Student Questions Exam 2

You are a new nurse providing foot care education to Uncle Dennyfigs who is diagnosed with type II diabetes. What is the best advice you can give to manage his foot? Select all that apply A. Go barefoot to air out open wounds B. Wear clean cotton or wool absorbent socks/stockings C. Use hot water bottles or heating pads to warm feet D. Use warm water and mild soap to wash feat daily E. Gently pat feet dry then apply lotion in between the toes to make it soft F. Apply dry dressing to cuts after washing with warm water and mild soap, then drying.

B (cotton or wool socks allow for breathability and keeps the feet dry), D (washing your feet daily with hot water will cause skin irritation and breakdown), F (ensure feet are dry when applying dressing to prevent fungal growth).

The condition this patient is experiencing is known as ______: A. Acromegaly B. Diabetes insipidus C. SIADH D. Water intoxication

B. Diabetes insipidus

A patient is diagnosed with pheochromocytoma. From your nursing knowledge, you know that the patient will present with hypertension, sweating, and palpitations due to excessive catecholamine production from the? A. Adrenal Cortex B. Adrenal Zona Fasciculata C. Adrenal Medulla D. Adrenal Glomerulosa

C. Adrenal Medulla secretes catecholamines.

Mr. Smith calls on the call light to tell you something is wrong with his chest tube. When you arrive to the room you note that the drainage system has fallen on its side and is leaking drainage into the floor from a crack in the system. What is PRIORITY? A. Notify the physician immediately B. Place the patient in supine position and clamp the tubing C. Disconnect the tubing from the drainage system and insert the tubing 1 inch into a bottle of sterile water and obtain a new system. D. Disconnect the drainage system and get a new one

C. Disconnect the tubing from the drainage system and insert the tubing 1 inch into a bottle of sterile water and obtain a new system.

What are some common risks factor for developing a brain tumor? a. Previous head injury b. Type 1 Diabetes Mellitus c. Playing video games for more than 40 hours a week d. Toxoplasmosis

a. Previous head injury

A nurse is reviewing the manifestations of hyperthyroidism with a client. Which of the following findings should the nurse include? Select all that apply. a. Anorexia b. Heat intolerance c. Constipation d. Palpitations e. Weight loss f. Bradycardia

b, d, e

A type of brain injury where the skull is fractured or when it is pierced by a penetrating object is classified as a: a. Focal brain injury b. Open brain injury c. Closed brain injury d. Diffuse brain injury

b. Open brain injury

You have a patient who has had a recent brain tumor removed. One of your orders is to perform a Romberg's test. Which action do you take first? a. Have the client stand erect with their eyes open b. Stroke the lateral aspect of the sole of the foot c. Strike a tuning fork and place it on the mastoid bone d. Introduce yourself

d. Introduce yourself

A nurse is assessing a patient who is diagnosed with diabetic ketoacidosis (DKA). What symptoms would the nurse expect to see on this patient? Select all that apply. A. Fruity odor breath B. Weight gain C. Oliguria D. Excessive thirst E. Deep rapid respirations

A, D, and E. Fruity odor breath, excessive thirst (polydipsia), and deep rapid respirations (Kussmaul respirations) are expected findings in someone with DKA. Fruity odor breath results from elevated levels of ketones in the blood. Polydipsia results when the body attempts to rehydrate due to excessive urination (polyuria). Kussmaul respirations occur in an attempt to excrete CO2 and acid due to metabolic acidosis. Weight loss instead of weight gain, and polyuria instead of oliguria is expected in someone who has DKA.

A patient is reported to have a flail chest. You understand this means what regarding the ribs? A. At least two neighboring ribs have sustained injury B. One or more ribs have been removed C. The ribs have been altered in a controlled surgical process D. The ribs are no longer attached to the intercostal muscles

A. At least two neighboring ribs have sustained injury A flail chest occurs when at least two neighboring ribs, usually on one side of the chest, sustain multiple fractures, causing instability of the chest wall and paradoxical chest wall movement. The other options may occur with a flail chest, but they are not always present.

