NUR 114 Fall 2017 Quiz 2

What should the nurse expect to include as a priority in the plan of care for a client with delirium based on the nurse's understanding of the disturbances in orientation associated with this disorder? A) eliminating the client's napping in the daytime as much as possible B) avoiding arguing with a suspicious client about his perceptions of reality C) engaging the client in reminiscing with relatives or visitors D) identifying self and making sure that the nurse has the client's attention

D) identifying self and making sure that the nurse has the client's attention

To encourage adequate nutritional intake for a client with Alzheimer's disease, a nurse should: A) fill out the menu for the client B) help the client fill out his menu C) give the client privacy during meals D) stay with the client and encourage him to eat

D) stay with the client and encourage him to eat

A client has a throbbing headache when nitroglycerin is taken for angina. The nurse should instruct the client that: A) taking the nitroglycerin with a few glasses of water will reduce the problem. B) nitroglycerin should be avoided if the client is experiencing this serious side effect. C) acetaminophen or ibuprofen can be taken for this common side effect. D) the client should lie in a supine position to alleviate the headache.

C) acetaminophen or ibuprofen can be taken for this common side effect.

A client receiving haloperidol reports a stiff jaw and difficulty swallowing. The nurse's first action should be to: A) administer an as needed dose of benztropine as ordered B) administer an as needed dose of haloperidol C) administer an as needed dose of benztropine I.M. as ordered D)reassure the client and administer an as needed lorazepam I.M.

C) administer an as needed dose of benztropine I.M. as ordered

A client with schizophrenia tells a nurse he hears the voices of his dead parents. To help the client ignore the voices, the nurse should recommend that he: A) Call a friend and discuss the voices and his feelings about them. B) sit in a quiet, dark room and concentrate on the voices. C) listen to a personal stereo through headphones and sing along with the music. D) engage in strenuous exercise.

C) listen to a personal stereo through headphones and sing along with the music

The nurse is assessing a client who has been admitted to the hospital with chest pain. The client has been taking simvastatin 40 mg daily for 3 years. The nurse notes that the client has yellow sclerae and a dark skin color. The client tells the nurse that urine is getting darker. The nurse should: A) tell the client to lower the amount of saturated fats in the diet. B) ask the client about alcohol intake. C) notify the health care provider. D) instruct the client to increase the fluid intake to prevent the concentration of the urine.

C) notify the health care provider.

A client with schizophrenia displays a lack of interest in activities, reduced affect, and poor ability to perform activities of daily living. What term would be used to describe this clustering of symptoms? A) Extrapyramidal symptoms B) Negative symptoms C) Physiologic symptoms D) Positive symptoms

B) Negative symptoms

A client with a history of angina and intermittent claudication reports pain in both legs with a need to stop and rest after ambulating down the hall. Which statement by the nurse best addresses this concern? A) "The pain is probably related to inadequately oxygenated blood getting through the arteries into the muscles of your legs." B) "You are experiencing leg pain because of venous congestion." C) "You are experiencing pain due to inadequate removal of carbon dioxide from the tissues in the legs." D) "The pain is related to atherosclerosis that is the same problem causing your angina."

A) "The pain is probably related to inadequately oxygenated blood getting through the arteries into the muscles of your legs."

A client with chronic schizophrenia receives 20 mg of fluphenazine decanoate by I.M. injection. Three days later, the client has muscle contractions that contort his neck. This client is exhibiting which extrapyramidal reaction? A) Dystonia B) Tardive dyskinesa C) Akathsia D) Akinesia

A) Dystonia

When assessing an individual with peripheral vascular disease, which clinical manifestation would indicate complete arterial obstruction in the lower left leg? A) coldness of the left foot and ankle B) aching pain in the left calf C) burning pain in the left calf D) numbness and tingling in the left leg

A) coldness of the left foot and ankle

The nursing student is caring for a client who is symptomatic for coronary artery disease (CAD). Which symptom does the student expect to find when obtaining data for this client? Select all that apply. A) jaw pain B) chest pain C) arm pain D) renal failure

