3270 Final Exam Review (₁)

Fred seems nervous and asks for a glass of water. After taking a drink, he attempts to set the glass down, but places the glass on the edge of the counter, causing it to crash to the floor. To follow up this situation, which assessment will provide the most useful data?

Visual field and depth perception. Under or over reaching for objects is an indication of a visual deficit. Assessment of visual field and depth perception will provide the most useful data related to this situation.

Which developmental milestone would the nurse expect when assessing a preschooler? A. Copying squares B. Running with difficulty C. Difficulty in walking stairs D. Jumping and hopping with ease.

Answer: A. Copying squares Rationale: A preschooler learns to copy crosses and squares. They begin to learn to jump and hop rather than perform the activity with ease.

The nurse is performing an assessment of fine motor skills on an infant. Which actions would the nurse observe? a. Crawling b. Creeping c. Sitting erect d. Holding a bottle e. Picking up objects f. Holding a baby bottle

Answer: D,E,F Rationale: These actions are demonstrations of fine motor skills.

Fred's visual acuity is measured using a Snellen chart. The reading obtained is 20/80 in the right eye and 20/200 in the left eye. How should the RN explain these findings to Fred?

"You are very near-sighted, especially in your left eye." The larger the denominator (bottom number), the poorer the visual acuity. This is commonly referred to as being near-sighted. Standing at 20 feet, the client can read what the person with normal vision can read at further distances, such as 80 feet (right eye) or 200 feet (left eye).

What should a nurse include in the plan of care for a client with vascular dementia? 1 Reeducation program 2 Supportive care interventions 3 Introduction of new leisure-time activities 4 Involvement in group therapy sessions

2. Supportive care interventions

Which biologic change is considered abnormal during the development of a male adolescent? Select all that apply. 1 Breast enlargement during mid-puberty. 2 Breast enlargement during late-puberty. 3 Penile erection before obtaining puberty. 4 Appearance of pubic hair during early-puberty. 5 Progression of pubic hair growth during mid-puberty. 6 Obtaining peak height velocity by the end of late-puberty

2, 6. In males, breast enlargement disappears during late-puberty, that is, within 2 years of their appearance in mid-puberty. Peak height velocity is obtained by the end of mid-puberty in most of the males. Breast enlargement is common and is seen in up to one third of the males during their mid-puberty. Ability for penile erection without seminal emission is present from birth. Pubic hair appears during early-puberty and progresses to grow though out mid-puberty.

What developmental skills does a preschooler exhibit? Select all that apply. 1 Personal identity 2 Specific reasoning 3 Increased curiosity 4 Magical thinking 5 Understanding of others

2,3,4

A client at the women's health clinic complains of swelling of the labia and throbbing pain in the labial area after sexual intercourse. For what condition does the nurse anticipate the client will be treated? 1 Urethritis 2 Bartholinitis 3 Vaginal hematoma 4 Inflamed Skene glands

2. The Bartholin glands are located beneath the vaginal vestibule; if cysts form and they become infected they cause labial, vaginal, or pelvic pain, particularly during or after intercourse (dyspareunia). Urethritis causes painful urination. A vaginal hematoma causes swelling in the vaginal wall, not the labia. The Skene glands are located in the urethra, not the labia.

During the assessment of Fred's hearing, the RN performs a series of tests, including Fred's ability to hear whispered and conversational tones. How will the RN assess for the presence of tinnitus?

Ask the client if he ever hears ringing in his ears. Tinnitus is the presence of ringing in the ears, which is often associated with hearing loss.

Which strategy would the nurse include in a plan of care for a client with Alzheimer's disease? A. Implement remotivational therapy B. Structure the environment for safety C. Arrange for long-term custodial care D. Stimulate thinking with new experiences

B. Structure the environment for safety.

As the interview continues, the RN notes that Fred is very pleasant and nods his head in agreement with all of the RN's statements, but that he often does not respond to simple requests during the assessment. Which nursing diagnosis is best supported by the data available?

Disturbed sensory alteration (auditory). Clients with impaired hearing often smile and nod in agreement with the person conversing even though they are unable to clearly hear the conversation. Appearing to be inattentive, speaking loudly, and difficulty following directions are other indications of a disturbance in auditory sensory function.

