exam 3
A client has developed hepatitis A after eating contaminated oysters. The nurse assesses the client for which expected assessment finding? 1. Malaise 2. Dark stools 3. Weight gain 4. Left upper quadrant discomfort
1. Malaise
The nurse is caring for a client with a diagnosis of chronic gastritis. The nurse monitors the client, knowing that this client is at risk for which vitamin deficiency? 1. Vitamin A 2. Vitamin B12 3. Vitamin C 4. Vitamin E
2. Vitamin B12
Using Maslow's hierarchy of needs, a nurse assigns the highest priority to which client need? A. Elimination B. Security C. Safety D. Belonging
A. Elimination
Which of the following would be included in the assessment of a patient with diabetes mellitus who is experiencing a hypoglycemic reaction? (Select all that apply.) a. Tremors b. Nervousness c. Extreme thirst d. Flushed skin e. Profuse perspiration f. Constricted pupils
A. Tremors B. Nervousness E. Profuse perspiration
the total lack of oxygen in body tissues A. Anoxia B. Gas C. Hypoxemia
Anoxia
When evaluating the concept of gas exchange, how would the nurse best describe the movement of oxygen and carbon dioxide? A. Oxygen and carbon dioxide are exchanged across the capillary membrane to provide oxygen to hemoglobin. B. Gas moves from an area of high pressure to an area of low pressure across the alveolar membrane. C. The level of inspired oxygen must be sufficient to displace the carbon dioxide molecules in the alveoli. D. Gases are exchanged between the atmosphere and the blood based on the oxygen-carrying capacity of the hemoglobin.
B. Gas moves from an area of high pressure to an area of low pressure across the alveolar membrane.
During the examination of the ear, a dark yellow substance is noted in the ear canal. The tympanic membrane is not visible. The patient's wife complains that he never hears what she says lately. These findings would suggest that the nurse prepare the patient for which procedure? a. Tympanoplasty b. Irrigation of the ear c. Pure tone test d. Otoscopic exam by a specialist
B. Irrigation of the ear
The home care nurse is assessing an older patient diagnosed with mild cognitive impairment (MCI) in the home setting. Which information is of concern? a. The patient's son uses a marked pillbox to set up the patient's medications weekly. b. The patient has lost 10 pounds (4.5 kg) during the last month. c. The patient is cared for by a daughter during the day and stays with a son at night. d. The patient tells the nurse that a close friend recently died.
B. The patient has lost 10 pounds (4.5 kg) during the last month.
What is the most significant modifiable risk factor for the development of impaired gas exchange? A. Age B. Tobacco use C. Drug overdose D. Prolonged immobility.
B. Tobacco use
is generated by cardiac output—the amount of blood pumped by the heart each minute. A. Tissue perfusion B. Perfusion ranges C. Central perfusion
Central perfusion
The nurse is developing a care plan for a patient newly admitted to a unit that cares forpatients with cognitive impairment. What is an important component of care for the patients on this unit? a. Allow food selections from a menu with several choices. b. Schedule frequent field trips off the unit for cognitive stimulation. c. Plan for attendance at activities with several other patients on the unit. d. Plan for a structured daily routine of events and caregivers
D. Plan for a structured daily routine of events and caregivers
an acute process characterized by abrupt.
Delirium
the process by which oxygen is transported to cells and carbon dioxide is transported from cells. A. Ischemia B. Anoxia C. Gas
Gas
reduced oxygenation of arterial blood. A. Hypoxia B. Hypoxemia C. Ischemia
Hypoxemia
insufficient oxygen reaching cells. A. Ischemia B. Hypoxia C. Hypoxemia
Hypoxia
insufficient flow of oxygenated blood to tissues that may result in hypoxemia and subsequent cell injury or death. A. Gas B. Ischemia C. Hypoxemia
Ischemia
refers to the ability of blood to transport oxygen-containing hemoglobin to cells and return carbon dioxide-containing hemoglobin to the alveoli. A. Transport B. Perfusion C. Ventilation
Perfusion
the process of inhaling oxygen into the lungs and exhaling carbon dioxide from the lungs. A. Transport B. Oxygen C. Ventilation
Ventilation
The nurse instructs a patient with type 1 diabetes mellitus to avoid which of the following drugs while taking insulin? a. Aldactone(Spironolactone) b. Dicumarol (Bishydroxycoumarin) c. Reserpine (Serpasil) d. Cimetidine (Tagamet)
a. Aldactone (Spironolactone)
The nurse is assessing a patient's differential white blood cell count. What implications would this test have on evaluating the adequacy of a patient's gas exchange? a. An elevation of the total white cell count indicates generalized inflammation. b. Eosinophil count will assist to identify the presence of a respiratory infection. c. White cell count will differentiate types of respiratory bacteria. d. Level of neutrophils provides guidelines to monitor a chronic infection.
a. An elevation of the total white cell count indicates generalized inflammation.
