Basic Adult Healthcare - Final Exam

A patient who presents for an eye examination is diagnosed as having a visual acuity of 20/40. The patient asks the nurse what these numbers specifically mean. What is a correct response by the nurse? "A person whose vision is 20/40 can see an object from 40 feet away that a person with 20/20 vision can see from 20 feet away." "A person whose vision is 20/40 can see an object from 20 feet away that a person with 20/20 vision can see from 40 feet away." "A person whose vision is 20/40 can see an object from 40 inches away that a person with 20/20 vision can see from 20 inches away." "A person whose vision is 20/40 can see an object from 20 inches away that a person with 20/20 vision can see from 40 inches away."

"A person whose vision is 20/40 can see an object from 20 feet away that a person with 20/20 vision can see from 40 feet away."

The management of the patient's gastrostomy is an assessment priority for the home care nurse. What statement would indicate that the patient is managing the tube correctly? "I clean my stoma twice a day with alcohol." "The only time I flush my tube is when I'm putting in medications." "I flush my tube with water before and after each of my medications." "I try to stay still most of the time to avoid dislodging my tube."

"I flush my tube with water before and after each of my medications."

The nurse is administering eye drops to a patient with glaucoma. After instilling the patient's first medication, how long should the nurse wait before instilling the patient's second medication into the same eye? 30 seconds 1 minute 3 minutes 5 minutes

5 minutes

The nurse should recognize the greatest risk for the development of blindness in which of the following patients? A 58yearold Caucasian woman with macular degeneration A 28yearold Caucasian man with astigmatism A 58yearold African American woman with hyperopia A 28yearold African American man with myopia

A 58yearold Caucasian woman with macular degeneration

A nurse who provides care in an ambulatory clinic integrates basic cancer screening into admission assessments. What patient most likely faces the highest immediate risk of oral cancer? A 65yearold man with alcoholism who smokes A 45yearold woman who has type 1 diabetes and who wears dentures A 32yearold man who is obese and uses smokeless tobacco A 57yearold man with GERD and dental caries

A 65yearold man with alcoholism who smokes

The nurse is caring for a patient who has a history of heart disease. What factor should the nurse identify as possibly contributing to a decrease in cardiac output? A change in position from standing to sitting A heart rate of 54 bpm A pulse oximetry reading of 94% An increase in preload related to ambulation

A heart rate of 54 bpm

A patient is being discharged home from the ambulatory surgical center after cataract surgery. In reviewing the discharge instructions with the patient, the nurse instructs the patient to immediately call the office if the patient experiences what? Slight morning discharge from the eye Any appearance of redness of the eye A "scratchy" feeling in the eye A new floater in vision

A new floater in vision

During a mumps outbreak at a local school, a patient, who is a school teacher, is exposed. She has previously been immunized for mumps. What type of immunity does she possess? Acquired immunity Natural immunity Phagocytic immunity Humoral immunity

Acquired immunity

A nurse has administered a child's scheduled vaccination for rubella. This vaccination will cause the child to develop which of the following? Natural immunity Active acquired immunity Cellular immunity Mild hypersensitivity

Active acquired immunity

A school nurse is caring for a 10yearold girl who is having an asthma attack. What is the preferred intervention to alleviate this client's airflow obstruction? Administer corticosteroids by metered dose inhaler Administer inhaled anticholinergics Administer an inhaled beta-adrenergic agonist Utilize a peak flow monitoring device

Administer an inhaled beta-adrenergic agonist

A diabetic nurse is working for the summer at a camp for adolescents with diabetes. When providing information on the prevention and management of hypoglycemia, what action should the nurse promote? Always carry a form of fast-acting sugar. Perform exercise prior to eating whenever possible. Eat a meal or snack every 8 hours. Check blood sugar at least every 24 hours

Always carry a form of fast-acting sugar.

