NSG 302 Final Exam
After teaching a client who is being treated for dehydration, a nurse assesses the client's understanding. Which statement by the client indicates the client correctly understood the teaching? "I will not drink liquids after 6 p.m. so I will not have to get up at night to use the bathroom. "I will use a salt substitute when making and eating my meals." "I will weigh myself each morning before I eat and drink." "I must drink a quart (liter) of water or other liquid each day."
"I must drink a quart (liter) of water or other liquid each day."
The nurse is evaluationg teaching on a client who has a sequential compression device. Which statement should indicate to the nurse the client understands teaching? "With this thing on, my leg muscles will not get weak." "This thing will increase blood flow through my leg." "This device is going to keep my joints in good shape." "This device will prevent skin breakdown."
"This thing will increase blood flow through my leg."
A nurse prepares to change a client's bed. Which actions will the nurse take to minimize the effects of the environment during this task? SELECT ALL THAT APPLY - Hold contaminated linen away from the body - Place pillows on the sink - Place used linen on the floor - Fold and place bedspread on the roommate's chair. - Avoid shaking the linen
- Avoid shaking the linen - Hold contaminated linen away from the body
$ Which actions should the nurse take for all clients to prevent falls regardless of risk for falls? SELECT ALL THAT APPLY Assist clients to ambulate to the bathroom with walker or cane as needed. Teach client to use grab bars when walking in the hall without assistive devices. Remind clients to call for help before getting out of bed or a chair. Teach clients and family about fall prevention to become safety partners. Help the incontinent client to the toilet a least once each shift. Monitor client's activities and behavior as often as possible. Remind the client to wear glasses and hearing aid. Clean up spills immediately.
- Clean up spills immediately - Monitor client's activities and behavior as often as possible - Teach clients and family about fall prevention to become safety partners. - Remind clients to call for help before getting out of bed or a chair - Teach client to use grab bars when walking in the hall without assistive devices.
Which tests are routinely ordered for men and women at risk for osteoporosis after age 50? SELECT ALL THAT APPLY Serum Vitamin D3 levels DXA (Dual x-ay absorptiometry) Serum magnesium levels Serum Calcium Levels
- DXA (Dual x-ay absorptiometry) - Serum calcium levels - Serum vitamin D3 levels
$ A nurse assesses a client who is admitted for treatment of fluid overload. Which signs and symptoms does the nurse expect to find? SELECT ALL THAT APPLY Skeletal muscle weakness Increased pulse rate Distended neck veins Decreased blood pressure Warm and pink skin Visual disturbances
- Distended neck veins - Increased pulse rate -
Which of the following are considered benefits of exercise? SELECT ALL THAT APPLY Increased size, shape, tone, and strenth of muscles (includeing the heart muscle). Improved gas exchange with decreased pooling of secretions in lungs. Appetite suppression. Facilitates peristalsis. Improved circulation of lymph through lymph nodes.
- Increased size, shape, tone, and strength of muscles (including the heart muscle). - Improved gas exchange with decreased pooling of secretions in lungs. - Facilitates peristalsis. - Improved circulation of lymph through lymph nodes.
$ Which of the following is a direct result of the effects of immobility? SELECT ALL THAT APPLY Orthostatic hypotension Osteoporosis Increased metabolic rate. Urinary retention Urinary incontinence.
- Orthostatic hypotension - Osteoporosis - Urinary retention - Urinary incontinence.
$ Which of the following are interventions that nurses can use to maintain normal respirations in their clients? SELECT ALL THAT APPLY Position patient with head of bed elevated to allow for maximum chest expansion. Promote comfort of patient , such as giving pain medication as indicated. Encourage bedrest Encourage ambulation Encourage deep breathing and coughing
- Position patient with HOB elevated to allow for maximum chest expansion. - Encourage ambulation - Encourage deep breathing and coughing
Which actions will the nurse take for a client who requires physical restraints? SELECT ALL THAT APPLY Provide soft, calming music. Encourage family members to go home at night. Check the patient every 30-60 minutes. Turn the television on if the client is agitated. Place the client in an area where he or she can be supervised. Release the restraints every 1 to 2 hours for turning, repositioning, and toileting.
- Provide soft, calming music - Check the patient every 30-60 minutes - Place the client in an area where he or she can be supervised. - Release the restraints every 1 to 2 hours for turning, repositioning, and toileting.