The nurse is listening for bowel sounds in a postoperative patient. The bowel sounds are slow, as they are heard only every 3-4 minutes. The patient asks the nurse why this is happening. What is the nurse's best response? a. Anesthesia during surgery and pain medication after surgery may slow peristalsis in the bowel. b. Some people have a slower bowel than others, and this is nothing to be concerned about. c. The foods you eat contribute to peristalsis, so you should eat more fiber in your diet. d. Bowel peristalsis is slow because you are not walking. Get more exercise during the day.
a. Anesthesia during surgery and pain medication after surgery may slow peristalsis in the bowel.
The nurse is examining the eyes of a newborn infant. If the nurse notes the absence of the red reflex, what is the nurse's priority action? a. Notify the physician. b. Document the finding in the records. c. Recheck the reflex after several hours. d. Monitor the eye movements and pupil reactions closely.
a. Notify the physician.
The acid-base status of a patient is dependent on normal gas exchange. Which patient would the nurse identify as having an increased risk for the development of respiratory acidosis? a. Chronic lung disease with increased carbon dioxide retention b. Acute anxiety, hyperventilation, and decreased carbon dioxide retention c. Decreased cardiac output with increased serum lactic acid production d. Gastric drainage with increased removal of gastric acid
a. Chronic lung disease with increased carbon dioxide retention
The nurse is reviewing the patient's arterial blood gas results. The PaO2 is 96 mm Hg, pH is 7.20, PaCO2 is 55 mm Hg, and HCO3 is 25 mEq/L. What might the nurse expect to observe on assessment of this patient? a. Disorientation and tremors b. Tachycardia and decreased blood pressure c. Increased anxiety and irritability d. Hyperventilation and lethargy
a. Disorientation and tremors
The nurse is teaching primary prevention of cognitive impairment at a community health fair. Which topics would be included in the presentation? (Select all that apply.) a. Do not use substances such as cannabis and alcohol. b. Wear helmets when riding bicycles and motorcycles. c. Complete a Mini Mental Status Exam (MMSE) yearly. d. Correct acid-base imbalances related to underlying disease processes. e. Wear a seat belt whenever riding in a motorized vehicle. f. Complete a Confusion Assessment Method (CAM) scale yearly.
a. Do not use substances such as cannabis and alcohol. b. Wear helmets when riding bicycles and motorcycles. e. Wear a seat belt whenever riding in a motorized vehicle.
The nurse is conducting a patient assessment. The patient tells the nurse that he has smoked two packs of cigarettes per day for 27 years. The nurse may find which data upon assessment? a. Elevated blood pressure b. Bounding pedal pulses c. Night blindness d. Reflux disease
a. Elevated blood pressure
During a physical examination, the nurse notes that the patient's skin is dry and flaking. What additional data would the nurse expect to find to confirm the suspicion of a nutritional deficiency? a. Hair loss and hair that is easily removed from the scalp b. Inflammation of the tongue and fissured tongue c. Inflammation of peripheral nerves and numbness and tingling in extremities d. Fissures and inflammation of the mouth
a. Hair loss and hair that is easily removed from the scalp.
Which patient finding would the nurse identify as being a risk factor for altered transport of oxygen? a. Hemoglobin level of 8.0 b. Bronchoconstriction and mucus c. Peripheral arterial disease d. Decreased thoracic expansion
a. Hemoglobin level of 8.0
During an assessment, the patient states that his bowel movements cause discomfort because the stool is hard and difficult to pass. As the nurse, you make which of the following suggestions to assist the patient with improving the quality of his bowel movement? (Select all that apply.) a. Increase fiber intake. b. Increase water consumption. c. Decrease physical exercise. d. Refrain from alcohol. e. Refrain from smoking
a. Increase fiber intake. b. Increase water consumption.
