Core Exam 4 (#2)

The physician diagnosis a client with Marfan Syndrome, the client asks the nurse what this means. What is the best response by the nurse? A. "It is a connective tissue disorder." B. "It is a skeletal muscle disorder." C. "It is an epitheleal tissue disorder." D. "It is a smooth muscle disorder."

A. "It is a connective tissue disorder."

A nurse is assessing several clients in a long term health care facility. Which client is at highest risk for development of a pressure ulcer? A. A 79 year-old malnourished client on bed rest B. An obese client who uses a wheelchair C. An incontinent client who has had 3 diarrhea stools D. An 80 year-old ambulatory diabetic client

A. A 79 year-old malnourished client on bed rest

Ethical principles for professional nursing practice in a clinical setting are guided by the principles of conduct that are written as the: A. American Nurses Association's (ANA's) Code of Ethics B. Nurse Practice Act (NPA) written by state legislation C. Standards of care from experts in the practice field D. Good Samaritan laws for civil guidelines

A. American Nurses Association's (ANA's) Code of Ethics

Which criterion is needed for someone to give consent to a procedure? A. An appointed guardianship B. Unemancipated minor C. Minimum of 21 years or older D. An advocate for a child

A. An appointed guardianship

Which statement about an institutional ethics committee is correct? A. The ethics committee is an additional resource for clients and healthcare professionals. B. The ethics committee relieves health care professionals from dealing with ethical issues. C. The ethics committee would be the first option in addressing an ethical dilemma. D. The ethics committee replaces decision making by the client and health care providers.

A. The ethics committee is an additional resource for clients and healthcare professionals.

When teaching the patient how to ambulate with a cane, you say: A. "When properly fitted, the cane length is twice the distance between the greater trochanter and the floor." B. "Place the cane on your stronger side for support." C. "After moving the cane, bear weight on the stronger side and swing yourself forward."

B. "Place the cane on your stronger side for support." Patients who use a cane should place the cane in the hand on the stronger side so that the cane and the stronger leg provide support and balance when ambulating.

Which best describes a healthcare proxy as part of an advance directive? A. The documentation kept on file about the person's end of life care decisions B. A person who makes healthcare decisions for the patient when he is unable to C. A statement that indicates exactly what the patient wants if he is unable to communicate D. A person who helps a patient fill out a living will

B. A person who makes healthcare decisions for the patient when he is unable to

The nurse is working with parents of a seriously ill newborn. Surgery has been proposed for the infant, but the chances of success are unclear. In helping the parents resolve this ethical conflict, the nurse knows that the first step is: A. Exploring reasonable courses of action B. Collecting all available information about the situation C. Clarifying values related to the cause of the dilemma. D. Identifying people who can solve the difficulty.

B. Collecting all available information about the situation

Which action describes the nurse verifying that the patient can sign informed consent? A. The patient has a family member who can translate when he does not speak English B. The patient is mentally competent to understand the procedure C. The nurse determines that the patient is at least 16 years old D. The nurse reviews the principles of the procedure, its benefits, and its risks

B. The patient is mentally competent to understand the procedure

Which of the following clients would least likely be at risk of developing skin breakdown? A. A client incontinent of urine feces B. A client with chronic nutritional deficiencies C. A client with decreased sensory perception D. A client who is unable to move about and is confined to bed

C. A client with decreased sensory perception

A patient is experiencing which type of incontinence if she experiences leaking urine when she coughs, sneezes, or lifts heavy objects? A. Overflow B. Reflex C. Stress D. Urge

C. Stress

To prevent pressure ulcers from occuring, the nurse is educating a client on things they can do to help out. Which of the following should the nurse include in the education? (select all that apply) A. Increase caloric intake B. Increase protein intake C. Decrease caloric intake D. Avoid too much liquid intake to avoid urinary incontinence. E. Stay active

A, B, E

The nurse recognizes that a client is experiencing insomnia when the client reports (select all that apply): A. Extended time to fall asleep B. Falling asleep at inappropriate times C. Difficulty staying asleep D. Feeling tired after a night's sleep

A, C, D

A client is at an increased risk of pressure ulcers in which situations? (select all that apply) A. Increased time in a wheelchair B. Obesity C. Gait disturbances D. Increased age E. Malnutrition

A, D, E

After assessing a patient, you document the following information: "Intact skin over the sacral area with a well-defined area of redness 2 cm in width and 3 cm in length. When palpated, the area feels boggy and is non-blanching." Which of the following is appropriate to add to your documentation of your patient's skin in the sacral area? A. "Patient has a stage I pressure ulcer." B."Patient has a stage II pressure ulcer." C. "Patient has partial-thickness skin loss."