Describe a condyloid joint

biaxial- flexion & extension, abduction and adduction, bones in carpals articulate with radius - think wrist joint

Which ethnic group has a greater incidence of osteoporosis due to musculoskeletal differences? A. Irish Americans B. African Americans C. Chinese Americans D. Egyptian Americans

C. Chinese Americans Rationale: Chinese Americans have an increased incidence of osteoporosis because they have shorter and smaller bones with lower bone density than the other ethnic groups presented in the question.

Immediately after birth, a newborn is dried before being placed in skin-to-skin contact with the mother. What type of heat loss would this intervention present?

Evaporation Rationale: Evaporative heat loss is a result of the conversion of moisture into vapor, which is avoided when the newborn is dried.

Describe Guillain-Barre Syndrome

Acquired inflammatory disease causing demyelination of the peripheral nerves w/ sparing of axons. Acute onset w/ ascending motor paralysis. Usually preceded by bacterial or viral infection - an intervention would include PT

Fred Johnson, a 76-year-old retired farmer, visits the Health Clinic where he tells the nurse that his vision is getting "awful blurry lately" and that he finds he has to "have the television up pretty loud" to hear clearly. The nurse prepares to complete an assessment of Fred's sensory function. Assessment During the initial interview, the registered nurse (RN) inspects the external anatomy of the eye. The eye is a sensory organ of vision, and it is well protected by a bony orbital cavity and surrounded with a cushion of fat.The RN notes that the cornea looks cloudy and an arcus senilis is seen around the cornea. Which action should the RN take first?

Assess whether the cornea looks thickened and raised and document the finding. As the lipid accumulates, the cornea may look thickened and raised. The assessment finding should be documented in the electronic medical record.

The nurse understands which condition as being contraindicated for St. John's wort herbal therapy? A. Anxiety B. Seizures C. Dementia D. Cardiac Disease

C. Dementia Rationale: St John's wort is contraindicated for dementia. This herbal therapy is used to treat anxiety.

Four days after a vaginal hysterectomy a client calls the follow-up service and tells the nurse that she has a yellowish-green vaginal discharge. The nurse advises the client to return to the clinic for an evaluation. What does the nurse need to assess when a vaginal infection is suspected? Select all that apply. 1 Abdominal pain 2 Urinary frequency 3 Rising temperature 4 Decreased pulse rate 5 Decreased blood pressure

1, 3. A pelvic infection is suspected. One characteristic of this disorder is abdominal pain. A rising temperature is a sign of infection. Urinary frequency is associated with cystitis, not a pelvic infection. Increases, not decreases, in pulse rate and blood pressure are expected because the metabolic rate increases in the presence of an increased temperature.

When determining whether a client has anorexia nervosa or bulimia nervosa, the nurse should identify those characteristics that relate only to anorexia nervosa. Select all that apply. 1 Cachexia 2 Binge eating 3 Constipation 4 Decreased blood pressure 5 Delayed psychosexual development

1, 5. A state of malnutrition with muscle wasting, weakness, and emaciation (cachexia) occurs with anorexia nervosa; clients usually are 15% to 30% below ideal body weight. Many clients with anorexia nervosa exhibit psychological symptoms, including a lack of age-appropriate interest in sex and relationships. Recurrent episodes of the rapid consumption of a large amount of food in a discrete period (binge eating) are associated with bulimia nervosa. Constipation can occur with both anorexia nervosa and bulimia nervosa, usually because of a lack of adequate fluids and intestinally stimulating foods. Hypotension can occur with both anorexia nervosa and bulimia nervosa, usually because of dehydration.

A nurse works in a crisis intervention center. A woman who has experienced sexual abuse comes in and says, "I've got to talk to someone or I'll go crazy. I shouldn't have dated him." What is most important for the nurse to identify after initially assessing the client's physical condition? 1 Support system 2 Sexual background 3 Ability to relay the facts 4 Knowledge of sexual assault terminology

1. Identification of a client's support system and relationships is a priority if the victim is to be helped after the immediate crisis is over. Sexual background and ability to relay the facts may eventually be of value, but at this time they are irrelevant in the assessment of the client's current condition and needs. Knowledge of sexual assault terminology is not necessary for care to be provided.

