medsurg - final

The nurse is monitoring a patient recovering from an emergency appendectomy. Which finding is most concerning?

Abdomen rigid on palpation

The nurse is caring for a patient at risk for primary open-angle glaucoma (POAG). Which finding is most concerning?

Headache and seeing halos around lights

A patient is receiving care for a torn ligament at the insertion site of an upper arm muscle. The patient asks the nurse how this condition will affect movement. Which information will the nurse correctly share?

The movement of the arm will seem normal.

A patient diagnosed with curvature of the spine asks the nurse why breathing is impacted by their spine. How should the nurse respond?

The thoracic cage has lost some flexibility.

A male patient reports that manifestations of benign prostatic hyperplasia (BPH) have been occurring for several years. On which problems related to this condition does the nurse focus when collecting health information? (Select all that apply.)

- Urosepsis - Renal insufficiency - Evidence of hydronephrosis - Recurrent urinary tract infections

A patient diagnosed with benign prostatic hyperplasia is prescribed the alpha-blocking medication to reduce symptoms. Which side effect is the most concerning?

-Hypotension

A patient with acute-angle glaucoma and a fractured femur who is scheduled for surgery is prescribed an opioid prn and an anticholinergic as a preoperative medication. What action should the nurse take?

Contact the health-care provider (HCP).

The nurse is collecting health history on a female client who is considered a high-risk pregnancy. Which information will the nurse record if the patient has had four pregnancies, a miscarriage at 16 weeks, one 22-week stillborn delivery, and delivery at term to a set of twins and a single birth?

G4P2A1

The nurse is collecting data on a patient in a HCP's office. The patient tells the nurse of recent flu-like symptoms. The nurse notices a skin rash on the palms of the hands and soles of the feet, and swollen lymph nodes. Which question should the nurse ask?

Have you had any painless sores lately?

The nurse is providing care for a patient with external fixation for a fracture involving severe bone damage. What is a priority of care?

Monitoring pin and wound sites for signs of infection

The nurse is providing care for a patient admitted with acute liver failure related to an acetaminophen overdose. What should the nurse prepare to deliver?

N-acetylcysteine

The nurse is providing care for a patient with a cerebral aneurysm and subarachnoid hemorrhage. Which statement by the patient requires additional teaching?

No strenuous activity until this condition is cured by surgery.

The nurse asks an older adult patient to count backward from 100 in increments of three. The patient is challenged with the process and often pauses but performs this accurately. What should the nurse document that the patient shows?

Normal delay in problem solving

The nurse is providing care for a patient admitted to the burn unit with burns to 15% of the body. After 3 days, the nurse notes that the patient's temperature is newly elevated at 100.2°F (37.9°C), and the patient exhibits new-onset agitation and confusion. Which action should the nurse take first?

Notify the RN or HCP.

The nurse reviews the laboratory results for a patient with malnutrition from a lack of intrinsic factor secretion. The results indicate a low hemoglobin level. What symptoms should the nurse inquire about?

Numbness and tingling

A female patient is at the HCP's office for an annual gynecological examination. When a bimanual examination is performed, the patient reports significant pain. Which medical condition is suspected?

PID

A female patient has not achieved pregnancy after 8 months of attempting to do so and is undergoing hormone testing. Which additional reason other than infertility does the nurse identify for hormone testing?

To assess hormone-producing tumors

A patient has an open skin lesion and the HCP prescribes the application of an antibiotic ointment with a dry sterile dressing applied. What is the reason for the dressing?

To enhance the absorption of the topical medication

A patient receives a diagnosis of Crohn disease and asks the nurse, "Will they be able to cure this?" How should the nurse reply?

With treatment, the symptoms will disappear for good, as long as you take the medications.

A 50-year-old woman tells the nurse, "It is such a relief not to need birth control any more. I haven't had a period in 3 months." How should the nurse reply?

Without confirmation, you are still considered to be perimenopausal and should continue birth control.

The nurse is assisting in the care of a patient with a circumferential burn to the leg. The HCP determines that an escharotomy is necessary. What is the nurse's priority action?

Checking for the return of distal pulses

The nurse notes that a patient with a history of hypertension is straining during defecation. What teaching should the nurse include?

It is important that you not strain because it could cause damage to your heart.

The nurse is providing care for a patient recently diagnosed with chlamydia. Which information does the nurse recommend be included in patient teaching? (Select all that apply.)

- Chlamydia can be transmitted sexually and by blood and body fluid contact. - The risk of ectopic pregnancy is increased in women with a history of chlamydia.

A patient is diagnosed with diabetic ketoacidosis. Which manifestations should the nurse expect to observe in this patient? (Select all that apply.)

- Dehydration - Kussmaul respirations

A patient diagnosed with SIADH is scheduled for surgery in a few days. Which does the nurse expect to be prescribed for this patient to help manage the symptoms until surgery? (Select all that apply.)

- Fluid restriction - Furosemide - Conivaptan - Hypertonic saline infusion

The nurse is preparing to reinforce teaching to a patient newly diagnosed with PKD. Which information does the nurse include? (Select all that apply.)

- Grape-like cysts will replace normal, functioning structures. - Initial symptoms are dull heaviness in the flank area and hematuria. - Patients are at risk for brain aneurysms and diverticulosis in the colon. - The disease is likely to require additional treatment for hypertension and UTIs.

A patient asks the difference between osteoarthritis and RA. Which manifestations does the nurse explain are characteristic of RA? (Select all that apply.)

