Med-Surg Final Exam Review Questions

A patient with renal failure is on a fluid restriction and complains of thirst. The nurse should offer:

Hard candy

A nurse is caring for a client with dementia. A family member of the client asks wha

"The most common cause of dementia in the elderly is Alzheimer's disease."

A client reports to the nurse that her grandmother with Alzheimer's disease recently moved in with her and her two school-aged children. The client states the grandmother becomes agitated and starts yelling and crying frequently. The woman asks, "What can I do?" The nurse first responds:

"What precipitates the outbursts?"

When evaluating crutch walking of a patient with a right long leg cast and no weight bearing, the patient should:

Advance the right leg and both crutches together and then the left leg

A patient arrives in the emergency department with ankle swelling and pain after twisting the ankle playing soccer. All of the following orders are written by the health care provider. Which one will the nurse act on first?

Evaluate the ankle and apply an ice pack

In teaching the family about a CSF leak post lumbar puncture, you would emphasize:

It is a leak of spinal fluid that surrounds the brain and cord

The critical care nurse is caring for 25-year-old man admitted to the ICU with a brain abscess. What is a priority nursing responsibility in the care of this client?

Monitoring neurologic status closely

A patient with a spinal cord injury has spinal shock. The nurse plans care for the patient based on the knowledge that

Resolution of spinal shock is manifested by spasticity, hyperreflexia, and reflex emptying of the bladder

You are admitting a 30-year-old who has a hearing impairment. The client is accompanied by family members. What information would be important to ask the family members to help you care for your client?

The client's preferred method of communication

An older adult develops sudden onset of confusion and is hospitalized. The family expresses concern that their loved one is developing Alzheimer disease. What response by the nurse is most appropriate?

"Several possible underlying factors could be causing the confusion. Alzheimer's usually does not present with sudden confusion"

A client with Alzheimer's disease is prescribed donepezil hydrochloride. When teaching the client and family about this drug, which of the following would the nurse include?

"The drug helps to control the symptoms of the disease."

An elderly client is admitted with the diagnosis of retinal detachment and is scheduled for laser surgery and scleral buckling procedure. The nurse anticipates which of the following symptoms to be exhibited in this client? Select all that apply.

-flashing lights -cobwebs in vision field

A patient admitted with a head injury has admission vital signs of temperature 98.6° F (37° C), blood pressure 128/68, pulse 110, and respirations 26.Which of these vital signs, if taken 1 hour after admission, will be of most concern to the nurse?

Blood pressure 176/60, pulse 50, respirations 14

A 33-year-old client presents at the clinic with reports of weakness, incoordination, dizziness, and loss of balance. The client is hospitalized and diagnosed with MS. What sign or symptom, revealed during the initial assessment, is typical of MS?

Blurred vision, intention tremor, and urinary hesitancy

The nurse is developing a plan of care for a client with Meniere's disease and identifies a nursing diagnosis of excess fluid volume related to fluid retention in the inner ear. Which intervention would be most appropriate to include in the plan of care?

Limit foods that are high in sodium.

A client has been admitted to the ICU after being recently diagnosed with an aneurysm and the client's admission orders include specific aneurysm precautions. What nursing action will the nurse incorporate into the client's plan of care?

Maintain the client on complete bed rest.

An appropriate intervention for a patient who has phantom limb pain post Symes cut is:

Medicating the patient with the prescribed opioid

The nurse is providing a health promotion session on the risk factors for various health conditions. When discussing brain tumors, the nurse should include in the session which known risk factors for brain tumors? Select all that apply.

-exposure to certain chemicals -having ionizing radiation

The nurse is caring for a 77-year-old woman with MS. She states that she is very concerned about the progress of her disease and what the future holds. The nurse should know that elderly clients with MS are known to be particularly concerned about what variables? Select all that apply.

-increasing disability -becoming a burden on the family -possible nursing home placement

A client diagnosed with a brain tumor is exhibiting focal symptoms. Which assessment findings are the nurse likely to note? Select all that apply.

-muscle weakness -sensory loss -aphasia -visual changes

A patient presents to an eye clinic with a number of symptoms related to his diminished vision. An initial history leads the nurse practitioner to suspect that the patient has acute angle-closure glaucoma. Which of the following symptoms would apply to this diagnosis? Select all that apply.