The nurse is teaching a client about the use of an incentive spirometer. Which statements below should be included by the nurse when teaching the client? SELECT ALL THAT APPLY The patient should inhale slowly to elevate the balls and keep then floating as long as possible. It is recommended that the client do 5-10 repetitions every hour while awake. The client should blow into the incentive spiromter apparatus to elevate the balls and keep them floating as long as possible. An incentive spirometer is used to encourage voluntary deep breathing to prevent atelectasis. Cough after the incentive effort. Relax and take several normal breaths before using the incentive spirometer again after initial use and after each subsequent use..
- The patient should inhale slowly to elevate the balls and keep then floating as long as possible. - It is recommended that the client do 5-10 repetitions every hour while awake. - An incentive spirometer is used to encourage voluntary deep breathing to prevent atelectasis. - Cough after the incentive effort. - Relax and take several normal breaths before using the incentive spirometer again after initial use and after each subsequent use..
$ Which statement (s) about obstructive sleep apnea (OSA) is/are true? SELECT ALL THAT APPLY Results from sinusitis Associated with frequent sleepwalking episodes A main feature is hypopnea Causes fragmented nightime sleep and daytime drowsiness Is most common in men Most commonly diagnosed by polysomnography
- a main feature is hypopnea - causes fragmented nighttime sleep and daytime drowsiness - is most common in men - most commonly diagnosed by polysomnography
Which clients will the nurse carefully assess for high risk oral cavity disorders? SELECT ALL THAT APPLY Clients with sexually transmitted diseases. Clients who are developmentally disabled. Clients who consume an unhealthy diet. Clients who work in a coal mine. Clients who regularly use tobacco or alcohol. Clients who are homeless or live in institutions.
- clients who are developmentally disabled - clients who consume an unhealthy diet - clients who regularly use tobacco or alcohol - clients who are homeless or live in institutions
Which client assessment findings alert the nurse to the possibility of uncomplicated community-acquired pneumonia? SELECT ALL THAT APPLY Fever Dyspnea Chest discomfort Increased sputum production Abdominal pain
- fever - dyspnea - chest discomfort - increased sputum production
The nurse is teaching a elderly patient with a history of constipation about healthy defacation. What would the nurse include in the teaching plan? SELECT ALL THAT APPLY Fluid intake of 2-3 liters/day Take OTC medication to treat constipation daily Establish a regular exercise regiment Allow time to defecate Decrease fiber in the diet to avoid flatulance
- fluid intake of 2-3 liters/day - establish a regular exercise regimen - allow time to defecate
Which of the following are common characteristics of constipation? SELECT ALL THAT APPLY Headache Abdominal Pain Distention of abdomen Cramps Nausea Incontinence
- headache - abdominal pain - distention of abdomen - cramps - nausea
In addtion to analgesics, many nonpharmacological measures can be used for patients with Osteoarthritis. Which are suggested to relieve pain? SELECT ALL THAT APPLY Heat applications Weight control Cold applications Joint positioning Rest, balanced with exercise.
- heat applications - weight control - cold applications - joint positioning - rest, balanced with exercise
Which assessment finding will the nurse expect to find when a client is experiencing EARLY mechanical small bowel obstruction? SELECT ALL THAT APPLY absence of bowell sounds high pitched bowel sounds abdominal rigidity cramping abdomininal distention visible peristaltic waves
- high pitched bowel sounds - cramping - abdominal distention - visible peristaltic waves
Which actions should the nurse caring for a client with COVID-19 implement to prevent contracting the virus? SELECT ALL THAT APPLY Check sputum cultures on the patient daily. Keep the door of client's room closed. Use a powered air purifying respirator (PAPR) when in the client's room. Wash hands after removing gowns, gloves, and masks. Wear eye protection during patient care.
