Med-Surg Midterm
When obtaining a health history from the newly admitted client who has chronic pain in the right knee, which pain assessment data would the nurse include? Select all that apply. A) Pain history, including location, intensity, and quality of pain B) Client's purposeful body movement in arranging the papers on the bedside table C) Pain pattern, including precipitating and alleviating factors D) Vital signs, such as increased blood pressure and heart rate E) The client's family statement about increases in pain with ambulation
A) Pain history, including location, intensity, and quality of pain C) Pain pattern, including precipitating and alleviating factors
Which action should the nurse implement when caring for a client following a lumbar laminectomy? A) Place a pillow between the client's legs before turning to the side. B) Elevate the head of the bed 30 degrees, and then turn the client to the side. C) Ak the client to flex the knees and push the heels into the bed during turning. D) Have the client grasp the side rail on the opposite side of the bed to help with turning
A) Place pillows between the legs before turning the client and when in the side-lying position to provide comfort and ensure alignment.
Which physiological change of the musculoskeletal system would the nurse associate with aging? Select all that apply. A) Slowed movement B) Cartilage degeneration C) Increased bone density D) Increased range of motion E) Increased bone prominence
A) Slowed movement B) Cartilage Degeneration E) Increased bone prominence
Which information would the nurse include in a community education session on decreasing the risk for musculoskeletal injures? Select all that apply. A) Use of seatbelts B) Obeying speed limits C) Wearing safety equipment D) Avoiding impaired vehicle use E) Refraining from distracted driving
A) Use of seatbelts B) Obeying speed limits C) Wearing safety equipment D) Avoiding impaired vehicle use E) Refraining from distracted driving
Which intervention would the nurse implement immediately for an alert and oriented client who arrived at the emergency department (ED) after a head injury that occurred while playing basketball? A) Assess full range of motion (ROM) to determine extent of injuries B) Call for immediate head computed tomography (CT) C) Immobilize the client's head and neck D) Open the airway with the head-tilt-chin-lift maneuver.
C) Immobilize the client's head and neck.
Which musculoskeletal abnormality would the nurse suspect in a client who exhibits short steps and drags a foot? A) Torticollis B) Pes Planus C) Spastic gait D) Steppage gait
C) Spastic gait
A client asks the nurse what causes the sudden loss of vision common in persons with multiple sclerosis. Which factor would the nurse include in the explanation? A) Virus-induced iritis B) Intracranial pressure C) Closed-angle glaucoma D) Optic nerve inflammation
d) Optic nerve inflammation
Upon assessing a client who underwent abdominal surgery 10 days ago, the client report abdominal pain. Which type of pain would the client experience? A) Visceral Pain B) Somatic Pain C) Referred pain D) Intractable pain
A) Visceral pain
Which steps listed by the nursing student are accurate regarding discharge planning? Select all that apply. A) "Plan the client's discharge at the time of leaving the hospital" B) "Teach the client the safe and effective use of medications and medical equipment C) "Remember that discharge planning is centralized, coordinated, interdisciplinary process" D) "Coordinate with just the primary health care provider when preparing discharge planning." E) "Develop a care plan that moves the client from the hospital to another level of health care."
B) "Teach the client the safe and effective use of medications and medical equipment C) "Remember that discharge planning is centralized, coordinated, interdisciplinary process" E) "Develop a care plan that moves the client from the hospital to another level of health care."
Which action by the nurse and other members of the healthcare team helps provide efficient client care? Select all that apply. A) Provide financial assistance to the client B) Follow interventions to reduce hospital stay C) Encourage the client to use herbal therapy D) Provide cost-effective treatment to the client E) Help the client in making health care decisions
B) Follow interventions to reduce hospital stay D) Provide cost-effective treatment to the client
Four clients who sustained head injuries are presented here. which client has the lowest score on the Glasgow Come Scale? Client A: Able to open eyes spontaneously, localize pain, and able to respond to verbal commands Client : Able to open eyes to sound, sensation and localized pain, and conversation is confused Client C: Able to open eyes to pain stimulus, normal flexion to pain, with inappropriate words. Client D: Able to open eyes to pain stimulus, localize pain, with confused verbal response.