-severe eye pain -reddening of the eye -sudden onset of visual disturbance -nausea/vomiting

the nurse is providing discharge education to an adult client who will begin a regimen of ocular medications for the treatment of glaucoma. How can the nurse best determine if the client is able to self-adminsiter these medications safely and effectively?

Ask the client to demonstrate the instillation of her medications

which type of glaucoma presents an ocular emergency?

Acute angle-closure glaucoma

The client has been diagnosed with aphasia after suffering a stroke. What can the nurse do to best make the client's atmosphere more conducive to communication?

Provide a board of commonly used needs and phrases.

The nurse is caring for a client with trigeminal neuralgia (tic douloureux). The care plan for this client reflects the client's problem eating due to jaw pain. To assist the client in meeting the adequate nutritional needs, what should the nurse suggest?

Take small meals of soft consistency

Following a renal biopsy, it is important that the nurse:

Test urine for microscopic bleeding with a dipstick

Some clients with acoustic neuromas have vertigo. What is a priority nursing action for clients with vertigo?

protect the client from injury

A client who presents for an eye examination is dx as having a visual acuity of 20/40. The client asks the nurse what these numbers specifically mean. What is a correct response by the nurse?

A person whose vision is 20/40 can see an object from 20 feet away that a person with 20/20 vision can see from 40 feet away

the nurse should recognize the greatest risk for the development of blindness in which of the following clients

A 58-year-old woman with macular degeneration

A patient has had cataract extractions and the nurse is providing discharge instructions. What should the nurse encourage the patient to do at home?

Avoid bending the head below the waist

Which of the following is a continent urinary diversion for bladder CA:

Barnett Pouch

A client dx with a cataract comes into the clinic. What assessments should the nurse observe in this client?

blurred or cloudy visual image

A family of a patient with Alzheimer's disease asks the nurse what causes this condition? Which response by the nurse would be most appropriate?

"Evidence shows that there are changes in nerve cells and brain chemicals."

The nurse is obtaining a health history for a 64-year-old patient with glaucoma who is a new patient at the eye clinic.Which information given by the patient will have the most implications for the patient's treatment?

"I take metoprolol (Lopressor) daily for angina."

A patient with AD in LT care is wandering the halls very agitated, asking for her family and crying. It is best to say:

"Let's make a card in the craft room."

A client with a hip fracture asks the nurse why Buck's extension traction is being applied before surgery. The nurse's response is based on the understanding that Buck's extension traction is primarily:

"Provides comfort by reducing muscle spasms and provides fracture immobilization."

the nurse is teaching the client to instill eye drops. Which statement is correct?

"wash your hands before and after instilling eye drops and do not touch the tip of the bottle"

A patient is being seen in the ophthalmology clinic for a suspected detached retina. What clinical manifestations does the nurse recognize as significant for a retinal detachment? Select all that apply.

- a visual field of floating particles -a definite area of blank vision -momentary flashes of light

A 69-year-old client is brought to the ED by ambulance because a family member found him lying on the floor disoriented and lethargic. The health care provider suspects bacterial meningitis and admits the client to the ICU. What interventions should the nurse perform? Select all that apply.

-administer antipyretics as prescribed -perform frequent neurologic assessments -monitor pain levels and administer analgesics

Postoperative health teaching for a patient who has had an intraocular lens implant is a vital nursing responsibility. Which of the following statements applies to this situation? Select all that apply.

-do not lift, pull, or push objects heavier than 15 pounds -wipe the closed eye from the inner canthus outward -avoid bending the head forward for an extended time

A client with a cerebral aneurysm exhibits signs and symptoms of an increase in intracranial pressure (ICP). What nursing intervention would be most appropriate for this client?

Absolute bed rest in a quiet, non-stimulating environment

The nurse receives an order for 0.4mg Flomax and prepares to administer the first dose. What is the MOST important action for the nurse to take?

Administer the medication at bedtime with a snack

When preparing a patient to ambulate the day after an ORIF for a hip fracture, which action is most important for the nurse to take?