A. "Patient has a stage I pressure ulcer."

A nurse will be getting an admit of a client with a stage II pressure ulcer, what should the nurse ensure is in the clients room to help reduce any furthering of the ulcer? A. An air mattress B. Wound cleansing materials C. A foley to negate urine from getting into the wound. D. Baby powder

A. An air mattress Beds that have pressure relieving materials such as foam, silicon gel, or air pads are necessary for a client with a pressure ulcer. Foley catheters should not be used unless clinically required, and never put baby powder on a client with a pressure ulcer.

Which nursing actions do you include in your patient's plan of care for a patient with a sacral pressure ulcer? A. Apply a moisture-barrier cream to the sacral area. B. Massage the skin over the bony prominences. C. Keep the head of the patient's bed elevated at least 45 degrees.

A. Apply a moisture-barrier cream to the sacral area.

Which action is appropriate when transferring the patient to the gurney using a slide board and three team members? A. Have one person hold the slide board steady while the other two pull the patient onto the gurney. B. Position the slide board under the patient and over the draw sheet. C. Adjust the height of the gurney so it is slightly higher than the height of the bed.

A. Have one person hold the slide board steady while the other two pull the patient onto the gurney. *****This probably won't be on test 4!! But it came from the ATI skills module so maybe it could be something we might see on our final idk!! *****

A 15 year old female comes into the emergency room seeking medical treatment for injury to her right ankle. Her parents are not with her to sign any consent to treat. The nurse knows that which of the following would permit this client to legally sign for themselves? A. The client is 23 weeks pregnant B. It is an emergency as there are broken bones that have penetrated the skin and the patient has lost large amounts of blood. C. There isn't ever a time that a child could legally sign consent for theirselves D. The child states, "I am emancipated from my parents." but cannot show any legal documentation.

A. The client is 23 weeks pregnant Rationale: Any pregnant female, no matter their age, are legally emancipated and can sign for theirselves. The child would still be treated if emergent care was needed but they would not legally be able to sign consent. An emancipated child requires legal documentation.

A patient who sustained a fractured arm requires range-of-motion exercises to promote circulation. The nurse assists the patient to perform active range of motion. Which of the following best describes how this motion is performed? A. The patient performs the exercises without help B. The nurse performs the exercises for the patient C. The nurse and the patient perform the exercises together D. The patient wears an electronic device that performs range of motion

A. The patient performs the exercises without help

You decide that both your patients should get out of bed, and plan to delegate assisting one of the patients to the nursing assistant. Which patient will you delegate to him? A. The patient who had a hip arthroplasty and needs one person to help him get out of bed to the chair B. The patient who had a lumbar repair and has a new activity order to ambulate with a walker

A. The patient who had a hip arthroplasty and needs one person to help him get out of bed to the chair Only nurses may teach

The nurse is instructing a 65-year-old female client diagnosed with osteoporosis. The most important instruction regarding exercise would be to A. exercise doing weight bearing activities B. exercise to reduce weight C. avoid exercise activities that increase the risk of fracture D. exercise to strengthen muscles and thereby protect bones

A. exercise doing weight bearing activities

A male client who has suffered a cerebrovascular accident (CVA) is too weak to move on his own. To help the client avoid pressure ulcers, the nurse should: A. turn him frequently. B. perform passive range-of-motion (ROM) exercises. C. reduce the client's fluid intake. D. encourage the client to use a footboard

A. turn him frequently.

Which of the following situations would involve mandatory reporting? A. An 18-year-old girl has a sexual relationship with a 29-year-old man B. A nurse suspects that an 11-year-old child is being abused in his home C. A physician sees a family perform cupping on the back of their 12-year-old son D. A 17-year-old female is seen in a clinic for a positive pregnancy test

B. A nurse suspects that an 11-year-old child is being abused in his home

In answering the risk manager, you explain that a disadvantage of a hydrocolloid dressing is that it... A. Must be changed several times a day. B. Does not allow visualization of the wound. C. Must be secured with the use of tape.

