Lifespan II, Exam 5
The nurse is teaching a group of adolescents at a local high school about skin infections. Which students should the nurse identify as being at increased risk for developing cellulitis? Select all that apply. A. A student with diabetes B. A student who applies moisturizer on a daily basis C. A student who squeezes pimples D. A student who is a member of the golf team E. A student who plucks her eyebrows
A. A student with diabetes C. A student who squeezes pimples E. A student who plucks her eyebrows
A client having difficulty sleeping asks if there is an herbal supplement that can help. How should the nurse respond to this client? A. "Chamomile tea is very soothing and may help you sleep." B. "Melatonin is a very useful sleep aid." C. "Chloral hydrate is an excellent choice to utilize as a sleep aid." D. "Valerian root can be taken daily and you should start sleeping better within a few days."
A. "Chamomile tea is very soothing and may help you sleep."
A client with a history of kidney stones formed from calcium phosphate asks the nurse, "Why are you recommending exercise to prevent another kidney stone?" Which response by the nurse is accurate? A. "Exercise will help move the calcium back into your bones." B. "Exercise will help excrete the calcium from your body." C. "Exercise promotes the retention of calcium in the bones." D. "Exercise will help you decrease your weight, which is a contributing factor to kidney stones."
A. "Exercise will help move the calcium back into your bones."
The nurse is preparing an educational program on risk factors for the development of prostate cancer. Which information is true concerning prostate cancer? (select all that apply) A. A diet high in fat and low fiber may increase risk B. Generally develops slowly with gradual symptom onset C. Early sexual activity increases risk D. Risk increases with age E. A family history of heart disease increases risk
A. A diet high in fat and low fiber may increase risk B. Generally develops slowly with gradual symptom onset D. Risk increases with age
The nurse is reviewing data collected during a health history and physical assessment and determines that a client is at risk for developing breast cancer. Which data supports this client's risk for developing breast cancer? (Select all that apply.) A. Age 60 B. Sister had breast cancer C. Menopause at age 58 D. Body mass index 22 E. Breastfed four children
A. Age 60 B. Sister had breast cancer
A client who is 4 days post-cholecystectomy has T-tube drainage totaling 600 mL in 24 hours. Which actions by the nurse are appropriate based on this data? Select all that apply. A. Assess drainage characteristics. B. Clamp the tube q 2 hours for 30 minutes. C. Encourage increased fluid intake. D. Notify the healthcare provider. E. Place the client in a supine position.
A. Assess drainage characteristics. D. Notify the healthcare provider.
A child with a severe allergy is at risk for an anaphylactic reaction to nuts. What would be the treatment of choice following and exposure at school? A. EpiPen auto injector B. Oral diphenhydramine 25mg C. Inhaled epineperine 1mg/2ml D. Intubation by trained personnel
A. EpiPen auto injector
On which region of the body would the nurse most expect to observe erysipelas? A. Face B. Back C. Neck D. Abdomen
A. Face Erysipelas, a superficial cellulitis of the skin caused by group A streptococcus, usually affects the lower extremities or the face. The involved area is bright red and raised with well-defined borders.
Which of the following is a pharmacologic therapy for acute pain? A. Opioid analgesics B. Stimulants C. Muscle relaxants D. Antidepressants
A. Opioid analgesics
A client receiving intravenous antibiotics for 3 days as treatment for cellulitis is being prepared for discharge. Which discharge order should the nurse anticipate for this client? A. Oral antibiotics to be continued at home B. Low-sodium diet prescribed C. Home healthcare aide for the client D. Orders for evaluation by physical therapy
A. Oral antibiotics to be continued at home Antibiotics should be taken for 10 days; therefore, the nurse anticipates oral antibiotics to be continued at home. A low-sodium diet is not indicated for cellulitis. The client may or may not need a home health aide. There is no evidence to suggest the client needs physical therapy.
