Which of the following actions most clearly demonstrates a nursing focus rather than a medical focus?
A) The nurse assesses the effect that a recent diagnosis of diabetes has had on the patient's lifestyle and routines.
B) The nurse assesses the merits of changing the patient to a new oral antihyperglycemic.
C) The nurse interprets the results of the patient's most recent glucose tolerance test.
D) The nurse recommends a change to the patient's insulin sliding scale.
The focus of nursing care is the diagnosis and treatment of human responses to actual or potential health problems or life processes. Management of a patient's medication regimen and interpretation of diagnostic tests are indicative of a medical focus.
A (The nurse assesses the effect that a recent diagnosis of diabetes has had on the patient's lifestyle and routines.
The focus of nursing care is the diagnosis and treatment of human responses to actual or potential health problems or life processes. Management of a patient's medication regimen and interpretation of diagnostic tests are indicative of a medical focus.)
A 72-year-old woman has sought care for restless leg syndrome, a problem that has been causing her increasing loss of sleep in recent weeks. The woman states that she attributes the problem to inadequate calcium intake and she has responded by integrating more dairy products into her diet. The nurse would recognize which of the following aspects of symptom examination (select all that apply)?
A) Personal meaning
C) Associated manifestations
D) Alleviating factors
The nurse would recognize that the patient possesses a theory regarding the etiology of the problem (personal meaning), a proposed solution to the problem (alleviating factor) and a knowledge of other problems that are associated with her complaint (associated manifestations). There is no indication of the quality of the restless leg syndrome in the patient's statements.
A, C, D (Feedback: CORRECT
The nurse would recognize that the patient possesses a theory regarding the etiology of the problem (personal meaning), a proposed solution to the problem (alleviating factor) and a knowledge of other problems that are associated with her complaint (associated manifestations). There is no indication of the quality of the restless leg syndrome in the patient's statements.)
In which of the following situations would the nurse most likely conduct a comprehensive assessment?
A) When admitting a patient to a medical unit from the emergency department
B) When assessing the progression of a patient's ascites and edema
C) When performing resuscitation on a trauma patient
D) When assessing the cognition of a patient who is receiving rehabilitation following a stroke
A. (A comprehensive assessment is most often performed at the beginning of a patient's course of care, such as when a patient is newly admitted to a unit or facility. Assessment of particular problems, such as ascites or decreased cognition, requires a focused assessment, whereas emergency assessment is most appropriate during the immediate management of trauma or resuscitation.)
Which of the following actions best demonstrates the nurses' awareness of learning styles and the role that they play in patient and caregiver teaching (select all that apply)?
A) Assess patients' learning styles prior to teaching.
B) Use materials that appeal to a variety of learning styles.
C) Prioritize the learning style with which he or she is most familiar and comfortable.
D) Provide written instructions to younger patients while using visual and audio aids when teaching older patients.
E) Provide visual and audio aids to younger patients while using written instructions when teaching older patients.
A, B (Assessing patients' learning styles and using a variety of materials that appeal to different learning styles are sound teaching strategies. It would be simplistic to choose materials solely based on patients' ages or to limit teaching to his or her own learning preference.)
The nurse notes that a male patient regularly asks about the purpose and potential side effects of each oral medication that he has received during his time in the hospital. How should the nurse best interpret the patient's questions?
A) The patient has an auditory learning style.
B) The patient is identifying his learning needs.
C) The patient is exhibiting a high level of health literacy.
D) The patient is experiencing anxiety related to his diagnosis and treatment.
B (The patient most likely is revealing his learning needs related to his medication regimen. It would be inaccurate to conclude that he has an auditory learning style and concluding that he is experiencing anxiety would be premature. It would be incorrect to conclude that because he has numerous questions about an aspect of his care that he necessarily has a high level of health literacy.)
When interviewing an elderly patient, it would be most appropriate for the nurse to
A) Ensure all assistive devices are in place.
B) Interview the patient and caregiver together.
C) Perform the interview before administering analgesics.
D) Move on to the next question if the patient does not respond quickly.
A. (All assistive devices, such as glasses and hearing aids, should be in place when interviewing an elderly patient. It is best to interview the patient and caregiver separately to ensure a reliable assessment related to elder mistreatment. The patient should be free from pain during the assessment and may need extra time to respond to questions.)