Administering Percocett pain medication

A client has informed the home health nurse that she recently noticed distortions when she looks at the Amsler grid that she has mounted on her fridge. What is the nurse's most appropriate action?

Arrange for the client to be assessed for muscular degeneration

Family members report to the nurse that their elderly grandmother has had a sudden onset of confusion and that they are having difficulty providing care for her. What is the nurse's best response?

Assess the grandmother for adventitious lung sounds

A patient is admitted to the emergency department with possible fractures of the bones of the left lower extremity. The initial action by the nurse should be to:

Check the popliteal, dorsalis pedis, and posterior tibial pulses

Which is a correct rationale for encouraging a client with otitis externa to eat soft foods?

Chewing may cause discomfort

A health care team is involved in caring for a client with advanced Alzheimer's disease. During a team conference, a newly hired nurse indicates that she has never cared for a client with advanced Alzheimer's disease. Which key point about the disease should the charge nurse include when teaching this nurse?

Clients with Alzheimer's disease are at high risk for injury because of their impaired memory and poor judgment.

When assessing the activity-exercise pattern of a patient with chronic vertigo syndrome, the nurse notes that the patient states,"I love to run for exercise, and I usually run five or six times a week, but now I feel dizzy when I run." Which action should be included in the plan of care?

Developing an exercise program that gradually increases time spent running

A client is being admitted to the neurologic ICU with suspected herpes simplex virus encephalitis. What nursing action best addresses the client's complaints of headache?

Dimming the lights and reducing stimulation

A client has recently brought her elderly mother home to live with her family. The client states that her mother has moderate Alzheimer's disease and asks about appropriate activities for her mother. The nurse tells the client to

Ensure that the mother does not have access to car keys or drive an automobile.

A 6-year-old is brought to the pediatric clinic for the assessment of redness and discharge from the eye and is diagnosed with viral conjunctivitis. What is the most important information to discuss with the parents and child?

Hand washing can prevent the spread of the disease to others

The 22 year old client with a severe head injury is admitted to the critical care unit. Some of the client's friends come to the nurses station requesting information. Which action would be most appropriate by the nurse?

Explain that no information can be shared with the friends.

Bell palsy is a disorder of which cranial nerve?

Facial (VII)

Mr. Claus has chronic renal failure and CAD from a diet rich in hot chocolate and heavy cream. Which of the following lab values are of most concern?

Glomerular filtration rate of 28 ml/min.

When reviewing the results of a patients CSF, the nurse will notify the health care provider about:

Glucose 30mg/dl.

The nurse is preparing to administer otic drops into the adults right ear. Which action should the nurse implement?

Grasp the auricle and pull up and out when putting drops in the ear

A male with CRF is admitted with severe infection and depression & anemia. The wife asks about the nursing care. The nurse explains the rationale of treatment:

His intake of protein is restricted so the kidneys can clear the body of waste

Discharge instructions to a patient who just had a AKA includes:

I should lay on my abdomen for 30 minutes 3-4 times a day

A patient is scheduled for a right tympanoplasty. Which statement indicated the client understands the preop teaching concerning the surgery?

If I have to sneeze or blow my nose, I will do it with my mouth open.

The public health nurse is addressing eye health and vision protection during an educational event. What statement by a participant best demonstrates an understanding of threats to vision?

Im certainly going to keep a close eye on my blood pressure from now on

A nurse is planning the care of a 28-year-old woman hospitalized with a diagnosis of myasthenia gravis. What approach would be most appropriate for the care and scheduling of diagnostic procedures for this client?

In the morning, with frequent rest periods

A patient suffers an injury to the shoulder while playing football. To identify abnormalities of cartilage and soft tissue surrounding the joint, the nurse would expect the patient to be evaluated with

MRI

A patient is hospitalized with acute angle-closure glaucoma. All the following orders are received. Which will the nurse implement first?

Mannitol (Osmitrol) 100 mg administered intravenously

The primary nurse in the neuro unit is very busy. Which nursing task must be implemented first?

Obtain a tracheostomy tray for a client with a C4 SCI who is exhibiting air hunger

A patient is diagnosed with cataracts. Which symptoms would the nurse expect the client to report?

