nur 233 tophat- exam 3

Which of the following are physical changes seen at the end-of-life? (Select all that apply) A) Decreased urination B) Mottling of hands and feet C) Loss of gag reflex D) Increased blood pressure E) Difficulty speaking

A) Decreased urination B) Mottling of hands and feet C) Loss of gag reflex E) Difficulty speaking

Which nursing problem is priority for the 76-year-old client diagnosed with gastroenteritis from staphylococcal food poisoning? A) Fluid Volume Deficit B) Nausea C) Risk for aspiration D) Impaired urinary elimination

A) Fluid Volume Deficit

The client diagnosed with AIDS is experiencing diarrhea. Which interventions should the nurse implement? Select all that apply. A) Monitor diarrhea charting amount character and consistency. B) Assess the client's tissue turgor every day C) Encourage the client to drink carbonates soft drinks D) Weigh the client daily in the same clothes and at the same time E) Assist the client with a warm sitz bath PRN.

A) Monitor diarrhea charting amount character and consistency. D) Weigh the client daily in the same clothes and at the same time E) Assist the client with a warm sitz bath PRN.

Which of the following procedures is an anti-reflux surgery performed to treat GERD A) Nissen fundoplication B) Endoscopic balloon dilation C) Gastropexy D) Pyloroplasty

A) Nissen fundoplication

A patient who had open reduction and internal fixation (ORIF) of left lower leg fractures continues to report severe pain in the leg 15 minutes after receiving the prescribed IV morphine. The nurse determines pulses are faintly palpable and the foot is cool to the touch. Which action should the nurse take next? A) Notify the health care provider B) Assess the incision for redness C) Reposition the left leg on pillows. D) Check the patient's blood pressure

A) Notify the health care provider

A patient who had total knee replacement continues to report severe pain in the leg 15 minutes after receiving the prescribed IV morphine. The nurse determines pulses are faintly palpable and the foot is cool to the touch. What action should the nurse take next? A) Notify the healthcare provider B) Assess the incision for redness C) Request an alternative PRN pain medication from the healthcare provider D) Check the patient's HR and BP

A) Notify the healthcare provider

Which intervention is an example of secondary prevention when discussing osteoporosis? A) Obtain a bone density evaluation test B) Perform non-weight-bearing exercises regularly C) Increase intake of dietary calcium D) Refer clients to a smoking cessation program

A) Obtain a bone density evaluation test

Which action should the nurse take when beginning bladder training using scheduled voiding? A) Offer the patient a bedpan every 2 hours while awake B) Increase the voiding interval by 30-60 minutes each week C) Frequently ask the patient whether they have the urge to void D) Increase the frequency between voiding even if urine leakage occurs

A) Offer the patient a bedpan every 2 hours while awake

For a patient who has had right hip arthroplasty, which nursing action can the nurse delegate to experienced unlicensed assistive personnel (UAP)? A) Reposition the patient every 1 to 2 hours B) Assess for skin irritation on the patient's back. C) Teach the patient quadriceps-setting exercises. D) Determine the patient's pain intensity and tolerance.

A) Reposition the patient every 1 to 2 hours

A patient returns to the community clinic after being diagnosed with Parkinson's disease. What should the nurse expect to see documented in the patient's medical record to support this diagnosis? A) Rigidity with ambulation B) Unremarkable electroencephalogram C) Results of basic metabolic panel and CBC D) Integrity of cerebral vessels after a cerebral angiogram

A) Rigidity with ambulation

The nurse is developing a plan of care for a client with late-stage Alzheimer's disease. The nurse identifies which client problem as having the highest priority? A) Risk for injury B) social isolation behaviors C) Role performance alterations D) Inability to communicate verbally

A) Risk for injury

The nurse notes that an older client with dementia is unable to care for herself. Which is an appropriate goal for this client? A) The client will function at the highest level of independence possible throughout their stay B) the client will be admitted to a longterm care facility to have activities of daily living (ADL) needs met C) The nursing staff will attend to all of the clients ADL needs during the hospital stay D) The client will complete all ADL independently within a 1-hour time frame

