Med-Surg: Final
A patient arrives at the emergency department with a diagnosis of a hemorrhagic stroke. What is the underlying cause of hemorrhagic stroke? a. A rupture in a vessel in the brain b. Damage to a vessel the brainstem c. Damage to an artery in the brainstem d. A blood clot lodging in a vessel in the brain
a. A rupture in a vessel in the brain
Anaphylactic shock is a subgroup of which type of shock? a. Distributive b. Obstructive c. Cardiogenic d. Hypovolemic
a. Distributive
The nurse knows that when a blood clot or plaque fragment is "traveling" through a blood vessel from an area outside the brain until it lodges in a cerebral artery, it causes which disorder? a. Embolic stroke b. Atrial fibrillation c. Hemorrhagic stroke d. Myocardial infarction
a. Embolic stroke
Which area of the brain is responsible for coordinating movement? a. Medulla b. Cerebellum c. Occipital lobe d. Temporal lobe
b. Cerebellum
A patient has recently undergone surgery to remove a large melanoma from his back. The patient is experiencing severe, incision-related pain and has been prescribed an opioid analgesic medication by the health care provider. Which symptoms is the patient likely to experience? a. Diarrhea b. Constipation c. Peripheral neuropathy d. Extrapyramidal symptoms
b. Constipation
The nurse is caring for a patient with quadriplegia who begins to appear flushed, is sweating profusely, and has a blood pressure of 210/100 mm Hg. Which aggravating factors would precipitate this autonomic dysreflexia response? (Select all that apply.) a. Depression b. Constipation c. Heart failure d. Renal calculi e. Distended bladder
b. Constipation d. Renal calculi e. Distended bladder
The patient complains of a bad headache following spinal anesthesia. Which intervention should the nurse try first? a. Call the provider for an analgesic order. b. Lie the patient flat if not contraindicated. c. Prepare the patient for a blood patch. d. Place the patient in semi-Fowlers position.
b. Lie the patient flat if not contraindicated.
A patient is admitted for pain to the arm and jaw. The patient is later diagnosed with angina. Which type of pain does the arm and jaw pain most likely represent? a. Phantom b. Referred c. Cramping d. Intractable
b. Referred
A patient returned to the nursing unit after a lumbar puncture. In which position should the patient be placed after the procedure to avoid complications? a. Prone b. Supine c. Mid-Fowler d. High-Fowler
b. Supine
Which patient statement alerts the nurse to a warning sign of cancer? a. "I have a bowel movement every 4 days." b. "I had a wart on my finger that lasted for 2 weeks." c. "I have a blister on my toe that never seems to get well." d. "I experience moderately heavy bleeding with my periods every month."
c. "I have a blister on my toe that never seems to get well."
The nurse is asking the patient who will be having surgery today about the use of taking any herbal medications. The nurse knows that all herbal medications to be discontinued within which time frame? a. 1 to 2 days before surgery b. 5 to 7 days before surgery c. 1 to 2 weeks before surgery d. 2 to 3 weeks before surgery
c. 1 to 2 weeks before surgery
The nurse is evaluating the patient using the Romberg test. What is the nurse assessing? a. Level of consciousness b. Cranial nerve function c. Coordination and balance d. Muscle strength
c. Coordination and balance
What is the underlying cause of the effects that a cerebrovascular accident (CVA) has on the body? a. Nerve damage b. Muscle deterioration c. Oxygen deprivation d. Neurotransmission deficit
c. Oxygen deprivation
The patient is suspected to have a cerebral aneurysm. Which diagnostic test does the nurse anticipate will be ordered? a. Lumbar puncture b. Electroencephalogram (EEG) c. Myelogram d. Cerebral angiography
d. Cerebral angiography
What is the most accurate reliable indicator of neurologic status? a. Vital signs b. Patient blood flow c. Pupillary evaluation d. Level of consciousness
d. Level of consciousness
The nurse is caring for a patient who is experiencing spastic paralysis. Which priority intervention would the nurse include in the patient's care during this period? a. Ensure adequate pain control. b. Encourage the patient to participate in rehabilitation. c. Perform range-of-motion exercises several times per day. d. Secure a strap across the patient's chest while in the wheelchair.
d. Secure a strap across the patient's chest while in the wheelchair.
A nurse is changing the postoperative dressing for a patient who had surgery 2 days ago. The wound drainage is a light pinkish color. This is documented as which type of drainage? a. Scant b. Serous c. Sanguineous d. Serosanguineous
d. Serosanguineous
The home health nurse is visiting the home of a patient with Parkinson syndrome. Which observation indicates the need for more education about fall prevention? a. The patient calls for assistance when getting out of bed. b. The patient uses a cane to ambulate. c. Throw rugs have been removed. d. The patient wears soft slippers when ambulating around the house.
d. The patient wears soft slippers when ambulating around the house.