A) jaw pain B) chest pain C) arm pain

On a routine visit to the physician, a client with chronic arterial occlusive disease reports that he's stopped smoking after 34 years. To relieve symptoms of intermittent claudication, a condition associated with chronic arterial occlusive disease, which additional measure should the nurse recommend? A) Reducing daily fat intake to less than 45% of total calories B) Taking daily walks C) Engaging in anaerobic exercise D) Abstaining from foods that increase levels of high-density lipoproteins (HDLs)

B) Taking daily walks

Which client is at greatest risk for coronary artery disease? A) a 56-year-old male with an HDL of 60 (3.3 mmol/L) who takes atorvastatin B) a 65-year-old female who is obese with an LDL of 188 (10.4 mmol/L) C) a 32-year-old female with mitral valve prolapse who quit smoking 10 years ago D) a 43-year-old male with a family history of CAD and cholesterol level of 158 (8.8 mmol/L)

B) a 65-year-old female who is obese with an LDL of 188 (10.4 mmol/L)

A nurse is educating a client who is at risk for coronary artery disease (CAD). The nurse knows that the client needs more education when he states that the risk factors that can be controlled or modified include: A) inactivity, stress, gender, and smoking. B) gender, family history, and older age. C) obesity, inactivity, diet, and smoking. D) stress, family history, and obesity.

B) gender, family history, and older age.

A client with peripheral vascular disease has poor circulation. The nurse should assess the client for changes in: (Select all that apply.) A) nausea B) pain in extremity C) fluid intake D) skin temperature E) nail bed color

B) pain in extremity D) skin temperature E) nail bed color

A client with known coronary artery disease reports intermittent chest pain, usually on exertion. The physician diagnoses angina pectoris and orders sublingual nitroglycerin to treat acute angina episodes. When teaching the client about nitroglycerin administration, which instruction should the nurse provide? A) "A burning sensation after administration indicates that the nitroglycerin tablets are potent." B) "Replace leftover sublingual nitroglycerin tablets every 9 months to make sure your pills are fresh." C) "Be sure to take safety precautions because nitroglycerin may cause dizziness when you stand up." D) "You may take a sublingual nitroglycerin tablet every 30 minutes, if needed. You may take as many as four doses."

C) "Be sure to take safety precautions because nitroglycerin may cause dizziness when you stand up."

The nurse instructs a client with coronary artery disease in the proper use of nitroglycerin. The client has had 2 previous episodes of coronary artery disease. At the onset of chest pain, what should the client do? A) Call 911 when five nitroglycerin tablets taken every 5 minutes are not effective. B) Take one tablet and then immediately call 911. C) Call 911 when three nitroglycerin tablets taken every 5 minutes are not effective. D) Go to the emergency department if two nitroglycerin tablets taken 5 minutes apart are not effective.

C) Call 911 when three nitroglycerin tablets taken every 5 minutes are not effective.

A nurse is reviewing laboratory values for a client diagnosed with hyperlipidemia 6 months ago. Which results indicate that the client has been following his therapeutic regimen? A) Low density lipoproteins (LDL) increase from 180 mg/dl (4.66 mmol/L to 190 mg/dl (4.92 mmol/L). B) Total cholesterol level increases from 250 mg/dl to 275 mg/dl (6.48 mmol/L to 7.12 mmol/L). C) High density lipoproteins (HDL) increase from 25 mg/dl (0.65 mmol/L) to 40 mg/dl (1.03 mmol/L). D) Triglycerides increase from 225 mg/dl (5.83 mmol/L) to 250 mg/dl (6.47 mmol/L).

C) High density lipoproteins (HDL) increase from 25 mg/dl (0.65 mmol/L) to 40 mg/dl (1.03 mmol/L).

A client who takes neuroleptic medication for treatment of chronic schizophrenia is admitted to the psychiatric unit. Nursing assessment reveals rigidity, fever, hypertension, and diaphoresis. Which life-threatening reaction do these findings suggest? A) Tardive dyskinesa B) Dystona C) Neuroleptic malignant syndrome D) Akathsia

C) Neuroleptic malignant syndrome

A man found wandering in a local park is unable to state who or where he is or where he lives. He is brought to the emergency department, where his identification is eventually discovered. The client's wife states that he was diagnosed with Alzheimer's disease 3 years earlier and has experienced increasing memory loss. She tells a nurse she is worried about how she'll continue to care for him. Which response by the nurse is most helpful? A) "You may benefit from a support group called Mates of Alzheimer's Disease Clients." B) "Do you have any children or friends who could give you a break from his care every now and then?" C) "Because of the nature of your husband's disease, you should start looking into nursing homes for him." D) "What aspect of caring for your husband is causing you the greatest concern?"