A) The client will function at the highest level of independence possible

The nurse is caring for a patient admitted with severe dehydration secondary to gastroenteritis. Which item on the patient's meal tray does the nurse question? A) Apple juice B) Coffee C) Broth D) Caffeine-free soda

B) Coffee

In providing care to a patient who underwent a colostomy 2 days ago for the treatment of colon cancer, which finding requires an immediate intervention? A) Serosanguineous drainage from the stoma B) Dark red, purplish color of the stoma C) Slight edema of the stoma D) Reddish-pink, moist stoma

B) Dark red, purplish color of the stoma

Which finding should the nurse expect when assessing a patient who has osteoarthritis (OA) of the knee? A) Presence of Herberden's nodules B) Discomfort with joint movement C) Redness and swelling of the knee joint D) Stiffness that increases with movement

B) Discomfort with joint movement

The nurse monitors for which clinical manifestations in the patient diagnosed with acute gastritis? A) Eructation B) Epigastric pain C) Constipation D) Peripheral edema

B) Epigastric pain

The nurse and the unlicensed assistive personnel (UAP) are caring for clients on a medical-surgical unit. Which task should not be assigned to the UAP? A) Turn and position the 89-year old client diagnosed with a pressure ulcer secondary to parkinson's disease B) Feed the 69-year-old client diagnosed with parkinson's disease who is having difficulty swallowing C) Assist the 54-year-old client diagnosed with Parkinson's disease with toilet-training activities D) obtain vital signs on a 72-year-old client diagnosed with pneumonia secondary to parkinson's disease

B) Feed the 69-year-old client diagnosed with parkinson's disease who is having difficulty swallowing

During morning rounds, the nurse notes that the unlicensed assistive personnel is assisting a patient with Parkinson's disease with breakfast. Which observation requires an immediate intervention? A) Patient sitting out of bed in a chair B) Head of the bed raised to 30 degree C) Thickener added to liquid menu items D) Oral suction catheter equipment turned on

B) Head of the bed raised to 30 degree

Which statement by the patient taking proton pump inhibitors for peptic ulcer disease indicates understanding about the action of this medication? A) "This medication coats the lining of my stomach" B) "This medication suppresses secretion of acid in my stomach" C) "This medication decreases vomiting" D) "This medication neutralizes the acid in my stomach"

B) "This medication suppresses secretion of acid in my stomach"

The male client tells the nurse he has been experiencing "heartburn" at night that awakens him. Which assessment question should the nurse ask? A) "How much weight have you gained recently?" B) "What have you done to alleviate the heartburn?" C) "Do you consume many milk and dairy products?" D) "Have you been around anyone with a stomach virus?"

B) "What have you done to alleviate the heartburn?"

A patient is admitted to the emergency department reporting a burning pain in the chest of a 7 on a 0 to 10 pain scale and diagnosed with gastroesophageal reflux disorder (GERD) secondary to hiatal hernia. Based on this data, what is the priority nursing diagnosis? A) Fluid volume deficit B) Acute pain C) Ineffective health maintenance D) Dysfunctional gastrointestinal motility

B) Acute pain

The nurse is examining a 18-year-old female who is complaining of pain, frequency, and urgency when urinating. Which question should the nurse ask the client first? A) "Have you noticed any change in the color of your urine?" B) "When was your last menstrual cycle?" C) "Are you sexually active?" D) "What have you taken for pain?"

C) "Are you sexually active?"

Which statement by the patient diagnosed with gastritis indicates the need for further teaching? A) "I will eat bland, non spicy foods." B) "I will eat smaller, more frequent meals." C) "I will take aspirin for headaches." D) "I will take an antacid if my symptoms continue."

C) "I will take aspirin for headaches."

