Health Concepts Exam 2 Answers

a

The nurse is caring for a client who is using fentanyl patch and immediate-release morphine for chronic cancer pain who develops new-onset confusion, dizziness, and a decrease in respiratory rate. Which of the following actions is the priority for the nurse to implement?

a) Remove the fentanyl patch

b) Notify the health care provider.

c) Continue to monitor the client’s status.

d) Give the prescribed PRN naloxone.

b

The nurse assesses a postoperative client who is receiving morphine through patient-controlled analgesia (PCA). Which information is most important to report to the health care provider?

a) The client complains of nausea after eating.

b) The client’s respiratory rate is 10 breaths/minute.

c) The client has not had a bowel movement for 3 days.

d) The client has a distended bladder and has not voided.

a

On the day of surgery, the nurse is admitting a client with a history of cigarette smoking. Which of the following actions is most important at this time?

a) Auscultate for adventitious breath sounds.

b) Ask whether the client has smoked recently.

c) Remind the client about harmful effects of smoking.

d) Calculate the cigarette smoking history in pack-years.

b

Before the administration of preoperative medications, the nurse is preparing to witness the client signing the operative consent form when the client says, “I do not really understand what the doctor said.” Which of the following actions is best for the nurse to take?

a) Provide an explanation of the planned surgical procedure.

b) Notify the surgeon that the informed-consent process is not complete.

c) Administer the prescribed preoperative antibiotics and withhold any ordered sedative medications.

d) Notify the operating room staff that the surgeon needs to give a more complete explanation of the procedure.

c

Which of the following topics is most important for the nurse to discuss preoperatively with a client who is scheduled for a colon resection?

a) Care for the surgical incision

b) Medications used during surgery

c) Deep-breathing and coughing techniques

d) Oral antibiotic therapy after discharge home

d

A client in surgery receives a neuro-muscular blocking agent as an adjunct to general anaesthesia. At completion of the surgery, it is most important that the nurse monitor the client for which of the following adverse effects?

a) Nausea

b) Confusion

c) Bronchospasm

d) Weak chest-wall movement

d

The perioperative nurse is encouraging a family member to remain with a client in the preoperative holding area until the client is taken into the operating room. Which of the following reasons is the primary reason for this encouragement?

a) Ensure proper identification of the client before surgery.

b) Protect client from cross-contamination with other clients.

c) Assist perioperative nurse to obtain a complete client history.

d) Help relieve the stress of surgery for the client and family member.

b

The nurse is caring for a client in the postoperative period who is on bed rest. Which of the following actions should the nurse implement?

a) Assist the client to the bathroom when required.

b) Implement active ROM exercise every 1–2 hours.

c) Place the client in a chair for 20 minutes TID.

d) Complete passive ROM exercises once per 12 hour shift.

a

The nurse is caring for a client who had abdominal surgery two days previously. Which of the following information about the client is most important to communicate to the health care provider?

a) The right calf is swollen, warm, and painful.

b) The client’s temperature is 37.5°C.

c) The 24-hour oral intake is 600 mL greater than the total output.

d) The client complains of abdominal pain at level 6 (0–10 scale).

a

The nurse is caring for a client who is just waking up after having a general anaesthetic and the client is agitated and confused. Which of the following actions should the nurse take first?

a) Check the O2 saturation.

b) Administer the ordered opioid.

c) Take the blood pressure and pulse.

d) Notify the anaesthesia care provider

d

The nurse is assessing a client in the clinic who has knee pain following an arthroscopic procedure 7 days previously and has just had an arthrocentesis. Which of the following findings should be of most concern to the nurse?

a) Scant thin fluid

b) Sanguineous fluid

c) Straw-coloured fluid

d) Purulent appearing fluid

c

The nurse is preparing to assess a client’s musculo-skeletal system. Which of the following actions should the nurse do first?

a) Feel for the presence of crepitus during joint movement.

b) Have the client move the extremities against resistance.

c) Observe the client’s body build and muscle configuration.

d) Check active and passive range of motion for the extremities.

a

The nurse is conducting a musculo-skeletal assessment on an older-adult client. Which of the following is an age-related change in this body system?

