exam 4 study

The nurse is providing information about hepatitis to a high school health occupations class. The students all volunteer examples of how hepatitis is transmitted. Which student statement indicates the need for further education? "Contaminated food or fluids." "An infected mosquito or tick bite." "Unprotected sexual intercourse." "Body piercing or tattoo with infected equipment."

"An infected mosquito or tick bite."

A patient newly diagnosed with a hiatal hernia asks the nurse what lifestyle changes are recommended. What is the best response by the nurse? "Lifting weights should be added to your exercise routine." "Tight fitting pants will provide abdominal support." "It is best to lay flat for 2 hours after eating." "Quitting smoking can help reduce symptoms."

*"Quitting smoking can help reduce symptoms."

A patient recovering from surgery to place a permanent colostomy as treatment for a bowel disorder is concerned that her spouse will no longer find her sexually attractive. Which response by the nurse is the most appropriate? "I will refer you to a counselor to talk about your concerns." "Do not worry about sex right now. It is more important to focus on recovery." "Would you like me to speak with your husband for you?" "Tell me more about the concerns you are having."

*"Tell me more about the concerns you are having."

An adult patient is scheduled for an upper GI series that will use a barium solution. What teaching should the nurse include related to expected post-procedure manifestations? "You should increase fluids to facilitate stool passage." "Your stool will be yellow for the first 24 hours." "The barium may cause diarrhea for the next 24 hours." "You may notice some anal bleeding as barium is passed."

*"You should increase fluids to facilitate stool passage."

A patient is scheduled for an electroencephalogram (EEG). Which of the following preprocedure information should the nurse emphasize with this patient? Do not wash the hair for two days prior to the test Refrain from eating or drinking for 12 hours prior to test. Restrict the intake of fluids for six hours after the test Avoid caffeine for 8 to 12 hours before the test

*Avoid caffeine for 8 to 12 hours before the test Withhold the daily dose of antiepileptic drug(Any ordered anti-seizure, antidepressant and tranquilizing medication will generally be held 48 hours before an EEG. Clients should wash the hair to remove any gel or hairsray. NPO is not necessary but CNS stimulants such as caffeine and nicotine should be avoided.

During a neurologic assessment the nurse asks a patient to close their eyes and identify the number drawn on the hand. Which of the following cortical sensory interpretations is the nurse assessing? Hyperesthesia Two-point discrimination Graphesthesia Stereognosis

*Graphesthesia

The nurse is caring for a patient with ulcerative colitis. Which diagnostic laboratory test should the nurse evaluate to determine the degree of hematochezia? Stool antigen Fecal ova and parasite White blood cell count Hemoglobin and hematocrit

*Hemoglobin and hematocrit

Which information would the nurse include regarding appliance care and maintenance, when teaching a client with a new colostomy? Select all that apply. 1Change the ostomy pouch on a routine basis. 2Replace the ostomy wafer weekly or sooner as needed. 3Remove the ostomy pouch when showering. 4Empty the ostomy pouch when three-quarters full of stool or gas. 5Empty the ostomy pouch before exercise and at bedtime.

1 2 5

46. Which statement by the female client indicates that the client understands factors that may precipitate seizure activity? 1. "It is all right for me to drink coffee for breakfast." 2. "My menstrual cycle will not affect my seizure disorder." 3. "I am going to take a class in stress management." 4. "I should wear dark glasses when I am out in the sun."

3. Tension states, such as anxiety and frustration, induce seizures in some clients, so stress management may be helpful in preventing seizures.

A nurse who provides care in a walk-in clinic assesses a wide range of individuals. The nurse should identify which of the following patients as having the highest risk for chronic pancreatitis? A)A 45-year-old obese woman with a high-fat diet B)An 18-year-old man who is a weekend binge drinker C)A 39-year-old man with chronic alcoholism D)A 51-year-old woman who smokes one-and-a-half packs of cigarettes per day

A 39-year-old man with chronic alcoholism

The nurse is caring for a patient who is hospitalized with an exacerbation of MS. To ensure the patient's safety, what nursing action should be performed?A) Ensure that suction apparatus is set up at the bedside.B) Pad the patient's bed rails.C) Maintain bed rest whenever possible.D) Provide several small meals each day.