The patient asks the nurse to explain the function of the sinoatrial node in the heart. What is the nurse's best response? a. It stimulates the heart to beat in a normal rhythm. b. It protects the heart from atherosclerotic changes. c. It provides the heart with oxygenated blood. d. It protects the heart from infection.
a. It stimulates the heart to beat in a normal rhythm.
A cognitively impaired patient newly admitted to the hospital is experiencing signs of sundown syndrome. Which intervention is best for the nurse to implement? a. Leave a night light on in the room at all times. b. Leave the television on at night with the volume up. c. Restrain the patient to maintain safety during the confusion. d. Administer a sleeping medication to help the patient sleep.
a. Leave a night light on in the room at all times.
The nurse is caring for a child with tonsillar enlargement. What is the nurse's priority concern? a. Low oxygen saturation b. Daytime fatigue c. Increased temperature d. Antibiotic administration
a. Low oxygen saturation
A patient complains of not being able to fall asleep at night and asks the nurse if there is a safe, non-prescription medication he can try. After consulting the healthcare provider, the nurse should recommend which naturally occurring hormone? a. Melatonin b. Cortisol c. Luteinizing hormone d. Estrogen
a. Melatonin
The nurse would identify which body systems as directly involved in the process of normal gas exchange? (Select all that apply.) a. Neurologic system b. Endocrine system c. Pulmonary system d. Immune system e. Cardiovascular system f. Hepatic system
a. Neurologic system c. Pulmonary system e. Cardiovascular system
An 82-year-old patient who is in the hospital awakens from sleep and is disoriented to where she is at the present time. The nurse reorients the patient to her surroundings and helps the patient return to sleep. What data does the nurse consider as a probable cause of the patient's confusion? a. Pain medication received earlier in the night b. The death of the patient's spouse 2 years ago c. The patient's history of diabetes d. The age of the patient
a. Pain medication received earlier in the night
The nurse would identify which patient condition as a problem of impaired gas exchange secondary to a perfusion problem? a. Peripheral arterial disease of the lower extremities b. Chronic obstructive pulmonary disease (COPD) c. Chronic asthma d. Severe anemia secondary to chemotherapy
a. Peripheral arterial disease of the lower extremities
When conducting a health history assessment, which information would be viewed as most important as related to the patient's elimination status? (Select all that apply.) a. Recent changes in elimination patterns b. Changes in color, consistency, or odor of stool or urine c. Time of day patient defecates d. Discomfort or pain with elimination e. List of medications taken by patient f. Patient's preferences for toileting
a. Recent changes in elimination patterns b. Changes in color, consistency, or odor of stool or urine d. Discomfort or pain with elimination e. List of medications taken by patient
The nurse enters a patient's room and the patient startles easily and appears to jerk his arms and legs before awakening. Which stage of non-rapid eye movement sleep did the patient most likely awaken from? a. Stage 1 b. Stage 2 c. Stage 3 d. Stage 4
a. Stage 1
The patient has recent bilateral, above-the-knee amputations and has developed C. difficile diarrhea. What assessments should the nurse use to detect ECV deficit in this patient? (Select all that apply.) a. Test for skin tenting. b. Measure rate and character of pulse. c. Measure postural blood pressure and heart rate. d. Check Trousseau sign. e. Observe for flatness of neck veins when upright. f. Observe for flatness of neck veins when supine.
a. Test for skin tenting. b. Measure rate and character of pulse. f. Observe for flatness of neck veins when supine.
During a nutritional assessment, the nurse calculates that a female patient's BMI is 27. The nurse would advise the patient to follow which of these recommendations? a. This measurement indicates that the patient is overweight and should follow a plan of diet and exercise to lose weight. b. This measurement indicates that the patient is underweight and will need to take measures to gain weight. c. This measurement indicates that the patient is morbidly obese and may be a candidate for bariatric surgery. d. This measurement indicates that the patient is of normal weight and should continue with current lifestyle.
a. This measurement indicates that the patient is overweight and should follow a plan of diet and exercise to lose weight.
The nurse is making a home visit to a child who has a chronic disease. Which finding has the most implication for acid-base aspects of this patient's care? a. Urine output is very small today. b. Whites of the eyes appear more yellow. c. Skin around the mouth is very chapped. d. Skin is sweaty under three blankets.
a. Urine output is very small today.