Painless blurry vision

During an exacerbation of MS, a client complains of urinary urgency and frequency. The initial nursing measure should be to :

Palpate the suprapubic area

Which of the following are true about retinal detachments:

Patients are often myopic and have a history of cataract surgery

A patient with a fractured pelvis is initially treated with bed rest with no turning from side to side permitted. The second day after admission, the patient develops chest pain, tachypnea, and tachycardia.The nurse determines that the patient's symptoms are most likely related to fat embolism when assessment of the patient reveals

Petechiae on the upper chest

A home health nurse is visiting a 74-year-old client with Alzheimer's disease. During the visit, the nurse notes bruising on the client's upper arms, and the client is more withdrawn than normal. The client is unable to communicate effectively because of his disease progression. The nurse suspects elder abuse. What is the nurse's responsibility in this situation?

Report the suspicion to the local agency on aging within 24 hours of the visit

A client with Alzheimer's disease is admitted for hip surgery after falling and fracturing the right hip. The client's spouse tells the nurse about feeling guilty for letting the accident happen and reports not sleeping well lately because the spouse has been getting up at night and doing odd things. Which nursing diagnosis is most appropriate for the client's spouse?

Risk for caregiver role strain related to increased client care needs

A client with otosclerosis has significant hearing loss. What should the nurse do to best facilitate with the client?

Sit or stand in front of the client when speaking

A client with Meniere's disease has a nursing diagnosis of risk for injury related to gait disturbances and vertigo. Which of the following would be most appropriate to include in this client's plan of care?

Sitting down at the first sign of feeling dizzy

The nurse is doing discharge teaching with a client newly diagnosed with Ménière's disease. Why would the nurse advise a low-sodium diet to this client?

To reduce the production of fluid in the inner ear

A client at an extended-care facility who has Alzheimer's disease is awake throughout the night. The nurse intervenes with activities that will promote sleep at night, which include

Walking the client in the facility yard during the day

A nurse needs to change a dressing on an abdominal wound for a patient who is hearing-impaired and whose speech is difficult to understand. Which of the following is the best approach for the nurse?

Write down the steps of the procedure for the patient to read before beginning the treatment

A client is being discharged home from the ambulatory surgical center after cataract surgery. In reviewing the discharge instructions with the client, the nurse instructs the client to immediately call the office if the client experiences what?

a new floater in vision

In a patient who has a corticospinal tract lesion, the nurse should assess for

extremity movement and strength

A client presents at the ED after receiving a chemical burn to the eye. What would be the nurse's initial intervention for this client?

generously flush the affected eye with normal saline or water

A client is ready to be discharged home after a cataract extraction with intraocular lens implant and the nurse is reviewing signs and symptoms that need to be reported to the MD immediately. Which of the client's statements best demonstrates an adequate understanding?

i need to call the doctor if I see flashing lights

The plan of care for a patient with advanced Alzheimer's disease includes the nursing diagnosis of risk for injury. The nurse has identified this nursing diagnosis most likely as related to which of the following?

impaired memory

A patient undergoing a TURP returns from surgery with a three-way urinary catheter with continuous bladder irrigation in place.The nurse observes that the urine output has decreased and the urine is clear red with multiple clots. The patient is complaining of painful bladder spasms. The most appropriate action by the nurse is to

instill 50 ml of saline with a bulb syringe to remove the clots.

Following a radical retropubic prostatectomy for prostate cancer, the patient is incontinent of urine. An appropriate nursing intervention for this patient is to teach the patient

pelvic floor muscle training.

When caring for a patient with a right-brain intra-cerebral hemorrhage, the nurse suspects possible supratentorial herniation and compression of the brainstem when the

right pupil is slow react to light

A nurse is assessing a pediatric client in a public health clinic. The parent states that the client has been sneezing and rubbing the eyes. The nurse observes the client's eyes and documents objective symptoms of watery and red eyes. When reporting to the physician the assessment findings, which word is appropriate?

signs and symptoms of conjunctivitis

A patient has chronic osteomyelitis of the femur and a culture is taken from a wound site. The nurse is aware that the most common pathogen to cause osteomyelitis is which of the following:

staph aureus

To encourage adequate nutritional intake for a client with Alzheimer's disease, a nurse should:

stay with the client and encourage him to eat.

