Quiz Review 5; Nursing - Medical Surgical Health Assessment Critical Care

Which is the most important information for the nurse to teach a client who is receiving cycloplegic drug therapy?

A patient who is taking rifampin (Rifadin) as part of treatment for tuberculosis asks about making an appointment for a urologist because the urine is "bright orange." What should the nurse realize this patient is experiencing?

3

A client demonstrates a positive Romberg's sign with eyes closed, but not with eyes open, during the course of the neurologic examination. What conclusion can the nurse make from this observation?

4

A patient underwent a thoracotomy 12 hours ago. The patient currently has an epidural catheter in place and is receiving continuous epidural analgesia with morphine

5

A nurse caring for an elderly client with COPD alters care knowing that in the older population.

6

The nurse is caring for a patient who is being treated for extensive burns. The nurse notes the presence of coffee-ground material in the Salem sump catheter. The nurse correctly recognizes that the probable cause is:

7

A patient states, "I feel so sad all of the time. I can't feel happy even doing things I used to like to do." He also states that he is tired, sleeps poorly, and has no energy. To differentiate between a dysthymic disorder and a major depressive disorder,

8

A postpartum mother requested her placenta be sent home with her spouse. The maternity nurse is upset and disgusted by the request and shares this view with the charge nurse. What is the best action taken by the charge nurse?

9

A nurse is developing a nursing plan of care for a client at risk for a pressure ulcer. Which of the below should be included in the plan? (Select all that apply.)

10

The client is a 56-year-old woman receiving intracavitary radiation for cervical cancer. Which nurse should be assigned to provide personal care to this client during the time the radiation source is within the client?

11

A client with paralysis who has been cared for at home for 5 years has just been admitted. A nurse finds a wound over his left trochanter that is about 4 inches in diameter and exposes the bone. How should the nurse document this finding?

12

A 55-year-old patient tells the nurse that he seems to be getting "more colds" as he gets older. Which of the following would explain what the patient is experiencing?

2

Rationale: The function of the immune system declines with age. The thymus gland, where T lymphocytes mature and differentiate, begins to atrophy early in life and continues to shrink until a person reaches middle age. Although T lymphocytes continue to be produced, their maturation and differentiation into the various functional T cells decreases. This places the older patient at higher risk for increased frequency and severity of infections accompanied by a decreased ability to resolve the infection. The thyroid gland plays no significant role in immunity. The ability of the immune system to discriminate between antigens that are "self" from those that are "non-self" would explain the increased incidence of autoimmune diseases in middle age and older patients. The body's immune system becoming less efficient at recognizing and destroying mutated cells can explain the increased incidence of cancer in the older adult.

13

During a family planning session, a young couple confides that they are hoping to conceive. Which action should the nurse suggest to potentially enhance conception?

14

The nurse is conducting a presentation to a health class for male high school students. A student questions the nurse about what semen "really is." Which contents compose semen? (select all that apply.)

15

Which type of debridement occurs when nonliving tissues sloughs away from uninjured tissues?

16

The nurse asks a client who has experienced ventricular dysrhythmias about substance abuse. The client asks, "Why do you want to know if I use cocaine?" How should the nurse respond?

17

The nurse is completing an assessment on a patient who was just admitted from the emergency department. Which assessment findings would require immediate attention? Select all that apply

18

A client has been prescribed a drug that specifically targets her cancer's proteins and pathways. How should the nurse explain the benefits of this drug?

19

The nurse is applying a warm moist compress to the client's right calf. Prior to putting the compress in place, which action by the nurse is the most appropriate?

20

The nurse is assessing the client's respiratory system. Which of the following methods will result in the most accurate assessment of the client's respiratory rate?

21

Which action does the nurse teach a client to reduce the risk for dehydration?

22

A cardiac surgery patient's new onset of signs and symptoms is suggestive of cardiac tamponade. As a member of the interdisciplinary team, what is the nurse's most appropriate action?

23

A nurse is caring for a child with a diagnosis of hemophilia. The child is in need of a blood transfusion, which her family's religious beliefs forbid. What term would best describe this religion's beliefs and their impact on health care for this child?

24

The nurse has completed the assessment of an elderly patient with the Braden Scale. The calculation of the patient's score is very low. This information suggests which of the following to the nurse?

25

The nurse is caring for a client who recently experienced a traumatic amputation of the left leg just below the knee due to a crushing injury at work while he was taking a smoke break

1. The client's report of pain in the area of the amputated foot is real.
2. Nerve regeneration to a reattached lower limb usually results in poor function.
3. Smoking is a significant risk factor for reattachment of limbs.