An African American is at an increased risk for which of the following? (Select all that apply.) a. Vitamin D deficiency b. Type 1 diabetes c. Celiac disease d. Type 2 diabetes e. Hypertension f. Metabolic syndrome
a. Vitamin D deficiency d. Type 2 diabetes e. Hypertension f. Metabolic syndrome
What is the nurse's best response about developing diabetes to the patient whose father has type 1 diabetes mellitus? a. You have a greater susceptibility for development of the disease because of your family history. b. Your risk is the same as the general population, because there is no genetic risk for development of type 1 diabetes. c. Type 1 diabetes is inherited in an autosomal dominant pattern. Therefore, the risk for becoming diabetic is 50%. d. Because you are a woman and your father is the parent with diabetes, your risk is not increased for eventual development of the disease. However, your brothers will become diabetic.
a. You have a greater susceptibility for development of the disease because of your family history.
A nurse working in a pediatric clinic recognizes that which child is most at risk for cognitive impairment? a. An infant who is being fed reconstituted powdered formula b. A toddler living in an older home that is being remodeled c. A preschooler who attends a play group 3 days a week d. A school-age child who rides a school bus 5 days a week
b. A toddler living in an older home that is being remodeled
The nurse is providing health teaching to a group of mothers of school-aged children. Which statement by a mother indicates the need for additional instruction? a. I will take my child to the audiologist because he doesn't seem to hear me except when I look directly at him. b. Both of my children have the same eye medication, which is a real bonus, because I only need to buy one bottle. c. Making my child wear ear plugs when she goes to a rock concert may save her hearing! d. I see now why when my child has a cold, he complains about everything tasting blah!
b. Both of my children have the same eye medication, which is a real bonus, because I only need to buy one bottle.
The nurse is explaining to a student nurse about impaired central perfusion. The nurse knows the student understands this problem when the student makes which statement? a. Central perfusion is monitored only by the physician. b. Central perfusion involves the entire body. c. Central perfusion is decreased with hypertension. d. Central perfusion is toxic to the cardiac system.
b. Central perfusion involves the entire body.
The nurse is caring for a patient who has suffered a spinal cord injury and is concerned about the patient's elimination status. What is the nurse's best action? a. Speak with the patient's family about food choices. b. Establish a bowel and bladder program for the patient. c. Speak with the patient about past elimination habits. d. Establish a bedtime ritual for the patient.
b. Establish a bowel and bladder program for the patient.
Which statements said by patients indicate that the nurse's teaching regarding prevention of acid-base imbalances is successful? (Select all that apply.) a. Baking soda is an effective and inexpensive antacid. b. I should take my insulin on time every day. c. My aspirin is on a high shelf away from children. d. I have reliable transportation to dialysis sessions. e. Fasting is a great way to lose weight rapidly.
b. I should take my insulin on time every day. c. My aspirin is on a high shelf away from children. d. I have reliable transportation to dialysis sessions
The patient has severe hyperthyroidism and will have surgery tomorrow. What assessment is most important for the nurse to perform in order to detect development of the highest risk acid-base imbalance? a. Urine output and color b. Level of consciousness c. Heart rate and blood pressure d. Lung sounds in lung bases
b. Level of consciousness
Which newborn should the nursery nurse identify as being at significant risk for hypothermic alteration in thermoregulation? a. Large for gestational age b. Low birth weight c. Born at term d. Well nourished
b. Low birth weight
The nurse is completing a nutritional assessment on a patient with hypertension. What foods would be recommended for this patient? a. Regular diet b. Low sodium diet c. Pureed diet d. Low sugar diet
b. Low sodium diet
The patient had diarrhea for 5 days and developed an acid-base imbalance. Which statement would indicate that the nurse's teaching about the acid-base imbalance has been effective? a. To prevent another problem, I should eat less sodium during diarrhea. b. My blood became too acid because I lost some base in the diarrhea fluid. c. Diarrhea removes fluid from the body, so I should drink more ice water. d. I should try to slow my breathing so my acids and bases will be balanced.
b. My blood became too acid because I lost some base in the diarrhea fluid.