B. Does not allow visualization of the wound **idk if we have to know this, but I just remember her briefly saying something about hydrocolloid dressings in class ***

Ethical dilemmas often arise over a conflict of opinion. Once the nurse has determined that the dilemma is ethical, a critical first step in negotiating the difference of opinion would be to: A. Consult a professional ethicist to ensure that the steps of the process occur in full. B. Gather all relevant information regarding the clinical, social, and spiritual aspects of the dilemma. C. List the ethical principles that inform the dilemma so that negotiations agree on the language of the discussion. D. Ensure that the attending physician has written an order for an ethics consultation to support the ethics process.

B. Gather all relevant information regarding the clinical, social, and spiritual aspects of the dilemma.

A nurse is filling out paperwork with a patient who is being admitted to the hospital. The nurse asks the patient if he has an advance directive. Which response from the patient indicates that he understands what a power of attorney document is? A. I do not want to be put on a breathing machine. B. My son is in charge of my healthcare decisions. C. I have paperwork that says I do not want CPR. D. My paperwork says I want all measures taken to keep me alive.

B. My son is in charge of my healthcare decisions.

The 10-year-old client has begun to sleepwalk, a parasomnia disorder. Which information should the nurse provide the parents of the child? A. Give the child a mild sedative 2 hours before bedtime B. Place a lock on the outer door out of the child's reach C. Make the child wake up when an episode occurs. D. Have the child practice guided imagery before bedtime

B. Place a lock on the outer door out of the child's reach This is a safety measure to keep the child from exiting the house during the night

A nurse is ambulating with a client who is using a cane. What is the proper side for the cane to be on? A. Affected side B. Unaffected side C. The affected side only if a nurse is ambulating with them D. The unaffected side only if the nurse is ambulating with them

B. Unaffected side

Nurse Gil is aware that the following statements describing urinary incontinence in the elderly is true? A. Urinary incontinence is a normal part of aging. B. Urinary incontinence isn't a disease. C. Urinary incontinence in the elderly can't be treated. D. Urinary Incontinence is a disease.

B. Urinary incontinence isn't a disease.

You determine that the patient performs the prescribed three-point gait appropriately when using his crutches because he: A. Positions each upper crutch pad centered in the axilla. B. Leans his upper torso forward slightly in the tripod position. C. Advances the crutches first, followed by the unaffected leg.

C. Advances the crutches first, followed by the unaffected leg.

Nurses agree to be advocates for their patients. Practice of advocacy calls for the nurse to: A. Seek out the nursing supervisor in conflicting situations B. Work to understand the law as it applies to the client's clinical condition. C. Assess the client's point of view and prepare to articulate this point of view. D. Document all clinical changes in the medical record in a timely manner.

C. Assess the client's point of view and prepare to articulate this point of view.

To assist an adult client to sleep better the nurse recommends which of the following? A. Drinking a glass of wine just before retiring to bed B. Eating a large meal 1 hour before bedtime C. Consuming a small glass of warm milk at bedtime D. Performing mild exercises 30 minutes before going to bed

C. Consuming a small glass of warm milk at bedtime

For a client with a flaccid bladder, the nurse is most likely to teach which of the following? A. Habit training: attempt voiding at specific time periods B. Bladder training: delay voiding according to a prescheduled timetable C. Credé maneuver: apply gentle manual pressure to the lower abdomen D. Kegel exercises: contract the pelvic muscles

C. Credé maneuver: apply gentle manual pressure to the lower abdomen

To assist the patient in transferring from the bed to the chair, you A. Position the chair at a 90° angle to the head of the bed. B. Keep your feet together while rocking the client up to a standing position. C. Flex your hips and knees while lowering patient to the chair.

C. Flex your hips and knees while lowering patient to the chair. Flexing the hips and knees while lifting weight reflects good body mechanics as this prevents injury due to poor body alignment. Flexion of the knees and hips lowers your center of gravity in relation to the object you are raising or lifting.