a) Decreased bone density

b) Decreased risk for cartilage disruption

c) Increased glycogen stores

d) Increased muscle cell diameter

a

Before assisting a client with ambulation on the day after a total hip replacement, which of the following actions is most important for the nurse to implement?

a) Administer the ordered oral opioid pain medication.

b) Instruct the client about the benefits of ambulation.

c) Ensure that the incisional drain has been discontinued.

d) Change the hip dressing and document the wound appearance.

d

Which of the following information obtained by the emergency department nurse when admitting a client with a left femur fracture is most important to report to the health care provider?

a) Bruising of the left thigh

b) Complaints of left thigh pain

c) Outward pointing toes on the left foot

d) Prolonged capillary refill of the left foot

c

The nurse is providing discharge teaching to a client who has a short-arm plaster cast applied. Which of the following client statements indicates a good understanding of the discharge teaching?

a) “I can get the cast wet as long as I dry it right away with a hair dryer.”

b) “I should avoid moving my fingers and elbow until the cast is removed.”

c) “I will apply an ice pack to the cast over the fracture site for the next 24 hours.”

d) “I can use a cotton-tipped applicator to rub lotion on any dry areas under the cast.

d

The nurse is caring for a client who has had a surgical reduction of an open fracture of the left tibia. Which of the following assessment findings is most important to report to the health care provider?

a) Left leg muscle spasms

b) Serous wound drainage

c) Left leg pain with movement

d) Temperature 38.6 degrees C (101.5 degrees F)

d

Which of the following menu choices by a client with osteoporosis indicates that the nurse’s teaching about appropriate diet has been effective?

a) Pancakes with syrup and bacon

b) Whole wheat toast and fruit jelly

c) Egg white omelette and a half grapefruit with sugar

d) Oatmeal with skim milk and fruit yogurt

d

The nurse is caring for a client who has acute osteomyelitis and is receiving tobramycin 80 mg IV twice daily. Which of the following actions should the nurse take before administering the gentamicin-like drug?

a) ask the client about any nausea.

b) Obtain the client’s oral temperature.

c) Change the prescribed wet-to-dry dressing.

d) Review the client’s blood urea nitrogen (BUN) and creatinine levels.

b

Which of the following findings should the nurse expect when assessing an older-adult client who has osteoarthritis (OA) of the left knee?

a) Heberden nodules

b) Pain upon joint movement

c) Redness and swelling of the knee joint

d) Stiffness that increases with movement

c

A client who has rheumatoid arthritis is seen in the outpatient clinic and the nurse notes that rheumatoid nodules are present on the client’s elbows. Which of the following actions should the nurse take?

a) Draw blood for rheumatoid factor analysis.

b) Teach the client about injection of the nodule.

c) Assess the nodules for skin breakdown or infection.

d) Discuss the need for surgical removal of the nodule.

b

Which of the following information should the nurse include when teaching range-of-motion exercises to a client with an exacerbation of rheumatoid arthritis?

a) Affected joints should not be exercised when pain is present.

b) Application of cold packs before exercise may decrease joint pain.

c) Exercises should be performed passively by someone other than the client.

d) Walking may substitute for range-of-motion (ROM) exercises on some days.

d

All of the following interventions are received for a client who has vomited 1,500 mL of bright red blood. Which order will the nurse implement first?

a) Insert a nasogastric (NG) tube and connect to suction.

b) Administer intravenous (IV) famotidine 40 mg.

c) Draw blood for typing and crossmatching.

d) Infuse 1,000 mL of lactated Ringer’s solution.

b

Which of the following information about a client who has just been admitted to the hospital with nausea and vomiting requires the most rapid intervention by the nurse?

a) The client has taken only sips of water.

b) The client is lethargic and difficult to arouse.

c) The client’s chart indicates a recent resection of the small intestine.

d) The client has been vomiting several times a day for the last 4 days.

c

The nurse is caring for a client with acute gastrointestinal (GI) bleeding who is receiving normal saline IV at a rate of 500 mL/hour. Which of the following findings obtained by the nurse is most important to communicate immediately to the health care provider?