A client who has been sexually abused tearfully says, "I'm no good now; there's nothing to live for." What is the most therapeutic response by the nurse? 1 "Tell me more about your feelings." 2 "I can understand why you feel worthless." 3 "Why do you feel that there's nothing to live for?" 4 "Do you feel this way because of what has happened?"

1. The response "Tell me more about your feelings" is on a feeling level and therefore encourages the exploration of feelings. The statement "I can understand why you feel worthless" supports the negative feelings of worthlessness. The response "Why do you feel that there's nothing to live for?" focuses on negative feelings; "why" questions are difficult and sometimes impossible to answer. The question "Do you feel this way because of what has happened?" will elicit a yes or no response and will not encourage the exploration of feelings. Test-Taking Tip: Pace yourself when taking practice quizzes. Because most nursing exams have specified time limits, you should pace yourself during the practice testing period accordingly. It is helpful to estimate the time that can be spent on each item and still complete the examination in the allotted time. You can obtain this figure by dividing the testing time by the number of items on the test. For example, a 1-hour (60-minute) testing period with 50 items averages 1.2 minutes per question. The NCLEX exam is not a timed test. Both the number of questions and the time to complete the test varies according to each candidate's performance. However, if the test taker uses the maximum of 5 hours to answer the maximum of 265 questions, each question equals 1.3 minutes.

A nurse is creating a therapy group for low-functioning clients. Which client is the most appropriate member? 1 A 77-year-old man with anxiety and mild dementia 2 A 52-year-old woman with alcoholism and an antisocial personality 3 A 38-year-old woman whose depression is responding to medication 4 A 28-year-old man with bipolar disorder who is in a hypermanic state

1. A 77-year-old man with anxiety and mild dementia

A sexually active client presents with a sore throat and a generalized rash. The client states that a chancre that had been present healed approximately 3 months ago. The physical assessment and the serologic test findings indicate a diagnosis of syphilis. Which stage should the nurse determine the client is in at this time? 1 Primary 2 Secondary 3 Latent 4 Tertiary

2. The client has secondary syphilis, which occurs 1 to 3 months after healing of the primary lesion and lasts for several weeks to as long as a year; it is the stage at which the individual is most infectious. Primary syphilis is the stage of initial infection and is characterized by the presence of a chancre, a painless lesion at the site of infection. Latent syphilis occurs after the secondary stage and before the late stage of syphilis; in latent syphilis the immune system is able to suppress the infection and there are no clinical signs and symptoms. Tertiary syphilis, also known as late syphilis, is the final stage of syphilis. At this stage it is a slowly progressive inflammatory disease that can involve many organs; the skin, brain, and heart can be affected.

Which finding in an older adult is associated with aging? A. Decrease in height B. Decreased neck rigidity C. Increased fine-motor dexterity D. Increased ROM

A. Decrease in height. Rationale: Loss of height and deformity and shortening of the trunk are common in older adults due to vertebral compression and degeneration. Rigidity in the neck, shoulders, back, hips, and knees increase with age because of loss of elasticity in ligaments, tendons, and cartilage.

A nursing student counsels a 70-year-old female client about changes in the reproductive system caused by aging. Which statement made by the client indicates effective learning? 1 "I should reduce my intake of dietary calcium." 2 "I should limit my Kegel exercises." 3 "I should undergo regular clinical breast examinations." 4 "I should report to my primary healthcare practitioner if my nipples do not become erect."

3. A 70-year-old female client may need regular clinical breast examinations to detect masses or other changes that may indicate the presence of cancer. The client should take an adequate amount of calcium to prevent osteoporosis. Performing Kegel exercises strengthens pelvic muscles and reduces urinary incontinence. The erection of the nipples decreases as age increases; this finding does not need to be reported to the primary healthcare provider. Test-Taking Tip: An elderly client has to be adequately educated regarding self-awareness regularly to identify the precancerous and cancerous cells and necessary tests to be undergone.