An office worker takes a cupcake that contains peanut butter. He begins wheezing, with an inspiratory stridor and air hunger and the occupational health nurse is called to the office. The nurse should recognize that the worker is likely suffering from which type of hypersensitivity? Anaphylactic (type 1) Cytotoxic (type II) Immune complex (type III) Delayedtype (type IV)

Anaphylactic (type 1)

The nurse is providing care for a patient who has experienced a type I hypersensitivity reaction. What condition is an example of such a reaction? Anaphylactic reaction after a bee sting Skin reaction resulting from adhesive tape Myasthenia gravis Rheumatoid arthritis

Anaphylactic reaction after a bee sting

A nurse is caring for a patient who has been hospitalized with an acute asthma exacerbation. What drugs should the nurse expect to be ordered for this patient to gain underlying control of persistent asthma? Rescue inhalers Anti-inflammatory drugs Antibiotics Antitussives

Anti-inflammatory drugs

A nurse is explaining the process by which the body removes cells from circulation after they have performed their physiologic function. The nurse is describing what process? The cellular immune response Apoptosis Phagocytosis Opsonization

Apoptosis

A patient diagnosed with Bell's palsy is being cared for on an outpatient basis. During health education, the nurse should promote which of the following actions? Applying a protective eye shield at night Chewing on the affected side to prevent unilateral neglect Avoiding the use of analgesics whenever possible Avoiding brushing the teeth

Applying a protective eye shield at night

A patient has just arrived to the floor after an enucleation procedure following a workplace accident in which his left eye was irreparably damaged. Which of the following should the nurse prioritize during the patient's immediate postoperative recovery? Teaching the patient about options for eye prostheses Teaching the patient to estimate depth and distance with the use of one eye Assessing and addressing the patient's emotional needs Teaching the patient about his post-discharge medication regimen

Assessing and addressing the patient's emotional needs

A nurse is providing care for a patient who has psoriasis. The nurse is aware of the sequelae that can result from this health problem. Following the appearance of skin lesions, the nurse should prioritize what assessment? Assessment of the patient's stool for evidence of intestinal sloughing Assessment of the patient's apical heart rate for dysrhythmias Assessment of the patient's joints for pain and decreased range of motion Assessment for cognitive changes resulting from neurologic lesions

Assessment of the patient's joints for pain and decreased range of motion

An adolescent patient's history of skin hyperreactivity and inflammation has been attributed to atopic dermatitis. The nurse should recognize that this patient consequently faces an increased risk of what health problem? Bronchitis Systemic lupus erythematosus (SLE) Rheumatoid arthritis Asthma

Asthma

A patient's NG tube has become clogged after the nurse instilled a medication that was insufficiently crushed. The nurse has attempted to aspirate with a large-bore syringe, with no success. What should the nurse do next? Withdraw the NG tube 3 to 5 cm and reattempt aspiration. Attach a syringe filled with warm water and attempt an in and out motion of instilling and aspirating. Withdraw the NG tube slightly and attempt to dislodge by flicking the tube with the fingers. Remove the NG tube promptly and obtain an order for reinsertion from the primary care provider.

Attach a syringe filled with warm water and attempt an in and out motion of instilling and aspirating.

A nurse is preparing to perform an admission assessment on a patient with COPD. It is most important for the nurse to review which of the following? Social work assessment Insurance coverage Chloride levels Available diagnostic tests

Available diagnostic tests

A patient with a peptic ulcer disease has had metronidazole (Flagyl) added to his current medication regimen. What health education related to this medication should the nurse provide? Take the medication on an empty stomach. Take up to one extra dose per day if stomach pain persists. Take at bedtime to mitigate the effects of drowsiness. Avoid drinking alcohol while taking the drug

Avoid drinking alcohol while taking the drug

The nurse is performing the health interview of a patient with chronic rhinosinusitis who experiences frequent nose bleeds. The nurse asks the patient about her current medication regimen. Which medication would put the patient at a higher risk for recurrent epistaxis? Afrin Beconase Sinustop Pro Singulair

Beconase

A 33-year-old patient presents at the clinic with complaints of weakness, incoordination, dizziness, and loss of balance. The patient is hospitalized and diagnosed with MS. What sign or symptom, revealed during the initial assessment, is typical of MS? Diplopia, history of increased fatigue, and decreased or absent deep tendon reflexes Flexor spasm, clonus, and negative Babinski's reflex Blurred vision, intention tremor, and urinary hesitancy Hyperactive abdominal reflexes and history of unsteady gait and episodic paresthesia in both legs

Blurred vision, intention tremor, and urinary hesitancy

A gerontologic nurse is teaching a group of nursing students about integumentary changes that occur in older adults. How should these students best integrate these changes into care planning? By avoiding the use of moisturizing lotions on older adults' skin By protecting older adults against shearing injuries By avoiding the use of ice packs to treat muscle pain By protecting older adults against excessive sweat accumulation

By protecting older adults against shearing injuries

A patient has just been diagnosed with psoriasis and frequently has lesions around his right eye. What should the nurse teach the patient about topical corticosteroid use on these lesions? Cataract development is possible. The ointment is likely to cause weeping. Corticosteroid use is contraindicated on these lesions. The patient may develop glaucoma.

