications? a. skin breakdown b. delirium c. sepsis d. infection of the humerus e. pneumonia

A, B, C , E

If non-pharmacologic strategies are used in combination with NSAID medications, pain can be well controlled with significantly reduced use of narcotics. A. True B. False

A

The nurse and a student are discussing the effects of bed immobility on patients. The nurse knows that the student nurse understands the concept of mobility when she states, "Patients with impaired bed mobility a. have an increased risk for pressure ulcers b. like to have extra visitors c. should always have a bedside commode d. need to have a mechanical soft diet

A