A mental health nurse is admitting a client with anorexia nervosa. When obtaining the history and physical assessment, the nurse expects the client's condition to reveal which symptom? 1 Edema 2 Diarrhea 3 Amenorrhea 4 Hypertension

3. Amenorrhea results from endocrine imbalances that occur when fat stores are depleted. The client is dehydrated; edema is not expected. Constipation, not diarrhea, may occur because of lack of fiber in the diet. Hypotension, not hypertension, may occur because of dehydration

The parents of a school-age child tell the nurse, "We evade any questions about sex that our child asks us. It is very embarrassing to discuss such things with our child." What does the nurse inform the parents? 1 "The child will feel depressed if you do not answer all queries." 2 "The child may engage in sexual activities if you explain it now." 3 "The child may speak with peers and get inaccurate information." 4 "It is right to evade questions now, because the child is still small."

3. If the parents refuse to answer any questions related to sex, the child obtains this information from peers who may provide inaccurate information. It is not correct to evade the child's questions related to sexual activity. Instead, the parents should discuss the topic honestly. If the parents do not answer the child's questions, the child will not feel depressed but will look for information elsewhere. Providing information about sex will not encourage the child to engage in sexual activity. Rather, it will minimize the feelings of embarrassment and uncertainty that accompany puberty.

A client complains of nocturia, bladder pain, urinary frequency, urgency, and dribbling at the end of urination. On physical examination, the nurse finds a smooth, firm, and enlarged prostate. The digital rectal examination report indicates enlargement of prostate tissue surrounding the urethra. Which condition does the nurse suspect in the client? 1 Prostatitis 2 Paraphimosis 3 Prostate cancer 4 Benign prostatic hyperplasia (BPH)

4. BPH is a benign enlargement of the prostate gland caused by excessive accumulation of dihydrotestosterone in the prostate cells, which can stimulate cell growth and overgrowth of prostate tissue surrounding the urethra. The clinical manifestations of BPH include nocturia, bladder pain, urinary frequency, urgency, and dribbling at the end of urination. Presence of fever, chills, back pain, and perineal pain, along with acute urinary symptoms such as dysuria, urinary frequency, urgency, and cloudy urine indicates prostatitis, which involves inflammation of the prostate gland. Tightness of the foreskin of the penis resulting in the inability to pull it forward from a retracted position and preventing normal return over the glans indicates paraphimosis. Symptoms of prostate cancer include dysuria, hesitancy, urinary urgency, and leaking or dribbling. Test-Taking Tip: Be alert for details. Details provided in the stem of the item, such as behavioral changes or clinical changes (or both) within a certain time period, can provide a clue to the most appropriate response or, in some cases, responses.

Which subjective statement made by the client helps in distinguishing bacterial vaginosis from other vaginal infections? 1 "I have painful urination." 2 "I have vaginal irritation." 3 "I have lower abdominal pain." 4 "I have a thin vaginal discharge with a fishy odor."

4. Bacterial vaginosis (BV) is manifested by a vaginal discharge characteristic fishy odor, which occurs due to the replacement of hydrogen peroxide producing lactobacillus with anaerobic bacteria. These anaerobes cause an increase in vaginal amines that lead to an alteration of the vaginal pH and cause the odor. Painful urination, vaginal irritations, and lower abdominal pain are common manifestations in other vaginal infections. Test-Taking Tip: Multiple-choice questions can be challenging, because students think that they will recognize the right answer when they see it or that the right answer will somehow stand out from the other choices. This is a dangerous misconception. The more carefully the question is constructed, the more each of the choices will seem like the correct response.

The registered nurse (RN) is teaching a nursing student about the care given to a female client before a prostate antigen-specific test. Which statement of the nursing student indicates a need for further teaching? 1 "I will observe breast changes in the client." 2 "I will ask if the client is having her menstrual cycle." 3 "I will observe the venipuncture site for hematoma." 4 "I will ask the client to have nothing by mouth (NPO)."

4. Before a prostate antigen-specific test, no fluid or food restrictions are required; therefore asking the client to have nothing by mouth (NPO) indicates a need for further teaching. The nurse should observe breast changes and any thick discharge from the nipples. The nurse should also know about the client's menstrual cycle. The nurse should observe the venipuncture site for a hematoma or bleeding.