What cells are responsible for secreting catecholamines? A. Chromaffin B. Langerhans C. Enkephalin D. Parietal

A. Chromaffin

For TBI patients, when doing your nursing assessment, what is one of the significant changes that would indicate an increase in ICP and would warrant notifying the provider immediately? A. Fixed (nonreactive) and dilated pupils B. Petechiae all over the body C. Capillary refill of less than 3 seconds D. Lower extremity edema

A. Fixed (nonreactive) and dilated pupils

Which action will the nurse include in the plan of care for a patient who has a cauda equina spinal cord injury? A. Catheterize the patient every 3 to 4 hours. B. Assist the patient to ambulate 4 times daily. C. Administer medications to reduce bladder spasm. D. Stabilize the neck when repositioning the patient.

ANS: A Patients with cauda equina syndrome have areflexic bladder, and intermittent catheterization will be used for emptying the bladder. Because the bladder is flaccid, antispasmodic medications will not be used. The legs are flaccid with cauda equina

The nurse determines that teaching about management of migraine headaches has been effective when the patient says which of the following? A. "I can take the (Topamax) as soon as a headache starts." B. "A glass of wine might help me relax and prevent a headache." C. "I will lie down someplace dark and quiet when the headaches begin." D. "I should avoid taking aspirin and sumatriptan (Imitrex) at the same time."

ANS: C It is recommended that the patient with a migraine rest in a dark, quiet area. Topiramate (Topamax) is used to prevent migraines and must be taken for several months to determine effectiveness. Aspirin or other nonsteroidal antiinflammatory medications can be taken with the triptans. Alcohol may precipitate migraine headaches.

A nurse is assessing a nurse who has a high thoracic spinal cord injury. The nurse should identify which of the following findings as a manifestation of autonomic dysreflexia? A. Flushing over the lower extremities B. Hypotension C. Tachycardia D. Report of a headache

ANS: D. Manifestations include throbbing headache; flushing of the face and neck; bradycardia; and extreme hypertension.

A nursing instructor asks a student to describe the pathophysiology that occurs in Cushing's disease. Which statement by the student indicates an accurate understanding of this disorder? A. "Cushing's disease is characterized by an oversecretion of insulin." B. "Cushing's disease is characterized by an oversecretion of glucocorticoid hormones." C. "Cushing's disease is characterized by an undersecretion of corticotropic hormones." D. "Cushing's disease is characterized by an undersecretion of glucocorticoid hormones."

Answer: B. "Cushing's disease is characterized by an oversecretion of glucocorticoid hormones.

A nurse is providing teaching to a patient with Addison's Disease about healthy snack foods. Which of the following food choices by the client indicates an understanding of teaching? A. Sliced bananas B. Baked potato C. Turkey and cheese sandwich D. Plain yogurt with peaches

Answer: C Rationale: A turkey and cheese sandwich is high in protein, carbohydrates, and sodium. A client with Addison's disease requires a diet low in potassium and high in sodium, carbohydrates, and protein. Addison's disease is a hormone deficiency caused by damage to the outer layer of the adrenal gland (adrenal cortex). Addison's disease occurs when the adrenal glands do not produce enough cortisol and in some cases, aldosterone.

A client is scheduled for a thoracentesis. What statement indicates further education is necessary? A. "This will be an invasive surgical procedure into my chest." B. "I will take a deep breath when the large-bore needle is inserted." C. "I will be leaning over a bedside table for the procedure." D. "This procedure will require local anesthetic rather than general anesthetic."

B. "I will take a deep breath when the large-bore needle is inserted." Thoracentesis is the surgical perforation of the chest wall and pleural space with a large-bore needle. The patient will sit at the bed and lean over a bedside table. Local anesthetic solution is injected. The patient must remain still during the procedure (no moving, coughing, deep breathing.

Increased ICP (increased intracranial pressure) is the leading cause of death from head trauma in patients who reach the hospital. As ICP increases, what happens? A. A decrease in systolic blood pressure. B. A decrease in cerebral perfusion leading to brain tissue ischemia and edema. C. An increase in heart rate (tachycardia). D. Increased cognition.