Client C
Which nurse would be best for the nurse manager to assign to give a unit of packed red blood cells to a client who is experiencing postoperative bleeding after abdominal surgery? A) An experienced licensed practical nurse (LPN) who works regularly on the postoperative unit. B) A registered nurse (RN) who is currently starting intravenous chemotherapy on another client C) A registered (RN) who is on-call and will be able to arrive on the unit in about 30 minutes D) A registered nurse (RN) who has floated from the post anesthesia care unit (PACU) for the day.
D) A registered nurse (RN) who has floated from the post anesthesia care unit (PACU) for the day.
The day after undergoing abdominal appendectomy a school-aged child is prepared for ambulation. Which nursing action would be most effective before the start of ambulation? A) Providing a rest period B) Offering a reward for walking C) Encouraging use of the spirometer D) Administering the prescribed pain medication
D) Administering the prescribed pain medication
A client asks the nurse what causes Parkinson disease. Which description of pathology would the nurse provide in response to the client? A) Disintegration of the myelin sheath B) Breakdown of upper and lower neurons C) Reduced acetylcholine receptors at synapses D) Degeneration of neuron's of the basal ganglia
D) Degeneration of neuron's of the basal ganglia
When interpreting findings from a pain assessment, which factors would the nurse consider the most significant influences on a client's perception of pain? A) Age and sex B) Physical and physiological status C) Intelligence and economic status D) Previous experience and cultural values
D) Previous experience and cultural values
Which action would be the highest priority for the nurse to implement for a client experiencing an eclamptic seizure? A) Prevent injury B) Assess fetal heart tones C) Place an oral airway D) Increase the magnesium sulphate infusion rate
a) Prevent injury
Which question asked by the nurse is most appropriate to assess the nature of the clients pain? A) "Can you describe the pain to me" B) "Is your pain associated with movement?" C) "Can you rate your pain on a scale of 0 to 10?" D) "Do you notice your pain worsening with any activity?"
A) "Can you describe the pain to me?"
Which action would the nurse take first when caring for a client who is admitted to the emergency department after experiencing a seizure? A) Ask the emergency provider for a prophylactic anticonvulsant. B) Obtain a history of seizure type and incidence C) Ask the client to remove any dentures and eyeglasses D) Observe client for increased restlessness and agitation.
B) Obtain a history of seizure type and incidence
Which instructions would the nurse give to an older adult with decreased perception of touch? Select all that apply. A) "Use of a cane for support when walking." B) "Hold on to handrails while ambulating." C) "Look where your feet are placed while walking." D) "Wear shoes that give good support while walking." E) "If you are unable to change your position frequently, request assistance."
B) "Hold on to handrails while ambulating." C) "Look where your feet are placed while walking." D) "Wear shoes that give good support while walking." E) "If you are unable to change your position frequently, request assistance."
Which finding would the nurse expect to identify in a client who has osteoarthritis that would not be present in clients with rheumatoid arthritis? A) Ulnar drift B) Heberden nodes C) Swan-neck deformity D) Boutonnière deformity
B) Heberden nodes
Which factor explains why a client who experiences an acute episode of rheumatoid arthritis has swollen finger joints? A) Urate crystals in the synovial tissue B) Inflammation in the joints synovial lining C) Formation of bony spurs on the joint surfaces D) Deterioration and loss of articular cartilage joints
B) Inflammation in the joints synovial lining
Which early sign of increased intracranial pressure (ICP) would the nurse monitor in a. client who sustained a head injury while playing soccer? A) Nausea B) Lethargy C) Sunset eyes d) Hyperthermia
B) Lethargy
Which autoimmune disease is directly related to the client's central nervous system? A) Rheumatic fever B) Multiple sclerosis C) Myasthenia gravis D) Goodpasture syndrome
B) Multiple sclerosis
The nurse advises a client recovering from a musculoskeletal injury to increase intake of which nutrient? A) Fat B) Protein C) Sodium D) Vitamin A
B) Protein
after the nurse has finished teaching methods of reducing fatigue to the client with multiple sclerosis, which statement made by the client indicates that the client has understood the nurse's instruction? A) Take a hot bath on a daily basis B) Rest in an air-conditioned room C) Increase the dose of muscle relaxants D) Avoid naps during the day