A hospitalized patient has the potential for significant fluid and electrolyte imbalances and has been placed on strict intake and output monitoring by the health care provider. The LPN is collecting data to tabulate the shift intake and output totals for the patient. Which information will the LPN include in the intake tabulation? (Select all that apply.) a. 240 mL of ginger ale b. 800 mL of 0.9 percent NaCl via IV c. 200 mL sodium phosphate enema d. 20 mL of 0.9 percent NaCl IV flushes e. 100 mL NaCl used to cleanse foot ulcer
a. 240 mL of ginger ale b. 800 mL of 0.9 percent NaCl via IV c. 200 mL sodium phosphate enema d. 20 mL of 0.9 percent NaCl IV flushes
A 58-year-old male patient who is a smoker is being seen by the health care provider for an annual physical. According to the American Cancer Society, which cancer screenings should be recommended every year for asymptomatic men? (Select all that apply.) a. A fecal occult blood stool test b. A prostate-specific antigen test c. A Papanicolaou test d. A low-dose helical CT (LDCT) e. A pelvic examination f. A colonoscopy
a. A fecal occult blood stool test d. A low-dose helical CT (LDCT)
After a patient has sustained a spinal cord injury, the realities of his situation may manifest by withdrawal, passive behavior, and decreased affect. Which nursing interventions would be helpful to the patient? (Select all that apply.) a. Active listening b. Acknowledging the patient's feelings c. Encouraging participation in self-care d. Giving advice from personal experiences e. Encouraging the patient to think positively
a. Active listening b. Acknowledging the patient's feelings c. Encouraging participation in self-care
The nurse is caring for a patient who was admitted with a stroke. The nurse knows that which are risk factors for stroke? (Select all that apply.) a. Age b. Smoking c. Low-fat diet d. Alcohol abuse e. Overstimulation f. Migraine headaches
a. Age b. Smoking d. Alcohol abuse f. Migraine headaches
The nurse is contributing to the data collection for a patient admitted with a diagnosis of delirium. The patient is actively participating in the interview and can state her name. She also reports that the date is 15 years earlier than it actually is and that she is in her home instead of the hospital. How would the nurse report this patient's orientation status? a. Alert and oriented ×1 b. Alert and oriented ×3 c. Obtunded and oriented ×1 d. Obtunded and oriented ×2
a. Alert and oriented ×1
Which symptom is the earliest indication of increased intracranial pressure (ICP)? a. Changes in level of consciousness b. Change from normal to dilated pupil c. Altered motor function on side opposite from mass d. Increasing systolic blood pressure without change in diastolic reading
a. Changes in level of consciousness
A patient is admitted for acute onset delirium of unknown etiology. The nurse anticipates that the provider will order which diagnostic tests to determine the cause of the delirium and direct treatment? (Select all that apply.) a. Complete blood count (CBC) b. Rapid strep test c. Oxygen saturation test d. Urine culture and sensitivity e. Head computerized tomography (CT) f. Urine drug screen
a. Complete blood count (CBC) c. Oxygen saturation test d. Urine culture and sensitivity f. Urine drug screen
A patient who sustained burn injuries has new intravenous infusion orders to include crystalloids. Why are crystalloids ordered for this patient? a. Crystalloids replace the fluid and electrolytes lost from the burn. b. Fluid challenges of up to 300 mL of crystalloid are designed to rule out hypovolemia. c. Crystalloids are hypotonic products with electrolytes and are needed to provide potassium to the cells. d. Crystalloids should not be ordered for a patient with burn injuries because they will pull more fluid into the cells.
a. Crystalloids replace the fluid and electrolytes lost from the burn.
The LPN is caring for an 88-year-old patient who is receiving intravenous (IV) 0.9% NaCl at a rate of 100 mL/hr. For which signs and symptoms of fluid overload will the nurse be alert? (Select all that apply.) a. Dyspnea b. Bounding pulse c. Crackles on auscultation d. Increasing blood pressure e. Decreasing respiratory rate f. Puffy eyelids
a. Dyspnea b. Bounding pulse c. Crackles on auscultation d. Increasing blood pressure f. Puffy eyelids
A patient with a history of hypertension and two previous cerebrovascular accidents (CVAs) is hospitalized with a third CVA. The patient is receiving intravenous (IV) fluids with potassium chloride. On the third day after admission, the LPN notes a trend of steadily decreasing urinary output despite no changes to the intravenous orders. The patient is at risk for developing which disorder? a. Hyperkalemia b. Urinary retention c. An impending CVA d. Dehydration
a. Hyperkalemia
The nurse is caring for a patient who is experiencing severe chemotherapy-induced nausea. Which actions can the nurse take to try to reduce the patient's nausea? (Select all that apply.) a. Instruct the patient to limit intake of spicy foods. b. Instruct the patient to avoid room temperature foods. c. Determine the best time for the patient to eat and drink. d. Encourage the patient to take small, frequent sips of water. e. Administer sedatives as ordered while antineoplastic drugs are being administered.
a. Instruct the patient to limit intake of spicy foods. c. Determine the best time for the patient to eat and drink. d. Encourage the patient to take small, frequent sips of water. e. Administer sedatives as ordered while antineoplastic drugs are being administered.
