Nursing 1200 Unit 3 Exam

A nurse in a provider's office is caring for a client who states that, for the past week, she has felt tired during the day and cannot sleep at night. Which of the following responses should the nurse ask when collecting date about the client's difficulty sleeping? (Select all that apply.) a) "Does your lack of sleep interfere with your ability to function during the day?" b) " Do you feel confused in the late afternoon?" c) "Do you drink coffee, tea, or other caffeinated drinks? If so, how many cups per day?" d) "Has anyone ever told you that you seem to stop breathing for a few seconds while you are asleep?" e) "Tell me about any personal stress you are experiencing."

a) "Does your lack of sleep interfere with your ability to function during the day?" c) "Do you drink coffee, tea, or other caffeinated drinks? If so, how many cups per day?" d) "Has anyone ever told you that you seem to stop breathing for a few seconds while you are asleep?" e) "Tell me about any personal stress you are experiencing."

A college student was referred to the campus health service because of difficulty staying awake in class. What should be included in the nurse's assessment? select all that apply. a) Amount of sleep he usually obtains during the week and on weekends b) How much alcohol he usually consumes c) onset and duration of symptoms d)whether or not his classes are boring e) what medications, including herbal remedies, he is taking

a) Amount of sleep he usually obtains during the week and on weekends c) onset and duration of symptoms e) what medications, including herbal remedies, he is taking.

Which nursing diagnoses is/are most applicable to a client with fecal incontinence? Select all that apply. a) Bowel Incontinence b) Risk for Deficient Fluid Volume c) Disturbed Body Image d) Social Isolation e) Risk for impaired Skin Integrity.

a) Bowel Incontinence c) Disturbed Body Image d) Social Isolation e) Rick for impaired skin integrity

A client who has an indwelling catheter reports a need to urinate. Which of the following actions should the nurse take? a) check to see whether the catheter is patent b) reassure the client that it is not possible for her to urinate c) Recatheterize the bladder with a larger-gauge catheter d) collect a urine specimen for analysis.

a) Check to see whether the catheter is patent

A nurse is planning care for a client who is on bed rest. Which of the following interventions should the nurse plan to implement? a) Encourage the client to perform antiemoblic exercises every 2 hr b) Instruct the client to cough and deep breathe every 4 hr. c) Restrict the client's fluid intake. d) Reposition the client every 4 hr.

a) Encourage the client to perform antiembolic exercises every 2 hr.

During a well-child visit, a mother tells the nurse that her 4-year-old daughter typically goes to bed at 10:30 pm and awakens each morning at 7 am. She does not take a nap in the afternoon. Which is the best response by the nurse? a)Encourage the mother to consider putting her daughter to bed between 8 and 9 pm. b) reassure the mother that it is normal for 4-year-olds to resist napping, but encourage her to insist that she rest quietly each afternoon. c) Recommend that her daughter be allowed to sleep later in the morning d) Reassure her that her daughter's sleep pattern is normal and that she has outgrown her need for an afternoon nap.

a) Encourage the mother to consider putting her daughter to bed between 8 and 9 pm.

A nurse is instructing a client, who has an injury of the left lower extremity, about the use of a cane. Which of the following instructions should the nurse include? (Select all that apply.) a) Hold the cane on the right side b) Keep two points of support on the floor. c) Place the cane 38 cm (15 in) in front of the feet before advancing. d) After advancing the cane, move the weaker leg forward. e) Advance the stronger leg so that it aligns evenly with the cane.

a) Hold the cane on the right side b) Keep two points of support on the floor d) After advancing the cane, move the weaker leg forward.

