Upgrade to remove ads
Only $35.99/year

Med-Surg 2 Final

Terms in this set (58)

The nurse is caring for pt suspected of having ketoacidosis. What manifestations are characteristics of ketoacidosis (select all)
1. fruity breath
2. polyuria
3. nausea
4. thirst
5. edema
Fruity breath, polyuria, nausea, thirst
The nurse is caring for a pt with a diagnosis of gastric ulcer. At what time would the nurse anticipate the pain would be most severe?
a. In the morning
b. erratically, without pattern
c. at bedtime
d. with meals
At bedtime
Hypertension is diagnosed by the finding of a blood pressure reading greater than:
130/80 twice, 2 weeks apart
To best assist a pt with dysphagia, the nurse should implement which actions?
a. encourage "practice swallowing" before the meal
b. Coach the pt to chew thoroughly
c. assist the pt to sit upright with the head forward and chin slightly tucked
d. offer fluid during the meal
e. give the patient thin liquids, such as water
a, b, c, d, e
the nurse uses the CAGE challenge to alcoholics who persist in denial. what does the G in the set of questions from CAGE represent
a. grief
b. guilty
Guilty
A nurse reminds the 60 year old moderately obese african american hypertensive diabetic male who smokes that he can modify his risk for heart disease by
a. smoking cessation
b. controlling diabetes
c. exercising regularly
d. getting younger
e. reducing weight
a, b, c, e
the pt in the ER with MI becomes pale, diaphoretic, and hypotensive and complains of feeling cold. The nurse recognizes that these signs are which post- MI complication?
a. Pleural effusion
b. V-fib
c. Pulmonary embolus
d. Cardiogenic shock
d. Cardiogenic shock
the nurse documents a schizophrenic's delusion of persecution when the pt says
a. did you know that I own this hospital
b. my doctor spent more time with the other patients. He doesn't want me to get better
c. the presidents speech tonight is going to give me a coded message
d. I am going to wait in front of the hospital this morning for my limousine to pick up and take me to my private jet.
b. My doctor spend more time with the other patients. He doesn't want me to get better
the nurse is aware that the patient is in respiratory failure when the blood gas findings are a PaO2 is ___ and the PaCO2 of ____
a. 50,45
b. 46,52
c. 52,42
d. 55,58
b. 46, 52
a resient in the LTC facility has been in a manic stage for 2 days. he has not slept and cannot focus long enough to eat a meal. The nurse can enhance his nutrition by:
a.insisting he sit down and eat at the table at reg times
b.spoon feeding him at table at reg times
c. Handing him small glasses of high protein drinks every hour
d. making up a game about who can finish a meal the fastest
Handing him small glasses of high protein drinks every hour
a patient is diagnosed with a thyroid disorder. the nurse anticipates that pt is most likely to have problems with
a. Metabolic rate
b. water reabsorption
c. bone fragility
d. increased blood glucose
a. metabolic rate
the nurse correctly recognizes that urinary output less than ___ mL/hr is considered inadequate
a. 15
b. 20
c. 30
d. 40
3. 30
the pt confides that sneezing makes her wet her pants. the nurse recognizes that his is a cardinal sign of ____ incontinence
a. urge
b. stress
c. functional
d. overflow
b. stress
a pt recently diagnosed with type 1 diabetes mellitus questions the nurs about her increased thirst level. what should be included in the response by the nurse?
Elevated levels of blood glucose pull cellular water into circulating volume of increasing thirst.
the nurse describes a concussion as a closed head injury in which:
a. the brain tissue is bruised
b. no loss of consciousness occurs
c. there is amnesia related to the incident
d. there are no subsequent symptoms
c. there is amnesia related to the incident
the nurse recommends that, in order to keep optimum flow through the urinary system, a person should have a minimum intake of ___ mL/day
a. 1000
b. 2000
c. 3000
d. 4000
b.2000
a person who has huntington disease akss if his disease will affect children he might have. which statement by the nurse is most accurate?