The nurse is assessing a patient for the adequacy of ventilation. What assessment findings would indicate the patient has good ventilation? (Select all that apply.) a. Respiratory rate is 24 breaths/min. b. Oxygen saturation level is 98%. c. The right side of the thorax expands slightly more than the left. d. Trachea is just to the left of the sternal notch. e. Nail beds are pink with good capillary refill. f. There is presence of quiet, effortless breath sounds at lung base bilaterally.
b. Oxygen saturation level is 98%. e. Nail beds are pink with good capillary refill. f. There is presence of quiet, effortless breath sounds at lung base bilaterally.
The patient is brought to the emergency department after a motor vehicle accident. The patient is diagnosed with internal bleeding. What is the priority of care for this patient? a. Mental alertness b. Perfusion c. Pain d. Reaction to medications
b. Perfusion
The nurse assessed four patients at the beginning of the shift. Which finding should the nurse report immediately to the physician? a. Swollen ankles in patient with compensated heart failure b. Positive Chvostek sign in patient with acute pancreatitis c. Dry mucous membranes in patient taking a new diuretic d. Constipation in patient who has advanced breast cancer
b. Positive Chvostek sign in patient with acute pancreatitis
The nurse must awaken a patient from Stage 4 non-rapid eye movement sleep in order to prepare the patient for a procedure. The patient is disoriented. What is the nurse's best action? a. Notify the healthcare provider. b. Re-assess the patient's orientation. c. Administer an anti-anxiety medication. d. Cancel the patient's procedure.
b. Re-assess the patient's orientation.
What is the most appropriate measure for a nurse to use in assessing core body temperature when there are suspected problems with thermoregulation? a. Oral thermometer b. Rectal thermometer c. Temporal thermometer scan d. Tympanic membrane sensor
b. Rectal thermometer
Which strategies should the nurse include in a community program for senior citizens related to dealing with cold winter temperatures? a. Avoiding hot beverages b. Shopping at an indoor mall c. Using a fan at low speed d. Walking slowly in the park
b. Shopping at an indoor mall
The nurse is making rounds on the hospital unit and observes a patient sleeping. The patient's pulse and respiratory rates are slower than baseline. The nurse realizes the patient has most likely just entered which stage of non-rapid eye movement sleep? a. Stage 1 b. Stage 2 c. Stage 3 d. Stage 4
b. Stage 2
When a diabetic patient asks about maintaining adequate blood glucose levels, which of the following statements by the nurse relates most directly to the necessity of maintaining blood glucose levels no lower than about 74 mg/dL? a. Glucose is the only type of fuel used by body cells to produce the energy needed for physiologic activity. b. The central nervous system cannot store glucose and needs a continuous supply of glucose for fuel. c. Without a minimum level of glucose circulating in the blood, erythrocytes cannot produce ATP. d. The presence of glucose in the blood counteracts the formation of lactic acid and prevents acidosis.
b. The central nervous system cannot store glucose and needs a continuous supply of glucose for fuel.
A patient who was diagnosed with senile dementia has become incontinent of urine. The patient's daughter asks the nurse why this is happening. What is the nurse's best response? a. The patient is angry about the dementia diagnosis. b. The patient is losing sphincter control due to the dementia. c. The patient forgets where the bathroom is located due to the dementia. d. The patient wants to leave the hospital.
b. The patient is losing sphincter control due to the dementia.
The patient is hyperventilating from anxiety and abdominal pain. Which assessment findings should the nurse attribute to respiratory alkalosis? (Select all that apply.) a. Skin pale and cold b. Tingling of fingertips c. Heart rate of 102 d. Numbness around mouth e. Cramping in feet
b. Tingling of fingertips d. Numbness around mouth e. Cramping in feet
At change-of-shift report, the nurse learns the medical diagnoses for four patients. Which patient should the nurse assess most carefully for development of hyponatremia? a. Vomiting all day and not replacing any fluid b. Tumor that secretes excessive antidiuretic hormone (ADH) c. Tumor that secretes excessive aldosterone d. Tumor that destroyed the posterior pituitary gland
b. Tumor that secretes excessive antidiuretic hormone (ADH)
The home health nurse is caring for a patient with a diagnosis of acute immunodeficiency syndrome (AIDS) who has chronic diarrhea. Which assessments should the nurse use to detect the fluid and electrolyte imbalances for which the patient has highest risk? (Select all that apply.) a. Bilateral ankle edema b. Weaker leg muscles than usual c. Postural blood pressure and heart rate d. Positive Trousseau sign e. Flat neck veins when upright f. Decreased patellar reflexes
b. Weaker leg muscles than usual c. Postural blood pressure and heart rate d. Positive Trousseau sign
A patient tells the nurse that he experiences daytime fatigue even after 7-8 hours of sleep each night. What is the best assessment question for the nurse to ask? a. Have you tried getting 10 hours of sleep instead of 8 hours? b. How long are you in the rapid eye movement (REM) stage? c. Do you also have any recent lifestyle or behavior changes? d. Do any of your close relatives have any sleep disorders?