A nurse is talking with a client about ways to help him sleep and rest. Which of the following recommendations should the nurse give to the client to promote sleep and rest? (Select all that apply). a) Practice muscle relaxation techniques. b) exercise each morning c) Take an afternoon nap. d) Alter the sleep environment for comfort e) Limit fluid intake at least 2 hr before bedtime

a) Practice muscle relaxation techniques b) exercise each morning d) Alter the sleep environment for comfort e) Limit fluid intake at least 2 hr before bedtime

A nurse is preparing a presentation at a local community center about sleep hygiene. When explaining rapid eye movement (REM) sleep, which of the following characteristics should the nurse include? (Select all that apply.) a) REM sleep provides cognitive restoration b) REM sleep lasts about 90 min c)It is difficult to awaken a person in REM sleep. d) Sleepwalking occurs during REM sleep. e) Vivid dreams are common during REM sleep.

a) REM sleep provides cognitive restoration c) It is difficult to awaken a person in REM sleep e) Vivid dreams are common during REM sleep

A nurse is preparing to administer a cleansing enema to an adult in preparation for a diagnostic procedure. Which of following steps should the nurse take? (Select all that apply.) a) Warm the enema solution prior to instillation. b) position the client on the left side with the right leg flexed forward c) slowly insert the rectal tube about 5 cm (2 in). d) Hang the enema container 61 cm (24 in) above the client's anus.

a) Warm the enema solution prior to instillation b) position the client on the left side with the right leg flexed forward

Five minutes after the client's first postoperative exercise, the client's vital signs have not yet returned to baseline. Which is an appropriate nursing diagnosis? a) Activity intolerance b) Risk for activity intolerance c) impaired physical mobility d) risk for disuse syndrome

a) activity intolerance

Clients should be taught that repeatedly ignoring the sensation of needing to defecate could result in which of the following? a) constipation b) diarrhea c) incontinence d) hemorrhoids

a) constipation

A nurse is caring for a client who has a prescription for a 24-hr urine collection. Which of the following action should the nurse take? a) discard the first voiding b) keep the urine in a single container at room temperature c) ask the client to urinate and pour the urine into a specimen container d) ask the client to urinate into the toilet, stop midstream, and finish urinating into the specimen container.

a) discard the first voiding

Performance of activities of daily living (ADLs) and active range-of-motion (ROM) exercises can be accomplished simultaneously as illustrated by which of the following? Select all that apply. a) elbow flexion with eating and bathing b) elbow extension with shaving and eating c) wrist hyper extension with writing d) thumb ROM with eating and writing e) hip flexion with walking

a) elbow flexion with eating and bathing d) thumb ROM with eating and writing e) hip flexion with walking

A nurse is reviewing factors that increase the risk of urinary tract infections (UTIs) with a client who has a recurrent UTIs. Which of the following factors should the nurse include? (Select all that apply.) a) Frequent sexual intercourse b) Lowering of testosterone levels c) Wiping from front to back d) location of urethra in relation to the anus e) frequent cauterization

a) frequent sexual intercourse d) location of urethra in relation to the anus e) frequent cauterization

Isotonic exercises such as walking are intended to achieve which of the following? Select all that apply. a) increase muscle tone and improve circulation b) Increase blood pressure c) Increase muscle mass and strength d) Decrease heart rate and cardiac output e) Maintain joint range of motion

a) increase muscle tone and improve circulation c) increase muscle mass and strength e) maintain joint range of motion

The catheter slips into the vagina during a straight catheterization of a female client. The nurse does which action? a) Leaves the catheter in place and gets a new sterile catheter b) leaves the catheter in place and ask another nurse to attempt the procedure c) removes the catheter and redirects it to the urinary meatus d) removes the catheter, wipes it with a sterile gauze, and redirects it to the urinary meatus.

a) leaves the catheter in place and gets a new sterile catheter

During assessment of the client with urinary incontinence, the nurse is most likely to assess for which of the following? Select all that apply. a) Perineal skin irritation b) Fluid intake of less than 1,500 mL/day c) history of antihistamine intake d) history of frequent urinary tract infections e) a fecal impaction

a) perineal skin irritation b) fluid intake of less that 1,500 mL/day d) history of frequent urinary tract infections e) a fecal impaction