a) The client’s blood pressure (BP) has increased to 142/94 mm Hg.

b) The nasogastric (NG) suction is returning coffee-ground material.

c) The client’s lungs have crackles audible to the midline.

d) The bowel sounds are very hyperactive in all four quadrants.

d

After receiving change-of-shift report, which of the following clients should the nurse assess first?

a) A client whose new ileostomy has drained 800 mL over the previous 8 hours

b) A client with familial adenomatous polyposis who has occult blood in the stool

c) A client with ulcerative colitis who has had six liquid stools in the previous 4 hours

d) A client who has abdominal distension and an apical heart rate of 136 beats/minute

b

When assessing the colour of a new stoma in the postoperative period, which of the following findings should cause the nurse to suspect anemia?

a) Meaty red to

b) Pale pink

c) Blanching, dark red to purple

d) Dark red

b

The nurse is admitting a client with an exacerbation of inflammatory bowel disease (IBD). Which of the following nursing actions should the nurse include in the plan of care?

a) Restrict oral fluid intake.

b) Monitor stools for blood.

c) Increase dietary fibre intake.

d) Ambulate four times daily

c

The nurse is admitting a client to the emergency department with acute exacerbation of inflammatory bowel disease who has been vomiting blood. Which of the following actions should the nurse take first?

a) Insert a large-gauge IV catheter.

b) Draw blood for coagulation studies.

c) Check BP, heart rate, and respirations.

d) Place the client in the supine position.

c

A client requests a prescription for birth control pills to decrease abdominal cramping and headaches during her menstrual periods. Which of the following actions should the nurse take first?

a) Determine whether the client is sexually active.

b) Suggest that the client use nonsteroidal anti-inflammatory drugs (NSAIDs) for symptom relief.

c) Take a personal and family health history from the client.

d) Teach the client about the adverse effects of oral contraceptives.

b

The nurse is caring for a client with persistent menorrhagia. Which of the following parameters should the nurse monitor?

a) Estrogen level

b) Complete blood count (CBC)

c) Gonadotropin-releasing hormone (GNRH) level

d) Serial -human chorionic gonadotropin (hCG) results

c

The nurse is teaching a client who is scheduled for a transurethral resection of the prostate (TURP) about continuous bladder irrigation. Which of the following information should the nurse include?

a) Bladder irrigation decreases the risk of postoperative bleeding.

b) Hydration and urine output are maintained by bladder irrigation.

c) Bladder irrigation prevents obstruction of the catheter after surgery.

d) Antibiotics are infused on a continuous basis with bladder irrigation.

b

The nurse is assessing a couple at the infertility clinic because they have not been able to conceive. When performing a focused examination to determine possible causes for infertility, which of the following risk factors should the nurse assess in the male client?

a) Hydrocele

b) Varicocele

c) Epididymitis

d) Paraphimosis

a

Treatment for ulcerative colitis in relation to nutrition includes the following: (high or low) _____calorie, _____protein, _____fibre

a) high, high, low

b) low, low, high

c) high, high, high

d) low, low, low

a

Are the following clinical manifestations representative of ulcerative colitis or crohn’s disease? Severe weight loss, cobblestoning of mucosa, fistulas, severe abdominal cramping

a) Crohn’s disease

b) ulcerative colitis

b

A 68-year-old female client presents to the gynecology clinic with complaints of painless vaginal bleeding. The nurse anticipates that the client will be tested for which condition?

a) Ovarian cyst

b) Cervical or uterine cancer

c) Polycystic ovarian syndrome

d) Endometriosis

b

What do we call substances that stop vomiting?

a) antihemolytic

b) antiemetic

c) antibiotic

d) antiseptic

a

Pancreatitis is inflammation of an organ in the abdomen called the pancreas.

a) true

b) false

b

What is the main function of the pancreas?

a) Filters toxins from the blood

b) Aids in digestion

c) Absorbs nutrients from blood

d) Regulates major body functions

d

What causes pancreatitis?

a) Genetic disorders

b) Excessive alcohol consumption

c) Gallstones

d) All of the above

a

The nurse knows which of the following is the main sign of pancreatitis?