B. A decrease in cerebral perfusion leading to brain tissue ischemia and edema.

You are providing care to Mr. Smith who has a chest tube. On assessment of the drainage system, you note continuous bubbling in the water seal chamber and oscillation. Which of the following is the correct nursing intervention for this finding? A. Continue to monitor the drainage system B. Check the drainage system for an air leak C. Reposition the patient because the tubing is kinked D. Increase the suction to the drainage system

B. Check the drainage system for an air leak

A nurse is caring for a 54 y/o male patient with DKA. His arterial blood gas shows: pH: 7.28, PaCO2: 30, and HCO3: 18. How would the nurse interpret this ABG result? A. Partially compensated respiratory acidosis B. Partially compensated metabolic acidosis C. Uncompensated respiratory acidosis D. Uncompensated metabolic acidosis

B. Partially compensated metabolic acidosis This ABG result shows a partially compensated metabolic acidosis. Kussmaul respiration or deep rapid respirations is a compensatory mechanism that excretes excess carbon dioxide from the blood. This is seen in the patient's ABG result as low PaCO2 level. This is only partially compensated because the pH level has not returned to a homeostatic level yet.

Which of the following risk factors is an indication a patient needs to be screened for diabetes? A. Patient with a BMI of 24 who is 32 years old. B. Patient with a BMI of 28 who reports a HgA1C greater than 5.7%. C. Patient with a BMI of 23 who has a consistent BP of 120/80 D. Patient with a BMI OF 24 who has no history of vascular disease.

B. Patient with a BMI of 28 who reports a HgA1C greater than 5.7%. A patient with a BMI over 28 and 5.7% HgA1C are both factors used to indicate the need to screen for diabetes

A nurse is caring for a client who is experiencing autonomic dysreflexia d/t a C5 spinal cord injury. After checking the client's vital signs, which of the following actions should the nurse perform next? A. Administer nifedipine B. Place the client in high-Fowler's position C. Check for urinary retention D. Check for fecal impaction

B. Place the client in high-Fowler's position

Which of the following statements from a new graduate nurse should allow a charge nurse to intervene when administering Insulin lispro? A. I should administer insulin before meals to control postprandial rise in glucose. B. Rapid onset is (30 to 60 min) C. I should administer insulin in conjunction with intermediate-or long-lasting insulin to provide glycemic control between meals at night.

B. Rapid onset is (30 to 60 min) Onset for rapid-acting insulin is between 10-30min.

A nurse is providing discharge teaching to a male client who had DKA. Which of the following statements by the client indicates the need for further teaching? A. "I will consume 2-3 L of fluid each day to prevent dehydration." B. "I need to notify my provider if my glucometer shows a blood sugar level 270 mg/dL." C. "I would monitor my blood glucose once a day when I am ill." D. "If my blood glucose is low, I would drink apple juice."

C. "I would monitor my blood glucose once a day when I am ill." When ill, he needs to monitor his glucose every 4 hours and continue to take insulin. All the other statements indicate understanding of the teaching. Fluid recommendation is 2-3 L/day to prevent dehydration, unless contraindicated by other health problems. A blood sugar level of 250 mg/dL or greater warrants the patient to notify his provider. If blood glucose levels are low, the patient should consume liquids with sugar to treat hypoglycemia.

A patient arrives to the clinic with complaints of excessive thirst and urination. Upon further assessment, you find they are hypotensive with poor skin turgor. You suspect this to be a deficiency in _______, produced by the posterior pituitary. A. Oxytocin B. Luteinizing hormone C. Antidiuretic hormone (Vasopressin) D. Prolactin

C. Antidiuretic hormone (Vasopressin)

Which set of arterial blood gases will the nurse expect to find in a client who developed a pulmonary embolism 15 minutes ago? A. pH, 7.30; HCO3-, 22 mEq/L; PCO2, 60 mm Hg; PO2, 66 mm Hg B. pH, 7.38; HCO3-, 22 mEq/L; PCO2, 45 mm Hg; PO2, 96 mm Hg C. pH, 7.47; HCO3-, 23 mEq/L; PCO2, 25 mm Hg; PO2, 82 mm Hg D. pH, 7.30; HCO3-, 28 mEq/L; PCO2, 65 mm Hg; PO2, 75 mm Hg

