QUESTIONS

C. perform a nursing assessment to identify the presence of etiologic and risk factors associated with constipation

A 67 y/o woman tells the nurse that she is becoming constipated as she gets older and is taking laxatives about every other day to promote bowel elimination. The most appropriate nursing intervention at this time is for the nurse to A. encourage the patient to drink at least 3000 ml of fluid a day B. inform the patient of the need to increase foods high in soluble fiber in her diet C. perform a nursing assessment to identify the presence of etiologic and risk factors associated with constipation D. advise the patient that stool softeners and lubricants are less likely to cause bowel dependence than are other types of laxatives

B. prevent transmission of the organism to others

A 78 y/o is transferred to the hospital from a nursing home upon developing abdominal pain and watery, incontinent diarrhea following a course of antibiotic therapy for PNA. Stool cultures reveal the presence of C. diff. In planning care for the patient, the nurse recognizes that a priority nursing goal is to recognizes that a priority nursing goal is to A. maintain normal nutritional intake B. prevent transmission of the organism to others C. promote relief of abdominal pain w/ comfort measures D. control the diarrhea w/ administration of antidiarrheal drugs

B. fatigue

A client is being evaluated for hypothyroidism. To plan care, the nurse should ask the client about which sign or symptom? A. corneal abrasion B. fatigue C. diarrhea D. weight loss

B. Risk for injury

A client is brought to the trauma center by ambulance after sustaining a high cervical spinal cord injury 1½ hours ago. Endotracheal intubation has been deemed necessary and the nurse is preparing to assist. What nursing diagnosis should the nurse associate with this procedure? A. Risk for impaired skin integrity B. Risk for injury C. Risk for autonomic dysreflexia D. Risk for suffocation

B. Watchful waiting and close monitoring

A client who has sustained a nondepressed skull fracture is admitted to the acute medical unit. Nursing care should include which of the following? A. Preparation for emergency craniotomy B. Watchful waiting and close monitoring C. Administration of inotropic drugs D. Fluid resuscitation

D. The client's urinary catheter became occluded.

A client who suffered a spinal cord injury is experiencing an exaggerated autonomic response. What aspect of the client's current health status is most likely to have precipitated this event? A. The client received a blood transfusion. B. The client's analgesia regimen was recently changed. C. The client was not repositioned during the night shift. D. The client's urinary catheter became occluded.

B. By protecting older adults against shearing injuries Cellular changes associated with aging include thinning at the junction of the dermis and epidermis, which creates a risk for shearing injuries. Moisturizing lotions can be safely used to address the increased dryness of older adults' skin. Ice packs can be used, provided skin is assessed regularly and the patient possesses normal sensation. Older adults perspire much less than younger adults, thus sweat accumulation is rarely an issue.

A gerontologic nurse is teaching a group of nursing students about integumentary changes that occur in older adults. How should these students best integrate these changes into care planning? A. By avoiding the use of moisturizing lotions on older adults' skin B. By protecting older adults against shearing injuries C. By avoiding the use of ice packs to treat muscle pain D. By protecting older adults against excessive sweat accumulation

B. Grave's disease

A middle-aged female client complains of anxiety, insomina, weight loss, the inability to concentrate, and eyes feeling "gritty." Thyroid function tests reveal the following: thyroid-stimulating hormone (TSH, normal 0.4 -40U/mL) 0.02 U/ml, thyroxine (T4, normal 0.7-1.9 ng/dl) 20g/dL, and triiodothyronine (T3, normal 80-180 ng/dL) 253 ng/d. A 6-hour radioactive iodine uptake test showed a diffuse uptake of 85%. Based on these assessment findings, the nurse should suspect: A. Hashimoto's thyroiditis B. Grave's disease C. multinodular goiter D. thyroiditis

D. Contact the client's provider, and discuss the fact that the client normally takes thyroid supplements. Even when the patient is stable, the nurse need to make the steps to intervene before an emergent situation occurs.

A newly-admitted client has told the nurse, " I always take a thyroid pill each morning but I do not think I have been prescribed it here in the hospital." The nurse confirms that the client's medication orders do not include this. What is the nurse's best action? A. Ask the client if there is a family member who can bring a supply of the medication from home. B. Explain that the body stores sufficient thyroid hormone for two to three weeks. C. Document the client's statement in the health record, and assess for signs of hypothyroidism. D. Contact the client's provider, and discuss the fact that the client normally takes thyroid supplements.

