part 2
Which patient in the women's health clinic will the nurse expect to teach about an endometrial biopsy?
A 25-yr-old patient who has a family history of hereditary nonpolyposis colorectal cancer
A patient who has benign prostatic hyperplasia (BPH) with urinary retention is admitted to the hospital with elevated blood urea nitrogen (BUN) and creatinine. Which prescribed therapy should the nurse implement first?
Insert a urinary retention catheter.
A patient has been taking phenytoin (Dilantin) for 2 years. Which action will the nurse take when evaluating for adverse effects of the medication?
Inspect the oral mucosa.
The nurse assesses a 78-yr-old who uses naproxen (Aleve) daily for hand and knee osteoarthritis management. Which information requires a discussion with the health care provider about an urgent change in the treatment plan?
Laboratory results indicate blood urea nitrogen (BUN) is elevated.
When caring for a patient with continuous bladder irrigation after having transurethral resection of the prostate, which action could the nurse delegate to unlicensed assistive personnel (UAP)?
Report any complaints of pain or spasms to the nurse.
A 31-yr-old patient who has been diagnosed with human papillomavirus (HPV) infection gives a health history that includes smoking tobacco, taking oral contraceptives, and having been treated twice for vaginal candidiasis. Which topic will the nurse include in patient teaching?
Risk factors for cervical cancer
Which action should the nurse take when a 35-yr-old patient has a Pap test result of minor cellular changes?
Schedule another Pap test in 4 months.
A patient seen in the outpatient clinic is diagnosed with mild cognitive impairment (MCI). Which action will the nurse include in the plan of care?
Schedule the patient for more frequent appointments.
During assessment of the patient with fibromyalgia, the nurse would expect the patient to report which of the following (select all that apply)?
Sleep disturbances, Multiple tender points, Widespread bilateral, burning musculoskeletal pain
A hospitalized patient with a history of cluster headache awakens during the night with a severe stabbing headache. Which action should the nurse take first?
Start the prescribed PRN O2at 6 L/min.
Which intervention will the nurse include in the plan of care for a patient with primary restless legs syndrome (RLS) who is having difficulty sleeping?
Suggest that the patient exercise regularly during the day.
A patient with rheumatoid arthritis (RA) complains to the clinic nurse about having chronically dry eyes. Which action by the nurse is appropriate?
Suggest the patient use over-the-counter (OTC) artificial tears.
Which action will the nurse plan to take for a patient with multiple sclerosis who has urinary retention caused by a flaccid bladder?
Teach the patient how to use the Credé method.
Which information will the nurse plan to include when teaching a young adult who has a family history of testicular cancer about testicular self-examination?
Testicular self-examination should be done in a warm room.
A patient is scheduled for an induced abortion using instillation of hypertonic saline solution. Which information will the nurse plan to discuss with the patient before the procedure?
The expulsion of the fetus may take 1 to 2 days.
A patient with dermatomyositis is receiving long-term prednisone therapy. Which assessment finding by the nurse is important to report to the health care provider?
The patient has painful hematuria.
A 29-yr-old woman is taking methotrexate to treat rheumatoid arthritis. Which information from the patient's health history is importantfor the nurse to report to the health care provider related to the methotrexate?
The patient is trying to get pregnant before her disease becomes more severe.
The home health nurse is making a follow-up visit to a patient with recently diagnosed rheumatoid arthritis (RA). Which assessment made by the nurse indicates more patient teaching is needed?
The patient sleeps with two pillows under the head.
The nurse is planning care for a patient with hypertension and gout who has a red, painful right great toe. Which nursing action will be included in the plan of care?
Use a footboard to hold bedding away from the toe.
The nurse suggests that a patient recently diagnosed with rheumatoid arthritis (RA) plan to start each day with
a warm bath followed by a short rest.
To determine the severity of the symptoms for a patient with benign prostatic hyperplasia (BPH), the nurse will ask the patient about
force of urinary stream.
A patient is diagnosed with moderate dementia after multiple strokes. During assessment of the patient, the nurse would expect to find
loss of recent and long-term memory.
Anakinra (Kineret) is prescribed for a patient with rheumatoid arthritis (RA). When teaching the patient about this drug, the nurse will include information about
self-administration of subcutaneous injections.
