NR 226 Final Exam - Questions and Answers (Complete Solutions) The RN is assessing a client who has hypercalcemia. Which of the following findings would
... [Show More] the nurse expect? Select all that apply. A .Nausea and vomiting B. Confusion C. Hyperreflexia D. Numbness/tingling E. Pallor The RN is reviewing lab values for a group of clients and notices a sodium level of 130 mEq/L. The nurse understands that which client is at highest risk for the development of this lab value? A. The client who is taking furosemide (a diuretic) B. The client who is in renal failure C. The client who takes a multi-vitamin D. The client who was admitted to hospice The body's fluid and electrolyte balance is maintained partially by hormonal regulation. Which of the following statements shows an understanding of this mechanism? A. "The pituitary secretes aldosterone." B. "The kidneys secrete antidiuretic hormone." C. "The adrenal cortex secretes antidiuretic hormone." D. "The pituitary gland secretes antidiuretic hormone." While reviewing a client's progress notes, the RN reads "insensible fluid loss of approximately 700 mL daily". The RN understands that this type of fluid loss can occur through: A. The GI tract B. Urine output C. Wound drainage D. The skin E. Emesis A senior student nurse delegates the task of intake and output to a new unlicensed assistive personnel (UAP). The student will verify that the UAP understands the task of I&O when the UAP states A. "I will record the amount of all voided urine." B. "I will not count liquid stools as output." C. "I will not record a café mocha as intake." D. "I will notate perspiration and record it as a small or large amount." A nurse is inserting an IV line into a client's vein. After the initial stick the nurse continues to advance the catheter if the nurse notes that: A. The catheter advances easily B. Blood returns shows in the flashback chamber C. The vein is distended under the needle D. The client does not complain of discomfort You are caring for a client who is depressed because the only child has gone away to college. The nurse will assess this type of depression as: A. actual loss B. perceived loss C. situational loss D. maturational loss Which of the following is an example of disenfranchised grief? A. A newly-widowed individual does not want to remove her husband's clothes from the closet B. A teenage client dies from a car accident and the client's mother is crying loudly in the hospital hallway C. A client verbalizes being upset by voluntarily giving a newborn up for adoption D. A person is unwilling to discuss the loss of a child for several months after the death A client has been told by the healthcare provider that remaining life expectancy is approximately 3 months. The client tells the immediate family that the doctor is incorrect and that he "will get better by my birthday in a month". Which stage of grieving is this client experiencing? A. Acceptance B. Denial C. Depression D. Anger Which of the following are appropriate in regard to postmortem care? Select all that apply. A. Provide privacy and time for the family to be with the deceased client. B. Maintain respect and dignity for the deceased client. C. Consider cultural preferences, state laws, and facility policies when providing care. D. Follow appropriate procedures related to organ donation. E. Allow for family to participate in care if requested and allowed per policy. All answers are correct As a first-year nursing student, you are assigned to care for a dying client. To best prepare you for this assignment, you will want to: A. complete a course on death and dying B. control your emotions about death and dying C. compare this experience to the death of a family member D. develop a personal understanding of your own feelings about grief and death You are a nurse working in the college student health center. You receive a call that an athlete has just fallen and has been injured. You know that according to the general adaptation syndrome, the athlete will be exhibiting: A. an increased appetite B. an increased heart rate C. a decrease in perspiration D. a decrease in respiratory rate A client comes into the emergency department complaining of chest pain. When discussing possible reasons why the chest pain has occurred, the nurse learns that the client is depressed because of the loss of a job. This type of crisis can be classified as: A. maturational B. situational C. sociocultural D. posttraumatic What is the best way to monitor fluid balance? Monitoring daily weight What is isotonic and when would we see this solution used? A solution with the same salt concentration as in cells 0.9% NS & Lactated Ringers (LR) What is hypotonic and when would we see this solution used? A solution that is diluted (makes the cell swell) Dextrose 5% in Water & 0.45% NS What is hypertonic and when would we see this solution used? A solution that is concentrated (makes the cell shrink) TPN, 3% NS, Dextrose 50% What is osmolality? A measure of the number of particles per kilogram of water What is the I&O calculation? Intake = Output *1L of fluid = 2.2 lbs = 1kg* What is the normal lab value for acid base balance? normal pH is 7.35-7.45 What is an example of fluid overload? Hypervolemia (fluid volume excess) What are some manifestations of hypervolemia? - Dyspnea (crackles or rhonchi) - Change in vitals (Tachycardia/pnea, HYPERtension) - JVD - Edema - Altered mental status/confusion What is an example of