c. Do you also have any recent lifestyle or behavior changes?
During a physical examination, the nurse notes that the patient's skin is dry and flaking, with patches of eczema. Which nutritional deficiency might be present? a. Vitamin C b. Vitamin B c. Essential fatty acid d. Protein
c. Essential fatty acid
The nurse is assigned a group of patients. Which patient finding would the nurse identify as a factor leading to increased risk for impaired gas exchange? a. Blood glucose of 350 mg/dL b. Anticoagulant therapy for 10 days c. Hemoglobin of 8.5 g/dL d. Heart rate of 100 beats/min and blood pressure of 100/60
c. Hemoglobin of 8.5 g/dL
A patient diagnosed with hypertension asks the nurse how this disease could have happened to them. What is the nurse's best response? a. Hypertension happens to everyone sooner or later. Don't be concerned about it. b. Hypertension can happen from eating a poor diet, so change what you are eating. c. Hypertension can happen from arterial changes that block the blood flow. d. Hypertension happens when people do not exercise, so you should walk every day
c. Hypertension can happen from arterial changes that block the blood flow.
A mother tells the nurse she is concerned because her 8-month-old infant sleeps all day and night and is only awake about 2-3 hours per day. What is the nurse's best response? a. This sleep pattern is very normal for an infant at this age. b. Adding an additional feeding will keep the child awake more. c. I recommend that you notify the child's pediatrician. d. Be sure you are laying the child on his back to sleep at night.
c. I recommend that you notify the child's pediatrician.
An 80-year-old patient is being discharged after he was diagnosed with diabetes mellitus and retinopathy. His daughter has been part of the discharge instruction process. Understanding of the instructions is evident when the daughter says which of the following? a. I will make sure that dad always wears warm socks. b. Dad needs to wear his glasses so he can delay the onset of macular degeneration. c. I will ask the home health aide to carefully inspect dad's feet every day when she helps him bathe. d. We will give him only warm foods, so that he doesn't burn his mouth.
c. I will ask the home health aide to carefully inspect dad's feet every day when she helps him bathe.
An older adult who is cognitively impaired is admitted to the hospital with pneumonia. Which sign or symptom would the nurse expect to be exhibited by the patient? a. Severe headache b. Flank pain c. Increased confusion d. Decreased blood glucose
c. Increased confusion
A diabetic patient is brought into the emergency department unresponsive. The arterial pH is 7.28. Besides the blood pH, which clinical manifestation is seen in uncontrolled diabetes mellitus and ketoacidosis? a. Decreased hunger sensation b. Report of no urine output c. Increased respiratory rate d. Decreased thirst
c. Increased respiratory rate
The patient with which diagnosis should have the highest priority for teaching regarding foods that are high in magnesium? a. Severe hemorrhage b. Diabetes insipidus c. Oliguric renal disease d. Adrenal insufficiency
c. Oliguric renal disease
A patient who is dehydrated has been experiencing confusion. The daughter is concerned about taking the patient home in a confused state. What statement by the nurse is correct? a. Don't worry; the patient should be fine once they are in a familiar environment. b. I can make a referral for a home health aide to assist with the patient. c. Once the dehydration is corrected, the patient's confusion should improve. d. I can show you how to care for the patient once you return home.
c. Once the dehydration is corrected, the patient's confusion should improve.
A nurse is explaining the concept of perfusion to a student nurse. The nurse knows the student understands the concept of perfusion when the student makes which statement? a. Perfusion is a normal function of the body, and I don't have to be concerned about it. b. Perfusion is monitored by the physician. c. Perfusion is monitored by vital signs and capillary refill. d. Perfusion varies as a person ages, so I would expect changes in the body.
c. Perfusion is monitored by vital signs and capillary refill.