The nurse is providing care for a pediatric client with bacterial conjunctivitis. Which interventions should the nurse use as part of the collaborative management of the client? Select all that apply. A. Recommending dark sunglasses B. Contacting the client's school nurse C. Performing careful hand hygiene D. Administering antiviral therapy E. Recommending removing contacts at night
A. Recommending dark sunglasses B. Contacting the client's school nurse C. Performing careful hand hygiene
The nurse is admitting a client with suspected urinary calculi. Which collaborative activity should the nurse anticipate as part of diagnosing urinary calculi and/or the possible complications associated with this diagnosis? (Select all that apply.) A. Renal ultrasound B. Intravenous pyelography (IVP) C. Chest x-ray D. Computed tomography (CT) scan of the kidney E. Urinalysis
A. Renal ultrasound B. Intravenous pyelography (IVP) D. Computed tomography (CT) scan of the kidney E. Urinalysis
The nurse is monitoring a client's blood transfusion. The client complains of developing mild back pain, rash on chest and neck, and scratchy throat. The nurse's initial action is to A. Stop the transfusion B. Contact the ordering care provider C. Contact the Blood Bank to check compatibilities D. Slow the rate of the infusion
A. Stop the transfusion
A client with right upper quadrant abdominal pain asks why so many tests are being scheduled. Which is the reason that the nurse should give to this client?(Select all that apply.) A. To diagnose the disorder B. To determine if gallstones are present C. To prevent recurrence D. To determine the location of gallstones E. To identify possible complications
A. To diagnose the disorder B. To determine if gallstones are present D. To determine the location of gallstones E. To identify possible complications Rationale: Diagnostic tests are used to identify the presence and location ofgallstones, identify possible complications of the gallstones, and help differentiate gallbladder disorders from other disease processes. Diagnostic tests do not prevent the formation of gallstones but can give information necessary for treatments that prevent recurrence.
A client reports pain as being an 8 on a scale from 1 to 10. Which findings should the nurse expect when assessing this client? (Select all that apply.) A. verbal complaint B. high stepping gait C. fever D. guarding E. facial grimace
A. verbal complaint D. guarding E. facial grimace
List 4 things that people can do to reduce the risk for developing cancer in general (universal precautions for all types of cancer [0.5 pts per correct response])
A. wear sunblock B. drink plenty of fluids C. Exercise (don't become obese) D. Healthy (balanced) Diet E. Don't smoke F. Self-exams
The parents report that their 6-year-old child is sleepy during the day and wakes up frequently throughout the night. Which question should the nurse ask the parents? A. "Does your child snore?" B. "Does your child sleepwalk?" C. "Does your child complain of headaches in the morning?" D. "Does your child lose control of muscle tone when awake?"
A. "Does your child snore?"
The nurse educator in a gastrostomy clinic is teaching a group of clients about factors that play a role in the formation of gallstones. Which client would the nurse identify as having the highest risk for gallstone formation? A. An African American, male client that eats fried foods B. A Native American, female, overweight client C. An Asian, thin, female client D. A Caucasian, post menopausal, female client
B. A Native American, female, overweight client
An 18-month-old toddler scheduled for routine vaccinations begins to cry when placed on the examination table. The parent attempts to comfort the toddler, but nothing is effective. Which action by the nurse is the most appropriate? A. Ask another nurse in the office to hold the toddler because the parent is not able to control the toddler's behavior. B. Allow the toddler to sit on the parent's lap and begin the assessment. C. Allow the toddler to stand on the floor until the crying stops. D. Instruct the parent to hold the toddler down tightly to complete the examination.
B. Allow the toddler to sit on the parent's lap and begin the assessment.
A client with cholelithiasis is in the clinic for a follow-up assessment after hospitalization. What lifestyle modification should the nurse teach the client to decrease the pain associated with the disease process? A. Increase fluids B. Decrease fat consumption C. Reduce sodium intake D. Decrease smoking
B. Decrease fat consumption
Which of the following lab results suggests that a client with gallbladder disease is experiencing obstructed bile flow in the biliary duct system? A. Decreased WBC count B. Elevated direct bilirubin C. Elevated WBC count D. Decreased direct bilirubin
B. Elevated direct bilirubin
The nurse is instructing a group of women between the ages of 40 and 50 about early detection of breast cancer. What should the nurse include in this teaching? A. Have a clinical breast exam performed by a healthcare provider every 5 years. B. Have a yearly mammogram. C. Perform annual breast self-exams. D. See an oncologist if there is a strong family history of breast cancer.
B. Have a yearly mammogram.
While assessing a client with right eye pain, the nurse finds red, irritated conjunctiva, and green to yellow exudate. The nurse should suspect bacterial conjunctivitis if the history included: A. prolonged exposure to the sun without wearing proper eye protection from UV rays. B. Room mate was diagnosed with conjunctivitis and prescribed tobramycin eye drops. C. New contact lens prescription D. Recent history of a common cold
B. Room mate was diagnosed with conjunctivitis and prescribed tobramycin eye drops.
A client with a history of insomnia is scheduled for a polysomnogram that requires an overnight stay in a sleep laboratory. The test will not include audio and video equipment. It will monitor the client's blood oxygen levels, heart rate, breathing, and eye and leg movements, and it will use an electroencephalogram to monitor brain waves. What disorder is least likely to be identified in this test? A. Periodic limb movement disorder B. Sleep talking C. Restless leg syndrome D. Sleep apnea
B. Sleep talking
What organism is most commonly responsible for cellulitis? A. Streptococcus pneumoniae B. Staphylococcus aureus C. Staphylococcus epidermidis D. Streptococcus viridans
B. Staphylococcus aureus The most common causative organism of cellulitis is Staphylococcus aureus, followed by group A Streptococcus. The other bacteria produce other types of infections.