C. Pustule A pustule is an example of a primary skin lesion. Primary skin lesions are original lesions arising from previously normal skin. Crusts, keloids and ulcers are secondary lesions.

A nurse in a dermatology clinic is reading the electronic health record of a new patient. The nurse notes that the patient has a history of a primary skin lesion. What is an example of a primary skin lesion? A. Crust B. Keloid C. Pustule D. Ulcer

C. Administer artificial tear drop to lubricate the eyes

A nurse is caring for a 58-year-old woman who has with rheumatoid arthritis who has also developed Sjogren's syndrome. Which of the following should be added to the patient's care plan? A. Provide daily skin care B. Restrict caffeine intake C. Administer artificial tear drop to lubricate the eyes D. Encourage fluids and fiber to prevent constipation

B. Promptly report these indications of venous congestion

A nurse is caring for a patient who has undergone neck resection with a radial forearm free flap. The nurse's most recent assessment of the graft reveals that it has a bluish color and that mottling is visible. What is the nurse's most appropriate action? A. Document the findings as being consistent w/ a viable graft B. Promptly report these indications of venous congestion C. Closely monitor the pt and reassess in 30 mins D. Reposition the pt to promote peripheral circulation

B. If you put a sample of the patient's blood on a slide, you will see an excessive number of cells called myeloblasts.

A nurse is caring for a patient with acute myelogenous leukemia (AML). The patient's family asks the nurse to describe this type of leukemia. The best response is: A. The patient's white blood cells are mutating B. If you put a sample of the patient's blood on a slide, you will see an excessive number of cells called myeloblasts. C. Mature leukocytes transform into immature cells so the patient cannot fight infection T-cells are no longer able to fight infection

A. Cataract

A nurse is preparing a training session for new employee is the Eye Clinic. She has selected the image which which common vision issue that typically occurs in the geriatric client? A. Cataract B. Glaucoma C. Detached retina D. Macular degeneration

D. Melanocytes Melanocytes are the special cells of the epidermis that are primarily responsible for producing the pigment melanin. Islets of Langerhans are clusters of cells in the pancreas. Squamous cells are flat, scaly epithelial cells. T cells function in the immune response.

A nurse is providing an educational presentation addressing the topic of "Protecting Your Skin." When discussing the anatomy of the skin with this group, the nurse should know what cells are responsible for producing the pigmentation of the skin? A. Islets of Langerhans B. Squamous cells C. T cells D. Melanocytes

D. Ineffective Tissue Perfusion Risk for Disuse Syndrome for neck dissection is the shoulders

A nurse is providing care for a pt whose neck dissection surgery involved the use of a graft. When assessing the graft, the nurse should prioritize data r/t what nursing diagnosis? A. Risk for Disuse Syndrome B. Unilateral Neglect C. Risk for Trauma D. Ineffective Tissue Perfusion

A. Fluid status

A patient has been admitted to a burn intensive care unit with extensive blistering rash over 25% of the body. After ensuring cardiopulmonary stability, what would be the nurse's immediate, priority concern when planning this patient's care? A. Fluid status B. Risk for infection C. Nutritional status D. Psychosocial coping

B. Administering beta blockers to reduce heart rate C. Applying interventions to reduce the patient's temperature Thyroid storm necessitates interventions to reduce heart rate and temperature. Diuretics, insulin, and steroids are not indicated to address the manifestations of this health problem.

A patient has been admitted to the critical care unit with a diagnosis of thyroid storm. What interventions should the nurse include in this patient's immediate care? Select all that apply. A. Administering diuretics to prevent fluid overload B. Administering beta blockers to reduce heart rate C. Applying interventions to reduce the patient's temperature D. Administering corticosteroids E. Administering insulin to reduce blood glucose levels

D. imbalanced nutrition: less than body requirements r/t inability to digest and absorb nutrients

A patient undergoes a total gastrectomy with an anastomosis of the esophagus to the jejunum for treatment of gastric CA. The nurse anticipates a long-term indication for the nursing diagnosis of A. pain r/t altered gastric function B. risk for infection r/t total parenteral nutrition C. risk for impaired skin integrity r/t leakage from jejunostomy tube D. imbalanced nutrition: less than body requirements r/t inability to digest and absorb nutrients

