Final Exam

which is a priority nursing diagnosis for a client with numerous episodes of diarrhea from dumping syndrome the past 24 hours

C

The nurse is creating a plan of care for a client receiving enteral feedings via a gastrostomy tube (G-tube). The nurse should plan to include which intervention in the plan of care?

Check around the stoma site for skin irritation.

A client had a new colostomy created 2 days earlier and is beginning to pass malodorous flatus from the stoma. What is the correct interpretation by the nurse? 1. this is a normal expected event 2. the client is experiencing early signs of ischemic bowel 3. the client should not have the NG tube removed 4. this indicates inadequate preoperative bowel preparation

1. this is a normal expected event

A pregnant client has been instructed on the prevention of genital tract infections. Which client statement indicates an understanding of these preventive measures? 1. "I can douche anytime I want." 2. "I can wear my tight-fitting jeans." 3. "I should avoid the use of condoms." 4. "I should wear underwear with a cotton panel liner."

"I should wear underwear with a cotton panel liner."

1. The most appropriate therapy for a patient with acute diarrhea caused by a viral infection is to a. increase fluid intake. b. administer an antibiotic c. administer an antimotility drug. d. quarantine the patient to prevent spread of the virus.

A

A 3-year-old child is seen in the health care clinic, and a diagnosis of encopresis is made. The nurse expects to provide teaching about which client problem? 1.Odor 2.Nausea 3.Malaise 4.Diarrhea

1.

The nurse presents a seminar on sexually transmitted infections. Which information about syphilis should the nurse include in this presentation? Select all that apply.

1. A blood test will confirm the diagnosis. 2.Syphilis signs and symptoms are divided into stages. 3.Syphilis can be spread through vaginal, anal, or oral sex.

The clinic nurse is performing a psychosocial assessment of a client who has been told that she is pregnant. Which assessment finding indicates to the nurse that the client is at risk for contracting human immunodeficiency virus (HIV)? 1. A client who has a history of intravenous drug use 2. A client who has a significant other who is heterosexual 3. A client who has a history of sexually transmitted infections 4. A client who has had one sexual partner for the past 10 years

1. A client who has a history of intravenous drug use A,C, E

The nurse is caring for a client with acute pancreatitis and is monitoring the client for paralytic ileus. Which assessment data would alert the nurse to this occurrence? 1. Inability to pass flatus 2. Loss of anal sphincter control 3. Severe, constant pain with rapid onset 4. Firm, nontender mass palpable at the lower right costal margin

1. Inability to pass flatus

A client who is human immunodeficiency virus seropositive has been taking stavudine. The nurse should monitor which most closely while taking this medication? A. Gait B. Level of consciousness C. Appetite D. Gastrointestinal function

A

A nursing student is doing a presentation on human papillomavirus (HPV) for a young adult group aged 18 to 20 years old. What information should the nursing student include in this presentation? Select all that apply. 1."Some forms of HPV can lead to cervical cancer." 2."You cannot get HPV if you have had only 1 sex partner." 3."There are no vaccinations available to protect against HPV." 4."HPV is most commonly spread during vaginal or anal sexual contact." 5."In some types, HPV will go away on its own and does not cause health issues."

1."Some forms of HPV can lead to cervical cancer." 4."HPV is most commonly spread during vaginal or anal sexual contact." 5."In some types, HPV will go away on its own and does not cause health issues." A,D,E,F

A postoperative client has been placed on a clear liquid diet. The nurse should provide the client with which items that are allowed to be consumed on this diet?

1.Broth 2.Coffee 3.Gelatin

The nurse is preparing a teaching plan for a client who had a cataract extraction with intraocular implanation. Which home care measures should the nurse include in the plan? Select all that apply A. Contact the surgeon if a decrease in visual acuity occurs B. Place an eye shield on the surgical eye at bedtime C. Avoid activities that require bending over D. Take acetaminophen for minor eye discomfort E. Expect episodes of sudden severe in the eye F. Contact the surgeon if eye scratches occurs

A, B, C, D

which of the following are treatments for constipation

A,B,C,D

The nurse is performing an assesssment on a client who suspects that she is pregnant and is checking the client for probable signs of pregnancy. The nurse should assess for which probable signs of pregnancy? Select all that apply A. Ballottement B. Outline of fetus via radiography/ultrasonography C. + Pregnancy Test D. Fetal heart rate detected E. Chadwicks Sign

A,C,E

A 22-year-old patient has presented to her primary care provider for her scheduled Pap smear. Abnormal results of this diagnostic test may imply infection with: a. Human papillomavirus (HPV) b. Trichomonas vaginalis c. Chlamydia trachomatis d. Candida albicans

A. HPV

Which stage of the general adaptation syndrome is characterized by increased cortisol levels and an increase in heart rate and blood pressure?