A patient who takes multiple medications develops acute gouty arthritis. The nurse will consult with the health care provider before giving the prescribed dose of
sertraline (Zoloft).
A 32-yr-old patient has oral contraceptives prescribed for endometriosis. The nurse will teach the patient to
take the medication every day for the next 9 months.
Which topic will the nurse include in the preoperative teaching for a patient admitted for an abdominal hysterectomy?
Purpose of ambulation and leg exercises
Which nonhormonal therapies will the nurse suggest for a healthy perimenopausal patient who prefers not to use hormone replacement therapy (HRT)(select all that apply)?
Reduce caffeine intake. Exercise several times a week. Take black cohosh supplements. Increase intake of dietary soy products
Which assessment information collected by the nurse may present a contraindication to a testosterone replacement therapy (TRT)?
The patient has had a gradual decrease in the force of his urinary stream
The nurse is concerned about a postoperative patient's risk for injury during an episode of delirium. The mostappropriate action by the nurse is to
assign unlicensed assistive personnel (UAP) to stay with and reorient the patient
The nurse teaching a support group of women with rheumatoid arthritis (RA) about how to manage activities of daily living suggests they should
avoid activities requiring repetitive use of the same muscles and joints.
A 40-yr-old patient is diagnosed with early Huntington's disease (HD). When teaching the patient, spouse, and adult children about this disorder, the nurse will provide information about the
option of genetic testing for the patient's children to determine their own HD risks.
A young patient who is trying to become pregnant asks the nurse how to determine when she is most likely to conceive. The nurse explains that
ovulation prediction kits can provide accurate information about ovulation.
The nurse will plan to teach a 67-yr-old patient who has been diagnosed with orchitis about
pain management
When performing discharge teaching for a patient after a vasectomy, the nurse instructs the patient that he
should continue to use other methods of birth control for 6 weeks.
The nurse taking a focused health history for a patient with possible testicular cancer will ask the patient about a history of
undescended testicles.
The nurse expects the assessment of a patient who is experiencing a cluster headache to include
unilateral ptosis
The nurse performing a focused examination to determine possible causes of infertility will assess for
varicocele
A 58-yr-old patient is on the medical-surgical unit after undergoing a radical vulvectomy for vulvar carcinoma. The greatestrisk to the patient at this time is
wound infection.
A patient has just been instructed in the treatment for a Chlamydia trachomatisvaginal infection. Which patient statement indicates that the nurse's teaching has been effective?
"Both my partner and I will need to take the medication for a full week."
The nurse is obtaining the pertinent health history for a man who is being evaluated for infertility. Which question focuses on a possible cause of infertility?
"Do you use medications to improve muscle mass?"
A 22-yr-old patient tells the nurse at the health clinic that he has recently had some problems with erectile dysfunction. Which question should the nurse ask to assess for possible etiologic factors in this age group?
"Do you use recreational drugs or drink alcohol?"
A 19-yr-old patient visits the health clinic for a routine checkup. Which question should the nurse ask to determine whether a Pap test is needed?
"Have you had sexual intercourse?"
The nurse is administering a mental status examination to a patient who has hypertension. The nurse suspects depression when the patient responds to the nurse's questions with
"I don't know."
A 70-yr-old patient who has had a transurethral resection of the prostate (TURP) for benign prostatic hyperplasia (BPH) is being discharged from the hospital today. Which patient statement indicates a need for the nurse to provide additional instruction?
"I should call the doctor if I have incontinence at home."
Which statement by the patient indicates that the nurse's teaching about treating vaginal candidiasis was effective?
"I should clean carefully after each urination and bowel movement."
The nurse determines additional instruction is needed when a patient diagnosed with scleroderma makes which statement?
"I should lie down for an hour after each meal."
After the nurse has finished teaching a patient with osteoarthritis (OA) of the right hip about how to manage the OA, which patient statement indicates a need for more teaching?
"I will take 1 g of acetaminophen (Tylenol) every 4 hours."
When the nurse brings medications to a patient with rheumatoid arthritis, the patient refuses the prescribed methotrexate. The patient tells the nurse, "My arthritis isn't that bad yet. The side effects of methotrexate are worse than the arthritis." The mostappropriate response by the nurse is
"It is important to start methotrexate early to decrease the extent of joint damage."