- keep the door of the client's room closed - wash hands after removing gowns, gloves, and masks - wear eye protection during patient care
What are some modifiable factors associated with Osteoporosis? SELECT ALL THAT APPLY Female over 50 years of age Lack of physical Exercise Chronic low calcium or vitamin D intake Current smoker Parental history of osteoporosis Poor nutrition
- lack of physical exercise - chronic low calcium or vitamin D intake - current smoker - poor nutrition
Which assessment finding in a 33 year old female client indicates to the nurse that she has an increased risk for type 2 diabetes? SELECT ALL THAT APPLY Mother , sister, and maternal grandmother all have type 2 diabetes Has irritable bowel symdrome with constipation A1C is 5.8% Fasting blood glucose (FBG) level is 119 mg/dL Weight is 25 Lbs above ideal weight Had a 10 lb baby 2 years ago
- mother, sister, and maternal grandmother all have type 2 diabetes - A1C is 5.8% (normal is under 5.7%) - fasting blood glucose (FBG) level is 119 mg/dL (normal is 70-100 mg/dL) - weight is 25 lbs above ideal weight - had a 10 lb baby 2 years ago
Which characteristics are most commonly associated with asthma? SELECT ALL THAT APPLY Narrowed airway lumen Excessive inflammation Dilated alveoli Chronic bronchitis Leukocyte activation Airway hyperresponsiveness/hypersensitivity Reversible airway obstruction Bronchiolar smooth muscle constriction
- narrowed airway lumen - excessive inflammation - leukocyte activation - airway hyper-responsiveness/hypersensitivity - reversible airway obstruction - bronchiolar smooth muscle constriction
Which of the risk factors for Colorectal Cancer are modifiable? SELECT ALL THAT APPLY Age Obesity Cigarette smoking Family history of colorectal polyps Lack of physical activity Race
- obesity - cigarette smoking - lack of physical activity
The nurse is preparing to perform an assessment on a client being seen in the clinic. The nurse notes the client has psoriasis. Which characteristics would the nurse expect to observe on assessment of the client's lesions? Tiny red vessicles that weep serous material Pink to read, patchy eruptions on the skin Large plaques covered by silvery scales Red, raised papules Erythema noted mostly under the breast area
- pink to red, patchy eruptions on the skin - large plaques covered by silvery scales - red, raised papules
The older client has been lying in a supine position for the past 3 hours. The nurse who is repositioning the client would be most concerned with examining which bony prominences of the client? SELECT ALL THAT APPLY Greater trochanter Sacrum Ankles Heels Elbows Back of head
- sacrum - heels - elbows - back of head
Which signs and symptoms will the nurse teach a client to take action to prevent harm as indicators of early or mild hypoglycemia? SELECT ALL THAT APPLY Cold, clammy skin Weakness Pallor Headache Irritability Tachycardia
- weakness - cold, clammy skin - pallor - headache - irritability - tachycardia
normal urine specific gravity
1.010-1.030
normal urine pH
4.6-8.0
Which age is recommended for screening of colorectal cancer consisting of high-sensitivity fecal occult blood testing, sigmoidoscopy, or colonoscopy? 50 years 60 years 35 years 45 years
45 years
A client sustains a burn injury to the entire right and left arms, the right leg, and the anterior thorax. According to the rule of nines, the nurse would assess that this injury constitutes which body percentage? __________ %
54%
Which older adult has the greatest risk for falls? A 73-year-old who takes frequent walking excursions. A 90-year-old who frequently calls for help to change position. An 80-year-old who uses a cane when ambulating. A 68-year-old who has decreased sensation in the lower extremities.
A 68-year-old who has decreased sensation in the lower extremities.
What support device for positioning patients maintains hip abduction to prevent hip dislocation following total hip replacement? Abduction pillow Footboard Heel guard boot Hand Roll
Abduction pillow
When using the SBAR method of communicating a client's condition, the nurse would include which info in the background section? - Patient states that he feels dizzy and light-headed. - Request fingerstick glucose monitoring. - Admission diagnosis is new -onset type 2 diabetes. - Blood pressure is 130/90 mm Hg; heart rate is 890 beats per minute.
Admission diagnosis is new -onset type 2 diabetes.
Whic client is at greatest risk for dehydration? A 79 year old with heart failure. A 53 year old who recently received intravenous fluids. A 42 year old who is prescribed long-term steroid therapy. An 80 year old who is cognitively impaired.
An 80 year old who is cognitively impaired.
A nurse is caring for a client who has fluid overload. What action by the nurse takes priority? Place a pressure-relieving overlay on the mattress. Administer loop diuretics. Weigh the client daily at the same time on the same scale. Assess the client's lungs every 2 hours.
Assess the client's lungs every 2 hours.