Yes. there is a 50% chance each child will have the disease
a nurse reviewing lab reports on kidney function identifies a result that suggests decreased renal function which is:
a. blood urea nitrogen 10.5 mg/dL
b. creatinine 0.6 mg/dL
c. BUN 15 mg/dL
d. creatinine 2.0 mg/dL
d. Creatinine 2.0 mg/dL
BUN: 7-20
Creatinine: 0.6-1.2
when a 90 year old resident in LTC facility becomes progressively confused and irritable, after assessing a Sa)2 of 94%, the nurse should
a. request an order for a UA
b. hold antihypertensive meds
c. assess for fecal impaction
d. decrease fluid intake
a. Request an order for urinanalysis
during an AM assessment, the nurse observes that a pt displays bulging flanks when supine with the knees flexed. which action should the nurse take next?
a. measure the pt abdominal girth
b. auscultate each quadrant of abdomen
measure the pt abdominal girth
a pt presents in the health clinic with low back pain that radiates into the buttocks and below the knee. the nurse suspects which condition
a. sciatica
b. spinal cord injury
c. muscle spasm in lower back
d. herniated disk
d. herniated disk
the nurse affirms that many skin lesions associated with sexually transmitted infections are in the genital area, but skin lesions of syphilis can be seen in which location
a. behind ears
b. at scalp margins
c. in the axillae
d. on palms of hands
d. on palms of hands
the nurse will encourage the pt who has GERD to modify her diet by:
a. avoiding highly seasoned or spiced foods
b. drinking carbonated beverages with meals
c. using straw to drink all fluids
d. eating three meals regularly spaced apart
a. avoiding highly seasoned or spiced foods
the nurse calculates BMI of a man who is 6 ft tall and weighs 200 pounds to be:
a. 15.15
b. 28.05
c. 50.50
d. 111.1
b. 28.05
formula: kg/m^2
in counseling a man with erectile dysfunction about a prescription for sildenafil (viagra), the nurse would suggest a different remedy if the patient was:
a. over 50 years of age
b. more than 50 lb overweight
c. taking nitroglycerin for angina
d. a long-term diabetic
c. taking nitroglycerin for angina
the nurse takes into consideration that the characteristics of personality disorders include:
a. impaired cognition
b. maladaptive response to life's events
c. inability to maintain relationships
d. poor impulse control
e. inappropriate emotional responses.
b, c, d, e
What 2 organs are in the right upper quadrant of the abdomen
a. descending colon and stomach
b. liver and gallbladder
c. Pancreas and rectum
d. ascending colon and pancreas
b. liver and gallbladder
The appropriate timing for assessing bowel sounds, if present, is to auscultate each quadrant for a period of _________seconds?
60
a sign/symptom of cholecystitis is referred pain to the
a. right, clavicle, shoulder area
b. right lower leg
c. left wrist left hand
d. left patella
a. right, clavicle, shoulder area
which type of hepatitis should all healthcare personnel be vaccinated against
B
prior to hemodialysis the nurse will withhold:
a. antihypertensive
b. antibiotics
c. anti-anxiety agents
d. antacids
antihypertensives
the nurse cautions the diabetic patient that ultimately the disease will affect the blood flow through the kidney due to:
a. Long-term elevated glucose levels
b. scleroses of the renal vessles
c. arterial spasm
d. long-term insulin use
Scleroses of the renal vessels
when a 25 year old woman presents in the ED with nonspecific urethritis, the nurse is prompted to inquire about the patient's use of:
a. tight-fitted underwear
b. alcohol consumption
c. bath salts
d. bicycle exercise
bath salts
a patient has just returned to the nursing unit after having a renal biopsy. Which intervention is most important to include in the patient's nursing care plan?
a. instruct the patient to avoid laughing and use pillow to splint when sneezing
b. keep the patient NPO for the first 4 hours after the procedure
c. teach the patient about the importance of limiting fluid intake
d. report hematuria immediately
instruct the pt to avoid laughing and use a pillow to splint when sneezing.
the nurse is preparing to discharge a client who has had a thyroidectomy where parathyroid glands were also removed. Which of the following regarding the patients diet is most appropriate for the nurse to include in discharge teaching?
a. "you will need to closely monitor your sodium intake."
b. "It will be important to add supplemental calcium into your diet."
c. "no changes need to be made to your diet following this procedure."
d. "it is recommended that you decrease the amount of potassium in your diet."