Alarm reaction stage

A complete blood cell count is performed on a client with systemic lupus erythematosus (SLE). The nurse suspects that which finding will be reported with this blood test? A. Increased red blood cell count B. Decreased numbers of all cell types C. Increased neutrophils D. Increased white blood cell count

B

A nurse is teaching a health class to a group of clients likely to be at highest risk for gonorrhea. What is the age range of the clients? a) 60 to 70 years b) 15 to 24 years c) 25 to 29 years d) 30 to 45 years

B

Max Thornton, a 24-year-old chef, is being seen by a physician at the urology group where you practice nursing. He has developed a painless ulcer on his penis and is rather concerned about his health. The urologist will be communicating his diagnosis of syphilis and prescribing treatment. What is the typical span of time between infection and developing symptoms with syphilis? a) 14 days b) 21 days c) 35 days d) 28 days

B

A child exposed to the human immunodeficiency virus (HIV) is seen in the health care clinic and tested for the virus. Which home care instruction would the nurse provide to the parents of the child? A. Wash your hands with half strength bleach if they come in contact with the childs blood B. Avoid sharing toothbrushes C. Avoid all immunizations until the diagnosis is established D. Wipe up any blood spills with a rag and allow them to air dry

B.

This diet is prescribed for patients with deceased mastication & dysphagia, head neck mouth surgery, intestinal stricture, or after a stroke. It includes foods that require minimal chewing such as: »Ground finely diced meats >Canned fruits >Soft cooked veggies »Cheese »Rice >Light bread

B. Mechanical Soft Diet

The nurse is assessing a pregnant client who is admitted for suspected abrupto placentae. Which assessment findings would the nurse expect to note if the condition is present? A. Absence of abdominal pain B. Soft abdomen C. painless, bright red vaginal bleeding D. Uterine Tenderness

D

After teaching a group of students about sexually transmitted infections (STIs), the instructor determines that additional teaching is necessary when the students identify which STI as curable with treatment?

Genital Herpes

A client has a history of syphilis infection. The nurse interprets that the client has been re-infected when which characteristic is noted in a penile lesion?

Induration and absence of pain

After undergoing weight loss gastric surgery, the client experiences fatigue and complains of numbness and tingling in the feet and difficulties with balance. Based on these symptoms, the nurse suspects which postoperative complication?

Pernicious anemia

What do you call it when someone expresses the opposite behavior or feelings from what is actually felt?

Reaction formation.

What is the subconscious or involuntary blocking of unpleasant feelings?

Repression

What level of anxiety is characterized by a feeling of terror or impending doom

Severe level anxiety

What do you call it when unacceptable impulses are transformed into socially acceptable behaviors?

Sublimation

Mild anxiety is beneficial for learning? True or false

True

The nurse instructs a client with chronic kidney disease who is receiving hemodialysis about dietary modifications. the nurse determines that the client understands these dietary mods if the client selects which items on the menu 1. Cream of wheat, blueberries, coffee 2. Sausage and eggs, banana, orange juice 3. Bacon, cantaloupe melon, tomato juice 4. Cured pork, grits, strawberries, OJ

cream of wheat, blueberries coffee

The client has been experiencing difficulty and straining when expelling feces. Which intervention should be taught to the client? 1. Explain that some blood in the stool will be normal for the client. 2. Instruct the client in manual removal of feces. 3. Encourage the client to use a cathartic laxative on a daily basis. 4. Place the client on a high-fiber diet.

4. Place the client on a high-fiber diet.

a client presents with diarrhea caused by escherichia coli (E. Coli) after a trip to Mexico. Which of the following medications is the most appropriate treatment for this clients symptoms

A

What signs and symptoms in your patient with HIV indicates the disease is worsening and the immune system is severely compromised? A. Open, oozing lesions around the mouth B. Cheesy white film on the tonsils and inside cheeks C. Vision changes D. White hair like spots on the side of the tongue

D

A patient recelving parenteral nutrition is administered via the following routes except: a. Subclavian line. b. Central Venous Catheter. c. PICC (Peripherally inserted central catheter) line. d. PEG tube.