A client on diuretic therapy has a serum potassium level of 3.4 mg/dL. Which food should the nurse encourage this client to choose from the dinner menu? Green beans Cantaloupe Baked chicken Iced tea
Cantaloupe
A patient has been on bed rest for over 4 days. On assessment, which sign associated with immobility does the nurse identify? Increase blood pressure. Decreased peristalsis. Decreased heart rate. Increased urinary output.
Decreased peristalsis
The nurse is planning care for a client who is on bedrest. Which intervention should the nurse plan to implement? Instruct the client to cough and deep breathe every 4 hours. Reposition the client every 4 hours. Restrict the client's fluid intake. Encourage the client to perform anti-embolic exercises every 2 hours.
Encourage the client to perform anti-embolic exercises every 2 hours.
T or F? Use an opiate medication for diarrhea, especially if etiology is infection.
False
What position is the best positionn for someone who is having difficulty breathing? Fowler's position Lateral position Prone position Dorsal recumbent position
Fowler's position
Which action will the nurse perform first for a client with an active nosebleed? Apply ice to the back of the patient's neck. Insert nasal packing. Apply direct lateral pressure to the nose. Have the client sit upright with the head leaning forward.
Have the client sit upright with the head leaning forward.
What action by the assisted living facility nurse is most appropriate to prevent influenza spread when a resident client tests positive for influenza A? Have the resident eat meals in his/her room. Prepare to administer antibiotics to all residents. Provide flu vaccines to all staff members. Arrange the client to provide a sputum specimen in 2 weeks as a follow up.
Have the resident eat meals in his/her room.
A nurse is teaching a client who has an injury of the righ lower extremity about the use of a cane. Which of the instructions should the nurse include? Advance the weaker leg so that it aligns with the cane. Hold the cane on my left side. Place the cane 14 inches in front of the feet before advancing. Hold the cane on my right side.
Hold the cane on my left side
Please choose the following explanation for why ketones might be present in a urine specimen. Impaired carbohydrate metabolism; Can be the result of diabetes, fever, fasting, high protein diets, starvation, vomiting, or in the postanesthesia period. Dairy products, citrus fruits, or a vegetarian diet. Ingestion of cranberry juice. Indicates the presence of bacteria, red blood cells, white blood cells, sperm, prostatic fluid, or vaginal discharge.
Impaired carbohydrate metabolism; Can be the result of diabetes, fever, fasting, high protein diets, starvation, vomiting, or in the postanesthesia period.
What is the most appropriate action for the nurse to take when a client who has used insulin for diabetes control for 15 years now has a spongy swelling at the site used most frequently for insulin injection? Assess the client fo other indications of cellulitis. Instruct the client to use a different site fo insulin injection. Document the finding as the only action. Apply ice to the area.
Instruct the client to use a different site for insulin injection
What type of enema is considered the safest enema solution to use because they exert the same osmotic pressure as the interstitial fluid surrounding the colon? Hypertonic Hypotonic Isotonic Soapsuds Mineral oil
Isotonic
The nurse suspects that a client's body is attempting to correct an acid-base imbalance. How will the imbalance be corrected? The cardiovascular system is the major buffer. Kidney regulation is powerfully effective. Primary regulation is through gastrointestinal system losses. Slow but efficient respiratory regulation will occur.
Kidney regulation is powerfully effective
When assessing a lesion diagnosed as basal cell carcinoma, the nurse most likely expects to note which findings? SELECT ALL THAT APPLY A small papule with a dry, rough scale A firm, nodular lesion topped with crust Location in the bald spot on top of the head that is exposed to outdoor sunlight A pearly papule with a central crater and a waxy border An irregularly shaped lesion
Location in the bald spot on top of the head that is exposed to outdoor sunlight A pearly papule with a central crater and a waxy border
A client tells the nurse about passing out after following a fasting diet for 5 days. Which acid-base imbalance should the nurse expect to assess in this client? Metabolic Alkalosis Metabolic Acidosis Respiratory Acidosis Respiratory Alkalosis
Metabolic acidosis
The nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client, knowing that the client is at risk for which acid-base disorder? Respiratory Acidosis Metabolic Acidosis Metabolic Alkalosis Respiratory Alkalosis
Metabolic alkalosis
What is the nurses's best first action when the client with rheumatoid arthritis has one knee that is much more swollen than any other joint, and is both reddened and hot to touch? Elevating the affected knee and applying ice Asking the client whether any recent injury has occurred to this joint Comparing the range of motion for this joint with that of the opposite knee Notifying the rheumatology health care provider immediately
Notifying the rheumatology health care provider immediately
Select all factors that may influence a person's hygiene practices SELECT ALL THAT APPLY - Personal preferences - Health - Culture - Religion - Energy level
Personal preferences Health Culture Religion Energy Level
$ A nurse is caring for an older client who exhibits dehydration and confusion. Which intervention by the nurse is best? Place the client in high-Fowler position. Measure intake and output every 4 hours. Assess client further for fall risk. Increase the IV flow rate to 250 mL/hr.
