Chronic Final

The nurse is providing information about strokes to a community group. Which of the following would the nurse identify as the primary initial symptoms of an ischemic stroke?

Weakness on one side of the body and difficulty with speech

A client is at risk for excess fluid volume. Which nursing intervention ensures the most accurate monitoring of the client's fluid status?

Weighing the client daily at the same time each day

A client is reporting her pain as "8" on a 0-to-10 pain intensity scale. Then, the client states the pain is "3." Before the nurse leaves the room, the client states her pain is "6." The best action of the nurse is to

Obtain a pain scale with faces for the client to measure her pain.

A nurse is educating a client about monitoring blood pressure readings at home. What will the nurse be sure to emphasize?

"Sit quietly for 5 minutes prior to taking blood pressure."

Which statement by the nurse demonstrates ethnocentrism?

"That client needs to learn that pain is best managed with traditional medications like morphine."

Which factors contribute to the concept of a culture? Select all that apply.

- Styles used for communication - Art and music - Beliefs about health practices - Language - Items and clothing worn

A nurse is teaching the client about use of the pictured item with a metered-dose inhaler (MDI). What instructions should the nurse include in the teaching? Select all that apply.

- Take a slow, deep inhalation from the device. - Activate the MDI once. - The device may increase delivery of the MDI medication.

The nurse is assigned to care for a patient in the ICU who is diagnosed with status asthmaticus. Why does the nurse include fluid intake as being an important aspect of the plan of care? (Select all that apply.)

- To combat dehydration - To loosen secretions - To facilitate expectoration

A new resident in a long-term care facility who was having difficulty adapting to the routine has begun participating in activities on a daily basis. Which stage of culture shock is this resident displaying?

Beginning resolution

The client experienced abdominal surgery the previous day and has just received an opioid medication for report of pain. The client is sitting in a chair next to the bed. An additional activity that the nurse uses to relieve pain is

encourage the client to watch television

A 64-year-old client reports symptoms consistent with a transient ischemic attack (TIA) to the health care provider in the emergency department. Which is the origin of the client's symptoms?

impaired cerebral circulation

A client with chronic obstructive pulmonary disease (COPD) is admitted to the medical-surgical unit. To help this client maintain a patent airway and achieve maximal gas exchange, the nurse should:

instruct the client to drink at least 2 L of fluid daily.

A nurse reviews the client's medical record and reads in the progress notes that the client has decreased left ventricular function. What assessment will validate the diagnosis?

orthopnea

Which statement describes emphysema?

A disease of the airways characterized by destruction of the walls of overdistended alveoli

The nurse is assessing the blood pressure for a patient who has hypertension and the nurse does not hear an auscultatory gap. What outcome may be documented in this circumstance?

A high diastolic or low systolic reading

A client with heart failure must be monitored closely after starting diuretic therapy. What is the best indicator for the nurse to monitor?

weight.

A client is brought to the emergency department in a confused state, with slurred speech, characteristics of a headache, and right facial droop. The vital signs reveal a blood pressure of 170/88 mm Hg, pulse of 92 beats/minute, and respirations at 24 breaths/minute. On which bodily system does the nurse focus the nursing assessment?

Neurovascular system

Which instruction about insulin administration should a nurse give to a client?

"Always follow the same order when drawing the different insulins into the syringe."

The newly hired nurse is collecting assessment data for an upcoming surgical procedure from a client who speaks the dominant language as a second language. Which statement or question made by the newly hired nurse would indicate to the nurse manager that intervention is needed?

"Do you have any questions about your cholecystectomy?"

A nurse is instructing the spouse of a client who suffered a stroke about the use of eating devices the client will be using. During the teaching, the spouse starts to cry and states, "One minute he is laughing, and the next he's crying; I just don't understand what's wrong with him." Which statement is the best response by the nurse?

"Emotional lability is common after a stroke, and it usually improves with time."

A nurse finds that a client has infiltration around the IV line that needs to be removed. What explanation should the nurse give to reduce the client's anxiety?

"I know that you are anxious, but the IV location needs to be changed."

A nurse is caring for a client with left-sided heart failure. During the nurse's assessment, the client is wheezing, restless, tachycardic, and has severe apprehension. The clients reports that these symptoms came on suddenly. The nurse knows that these are symptoms of what condition?

Acute pulmonary edema

Which condition contributes to secondary hypertension?

Arterial vasoconstriction

The diagnosis of heart failure is usually confirmed by which of the following?

Echocardiogram

The nurse is caring for a client with a history of heart failure and a sudden onset of tachypnea. What is the nurse's priority action?

Elevate the head of the bed.

When the nurse is caring for a patient with type 1 diabetes, what clinical manifestation would be a priority to closely monitor?

Hypoglycemia

A nursing student understands the importance of the psychosocial aspects of disease processes. When working with a patient with COPD, the student would rank which of the following nursing diagnoses as the MOST important when analyzing the psychosocial effects?