The nurse has implemented a care plan for an adult patient with gastroesophageal reflux disorder (GERD). On the next clinic visit, which statement by the patient indicates adherence to the plan of care? A) "I still like wearing my Spandex camisoles." B) "I have switched from margaritas to wine." C) "I've lost 6 pounds because I eat every 3 hours and never before bed." D) "I lay down flat after eating to promote digestion."

C) "I've lost 6 pounds because I eat every 3 hours and never before bed."

The nurse is assisting the client in caring for her ostomy. The client states, "Oh, this is so disgusting. I'll never be able to touch this thing." The nurse's best response is A) "I'm sure you will get used to taking care of it eventually." B) "Yes, it is pretty messy, so I'll take care of it for you today." C) "It sounds like you are really upset." D) "You sound very angry. Should I call the chaplain for you?"

C) "It sounds like you are really upset."

A patient returns to the clinic for an evaluation 2 weeks after total hip replacement. Which statement by the patient indicates the need for further teaching? A) "My daughter helps me put on my elastics stockings every morning." B) "Even though I use my walker, I still have a limp." C) "Now that I am stronger, I no longer need to use the raised toilet seat." D) "Each day I try to increase my walking time by 10 minutes."

C) "Now that I am stronger, I no longer need to use the raised toilet seat."

An older patient is admitted to the hospital with a urinary infection and possible bacterial sepsis. The family is concerned because the patient is confused and not able to carry on a conversation. Which statement by the nurse is most appropriate? A) "Depression is a common cause of confusion in older adults in the hospital." B) "It is normal for an older person to have cognitive problems while in the hospital." C) "The mental changes are most likely caused by the infection and most often reversible." D) "Drug therapy with antipsychotic agents is indicated to slow the progression of dementia."

C) "The mental changes are most likely caused by the infection and most often reversible."

The client being admitted from the emergency department is diagnosed with a fecal impaction. Which nursing intervention should be implemented? A) Administer anti-diarrheal medication everyday PRN B) Perform bowel training every two (2) hours. C) Administer an oil retention enema D) prepare for an upper gastrointestinal series x-ray

C) Administer an oil retention enema

The nurse monitors for which clinical manifestations in the patient diagnosed with Parkinson's disease? A) Photophobia B) Nuchal rigidity C) Bradykinesia D) Decreased level of consciousness

C) Bradykinesia

The nurse is assessing the patient for palliative care. When assessing the psychosocial and psychiatric domain, which should the nurse include? A) Financial concerns B) Pain C) Depression D) Spiritual concerns

C) Depression

What finding should the nurse expect when assessing a patient with osteoarthritis of the knee? A) Bouchard's nodes B) A fever C) Discomfort with joint movement D) Redness and swelling of the joint

C) Discomfort with joint movement

One month after discharge, a client who had a left total hip replacement calls a clinic reporting acute constant pain in the left groin and hip area and feeling like the left leg is shorter than the right. A nurse advises the client to come to the clinic immediately suspecting: A) Wound infection B) Deep Vein Thrombosis C) Dislocation of the prosthesis D) Aseptic loosening of the prosthesis

C) Dislocation of the prosthesis

Transverse colostomy

semiliquid to semiformal stool

The nurse identifies the diagnosis Impaired Urinary Elimination in an older adult patient admitted after a stroke. Impaired Urinary Elimination places the patient at risk for which complication? A) Skin breakdown B) UTI C) Bowel incontinence D) Renal calculi

skin breakdown

Which statements by the patient diagnosed with celiac disease indicate the need for further teaching? Select all that apply. A) "I am glad this can be cured with surgery" B) "I cannot have any gluten in my diet" C) "I ash all my dishes with water only" D) "I may become anemic because of this disease" E) "I am at risk for osteoporosis"

A and C

The nurse is educating the family of a patient in hospice care who is receiving morphine for pain because of a terminal illness. Which statement by the family member indicates the need for further teaching? A) "I can only give the pain medications when requested." B) "I can give the pain medications if the patient is groaning and restless." C) "It is important to try to give these medications to manage the pain." D) "The morphine may also help the breathing difficulties.