During admission to a hospital unit, the client tells the nurse that her sleep tends to be very light and that it is difficult for her to get back to sleep if she's awakened at night. Which interventions should the nurse implement? Select all that apply. a) Remind colleagues to keep their conversation to a minimum at night. b) encourage the client's family members to bring in a radio to play soft music at night. c) deliver necessary medications and procedures at 1.5- or 3-hour intervals between 11 pm and 6 am. d) Encourage the client to ask family members to bring in a fan to provide white noise. e) increase the temperature in the room.

a) remind colleagues to keep their conversation to a minimum at night. c) deliver necessary medications and procedures at 1.5- 3- hour intervals between 11 pm and 6 am d) encourage the client to ask family members to bring in a fan to provide white noise.

When assessing a client's gait, which does the nurse look for and encourage? a) the spine rotates, initiating locomotion b) gaze is slightly downward c) toes strike the ground before the heel d) arm on the same side as the swing-through foot moves forward at the same time

a) the spine rotates, initiating locomotion

a new nursing graduate's first job requires 12-hour night shifts. which strategy will make it easier for the graduate to sleep during the day and remain awake at night? a) wear dark wrap-around sunglasses when driving home in the morning, and sleep in a darkened bedroom. b) exercise on the way home to avoid having to stand around waiting for equipment at the gym. c) drink several cups of strong coffee or 16 oz of caffeinated soda when beginning the shift. d) try to stay in a brightly lit area when working at night.

a) wear dark wrap-around sunglasses when driving home in the morning, and sleep in a darkened bedroom.

Which statement provides evidence that an older adult who is prone to constipation is need of further teaching? a) "I need to drink one and a half to two quarts of liquid each day." b) "I need to take a laxative such as Milk of Magnesia if I don't have a BM every day." c) "If my bowel pattern changes on its own, I should call you." d) "Eating my meals at regular times is likely to result in regular bowel movements."

b) "I need to take a laxative such as Milk of Magnesia if I don't have a BM every day."

A nurse is instructing a client who has a new diagnosis of narcolepsy about measures that might help with self-management. Which of the following statements should the nurse identify as an indication that the client understands the instructions? a) "I'll add plenty of carbohydrates to my meals." b) "I'll take a short nap whenever I feel a little sleepy." c) "I'll make sure I stay warm when I am at my desk at work." d) "It's okay to drink alcohol as long as I limit it to one drink per day."

b) "I'll take a short nap whenever I feel a little sleepy."

A nurse is evaluating teaching on a client who has a new prescription for a sequential compression device. Which of the following client statements should indicate to the nurse the client understands the teaching? a) "This device will keep me from getting sores on my skin." b) "This thing will keep the blood pumping through my leg." c) "With this thing on, my leg muscles won't get weak." d) "This device is going to keep my joints in good shape."

b) "This thing will keep the blood pumping through my leg."

A client with a new stoma who has not had a bowel movement since surgery last week reports feeling nauseous. What is the appropriate nursing action? a) Prepare to irrigate the colostomy. b) After assessing the stoma and surrounding skin, notify the surgeon. c) Assess bowel sounds and administer antiemetic. d) Administer a bulk-forming laxative, and encourage increased fluids and exercise.

b) After assessing the stoma and surrounding the skin, notify the surgeon.