Place the client in high-fowler's
A nurse is caring for a client who has been sitting in a chair for 2 hours. What is the greatest risk to the patient? Fecal impaction Pressure ulcer formation Muscle atrophy Bone demineralization
Pressure ulcer formation
A nurse has been teaching a student how to perform mouth care for the unconscious patient. The student will show evidence of learning if the patient is placed in which position? Side-lying Semi-Fowler's Prone Supine
Side-lying
What is the nurse's best response to a client with COPD who states that there is no reason to quit smoking now that the disease has already been diagnosed? If you stop smoking now, the damage to your lungs can be reversed. Smoking cessation can slow the rate of your disease progression. You can serve as a role model to others by quitting smoking. You are correct, nothing will change the course of the disease now.
Smoking cessation can slow the rate of your disease progression.
How will the nurse evaluate the level of glycemic control for a client with diabetes whose laboratory values include a fasting blood glucose (FBG) of 89 mg/dL and an A1C of 8.3%? The values indicate that the client has managed his or her disease well. The client's glucose control for the past 24 hours has been poor but the overall control is good. The client's glucose control for the past 24 hours has been good but the overall control is poor. The values indicate that the client has poorly managed his or her disease well.
The client's glucose control for the past 24 hours has been good but the overall control is poor.
T or F? Bismuth preparations (Pepto-Bismol) used to treat diarrhea may contain aspirin (ASA) and should not be given to children and teenagers with chicken pox, influenza, and othe viral infections.
True
T or F? Long term use of OTC medications (loperimide hydrochloride/Immodium) can produce dependence.
True
T or F? Some antidiarrheal agents can cause drowsiness.
True
Which classification of pressure ulcer injury is defined as full-thickness loss in which the extent of tissue damage within the ulcer cannot be determined because is is obscured by slough or eschar? Stage 3 pressure injury Stage 2 pressure injury Stage 4 pressure injury Stage 1 pressure injury Unstageable pressure injury
Unstageable pressure injury
When a client is receiving oxygen via nasal canula, at what point is humidification necessary and then added to oxgen therapy? When the patient is at 3 liters per minute. When the patient is at 4 liters per minute. When the patient is at 2 liters per minute. When the patient is at 1 liter per minute.
When the patient is at 4 liters per minute
For which side effect will the nurse most closely monitor an older client receiving an opioid drug for pain control after total hip replacement surgery? Acute confusion Dark, tarry stools Sudden onset hypertension Urinary retention
acute confusion
A client with a 3-day history of nausea and vomiting presents to the ED. The client is hypoventilating with a resiratory rate of 10. The ECG monitor shows tachycardia with a heart rate of 120. Which results from an arterial blood gas would be expected by the nurse? An increased pH with an increased HCO3- A decreased pH and a decreased HCO3- A decreased pH and an increased CO2 An increased pH and a decreased CO2
an increased pH with an increased HCO3-
What does the nurse suspect when a client comes into the emergency department (ED) with right lower quadrant cramping pain, nausea, vomiting, and guarding with rigidity of the abdomen? Gastroenteritis Ulcerative colitis Crohn's disease Appendicitis
appendicitis
What is the priority action for a nurse to take to prevent harm when caring for a client with fresh packing in place for a posterior nosebleed? Assessing the airway. Preventing dehydration. Monitoring for potential infection. Ensuring adequate humidification.
assessing the airway
The nurse is teaching nursing assistive personnel how to give a complete bed bath. Which instruction should the nurse include? - "Cleanse only those areas likely to cause odor." - "Wash the patient's back, buttocks, and perineum first." - "Provide the patient with warm water for washing his perineum." - "Bathe the patient from head -to-toe, cleanest areas first."