A nurse is caring for an obese patient who had an abdominal surgical procedure 3 days ago. The patient reported a sudden "popping" feeling in the abdomen during ambulation and now can see something protruding from the surgical site. Which action by the nurse is appropriate? a. Keep the patient calm with legs and knees flexed. b. Administer the prescribed dosage of PRN opioid analgesic. c. Saturate a dressing with water, and cover the protruding organ. d. Position the patient on the side and place a pillow between the knees for support.
a. Keep the patient calm with legs and knees flexed.
The LPN is providing care to an older adult resident in a long-term care facility. The resident receives several medications daily. The LPN notes that one of the medications has the potential to cause significant electrolyte imbalances. The LPN reviews the care plan for the resident and recognizes which as the most accurate way to monitor electrolyte data? a. Laboratory tests b. Weekly vital signs c. Annual 24-hour urine d. Daily intake and output
a. Laboratory tests
A patient presents to the clinic for her annual mammogram. She asks the nurse what actions she can take to reduce her risk for cancer. Which actions are most appropriate? (Select all that apply.) a. Limit intake of fatty foods. b. Abstain from alcohol consumption. c. Drink six to eight glasses of water each day. d. Consume at least three servings of fruits and vegetables each day. e. Participate in moderate exercise for at least 30 minutes most days of the week.
a. Limit intake of fatty foods. b. Abstain from alcohol consumption. e. Participate in moderate exercise for at least 30 minutes most days of the week.
A patient presents to the clinic with complaints of a severe headache, nuchal rigidity, photophobia, and positive Kernig and Brudzinski signs. What condition do these symptoms suggest? a. Meningitis b. Encephalitis c. Poliomyelitis d. Guillain-Barré syndrome
a. Meningitis
A nurse is assessing the pain status of a postoperative patient who is receiving morphine for pain control. Vital signs are pulse, 62 beats/min; blood pressure, 100/58 mm Hg; and respiratory rate, 6 breaths/min, and the patient is difficult to arouse. The nurse may expect to administer which medication? a. Naloxone (Narcan) b. Phenytoin (Dilantin) c. Methylphenidate (Ritalin) d. Promethazine (Phenergan)
a. Naloxone (Narcan)
The patient with a cervical spinal cord injury arrives at the emergency department with an oxygen saturation of 81% while receiving 100% oxygen through nasal cannula at 2 L/min. The nurse can hear a snoring sound and knows that the patient's tongue is obstructing the airway. What should the nurse do to alleviate the patient's airway obstruction and oxygen saturation? a. Perform a jaw thrust. b. Perform a head tilt and chin lift. c. Place a pillow under the patient's head and neck. d. Increase the flow of oxygen to 8 L/min through the nasal cannula.
a. Perform a jaw thrust.
What are some interventions for a patient who is in anaphylactic shock from a bee sting? (Select all that apply.) a. Prepare for surgical management of the airway. b. Culture the site of the bee sting and administer antibiotics. c. Administer diphenhydramine (Benadryl), which is an H1 receptor antagonist. d. Administer theophylline (aminophylline) intravenously for bronchospasms. e. Provide sips of water to moisten the mouth and throat, which is dry from the tachypnea.
a. Prepare for surgical management of the airway. c. Administer diphenhydramine (Benadryl), which is an H1 receptor antagonist. d. Administer theophylline (aminophylline) intravenously for bronchospasms.