Cataract development is possible.

An 87yearold patient has been hospitalized with pneumonia. Which nursing action would be a priority in this patient's plan of care? Nasogastric intubation Administration of probiotic supplements Bedrest Cautious hydration

Cautious hydration

A nurse is explaining the importance of sunlight on the skin to a woman with decreased mobility who rarely leaves her house. The nurse would emphasize that ultraviolet light helps to synthesize what vitamin? E D A C

D

The nurse's assessment of a patient with significant visual losses reveals that the patient cannot count fingers. How should the nurse proceed with assessment of the patient's visual acuity? Assess the patient's vision using a Snellen chart. Determine whether the patient is able to see the nurse's hand motion. Perform a detailed examination of the patient's external eye structures. Palpate the patient's periocular regions.

Determine whether the patient is able to see the nurse's hand motion.

A patient's electronic health record notes that the patient has hallux valgus. What signs and symptoms would the nurse expect this patient to manifest? Deviation of a great toe laterally Abnormal flexion of the great toe An exaggerated arch of the foot Fusion of the toe joints

Deviation of a great toe laterally

A public health nurse is teaching a health promotion workshop that focuses on vision and eye health. What should this nurse cite as the most common causes of blindness and visual impairment among adults over the age of 40? Select all that apply. Diabetic retinopathy Trauma Macular degeneration Cytomegalovirus Glaucoma

Diabetic retinopathy Macular degeneration Glaucoma

A middle-aged woman has sought care from her primary care provider and undergone diagnostic testing that has resulted in a diagnosis of MS. What sign or symptom is most likely to have prompted the woman to seek care? Cognitive declines Personality changes Contractures Difficulty in coordination

Difficulty in coordination

A patient receiving tube feedings is experiencing diarrhea. The nurse and the physician suspect that the patient is experiencing dumping syndrome. What intervention is most appropriate? Stop the tube feed and aspirate stomach contents. Increase the hourly feed rate so it finishes earlier. Dilute the concentration of the feeding solution. Administer fluid replacement by IV.

Dilute the concentration of the feeding solution.

A nurse is reviewing gerontologic considerations relating to the care of patients with dermatologic problems. What vulnerability results from the age-related loss of subcutaneous tissue? Decreased resistance to ultraviolet radiation Increased vulnerability to infection Diminished protection of tissues and organs Increased risk of skin malignancies

Diminished protection of tissues and organs

A female patient has been experiencing recurrent urinary tract infections. What health education should the nurse provide to this patient? Bathe daily and keep the perineal region clean. Avoid voiding immediately after sexual intercourse. Drink liberal amounts of fluids. Void at least every 6 to 8 hours.

Drink liberal amounts of fluids.

The clinic nurse caring for a patient with Parkinson's disease notes that the patient has been taking levodopa and carbidopa (Sinemet) for 7 years. For what common side effect of Sinemet would the nurse assesses this patient? Pruritus Dyskinesia Lactose intolerance Diarrhea

Dyskinesia

How should the nurse best position a patient who has leg ulcers that are venous in origin? Keep the patient's legs flat and straight. Keep the patient's knees bent to 45degree angle and supported with pillows. Elevate the patient's lower extremities. Dangle the patient's legs over the side of the bed.

Elevate the patient's lower extremities.

The nurse is caring for a patient with an indwelling urinary catheter. The nurse is aware that what nursing action helps prevent infection in a patient with an indwelling catheter? Vigorously clean the meatus area daily. Apply powder to the perineal area twice daily. Empty the drainage bag at least every 8 hours. Irrigate the catheter every 8 hours with normal saline.

Empty the drainage bag at least every 8 hours.

The nurse is caring for a patient who is hospitalized with an exacerbation of MS. To ensure the patient's safety, what nursing action should be performed? Ensure that suction apparatus is set up at the bedside. Pad the patient's bed rails. Maintain bed rest whenever possible. Provide several small meals each day.