Ineffective coping related to anxiety

An emergency department nurse is interviewing a client who is presenting with signs of an ischemic stroke that began 2 hours ago. The client reports a history of a cholecystectomy 6 weeks ago and is taking digoxin, warfarin, and labetalol. What factor poses a threat to the client for thrombolytic therapy?

International normalized ratio greater than 2

The nurse observing an interaction between a mother and her child appropriately identifies the interaction as which communication zone?

Intimate

Which teaching statement best exemplifies cultural competence in relation to time for the American culture?

It is important to be on time for your health care appointment.

The nurse is discussing aging and the incidence of hypertension with an older adult. What lifestyle change will lower blood pressure for the older adult?

Keep weight stable

Which of the following is a physiologic response to pain?

Pallor

Laboratory studies indicate a client's blood glucose level is 185 mg/dl. Two hours have passed since the client ate breakfast. Which test would yield the most conclusive diagnostic information about the client's glucose use?

Serum glycosylated hemoglobin (Hb A1c)

While providing information to a community group, the nurse tells them the primary initial symptoms of a hemorrhagic stroke are

Severe headache and early change in level of consciousness

A newly hired young nurse overheard the charge nurse talking with an older nurse on the unit. The charge nurse said, "All these young nurses think they can come in late and leave early." What cultural factor can the new nurse assess from this conversation?

Stereotyping

The nurse is obtaining a health history from a client with a blood pressure of 146/88 mm Hg. The client states that lifestyle changes have not been effective in lowering blood pressure. Which medication classification does the nurse anticipate first?

Thiazide diuretic

The nurse is caring for a client with heart failure. What sign will lead the nurse to suspect right-sided and left-sided heart failure?

ascites

A client with chronic obstructive pulmonary disease (COPD) is recovering from a myocardial infarction. Because the client is extremely weak and can't produce an effective cough, the nurse should monitor closely for:

atelectasis.

A client has chronic obstructive pulmonary disease (COPD) and is exhibiting shallow respirations of 32 breaths per minute and a pulse oximetry of 93% despite receiving nasal oxygen at 2 L/minute. What action should the nurse take?

Encourage the client to exhale slowly against pursed lips.

A client being treated for rheumatoid arthritis has been prescribed a glucocorticosteroid. How should the nurse best ensure this client's safety during treatment?

Ensure the client knows to taper down the dose if it is discontinued by the care provider.

Which exposure accounts for most cases of COPD?

Exposure to tobacco smoke

The nurse in an oncology clinic notes that the client being treated has hypertension. What tumor is a predisposing condition for secondary hypertension?

Pheochromocytoma

Which client statement indicates a good understanding of the nutritional modifications needed to manage hypertension?

"Limiting my salt intake to 2 grams per day will improve my blood pressure."

During an admission intake assessment, a nurse uses open-ended questions to gather information. An example of an open-ended question is:

"What did your health care provider tell you about your need to be admitted?"

A client is prescribed morphine for a possible ankle fracture. When the nurse brings in a second dose of the medication, the client states, "This medicine made me sick." The nurse replies

"What do you mean by the word sick?"

A nurse is completing a health history with a client being admitted for a mastectomy. During the interview the client states, "I do not know what to do. I am not sure if I really need this surgery." Which response by the nurse demonstrates active listening?

"You seem unsure. Tell me your concerns about your surgery."

A client has just been diagnosed with type 1 diabetes. When teaching the client and family how diet and exercise affect insulin requirements, the nurse should include which guideline?

"You'll need less insulin when you exercise or reduce your food intake."

A physician orders blood glucose levels every 4 hours for a 4-year-old child with brittle type 1 diabetes. The parents are worried that drawing so much blood will traumatize their child. How can the nurse best reassure the parents?

"Your child will need less blood work as his glucose levels stabilize."

When providing care to a client, the nurse refers to the client's ethnic group. Which aspects would the nurse include as pertaining to this concept? Select all that apply.

- Shared beliefs of origin - Religious beliefs - Language

The nurse is conducting a service project for a local elderly community group on the topic of hypertension. The nurse will relay that which risk factors and cardiovascular problems are related to hypertension? Select all that apply.

- Smoking - Overweight/obesity - Age ≥65 in women

The nurse is using nonverbal communication when caring for a group of clients. Which situation(s) reflects nonverbal communication? Select all that apply.

- The nurse is maintaining eye contact when changing a client's dressing. - The nurse has a smile when being thanked for caring for a family member. - The nurse assess a client is in pain from a grimace.

For which purposes would observing silence be appropriate? Select all that apply.

- To allow the client time to reflect on the client's thoughts - To allow the client time to reflect on communication that has occurred - To allow the client time to formulate an answer after asking the client a question - To allow the client time to compose oneself when the client is upset

A client arrives in the emergency room with emphysema and has developed an exacerbation of COPD with respiratory acidosis from airway obstruction. What is the highest priority for the nurse?