D) "What aspect of caring for your husband is causing you the greatest concern?"

Following diagnosis of angina pectoris, a client reports being unable to walk up two flights of stairs without pain. Which instruction would most likely help the client prevent this problem? A) Climb the steps early in the day. B) Rest for at least an hour before climbing the stairs. C) Lie down after climbing the stairs. D) Take a nitroglycerin tablet before climbing the stairs.

D) Take a nitroglycerin tablet before climbing the stairs.

The nurse is assessing the level of consciousness for a client who just had open heart surgery. When asked, the client can give his name but is not sure about where he is or the time of day. What should the nurse do? A) Encourage the client's wife to orient the client. B) Notify the surgeon. C) Rub the client's sternum to arouse the client. D) Tell the client where he is and the time of day.

D) Tell the client where he is and the time of day.

A client with Alzheimer's disease mumbles incoherently and rambles in a confused manner. To help redirect the client's attention, the nurse should encourage the client to: A) participate in a game of charades. B) play cards with another client. C) perform an aerobic exercise. D) fold towels and pillowcases.

D) fold towels and pillowcases.

Which intervention is essential when caring for a client who is experiencing delirium? A) manipulating the environment to increase orientation. B) controlling behavioral symptoms with low dose psychotropics. C) decreasing or discontinuing all previously prescribed medications. D) identifying the underlying causative condition or illness.

D) identifying the underlying causative condition of illness.

A man is brought to the hospital by his wife, who states that he has refused all meals for the past week and accused her of trying to poison him. During the initial interview, the client's speech, only partly comprehensible, reveals that his thoughts are controlled by delusions that he is possessed by the devil. A physician diagnoses paranoid schizophrenia. Schizophrenia is best described as a disorder characterized by: A) preoccupation with persecutory delusions, anxiety, anger and potential for violence. B) auditory and tactile hallucinations C) multiple personalities, one of which is more disruptive than the others. D) severe mood swings and periods of low to high activity.

preoccupation with persecutory delusions, anxiety, anger, and potential for violence.

A client is sitting in the corner of the dayroom cocking his head to one side as if he hears something, but no one is nearby. The nurse suspects he is having auditory hallucinations. Which question should the nurse ask first? A) "Are you seeing someone other than me?" B) "What are you hearing right now?" C) "Do you want to go to the recreation room?" D) "What is going on with you right now?"

B) "What are you hearing right now?"

A client is receiving nitroglycerin ointment to treat angina pectoris. The nurse evaluates the therapeutic effectiveness of this drug by assessing the client's response and checking for adverse effects. Which vital sign is most likely to reflect an adverse effect of nitroglycerin? A) Pulse rate of 84 beats/minute B) Blood pressure 84/52 mm Hg C) Temperature of 100.2° F (37.9° C) D) Respiration 26 breaths/minute

B) Blood pressure 84/52 mm Hg

The nurse is assessing a client who has been admitted to the acute care facility. The client experiences an acute onset of altered level of consciousness and recent memory loss. Which of the following does the nurse anticipate the client will be evaluated for? A) Depression B) Delirium C) Dementia D) Tertiary syphilis

B) Delirium

A nurse on the geropsychiatric unit receives a call from the son of a recently discharged client. He reports that his father just got a prescription for memantine to take "on top of his donepezil." The son then asks, "Why does he have to take extra medicines?" The nurse should tell the son: A) "Maybe the donepezil alone is not improving his dementia fast enough or well enough. B) Donepezil has a short half-life and memantine has a long half-life. They work well together." C) Memantine and donepezil are commonly used together to slow the progression of dementia." D) Memantine is more effective than donepezil. Your father will be tapered off the donepezil.

C) Memantine and donepezil are commonly used together to slow the progression of dementia."