A nurse is caring for a client who is postoperative. Which of the following interventions should the nurse take to reduce the risk of thrombus development? (Select all that apply.) a) Instruct the client not to perform the Valsalva maneuver b) Apply elastic stockings c) Review laboratory values for total protein level d) Place pillows under the client's knees and lower extremities e) Assist the client to change position often

b) Apply elastic stockings e) Assist the client to change position often

A nurse in a provider's office is evaluating a client who reports losing control of urine whenever she coughs, laughs, or sneezes. The client relates a history of three vaginal births, but no serious accidents or illnesses. Which of the following interventions should the nurse suggest for helping to control or eliminate the client's incontinence? (Select all that apply.) a) Limit total daily fluid intake b) Decrease or avoid caffeine. c) Take calcium supplements. d) avoid drinking alcohol e) Use the Crede maneuver

b) Decrease or avoid caffeine d) avoid drinking alcohol

A nurse is talking with a client who reports constipation. When the nurse discusses dietary changes that can help prevent constipation, which of the following foods should the nurse recommend? a) Macaroni and cheese b) Fresh fruit and whole wheat toast c) Bread pudding and yogurt d) Roast chicken and white rice

b) Fresh fruit and whole wheat toast

A nurse is preparing to initiate a bladder-retraining program for a client who has incontinence. Which of the following action should the nurse take? (Select all that apply) a) Establish a schedule of urinating prior to meal times b) Have the client record urination times c) Gradually increase the urination intervals d) Remind the client to hold urine until the next scheduled urination time. e) provide a sterile container for urine.

b) Have the client record urination time c) gradually increase the urination intervals d) remind the client to hold urine until the next scheduled urination time.

A nurse is caring for a client who has had diarrhea for 4 days. When assessing the client, the nurse should expect which of the following findings? (Select all that apply.) a) Bradycardia b) Hypotension c) Elevated temperature d) Poor skin turgor e) peripheral edema

b) Hypotension c) Elevated temperature d) poor skin turgor

The nurse will need to assess the client's performance of clean intermittent self-catheterization (CISC) for a client with which urinary diversion? a) Ileal conduit b) Kock pouch c) Neobladder d) vesicostomy

b) Kock pouch

Which of the following behaviors indicates that the client on a bladder training program has met the expected outcomes? Select all that apply. a) Voids each time there is an urge. b) Practices slow, deep breathing until the urge decreases. c) Uses adult diapers, for "just in case." d) Drinks citrus juices and carbonated beverages. e) Performs pelvic muscle exercises.

b) Practices slow, deep breathing until the urge decreases. e) Performs pelvic muscle exercises.

A female client has a urinary tract infection (UTI). Which teaching points by the nurse would be helpful to the client? Select all that apply. a) Limit fluids to avoid the burning sensation on urination. b) review symptoms of UTI with the client c) Wipe the perineal area from back to front. d) Wear cotton underclothes e) Take baths rather than showers

b) Review symptoms of UTI with the client d) wear cotton underclothes

To increase stability during client transfer, the nurse increases the base of support by performing which action? a) leaning slightly backward b) Spacing the feet farther apart c) Tensing the abdominal muscles d) bending the knees

b) Spacing the feet further apart

Which goal is the most appropriate for clients with diarrhea related to ingestion of an antibiotic for an upper respiratory infection? a) The client will wear a medical alert bracelet for antibiotic allergy. b) The client will return to his or her previous fecal elimination pattern c) The client will verbalize the need to take an antidiarrheal medication prn. d) The client will increase intake of insoluble fiber such as grains, rice, and cereals

b) The client will return t his or her previous fecal elimination pattern.

which action represents the appropriate nursing management of a client wearing a condom catheter? a) ensure that the tip of the penis fits snugly against the end of the condom b) check the penis for adequate circulation 30 minutes after applying c) change the condom every 8 hours d) tape the collecting tubing to the lower abdomen

b) check the penis for adequate circulation 30 minutes after applying

The nurse is performing an assessment of an immobilized client. Which assessment causes the nurse to take action? a) heart rate 86 beats/min b) reddened area on sacrum c) nonproductive cough d) urine output of 50 mL/h

b) reddened area on sacrum

because of significant concerns about financial problems, a middle-aged client complains of difficulty sleeping. Which outcome would be the most appropriate for the nursing care plan? "By day 5, the client will: a) sleep 8 to 10 hours per day." b) report falling asleep withing 20 to 30 minutes. c) have a plan to pay all the bills." d) decrease worrying about financial problems and will keep busy until bedtime.

b) report falling asleep withing 20 to 30 minutes.