A. ask the patient to describe the character of the stools and any associated symptoms

A patient with acute diarrhea of 24 hours' duration calls the clinic to ask for directions for care. In talking with the patient, the nurse should A. ask the patient to describe the character of the stools and any associated symptoms B. advise the patient to use OTC loperamide (Imodium) to slow GI motility C. inform the pt that lab testing of blood and stool specimens will be necessary D. advise the pt to drink clear liquid fluids w/ electrolytes, such as Gatorade or Pedialyte

D. Subcutaneous tissue The subcutaneous tissues and the amount of fat deposits are important factors in body temperature regulation. The epidermis is an outermost layer of stratified epithelial cells. Merkel cells are receptors that transmit stimuli to the axon through a chemical synapse. The dermis makes up the largest portion of the skin, providing strength and structure. It is composed of two layers: papillary and reticular.

A patient with an exceptionally low body mass index has been admitted to the emergency department with signs and symptoms of hypothermia. The nurse should know that this patient's susceptibility to heat loss is related to atrophy of what skin component? A. Epidermis B. Merkel cells C. Dermis D. Subcutaneous tissue

A. Infection

A patient with system lupus erythematosus (SLE) is prescribed cyclophosphamide (Cytoxan). The nurse should assess for which potential side effect? A. Infection B. Increased risk of bleeding C. Acute confusion D. Sedation

C. Immerse the child in a cool bath. After the flames or heat source have been removed or extinguished, the burned area and adherent clothing are soaked with cool water briefly to cool the wound and halt the burning process. Cool water is the best first-aid measure. Butter is contraindicated. Appropriate first aid necessitates touching the burn. Applying antibiotic ointment might be appropriate for later care. The most important initial response is to stop the spread of the blisters.

A triage nurse in the ED receives a phone call from a frantic father who saw his 4-year-old child tip a pot of boiling water onto her chest. The father has called an ambulance. What would the nurse in the ED receiving the call instruct the father to do? A. Apply antiseptic ointment immediately B. Apply butter to the area that is burned. C. Immerse the child in a cool bath. D. Avoid touching the burned area under any circumstances

D. Increased time required for wound healing Wound healing becomes slower with age, requiring more time for older adults to recover from surgical and traumatic wounds. There are no changes in skin flora with increased age. Vascular supply and skin thickness both decrease with age.

An 82-year-old patient is being treated in the hospital for a sacral pressure ulcer. What age-related change is most likely to affect the patient's course of treatment? A. Increased thickness of the subcutaneous skin layer B. Increased vascular supply to superficial skin layers C. Changes in the character and quantity of bacterial skin flora D. Increased time required for wound healing

C. The 52-year-old maintenance man who states " a pool cleaning chemical was splashed in my eyes about 15 minutes ago."

An RN is working the triage desk at a busy ER. Which patient should she room first? A. The 30-year-old male who thinks he scratched his eye in his sleep a couple of days ago. B. The 14-year-old girl who is experiencing reddened itching eyes for the last week. C. The 52-year-old maintenance man who states " a pool cleaning chemical was splashed in my eyes about 15 minutes ago." D. The 25-year-old male with periorbital edema and reddened, itchy eyes.

B. Increased fiber intake D. Reduced fat intake

An adult patient has been diagnosed w/ diverticular disease after ongoing challenges w/ constipation. The pt will be treated on outpatient basis. What components of treatment should the nurse anticipate? Select all that apply. A. Anticholinergic meds B. Increased fiber intake C. Enemas on alternating days D. Reduced fat intake E. Fluid reduction

D. acknowledge his behavior as reflective of a difficult situation for him and provide privacy during hygiene

An elderly main is hospitalized w/ a dx of Giardia lamblia inf. He frequently has explosive diarrhea stools that he is unable to control. He closes his eyes and will not talk to the nurse when his linens are changed and skin care is performed. To help maintain the patient's self-esteem, the nurse should A. use incontinence briefs for the pt so that cleaning him is less cumbersome and embarrassing B. request an order for an antidiarrheal drug from the physician to help control the diarrhea episodes C. assure the patient that his lack of control is temporary and will resolve with treatment of the disorder D. acknowledge his behavior as reflective of a difficult situation for him and provide privacy during hygiene