Which of the following assessment findings would alert the nurse to possible elder mistreatment (select all that apply)?
A B D E
C) Weight gain
D) Weight loss
Agitation and depression may be manifestations of psychologic abuse or neglect. Hypernatremia may signify dehydration caused by physical neglect. A loss of body weight, rather than weight gain, is another clinical manifestation of physical neglect.)
A 67-year-old woman who has a long-standing diagnosis of incontinence is in the habit of arriving 20 minutes early for church in order to ensure that she gets a seat near the end of a row and close to the exit so that she has ready access to the restroom. Which of the following tasks of the chronically ill is the woman enacting (select all that apply)?
A) Controlling symptoms
B) Preventing social isolation
C) Preventing and managing a crisis
D) Denying the reality of the problem
E) Adjusting to changes in the course of the disease
A, C (The woman's efforts to ensure that she can continue in her lifestyle of church attendance while accommodating the frequent elimination caused by her health problem are an example of controlling her symptoms and preventing a personal crisis.)
Which of the following nursing interventions is most appropriate when preparing to administer an opioid analgesic agent?
A) Give the medication on an empty stomach.
B) Count the number of doses on hand before administration.
C) Give the medication with a glass of juice or other cold beverage.
D) Assess the patient for allergies to aspirin before administration.
You are caring for a patient who is receiving morphine sulfate via PCA. Which of the following patient assessment data demonstrate the most therapeutic effect of this medication?
A) Pain rating 1/10, drowsy but arousable, respirations 16
B) Pain rating 2/10, awake and alert, respirations 18
C) Pain rating 3/10, awake and alert, respirations 20
D) Pain rating 2/10, drowsy but arousable, respirations 18
You are caring for a postoperative patient receiving epidural fentanyl for pain relief. For which of the following common side effects will you monitor the patient (select all that apply)?
C) Urinary retention
A B C
A patient is ordered to receive acetaminophen 650 mg per rectum every 6 hours as needed for fever greater than 102° F. Which of the following parameters would the nurse monitor, other than temperature, if the patient requires this medication?
A) Pain level
B) Intake and output
C) Oxygen saturation
D) Level of consciousness
B (fever can lead to excessive perspriation)
A patient with pneumonia is having a fever of over 103o F. The nurse should manage the patients fever by
A) Administering aspirin on a scheduled basis around the clock.
B) Providing acetaminophen every 4 hours to maintain consistent blood levels.
C) Providing drug interventions if complementary and alternative therapies have failed.
D) Administering acetaminophen when the patients oral temperature exceeds 103.5° F.
B (prevents acute swings in temp)
Standard precautions should be used when providing care for
A) All patients regardless of diagnosis.
B) Pediatric and gerontologic patients.
C) Patients who are immunocompromised.
D) Patients with a history of infectious diseases.
A (SP are for all patients)
The nurse is caring for a patient receiving an initial dose of chemotherapy to treat a rapidly growing metastatic colon cancer. The nurse is aware that this patient is at risk for tumor lysis syndrome (TLS) and will monitor the patient closely for which of the following abnormalities associated with this oncologic emergency?
B (TLS is a metabolic complication characterized by rapid release of intracellular components in response to chemotherapy. This can rapidly lead to acute renal failure. The hallmark signs of TLS are hyperuricemia, hyperphosphatemia, hyperkalemia, and hypocalcemia.)
Which of the following nursing diagnoses is most appropriate for a patient experiencing myelosuppression secondary to chemotherapy for cancer treatment?
A) Acute pain
D) Risk for infection
D (Myelosuppression is accompanied by a high risk of infection and sepsis. Hypothermia, powerlessness, and acute pain are also possible nursing diagnoses for patients undergoing chemotherapy, but the threat of infection is paramount.)
Previous administrations of chemotherapy agents to a cancer patient have resulted in diarrhea. Which of the following dietary modifications should the nurse recommend?
A) A bland, low-fiber diet
B) A high-protein, high-calorie diet
C) A diet high in fresh fruits and vegetables
D) A diet emphasizing whole and organic foods
Peripheral edema, distended neck veings, bounding pulse, low BUN and hematocrit may indicate what