MS Final Review
a nurse reviews the health history of a patient with an over-secretion of renin. which disorder should the nurse correlate with this assessment finding?
hypertension
a nurse asks a patient to take deep breaths during an electroencephalography. the patient asks "why are you asking me to do this?" how would the nurse respond
hyperventilation causes cerebral vasoconstriction and increases the likelihood of seizure activity
after teaching a patient who is scheduled for magnetic resonance imaging (MRI), the nurse assesses the patients understanding. which patient statement indicates a correct understanding of the teaching
i can return to my usual activities immediately after the MRI
a nurse cares for a patient with a urine specific gravity of 1.040. what action should the nurse take?
increase the patients fluid intake
a nurse cares for a patient who has excessive catecholamine release. which assessment finding would the nurse correlate with this condition?
increased pulse
a nurse cares for a patient with a deficiency of aldosterone. which assessment finding would the nurse correlate with this deficiency?
increased urine output
a nurse teaches a patient who is scheduled for a positron emission tomography scan of the brain. what statement would the nurse include in this patients teaching?
avoid caffeine-containing substances for 12 hours before the test
which of the following patients has sustained a fracture of a bone that would normally function to protect vital organs?
has sternal fractures secondary to being thrown from a motorcycle
a nurse cares for a patient who is prescribed a drug that blocks a hormone's receptor site. which therapeutic effect would the nurse expect?
decreased hormone activity
a nurse cares for a patient who has elevated levels of ADH. which disorder should the nurse identify as a trigger for the release of this hormone?
dehydration
a nurse assesses a patient who demonstrates a positive Rombergs sign with eyes closed but not with eyes open. which condition does the nurse associate with this finding
difficulty with proprioception
a nurse obtains a focused health history for a patient who is scheduled for magnetic resonance angiography. which priority question would the nurse ask before the test?
do you have any allergies to iodine or shellfish
a nurse assesses the L plantar reflexes of an adult patient and notes the response shown in the photo below. which action would the nurse take next
document the finding and continue the assessment
a nurse cares for a patient with a urine specific gravity of 1.018. what action should the nurse take
document the finding in the chart and continue to monitor
what is the name of the 1st 12 in of the small intestine?
duodenum
the nurse would ask the patient to perform extension and flexion to assess full ROM for which joint
elbow joint
a nurse plans care for an 83 year old patient who is experiencing age-related perception changes. which intervention would the nurse include in this patients plan of care
ensure that the path to the bathroom is free from clutter
a nurse assesses a patient diagnosed with adrenal hypofunction. which patient statement would the nurse correlate with this diagnosis?
I have a terrible craving for potato chips
a nurse contacts the healthcare provider after reviewing a patients lab results and noting a blood urea nitrogen (BUN) of 35mg/dL and a creatinine of 1.0 mg/dL. what collaborative care measure does the nurse consent with the provider about?
IV fliuds
which hormone responds to a low serum calcium blood level by increasing bone resorption?
PTH
after assessing a client, a nurse documents the state of awareness as confused. what part of the brain controls awareness
RAS
a nurse assesses a patient with renal insufficiency and a low RBC count. the patient asks "is my anemia related to the renal insufficiency?" how should the nurse respond?
RBCs produce erythropoietin, which increases blood flow to the kidneys
a patient had an endoscopic retrograde chaolangiopancreatography (ERCP). the nurse instructs the patient and family about the signs of potential complication, which include what problems? (Select all that apply)
Sepsis Cholangitis Perforation Pancreatitis
a patient had an arthroscopy 1 hr ago on the left knee. the nurse finds the left lower leg to be pale and cool, with 1+/4+ pedal pulses. what action by the nurse is best
assess the neurovascular status of the right leg
a patient is recovering from an esophagogastroduodenoscopy (EGD) and requires something to drink. what action by the nurse is best?
assess the patients gag reflex
a nurse cares for a patient who is recovering from a closed percutaneous kidney biopsy. the patient states "my pain has suddenly increased from a 3 to a 10 on a scale of 0 to 1." which action should the nurse take first
assess the pulse rate and BP
what is the most reliable method of assessing the return of peristalsis?
assess whether the patient has passed flatus or stool
a nurse evaluates laboratory results for a male patient who reports fluid secretion from his breasts. which hormone value would the nurse assess first?
anterior pituitary hormones
a nurse is teaching a patient with cerebellar function impairment. which statement would the nurse include in this patients discharge teaching
ask a friend to drive you to your follow up appointments
a patient is distressed at body changed related to kyphosis. what response by the nurse is best
ask the patient to explain more about these findings
a patient is undergoing computed tomography (CT) of a joint. what action by the nurse is most important before the test
assess for seafood or iodine allergy
a school nurse is conducting a scoliosis screening. in screening the patient, what technique is most appropriate
bending forward from the hips
which mechanism is used to transport substances produced by the endocrine glands to their target tissue?
