Unit 2 Giddens

During a nutritional assessment, the nurse calculates that a female patient's BMI is 27. The nurse would advise the patient to follow which of these recommendations? a. This measurement indicates that the patient is overweight and should follow a plan of diet and exercise to lose weight. b. This measurement indicates that the patient is underweight and will need to take measures to gain weight. c. This measurement indicates that the patient is morbidly obese and may be a candidate for bariatric surgery. d. This measurement indicates that the patient is of normal weight and should continue with current lifestyle.

a. This measurement indicates that the patient is overweight and should follow a plan of diet and exercise to lose weight.

An African American is at an increased risk for which of the following? (Select all that apply.) a. Vitamin D deficiency b. Type 1 diabetes c. Celiac disease d. Type 2 diabetes e. Hypertension f. Metabolic syndrome

a. Vitamin D deficiency d. Type 2 diabetes e. Hypertension f. Metabolic syndrome

During a physical examination, the nurse notes that the patient's skin is dry and flaking, with patches of eczema. Which nutritional deficiency might be present? a. Vitamin C b. Vitamin B c. Essential fatty acid d. Protein

c. Essential fatty acid

A nurse is instructing her patient with ulcerative colitis regarding the need to avoid enteric coated medications. The nurse knows that the patient understands the reason for this teaching when he states which of the following? a. "The coating on these medications is irritating to my intestines." b. "I need a more immediate response from my medications than can be obtained from enteric coated medications." c. "Enteric coated medications are absorbed lower in the digestive tract and can be irritating to my intestines or inadequately absorbed by my inflamed tissue." d. "I don't need to use these medications because they cause diarrhea, and I have had enough trouble with diarrhea and rectal bleeding over the past weeks."

c. "Enteric coated medications are absorbed lower in the digestive tract and can be irritating to my intestines or inadequately absorbed by my inflamed tissue."

During an assessment, the patient states that his bowel movements cause discomfort because the stool is hard and difficult to pass. As the nurse, you make which of the following suggestions to assist the patient with improving the quality of his bowel movement? (Select all that apply.) a. Increase fiber intake. b. Increase water consumption. c. Decrease physical exercise. d. Refrain from alcohol. e. Refrain from smoking.

a. Increase fiber intake. b. Increase water consumption.

The nurse assesses the patient and notes all of the following. Select all of the findings that indicate the systemic manifestations of inflammation. a. Oral temperature 38.6° C/101.5° F b. Thick, green nasal discharge c. Patient complaint of pain at 6 on a 0 to 10 scale on palpation of frontal and maxillary sinuses d. WBC 20 cells/McL X 10^9/L e. Patient reports, "I'm tired all the time. I haven't felt like myself in days."

a. Oral temperature 38.6° C/101.5° F d. WBC 20 cells/McLX 10^9/L e. Patient reports, "I'm tired all the time. I haven't felt like myself in days."

An 18-month-old female patient is diagnosed with her fifth ear infection in the past 10 months. The physician notes that the child's growth rate has decreased from the 60th percentile for height and weight to the 15th percentile over that same time period. The child has been treated for thrush consistently since the third ear infection. The nurse understands that the patient is at risk for which condition? a. Primary immunodeficiency b. Secondary immunodeficiency c. Cancer d. Autoimmunity

a. Primary immunodeficiency

When conducting a health history assessment, the nurse would want to know what most important information about the patient's elimination status? (Select all that apply.) a. Recent changes in elimination patterns b. Changes in color, consistency, or odor of stool or urine c. Time of day patient defecates d. Discomfort or pain with elimination e. List of medications taken by patient f. Patient's preferences for toileting

a. Recent changes in elimination patterns b. Changes in color, consistency, or odor of stool or urine d. Discomfort or pain with elimination e. List of medications taken by patient

A patient is being treated with an antibiotic for an infected orthopedic injury. What explanation should the nurse give to the patient about this medication? a. "Antibiotics will decrease the pain at the site." b. "An antibiotic helps to kill the infection causing the inflammation." c. "An antibiotic inhibits cyclooxygenase, an enzyme in the body." d. "Antibiotics will reduce the patient's fever."

b. "An antibiotic helps to kill the infection causing the inflammation."