A patient with two school-age children has recently been diagnosed with rheumatoid arthritis (RA) and tells the nurse that home life is very stressful. Which initial response by the nurse is mostappropriate?
"Tell me more about the situations that are causing you stress."
After a thymectomy, a patient with myasthenia gravis receives the usual dose of pyridostigmine (Mestinon). An hour later, the patient complains of nausea and severe abdominal cramps. Which action should the nurse take first?
Notify the patient's health care provider
A 22-yr-old patient tells the nurse that she has not had a menstrual period for the past 3 months. Which action is most important for the nurse to take?
Obtain a urine specimen for a pregnancy test.
The spouse of a 67-yr-old male patient with early stage Alzheimer's disease (AD) tells the nurse, "I am exhausted from worrying all the time. I don't know what to do." Which actions are best for the nurse to take next(select all that apply)?
Offer ideas for ways to distract or redirect the patient. Teach the spouse about adult day care as a possible respite. Ask the spouse what she knows and has considered about dementia care options.
A healthy 24-yr-old patient who has been vaccinated against human papillomavirus (HPV) has a normal Pap test result. Which information will the nurse include in patient teaching when calling the patient with the results of the Pap test?
Pap testing is recommended every 3 years for women your age.
Which information about a patient who has a new prescription for phenytoin (Dilantin) indicates that the nurse should consult with the health care provider before administration of the medication?
Patient has minor elevations in the liver function tests
After change-of-shift report on the Alzheimer's disease/dementia unit, which patient will the nurse assess first?
Patient who developed a new cough after eating breakfast
After change-of-shift report, which patient should the nurse assess first?
Patient with myasthenia gravis who is reporting increased muscle weakness
Which hospitalized patient will the nurse assign to the room closest to the nurses' station?
Patient with new-onset confusion, restlessness, and irritability after surgery
A patient undergoes an anterior and posterior (A&P) colporrhaphy for repair of a cystocele and rectocele. Which nursing action will be included in the postoperative care plan?
Perform urinary catheter care.
The home health registered nurse (RN) is planning care for a patient with a seizure disorder related to a recent head injury. Which nursing action can be delegated to a licensed practical/vocational nurse (LPN/LVN)?
Place medications in the home medication organizer.
A patient with Alzheimer's disease (AD) who is being admitted to a long-term care facility has had several episodes of wandering away from home. Which action will the nurse include in the plan of care?
Place the patient in a room close to the nurses' station
A patient with Parkinson's disease is admitted to the hospital for treatment of pneumonia. Which nursing interventions will be included in the plan of care (select all that apply)?
Provide an elevated toilet seat, Cut patient's food into small pieces, Place an armchair at the patient's bedside
Which intervention will the nurse include in the plan of care for a patient with moderate dementia who had a fractured hip repair 2 days ago?
Remind the patient frequently about being in the hospital.
Which assessment is most important for the nurse to make regarding a patient with myasthenia gravis?
Respiratory effort
A patient with pelvic inflammatory disease (PID) is being treated with oral antibiotics as an outpatient. Which instruction will be included in patient teaching?
Return for a follow-up appointment in 2 to 3 days.
A patient who has been treated for status epilepticus in the emergency department will be transferred to the medical nursing unit. Which equipment should the nurse have available in the patient's assigned room (select all that apply)?
Side-rail pads, Oxygen mask, Suction tubing
A patient with Parkinson's disease has bradykinesia. Which action will the nurse include in the plan of care?
Suggest that the patient rock from side to side to initiate leg movement.
A 19-yr-old patient has been diagnosed with primary dysmenorrhea. How will the nurse suggest that the patient manage discomfort?
Take nonsteroidal antiinflammatory drugs (NSAIDs) when her period starts.
A patient requests a prescription for birth control pills to control severe abdominal cramping and headaches during her menstrual periods. Which action should the nurse take first?
Take the patient's personal and family health history.
Which action by the unlicensed assistive personnel (UAP) who are assisting with the care of male patients with reproductive problems indicates that the nurse should provide more teaching?
The UAP leave the foreskin pulled back after cleaning the glans of a patient who has a retention catheter.
A patient who had arthroscopic surgery of the right knee 7 days ago is admitted with a red, swollen, hot knee. Which assessment finding by the nurse should be reported to the health care provider immediately?