The nurse identifies which of the following as a high-priority goal for a client with stress incontinence? A. Identifies products for protecting clothes and furniture B. States chronic and benign nature of the disorder C. Performs pelvic floor muscle exercises twice a day D. Limits intake of beverages with artificial sweeteners

C. Performs pelvic floor muscle exercises twice a day

Nurse Melinda is caring for an elderly bedridden adult. To prevent pressure ulcers, which intervention should the nurse include in the plan of care? A. Turn and reposition the client at least once every 8 hours. B. Vigorously massage lotion into bony prominences. C. Post a turning schedule at the client's bedside. D. Slide the client, rather than lifting, when turning.

C. Post a turning schedule at the client's bedside.

A patient with sleep apnea has a nursing diagnosis of Sleep Deprivation related to disrupted sleep cycle. Which action should you delegate to the nursing assistant? A. Discuss weight-loss strategies such as diet and exercise with the patient B. Teach the patient how to set up the BiPAP machine before sleeping C. Remind the patient to sleep on his side instead of his back. D. Administer modafinil (Provigil) to promote daytime wakefulness

C. Remind the patient to sleep on his side instead of his back.

A client who had a "Do Not Resuscitate" order passed away. After verifying there is no pulse or respirations, the nurse should next: A. Have family members say goodbye to the deceased. B. Call the transplant team to retrieve vital organs. C. Remove all tubes and equipment (unless organ donation is to take place), clean the body, and position appropriately. D. Call the funeral director to come and get the body.

C. Remove all tubes and equipment (unless organ donation is to take place), clean the body, and position appropriately.

Nurse Rob has observed a co-worker arriving to work drunk at least three times in the past month. Which action by Nurse Rob would best ensure client safety and obtain necessary assistance for the co-worker? A. Ignore the co worker's behavior, and frequently assess the clients assigned to the co-worker. B. Make general statements about safety issues at the next staff meeting. C. Report the coworker's behavior to the appropriate supervisor. D. Warn the co-worker that this practice is unsafe.

C. Report the coworker's behavior to the appropriate supervisor. The nurse is obligated by ethical considerations of client safety, as well as by nurse practice acts in many states, to report substance abuse in health care workers. Most healthcare facilities have an employee assistance program to help workers with substance abuse problems. Warning the co-worker is inadequate; it does not ensure client safety or helps him receive necessary aid.

The priority nursing intervention in the prevention of pressure ulcers is what? A. Give the client protein shakes daily. B. Have the client wear socks. C. Turn the client frequently. D. Put heating pads on suspicious areas.

C. Turn the client frequently.

A nurse is caring for a patient with reduced mobility following hip surgery. Which best describes how the nurse would intervene to prevent skin breakdown from immobility? A. Help the patient to maintain skin integrity by teaching him how to move up in bed B. Turn and reposition the patient every 4 hours C. Use padding and cushions under the heels and other bony prominences D. Massage bony prominences with emollient cream after giving the patient a bath

C. Use padding and cushions under the heels and other bony prominences

A patient tells the nurse that she is afraid that she has sleep apnea. She says that she does not feel rested in the morning and that she snores. Her husband says that he notices that she seems to stop breathing on several occasions during the night. The client asks the nurse how sleep apnea is diagnosed. Which answer from the nurse is correct? A. The doctor usually orders a multiple sleep latency test. B. You will probably have to wear a halter monitor for 7 days to track your sleep. C. You will most likely need a PSG, which is a nighttime sleep study. D. You will need a CT scan of your face and neck.

C. You will most likely need a PSG, which is a nighttime sleep study.

A document that lists the medical treatment a person chooses to refuse if unable to make decisions is the: A. Durable power of attorney B. Informed consent C. Living will D. Advance directives

D. Advance directives

Which of your four patients should you see first? A. The patient who had a fractured femur repaired and must demonstrate proper crutch walking B. The patient who had a hip arthroplasty and needs one person to help him get out of bed to the chair C. The patient who had a lumbar repair and is on strict bed rest D. The patient with quadriplegia who had sacral redness when last turned 2 hours ago

D. The patient with quadriplegia who had sacral redness when last turned 2 hours ago

A nurse is caring for a client who reports problems with urinary stress incontinence. The nurse would expect the client to state that the incidence of stress incontinence occurs during which activity? A. Reading B. Coughing C. Sleeping D. Walking