A) "I can only give the pain medications when requested."

Which response by the nurse indicates the use of reflective listening when communicating with the family of a patient who is in the process of dying? A) "I can see this is difficult for you." B) "Thank you for taking such good care of your mother." C) "Your mother is experiencing quite a bit of pain at the moment." D) "A social worker will be able to answer all the questions that you have."

A) "I can see this is difficult for you."

The client diagnosed with a hiatal hernia is scheduled for a laparoscopic Nissen fundoplication. Which statement indicates the nurse's teaching is effective? A) "I will have four (4) to five (5) small inclusions?" B) "I will be in the hospital for at least one (1) week" C) "I will not have any pain because this is a laparoscopic surgery" D) "I will be returning to work the day after my surgery"

A) "I will have four (4) to five (5) small inclusions?"

The client diagnosed with hiatal hernia is scheduled for a laparoscopic nissan fundoplication. Which statement indicates the nurses teaching is effective? A) "I will have four to five small incisions" B) "I will be in the hospital for at least one week" C) "I will not have any pain because this is a laparoscopic surgery" D) "I will be returning to work the day after my surgery"

A) "I will have four to five small incisions"

A 68-year-old patient who is hospitalized with pneumonia is disoriented and confused 3 days after admission. Which information indicates that the patient is experiencing delirium rather than dementia? A) The patient was alert and oriented when admitted B) The patient's speech is fragmented and incoherent C) The patient is oriented to person but disoriented to place and time D) The patient has a history of increasing confusion over several years

A) The patient was alert and oriented when admitted

The student nurse asks for an indwelling urinary catheter for a hospitalized patient who is incontinent. Which response should the nurse make about the use of catheters only being absolutely necessary? A) They are the leading cause of infection B) They are too expensive for routine use C) They contain latex, increasing the risk for allergies D) Insertion is painful for most patients

A) They are the leading cause of infection

Which problem is most appropriate for the nurse to identify for the client with diarrhea? A) Alteration in skin integrity B) Chronic pain perception C) Fluid volume excess D) Ineffective coping

A) alteration in skin integrity

Which information indicates to the nurse the client teaching about treatment of urinary incontinence has been effective? A) prepares a scheduled voiding plan B) The client verbalizes the need to increase fluid intake C) The client explains how to perform pelvic floor exercises. D) the client attempts to retain the vaginal cone in place the entire day

A) prepares a scheduled voiding plan

The nurse is providing care to a patient who is diagnosed with terminal lung cancer. Which clinical manifestations indicate imminent death? Select all that apply. A) Diaphoresis B) Increased cardiac output C) Decreased blood pressure D) Tachycardia followed by bradycardia E) An increase in urine output F) Loss of gag reflex G) Difficulty speaking

A, C, D, F, G

The nurse correlates which data in a female patient's history to an increased risk of urinary tract infection (UTI)? Select all that apply. A) 25 year old who is sexually active B) Drink 2L of water per day C) 28 weeks pregnant D) History of back strain E) History of renal calculi

A, C, E

Sigmoid colostomy

Formed stool

The wife of a patient with end-stage chronic obstructive pulmonary disease (COPD) tells the nurse that she wishes her husband were eligible for hospice care, but she thinks that hospice is only available for cancer patients and would require a change in healthcare providers. Which responses by the nurse are appropriate? Select all that apply. A) Inform her that hospice care is very expensive B) Inform her that a diagnosis of cancer is not required for hospice care C) Inform her that all hospice programs provide care 24 hours per day, 7 days per week D) Inform her that her husband can retain his provider when transitioning to hospice care. E) Inform her that her husband is not eligible for hospice care with the current diagnosis of COPD.