bloodstream
the patients chart indicates genu varum. what does the nurse understand this to mean
bow legged
the nurse hears in report that the patient has chronic muscle weakness in the upper extremities. what question is the nurse most likely to ask the off-going nurse?
how much assistance is required for activities of daily living?
a nurse cares for a patient who is experiencing deteriorating neurologic functions. the patient states "i am worried i will not be able to care for my young children." how would the nurse respond
give me more info about what worries you, so we can see if we can do something to make adjustments
a nurse cares for a patient with excessive production of thyrocalcitonin (calcitonin). for which electrolyte imbalance would the nurse assess?
calcium
which is the major function of the hormone produced by the adrenal cortex?
calcium and stress regulation
what ethnic group is at highest risk for developing osteoporosis
caucasian women
a nurse assesses an older patient. which assessment findings would the nurse identify as normal changes in the nervous system related to aging. select all that apply
change in sleep patterns slower processing time
the nurse is aware of the 2014 american cancer society screening guidelines for colon cancer. which include which testing modalities for people over the age of 50?
colonoscopy every 1o yr computed tomography (CT) colonography every 5 years
a nurse assesses a patient and notes the patients position as indicate in the illustration below. how would the nurse document this finding
decorticate posturing
a nurse plans care for an older adult who is admitted to the hospital for pneumonia. the patient has no known drug allergies and no significant health history. which action would the nurse include in this patients plan of care?
offer fluids every hour or two
a client says "what is that awful smell?" what sense is being used
olfactory
a nurse assesses a patient recovering from cerebral angiography via the patients right femoral artery. which assessment would the nurse complete
palpate bilateral lower extremity pulses
a patient reports decreased appetite over the past month along with simultaneous decreased intake or oral nutrition as well as episodes of nausea. what priority info should the nurse inquire about next?
patient weight
a nurse reviews the urinalysis of a patient and notes the presence of glucose. what action should the nurse take
perform a bedside blood glucose assessment
what would a nurses priority goal be for an older patient that has impaired coordination and muscle strength, during their shift
prevent falls
a patient is having an esophagogastriduodenoscopy (EGD) and has been given midazolam hydrochloride (Versed). the patients respiratory rate is 8 breaths/min. what action by the nurse is best?
provide physical stimulation
a nurse plans care for a patient who has a hypoactive response to a test of deep tendon reflexes. which intervention would the nurse include in this patients plan of care
provide the patient with assistance when ambulating
the nurse knows that hematopoiesis occurs in what part of the musculoskeletal system
red marrow
a hospitalized patients strength of the upper extremities is rated at 3. what does the nurse understand about this patients ability to perform activities of daily living (ADLs)
the patient is able to perform ADLs but not lift some items
a nurse teaches a patient who has been prescribed a 24-hour urine collection to measure excreted hormones. the patient asks "why do i need to collect urine for 24 hours instead of providing a random specimen?" how would the nurse respond?
this test will assess for a hormone secreted on a circulation rhythm
a nurse performs an assessment of pain discrimination on an older adult patient. the patient correctly identifies, with eyes closed, a sharp sensation on the right hand when touched with a pin. which action would the nurse take next
touch the pin on the same area of the left hand
lordosis is a common finding among patients with abdominal obesity
true
the PTH helps the body in maintaining optimal calcium levels
true
the pelvis joint is an example of a diarthrodial joint
true
the radioulnar area is an example of a pivot joint
true
a 55 year old, thin, caucasian women, aware of her high risk of developing osteoporosis, asks the nurse what she can do to slow progression. what should the nurse suggest?
walking w/ arm weights
a nurse cares for a patient who is recovering from a single photon emission computed tomography (SPECT) with a radiopharmaceutical agent. which statement would the nurse include when discussing the plan of care with the patient?
you are radioactive and must use a private bathroom
a nurse obtains a focused health history for a patient who is scheduled for magnetic resonance imaging (MRI). which condition would alert the nurse to contact the provider and cancel the procedure
internal insulin pump
a nurse collaborated with an unlicensed assistive personnel (UAP) to provide care for a patient who is prescribed a 24hour urine specimen collection. which statement would the nurse include when delegating this activity to the UAP?
note the time of the patients 1st void and collect urine for 24hrs
a patient presents to the ER reporting severe abdominal pain. on assessment, the nurse finds a bulging, pulsating mass in the abdomen. what action by the nurse is priority?
