MED SURG Power Point Questions

A patient with GBS asks the nurse how this condition developed. What should the nurse respond about the pathophysiology of this condition? 1. An infection destroys the nerve endings 2. An infection enters the spinal cord and erodes the nerves at their roots3. The nerves are killed by infiltration of your body's white blood cells used to fight an infection4. The covering of nerves that conduct impulses are damaged.

4

What clinical indicator does the nurse expect to identify when assessing a client with a brain tumor in the occipital lobe? ◦1. Hemiparesis◦2. Receptive aphasia◦3. Personality changes ◦4. Visual hallucinations

4

Which is the best position for the nurse to place a patient with increased intracranial pressure (ICP) and decreased intracranial compliance?◦ 1. Flat◦ 2. Prone◦ 3. Side-lying with the neck flexed◦ 4. Semi-Fowler's with the neck in a neutral position

4

Which nurse monitors for which late clinical manifestations of chronic aspirin overdose?• 1. Emesis• 2. Nausea• 3. Tinnitus• 4. Hyperthermia

4

Which nursing action is appropriate when conducting a secondary survey during the emergency assessment?• 1. Maintaining privacy• 2. Having suction available• 3. Giving supplemental oxygen• 4. Completing a pain assessment

4

Which nursing intervention is most helpful in meeting the needs of an older adult with the diagnosis of dementia of Alzheimer type?◦ 1. providing nutritious foods high in carbohydrates and proteins ◦ 2. offering opportunities for choices in the daily schedule to stimulate interest ◦ 3. developing a consistent plan with fixed time schedules to provide for emotional needs ◦ 4. simplifying the environment as much as possible and eliminating the need for decisions and choices

4

The healthcare provider instructs the patient on which ear protective measures? (Select all that apply.) A. Earbuds to reduce noise in areas with high-decibel noise levels B. Earbuds to help prevent water from entering the ear canal C. Headphones to listen to music at medium to high decibel ranges D. Earplugs to help decrease water from entering the canal while swimming E. Wearing earmuffs in the winter

A

It is believed that a patient's migraine headaches are caused by vascular constriction. The nurse correlates the action of which medication is indicated for this patient?◦ Celexa◦ Tofranil ◦ Norvasc◦ Lamictal

Norvasc

Breathing must be assessed, and patient airway established immediately during the initial minutes of emergency burn care T/F

T

In addition to focused examinations of the eyes, what other data should Melanie's provider assess?A. Immunization history B. Dietary history C. Travel historyD. Obstetrical history

a

A patient sustained a burn injury, partial and full thickness burns to half of left arm, entire left leg, and perineum. What is the percentage of burn to this patient?• A. 28% • B. 23.5%• C. 45.5% • D. 16%

b

Based on her clinical presentation, Melanie's provider is most likely to offer which suggestion?A. Increase the intake of carrots in her diet to help stimulate her visual acuity. B. Use lubricating eye drops for 2 weeks, and then return for a follow-up examination. C. Get at least 8 hours of sleep at night. D. Schedule a follow-up examination with an eye care specialist.

b

Erin's ability to hear better after her physical examination is directly related to which action? A. The removal of the embedded wax from the ear canal B. The examination with an otoscope C. It is not clear why Erin is hearing more clearly. D. The stretching of the ear canal while an otoscopic examination is completed

b

The nurse is caring for Ms. Wiley in the presurgical suite. The patient asks, "Will you hold my hand? I am getting nervous. My mom told me this morning that I could die from this surgery." Which action by the nurse is best?• Patting the patient on the shoulder and covering her up • B. Asking her if she would like some alprazolam (Xanax) to calm her down • C. Holding her hand and listening to her concerns • D. Explaining that the percentage of people who die from bariatric surgery is small

c

What teaching is most important for the provider to provide to Erin during this visit?A. Not using cotton swabs or other similar instruments in the ear canal B. Ways to remove the waxy buildup from the ear canal C. What to do if the patient starts to notice hearing loss D. Use of earbuds for listening to music

c

Which tests will Melanie's provider order based on her presenting clinical manifestations and history?A. Visual acuity test with ophthalmic examination B. A CT scan to rule out the presence of tumors or other pathology C. Ophthalmic examination using fluorescein to check for foreign bodies D. Ophthalmic ultrasound to rule out the presence of cataracts

c

Erin does not notice any hearing changes; the provider verifies Erin's ability to hear by using which test?A. An M R I for the most definitive testing B. Audioscopy C. A C T scan of the headD. Electronystagmography (E N G)