B) Inform her that a diagnosis of cancer is not required for hospice care D) Inform her that her husband can retain his provider when transitioning to hospice care.

Which nursing interventions should be included in the care plan for the 84-year-old client diagnosed with acute gastroenteritis? Select all that apply. A) Assess the skin turgor on the back of the client's hands. B) Monitor the client for orthostatic hypotension. C) Record the frequency and characteristics of sputum D) Use standard precautions when caring for the client E) Institute safety precautions when ambulating the client

B) Monitor the client for orthostatic hypotension D) Use standard precautions when caring for the client E) Institute safety precautions when ambulating the client

The nurse is providing care for a patient receiving curative care who is experiencing chronic pain as a result of cancer. Which type of care should the nurse plan for on discharge for this patient? A) Home healthcare B) Palliative care C) Hospice care D) Rehabilitative care

B) Palliative care

The nurse is caring for an older client following surgical repair of a hip fracture. On assessment of the client, the nurse notes that the client is disoriented and is attempting to get out of bed. Which is the most appropriate initial nursing intervention? A) Apply restraints to the client B) Place a bed alarm pad under the patient C) collaborative with the health care provider for a prescription or a sedative D) Have the unlicensed assistive personnel check the client every half hour

B) Place a bed alarm pad under the patient

The nurse is working on an orthopedic floor. Which client should the nurse assess first after the change-of-shift report? A) The 84-year-old female with a fractured right femoral neck in Buck's traction B) The 64-year-old female with a left total knee replacement who has confusion C) The 88-year-old male post-right total hip replacement with an abduction pillow. D) The 50-year-old postop client with a continuous passive motion (CPM) device.

B) The 64-year-old female with a left total knee replacement who has confusion

The nurse is caring for an elderly client who has an indwelling catheter. Which data warrant further investigation? A) The clients temperature is 98 degrees Fahrenheit B) The client has become confused and irritable. C) The client's urine is clear and light yellow D) The client feels the need to urinate

B) The client has become confused and irritable.

A client diagnosed with delirium becomes disoriented and confused at night. Which intervention should the nurse implement initially? A) Move the client next to the nurses' station B) use an indirect light source and turn off the television C) Keep the television and a soft light on during the night D) Play soft music during the night, and maintain a well-lit room.

B) use an indirect light source and turn off the television

The nurse instructs a woman about providing a clean-catch urine specimen. Which statement indicates that the patient correctly understands the procedure? A)"I will be sure to urinate into the 'hat' you placed on the toilet seat" B)"I will wipe my genital area from front to back with the wipes provided before I collect the specimen midstream" C)"I will need to lie still while you put in a urinary catheter to obtain the specimen" D)"I will collect my urine each time I urinate for the next 24 hours"

B)"I will wipe my genital area from front to back with the wipes provided before I collect the specimen midstream"

What does the nurse include in the education of a patient who is being discharged after a laparoscopic Nissen fundoplication? Select all that apply. A) Follow a soft diet for 1 month B) Avoid foods that are not easy to swallow C) Lie down immediately after eating D) Avoid carbonated beverages E) No heavy lifting until cleared by surgeon

B, D, E

In providing care to the patient admitted for gastritis, which clinical manifestation requires immediate notification of the healthcare provider? A) Nausea B) Anorexia C) Hematemesis D) Epigastric pain

C) Hematemesis

For what purpose would the nurse use the Mini-Mental State Examination to evaluate a patient with cognitive impairment? A) It is a good tool to determine the etiology of dementia B) It is a good tool to evaluate mood and thought processes C) It can help to document the degree of cognitive impairment D) It is a definitive test for Alzheimer's

C) It can help to document the degree of cognitive impairment

A patient is being discharged 4 days after hip arthroplasty using the posterior approach. Which patient action requires intervention by the nurse? A) using crutches with a swing-to gait B) Sitting upright on the edge of the bed C) Leaning over to pull on shoes and socks D) Bending over the sink while brushing teeth

