Term 1 Final review

The nurse is assessing the vision of an older adult patient. Which finding is not associated with the aging process?

Visualization of half of the field

A nurse is caring for a client who received a sedative medication at bedtime and becomes confused during the night. The client falls while getting out of bed, sustaining a laceration to the head that requires suturing. Which of the following notations should the nurse make when documenting in the client's medical record?

"Client found lying on the floor with a 3-cm laceration 1 cm above left eyebrow. Client oriented to name only."

A nurse is reviewing HIPAA with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates a need for further instruction?

"Information about a client can be disclosed to family members at any time."

Which of the following vitamins are water soluble? (SATA-2)

1. B 2. C

Which of the following is a physical sign or symptom of neglect? (SATA-3)

1. dehydration 2. malnutrition 3. poor personal hygiene

Select foods that have the richest content in Vitamin C. (SATA-3)

1. orange juice 2. green bell peppers 3. strawberries

Major functions of the skin and related structures include: (SATA-3)

1. protection 2. thermoregulation 3. Vitamin D synthesis

Nursing interventions for the patient with a urinary drainage system are aimed at early detection and prevention of infection and trauma. Which interventions are included in the nurse's plan of care? (SATA-3)

1. record fluid intake and output 2. perform catheter care twice daily or before every shift 3. secure the catheter tubing to prevent tension

Pre-hypertensive SYSTOLIC blood pressure for an adult is:

120-139 mm/Hg

Which of the following clients is the best candidate for rehabilitative health services in a long-term care setting?

A 75-year-old hemiplegic client recovering from a recent stroke

The nurse leaves their post prior to the arrival of a relief nurse, after assuming the obligation of that patient's care, this is termed as:

Abandonment

The nurse explains that when range-of-motion is performed by the client alone, it is called:

Active

Regulating metabolism and interacting with the sympathetic nervous system in response to stress are functions of the:

Adrenal glands

A nurse is assisting with the admission of a client who has tuberculosis with a productive cough. Which type of isolation precautions should the nurse initiate for the client?

Airbone

The mitral valve is also known as the:

Biscuspid valve

During a physical assessment, the nurse notes that a patient's heart rate is only 56 beats/min. What should the nurse document that the patient is experiencing?

Bradycardia

The central nervous system includes which set of structures?

Brain and spinal cord

A 15-year-old trauma patient has been started on NG feedings. Shortly after, the patient complains of abdominal cramping & nausea. What is an appropriate nursing action?

Check the formula rate, strength and volume, any of these may be too high

An adult elderly client has refused an intramuscular injection. The nurse waits until the client is asleep and gives the injection anyway. The nurse could be charged with:

Civil battery

A nurse is caring for a client in the emergency department who had a traumatic amputation of his left arm in an industrial accident 1 hr ago. The nurse should expect the client to be in which of the following stages of grief?

Denial

A nurse is caring for a client who requests pain medication. Which of the following actions should the nurse perform first?

Determine the location of the pain

Bile can split fat globules into tiny pieces to be broken down and absorbed. What is this process called?

Emulsification

Which type of gland secretes hormones into the blood?

Endocrine

The opening in a bone through which blood vessels, nerves, and ligaments pass is called a:

Foramen

What theory claims that there is a hereditary basis for aging?

Genetic theory

What the clusters of filtering capillaries in the renal tubes?

Glomerulus

The nurse tells the patient that the most important preventive technique for interrupting the infection process is:

Handwashing

When the nurse performs nursing interventions as stated on the care plan, it is recognized that she is participating in which phase of the nursing process?

Implementation

Which of the following best described surgical asepsis?

It is the same as sterile technique

What is the name of the curvature of the thoracic spine that causes a bent-over appearance in some older adults?

Kyphosis

Which factor contributes to constipation in an older person?

Lack of dietary fiber

The nurse reassures that most acute pain is intense and of short duration, usually lasting:

Less than 6 months

In terms of negative feedback, additional TSH will be secreted in response to ___ blood levels of T3 & T4?

Low

What is the probable source of bright red blood in stool?

Lower GI tract

A nurse is administering a tap-water enema to a client. The client reports cramping as the nurse instills the irrigating solution. Which of the following actions should the nurse take to relieve the client's discomfort?

Lower the height of the solution container

A nurse is caring for a patient with dysphagia. Which of the following diet is most suitable for this patient?

Mechanical soft diet

The nurse stresses that nutrients are part of a combination of all chemical process that take place in the body to regulate body processes. This basic process is called:

Metabolism

The structure is the second portion of the pharynx

Oropharynx

Which cells in bone tissue secret an intercellular matrix?

Osteoblasts

The nurse is reviewing documentation from the previous shift. The nurse is correct when determining the patient has a stage 2 pressure injury based on which note?

Partial thickness tissue loss of dermis; shallow open area with 0.2 cm blister

Utilizing Maslow's model, a nurse understands that a patient wants to use the bathroom before taking his medication is attempting to meet which need?

Physiologic

The nurse is caring for a patient who was diagnosed with vascular dementia. The nurse understands that the patient has likely also experienced which condition?

Progressive damage from several small strokes

In which position is the patient lying face down or chest down?

Prone

In males, the gland surrounding the urethra is called the:

Prostate

A nurse is assisting with the care of a client who is 2 days postoperative following the creation of a tracheostomy. Which of the following actions should the nurse plan to take?

Provide humidified air

The nurse is working in a long-term care facility. Which activity will help the residents to meet the developmental task of ego integrity as described by Erikson?

Reminiscing about past important events

A nurse is contributing to the plan of care for a client who practices the Muslim faith. Which of the following actions should the nurse include in the plan?

Request a meal tray without pork

A nurse is performing tracheostomy care for a client. Which of the following actions should the nurse take?

Secure new tracheostomy ties before removing the old ones

A nurse is performing a dressing change on a 2-day post-surgical client. Which term should the nurse document to describe a pale, red, watery drainage?

Seroussanguineous

Anaerobic organisms tend to grow within body cavities. What will the nurse use to collect an anaerobic speciment?

Sterile syringe tip

What is an example of mechanical digestion?

Stomach mixing and churning food to chyme

Each alveolus is coated with a thin coating of a detergent-like substance that prevents it from collapsing after each breath. The liquid substance is called:

Surfactant

The seven short bones that make up each ankle are called:

Tarsals

A newly licensed nurse is preparing to insert an indwelling urinary catheter in an elderly male patient with a history of enlarged prostate. Which type of catheter will the nurse select?

The Coude catheter

Which client can receive a blood transfusion from any donor?

The client with Type AB

To focus on an object that is close or at a distance, the ciliary muscle contract and relax to change the shape of what structure?

The lens

Which of the following principles should the nurse remember when admitting, discharging, or transferring a client?

The patient is human being deserves dignity, courtesy, and respect

How should the nurse position the earpieces on a stethoscope to ensure optimum reception?

Towards the face

The primary function of a mature erythrocyte is:

Transport oxygen to the tissues

A nurse in a long-term care facility is caring for a client who is unresponsive. When performing oral hygiene for the client, which of the following actions should the nurse take?

Turn the client on his side before starting oral care