C. pH, 7.47; HCO3-, 23 mEq/L; PCO2, 25 mm Hg; PO2, 82 mm Hg

Your postpartum patient is breast-feeding her newborn. Her provider enters the room for an assessment and says her "posterior pituitary must be doing its job." After the provider leaves, your patient asks you what her posterior pituitary has to do with breastfeeding. You respond by saying: A. "Your doctor must be confused. They're not related at all." B. "It produces luteinizing hormone, which triggers ovulation. But it is not connected to breastfeeding." C. "It produces oxytocin, which helps your uterus contract after delivery. It doesn't assist with breastfeeding." D. "It produces oxytocin, which stimulates the ejection of breast milk."

D. "It produces oxytocin, which stimulates the ejection of breast milk."

Which physiological effect of a pulmonary embolism would initially affect oxygenation? A. A blood clot blocks ventilation; perfusion is unaffected. B. A blood clot blocks ventilation, producing hypoxia despite normal perfusion. C. A blood clot blocks perfusion and ventilation, producing profound hypoxia. D. A blood clot blocks perfusion, producing hypoxia despite normal or supernormal ventilation.

D. A blood clot blocks perfusion, producing hypoxia despite normal or supernormal ventilation.

What statement is true about pneumothorax and a hemothorax? A. Pneumothorax is in the lungs while hemothorax is within the pericardium B. Pneumothorax relates to the accumulation of only blood C. Hemothorax relates to the accumulation of both blood and gas/air D. Hemothorax is located within the pleural space

D. Hemothorax is located within the pleural space A hemothorax is an accumulation of blood within the pleural space.

A nurse in the ED has assessed a client's airway, breathing, and circulation (ABC) following a head injury from a fall at work. Which of the following actions is the priority for the nurse to perform next? A. Question the client's coworkers about the mechanism of injury B. Check the client's pupils for equality and reaction to light C. Measure the client's alertness using the Glasgow Coma Scale D. Immobilize the client's cervical spine.

D. Immobilize the client's cervical spine.

A nurse is assessing a client who has a high-thoracic spinal cord injury. The nurse should identify which of the following findings as a manifestation of autonomic dysreflexia? A. Flushing if the lower extremities B. Hypotension C. Tachycardia D. Report of a headache

D. Report of a headache

Which client is at greatest risk for the development of a pulmonary embolism? a. A young adult athlete who lifts weights and was diagnosed with a pneumothorax yesterday b. A middle-aged woman who has used oral contraceptives for the past 15 years and who had abdominal surgery yesterday for cancer c. A middle-aged woman who has fragile capillaries and bruises very easily d. An older man who caught his right hand in a piece of machinery and has five broken fingers, with extensive soft tissue damage

b. A middle-aged woman who has used oral contraceptives for the past 15 years and who had abdominal surgery yesterday for cancer

A nurse in a provider's office is reviewing laboratory results of a client who is being evaluated for secondary hypothyroidism. Which of the following laboratory findings is expected? a. Elevated T4 b. Decreased T3 c. Elevated thyroid stimulating hormone d. Decreased cholesterol

b. Decreased T3

Which of the following indicates to a nurse a patient may have a brain tumor? a. Left side Neglect b. Sudden personality change c. WBC of 9421 d.FBS above 9000

b. Sudden personality change

A nurse is assessing a client who is 12 hr postoperative following a thyroidectomy. Which of the following findings is indicative of thyroid crisis? Select all that apply. a. Bradycardia b. Hypothermia c. Dyspnea d. Abdominal pain e.Mental confusion

c, d, e

What is the purpose of chest tubes? a) drain fluid, blood, air from pleural space b) reestablish a negative pressure c) facilitate lung expansion d) restore normal pleural pressure e) all of the above f) none of the above

e) all of the above