"It will be important to add supplemental calcium into your diet."
which data is most important for the nurse to monitor in a pt with pheochromocytoma?
a. vital signs
b. daily weight
c. peripheral pulses
d. bowel sounds
Vital signs
the nurse is educating a 50 year old patient about diabetes monitoring. Which statement reinforces the American diabetes association's recommendations?
a. obtain regularly scheduled fasting blood glucose level testing.
b. strictly adhere to weight reduction diets.
c. exercise regularly in intervals lasting a minimum of 30 minutes
d. use stress reduction techniques
Obtain regularly scheduled fasting blood glucose level testing.
the nurse is aware that is estimated that approximately ___% of the US is affected with schizophrenia?
a. 5
b. 3
c. 1
d. 2
1
depression is thought to be the result of deficit of: ____
serotonin
the needing of substance in order to feel good is known as?
a. tolerance
b. withdrawal
c. abuse
d. psychological dependence
psychological dependence
needs an increasing amount of substance to achieve desired affect?
a. tolerance
b. abuse
c. withdrawal
d. physiological dependence
tolerance
when assessing a patient with complaints of hypertension, the nurse will inquire if the patient routinely takes:
a. vitamins
b. cold remedies
c. laxatives
d. antacids
cold remedies
the nurse is caring for a patient with DVT. Which medication would likely be used for initial inpatient treatment?
a. warfarin (Coumadin)
b. edoxaban (Lixiana)
c. Heparin
d. dabigatran (Pradaxa)
Heparin
a nurse is reinforcing teaching with a patient who is scheduled for a stress test. Which of the following statements should the nurse include in the teaching?
a. "You will exercise your heart by walking on a treadmill."
b. "You should eat a full meal to give me energy to walk on the treadmill."
c. "A chest X-ray will be obtained following the test."
d. "You can have a cigarette to calm your nerves right before the test."
"You will exercise your heart by walking on a treadmill."
Diastole is when:
a. the ventricles are relaxing
b. the blood pressure is the highest
c. the ventricles are contracting
d. the atria are contracting
the ventricles are relaxing
The nurse may record a positive Romberg's test if during the test the patient?
a. cannot keep his/her eyes closed
b. cannot touch his/her nose with eyes closed
c. complains of dizziness
d. sways from side to side
sways from side to side
if you request a patient to stick out his/her tongue and move it rapidly from side to side is assessing the ___ nerve.
hypoglossal
a fully alert patient will present with a score of _____ on the Glascow Coma Scale.
15
which position is best for an unconscious patient with a right-sided closed head injury?
a. right side lying
b. HOB 20-30 degrees
c. high fowler
d. flat with small pillow under head
HOB 20-30 degree
Which indicates an abnormality in the motor control pathways from the brainstem?
a. Babinski's reflex
b. flexor posturing (Decorticate)
c. extensor posturing (Decerebrate)
d. romberg
Extensor Posturing (Decerebrate)
treatment for neurogenic shock is:
a. epinephrine
b. glucose
c. vasoconstrictors
d. fluids
e. none of the above
vasoconstrictors
The patient who has been given a prescription for tadalafil (Cialis) is warned about the possibility of the complication of:
a. urethritis
b. obstructed urethra
c. hydronephrosis
d. priapism
priapism
the patient complains to the nurse about a sharp pain in the lower quadrants every month at midcycle that lasts for several hours. The nurse clarifies that this phenomenon is related to:
a. endometrial changed
b. mittelshcmerz, a pain associated with ovulation
c. he premenstrual uterine enlargement
d. the stretching of the round ligaments supporting the uterus
Mittelschmerz, a pain associated with ovulation
how long after exposure does the incubation period for gonorrhea last?
a. 2-6 days
b. 1 week
c. 2 weeks
d. 4 weeks
2-6 days
after having the patient deep breathe and cough, the nurse should offer?
a. oxygen by mask
b. a warm drink
c. mouth care
d. an iced drink
mouth care
the patient with sleep apnea is fitted with continuous positive airway pressure (CPAP) mask and asks the nurse how this device will help. The nurse correctly responds with which statement?
a. "the device delivers constant positive pressure to keep your airway open."
b. "the device will require you to be intubated to open your airway."
c. "the device delivers oxygen only when you are apneic."
d. "the device delivers negative pressure to stimulate your respirations."
The device delivers constant pressure to keep your airway open.
the nurse is educating an asthma patient about proper use of the peak flowmeter. The nurse determines that the patient needs further teaching when observing which action?
a. the patient repeats the procedure and obtains three readings
b. the patient inhales deeply through the mouthpiece
c. the patient stands while performing the test.
d. the patient reports the highest reading on the peak flow sheet.
The patient inhales deeply through the mouthpiece.
A "normal" peripheral pulses noted on a patient at Sanford or Avera would be recorded as:
a. 1+
b. 2+
c. 3+
d. 4+
e. 0
2+
Students also viewed