Final Med Surg 3
A patient with multiple food and environmental allergies tells the nurse that he is frustrated and angry about having to be so watchful all the time and wonders if it is really worth it. What would be the nurse's best response? A) "I can only imagine how you feel. Would you like to talk about it?" B) "Let's find a quiet spot and I'll teach you a few coping strategies." C) "That's the same way that most patients who have a chronic illness feel." D) "Do you think that maybe you could be managing things more efficiently?"
A) "I can only imagine how you feel. Would you like to talk about it? "To assist the patient in adjusting to these modifications, the nurse must have an appreciation of the difficulties encountered by the patient. The patient is encouraged to verbalize feelings and concerns in a supportive environment and to identify strategies to deal with them effectively. The nurse should not suggest that the patient has been mismanaging his health problem and the nurse should not make comparisons with other patients. Further assessment should precede educational interventions.
An office worker takes a cupcake that contains peanut butter. He begins wheezing, with an inspiratory stridor and air hunger and the occupational health nurse is called to the office. The nurse should recognize that the worker is likely suffering from which type of hypersensitivity? A) Anaphylactic (type 1) B) Cytotoxic (type II) C) Immune complex (type III) D) Delayed-type (type IV)
A) Anaphylactic (type 1) The most severe form of a hypersensitivity reaction is anaphylaxis. An unanticipated severe allergic reaction that is often explosive in onset, anaphylaxis is characterized by edema in many tissues, including the larynx, and is often accompanied by hypotension, bronchospasm, and cardiovascular collapse in severe cases. Type II, or cytotoxic, hypersensitivity occurs when the system mistakenly identifies a normal constituent of the body as foreign. Immune complex (type III) hypersensitivity involves immune complexes formed when antigens bind to antibodies. Type III is associated with systemic lupus erythematosus, rheumatoid arthritis, certain types of nephritis, and bacterial endocarditis. Delayed-type (type IV), also known as cellular hypersensitivity, occurs 24 to 72 hours after exposure to an allergen.
A patient has been diagnosed with chronic obstructive pulmonary disease. The patient is to be administered tiotropium bromide (Spiriva HandiHaler). The patient's creatinine level is 25. What is the patient at risk for developing? A) Drug toxicity B) Pneumonia C) Hepatotoxicity D) Central nervous system depression
A) Drug toxicity Feedback: The patient has an elevated creatinine level. Tiotropium bromide is eliminated by the renal system, and patients with moderate to severe renal dysfunction should be carefully monitored for drug toxicity.
A patient has been brought to the emergency department by EMS after being found unresponsive. Rapid assessment reveals anaphylaxis as a potential cause of the patient's condition. The care team should attempt to assess for what potential causes of anaphylaxis? Select all that apply. A) Foods B) Medications C) Insect stings D) Autoimmunity E) Environmental pollutants
A) Foods B) Medications C) Insect stings Substances that most commonly cause anaphylaxis include foods, medications, insect stings, and latex. Pollutants do not commonly cause anaphylaxis and autoimmune processes are more closely associated with types II and III hypersensitivities.
A patient has been admitted to the emergency department with signs of anaphylaxis following a bee sting. The nurse knows that if this is a true allergic reaction the patient will present with what alteration in laboratory values? A) Increased eosinophils B) Increased neutrophils C) Increased serum albumin D) Decreased blood glucose
A) Increased eosinophils Higher percentages of eosinophils are considered moderate to severe eosinophilia. Moderate eosinophilia is defined as 15% to 40% eosinophils and is found in patients with allergic disorders. Hypersensitivity does not result in hypoglycemia or increased albumin and neutrophil counts.
After the completion of testing, a child's allergies have been attributed to her family's cat. When introducing the family to the principles of avoidance therapy, the nurse should promote what action? A) Removing the cat from the family's home B) Administering OTC antihistamines to the child regularly C) Keeping the cat restricted from the child's bedroom D) Maximizing airflow in the house
A) Removing the cat from the family's home In avoidance therapy, every attempt is made to remove the allergens that act as precipitating factors. Fully removing the cat from the environment is preferable to just keeping the cat out of the child's bedroom. Avoidance therapy does not involve improving airflow or using antihistamines.
