NUR 322 Final

A patient with a recent diagnosis of terminal cancer states, "I can't believe I am going to die. Why me? What is your best response? (CO7)

This must be difficult for you

Family members and significant others often disrupt care in complex health situations and should be eliminated from care planning for the patient. (CO7)

False

For those Americans over the age of 65, the most common place for death remains the home. (CO3)

False

Most materials in contact with the surgical wound or used within the sterile field must be sterile. (CO4)

False

Patients and their families may request alternative therapies, but should be discouraged and encouraged to follow only professional health care guidelines. (CO6)

False

Patients receiving internal radiation for palliative care do not emit radiation while the implant is in place allowing family to visit freely. (CO4)

False

Palliative care focuses on caring for the patient in the following manner: Select all that apply. (CO4)

Family and patient support Symptom management Pain and symptom control

The most commonly used opioid IV medication that may cause chest wall rigidity is? (CO3)

Fentanyl

A client with pulmonary edema has an order for oxygen. The nurse will administer the oxygen using a: (CO3)

Non-rebreather mask

The nurse is caring for a client with an endotracheal tube who is on a ventilator. When assessing he client, the nurse knows to maintain what cuff pressure to maintain appropriate pressure on the tracheal wall? (CO5)

20 and 25 mm Hg

The nurse should recognize that a patient with HIV is considered to have AIDS at the poitn when the CD4+T-lymphocyte cell count drops below what mark? (CO4)

200 cells/mm3 of blood

The pathophysiology of an ischemic stroke involves the ischemic cascade, which includes the following steps: (CO3) 1. Change in pH 2. Blood flow decreases 3. A switch to anaerobic respiration 4. Membrane pumps fail 5. Cells cease to function 6. Lactic acid is generated

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A nurse who works in the specialty of palliative care frequently encounters issues and situations that constitute ethical dilemmas. What issue has most often presented challenging ethical issues, especially in the context of palliative care? (CO2)

Ability of technology to prolong life beyond meaningful quality of life.

The current phase of a patient's treatment for a burn injury prioritizes wound care, nutritional support, and prevention of complications such as infection. Based on this care, the patient is in what phase of burn care? (CO3) (CO4)

Acute

What nursing action is most likely to increase the likelihood of successful antiretroviral therapy? (CO3) (CO4)

Addressing the possible barriers to adherence

A nurse who sits on the hospital's ethics committee is reviewing a complex case that has many of the hallmarks of assisted suicide. Which of the following would be an example of assisted suicide? (CO3)

Administering a lethal dose of medication to a patient whose death is imminent.

The nurse should be aware of what cardinal signs of brain death? Select all that apply? (CO3)

Apnea Coma Absence of brain stem reflexes

The nurse has implemented interventions aimed at facilitating family coping in the care of a patient with a traumatic brain injury (TBI). How can the nurse best facilitate family coping?(CO7)

Assist the family in setting short-term goals

What health education should the nurse provide to a patient diagnosed with a back strain? (CO4).

Avoid lifting more than one-third of body weight without assistance.

The nurse is caring for a 39-year-old woman with a family history of breast cancer. Her diagnosis is stage four breast cancer, with stage four nodule involvement with metastasis to the spinal column. In order to reduce her back pain, her surgeon decided to a debulking procedure. This surgery is an example of what type of oncological surgery? (CO3)

Palliative surgery

A nurse who provides care on an acute medical unit has observed that physicians are frequently reluctant to refer patients to hospice care. What are contributing factors that are known to underlie this tendency? Select all that apply. (CO3)

Patient reluctance to accept this type of care Financial pressures on health care providers Advances in curative treatment in late-stage illness

The stage of grief where a terminally ill patient pleads for more time to reach a goal is known as: (CO4)

Bargaining

The acute medical nurse is preparing to wean a patient from the ventilator. Which assessment parameter is most important for the nurse to assess?(CO4)