fluid deficit? Hypovolemia (dehydration) What are some manifestations of hypovolemia? - Thirst/dry mucous membranes/poor skin turgor - Change in vitals (Tachy, HYPOtension, fever) - Flattened neck veins - Weight loss - Altered mental status/confusion What are some treatments for hypervolemia? - Monitor fluid overload in lungs - Restrict sodium/fluid intake - Diuretics - Monitor daily weight/I&O - Patient education What are some treatments for hypovolemia? - Monitor for hypovolemic shock - Encourage PO fluids - IV fluids - Monitor daily weight/I&O - Patient education What are some risk factors for fluid and electrolyte imbalances? - Age - Medical diagnosis - Intake & Output imbalance - Medications What is the electrolyte range for Hyponatremia? less than 136 What is the electrolyte range for Hypernatremia? more than 145 What is the electrolyte range for Hypokalemia? less than 3.5 What is the electrolyte range for Hyperkalemia? more than 5.0 What is the electrolyte range for Hypophosphatemia? less than 3.0 What is the electrolyte range for Hyperphosphatemia? more than 4.5 What is the electrolyte range for Hypocalcemia? less than 9.0 What is the electrolyte range for Hypercalcemia? more than 10.5 What is the electrolyte range for Hypomagnesemia? less than 1.3 What is the electrolyte range for Hypermagnesemia? more than 2.1 How does Potassium effect an ECG? Causes a peaked T-wave (could lead to V-fib) *Hyperkalemia* What is the ABG interpretation method? ROME- Respiratory Opposite, Metabolic Equal What is the normal Respiratory PaCO2 level (ABG)? PaCO2= 35-45 What is the normal Metabolic HCO3 level (ABG)? HCO3= 21-28 What is General Adaptation Syndrome? A model of the body's stress response, consisting of three stages What are the 3 stages of the General Adaptation Syndrome? - Alarm - Resistance - Exhaustion How does general adaptation syndrome affect the body? It causes stress on the body and if not resolved, it can cause to physical and mental harm to the body What is chronic stress? Occurs in stable conditions and results from stressful roles What is acute stress? Time-limited events that threaten a person for a brief period What is a crisis? a sudden event in one's life, during which usual coping mechanisms cannot resolve the problem; the crisis disturbs homeostasis What is compassion fatigue and how can you combat it? A state of burnout and secondary traumatic stress. Can be overwhelming to healthcare providers and cause physical/mental/emotional health issues or emotional exhaustion What is PTSD? Begins when a person experiences or witnesses a traumatic event and responds with intense fear or helplessness What are the 5 types of grief? - Normal (uncomplicated) - Anticipatory - Disenfranchised - Ambiguous - Complicated What is normal grief? Universal reaction characterized by complex emotional, cognitive, social, physical, behavioral, and spiritual responses to loss and death What is anticipatory grief? Unconscious process of "letting go" before the actual loss/death occurs What is disenfranchised grief? Grief or mourning that persons experience when they incur a loss that is not or cannot be openly acknowledged, publicly mourned, or socially supported. Situations in which this occur often relate to a socially unacceptable loss that cannot be spoken about, such as suicide, abortion, or giving a child up for adoption. What is ambiguous grief? Person is who lost is physically present but not psychologically available What is complicated grief? May take years, struggle through stages of grief, a prolonged or difficult time moving forward after a loss What are the stages of dying? - Denial - Anger - Bargaining - Depression - Acceptance What factors influence loss and grief? -human development -personal relationships -nature of the loss -coping strategies -socioeconomic status -culture -spiritual and religious beliefs A nurse is caring for a client whose partner passed away 4 months ago and has been recently diagnosed with diabetes mellitus. He is tearful and states, "How could you possibly understand what I am going through?" Which of the following responses should the nurse make? A. "It takes time to get over the loss of a loved one." B. "You are right. I cannot really understand. Perhaps you'd like to tell me more about what you're feeling." C. "Why don't you try something to take your mind off your troubles, like watching a funny movie." D. "I might not share your exact situation, but I do know what people go through when they deal with a loss." A nurse is caring for a client awaiting transport to the surgical suite for a coronary artery bypass graft. Just as the transport team arrives, the nurse takes the client's vital signs and notes an elevation in blood pressure and heart rate. The nurse should recognize this response as which part of the general adaptation syndrome (GAS)? A. Exhaustion stage B. Resistance stage C. Alarm reaction D. Recovery reaction A nurse is caring for a client who has left sided hemiplegia resulting from a cerebrovascular accident. The client works as a carpenter and is now experiencing a situational role change based on physical limitations. The client is the primary wage earner in the family. Which of the following describes the client's role problem? A. Role conflict B. Role overload C. Role ambiguity D. Role strain A nurse is caring for a client who has a new diagnosis of type 2 diabetes mellitus. Which of the following nursing interventions for stress, coping, and