An adolescent approaches a nurse acknowledging sexual orientation towards same-gender relationships. How would a nurse intervene in such a situation? 1 Encourage the adolescent to disclose it to his or her family 2 Reassure that these feelings are only a passing phase 3 Advise the adolescent to keep the feelings of same-gender attractions hidden 4 Provide referral to an agency providing support service or social opportunities

4. Whenever an adolescent is expressing feelings of sexual orientation for the same gender, it is best advised to refer them to any agency that provides support services or social opportunities to gay, lesbian, and bisexuals. The nurse should never encourage them to disclose their sexual orientation to their families without a safety plan, if they are not supportive. The nurse should never reassure them that these feelings are only a passing phase because they are not suppressed gradually as time goes on. The adolescent may use alcohol or other drugs to mask their anxiety or show suicidal tendencies if they suppress their feelings of same-gender attractions. So, it is not advisable to hide their sexual orientation.

A client with hemiparesis voices a reluctance to use a cane. Which rationale would the nurse use to explain the cane's purpose to the client? A. Maintain balance to improve stability. B. Relieve pressure on weight-bearing joints C. Prevent further injury to weakened muscles D. Aid in controlling involuntary muscle movements.

A. Maintain balance to improve stability. Rationale: Hemiparesis creates instability. Using a cane provides a wider base of support and therefore greater stability. Joints are not directly affected, hemiparesis affects muscles on one side of the body.

When a client injures the amphiarthrodial joint, which joint did the client injure? A. Knee joint B. Pelvic joint C. Elbow joint D. Cranial Joint E. None of the above

B. Pelvic joint Rationale: Amphiarthrodial joints are those that permit slight movements. Knee and elbow joints are diarthrodial, which are freely moving. The cranial joint is synarthrodial, which is immovable.

A recently hospitalized client with multiple sclerosis is concerned about generalized weakness and fluctuating physical status. What is the priority nursing intervention for this client? A. Encouraging bed rest for the client B. Space Activities throughout the day C. Teach limitations imposed by the disease D. Have one of the client's relatives stay at the bedside.

B. Space activities throughout the day. Rationale: Spacing activities will encourage maximum functioning within the limits of strength and fatigue. Bed rest and limitation of activity may lead to muscle atrophy and calcium depletion.

A male client with the diagnosis of gender identity disorder has been dressing and functioning in society as a woman for 2 years and has decided to have sex-reassignment surgery. He tells a nurse that all his life he has considered himself female. Place the following nursing interventions in order of priority. 1. Treating the client with respect 2. Encouraging the client to explore his feelings 3. Investigating one's own feelings about sexuality 4. Exploring ways in which the decision can be shared with significant others 5. Accepting the client's decision to have sex-reassignment surgery

Because the self is the most important factor the nurse brings to the nurse-client therapeutic relationship, the nurse must understand personal feelings about issues surrounding this client's situation and needs; this is part of the preorientation phase of a therapeutic relationship. In a therapeutic relationship the client is the focus of care, and the relationship should be based on respect. In an atmosphere of respect, the client is more likely to express feelings. The client considering sex-reassignment surgery should explore all alternatives. However, once the decision is made the nurse should support it. After this important decision is made, the client may need assistance in informing significant others.

Which type of joint permits movement in any direction? A. Pivot B. Hinge C. Biaxial D. Ball and socket

D. Ball and socket Rationale: These joints permit movement in any direction. (Think shoulders).

To keep the client with Alzheimer's disease who has hyperorality safe, which parameter would the nurse have the staff closely monitor? A. For choking at mealtimes B. For the presence of mouth ulcers C. For injuries from touching hot foods D. For attempts at eating inedible objects

D. For attempts at eating inedible objects Rationale: Hyperorality is the compulsive need to taste, chew, and put everything in the mouth.

Which intervention would the nurse include when developing a plan of care for an older client with dementia? A. Explain to the client the details of the regimen B. Demonstrate interest in the client's various likes and dislikes C. Be firm when dealing with the client's attitudes and behaviors D. Provide consistency in carrying out nursing activities for the client

D. Provide consistency in carrying out nursing activities for the client.

In identifying this problem, the RN clusters the subjective and objective assessment data and compares it with which information?

Defining characteristics of the problem. The assessment data is compared with the defining characteristics of the problem to ensure that the correct problem is identified.