The blood pressure is 86/50 mm Hg.
Which assessment information obtained by the nurse indicates a patient with an exacerbation of rheumatoid arthritis (RA) is experiencing a side effect of prednisone?
The patient's blood glucose is 165 mg/dL.
A patient is being evaluated for Alzheimer's disease (AD). The nurse explains to the patient's adult children that
a diagnosis of AD is made only after other causes of dementia are ruled out.
When a 74-yr-old patient is seen in the health clinic with new development of a stooped posture, shuffling gait, and pill rolling-type tremor, the nurse will anticipate teaching the patient about
antiparkinsonian drugs.
A nursing diagnosis that is likely to be appropriate for a 67-yr-old patient who has just been diagnosed with stage III ovarian cancer is
anxiety related to cancer diagnosis and need for treatment decisions.
The nurse's initialaction for a patient with moderate dementia who develops increased restlessness and agitation should be to
assess for factors that might be causing discomfort.
The nurse observes a patient ambulating in the hospital hall when the patient's arms and legs suddenly jerk and the patient falls to the floor. The nurse will first
assess the patient for a possible injury
A patient has an induced abortion with suction curettage at an ambulatory surgical center. Which instructions will the nurse include when discharging the patient?
"Abstain from sexual intercourse for the next 2 weeks."
A 49-yr-old patient tells the nurse that she is postmenopausal but has recently had occasional spotting. Which initialresponse by the nurse is appropriate?
"Are you using prescription hormone replacement therapy?"
The nurse will plan to teach a 34-yr-old patient diagnosed with stage 0 cervical cancer about
conization.
Which medication taken by a patient with restless legs syndrome should the nurse discuss with the patient?
Diphenhydramine
A 72-yr-old patient is brought to the clinic by the patient's spouse, who reports that the patient is unable to solve common problems around the house. To obtain information about the patient's current mental status, which question should the nurse ask the patient?
"What did you eat for lunch?"
A 47-yr-old patient asks whether she is going into menopause if she has not had a menstrual period for 3 months. Which response by the nurse is appropriate?
"What was your menstrual pattern before your periods stopped?"
A 34-yr-old patient who is discussing contraceptive options with the nurse says, "I want to have children but not for a few years." Which response by the nurse is accurate?
"Women often have more difficulty becoming pregnant after about age 35."
A patient who is having an acute exacerbation of multiple sclerosis has a prescription for methylprednisolone (Solu-Medrol) 150 mg IV. The label on the vial reads: methylprednisolone 125 mg in 2 mL. How many mL will the nurse administer?
2.4
The following male patients recently arrived in the emergency department. Which one should the nurse assess first?
A 19-yr-old patient who is complaining of severe scrotal pain
The nurse in the women's health clinic has four patients who are waiting to be seen. Which patient should the nurse see first?
A 19-yr-old patient with menorrhagia who has been using superabsorbent tampons and has fever with weakness
Several patients call the urology clinic requesting appointments with the health care provider as soon as possible. Which patient will the nurse schedule to be seen first?
A 22-yr-old patient who has noticed a firm, nontender lump on his scrotum
The nurse in the clinic notes elevated prostate specific antigen (PSA) levels in the laboratory results of these patients. Which patient's PSA result is not expected to be elevated?
A 48-yr-old patient whose father died of metastatic prostate cancer
Which patient seen by the nurse in the outpatient clinic is mostlikely to require teaching about ways to reduce the risk for osteoarthritis (OA)?
A 56-yr-old woman who works on an automotive assembly line
The nurse in a health clinic receives requests for appointments from several patients. Which patient should be seen by the health care providerfirst?
A 58-yr-old patient who has a painful erection that has lasted more than 6 hours
Which information will the nurse include when teaching a patient with newly diagnosed systemic exertion intolerance disease (SEID) about self-management?
A gradual increase in daily exercise may help decrease fatigue.
The nurse has just received change-of-shift report about the following four patients. Which patient should be assessed first?
A patient with a possible ectopic pregnancy who is complaining of shoulder pain
Which action will the nurse include in the plan of care for a patient with a new diagnosis of rheumatoid arthritis (RA)?
Encourage the patient to take a nap in the afternoon.