D. PEG tube

The client seen in the health care clinic has tested positive for gonorrhea. The nurse anticipates that which medication will be prescribed based on this finding? 1.Acyclovir 2.Ceftriaxone 3.Azithromycin 4.Penicillin G benzathine

2. Ceftriaxone

Which client is most at risk to develop constipation? 1. The pediatric client who takes antibiotics for ear infections 2. The elderly client who routinely takes a stimulant laxative twice daily. 3. The young client in the hospital for an appendectomy 4. The middle-aged client who uses an enema when he travels

2. The elderly client who routinely takes a stimulant laxative twice daily

During the early postoperative period, the client who had a cataract extraction complains of nausea and severe eye pain over the operative site. The initial nursing action is to: A. Call the physician B. Administer the ordered main medication and antiemetic C. Reassure the client that this is normal. D. Turn the client on his or her operative side

A. call the surgeon

The nurse must irrigate the colostomy of a patient who is unable to move independently.How should the nurse position the patient for this procedure? 1) Semi-Fowler's position 2) Left side-lying position 3) Supine, with the head of the bed lowered flat 4) Supine, with the head of bed raised to 30 degrees

2) Left side-lying position

The nurse is assigned to a client receiving total parenteral nutrition (TPN) who had a blood glucose measurement done at 06:00. The nurse documents on the client's clinical worksheet for the day that the blood glucose level should be checked next at which time? 1. 08:00 2. 12:00 3. 16:00 4. 18:00

2. 12:00

A client who is recovering from a surgery has been advanced from a clear liquid diet to a full liquid diet. The client is looking forward to the diet change because he has been bored with the clear liquid diet. The nurse should offer which full liquid item to the client? 1. Tea 2. Gelatin 3. Custard 4. Ice pop

3. Custard

The nurse checks the gastric residual of an unconscious client receiving nasogastric tube feedings continuously at 50 mL/hr. The nurse notes that the residual is 250 mL at 0800 and 300 mL at 0900. The nurse determines that the client is experiencing which complication? 1.Air in the stomach 2.Too slow an infusion rate 3.Delayed gastric emptying 4.Early signs of peptic ulcer

3. Delayed gastric emptying

A nurse is preparing to hang the first bag of TIPN solution via a central line in the patient. The nurse should obtain which most essential piece of equipment before hanging the solution? 1. Urine test strips 2. Blood glucose meter 3. Electronic infusion pump 4. Noninvasive blood pressure monitor

3. Electric Infusion Pump

A client has an as needed prescription for loperamide hydrochloride. For which condition should the nurse administer this medication? 1. constipation 2. abdominal pain 3. an episode of diarrhea 4. hematest-positive nasogastric tube drainage

3. an episode of diarrhea

The nurse is assessing a patient who underwent bowel resection 2 days ago. As she auscultates the patient's abdomen, she notes low-pitched, infrequent bowel sounds. How should she document this finding? 1) Hyperactive bowel sounds 2) Abdominal bruit sounds 3) Normal bowel sounds 4) Hypoactive bowel sounds

4) Hypoactive bowel sounds

A pregnant woman has a positive history of genital herpes but has not had lesions during this pregnancy. What should the nurse should plan to tell the client? 1. "You will be isolated from your newborn infant after delivery." 2. "Vaginal deliveries can reduce neonatal infection risks, even if you have an active lesion at the time." 3. "There is little risk to your newborn infant during this pregnancy, during the birth, and after delivery." 4. "You will be evaluated at the time of delivery for herpetic genital tract lesions, and if any are present, a cesarean delivery will be needed."

4. "You will be evaluated at the time of delivery for herpetic genital tract lesions, and if any are present, a cesarean delivery will be needed."

The nurse is preparing to care for a child with a diagnosis of intussusception. The nurse reviews the child's record and expects to note which sign of this disorder documented? 1. Watery diarrhea 2. Ribbon-like stools 3. Profuse projectile vomiting 4. Bright red blood and mucus in the stools

4. Bright red blood and mucus in the stools

The nurse is teaching a client who has iron deficiency anemia about foods she should include in her diet. The nurse determines that the client understands the dietary modifications if she selects which items from her menu? 1. Nuts and milk 2. Coffee and tea 3. Cooked rolled oats and fish 4. Oranges and dark green leafy vegetables

4. Oranges and dark green leafy vegetables

A nurse is assisting with a physical examination of a male client. Which of the following signs and symptoms is most clearly suggestive of primary genital herpes? a) Emergence of hard, painless nodules on the shaft of the penis b) Presence of purulent, whitish discharge from the penis c) Production of cloudy, foul-smelling urine d) Itching, pain, and the emergence of pustules on the penis

D. Itching, pain, and the emergence of pustules on the penis