adherence to the treatment plan should the nurse initiate at this time? (Select all that apply): A. Suggest coping skills for the client to use in this situation B. Allow the client to provide input in the treatment plan C. Assist the client with time management, and address the client's priorities. D. Provide extensive instructions on the client's treatment regimen E. Encourage the client in the expression of feelings and concerns A nurse is caring for a family who is experiencing a crisis. Which of the following approaches should the nurse use when working with a family using an open structure for coping with crisis? A. Prescribing tasks unilaterally B. Delegating care to one member C. Speaking to the primary client privately D. Convening a family meeting A nurse is caring for a client who has terminal lung cancer. The nurse observes the client's family assisting with all ADLs. Which of the following rationales for self-care should the nurse communicate to the family? A. Allowing the client to function independently will strengthen her muscles and promote hearing B. The client needs to be given privacy at all times for self-reflecting and organizing her life C. The client's sense of loss can be lessened through retaining control of certain areas of her life D. Performing ADLs is required prior to discharge from an acute facility A nurse is caring for a client who has stage IV lung cancer and is 3 days postoperative following a wedge resection. The client states, "I told myself that I would go through with the surgery and quit smoking, if I Could just live long enough to attend my daughter's wedding." Based on Kubler-Ross' model, which stage of grief is the client experiencing? A. Anger B. Denial C. Bargaining D. Acceptance A nurse is consoling the partner of a client who just expired after a long battle with liver cancer. The partner is displaying grief and states, "I hate him for leaving me." Which of the following statements by the nurse successfully facilitate mourning for the grieving partner? A. "Would you like me to contact the chaplain to come speak to you?" B. "You will feel better soon. You have been expecting this for a while now." C. "Let's talk about your children and how they are going to react." D. "You know, it is quite normal to feel anger toward your husband at this time." E. "Tell me more about how you are feeling." A nurse is caring for a client who has a terminal illness. Death is expected within 24hr. The client's family is at the bedside and asks the nurse about anticipated findings at this time. Which of the following findings should the nurse include in the discussion? A. Regular breathing patterns B. Warm extremities C. Increased urine output D. Decreased muscle tone A nurse is assisting a newly licensed nurse with postmortem care of a client. The family wishes to view the body. Which of the following findings should the nurse include in this discussion? (Select all that apply): A. "I will remove the dentures from the body." B. "I will make sure the body is lying completely flat." C. "I will apply fresh linens and place a clean gown on the body." D. "I will remove all equipment from the bedside." E. "I will dim the lights in the room A nurse is performing an admission assessment on a client who has hypovolemia due to vomiting and diarrhea. The nurse should expect which of the following findings? (Select all that apply): A. Distended neck veins B. Hyperthermia C. Tachycardia D. Syncope E. Decreased skin turgor A nurse on a medical-surgical unit is caring for a group of clients. The nurse should identify that which of the following clients is at risk for hypovolemia? A. A client who has nasogastric suctioning B. A client who has chronic constipation C. A client who has syndrome of inappropriate antidiuretic hormone D. A client who took an overdose of sodium bicarbonate antacids A nurse is reviewing the laboratory test results for a client who has an elevated temperature. The nurse should recognize which of the following findings is a manifestation of dehydration? (Select all that apply): A. Hematocrit 55% B. Serum osmolarity 260 mOsm/kg C. Serum sodium 150 mEq/L D. Urine specific gravity 1.035 E. Serum creatinine 0.6 mg/dL A nurse on a medical-surgical unit is caring for a group of clients. For which of the following clients should the nurse anticipate a prescription for fluid restriction? A. A client who has a new diagnosis of adrenal insufficiency B. A client who has heart failure C. A client who is receiving treatment for diabetic ketoacidosis D. A client who has abdominal ascites A nurse is planning care for a client who has dehydration. Which of the following actions should the nurse include? A. Administer antihypertensive on schedule B. Check the client's weight each morning C. Notify the provider of a urine output greater than 30 mL/hr D. Encourage independent ambulation four times a day A nurse is planning care for a client who has hypernatremia. Which of the following actions should the nurse anticipate including in the plan of care? A. Infuse hypotonic IV fluids B. Implement a fluid restriction C. Increase sodium intake D. Administer sodium polystyrene A nurse is reviewing the medical record of a client who has hypocalcemia. The nurse should identify which of the following findings as risk factors for the development of this electrolyte imbalance? A. Crohn's disease B. Postoperative following appendectomy C. History of bone cancer D. Hyperthyroidism [Show Less]