NUR215 Exam 1

Cocaine

During physical assessment of a patient who has frequent nosebleeds the nurse find nasal sores and necrosis of the nasal septum. The nurse should ask the patient specifically about the use of which drug?

Do you have any other symptoms along with the spells?

During the health history interview a patient tells the nurse about periodic fainting spells. Which question should the nurse ask to elicit any associated clinical manifestations?

The problem, it's causes, and the signs and symptoms of the problem

The nurse admits a patient to the hospital and develops a plan of care. What components should the nurse include in the patient problem statement?

focused assessment

The nurse asks an older adult patient with rectal bleeding, "have you ever had a colonoscopy?"The nurse is performing what type of assessment

Risk for injury related to altered perception

The nurse cares for an agitated patient who was admitted to the emergency department after taking a hallucinogenic drug and trying to jump from a third- story window. Which patient problem should the nurse assign as the highest priority?

Refer the patient to social services for further assessment

The nurse cares for an alert homeless older adult patient who was admitted to the hospital with a chronic foot infection. Which intervention is the priority for the nurse to include in the discharge plan for this patient?

Ensurers transportation to appointments with the healthcare provider

The nurse cares for an older adult patient who lives in a rural area. Which intervention should the nurse plan to implement to meet this patient's needs

In addition to caring for you while you are sick the nurse will assist you to develop an individualized plan to maintain your health

The nurse completes an admission database and explains that the plan of care and discharge goals will be developed with the patient's input. The patient asks , "how is this different from what the doctor does?Which response would be most appropriate for the nurse to make?

Recommendations are based on research, clinical expertise and patient preferences

The nurse describes to a student nurse how to use evidence-based practice (EBP) when caring for patients. Which statement by the nurse accurately describes the use of EBP?

Perform the physical assessment before interviewing the patient

The nurse is admitting an acutely ill older patient to the hospital which action should the nurse take?

Use simple gestures to demonstrate meaning while talking to the patient

The nurse is caring for a patient who speaks a different language if an interpreter is not available which action by the nurse is appropriate?

Transitional care facility

The nurse is caring for an older adult patient who needs continued nursing care and physical therapy to improve mobility after surgery to repair a fractured hip. The nurse would help to arrange for transfer of the patient to which facility?

Stethoscope

The nurse is preparing to perform a focused assessment for a patient reporting shortness of breath which equipment will be needed?

Improve sleep

The nurse plans postoperative care for a patient who smokes 2 packs of cigarettes daily. Which goal should the nurse include in the plan of care for this patient?

Nutritional status

The nurse records the following general survey: The patient is a 50-year-old Asian female accompanied by her husband and two daughters. Alert and oriented. Does not make eye contact with the nurse and response slowly but appropriately to questions. No apparent disabilities or distinguishing features. What additional information should the nurse add to this general survey?

The nursing process is a problem-solving tool used to identify and treat patients health needs

The nurse teaches a student nurse about how to apply the nursing process when providing patient care. Which statement by the student nurse indicates that teaching was successful?

Invite the patient to use the bathroom

The nurse will assess an older patient who takes diuretics and has a possible urinary tract infection (UTI) which action should the nurse take first?

Assess the perception of community members about the care at the clinic

The nurse working in a clinic in a primarily black community notes a higher incidence of uncontrolled hypertension in the patients. To address this health disparity and promote health equity which action should the nurse take first?

Teach clinic staff about Hispanic health beliefs

The nurse works in a clinic located in a community where many of the residents are Hispanic. Which strategy if implemented by the nurse would decrease healthcare disparities and promote health equity for this community?

Take the patient's temperature, pulse, and blood pressure

The registered nurse (RN) cares for a patient who was admitted a few hours previously with back pain after a fall. Which action can the RN delegate to unlicensed assistive personnel (UAP)?

Most common causes of death

What information should the nurse collect when assessing the health status of a community?

Question the patient about the use of over-the-counter sleep aid

What is the first action the nurse should take in addressing a patient's concerns about insomnia and daytime fatigue?

Assist a patient to place the CPAP device correctly over the nose and mouth at bedtime

When caring for patients with sleep disorders which activity can the nurse appropriately delegate to unlicensed assistive personnel (UAP)?

Coordinate the use of folk treatments with ordered medical therapies

Which action should the nurse include in the plan of care for a hospitalized patient who uses culturally based treatments?

Organize the sequence to minimize the position changes

Which adaptations to the physical examination techniques should the nurse include for an alert older adult patient?

Abdominal tenderness

Which assessment findings should alert the nurse to ask the patient about alcohol use?