C) Leaning over to pull on shoes and socks

A competent older adult patient has an advance directive that expresses the patient's desire to avoid resuscitation and heroic life support measures. The patient's family, however, is not supportive of this directive and plans to contest the living will. Which nursing action is appropriate based on the current situation? A) Notify the hospital attorney B) Contact the social services department C) Place the document in the patient's medical record D) Explain to the patient that the conflict could invalidate the document

C) Place the document in the patient's medical record

A patient with Alzheimer's disease (AD) who is being admitted to a long-term care facility has had several episodes of wandering away from home. Which action will the nurse include in the plan of care? A) Reorient the patient several times daily B) Have the family bring in familiar items C) Place the patient in a room close to the nurse's station D) Remind the patient not to wander from the nursing unit

C) Place the patient in a room close to the nurse's station

Which task can the nurse safely delegate to the nursing assistive personnel? A) Palpate the bladder of a patient who is unable to void B) Administering a continuous bladder irrigation C) Providing indwelling urinary catheter care D) Obtaining the patient's history and physical assessment

C) Providing indwelling urinary catheter care

The nurse is preparing a client diagnosed with GERD for surgery. Which information warrants notifying the HCP? A) The clients Bernstein esophageal test was positive B) The client's abdominal x-ray shows a hiatal hernia C) The client's WBC count is 14,000/mm3 D) The clients hemoglobin is 13.8g/dL

C) The client's WBC count is 14,000/mm3

Frequent assessment of patients with urinary tract infections is important for the recognition and early treatment of what potentially lethal complication? A) Pyelonephritis B) Hydronephrosis C) Urosepsis D) Cystitis

C) Urosepsis

The nurse is caring for a client with Parkinson's disease. Which finding about gait should the nurse expect to note in the client? A) Walking on the toes B) Unsteady and staggering C) shuffling and propulsive D) broad-based and waddling

C) shuffling and propulsive

The client presents to the outpatient clinic complaining of diarrhea for two (2) days. Which laboratory data should the nurse monitor? A) the sodium level B) the albumin level C) the potassium level D) the glucose level

C) the potassium level

Which patient statement indicates the need for additional teaching for the patient being discharged after total knee placement (TKR)? A) "Narcotics may cause constipation, so I will increase my water intake." B) "I will use an electric razor while I am on the blood thinners after surgery." C) "I will report pain, tenderness, or warmth in my calf to my doctor immediately." D) "I need to increase my intake of green, leafy vegetables to aid healing."

D) "I need to increase my intake of green, leafy vegetables to aid healing."

The client is being prescribed alendronate (Fosamax) to slow the progression of her osteoporosis. You know she will need more patient teaching when she says A) "I should take this medication early in the morning." B) "I should not lie down for 1 hour after taking this medication." C) "I should drink a full glass of water after taking this medication." D) "Now that I am taking this medication, I will not need to take vitamin D with my calcium supplement."

D) "Now that I am taking this medication, I will not need to take vitamin D with my calcium supplement."

The patient asks the nurse, "How did I get this urinary tract infection?" The nurse should explain that in most instances, in females, it is usually caused by: A) Congenital strictures in the urethra. B) An infection elsewhere in the body. C) Urine stasis in the bladder D) An ascending infection from the urethra

D) An ascending infection from the urethra

As the nurse admits a patient in end-stage renal disease to the hospital, the patient tells the nurse, "If my heart or breathing stop, I do not want to be resuscitated." Which action should the nurse take first? A) Place a "Do Not Resuscitate" (DNR) notation in the patient's care plan. B) Invite the patient to add a notarized advance directive in the health record C) Advise the patient to designate a person to make future health care decisions. D) Ask if the decision has been discussed with the patient's health care provider.

D) Ask if the decision has been discussed with the patient's health care provider.