Baseline arterial blood gas (ABG's) levels

A patient with a new diagnosis of ischemic stroke is deemed to be a candidate for treatment with tissue plasminogen activator (t-PA. The nurse monitors for what complication of this treatment? (CO3)

Bleeding

What clinical manifestation would the nurse expect to see in autonomic dysreflexia? (CO3)

Bradycardia and hypertension

What physical finding is suggestive of a basilar skull fracture? (CO3)

Bruising over the mastoid

The patient diagnosed with a right-sided stroke is presently experiencing hemianopsia. How would the nurse help the patient manage potential sensory and perceptional difficulties? (CO3)

Place the patient's extremities where the patient can see them.

What is the most common life-threatening infection of an HIV patient whose CD4+ count has fallen. (CO3)

Pneumocystis pneumonia

A patient has come into the free clinical asking to be tested for HIV infection. The patient asks the nurse how the test works. The nurse responds that if the testing shows that antibodies to the AIDS virus are present in the blood, this indicates what? (CO3) (CO4)

The patient has been infected with HIV.

A nurse is providing a class to adults at a senior community center. In an effort to prevent osteoporosis, the nurse should encourage participants to ensure that they consume the recommended intake of what nutrients? Select all that apply. (CO3) (CO4)

Calcium Vitamin D

The nurse is preparing a patient for surgery. The patient states that she is nervous and really does not understand what the surgical procedure is for or how it will be preformed. What is the most appropriate nursing action for the nurse to take? (CO4)

Call the physician to review the procedure clearly to the patient and her family.

A major nursing diagnosis in the postoperative period may include decreased _______________ output related to shock or hemorrhage.(CO3)

Cardiac

The hospice nurse has just admitted a new patient to the program. What principles guide hospice care? (CO3)

Care addresses the needs of the patient as well as the needs of the family

What principle of care should the nurse inform the family of a patient who has experienced an ischemic stroke? (CO7)

The patient should mobilize as soon as physically able.

In anticipation of a patient's scheduled surgery, the nurse is teaching the patient to perform deep breathing and coughing to use postoperatively. What action should the nurse teach the patient?. (CO3)

The patient should take a deep breath through the mouth and exhale through the mouth, take a short breath, and cough deep in the lungs.

A nurse is conducting a health program regarding grief. Considering concepts related to loss, which client is most likely to experience an unsuccessful grief response? (CO4)

The young child experiencing sudden death of a parent

The healthcare provider is caring for a patient on a ventilator with an endotracheal tube in place. What assessment data indicate the tube has migrated too far down the trachea? (CO3)

Decreased breath sounds on the left side of the chest

The nurse is providing postoperative care to a patient who had limb-sparing surgery which removed a metastatic bone tumor. What complication should the nurse assess for following the procedure? (CO4).

Delayed wound healing

In phase III of postanesthesia care, you would be preparing the patient for what part of nursing care? (CO5)

Discharge

The nurse is assessing a patient who is known to have right-sided heart failure (HF). What assessment finding is most consistent with this patient's diagnosis? (CO3)

Distended neck veins

A nurse in the preoperative holding area is admitting a woman prior to a mastectomy. What should the nurse include in the care given to this patient? Select all that apply.(C03).

Establishing an IV line Taking measure to ensure the patient's comfort Verifying the surgical site with the patient

The stage of general anesthesia which is characterized by struggling, shouting, laughing, or crying and can often be avoided if the anesthetic is administered smoothly and quickly. (CO4)

Excitement

A patient is brought to the emergency department with a burn that involves the epidermis, dermis, muscle and the bone of his right arm. On inspection, the skin feels charred. Based on these assessment findings, what is the depth of the burn? (CO3)

Full-thickness

A headache, an after-effect of spinal anesthesia, is related to three factors: the size of the spinal needle used, leakage of fluid from the subarachnoid space through the puncture site, and the patients? (CO3)