A client with glaucoma has presented for a scheduled clinic visit and tells the nurse that she has begun taking a herbal remedy for her condition that was recommended by a work colleague. what instructions should the nurse provide to the client?

the client should discuss this new remedy with her ophthalmologist

a colleague has been splashed in the eye with cleaning solution. Which of the following would be the priority?

irrigating the eye immediately with tap water

A 56-year-old client has come to the clinic for his routine eye examination and is told he needs bifocals. The client asks the nurse what change in the eyes has caused his need for bifocals. How should the nurse respond?

there is a gradual thickening of the lens of the eye and it can limit the eye's ability for accommodation

A patient is prepared for discharge following outpatient cataract surgery. To evaluate whether the patient understands the postoperative regimen and procedures, the nurse asks the patient

to demonstrate administration of eye drops

A patient with irritative and obstructive bladder symptoms has an enlarged prostate on digital rectal examination (DRE) and an extremely high PSA level. The nurse will anticipate that the patient will need teaching about

transrectal ultrasonography (TRUS).

A week following a SCI at t2, a patient experiences movement in his leg and tells the nurse he is recovering some function. The nurse's best response to the patient is:

"That could be a really positive finding. Can you show me the movement?"

The wife of a patient who has undergone a TURP and has continuous bladder irrigation asks the nurse about the purpose of the continuous bladder irrigation. Which response by the nurse is appropriate?

"The irrigation is needed to keep the catheter from being occluded by blood clots."

Nursing students are reviewing statistics related to the older adult population and leading causes of death in this age group. The students demonstrate understanding of this information when they rank the following conditions in the order from highest to lowest.

-heart disease -malignant neoplasms -cerebrovascular disease -COPD -alzheimer's disease -diabetes

You are the nurse caring for a client with Guillain-Barré syndrome (GBS). The client also has an ascending paralysis. Knowing the complications of the disorder, what should you keep always ready at the bedside?

Intubation tray and suction apparatus

Several residents of a long-term care facility have developed signs and symptoms of viral conjunctivitis. What is the most appropriate action of the nurse who oversees care in the facility?

Isolate affected residents from residents who have not developed conjunctivitis.

A patient with Ménière's disease is admitted with vertigo, nausea, and vomiting. Which nursing intervention will be included in the care plan?

Keep the patient's room darkened.

During assessment of the musculoskeletal system of a 74-year-old woman, the nurse notes that the patient has lost 1 inch in height since the previous visit two years ago.The nurse will plan to teach the patient about

MRI

The nurse is performing an initial assessment on a client admitted to rule out Guillain-Barre syndrome. On which of the following areas will the nurse focus most heavily?

Respiratory

While caring for a patient who has just been admitted with meningococcal meningitis, the RN observes all of the following.Which one requires action by the RN?

The nursing assistant goes into the patient's room without a mask

A patient who had cataract extraction and intraocular lens implantation the previous day calls the eye clinic and gives the nurse all of the following information. Which information will be of most concern to the nurse?

The patient has eye pain rated at a 5 (on a 0-10 scale).

the nurse on the medical-surgical unit is reviewing discharge instructions with a client who has a hx of glaucoma. the nurse should anticipate the use of what medications

cholinergics

A nurse is caring for an elderly adult client admitted to the hospital from a nursing home because of a change in behavior. The client has a diagnosis of Alzheimer's disease and has started to experience episodes of incontinence. The hospital staff is having difficulty with toileting because the client wanders around the unit all day. To assist with elimination, a nurse should

incorporate the client's toileting schedule into the pattern of his wandering

a nurse is teaching a client with glaucoma how to administer eye drops to achieve max absorption. The nurse should teach the client to perform what action?

instill the medication in the conjunctival sac

When performing a focused assessment on a patient with a lesion of the left posterior temporal lobe, the nurse will assess for

understanding of written and oral language

A client with Alzheimer's disease is being treated for malnutrition and dehydration. The nurse decides to place him closer to the nurses' station because of his tendency to:

wander