A) Ensure that suction apparatus is set up at the bedside.

A patient has been scheduled for an ultrasound of the gallbladder the following morning. What should the nurse do in preparation for this diagnostic study? A)Have the patient refrain from food and fluids after midnight. B)Administer the contrast agent orally 10 to 12 hours before the study. C)Administer the radioactive agent intravenously the evening before the study. D)Encourage the intake of 64 ounces of water 8 hours before the study.

A)Have the patient refrain from food and fluids after midnight.

A patients abdominal ultrasound indicates cholelithiasis. When the nurse is reviewing the patients laboratory studies, what finding is most closely associated with this diagnosis? A)Increased bilirubin B)Decreased serum cholesterol C)Increased blood urea nitrogen (BUN) D)Decreased serum alkaline phosphatase level

A)Increased bilirubin

The nurse is providing discharge education to an adult patient who will begin a regimen of ocular medications for the treatment of glaucoma. How can the nurse best determine if the patient is able to self-administer these medications safely and effectively? Ask the patient to demonstrate the instillation of the medications Assess the patient's functional status Have the patient describe how to instill the medications Evaluate the patient for any previous inability to self-manage medications

Ask the patient to demonstrate the instillation of the medications

Which of the following tests or tools could the nurse use to assess the cranial nerve VIII, the acoustic nerve, of a patient? Pen light Reflex hammer Romberg Test Audiometry

Audiometry

When educating a patient with migraine headaches, the nurse would include which of the following interventions in the teaching? Drink a lot of caffeinated products Stop taking your birth control pills immediately For prevention, take your triptan medication everyday Avoid possible triggers

Avoid possible triggers

A patient with multiple sclerosis has developed dysphagia as a result of cranial nerve dysfunction. Which of the following actions should the nurse consequently perform? Position the patient upright during feeding Suction the patient following each meal Withhold liquids until the patient has finished eating Arrange for the patient to receive a low residue diet

B) Position the patient upright during feeding.

While reviewing the health history of an older adult experiencing hearing loss the nurse notes the patient has had no trauma or loss of balance. What aspect of this patient's health history is most likely to be linked to the patient's hearing deficit? A) Recent completion of radiation therapy for treatment of thyroid cancer B) Routine use of quinine for management of leg cramps C) Allergy to hair coloring and hair spray D) Previous perforation of the eardrum

B) Routine use of quinine for management of leg cramps

A patient who had surgery for gallbladder disease has just returned to the postsurgical unit from postanesthetic recovery. The nurse caring for this patient knows to immediately report what assessment finding to the physician? A)Decreased breath sounds B)Drainage of bile-colored fluid onto the abdominal dressing C)Rigidity of the abdomen D)Acute pain with movement

C)Rigidity of the abdomen

Following a motorcycle accident, a 17-year-old man is brought to the ED. What physical assessment findings related to the ear should be reported by the nurse immediately? A) The malleus can be visualized during otoscopic examination. B) The tympanic membrane is pearly gray. C) Tenderness is reported by the patient when the mastoid area is palpated. D) Clear, watery fluid is draining from the patient's ear.

D) Clear, watery fluid is draining from the patient's ear.

The nurse asks the client with liver disease to raise the arms to shoulder level and dorsiflex the hands. A few moments later, the hand begins to flap upward and downward. How does the nurse correctly document this in the medical record? A. Positive Babinski's sign B. Hyperreflexia C. Kehr's sign D. Asterixis

D. Liver flap or asterixis is related to increased serum ammonia levels. The dorsiflexed hands begin to flap upward and downward when outstretched for a few moments.

Which is important for the nurse to include in the plan of care for a client who is to undergo paracentesis later today? A. Measure and record drainage. B. Monitor LFTs C. Obtain informed consent for the procedure. D. Have the client void before the procedure is performed.

D. Voiding before the procedure prevents bladder injury.

A patient with morbid obesity undergoes gastric bypass surgery. The nurse teaches the patient how to avoid dumping syndrome by doing which of the following? Eliminating fluids until after a meal Consuming 2 large meals per day Increasing carbohydrates in the patient's diet Instructing the patient to ambulate after meals

Eliminating fluids until after a meal

A nurse is communicating with a client who has aphasia after having a stroke. Which action should the nurse take?Use one long sentence to say everything that needs to be said.Keep the television on while she speaks.Talk in a louder than normal voice.Face the client and establish eye contact.

