Tophat Questions Midterm NUR233-

A nurse is counseling a patient who lost her husband three months ago. The patient expresses feelings of anger toward her husband for "leaving her alone." Which stage of grief is the patient most likely experiencing?

Anger

A nurse is using the Braden scale to predict the pressure ulcer risk of a client in a long-term care facility. Using this scale, which of the following parameters should the nurse evaluate?

Nutrition

Which patient problem would the nurse identify as of highest priority for a patient who has Parkinson's disease and is unable to move the facial muscles?

Nutritionally compromised

Which nursing action could the nurse delegate to assistive personnel (AP) when caring for a patient who is using a fentanyl (narcotic/opioid) patch and a heating pad for the treatment of chronic back pain?

Obtain the respiratory rate every 2 hours.

The spouse of a 67-yr-old male patient with early stage Alzheimer's disease (AD) tells the nurse, "I am exhausted from worrying all the time. I don't know what to do." Which actions are best for the nurse to take at this time? (Select all that apply.)

Offer ideas for ways to distract or redirect the patient Teach the spouse about adult day care as a possible respite Ask the spouse what she knows and has considered about dementia care options

According to the Uniform Determination of Death Act (UDDA), made into law in all the 50 states:"An individual who has sustained either (1) irreversible cessation of circulatory and respiratory functions, or (2) irreversible cessation of all functions of the entire brain, including the brain stem, is dead."Determination of Death, Uniform Determination of Death Act § 1 (2015).

true

A nurse is providing education to a patient diagnosed with chronic obstructive pulmonary disease (COPD). Which of the following statements by the patient indicates a correct understanding of pursed-lip breathing as a technique to manage their symptoms?

"By exhaling through pursed lips, I can improve oxygen exchange and prevent airway collapse."

A patient with chronic neck pain is seen in the clinic for follow-up. Which question would the nurse select as most useful for evaluating the pain management outcome?

"Does pain keep you from activities that you enjoy?"

Which question asked by the nurse would elicit the most information about the patient's metastatic bone cancer pain?

"How would you describe your pain?"

The nurse is caring for a hospitalized pt who normally works the night shift at their job. The pt states, "I dont know what is wrong with me. I have been napping all day and cant seem to think clearly." The nurse's best response is"

"There has been a disruption in your circadian rhythm. What can I do to help you sleep better at night?"

A patient is diagnosed with VRE (Vancomycin-Resistant Enterococcus). Which statement made by the nursing staff indicates a correct understanding of VRE?

"VRE can be transmitted through direct contact with infected individuals or contaminated surfaces."

A patient presents with a swollen, painful ankle after a recent sprain. The nurse understands the principles of heat and cold application for pain treatment. Which of the following interventions is MOST appropriate initially for this patient's condition?

Administering a cold pack to minimize swelling and reduce pain.

You are taking care of Mr. Davis, a 74-year-old male patient with a BMI of 32 kg/m2, who is partially restricted to bed due to recent knee surgery. Which factors would offer more risk of this patient developing a wound? Select all that apply.

Age Mobility status Poor nutrition

A pt with new onset confusion and hyponatremia is being admitted. Which action would the hcarge nurse take when making room assignments

Assign the patient to a room near the nurse's station.

Which of the images better suggest an acute wound?

C

A nurse is preparing to assess the oxygen saturation of a patient using a pulse oximeter. Which of the following actions should the nurse take to ensure an accurate reading?

Choose a well-perfused site that is free from nail polish.

Three days after abdominal surgery, the nurse notes 4-cm periwound erythema and swelling at the distal end of a client's incision. The area is tender and warm to the touch. Staples are intact along the incision, and there is no obvious drainage. Heart rate is 96 beats/min and oral temperature is 100.8°F (38.2°C). What kind of complication should the nurse suspect this client is experiencing?

Infection at the incisional site

Which of the following are common modes of transmission for MRSA (Methicillin-resistant Staphylococcus aureus)? Select all that apply.

Direct contact with an infected person. Touching surfaces contaminated with MRSA. Airborne transmission. Sharing personal items such as towels or razors.

Monkeypox is a rare disease that can be transmitted to humans. Which of the following are potential sources or transmission methods of Monkeypox? Select all that apply.

Direct contact with infected animals or animal products. Respiratory droplets from an infected person. Sexual relations with someone infectious. Touching surfaces contaminated with the virus.