A patient exhibiting an uncoordinated gait has presented at the clinic. Which of the following is the most plausible cause of this patient's health problem? A)Cerebellar dysfunction B)A lesion in the pons C)Dysfunction of the medulla D)A hemorrhage in the midbrain
Ans: A) Cerebellar Dysfunction Feedback: The cerebellum controls fine movement, balance, position sense, and integration of sensory input. Portions of the pons control the heart, respiration, and blood pressure. Cranial nerves IX through XII connect to the brain in the medulla. Cranial nerves III and IV originate in the midbrain.
A nurse is teaching a patient about her prescription for Tylenol #3 that she will take at home. This medication consists of acetaminophen and what other drug? A) Codeine B) Acetylsalicylic acid (aspirin) C) Methadone (Dolophine) D) Tramadol (Ultram)
Ans: A) Codeine Feedback: Tylenol #3 is acetaminophen (Tylenol) and codeine. Acetylsalicylic acid (aspirin) is not combined with acetaminophen (Tylenol). Methadone (Dolophine) is not combined with Tylenol. Tramadol (Ultram) is not combined with Tylenol.
A patient is admitted to the emergency room in status epilepticus. What medication may be administered intravenously to assist in reducing seizure activity? A) Diazepam (Valium) B) Hydromorphone (Dilaudid) C) Insulin D) Meperidine (Demerol)
Ans: A) Diazepam (Valium) Feedback: IV diazepam is an adjunctive skeletal muscle relaxant administered for the treatment of severe recurrent convulsive seizures and status epilepticus. Ethosuximide (Zarontin) is not administered for status epilepticus. Meperidine (Demerol) and insulin are not administered for status epilepticus.
A gerontologic nurse educator is providing practice guidelines to unlicensed care providers. Because reaction to painful stimuli is sometimes blunted in older adults, what must be used with caution? A)Hot or cold packs B)Analgesics C)Anti-inflammatory medications D)Whirlpool baths
Ans: A) Hot or cold packs Feedback: Reaction to painful stimuli may be decreased with age. Because pain is an important warning signal, caution must be used when hot or cold packs are used. The older patient may be burned or suffer frostbite before being aware of any discomfort. Any medication is used with caution in the elderly, but not because of the decreased sense of heat or cold. Whirlpool baths are generally not a routine treatment ordered for the elderly.
The patient has been diagnosed with aphasia after suffering a stroke. What can the nurse do to best make the patients atmosphere more conducive to communication? A) Provide a board of commonly used needs and phrases. B) Have the patient speak to loved ones on the phone daily. C) Help the patient complete his or her sentences. D) Speak in a loud and deliberate voice to the patient.
Ans: A) Provide a board of commonly used needs and phrases. Feedback: The inability to talk on the telephone or answer a question or exclusion from conversation causes anger, frustration, fear of the future, and hopelessness. A common pitfall is for the nurse or other health care team member to complete the thoughts or sentences of the patient. This should be avoided because it may cause the patient to feel more frustrated at not being allowed to speak and may deter efforts to practice putting thoughts together and completing a sentence. The patient may also benefit from a communication board, which has pictures of commonly requested needs and phrases. The board may be translated into several languages.
A patient who suffered an ischemic stroke now has disturbed sensory perception. What principle should guide the nurses care of this patient? A) The patient should be approached on the side where visual perception is intact. B) Attention to the affected side should be minimized in order to decrease anxiety. C) The patient should avoid turning in the direction of the defective visual field to minimize shoulder subluxation. D) The patient should be approached on the opposite side of where the visual perception is intact to promote recovery.
Ans: A) The patient should be approached on the side where visual perception is intact. Feedback: Patients with decreased field of vision should first be approached on the side where visual perception is intact. All visual stimuli should be placed on this side. The patient can and should be taught to turn the head in the direction of the defective visual field to compensate for this loss. The nurse should constantly remind the patient of the other side of the body and should later stand at a position that encourages the patient to move or turn to visualize who and what is in the room.