Which statement from a client with one weak leg regarding use of crutches when using stairs indicates a need for increased teaching? a)"Going up, the strong leg goes first, then the weaker leg with both crutches." b) "Going down, the weaker leg goes first with both crutches, then the strong leg." c) "The weaker leg always goes first with both crutches." d) " A cane or single crutch may be used instead of both crutches if held on the weaker side."

c) "The weaker leg always goes first with both crutches."

Which statement indicates a need for further teaching of the home care client with a long-term indwelling catheter? a) "I will keep the collecting bag below the level of the bladder at all times." b) "intake of cranberry juice may help decrease the risk of infection." c) "soaking in a warm tub may ease the irritation associated with the catheter." d) "I should use clean technique when emptying the collecting bag."

c) "soaking in a warm tub may ease the irritation associated with the catheter."

The nurse is answering questions after a presentation on sleep at a local senior citizens center. A women in her late 70s asks for an opinion about the advisability of allowing her husband to nap for 15 to 20 minutes each afternoon. Which is the nurse's best response? a) :taking an afternoon nap will interfere with his being able to sleep at night. If he's tired in the afternoon, see if you can interest him in some type of stimulating activity to keep him awake." b) "He shouldn't need to take an afternoon nap if he's getting enough sleep at night." c) "unless your husband has trouble falling asleep at night, a brief afternoon nap is fine." d) "Encourage him to consume coffee or some other caffeinated beverage at lunch to prevent drowsiness in the afternoon."

c) "unless your husband has trouble falling asleep at night, a brief afternoon nap is fine."

A client weighs 250 pounds and needs to be transferred from the bed to a chair. Which instruction by the nurse to the unlicensed authorize personnel (UAP) is most appropriate" a) "using proper body mechanics will prevent you from injuring yourself." b) "You are physically fit and at lesser risk for injury when transferring the client." c) "use the mechanical lift and another person to transfer the client from the bed to the chair." d) use the back belt to avoid hurting your back."

c) "use the mechanical lift and another person to transfer the client from the bed to the chair."

A nurse is caring for an older adult client who has been following the facility's routine and bathing in the morning. However, at home, she always takes a warm bath just before bedtime. Now she is having difficulty sleeping at night. Which of the following actions should the nurse take first? a) Rub the client's back for 15 min before bedtime b) Offer the client warm milk and crackers at 2100 c) Allow the client to take a bath in the evening d)Ask the provider for a sleeping medication

c) Allow the client to take a bath in the evening

Which focus is the nurse most likely to teach for a client with a flaccid bladder? a) Habit training: Attempt voiding at specific time periods. b) Bladder training: Delay voiding according to a preschedule timetable. c) crede's maneuver: apply gentle manual pressure to the lower abdomen. d) kegel exercises: contract the pelvic muscles.

c) Crede's maneuver: apply gentle manual pressure to the lower abdomen.

A nurse is caring for a client who has been sitting in a chair for 1 hour. Which of the following complications is the greatest risk to the client? a) Decreased subcutaneous fat b) Muscle atrophy c) pressure ulcer d) fecal impaction

c) pressure ulcer

The nurse assesses a client's abdomen several days after abdominal surgery. It is firm, distended, and painful to palpate. the client reports feeling "bloated." The nurse consults with the surgeon, who orders an enema. The nurse prepares to give what kind of enema? a)Soapsuds b) Retention c) Return flow d) Oil retention

c) return flow

which of the following is most likely to validate that a client is experiencing intestinal bleeding? a) Large quantities of fat mixed with pale yellow liquid stool b) Brown, formed stools c) Semisoft black-colored stools d) Narrow, pencil-shaped stool