A nurse is educating a group of healthcare students about the various sociocultural determinants that can influence a person's perception and expression of pain. Which of the following are recognized as sociocultural determinants of pain? (Select all that apply.)

Cultural beliefs and values. Gender roles and expectations. Previous experiences with pain. Economic status and education level.

The nurse admits a terminally ill patient to the hospital. Which action would the nurse plan to complete first?

Determine the patient's wishes about end-of-life care.

A home health nurse is visiting a patient diagnosed with chronic obstructive pulmonary disease (COPD). Which of the following nursing interventions is the most appropriate to help manage the patient's condition at home?

Educate the patient on the importance of regular pulmonary exercises and controlled breathing techniques.

You are the nurse caring for a 45-year-old patient who presents with recurrent episodes of rhinosinusitis. Which of the following considerations is most important when caring for patients with recurrent rhinosinusitis?

Educating the patient on the importance of regular saline nasal irrigations and avoiding known irritants.

A nurse is caring for a patient diagnosed with bacterial pneumonia. Which of the following nursing interventions are appropriate for this patient? (Select all that apply.)

Encouraging fluid intake to maintain hydration. Promoting coughing and deep breathing exercises. Administering prescribed antibiotics on schedule. Assisting with incentive spirometry to promote lung expansion.

Which nursing intervention would you first propose to prevent Mr. Davis from developing a wound?

Ensure the nursing assistive personnel (CNA) changes/helps change the patient's position in bed every 2 hours.

Which is a characteristic of chronic wounds?

Exceed the typical healing time.

A nurse is caring for a patient diagnosed with C. diff. Which type of Personal Protective Equipment (PPE) is MOST essential when entering this patient's room?

Gloves and gown

The nurse is providing care for a client admitted with a diagnosis of muscular dystrophy resulting in inadequate muscle strength to draw enough air into the lungs. What nursing diagnosis would be most appropriate for this client?

Impaired spontaneous ventilation

The floor nurse plans care for a patient with chronic arthritis in the left shoulder. The patient reports pain and stiffness, especially in the mornings. Which of the following interventions is most appropriate to help manage the patient's pain and improve function?

Implement active-assisted ROM exercises to the left shoulder as part of the daily routine.

A nurse is discussing collaborative care strategies with the healthcare team for a hospitalized pt diagnosed with insomnia. Which of the following interventions are recommended as first-line treatments for insomnia?

Implementing non-pharmacological therapy for insomnia.

A nurse is reviewing guidelines associated with determining death. Which of the following criteria are commonly accepted for the determination of death? (Select all that apply.)

Irreversible cessation of circulatory and respiratory functions. Prolonged asystole on the cardiac monitor without any other signs of life. Irreversible cessation of all functions of the entire brain including the brainstem. Inability to independently maintain ventilatory and circulatory functions.

Which of the following statements regarding Herpes Zoster (Shingles) are accurate? Select all that apply.

It is caused by the same virus that leads to chickenpox. A person can get herpes zoster from someone who has active shingles. The primary symptom is a painful and blistering rash. It can be prevented by a vaccine. Airborne and droplets can transmit it in addition to contact with fluid in the blisters.

The day shift nurse at the long-term care facility learns that a patient with dementia experienced sundowning late in the afternoon on the previous two days. Which action would the nurse take?

Keep window blinds open during the day.

A patient is diagnosed with moderate dementia after having multiple strokes. Which assessment finding would the nurse expect?

Loss of recent and long-term memory.

Regarding COVID-19, select all the primary symptoms commonly associated with the infection:

Loss of taste or smell.

A nurse is assessing a patient who is suspected to have obstructive sleep apnea (OSA). Which of the following clinical manifestations can be consistent with OSA? (Select all that apply.)

Loud snoring interrupted by periods of silence Morning headaches Daytime sleepiness

Standard precautions in healthcare settings are primarily designed to:

Minimize the risk of transmission of pathogens between the healthcare provider and the patient.

A nurse is caring for an older adult patient diagnosed with asthma. The healthcare provider prescribes medication therapy to manage the condition. Which of the following considerations is most important when administering asthma medications to older adults?

Monitoring closely for potential side effects, given that older adults may metabolize medications differently.