A nurse is caring for a patient diagnosed with a hemorrhagic stroke. When creating this patients plan of care, what goal should be prioritized? A) Prevent complications of immobility. B) Maintain and improve cerebral tissue perfusion. C) Relieve anxiety and pain. D) Relieve sensory deprivation.
Ans: B) Maintain and improve cerebral tissue perfusion. Feedback: Each of the listed goals is appropriate in the care of a patient recovering from a stroke. However, promoting cerebral perfusion is a priority physiologic need, on which the patients survival depends.
A family member brings the patient to the clinic for a follow-up visit after a stroke. The family member asks the nurse what he can do to decrease his chance of having another stroke. What would be the nurses best answer? A) Have your heart checked regularly. B) Stop smoking as soon as possible. C) Get medication to bring down your sodium levels. D) Eat a nutritious diet.
Ans: B) Stop smoking as soon as possible. Feedback: Smoking is a modifiable and highly significant risk factor for stroke. The significance of smoking, and the potential benefits of quitting, exceed the roles of sodium, diet, and regular medical assessments.
A patient is instructed to take diphenhydramine (Benadryl) after an allergic reaction. Which of the following statements by the patient indicates successful teaching concerning the safe and effective use of diphenhydramine? A) "I will still be able to have my after-dinner drink with this medication." B) "I will eat a diet low in sodium while taking this medication." C) "I should not drive my car after taking this medication." D) "I can take this medication every 2 hours until I feel better."
Ans: C) "I should not drive my car after taking this medication." Feedback: The administration of diphenhydramine (Benadryl) causes drowsiness, and the patient should not operate machinery, such as driving. The patient should not combine diphenhydramine with alcohol due to central nervous system depression. The patient will not need to limit sodium with this medication. The patient should adhere to the dosing schedule and not take the medication every 2 hours.
An elderly patient is being discharged home. The patient lives alone and has atrophy of his olfactory organs. The nurse tells the patient's family that it is essential that the patient have what installed in the home? A)Grab bars B)Nonslip mats C)Baseboard heaters D)A smoke detector
Ans: D) Smoke Detector The sense of smell deteriorates with age. The olfactory organs are responsible for smell. This may present a safety hazard for the patient because he or she may not smell smoke or gas leaks. Smoke detectors are universally necessary, but especially for this patient.
The critical care nurse is caring for 25-year-old man admitted to the ICU with a brain abscess. What is a priority nursing responsibility in the care of this patient? A) Maintaining the patients functional independence B) Providing health education C) Monitoring neurologic status closely D) Promoting mobility
Answer C) ) Monitoring neurologic status closely Feedback: Vigilant neurologic monitoring is a key aspect of caring for a patient who has a brain abscess. This supersedes education, ADLs, and mobility, even though these are all valid and important aspects of nursing care.
A patient has atony of the smooth muscle of the gastrointestinal tract. Which type of medication may be administered to increase smooth muscle strength? A) Anticholinergic drugs B) Cholinergic drugs C) Muscle relaxants D) Selective serotonin reuptake inhibitors
B) Cholinergic drugs Feedback: Cholinergic drugs are used to treat atony of the smooth muscle of the gastrointestinal tract and urinary systems. Anticholinergic agents will decrease muscle strength. Muscle relaxants will decrease muscle strength. Selective serotonin reuptake inhibitors are not used for atony of the smooth muscle of the gastrointestinal tract
A nurse is providing care for a patient who has just been diagnosed as being in the early stage of rheumatoid arthritis. The nurse should anticipate the administration of which of the following? A) Hydromorphone (Dilaudid) B) Methotrexate (Rheumatrex) C) Allopurinol (Zyloprim) D) Prednisone
B) Methotrexate (Rheumatrex) In the past, a step-wise approach starting with NSAIDs was standard of care. However, evidence clearly documenting the benefits of early DMARD (methotrexate [Rheumatrex], antimalarials, leflunomide [Arava], or sulfasalazine [Azulfidine]) treatment has changed national guidelines for management. Now it is recommended that treatment with the non-biologic DMARDs begin within 3 months of disease onset. Allopurinol is used to treat gout. Opioids are not indicated in early RA. Prednisone is used in unremitting RA.