bathe the patient from head-to-toe, cleanest areas first
overflow urinary incontinence
bladder overfills and urine leaks out due to pressure on urinary sphincter
Which assessment in a client who has a fracture of the right wrist alerts the nurse to a possible early indication of a complication? Client reports numbness and tingling Wiggling fingers causes pain Fingers are cold and pale; pulses are impalpable Pain is severe and seems out of proportion to injury
client reports numbness and tingling
Halux Valgus deformity
common disorder where the great toe drifts laterally at the first metatarsophalangeal joint
functional urinary incontinence
connected with a cognitive or physical impairment
serous exudate
consists of serum (clear portion of the blood)
sanguinous exudate
contains large amount of blood cells (seen in open wounds)
Nasal cannula
delivers 24-25% oxygen at 2-6 liters/minute
venturi mask
delivers 24-50% oxygen at 4-10 liters/minute
face tent
delivers 28% oxygen at 8-12 liters/minute
simple face mask
delivers 35-65% oxygen at 8-12 liters/minute
partial rebreather mask
delivers 40-60% oxygen at 6-10 liters/minute
nonrebreather mask
delivers 60-100% oxygen at 6-15 liters/minute
A client is admitted to the ED after receiving a burn injury in a house fire. The skin on the trunk is tan, dry, and hard. It is edematous, but not very painful. The nurse determines that this client's burn should be classified as which type? Full-Thickness Superficial Partial-thickness superficial Deep Partial Thickness
full-thickness
Which types of ulcers does the nurse teach a client about when discussing peptic ulcer disease? Gastric ulcers Colon ulcers Pressure ulcers Esophageal ulcers
gastric ulcers
A health care provider has prescribed oxygen via nasal cannula for your patient at 2 liters per minute. List in order the steps that you would follow to complete the order. (Some answers will not be used because they are incorrect) a. Place prongs of nasal cannula in client's nostrils, w/ prongs pointing up. b. Place tubing over client's ears and position adjuster under client's chin. c. Open oxygen tubing and connect to flow meter adapter. d. Provide patient education. e. Place prongs of nasal cannula in client's nostrils w/ prongs pointing down. f. Verify client identification. g. Ensure client is in safe position prior to leaving room and has call light within reach. h. Introduce yourself to client, perform hand hygiene, and AIDET. i. Adjust the flow rate to prescribed rate of 4 liters of oxygen per minute. j. Adjust the flow rate to prescribed rate of 2 liters of oxygen per minute.
h, f, d, c, j, e, b, g
Which question would the nurse ask to identify an immediate physiologic consequence when a older adult's teeth are in poor condition and the client says that he or she only eats soft foods? "Would you like me to help you make an appointment with the dentist?" "Have you lost any weight recently?" "Do you have any problems with your bowel movements?" "Do you take any over-the-counter vitamin supplements?"
have you lost any weight recently?
Which scheduled hygiene care is usally thought of as including a back massage to help the patient relax? - Early morning care - Hour of sleep care - As needed (PRN) care - Morning care
hour of sleep care
WBC's in urine
indicate infection
bacteria, yeasts, or parasites in urine
indicate presence of urinary Eschericia coli
RBC's in urine
indicate trauma or disease of urinary anatomy
crystals in urine
indicates increased risk of renal calculi development
Casts in urine
indicates renal disease
osteomyelitis
infection in bone
plantar fasciitis
inflammation of the area on the sole of the foot
What is the nurse's priority intervention for an older client with urinary incontinence who is alert and oriented but refused to call for help and has had a previous fall when trying to get to the bathroom alone? Initiating fall precautions Managing incontinence Managing noncompliance Accurately measuring output
initiating fall precautions
Isokinetic muscle action
involves muscle tension against resistance. Special machines/devices provide the resistance.
Hematoma
localized collection of blood underneath the skin; usually appearing reddish blue in color
osteosarcoma
malignant bone tumor
The community heath nurse is visiting a homeless shelter and is assessing the client in the shelter for the presence of scabies. Which assessment finding should the nurse expect to note if scabies is present? Multiple straight or wavy threadlike lines underneath the skin Pustulles on the trunk of the body Brown-red macules with scales White patches noted on the elbows and knees
multiple straight or wavy threadlike lines underneath the skin
anaerobic activity
muscles cannot draw out enough oxygen from the blood stream during an activity such as endurance training (weightlifting, sprinting, etc.)