Ensure that suction apparatus is set up at the bedside.

A nurse is caring for a patient who just has been diagnosed with a peptic ulcer. When teaching the patient about his new diagnosis, how should the nurse best describe a peptic ulcer? Inflammation of the lining of the stomach Erosion of the lining of the stomach or intestine Bleeding from the mucosa in the stomach Viral invasion of the stomach wall

Erosion of the lining of the stomach or intestine

The nurse is developing a plan of care for a patient newly diagnosed with Bell's palsy. The nurse's plan of care should address what characteristic manifestation of this disease? Tinnitus Facial paralysis Pain at the base of the tongue Diplopia

Facial paralysis

A patient presents to the clinic complaining of symptoms that suggest diabetes. What criteria would support checking blood levels for the diagnosis of diabetes? Fasting plasma glucose greater than or equal to 126 mg/dL Random plasma glucose greater than 150 mg/dL Fasting plasma glucose greater than 116 mg/dL on 2 separate occasions Random plasma glucose greater than 126 mg/dL

Fasting plasma glucose greater than or equal to 126 mg/dL

An older adult patient with type 2 diabetes is brought to the emergency department by his daughter. The patient is found to have a blood glucose level of 623 mg/dL. The patient's daughter reports that the patient recently had a gastrointestinal virus and has been confused for the last 3 hours. The diagnosis of hyperglycemic hyperosmolar syndrome (HHS) is made. What nursing action would be a priority? Administration of antihypertensive medications Administering sodium bicarbonate intravenously Reversing acidosis by administering insulin Fluid and electrolyte replacement

Fluid and electrolyte replacement

A patient with a diagnosis of colon cancer is 2 days postoperative following bowel resection and anastomosis. The nurse has planned the patient's care in the knowledge of potential complications. What assessment should the nurse prioritize? Close monitoring of temperature Frequent abdominal auscultation Assessment of hemoglobin, hematocrit, and red blood cell levels Palpation of peripheral pulses and leg girth

Frequent abdominal auscultation

A patient presents at the ED after receiving a chemical burn to the eye. What would be the nurse's initial intervention for this patient? Generously flush the affected eye with a dilute antibiotic solution. Generously flush the affected eye with normal saline or water. Apply a patch to the affected eye. Apply direct pressure to the affected eye.

Generously flush the affected eye with normal saline or water.

A student with diabetes tells the school nurse that he is feeling nervous and hungry. The nurse assesses the child and finds he has tachycardia and is diaphoretic with a blood glucose level of 50 mg/dL (2.8 mmol/L). What should the school nurse administer? A combination of protein and carbohydrates, such as a small cup of yogurt Two teaspoons of sugar dissolved in a cup of apple juice Half of a cup of juice, followed by cheese and crackers Half a sandwich with a protein-based filling

Half of a cup of juice, followed by cheese and crackers

A patient is brought into the ED by family members who tell the nurse the patient grabbed his chest and complained of substernal chest pain. The care team recognizes the need to monitor the patient's cardiac function closely while interventions are performed. What form of monitoring should the nurse anticipate? Left-sided heart catheterization Cardiac telemetry Transesophageal echocardiography Hardwire continuous ECG monitoring

Hardwire continuous ECG monitoring

A group of high school students is attending a concert, which will be at a volume of 80 to 90 dB. What is a health consequence of this sound level? Hearing will not be affected by a decibel level in this range. Hearing loss may occur with a decibel level in this range. Sounds in this decibel level are not perceived to be harsh to the ear. Ear plugs will have no effect on these decibel levels.

Hearing loss may occur with a decibel level in this range.