Rationale: The client's report of pain in the area of the amputated foot is real. The patient may have bizarre sensations, such as feeling like the absent foot is cold or itchy. These are called phantom limb sensations. Nerve regeneration to a reattached lower limb usually results in poor function. Surgical reattachment of a severed limb is done only under certain circumstances because the surgery is difficult. For adults, it is nearly impossible for nerves to regenerate in the lower extremity, and the reattached limb may be painful and dysfunctional. Smoking is a significant risk factor for reattachment of limbs. Only cleanly separated traumatic amputations in patients without significant risk factors for impaired healing such as smoking are considered for reattachment. The recovery period for a limb reattachment would be similar to one for a surgical amputation. Complete amputation and prosthesis could allow a patient to return to normal activities in days to weeks, whereas reconstruction of mangled limbs can span over years, with a huge psychological strain and impact on function and occupation. Crushing injuries are usually suitable for reattachment of the limb. Reattachment in crush-type amputations is not attempted due to the poor outcome.

26

During a breast examination, the nurse recognizes which finding as normal?

27

A terminally ill patient and the family agree that the physician will write a do-not-resuscitate order for the patient. What should the nurse implement when following this order?

28

A nurse reminds a patient that communication in the family unit involves continual exchange of information. Which is the best example of this concept?

29

The client who is being mechanically ventilated has copious amounts of secretions ranging from thick and tenacious to frothy. In preparing to suction this client, the nurse should:

30

The nurse has received change-of-shift report about the following patients on the progressive care unit. Which patient should the nurse see first?

31

A student nurse is developing a teaching plan for an adult patient with asthma. Which teaching point should have the highest priority in the plan of care that the student is developing?

32

Which of the following is an important teaching point for a client who has undergone arthrography?

33

Which action by the nurse demonstrates understanding of a best practice intervention for client education?

34

What is a minimally invasive surgical approach that is diagnostic for cancer and has, in some instances, replaced lymph node dissections?

35

The nurse is caring for a patient in the immediate postoperative phase after having a colostomy created. What type of appliance should the nurse use at this time?

36

An _______________ is the surgical dissection of a body after death

37

A diabetic client received instructions from the nurse discussing ways to minimize the any further damage to the heart from heart failure. The client understands the instructions when the client states the following:

38

Which technique should the nurse use when infusing fresh frozen plasma?

39

While performing data collection for a client who has recently had her pregnancy confirmed, the client reports taking daily herbal supplements. What action by the nurse is of the highest priority?

40

A 30-year-old man is in the clinic for a routine yearly exam. As part of the teaching plan, the nurse would instruct the client to have a clinical testicular exam at which frequency?

41

When the client who had a myocardial infarction develops dependent edema, the nurse would assess that this could be an early manifestation of

42

You are admitting a patient who is terminally ill to the hospice facility where you work. Part of the admission process is assessing the patient's spiritual strength

43

What types of neurons transmit impulses from receptors in the internal organs to the central nervous system?

44

A patient is planning to perform incentive spirometry after abdominal surgery. The nurse should encourage the patient to do which of the following?

45

Through what process do the patient and the nurse work together to develop a plan of care?

46

The nurse is caring for a client who is critically ill and has high radiation levels in the system. When discussing the needs of patient care and the need to protect nursing staff, which is discussed as the optimal barrier against gamma radiation?

47

When doing a shift assessment on a new patient, the nurse notes that the popliteal pulses are within normal limits (WNL). How would the nurse chart this?

48

An adult patient has been diagnosed with diverticular disease after ongoing challenges with constipation. The patient will be treated on an outpatient basis. What components of treatment should the nurse anticipate? Select all that apply

49

An example of guided imagery for a critical care patient in the ICU is

50

What action should a nurse implement to initiate the Chvostek sign?

51

An elderly client with septic leg wounds develops multi-system organ failure. The physicians discuss treatment options with the family but explain that success to reverse the condition is minimal

52

The nurse should explain to a patient in heart failure that an aldosterone antagonist works by:

53

If a diagnostic study has high sensitivity, this indicates a:

54

The nurse is caring for a 90-year-old resident in a long-term care facility who is becoming progressively confused and irritable. What should the nurse do next?

55

A patient has just been diagnosed with trigeminal neuralgia. What would the nurse teach this patient about treatment for this disorder?

56

A nurse is working with a new group of immigrants and wants to learn more about their culture. Which method of cultural assessment should the nurse perform to gain a long-term understanding of this culture?

57

A nurse is caring for a client who is prescribed a computed tomography (CT) scan with iodine-based contrast. Which actions should the nurse take to prepare the client for this procedure? (Select all that apply.)

58

A low-risk patient’s vaginal exam reveals that her cervix is dilated to 8 cm with 75% effacement. How frequently should the nurse assess this patient's blood pressure, pulse, and respirations?

59

The nurse is developing a plan of care for a toddler-age client diagnosed with respiratory syncytial virus (RSV). Which intervention is inappropriate for this client?

60

A 68-year-old patient has been admitted to the coronary care unit after an inferior myocardial infarction. Age-related changes in myocardial pumping ability may be evidenced by

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Quiz Review 5; Nursing - Medical Surgical Health Assessment Critical Care

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