- Low-grade fever - Autoimmune disease, - Early morning stiffness

The nurse in a school clinic is aware of an unusually high incidence of cold sores among the student population. What action can the nurse take to control the spread?

Educate all students on the importance of abstaining from sharing lip products, drinks, and foods.

A patient is scheduled for a surgical biopsy for removal of a section of a lesion suspected to be breast cancer. How should the nurse approach care?

Present with a calm and understanding attitude.

A patient shares a long-standing problem of urinary incontinence with the nurse. Which intervention does the nurse recognize as taking priority?

Providing caring support to the patient

The nurse is providing care for a patient admitted with joint pain, hair loss, mouth sores and lymphadenopathy. Which finding should be reported to the HCP?

Reddish-brown rash on the hands

The nurse is providing care for a client with multiple injuries from a serious car accident. The HCP prescribes a diet as tolerated and administration of sucralfate orally. Which condition and goal does the nurse associate with the HCP's prescriptions?

Reduced formation of stress ulcers

The nurse is collecting data on a patient in a HCP's office. Data includes the following: 65-year-old male, waist circumference 42 inches, blood pressure (BP) 140/88 mm Hg, and fasting glucose 120 mg/dL. Which identifies the nurse's concerns?

Risk for heart disease, type 2 DM, and hypertension

The nurse is providing care for a patient diagnosed with celiac disease. The patient presents with weight loss. What additional findings should the nurse monitor for?

Steatorrhea

A patient is brought to the health-care provider's (HCP's) office with a headache, lethargy, nausea, vomiting, and a fever, which has developed over the past few days. The nurse begins collecting data about the possible causes of the symptoms. Which information supports a concern for encephalitis being the cause?

The patient has been camping within the last few weeks.

A patient's Snellen chart findings are 20/60. What does this information represent?

The patient must be at 20 feet to see what someone else can see at 60 feet.

The nurse is reinforcing teaching provided to a patient about caring for a new AV fistula in the left arm for dialysis. Which patient statements indicate correct understanding? (Select all that apply.)

- I should not sleep on my arm. - I should wear loose clothing on my left arm. - I will avoid carrying heavy things with my left arm.

A patient with a spinal cord injury at T3-T4 experiences a sudden increase in BP and has cool, pale, gooseflesh skin on the lower extremities. Which action does the nurse perform while awaiting physician orders? (Select all that apply.)

- Monitor BP every 5 minutes. - Check to see if the indwelling catheter is patent. - Perform a rectal examination to determine if impaction is present.

The nurse is assisting with teaching to a woman who is having difficulty conceiving. Which instruction does the nurse provide about keeping a basal body temperature chart?

- Starting with the first day of your period, record your temperature first thing each morning.

A patient with hepatitis B virus (HBV) delivers a healthy baby. Which action does the nurse anticipate will be needed for the infant?

- Testing for transmission of hepatitis B

A patient who had extensive gastric surgery for stomach cancer reports feeling sick and diaphoretic with abdominal cramping about 20 minutes after eating. The nurse is providing information about dumping syndrome. Which information is correct? (Select all that apply.)

- The patient is experiencing one of the most common complications. - Food enters the jejunum without adequate amounts of digestive juices. - High concentrations of electrolytes and sugar draw fluid into the bowel.

A client is identified with a thyroid disorder resulting in hormone deficiency. The HCP prescribes a stimulation test. What should the nurse explain to the patient about undergoing this test?

A substance will be injected into your vein.

A patient is being admitted to a long-term care facility after a recent stroke with dysarthria. What should the nurse consider in providing care?

A picture board will help the patient with word searching.

The nurse reviews the results of a patient's stool occult blood test, which tests positive. What question should the nurse ask the patient?

Have you eaten turnips, fish, or horseradish prior to testing?

The nurse is collecting data from a patient with liver failure to detect hepatic encephalopathy. Which instruction should the nurse give to the patient to collect the data?

Hold out your arms and hands.

A patient is being treated for acute cholecystitis. The patient is instructed on dietary measures to reduce the possibility of recurrent episodes. Which patient comment indicates a need for additional teaching?

I need to follow a very low-calorie diet.

A patient is diagnosed with dermatomycosis. Which statement by the patient gives the nurse an idea of where the infection was acquired?

I work out and shower at the gym.

A mother of two young children has a 1-year history of MS and recently stopped helping in the children's classrooms because of fatigue and weakness. What advice should the nurse give to help the patient best cope with the problem?

You may plan to be there for shorter visits so you can rest.

A patient presents at the HCP's office with epigastric pain. The patient's temperature and pulse and respiration rates are all elevated. Which additional symptom will the nurse associate as a possible sign of cholelithiasis?

Jaundice

A patient being treated with metformin for type 2 DM is receiving a routine follow-up assessment. In addition to HbA1c and a fasting plasma glucose test, which other laboratory test should the nurse expect to be monitored in this patient?

Kidney function tests

A patient has been hospitalized requiring IV antibiotics for the treatment of pelvic inflammatory disease (PID). The patient asks the nurse about how this will impact her ability to conceive one day. What should the nurse reinforce?

The importance of taking antibiotic therapy as prescribed

A patient has an injury resulting in major damage to the pinna of the right ear and is afraid that it may cause hearing loss. Which statement by the nurse will alleviate the patient's fear?

The impulses for hearing come from the middle and inner ear, not your outer ear.