A patient with a history of progressively worsening fatigue is undergoing a comprehensive assessment which includes test of renal function relating to erythropoiesis. When assessing the oxygen transport ability of the blood, the nurse should prioritize the review of what blood value? Hematocrit Hemoglobin Erythrocyte sedimentation rate (ESR) Serum creatinine

Hemoglobin

The nurse caring for a patient with a leg ulcer has finished assessing the patient and is developing a problem list prior to writing a plan of care. What major nursing diagnosis might the care plan include? Risk for disuse syndrome Ineffective health maintenance Sedentary lifestyle Imbalanced nutrition: less than body requirements

Imbalanced nutrition: less than body requirements

A patient with a family history of allergies has suffered an allergic response based on a genetic predisposition. This atopic response is usually mediated by what immunoglobulin? Immunoglobulin A Immunoglobulin M Immunoglobulin G Immunoglobulin E

Immunoglobulin E

The nurse is caring for a patient at risk for atelectasis. The nurse implements a first-line measure to prevent atelectasis development in the patient. What is an example of a first-line measure to minimize atelectasis? Incentive spirometry Intermittent positive-pressure breathing (IPPB) Positive endexpiratory pressure (PEEP) Bronchoscopy

Incentive spirometry

An 82 year old patient is being treated in the hospital for a sacral pressure ulcer. What age-related change is most likely to affect the patient's course of treatment? Increased thickness of the subcutaneous skin layer Increased vascular supply to superficial skin layers Changes in the character and quantity of bacterial skin flora Increased time required for wound healing

Increased time required for wound healing

You are caring for a patient who is diagnosed with Raynaud's phenomenon. The nurse should plan interventions to address what nursing diagnosis? Chronic pain Ineffective tissue perfusion Impaired skin integrity Risk for injury

Ineffective tissue perfusion

A 35 year old male patient presents at the emergency department with symptoms of a small bowel obstruction. In collaboration with the primary care provider, what intervention should the nurse prioritize? Insertion of a nasogastric tube Insertion of a central venous catheter Administration of a mineral oil enema Administration of a glycerin suppository and an oral laxative

Insertion of a nasogastric tube

The nurse is creating a plan of care for a patient who has a recent diagnosis of MS. Which of the following should the nurse include in the patient's care plan? Encourage patient to void every hour. Order a low-residue diet. Provide total assistance with all ADLs. Instruct the patient on daily muscle stretching.

Instruct the patient on daily muscle stretching.

The nurse is caring for a patient who needs education on his medication therapy for allergic rhinitis. The patient is to take cromolyn (Nasalcrom) daily. In providing education for this patient, how should the nurse describe the action of the medication? It inhibits the release of histamine and other chemicals. It inhibits the action of proton pumps. It inhibits the action of the sodium-potassium pump in the nasal epithelium. It causes bronchodilation and relaxes smooth muscle in the bronchi.

It inhibits the release of histamine and other chemicals.

A nurse is providing patient education for a patient with peptic ulcer disease secondary to chronic nonsteroidal anti-inflammatory drug (NSAID) use. The patient has recently been prescribed misoprostol (Cytotec). What would the nurse be most accurate in informing the patient about the drug? It reduces the stomach's volume of hydrochloric acid It increases the speed of gastric emptying It protects the stomach's lining It increases lower esophageal sphincter pressure

It protects the stomach's lining

A patient is concerned about leakage of gastric contents out of the gastric sump tube the nurse has just inserted. What would the nurse do to prevent reflux gastric contents from coming through the blue vent of a gastric sump tube? Prime the tubing with 20 mL of normal saline. Keep the vent lumen above the patient's waist. Maintain the patient in a high Fowler's position. Have the patient pin the tube to the thigh

Keep the vent lumen above the patient's waist.

The nurse is assessing placement of a nasogastric tube that the patient has had in place for 2 days. The tube is draining green aspirate. What is the nurse's most appropriate action? Inform the physician that the tube may be in the patient's pleural space. Withdraw the tube 2 to 4 cm. Leave the tube in its present position. Advance the tube up to 8 cm.

Leave the tube in its present position.

A nurse is assessing a patient with an acoustic neuroma who has been recently admitted to an oncology unit. What symptoms is the nurse likely to find during the initial assessment? Loss of hearing, tinnitus, and vertigo Loss of vision change in mental status, and hyperthermia Loss of hearing, increased sodium retention, and hypertension Loss of vision, headache, and tachycardia

Loss of hearing, tinnitus, and vertigo

A staff educator is reviewing the causes of gastroesophageal reflux disease (GERD) with new staff nurses. What area of the GI tract should the educator identify as the cause of reduced pressure associated with GERD? Pyloric sphincter Lower esophageal sphincter Hypopharyngeal sphincter Upper esophageal sphincter

Lower esophageal sphincter

The nurse is working with a patient who is newly diagnosed with MS. What basic information should the nurse provide to the patient? MS is a progressive demyelinating disease of the nervous system. MS usually occurs more frequently in men. MS typically has an acute onset. MS is sometimes caused by a bacterial infection.