d

The nurse is caring for Ms. Wiley in the post-anesthesia recovery unit. The patient is 2 hours post-gastric bypass surgery and has a nasogastric tube (N G T). The orders state that the N G T should be hooked up to low continuous suction. There is scant blood-tinged drainage coming from the tube. What action should the nurse take? • A. Call the surgeon right away. • B. Reposition the N G T. • C. Discontinue the N G T. • D. Document the findings

d

What is the rationale for Melanie's provider to perform the Rosenbaum test? A. Assesses Melanie's near vision B. Assesses Melanie's far vision C. Assesses Melanie's peripheral vision D. Assesses Melanie's C N IV function

d

Which long-term complication of bariatric surgery does the nurse include in the teaching session for a patient who is considering this procedure for weight loss?• 1. Anemia• 2. Infection• 3. Anastomosis leak• 4. Pulmonary embolism

1

Which technique should the nurse use to assess a patient's cranial nerve (CN) IX? 1. Apply a tongue depressor to the back of the throat. 2. Ask the patient to read from a book or a newspaper. 3. Ask the patient to smile, frown, puff cheeks, and raise eyebrows. 4. Ask the patient to follow the examiners finger as it moves

1

A recently hospitalized client with MS is concerned about general weakness and fluctuating physical status. What is the priority nursing intervention for this client? • 1. encourage bed rest • 2. space activities throughout the day • 3. teach the limitations imposed by the disease • 4. have one of the client's relatives stay at the bedside

2

During a home visit the nurse considers physical therapy for a patient recovering from encephalitis. What would be the best explanation for this referral? ◦ 1. rehabilitation from hemiparesis ◦ 2. deconditioning from extended bedrest ◦ 3. improve use of limbs because of paresthesias ◦ 4. improve balance because of cerebellum dysfunction

2

In assessing a patient with increased intracranial pressure, the nurse notes that the patient's left pupil is larger than the right pupil. The nurse correlates the larger left pupil to compression of which cranial nerve?◦ 1. Left optic nerve◦ 2. Left oculomotor nerve◦ 3. Right optic nerve◦ 4. Right oculomotor nerve

2

In monitoring a patient with increased intracranial pressure (ICP) who is mechanically ventilated, the nurse correlates which arterial blood gas value to effective management of the increased ICP?◦ 1. pH 7.32◦ 2. PaCO2 32 mm Hg◦ 3. PaO2 85 mm Hg◦ 4. HCO3- 22 mEq/L

2

The nurse is caring for a client who has experienced a thoracic spinal cord injury . In the event spinal shock occurs, what IV fluid will be given?• 1. Dextran• 2. .9% normal saline• 3. 5% dextrose in water • 4. 5% dextrose in 9% normal saline

2

The nurse is preparing information on the integumentary system for a group of high school students. Which layer of the skin should the nurse explain plays an initial role in immunity? 1. Dermis 2. Hypodermis 3. Innermost layer of the epidermis 4. Outermost layer of the epidermis

2

The nurse monitors for which initial clinical manifestations in the patient being treated for drowning?• 1. Alkalosis• 2. Tachycardia• 3. Elevated temperature• 4. Hypocarbia

2

To decrease intraocular pressure following cataract surgery what should the nurse instruct the client to avoid? 1. lying supine 2. coughing 3. deep breathing 4. ambulation

2

Which statement by the patient scheduled for Roux-en-Y gastric bypass (RYGB) indicates the need for further teaching?• 1. "This procedure involves the creation of a pouch."• 2. "There are less complications with this procedure."• 3. "This procedure leads to decreased absorption of food."• 4. "Part of my small intestine will be removed."

2

The nurse is caring for a client with severe burns who is receiving fluid resuscitation. Which finding indicates that the client is responding to the fluid resuscitation?• 1. pulse rate 112 BPM• 2. blood pressure of 94/64• 3. urine output of 30 ml/hr• 4. serum sodium level of 136 mEq/L

3

Which action does the nurse take in the management of a patient with a snake bite?• 1. Placing a tourniquet above the bite• 2. Applying ice to the bite• 3. Cleaning the site with soap and water• 4. Scrubbing the bite with alcohol

3

n completing a primary survey, the nurse assesses which factor to determine the "E" in the ABCDE sequence?• 1. Emotion• 2. Estimated blood loss• 3. Exposure• 4. Extremities

3

A patient presents with progressively deteriorating motor and sensory function. What question should the nurse ask this patient as part of their health history? 1. Have you been around any small children? 2. When was the last time you had anything to eat? 3. When was the last time you traveled out of the country? 4. Have you recently experienced any lung or GI infections?

