1) A nurse witnesses a client begin to experience a tonic-clonic seizure and loss of consciousness. What action would the nurse take first?
a. Protect fro... [Show More] m injury slowly lower pt to ground. Maintain airway, turn client to side.
2) A patient in the oncology clinic reports her family is frustrated at her ongoing fatigue 4 months after radiation therapy for breast cancer. What response by the nurse is most appropriate.
a. It is normal to be fatigued even for years afterwards.
3) A nurse care for a patient with ulcerative colitis. The patient states, “I feel like I am tied to the toilet. This disease is controlling my life.” How would the nurse respond?
a. Lets discuss potential factors that increase your symptoms
4) A patient scheduled for a percutaneous transhepatic cholangiography (PTC) denies allergies to medication. What action by the nurse is best?
a. Ask about shellfish allergies
5) A nurse delegates care for a client with early-stage Alzheimers disease to an unlicensed assistive personal (UAP). Which statement would the nurse include when delegating the clients care?
a. Allow client to be as independent as possible with all activities.
6) A patient with osteoarthritis is going home, where the patient lives alone. What action by the nurse is best?
a. Arrange home safety evaluation
7) The student nurse studying the gastrointestinal system understand that chyme refers to what?
a. Liquified food ready for digestion
8) The nurse knows that a patient with prolonged prothrombin time (PT) values (not related to medication) probably has dysfunction in which organ?
9) After teaching a patient who has diverticulitis, a nurse assesses the patients understanding. Which statement made by the patient indicates a need for additional teaching?
a. I will take a laxative nightly at bedtime to avoid becoming constipated.
c. I must try to include 25 g of fiber in my diet every day
10) A patient is in the internal medicine clinic reporting bone pain in the lower leg. The patients alkaline phosphatase level is elevated. What action by the nurse is most appropriate?
a. Assess client for leg bowing
11) A nurse prepares to discharge a client with Alzheimers disease. Which statement would the nurse include in the discharge teaching for this clients caregiver?
a. install deadbolt locks on all outside doors
12) A nurse in the oncology clinic is providing preoperative education to a patient just diagnosed with cancer. The patient has been scheduled for surgery in 3 days. What action by the nurse is best?
a. Call the client at home the next day to review teaching
13) A nurse cares for a client who has Alzheimers disease. The clients wife states, “I am having trouble managing his behaviors at home.” Which questions would the nurse ask to assess potential causes of the client’s behavior problems? (Select all that apply)
a. Do you have a clock and calendar in the bedroom and kitchen?
b. Does this behavior become worse around large crowds?
c. Does your husband bathe and dress himself independently?
14) A nurse reviews the chart of a patient who has Crohns disease and a draining fistula. Which documentation would alert the nurse to urgently contact the provider for additional prescriptions?
a. Serum potassium of 2.6
15) A nurse witnesses a client with late-stage Alzheimers disease eat breakfast. Afterward the client states, “I am hungry and want breakfast.” How would the nurse respond?
a. I see you are still hungry. I will get you some toast.
16) A nurse plans care for a patient with Crohn’s disease who has a heavily draining fistula. Which intervention would the nurse indicate as the priority action in this patient’s plan of care?
a. Skin protection
17) A patient tells the oncology nurse about an upcoming vacation to the beach to celebrate completing radiation treatments for cancer. What response by the nurse is most appropriate?
a. Do not expose the radiation area to direct sunlight
18) After teaching the wife of a client who has Parkinson disease, the nurse assesses the wifes understanding. Which statement by the clients wife indicates that she correctly understands changes associated with this disease?
a. He may have trouble chewing, so I will offer bite-sized portions.
19) A patient has received a dose of ondansetron (Zofran) for nausea. What action by the nurse is most important?
a. Assist the client in getting out of bed
20) A nurse plans care for an 83 y.o. ambulatory patient who is experiencing age-related sensory perception changes. Which is best intervention would the nurse include in this patients plan of care?
a. Keep room clean, remove clutter, clear walkways. Ensure path to bathroom is free from equipment.
21) A nurse assesses a patient who is hospitalized with an exacerbation of Crohn’s disease. Which clinical manifestation would the nurse expect to find?
a. High-pitched, rushing bowel sounds in the right lower quadrant
22) What information does the nurse teach a women’s group about osteoporosis?
a. For 5 years after menopause you lose 2% of bone mass yearly
23) A nurse is caring for a terminally ill patient who has just died in a hospital setting with family members at the bedside. Which action will the nurse take first?
a. Ask family members if they would like to spend time alone with the client.