B. Coughing

A confused client who fell out of bed because side rails were not used is an example of which type of liability? A. Felony B. Assault C. Battery D. Negligence

D. Negligence

When a client is confused, left alone with the side rails down, and the bed in a high position, the client falls and breaks a hip. What law has been broken? A. Assault B. Battery C. Negligence D. Civil tort

C. Negligence

The evening nurse reviews the nursing documentation in the male client's chart and notes that the day nurse has documented that the client has a stage II pressure ulcer in the sacral area. Which of the following would the nurse expect to note on assessment of the client's sacral area? A. Intact skin B. Full-thickness skin loss C. Exposed bone, tendon, or muscle D. Partial-thickness skin loss of the dermis

D. Partial-thickness skin loss of the dermis

Even though the nurse may obtain the client's signature on a form, obtaining informed consent is the responsibility of the: A. Client B. Physician C. Student nurse D. Supervising nurse.

B. Physician

A nurse is helping a patient to develop a sleep hygiene program to improve his sleep habits. Which of the following would the nurse suggest for this patient as part of sleep hygiene? Select all that apply. A. The patient should develop a familiar nighttime routine B. The patient should go to bed later than usual C. The patient may sleep better if another person is in the room D. The patient should try to wake up at an earlier time than usual E. The patient should try to find a comfortable position for sleeping

A and E

A student nurse who is employed as a nursing assistant may perform any functions that: A. Have been learned about in school B. Are expected of a nurse at that level C. Are identified in the positions job description D. Require technical rather than professional skill.

C. Are identified in the positions job description

A female client verbalizes that she has been having trouble sleeping and feels wide awake as soon as getting into bed. The nurse recognizes that there are many interventions the promote sleep. Check all that apply. 1. Eat a heavy snack before bedtime 2. Read in bed before shutting out the light 3. Leave the bedroom if you are unable to sleep 4. Drink a cup of warm tea with milk at bedtime 5. Exercise in the afternoon rather than the evening 6. Count backwards from 100 to 0 when your mind is racing.

3, 5, 6

Narcolepsy can be best explained as: 1. A sudden muscle weakness during exercise 2. Stopping breathing for short intervals during sleep 3. Frequent awakenings during the night 4. An overwhelming wave of sleepiness and falling asleep

4. An overwhelming wave of sleepiness and falling asleep

To prevent pressure ulcers from occuring, the nurse is educating a client on things they can do to help out. Which of the following should the nurse include in the education? (select all that apply) A. Inspect skin daily B. Change positions frequently C. Use cushions for bony prominences D. Wear briefs to avoid having urine saturate the clothing E. Use lotion to keep the skin moist

A, B, C

To prevent pressure ulcers from occuring, the nurse is educating a client on things they can do to help out. Which of the following should the nurse include in the education? (select all that apply) A. Quit smoking B. Stay active C. Keep hydrated D. Wear jeans E. Adjust self Q3 hours

A, B, C

Which of the following are risk factors for pressure ulcers? A. Incontinence B. Smoking C. Impaired cognitive ability D. Darkly pigmented skin E. Braden score below 16

A, B, C, E

A nurse is assessing an older adult who is at risk of impaired skin integrity. The nurse is using the Braden Scale for assessment. Which of the following is an element of the Braden Scale? Select all that apply. A. Sensory perception B. Circulation C. Moisture D. Activity E. Edema

A, C, D

Mrs. Kennedy had a CVA (cerebrovascular accident) and has severe right-sided weakness. She has been taught to walk with a cane. The nurse is evaluating her use of the cane prior to discharge. Which of the following reflects correct use of the cane? A. Holding the cane in her left hand, Mrs. Kennedy moves the cane forward first, then her right leg, and finally her left leg B. Holding the cane in her right hand, Mrs. Kennedy moves the cane forward first, then her left leg, and finally her right leg C. Holding the cane in her right hand, Mrs. Kennedy moves the cane and her right leg forward, then moves her left leg forward. D. Holding the cane in her left hand, Mrs. Kennedy moves the cane and her left leg forward, then moves her right leg forward