The patient complains of new onset of sadness and depression

Which information is most important for the nurse to report to the healthcare provider about a patient who has been using varenicline (Chantix)?

Listen to bowel sounds

Which physical assessment action should the nurse take after inspecting a patient's abdomen

Obtain bedside blood glucose on a patient before insulin administration

Which task is appropriate for the nurse to delegate to a licensed practical/vocational nurse (LPN/VN)?

health perception-health management

While the nurse is taking the health history a patient states my mother and sister both had a double Mastectomies and were unable to exercise for weeks which functional health pattern is represented by this patient's statement?

Screening test geriatric version

A 73-year-old patient is admitted with pancreatitis. Which tool would be the most appropriate for the nurse to use during the admission assessment?

Question the patient about use of the patch at night

A newly admitted patient reports waking frequently during the night. The nurse observes the patient wearing a nicotine patch on the right upper arm. Which actions should the nurse take first?

Patient denies having pain when the area over the fracture is palpated

A nurse performs a health history and physical examination with a patient who has a right leg fracture. Which assessment would be a pertinent negative finding?

Ask the patient about music preferences

A nurse prepares an adult patient with a severe burn injury for a dressing change. The nurse plans to try providing music to help the patient relax. Which action is best for the nurse to take?

Monitor frequently for anxiety hyperreflexia and sweating

A patient admitted to the hospital after an automobile crash is alert and does not appear to be highly intoxicated. The blood alcohol concentration (BAC) is 110 mg/dL (0.11%). Which action by the nurse is appropriate?

What health problems do you think smoking has caused

A patient admitted with shortness of breath and chest pain who is a pack-a-day smoker tells the nurse I am just not ready to quit smoking yet which response by the nurse is appropriate for the patient's stage of change?

Emergency assessment

A patient has arrived at the hospital with severe abdominal pain and hypotension. Which type of assessment should the nurse do at this time?

Relaxation breathing, guided imagery

A patient is extremely anxious a few minutes before having a biopsy on a femoral lymph node. Which technique should the nurse recommended that the patient use during the procedure?

Thiamine (vitamin B1) 100mg daily

A patient presents to the emergency department with a blood alcohol concentration (BAC) of 0.18% after reviewing the prescribe medications which drug should the nurse in minister first?

Ask the patient to keep a 2- week sleep diary

A patient reports difficulty falling asleep and daytime fatigue for the past 6 weeks. What is the best initial action for the nurse to take in determining whether this patient has chronic insomnia

Naloxone (Narcan)

A patient who has a history of ongoing opioid use is hospitalized for surgery. After a visit by a friend the nurse finds that the patient is unresponsive with pinpoint pupils. Which prescribed medication should the nurse expect to administer?

Have staff members write notes welcoming the patient to the facility

A patient who has just relocated to a long-term care facility is exhibiting signs of stress related to the move. Which actions should the nurse include in the plan of care?

I am older and wiser now and I think I can change my drinking behavior

A patient with a history of heavy alcohol use is diagnosed with acute gastritis. Which statement by the patient indicates a willingness to stop alcohol use?

Provide a quiet well lit environment

A patient with alcohol dependence is admitted to the hospital with back pain after a fall. Twenty-four hours after admission the patient becomes tremulous and anxious. Which action by the nurse is appropriate?

Try to go to bed at the same time every evening

A patient with chronic insomnia ask the nurse about ways to improve sleep quality. Which response by the nurse is accurate?

To determine if interventions have been effective in meeting patient outcomes

After administering medication,the nurse asks the patient if pain was relieved. What is the purpose of the evaluation phase of the nursing process?

Recheck the blood pressure after the patient has been assessed

An adult patient who arrived at the triage desk in the emergency department (ED) with minor facial lacerations after a motor vehicle accident has a blood pressure (BP) of 182/94 which action by the nurse is appropriate?

Anxiety

An adult patient who is hospitalized after a motorcycle crash tells the nurse I didn't sleep last night because I was worried about missing work at my new job and losing my insurance coverage which patient problem is appropriate to include in the plan of care?

Risk for injury related to drug interactions

An alert older patient who takes multiple medications for chronic cardiac and pulmonary disease lives with a daughter who works during the day. During a clinic visit the patient tells the nurse that she has a strained relationship with her daughter and does not enjoy being alone all day. In planning care for this patient which problem should the nurse consider as the priority?

I am concerned that you may be over using the Xanax let's make an appointment for you to see the doctor

An older adult patient who has been taking alprazolam (Xanax) calls the clinic asking for a refill of the prescription 1 month before the alprazolam should need to be refilled. Which response by the nurse is best?