The nurse is assessing the client with a history of chronic obstructive pulmonary disease (COPD). At this time, the client's pulse oximetry reading is 93%. What other findings would indicate adequate tissue and organ oxygenation? Select all that apply.

Normal urine output Strong peripheral pulses Pink mucous membranes

A nurse is assessing an older adult patient who recently underwent surgery. Which of the following findings would indicate a potential need for supplemental oxygen? (Select all that apply.)

Oxygen saturation (SpO2) of 91% on room air. Increased confusion not related to medications or baseline cognitive function. Respiratory rate of 28 breaths per minute. Pale and dry mucous membranes.

The nurse is admitting to the medical-surgical unit an older adult diagnosed with pulmonary hypertension and right-sided heart failure. The client complains of shortness of breath, and the nurse observes conversational dyspnea. What is the first action the nurse should take?

Perform a quick physical examination of breathing, circulation, and oxygenation.

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?

Place the patient in a room close to the nurses' station.

A nurse is planning care for a hospitalized pt who has been experiencing poor sleep patterns. Which of the folowing interventions should the nurse include in the plan of care

Provide a quiet environment by minimizing disruptions and reducing ambient noise Schedule medication administration to avoid disturbing the patient during sleep hours. Keep the room darkened and adjust the room temperature to the patient's comfort. Offer warm non-caffeinated beverages such as chamomile tea in the evening.

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?

Risk for injury

The nursing staff on a subacute medical unit of a hospital have noted that an 80-year-old client with a diagnosis of Alzheimer's disease tends to become agitated in the evening and early at night. Which intervention would be most appropriate to implement to address the client's behavior?

Schedule physical therapy in the afternoon hours.

A patient is recovering from surgery for a ruptured appendix. Because the surgeon did not surgically close the wound, what wound healing process will occur?

Secondary intention.

While assessing a new wound, the nurse notes red, watery drainage. What type of drainage will the nurse document this as?

Seroanguineous

A concerned adult son brings his 72-year-old mother to a neurologist for a workup after "recent" memory loss. Clinical manifestations associated with Alzheimer's Disease (AD) include short-term memory decline, forgetfulness that progresses with time, cognitive impairment, and inability to handle personal finances. Given the clinical manifestations described, which of the following is the most likely reason for the 72-year-old mother's visit to the neurologist?

She recently paid the same bill three times in one month and cannot recall any of the transactions.

A young adult patient with metastatic cancer who is very close to death appears restless. The patient keeps repeating, "I am not ready to die." Which action by the nurse would show respect for the patient?

Sit at the bedside and ask if there is anything the patient needs.

A pt who is taking a potassium depleting diuretics for the treatment of HTN reports generalized weakness. Which action would the nurse take

Suggest that the health care provider order a basic metabolic panel.

A patient with Parkinson's disease (PD) has bradykinesia. Which action would the nurse include in the plan of care?

Suggest that the patient use the arms of the chair to help push up to standing.

A nurse is reviewing the ECG and clinical manifestations of a pt suspected of having hyperkalemia

Tall peaked T-waves on ECG Palpitations Muscle weakness Irregular heart rhythms

A nurse is assessing a postoperative patient's pain using the Numeric Rating Scale (NRS). The patient rates their pain as 7 on a scale of 0 to 10. Which of the following is the best interpretation of this rating?

The pain is severe and requires immediate intervention.

A nurse is caring for a patient who was recently admitted for shortness of breath. Which of the following is the most appropriate method for the nurse to assess the patient's oxygenation level directly?

Using a pulse oximeter to determine oxygen saturation.

A nurse is caring for a patient with chronic obstructive pulmonary disease (COPD) who requires supplemental oxygen but also needs a variable oxygen concentration due to the risk of hyperoxygenation. Which of the following oxygen delivery devices would be the most appropriate for this patient?

Venturi mask

A patient recovering from abdominal surgery has an extensive incision that has been closed by primary intention, and the staples are intact. To provide more support to the incision site and decrease the risk of dehiscence, what would be appropriate to apply?

abdominal binder

When removing PPE after caring for a patient with a multidrug-resistant infection, which piece of equipment should the nurse remove FIRST?

gloves

What dressing would you choose for this wound?

hydrogel

For which sleep disorder would the nurse most likely need to include safety measures in the clint's plan of care

narcolepsy

How would you classify this drainage

purulent