A. Holding the cane in her left hand, Mrs. Kennedy moves the cane forward first, then her right leg, and finally her left leg

The nurse understands that the most vivid dreaming occurs during: A. REM sleep B. Stage 1 NREM C. Stage 4 NREM D. Transition period from NREM to REM sleep

A. REM sleep

The scope of Nursing practice is legally defined by: A. State nurses practice acts B. Professional nursing organizations C. Hospital policy and procedure manuals D. Physicians in the employing institutions

A. State nurses practice acts

Nurses are bound by a variety of laws. Which description of a type of law is correct? A. Statutory law is created by elected legislature, such as the state legislature that defines the Nurse Practice Act (NPA). B. Regulatory law includes prevention of harm for the public and punishment for those laws that are broken. C. Common law protects the rights of the individual within society for fair and equal treatment. D. Criminal law creates boards that pass rules and regulations to control society.

A. Statutory law is created by elected legislature, such as the state legislature that defines the Nurse Practice Act (NPA).

A nurse is caring for a patient with insomnia. The nurse has given this patient a nursing diagnosis of Sleep Pattern Disturbance. Which of the following would be an appropriate outcome for this nursing diagnosis? Select all that apply. A. The patient states that he does not dream while sleeping B. The patient sleeps through the night consistently C. The patient feels refreshed after sleeping D. The patient does not require sleep aids to achieve sleep E. The patient can sleep in another location beyond his bed

B, C, D

You have a patient that might have a urinary tract infection (UTI). Which statement by the patient suggests that a UTI is likely? A. "I pee a lot." B. "It burns when I pee." C. "I go hours without the urge to pee." D. "My pee smells sweet."

B. "It burns when I pee."

A patient who is bedridden is complaining of joint pain. Which of the following interventions would be most helpful for providing comfort? A. Apply a cold pack or an ice bag to the affected joints B. Apply a heating pad for 15 minutes to painful joints C. Encourage the patient to lie still and do not move the affected joints D. Administer anticonvulsant medications to use as an adjuvant therapy

B. Apply a heating pad for 15 minutes to painful joints

The nurse puts a restraint jacket on a client without the client's permission and without the physicians order. The nurse may be guilty of: A. Assault B. Battery C. Invasion of privacy D. Neglect

B. Battery

A patient is being seen in the primary care clinic for symptoms of stress incontinence. The nurse is teaching the patient about the forms of treatment available for this condition. Which type of treatment would most likely be prescribed for management of A. Bladder neck reconstruction surgery B. Behavioral techniques C. Intermittent catheterization D. Limiting fluid intake

B. Behavioral techniques

A client is frustrated and embarrassed by urinary incontinence. Which of the following measures should Nurse Ginny include in a bladder retraining program? A. Establishing a predetermined fluid intake pattern for the client B. Encouraging the client to increase the time between voidings C. Restricting fluid intake to reduce the need to void D. Assessing present elimination patterns

D. Assessing present elimination patterns

When assessing a client for obstructive sleep apnea (OSA), the nurse understands the most common symptom is: A. Headache B. Early awakening C. Impaired reasoning D. Excessive daytime sleepiness

D. Excessive daytime sleepiness

When signing a form as a witness, your signature shows that the client: A. Is fully informed and is aware of all consequences. B. Was awake and fully alert and not medicated with narcotics. C. Was free to sign without pressure D. Has signed that form and the witness saw it being done

D. Has signed that form and the witness saw it being done

A nurse assesses an 86-year-old patient who is a client at a long-term care facility. The nurse uses the Braden scale to determine the patients level of risk for skin breakdown. After completing the assessment the nurse gives the patient a score of 8. Which of the following best describes this patients risk of skin breakdown? A. Very low risk B. Mild risk C. Moderate risk D. High risk

D. High risk

The nurse recognizes that urinary elimination changes may occur even in healthy older adults related to what factor? 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.

An older female client tells the nurse she is unable to maintain continence after she senses the urge to void and becomes incontinent on the way to the bathroom. Which of the following nursing diagnoses is most appropriate? A. Stress Urinary Incontinence B. Reflex Urinary Incontinence. C. Functional Urinary Incontinence D. Urge Urinary Incontinence

D. Urge Urinary Incontinence