a) Pain in the upper-mid abdomen

b) Constipation

c) Headache

d) Fatigue

b

__________________is most commonly found in the terminal ileum and beginning of the colon.

a) Ulcerative colitis

b) Crohn's Disease

b

Which type of bowel disease is most likely to cause severe malnourishment?

a) Ulcerative colitis

b) Crohn's Disease

a

A patient has the following symptoms: urgent and frequent bowel movements of diarrhea that contains blood with pus and mucous, low hemoglobin/hematocrit, potassium level of 2.0. Based on the patient’s signs and symptoms, which disease does this describe?

a) Ulcerative colitis

b) Crohn's Disease

d

Which of the following represents the correct order of events during the menstrual cycle?

a) FSH rise, ovulation, LH surge, luteal phase, menstruation

b) Luteal phase, menstruation, FSH rise, ovulation, follicular phase

c) Follicular phase, luteal phase, FSH rise, ovulation, menstruation

d) Menstruation, FSH rise, LH surge, ovulation, luteal phase

b

The term 'arthritis' refers to stiffness in the joints.

a) true

b) false

a

Paraphimosis is 

a) ulcer and edema from the foreskin that remains contracted over the prepuce

b) inability to retract the foreskin due to secondary lesions on the prepuce

c) a form of epididymitis that prevents erection

d) none of the above

d

The following collaborative management techniques is used to treat prostatitis EXCEPT?

a) Antibiotics

b) Pain management

c) High fluid intake

d) IM injections of estrogen

a

Which of the following is a nursing diagnosis for a patient with prostate cancer?

a) Urinary retention

b) Hypotension related to diagnosis

c) Cardiac tamponade as evidenced by erectile dysfunction

d) None of the above

d

Which of the following is the most appropriate question to ask the client with painful menstruation, to differentiate primary from secondary dysmenorrhea?

a) "Does your pain become worse with activity or overexertion?"

b) "Have you had a recent personal crisis or change in your lifestyle?"

c) "Is your pain relieved by nonsteroidal anti-inflammatory medications?"

d) "When in your menstrual history did the pain with your period begin?"

c

The nurse is caring for a client after an ectopic pregnancy was surgically removed. What should the nurse advise the recovering client?

a) She has an increased risk for salpingitis

b) Bed rest must be maintained for 7 days to assist healing

c) Having one ectopic pregnancy increases her risk for another

d) intrauterine devices and infertility treatments should be avoided

c

The nurse is teaching a client who chooses not to take hormone therapy how to prevent or decrease age-related changes that occur after menopause. Which of the following is the most important self-care measure that the nurse should teach?

a) Maintaining usual sexual activity

b) Increasing the intake of dairy products

c) Performing regular aerobic, weight-bearing exercise

d) Taking vitamin E and B-complex vitamin supplements

b

An older male client is experiencing difficulty initiating voiding and a feeling of incomplete bladder emptying. What are these symptoms of BPH primarily caused by?

a) Obstruction of the urethra

b) Untreated chronic prostatitis

c) Decreased bladder compliance

d) Excessive secretion of testosterone

a

A client scheduled for a prostatectomy for prostate cancer expresses the fear that he will have erectile dysfunction (ED). In responding to this client, what should the nurse keep in mind?

a) ED can occur even with a nerve-sparing procedure

b) Retrograde ejaculation affects sexual function more frequently than erectile dysfunction

c) The most common complication of this surgery is postoperative bowel incontinence

d) Preoperative sexual function is the most important factor in determining postoperative erectile dysfunction

d

Which manifestations of testicular cancer would the nurse observe for when assessing a client for this disease?

a) Acute back spasms and testicular pain

b) Rapid onset of scrotal swelling and fever

c) Fertility challenges and bilateral scrotal tenderness

d) Painless mass and sensation of heaviness in the scrotal area

d

What should the nurse explain to the client who has had a vasectomy?

a) The procedure blocks the production of sperm

b) ED is temporary and will return with continued sexual activity

c) The ejaculate will be about half the volume it was before the procedure

d) An alternative form of contraception will be necessary until sperm count is verified at zero in two tests