4

A client is receiving dilantin for a seizure disorder. They ask the nurse about this medication at discharge. The nurse's best response is ◦ 1. This medication will probably be continued for life 2. This medication prevents the occurrence of seizures 3. This medication needs to be taken during periods of emotional distress 4. This medication can be stopped after 1 year if no further seizures occur

1

A patient in a barbiturate coma for increased intracranial pressure (ICP) has audible gurgling through the endotracheal tube. What should the nurse do first before suctioning this patient?◦ 1. Administer 100% oxygen.◦ 2. Elevate the head of the bed.◦ 3. Interrupt sedative administration.◦ 4. Place the head in a neutral position.

1

After the nurse secures the airway of a trauma patient in the emergency department (ED), what is the next conduct in the primary survey?• 1. Assess the patient's respiratory rate.• 2. Monitor the patient's blood pressure.• 3. Assess the patient's pupillary reaction.• 4. Cover the patient with a warm blanket

1

During a neurological assessment, the nurse asks a patient to close their eyes to identify a paper clip placed in their hand. What is the nurse assessing? 1. Stereognosis 2. Hyperesthesia 3. Graphesthesia 4. Two-point discrimination

1

Formulas are only a guide for burn care fluid resuscitation. How often must a patient's response to fluid therapy (heart rate, BP, and urine output) be evaluated?• 1.Every hour• 2. Every 2 hours• 3. Every 3 hours• 4. Every 4 hours

1

The nurse conducts a neuro assessment on a patient. Which finding correlates to a parasympathetic stimulation of the ANS? 1. pupils are constricted2. blood glucose increased 3. heart rate increases4. Decreased saliva production

1

The nurse is monitoring a patient who is receiving triple H therapy for vasospasm secondary to a subarachnoid hemorrhage. Which finding requires the nurse to immediately contact the healthcare provider? 1. Blood pressure 100/60 2. Heart rate 88 3. Glasgow Coma Scale score 13 4. Complaints of a headach

1

The nurse notes that a patient has ataxia. Which test does the nurse use to gain more information about this patient's gait? 1. Romberg 2. Patellar reflex 3. Plantar flexion 4. Achilles reflex

1

What should the nurse assess for when a client with a cervical injury reports a sever headache and nasal congestion? • 1. suprapubic distention• 2. increased spinal reflexes • 3. adventitious breath sounds • 4. imminent development of shock

1

When helping a client with Parkinson's disease to ambulate, what instructions should the nurse give the client? ◦ 1. avoid leaning forward◦ 2. hesitate between steps ◦ 3. rest when tremors are experienced◦ 4. keep arms close to center of gravity

1

Which factor places a client at greater risk for skin cancer? 1. fair skin and history of chronic sun exposure 2. Caucasian race and history of HTN3. Dark skin and family history of skin cancer 4. Dark skin and history of HTN

1

A nurse is assessing a client with a brain tumor. Which clinical findings indicate an increase in intercranial pressure. *Select all that apply ◦ 1. Fever◦ 2. Stupor◦ 3. Orthopnea◦ 4. Rapid pulse◦ 5. Hypotension.

12

There has been a fire in an apartment building and all residents have been evacuated. Many are burned and you are acting as triage nurse- which patients should be immediately transported to the burn center? Select all that apply • 1. 8 y/o with 3rd degree burns over 10% BSA • 2. 20 y/o who inhaled smoke of the fire• 3. 50 y/o diabetic with 1st and 2nd degree burns on left forearm (approx. 5% BSA)• 4. 30 y/o with second degree burns on back of left leg ( approx. 9% BSA) • 5. 40 y/o with 2nd degree burns on right arm (approx. 10% BSA)

123

What clinical indicators does the nurse expect a client with Parkinson's disease to exhibit. Mark all that apply◦ 1. resting (nonintention) tremors ◦ 2. flattened affect◦ 3. muscle flaccidity ◦ 4. tonic-clonic seizures ◦ 5. slow voluntary movements

125

The nurse is admitting an 8-month old infant because of bacterial meningitis is suspected. List in order of priority the nursing actions that should be taken ◦ 1. institute respiratory isolation ◦ 2. assist with lumbar puncture ◦ 3. insert an IV ◦ 4. Administer prescribed antibiotics ◦ 5. Monitor for signs of nuchal rigidity

13245

A client who has been treated for chronic open angle glaucoma for 5 years asks the nurse how does glaucoma damage my eyesight- what should you tell the client? 1. Result from chronic inflammation 2, Causes increase in ICP 3. Leasds to detached of retina 4. Is caused by decreased blood flow to the retina

2

A patient who suffered a thrombotic stroke has residual left lower extremity motor deficit and dysphagia. The nurse identifies which of the following as the priority nursing diagnosis? 1. High Risk for Impaired Skin Integrity 2. High Risk for Aspiration 3. High Risk for Injury: Falls 4. High Risk for Impaired Verbal Communication