A patient tells the nurse about using acetaminophen (Tylenol) several times every day for recurrent bilateral headaches. Which action will the nurse plan to take first?
Discuss the need to stop taking the acetaminophen
Which information will the nurse include when teaching a patient with newly diagnosed ankylosing spondylitis (AS) about management of the condition?
Do daily deep-breathing exercises.
A patient with gout has a new prescription for losartan (Cozaar) to control the condition. The nurse will plan to monitor
blood pressure.
Which nursing action can the registered nurse (RN) delegate to unlicensed assistive personnel (UAP) who are assisting with the care of a patient with scleroderma?
Document the patient's oral intake.
After reviewing the electronic medical record shown in the accompanying figure for a patient who had transurethral resection of the prostate the previous day, which information requires the mostrapid action by the nurse?
Bladder spasms and urine output
Which finding for a patient who is taking hydroxychloroquine (Plaquenil) to treat rheumatoid arthritis is likely to be an adverse effect of the medication?
Blurred vision
A hospitalized patient complains of a bilateral headache (4/10 on the pain scale) that radiates from the base of the skull. Which prescribed PRN medications should the nurse administer initially?
Acetaminophen (Tylenol)
Which prescribed intervention will the nurse implement firstfor a patient in the emergency department who is experiencing continuous tonic-clonic seizures?
Administer lorazepam (Ativan) 4 mg IV.
Which actions could the nurse delegate to a licensed practical/vocational nurse (LPN/LVN) who is part of the team caring for a patient with Alzheimer's disease (select all that apply)?
Administer the prescribed memantine (Namenda). Remove potential safety hazards from the patient's environment.
The health care provider has prescribed the following interventions for a patient who is taking azathioprine (Imuran) for systemic lupus erythematosus. Which order will the nurse question?
Administer varicella vaccine.
Which action will the nurse include in the plan of care for a patient with newly diagnosed ankylosing spondylitis?
Advise the patient to sleep on the back with a flat pillow.
A new clinic patient with joint swelling and pain is being tested for systemic lupus erythematosus. Which test will provide the most specificfindings for the nurse to review?
Anti-Smith antibody (Anti-Sm)
Which information will the nurse include when preparing teaching materials for a patient with an exacerbation of rheumatoid arthritis?
Applying cold packs before exercise may decrease joint pain
A 58-yr-old patient with erectile dysfunction (ED) tells the nurse he is interested in using sildenafil (Viagra). Which action should the nurse takefirst?
Ask the patient about any prescription drugs he is taking.
The nurse notices a circular lesion with a red border and clear center on the arm of a summer camp counselor who is in the clinic complaining of chills and muscle aches. Which action should the nurse take to follow up on that finding?
Ask the patient about recent outdoor activities.
A 27-yr-old patient who has testicular cancer is being admitted for a unilateral orchiectomy. The patient does not talk to his wife and speaks to the nurse only to answer the admission questions. Which action is appropriate for the nurse to take?
Ask the patient if he has any questions or concerns about the diagnosis and treatment.
A 22-yr-old patient seen at the health clinic with a severe migraine headache tells the nurse about having similar headaches recently. Which initialaction should the nurse take?
Ask the patient to keep a headache diary.
A 28-yr-old patient reports anxiety, headaches with dizziness, and abdominal bloating occurring before her menstrual periods. Which action is bestfor the nurse to take at this time?
Ask the patient to keep track of her symptoms in a diary for 3 months.
When administering the Mini-Cog exam to a patient with possible Alzheimer's disease, which action will the nurse take?
Ask the person to use a clock drawing to indicate a specific time.
A patient being seen in the clinic has rheumatoid nodules on the elbows. Which action will the nurse take?
Assess the nodules for skin breakdown or infection.
A patient brought to the emergency department reports being sexually assaulted. The patient is confused about where she is and she has a laceration above the right eye. Which action should the nurse take first?
Assess the patient's neurologic status.
Which nursing actions can the nurse working in a women's health clinic delegate to experienced unlicensed assistive personnel (UAP) (select all that apply)?
Assist the health care provider with performing a Pap test. Draw blood for CA-125 levels for a patient with ovarian cancer.
A patient who has amyotrophic lateral sclerosis (ALS) is hospitalized with pneumonia. Which nursing action will be included in the plan of care?