Face the client and establish eye contact.

The nurse is providing care to a patient who is diagnosed with cirrhosis. Which term should the nurse use to document a sweet fecal smell of the breath? Fetor hepaticus Hepatic encephalopathy Halitosis Asterixis

Fetor hepaticus

A client with a neurological disorder has difficulty swallowing. The nurse should take special care with the client's diet because of a potential risk of imbalanced nutrition. Which measure may be taken by the nurse to ensure that the client's diet allows for easy swallowing?Instruct the client to lie on the bed when eatingOffer liquids frequently, in large quantitiesHelp the client sit upright when eating and feed slowlyAllow optimum physical activity before meals to expedite digestion

Help the client sit upright when eating and feed slowly

A nurse is planning the care of a 28-year-old woman hospitalized with a diagnosis of myasthenia gravis. Which of the following approaches would be most appropriate for the care and scheduling of diagnostic procedures for this client? Before meals, to stimulate her appetite Before bedtime, to promote rest In the morning, with frequent rest periods All at one time, to provide a longer rest period

In the morning, with frequent rest periods

The nurse is evaluating care provided to a patient recovering from surgery for Crohn's disease. Which finding indicates the need for further intervention by the nurse? Patient performs morning care with help from the nursing assistant Patient states family members will perform all ostomy care at home Patient has an average output of 45 mL per hour of clear yellow urine Patient tolerates full liquid diet and is requesting solid food

Patient states family members will perform all ostomy care at home

A nurse is assisting with serving dinner trays on the unit. Upon receiving the dinner tray for a patient admitted with acute cholelithiasis, the nurse should remove which of the following foods on the tray? Salmon Mashed potato Pork sausage Fruit cocktail

Pork sausage

The patient with cirrhosis has developed ascites. Which inappropriate order would cause the nurse to seek clarification when providing care to this patient? Assist with paracentesis Three gram sodium diet Restrict all protein intake Administer furosemide

Restrict all protein

A patient diagnosed with Alzheimer's is being evaluated for suspicions of aspiration after developing adventitious lung sounds. Which of the following diet modifications would the nurse anticipate for this patient? Soft food diet with thickened liquids Total parenteral nutition (TPN) Full liquid diet with no restrictions Minced foods with fluid restrictions

Soft food diet with thickened liquids

A patient diagnosed with Bell's palsy is being cared for on an outpatient basis. During health education, the nurse should promote which of the following actions? Wearing a protective eye shield at night Chewing on the affected side to prevent unilateral neglect Applying ice packs as needed for pain Avoiding brushing the teeth

Wearing a protective eye shield at night

The nurse is caring for a patient who had a hemorrhagic stroke. Which of the following assessment finding constitutes an early sign of deterioration? Shortness of breath Tonic-clonic seizures Generalized pain Alteration in level of consciousness (LOC)

alteration in level of consciousness (LOC)

A nurse is planning discharge teaching regarding wound care for an 80-year-old patient with early stage (mild) Alzheimer's disease. When planning health education for this patient, what should the nurse plan to do? a. Set long-term goals with the patient b. Provide a list of useful Web sites to supplement learning c. Keep visual cues to a minimum to enhance the patient's focus d. Keep teaching periods short

d. Keep teaching periods short

A provider orders enoxaparin (Lovenox) 1mg/kg subcutaneous BID. The pharmacy provides enoxaparin 100 mg/mL. The patient weighs 121 lbs. How many mL(s) per dose should the nurse administer? _________mL(s) (Round to the nearest tenth, if applicable)

find the pt weight in KG (121/2.2= 60.5) Desired over have: 60.5/100= .605, rounded to tenth would be 0.6

Which blood product is mostly preferred in patients with septic shock?

platelets

The nurse is providing discharge education for a patient with a new diagnosis of Ménière disease. Which of the following foods should the nurse instruct the patient to limit or avoid in their diet? Frozen yogurt Shellfish Red meat Sweet pickles

sweet pickles