The nurse is caring for a patient who had a transient ischemic attack (TIA). The nurse knows that which are signs and symptoms of TIA? (Select all that apply.) a. Ptosis b. Diarrhea c. Dizziness d. Chest pain e. Costochondritis f. Drooping mouth
a. Ptosis c. Dizziness f. Drooping mouth
A patient sustains a fall and severs the spinal cord between C5 and C6 and is in neurogenic shock. What sign or symptom will be evident that is different from all other forms of shock? a. Pulse rate of 52 beats/min b. Respirations of 30 breaths/min c. Blood pressure of 198/86 mm Hg d. Decreased urinary output
a. Pulse rate of 52 beats/min
Which level of the spinal column controls sexual function? a. Sacral b. Lumbar c. Cervical d. Thoracic
a. Sacral
A patient who was in an automobile accident arrives to the emergency department with a suspected cervical spinal cord injury. What is the most important first step on the patient's arrival? a. Securing the airway b. Obtaining spinal films c. Supporting circulation d. Controlling hemorrhaging
a. Securing the airway
A patient has been diagnosed with amyotrophic lateral sclerosis, commonly known as Lou Gehrig disease. Which symptoms might the patient display? (Select all that apply.) a. Slurred speech b. Muscle weakness c. Difficulty swallowing d. Difficulty clearing the airway e. Altered intellectual ability f. Loss of vision and hearing
a. Slurred speech b. Muscle weakness c. Difficulty swallowing d. Difficulty clearing the airway
The nurse is assisting with data collection for a patient who is scheduled to have abdominal surgery requiring general anesthesia. Which finding would alert the nurse that the patient may be at increased risk for a postoperative complication? a. Smokes one to two packs of cigarettes per day b. Family history of cirrhosis of the liver c. Drinks 1 glass of wine per day d. Removal of a breast tumor
a. Smokes one to two packs of cigarettes per day
A patient is experiencing decreased responsiveness and lack of spontaneous motor activity. What term would the nurse use to describe the patient's level of conscious? a. Stupor b. Somnolence c. Lethargy d. Comatose
a. Stupor
The nurse is caring for a patient with symptoms that are described in the medical record as "transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischemia, without acute infarction." The nurse knows that this is also documented as which event? a. TIA b. TAI c. MIA d. TND
a. TIA
The nurse had admitted a patient with a history of chronic alcoholism who is scheduled for surgery in the morning. The nurse anticipates that this patient's history will affect anesthesia in which way? a. The patient will require more general anesthesia. b. The patient should only receive spinal anesthesia. c. The patient will require less general anesthesia. d. The patient should only receive conscious sedation.
a. The patient will require more general anesthesia.
A patient returned to the unit 3 hours after having a lumbar puncture. Which findings would be of concern if noted on the postprocedure assessment? (Select all that apply.) a. Tingling in the extremities b. Bright red blood oozing from the puncture site c. Requests pain medication for severe headache d. Lab result of cerebral spinal fluid at pH level 7.35 e. Cerebrospinal fluid noted as clear and colorless
a. Tingling in the extremities b. Bright red blood oozing from the puncture site c. Requests pain medication for severe headache
A patient underwent cranial surgery and now has an external ventricular drainage system. Which intervention should the nurse question? (Select all that apply.) a. Use sterile technique when changing the insertion site dressing. b. Keep the zero reference point of the drip chamber of the drainage bag above the head. c. Clamp the drainage tube during patient repositioning. d. Keep the head of the bed at 30 degrees.
a. Use sterile technique when changing the insertion site dressing. b. Keep the zero reference point of the drip chamber of the drainage bag above the head. c. Clamp the drainage tube during patient repositioning. d. Keep the head of the bed at 30 degrees.
Which drug is a vasoconstrictor often used in treatment of cardiogenic shock? a. Vasopressin b. Nitroprusside c. Nitroglycerine d. Naloxone (Narcan)
a. Vasopression
The nurse is caring for a patient who has recently been diagnosed with delirium. Which information provided by the patient's husband is most closely correlated with this diagnosis? a. "The health care provider says she will most likely never improve." b. "She was missing for hours because she forgot how to get home from the grocery store." c. "At first, she kept misplacing her keys. As months passed, the memory loss became more noticeable." d. "She has had trouble remembering new acquaintances for ages. Now, she doesn't recognize me, either."
b. "She was missing for hours because she forgot how to get home from the grocery store."
What type of information is most relevant to a 21-year-old patient who will be undergoing surgery and radiotherapy for treatment of cancer of the testis? a. A discussion about deep breathing to prevent pneumonia b. A discussion about sperm banking because of possible sterility c. A referral to the Look Good, Feel Better program because of altered body image d. A referral to the Agency for Healthcare Research and Quality to manage cancer pain
b. A discussion about sperm banking because of possible sterility
On a postsurgical unit, the nurse cares for many patients who are experiencing pain. In which instance is a patient's pain threshold likely to be lower? a. It is the same for all patients who have had surgery. b. A patient who is anxious may have a lower pain threshold. c. A patient who is awaiting biopsy results may have a higher pain threshold. d. A patient who is having difficulty sleeping in the hospital setting will likely have a higher pain threshold.
b. A patient who is anxious may have a lower pain threshold.