B) Rest in an air-conditioned room
Which individual's activities increase the risk of developing carpal tunnel syndrome? A) Housekeeper B) Software engineer C) Health care worker D) Professional athlete
B) Software engineer
Which action would the nurse take first for a post surgical client who is still intubated but becoming restless, with an increased pulse rate and blood pressure, when it has been 4 hours since the last dose of pain medication? A) Notify the provider B) Perform a full physical assessment C) Administer the prescribed pain medication D) play soft, relaxing music to help calm the patient
C) Administer the prescribed pain medication
Which action would the nurse take first when caring for a postoperative client who reports pain? A) Provide an ice bag B) Administer pain medication as prescribed C) Perform a focused assessment of the client D) Document the client's complaint in the chart
C) Perform a focused assessment of the client
Which behaviour would the nurse include when teaching a family what to expect from a client who experienced a stroke on the left side of the brain? Select all that apply. A) Impaired judgement B) Spatial-perceptual deficits C) Slow performance and caution D) Impaired speech/language aphasias E) Tendency to deny or minimize problems F) Awareness of deficits with depression and anxiety
C) Slow performance and caution D) Impaired speech/language aphasias F) Awareness of deficits with depression and anxiety
The Daughter of a client with early familial Alzheimer's disease (AD) asks how AD can be detected. Which information should the nurse include about early warning signs of AD? A) Forgetting a colleague's name at a party B) Repeatedly misplacing car keys or a wallet C) Leaving a pot on the stove that boils dry and burns D) Having no memory of preparing a meal and forgetting to serve or eat it.
D) Having no memory of preparing a meal and forgetting to serve or eat it.
The nurse is assessing the client with arthritis. Which statement made by the client indicates a precipitating factor? A) "The pain is usually present in my fingers and knees" B) "I observed swelling and redness near the pain area" C) "I feel pain in each and every joint of my hands and legs" D) "I run for 30 minutes every day; this exercise increases my pain"
D) I run for 30 minutes every day; this exercise increases my pain
Which consideration is the nurse's concern when responding to the request of a hospice client who has severe pain and asks for another dose of oxycodone? A) Prevent addiction B) Determine why the medication is needed C) Provide alternative comfort measures D) Reduce the client's pain
D) Reduce the clients pain
Which health problem history would increase an older adult's risk for experiencing a cerebrovascular accident (CVA)? A) Glaucoma B) Hypothyroidism C) Continuous nervousness, stress D) Transient ischemic attacks (TIAs)
D) Transient ischemic attacks (TIAs)
A client with Alzhemier's disease has a nursing diagnosis of impaired memory related to effects of dementia. Which is an appropriate nursing intervention for the client? A) Let the client know what behaviour is socially appropriate B) Assist the client with all self-care to maintain self esteem. C) Maintain familiar routines of sleep, meals, drug administration and activities. D) At every encounter with the client, ask the day, time, and place to promote orientation.
C) Maintain familiar routines of sleep, meals, drug administration, activities.
Which cytokine would the nurse teach a client is treatment for multiple-sclerosis? A) Beta-Interferon B) Interleukin-2 C) Erythropoietin D) Colony-stimulating factor
A) Beta-Interferon
Which radiographic test would be used to view the entire skeleton? A) Bone scan B) Gallium and thallium scan C) Computed tomography (CT) D) Magnetic resonance imaging (MRI) scan
A) Bone scan
Damage to which cranial nerve may lead to decreased olfactory acuity? A) Cranial nerve I B) Cranial nerve X C) Cranial nerve V D) Cranial nerve VIII
A) Cranial nerve I
Which factor contributes to a client's slow rate of healing? Select all that apply. A) Diabetes B) Cataract C) Smoking D) Dermatitis E) Alcohol abuse
A) Diabetes C) Smoking E) Alcohol abuse
Which action would the nurse encourage a client who has multiple sclerosis in remission and is the parent of two active preschoolers take? A) Develop a flexible schedule for completion of routine daily activities B) Plan a schedule of specific times each day for playtime with the children. C) Meet with a self-help group for people with the diagnosis of multiple sclerosis. D) Provide support to other people with multiple sclerosis who also have young children.
A) Develop a flexible schedule for completion of routine daily activities.