MS is a progressive demyelinating disease of the nervous system.

A patient with a history of type 1 diabetes has just been admitted to the critical care unit (CCU) for diabetic ketoacidosis. The CCU nurse should prioritize what assessment during the patient's initial phase of treatment? Monitoring the patient for dysrhythmias Maintaining and monitoring the patient's fluid balance Assessing the patient's level of consciousness Assessing the patient for signs and symptoms of venous thromboembolism

Maintaining and monitoring the patient's fluid balance

A patient has been diagnosed with a small bowel obstruction and has been admitted to the medical unit. The nurse's care should prioritize which of the following outcomes? Preventing infection Maintaining skin and tissue integrity Preventing nausea and vomiting Maintaining fluid and electrolyte balance

Maintaining fluid and electrolyte balance

A patient's absolute neutrophil count (ANC) is 440/mm3. But the nurse's assessment reveals no apparent signs or symptoms of infection. What action should the nurse prioritize when providing care for this patient? Meticulous hand hygiene Timely administration of antibiotics Provision of a nutrientdense diet Maintaining a sterile care environment

Meticulous hand hygiene

A medical nurse is aware of the need to screen specific patients for their risk of hyperglycemic hyperosmolar syndrome (HHS). In what patient population does hyperosmolar nonketotic syndrome most often occur? Patients who are obese and who have no known history of diabetes Patients with type 1 diabetes and poor dietary control Adolescents with type 2 diabetes and sporadic use of antihyperglycemics Middle-aged or older people with either type 2 diabetes or no known history of diabetes

Middle-aged or older people with either type 2 diabetes or no known history of diabetes

The nurse is assessing a patient with multiple sclerosis who is demonstrating involuntary, rhythmic eye movements. What term will the nurse use when documenting these eye movements? Vertigo Tinnitus Nystagmus Astigmatism

Nystagmus

A 16yearold has been brought to the emergency department by his parents after falling through the glass of a patio door, suffering a laceration. The nurse caring for this patient knows that the site of the injury will have an invasion of what? Interferons Phagocytic cells Apoptosis Cytokines

Phagocytic cells

A patient is admitted with cellulitis and experiences a consequent increase in white blood cell count. The nurse is aware that during the immune response, pathogens are engulfed by white blood cells that ingest foreign particles. What is this process known as? Apoptosis Phagocytosis Antibody response Cellular immune response

Phagocytosis

An individual has accidentally cut his hand, immediately initiating the process of hemostasis. Following vasoconstriction, what event in the process of hemostasis will take place? Fibrin will be activated at the bleeding site. Platelets will aggregate at the injury site. Thromboplastin will form a clot. Prothrombin will be converted to thrombin.

Platelets will aggregate at the injury site.

The nurse is caring for an 82yearold patient with a diagnosis of tracheobronchitis. The patient begins complaining of right-sided chest pain that gets worse when he coughs or breathes deeply. Vital signs are within normal limits. What would you suspect this patient is experiencing? Traumatic pneumothorax Empyema Pleuritic pain Myocardial infarction

Pleuritic pain

he nurse's comprehensive assessment of a patient includes inspection for signs of oral cancer. What assessment finding is most characteristic of oral cancer in its early stages? Dull pain radiating to the ears and teeth Presence of a painless sore with raised edges Areas of tenderness that make chewing difficult Diffuse inflammation of the buccal mucosa

Presence of a painless sore with raised edges

The nurse caring for a patient diagnosed with Parkinson's disease has prepared a plan of care that would include what goal? Promoting effective communication Controlling diarrhea Preventing cognitive decline Managing choreiform movements

Promoting effective communication

The nurse is caring for a patient with a large venous leg ulcer. What intervention should the nurse implement to promote healing and prevent infection? Provide a high-calorie, high-protein diet. Apply a clean occlusive dressing once daily and whenever soiled. Irrigate the wound with hydrogen peroxide once daily. Apply an antibiotic ointment on the surrounding skin with each dressing change.

Provide a high-calorie, high-protein diet.