A patient comes to the clinic with a complaint of painful, itchy feet. On interview, the patient tells the nurse that he is a college student living in a dormitory apartment that he shares with five other students. What teaching should the nurse provide for this patient? a. "Don't eat with the other students." b. "Avoid sharing razors and other personal items." c. "Have a complete blood count (CBC) checked monthly." d. "Disinfect showers and bathroom floors weekly after use."

b. "Avoid sharing razors and other personal items."

A patient is diagnosed with a sprain to her right ankle after a fall. The patient asks the nurse about using ice on her injured ankle. What is the nurse's best response? a. "Use ice only when the ankle hurts." b. "Ice should be applied for 15 to 20 minutes every 2 to 3 hours over the next 1 to 2 days." c. "Wrap an ice pack around the injured ankle for the next 24 to 48 hours." d. "Ice is not recommended for use on the sprain because it would inhibit the inflammatory response."

b. "Ice should be applied for 15 to 20 minutes every 2 to 3 hours over the next 1 to 2 days."

A patient who was diagnosed with senile dementia has become incontinent of urine. The patient's daughter asks the nurse why this is happening. What is the nurse's best response? a. "The patient is angry about the dementia diagnosis." b. "The patient is losing sphincter control due to the dementia." c. "The patient forgets where the bathroom is located due to the dementia." d. "The patient wants to leave the hospital."

b. "The patient is losing sphincter control due to the dementia."

The parents of a newborn question the nurse about the need for vaccinations: "Why does our baby need all those shots? He's so small, and they have to cause him pain." The nurse can explain to the parents that which of the following are true about vaccinations. (Select all that apply.) a. Are only required for infants b. Are part of primary prevention for system disorders c. Prevent the child from getting childhood diseases d. Help protect individuals and communities e. Are risk free f. Are recommended by the Centers for Disease Control and Prevention (CDC)

b. Are part of primary prevention for system disorders d. Help protect individuals and communities f. Are recommended by the Centers for Disease Control and Prevention (CDC)

The nurse is caring for a patient who is being discharged home after a splenectomy. What information on immune function needs to be included in this patient's discharge planning? a. The mechanisms of the inflammatory response b. Basic infection control techniques c. The importance of wearing a face mask in public d. Limiting contact with the general population

b. Basic infection control techniques

The nurse is caring for a patient who has suffered a spinal cord injury and is concerned about the patient's elimination status. What is the nurse's best action? a. Speak with the patient's family about food choices. b. Establish a bowel and bladder program for the patient. c. Speak with the patient about past elimination habits. d. Establish a bedtime ritual for the patient.

b. Establish a bowel and bladder program for the patient.

The nurse is completing a nutritional assessment on a patient with hypertension. What foods would be recommended for this patient? a. Regular diet b. Low sodium diet c. Pureed diet d. Low sugar diet

b. Low sodium diet

The home care nurse is assessing an older patient diagnosed with mild cognitive impairment (MCI) in the home setting. Which information is of concern? a. The patient's son uses a marked pillbox to set up the patient's medications weekly. b. The patient has lost 10 pounds (4.5 kg) during the last month. c. The patient is cared for by a daughter during the day and stays with a son at night. d. The patient tells the nurse that a close friend recently died.

b. The patient has lost 10 pounds (4.5 kg) during the last month.

While caring for a patient preparing for a kidney transplant, the nurse knows that the patient understands teaching on immunosuppression when she makes which statement? a. "My body will treat the new kidney like my original kidney." b. "I will have to make sure that I avoid being around people." c. "The medications that I take will help prevent my body from attacking my new kidney." d. "My body will only have a problem with my new kidney if the donor is not directly related to me."

c. "The medications that I take will help prevent my body from attacking my new kidney."