An adult client is admitted to the hospital with a diagnosis of kidney stones. The healthcare provider prescribes IV fluids, x-rays, blood work, and a Foley catheter for the client. The nurse is caring for the client 3 days after admission and documents morning vital signs of 101°F, heart rate 92, respirations 25, and blood pressure 120/80. The urinary output has decreased, and the urine is cloudy and dark amber. Based on this data, which conclusion by the nurse is the most appropriate? A. The client has developed nephritis B. The client has a probable urinary tract infection. C. The client is in acute renal failure. D. The client has developed a respiratory infection.
B. The client has a probable urinary tract infection.
An older adult client is talking with the nurse about sleep problems. Which fact regarding sleep should the nurse teach this client? A. All elderly individuals experience disrupted sleep and depression. B. The elderly do not experience as much deep sleep as a younger person. C. The need for sleep decreases progressively with age. D. Sleep problems signal the onset of other developing serious medical conditions.
B. The elderly do not experience as much deep sleep as a younger person.
A woman has a family history of breast cancer, and genetic testing has revealed a mutation in BRCA2. What is true concerning this information? A. It is recommended to have prophylactic radical mastectomy. B. This information reveals there is a significant risk for developing breast cancer. C. There is not enough information to assess risk for breast cancer. D. This information reveals there is a low risk for developing breast cancer.
B. This information reveals there is a significant risk for developing breast cancer.
Mild symptoms for hypersensitivity can be treated with OTC medications. Which is an example of a medication used to treat these symptoms? A. Epi Pen B. diphenhydramine C. corticosteroids D. epinephrine
B. diphenhydramine
A common cause of appendicitis is a A. diverticula B. fecalith C. monotlith D. parasite
B. fecalith
A nurse is teaching a community group about for sleep apnea. Which risk factor for obstructive sleep apnea should the nurse emphasize? A. seasonal allergies B. obesity C. female gender D. over the age of 50
B. obesity
The nurse is assessing a college student who presents with red, swollen eyes; photophobia; and yellowish drainage from the conjunctiva. Which question should the nurse ask the client first? A. "Have you been exposed to HIV?" B. "Have you had extra caffeine this week?" C. "Have any of your friends experienced these symptoms?" D. "Did you get sand in your eye recently?"
C. "Have any of your friends experienced these symptoms?" The client is exhibiting signs and symptoms of conjunctivitis. The nurse should explore ways in which the client may have been exposed. Most cases of conjunctivitis are spread by hand to eye contact. Exposure to HIV, sand in the eye, and caffeine are not known causes of conjunctivitis and would not be appropriate questions to ask this client to determine the cause of the symptoms.
The nurse is admitting a client with suspected urinary calculi. Which intervention should the nurse anticipate as part of early symptom management? A. Using a filter to strain all urine output B. Urinalysis C. Administration of analgesics D. CT scan
C. Administration of analgesics
The nurse is assessing a client who presents with purulent drainage and crusting of the eye. The nurse should recognize that these findings are most consistent with which type of infection? A. Viral conjunctivitis B. Fungal conjunctivitis C. Bacterial conjunctivitis D. Allergic conjunctivitis
C. Bacterial conjunctivitis The major difference between bacterial and viral conjunctivitis is that bacterial conjunctivitis has a purulent discharge that may result in crusting, whereas the discharge from viral conjunctivitis is serous (watery). Allergic conjunctivitis produces watery to thick drainage and is characterized by itching. Fungi do not cause conjunctivitis.
When assessing a client diagnosed with melanoma,which assessment should the nurse include in the client's health history? A. Measurement of skin lesions B. Inspection of skin color C. Family history of skin cancer D. Palpation of skin texture
C. Family history of skin cancer
Why might a laparotomy be the surgery of choice for a perforated appendix? A. Laparotomy allows for direct visualization of the damaged appendix, whereas laparoscopy does not. B. Laparotomy involves a shorter period of postoperative hospitalization than laparoscopy. C. Surgeons are better able to remove contaminants from the peritoneal cavity via laparotomy than via laparoscopy. D. Laparotomy requires a smaller incision than laparoscopy and thus involves less blood loss.
C. Surgeons are better able to remove contaminants from the peritoneal cavity via laparotomy than via laparoscopy.
Which client is exhibiting hypersomnia? A. The client experiences repetitive involuntary leg movements that interfere with sleep. B. The client consistently has trouble getting to sleep and often lies awake for hours after bedtime. C. The client gets roughly 8 hours of sleep each night but can't stay awake during the day. D. The client only gets about 5 or 6 hours of sleep each night.