During orientation to an emergency department, the nurse educator would be concerned if the new nurse listed which of the following as a risk factor for impaired thermoregulation? a. Impaired cognition b. Occupational exposure c. Physical agility d. Temperature extremes
c. Physical agility
The nurse associates which assessment finding in the diabetic patient with decreasing renal function? a. Ketone bodies in the urine during acidosis b. Glucose in the urine during hyperglycemia c. Protein in the urine during a random urinalysis d. White blood cells in the urine during a random urinalysis
c. Protein in the urine during a random urinalysis
The nurse admitting a patient to the emergency department on a very hot summer day would suspect hyperthermia when the patient demonstrates which assessment finding? a. Decreased respirations b. Low pulse rate c. Red, sweaty skin d. Slow capillary refill
c. Red, sweaty skin
The process of digestion is important for every living organism for the purpose of nourishment. Where does most digestion take place in the body? a. Large intestine b. Stomach c. Small intestine d. Pancreas
c. Small intestine
The patient who had a hip replacement yesterday has a visual acuity of 20/200 after correction. What is the nurse's best action to provide recreational activities during the rehabilitation phase? a. Place the television to the left or right of patient's visual field. b. Encourage the patient to learn braille. c. Suggest use of talking books. d. Provide headphones for listening to music.
c. Suggest use of talking books.
The nurse is reviewing new medication orders for several patients in a long-term care facility. Which patient does the nurse recognize as being at the highest risk for having cognitive impairment related to prescribed medications? a. The patient prescribed an antibiotic for a urinary tract infection b. The patient prescribed a cholinesterase inhibitor for early Alzheimer disease c. The patient prescribed a B-blocker for hypertension d. The patient prescribed a bisphosphonate for osteoporosis
c. The patient prescribed a B-blocker for hypertension
The nurse is sitting with the family of a patient who has just received the diagnosis of dementia. The family asks for information on what treatment will be needed to cure the condition. What is the nurse's best response? a. Hormone therapy will reverse the condition. b. Vitamin C and zinc will reverse the condition. c. There is no treatment that reverses dementia. d. Dementia can be reversed with diet, exercise, and medications.
c. There is no treatment that reverses dementia.
The nurse is assessing a patient before hanging an IV solution of 0.9% NaCl with KCl in it. Which assessment finding should cause the nurse to hold the IV solution and contact the physician? a. Weight gain of 2 pounds since last week b. Dry mucous membranes and skin tenting c. Urine output 8 mL/hr
c. Urine output 8 mL/hr
During an interview, the nurse is discussing dietary habits with a patient. Which tool would be the best choice to use as a quick screening tool to assess dietary intake? a. Food diary b. Calorie count c. Comprehensive diet history d. 24-hour recall
d. 24-hour recall
A 3-month-old infant is at increased risk for developing anemia. The nurse would identify which principle contributing to this risk? a. The infant is becoming more active. b. There is an increase in intake of breast milk or formula. c. The infant is unable to maintain an adequate iron intake. d. A depletion of fetal hemoglobin occurs.
d. A depletion of fetal hemoglobin occurs.
A patient's serum electrolytes are being monitored. The nurse notices that the potassium level is low. What should the nurse monitor for in this patient? a. Tissue ischemia b. Brain malformations c. Intestinal blockage d. Cardiac dysrhythmia
d. Cardiac dysrhythmia
The patient is receiving tube feedings due to a jaw surgery. What change in assessment findings should prompt the nurse to request an order for serum sodium concentration? a. Development of ankle or sacral edema b. Increased skin tenting and dry mouth c. Postural hypotension and tachycardia d. Decreased level of consciousness
d. Decreased level of consciousness
The nurse has telephone messages from four patients who requested information and assistance. Which one should the nurse refer to a social worker or community agency first? a. Is there a place that I can dispose of my unused morphine pills? b. I want to lose at least 20 pounds without getting sick this time. c. I think I have asthma because I cough when dogs are near. d. I ran out of money and am cutting my insulin dose in half.
d. I ran out of money and am cutting my insulin dose in half.