2

A patient with increased intracranial pressure (ICP) is sensitive to fluid-volume shifts. The nurse recognizes which approach as safest to reduce this patient's cerebral edema?◦ 1. Mannitol◦ 2. 3% sodium chloride◦ 3. 0.9% normal saline◦ 4. Packed red blood cells

2

A client has a wound on the ankle that is not healing. The nurse should assess the client for which of the following risk factors that can delay wound healing. Select all that apply: 1. atrial fibrillation 2. advancing age 3. Type 2 DM 4. HTN 5. Smoking

235

A client has a history of macular degeneration. What is the priority nursing goal while the client is in the hospital? 1. Provide education regarding community services for the client 2. Provide health care related to monitoring the eye condition 3. Promote a safe effective care environment 4. Improve vision

3

A client is brought to the ER with suspected closed head injury and spinal injury. Which assessment will the nurse perform first? • 1. level of consciousness • 2. pulse and blood pressure • 3. respiratory rate and depth • 4. ability to move extremities

3

A nurse enters the room of a client with MG and identifies that the client is experiencing increased dysphagia. What should the nurse do first? 1. administer oxygen 2. Raise the HOB3. Perform tracheal suctioning 4. Call the healthcare provider

3

A nurse is conducting a mini-mental status examination on an older client. What should the nurse ask the client to do when testing short-term memory? ◦ 1. subtract serial 7's from 100◦ 2. Copy one simple geometric symbol ◦ 3. state 3 random words mentioned earlier in the exam ◦ 4. name two common objects when the nurse points to them

3

A patient is admitted with a stroke/brain attack. The nurse correlates which predisposing factor in the patient's history places as placing this patient at greatest risk for embolic stroke? 1. Immobility as a result of back injury 2. Seizure history 3. Carotid plaque 4. Deep vein thrombus (DVT) in subclavian vein

3

A patient is diagnosed with a health problem that causes demyelization of the peripheral nerves. Which cell structure is being affected? 1. Microglia 2. Astrocytes 3. Schwann cells 4. Oligodendrocytes

3

A patient with low back pain asks what aspirin is supposed to do to help with the pain. How should the nurse respond? • 1. It depresses the central nervous system • 2. It blocks sodium channels and stops the formation of nerve impulses • 3. It blocks enzymes and chemicals in the body to decrease pain and inflammation • 4. It blocks the production of substances that trigger allergic and inflammatory reactions

3

An older adult is having abdominal surgery. The nurse should assess the client for which postoperative concern related to normal changes in the integumentary system of an older adult? 1. increased scarring 2. decreased melanin and melanocytes 3. decreased healing 4. increased immunocompetence

3

An older patient says that sunlight has always been avoided because of the risk for developing skin cancer. Which function of the skin has been most affected by this patient's practice? 1. Sensation 2. Protection 3. Vitamin D metabolism 4. Temperature regulation

3

One dat after cataract surgery the client is having discomfort from bright light. What should the nurse advise them to do? 1. Dim lights in the house and stay inside for a week 2. Attach sun shields to existing eyeglasses when in direct sunlight 3. Use sunglasses that wrap around the side of the face hen the bright light 4. Patch the affected eye when in bright light

3

The nurse correlates which finding in a patient's history as the highest risk for a stroke? 1. Body mass index 24.8 2. Heart rate 90 bpm 3. Blood pressure 182/90 mm Hg 4. Pulse oximetry 90% on room air

3

The nurse is assessing a client who is immobile and notes that an area of sacral skin is reddened, but not broken. The reddened area continues to blanch and refill with fingertip pressure. What should the nurse do next? 1. apply a moist to moist dressing, being careful just to pack the wound bed 2. consult with wound-ostomy nurse specialist 3. Reposition the client off the reddened area and reassess in a few hours 4. Complete and document a Braden skin breakdown risk score for the client

3

The nurse is assessing a client with dark skin for the presence of stage 1 pressure ulcer. Which is the best approach to making this assessment? 1. use a fluorescent light source to assess the skin 2. Inspect the skin only when the Braden Score is above 12 3. Look for skin color that is darker than the surrounding tissue 4. Avoid touching the skin during inspection

3

A client is diagnose with detached retina in the right eye. What should the nurse do first? 1. Apply a compress to the eye 2. Instruct the client to like prone 3. Remove all bed pillows 4. Promote measures that limit mobility

4

A nurse is caring for a ALS patient at home. Which position should the nurse recommend that the client assume after eating? • 1. SIMS• 2. Sitting • 3. Side lying • 4. Semi-Fowler

4