C. The client gets roughly 8 hours of sleep each night but can't stay awake during the day.
A labor and delivery nurse is providing care for a neonate in the first few minutes after birth. One action the nurse will take to promote eye health and prevent conjunctivitis in the infant is administration of A. ceftriaxone as an eye drop. B. oral tetracycline. C. erythromycin eye ointment. D. parenteral acyclovir.
C. erythromycin eye ointment. Prevention of conjunctivitis in a newborn is provided by the administration of an antibiotic eye ointment, usually erythromycin. Tetracycline may be used instead of erythromycin immediately after birth, but it will be used as an eye ointment, not as an oral formulation. Ceftriaxone is only administered for a confirmed case of gonococcal conjunctivitis. Parenteral acyclovir is only administered for a confirmed case of conjunctivitis due to herpes simplex virus
A nurse checking for tenderness at McBurney's point for a client with suspected appendicitis will palpate which area? A. right upper quadrant B. left lower quadrant C. right lower quadrant D. centrally below the umbilicus
C. right lower quadrant
A client is admitted to the hospital with an elevated temperature, nausea, and pain and tenderness in the lower right quadrant of the abdomen. After receiving pain medication, the client continues to complain of pain at a level of 8 on a 0-10 pain scale. The client is not scheduled to receive pain medications for at least another 2 hours. Given these circumstances, which statement by the nurse is most appropriate? A. "I do not have any medications ordered for you at this time." B. "Try to rest for a while longer until it is time to receive your medication" C. "Let's try a heating pad or warm blanket to see if that helps with your discomfort." D. "I will inform the healthcare provider about your continued pain."
D. "I will inform the healthcare provider about your continued pain."
The nurse is teaching a client with cholelithiasis about lifestyle modification. Which statement made by the client indicates that the nurse's teaching has been successful? A. "I can fry food as long as I use olive oil instead of vegetable oil." B. "I will eliminate salt from my diet." C. "I will use more ground beef in my meal preparation." D. "I will walk three times a week for 20 minutes each day."
D. "I will walk three times a week for 20 minutes each day." Rationale: Obesity is commonly associated with the development of gallbladder disease. A balanced diet and exercise will help keep the client's weight within normal limits. There is no reason to eliminate salt from the diet. Ground beef is high in fat and should be limited. Frying adds additional fat and should be avoided.
The nurse is teaching a mother how to administer optical antibiotics to her child who has conjunctivitis. Which statement made by the mother indicates teaching has been effective? A. "I will drop the medication onto the eyeball." B. "I will wait 10 seconds between different drops." C. "I will rub the eye with a cotton ball after I administer the medication." D. "I will wash my hands before instilling the medication."
D. "I will wash my hands before instilling the medication." Teach the client to wash hands thoroughly before and after instilling eye medications. Handwashing is the single most important means of preventing transmission of infection. Medication is dropped into the lower conjunctival sac and should not be rubbed after instillation. The time between drops is 1 to 5 minutes, depending on the type of medication.
A nurse is caring for a client with severe acute abdominal pain secondary to cholelithiasis. Which nursing actions promote pain management most effectively? A. Place the patient in supine position to relieve abdominal pain. B. Insert nasogastric tube and connect to high suction. C. Withhold oral food and fluids. D. Administer morphine, meperidine, or another opioid analgesic as ordered.
D. Administer morphine, meperidine, or another opioid analgesic as ordered.
The nurse, caring for an older school-age client recovering from an appendectomy, is preparing to help the family ambulate the child for the first time after surgery. Which nonpharmacologic nursing strategy would be most appropriate for this client? A. Administering appropriate narcotic analgesics B. Applying an ice pack over the site of the incision C. Stretching the abdominal muscles D. Holding a splint pillow against the abdomen when moving or coughing
D. Holding a splint pillow against the abdomen when moving or coughing
A nurse develops contact dermatitis from the use of latex gloves from frequent use over the years. This is an example of type ___ or delayed hypersensitivity. A. III B. II C. I D. IV
D. IV
The results of a client's biopsy indicates neoplasm. The nurse understands that which characteristic indicates that the neoplasm is benign? A. Noncohesive B. Invades surrounding tissues C. Rapid growth D. Well-defined borders
D. Well-defined borders Rationale: A benign neoplasm has well-defined borders, slow growth, is cohesive, and pushes other tissues out of the way. A malignant neoplasm invades surrounding tissues, is noncohesive, does not stop at tissue borders, and grows rapidly.
Which sleep-rest disorder should the nurse identify as being the most common? A. hypersomnia B. parasomnia C. dysomnia D. insomnia
D. insomnia