A nurse is caring for a patient who is experiencing pain related to a musculoskeletal disorder. Which statement regarding chronic pain is most accurate? a. Chronic pain is limited and short in duration. b. Chronic pain may not manifest in a change of vital signs. c. A patient with chronic pain may have physical signs of tissue injury. d. Chronic pain could cause restlessness, pacing, grimacing, and other facial expressions of pain.
b. Chronic pain may not manifest in a change of vital signs.
Which type of spinal cord injury describes absence of perianal sensation and sphincter tone? a. Partial b. Complete c. Incomplete d. Hemiparesis
b. Complete
The patient with a brain injury is at risk for increased intracranial pressure (ICP). Which intervention on the care plan should the nurse question? a. Frequent suctioning b. Elevate head of bed c. Strict intake and output d. Saline lock IV
b. Elevate head of bed
A patient who has had a surgical procedure is at risk for development of a postoperative wound infection. Which interventions by the nurse are appropriate for prevention? (Select all that apply.) a. Report a low-grade fever to the surgeon. b. Follow aseptic technique when performing dressing changes. c. Report increasing redness to the primary care physician. d. Assess the wound every hour for bleeding during the first 24 hours. e. Collect a wound culture each day that the patient remains in the hospital. f. Maintain the patient on protective isolation to protect from microorganisms.
b. Follow aseptic technique when performing dressing changes. c. Report increasing redness to the primary care physician.
The nurse is attempting to turn in bed a patient who is experiencing delirium. The patient begins to strike out, thrash, and scream that a monster is attacking him. What should be the nurse's priority intervention? a. Call for help. b. Make the patient's surroundings as safe as possible. c. Step out of the room; the patient clearly does not want to be turned. d. Tell the patient that he is in a safe place and that the monster is not real.
b. Make the patient's surroundings as safe as possible.
The patient with a history of seizures experiences an episode of brief stiffening. What type of seizure is the patient most likely having? a. Tonic-clonic b. Myoclonic c. Absence d. Atonic
b. Myoclonic
A patient arrives at the emergency department via ambulance after a motor vehicle accident. The diagnosis is tension pneumothorax. The patient's blood pressure was 130/72 mm Hg at the accident scene and currently is 70/40 mm Hg. Which type of shock would be suspected? a. Septic b. Obstructive c. Cardiogenic d. Anaphylactic
b. Obstructive
The nurse is applying cold therapy for a patient who was diagnosed with a sprained ankle. Which statement regarding the application of cold is correct? a. Cold applications should be limited to 30 minutes per session. b. Patients with peripheral vascular disease should not receive cold therapy. c. Continuous application of cold is more effective than intermittent therapy. d. Abdominal cramping and muscle and joint pain are relieved with applications of cold.
b. Patients with peripheral vascular disease should not receive cold therapy.
What is the greatest threat to a person with Guillain-Barré Syndrome (GBS)? a. Paresthesias b. Respiratory dysfunction c. Infection d. Visual and hearing disturbances
b. Respiratory dysfunction
The nurse is caring for a male patient who recently sustained an L3 to L4 spinal cord injury. The patient's wife asks the nurse if they will be able to have intercourse again. The nurse bases her response on the knowledge that sexual dysfunction results from spinal cord injuries above which spinal level? a. S5 b. S4 c. C6 d. T11
b. S4
The nurse is caring for an older adult patient who was admitted for delirium caused by a urinary tract infection. Which signs or symptoms would the nurse expect the patient to exhibit? (Select all that apply.) a. Hyperfocused b. Slurred speech c. Delusional thinking d. Aimless repetition of phrases e. Symptoms improve during the night
b. Slurred speech c. Delusional thinking d. Aimless repetition of phrases
A new patient is being seen at the health clinic. Upon assisting with data collection and reviewing the patient's health history, the nurse notes that he had many risk factors for cerebrovascular accident. Which are modifiable risk factors? a. Male, diabetes, and smoker b. Smoker, diabetes, and hypertension c. Smoker, 62 years of age, and hypertension d. Hypertension, 62 years of age, body mass index greater than 40
b. Smoker, diabetes, and hypertension
A patient is admitted with a diagnosis of septic shock. What collaborative interventions would be anticipated? (Select all that apply.) a. Administration of a thrombolytic (streptokinase) b. Temperature control for either hypothermia or hyperthermia c. Vigorous intravenous fluid resuscitation with 0.9% sodium chloride d. Blood cultures from all suspected sources before administration of antibiotics e. Administration of cardiotonic agents such as dopamine, dobutamine, or norepinephrine f. Subcutaneous administration of epinephrine (1:1000) 0.5 to 1 mL every 5 to 15 minutes
b. Temperature control for either hypothermia or hyperthermia c. Vigorous intravenous fluid resuscitation with 0.9% sodium chloride d. Blood cultures from all suspected sources before administration of antibiotics e. Administration of cardiotonic agents such as dopamine, dobutamine, or norepinephrine
The nurse is screening the patient with a stroke for tPA eligibility. Which factor would likely prevent the patient from receiving the drug? a. The patient is 18 years old. b. The patient's symptoms suggest a hemorrhagic stroke. c. Stroke symptoms started 2 hours ago. d. The patient had intracranial surgery 10 years ago.
b. The patient's symptoms suggest a hemorrhagic stroke.