A nurse is creating a health promotion intervention focused on chronic obstructive pulmonary disease (COPD). What should the nurse identify as a complication of COPD? Lung cancer Cystic fibrosis Respiratory failure Hemothorax

Respiratory failure

The nurse is planning the care of a patient who has a diagnosis of atopic dermatitis, which commonly affects both of her hands and forearms. What risk nursing diagnosis should the nurse include in the patient's care plan? Risk for Disturbed Body Image Related to Skin Lesions Risk for Disuse Syndrome Related to Dermatitis Risk for Ineffective Role Performance Related to Dermatitis Risk for Self-Care Deficit Related to Skin Lesions

Risk for Disturbed Body Image Related to Skin Lesions

The nurse is planning the care of a patient with a diagnosis of vertigo. What nursing diagnosis risk should the nurse prioritize in this patient's care? Risk for disturbed sensory perception Risk for unilateral neglect Risk for falls Risk for ineffective health maintenance

Risk for falls

The cardiac care nurse is reviewing the conduction system of the heart. The nurse is aware that electrical conduction of the heart usually originates in the SA node and then proceeds in what sequence? SA node to bundle of His to AV node to Purkinje fibers SA node to AV node to Purkinje fibers to bundle of His SA node to bundle of His to Purkinje fibers to AV node SA node to AV node to bundle of His to Purkinje fibers

SA node to AV node to bundle of His to Purkinje fibers

An African American is admitted to the medical unit with liver disease. To correctly assess this patient for jaundice, on what body area should the nurse look for yellow discoloration? Elbows Lips Nail beds Sclerae

Sclerae

A patient with Parkinson's disease is undergoing a swallowing assessment because she has recently developed adventitious lung sounds. The patient's nutritional needs should be met by what method? Total parenteral nutrition (TPN) Provision of a low-residue diet Semisolid food with thick liquids Minced foods and a fluid restriction

Semisolid food with thick liquids

A patient has been diagnosed with hearing loss related to damage of the end organ for hearing or cranial nerve VIII. What term is used to describe this condition? Exostoses Otalgia Sensorineural hearing loss Presbycusis

Sensorineural hearing loss

A nursing is planning the care of a patient with emphysema who will soon be discharged. What teaching should the nurse prioritize in the plan of care? Taking prophylactic antibiotics as ordered Adhering to the treatment regimen in order to cure the disease Avoiding airplanes, buses, and other crowded public places Setting realistic short-term and long-range goals

Setting realistic short-term and long-range goals

A man suffers a leg wound which causes minor blood loss. As a result of bleeding, the process of primary hemostasis is activated. What occurs in primary hemostasis? Severed blood vessels constrict. Thromboplastin is released. Prothrombin is converted to thrombin. Fibrin is lysed.

Severed blood vessels constrict.

A 42yearold woman comes to the clinic complaining of occasional urinary incontinence when she sneezes. The clinic nurse should recognize what type of incontinence? Stress incontinence Reflex incontinence Overflow incontinence Functional incontinence

Stress incontinence

The clinic nurse is preparing a plan of care for a patient with a history of stress incontinence. What role will the nurse have in implementing a behavioral therapy approach? Provide medication teaching related to pseudoephedrine sulfate. Teach the patient to perform pelvic floor muscle exercises. Prepare the patient for an anterior vaginal repair procedure. Provide information on periurethral bulking.

Teach the patient to perform pelvic floor muscle exercises.

he nurse is discussing macrovascular complications of diabetes with a patient. The nurse would address what topic during this dialogue? The need for frequent eye examinations for patients with diabetes The fact that patients with diabetes have an elevated risk of myocardial infarction The relationship between kidney function and blood glucose levels The need to monitor urine for the presence of albumin

The fact that patients with diabetes have an elevated risk of myocardial infarction

A patient diagnosed with arthritis has been taking aspirin and now reports experiencing tinnitus and hearing loss. What should the nurse teach this patient? The hearing loss will likely resolve with time after the drug is discontinued. The patient's hearing loss and tinnitus are irreversible at this point. The patient's tinnitus is likely multifactorial, and not directly related to aspirin use. The patient's tinnitus will abate as tolerance to aspirin develops.

The hearing loss will likely resolve with time after the drug is discontinued.