Hydration status

What abnormal laboratory values would you expect to find in the emergent/resuscitative phase of a burn injury? (CO3) (CO4)

Hyperkalemia, hyponatremia,elevated hemocrit, and metabolic acidosis

The intraoperative nurse is implementing a care plan that addresses the surgical patient's risk for vomiting. Interventions that address the potential for vomiting reduce the risk of what subsequent surgical complication? (C03)

Hypoxia

The Glasgow Come Scale (GCS) allows the nurse to gauge what aspect of the patient's status? (CO3)

Level of consciousness

After a major ischemic stroke, a possible complication is cerebral edema. What is the nursing care during the immediate recovery period from an ischemic stroke? (CO3)

Positioning to avoid hypoxia

A patient with a T2 spinal cord injury is exhibiting signs of neurogenic shock. In addition to monitoring the patient, what would be the nurse's most appropriate action? (CO3)

Prepare for interventions to increase the patient's blood pressure

The nurse is caring for a patient in the ICU who has been diagnosed with multiple organ dysfunction syndrome (MODS). The nurse's plan of care should include which of the following interventions? (CO4)

Promoting communication with the patient and family along with addressing end of life issues.

A patient experienced a 33% TBSA burn 72 hours ago. The nurse observes that the patient's hourly urine output has been steadily increasing over the past 24 hours. How should the nurse best to this finding?

Recognize that the patient is experiencing an expected onset of diuresis.

A patient presents a a clinic complaining of back pain that goes all the way down the back of the leg to the foot. The nurse should document the presence of what type of pain? (CO3) (CO4)

Sciatica

A client receiving a transfusion of packed red blood cells (PRBCs) begins to vomit. The client's blood pressure is 90/50 mm Hg from a baseline of 125/78 mm Hg. The client's temperature is 100.8 ° F orally from a baseline of 99.2 ° F orally. The nurse determines that the client may be experiencing which complication of a blood transfusion? (C03)

Septicemia

The nurse caring for a patient with an endotracheal tube recognized several disadvantages of an endotracheal tube. What would the nurse recognized as a disadvantage of endotracheal tubes? (CO3)

The cough reflex is suppressed.

The nurse overseeing care in the ICU review the shift report on four patients. The nurse recognizes which patient to be at the greatest risk for the development of cardiogenic shock? (CO3)

The patient admitted with a MI

A nurse is providing palliative care to a patient with a diagnosis of end-stage chronic obstructive pulmonary disease (COPD). What is the primary goal of this nurse's care? (CO4)

To improve the patient's and families quality of life

The nurse caring for a client with Guillain-Barre syndrome sill communicate the possibility of what signs and symptoms of the disease? (CO3)

Tongue enlargement

A durable power of attorney for health care is an advanced directive that authorizes another person to make medical decisions when the person is no longer able to do so. (CO2)

True

Alternative therapies such as music therapy may assist in relaxation and pain control. (CO6)

True

Assessment of respiratory status in the hospitalized postoperative patient is imperative because pulmonary complications are the most frequent problem encountered by the surgical patient. (CO4)

True

At the irreversible stage of shock introducing palliative care could be of benefit to the patient and family. (CO3)

True

In the 20th century, the major causes of death will continue to be chronic, degenerative diseases. (CO3)

True

An uncommon yet serious complication of surgery that can result in hypovolemic shock and death is _________________. (CO3)

hemorrhage

The nurse is planning the care of a patient with HF. The nurse should identify what overall goals of this patient's care? Select all that apply. (CO3)

Improve functional status Extend survival Relieve the patient's symptoms

The nurse is creating a plan of care for a client with cardiomyopathy. What priority goal should underlie most of the assessments and interventions that are selected for this patient? (CO3)

Improved cardiac output

The patient admitted to the medical unit with heart failure (HF) is exhibiting signs and symptoms of pulomonary edema. The nurse is aware that positioning will improve circulation. (CO4)