The nurse is caring for a patient who requires compromised host precautions. Which action by the patient's visitor indicates more education is needed? a. The visitor washes his hands before entering the room. b. The visitor brings fresh flowers to the patient. c. The visitor encourages the patient to drink orange juice. d. The visitor assists the patient to the couch to eat.
b. The visitor brings fresh flowers to the patient.
A 79-year-old patient reports a pain level of 3 of 10 but states, "Don't worry; this is just part of getting old." What is the nurse's best response? a. "Okay then; let me know if you need anything." b. "Pain is sometimes part of getting old. What is causing the pain?" c. "I understand you have had the pain for a while. Let's check this further." d. "That is not bad. Let me know if your pain becomes greater than 4 of 10; then we can treat it."
c. "I understand you have had the pain for a while. Let's check this further."
The nurse is educating the daughter of an older adult patient who was diagnosed with delirium. Which statement made by the daughter indicates a need for further teaching? a. "My mother is likely to have symptoms that are worse at night." b. "It is possible my mother will also experience depression and anxiety." c. "Regardless of treatment, my mother's mental status will not improve." d. "My mother may experience difficulties understanding her environment."
c. "Regardless of treatment, my mother's mental status will not improve."
The nurse is giving discharge instruction for a patient who has been newly diagnosed with seizure disorder. Which statement if made by the client indicates a need for additional teaching regarding the seizure medication? a. "I do not drink alcohol." b. "Proper diet and exercise is important to my recovery." c. "When I finish this prescription, I will not need to get a refill." d. "I registered for a meditation and visualization class to help with stress relief."
c. "When I finish this prescription, I will not need to get a refill."
The nurse is reviewing the medication administration record and notes that the patient has an order to receive donepezil (Aricept) 5 mg PO every day at bedtime. The nurse knows that this patient has been diagnosed with which disorder? a. Vascular dementia b. Huntington disease c. Alzheimer disease d. Frontotemporal dementia
c. Alzheimer disease
A 55-year-old patient with a BMI of 29 is concerned that her identical twin has just been diagnosed with breast cancer. She is highly motivated to reduce her risk for developing cancer. Which diet and lifestyle factors are recommended for reducing cancer risk? a. Avoid grains, cereals, pasta, and beans. b. Engage in physical activity once a week. c. Attain and maintain a healthy body weight. d. Consume a diet rich in preserved and cured foods.
c. Attain and maintain a healthy body weight.
An older adult resident of a long-term care facility has decreased oral intake over 2 days. The LPN/LVN is careful to assess the resident for which signs and symptoms of dehydration? a. Pale urine, elevated blood sugar, and slow respiratory rate b. Decreased blood sugar; elevated blood pressure; agitation; and warm, damp skin c. Dark, concentrated urine; confusion; decreased blood pressure; and increased heart rate d.Muscle cramping; decreased heart rate; increased respiratory rate; and cool, clammy skin
c. Dark, concentrated urine; confusion; decreased blood pressure; and increased heart rate
The student nurse notes that the unlicensed assistive personnel (UAP) spend considerable time and effort cueing and encouraging older adult long-term care residents to consume fluids at mealtime. The clinical instructor explains that the activity is most important for which reason? a. The activity allows for increased interaction and socialization. b. Many of the fluids offered to the residents also contain medication. c. Older adults have a decreased sense of thirst and increased risk for dehydration. d. Wasting resources, even food and fluids, is contrary to established nursing ethics.
c. Older adults have a decreased sense of thirst and increased risk for dehydration.