The nurse is doing an initial assessment on a patient newly admitted to the unit with a diagnosis of cerebrovascular accident (CVA). The patient has difficulty copying a figure that the nurse has drawn and is diagnosed with visual-receptive aphasia. What brain region is primarily involved in this deficit? A)Temporal lobe B)Parietal-occipital area C)Inferior posterior frontal areas D)Posterior frontal area
B) Parietal-occipital area Difficulty copying a figure that the nurse has drawn would be considered visual-receptive aphasia, which involves the parietal-occipital area. Expressive aphasia, the inability to express oneself, is often associated with damage to the frontal area. Receptive aphasia, the inability to understand what someone else is saying, is often associated with damage to the temporal lobe area.
A patient with rheumatoid arthritis comes to the clinic complaining of pain in the joint of his right great toe and is eventually diagnosed with gout. When planning teaching for this patient, what management technique should the nurse emphasize? A) Take OTC calcium supplements consistently. B) Restrict consumption of foods high in purines. C) Ensure fluid intake of at least 4 liters per day. D) Restrict weight-bearing on right foot.
B) Restrict consumption of foods high in purines. Although severe dietary restriction is not necessary, the nurse should encourage the patient to restrict consumption of foods high in purines, especially organ meats. Calcium supplementation is not necessary and activity should be maintained as tolerated. Increased fluid intake is beneficial, but it is not necessary for the patient to consume more than 4 liters daily.
A nurse is providing care for a patient who has a rheumatic disorder. The nurse's comprehensive assessment includes the patient's mood, behavior, LOC, and neurologic status. What is this patient's most likely diagnosis? A) Osteoarthritis (OA) B) Systemic lupus erythematosus (SLE) C) Rheumatoid arthritis (RA) D) Gout
B) Systemic lupus erythematosus (SLE) SLE has a high degree of neurologic involvement, and can result in central nervous system changes. The patient and family members are asked about any behavioral changes, including manifestations of neurosis or psychosis. Signs of depression are noted, as are reports of seizures, chorea, or other central nervous system manifestations. OA, RA, and gout lack this dimension.
A junior nursing student is having an observation day in the operating room. Early in the day, the student tells the OR nurse that her eyes are swelling and she is having trouble breathing. What should the nurse suspect? A) Cytotoxic reaction due to contact with the powder in the gloves B) Immune complex reaction due to contact with anesthetic gases C) Anaphylaxis due to a latex allergy D) Delayed reaction due to exposure to cleaning products
C) Anaphylaxis due to a latex allergy Immediate hypersensitivity to latex, a type I allergic reaction, is mediated by the IgE mast cell system. Symptoms can include rhinitis, conjunctivitis, asthma, and anaphylaxis. The term latex allergy is usually used to describe the type I reaction. The rapid onset is not consistent with a cytotoxic reaction, an immune complex reaction, or a delayed reaction.
A patient is being admitted to the neurologic ICU with suspected herpes simplex virus encephalitis. What nursing action best addresses the patients complaints of headache? A) Initiating a patient-controlled analgesia (PCA) of morphine sulfate B) Administering hydromorphone (Dilaudid) IV as needed C) Dimming the lights and reducing stimulation D) Distracting the patient with activity
C) Dimming the lights and reducing stimulation Feedback: Comfort measures to reduce headache include dimming the lights, limiting noise and visitors, grouping nursing interventions, and administering analgesic agents. Opioid analgesic medications may mask neurologic symptoms, therefore, they are used cautiously. Non-opioid analgesics may be preferred. Distraction is unlikely to be effective, and may exacerbate the patients pain.