notify the provider immediately
a nurse is caring for a patient with a history of renal insufficiency who is scheduled for a compound tomography scan of the head with contrast medium. which priority intervention would the nurse implement
obtain a prescription for IV fluids
which of the following findings most strongly suggests that the patient is having a dysfunction of the musculoskeletal system
red cell count is low
a patient has a colonoscopy and biopsy yesterday and calls the GI clinic to report a spot of bright red blood on the toilet paper today. what response by the nurse is best?
remind the patient that a small amount of bleeding is possible
a nurse reviews the allergy list of a patient who is scheduled for a contrast-enhanced CT. which patient allergy should alert the nurse to urgently contact the healthcare provider?
seafood
a nurse prepares a patient for lumbar puncture (LP) what assessment finding would alert the nurse to contact the provider
shingles on the patients back
what GI problem is related to anorexia?
loss of appetite
a nurse reviews lab results for a patient who was admitted for a myocardial infarction and cardiogenic shock 2 days ago. which lab test result should the nurse expect to find?
BUN of 52mg/dL
the nurse delegates completing a bladder scan to an unlicensed assistive personnel (UAP). which action indicated that the nurse must provide additional instructions when delegating this task?
selecting the female icon for all female patients and male icon for all male patients
the nurse is assessing 4 patients with musculoskeletal disorders. the nurse would assess the patient with which lab result first?
serum phosphorus 2mg/dL
a nurse delegates care to the UAP. which statement would the nurse include when delegating care for a patient with cranial nerve II impairment
tell the patient where food items are on the breakfast tray
A nurse reviews the urinalysis results of a client and notes a urine osmolality of 1200 mOsm/L. Which action should the nurse take?
encourage the patient to drink more fluids
a nurse prepares a patient who is scheduled for an arthroscopy of the shoulder. which action by the nurse is most important
ensure that informed consent is on the chart
the patient tells the nurse that she is experiencing emotional stress related to concerns about her children and husband and whether she will be able to return to her job. Which GI condition is she at increased risk for?
exacerbation of irritable bowel syndrome
a nurse assesses a patient who is prescribed a medication that stimulates beta1 receptors. which assessment finding would alert the nurse to urgently contact the healthcare provider?
heart rate of 50 BPM
the nurse working with patients who have GI problems knows that which one of the following lab values are related to what organ dysfunction?
ALT: biliary system
a nurse prepares a patient for a percutaneous kidney biopsy. what actions should the nurse take PRIOR to this procedure? select all that apply
keep the patient NPO for 4-6 hrs Admin antihypertensive meds obtain coagulation study results
a nurse reviews a patients lab results. which results from the patients urinalysis should the nurse recognize as abnormal?
ketone bodies present
while performing a physical exam on a client, the nurse observes that the client has scoliosis based on
lateral deviation of the thoracic spine
to promote comfort after a colonoscopy, in what position does the nurse place the patient
left lateral
when assessing gait, what features does the nurse inspect
length of stride ease of stride steadiness balance
a nurse is providing education about preventing traumatic musculoskeletal injuries related to car crashes. which group does the nurse target as the priority for this education
high school male football team
what would be the critical significance of an elevated alkaline phosphate (ALP)
ALP increases with liver and bone damage
a nurse cares for a patient who is recovering from a colonoscopy. which of the following action would NOT be necessary for the nurse to take?
monitor the patients glucose level
a nurse assesses a patient who is recovering from a lumbar puncture (LP). which complication of this procedure would alert the nurse to urgently contact the provider
nausea and vomiting
a nurse prepares to palpate a patients thyroid gland. what action would the nurse take when performing this assessment?
place the patient in a sitting position with the chin tucked down
a nurse cared for a patient who is prescribed a serum catecholamine test. what action would the nurse take when obtaining the sample
place the sample on ice and send to the lab immediately
a nurse cares for a patient with diabetes mellitus who is prescribed metformin (Glucophage) and is scheduled for a contrast-enhanced CT. what action should the nurse take first?
contact the provider and recommend discontinuing the metformin
a nurse assess a female patient who presents with hirsutism. which question would the nurse ask when assessing this patient?
how do you feel about yourself?
a patient is scheduled for a colonoscopy and the nurse has provided instructions on the bowel cleansing regimen. what statement by the patient indicated a need for further teaching?
its a good thing i love orange and cherry gelatin
the student nurse studying the GI system understands that chyme refers to what?
liquefied food ready for digestion
the nurse knows that a patient with prolonged prothrombin time (PT) values (not related to medication) probably has dysfunction in which organ?
liver
a nurse teaches an 80 year old patient with diminished touch sensation. which statement would the nurse include in this patients teaching
look at the placement of your feet when walking
an older patient has had an instance of drug toxicity and asks why this happens, since the patient has been on this medication for years at the same dose. what response by the nurse is best?
your body probably cant tolerate as much medication anymore