Apply supplemental oxygen as ordered.

A client has experienced an ischemic stroke that has damaged the lower motor neurons of the brain. Which of the following deficits would the nurse expect during assessment?

Lack of deep tendon reflexes

A patient who has suffered a stroke begins having complications regarding spasticity in the lower extremity. What ordered medication does the nurse administer to help alleviate this problem?

Lioresal (Baclofen)

Which type of insulin acts most quickly?

Lispro

A patient comes into the clinic frequently with complaints of pain. What would the nurse recognize as chronic benign pain in a patient?

Low back pain

Insulin is a hormone secreted by the Islets of Langerhans and is essential for the metabolism of carbohydrates, fats, and protein. The nurse understands the physiologic importance of gluconeogenesis, which refers to the:

Synthesis of glucose from noncarbohydrate sources.

A nurse is reading a journal article about stroke and the underlying causes associated with this condition. The nurse demonstrates understanding of the information when identifying which subtype of stroke as being due to atrial fibrillation?

cardio embolic

A patient is admitted via ambulance to the emergency room of a stroke center at 1:30 p.m. with symptoms that the patient said began at 1:00 p.m. Within 1 hour, an ischemic stroke had been confirmed and the doctor ordered tPA. The nurse knows to give this drug no later than what time?

4:00 p.m.

A home care nurse discusses with a client when visits will occur and how long they will last. In what phase of the nurse-client relationship is this type of agreement established?

Orientation phase

The nurse is caring for a client who is a victim of sexual assault. Which action would the nurse take to develop a trusting rapport with the client?

Approach the client with empathy and understanding and allow the client to share feelings without being judged.

The nurse is performing a respiratory assessment for a patient in left-sided heart failure. What does the nurse understand is the best determinant of the patient's ventilation and oxygenation status?

Arterial blood gases

While assessing an older adult client's upper back, the nurse notes round, raised red spots along the client's back. The client's daughter says, "Oh, that is just cupping." What action should the nurse take?

Ask about the practice of cupping.

A nurse is conducting an ethnographic interview with a client. Which step would the nurse do first?

Ask an open-ended, general question

A nurse is providing care to a client from a culture different from the nurse's own. The nurse is having difficulty relating to the client. What intervention by the nurse is most appropriate?

Ask the client how the client wants to be treated based on the client's values and beliefs.

A client with a terminal illness grimaces and begins to cry when being turned and repositioned in bed. Which action will the nurse take at this time?

Ask the client to rate the pain.

Which exposure acts as a risk factor for and accounts for the majority of cases of chronic obstructive pulmonary disease (COPD)?

Exposure to tobacco smoke

The nurse is assessing a patient with severe hypertension. When performing a focused assessment of the eyes, what does the nurse understand may be observed related to the hypertension?

Papilledema

Which clinical characteristic is associated with type 1 diabetes (previously referred to as insulin-dependent diabetes mellitus)?

Presence of islet cell antibodies

The nurse is caring for a client with severe compensated heart failure. What human brain natriuretic peptide (BNP) medication may be used in a critical care unit with hemodynamic monitoring?

Natrecor

When measuring the blood pressure in each arm of a healthy adult client, the nurse recognizes that which statement is true?

Pressures should not differ more than 5 mm Hg between arms.

The nurse is caring for a patient who has been hospitalized on several occasions for lower abdominal pain related to Crohn's disease. How may this chronic pain be described?

Prolonged in duration

A client is admitted to the hospital with systolic left-sided heart failure. The nurse knows to look for which assessment finding for this client?

Pulmonary congestion

The labor and delivery nurse is getting report from the previous shift regarding a client with Asian heritage. The departing nurse states that the client did not ask for pain medication because "Asian people can handle pain." The nurse receiving report understands that this an example of what?

Stereotyping

A client who speaks Korean only had emergency surgery. No pain scale was established prior to surgery. To assess the client's pain postoperatively, the nurse

Uses a language translation phone line

The nurse informs the patient that a preventive approach for pain relief will be used, involving nonsteroidal anti-inflammatory drugs. What will this mean for the patient?

The pain medication will be administered before the pain is experienced.

A client receives a daily injection of glargine insulin at 7:00 a.m. When should the nurse monitor this client for a hypoglycemic reaction?

This insulin has no peak action and does not cause a hypoglycemic reaction.

A client with type 2 diabetes asks the nurse why he can't have a pancreatic transplant. Which of the following would the nurse include as a possible reason?

Underlying problem of insulin resistance

An experienced nurse has been working with a client with heart failure. The client's lungs were clear to auscultation during the morning assessment; however, the afternoon assessment revealed bibasilar crackles and tachypnea. The nurse calls to give SBAR report to the covering health care provider. In the final step of the report the nurse should:

recommend 40 mg of furosemide be administered because the client had improvement with past administration.