c) semisoft black-colored stools

The nurse is most likely to report which finding to the primary care provider for a client who has an established colostomy? a) The stoma extends 1/2 in. above the abdomen. b) The skin under the appliance looks red briefly after removing the appliance c) The stoma color is a deep red-purple d) the ascending colostomy delivers liquid feces

c) the stoma is a deep red-purple

While a nurse is administering a cleansing enema, the client reports abdominal cramping. Which of the following actions should the nurse take? a) Have the client hold his breath briefly and bear down. b) Discontinue the fluid instillation. c) Remind the client that cramping is common at this time d) Lower the enema fluid container

d) Lower the enema fluid container

A nurse is caring for a client who will perform fecal occult blood testing at home. Which of the following information should the nurse include when explaining the procedure to the client? a) Eating more protein is optimal prior to testing. b) One stool specimen is sufficient for testing. c) A red color change indicates a positive test. d) The specimen cannot be contaminated with urine.

d) The specimen cannot be contaminated with urine

During shift report, the nurse learns that an older female client is unable to maintain continence after she senses the urge to void and becomes incontinent on the way to the bathroom. Which nursing diagnosis is most appropriate? a) Stress Urinary Incontinence b) Reflex Urinary Incontinence c) Functional Urinary Incontinence d) Urge Urinary Incontinence

d) Urge Urinary Incontinence

The client is ambulating for the first time after surgery. The silent tells the nurse, "I feel faint.: Which is the best action by the nurse? a)find another nurse for help. b) return the client to her room as quickly as possible c) tell the client to take rapid, shallow breaths. d) assist the client to a nearby chair.

d) assist the client to a nearby chair

a client reports to the nurse that she has been taking barbiturate sleeping pills every night for several months and now wishes to stop taking them. Which statement is the most appropriate advice for the nurse to provide the client? a) take the last pill on a Friday night so disrupted sleep can be compensated on the weekend b) continue to take the pills since sleeping without them after such a long time will be difficult and perhaps impossible. c) discontinue taking the pills d) continue taking the pills and discuss tapering the dose with the primary care provider.

d) continue taking the pills and discuss tapering the dose with the primary care provider

A client has a history of sleep apnea. Which is the most appropriate question for the nurse to ask? a) Do you have a history of cardiac irregularities? b) Do you have a history of any kind of nasal obstruction? c) Have you had chest pain with or without activity? d) do you have difficulty with daytime sleepiness?

d) do you have difficulty with daytime sleepiness

A client is scheduled for a colonoscopy. The nurse will provide information to the client about which type of enema? a) oil retention b) return flow c) High, large volume d) low, small volume

d) low, small volume

During a yearly physical, a 52-year-old male client mentions that his wife frequently complains about his snoring. During the physical exam, the nurse notes that his neck size is 18 inches, his soft palate and uvula are reddened and swollen, and he is overweight. What is the most appropriate nursing intervention for the nurse to recommend to this client? a)Recommend that he and his wife sleep in separate bedrooms so that his snoring does not disturb his wife. b) Refer him to a dietitian for a weight loss program. c) caution him not to drink or take sleeping pills since they may make his snoring worse. d) refer him to a sleep disorders center for evaluation and treatment of his symptoms.

d) refer him to a sleep disorders center for evaluation and treatment of his symptoms.

The nurse recognizes that urinary elimination changes may occur even in healthy older adults because of which of the following? a) The bladder distends and its capacity increases b) older adults ignore the need to void c) urine becomes more concentrated d) the amount of urine retained after voiding increases.

d) the amount of urine retained after voiding increases.

A nurse is teaching a client about active rang-of-motion (ROM) exercises. The nurse then watches the client demonstrate these principles. The nurse would evaluate that teaching was successful when the client does which of the following? a) Exercises past the point of resistance b) performs each exercise one time. c) Performs each series of exercises once a day d) uses the same sequence during each exercise session.

d) uses the same sequence during each exercise session