Assist with active range of motion (ROM).
Which information about continuous bladder irrigation will the nurse teach to a patient who is being admitted for a transurethral resection of the prostate (TURP)?
Bladder irrigation prevents obstruction of the catheter after surgery.
The nurse is caring for a patient with pelvic inflammatory disease (PID) requiring hospitalization. Which nursing intervention will be included in the plan of care?
Elevate the head of the bed at least 30 degrees.
Which result for a patient with systemic lupus erythematosus (SLE) is mostimportant for the nurse to communicate to the health care provider?
Elevated blood urea nitrogen (BUN)
Which laboratory result will the nurse monitor to determine if prednisone has been effective for a patient with an acute exacerbation of rheumatoid arthritis?
C-reactive protein
The nurse will anticipate the need to teach a patient who has osteoarthritis (OA) about which medication?
Capsaicin cream (Zostrix)
The health care provider prescribes the following interventions for a patient with acute prostatitis caused by Escherichiacoli. Which intervention should the nurse question?
Catheterize the patient as needed if symptoms of urinary retention develop.
Which information will the nurse include when teaching a patient who has developed a small vesicovaginal fistula 2 weeks into the postpartum period?
Change the perineal pad frequently to prevent perineal skin breakdown.
A patient who is scheduled for a routine gynecologic examination tells the nurse that she has had intercourse during the past year with several men. The nurse will plan to teach about the reason for
Chlamydia testing.
A patient who has been recently diagnosed with benign prostatic hyperplasia (BPH) tells the nurse that he does not want to have a transurethral resection of the prostate (TURP) because it might affect his ability to have sexual intercourse. Which action should the nurse take?
Clarify that TURP does not commonly affect erection.
Which finding will the nurse expect when assessing a patient who has osteoarthritis (OA) of the knee?
Discomfort with joint movement
A patient with psoriatic arthritis and back pain is receiving etanercept (Enbrel). Which finding is most important for the nurse to report to the health care provider?
Crackles are auscultated in the lung bases.
When reviewing the health record for a new patient with rheumatoid arthritis, the nurse reads that the patient has swan neck deformities. Which deformity will the nurse expect to observe when assessing the patient?
D
The nurse in the infertility clinic is explaining in vitro fertilization (IVF) to a couple. The woman tells the nurse that they cannot afford IVF on her husband's salary. The man replies that if his wife worked outside the home, they would have enough money. Which nursing diagnosis is appropriate?
Defensive coping related to anxiety about lack of conception
A high school teacher who has been diagnosed with epilepsy after having a generalized tonic-clonic seizure tells the nurse, "I cannot teach any more. It will be too upsetting if I have a seizure at work." Which response by the nurse specifically addresses the patient's concern?
Epilepsy usually can be well controlled with medications
A patient who was admitted to the emergency department with severe abdominal pain is diagnosed with an ectopic pregnancy. The patient begins to cry and asks the nurse to leave her alone to grieve. Which action should the nurse take next?
Explain the reason for taking vital signs every 15 to 30 minutes.
A patient reports feeling numbness and tingling of the left arm before experiencing a seizure. The nurse determines that this history is consistent with what type of seizure?
Focal
A patient is considering the use of combined estrogen-progesterone hormone replacement therapy (HRT) during menopause. Which information will the nurse include during their discussion?
HRT decreases osteoporosis risk and increases the risk for cardiovascular disease and breast cancer.
A patient with urinary obstruction from benign prostatic hyperplasia (BPH) tells the nurse, "My symptoms are much worse this week." Which response by the nurse is appropriate?
Have you taken any over-the-counter (OTC) medications recently
Which nursing action will be most effective in ensuring daily medication compliance for a patient with mild dementia?
Having the patient's family member administer the medication
A patient tells the nurse that she would like a prescription for oral contraceptives to control her premenstrual dysphoric disorder (PMD-D) symptoms. Which patient information that contraindicates oral contraceptives should be communicated to the health care provider?
History of migraine headaches
A 33-yr-old patient with multiple sclerosis (MS) is to begin treatment with glatiramer acetate (Copaxone). Which information will the nurse include in patient teaching?
How to draw up and administer injections of the medication
The nurse determines that teaching about management of migraine headaches has been effective when the patient says which of the following?