Before surgery, the nurse knows that the patient must sign a legal form called informed consent. The nurse knows that explaining the procedure and risks to the patient is the responsibility of which member of the health care team? a. Staff nurse b. Resource nurse c. Physician d. Operating room nurse
c. Physician
The nurse is preparing preoperative medications for a patient who will be undergoing abdominal surgery. The nurse is aware that an anticholinergic drug is most likely ordered for which reason? a. Sedative b. Antiemetic c. Reduce salivation d. Produce sedation
c. Reduce salivation
A family member of an acutely ill patient becomes very anxious after speaking with the patient's health care provider. The LPN notices that the family member has moved away from the other visitors and is standing off to one side, breathing very rapidly. The LPN approaches the family member with the understanding that the family member is at risk for developing which acid-base imbalance? a. Respiratory acidosis b. Metabolic acidosis c. Respiratory alkalosis d. Metabolic alkalosis
c. Respiratory alkalosis
The nurse in the emergency department is preparing for the arrival of a patient with a high cervical injury. The nurse expects this patient, if he survives, to have which condition? a. Paraplegia b. Hemiplegia c. Tetraplegia d. Normoplegia
c. Tetraplegia
A nurse is caring for a patient who is receiving analgesics as needed (PRN) for pain control rather than around the clock (ATC). What is a disadvantage of receiving PRN rather than ATC medications? a. Therapeutic blood levels are more effectively managed. b. It is based on how long the drug lasts in the bloodstream. c. There may be frequent periods of unrelieved pain and side effects. d. The nurse will have to assess the patient for unrelieved pain at more frequent intervals.
c. There may be frequent periods of unrelieved pain and side effects.
A patient was admitted to the hospital yesterday morning with complaints of sudden onset of dizziness, slurred speech, and numbness and tingling on the left side of the body. The patient is now resting without complaints of the previous symptoms. These symptoms are associated with which disorder? a. Myocardial infarction b. Intracranial hemorrhage c. Transient ischemic attack d. Cerebrovascular accident (CVA)
c. Transient ischemic attack
The LPN/LVN is supervising the care of a patient with confusion. Which action by the unlicensed assistive personnel (UAP) would prompt the LPN/LVN to intervene? a. Putting on the patient's glasses so the patient can see b. Putting in the patient's hearing aids so the patient can hear c. Turning off all the lights in the patient's room so the patient can sleep d. Placing the patient's clock in a prominent position so the patient knows what time it is
c. Turning off all the lights in the patient's room so the patient can sleep
Which statement made by the parent of a patient with a history of grand mal seizures indicates a need for additional teaching? a. "I should place my child on one side if possible." b. "If the seizure continues for more than 4 minutes, I should call 911." c. "When a seizure starts, I must remove hazardous objects from the area." d. "Always place a stick or spoon in the mouth to prevent tongue swallowing."
d. "Always place a stick or spoon in the mouth to prevent tongue swallowing."
A nurse is obtaining a health history on a patient who was admitted with lung cancer. Which question is most important for the nurse to ask to gather data about the chief complaint? a. "How often, if ever, do you drink alcohol?" b. "Do you see a primary care health care provider regularly?" c. "Do you have any history of serious diseases or cancer in your immediate family?" d. "Can you tell me more about the problem that caused you to come to the hospital?"
d. "Can you tell me more about the problem that caused you to come to the hospital?"
A patient who is admitted to the psychiatric unit is exhibiting irritability, jumps when someone touches him, startles easily, and reports difficulty sleeping at night. What could have caused the patient's behavior? a. A family history of mental illness. b. Laboratory tests that reveal hormone dysregulation in the body. c. Diagnostic studies that show structural abnormalities of the brain. d. A recent break-in and robbery at gunpoint in which the patient received multiple gunshot wounds.
d. A recent break-in and robbery at gunpoint in which the patient received multiple gunshot wounds.
The nurse is administering haloperidol (Haldol) to a patient who was admitted to the psychiatric unit. To detect a common untoward effect of haloperidol, the nurse should assess the patient for the possible development of which sign(s) or symptom(s)? a. Hair loss b. Gynecomastia c. Nausea, vomiting, and diarrhea d. Abnormal involuntary movements
d. Abnormal involuntary movements
The LPN is reviewing orders for a patient who was recently admitted with diagnoses of hypokalemia and congestive heart failure. The LPN would alert the RN to which order? a. Encourage potassium-rich foods with meals. b. Administer 10 MEQ KCl twice daily by mouth. c. Add 10 MEQ KCl to each 1000 mL of 0.9 percent NaCl. d. Administer 10 MEQ KCl by intravenous push (IVP) twice daily.
d. Administer 10 MEQ KCl by intravenous push (IVP) twice daily.
The nurse is assisting with activities of daily living for a patient with moderate dementia. What is the best way for the nurse to maximize functional ability during oral care? a. Repeatedly tell the patient to brush his teeth. b. Brush the patient's teeth without the patient's assistance. c. Have the patient hold the tube of toothpaste to keep him occupied. d. Break the task of brushing the patient's teeth into more manageable tasks.
d. Break the task of brushing the patient's teeth into more manageable tasks.
The patient with a C4 spinal cord injury develops nasal congestion, facial flushing, and a pounding headache. His blood pressure is 235/118. What is the priority nursing intervention? a. Administer an antihistamine. b. Give the patient an enema. c. Reposition the patient. d. Check the indwelling catheter for possible occlusion.
d. Check the indwelling catheter for possible occlusion.