Which action would the nurse classify as a priority when caring for a client with tonic-clonic seizures? A) Ensuring patient airway B) Administering intravenous (IV) fluids C) Monitoring level of consciousness D) Protecting the client from injury during seizures
A) Ensuring patient airway
During an annual physical assessment, a client reports not being able to smell coffee and most foods. Which cranial nerve function would the nurse assess? A) I B) II C) X D) VII
A) I
Which assessment finding indicates that a client has had a stroke? Select all that apply. A) Lopsided smile B) Unilateral vision C) Incoherent speech D) Unable to raise right arm E) Symptoms started 2 hours ago
A) Lopsided smile B) Unilateral vision C) Incoherent speech D) Unable to raise right arm E) Symptoms started 2 hours ago
Which action would the nurse take when caring for a client who has a possible skull fracture as a result of trauma? A) Monitor the client for signs of brain injury B) Check for hemorrhaging from the oral cavity C) Elevate the foot of the bed if the client develops symptoms of shock D) Observe for indicators of decreased intracranial pressure and temperature.
A) Monitor client for signs of brain injury
Which finding would the nurse expect when assessing a client who is in an early stage of multiple sclerosis? Select all that apply. A) Headache B) Nystagmus C) Skin infection D) Scanning speech E) Intention tremors
B) Nystagmus D) Scanning speech E) Intention tremors
Which action would the nurse take to understand the nature of a clients pain? Select all that apply. A) Cover the area of discomfort B) Observe where the client locates the pain C) Refrain from touching the area of tenderness D) Note whether the pain radiates to any other part of the body E) Instruct the client to not move so as not to increase pain
B) Observe where the client locates the pain D) Note whether the pain radiates to any other part of the body.
Which action would the nurse take first after serving serosanguineous drainage on the abdominal dressing of a client in the postanesthasia care unit (PACU) who had an abdominal cholecystectomy? A) Change the dressing. B) Reinforce the dressing. C) Replace the tape with Montgomery ties D) Support the incision with an abdominal binder
B) Reinforce the dressing.
Which intervention would the nurse implement immediately for an alert and oriented client who arrived at the emergency department (ED) after a head injury that occurred while playing basketball? A) Assess full range of motion (ROM) to determine extent of injuries B) Call for immediate head computed tomography (CT) C) Immobilize the client's head and neck D) Open the airway with the head-tilt chin-lift maneuver
C) Immobilize the client's head and neck
Which information would the nurse provide to the client about the benefits of rehabilitation? Select all the apply. A) "Specialized rehabilitation services help clients and caregivers to adjust to lifestyle changes>" B) "Rehabilitation helps prevent complications associated with illness or injury at the initial stages." C) "Clients who receive rehabilitation attain their fullest physical, mental, social, vocational and economic potential." D) "Programs are used solely to help clients become free from drug dependence." E) "Services focus on maximizing a client's functioning and level of independence at the initial stages. "
A) "Specialized rehabilitation services help clients and caregivers to adjust to lifestyle changes>" B) "Rehabilitation helps prevent complications associated with illness or injury at the initial stages." C) "Clients who receive rehabilitation attain their fullest physical, mental, social, vocational and economic potential."
The nurse is questioning a client who reports pain. Which questions asked by the nurse are correct? Select all that apply A) "where does it hurt?" B) "What makes the pain worse?" C) "How long have you noticed it?" D) "How severe is your pain on a scale of 0 to 10?" E) "Have you been treated for pain previously?"
A) "Where does it hurt?" B) "What makes the pain worse?" C) "How long have you noticed it?" D) "How severe is your pain on a scale of 0 to 10?"
Which finding would the nurse expect when completing an admission physical for a client with Parkinson disease? A) Muscle rigidity B) Blank facial expression C) Leaning toward the affected side D) Intention tremors with movement E) Hyperextension of the affected extremity
A) Muscle rigidity B) Blank facial expression
Which finding would the nurse expect when completing an admission physical for a client with Parkinson disease? Select all that apply. A) Muscle rigidity B) Blank facial expression C) Leaning toward the affected side D) Intention tremors with movement E) Hyperextension of the affected extremity
A) Muscle rigidity B) Blank facial expression