B. The location(s) on the body of the rash: localized versus global

An emergency department nurse has just admitted a patient with blistering rash. What characteristic of the rash primarily identifies whether the patient is experiencing a system response? A. The length of time since the rash began B. The location(s) on the body of the rash: localized versus global C. The shape of the blisters D. The size of the blisters

A. Ensure the patient has a patent airway The nurse's priority is almost always that of ensuring a patent airway.

An emergency department nurse learns from the paramedics that they are transporting a patient who has a blistering rash affecting the mouth, nares, throat and eyes. Which of the following is the nurse's first action? A. Ensure the patient has a patent airway B. Provide pain control C. Provide a liquid diet D. Prevent damage to the eyes

D. Interference with focusing of a sharp image.

An ophthalmologist tells a patient that he has a cataract. The nurse explains to the patient that this means there is: A. Distortion and loss of central vision. B. A tendency for the retina to tear. C. Increased corneal exposure. D. Interference with focusing of a sharp image.

B. Glaucoma

And, which is the common vision issue is represented by this image? A. Macular degeneration B. Glaucoma C. Diabetic retinopathy D. Cataract

C. Bruising over the mastoid

The ED nurse is caring for a client who has been brought in by ambulance after sustaining a fall at home. What physical assessment finding is suggestive of a basilar skull fracture? A. Epistaxis B. Periorbital edema C. Bruising over the mastoid D. Unilateral facial numbness

A. Prolonged exposure to sunlight

The nurse caring for a patient with systemic lupus erythematous (SLE) should warn the patient that the factor most likely to cause an exacerbation of this disorder is A. Prolonged exposure to sunlight B. A diet high in saturated fats C. A diet rich in complex carbohydrates D. Ingestion of aspirin

C. a client diagnosed with hypothyroidism and a heart rate of 48 beats per minute

The nurse is assigned to care for the following clients. Which client should the nurse see first? A. a client diagnosed with Graves disease and a heart rate of 94 beats per minute B. a client diagnosed with type 2 diabetes and a glucose level of 137 mg/dL C. a client diagnosed with hypothyroidism and a heart rate of 48 beats per minute D. a client diagnosed with Cushing disease and 1+ edema

B. 4,3,1,2,5

The nurse is preparing a patient for a bone marrow aspiration. The patient states she is nervous and requests something to help her relax. The nurse receives an order of 0.5mg Ativan PO. In what order should the nurse perform the following steps? 1. Administer the Ativan, as ordered. 2. Ensure that a pre-procedure time out is conducted. 3. Obtain the patient's signature for informed consent. 4. Verify the risks, benefits and alternatives to the procedure have been explained. 5. Monitor the patient for bleeding. A. 5,1,2,3,4 B. 4,3,1,2,5 C. 4,3,2,1,5 D. 5,4,3,2,1

C. hemorrhagic diarrhea

The nurse suspects the possibility of E. coli food poisoning when several individuals eating at the same establishment develop the onset of A. fever and chills B. nausea n vomiting C. hemorrhagic diarrhea D. headache, dizziness, and muscular incoordination

B. Presence of a painless sore w/ raised edges

The nurse's comprehensive assessment of a patient includes inspection for signs of oral CA. What assessment finding is most characteristic of oral CA in its early stages? A. Dull pain radiating to the ears and teeth B. Presence of a painless sore w/ raised edges C. Areas of tenderness that make chewing difficult D. Diffuse inflammation of the buccal mucosa

B. Prepare for interventions to increase the client's BP.

The staff educator is precepting a nurse new to the critical care unit when a client with a T2 spinal cord injury is admitted. The client is soon exhibiting manifestations of neurogenic shock. In addition to monitoring the client closely, what would be the nurse's most appropriate action? A. Prepare to transfuse packed red blood cells. B. Prepare for interventions to increase the client's BP. C. Place the client in the Trendelenburg position. D. Prepare an ice bath to lower core body temperature.

A. Occlude the puncta after applying the medication.

When administering a client's eye drops, the nurse recognizes the need to prevent absorption by the nasolacrimal duct. How can the nurse best achieve this goal? A. Occlude the puncta after applying the medication. B. Encourage self-administration of eye drops. C. Ensure that the client is well hydrated at all times. D. Position the client supine before administering eye drops.

B. Prevent optic nerve damage

Which of the following is the overall aim of glaucoma treatment? A. Optimize the patient's remaining vision B. Prevent optic nerve damage C. Reverse optic nerve damage D. Reattach the retina