I will lie down someplace dark and quiet when the headaches begin
After the nurse has taught a 28-yr-old with fibromyalgia, which statement by the patient indicates a good understanding of effective self-management?
I will need to stop drinking so much coffee and soda.
Which statement by a patient with systemic lupus erythematosus (SLE) indicates the patient has understood the nurse's teaching about the condition?
I will use sunscreen when I am outside.
Which nursing diagnosis is of highestpriority for a patient with Parkinson's disease who is unable to move the facial muscles?
Imbalanced nutrition: less than body requirements
Which information will the nurse teach a patient who has chronic prostatitis
Intercourse or masturbation will help relieve symptoms
A patient has scleroderma manifested by CREST (calcinosis, Raynaud's phenomenon, esophageal dysfunction, sclerodactyly, and telangiectasia) syndrome. Which action will the nurse include in the plan of care?
Keep the environment warm and draft free.
The day shift nurse at the long-term care facility learns that a patient with dementia experienced sundowning late in the afternoon on the previous two days. Which action should the nurse take?
Keep window blinds open during the day.
A patient in the emergency department reports that she has been sexually assaulted. Which action by the nurse will help to maintain the medicolegal chain of evidence?
Labeling all specimens and other materials obtained from the patient
Which nursing assessment finding in a patient who recently started taking hormone replacement therapy (HRT) requires discussion with the health care provider about a change in therapy?
Left calf swelling
A woman who has multiple sclerosis (MS) asks the nurse about risks associated with pregnancy. Which response by the nurse is accurate?
MS symptoms may be worse after the pregnancy
A patient who has severe Alzheimer's disease (AD) is being admitted to the hospital for surgery. Which intervention will the nurse include in the plan of care?
Maintain a consistent daily routine for the patient's care.
After a transurethral resection of the prostate (TURP), a 64-yr-old patient with continuous bladder irrigation complains of painful bladder spasms. The nurse observes clots in the urine. Which action should the nurse take first?
Manually instill and then withdraw 50 mL of saline into the catheter.
The health care provider is considering the use of sumatriptan (Imitrex) for a 54-yr-old male patient with migraine headaches. Which information obtained by the nurse is most important to report to the health care provider?
The patient had a recent acute myocardial infarction.
Which information about a 60-yr-old patient with multiple sclerosis indicates that the nurse should consult with the health care provider before giving the prescribed dose of dalfampridine (Ampyra)?
The patient has an increased serum creatinine level
Which assessment finding for a patient using naproxen (Naprosyn) to treat osteoarthritis is likely to require a change in medication?
The patient has dark-colored stools.
A patient with an acute attack of gout in the right great toe has a new prescription for probenecid. Which information about the patient's home routine indicates a need for teaching regarding gout management?
The patient takes one aspirin a day to prevent angina.
A patient who is hospitalized with pneumonia is disoriented and confused 3 days after admission. Which information indicates that the patient is experiencing delirium rather than dementia?
The patient was oriented and alert when admitted.
A 62-yr-old patient who has Parkinson's disease is taking bromocriptine (Parlodel). Which information obtained by the nurse may indicate a need for a decrease in the dosage?
The patient's blood pressure is 92/52 mm Hg.
A 50-yr-old patient is diagnosed with uterine bleeding caused by a leiomyoma. Which information will the nurse include in the patient teaching plan?
The symptoms may decrease after the patient undergoes menopause.
Which laboratory result is important to communicate to the health care provider for a patient who is taking methotrexate to treat rheumatoid arthritis (RA)?
The white blood cell (WBC) count is 1500/µL.
While the nurse is transporting a patient on a stretcher to the radiology department, the patient begins having a tonic-clonic seizure. Which action should the nurse take?
Time and observe and record the details of the seizure and postictal state.
After reviewing the health record shown in the accompanying figure for a patient who has multiple risk factors for Alzheimer's disease (AD), which topic will be most important for the nurse to discuss with the patient?
Tobacco use
A patient is being treated with carbidopa/levodopa (Sinemet) for Parkinson's disease. Which information indicates a need for change in the medication or dosage?
Uncontrolled head movement
A patient is on the surgical unit after a radical abdominal hysterectomy. Which finding requires a report to the health care provider?