A child is undergoing testing for food allergies after experiencing unexplained signs and symptoms of hypersensitivity. What food items would the nurse inform the parents are common allergens? A) Citrus fruits and rice B) Root vegetables and tomatoes C) Eggs and wheat D) Hard cheeses and vegetable oils C) Eggs and wheat
C) Eggs and wheat The most common causes of food allergies are seafood (lobster, shrimp, crab, clams, fish), legumes (peanuts, peas, beans, licorice), seeds (sesame, cottonseed, caraway, mustard, flaxseed, sunflower seeds), tree nuts, berries, egg white, buckwheat, milk, and chocolate.
A nurse is performing the health history and physical assessment of a patient who has a diagnosis of rheumatoid arthritis (RA). What assessment finding is most consistent with the clinical presentation of RA? A) Cool joints with decreased range of motion B) Signs of systemic infection C) Joint stiffness, especially in the morning D) Visible atrophy of the knee and shoulder joints
C) Joint stiffness, especially in the morning In addition to joint pain and swelling, another classic sign of RA is joint stiffness, especially in the morning. Joints are typically swollen, not atrophied, and systemic infection does not accompany the disease. Joints are often warm rather than cool.
As part of a start-of-shift nursing assessment, the nurse is documenting a patient's neurological status according to the Glasgow Coma Scale (GCS). What responses will the nurse assess to determine the patient's GCS score? Select all that apply.- A) Best sensory response B) Best judgment C) Best eye opening D) Best motor response E) Best verbal response
Correct response: Best eye opening Best verbal response Best motor response Explanation: The three domains of the GCS are best eye opening, best verbal response, and best motor response.
A female patient who is recovering from a stroke has begun eating a minced and pureed diet after passing the speech pathologist's swallowing assessment. This morning, the nurse set up the patient with her breakfast tray and later noticed that the woman was swallowing her food well but dribbling small amounts of food out of affected side of her mouth. How should the nurse follow up this observation? A) Provide oral suctioning after each bite that the patient swallows. B) Remove the patient's tray because of the risk of aspiration. C) Cue the patient to the fact that she is dribbling food while commending her for eating. D) Make the patient NPO and encourage the care provider to consider enteral nutrition.
Correct response: Cue the patient to the fact that she is dribbling food while commending her for eating. Explanation: Dribbling of food should be noted and addressed but does not necessarily constitute an acute risk of aspiration. Close observation is warranted but enteral feeding and NPO status are not likely necessary. Suctioning after each bite of food is not necessary.
A nurse is caring for a patient who is exhibiting signs and symptoms of autonomic dysreflexia. What clinical manifestations would the nurse expect in this patient? A) Tachycardia and hypertension B) Bradycardia and hypertension C) Tachycardia and hypotension D) Bradycardia and hypotension
Correct response: Bradycardia and hypertension Explanation: Autonomic dysreflexia is characterized by a pounding headache, profuse sweating, nasal congestion, piloerection ("goose bumps"), bradycardia, and hypertension. It may occur in cord lesions above T6 after spinal shock has resolved.
A patient has developed severe contact dermatitis with burning, itching, cracking, and peeling of the skin on her hands. What should the patient be instructed to do? - Wear powdered latex gloves. - Wash her hands with antibacterial soap. - Maintain the room temperature at 80°F. - Keep her hands well moisturized.
Correct response: Keep her hands well moisturized. Explanation: Treatment of patients with atopic dermatitis must be individualized. Guidelines for treatment include decreasing itching and scratching by wearing cotton fabrics, washing with a mild detergent, humidifying dry heat in the winter, maintaining a moderate room temperature, using antihistamines such as diphenhydramine, and avoiding animals, dust, sprays, and perfumes. Keeping the skin moisturized with daily baths to hydrate the skin and topical skin moisturizers is encouraged.
A nursing educator is talking with nurses about the effects of the aging process and neurologic changes. What would the educator identify as a normal neurological change that accompanies the aging process? A) Hypersensitivity to painful stimuli B) Hyperactive deep tendon reflexes C) Reduction in cerebral blood flow (CBF) D) Increased cerebral metabolism
Correct response: Reduction in cerebral blood flow (CBF) Explanation: Reduction in CBF is a change that occurs in the normal aging process. Deep tendon reflexes can be decreased or in some cases absent. Cerebral metabolism decreases as the patient advances in age. Reaction to painful stimuli may be decreased with age. Because pain is an important warning signal, caution must be used when hot or cold packs are applied.