24) A nurse obtains a focused health history for a patient who is scheduled for magnetic resonance angiography. Which priority question would the nurse ask before the test?
a. Do you have any allergies to iodine or shellfish
25) A nurse assesses a client with a history of epilepsy who experiences stiffening of the muscles of the arms and legs, followed by an immediate loss of consciousness and jerking of all extremities. How would the nurse document this activity?
a. Tonic-clonic seizures
26) A nurse assesses a client who has Parkinson disease. Which manifestations would the nurse recognize as a key feature of this disease? (select all that apply)
a. Tremors (pill-rolling), bradykinesia, rigidity, depression, masklike facial expression, urinary incontinence
27) A nurse cares for a client with advanced Alzheimers disease. The clien’ts caregiver states, “She is always wandering off. What can I do to manage this restless behavior?” How would the nurse respond?
a. Engage the client in scheduled activities throughout the day.
28) A school nurse is conducting scoliosis screening. In screening the patient, what technique is most appropriate?
a. Bending forward from hips
29) A nurse assesses a client with Alzheimers disease who is recently admitted to the hospital. Which psychosocial assessment would the nurse complete?
a. Evaluate the clients reactions to a change of environment
30) After teaching a client who is diagnosed with new-onset status epilepticus and prescribed phenytoin (Dilantin), the nurse assess the clients understanding. Which statement by the client indicates a correct understanding of the teaching?
a. Even when my seizures stop, I will continue to take this drug.
31) A nurse is caring for a patient who has lung cancer and is dying. Which prescription does the nurse question?
a. Morphine 10 mg sublingual PRN for pain greater than 5
32) A nurse is assessing four patients with musculoskeletal disorders. The nurse would assess the patient with which laboratory result first?
a. Serum phosphorus 2 mg/dL
33) A patient is scheduled for a colonoscopy and the nurse has provided instructions on the bowel cleansing regimen. What statement by the patient indicates a need for further teaching?
a. It’s a good thing I love orange and cherry gelatin
34) A nurse assesses clients on a medical-surgical unit. Which clients would the nurse identify as at risk for secondary seizures? (select all that apply)
a. A 26 year old woman with left temporal brain tumor
b. 38 year old male client in alcohol withdrawal program
c. 42 year old football player with traumatic brain injury
35) After teaching a client newly diagnosed with epilepsy, the nurse assess the client’s understanding. Which statement by the client indicates a need for additional teaching?
a. If I am nauseated, I will not take my epilepsy medication.
36) A nurse plans care for a patient who is nearing end of life. Which question will the nurse ask when developing this patient’s plan of care?
a. Do you want to be at home at the end of your life?
37) A nurse cares for a client who is experiencing status epilepticus. Which prescribed medication would the nurse prepare to administer?
a. Lorazepam (Ativan)
38) A nurse is teaching the daughter of a client who has Alzheimers disease. The daughter asks, “Will the medication my mother is taking improve her dementia?” How would the nurse respond?
a. It will not improve her dementia but can help control emotional responses
39) After teaching a patient with diverticular disease, a nruse assesses the patients understanding. Which menu selection made by the patient indicates the patient correctly understood the teaching?
a. Baked fish with steamed carrots and a glass of apple juice
40) A nurse assesses a patient who has ulcerative colitis and sever diarrhea. Which assessment would the nurse complete first?
a. Heart rate and rhythym
41) A nurse plans care for a client with Parkinson disease. Which intervention would the nurse include in this client’s plan of care?
a. Keep the head of bed at 30 degrees or greater
42) A nurse plans care for a patient with Crohn’s disease who has a heavily draining fistula. What intervention would the nurse indicate as the priority action in this patients plan of care?
a. Skin protection
43) A patient tells the oncology nurse about an upcoming vacation to the beach to celebrate completing radiation treatments for cancer. What response by the nurse is most appropriate?
a. Do not expose radiation area to direct sunlight.
44) After teaching a patient about advance directives, a nurse assesses the patients understanding. Which statement indicates that the patient understands the teaching?
a. An advance directive will specify what I want done when I can no longer make decisions about health care.
45) An older patient with diabetes is admitted with a heavily draining leg wound. The patients white blood cell count is 38,000/mm3 but the patient is afebrile. What action does the nurse take first?
a. Place client on contact isolation [Show Less]