The nurse is caring for a client diagnosed with GERD. Which nursing interventions should be implemented? A) place the client prone in bed and administer nonsteroidal anti-inflammatory medications B) Have the client remain upright at all times and walk for 30 minutes three (3) times a week. C) Instruct the client to maintain a right lateral side-lying position and take antacids before meals D) Elevate the head of the bed (HOB) 30 degrees and discuss lifestyle modifications with the client

D) Elevate the head of the bed (HOB) 30 degrees and discuss lifestyle modifications with the client

Which intervention would help to prevent or relieve persistent nausea? A) Assess for signs of dehydration. B) Provide dietary supplements. C) Have the patient sit in an upright position for 30 minutes after eating. D) Immediately remove any food that the patient cannot eat.

D) Immediately remove any food that the patient cannot eat.

Which menu choice by a patient with osteoporosis indicates the nurse's teaching about appropriate diet has been effective? A) Pancakes with syrup and bacon B) Whole wheat toast and fresh fruit C) Egg-white omelet and half a grapefruit D) Oatmeal with skim milk and and fruit yogurt

D) Oatmeal with skim milk and and fruit yogurt

The nurse explains to the patient with gastroesophageal reflux disease (GERD) that this disorder: A) Results in acid erosion of the esophagus from frequent vomiting. B) Will require surgical wrapping or repair of the pyloric sphincter to control the symptoms. C) Is the protrusion of a portion of the stomach into the esophagus through an opening in the diaphragm. D) Often involves relaxation of the lower esophageal sphincter (LES), allowing stomach contents to back up into the esophagus.

D) Often involves relaxation of the lower esophageal sphincter (LES), allowing stomachcontents to back up into the esophagus.

A client asks the nurse to take a laxative, as he or she has not had a bowel movement today. What is the first information the nurse should obtain prior to administering the laxative? A) The amount of fiber in daily diet B) The last dose of laxative received C) If the client has had any flatus D) The client's normal bowel elimination pattern

D) The client's normal bowel elimination pattern

Which diagnostic test does the nurse correlate to the diagnosis of an active infection with Helicobacter pylori for a patient diagnosed with gastritis? A) Guaiac B) Hematest C) Hemoccult D) Urea breathing test

D) Urea breathing test

An older client is brought to the hospital emergency department by a neighbor who heard the client talking and found him wandering in the street at 3 a.m. The nurse should first determine which data about the client? A) His insurance status B) blood toxicology levels C) Whether he ate his evening meal D) Whether this is a change in usual level of orientation

D) Whether this is a change in usual level of orientation

D.B. is admitted to a long-term care facility. He has a nursing diagnosis of impaired memory related to effects of dementia. An appropriate nursing intervention for him is to A) let him know what behavior is socially appropriate. B) assist him with all self-care to maintain self-esteem. C) maintain familiar routines of sleep, meals, drug administration, and activities. D) promote orientation at every encounter with the patient by asking the day, time, and place.

D) promote orientation at every encounter with the patient by asking the day, time, and place.

A patient complains that urine is passed when coughing or sneezing. How should the nurse document this complaint in the patient's healthcare record? A) Transient incontinence B) overflow incontinence C) Urge incontinence D) stress incontinence

D) stress incontinence

Which diagnostic test should the nurse anticipate when providing care to a patient who is suspected of having a hiatal hernia? A) CBC B) Lower abdominal x-ray C) Barium enema D)Esophagogastroduodenoscopy (EGD)

D)Esophagogastroduodenoscopy (EGD)

In assessing pain in the patient with a urinary tract infection, which clinical manifestation does the nurse correlate to progression of the infection to pyelonephritis? A) dysuria B) Flank pain C) hematuria D) Urinary frequency

Flank Pain

Ileostomy

Liquid to semiliquid stool

Descending colostomy

Semiformal stool

Ascending colostomy

Semiliquid stool

The nurse correlates which physiological factor to the decreased risk of urinary tract infection in men compared with women? A) increased urine flow B) ureter length C) Prostate enlargement D) Urethral length

urethral length