The nurse is preparing to administer medications to a patient with rheumatoid arthritis (RA). The nurse should explain which goal of treatment to the patient. a. Eradicate the disease b. Enhance immune response c. Control inflammation d. Manage pain

c. Control inflammation

The nurse reviews the patient's complete blood count (CBC) results and notes that the neutrophil levels are elevated, but monocytes are still within normal limits. This indicates what type of inflammatory response? a. Chronic b. Resolved c. Early stage acute d. Late stage acute

c. Early stage acute

The process of digestion is important for every living organism for the purpose of nourishment. Where does most digestion take place in the body? a. Large intestine b. Stomach c. Small intestine d. Pancreas

c. Small intestine

The nurse is listening for bowel sounds in a postoperative patient. The bowel sounds are slow, as they are heard only every 3 to 4 minutes. The patient asks the nurse why this is happening. What is the nurse's best response? a. "Anesthesia during surgery and pain medication after surgery may slow peristalsis in the bowel." b. "Some people have a slower bowel than others, and this is nothing to be concerned about." c. "The foods you eat contribute to peristalsis, so you should eat more fiber in your diet." d. "Bowel peristalsis is slow because you are not walking. Get more exercise during the day."

a. "Anesthesia during surgery and pain medication after surgery may slow peristalsis in the bowel."

On admission to the clinic, the nurse notes a moderate amount of serous exudate leaking from the patient's wound. The nurse realizes what information about this fluid? a. Contains the materials used by the body in the initial inflammatory response. b. Indicates that the patient has an infection at the site of the wound. c. Is destroying healthy tissue. d. Results from ineffective cleansing of the wound area.

a. Contains the materials used by the body in the initial inflammatory response.

During a physical examination, the nurse notes that the patient's skin is dry and flaking. What additional data would the nurse expect to find to confirm the suspicion of a nutritional deficiency? a. Hair loss and hair that is easily removed from the scalp b. Inflammation of the tongue and fissured tongue c. Inflammation of peripheral nerves and numbness and tingling in extremities d. Fissures and inflammation of the mouth

a. Hair loss and hair that is easily removed from the scalp

The nurse is caring for a postoperative patient who had an open appendectomy. The nurse understands that this patient should have some erythema and edema at the incision site 12 to 24 hours post operation dependent on which condition? a. His immune system is functioning properly. b. He is properly vaccinated. c. He has an infection. d. The suppressor T-cells in his body are activated.

a. His immune system is functioning properly.

The nurse is assisting a 79-year-old patient with information about diet and weight loss. The patient has a body mass index (BMI) of 31. How should the nurse instruct this patient? a. "Your weight is within normal limits. Continue maintaining with current lifestyle choices." b. "You are a little overweight. Cut down on calories and increase your activity, and you should be fine." c. "You are morbidly obese, and we would like to schedule you an appointment to speak with a bariatric specialist about surgery." d. "You are considered obese and will need to consult with your doctor about a plan that includes exercises, not diet, to decrease weight."

d. "You are considered obese and will need to consult with your doctor about a plan that includes exercises, not diet, to decrease weight."

During an interview, the nurse is discussing dietary habits with a patient. Which tool would be the best choice to use as a quick screening tool to assess dietary intake? a. Food diary b. Calorie count c. Comprehensive diet history d. 24-hour recall

d. 24-hour recall

The nurse is caring for a patient who was started on intravenous antibiotic therapy earlier in the shift. As the second dose is being infused, the patient reports feeling dizzy and having difficulty breathing and talking. The nurse notes that the patient's respirations are 26 breaths/min with a weak pulse of 112 beats/min. The nurse suspects that the patient is experiencing which condition? a. Suppressed immune response b. Hyperimmune response c. Allergic reaction d. Anaphylactic reaction

d. Anaphylactic reaction

What is a primary prevention tool used for colon cancer screening? a. Abdominal x-rays b. Blood, urea, and nitrogen (BUN) testing c. Serum electrolytes d. Occult blood testing

d. Occult blood testing