Urine output of 125 mL in the first 8 hours after surgery
A patient who has a large cystocele was admitted 10 hours ago but has not yet voided. If the patient reports no urge to void, which action should the nurse take first?
Use an ultrasound scanner to check for urinary retention.
Which action will help the nurse determine whether a new patient's confusion is caused by dementia or delirium?
Use the Confusion Assessment Method tool
When administering a mental status examination to a patient with delirium, the nurse should
choose a place without distracting stimuli.
When caring for a 58-yr-old patient with persistent menorrhagia, the nurse will plan to monitor the
complete blood count (CBC).
A patient hospitalized with a fever and red, hot, painful knees is suspected of having septic arthritis. Information obtained during the nursing history that indicates a risk factor for septic arthritis is that the patient
is sexually active with multiple partners.
The nurse will plan to teach the patient who is incontinent of urine following a radical retropubic prostatectomy to
do pelvic muscle exercises.
A patient reporting painful urination and knee pain is diagnosed with reactive arthritis. The nurse will plan to teach the patient about the need for several months of therapy with
doxycycline (Vibramycin).
When caring for a patient who has a radium implant for treatment of cervical cancer, the nurse will
encourage the patient to discuss any concerns by telephone
A 56-yr-old patient is concerned about having a moderate amount of vaginal bleeding after 5 years of menopause. The nurse will anticipate teaching the patient about
endometrial biopsy.
The plan of care for a patient immediately after a perineal radical prostatectomy will include decreasing the risk for infection related to
fecal wound contamination
The nurse will inform a patient with cancer of the prostate that side effects of leuprolide (Lupron) may include
flushing.
The health care provider prescribes finasteride (Proscar) for a patient who has benign prostatic hyperplasia (BPH). When teaching the patient about the drug, the nurse informs him that
his interest in sexual activity may decrease while he is taking the medication.
The nurse will plan to teach the patient scheduled for photovaporization of the prostate (PVP)
how to care for an indwelling urinary catheter.
The nurse will plan to teach the female patient with genital warts about the
importance of regular Pap tests.
When obtaining a health history and physical assessment for a 36-yr-old female patient with possible multiple sclerosis (MS), the nurse should
inquire about urinary tract problems
To prevent pregnancy in a patient who has been sexually assaulted, the nurse in the emergency department will plan to teach the patient about the use of
levonorgestrel (Plan-B One-Step).
A patient was recently diagnosed with polycystic ovary syndrome. It is most important for the nurse to teach the patient
methods to maintain appropriate weight.
The nurse advises a patient with myasthenia gravis (MG) to
perform physically demanding activities early in the day.
A 53-yr-old patient is scheduled for an annual physical examination. The nurse will plan to teach the patient about the purpose of
prostate specific antigen (PSA) testing.
A female patient tells the nurse that she has been having nightmares and acute anxiety around men since being sexually assaulted 3 months ago. The mostappropriate nursing diagnosis for the patient is
rape-trauma syndrome related to rape experience.
The nurse determines that colchicine has been effective for a patient with an acute attack of gout upon finding
reduced joint pain.
A patient hospitalized with polymyositis has joint pain; erythematous facial rash; eyelid edema; and a weak, hoarse voice. The safety priority for the patient is addressing the
risk for aspiration.
A patient tells the nurse that he decided to seek treatment for erectile dysfunction (ED) because his wife "is losing patience with the situation." The nurse's follow-up questions should focuson the man's identified concern with
role performance
A patient who has been diagnosed with stage 2 prostate cancer chooses the option of active surveillance. The nurse will plan to
schedule the patient for annual prostate-specific antigen testing.
A 25-yr-old female patient with systemic lupus erythematosus (SLE) who has a facial rash and alopecia tells the nurse, "I never leave my house because I hate the way I look." The nurse will plan interventions with the patient to address the nursing diagnosis of
social isolation.
A patient with endometriosis asks why she is being treated with medroxyprogesterone, a medication that she thought was a contraceptive. The nurse explains that this therapy
suppresses the menstrual cycle by mimicking pregnancy.
The nurse will anticipate that a 61-yr-old patient who has an enlarged prostate detected by digital rectal examination (DRE) and an elevated prostate specific antigen (PSA) level will need teaching about
transrectal ultrasonography (TRUS).