A client with systemic lupus erythematosus (SLE) has the classic rash of lesions on the cheeks and bridge of the nose. What term should the nurse use to describe this characteristic pattern? A) Butterfly rash B) Papular rash C) Pustular rash D) Bull's eye rash
Correct response:Butterfly rash Explanation: In the classic lupus rash, lesions appear on the cheeks and the bridge of the nose, creating a characteristic butterfly pattern. The rash may vary in severity from malar erythema to discoid lesions (plaque). Papular and pustular rashes aren't associated with SLE. The bull's eye rash is classic in client's with Lyme disease.
The physician has ordered scopolamine transdermally for motion sickness. Which of the following statements by the patient indicates an understanding of the medication's administration guideline? A) "I will place it on my chest each morning." B) "I will use it when I am sick to my stomach." C) "I will change the patch every 4 hours." D) "I will change the patch every 3 days."
D) "I will change the patch every 3 days." Feedback: Scopolamine is used for motion sickness. The disk (Transderm-V) protects against motion sickness for 72 hours. The scopolamine patch is applied behind the ear, not to the chest. The patch is used prior to the patient experiencing nausea. The patch is not changed every 4 hours.
Antihistamines are used to treat nasal congestion. Which of the following patients should not be administered an antihistamine? A) A male patient with Parkinson's disease B) A female patient with asthma C) A male patient with diabetes mellitus D) A male patient with prostatic hypertrophy
D) A male patient with prostatic hypertrophy Feedback: Antihistamines are contraindicated in patients with prostatic hypertrophy. Antihistamine agents can be administered to patients with Parkinson's disease, asthma, and diabetes mellitus.
A nurse is preparing a patient for allergy skin testing. Which of the following precautionary steps is most important for the nurse to follow? A) The patient must not have received an immunization within 7 days. B) The nurse should administer albuterol 30 to 45 minutes prior to the test. C) Prophylactic epinephrine should be administered before the test. D) Emergency equipment should be readily available.
D) Emergency equipment should be readily available. Emergency equipment must be readily available during testing to treat anaphylaxis. Immunizations do not contraindicate testing. Neither epinephrine nor albuterol is given prior to testing.
When administering anticholinesterase drugs, what assessment finding would indicate the patient is experiencing a toxic effect of the medication? A) Loss of consciousness B) Abdominal distention C) Hypertension D) Muscle weakness
D) Muscle weakness Feedback: The administration of anticholinesterase medications can result in profound muscle weakness. Decreased LOC, abdominal distention, and hypertension are not characteristic adverse effects of the anticholinesterase medications.
The nurse is admitting a patient to the unit who is diagnosed with a lower motor neuron lesion. What entry in the patient's electronic record is most consistent with this diagnosis? A)"Patient exhibits increased muscle tone." B)"Patient demonstrates normal muscle structure with no evidence of atrophy." C)"Patient demonstrates hyperactive deep tendon reflexes." D)"Patient demonstrates an absence of deep tendon reflexes."
D)"Patient demonstrates an absence of deep tendon reflexes." Lower motor neuron lesions cause flaccid muscle paralysis, muscle atrophy, decreased muscle tone, and loss of voluntary control.
The nurse is planning the care of a 28-year-old female hospitalized with a diagnosis of myasthenia gravis. What schedule would be most appropriate for the organization of diagnostic procedures for this patient? A) All at one time, to provide a longer rest period B) Before meals, to stimulate her appetite C) In the morning, with frequent rest periods D) Before bedtime, to promote rest
In the morning, with frequent rest periods. Feedback: Myasthenia gravis, an autoimmune disorder affecting the myoneural junction, is characterized by varying degrees of weakness of the voluntary muscles. Procedures should be spaced to allow for rest in between. Procedures should be avoided before meals, or the patient may be too exhausted to eat. Procedures should be avoided at bedtime.