The nurse requests that a mother give permission for a hearing test in a newborn infant. The mother questions the importance of such a test. The nurse correctly responds with which of the following statements? a. This will help us to identify your baby's risk for ear infections the first year of life. b. Hearing is important so your baby hears and responds to your voice, which makes you feel like a mother. c. Socialization skills include the need to hear in order to interpret the emotional aspect of the words that are spoken to your child. d. Imitation of sounds is the first step in language development, and it is important to identify alterations early.
d. Imitation of sounds is the first step in language development, and it is important to identify alterations early.
The patient's laboratory report today indicates severe hypokalemia, and the nurse has notified the physician. Nursing assessment indicates that heart rhythm is regular. What is the priority nursing intervention? a. Raise bed side rails due to potential decreased level of consciousness and confusion. b. Examine sacral area and patient's heels for skin breakdown due to potential edema. c. Establish seizure precautions due to potential muscle twitching, cramps, and seizures. d. Institute fall precautions due to potential postural hypotension and weak leg muscles.
d. Institute fall precautions due to potential postural hypotension and weak leg muscles.
The nurse recognizes which patient as having the greatest risk for undiagnosed diabetes mellitus? a. Young white man b. Middle-aged African-American man c. Young African-American woman d. Middle-aged Native American woman
d. Middle-aged Native American woman
What is a primary prevention tool used for colon cancer screening? a. Abdominal x-rays b. Blood, urea, and nitrogen (BUN) testing c. Serum electrolytes d. Occult blood testing
d. Occult blood testing
A volunteer at the senior center asks the visiting nurse why the senior citizens always seem to be complaining about the temperature. What is the nurse's best response? a. Older people have a diminished ability to regulate body temperature because of active sweat glands. b. Older people have a diminished ability to regulate body temperature because of increased circulation. c. Older people have a diminished ability to regulate body temperature because of peripheral vasoconstriction. d. Older people have a diminished ability to regulate body temperature because of slower metabolic rates.
d. Older people have a diminished ability to regulate body temperature because of slower metabolic rates.
A 75-year-old woman walks into the emergency department with complaints of <not feeling well. Her blood pressure is 145/95, pulse 85 beats/min, respirations 24 breaths/min, and blood sugar 300. Upon inspection, the nurse notices that the woman has an open wound on the bottom of her foot, but the patient states she is not aware of this. How should the nurse interpret these findings? a. Normal in the older adult b. A need for the patient to be evaluated for cognitive impairment c. A side effect of anti-hypertensive medication d. Pathologic impairment of sensory responses
d. Pathologic impairment of sensory responses
Which similar exemplar should the nurse consider when planning care for a patient with hypothermia? a. Heat exhaustion b. Heat stroke c. Infection d. Prematurity
d. Prematurity
Which clinical management prevention concept would the nurse identify as representative of secondary prevention? a. Decreasing venous stasis and risk for pulmonary emboli b. Implementation of strict hand washing routines c. Maintaining current vaccination schedules d. Prevention of pneumonia in patients with chronic lung disease
d. Prevention of pneumonia in patients with chronic lung disease
What is the priority nursing action for a patient suspected to be hypothermic? a. Assess vital signs. b. Hydrate with intravenous (IV) fluids. c. Provide a warm blanket. d. Remove wet clothes
d. Remove wet clothes
The nurse is assisting a 79-year-old patient with information about diet and weight loss. The patient has a body mass index (BMI) of 31. How should the nurse instruct this patient? a. Your weight is within normal limits. Continue maintaining with current lifestyle choices. b. You are a little overweight. Cut down on calories and increase your activity, and you should be fine. c. You are morbidly obese, and we would like to schedule you an appointment to speak with a bariatric specialist about surgery. d. You are considered obese and will need to consult with your doctor about a plan that includes exercises, not diet, to decrease weight.
d. You are considered obese and will need to consult with your doctor about a plan that includes exercises, not diet, to decrease weight.
An adult male patient is complaining of decreased appetite. He states he just finished taking his antibiotics for an episode of pneumonia. What is the nurse's best response? a. Your wife should increase the spices in your food, as the pneumonia changes your sense of smell. b. Notify your doctor immediately, because this is a concerning reaction to the medication. c. You need to take an appetite stimulant, as your body will need good nutrition to recover from the infection. d. You should see an improvement in the next week or so. Call if this continues.
d. You should see an improvement in the next week or so. Call if this continues.