The nurse is performing an admission assessment on a client diagnosed with paronychia. The nurse should plan to assess which part of the integumentary system first? Hair follicles Nails Epithelial layer of skin Pilosebaceous glands
nails
protein in urine
no more than 8 mg/100mL
nitrites in urine
normally not present; indicates specific types of infection
glucose in urine
not normally present
stress urinary incontinence
occurs because the pelvic floor muscles are weak (most common)
For which reason will the nurse carefully examine the mouth of an older adult for candidiasis? Older adults' immune systems decline with aging increasing their risk for candidiasis. Older clients are more likely to wear dentures which increases the risk for candidiasis. Older adults on fixed incomes consume fewer fresh vegetables and fruits. Older clients are less likely to see a dentist and have healthy oral hygiene.
older adults' immune systems decline with aging increasing their risk for candidiasis
Which assessment finding on an older client who fell while getting out of bed indicates to the nurse a possible fracture? The client is extremely confused and trying to get up The skin of both legs is cooler and darker than that of the upper extremities The client cries out when the nurse attempts to examine him One leg is shorter than the other and has a protruding bump on the side
one leg is shorter than the other and has a protruding bump on the side
Which of the disorders is a chronic disease of cellular regulation and results in bone loss which causes significant density and possibility of a fragility fracture? Osteopenia Osteoporosis Osteomalacia Osteoarthritis
osteoporosis
Urgency Urinary Incontinence
overactive bladder; urgent need to void and inability to stop leakage
Which assessment is priority for the nurse to perform on a client admitted to the ED with multiple rib fractures? Pulses in all four extremities Pulse rate and rhythm Pain intensity Oxygen saturation
oxygen saturation
Dehiscence
partial or total separation of wound layers
Which complication does the nurse suspect when a client with peptic ulcer disease (PUD) suddenly develops sharp epigastric pain that spreads over the entire abdomen? Gastric Cancer Hemorrage Gastric erosion Perforation
perforation
Which serum electrolyte level is most important for the nurse to monitor closely to prevent harm in a client who has hyperglycemia? Potassium Sodium Chloride Magnesium
potassium
bilirubin in urine
presence suggests biliary or liver disease
evisceration
protrusion of viscera (internal organs) through an incision
$ What is the nurse's best first action for the patient with COPD who is first day postoperative and has a SpO2 of 85%? Raise the head of the bed. Encourage the client to cough and deep breathe. Instruct the client to use the incentive spirometer immediately. Apply oxygen at 2 liters per minute via nasal cannula.
raise the head of the bed
transient urinary incontinence
results from factors outside of urinary tract (medications, delirium, constipation)
ganglion
round benign cyst found on foot or wrist joint
When discussing the healing process in wounds, closure of the wound is classified as primary, secondary, or tertiary intention. A wound that is not approximated and heals by granulation tissue formation, wound contraction, and epithelialization would be healed by ______________ intention. Tertiary Quaternary Primary Secondary
secondary
A client has sustained a superficial skin tear to the arm. The nurse should apply which dressing as the best type of bandage for this wound? Semipermeable transparent film dressing Gelfoam sponge dressing Wet to dry dressing Dry sterile dressing
semipermeable transparent film dressing
Which complication of nasal fracture does the nurse suspect when a client's clear nasal secretions react positively when tested for glucose? Vertebral fracture Facial fracture Jaw fracture Skull fracture
skull fracture
aerobic activity
the amount of oxygen taken in to the body is greater than the amount used for an activity
isometric muscle action
the muscle contraction occurs without moving the joint (muscle length does not change) such as exerting pressure against a solid object
Isotonic muscle contraction
the muscle shortens to produce muscle contraction and active movement such as in running or walking.
The nurse has been working with the client diagnosed with candidiasis (thrush). What should the nurse assess for in this client? The presence of blisters The presence of purple patches The presence of white patches The presence of numerous small, red, pinpoint lesions
the presence of white patches
purulent exudate
thick, consisting of leukocytes, liquified dead tissue debris, and dead/living bacteria
Dupuytren contracture
thickening of palmar fascia resulting in deformity of 4th or 5th finger
eschar
wound covering of dried plasma proteins and dead cells (in burns)
granulation
young connective tissue with new capillaries formed in the wound healing process