A resident of a long-term care facility has complained to the nurse of chest pain. What aspect of the resident's pain would be most suggestive of angina as the cause? The pain is worse when the resident inhales deeply. The pain occurs immediately following physical exertion. The pain is worse when the resident coughs. The pain is most severe when the resident moves his upper body.

The pain occurs immediately following physical exertion.

An older adult patient has been diagnosed with COPD. What characteristic of the patient's current health status would preclude the safe and effective use of a metered-dose inhaler (MDI)? The patient has not yet quit smoking. The patient has severe arthritis in her hands. The patient requires both corticosteroids and beta2agonists. The patient has cataracts.

The patient has severe arthritis in her hands.

A patient with gastroesophageal reflux disease (GERD) has a diagnosis of Barrett's esophagus with minor cell changes. Which of the following principles should be integrated into the patient's subsequent care? The patient will require an upper endoscopy every 6 months to detect malignant changes. Liver enzymes must be checked regularly, as H2 receptor antagonists may cause hepatic damage. Small amounts of blood are likely to be present in the stools and are not cause for concern. Antacids may be discontinued when symptoms of heartburn subside.

The patient will require an upper endoscopy every 6 months to detect malignant changes.

A patient's decline in respiratory and renal function has been attributed to Goodpasture syndrome, which is a type II hypersensitivity reaction. What pathologic process underlies the patient's health problem? Antigens have bound to antibodies and formed inappropriate immune complexes. The patient's body has mistakenly identified a normal constituent of the body as foreign. Sensitized T cells have caused cell and tissue damage. Mast cells have released histamines that directly cause cell lysis.

The patient's body has mistakenly identified a normal constituent of the body as foreign.

A nurse is explaining to a patient with asthma what her new prescription for prednisone is used for. What would be the most accurate explanation that the nurse could give? To ensure long-term prevention of asthma exacerbations To cure any systemic infection underlying asthma attacks To prevent recurrent pulmonary infections To gain prompt control of inadequately controlled, persistent asthma

To gain prompt control of inadequately controlled, persistent asthma

The patient has sought care, stating that she developed hives overnight. The nurse's inspection confirms the presence of urticaria. What type of allergic hypersensitivity reaction has the patient developed? Type I Type II Type III Type IV

Type I

he nurse is providing care for a patient who has just been diagnosed with peripheral arterial occlusive disease (PAD). What assessment finding is most consistent with this diagnosis? Numbness and tingling in the distal extremities Unequal peripheral pulses between extremities Visible clubbing of the fingers and toes Reddened extremities with muscle atrophy

Unequal peripheral pulses between extremities

A nurse is creating a care plan for a patient with a nasogastric tube. How should the nurse direct other members of the care team to check correct placement of the tube? Auscultate the patient's abdomen after injecting air through the tube. Assess the color and pH of aspirate. Locate the marking made after the initial x-ray confirming placement. Use a combination of at least two accepted methods for confirming placement.

Use a combination of at least two accepted methods for confirming placement.

A nurse is caring for a patient who has been diagnosed with psoriasis. The nurse is creating an education plan for the patient. What information should be included in this plan? Use caution when taking nonprescription medications. Avoid public places until symptoms subside. Wash skin frequently to prevent infection. Liberally apply corticosteroids as needed.

Use caution when taking nonprescription medications.

An older adult is newly diagnosed with primary hypertension and has just been started on a betablocker. The nurse's health education should include which of the following? Increasing fluids to avoid extracellular volume depletion from the diuretic effect of the betablocker Maintaining a diet high in dairy to increase protein necessary to prevent organ damage Use of strategies to prevent falls stemming from postural hypotension Limiting exercise to avoid injury that can be caused by increased intracranial pressure

Use of strategies to prevent falls stemming from postural hypotension

A nurse's assessment reveals that a client with COPD may be experiencing bronchospasm. What assessment finding would suggest that the patient is experiencing bronchospasm? Fine or coarse crackles on auscultation Wheezes or diminished breath sounds on auscultation Reduced respiratory rate or lethargy Slow, deliberate respirations

Wheezes or diminished breath sounds on auscultation

A patient with suspected Parkinson's disease is initially being assessed by the nurse. When is the best time to assess for the presence of a tremor? When the patient is resting When the patient is ambulating When the patient is preparing his or her meal tray to eat When the patient is participating in occupational therapy

When the patient is resting