In a high Fowler's position

A nurse has participated in organizing a blood donation drive at a local community center. Which of the following individuals would most likely be disallowed from donating blood? (CO4)

A woman whose blood pressure is 88/51 mm Hg

A patient with Myasthenia Gravis has begun treatment with pyridostigmine bromide (Mestinon). What change in status would clearly suggest a therapeutic benefit of this medication? (CO3)

Increased muscle strength

The nurse is caring for a patient with severe left ventricular dysfunction who has been identified as being at risk for sudden cardiac death. What medical interventions can be performed that may extend the survival of the patient? (CO3)

Insertion of an implantable cardioverter defibrillator

A patient's burn are estimated at 36% of total body surface area: fluid resuscitation has been ordered. What should the nurse anticipate the administration of what fluid? (CO3) (CO4)

Lactated ringers

A nurse is providing preoperative teaching to a patient which includes exercises of the extremities. What is the purpose of teaching patients leg exercises after surgery? (CO3)

Leg exercises improve the circulation and prevent venous thrombosis.

What is the preferred anesthetic method in any surgical procedure? (CO3).

Local

What primary neuroimaging diagnostic tool is used to evaluate a patient with diffuse axonal injury? (CO3)

MRI

What basic information should the nurse provide to client diagnosed with MS?. (CO3)

MS is a progressive demyelinating disease of the nervous system.

The nurse is creating a care plan for an adult patient requiring mechanical ventilation. What nursing action is most appropriate? (CO3, CO4)

Monitor cuff pressure every 8 hours

A nurse is caring for a patient who is terminally ill with lung cancer. Which assessment would clearly indicate that death is imminent? (CO3)

Mottling of the lower extremities

What assessment finding would the nurse expect with a patient diagnosed with bacterial meningitis? (CO3)

Neck flexion produces flexion of knees and hip

The healthcare provider is caring for a patient who has a pneumothorax. When assessing the patient and the chest tube drainage system, a large fibrin clot is noted in the tubing. Which additional assessment finding requires immediate action by the healthcare provider? (CO3)

No fluctuations in the water seal chamber

Collaboration with members of the interprofessional team for burn patients may include; pharmacists, physical, occupational, and speech therapies, dietitians, and mental health professionals. (CO7)

True

Inadvertent hypothermia during surgery can depress neuronal activity and decrease cellular oxygen requirements below the minimum levels normally required for continued cell viability. (CO3)

True

Patients and their families need psychosocial support when faced with trauma associated with burns. (CO3)

True

The Valsalva maneuver can prevent wound healing by producing tension on surgical wounds. (CO3)

True

The first symptom of deep vein thrombosis may be a pain or a cramp in the calf. (CO3)

True

The most common cause of cardiovascular disease in the United States is atherosclerosis, which is an abnormal accumulation of lipid, or fatty substances and fibrous tissue in the lining of arterial blood vessel walls. (CO3)

True

Versed is an intravenous anesthetic agent that acts as a hypnotic and amnesic. (CO3)

True

A patient with a metastatic brain tumor is having a generalized seizure and begins to vomit. What should the nurse do first? (CO3)

Turn the patient on the side.

A patient has just died following urosepsis that progressed to septic shock. The patient's spouse says, "I knew this was coming, but I feel so numb and hollow inside." The nurse should know that these statements are characteristics of what? (CO7)

Uncomplicated grief and mourning

A patient with a severe exacerbation of COPD requires reliable and precise oxygen delivery. Which mask will the nurse expect the physician to order? (CO3, CO4)

Venturi mask

A patient was tested for HIV using enzyme immunoassay(EIA) and the results were positive. The nurse should expect the primary care provider to order what test to confirm the EIA test results? (CO3)

Western blot test

When is the best time to assess a patient with Parkinson's disease for a presence of a tremor? (CO3)

When the patient is resting