The LPN/LVN notices that one of the older adult residents in the long-term care facility has decreased intake of fluids at the noon meal. Reviewing the resident's record, the nurse discovers that the recorded oral intake is 300 mL over the past 24 hours. What should be the nurse's next action? a. Wait a few more days to see what happens. b. Immediately notify the health care provider. c. Instruct the dietary department to send additional fluids. d. Collect further data focused upon the resident's fluid balance.
d. Collect further data focused upon the resident's fluid balance.
A patient is receiving fentanyl (Duragesic) transdermal patches to relieve chronic pain associated with cancer. This patient is experiencing multiple side effects of the medication. Which of the side effects listed will continue, even with development of tolerance? a. Nausea b. Sedation c. Vomiting d. Constipation
d. Constipation
The nurse is caring for a patient in the preoperative area who will be undergoing palliative surgery. Which is an example of palliative surgery? a. Breast augmentation b. Replacement of a knee that has severe osteoarthritis c. Opening of the abdomen to discover the source of unexplained pain d. Creation of an ostomy for a patient with malignant metastatic tumor of the intestine
d. Creation of an ostomy for a patient with malignant metastatic tumor of the intestine
A patient with new third-degree burns over 60% of the body is confused and presents with a blood pressure of 79/56 mm Hg, heart rate of 132 beats/min, and respirations of 28 breaths/min with crackles on auscultation. The patient's body temperature is 76° F, and the skin is pale and clammy. Which stage of shock is this patient experiencing? a. Preshock b. Irreversible c. Early reversible d. End-organ dysfunction
d. End-organ dysfunction
The patient with multiple sclerosis takes amantadine for which symptom? a. Spasticity b. Neuropathic pain c. Urinary retention d. Fatigue
d. Fatigue
An athlete has been practicing twice a day in the heat and reports being dizzy. The patient's vital signs are blood pressure of 100/72 mm Hg, pulse rate of 100 beats/min, and respiratory rate of 26 breaths/min; the patient does not remember the last voiding time. The skin is cool to touch and pale in color. What type of shock is the patient experiencing? a. Neurogenic shock b. Cardiogenic shock c. Anaphylactic shock d. Hypovolemic shock
d. Hypovolemic shock
After eating an entire Italian submarine sandwich, a patient complains of extreme thirst and then purchases and consumes two large bottles of water. The LPN explains to the patient that the thirst is being driven by which mechanism? a. An overall fluid deficit that results in thirst. b. A lack of sufficient fluid intake earlier in the day. c. Drying of the oral mucosa from the starches in the bread. d. Increased blood sodium concentration from cured meats.
d. Increased blood sodium concentration from cured meats.
The nurse is performing a neurologic exam on an elderly patient. Which finding is normal? a. Balance problems b. Absent reflexes c. Dilated pupils d. Jerky eye movements
d. Jerky eye movements
The nurse is caring for a patient who has an initial diagnosis of transient ischemic attack (TIA). The nurse knows that the physician may order which diagnostic examination to confirm this diagnosis? a. Electrocardiogram (ECG) b. Electroencephalogram (EEG) c. Computed tomography (CT) scan d. Magnetic resonance imaging (MRI)
d. Magnetic resonance imaging (MRI)
The nurse is caring for a patient who is scheduled for a biopsy of a tumor. The patient asks what distinguishes benign tumors from malignant tumors. Which information should the nurse provide the patient? a. Benign tumors are usually composed of more rapidly growing cells. b. Benign tumors are incapable of causing damage to nearby tissues or organs. c. Whereas malignant tumors are usually encapsulated, benign tumors lack specific form. d. Malignant tumors are composed of abnormal cells that may spread to other parts of the body.
d. Malignant tumors are composed of abnormal cells that may spread to other parts of the body.
What activates the afferent pathways causing the patient to feel pain? a. Cortex b. Spinal cord c. Endorphins d. Nociceptors
d. Nociceptors
The nurse is caring for a patient who was diagnosed with vascular dementia. The nurse understands that the patient has likely also experienced which condition? a. Hip fracture b. Tertiary syphilis c. Massive myocardial infarction d. Progressive damage from several small strokes
d. Progressive damage from several small strokes
An LVN/LPN is at the bedside of a patient with meningitis. Which intervention if found in the nursing care plan should the nurse view as the greatest concern? a. Monitor the level of consciousness frequently. b. Position the patient to maintain a patent airway. c. Elevate the head of the bed at a 45-degree angle. d. Restrain the patient with chest restraint if restless.
d. Restrain the patient with chest restraint if restless.
